If seclusion prompted serious debate amongst mental health professionals in the late 1980s and early 1990s, then the question of physical restraint as a therapeutic intervention for managing aggression is increasingly becoming an area of concern at the start of the twenty-first century.
As a consequence of this, there appears to be an upsurge of interest in anger management interventions; for example, there has been considerable growth in anger management group work in prisons. It seems likely that anger management work will continue to be a growth area. A positive upsurge of interest such as this lends itself to the question: Can anger management as a therapeutic intervention become the next trend for mental health practitioners, diminishing, if not eliminating, the need to use such restraints as physical restraint or seclusion?
Both British and American researchers have stressed in recent studies that despite the growth in the interest and practice of anger management work, the use of restraint has become part of routine hospital care, particularly when assisting in the management of difficult/challenging behavior. Restraint is the most frequently cited intervention.
Therefore, from the introduction above, the author would conclude that there appears to be two major therapeutic interventions: anger management, which is increasing in use within practice as a therapeutic intervention, and restraint use, which is the most frequently used therapeutic intervention. In practice, however, it could be suggested that with each of these interventions the problems lay in determining the most appropriate response in any given situation, especially when addressing challenging/selfinjurious behavior.
Drawing from relevant literature, including the presentation of a case study, the author has critically analysed the use of restraint as a therapeutic intervention in comparison and contrast with anger management as a therapeutic intervention.
Responding to violent incidents: physical restraint
Coping with violent patients has been the routine of psychiatry for hundreds of years. Prior to the introduction of the Code of Practice (1983) and the Mental Health Act (1983), clinical guidelines designed to address the problem of violence have been dependent upon subjective views of the person in charge of the clinical environment.
In 1981, the Home Office via the prison service introduced a system of interventions based around the martial art of jujitsu. The aim of this technique – named control and restraint – was to manage violence in a consistent and effective method. Obviously impressed with the effectiveness of these techniques, hospitals throughout the country embraced control and restraint, and subsequently staff begun training in these techniques.
Twenty years on, and both the MHA and the Code of Practice have acknowledged the effectiveness of the use of control and restraint within the clinical environment.
Despite these acknowledgements, control and restraint, including physical restraint, is still questioned by forensic practitioners and researchers. This could be due to the growing concerns and criticisms of those applying the technique and those receiving it. In addition, it has been recognized by the Department of Health (1992) that there is misinterpretation amongst practitioners as to when restraint should be used through to its misuse.
Despite such insecurities amongst practitioners, control and restraint is considered to be the best choice from a poor selection. Stanton-Greenwood (1999) claims physical restraint as a technique is not a behavioral management strategy and, if conducted as such, is not valued as a therapeutic intervention.
Thus, the question arises that if control and restraint are not beneficial or therapeutic when addressing challenging behavior as nursing interventions – and are depicted as the best intervention from a poor selection – why are they adopted by clinicians as therapeutic interventions? Stanton-Greenwood (1999) argues that physical restraint could be regarded as a failure as a preventative or therapeutic measure.
Taking into consideration views such as these, it is necessary to adopt a philosophy of care when educating clinicians in its application to the patient. Vague statements such as ‘use minimum force’, which are found in care and control policies, are of little value when confronted with a violent situation. Thus, the question arises, how can practitioners maximize the benefits and safe application of control and restraint? Regular control and restraint training and updates, and making it easier to locate the policies, procedures and guidelines of the establishment may achieve this. More importantly, is the inclusion of a control and restraint care strategy in the risk assessment of each individual client, the surrounding environment and its activities.
Nevertheless, restraint (whether in the form of mental health legislation, seclusion, control and restraint or medication) can only conflict with a nurse’s respect for an individual’s autonomy. Such coercive controls, which directly manipulate body processes (physically or chemically), bypassing the patients’ own thinking mechanisms, help to create a sense of helplessness and loss of control, which in turn can lead to increased levels of violence through its own violation.
It is clear that much needs to be done before control and restraint methods, such as physical restraint, can be considered safe, therapeutic, measurable interventions, that are compatible with the role of the clinician as a carer.
