Note No. 9, 4 November 2022. John Baker, Kathryn Berzins, Sarah Kendal
In many institutions in the UK, when an adult or child is distressed or agitated, staff may use techniques such as physical restraint and/or being locked in a seclusion room to contain the situation. These ‘restrictive practices’ can be physically harmful and cause psychological trauma. We systematically reviewed interventions to reduce the use of restrictive practices in institutional settings and found the most effective interventions combined techniques from a common pool. Health, education and criminal justice sectors should be encouraged to prioritise evidence backed interventions to prevent harm, reduce associated costs, and improve care.
In institutional settings such as hospitals, residential care, schools and prisons, adults and children can become distressed, leading staff to respond by holding them (restraint) or putting them in a room on their own (seclusion), so called restrictive practices. Restrictive practices carry high risks of serious physical and psychological trauma, and can lead to deaths. Pain inducing techniques (which work by deliberately inflicting pain just below the ear, or by bending back the wrist or thumb) can legally be used on children in the UK. In 2015 alone, there were 429 injuries to children resulting from restraint in youth custody and a number of deaths within inpatient facilities.
Practitioners, pressure groups, lawyers and politicians across the world are concerned about the use of restrictive practices. The United Nations raised concerns about the overuse of restrictive practices in the UK in 2017. Voluntary organisations such as the mental health campaigners Mind, and the human rights advocacy groups Article 39 and Agenda, have long-standing campaigns to reduce the use of restrictive practices.
The UK Government is aware of this issue. In 2012, the Ministry of Justice implemented ‘Minimising and Managing Physical Restraint’, a new behaviour management and restraint system. Department of Health guidance launched in 2014 aimed to phase out face-down restraint and deemed physical restraint a ‘last resort’. The Mental Health Units (Use of Force) Act 2018 set out measures to prevent inappropriate use of force in mental health hospitals.
Although pain-inducing restraint techniques are now unlawful in Department of Education and Department of Health settings, they remain lawful in Ministry of Justice settings, including with children.
There is a moral imperative to reduce the use of restrictive practices. Further action has the potential to prevent harm to those who use and deliver services, improve the quality of care, and reduce costs associated with injury – but to achieve this, we must invest in changing working practices, and offer support and training.
Systematic evidence review
Funded by the National Institute of Health and Care Research, we systematically mapped interventions that aim to reduce restrictive practices in all children’s institutional and adult mental health settings. We conducted two systematic reviews of the evidence, looking at nearly 300 records covering 225 different interventions, and assessed the quality of research on each.
Out of the 225 different interventions reviewed, a number of techniques were found to be most effective at reducing the use of restrictive techniques in institutional settings. These include:
- Setting goals for staff to work towards, such as reducing the number of times they use a restrictive practice.
- Educating staff to improve knowledge and skills, eg training in therapeutic techniques that are sensitive to traumas that people may have experienced. (For example, a child or adult who has had previous experience of being held down and assaulted is likely to be re-traumatised if staff attempt to physically restrain them.)
- Improving the physical environment (eg by ensuring rooms are clean, airy and attractive), the social atmosphere (eg staff working to develop friendly relationships with people using services), and staffing provision (eg ensuring that there are enough staff with appropriate skills and qualifications, and recruiting staff whose personalities and values enhance the service that is provided), in order to create a calm atmosphere that will help prevent tensions from developing into incidents where a restrictive practice is used.
- Giving staff feedback about incidents, eg how often they occurred, in what circumstances, who was involved, and what the consequences were.
The most successful interventions were more likely to include a combination of these common techniques. The economic impact of reducing restraints still needs to be established.
We recommend using these evidence-based strategies for reducing restrictive practices safely, in order to improve the experiences of everyone who receives or delivers services within health, education and criminal justice settings.
Restrictive practices are used too frequently in a wide array of institutional settings, so coordination across different areas of policy will be essential to create a reduction in their use. The strategies for developing sector-specific changes will, nonetheless, need to be tailored for each setting. Organisational leaders should look at the environments they offer to see what improvements could be made to reduce restrictive practices.
All staff working in institutions or roles where restrictive practices are used should be supported with sufficient training for them to make interventions confidently and without the need for physical restraints or seclusion. When a restrictive practice is used, the incident should be reviewed along with whether or how the restrictive practice could have been avoided, and key learning points should be shared with staff.
Book a time to speak to the team as part of Evidence Week in Parliament 2022, Tuesday 15 November 9am to 12pm, Jubilee Room, Westminster.
This briefing has been supported by the Leeds Interdisciplinary Mental Health Research Network (LIMHRN). LIMHRN aims to promote interdisciplinary research that tackles local, national and global mental health challenges across clinical and community settings. We work together to understand mental health and to support diverse settings, organisations, communities and people towards good mental health for all.
To cite this policy note, please reference: Baker et al. (2022) Reducing restrictive practices across health, education and criminal justice settings. Note 9, Policy Leeds, University of Leeds. https://doi.org/10.48785/100/105
- Baker J, Berzins K, Canvin K, Kendal S, Branthonne-Foster S, Wright J, et al. (2022) Components of interventions to reduce restrictive practices with children and young people in institutional settings: the Contrast systematic mapping review. Health Soc Care Deliv Res 2022;10(8) https://doi.org/10.3310/YVKT5692
- Baker J, Kendal S, Berzins K, Canvin K, Branthonne-Foster S, McDougall T, Goldson B, Kellar I, Wright J, Duxbury J. (2022) Mapping review of interventions to reduce the use of restrictive practices in children and young people’s institutional settings: The CONTRAST study. Children and Society. https://doi.org/10.1111/chso.12581
- Baker J, Berzins K, Canvin K, Benson I, Kellar I, Wright J, et al. (2021) Non-pharmacological interventions to reduce restrictive practices in adult mental health inpatient settings: the COMPARE systematic mapping review. Health Serv Deliv Res 2021;9(5) https://doi.org/10.3310/hsdr09050