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According to conventional wisdom, a great power engaging in international retrenchment regularly incurs tremendous costs. Following its withdrawal from a commitment abroad, the argument goes, windows of opportunity emerge that rivals exploit to their benefit, thus imposing significant costs on the retrenching great power. I argue that pundits and policymakers consistently overestimate the dangers associated with strategic withdrawals: great powers can – and in the past frequently have – successfully engaged in international retrenchment without creating opportunities for their rivals to gain significant strategic benefits. To make this case, I develop a new typology of international retrenchment strategies based on the kind and degree of disengagement they entail and demonstrate that most types do not regularly pave the way for rival gains. I support my argument through a series of plausibility probes: the Soviet retrenchment from Romania in the 1950s; the US retrenchment from Korea in the 1970s; and the US retrenchment from Western Europe in the 1990s.
This is a general introduction to the book, explaining that the purpose of the book is to provide a concise but detailed explanation of the core rules of international humanitarian law. The contents of each chapter are summarised. It explains that the book looks at the major areas of IHL, putting them in historical context, so as to better understand how the law has evolved. This book also examines the current challenges for and pressures on the existing law, as IHL rules adopted in the time of cavalry and bayonets must adapt to deal with issues like drones, cyber warfare and autonomous weaponry. It notes that the third edition has been updated to reflect new developments in the law of armed conflict up to May 2023.
Edited by
Roland Dix, Gloucestershire Health and Care NHS Foundation Trust, Gloucester,Stephen Dye, Norfolk and Suffolk Foundation Trust, Ipswich,Stephen M. Pereira, Keats House, London
This chapter explores the evolving use of rapid tranquillisation (RT) through the years, examining the complexities surrounding its definition and the factors that need consideration before, during and after its administration. Every acute disturbance experienced by a patient is different and a multidisciplinary approach with good communication is key. The chapter discusses the use of covert medication in
RT, the SafeWards approach to creating engaging and meaningful ward programmes for patients, laws for governing the use of restrictive procedures, and the medications used for RT and their routes of administration along with their potential side effects.
The Mental Capacity Act (MCA) 2005 came into force in 2007 and covers England and Wales. It provides a statutory framework for anyone over the age of 16 who lacks capacity to make decisions for themselves, for whatever reason. The MCA was drafted by the Law Commission partly in response to the increased prevalence of dementia and the lack of legislation to deal with the challenges of so many people living longer and losing their ability to make decisions. It is the loss of ability to make decisions, because of the disease, which makes the key link between providing care and treatment with the application of the law. This is why the MCA is perhaps the most important of all the pieces of legislation we consider. The practical applications of the Act will be dealt with in more detail in the chapters to follow. More detailed guidance can be found in the Mental Capacity Act 2005: Code of Practice (for England and Wales), revised in 2022. We include some of the main amendments to the Code at the end of this chapter and these are also covered in the relevant sections of the book.
When undertaking any intervention for an individual, you must be mindful of the legal authority or justification for the act. By intervention, we mean the full gamut of medical treatments or any act that relates to the care or welfare of that person. In this chapter, we will first consider the general legal principles that apply in almost any setting, but we have then divided the subsequent sections based on the location where care is predominantly provided (i.e. a domestic/home situation, care home or hospital). Although this is somewhat arbitrary, it broadly correlates with the progressive deterioration of the clinical state and in the transitions from living at home, to hospital or care home and through to the end of life. It therefore allows us to consider some situation-specific questions and how the law applies in negotiating the moves between locations or care settings.
