Restraint in
mental health
services
What the
guidance says
Acknowledgements
We are very grateful to our advisory group, people who shared their
experience and insights in focus groups or through questionnaires,
and campaigners and their colleagues who shared their stories. They
include: Niki Glazier, Henderson E. Goring, Dorothy Gould, Carolyn
Green, Naomi Good, Gary Molloy, Hannah Moore, Kim Parker, Sarah
Rae, Sarah Yiannoullou, Derby Mental Health Action Group, Healthy
Minds (Calderdale), Maat Probe Group (Sheffield), People’s Network
(Hackney), Viewpoint (Hertfordshire).
This report provides information about restraint and other restrictive
interventions in mental health services. It goes with the companion
guide Restraint in mental health services: Influencing change in your
area, which sets out how you can get involved in shaping your
services and campaigning locally.
Wales
This report focuses more on England because it builds on Mind’s
campaigning in England; one of its aims is to spread awareness of
Department of Health guidance. However, much of the information
applies in Wales as well and we have included Wales-specific data
and references.
This guide’s companion document, Restraint in mental health
services: Influencing change in your area, is for people in England
and Wales.
For more information about restraint campaigning in Wales please
contact Rhiannon Hedge at r[email protected]
This information was written and produced by Mind’s
Policy & Campaigns team in partnership with the
National Survivor User Network.
Published in 2015 © Mind 2015
To be reviewed in 2018
Foreword by NSUN (National 4
Survivor User Network)
Introduction 7
Mind’s view on face down 7
(prone) restraint
What this report is for 7
What we aim to achieve 7
What is restraint? 8
Overview 8
The purpose of restraint 10
The context of restraint 10
The scale of use of restraint 11
Experiences of restraint 12
What do people want to change? 16
What does the guidance say? 17
The guidance available 17
Key points from the guidance 18
What good practice initiative 20
are there?
4Pi National Involvement Standards 20
No Force First 20
Positive and Safe Champions Network 20
PROMISE 21
RESPECT 21
Restraint Reduction Network
TM
21
REsTRAIN YOURSELF 21
Safewards 21
Campaigners’ stories 22
Maat Probe: Group campaign 22
in Sheffield
PROMISE: Spark to a flame 24
Campaigning on the use of seclusion 26
and restraint in Derbyshire
Where can I find out more? 28
Mental health organisations 28
Guidance in England 28
Guidance in Wales 28
Guidance in England and Wales 29
Good practice initiatives 29
Endnotes 30
Contents
Foreword
National Survivor User
Network
Being physically restrained by staff as a patient
on a psychiatric ward is not only humiliating and
distressing, it can also be dangerous – even
life-threatening. In 2011–12 there were almost 1,000
incidents of physical injury reported after restraint
had been used.
1
But the emotional damage is
costly, traumatising and can last a lifetime.
Restraint is not just about physically restraining
people. It includes the use of medication to subdue
patients, and the use of seclusion to confine and
isolate someone on the ward. Abusive restraint
can, however, take more subtle forms than these
restrictive interventions. People tell of being
subject to controlling behaviour and psychological
manipulation on wards with a coercive culture.
Common experiences are being unnecessarily
prevented from going outside, accessing the
internet or making a phone call. All of these acts
potentially violate an individual’s human rights.
Often coming on top of the loss of liberty, they
can be profoundly psychologically damaging.
Recognising the overuse and abuse of
restraint, the Department of Health published
guidance for health and social care providers in
2014.
2
It called upon them to reduce the use of all
forms of restraint and restriction, and to eliminate
the dangerous practice of face down restraint. We
do not know, however, how much this guidance is
being acted upon on the ground. Even the CQC
acknowledges, with many trusts failing to submit
the necessary data, the extent of the misuse of
restraint nationally cannot be reliably assessed.
3
The CQC are now paying closer attention to
restraint, and providers’ practice affects their
ratings and sometimes leads to enforcement
action.
4
This guide is intended to empower people to
challenge how restraint is used in their local mental
health services and to hold NHS professionals to
account. NSUN exists to promote and support the
rights of people – ensuring we have a voice, and
are able to challenge damaging practices. Working
together, we can end the abuse of restraint in our
mental health services, a practice which has no
place in modern, civilised society.
Sarah Yiannoullou and Naomi Good
National Survivor User Network
About the artwork
Having spent 10 years in and out of hospital
through the nineties with bipolar disorder, I would
experience being restrained on many occasions.
From these experiences, there seemed to be a
lack of empathy and compassion around the use
of restraint.
My painting ‘Harmonia’ is about the importance
of empathy and compassion around restraint
and how both of these aspects should be at the
forefront of discussions around restraint as we
move forward.
We hear so much about mindfulness these days.
‘Harmonia’ is about heartfulness – connecting with
the heart to develop and maintain wellbeing, and
to aid healing and recovery.
Gary Molloy
Artist & advisory group member
Restraint in mental health services: What the guidance says 5
Introduction
What this report is for
Together with Restraint in mental health services:
Influencing change in your area, this report is a
resource for people who want to change the
practice of restraint in mental health services and
end reliance on force, particularly on adult mental
health wards. It is mainly aimed at people who
use mental health services, carers, advocates
and campaigners.
This report provides information about restraint,
people’s experiences, official guidance, good
practice and campaigners’ stories.
Restraint in mental health services: Influencing
change in your area provides practical
information about how you can influence practice.
