Willis's restraining chair

This entry is listed for history and for safety. Willis's restraining chair and strait-waistcoat were coercive measures that frightened, confined and humiliated the person they were used on. They are not recommended, and this guide does not teach any form of restraint. Section 4 covers only the psychotherapist's own work: historical literacy, recognition, assessment, safeguarding, reporting, referral, advocacy and work with people affected by restraint.

1. Introduction

Version followed: the account of the 1788–89 illness of King George III and his treatment by Francis Willis given by the Royal College of Physicians Museum (Shepley 2014; Lancashire 2022), Tate Papers (Tromans 2010) and the 2010 History of Psychiatry re-examinations by Peters and colleagues. Present-day standards follow the Mental Health Units (Use of Force) Act 2018 (England), NICE guideline NG10, US federal hospital rule 42 CFR 482.13(e), and the CQC's restraint reviews.

What it was. In late 1788 King George III became acutely mentally unwell. In November he was moved from Windsor Castle to Kew Palace at the urgent request of his senior physicians [source: RCP Museum, Shepley 2014]. On 5 December 1788 Francis Willis was called in at the Queen's request [source: Hektoen International 2022]. Willis was a clergyman who kept a private madhouse in Lincolnshire, and the court physicians regarded him as "little better than a quack" [source: RCP Museum, Shepley 2014]. Willis brought in the strait-waistcoat; the king's bulletins record "the strait waistcoat during the whole night" [source: RCP Museum, Shepley 2014]. He also had a restraining chair made for the king, which a courtier mockingly called the "Coronation Chair" [source: Tromans 2010, Tate Papers 13]. The king recovered by late February 1789 and Willis was well rewarded [source: RCP Museum, Shepley 2014; Hektoen International 2022]. The illness came back in 1801, 1804 and 1810–11, and continued in episodes until the king died in 1820. Willis's sons were involved in his later care [source: RCP Museum, Lancashire 2022; Hektoen International 2022].

Its core idea of how change happens, as the historians present it. Willis and others of his time held that a disordered mind could be brought back under control by mastering the patient. Fear, confinement and the doctor's commanding presence were treated as clinical tools. In January 1789 a parliamentary committee questioned Willis, and his methods were reported as "both amateurish and intimidatory." Asked how he terrified patients into obedience, he pointed to "the eye" [source: Tromans 2010]. Tromans describes the devices of the early asylum, from restraining and tranquillising chairs to rotating machines and surprise baths, as aiming "to repossess the patient's mind through total control of their body" [source: Tromans 2010].

Why it matters to a psychotherapist today. The chair itself is a historical object, but the logic behind it is still present wherever restraint, seclusion or fear are used to manage distress. Clients bring this history in several ways: as survivors of restraint in hospitals, care homes, schools or secure settings; as relatives; as staff; or through interest in the "madness of King George" story. The king's diagnosis is still debated, between porphyria (Macalpine and Hunter) and recurrent mania (Peters and colleagues), and the guide does not settle it [source: historypsychiatry.com 2010; RCP Museum, Shepley 2014].

2. Framework

The Framework describes two things: the historical phases of the practice, in outline, and the phases of the psychotherapist's own work. Session number and length follow the client's needs and the setting [synthesis].

Historical phases (outline)

Pre-1789: restraint as routine. Restraining garments were "universally used until the end of the 1700s" [source: Science Museum Group, object A629640]. Private madhouses such as Willis's were part of this world [source: RCP Museum, Shepley 2014].
1788–89: the king's illness. Willis brought in strait-waistcoat confinement, a purpose-made chair and intimidation at Kew. The court physicians used the standard remedies of the time: purging, bloodletting and blistering [source: RCP Museum, Shepley 2014; Tromans 2010]. The case became public through Parliament's questioning during the regency crisis [source: Tromans 2010].
c. 1789–1830: the age of devices. Restraining, tranquillising and rotating chairs and shock baths were promoted, for example by Joseph Mason Cox and by Benjamin Rush, whose 1811 "Tranquillizing" chair was meant to "overwhelm every motion and sense" [source: Tromans 2010].
1800s: moral treatment and non-restraint. At Hanwell Asylum, John Conolly gave up mechanical restraint in favour of "moral treatment" [source: Science Museum Group, object A629640].
Today: regulation of restraint. Mechanical restraint is defined in law and restricted (England, Use of Force Act 2018; NICE NG10; US 42 CFR 482.13(e)). Regulators keep finding overuse, especially for autistic people and people with a learning disability [source: CQC 2022 progress report on Out of sight – who cares?].

