14 CPT: 16TH GENERAL REPORT MEANS OF RESTRAINT IN PSYCHIATRIC ESTABLISHMENTS FOR ADULTS Preliminary remarks On the use of restraint in general 36. In its 8th General Report covering the year 1997, the CPT addressed the issue of involuntary placement in psychiatric establishments for adults. In this context, the Committee made a number of remarks concerning the restraint of agitated and/or violent patients. During the intervening nine years, the debate over the use of restraint has continued to fire passions, with different psychiatric traditions advocating alternative approaches for managing such patients. 37. As a matter of principle, hospitals should be safe places for both patients and staff. Psychiatric patients should be treated with respect and dignity, and in a safe, humane manner that respects their choices and self-determination. The absence of violence and abuse, of patients by staff or between patients, constitutes a minimum requirement. In many psychiatric establishments, recourse to means which limit the freedom of movement of agitated and/or violent patients may on occasion be necessary. Given the potential for abuse and illtreatment, such use of means of restraint remains of particular concern for the CPT. Consequently, visiting delegations examine carefully the procedures and practice in psychiatric establishments as regards restraint as well as the frequency of resort to such means. Regrettably, it would appear that in many of the establishments visited there is an excessive recourse to means of restraint. The CPT believes that the time is ripe to expand upon its earlier remarks and would welcome the comments of practitioners on this section of the General Report. It is in this spirit of constructive dialogue, with a view to assisting health-care staff in performing their arduous tasks and providing patients with appropriate care, that the following remarks are made. That said, on occasion the use of physical force against a patient may be unavoidable in order to ensure the safety of staff and patients alike. Creating and maintaining good living conditions for patients, as well as a proper therapeutic climate - a primary task for hospital staff - presupposes an absence of aggression and violence amongst patients and against staff. For this reason, it is essential that staff be provided with the appropriate training and leadership to be capable of meeting in an ethically appropriate manner the challenge posed by an agitated and/or violent patient. 38. The line separating proportional physical force to control a patient from acts of violence can be a fine one. When that line is crossed, it is often due to inadvertence or unpreparedness rather than a result of malevolent intention. In many cases staff are simply not properly equipped to intervene when confronted with agitated and/or violent patients. It should also be emphasised that CPT delegations have found that an active and alert role by management with respect to resort to means of restraint in a given establishment has usually resulted in a steady decline in their use.