‘Early impressions are that these initiatives help place the importance of psychologically driven care in a more central position.’

In 2015, the Mental Health Act Code of Practice prompted mental health services to commit to reducing restrictive interventions. These interventions include the use of restraint, seclusion and rapid tranquilisation, but also wider practices, for example imposing blanket bans that restrict a person’s liberty and other rights, such as stopping them from accessing outdoor space.

The Care Quality Commission’s (CQC) report on the ‘State of Care in Mental Health Services 2014 to 2017’ highlighted concerns that care for some patients was overly restrictive. In December 2017 the CQC published an informative document ‘Mental Health Act. A focus on restrictive intervention reduction programmes in inpatient mental health services’.

The Reducing Restrictive Practice (RRP) collaborative is part of a wider Mental Health Safety Improvement Programme (MHSIP) which was established by NHS Improvement (NHSI) in partnership with the Care Quality Commission (CQC) in response to a request made by the Secretary of State. The aim of the RRP is to reduce restrictive practice by 33% by April 2020 (measured by number of restraints, seclusions and rapid tranquilisations) in the wards that are selected to take part. Clinical psychologists have been asked through ACP-UK to support that programme.

The programme website provides a wide range of relevant materials. Many of these refer implicitly, but rarely explicitly, to the use of psychological techniques and procedures. They are largely whole-system change programmes shared by all staff and some of them have been co-produced with experts by experience to promote a therapeutic milieu and a caring response to distress. They include de-escalation of tension to prevent violence, positive behaviour support, improvement in communication between staff and patients, increasing activities, a sleep hygiene project, reflective practice in supervision and blame-free debriefings following restraint incidents.

This is an initiative which clinical psychologists working in psychiatric in-patient settings will of course wish to support and many of us are involved in leading these initiatives. The everyday experience of those of us working in these acute psychiatric ward settings is largely of staff of all professions pulling together to provide the best quality of care to our clients. Our experience also reminds us of some reasons for the high levels of disturbance, which are sometimes managed as a last resort by restraint and time-limited seclusion for the safety and dignity of all.

Increasingly over the past decade attempts to drive down costs have motivated significant reductions in bed numbers nationally and an emphasis on very short lengths of stay, leading to an increase in the concentration of severity on the wards as only the most at-risk patients are admitted. Those clients admitted under duress or continuing to cope by the use of street drugs are sometimes unable to engage easily in the therapeutic endeavour within their time frame as inpatients. This is not generally mitigated by priority routes to timely and high-quality therapy in the community, and the rapid turnover of highly disturbed patients makes it more difficult to provide a relaxed and therapeutic intervention during admission. Levels of nursing, psychology and psychiatry staff are thinly stretched, making it difficult for staff to be released for psychological supervision despite their enthusiasm to develop these skills. If these difficulties are to remain fixed whilst these wards are under-resourced and recruitment problems persist, it is more important than ever to use whatever means we have to draw attention to the need of our patients for humane and compassionate care, and the right of our staff to safe and pleasant work environments, and we are keen to continue to apply our psychological skills in supporting these developments.

Early impressions are that these initiatives help place the importance of psychologically driven care in a more central position. Staff are beginning to value and use the language of psychological formulation. In addition psychologists have been able to use focused teaching sessions as a vehicle to introduce trauma-informed care, reinforcing the message through example in working together with multidisciplinary colleagues, which goes some way towards compensating for there being insufficient time for staff to attend targeted supervision or to spend the extra time required for delivering psychologically informed interventions.

Staff appreciate the hopeful message about the potential of clients to respond positively to empathic care, which may in turn reduce patients’ level of distress and the prevalence of aggression. They also value the support of the organisation when it endorses zero tolerance of violence towards staff and supports them to reinforce boundaries by escalating assaults by clients with capacity or insight to our police colleagues. This touches on the sensitive question of how we judge the level of responsibility of our clients for any violent actions whilst under mental health care and exposes different standards between our caring agencies. For these reasons the focus that this initiative brings to the whole issue of responsibility, violent behaviour, the potential for deescalation and the place of forcible restraint and seclusion periods, is welcome. It is important to make this work, not least for the sake of staff morale and the retention of staff willing to work in such challenging environments.

It will also be important to be clear to frontline staff that we neither hold them responsible for these high levels of patient distress, nor do we expect such changes in staff practices around restraint to compensate fully for the effects of the growing discrepancy between high levels of need and the resource available to provide high quality mental health care. The concentration of patients at only the greatest levels of risk and distress combined with low levels of staff and frequent patient turnover rates poses unprecedented challenges to maintaining a therapeutic ward environment. Short lengths of stay are appropriate if and only if there is onward, seamless progression to community therapy and support, but this is typically no longer the case. Some clients are less able to engage in therapy than others, and will require supported living arrangements after discharge. But this is a further squeezed resource which often leads to frustration, delayed discharges and the need for readmission, again in distress that requires further deescalation. It is therefore evident that, in addition to participating in initiatives such as this, we need to appraise the issue of restraint in our inpatient services within the wider context of the role and function of wards in service provision as a whole. The onus will then be on us as one of the multiple provider professions to engage in dialogue with the commissioners of services and professional training numbers, to determine and provide the quantity as well as the quality required.

The author is a Consultant Clinical Psychologist but to prevent identification of the sensitive resource issues with any individual NHS trust they choose to remain anonymous.