The context

The use of mechanical restraint and other coercive measures has existed in the discipline of psychiatry since its very origin. ^(1,2,3 From a conceptual point of view, the definition of the term mechanical restraint varies among authors. In Spanish it is common for the terms sujeción mecánica [mechanical restraint] and inmovilización terapéutica [therapeutic immobilization] to be used interchangeably. In this study we will use the term mechanical restraint to refer to any procedure that, through a mechanical device, limits a person’s freedom of movement through immobilizing one or more parts of their body.⁴ We dismiss other terminologies as we consider them ambiguous (a person can be contained without being restrained) o euphemistic (presupposing a therapeutic action).

The use of mechanical restraints in health contexts is permitted in Spain. Nevertheless, in contrast to involuntary commitments “due to psychic disorder” that are regulated by law,⁵ there is no regulation of mechanical restraint through any specific legal precept whatsoever, and such oversight is left to local ordinances and hospital protocols. The relevance of the critical reflection regarding mechanical restraint and coercion in psychiatry has focused on different factors^6,7: the elevated frequency of these practices,^8,9 their ubiquity,^{10,11,12,13,14,15} the variability of the normative frameworks that regulate them,^16,17 the controversies surrounding their use^{2,16,17,18,19} in relation to human rights violations, the Convention on the Rights of Persons with Disabilities²⁰ and the recommendations of organizations dedicated to the defense of these rights,^20,21,22 the ethical conflicts in everyday clinical practice,^22,23,24,25 the lack of evidence regarding their therapeutic effects,^2,26,27 their harmful consequences in users and professionals,^{25,28,29,30,31,32,33} the risk of abuse,²¹ and the rise in and increasing pressure from user organizations³⁴ when known alternatives exist.³⁵

This controversy is also observed in Spain.^34,36 However, despite various efforts to transform mental health systems,^19,35 the use of these practices is still widespread both in nearby countries^17,37,38 and in Spain itself.^17,39,40,41

In general, there is a lack of studies of quality regarding the use of coercive measures¹⁸ and to date no clear conclusions can be reached regarding their relation to sociodemographic variables (certain population groups) or clinical variables (specific disorders or symptoms). Nevertheless, a number of studies highlight the importance of the experience of professionals and the characteristics of the context in understanding factors related to the use of restraints.^42,43 Some authors¹⁷ and organizations⁴⁴ suggest that the use of these practices depends more on non-clinical variables - such as the philosophy of the service,⁴⁵ values and customs,⁴⁶ characteristics of the centers⁸ or cultural, educational and organizational factors⁴² - than clinical issues (diagnoses, user characteristics).

After carrying out an extensive search of the literature, we found different types of qualitative studies that look into the experiences of users,^47,48 as well as multiple quantitative studies on the frequency, demographic characteristics and other epidemiological data^17,49 regarding mechanical restraint and other coercive measures, but very little based on the experiences of professionals.^50,51 The absence of studies on professionals in training is particularly marked.⁵²

Our study

Despite the generalized belief that coercion is damaging to the liberty of the people who experience it and therefore should be considered erroneous, there is also a strong social tendency to justify it as necessary for the proper functioning of our societies.⁵³ Situations that are (potentially) violent challenge professionals to respond in a way that guarantees safety, without overlooking the users’ needs for support and care in moments of maximum vulnerability.⁵⁴ Due to its consequences for the users, mechanical restraint has been defined as a high-risk procedure.^55,56 Such consequences are emotional (fear, traumatization, impotence, dehumanization),⁵⁵ as well as physical⁵⁷ to the point of being mortal.^19,32,58 It has been suggested that it is also relevant to study this phenomenon in relation to professionals, as the impact for them is also significant.^19,32,43

The research we present here seeks to study the experience of mental health professionals in training (residents) in relation to mechanical restraint. We understand experience as the knowledge derived or acquired from having personally undergone a situation or circumstance,⁵⁹ a type of knowledge acquired from what one has encountered. The questions that have guided our research are: 1) How do health professionals in training describe their experience in relation to the decision to use or carry out mechanical restraint? and 2) What aspects of this experience influence professionals when deciding to use mechanical restraints, and in what way? Preliminary results of this study, prior to the development of the grounded theory, can be found in a technical document of the Asociación Española de Neuropsiquiatría.⁶⁰