If you need to complain or report abuse and want
to find out more, please see Restraint in mental
health services: Influencing change in your area
or contact Mind’s legal line on 0300 466 6463 or
What we aim to achieve
We want to spread good practice and end
reliance on force. Both Mind and NSUN have
campaigned for people using mental health
services to be treated fairly, positively and with
respect. Mind’s 2013 campaign about the use of
physical restraint helped lead to new national
guidance in England, Positive and Proactive Care.
Now we hope that more people will get involved
in shaping policies and improving practice.
Mind’s view on face down
(prone) restraint
When we launched our campaign in 2013
we called for an end to face down restraint.
Reactions to this highlighted different views about
the risks of different physical holds and what
might be necessary in some circumstances.
We still want to see an end to this practice and
to other restraint techniques that are hazardous
or cause fear or pain.
We think the main way to do this is to make
wards calmer and safer places, where staff and
patients know each other better, where there is
a determination not to rely on force, and using
the kinds of good practice described in this
guide. Where wards become better places to be,
evidence shows that frustration and agitation are
reduced along with the need for restraint. Then,
if physical intervention cannot be avoided, it
should be done without holding people down if
at all possible.
Restraint in mental health services: What the guidance says 7
What is restraint?
Restraint
We are using ‘restraint’ as shorthand for all the
restrictive interventions listed in the box across
the page.There are other practices on this
spectrum which people experience as restrictions
or restraint: psychological coercion and
manipulation, and withdrawal of care, resources
and/or information. They are not ‘interventions’
because they are not methods that that staff are
expected or allowed to use, but can occur where
there is a coercive or controlling ward culture.
Overview
Restraint can mean different things to different people. Different terms
all have slightly different meanings.
Restrictive practice
‘Restrictive practice’ has been explained as
making someone do something they don’t want to
do or stopping someone doing something they
want to do.
5
It can include stopping people from
going outside or from using the internet or phone.
The Mental Health Act Code of Practice says
these restrictions should not be imposed as
blanket rules (where they apply to everyone on a
ward regardless), but only if they are necessary
because of a specific individual risk.
Restrictive interventions
‘Restrictive interventions’ include observation,
seclusion, manual restraint, mechanical restraint
and chemical restraint which may include rapid
tranquillisation (see box across page). These are
all deliberate acts that restrict someone’s
movement or freedom so as to take control of a
dangerous situation or to end or reduce danger
to the person concerned or others.
6
Acts like
these all have the potential to violate the person’s
human rights.
8 Restraint in mental health services: What the guidance says
Definitions and explanations taken from official sources*
Any direct physical contact where the intention is to prevent,
restrict, or subdue movement of the body (or part of the body)
of another person. (Positive and proactive care and Mental
Health Act Code of Practice)
The use of a device to prevent, restrict or subdue movement
of a person’s body, or part of the body, for the primary
purpose of behavioural control. (Positive and Proactive Care
and Mental Health Act Code of Practice)
The use of medication which is prescribed, and administered
for the purpose of controlling or subduing disturbed/violent
behaviour. This does not include where it is prescribed for the
treatment of a formally identified physical or mental illness.
(Positive and proactive care)
Rapid tranquillisation is the use of medication to calm or lightly
sedate an individual to reduce the risk of harm to self or
others and to reduce agitation and aggression. (Code of
Practice)
The Code of Practice says it may include oral medication or
injections; NICE says it refers to an injection given if oral
medication is not possible or appropriate and urgent sedation
with medication is needed. Both are clear that oral medication
should always be considered first.
Use of medication by the parenteral route (usually
intramuscular or, exceptionally, intravenous) if oral medication
is not possible or appropriate and urgent sedation with
medication is needed. (NICE)
The supervised confinement and isolation of a patient, away
from other patients, in an area from which the patient is
prevented from leaving, where it is of immediate necessity
for the purpose of the containment of severe behavioural
disturbance which is likely to cause harm to others. (Mental
Health Act Code of Practice)
Type of restraint
Physical restraint
Holding – also called manual
restraint
Mechanical restraint
Handcuffs or other equipment.
Used in high secure hospital or
when people are moving between
secure hospitals
Chemical restraint
Medication
Seclusion
Taken from:
Mental Health Act 1983: Code of Practice
Positive and proactive care: reducing the need for restrictive
interventions (Department of Health guidance)
Violence and aggression: short-term management in mental
health, health and community settings (NICE guidance)
Restraint in mental health services: What the guidance says 9
The purpose of restraint
Healthcare staff do a challenging job and have to
intervene where a person is a risk to themselves
or others. However, restraint should only be
used as a last resort, when prevention and de-
escalation have not worked. It should be done
in a way that avoids pain and reduces fear and
distress, with continuing efforts to de-escalate.
People expect staff to act where there is risk
of harm – to be proactive in preventing difficult
situations arising and to use their skills to
de-escalate situations that do arise. Even when
physical intervention is used, people have said
it was okay when it was appropriate and done
well, and in these cases could make you feel
secure and cared for, or stop you hurting
yourself. However we have also heard about
a lot of restraint that was unnecessary and
traumatising.
The context of restraint
The culture and environment of wards can
create the situations where restraint is used.
If people are not listened to or given the
opportunity to have a say in their care, have
nothing to do or no-one to talk to, tensions can
rise and people may become frustrated and
distressed. Over-crowding, blanket or arbitrary
rules and restrictions, and not being able to
go out, all add to the pressure.