Phases of the psychotherapist's work

Recognition and assessment. Goal: find out whether, where and how the client met restraint, seclusion or coercive control, and how it affects them now. Move on once the client has given an account they chose to give and current safety is known [synthesis].
Safety, rights and safeguarding. Goal: deal with any current risk, ongoing restrictive practice or safeguarding concern, and make sure the client knows their rights (Use of Force Act s.4; NICE NG10 advance statements). Move on once current risk is managed and any reporting has been started [source: legislation.gov.uk 2018; NICE NG10].
Processing and repair. Goal: work through fear, shame, powerlessness and lost trust, using trauma-focused care where it is indicated. Signs of progress are less avoidance, more agency and a usable relationship with services [synthesis; harms themes per Cusack et al. 2018].
Advocacy, meaning-making and follow-up. Goal: complaints or reviews where the client wants them, plans for future crises (advance statements), and, where it helps, placing the client's experience in history. This phase ends when the client chooses [synthesis].

3. Guiding principles

Never coerce. Fear is not a treatment. Willis's "the eye" is the opposite of a therapeutic stance. In practice: the therapist never uses intimidation, threat or control to get compliance [source: Tromans 2010; synthesis].
Restraint is a last resort that others use, never a therapy you provide. In practice: you do not teach, recommend, supervise or refer for restraint. You know the legal limits so that you can recognise misuse [source: NICE NG10; 42 CFR 482.13(e)].
Restraint and seclusion are never for coercion, discipline, convenience or retaliation. In practice: an account of restraint used as punishment or for staff convenience is a rights and safeguarding concern [source: 42 CFR 482.13(e); NICE NG10].
Least restrictive, shortest possible, proportionate. In practice: use this standard when you listen to accounts and when you advocate [source: NICE NG10; 42 CFR 482.13(e)].
Assume restraint may be traumatic. Reviews describe retraumatisation, distress, fear, power and dehumanising conditions. In practice: ask about it gently and expect it to show up in the room [source: Cusack et al. 2018].
Give the person their own account. NICE asks that service users have the chance to discuss an incident and write their own account of it. In practice: invite the client's version and believe that it matters [source: NICE NG10].
Rights belong to the person. In practice: help clients find published information on their rights about use of force [source: Use of Force Act 2018 s.4].
Be accurate about history. Attribute claims to sources, and keep the diagnosis debate open. In practice: do not tell a client "the king had porphyria" as fact [source: historypsychiatry.com 2010; RCP Museum 2014].
Respect dignity, including that of historical figures. In practice: talk about George III as a person who suffered, not as a figure of fun [synthesis; cf. the courtier's "Coronation Chair" jibe, Tromans 2010].
Avoid moralising. The facts carry the weight. In practice: describe what happened and its effects, without polemic [synthesis].
Mind the power in your own role. In practice: if you work on a unit that uses restraint, keep your therapy role separate from roles in restrictive decisions where you can, and name the tension [synthesis; APA Ethics Code Standard 3.05].
Children and adults at risk come first. In practice: when restraint of a child or an adult at risk may be unlawful or harmful, safeguarding routes take priority over therapeutic exploration [synthesis].
No medical advice. In practice: never advise starting, stopping or changing a medicine, including medicines given as chemical restraint; route such questions to the prescriber [synthesis].
Touch only with consent. In practice: any touch needs consent before and during, with a right to stop, and is never sexual. For clients who were restrained, take extra care with any contact or with positioning in the room [synthesis].

4. Intervention inventory

The interventions below are the psychotherapist's own work; steps not drawn from a cited source are marked [synthesis].