Study design and theoretical framework

In order to adequately answer these questions, we adopted a qualitative methodology using focus groups. Qualitative methods assume reality and knowledge to be multiple and complex, influenced by the context and sociocultural values and also constructed by what people think, feel and do.^61,62 The choice of this approach allows us, through dialogue, interaction and discourse analysis, to understand the experiences from the perspective of the people who personally encounter the phenomenon of restraints, in the natural timeframe and sociocultural context in which they are situated.⁶³ This approach is carried out from a phenomenological perspective, that emphasizes how the world makes itself present int the subjectivity of the participants and in the meanings that they offer, in their own terms.⁶⁴ Our method is hermeneutical, based on a theory of interpretation that is especially useful for generating hypotheses that give meaning to a complex and conflictive issue about which there is little research.⁶⁵ The data collection was carried out using focus groups, which allowed participants the opportunity to freely express their ideas and opinions⁶⁶ through interactions and discussion based on the attitudes, points of view and discourses of each participant, supporting the exploration, clarification and deepening of individual contributions. Interactions involve attentive listening and observation in which knowledge emerges in the interplay among the subjectivity of the researchers, the context, and the object of research.⁶⁴

Selection strategy and type of sampling

The strategy for participant selection was intentional and judgmental. The participants were chosen in relation to their representativity and the variability of discourses existing in the population and not using statistical probability. The selection was carried out in the following way: 1) profiles with certain characteristics were defined (based on the experience of the research team, consulted experts and the literature reviewed) to create specific groups relevant for representing the structure of the reference population (structural sample); 2) the selection was carried out through key informants who could identify professionals with the characteristics we were looking for and, once located, an informative sheet and informed consent form were provided; 3) when an adequate number was reached, the distribution into groups was carried out in such a way as to favor the richness and heterogeneity of the discourses. During the selection process, great effort was made to assure that the participants did not have a close relationship with other participants or with the team. Nevertheless, it was inevitable that some participants had previously crossed paths in other spaces, given the specificity of the reference population and the existence of shared educational environments outside the workplace. In the few cases in which people already knew one another, it was assured the relationship between them was not close and that each person’s participation would not be conditioned by the presence of the other.

As inclusion criteria, those considered were mental health professionals in training, who worked in the public health network of the Community of Madrid and who volunteered to participate. As we mentioned, in order for the experiences of the participants to be as similar as possible to those in the natural population to which they belong, profiles were defined that were then used as a reference for the selection of the sample. In the creation of the profiles, different variables were taken into account that divide the population and that it was thought would have a significant influence upon the phenomenon under study.

Description of the population and the spatial distribution of the study

The study included 21 residents, distributed into three different focus groups with seven people each. One resident decided not participate in a group due to time constraints and could be replaced. The day the focus groups met, two people were unable to attend, and the total number was reduced to 19 residents: seven residents of psychiatry (MIR), six nursing residents (EIR) and six residents of clinical psychology (PIR). The participants included twelve women and seven men, with different amounts of training (some were just beginning, others were well within the training process and others were coming to the end of the specialization). Initially participants from eleven public hospitals of the Community of Madrid were included, but with the loss of two participants, nine hospitals remained in the sample, although the different theoretical positions according to the different teaching units continued to be represented. During the training period all the residents carry out rotations through hospital units in which they come in contact with mechanical restraints and the decision-making process that surrounds them.

Data collection

The focus groups were conducted during the year 2017. Each encounter had a duration of approximately an hour and a half, and were carried out using a semi-structured guide developed by the research team under the supervision of the most experienced researcher. The guide did not act as a rigid questionnaire, but rather as a flexible framework for exploring areas of interest, using open questions to obtain unconditioned answers, as well as focused questions to obtain unique and useful answers. The guide also served to homogenize the interventions of the different moderators, including instructions previously agreed upon by the team regarding how to carry out the interview process. The most important themes centered on the experiences of the professionals with mechanical restraint (attitudes, thoughts, emotions, and actions). The groups took place outside of the hospital, in a calm environment that facilitated an unstructured atmosphere without institutional pressures. Before starting the group, the nature of the study was again explained and informed consent was requested to verify that the information was clear and that participation was voluntary. Instructions were then given to facilitate the proper functioning of the focus group, reminding the participants that they were free to express themselves and converse, without the need to come to an agreement on anything. During the groups, the conversation was fluid and dynamic, with adequate interaction among participants. The groups were conducted by a moderator who was responsible for facilitating and guiding participation and discourse elaboration, while another person observed without intervening in the natural development of the interview, taking note of what happening and recording the content of interview in both audio and video formats.

