Restraint & seclusion

Did you know?

Use of restraint on people with learning disabilities rose by 50% in 2018
78% of families said restrictive practices worsened their relative’s behaviour
22,000 restrictive interventions take place in mental health hospitals every year.[Source: Bild Restraint Reduction Network]

What is a restrictive intervention?

A restrictive intervention includes anything that stops someone from harming themselves, others or things in their environment.

In other words, restrictive interventions force someone do something they don’t want to do or stop them from doing something they do want to do. Restraint includes:

The use, or threat of the use of, of physical force to make a person do something they are resisting.
Mechanical restraint such as lap-straps, harnesses, hand-cuffs, bedrails, locks on doors and other devices of behavioural control
Chemical restraint, such as rapid tranquilisation medications, sedatives which subdue the person’s body
Isolation and segregation, which includes both short-term and long-term situations.

The use of force is inherently risky. Moreover, it is usually traumatic for the person. It is also distressing for bystanders who witness it and can affect staff too.

Why is change needed?

Force has been used too often and for too long. Data shows that the use of force is at an all-time high.

Certain groups of patients/service users have experienced high levels of restraint without question.

Misuse of and abuse of restraint happens too often. The potentially dangerous practice of prone restraint is also used too often. This must change.

Everyone has the right to be treated with dignity. Everyone, no matter what their disability or condition, deserves a caring environment free from abuse. Sometimes restraint or seclusion will be necessary for everyone’s safety, but it must always be done in the least restrictive way. We must all work towards reducing restraint.

Record-keeping about situations when restraint or seclusion has been used has been patchy in the past. That makes it difficult to monitor trends and identify what needs to change.

But more than that, the focus needs to shift to prevention. Only by preventing situations from escalating, will people be truly safeguarded.

Who is most at risk of being restrained or secluded?

Sadly, the data reveals that some groups of people are disproportionately restrained or secluded. People who are most likely to be restrained or secluded:

of black or a minority ethnicity
female
Autistic or have a learning disability
Have mental health needs

When is restraint acceptable?

All forms of restraint and seclusion are an infringement or violation of someone’s human rights.

However, restraint is permissible under law in certain situations. Legislation allows the police, prison services and health services to restrain someone in defined situations.

No matter where or by whom the restraint takes place, for the restraint to be lawful, it must meet certain criteria.

For example, the Mental Health Act 1983 Code of Practice outlines that restrictive interventions may only be used

to take immediate control of a dangerous and harmful situation; or
to end or reduce danger.

Can restraint be used when someone is resisting care?

Sometimes a person lacks capacity for care to be provided and it is in their best interests for this action to happen, but they resist this care. In these situations, the Mental Capacity (2005) applies. It is important to take a person-centred approach. Restraint can be applied under the MCA to provide the care as long as it is:

required and as a last resort
in their best interests
deemed necessary to prevent harm occurring and
where the restraint is proportionate response to the likelihood of the person experiencing harm as well as the seriousness of that harm.

Furthermore, there may be situations where not appropriately restraining somebody who lacks capacity when it is in their best interests, could lead to the person becoming seriously harmed and lead to a failure in duty of care.

Where the restrictions and restraints in place amount a deprivation of liberty, this needs to be properly authorised.

Under common law, anyone can restrain someone else if there is a serious risk of harm to life or limb. Again, this would need to be proportionate and justifiable in the circumstances.

What are the principles underpinning use of restraint or seclusion?

People’s fundamental human rights matter regardless of who they are
Be person-centred – blanket policies around restraint or seclusion are likely to breach people’s human rights
Apply the Mental Capacity Act where required and think about the person’s best interests and balance with the principle of less restriction.
Therapeutic approaches are helpful in supporting people when they are distressed
Reducing restraint generally improves the quality of life of those being restrained and those supporting them
Promoting positive culture and practice that focuses on prevention, de-escalation and reflective practice is generally better in the long-run
Try to understand the root causes of behaviour and recognise that many behaviours are the result of distress due to unmet needs
People may not initially be open about their previous trauma. In fact, they may go to great lengths to hide their traumatic experiences. They may not even have much insight themselves into how their past experiences are affecting their current behaviour. So, adopting a trauma-informed approach with everyone you work with is advised.
A restrictive intervention such as seclusion or physical restraint is in itself potentially traumatising. The experience could also trigger memories about previous traumas.

Is restraint reduction realistic?

Absolutely! A good example is the work that was led by the University of Central Lancashire.

They developed a programme REsTRAIN YOURSELF’ which was set out to challenge staff assumptions and expectations of using restraint.

Seven mental health trusts took part in the project. Four out of the seven mental health trusts exceeded the 40% reduction in restraint target.

There was also a noticeable change in the culture of ward teams. Staff said the project made them think before using restraint. Staff also became more paced and thoughtful in response to self-harming behaviour.

When all other options have run out, use the safest and most dignified restrictive interventions possible.Any restraint used needs to be carried out in accordance with any risk assessments or care plans. A care plan involving restraint, needs to be regularly reviewed.

Why does a trauma-informed approach matter?

It is useful to avoid labelling behaviour as ‘challenging behaviour’ and instead think of it as ‘distress behaviour’. This simple shift in attitude is just one of the trauma-informed ways of working that can ultimately help to reduce restraint and seclusion.

When should you raise a safeguarding concern about restraint or seclusion?

Report a concern if you suspect that:

restrictive interventions are being used to ‘punish’ someone
restrictive interventions are clearly motivated by cruelty – with a clear intent to inflict pain, suffering or humiliation
where the restrictive interventions are being used for longer than necessary
restrictive interventions are disproportionate or
are not the least restrictive option available
an organisation has ‘blanket policies’ for restrictive practices which don’t take into account an individual’s needs
proper records are not being kept about restrictive practices used.
Where an unauthorised deprivation of liberty is occurring and the care is being provided in a way which is overly restrictive and the person is experiencing harm