4.1 Building your own historical literacy

Purpose / when: before working with restraint survivors, staff, or clients interested in psychiatric history. This lets you talk about the Willis case and the age of devices accurately, without sensationalising it [synthesis].
Steps: (1) Learn the core facts and who reports them: the move to Kew in November 1788, Willis called in in December 1788, strait-waistcoat confinement and a purpose-made chair, recovery in February 1789, and later episodes up to 1820 [source: RCP Museum 2014; Tromans 2010; Hektoen 2022]. (2) Learn the logic historians describe, "total control of their body" [source: Tromans 2010]. (3) Learn the reform that followed, Conolly's non-restraint at Hanwell [source: Science Museum Group A629640]. (4) Learn the diagnosis debate: porphyria according to Macalpine and Hunter, against recurrent mania according to Peters and colleagues [source: historypsychiatry.com 2010]. (5) Note what is uncertain, for example any account of the chair's construction, which this guide leaves out on purpose.
Example language (illustrative): "Historians describe Willis as relying on fear and control. Treatment was understood very differently then, and the reforms that followed rejected much of it."
Watch for: repeating popular myths, such as presenting porphyria as settled. Being drawn into graphic detail. Working: you can answer a client's question in two or three accurate, attributed sentences.

4.2 Responding to a client's interest in the George III story

Purpose / when: a client brings up the king, the play or film about him, or a museum visit, often as a way into their own experience of mental illness or of being controlled [synthesis].
Steps: (1) Ask what draws them to it. (2) Share facts briefly and with attribution (4.1). (3) Gently explore any parallels they make, such as being confined, not believed, or managed by others. (4) Do not diagnose the king, and do not use his story to diagnose the client. (5) Return to the client's own meaning.
Example language (illustrative): "You mentioned the king being strapped into a chair while doctors argued over him. What part of that stays with you?"
Watch for: over-identification and despair ("that's what they'll do to me"); a bipolar diagnosis being equated with the king's fate; humour used to deflect. Working: the client moves from the story to their own experience at a pace they choose.

4.3 Accurate psychoeducation on the diagnosis debate

Purpose / when: a client with bipolar disorder or porphyria asks "what did George III really have?" [synthesis].
Steps: (1) Say that it is debated. (2) Give each position with its source: Macalpine and Hunter proposed porphyria in 1966, and Dent disputed it in 1968 [source: Hektoen 2022]. Peters and Wilkinson (2010) argue that the porphyria evidence is weak and was selectively read. Peters and Beveridge (2010) conclude recurrent mania [source: historypsychiatry.com 2010]. (3) Say that retrospective diagnosis is uncertain [source: Hektoen 2022, citing Pearce 2017]. (4) Explain that his treatment reflected the beliefs of 1788, not what care looks like now.
Example language (illustrative): "Researchers still disagree. Some argued for a blood disorder, others for recurrent mania. Either way, the treatment he got was of its time, and care for mania today looks very different."
Watch for: the client drawing conclusions about their own medication. Never advise on medicines; route those questions to the prescriber. Working: the client holds the uncertainty without alarm.

4.4 Trauma-informed assessment of past restraint or seclusion

Purpose / when: any client with a history of psychiatric admission, secure care, residential schooling, care homes, police custody, or a learning disability or autism diagnosis. The CQC found restrictive practices widely used with autistic people and people with a learning disability [source: CQC 2022 progress report].
Steps: (1) Ask openly, with permission, whether they were ever held, confined, secluded or given medicine against their will. (2) Let them choose how much detail to give; you do not need a step-by-step account. (3) Ask about the effects then and now: fear, distress, feeling ignored, loss of control, feeling dehumanised (themes from Cusack et al. 2018). (4) Ask about current triggers. (5) Record carefully and factually.
Example language (illustrative): "Some people who have been in hospital were held or kept alone against their wishes. Has anything like that happened to you? You can tell me as much or as little as you want."
Watch for: dissociation, shutting down, or anger at the question. Pause and ground. Working: the client describes the experience and its effects with some sense of control over the telling.

4.5 Mapping triggers and adapting the room

Purpose / when: the client reacts to being blocked in, to chairs with arms, to closed doors, to being touched, or to authority figures standing over them [synthesis].
Steps: (1) Identify triggers together. (2) Let the client choose their seat, keep a clear route to the door, and decide whether the door is open or closed. (3) Agree a stop signal. (4) Avoid touch unless explicitly agreed; consent comes before and during, with a right to stop. (5) Review the arrangements regularly.
Example language (illustrative): "Where would you like to sit? You can have the chair nearest the door, and you can stop or step out at any point."
Watch for: the client agreeing to arrangements just to please you. Check again later. Working: physical arousal drops during sessions.

