When a woman or girl is admitted to a mental health unit, her expectation should be of a caring, supportive environment where she can get the treatment she needs to get better. Unfortunately, we now know from Agenda’s latest research on restraint that many are instead in an environment where physical force has become shockingly routine.
Agenda is an alliance of more than 70 organisations campaigning on behalf of women and girls at risk. We decided to ask for data about the use of restraint because previous research we carried out on mental health trusts’ strategies and policies – as part of our Women in Mind campaign – showed that most were failing to take into account women’s specific needs.
If this was the case with strategy and policy, what was the reality in service delivery? We submitted a freedom of information request to all mental health trusts in England to find out.
Our research showed that one in five women and girls were physically restrained in mental health settings and that the use of face-down restraint continues to be widespread, with women and girls treated this way on thousands of occasions.
Such frequent use of restraint is particularly concerning because of the potential it has to re-traumatise the many women and girls who have experienced abuse and violence. In some trusts, restraint against women and girls was commonplace, with three-quarters being physically restrained, and up to a third restrained face-down.
There were nearly 2,300 incidents of face-down restraint against girls, compared with fewer than 300 against boys. There were also 4,000 incidents of face-down restraint against women, which was more than that of men – despite women being a smaller proportion of patients.
One woman who had experienced restraint repeatedly over a number of years told me about the fear it provoked. Not only was there the physical discomfort; it also brought back memories of the abuse and trauma she had suffered as a child.
More than half of women who have mental health problems have experienced abuse – and the links are particularly pronounced for those with more severe illnesses.
Being physically held down and having your clothes pulled out of place, often in front of others, can be an extremely humiliating, as well as frightening, experience. Not only that, but restraint is often carried out by male nurses, another factor that compounds the fear and trauma of those women and girls who have histories of abuse and violence at the hands of men.
One explanation is that women and girls may be seen as physically easier to restrain. Another is their higher rates of self-harm – with restraint being used to prevent or control that behaviour. But when a female is feeling vulnerable and ill, is the best solution really to hold her face-down on the floor, unable to move? It is an extreme step. As a leading restraint expert told us, in some circumstances what might be more helpful is simply a hug. Of course there may be circumstances in which restraint is necessary to prevent harm to a patient or those around them. But such circumstances should be exceptional, not routine.
The fact that some trusts appear to have almost eliminated physical restraint and to have stopped using face-down restraint altogether shows that change is possible, and alternative de-escalation techniques can and do work. Those trusts with high rates of restraint need to follow their lead – and government guidelines– and end the use of face-down restraint, using other forms of physical restraint only as a last resort.
Recognising women and girls’ specific needs is vital to helping them get better. This needs to happen in national mental health policy and strategy as well as at local level. In particular, women and girls’ histories of trauma need to be taken into account in mental health services and support given to tackle the underlying issues they face. This must include staff receiving training to understand that women’s mental health, trauma and abuse are often closely linked.
These changes are needed if mental health units are to be the compassionate, therapeutic environments they should be.
Katharine Sacks-Jones is the director of Agenda, the alliance for women and girls at risk. Agenda brings together more than 70 organisations that want to see change for the most marginalised women and girls. Prior to joining Agenda, Katharine led the policy and campaigns team at Crisis. She has 15 years’ experience working in policy, public affairs and parliament.