Restraint

Our science enables us to call your madness illness and diagnose a madness in you that prevents you being a patient like other patients: hence you will be a mental patient.1

Unlike most other medical specialists, psychiatrists have the legal power to coerce patients into accepting treatment. In a UK post-asylum era, it is tempting to suggest that the complex ethical questions about

coercion in treatment are somehow less relevant or less important than they once were. Nothing could be further from the truth. Coercion in its various forms continues to play a central role in mental health practice both in the United Kingdom and across the world. This chapter briefly explores the history of coercion, and discusses its use in contemporary practice. The primary focus will be on an evaluation of whether (and if so how) restraint, seclusion and compulsory medication can be justified ethically. For the purpose of this chapter, however, both seclusion and compulsory medication will be considered sub-types of restraint: seclusion, because substituting a locked door for a restraining hand or belt, merely replaces one means of restricting movement with another; compulsory medication – particularly rapid tranquilisation – because ‘a medication used to control behaviour or to restrict a patient’s freedom of movement’, is in reality ‘not treatment but restraint’.2 The focus of the discussion will be on their use in services for working age adults but it is acknowledged that such interventions are used in other services. As Thomas Szasz3 observed, state legitimised coercive interventions whilst ‘always morally

problematic’ are also always ‘inherently political in nature’. This chapter eschews therefore the use of a more conventional ethical framework in favour of two post-modernist constructions of validity: the ‘pragmatic’ and the ‘psychopolitical’. The decision to do so requires, however, some justification for those unfamiliar with this approach. Validity as a concept has several well-known dimensions central to the positivist tradition in research in the behavioural sciences, particularly ‘content’, ‘construct’ and ‘predictive’ validity.4 This ‘traditional’ construction of validity reflects a modernist worldview, whereby knowledge provides a map of a reality, which is assumed to be objective. If instead an alternative post-modern worldview is taken the search for certainty in knowledge is replaced by that of identifying defensible ‘claims’ regarding all knowledge. Validation then becomes the process of choosing among competing interpretations each framed as potentially falsifiable and thus open to exploration.5 Truth in this context is not defined with reference to an objective reality but retains significant value as a concept, albeit interpreted now, in terms not of accuracy, but of utility, in the sense of ‘whatever assists us to take actions that produce the desired results’.6 The process however, whereby ‘the results desired’ are agreed upon, involves consideration of both values and

ethics. The consequence is that validity itself becomes an ethical question and it is this perspective, which will inform the exercise undertaken.7