This resource has been developed with the intention to raise awareness among staff of the range of restrictive practices that are used within mental health inpatient services and their impact on patients. Preventative measures to reduce the use of restrictive practices in mental health services can only be effectively designed and implemented if all types of restrictive practice and their contributing factors are identified and reported. Reducing the use of restrictive practices is consistent with the Culture of Care Standards for mental health inpatient services. These set out what is needed to create a positive culture of care and the conditions for people to thrive through trauma informed, autism informed and culturally competent care.

This resource is intended for all NHS-funded mental health inpatient services, across all age groups and populations, including older adults, children, young people, people with a learning disability, and autistic people. It should be read alongside the Mental Health Act 1983 Code of Practice and other statutory guidance. It does not amend or replace statutory requirements, and staff remain under a duty to have regard to the Code of Practice. As restrictive practices occur in a range of settings, this resource also aims to raise awareness and support reduction of restrictive practices more broadly.

‌’Restrictive practices’ is a collective term for different types of restraint. They are sometimes also known as restrictive interventions. The definition of restraint used in this resource draws on the Equality and Human Rights Commission’s Human Rights Framework for Restraint which itself is largely based on the Mental Health Act 1983 and its Code of Practice (para 26.36). This states ‘Restraint’ is an act carried out with the purpose of restricting an individual’s movement, liberty and/or freedom to act independently. Restrictions may be in place on mental health wards to enhance physical safety, but paradoxically they can increase conflict and be the direct cause of harm and trauma. Where restraint is necessary, the least restrictive option should always be adopted.

It should be recognised that admission to hospital constitutes a form of restriction. Within mental health settings, the structure and operation of wards inherently place staff in a position of authority over patients. While certain restrictions may be implemented with the intention of enhancing physical safety, they can, paradoxically, contribute to heightened tension and conflict within the ward environment.

This resource defines and gives examples of 8 types of restrictive practice used in mental health, learning disability and autism inpatient services. These align with practices identified by the Restraint Reduction Network and they also correspond  with the Welsh Government’s Reducing restrictive practice framework. We explain how the individual restrictive practices can impact on people’s human rights (as defined in the Human Rights Act 1998) and the harm and trauma they may cause. We also signpost to resources that provide information on minimising their use.

The Mental Health Units (Use of Force) Act 2018 applies in mental health units in England. It defines “use of force” as physical, mechanical or chemical restraint, and the use of seclusion/isolation. These practices must be recorded and reported to the NHS England Mental Health Services Data Set.  Most staff will recognise that restraint, seclusion and segregation are restrictive practices. However, they may be less aware that other practices such as a ward or service’s blanket restrictions or cultural and psychological forms of restraint are also restrictive. While these broader practices, are not currently subject to statutory reporting requirements, this resource encourages staff to be aware of them, reflect on their impact, and work to reduce their use.

The Mental Capacity Act 2005 (section 6) explains that “restraint” means not only using force but also threatening to use force to make someone do something they are don’t want to do. The Mental Health Act Code of Practice (para 26.37) repeats this point. This resource aims to raise awareness of all forms of restraint. It’s important that staff also remember the legal definitions in the Mental Capacity Act and the Mental Health Act Code of Practice when thinking about their own practice.

We refer to ‘patient’ where we want to make it clear this is the person on the receiving end of a restrictive practice, not staff or people more generally, and make explicit the power differentials in inpatient settings. ‘Patient’ was considered the least objectionable term in a questionnaire-based study (Service user, patient, client, user or survivor: describing recipients of mental health services) and this is also the consensus within our working group, which includes people with lived experience. Where we refer to ‘people’, this is patients, staff and visitors.

Protecting Human Rights

Staff need to understand and  comply with their responsibilities under the Human Rights Act 1998 and Human Rights Framework for Restraint, as well as the Mental Health Act 1983 and its Code of Practice, Mental Capacity Act 2005 (for people 16 or over), the Mental Health Units (Use of Force) Act 2018  and the Equality Act 2010.

The Human Rights Act 1998 says that it is unlawful for public authorities to act in a way incompatible with a Convention Right. Relevant rights are set out in Schedule 1 and include the right to freedom from torture, inhuman and degrading treatment (Article 3), respect for private life including (but not limited to) autonomy, physical and psychological integrity (Article 8) and non-discrimination (Article 14). As public authorities, hospitals should uphold these rights.

Use of any type of restrictive practice has the potential to interfere with these rights. All use of restrictive practices should  therefore adhere to the principles set out in the Human Rights Framework for Restraint (Equality and Human Rights Commission (EHRC), 2019). The framework specifies that use of restrictive practice must be lawful, proportionate and the least restrictive option available. It also explains that there are some circumstances where the use of restrictive practices is never lawful; for example, when the intent of use is to humiliate, distress or degrade someone.