Reducing the use of restraint starts with getting
the quality of care right.
One time I kicked a door, a couple of members of
staff talked me down… They were reassuring and they
explained that they weren’t going to restrain me or
isolate me. They asked me what the matter was.
10 Restraint in mental health services: What the guidance says
The scale of use of restraint
In England
During the month of August 2015, in England,
there were 9600 uses of restraint reported
across all mental health trusts and 15 independent
mental health service providers. This includes
physical and mechanical restraint and rapid
tranquillisation. Of all these, 16.5 per cent (1,591)
were prone/face down restraint.
7
Physical restraint was used most frequently in
child and adolescent mental health services,
acute wards in learning disability services and
psychiatric intensive care. Face down or prone
restraint was used most frequently in child and
adolescent forensic mental health services and
psychiatric intensive care.
There were also 1,671 incidents of seclusion.
People were most likely to have been secluded in
child and adolescent forensic mental health
services, psychiatric intensive care and medium
secure learning disability services.
This and further data is expected to be published
on gov.uk and linked from the Positive and Safe
Champions web page on england.nhs.uk
In Wales
There were 382 recorded uses of face down
restraint in Wales 2014–15. The figures for Betsi
Cadwaladr and Cwm Taf were similar to the
previous year, but in Aneurin Bevan there were
more than five times as many uses reported as
the year before. Hywel Dda’s figures quadrupled
over a three year period from 10 in 2010 to 41 in
2013. They’ve also almost quadrupled over the
last two years. Cardiff and Vale health board
stopped using face down restraint ten years ago,
Abertawe Bro Morgannwg do not record the
types of restraint used, and Powys does not have
in-patient mental health services.
8
Board No. of cases
Aneurin Bevan Health Board 150
Betsi Cadwaladr Health Board 64
Cwm Taf Health Board 15
Hywel Dda Health Board 153
It takes one person to talk to you. It takes four people
to restrain you.
Restraint in mental health services: What the guidance says 11
Experiences of restraint
Poor communication
People told us that they did not fully understand
what would happen when they were admitted to
hospital, or if they said no to medication, or left
the ward. Non-verbal communication is also
powerful; an aggressive stance can strike fear
into the heart and make things worse. Good
communication and empathy are vital to help
allay fears and avoid misunderstandings.
Avoidable escalation
When the rapid response staff act energetically
or aggressively instead of behaving calmly, it can
make the situation worse. People told us that the
nurse or police team who are called to respond
to a situation on a ward will “do what they have
come to do” even if the person has calmed down.
Provocation and bullying
We heard examples of harassment and verbal
put downs, threats and provocation, bullying
behaviour and manipulation where people felt
they were being forced to be a certain way, or
being wound up. This is far from the empathy
that characterises some practice and that we
want to see everywhere. Restraint was described
as punishment for infringement of arbitrary rules.
Threats included sectioning, restraint, forced
medication and tasers. Psychological threats
included withdrawing leave or visits, that is,
without a good reason.
Making assumptions about people
Assumptions based on people’s personal
characteristics, physical appearance or past
history can have a negative influence on staff
actions and the use of restraint. For example
staff can over-anticipate and assume that
someone will become aggressive or need
medication based on a previous incident; this
doesn’t recognise that people change and
recover.
12 Restraint in mental health services: What the guidance says
Ethnicity and culture
Assumptions can also be made based
stereotypes or misunderstandings. Well-
documented cultural stereotypes and
misunderstandings persist in practice.
Gender
Both women and men may be re-traumatised by
restraint that parallels past physical or sexual
abuse. The gender of staff involved in restraint
may be relevant and make this more likely to
occur, or be worse if it does. Staff expectations
of, and responses to, behaviour may differ for
men and women too.
Aftercare
It is important that emotional support or other
aftercare is offered following times when you
have been upset or angry. People told us that
activities can be helpful distractions, such as art
therapy, relaxation, chess, drama, gym.
Post-incident review and debrief
Very few of the people we spoke to had been
offered the opportunity to be debriefed. Where
people had been approached after an incident it
was not always at the right time or done in the
right way – before the person was ready to talk,
or in a way that felt like a telling off or character
assassination.
Complaints
People told us they did not know how to
complain, did not expect to get anywhere with a
complaint or were afraid of the repercussions
when they were still in the hospital or might need
to use the service again. Advocacy is clearly
important to assist people to complain.
Restraint in mental health services: What the guidance says 15
What do people want to change?
These are things people said helped them or that they wanted to see
happen. They may help your thinking about positive changes that could
be made in your local services.
Environments and culture
• Culture of rights and positive attitude
• Acceptance of individual cultures and beliefs
• Sensitivity to people’s gender, ethnicity, age,
sexual orientations, physical health conditions/
physical, learning and sensory disabilities
• More choice of treatments and activities,
occupational therapy and alternatives to
medication and medical model approaches
Organisational responsiveness
• Management and leadership focus on
prevention
• Involving patients in service design and delivery
• Including patient perspectives in incident
reports/records
Information and support
• Mutual support from other patients
• Staff talking to you, being open and supportive
• Support from advocates and advisers
• Rights information, Mental Health Act Code of
practice on wards
• A patients’ survival guide with tips
Staffing, training and attitudes
• Staff selection, training and assessment to
include compassion and person-centredness
• Peer workers involved in de-escalation
• Training by service users
• Promoting empathy and compassion, where
staff imagine how it feels to be on the receiving
end of restraint and choose the least restrictive
option.