4.6 Rights information and advance statements

Purpose / when: the client may be admitted again, or is an inpatient now. The Use of Force Act requires units in England to publish information on patients' rights about force and to help patients understand it. NICE asks staff to check for advance decisions and advance statements and to encourage them [source: legislation.gov.uk 2018 s.4; NICE NG10].
Steps: (1) Help the client get the unit's published rights information. (2) Explain that NICE distinguishes advance decisions, which are legally binding, from advance statements, which are not [source: NICE NG10]. (3) Help the client write down their preferences, such as what calms them, who to call, and cultural or religious needs [source: NICE NG10 on barriers such as religious or cultural practices]. (4) Encourage them to share it with their care team. (5) In the US, point clients to the hospital patient-rights rule (42 CFR 482.13) and the hospital's patient advocate [synthesis].
Example language (illustrative): "If things ever got that bad again, what would you want staff to know about what helps and what makes it worse? We can write that down."
Watch for: hopelessness ("they won't read it"); confusion about what is legally binding. Get legal advice where needed [synthesis]. Working: a written plan exists and the client knows who holds it.

4.7 Supporting the client's own account after an incident

Purpose / when: the client was recently restrained or secluded. NICE asks that, after an intervention, the service user has a supported chance to discuss it and to write their own account [source: NICE NG10].
Steps: (1) Check physical injury first and route to medical care where needed. (2) Offer to help them write their account in their own words. (3) Explain that they can ask for it to be added to their records or sent to the service [synthesis]. (4) Explore emotional effects without pushing for detail. (5) Agree next steps: complaint, advocacy, or simply recovery.
Example language (illustrative): "You have a right to give your own account of what happened. Would it help to write it down together, in your words?"
Watch for: injuries left unchecked. After any death or serious injury, the unit must have regard to investigation guidance [source: Use of Force Act s.9]. Watch also for self-blame. Working: the client's account exists and their distress is easing.

4.8 Processing restraint-related trauma

Purpose / when: intrusive memories, avoidance of services, hypervigilance or nightmares linked to restraint or seclusion. Cusack et al. (2018) describe trauma and retraumatisation as themes [source: Cusack et al. 2018].
Steps: (1) Assess for post-traumatic stress with standard clinical assessment. (2) Stabilise first: grounding and emotion regulation. (3) Where indicated, offer or refer to an evidence-based trauma-focused psychological therapy. (4) Give the client control over pace, pauses and stopping. (5) Address any earlier trauma that the restraint reactivated.
Example language (illustrative): "You're in charge of the pace here. We can stop whenever you say, and nothing will be done to you in this room."
Watch for: retraumatisation through exposure-based work without consent or stabilisation; contraindications such as acute risk or active psychosis, which call for coordination with the treating team. Working: fewer intrusions, less avoidance [synthesis; trauma-specific guideline recommendations: uncertain: not verified].

4.9 Working with shame, humiliation and powerlessness

Purpose / when: the client feels degraded or ashamed, or believes they "deserved it." Reviews name power, control and dehumanising conditions as themes [source: Cusack et al. 2018]. NICE states that restrictive interventions must never be used to punish or humiliate [source: NICE NG10].
Steps: (1) Name the shame gently. (2) Separate the client's distress at the time from what staff decided to do. (3) Share the standard that restraint is never meant to punish or humiliate. (4) Work toward self-compassion and agency. (5) Explore whether action such as a complaint would restore a sense of power, but do not push it.
Example language (illustrative): "Being held down when you're already frightened can leave people feeling ashamed. The guidance is clear that restraint must never be used to humiliate anyone."
Watch for: the client feeling that their behaviour is being excused or blamed, or worry about being seen as "difficult." Working: less self-blame, and the client tells their story with less shame.