Resources

Helping Children and Young people to understand their rights: NHS England (2023). My Rights Magazine

The 8 types of restrictive practice

1. Cultural restraint

Cultural restrictions can result in people having to act against their personal beliefs or prevent them from engaging in activities that are meaningful to their cultural or religious identity. Examples Include not supporting someone to find an appropriate space or time to pray or expecting them to eat food they exclude on religious grounds or is not typical for their diet.

It is important to note that cultural restraint can also be a consequence of blanket restrictions.

Impact

Cultural restrictions in mental health inpatient settings can significantly impact on patient care, experience and outcomes.

Inpatient settings that do not accommodate cultural practices or dietary needs are likely to cause patients discomfort or distress.

Care that is not culturally informed may impede recovery and reduce patient satisfaction with the treatment process, (Vandecasteele et al 2024) and cultural misunderstandings can lead to the overuse of restrictive interventions, such as seclusion or restraint, particularly among minority groups. (Payne-Gill et al 2021).

Language and cultural differences can also hinder effective communication between patients and staff. This communication gap may prevent patients from fully expressing their needs or concerns, leading to feelings of isolation and frustration (Huang and Zane 2016).

Considerations for practice

Culturally competent care practices should be implemented. This will require staff training, policy reforms and cultural considerations in treatment planning.

Such measures can improve patient experience, engagement and treatment outcomes, and ensure that mental health care is respectful of and responsive to the cultural needs of all patients (see section Reducing the use of restrictive practice through a culture of care, page 15).

Resources

Perkins P et al (2024). Recovering adult acute psychiatric inpatient wards: creating recovery-focused, trauma-informed and neuro-inclusive culture, relationships and practice.

2. Surveillance

Surveillance is when staff watch and/or listen into people, places and property. This may involve human surveillance – staff physically observing a person – but also the use of technology, such as cameras, microphones or GPS trackers.

Impact

Observations are carried out in mental health settings with the aim to enhance patient safety, but patients can find them intrusive and distressing (Barnicot et al 2017; Chu 2016; Reen et al 2020) and any need for staff to continuously observe a patient as part of their workload contributes to the stress they feel (Duffy, Avalos and Dowling 2015).

A recent rapid review showed that reliance on surveillance technologies can reduce human interaction between staff and patients – the interaction that is crucial for effective mental health care. Additionally, the presence of cameras does not guarantee the prevention of adverse events and may, in some cases, lead to complacency in active monitoring by staff (Simpson 2023).

Considerations for practice

Guidance from the National Institute for Health and Care Excellence states that observation of patients should be seen as an “opportunity for active engagement as well as sensitive supervision” and be at the least intrusive level necessary, balancing the patient’s safety, dignity and privacy with the need to maintain the safety of those around them.

The Health Services Safety Investigation Body (HSSIB) report on continuous observations in May 2024 found that to create the conditions in which staff can best carry out continuous observation, human factor principles need to be considered to understand the complexities of this intervention and the environments in which it may take place. Staff and providers should also consider the impact of surveillance on a patient’s right to privacy, which is enshrined in Article 8 of the Human Rights Act.

The British Institute of Human Rights has published guidance on human rights considerations for staff and healthcare providers when using cameras and other recording equipment.

NHS England has published principles for aligning the use of digital technologies in inpatient mental health settings with the culture of care standards. These principles set out the circumstances in which the use of digital technologies could be considered unlawful and the requirements relating to obtaining consent and/or establishing an appropriate legal framework.

In 2025, CQC published guidance for inspectors on digital contactless patient monitoring technologies in mental health in-patient services. This guidance sets out what inspectors and Mental Health Act reviewers should look at when assessing or inspecting mental health in-patient services that use digital contactless patient monitoring technologies.

3. Blanket restrictions

Blanket restrictions are the rules or policies that a service routinely applies to all patients or certain classes of patients using it, without individual risk assessments to justify their application. These may restrict patients’ liberty or other rights or freedoms. Examples are set mealtimes and bedtimes, and restrictions on access to cigarettes and vapes, personal possessions and fresh air.

Impact

Many people who use mental health services will have a history of trauma. Blanket restrictions can foster their sense of powerlessness, and this can impact on their emotional and psychological safety.

Personalised safety planning is paramount in mental health settings and blanket restrictions risk breaching the Equality Act 2010 if they are not justified, proportionate or flexible.

