Andrew Hider is a consultant clinical and forensic psychologist and approved clinician. He currently works as clinical director for Ludlow Street Healthcare in Cardiff. For 22 years he has worked solely in services for people with severe and complex mental health problems, with and without associated neurodevelopmental conditions and forensic histories. He currently provides clinical services for people in both inpatient and community social care services.

Reducing Restrictive Practice – the Role and Contribution of Clinical Psychology

The recent focus on systematic operational change in the mental health system using legislative and regulatory levers (Department of Health, 2014) to reduce the use of restrictive practices such as restraint and seclusion – particularly restraint and seclusion – is clearly welcome (Department of Health, 2014).  This article does not aim to discuss these changes in detail – the interested reader can find a helpful overview here. Rather, this article will attempt to address the issue of the specific contribution and role of clinical psychology in both the development and implementation of the recent changes. It will address the question of why the profession of clinical psychology has lacked visibility as a leader of policy and statutory change in this area, despite many of the recommended interventions deriving from an essentially psychological evidence base. Suggestions are also made as to how psychological science can support successful implementation of new models of care. .

Clinical Psychology – Identity, Structure and Focus

The history of clinical psychology as a profession is well documented and shares with psychiatry a history of theoretical diversity. This is unsurprising given that the human mind and human behaviour is not fully understood. Independent of this theoretical diversity however is the core empirical commitment to apply the science of psychology to clinical problems in the service of improving quality of life. This is probably the only area of consensus identity within the profession.

In relation to the matter of the application of psychology to human systems and to clinical problems, the profession has arguably splintered in terms of its structure and focus. With perhaps particular relevance to the current issue of approaches to ‘challenging behaviour’, this splintering can be observed in the stance towards behaviourism, which has varied dramatically across subspecialisms. Specifically, the learning (now intellectual) disability specialism has maintained a focus on the use of technical behavioural interventions to drive both individual and systemic interventions. This work has informed and has been a substantial intellectual driver behind much of the current policy and legislative agenda in relation to restrictive interventions eg. see  Allen et. al. (2005)

Conversely, the adult specialism has, arguably, increasingly moved away from technical behaviourism, both in terms of the widespread of adoption of cognitive therapies but also more recently in the growing influence of social constructionism with its privilege of subjectivism and of issues of identity and meaning. The corollary of this move has in the case of the former, been a focus on individual therapy (Layard and Clark, 2015). In the case of the latter we have seen an increased focus on and interest in political and sociological analysis (eg Smail, 2015). In keeping with these developments, in the case of the former, organised clinical psychology has (successfully) focused on policy developments that have made the provision of psychological therapy in the UK the focus of international attention as an exemplar of the delivery of evidence based approaches to psychological health at scale. In the case of the latter, the profession has focused on challenging medical paradigms of psychological distress and in response has attempted to systematise one of the profession’s core and formative activities (psychological formulation) around a new framework (Johnstone and Boyle, 2018). The merits of both areas of focus are the subject of ongoing debate within the profession. Alongside these foci, the involvement of clinical psychologists and structure of clinical psychology in secondary care and inpatient provision has received less attention within the profession. Given that this area supports people with the most severe distress and where a psychological approach may have substantial benefits in reducing harm and supporting efforts to reduce restrictive practice, it is arguably time for us to be more visible.

Alongside these developments, the ability of the profession to influence operational function and strategy in some areas of the NHS has been impaired due to the relative weakness of the profession in maintaining its structure during a time of severe financial constraint. This has resulted in a diminution of senior, operational leadership posts in the profession, both at trust / health board level but also in national mental health roles. This has occurred in the context of mental health as a whole being historically marginalised in the health service (although recent changes here are encouraging). Such an environment has compromised the ability of a relatively small, mental health specific, profession, to assert its own deployment so that services derive full benefit of the training of its practitioners. Consequently, the deployment and influence of the profession in many areas where it could potentially improve outcomes, user experience, and costs, has continued to be frustrated (and frustrating). For example, the ongoing fact that the profession is consistently oversubscribed, while the system is simultaneously straining under workforce shortages in other professions, remains curiously neglected by policy makers as a potential solution to the mental health workforce crisis. However, despite these headwinds, clinical psychology is not that small and for its size and the extent of training of its practitioners, it is arguably underperforming in terms of its societal influence. We need to look internally as well as externally in order to understand this.