Data analysis

As a guide, we used the recommendations of Berenguera et al.⁶¹ and Charmaz’s constructivist reading of Glaser and Strauss.^69,70 Our analysis was a progressive process starting with the description of the data, continuing with the construction and ordering of concepts and categories, and ending with theorization (Figure 1). The recordings of the groups were literally transcribed by the researchers, and notes were added regarding the nonverbal information. The names of the informants were not transcribed, but rather they were assigned alphanumeric codes. The content of the transcriptions was unified in a single textual corpus to facilitate reading and analysis and was read several times by all the researchers to assure familiarity with the raw data. In the re-readings, preliminary notes were made regarding possible thematic codes and categories, and this exercise was discussed as a team, based on our first intuitions and ideas (“naive reading”).⁷¹ The qualitative data analysis program Atlas.ti version 1.6.0 for Mac was used as an auxiliary tool for the labeling and coding. An initial coding was assigned by fragmenting the text into quotations (lines or paragraphs) that act as a unit of meaning regarding some aspect of the experience. The first codes are descriptive, connected to the literal content of the quotation. The coding process becomes increasingly sophisticated during the analysis through the iterative and detailed reading of what emerges.⁷² Through the constant comparative method and reiterative interpretation and abstraction, relations are sought among the codes to refine them and group them into conceptual categories, that make up more descriptive categories, reaching the central categories and subcategories (axial coding) when data saturation is adequate. Lastly, theoretical coding takes place, relating the results and the hypotheses with the data, with the objective of understanding the emerging meanings.⁷² During the process, the categorization and coding of the content is compared to verify that the emerging theory has its base in what was said, in a logical, systematic and explanatory schema of the constructed concepts.

Source: Own elaboration based on Tweed and Charmaz.⁷⁰.

Figure 1 Visual representation of the Grounded Theory methodology. 

Strategies to guarantee the quality and rigor of the research

The manner of evaluating the quality of qualitative research is an important object of debate.⁷³ To guarantee the quality of our research, the proposals of a number of authors were followed.^61,74,75 An effort was made to illustrate the methodological agreement among objectives, methodology and methods, carrying out a detailed monitoring of the rigor of the design and the steps taken in a commitment to transparency. To increase the reliability and validity of the study, rigorous sampling and analysis were carried out, employing triangulation techniques to verify the results and their representativity: triangulation of data, researchers, and theories. A critical, careful and reflexive attitude was maintained regarding the construction of our study, in relation to the object of study as well as in relation to our subjectivity as researchers.

Ethical aspects

All participants received information regarding the study, offered oral and written informed consent, and voluntarily and anonymously agreed to participate. They were aware that they were free to leave the study at any time and that their participation would not be compensated. To assure compliance with ethical requirements, the evaluation of the Research Ethics Committee of the Hospital Universitario La Paz (code HULP: PI-2928) was requested, and the study was approved in October 2017. Subjects were selected fairly, without discrimination among those who met the requirements sought. Possible risks related to known participation in the study were taken into account, and great care was taken to assure anonymity, intimacy and confidentiality in relation to the data and participants.⁷⁶ Treatment and communication of data was carried out according to local normative frameworks, ARCO rights, and the principles of the Declaration of Helsinki.⁷⁸