16 Restraint in mental health services: What the guidance says
What does the guidance say?
Positive and Proactive care: reducing
the need for restrictive interventions
This Department of Health guidance was
published in 2014. It aims to promote the
development of therapeutic environments and
minimise all forms of restrictive practices so they
are only used as a last resort. It applies across
all adult health and social care in England and
there is a two year programme called Positive
and Safe to put it into practice.
Mental Health Act Code of Practice
The Code of Practice is statutory guidance
for professionals in how they carry out their
functions under the Mental Health Act 1983,
the Act under which you can be sectioned and
detained in hospital for mental health treatment.
It was revised in 2015 and includes an updated
chapter, Safe and therapeutic responses to
disturbed behaviour.
NICE guideline on managing violence
The National Institute for Health and Care
Excellence (NICE) published updated guidance
in 2015 on Violence and aggression: short-term
management in mental health, health and
community settings. This says how staff should
work with you and how different interventions
should be used if necessary.
The guidance available
These guidance documents set out how staff and organisations should
treat you and how you should be involved. Details of where you can
access this guidance can be found in the ‘Where can I find out more?’
section at the back of this guide.
Care Quality Commission fundamental
standards
These are standards below which care must
never fall. They include procedures and
processes to prevent service users from being
abused, which includes unnecessary or
disproportionate restraint of different kinds.
In Wales
For guidance in Wales please see the Mental
Health Act 1983: Code of Practice for Wales
(2008), which is being revised in 2015/16;
the Welsh Government’s Framework for
restrictive physical intervention policy and
practice (2005); and NHS Wales All Wales
Violence and Aggression Training Passport
and Information Scheme which sets a
common standard for staff training in Wales.
The NICE guideline also applies in Wales.
Restraint in mental health services: What the guidance says 17
Physical (manual) restraint
Staff should avoid, if at all possible, holding you
down on the floor or any other surface.
9
Most
importantly, you must not be held in any way
that makes it hard for you to see, hear, speak
or breathe, or that affects your blood circulation.
This means that the person holding you shouldn’t
press on your rib cage, neck or abdomen, or
cover your eyes, ears, nose or mouth. You
should be held for as short a time as possible;
NICE says this should not usually be for more
than 10 minutes. But any restraint must always
be ended as soon as possible. One of the staff
members involved in the restraint should keep
communicating with you from before the restraint
and during it, continually trying to de-escalate
the situation.
Mechanical restraint
Mechanical restraint should only happen in high-
secure settings in exceptional circumstances. It
should only as a last resort to manage extreme
violence directed at other people or to limit self-
injurious behaviour of extremely high frequency
or intensity. The Mental Health Act Code of
Practice sets out how mechanical restraint should
be authorised, recorded, reviewed and ended.
Chemical restraint
The decision to use medication, and which
medication to use, should take your views
(including any advance statements or decisions),
your previous experience of the medication, and
any physical problems you have in to account.
Before giving an injection, staff should consider
offering a tablet instead.
Seclusion
This should only be used if you are detained
under the Mental Health Act, unless it is an
emergency. In that case it should be used for the
shortest time possible while the emergency is
being managed and an assessment for detention
should be undertaken. There are procedures in
the Mental Health Act Code of Practice on
seclusion including how it is reviewed and ended.
How staff should work with you
You should be treated with compassion, dignity
and kindness. Your human rights and personal
characteristics – gender, ethnicity, age, sexuality,
disability, or religion and beliefs – should be
respected. You must not be discriminated against
because of these characteristics, and services
should be actively shaped to suit these. You have
Key points from the guidance
Physical restraint and other restrictive interventions must only be used
as a last resort when there is a real possibility of harm if no action is
taken. The action must be proportionate to the risk of harm and its
seriousness, and the least restrictive thing staff can do. It must be
imposed for no longer than is absolutely necessary. It must never be
used to punish, hurt or humiliate.
18 Restraint in mental health services: What the guidance says
a right to follow religious and cultural practices
while in hospital.
Ward environments and culture
NICE says your ward should be as pleasant and
comfortable as possible. It should be easy to find
your way around and doors shouldn’t be locked
unless necessary. You should be able to have some
privacy, go outside and take physical exercise.
You should be able to access psychological
therapies (if suitable) and leisure activities such
as a film or reading club. Wards should not be
oppressive or enforce blanket restrictions.
Care planning and decision-making
• Anyone who could be at risk of being restrained
in a health or care service should have an
individualised support plan (sometimes called
behaviour support plans).
• Your care team should learn what triggers
these feelings for you and try to avoid setting
off these triggers. They should also encourage
you to get to know your own triggers and ways
that you can control them.
• Your care plan should include how to prevent
incidents arising, how to de-escalate or calm
things down, and how to respond safely if
incidents do still occur.
• You can include your wishes about particular
medications, what staff can do to help you calm
down or, if you need to be held, how to make
this less distressing.
10
11
Post incident reviews
• Following restraint you should always have the
opportunity to give the organisation your
perspective on what happened.
• This is so the organisation understands from your
point of view what you needed, what upset you
most, what staff did that helped or was wrong
and how things could be better next time.
• NICE says that, in addition to being debriefed,
there should also be a formal external post-
incident review led by a service user experience
monitoring unit or equivalent. This should be
done as soon as possible and no later than
72 hours after the incident.