4.10 Repairing trust in services and in the therapy relationship

Purpose / when: the client avoids help or distrusts all clinicians after coercive experiences [synthesis].
Steps: (1) Expect testing and mistrust, and accept them as valid. (2) Be transparent about your role, your confidentiality limits and when you would have to act. (3) Never threaten admission or use it as leverage. (4) Repair openly when you get things wrong. (5) Help the client make graded, chosen contact with other services.
Example language (illustrative): "I want you to know exactly when I would have to share information, so nothing comes as a surprise."
Watch for: your own drift into controlling behaviour when you are anxious about risk; the client cancelling sessions after disclosures. Working: the client returns, raises disagreements and engages with care.

4.11 Working with families of people who were restrained

Purpose / when: relatives who saw or learned of restraint, or who agreed to it under pressure, and who carry guilt, anger or fear about the next crisis [synthesis].
Steps: (1) Hear their account and their feelings. (2) Explain the standards: last resort, least restrictive, never punitive [source: NICE NG10]. (3) NICE says to involve carers in care and risk plans where the service user agrees, so help families prepare for that [source: NICE NG10]. (4) Talk through complaint and advocacy routes. (5) Support any repair work between the relative and the client.
Example language (illustrative): "It sounds like you agreed to things in a crisis that you now feel uneasy about. Let's look at what would help next time, and who you can raise it with."
Watch for: family conflict about who is to blame; confidentiality limits when the client has not agreed to their involvement. Working: the family has a shared crisis plan and less guilt.

4.12 Working with family history of asylum confinement

Purpose / when: a client discovers an ancestor's asylum records, or carries a family story of a relative "put away" and restrained [synthesis].
Steps: (1) Explore what they found and what it means to them. (2) Give historical context: restraint was routine before reform, and non-restraint followed at institutions such as Hanwell [source: Science Museum Group A629640]. (3) Address fears of inherited illness with care, and refer for genetic or medical advice where it is relevant. (4) Explore inherited shame and silence in the family. (5) Support meaning-making and commemoration if the client wants it.
Example language (illustrative): "What was it like to read that about your great-grandmother? What would you want people to understand about her?"
Watch for: the client reading the past as their own fate; distress from graphic records. Working: the client tells a family story that includes understanding of what happened.

4.13 Preparing a client for museum or heritage encounters

Purpose / when: a client plans to visit an exhibition holding restraint objects, or was upset by one. The Museum of the Mind at Bethlem describes its manacles, strait-jackets and "strong clothing" as objects that may provoke "strong emotional responses" [source: Museum of the Mind blog].
Steps: (1) Ask why they want to go and what they expect. (2) Plan for triggers: go with company, take breaks, plan when to leave. (3) Afterwards, process the visit. (4) If they were upset by an unplanned encounter, normalise the reaction and ground them.
Example language (illustrative): "Seeing those objects in a case can bring back what happened to you. Would it help to plan how you'd step out if you needed to?"
Watch for: avoidance turning into fear of all reminders; the visit used as unplanned self-exposure. Working: the client goes, or decides not to, by choice, and processes it afterwards.

4.14 Recognising current restrictive practice that may be unlawful or harmful

Purpose / when: a client, relative or colleague describes restraint or seclusion happening now [synthesis].
Steps: (1) Compare the account with the standards. Was it used only for immediate physical safety? Were less restrictive measures tried first? Was it ended as soon as possible? Was it used as coercion, discipline, convenience or retaliation? [source: 42 CFR 482.13(e); NICE NG10] (2) In England, note that mechanical restraint of adults is limited by NICE to high-secure settings, apart from transfers [source: NICE NG10], and that units must record every use of force [source: Use of Force Act s.6]. (3) Note any injury, any death, and anyone else at risk. (4) Decide whether this is a safeguarding concern (see 4.15).
Example language (illustrative): "From what you describe, the restraint went on after you'd calmed down. That isn't what the standards allow. Would you like to think about raising it?"
Watch for: minimising ("that's just how wards are"); your own wish to rescue. Working: concerns are clear, recorded and acted on.