Experiences preceding mechanical restraint

Dynamics of the teams and institution

For the residents, discrepancies regarding coercive measures exist between psychiatrists and nurses, as does a lack of coordination and communication in the context of mechanical restraint, which facilitates the appearance of conflicts over the norms and over these measures. In fact, one of the motives for carrying out restraints is to avoid conflict among personnel. The existence of a hierarchy in deciding mechanical restraint can be perceived, in which the criteria of the psychiatric doctors in the end prevails. When there is disagreement, the hierarchy is experienced with frustration as well as relief for not having to take responsibility for a decision considered to be difficult. They also describe a series of attitudes and actions in the teams that can lead to conflicts that end up justifying mechanical restraint: deceptions, incoherent messages (contradictions among different shifts), imposing attitudes and lack of dialogue, yelling and threats, etc. This is something that affects professionals from other specialties who care for people with mental suffering, especially in Urgent Care. In these professionals, the residents perceive a lack of interest or collaboration, derogatory language or attitudes, and unequal treatment towards people with psychic suffering. Lastly, in relation to the institution, they feel that little support exists to implement alternative measures and that it would be necessary to change the institutional organization and culture.

Experiences during the indication of mechanical restraint

The majority state that there are two types of “pressures” that push them to make the decision to indicate mechanical restraint, and these appear as a consequence of the interaction among the previous points: the environmental and contextual factors, the behavior of users, and the prior belief systems of each professional. These pressures can be experienced as fear of the consequences of not carrying out a restraint, and/or as external pressures for them to be carried out. The residents frequently describe the indication to be inappropriate. The factors that can move the decision in a different direction or reinforce the indication of mechanical restraint are considered further on.

Experiences after the use of mechanical restraint

Among the experiences stemming from the use of restraints, we can find a number of categories worth highlighting.

Culture of coercion, biomedical model and disabling environments

One of the most significant aspects that emerges from this study is the existence of an institutional culture of coercion with its base in the biomedical model and the management of individual and social risks. Our results support the observations of Dainius Pūras, Special Rapporteur of the United Nations, in his report on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health,²² regarding the underlying justifications of coercive measures: “medical necessity” and “dangerousness.” The findings support that this approach is so relevant that it impregnates the entire institutional organization and the subjective experiences of the professionals,⁵² at the same time that it connects to the normative and contextual frameworks in which professionals develop their practice, favoring a work model based on paternalism and beneficence, protection⁷⁹ and risk avoidance.⁸⁰

Our research reflects the integration of the positivist biomedical model on the part of the professionals through the concept of “lack of illness insight” and the influence of diagnostic labels in the interpretation of the behaviors and discourses of users and the actions that they carry out. Although authors and organizations exist that have defended the need to expand the biomedical model as a means to reducing stigma,^81,82,83 our results support the idea that such an approach, which explains mental suffering using neurobiological theory, does not (sufficiently) take into account contexts and relationships,²² intensifies stigmatization,⁸⁴ favors paternalist attitudes, and strips people with mental suffering of their rights, justifying damages to their liberty with the objective of achieving a higher good.^6,79 Additionally, this model promotes training that provides few tools to facilitate an effective relationship with users.⁸⁰ In our study, a tendency was observed to justify the use of mechanical restraint based on the need to intervene in behaviors (or possible behaviors) of the people who receive mental health care, when it is considered that they require an indispensable treatment, whether or not the person has demonstrated “dangerous” behaviors, if the professional considers that the patient does not have an adequate understanding of what is best for them. This internalized concept of the lack of illness insight serves as an epistemological base for the professionals to limit or suspend the subject’s autonomy, and facilitates a shift in attention from the meanings of values of the person who suffers to their behaviors and the evaluation of these behaviors, as their discourse is not considered beyond the illness itself.⁶

In this sense, our research makes evident the priority given to the evaluation and management of risk or danger in everyday practice. Placed above the needs of the individual, risk management is an essential principle in mental health.¹⁸ Other studies have also suggested²⁸ that coercion is one of the first responses to appear in personnel when they perceive that their own safety or that of others is at risk,^85,86 but an overestimation of risk also exists based on an assessment of the behavior of the user,^28,86 and this overestimation of the threat perceived by professionals is related to fear from previous violent incidents, which impedes the exploration of non-coercive care alternatives.^28,85 Indeed, the consideration of people diagnosed with mental disorders as dangerous does not hold with the evidence⁸⁷ and tends to be justified through inappropriate prejudices.²² On the other hand, it is paradoxical that the professionals consider mechanical restraint to be a safety measure when they admit the harmful impact they have on themselves as professionals as well as on the users and the therapeutic relationship, a finding supported by other authors.^{25,33,88,89,90} For these and other reasons, it has been considered necessary to move from a model in which mechanical restraint is considered a tool that provides safety to a model in which its use is considered a sentinel event, an undesirable, unexpected event that is accompanied by risks and damages, some of them severe, and that therefore requires the implementation of measures to reduce and eliminate it.⁵⁶

