CPT: 16TH GENERAL REPORT Types of restraint in use 39. The CPT has come across various methods of controlling agitated and/or violent patients, which may be used separately or in combination: shadowing (when a staff member is constantly at the side of a patient and intervenes in his/her activities when necessary), manual control, mechanical restraints such as straps, straitjackets or enclosed beds, chemical restraint (medicating a patient against his/her will for the purpose of controlling behaviour) and seclusion (involuntary placement of a patient alone in a locked room). As a general rule, the method chosen in respect of a particular patient should be the most proportionate (among those available) to the situation encountered; for example, automatic resort to mechanical or chemical restraint is not called for in cases when a brief period of manual control combined with the use of psychological means of calming the person down would suffice. As one might expect, using oral persuasion (i.e. talking to the patient to calm him/her down) would be the CPT’s preferred technique but, at times, it may be necessary to resort to other means directly limiting the patient’s freedom of movement. 40. Certain mechanical restraints, which are still to be found in some psychiatric hospitals visited by the CPT, are totally unsuitable for such a purpose and could well be considered as degrading. Handcuffs, metal chains and cage-beds clearly fall within this category; they have no rightful place in psychiatric practice and should be withdrawn from use immediately. The use of net-beds, widespread in a number of countries until only a few years ago, appears to be in steady decline. Even in those few countries where they are still in use, net-beds are resorted to on a diminishing basis. This is a positive development and the CPT would like to encourage States to continue making efforts to reduce further the number of net-beds in use. 41. If recourse is had to chemical restraint such as sedatives, antipsychotics, hypnotics and tranquillisers, they should be subjected to the same safeguards as mechanical restraints. The side-effects that such medication may have on a particular patient need to be constantly borne in mind, particularly when medication is used in combination with mechanical restraint or seclusion. 15 42. As regards seclusion, this particular measure is not necessarily a proper alternative to the use of mechanical, chemical or other means of restraint. Placing a patient in seclusion may produce a calming effect in the short term, but is also known to cause disorientation and anxiety, at least for certain patients. In other words, placement in a seclusion room without appropriate, accompanying safeguards may have an adverse result. The tendency observed in several psychiatric hospitals to routinely forgo resort to other means of restraint in favour of seclusion is of concern to the CPT. When to restrain a patient 43. As a general rule, a patient should only be restrained as a measure of last resort; an extreme action applied in order to prevent imminent injury or to reduce acute agitation and/or violence. In reality, the CPT often finds that patients are restrained, usually with mechanical restraints, as a sanction for perceived misbehaviour or as a means to bring about a change of behaviour. Moreover, in many psychiatric establishments visited by the CPT, the application of restraints is resorted to as a means of convenience for the staff; securing difficult patients while other tasks are performed. The usual justification provided to the CPT is that a lack of staff necessitates an increase in recourse to means of restraint. This reasoning is unsound. The application of means of restraint in the correct manner and appropriate environment requires more - not fewer medical staff, as each case of restraint necessitates a member of staff to provide direct, personal and continuous supervision (cf. paragraph 50). Voluntary patients should only be restrained with their consent. If the application of restraint to a voluntary patient is deemed necessary and the patient disagrees, the legal status of the patient should be reviewed.