Considerations for practice

The Mental Health Act 1983: Code of Practice states that blanket restrictions should be avoided unless they can be justified as a necessary and proportionate response. Where restrictions are deemed necessary, staff should ensure that they place the least possible restriction on patients’ human rights and, where possible, have considered individual circumstances and made reasonable adjustments.

Mental health, learning disability and autism inpatient services do need to prohibit, for example, weapons, and ‘contraband’ items (for example, drugs and alcohol) and impose smoking policies to comply with national legislation and guidance. Additionally, in secure services blanket and individual restrictions may be in place for public protection.

Resources

Restraint Reduction Network. RRN blanket restrictions resource toolkit.

4. Mechanical restraint

The Mental Health Act 1983: Code of Practice defines mechanical restraint as “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”.

Impact

While mechanical restraint may be used to prevent harm, its use carries substantial risks that can undermine patient wellbeing and the therapeutic process. Mechanical restraint carries the risk of a range of physical injuries as well as patients experiencing increased levels of distress, trauma and anxiety.

Considerations for practice

The Mental Health Act 1983: Code of Practice lays out the requirements for recording, reporting and reviewing use of mechanical restraint.

Regardless of the type of mechanical device used for restraint or the decision-making process for its use, where use meets the criteria set out in the Code, it should be reported and recorded as a form of mechanical restraint.

Under The Mental Health Units (Use of Force) Act 2018 and its associated statutory guidance all forms of mechanical restraint are defined as non-negligible force. This means that any use of mechanical restraint, regardless of type or intensity must be recorded and reported to the NHS England Mental Health Services Data Set.

5. Physical restraint

The Code of Practice: Mental Health Act defines physical restraint as “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”.

Physically restraining someone in a way that restricts their breathing (known as positional asphyxia) carries significant risk for the person. The Code states that “unless there are cogent reasons for doing so, there must be no planned or intentional restraint of a person in a prone position (whereby they are forcibly laid on their front) on any surface, not just the floor”.

The Restraint Reduction Network defines physical restraint as “when a person or persons use their body to make someone do something they don’t want to or stop them from doing something they do want to do”. (Physical Restraint – Restraint Reduction Network)

Impact

In a systematic review of patients’ and staff members’ experiences of restrictive practices in acute mental health inpatient settings, patients described “experiencing intense feelings of fear, powerlessness and humiliation while being restrained” (Butterworth et al 2022). Patients with past experiences of physical or sexual abuse described themselves as “being re-traumatised”. Staff who had used restrictive methods reported predominantly negative psychological consequences for themselves, including guilt, self-doubt and feeling that they have failed at their job.

Patients and staff both agree that the use of restrictive practices damages the staff–patient relationship. This relationship is the single biggest predictor of positive outcomes for people using mental health services (Gilburt et al 2008).

Considerations for practice

Increased use of physical restraint directly correlates with an increase in injuries for both patients and staff. Any use of physical restraint must be informed by a personalised safety plan, that considers patient sensory needs.

Post-incident review or debrief is crucial in understanding the impact on patients and staff and should inform the care plan to reduce likelihood of further incidents. This should include consideration of support for patients, staff and family members who may have witnessed the restraint.

Appropriate and clearly welcomed physical contact can help some people feel connected. Equally, some people are sensitive to physical contact with others, and this must be recognised and respected.

Cultural norms around physical contact and personal space vary widely so any physical contact must be appropriate to the person and their situation and consent must have been given in all circumstances.

Resource

Sweeney A et al (2018). A paradigm shift: relationships in trauma-informed mental health services. BJPsych Advances 245: 319–33.

6. Chemical restraint

The Mental Health Units (Use of Force) Act 2018 defines chemical restraint as “the use of medication which is intended to prevent, restrict or subdue movement of any part of the patient’s body. This includes the use of rapid tranquillisation”.

In Positive and proactive care: reducing the need for restrictive interventions (2014) the Department of Health defined chemical restraint as “the use of medication which is prescribed and administered for the purpose of controlling or subduing disturbed/violent behaviour, where it is not prescribed for the treatment of a formally identified physical or mental illness”.

Impact

The use of chemical restraint has a significant and often negative impact on patients, ranging from physical risks to psychological harm, including the loss of capacity to make decisions for short or prolonged periods depending on the medication used.

Patients can experience severe side effects or toxicity if dosages are not carefully monitored and the involuntary nature of chemical restraint often leads patients to feel powerless and fearful, particularly those with a history of trauma.

Considerations for practice

The use of medication, regardless of whether the intention is to control behaviour, should always be carefully controlled and monitored given the risks associated with overuse.