4.15 Safeguarding and reporting

Purpose / when: a child or an adult at risk may be subject to abusive or unlawful restraint, or someone has been harmed [synthesis].
Steps: (1) Follow your local safeguarding procedures and mandatory-reporting duties. For children, this means child-protection services and, where required, police. (2) In England, raise concerns with the provider's use-of-force responsible person, the local safeguarding team and the CQC [source: Use of Force Act s.2; CQC 2022]. (3) In the US, use state abuse reporting, state survey agencies and hospital patient advocates [synthesis]. (4) Record facts, dates and what you did. (5) Tell the client what you are doing and why, unless that would increase risk.
Example language (illustrative): "What you've told me means I need to pass this on to keep you and others safe. I'll tell you exactly what I'm sharing and with whom."
Watch for: delay while you wait for certainty; breaking a child's trust by not explaining. Working: the report is made and the client stays engaged.

4.16 Duties when a colleague or institution misuses restraint

Purpose / when: you work in, or alongside, a service where restraint is used as punishment, for convenience, or beyond what the standards allow [synthesis].
Steps: (1) Raise it with the colleague or a manager where that is safe. (2) Escalate to the responsible person for use of force, clinical governance, or whistleblowing routes [source: Use of Force Act s.2; synthesis]. (3) Report to the regulator (CQC in England; state agencies in the US) and to the clinician's professional regulator where appropriate [synthesis]. (4) If you hold more than one role in the unit (for example therapist and member of the ward team), consider how that affects the client and your objectivity [source: APA Ethics Code Standard 3.05]. (5) Never take part in or supervise punitive restraint.
Example language (illustrative, to a manager): "I'm concerned that restraint is being used after the risk has passed. I'd like this reviewed under our use-of-force policy."
Watch for: retaliation against you; the client being treated worse after a complaint. Working: a review happens and practice changes.

4.17 Supporting staff who have used restraint

Purpose / when: nurses or care staff in therapy carry distress, moral injury or fear after restraint incidents. NICE's debrief covers the emotional impact on staff and witnesses as well as service users [source: NICE NG10].
Steps: (1) Hear their account without condoning or condemning. (2) Separate their distress from any accountability issues. Do not give legal or employment advice. (3) Explore values and moral injury. (4) Support their part in reducing restraint, for example training aligned with the Restraint Reduction Network standards [source: RRN Training Standards 2019, via VODG]. (5) Keep safeguarding duties in mind if they disclose abuse.
Example language (illustrative): "Part of you knew it was needed in that moment, and part of you feels it went against why you came into nursing. Can we make room for both?"
Watch for: disclosures that trigger a duty to report; burnout and avoidance. Working: less self-blame, and more confidence in prevention and de-escalation.

4.18 Working with a client or family drawn to coercive "control"

Purpose / when: a relative wants someone "controlled" or "made to comply," or a client believes harsh restriction is the cure, echoing Willis's mastery logic [synthesis; Tromans 2010].
Steps: (1) Explore the fear underneath the wish. (2) Explain that current standards treat restrictive interventions as a last resort and never as treatment or punishment [source: NICE NG10]. (3) Redirect to supported care: crisis planning, community mental-health services, and prevention and de-escalation approaches [source: NICE NG10]. (4) Assess carer strain and offer support.
Example language (illustrative): "It sounds like you're exhausted and frightened for him. Let's look at what helps in a crisis that doesn't depend on force."
Watch for: safeguarding risk to the person; carer burnout. Working: the family's requests shift toward supported care.

4.19 Suicide-risk assessment after coercive experiences

Purpose / when: a client is hopeless, especially about future crises or contact with services, after restraint or seclusion [synthesis].
Steps: (1) Ask directly about suicidal thoughts. (2) Assess current risk with standard practice. (3) Make a collaborative safety plan, including lethal-means counselling (safe storage and removal only). (4) Give crisis resources: 988 in the US; Samaritans on 116 123 in the UK and Ireland. (5) Take account of the client's fear that disclosing will lead to restraint, and be transparent about what you would do.
Example language (illustrative): "Sometimes after being held or locked in, people feel there's no point asking for help. Have you had thoughts of ending your life?"
Watch for: hiding risk out of fear of admission. Respond with transparency and choice where that is safe. Working: an honest risk conversation and a plan the client owns.

