Surviving Restrictive and Least Restrictive Practice: ‘Hold me up, don’t hold me down’

Content note: descriptions of mistreatment and neglect in psychiatric inpatient settings

N.B. I live with Dissociative Identity Disorder and refer to ourselves using plural pronouns, when applicable, throughout this piece.

Eight years ago, we were living in the community with our life teetering in the balance of my (then) partners’ arms. Frequent visits to A&E, resulting in repeated surgeries. Community services failed to provide sufficient support or keep us safe. My partner was at risk of losing her job, suffering from sleep deprivation, Secondary PTSD and permanently worried sick that she would lose us. We faced repeated Mental Health Act Assessments in which I fought tooth and nail to keep us out of hospital, oblivious to how serious the situation actually was. The final ‘incident’, resulting in our detention of now eight years, happened in Asda, of all places. We were suddenly considered a danger to the public as well as ourselves.

Upon admission, we were catapulted into the world of restrictive practice, our every move was followed by strangers at arm’s length, we were stripped of clothing and I frequently found myself wearing a weighted ‘safety dress’ or ‘strongs’ (anti-ligature clothing). Attempts to self-harm or end our life were met with long, painful and re-traumatising restraints, forced rapid tranquilisation and the four walls of a seclusion room. Thankfully, ‘I’ remember very little from this time. But the other personality states who share my body do remember. I would ‘come to’ feeling sedated and confused, having lost hours or even days. In moments of clarity, I remember feeling trapped, misunderstood and desperate to go home.

Little did we know we would still be sat here, eight years later, in a Psychiatric Intensive Care Unit (PICU), awaiting our long-overdue discharge (due to funding delays). In regards to restrictive practice, the tide has changed immeasurably in those eight years. We have experienced both extremes of restrictive and least restrictive practice and it is of my opinion that neither approach is therapeutic or beneficial to the vast majority of patients, nor those delivering care on ground level.

Our story is one of many that often go unheard, silenced by the walls of the institutions we reside in. Institutions that arguably save lives but also destroy lives. It’s a conundrum, an inherent catastrophe and one which service providers and NHS trusts across the country need to face up to. I’ve seen many, perhaps hundreds of people come and go from inpatient services and know of others who have tragically lost their lives as a result of restrictive or least restrictive practice. Recently there has been an increase in the media reporting of systematic abuse within psychiatric settings. Sadly, these cases are not isolated; they are just the tip of the iceberg.

During the ‘reign’ of restrictive practice, our body was pinned down to the floor in supine restraint on a regular basis, for lengthy periods of time. Once, for the majority of four hours, despite NICE guidance clearly stating to “not routinely use manual restraint for more than 10 minutes”. We were not offered the option of oral PRN medication for almost two years and instead had to endure the ordeal of forced rapid tranquillisation that only increased the severity and length of incidents, not to mention our trauma responses and dissociation. Our body was dragged down corridors, clothes and personal possessions were forcibly removed. At times we were denied visits, access to legal advice and physical healthcare, the latter were supposedly because our risks were ‘too high’.

In contrast, the sudden departure of restrictive practice led to the seemingly rapid introduction of the new and shiny ‘least restrictive practice’. A long-awaited freedom? Or an excuse for professionals to stand back and state “there is nothing we can do”? Suddenly, Health Care Support Workers lost their autonomy and the ability to use their knowledge and experience to make on-the-spot decisions. Physical interventions such as restraint were virtually black-listed, even in situations where patients were posing an immediate high risk to themselves or others. We were left to ligature or choke until we were turning blue, watched with a running commentary as we bashed our head repeatedly off hard surfaces whilst waiting for a qualified nurse to decide when or if staff should intervene. These decisions cause conflict amongst staff and can lead to prolonged incidents, sometimes involving a heavy-handed restraint as a last resort, when perhaps ‘gentle physical redirection’ (as affectionately referred to) would have been enough to halt an incident before it escalated.

The notion of contraband in itself (aside from drugs and alcohol) has become ‘contraband’. For example, wires, cans and plastic bags are now allowed on PICU wards, with risk items such as crockery also being introduced onto wards where patients are a high risk to themselves and/or others. The elimination of blanket policies is definitely a step forward, however, lifting blanket policies can also compromise the safety of some patients and should be implemented carefully, with thorough risk assessments involving individual patients and the teams providing care and treatment at the very core of every decision. My critique of least restrictive policy is shared by many of the professionals who have been involved in our care and treatment, particularly Health Care Support workers, who are forced to implement and comply with policy changes on ground level. They too are concerned about the safety of patients, themselves and work colleagues, but their voice is also seemingly unheard by policy makers.

There is no denying that restrictive practice may have fundamentally saved my life, but also led to further traumatisation, loss of independence and infringement of our human rights. In some ways, least restrictive practice has been a welcome change. However, at times it has also endangered our life, compromised the safety of those around us and led to further restrictive practice as a ‘last resort’. I’ve also queried whether least restrictive practice is in fact ‘least restrictive’ when there is little or no attempt to involve patients in the development of such policies nor ask the crucial question of “What do you feel restricted from doing?”.

Focusing all the attention on ‘restriction’ (or lack of) rather than a person-centred assessment of individual needs and safety appears to be the crux of the problem.

I believe the solution cannot be found without structural change within services. We need policy makers to sit back and listen, carefully. To hear the voices of those who are subjected to restrictive practices and to those who have suffered as a result of least restrictive practice. I am fully aware that it is impossible to meet the needs of everyone in settings such as psychiatric wards, but there must be a concentrated effort to find a balance, to implement restrictions when absolutely necessary and to reduce them with individual need and risks in mind. Too often, policies are implemented haphazardly and only when things go wrong are they scrutinised. Patient experience should not just matter in ‘lessons learned’ situations, it should inform the development and design of such policies in the first place.

About Fruit Bat

I’m a 36 year old (possibly neuro-divergent) female living with Dissociative Identity Disorder. Currently attempting to fight my way out of an 8 year detention under the MHA which ultimately kept me alive but has led to further traumatisation and development of agoraphobia and an unhealthy dependency on others. I have received what I consider to be some of the best and some of the worst care and treatment during my 8 year stint in inpatient services. I’m having to develop a new sense of self as long term hospitalisation stripped me of my already diluted sense of self. What I do know is I’m a proudly queer, introverted, vegan, feminist, pacifist. I am completely and utterly intolerant to all forms of discrimination. I love walking, nature, animals, have an eclectic taste in music and luckily an equally eclectic group of close friends who have stuck by me through everything.

This blog is part of our series on safety and care in healthcare settings. You can find the other pieces in the series here.