Organisational responsibility and
accountability
Health and care organisations should have:
• Strategy for reducing restraint (see examples
on page 20)
• Clear organisational policies on restrictive
interventions, clear and accurate recording of
their use and a published accessible report that
is updated annually
• A board level, or equivalent, person with lead
responsibility for increasing individualised
support planning and reducing restrictive
interventions. The board, or equivalent, should
approve the interventions that are used by staff.
Involvement
People who use services, families and carers must
be involved in planning, reviewing and evaluating
all aspects of care and support. As well as your
individual care this includes involvement in:
• Producing policies on restrictive interventions
• Planning, monitoring and reviewing the use of
restrictive interventions and in determining the
effectiveness of restrictive intervention
reduction programmes
• Training and staff development.
Restraint in mental health services: What the guidance says 19
What good practice initiatives
are there?
No Force First
No Force First aims to change ward cultures
from containment to recovery and ultimately
create coercion free environments. This
approach, which also originated in the US, is
being adopted by some mental health trusts that
are part of ImROC (Implementing Recovery
through Organisational Change, a joint initiative
by the Centre for Mental Health and NHS
Confederation).
Positive and Safe
Champions Network
A Department of Health led network to promote
good practice and implementation of guidance.
There are resources from other initiatives on
their pages on NHS England’s website.
Around the country there are good practice initiatives where
organisations are working to minimise restraint, uphold people’s rights,
facilitate recovery and make wards calmer, safer places to be. They
mostly prioritise service user involvement and we think this is essential
to creating change. Details of these organisations can be found in the
‘Where can I find out more?’ section at the back of this guide.
4Pi National Involvement
Standards
Meaningful involvement is important because it
can transform individual lives, improve services
and build resilience within communities. The
National Involvement Partnership project, led by
NSUN and made up of mental health service
users and carers, has developed national
standards for involvement.
Motivated by the motto ‘Nothing about us without
us’, their aim was to ‘hard wire’ the service user
and carer voice and experience into the planning,
delivery and evaluation of health and social care
services. The framework is based on principles,
purpose, presence, process and impact (4Pi) and
is simply a means to enable services, organisations
and individuals to think about how to make
involvement work well.
Involvement for Influence: the 4Pi Standards
for Involvement (NSUN, 2014) is available from
nsun.org.uk or through calling 020 7820 8982
20 Restraint in mental health services: What the guidance says
PROMISE
PROMISE (PROactive Management of Intergrated
Services and Environments) is a Cambridge-
based initiative between staff and service users
that is working towards eliminating reliance on
force in mental health services globally. It was
sparked by a conversation between an expert by
experience and professional, and you can read
Sarah’s account on page 26.
RESPECT
A training approach supervised by Lincolnshire
social enterprise NAViGO Health and Social
Care. It is based on supportive de-escalation,
empowerment and physical interventions that do
not cause pain or panic. A service user group in
Sheffield (see page 22) campaigned for it locally
as their preferred alternative to control and
restraint.
Restraint Reduction
Network
TM
Restraint Reduction Network brings together
and supports organisations that wish to make
meaningful changes to the services and support
they offer, so that coercive or restrictive practices
are minimised, and the misuse and abuse of
restraint is prevented. Working towards restraint-
free services.
REsTRAIN YOURSELF
A UK adaptation of Six Core Strategies
©
,
an approach developed in the US. Run by
Advancing Quality Alliance (AQuA), it is being
trialled in eight mental health trusts in the north
west of England. It is based on evidence that
a lot of use of seclusion and restraint can be
prevented if issues like ward design, staff
numbers, poor communication and negative
behaviour by staff are addressed
Safewards
A model for making wards safer for everyone,
which includes evidence-based tools and
resources such as advice for staff on how to talk
in ways that foster collaboration rather than
confrontation, how to talk someone down, and
what calming equipment it is good to keep on
wards (such as scented pillows, blankets, music,
massage balls and ear plugs).
Restraint in mental health services: What the guidance says 21
Campaigners’ stories
A successful campaign
Maat Probe Group, who are service users based
at Sheffield African Caribbean Mental Health
Association, successfully campaigned to change
restraint practice in Sheffield. Inspired by a
speech about how to make change, they got a
grant to investigate African Caribbean people’s
experiences of mental health services. Their 2009
report Can you handle the truth showed how
much worse people’s experience was of inpatient
compared to community care, and that a lot of
people had experienced aggressive restraint.
The group set out to find a better alternative to
control and restraint. They researched different
training programmes for de-escalation and
minimising trauma and chose the Grimsby Model,
RESPECT. This is based on a philosophy of
support and empowerment and teaches prevention,
de-escalation and physical interventions that do
not cause pain or panic. They lobbied Sheffield
Health and Social Care NHS Foundation Trust
(SHSC) to adopt it and by 2013 it was being fully
implemented.
Now the group have evaluated the impact of
RESPECT in Sheffield, by interviewing people
who had been inpatients both before and after its
implementation. They found that 75 per cent of
people thought things had changed for the better.
Seventy-seven per cent had not seen the old
style control and restraint being used while 23
per cent had.
Maat Probe Group’s campaign in Sheffield
This account is based on a group discussion with Maat Probe Group
members and additional input from Kim Parker, a senior nurse in
Sheffield Health and Social Care Trust.