Edited by
Masum Khwaja, Imperial College of Science, Technology and Medicine, London,Peter Tyrer, Imperial College of Science, Technology and Medicine, London
The illegal killing of George Floyd led to Black Lives Matter protests around the world and energised the call for discrimination to be addressed in society. In this chapter we explore evidence of mental health inequalities in those from BAME communities and acknowledge that some groups in society, who may or may not identify as BAME, such as asylum seekers travellers and the LGBTQ+ community, also face discrimination. We mention the theory of intersectionality, racial gaslighting and the detrimental impact of austerity on health outcomes. Readers are reminded of the historical reports into the deaths of Michael Martin, Joseph Watts and David ‘Rocky’ Bennett and of the 2002 Sainsburys Centre review which identified a ‘circle of fear’. The finding of the independent review of the MHA and the recently published rapid review of ethnic health disparities by the NHS Race and Health Observatory are highlighted. NHS England and NHS Improvement’s Advancing Mental Health Equalities Strategy, the RCPsych equality action plan, and The Patient and Carers Race Equalities Framework (PCREF) are explained. Stereotyping of black males and the disproportionate use of force (including tasers), is discussed and the authors call for the implementation of mandatory training covering the nature of discrimination.
Edited by
Masum Khwaja, Imperial College of Science, Technology and Medicine, London,Peter Tyrer, Imperial College of Science, Technology and Medicine, London
Violence and aggression never present themselves in a vacuum, yet this is typically the way policymakers approach the subject, its prevention and its management. Although guidelines exist in different sectors, too often little or no consideration is given to many of the wider issues in play, particularly the use of restraint when it becomes necessary. Despite the long-standing call for a common set of guidelines, we are only now looking at the introduction of the Restraint Reduction Network training standards, and it seems that anything approaching a set of common guidelines that all settings can embrace is a long way off. The aim of any good guidance seeking to influence practices in the prevention and management of violence and aggression should be to minimise the need for any restrictive intervention but where necessary to apply techniques as safely as possible within the relevant legislative framework. Certain staff in healthcare settings need to receive training to increase the organisation’s capacity and capability to deal with potentially violent situations without recourse to external agencies, such as police, who operate to a different set of standards to those within healthcare settings and who use techniques that healthcare staff would not wish to see used in their settings.
To identify the clinical characteristics of patients receiving nasogastric tube (NGT) feeding under physical restraint. Clinicians participated via professional networks and subsequent telephone contact. In addition to completing a survey, participants were invited to submit up to ten case studies.
Results
The survey response rate from in-patient units was 100% and 143 case studies were submitted. An estimated 622 patients received NGT feeding under restraint in England in 2020–2021. The most common diagnosis was anorexia nervosa (68.5–75.7%), with depression, anxiety and autism spectrum disorder the most frequent comorbidities. Patients receiving the intervention ranged from 11 to 60 years in age (mean 19.02 years). There was wide variation in duration of use, from once to daily for 312 weeks (mode 1 week; mean 29.1 weeks, s.d. = 50.8 weeks).
Clinical implications
NGT feeding under restraint is not uncommon in England, with variation in implementation. Further research is needed to understand how the high comorbidity and complexity contribute to initiation and termination of the intervention.
Can sexual restraint be good for you? Many Victorians thought so. This book explores the surprisingly positive construction of sexual restraint in an unlikely place: late nineteenth-century Decadence. Reading Decadent texts alongside Victorian writing about sexual health, including medical literature, adverts, advice books, and periodical articles, it identifies an intellectual Paterian tradition of sensuous continence, in which 'healthy' pleasure is distinguished from its 'harmful' counterpart. Recent work on Decadent sexuality concentrates on transgression and subversion, with restraint interpreted ahistorically as evidence of repression/sublimation or queer coding. Here Sarah Green examines the work of Walter Pater, Lionel Johnson, Vernon Lee, and George Moore to outline a co-extensive alternative approach to sexuality where restraint figured as a productive part of the 'aesthetic life', or a practical ethics shaped by aesthetic principles. Attending to this tradition reveals neglected connections within and beyond Decadence, bringing fresh perspective to its late nineteenth- and twentieth-century reception.
This paper explores factors linking gender with increased perceived coercion, perceived negative pressures and procedural injustice during psychiatric admission.
Methods:
We used validated tools to perform detailed assessments of 107 adult psychiatry inpatients admitted to acute psychiatry admission units at two general hospitals in Dublin, Ireland, between September 2017 and February 2020.