Clinical Psychology and the Six Core Restraint Reduction Strategies

A positive take on the above would laud clinical psychology for its epistemological diversity. A more skeptical take would be that in our diversity we risk becoming incoherent, in retreat from our central science (i.e.: the science of human behaviour) and therefore less able to speak with a unified voice. A balanced position is that it is time to reorient ourselves to the task of helping to solving problems in the health and social care system, many of which at root are influenced by human behaviour. The current social and policy movement, broadly centred around restraint reduction and person centred care in inpatient settings for all client groups is an arena where we really should be pulling our weight.  However, we need influence (and allies)  in order to be able to do this. We may benefit from starting by strategically supporting the six ‘core’ restraint reduction strategies (Wieman, Camacho-Gonsalves, Huckshorn, & Leff, 2014; Restraint Reduction Network, 2016). These are helpful in supporting service to orient themselves around quality improvement in those areas that evidence suggests can effect reductions in the use of restraint and other restrictive practices. It seems important for us to attempt to articulate how the specific skills of clinical psychologists can help services – their users and our multidisciplinary colleagues –  achieve their aims. Connections between the remit of clinical psychology and the six strategies are discussed here in turn:

Leadership Supporting Organisational Change

Clinical Psychology has a strong history of analysing the psychological underpinnings of successful leadership (Division of Clinical Psychology, 2010), and has contributed to policy and practice developments in these areas (Department of Health, 2007). Its role as a core NHS discipline, its practitioners trained and schooled in NHS practice, should serve it well to support the kinds of leadership that any large scale improvement requires. In particular, recent developments in the literature on the critical role that psychological safety has in supporting reliable healthcare systems and improving patient safety (e.g. Edmondson & Lei, 2014), require continual championing by clinical psychologists in both general practice and formal leadership roles. The profession needs to step up its use of evidence to advocate for its practitioners having access to leadership roles from which we are still on occasion excluded, as a result of national and/or local politics and policy. Recent research into improved outcomes in services where clinical psychologists act as approved clinicians provides a good example of this kind of evidence (Ebrahim, 2018). It is not enough to assert our entitlement to these roles on the basis of qualification: we need to provide evidence of value. Delivery of the outcomes required by the restraint reduction agenda also requires diverse leadership, from multiple perspectives and disciplines, and from traditional hierarchical management to day to day practice leadership. We need to be flexible in response to these demands.

Using Data to Inform Practice

Doctorally trained Clinical Psychologists should all be proficient in quantitative data analysis and the design of quantitative data sets. Many should also have advanced skills in qualitative methodology. A key rationale for the doctoral level training of clinical psychologists is the level of skill they acquire in research and the scientific method generally. A consequence of this high level training is that clinical psychology should essentially be seen as a thousands strong ‘go to’ resource for advice on data driven service evaluation and appropriate analytic approaches to quality improvement and reduction in restrictive practice. In order to fulfil this, the profession should increase its communication to wider stakeholders of the specific training of clinical psychologists in this area. We are, too often, still seen as therapists only and commissioned accordingly.  Further, one consequence of the partial scientific retreat of the profession referred to above is that sometimes, quantitative data analysis can be marginalised as a ‘hard skill’, and devalued in the profession itself. In fact, rigorous and accurate data analysis is critical to the safety of human systems and in this instance, in the monitoring of the use of restrictive practice and the effectiveness of interventions designed to reduce its use. We ill serve the systems in which we work if we downplay or minimise the degree to which data analysis is a part of the clinical psychologist’s skill set.

Workforce Development

Anyone with even cursory involvement in HR processes and professional literature will be aware of the extent to which psychological concepts and research shape discussions in the field (e.g. Guest, 2017). Yet despite clear evidence of the extent to which recruitment and management practice and behaviour inform and influence the values and behaviours of direct care staff, the system remains troubled by frequent examples of poor management culture and inadequate focus on staff supervision and support. Psychologists are all specifically trained to understand the relationship between human capabilities and work performance and, particularly, how performance is influenced by emotion. The degree of emotional labour required of staff working in environments most vulnerable to the use of coercive and restrictive practice is profound  (Mitchell, G., & Hastings, R. P. (1998), Whittington & Burns, 2005). Restricting the deployment of clinical psychologists to the provision of direct therapy in the presence of such pervasive psychological stressors in the systems in which they work risks wasting resource. People using services will not improve in environments staffed with people whose stress is such that they cannot pay mind to the needs of those in their care, even if the system is delivering the best, high quality evidence based individual treatments available. The consultation and supervision role of the profession requires greater focus, and professional guidelines need to be updated to provide a more evidence based structure to such work, and to provide guidance on the WTE allocation that should be given to such work for clinical psychology posts in these environments.