The management of behavior: anger management
Over the past decade there has been an apparent upsurge of interest in anger management interventions within the mental health services and civil justice system. For example, the considerable growth in the area of anger management group work in prisons in the 1990s. In a recent national survey, anger management group work accounted for 10% of all group work undertaken in prisons. Schlichter & Horan (1981) reported a comparative study of anger management techniques, simple relaxation and no treatment across a range of measures with groups of aggressive institutionalized male delinquents. The study found that both active interventions were superior to the non-treatment control. Feindler et al. (1984) used anger control training with students attending a specialized programme after being suspended from school because of offending. The intervention consisted of learning the self-management skills needed, together with performance skills and application training compared with a non-treatment control group. The anger control group showed a number of improvements both after training and at follow-up.
In considering research views, it could be concluded that forensic practitioners have some level of expertise in coping with violent situations. However, several researchers have suggested that practitioners have limited expertise in areas such as triggers of violence and de-escalation techniques, stress management and the concept of victimology.
Taking into view the above studies, I would suggest that there is a need to both develop and restore non-touch interventions, rather than relying upon such restraints as physical, chemical or seclusion. It is also important to note that the knowledge and skilled application of these techniques may enable care staff to successfully prevent anger from becoming aggression, or aggression developing into violence.
Thus, it seems quite illogical that staff are provided with training in just one aspect of aggression management when it is clearly evident that there are vital aspects of individual autonomy being neglected.
Researchers suggest that it seems likely that anger management work will continue to be a growth area through out the twenty-first century within psychiatric settings. There are already some significant signs of expansion in the prison service; for example, a national ‘treatment programme’ in prison services in England and Wales developed within the past 4 years was designed specifically for violent offenders. The programme will partly involve the application of anger management interventions.
However, despite such growth in the interest and practice of anger management work, it seems that there remains a great deal of conceptual confusion and potentially illinformed practice within this area. This is partly due to the lack of understanding of anger as an expression and partly due to the lack of insight into the cognitive process of anger maladaptive behavioral process. Thus the author feels that an understanding into ‘justifiable anger’ would aid the reader and the practitioner in identifying the difference between anger as a natural human expression and anger as a maladaptive cognitive behavioral expression.
Researchers Towl & Crighton (1996) maintain it is a common experience to become angry without becoming aggressive or violent. However, a key difficulty experienced by many offenders is in the expression of their anger. Towl & Crighton (1996) have stressedthat poor anger management strategies may result in the physical and mental ill health of the individual and those who are affected by it. Thus it is conceivable that the aggressive behavior of a distressed person may not be irrational. It may represent the expression of justifiable anger.
In such circumstances, persons who react aggressively or violently may be attempting to reaffirm their own sense of personal identity, the validity of their own perceptions and the right to be distressed or angry about their own life experiences as they subjectively understand them. In such a situation, attempts to restrain the individual could be perceived as an assault on that person’s individual autonomy and would therefore be unethical.
Psychiatric patients are dependent upon psychiatrists, nurses and other mental health professionals for validation of their experiences, and will often be deemed to be psychologically well-adjusted by mental health professionals insofar as they accept their diagnosis and the treatment imposed upon them. However, Hopton (1995) suggests that aggressive acts by mental health service users may be inherently therapeutic, as they represent an ‘open reassertion’ or releaser of the clients right to make sense of their own psychological and emotional experiences.
Nevertheless, I would suggest that nurse specialists should not accept anger and aggression that results in harm or injury. Instead, therapeutic alternatives should be adopted as nursing interventions.
At this stage, the author would like to present a case study of a male displaying aggressive behavior and the effectiveness of anger management as a therapeutic intervention.
-Lewis, D. M. Journal of Psychiatric and Mental Health Nursing. December 2001
Reflection Exercise #1
The preceding section contained information
about responding to a violent incident. Write three
case study examples regarding how you might use the content of this section in
What do restraint methods that directly manipulate body processes and bypass the patients’ own thinking mechanisms help to create? Record the letter of the correct answer the .