This conceptualization has clinical consequences, as the majority of the alternatives proposed have to do with developing other ways of controlling behavior and avoiding risks, rather than transforming the paradigm that generates and sustains such measures.³⁵ Our analysis suggest that coercion functions in a continuous spectrum, in such a way that having experienced a coercive measure in the past or present predisposes one to new coercive measures in the future.^3,6

The attribution of dangerousness and incapacity to people with emotional suffering in the residents’ discourses finds resonance in the set of legal-normative systems that not only legitimize but pressure and force professionals to use coercive measures, preventively even, as a social mandate,⁶ blaming the professionals if violent behaviors appear⁸⁰; behaviors that, on the other hand, are always difficult to predict.⁹¹ Some authors mention the feelings of professionals regarding being observed and assessed.³⁹ Indeed, the discourses of residents regarding mechanical restraint cannot be separated from terms related to norms, duty and safety. A recent review⁹² highlights the particularity of the legal framework in Spain as compared to other countries, as the legal precept that regulates involuntary hospitalization⁵ does not mention at any time the involuntary nature of the treatment, in such a way that the responsibility of applying, after the hospitalization, any other measure considered necessary, including mechanical restraint, falls directly upon the professionals.

The general lack of resources of mental health systems put into evidence by the Rapporteur²² coincides with the experience of the participants, who denounce the material and structural deficiencies as well as the lack of adaptation of work spaces that, rather than promoting wellbeing, are disabling spaces that impede the use of non-coercive alternatives.^88,93 Some researchers do not consider there to be definite proof to show that differences in the incidence of coercive measures are due to lacks in professional training, the funding of mental health services or the user-professional ratio, and suggest that the differences are essentially due to cultural factors, policies, and the traditions of each setting.¹⁷ Nevertheless, others consider that in order to avoid the use of mechanical restraint resources are fundamental, including the amount of time professionals can spend with users.¹⁹ Indeed, structural and material deficiencies stemming from underfunding has been proposed as one of the elements favoring the violation of human rights in psychiatry.²²

Residents identify dynamics in the teams that favor the use of restraints. The hierarchy, in symbolic form or manifested as a direct order, is considered a defining factor in the use of restraints, which professionals indicate despite feeling distress or disagreeing with the decision. As Pértega highlights, certain medical orders are experienced as difficult to question even when others (residents, nurses, etc.) have to execute them.¹⁹ The contribution of the hierarchical structure in this dynamic is crucial, as it generates asymmetry in the distribution of the assigned resources, responsibilities and the separation of roles, spaces and tasks. Residents are part of those who are not experts, that, even though they spend a great deal of time with the user, do not have the same resources nor abilities to resolve certain situations, resorting to power and force.

Risk of abuse and improper use of mechanical restraint

The narratives of the residents regarding the experience of tendencies toward an inappropriate use of mechanical restraint contradicts other studies in which professionals show themselves to be mostly in agreement that the use made of restraints is “correct.”⁹⁴ In our opinion, this finding emphatically encourages the use of these practices to be reexamined; however, we have not found other studies in our region with which to compare these results. On the other hand, the results highlight concepts that could be considered problematic: “agitation,” “therapeutic,” “dangerousness,” “illness insight,” “risk of absconding,” “last resort,” etc.^88,95 All of these terms are central to the creation of a discourse that justifies the use of restraints and, nevertheless, in the experience of the professionals, are also unspecific, polysemic, and subjective. These terms are open to wide interpretation, they are not supported by research, and, according to the Rapporteur,²² they can favor arbitrariness in the use of mechanical restraint.²¹ The perception of the residents regarding the criteria for restraints is that, similar to the diagnosis, the assessment of users and of risks has an important subjective component and the protocols do not effectively guide the actions of professionals regarding these measures. Other works have similar findings.¹⁹