Use of Seclusion/Restraint Reduction Tools and Technologies

Any retreat from science will necessarily reduce the profession’s focus on the development and use of formal measurement tools. Standardised measurement, and the operationalisation of psychological and behavioural phenomena to allow their measurement, is formative to clinical psychology and remains fundamental to a large body of clinical psychology research and practice. Ongoing support for this area of practice would be advisable – the evidence is that in healthcare settings standardisation generally improves patient safety (Rozich et al., 2004) and the use of standardised tools is effective in measuring components of clinical environments that require monitoring if restrictive practice reduction is to be achieved (Vojt, Marshall, & Thomson, 2010). Such tools are also invaluable in supporting clinical triage and clinical prioritization, which is clearly important given the significant patient safety implications of the use of restrictive interventions. Given its foundation in the operationalization and measurement of behavior, Clinical Psychology should be at the forefront of the development of standardised measures – the absence of a number of which has been highlighted in recent research in the area of restraint reduction (Tölli, Partanen, Kontio, & Häggman-Laitila, 2017). This core strategy is also an area where clinical psychologists could most effectively work alongside nurse leaders to help develop metrics, measures and appropriately designed clinical tools that can be deployed to support and evaluate restraint reduction interventions.

Service User Involvement in Inpatient Settings

One great strength of the profession in recent years has been the increased visibility of psychologists working in adult mental health care as supporters and enablers of service user involvement. Recent policy change is probably in part a byproduct of what has become an important social movement driven by the voices of service users and carers (Mind 2013). The profession has a strong history of this kind of work: the role of psychologists in the learning disability specialism in the social role valorisation movement in the 1970s (Wolfensberger, 1983, 2011) and in the promotion of positive behaviour support (Lavigna, Willis and Donovan, 1989; Allen and Felce, 1999) as a vehicle to support both restraint reduction, quality of life improvements and person centred care, has been substantial. Arguably, this has resulted in systemic impact in that, in the author’s experience, learning disability clinical environments are not subject to the same degree of epistemological conflict about the importance of trauma informed, person centred and psychologically informed care as their mental health equivalents (although as with all such environments, delivery often lags behind will). The profession clearly needs to maintain and increase its advocacy and organisational support for service user involvement and, increasingly, service user control, over service provision. This is a good in itself, but it is unsurprising that the power dynamics operating in environments where coercion is used underpin many incidents that result in the use of restraint and other forms of restrictive practice (e.g. see Duxbury & Whittington, 2005). Clinical Psychology will achieve these aims more effectively if its practitioners are able to influence decision making, since despite this vocal support for values driven, person centred services, reality often outstrips the rhetoric increasingly spoken by organisations across the health and social care space.

Debriefing Strategies

Debrief following incidents involving restraint, for both service users and staff,  has been identified as a key performance marker for services that successfully work at reducing the use of restraint (Mangaoil, Cleverley, & Peter, 2018). Effective post incident debrief requires the deployment of both interpersonal/ relational and technical/procedural (perhaps better described as ‘hard’ and ‘soft’?) psychological skills. The learning approach that this core strategy depends on is strongly dependent on a systematic approaches to understanding behaviour. Understanding behaviour requires the use of (among other things) functional analysis, again a formative skill of the profession. In recent years, however, it may be that technical behavioural intervention has been underplayed as a core skill within the profession, sometimes due to (in the author’s view, intellectually incoherent) concerns that a behavioural approach is in some way intrinsically suspect from an ethical perspective, or incompatible with a (insert preferred brand) psychotherapeutic approach. This typically stems from the characterisation of behavioural approaches as involving crude ‘punishment and reward’ analyses alone, or of having a mechanistic and impersonal view of human beings. In fact, the development and application of non-aversive behavioural approaches has gone hand in hand with the emerging narrative of person centred and values based practice in clinical psychology  (Division of Clinical Psychology, 2018).