Results:
Among female inpatients (n = 48), perceived coercion on admission was associated with younger age and involuntary status; perceived negative pressures were associated with younger age, involuntary status, seclusion, and positive symptoms of schizophrenia; and procedural injustice was associated with younger age, involuntary status, fewer negative symptoms of schizophrenia, and cognitive impairment. Among females, restraint was not associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation; seclusion was associated with negative pressures only. Among male inpatients (n = 59), not being born in Ireland appeared more relevant than age, and neither restraint nor seclusion were associated with perceived coercion on admission, perceived negative pressures, procedural injustice, or negative affective reactions to hospitalisation.
Conclusions:
Factors other than formal coercive practices are primarily linked with perceived coercion. Among female inpatients, these include younger age, involuntary status, and positive symptoms. Among males, not being born in Ireland appears more relevant than age. Further research is needed on these correlations, along with gender-aware interventions to minimise coercive practices and their consequences among all patients.
Coercive measures (such as seclusion, mechanical restraint, and forced medication) during psychiatric inpatient treatment should be avoided whenever possible. Different interventions were already developed to reduce coercion, but for their effective application, it is crucial to know the risk factors of individuals and clinical situations that might be associated with coercion. Since the results of previous studies differ considerably the current study aims to fill this gap by evaluating the course of the exertion of coercion in detail.
Methods
In this study, we analyzed clinical, procedural, and sociodemographic data from patients (n = 16,607 cases) who were treated as inpatients in Switzerland’s largest psychiatric institution with 320 beds during the years 2017 to 2020. We used regression models to identify predictors for the exertion of coercion, the number of coercive measures during a treatment episode and time until exertion of the first and last coercive measure.
Results
Coercive measures are mostly used during the first days of treatment. We identified clinical parameters such as manic or psychotic episodes to be the most relevant predictors for the exertion of coercion. Cases with those disorders also received coercion more often and earlier in their treatment course than other diagnostic groups. Other promoting factors for frequency and early application of coercion were involuntary admission and factors of chronicity and clinical severity.
Conclusions
Knowing the risk factors may help to target preventive strategies for those at highest risk. In particular, interventions should focus on the critical timeframe at the beginning of treatment.
Published information provides scientific evidence that traditional, involuntary restraint techniques of research non-human primates are intrinsically a source of distress resulting from fear. It has been documented that common methods of enforced restraint result in significantly increased adrenal activity as well as significant changes in a variety of other physiological parameters. There is no scientific evidence that the animals adequately habituate to involuntary restraint. Numerous reports have been published demonstrating that non-human primates can readily be trained to cooperate rather than resist during common handling procedures such as capture, venipuncture, injection and veterinary examination. Cooperative animals fail to show behavioural and physiological signs of distress. It was concluded that the advantages of training techniques over traditional restraint techniques will have to be explored more extensively in the future for the sake of research subjects and scientific methodology.
The purpose of this experiment was to investigate the welfare of pregnant mares kept in straight stalls and given only limited exercise, conditions that are similar to those encountered in the pregnant mare urine industry. Sixteen pregnant mares (eight in each of two years) were randomly assigned to two groups: Ex (exercised in a paddock for 30 min per day) or NoEx (exercised for one 30 min period every 14 days). The horses were housed in straight (or ‘tie’) stalls for six months and had ad libitum access to grass hay. Each horse's behaviour was recorded on videotape once per week for 24 h. The major behaviours were eating hay, standing, and stand-resting (head down and one hind limb flexed). There was no difference between the behaviours or the number of foot lifts per min of the Ex and NoEx groups in their stalls. Nine of 16 mares were not observed in recumbency throughout the whole of the six-month observation period, suggesting that horses with no previous experience in straight stalls may be reluctant to lie down. Thirteen of 16 mares dropped to their knees at least once, probably when they were REM sleeping while standing. There were no significant differences between the Ex and the NoEx mares in baseline plasma Cortisol levels or in Cortisol response to ACTH. Following 30 min of exercise, NoEx mares showed an increase in Cortisol from 5.0 to 5.4 μg dL−1, whereas Ex mares showed a decrease from 4.6 to 3.6 µg dL−1. The NoEx horses that had been confined for two weeks trotted more (NoEx = 22 [6-38; median and range]% of time; Ex = 2.4 [0-8.7]%) and galloped more (NoEx = 6 [2-8]%; Ex = 0 [0-4]%) than the Ex that were released daily, but walked less (NoEx = 17 [10-26]%; Ex = 35 [20-40]%) and grazed less (NoEx = 0%; Ex = 3 [0-12]%). Confined horses show rebound locomotion — that is, a compensatory increase — when released from confinement, indicating a response to exercise deprivation.