Speaking for the Trust, Kim Parker told us that
they learned a lot as they went along. They have
done a significant amount of work to reduce
seclusion and, while improved reporting means
that more assaults on staff have been recorded,
the severity of assaults has not increased.
Communication and relationships between staff
and patients are better. One change, popular with
patients and staff, was the creation of ‘green
rooms’ – therapeutic, safe spaces for de-
escalation – and ‘green bags’ filled with portable
items which enable staff to create a calming,
relaxing space wherever the patient may be.
Challenges
Introducing change was a slow process. The
group found it frustrating when nothing seemed
to be happening despite lots of meetings and
discussions. Kim told us that when they were
approached by Maat Probe they were keen to
look at their practices and see what they could
do differently, but it took time to get right. They
started with a thorough review before making
any changes to practice, which in itself took 18
months.
Maat Probe Group members said that at first staff
thought that the Respect approach was ‘too
gentle’; both frontline staff and trainers thought
they would be more at risk if they didn’t use
physical restraint. However staff have since
reported that Respect has positively changed
their practice and perception. In fact one
22 Restraint in mental health services: What the guidance says
challenge for the Trust is how to keep staff’s
skills in physical intervention up-to-date when
they use them so much less.
Another problem of success was that the group
got national recognition - becoming famous and
frequently cited as good practice – but not direct
action or support. Burn out and disillusionment is
a real concern when trying to change practice
within a large system.
What helped
So what helped the group’s success? First,
they used a creative approach to get people
together and sharing their stories, by holding
a BBQ with music. It was fun, but it was still
research, and using a research methodology
provided credibility – their evidence couldn’t be
so easily dismissed as ‘anecdotal’. But it was
sharing those personal stories with frontline staff
and trainers that made a powerful impact and
helped communicate what worked. And the fact
that the group had found a model – Respect –
that embodied what they wanted to achieve,
meant they had a compelling solution that they
believed in.
Support from within the group, the grants
programme, the service user group in Grimsby
who helped develop the model, and Sheffield
African Caribbean Mental Health Association all
enabled the group to achieve what it has today –
individually and together.
Maat Probe members recommend persistence,
perseverance and keeping the common goal in
mind.
Next steps
The group is now working to get Respect used
nationally, to secure further funding for their
group, and to have their findings and
recommendations taken forward in Sheffield and
in national policy. They are working towards
helping the police to improve their good practice
with service users.
Maat Probe
‘The group chose its name from our ancient
Egyptian heritage. As an African Caribbean
service user group we found trying to
campaign for better practice in services can
be a discouraging experience. The group was
told in the early days by someone “be careful
not to bite the hand feeds you”. As a group part
of our development we watch videos and read
Afro-centric perspective on combatting and
understanding racism. We do this to keep us
strong so that we can be unapologetic when we
work to change the continuing poor experience
many of us have experienced going back many
decades. We have drawn strength from our
culture and heritage to campaign for best practice
ultimately for all mental health service users.
Truth and justice are universal human needs.’
Restraint in mental health services: What the guidance says 23
Campaigning on the use of seclusion and restraint in Derby
Niki Glazier tells the story of Derby Mental Health Action Group’s
campaign and Carolyn Green shares a view from the Trust.
Involvement in monitoring and review
The trust established a Seclusion Project Group
which we and another Derbyshire service
receiver group attended regularly. It was a long
journey with many obstacles and hindrances but
our continued presence helped to urge them on
and reassured us that progress was being made.
Through that group we were able to monitor the
numbers of seclusion in significant detail –
gender, age, ethnicity, point of hospital stay,
triggers to seclusion incidents etc. We were
able to ask questions about how lessons were
being learnt and applied from the reviewing of
seclusion incidents especially from the patient
perspective. It was certainly clear that in some
cases an earlier therapeutic intervention may
well have prevented the situation escalating into
restraint and seclusion. All of this information
was vital for the trust to work out new initiatives
in patient care.
Winning hearts and minds
We were also commissioned by our healthcare
trust to produce a DVD of our members’
experiences of seclusion. This was filmed and
produced by two of our members who then
interviewed others about their experiences. It
resulted in a very powerful tool which will be
used in future staff training both as a reminder
of the damaging effects of seclusion and to
reinforce the commitment to work in more
proactive and therapeutic ways. This is
Being heard
Back in 2011 we became aware of some very
harrowing experiences that our members had
gone through as a result of being secluded. Such
was its impact on us that we knew this voice of
experience had to be heard and our role was to
make sure it was heard in the right places. We
approached the General Manager of our local
mental health trust who we knew to be sympathetic
to the experience of our members. A meeting
was set up with him, being careful to ensure
support for those sharing their very personal
experiences of seclusion.
We discovered that this was fortuitous timing
as the trust had just recently commissioned an
internal survey of nurse practice and patient
experience in relation to seclusion and restraint.
This work had confirmed their increasingly
uneasy feelings about seclusion, concluding that
in some instances, at least, it probably was or
should have been avoidable. They were keen
to explore a better way forward.
Being able to listen first hand to the patient
experience – how it had felt to be in their
shoes before, during and after the experience
of seclusion – clearly impacted the General
Manager greatly. It drew a line in the sand
and from that point onward we saw a resolve
at the most senior level to tackle the use
(and potential abuse) of seclusion.
24 Restraint in mental health services: What the guidance says
something we would highly recommend in
winning hearts and minds.