Misapplied or high duration restraint can have negative (and sometimes, catastrophic) consequences for service users and staff. Individualised functional analysis has a key role in helping formulate interventions designed to reduce the occurrence of restraint. All clinical psychologists should be equipped with a sound understanding of the clinical applications of behavioural theory, of the use of behavioural assessment tools, and have the ability to ethically implement behavioural interventions,  based on empirically derived functional analysis. These are sometimes seen as core skills of practitioners only in the learning disability (and perhaps older adult) specialisms, but, particularly given the policy focus on the use of positive behavior support across all inpatient clinical settings in which the profession is deployed, the competencies are now relevant for all specialisms. This should not be an optional skill set : information obtained from incident debrief is information that supports functional analysis and thereby can be used in intervention design. In fact, debrief itself is, in large part, substantially about evaluation of psychological intervention by service users and staff  : What were we supposed to do/say? Howe were we supposed to do/say it? Why? Did we do it? If not, why not? Did it help? If not, why? Supporting efficient feedback loops from debrief, into behavior support plans is an obvious area in which clinical psychologists can support the effective use of debrief following incidents where restraint is used.

Such an emphasis on technical skill is wholly compatible with equivalent use of psychotherapeutic skills to support emotional resolution of both service users and staff after adverse incidents in inpatient settings. We have to do, and be proficient in, both, and we shouldn’t have the choice of being proficient in one or the other.

A seventh core principle? Human factors and mental health settings

The use of human factors research increasingly plays a significant role in service delivery, quality improvement and process design in physical healthcare (Care Quality Commission, 2018),  but has received little attention in the area of psychological and behavioural healthcare outside of the incorporation of attribution theory (e.g. Markham & Trower, 2003). Clinical integration of human factors research is particularly important since, increasingly, clinicians are responsible for designing interventions delivered by others – often unqualified support staff – and training them to do so. Much of the research and practice guidance in the broad areas connected to restraint reduction:  positive behaviour support, trauma informed care, and debrief, are heavily reliant on supporting staff to implement interventions based on a psychological understanding of behaviour in context, in order to support a psychologically informed environment (Johnson & Haigh, 2010).

The behavioural literature speaks about the dangers of separating psychological technology from the values and motivators of people delivering care (Tharp and Wetzel 1969). Successful implementation requires support for and belief in the explanatory models that are used to help understand behavior and distress. It may be that there are cognitive factors intrinsic to human psychology that are likely to influence staff’s ability to engage with and apply the principles of psychologically informed care, and that failure to acknowledge these can be instrumental in causing service delivery failure, staff – service user conflict and low service user and staff satisfaction. This in turn can have a significant impact on patient safety. There is a strong tradition of this kind of analysis in the learning disability specialism (e.g. Oliver et. al. 1996), and it would be fruitful for these understandings and findings to be applied by clinical psychologists working in mental health settings in their work towards delivery of trauma informed care and psychologically informed environments.

Further, the scientific understanding and application of findings from cognitive psychology, particularly Kahneman’s (2012) two system model of human cognition, may support a connected theoretical account of the human factors issues connected to the delivery of psychologically informed care. Psychologists could use this understanding to make practical suggestions in the areas of service and training design, ergonomics of materials and technology, team functioning and leadership that might minimise risks stemming from these unavoidable human factors. This may be more fruitful than objecting to the failure of systems to, with full commitment, come round to our way of (psychological) thinking.

As a profession we should, rather, argue for an increased focus in mental health services on the use of the human factors literature in the design, prescription and communication of psychological interventions delivered by direct care staff. The core argument here is that psychological thinking is hard, and effortful and in many ways counterintuitive and ‘unnatural’- people generally prefer stable, internal, simple, low effort explanations over contextual, external, complex, effortful explanations for behaviour.  This construal explains empirical findings such as those of Cottle et. al. (1995), who found that staff made internal explanations for violent behavior in inpatient settings.  This preference may be fundamental to human reasoning, and understanding the kind of training and practice leadership that minimizes harm stemming from these psychological factors is of critical importance.

Consideration of these intrinsic barriers to psychological thinking becomes more important as the complexity of distress within a mental health service increases, and the emotional load on us ‘shuts down’ our capacity and time to think. It is an empirical, psychological, question as to whether these factors underpin the ongoing difficulties in widespread adoption of psychologically informed practice in mental health inpatient settings, and in the persistence of coercive practice despite the regulatory and statutory push. Given the human costs, though, the urgency to effect improvement and to understand why psychological approaches often fail to achieve traction, is great.

