Physically restricting mental health patients can often harm them – my new study suggests compassion could change that

Restrictive practices in mental health settings – such as physical restraint and seclusion – are meant to be a last resort, used only when patients pose a risk to themselves or others.

In 2021 and 2022 alone, NHS England reported that 6,600 mental health patients were subjected to physical restraint, and 4,500 to seclusion. Figures such as these have led numerous experts and policymakers to conclude that restrictive practices are overused in mental health inpatient settings.

The consequences can be devastating. Restrictive practices are associated with trauma, worsening mental health, and even death. For decades, clinicians, researchers and policymakers have called for their reduction. Progress, however, remains painfully slow.

For the past five years, I have been researching the use of restrictive practices in mental health services and exploring how to reduce them. My new research demonstrates the importance of using compassion to support staff to promote the dignity and wellbeing of patients as a priority.

Restrictive practices have a long history that predates the development of asylums and psychiatry as a medical discipline. The use of legislation to detain people on the basis of their mental health in England, for example, dates back to at least the 14th century. Early examples of restrictive practices included patients being bound and beaten with rods in order to “restore sanity”.

During the first three decades of the 19th century, mechanical restraints such as straitjackets, chains and restraint chairs and confining patients in locked rooms were widely accepted methods of controlling violent people in British asylums. But in the 1830s, some clinicians recognised the moral and ethical problems with using such practices, and a campaign began to abolish them.

The UN has long recognised restrictive practices in mental healthcare as a human rights issue. In 2008, the UN’s special rapporteur on torture stated that methods such as solitary confinement violate articles 14 and 15 of the Convention on the Rights of Persons with Disabilities, which protect against arbitrary detention and cruel, inhuman or degrading treatment.

This stance was reaffirmed in 2021 when the UN declared that restrictive practices breach the fundamental rights of patients. This underscores the urgent need for reform in mental healthcare systems worldwide.

Harmful effect

Research shows that restrictive practices may not only harm patients but contradict the goals of mental healthcare. Many mental health problems stem from traumatic experiences that leave people feeling powerless, unsafe and distressed. Using methods that reinforce these feelings can worsen the very issues services aim to address.

In extreme incidents, people have died as a result of restrictive practices use.

In my research, I have developed a theoretical model identifying core factors that perpetuate the use of restrictive practices in mental health services. These include the emotional challenges faced by staff working in high-stress environments, and how these challenges influence their decision-making.

Mental health wards can be highly stressful environments, with frequent incidents of aggression. In such settings, staff can often feel anxious and hyper-vigilant, which can make it harder for them to respond to patients with compassion.

Research shows that threat-based emotions like fear and anger are linked to a greater likelihood of using restrictive measures. So, this cycle perpetuates the use of these harmful practices.

Compassion may hold the key

Using restrictive practices to control or remove people who are perceived as a threat can provide staff with a sense of immediate safety, which may inadvertently reinforce their use. To address this, I wanted to explore whether supporting staff to manage their emotions more effectively could reduce their reliance on restrictive practices, and foster a more compassionate approach to care.

As part of my research, I introduced compassion-focused support groups for staff in several forensic mental health wards, advocating for a more empathetic and patient-centred approach. These groups tried to equip participants with skills to better manage challenging emotional experiences while fostering greater compassion for both themselves and the people in their care.

The aim was to help staff cultivate an inner sense of safety, reducing their reliance on restrictive practices as a means of managing their own feelings of threat. This intervention was encouraging, leading to reductions in the use of restrictive practices in some conditions – demonstrating the potential of using compassionate care for these purposes.

My study was the first of its kind – bur these initial results highlight the need for further research into how the emotional management of staff influences care decisions. The journey toward change is slow, but it is possible. Compassion may hold the key to addressing a deeply entrenched issue that has shaped the treatment of mental health patients for centuries.

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