A key factor in enabling progress was getting
the ward staff themselves on side, reassuring
them that the trust at the most senior level would
support them as they adjusted to the closure of
seclusion rooms. We found that the importance
of this can easily be underestimated. Ensuring
that a cohesive message of support was sent
all the way through from senior and middle
management was vital.
Practical progress
Seclusion rooms were gradually re-furbished to
provide de-escalation/relaxation areas and new
policies were developed around safety and care.
Another crucial step forward was for the Trust
to host a presentation to staff of The Safewards
Project (safewards.net) led by Len Bowers and
subsequently to embrace the Department of
Health‘s Positive and Proactive Care initiatives.
They are just about to publish their own Safe and
Positive Policy which sets out very clearly the
need for change and acknowledges that the
driving force has been the shared experiences
of their customers. Service receiver groups such
as ourselves have been invited to sit on their
Safe and Positive Steering Group whose role
will be to ensure that all the necessary initiatives
and changes are driven forward.
At the point in time at which I write this piece
our local trust has closed all its seclusion rooms
apart from two remaining rooms on the Enhanced
Care Ward. For the time being it has been felt
necessary to retain these seclusion rooms for
use in only the most extreme circumstances.
However we have seen a very considerable drop
in the use of seclusion overall. As the Safe &
Positive policy rolls out who knows where it can
take us in the future.
Thanks to people sharing painful
experiences
We, in Derbyshire, continue to face enormous
challenges caused by funding deficits and the
effects of the plethora of legal highs available on
our streets. We will not deny that the journey so
far has been very slow and frustrating at times
but we have crossed an important line in relation
to seclusion. That has only been possible
because some extremely brave people have
shared their own very painful experiences
including past life traumas which had been re-
triggered by the use of seclusion and restraint.
Our admiration and grateful thanks goes to them.
Niki Glazier, Co-ordinator,
Mental Health Action Group (Derbyshire)
Affiliated to Derbyshire Mind
Working to get it right
As a nurse and a health professional when
I hear that seclusion is in use I have very mixed
reactions. Restrictive practices, both restraint and
seclusion, do not sit comfortably with many staff
who work in mental health. I often think that at
a point in the future we will look back at our
care provision and be ashamed; I am sometimes
now, I am continually very torn. How can it be
therapeutic to place a person in a locked room on
their own? I am not alone in these thoughts in my
organisation. We want to dramatically reduce the
use of seclusion and restrictive practices. One
day I hope we will get to a place that seclusion
is not used and that everyone who leaves our
wards and bed-less services says ‘you got it
Restraint in mental health services: What the guidance says 25
right’. We are not there yet. But one day I hope
we will be. I believe where this is a will there is
way. We have the will; we have to keep making
our way. It’s hard and we have had bumps in the
road in reducing restrictive practices, we will
have more, but we will dust ourselves off and
keep going. We would not have come so far
without our colleagues and our services are
PROMISE: (PROactive Management of Intergrated Servives
and Environments) – Spark to a Flame
Sarah Rae describes what she did to instigate change in her Trust and
how the initiative she jointly leads is developing locally and globally.
fundamentally better with their expertise. My
admiration and grateful thanks goes to Mental
Health Action Group and to those individuals
who are helping us to get it right.
Carolyn Green, Director of Nursing and
Patient Experience, Derbyshire Healthcare
Foundation Trust
Force is incompatible with a vision of recovery.
This belief forms the foundation of PROMISE, a
new initiative aiming to eliminate reliance on force
in mental health services. Begun in Cambridge,
it is now a global alliance between Cambridge,
Yale, Prague, Brisbane and Cape Town. And
it all started from a conversation, a conversation
between an expert by experience (myself) and
a professional (Dr Manaan Kar Ray).
Reading Mind’s 2013 campaign report about
physical restraint made me wonder what my local
NHS trust was doing to reduce restraint. So I
approached Manaan (who is a Clinical Director
within Cambridgeshire and Peterborough NHS
Foundation Trust) to find out.
Until then, I’d only know Manaan from a distance,
but I knew he was a keen proponent of recovery
and that shifting the balance of power between
patients and professionals was close to his heart.
By the end of our meeting we were discussing a
possible research bid to explore staff and patient
experiences of physical restraint, and their
suggestions for reducing restraint and promoting
proactive care.
In the coming months Manaan and I established a
working group, secured funding and co-authored
a story ‘Navigating Rocky Waters’ to capture the
imagination of the workforce. We involved
frontline staff and service users in steering the
project, which taps into the innovation that exists
within staff but is rarely called on. This has
enabled us to list over 200 initiatives over the last
year, which we are turning into a PROMISE
toolkit. They include:
• Tea and toast evening reflection group for staff
and patients to talk about their day and get rid
of any frustrations before going to bed.
• Open Door is a shared agreement between the
assessment unit and patients with severe
26 Restraint in mental health services: What the guidance says
personality disorder which allows them to
request a 2 night admission when needed.
• Comfort in a box where people are supported
to make their own box of things they personally
find comforting and soothing
• ‘No’ audit where staff reflect whenever they
say no to a patient, to see if they can reframe
and find a way to say yes.
The fact that the PROMISE project is co-led by a
psychiatrist and someone with lived experience
has had a tremendous impact on staff and
management. It has enabled us to influence policy
and practice in a way that I could never have
done as a lone campaigner. Looking back I feel it
is important to put thought into who to approach.