Belief systems, fears, insecurity and uncertainty

Parallel to Bourdieu’s concept of habitus, we consider there to be a correspondence between mental and social-institutional structures.⁹⁶ In this way, the perceptions and experiences of the professionals, their categories of representations and views of the world, are the product of the incorporation of structures of the social space. That is, beyond objective events, their experience depends on the internalization of certain schema regarding the world that informs their perceptions, feelings and actions. Based on the interaction between the professional-subject and the group and institutional culture, a system of dispositions that are both structural and structuring are built.⁹⁷ In this way, what we have called the culture of coercion influences the symbolic systems and informs the perceptions and actions of the residents who, at the same time, are active agents in the construction of reality in the clinical-institutional space. The power relations, hierarchies, conceptualizations of suffering based on the biomedical model and other elements of this culture are internalized and incline the residents to perceive the clinic as it stands today as evident and natural. The consideration of mechanical restraint as indispensable, fear regarding the elimination of its use, the assimilation over time of restraint as something that forms part of their work, and the tendency to justify its use could be understood as the product of the internalization of this culture that they perpetuate through reproduction. These experiences have also been presented by other researchers.^98,99

A transposition appears to exist regarding the feeling of insecurity and unpredictability of the social toward the mental health network. The existence of similar experiences and elements have been described by Pértega¹⁹: the failure to establish objective criteria that aid professionals faced with the social (and legal) mandates delegated to them to evaluate and manage risk, added to the real impossibility of preventing and controlling all instability in the environments and behaviors of users, submerges the residents in an uncertainty-insecurity in which mechanical restraint serves to generate certainties for the professionals responsible for an impossible task. Indeed, in a number of participants concern was observed regarding the possible elimination of mechanical restraint, without which they felt unprotected.

In relation to the psychological process that underlies the use of mechanical restraint in this situation, fear appears as a primordial part of the professional experiences, fear of both real physical harm and the consequences that can arise if such harm is produced. In this climate of uncertainty, avoiding risk prevails over any potential degradation of rights and other harms that might appear. Although it could be argued that the fear of professionals has a solid base in prior experiences in which, for example, professionals have been harmed due to postponing the indication of mechanical restraint,^100,101 we consider it indispensable that in the analysis of phenomena as complex as aggression or psychomotor agitation other factors be taken into account (for example, relational factors) or that reflections take place regarding how the lack of preparation or awareness of the influence one’s presence and the environment exert on others can determine whether or not a situation of these characteristics occurs.^93,102 Along these same lines, Dozza uses the concept “dreaded scenes”¹⁰³ to name those imagined situations that we fear will occur, and that are accompanied by disorientation, not knowing how to respond, a sense of lacking the abilities and tools to resolve the imagined situation¹⁰⁴; this could explain the influence the collective beliefs exercise in the decision-making of the professionals. From their discourses it can be understood that, on occasion, the use of restraints is more directed at avoiding this dreaded scene than toward the needs and care that the user requires. Such scenes are closely related to “catastrophic fantasies,” that is, situations for which a professional could be judged or penalized by the institution (suicides, murders, fights) or those that could result in physical harm to the professional themselves (physically, psychologically, or in relation to their work, etc.).¹⁰⁴ These fantasies, that in general are not conscious, produce a series of emotions and cognitions that push professionals to adopt conservative and overprotective behaviors, often stereotyped, in order to avoid risks. Often the fantasies and scenes are shared collectively (in the institution, society, teams, etc.) and have a significative influence in subjects initiating their training through the work cultures and philosophy.¹⁰⁵