Housing conditions can alter both the physiology and behaviour of laboratory animals. Forced-air-ventilated micro-isolation systems increase the efficient use of space, decrease the incidence of disease among laboratory rodents, and provide better working conditions for animal care staff; however, such systems can increase breeding variability and mortality. We examined the possibility that stressors associated with automated housing conditions evoke subtle changes among immune, endocrine, and behavioural parameters in mice housed in a static versus a forced-air-ventilated micro-isolation system. In addition, we assessed the effects of housing in the forced-air-ventilated micro-isolation system both with and without the use of an automatic watering system. Housing in the forced-air-ventilated micro-isolation system, using the automatic watering system, suppressed delayed-type hypersensitivity (DTH) responses, a measure of cell mediated immune function, compared with the responses of mice housed in static cages. Hypothalamic–pituitary–adrenal axis function was also altered by housing in the forced-air-ventilated micro-isolation system with the use of the automatic watering system, such that mice in this housing system had lower resting corticosterone concentrations and increased reactivity to restraint. Despite these changes in corticosterone, housing condition did not alter activity level or exploratory, anxiety-like, or depressive-like behaviours. These results suggest that investigators should carefully consider housing conditions in studies of immune and endocrine function.
Minimising the effects of restraint and human interaction on the endocrine physiology of animals is essential for collection of accurate physiological measurements. Our objective was to compare stress-induced cortisol (CORT) and noradrenalin (NorA) responses in automated vs manual blood sampling in pigs. A total of 16 pigs (30 kg) were assigned to either: (i) automated blood sampling via an indwelling catheter using a novel-penning system called PigTurn® which detects the pig's rotational movement and responds by counter-rotating, allowing free movement while preventing catheter twisting; (ii) automated sampling while exposed to visual and auditory responses of manually sampled pigs; or (iii) manual sampling by jugular venipuncture while pigs were restrained in dorsal recumbency. During sampling of (i), personnel were not permitted in the room; samplings of (ii) and (iii) were performed simultaneously in the same room. Blood samples were collected every 20 min for 120 min and measured for CORT (ng ml−1) using mass spectrometry and NorA (pg ml−1) using High Performance Liquid Chromatography (HPLC). Effects of treatment and time were computed with mixed models adjusted by Tukey post hoc. CORT and NorA concentrations were lowest in group (i) followed by group (ii), which were not different. However, CORT and NorA levels in manually sampled animals (iii) were highest compared to automated methods (i) and (ii). Plasma concentrations across time were not different for CORT, but NorA concentration at time 0 min was higher than at 120 min. The presence of visual and auditory stimuli evoked by manual sampled animals did not affect non-handled pigs’ responses. Restraint and manual sampling of pigs can be extremely stressful while the automated blood sampling of freely moving pigs, housed in the PigTurn® was significantly less stressful for the animals.