Conclusion

Finally, the open and welcome focus of our multidisciplinary colleagues on psychologically informed care means that, in this domain, we are truly pushing on an open door. For example, the restraint reduction network has in January 2019 published in partnership with Health Education England a draft training manual designed to support the integration of the 6 core principles into training (Restraint Reduction Network, Ridley, & Leitch, 2019). It is therefore in this area – working with the psychology of psychological care delivery, and supporting systems to work with this in mind, that we may be able to make our most distinctive contribution. We are more likely to be able to do this if we are able to support and help to deliver standardised and measurable approaches to the operational delivery of mental and behavioural healthcare across all specialisms in which clinical psychology is deployed. We need to nest our work in a coherent professional identity and ensure that others are aware of what we are trained and skilled to deliver and support. Standardisation and measurement of the general process of care delivery is not incompatible with person-centred approaches. To the contrary, it should be seen as supporting their effective delivery.  Therefore, nested in such systems has to be a commitment to individualized clinical psychological care and treatment, delivered by clinicians who are at once technically competent, systemically aware, evidence directed and evidence generating.

Thanks to Dr Andrea Davies, Dr Hayley Thomas, Dr Vaughn Price and Dr Fiona Pipon-Young for comments and suggestions on the first draft of this blog.

References

Allen, D. & Felce, D. Service responses to challenging behavior (1989). In: Psychiatric and Behavioural Disorders in Developmental Disabilities (ed. N. Bouras), Cambridge University Press, Cambridge.

Allen, D., James, W., Evans, J., Hawkins, S., & Jenkins, R. (2005). Positive Behavioural Support: Definition, Current Status and Future Directions. Tizard Learning Disability Review, 10(2), 4–11.

British Psychological Society : Division of Clinical Psychology. (2018). Positive Behaviour Support (PBS) : Committee and Working Group Position Statement. Retrieved from https://www1.bps.org.uk/system/files/user-files/Division%20of%20Clinical%20Psychology/public/REP118%20Positive%20
behaviour%20ID1961%20WEB.pdf

British Psychological Society : Division of Clinical Psychology (2010). Clinical Psychology Leadership Development Framework. Leicester: British Psychological Society

Department of Health. (2007). Mental Health: New Ways of Working for Everyone Developing and sustaining a capable and flexible workforce. Retrieved from https://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074495.pdf

Department of Health (2014) Positive and Proactive Care: Reducing the Need for Restrictive Interventions. Available at: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
attachment_data/file/300293/JRA_DoH_Guidance_on_RP_web_accessible.pdf (accessed 28th January 2019)

Duxbury, J., & Whittington, R. (2005). Causes and management of patient aggression and violence: staff and patient perspectives. Journal of Advanced Nursing, 50(5), 469–478. https://doi.org/10.1111/j.1365-2648.2005.03426.x

Care Quality Commission. (2018). Opening the door to change – NHS Safety Culture and the Need for Transformation. Retrieved January 27, 2019, from https://www.cqc.org.uk/publications/themed-work/opening-door-change

Department of Health. (2007). Mental Health: New Ways of Working for Everyone Developing and sustaining a capable and flexible workforce. Retrieved from https://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_074495.pdf

Ebrahim, S. (2018). Multi-professional approved clinicians’ contribution to clinical leadership. The Journal of Mental Health Training, Education and Practice, 13(2), 65–76. https://doi.org/10.1108/jmhtep-03-2017-0019

Edmondson, A. C., & Lei, Z. (2014). Psychological Safety: The History, Renaissance, and Future of an Interpersonal Construct. Annual Review of Organizational Psychology and Organizational Behavior, 1(1), 23–43. https://doi.org/10.1146/annurev-orgpsych-031413-091305

Guest, D. E. (2017). Human resource management and employee well-being: towards a new analytic framework. Human Resource Management Journal, 27(1), 22–38. https://doi.org/10.1111/1748-8583.12139

Johnson, R., & Haigh, R. (2010). Social psychiatry and social policy for the 21st century ‐ new concepts for new needs: the ‘psychologically‐informed environment’. Mental Health and Social Inclusion, 14(4), 30–35. https://doi.org/10.5042/mhsi.2010.0620

Johnstone, L., & Boyle, M. (2018). The Power Threat Meaning Framework: An Alternative Nondiagnostic Conceptual System. Journal of Humanistic Psychology, , 002216781879328. https://doi.org/10.1177/0022167818793289

Kahneman, D. (2012). Thinking, Fast and Slow. London: Penguin Books.