4.20 Advocacy, meaning-making and the profession's history

Purpose / when: a client wants their experience to matter, through complaint, service-user involvement or testimony. NICE asks that external post-incident reviews be led by service-user groups [source: NICE NG10].
Steps: (1) Explore what kind of action fits the client. (2) Signpost advocacy, complaint and involvement routes. (3) Where it helps, place their experience in the history from Willis to non-restraint to today's laws, which shows that practice can change [source: Tromans 2010; Science Museum Group A629640; Use of Force Act 2018]. (4) Protect their wellbeing during any process.
Example language (illustrative): "Restraint practices have changed before because people spoke up. If you want to, we can look at how your experience could feed into that."
Watch for: retraumatisation through long processes; pressure from others to campaign. Working: the client acts by choice and feels more agency.

5. Handling problems

The problems below are the psychotherapist's own synthesis [synthesis]; a source tag marks any point drawn from a cited source.

The client is stuck in reliving the episode. Go back to stabilisation (4.8). Shorten the trauma work, give the client more control over pace, and check whether something is still happening now, such as an ongoing admission or a pending review.
The client resists talking about restraint ("it's in the past"). Respect that. Offer the topic again later, and work on current goals. Avoidance may be protective. Note it, and do not press.
The client is overwhelmed in session. Stop, ground, and point out that they are free to move and to leave. Check that the seating and door arrangements still suit them (4.5). Agree how to end the session safely.
The client does not follow through on complaints or advance statements. Explore what is in the way, often fear of retaliation or hopelessness. Make the steps smaller. Accept the client's choice not to act.
Rupture: the client feels you are "on the side" of services. Name it and validate it. Be clear about your independence and its limits (4.10). Admit any part you played.
Rupture: you have to act on risk. Be transparent before, during and after. Explain the least restrictive option you are pursuing. Repair afterwards. Expect this to echo the original coercion.
Modality-specific: the client asks you to explain or show restraint, or wants detail about historical devices. Decline to describe methods or devices. Redirect to what they need to understand: effects, rights and history in outline (this guide's scope).
Modality-specific: the client romanticises or mocks the king's treatment. Gently restore the person behind the story. The king was frightened and suffering. Patients' sense of degradation is a documented harm theme [source: Cusack et al. 2018; RCP Museum, Lancashire 2022].
Modality-specific: the client is still an inpatient and is being restrained now. Prioritise current safety and rights (4.6, 4.14, 4.15). Coordinate with the treating team with the client's consent. Use safeguarding routes if there is abuse.
Modality-specific: the client is a staff member who discloses abusive restraint. Your safeguarding duty overrides confidentiality (4.15, 4.17). Explain this and act.
Medication questions (chemical restraint). Never advise starting, stopping or changing a medicine. Refer to the prescriber or a pharmacist, and support the client in asking their questions.
Physical after-effects, such as pain or injury. Route the client to medical assessment. Do not interpret physical symptoms psychologically without that assessment.
Suicide risk rises. Follow 4.19. Use safe-messaging principles, with no method detail. Give crisis resources: 988 (US), Samaritans 116 123 (UK and Ireland).
Your own reactions (anger at services, or anxious control). Take it to supervision. Watch for drifting into either rescuing the client or controlling them.

Harm account

What was actually done

In the winter of 1788–89, during King George III's first major episode of mental illness, Francis Willis, a Lincolnshire clergyman who kept a private madhouse, was brought to Kew Palace. He confined the king in a strait-waistcoat, at times through whole nights, as the king's own bulletins record [source: RCP Museum, Shepley 2014]. He had a restraining chair made specially for the king; a courtier recorded that the king "eyed it with some degree of Awe" when it was first brought in, and bitterly nicknamed it his "Coronation Chair" [source: Tromans 2010]. When Parliament questioned Willis in January 1789, his approach was reported as intimidating, and he credited his command over patients to "the eye" [source: Tromans 2010]. At the same time the court physicians gave the standard remedies of the day, which the RCP Museum calls a "brutal regime of bloodletting and blistering" (blisters were deliberately raised on the skin), with repeated purgatives and emetics, among them antimony, which the Museum notes was highly toxic [source: RCP Museum, Shepley 2014]. Willis's own prescriptions included blistering and calomel, a mercury compound, and he kept the king in a strait-jacket while allowing him some liberties [source: Hektoen International 2022]. In the king's later illnesses (1801, 1804, 1810–20) Willis's sons were involved in his care. Their letters press for "every means possible" to "control" the king, and the king was sometimes put in a straitjacket [source: RCP Museum, Lancashire 2022]. The Willis case belongs to a wider period, roughly 1789–1830, of restraining, tranquillising and rotating chairs and shock baths. Historians describe these as meant to subdue, frighten or shock the patient [source: Tromans 2010]. The guide records what was used, on whom and why, and gives no construction or fastening detail.

