A Narrative study: Mental health service users’ experiences of physical restraint

Abstract

During the past thirty years, there has been increasing concern regarding physical restraint and its association with death, injury, pain and emotional upset. Internationally there has been a shift to reduce the use of all forms of restraint. Policy and guidance in the United Kingdom, for health and social care staff, advises a preventative and de-escalatory approach in managing service user aggression and violence. If restrictive interventions are deemed necessary, these should be used for the shortest time possible, with staff using the least restrictive means to meet the immediate presenting need and physical restraint reserved for only when absolutely necessary. Yet disparities in the use of restraint remain, questioning this professional rhetoric of last resort.

This thesis reports on a study exploring the narratives of service users who have experienced physical restraint. This qualitative study collected data from interviews with 11 service users who have experienced physical restraint. Stories were analysed using Frank's (2010) guiding questions for analysis and his suggestion for focused attention on a selection of stories. In keeping with this approach four stories are presented, three involving a quest narrative; Rory: a story of a resistance; Jane: a story of injustice; Rose: a story of trauma; and one a restitution narrative; Finlay: A story of saving life. While each story is unique, there are also similarities across all stories.

Consideration was given to the inter-relationship with other stories told about mental health service users and some of the grander narratives which underpin care practices or are influential within society. In this sense, individual stories were considered in the context of the narrative inter-relationships between all of the stories which acts to construct our knowledge of the world and even our sense of who we are. The powerful narratives of neoliberalism and biomedicine, in particular, are considered for their potential influence in the social process of conceiving and telling of these stories.

The concept of last resort and least restrictive measure are misnomers, as the physical and emotional aspects of restraint are revealed. The ‘otherness’ of service users is also divulged as service users discuss such concepts as a lack of dignity, dehumanisation and feeling ignored. However, the calming impact of restraint is also uncovered as viewed through the lens of one storyteller. The importance of the therapeutic alliance is a strong theme within all stories and is considered against a backdrop of the contemporary pressures on nursing staff. Related to this, are the organisational perspectives of staff working within mental inpatient health settings, including the somewhat difficult issue of balancing care and control in a mental health system, which legitimises the use of violence to some extent. Narratives of mental illness, distress, trauma, violence, power and control are storied by participants in this study. The powerful meta-narratives surrounding these concepts, including the stories told about mental health service users are similarly reflected upon.

The storytellers also reveal the different facets of their identities including those of ethnicity, gender and survivor. The loss of identity and a medicalised illness identity were storied by some participants, yet towards the end of their stories participants presented themselves with more empowered identities, emphasising their sense of the importance of organisations that seek to work in a co-productive manner. Three of the four service users are positioned in their stories as ‘formal’ experts by experience, displaying their perception of this role in its contribution to mental health services in contemporary practice.

Recommendations for future practice are considered including no restraint environments and restraint reduction initiatives, such as Safewards and the Six Core Strategies©, including the REsTRAIN YOURSELF Programme in the United Kingdom. Connected to this are considerations regarding the ward environment and organisational culture, which are also deliberated upon within this thesis.

Ultimately, individuals’ narratives are somewhat constrained by a powerful hegemony of neoliberal and bio-psychiatric power but this need not preclude resistance and potential for change. The Power Threat and Meaning Framework is suggested as a conceptual and empirical basis for the provision of help and support that is more reflective of both individual narratives and their interaction with wider social narratives. Narrative re-storying is implicated as one way to support individuals and communities, which challenges the narrative of individual deficit and medicalised illness. Professionals may need to develop more sophisticated ways of understanding and working with narrative in the work of recovery. There is no ready-made roadmap to get to absolutely non-coercive mental health care, however, attending to the stories offered by service users, such as those in this study, may point the way towards a more values-based, or moral, turn in services.