The need to overcome the “global burden of obstacles” to end physical restraints in pediatric psychiatric care

Section: Editorial


Elvira Pértega


PhD. New York University. Universidad Autónoma de Madrid. International Diploma in Mental Health Law and Human Rights. Enfermera especialista en Salud Mental (vía EIR). Licenciada en Antropología Social y Cultural.

Mental health has been a neglected issue throughout human history having as a prevailing legacy the unacceptable human rights violations within mental health facilities. In response to this, the 2030 Sustainable Development Agenda has recognized mental health as a global imperative and the Convention on the Rights of Persons with Disabilities established the international commitment for a paradigm shift to move from coercion and discrimination to trust and dignity. Hence, there is an urgent need to challenge the current status quo and find concrete measures to end all forms of involuntary treatment and confinement.

A particular form of coercion is the use of physical restraints (PR), which continues as a common and controversial practice confining patient’s bodily movements, to control behavior. Some view this as the oldest unsolved problem remaining in worldwide institutional psychiatry today. The frequency of use is noted in the high rates and the harmful consequences increase concerns about PR. Importantly, youth are at much higher risk than adults to undergo PR also suffering more serious emotional and physical sequelae. This is particularly worrisome since PR guidelines mainly refer to adult population, without considering the children’s particular vulnerability.

Given the relevance of the issue, numerous efforts have aimed to reduce PR use while their limited success shows that the eventual elimination of this practice will not be easily achievable. A possible reason for this failure is that these programs have been designed without a prior understanding of the essential elements affecting professionals’ decisions to use coercion (i.e. PR).

In order to address this knowledge gap a prior qualitative research explored professionals’ decision-making process about PR use in impatient pediatric psychiatric units, finding an intricate interplay between structural, contextual, cultural, interpersonal, moral and psychological factors reflecting the complex causal reality of PR decisions in pediatric psychiatric units. These findings are aligned with the so-called “global burden of obstacles: power asymmetries, prevalence of biomedical model and biased used of evidence”” that hinder mental health care to adopt a human rights approach. In relation to “power asymmetries”, Pértega found that the use of power in the form of coercion in mental health settings is a response to a sense of insecurity that patients’ unpredictable behavior generates among professionals whose perceived role is to ensure safety and maintain control. Nevertheless, decisions to use coercion are legally exclusive to psychiatrists while in practice nurses are the main PR decision makers. This paradox may relate to the hierarchical distribution of resources and responsibilities that concentrate in psychiatrists, leaving professionals in charge of implementing units’ rules and medical orders lacking resources except PR to do so. Thus, hierarchy may help respond to the critical question about how “the last resort principle” is perceived and practiced.

Closely related to “power asymmetries” the second obstacle “prevalence of biomedical model” also prevents the use of PR to end. In this case, patients’ refusal to comply with psychiatric orders was the main trigger for PR since professionals cannot implement medical orders without patients’ consent unless they use PR. This practice is in turn a manifestation of the third obstacle “biased used of evidence” since empirical evidence shows that PR is counterproductive for being harmful, traumatic, a form of punishment and ineffective to ensure safety. In addition, while current PR guidelines require professionals to use rule-based thinking to follow PR protocols objectively, professionals referred to use “intuition” mediated by prior experiences and rapport with the patient. Moreover, PR events happen in emergency situations that reduce cognitive capacity to consider all available alternatives and so avoid using PR as “last resort”.

The Special Rapporteur asked for an open dialogue to overcome the “global burden of obstacles” that makes coercion prevail in mental healthcare. The presented arguments show that such goal is feasible but not easy, as it requires a profound transformation of mental healthcare principles and organization. In order to trigger this necessary change I would suggest start revitalizing the values of 1) justice, moving from hierarchy-based towards organizational justice-based healthcare settings, and 2) wisdom, moving from detached-intellectual unilateral decisions based on empirical evidence towards involved-intuitive collaborative care based on compassionate understanding.