The restraint and sedation of wild animals has welfare implications, thus animal handling procedures should be well-informed and optimised to adhere to welfare standards. Furthermore, it is important that handling procedures should not cause future trap avoidance. This is of particular pertinence to European badgers (Meles meles), subject to extensive cage-trapping, relating to bovine tuberculosis epidemiology. We examined 4,288 capture/recapture events for 856 individual badgers, occurring between May 1999-September 2011, recording initial observed behaviour and reaction provoked by injection, on a scale ranging from still (0) to distressed/aggressive (3). Eighty-seven percent of adults and 76% of cubs were still (0) when approached initially and 75% of adults and 62% of cubs remained still when injected. Cubs exhibited significantly higher behavioural responses than adults, while female adults scored higher provoked scores than males. Importantly, the initial behaviour of an individual dictated its provoked response. Previous experience of capture was associated with lower subsequent behavioural response scores, while naïve badgers were most prone to score highly. Individuals first caught as cubs scored lower initial responses than those first caught as adults. Lower initial responses occurred in spring and summer and higher responses were associated with lice infestation. Behavioural criteria have potential to inform and optimise welfare in badger capture operations. This contributes to techniques allowing simple, non-invasive assessment of how wild animals in general respond to temporary restraint, where the psychological perception acts as the precursor to physiological stress.
The stunning of ostriches (Struthio camelus) has traditionally been carried out with hand-held tongs whilst birds are held in a restraining area by applying pressure normally from behind by gently pushing on the tail feathers. The area is often a V-shaped structure, high enough that the stunning operator is not kicked. After stunning, the birds are rocked backwards and a rubberised leg clamp placed over the legs at the tarso-metatarsal bone allowing the birds to be chain-shackled by the big toes. This stunning procedure has been replaced by a new restraining and stunning mechanism which completely envelops the ostrich in a padded clamp holder. Double-padded sides restrain the bird's upper thighs and a rubberised foot clamp holds the feet so there is no physical damage to the bird. As the bird is electrically stunned with electrodes placed both sides of the head, the entire stunning box rotates 180° so that toe clamps can be applied without any danger to the stunning operators. Within 20 s of stunning, the birds are bled by means of a complete ventral cut to the neck and/or by thoracic sticking.
This article reviews current evidence on the use of coercive measures, including seclusion and restraint, in psychiatric in-patient settings in Europe. There is a particular focus on evidence regarding the use of mechanical restraint. The review seeks to describe when the use of restrictive interventions such as restraint may be necessary, to explore the use of restraint in certain specialist settings and to investigate current laws and European policies on seclusion and restraint. The current rates of restraint in European psychiatric settings are explored, with a discussion of the limitations of the evidence currently available. The article discusses various consequences of seclusion and restraint, potential alternatives to their use and strategies to minimise their use and harm to patients. The use of coercive measures from an international context is considered, to provide context.
Restrictive interventions (seclusion, restraint and special observations) are used on psychiatric wards when there are no other means available to keep a patient or others safe. These measures can be traumatic, and the Mental Health Commission and the Health Service Executive are focused on minimising their use. We set out to determine whether, following a COVID related reduction in bed numbers on a high dependency psychiatric ward in St John of God Hospital in Dublin, there was a change in their incidence.
Methods:
Data on restrictive interventions and challenging behaviours were gathered for 9-month periods before and after March 2020 when COVID related ward changes took place. Figures were also collected on seclusion and restraint for the previous 18 months for a longer-term view. Ward and hospital occupancy levels were also recorded.
Results:
Between the two time periods, episodes of seclusion fell by 53% and episodes of restraint by 56%. The hours devoted to special observation declined by 30% and incidents of challenging behaviours fell by 26%. Ward occupancy levels fell by only 5%. The longer-term comparison of figures for seclusion and restraint point towards a downward trend from mid-2019 that was accentuated in the post-COVID period.
Conclusions:
The changes found may relate to reduced crowding on the ward or other COVID related factors such as the emphasis on social distancing and a shared sense of purpose on the ward. The longer-term trend points towards an emerging cultural shift. The challenge now is to sustain and build upon these changes.
Eating disorders have the highest mortality rate of any psychiatric condition. Since the COVID-19 pandemic, the number of patients who have required medical stabilisation on paediatric wards has increased significantly. Likewise, the number of patients who have required medical stabilisation against their will as a lifesaving intervention has increased. This paper highlights a fictional case study aiming to explore the legal, ethical and practical considerations a trainee should be aware of. By the end of this article, readers will be more aware of this complex issue and how it might be managed, as well as the impact it can have on the patient, their family and ward staff.