How it caused harm

The purpose of the methods was to master the patient through fear and total bodily control [source: Tromans 2010]. The RCP Museum's archivist calls the treatments "brutal" and says they would not have eased the king's mental pain. According to his physician's letter, the king did not want his doctors to attend him because their presence would make him worse [source: RCP Museum, Lancashire 2022]. The king's confinement was also political: the physicians and politicians around him were concerned with their own positions [source: RCP Museum, Lancashire 2022]. Modern evidence on restraint in mental health inpatient settings describes trauma and retraumatisation, distress, fear, feeling ignored, power and control, and dehumanising conditions, although the authors note that direct evidence on physical and psychological harm is limited [source: Cusack et al. 2018]. The Use of Force Act requires that deaths and serious injuries linked to force are recorded and reviewed [source: legislation.gov.uk 2018, ss.6, 8, 9].

Recognising it today

In law and regulation. In England, "mechanical restraint" means using a device "for the primary purpose of behavioural control" [source: Use of Force Act 2018 s.1]. In US hospitals, restraint includes any device that "immobilizes or reduces the ability of a patient to move" freely. It may not be used for coercion, discipline, convenience or retaliation [source: 42 CFR 482.13(e)].
Signs in a client's account: restraint continued after the danger had passed; restraint used as punishment, threat or to save staff time; repeated mechanical restraint outside high-secure settings (England) [source: NICE NG10]; no debrief and no chance to give one's own account [source: NICE NG10]; long segregation, especially of autistic people or people with a learning disability [source: CQC 2022].
Echoes of the Willis logic: staff relying on intimidation, a commanding presence or fear to get compliance; the claim that control itself is the treatment [source: Tromans 2010; synthesis].
In the culture: the story of George III, and restraint objects in museums [source: Museum of the Mind blog; Science Museum Group A629640].

What to do instead and how to help those harmed

Supported care, as professional bodies set it out: prevention and de-escalation first. Restrictive interventions only as a last resort, proportionate, least restrictive and as short as possible. Never to punish or humiliate. Involve service users and carers, use advance statements, and hold post-incident debriefs that include the service user's own account and emotional support [source: NICE NG10]. Train staff to cross-sector standards focused on human rights, prevention and person-centred approaches [source: RRN Training Standards 2019, via VODG]. Historically, Conolly's non-restraint at Hanwell showed an alternative [source: Science Museum Group A629640].
Helping survivors: trauma-informed assessment, processing and repair of trust (4.4–4.10), rights and advance statements (4.6), and the person's own account (4.7).
Families: see 4.11–4.12 and 4.18.
Reporting duties and legal routes: local safeguarding and child-protection services. In England: the provider's use-of-force responsible person, the CQC, and investigation duties after deaths or serious injuries [source: Use of Force Act ss.2, 9]. In the US: hospital patient-rights processes under 42 CFR 482.13 and state agencies [synthesis]. Get legal advice for claims [synthesis].
Survivor and service-user organisations: point clients to local service-user-led and survivor organisations, described as they describe themselves, after checking them yourself [synthesis]. NICE recommends service-user-led external post-incident review [source: NICE NG10].

Sources

Web pages:

Works cited:

Cusack, P., Cusack, F., McAndrew, S., McKeown, M. and Duxbury, J. (2018). An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursing, 27(3), 1162–1176.
Peters, T. J. and Wilkinson, D. (2010). King George III and porphyria: a clinical re-examination of the historical evidence. History of Psychiatry [volume and pages uncertain: not verified].
Peters, T. J. and Beveridge, A. (2010). The madness of King George III: a psychiatric re-assessment. History of Psychiatry [volume and pages uncertain: not verified].
Macalpine, I. and Hunter, R. (1969). George III and the Mad-Business [uncertain: not verified]. Their 1966 BMJ porphyria paper is as cited in Hektoen International 2022.
Tromans, N. (2010). The Psychiatric Sublime. Tate Papers, no. 13.

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