What is Anti-Ligature Clothing?
Anti-ligature clothing is used to promote the safety of vulnerable and often segregated individuals, preventing incidents of self-harm and suicide, whether in psychiatric hospitals, mental health hospitals, secure care facilities, custodial settings, or any other setting where an individual might be legally placed in seclusion.
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Emma Pring, a young woman, tragically took her own life on April 20, 2021, while receiving treatment at a privately operated mental health care facility. She was wearing anti-ligature clothing that, in my professional assessment, was not suitable for its intended purpose. The coroner will have been appalled at the absence of national standards regarding the production of anti-ligature clothing in the UK.
The objective of this article is to explore and highlight the precise
application and benefits of anti-ligature clothing.
While extensive mental health research in recent years has
focused on components of quality of care, published research lacks focus on the
science of patient safety, especially the safety of those placed in involuntary
confinement.
At the early stage of drafting this article and when discussing
this subject with some experts, it was Ross Ferguson, who highlighted to me the
article: ‘Suicide
and Language.’ Ross has spent almost 34 years as
‘Violence Reduction Lead’ at one of the UK’s High Security Hospitals.
This excellent article urged me to consider terms, such as “commit
suicide,” “successful suicide,” or “failed suicide attempt.” According to the
article, to “commit” suicide has criminal overtones which refer to a past time
when it was illegal to kill oneself. “Committing suicide” was like committing
murder or rape. The original negative reputation of the word may have decreased
over time, but the underlying residue remains (Sommer
– Rottenburg, p.239).
Then there are also phrases which paradoxically include positive
terminologies when a suicide is carried through, and negative terminologies
when a suicide is attempted but does not result in death. Based on that, we
should consider replacing phrases, such as “completed suicide,” “successful
suicide,” or “failed suicide attempt.” In this context I would welcome open
discussions among healthcare professionals, to establish more suitable
terminologies.
Furthermore, it is also worth acknowledging a study carried
out in 2012 into cases of suicide within psychiatric wards in England and
Wales. The study found that of the 448 suicides that occurred between
1999-2007, 77% were by hanging. The study highlighted the most common ligature
points as doors, hooks, handles, and windows. The most common ligatures used
were belts, sheets, and towels.
A further truly excellent read highlighting additional data
is the 2022
National Confidential Inquiry Into Suicide and Safety in Mental Health.
An expert’s view on anti-ligature
clothing
It is of greatest importance to understand that it must be a
last resort to seclude an individual. Any such restriction must be for the
safest and shortest time possible. It must be no longer than necessary, and the
person’s dignity and freedom of movement should remain a priority. All other
methods must be tried, and great care should be taken when identifying if other
options were more suitable to legally place an individual in seclusion.
Pete Turner, Principle Associate of SWC Expert Group,
who spent over 31 years as Violence Reduction Lead at another High Security
Hospital in the UK, pointed out there are several benefits in ensuring an
individual at risk of self-harm or suicide is wearing anti-ligature clothing:
“Of course, it significantly reduces the patient's opportunities to self-harm,
but it will also keep the area and person sterile and make it less likely for a
member of staff to have to re-enter a secure area to reengage if personal
clothing has been damaged (increased likelihood of active violence, injuries
and trauma etc.). It can also provide comfort and reassurance to some patients
knowing that they were unable to carry out their intended acts to harm
themselves, often expressed with gratitude post the prescribed intervention.”
This statement really got to me when I read it the first time.
As desperate as some might appear when aiming to harm themselves or take their
lives, this statement highlighted to me once again that there really is a
‘light at the end of a tunnel,’ even if many seem to be unable to see that light
in moments of ‘insufferable darkness’.
However, we also must acknowledge that some individuals are
driven, or influenced by unique biological, psychological, socioeconomical and
environmental factors. Due to these factors, their relentless pursue to harm
themselves or take their lives can often be final.
When speaking about anti-ligature clothing, Pete Turner strongly
emphasises the moral aspects, and concluded: “If used unlawfully, such clothing
can be degrading, traumatic, unethical, and very damaging to the staff and
patient therapeutic relationship and have no clinical function or recovery
benefits. However, when such clothing is being used for the correct reasons,
and with care and compassion to safely manage and reduce the observed levels of
risk, they are extremely supportive of the therapeutic delivery and patients'
recovery.”
“We must always be aware of the danger that if this practice is
not carefully monitored and regularly reviewed, it can become a cultural and
habitual blanket approach. This has the potential of contributing to the
vicious cycle of violence and the internal justification for their use of
restrictive responses. We must aim to reduce practises whereby the patient can
become unintentionally dehumanised to ensure the safety of themselves and
others.”
Key Objectives of Anti-Ligature Clothing
The
overall structural strength of anti-ligature clothing is, of course, of immense
importance. However, there is no question about it, ‘comfort’ and ‘wearability’
is of equal significance, as it will help the wearer’s
sense of self-worth, especially when the garment is being worn over a longer
period. The more comfortable such a garment
is, the less severe the behavioural disturbance the person may demonstrate, and
that this likely will to reduce the risk that
person may represent to themselves and others.
This type of clothing is to be worn by potentially vulnerable, high-risk,
distressed, and possibly volatile individuals. I strongly believe the more
comfortable such garment, the less severe the behavioural disturbance the
person may demonstrate, and that is likely to reduce the risk that person may
represent to themselves and others.
Doug Melia, Director of Safer Handling, who works
internationally supporting cross sector organisations on restraint safety
states: “Involuntary isolation may serve as an immediate reprieve from the
emotional stress of being monitored in close proximity
or the trauma and distress associated with clinical holding. A patient in
crisis, inclined to act without rational thought, or so determined at a
particular time to hurt themselves must have access to appropriate support
ensuring the right care, for the right person. Anti-ligature clothing can be
such appropriate support. It can facilitate a pathway to normality for the
patient, without compromising on safety or dignity.”
From the legal point, the situation is simple. Laws, rules, and
regulations in all countries may, of course, vary. Nevertheless, the overall
message is clear, the risk of patients, service users or inmates harming
themselves or carrying out suicide must be managed and effectively mitigated.
From the moral point, the benefits for you are clear. Issuing such protective garments at the right time and for the right reasons, will give you the assurance that your professional contributions and decision making remains highly moral, ethical, lawful, and compassionate.
What is your take on anti-ligature clothing? What is your
organisation doing to prevent self-harm and suicide? What else can we do
together to save the lives of those in our care?
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