The person not only needs to have influence
over services but also must have a passion for
the kind of change you want to make. In my case
I was pushing at an open door.
My advice to anyone who is thinking about
approaching an organisation is to do their
homework first and then give it a go because
you never know what might transpire and every
patient can be a catalyst for change.
Restraint in mental health services: What the guidance says 27
Briefing on
Positive and proactive care:
reducing the need for restrictive intervention
Mental Health Network NHS Confederation with
the Care Quality Commission, 2014
nhsconfed.org
NHS Confederation 0870 444 5841
Safeguarding service users from abuse and
improper treatment
Health and Social Care Act 2008 (Regulated
Activities) Regulations 2014, Regulation 13
Care Quality Commission Fundamental Standards
Available at: cqc.org.uk
Meeting needs and reducing distress:
management of clinically related challenging
behaviour in NHS settings
NHS Protect, 2014
Guidance, information and training resources
nhsprotect.nhs.uk/reducingdistress
Guidance in Wales
Framework for restrictive physical
intervention policy and practice
Welsh Assembly Government, 2005
gov.wales
All Wales Violence and Aggression Training
Passport and Information Scheme
NHS Wales, 2004
wales.nhs.uk
Where can I find out more?
Mental health organisations
Mind
mind.org.uk
020 8519 2122
Mind Infoline - 0300 123 3393, text 86463
9am to 6pm, Monday to Friday except bank holidays
Mind Legal Line - 0300 466 6463
9am to 6pm, Monday to Friday except bank holidays
National Survivor User Network (NSUN)
nsun.org.uk
020 7820 8982
Guidance in England
Positive and proactive care: reducing the
need for restrictive interventions
Department of Health, 2014
gov.uk
Department of Health, Richmond House,
London SW1A 2NS
Mental Health Act 1983: Code of Practice
Department of Health, 2015, The Stationery Office
Available at: gov.uk
Order from the TSO on 0870 600 5522
A positive and proactive workforce: A guide
to workforce development for commissioners
and employers seeking to minimise the use of
restrictive practices in social care and health
Skills for Care, Skills for Health and Department
of Health, 2014
skillsforcare.org.uk
Skills for Care 0113 245 1716
Skills for Health 0117 922 1155
28 Restraint in mental health services: What the guidance says
Mental Health Act 1983: Code of Practice
for Wales
Welsh Assembly Government, 2008
wales.nhs.uk
Copies from mentalhealthandvulnerablegroups@
wales.gsi.gov.uk
Currently being revised.
Enquiries about these publications:
0300 0603300 (English), 0300 0604400 (Welsh).
Guidance in England
and Wales
Violence and aggression: short-term
management in mental health, health and
community settings
(NICE guideline NG10)
National Institute for Health and Care
Excellence, 2015
nice.org.uk
NICE 0300 323 0140
Good practice initiatives
4Pi National Involvement Standards
National Survivor User Network (NSUN)
020 7820 8982
nsun.org.uk
No Force First
ImROC
c/o Mental Health Network NHS Confederation
020 7799 8702
imroc.org
Positive and Safe champions network
england.nhs.uk
PROMISE
www.promise.global
07519 735137
RESPECT Training Solutions
NAViGO
respecttrainingsolutions.co.uk
01472 583030
Restraint Reduction Network
TM
restraintreductionnetwork.org
0161 929 9777
REsTRAIN YOURSELF
Advancing Quality Alliance (AQuA)
aquanw.nhs.uk
0161 206 8938
Safewards
The Section of Mental Health Nursing,
PO Box 30, David Goldberg Building,
Institute of Psychiatry, De Crespigny Park,
Denmark Hill, London SE5 8AF
safewards.net
Restraint in mental health services: What the guidance says 29
Endnotes
1. Mental health crisis care: physical restraint in
crisis, Mind 2013
2. Positive and proactive care, Department of
Health 2014
3. Monitoring the Mental Health Act in 2013/14,
Care Quality Commission 2015
4. Monitoring the Mental Health Act in 2014/15,
Care Quality Commission 2015
5. Skills for Care and Skills for Health (2014)
A positive and proactive workforce
6. Based on the definition in the Mental Health
Act Code of Practice
7. Department of Health communication about this
NHS Benchmarking Network data, 2015
8. Taken from responses to a Freedom of
Information request by Mind Cymru.
9. Positive and proactive care says that prone
restraint (face down on your front) should not be
used deliberately. The Mental Health Act Code of
Practice and NICE both strongly advise against it,
but allow it.
10. Read about people’s experiences of the Care
Programme Approach in Gould, D. (2012) Service
Users’ Experiences of Recovery Under the 2008
Care Programme Approach, London: National
Survivor User Network and Mental Health
Foundation nsun.org.uk/about-us/our-work/cpa-
and-recovery/
11. You can plan for future care through advance
decisions and advance statements – mind.org.uk/
information-support/legal-rights/mental-capacity-
act-2005/advance-decisions/#nine
30 Restraint in mental health services: What the guidance says
Please let us know whether you have used
this report and if you found it helpful.
For enquiries about this publication or
feedback, please contact our Policy and
Campaigns team:
020 8519 2122
mind.org.uk
@mindcharity
mindforbettermentalhealth
This information was written and produced by Mind’s
Policy & Campaigns team in partnership with the
National Survivor User Network
Published in 2015 © Mind 2015
To be reviewed in 2019