Emotional impact and processes of adaptation

The negative impact of mechanical restraint at the emotional and psychological level has been referenced in a number of studies.^25,106 Guilt, remorse, impotence, rage and frustration are emotions frequently referenced.⁵² In this sense, Bloom uses the concept of parallel processes to address the symmetrical effect that the use of power to manage behavioral alterations has in professionals and users: on the one hand, it makes users fear and distrust the staff and makes them less collaborative and participatory and, at the same time, it incites professionals to feel frustrated and unsatisfied, which favors them using power and control even more.¹⁰⁷ But how does one move beyond the impact following the use, acceptance and reproduction of these measures? Among the psychological processes observed, the residents describe the development of forms of adaptation similar to those detailed by Pértega.¹⁹ The participants narrate a transformation over time in the way in which they experience mechanical restraint. According to their statements, progressively, and through different passive and active psychological mechanisms, desensitization, habituation and automatization regarding the use of restraints take place, with a reduction in the associated distress and the integration of these measures as part of their everyday practice, diminishing the conflict generated by ethical dilemmas and the dissonance between beliefs and actions. The process identified by Pértega can explain the adaptation of residents during three consecutive phases of their training: 1) traumatization and estrangement in the first mechanical restrains; 2) rationalization, frustration and impotence as a defense toward the distress that these measures generate; and 3) incorporation and acceptance of mechanical restraint, when they begin to be considered “part of the job.”^19,89 Nevertheless, Pértega suggests at the same time one has the feeling of having become more defensive, less sure of oneself at work, believing that one must protect oneself, without ever having lost the feeling of estrangement and questioning of one’s work.

Experiences of conflict

Lastly, not all existing studies recover the professionals’ conflictive experiences with coercive measures. For example, coercive measures such as seclusion have been described by some professionals as “very necessary” and “highly therapeutic,” and they have suggested that they guarantee safety without being punitive.¹⁰⁸ Other researchers have found that the majority of professions see coercive measures as necessary to guarantee care and safety, putting in to doubt that significant moral conflicts exist.¹⁰⁹ Nevertheless, the results of our work illustrate that the shared experience of the majority of residents in the context of Madrid can be characterized as presenting multiple contradictions that surface when they decide to indicate or carry out mechanical restraint. This difference might be owing to the fact that the denunciation of the consequences of mechanical restraint and the dilemmas surrounding its use have become much more present in the professional and public discourse in the last years. Considering mechanical restraint to be a necessary but damaging measure for the user and the therapeutic relationship puts residents before conflicts whose resolution depends on self-justification, negation of dissonance,⁹⁹ and the acceptance of this contradiction as inherent to present-day psychiatry. This can be seen in the decision-making process,¹⁹ conflict with the professional role⁸⁹ or in the ethical dilemmas produced.³⁷

Strengths and weaknesses

One of the primary strengths of this study is the novel contribution it makes to the literature regarding mechanical restraint in Spain, where the lack of studies on the subject is noteworthy. It also differs from the majority of English-language publications, which tend to be particularly centered on nursing personnel. Having considered the experience of residents of different specialties enriches the understanding of the phenomenon and allows for comparisons with professionals with greater experience. Among the limitations, the controversy surrounding mechanical restraint renders it a topic of high social desirability, which can influence the narratives of the participants. Furthermore, although methodological tools were used to favor the representativity of the sample and the heterogeneity of discourses, it is possible that those with the greatest indifference toward these practices or those that might have felt threatened by the exposure decided not to take part in the study. On the other hand, the data collected should be understood in the context of a particular place and time, and therefore it is important to repeat this study in other environments in order to gain a deeper understanding of the phenomenon where it occurs. Lastly, regarding the analysis, the influence of the researchers’ history and subjectivity should be acknowledged; they have been in contact with the use of mechanical restraint in their professional practice, although this does not necessarily represent a limitation, as it was an element that enriched the design and development of the study.

Implications in clinical practice

The results of this research push us to demand radical change in the paradigm that promotes the metamorphosis of our practice. This implies that the transformations should transcend concrete areas of intervention and seek political, legislative, institutional and cultural changes, without ignoring the role of teams and professionals. The use of mechanical restraints, because of its implications, should be recognized as a failure in care and a measure to be eradicated. Our study suggests paths towards the elimination of restraints that take into account the complexity of the phenomenon.

CONFLICTS OF INTEREST

This project did not receive any type of funding. Researchers and participants did not receive any type of economic benefit or compensation, direct or indirect. No particular interests (economic, academic, or others) have been identified that could enter into conflict with the strictly scientific interest of the study.