LaVigna, G. W., Willis, T. J., Donnellan, A. M. 1989 The role of positive programming in behavioural treatment. In: The Treatment of Severe Behaviour Disorders. Behaviour Analysis Approaches(ed. E. Cipani), pp. 59 83. American Association on Mental Retardation, Washington, DC.

Layard, R., & Clark, D. M. (2015). Thrive: The Power of Psychological Therapy. London: Penguin Books

Mangaoil, R. A., Cleverley, K., & Peter, E. (2018). Immediate Staff Debriefing Following Seclusion or Restraint Use in Inpatient Mental Health Settings: A Scoping Review. Clinical Nursing Research,  105477381879108. https://doi.org/10.1177/1054773818791085

Markham, D., & Trower, P. (2003). The effects of the psychiatric label ‘borderline personality disorder’ on nursing staff’s perceptions and causal attributions for challenging behaviours. British Journal of Clinical Psychology, 42(3), 243–256. https://doi.org/10.1348/01446650360703366

Mind. (2013). Mental health crisis care: physical restraint in crisis A report on physical restraint in hospital settings in England. Retrieved from https://www.mind.org.uk/media/197120/physical_restraint_final_web_version.pdf

Mitchell, G., & Hastings, R. P. (1998). Learning disability care staffs emotional reactions to aggressive challenging behaviours: Development of a measurement tool. British Journal of Clinical Psychology, 37(4), 441–449. https://doi.org/10.1111/j.2044-8260.1998.tb01401.x

Oliver, C., Hall, S., Hales, J., Head, D. (1996). Self‐injurious behaviour and people with intellectual disabilities: assessing the behavioural knowledge and causal explanations of care staff. Journal of Applied Research in Intellectual Disabilities, 9, 229 39.

Restraint Reduction Network, Ridley, J., & Leitch, S. (2019). Restraint Reduction Network : Draft Training Standards 2019 : Ethical Training Standards to Protect Human Rights and Minimise Restrictive Practices. Retrieved from hhttp://restraintreductionnetwork.org/wp-content/uploads/2019/01/RRN_Training_Standards_2019_DRAFTv2.pdf

Restraint Reduction Network. (2018). Six Key Restraint Reduction Strategies. Retrieved January 30, 2019, from http://restraintreductionnetwork.org/wp-content/uploads/2016/11/Six-Key-Restraint-Reduction-Strategies.pdf

Royal College of Psychiatrists. (2018). Reducing restrictive practice. Retrieved January 27, 2019, from https://www.rcpsych.ac.uk/improving-care/nccmh/reducing-restrictive-practice

Rozich, J. D., Howard, R. J., Justeson, J. M., Macken, P. D., Lindsay, M. E., & Resar, R. K. (2004). Standardization as a Mechanism to Improve Safety in Health Care. The Joint Commission Journal on Quality and Safety, 30(1), 5–14. https://doi.org/10.1016/s1549-3741(04)30001-8

Smail, D. (2015). The Origins of Unhappiness: A New Understanding of Personal Distress. London: Karnac Books.

Tharp, R. G. & Wetzel, R. J. 1969. Behaviour Modification in the Natural Environment. Academic Press. New York, NY.

Tölli, S., Partanen, P., Kontio, R., & Häggman-Laitila, A. (2017). A quantitative systematic review of the effects of training interventions on enhancing the competence of nursing staff in managing challenging patient behaviour. Journal of Advanced Nursing, 73(12), 2817–2831. https://doi.org/10.1111/jan.13351

Vojt, G., Marshall, L. A., & Thomson, L. D. (2010). The assessment of imminent inpatient aggression: a validation study of the DASA-IV in Scotland. Journal of Forensic Psychiatry & Psychology, 21(5), 789–800. https://doi.org/10.1080/14789949.2010.489952

Wieman, D. A., Camacho-Gonsalves, T., Huckshorn, K. A., & Leff, S. (2014). Multisite Study of an Evidence-Based Practice to Reduce Seclusion and Restraint in Psychiatric Inpatient Facilities. Psychiatric Services, 65(3), 345–351. https://doi.org/10.1176/appi.ps.201300210

Whittington, A., & Burns, J. (2005). The dilemmas of residential care staff working with the challenging behaviour of people with learning disabilities. British Journal of Clinical Psychology, 44(1), 59–76. https://doi.org/10.1348/014466504×19415

Wolf Wolfensberger (2011) Social Role Valorization: A Proposed New Term for the Principle of Normalization. Intellectual and Developmental Disabilities: December 2011, Vol. 49, No. 6, pp. 435-440.