Chemical restraint is an extraordinary practice and not to be used lightly (Currier 2003). The use of non-pharmacological interventions and co-produced personalised care plans can minimise reliance on chemical restraint.

People with a learning disability are 16 times more likely and autistic people 7 times more likely to be prescribed an antipsychotic than the general population. The STOMP/STAMP programme sets out what services should do to stop the inappropriate prescribing of psychotropic medications.

7. Psychological restraint

Psychological restraint involves the use of verbal or non-verbal strategies that apply psychological pressure or coercion influencing a person’s behaviour or decisions in a way that limits their autonomy. These strategies may sometimes be subtle, context -specific, and embedded in a ward or service culture making them difficult to identify. Examples can include manipulation, implied threats, withholding of information, or the use of guilt or intimidation. It is important to distinguish between encouragement to support people’s recovery (e.g. explaining options, offering reassurance, or motivating engagement) which are legitimate aspects of care, and coercion (e.g. manipulation, implied threat, withholding information, inducing guilt) which constitutes psychological restraint.

While techniques such as reassurance and encouragement are often part of safe and appropriate care, staff should remain aware of when such approaches may cross the line into undue psychological pressure. The distinction lies in whether the person feels they are being supported to make a choice.   Psychological restraint occurs from the point at which a person feels they have no choice but to comply.

Impact

The use of psychological restraint undermines a person’s rights, dignity, and ability to make informed choices. Staff should prioritise approaches that promote voluntary engagement, informed consent, and respect for individual autonomy.

Psychological restraint can damage the therapeutic relationship by undermining trust and result in poor treatment outcomes for the person (Restraint Reduction Network’s psychological restraint guide).

Considerations for practice

Working in collaboration with patients and offering choice can help balance the power differential between patients and staff and support patients to have an active role in their care and treatment.

Several methods have been developed to reduce the use of coercive measures in mental health care including Safewards and Six core strategies.

Resources

Restraint Reduction Network: Psychological Restraint Animation

NHS England Reducing restrictive practice through least coercive care.

8. Environmental restraint

The Restraint Reduction Network defines environmental restraint as “using the physical environment to make someone do something they don’t want to, or stop them from doing something they do want to do” (Restraint Reduction Network).

Environmental restraint includes the use of obstacles, barriers or locks to prevent a person from moving around freely. This may include isolation from other people. The Mental Health Units (Use of Force) Act 2018 statutory guidance states that isolation is any seclusion or segregation that is imposed on a patient.

The Mental Health Act 1983: Code of Practice 2015 defines seclusion as the “supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving”.

For the purpose of the collaboration between NHS England, the Care Quality Commission (CQC) and Department for Health and Social Care, long-term segregation is defined as: “Nursing or caring for a person in enforced isolation, regardless of whether the procedures and requirements of the MHA Code of Practice 2015 for long-term segregation are met. The enforced isolation must have been in place for 48 hours or more. It should still be considered segregation even if the person is allowed periods of interaction with staff and or peers”.

In her 2023 report, My heart breaks – solitary confinement in hospital has no therapeutic benefit for people with a learning disability and autistic people, Baroness Hollins uses the umbrella term solitary confinement, defined as enforced isolation from meaningful human contact with peers. It covers all practices that deny people meaningful contact with other people, including but not limited to those currently referred to as seclusion, time-out or long-term segregation.

Impact

Isolation from others, for any length of time and in any setting, exposes people to psychologically painful experiences that undermine their “sense of belonging, control, self-esteem, and meaningfulness, reduces pro-social behaviour, and impairs self-regulation” (Bastian and Haslam 2010).

The harms of such practices are dose dependent – the more often they occur and the longer they last, the greater the risk of harm for all involved (Haney 2018).

Considerations for practice

Informed, sensitive adjustments to the sensory environments of mental health services will make a significant difference to patient wellbeing and recovery. Environments that are not sensory friendly can impede the effectiveness or hamper delivery of therapeutic interventions, exacerbate poor mental health and lead to the use of restrictive interventions.

The Mental Health Act 1983: Code of Practice sets out the standards that must be adhered to when caring for someone in seclusion or long-term segregation.

Resources

NHS England (2023). Health Building Note 03-01 Supplement 1: Medium and low secure mental health facilities for adults Table 4 gives considerations for creating a sensory-friendly environment.

National Development Team for Inclusion (2020). Its not rocket science: Considering and meeting the sensory needs of autistic children and young people in CAMHS inpatient services.

Inequalities and restrictive practice

Mental Health Act Statistics, Annual Figures – NHS England , the Learning Disability Services Statistics – NHS England, and LeDeR reports show that certain groups of people, such as those from ethnic minority communities, autistic people and people with a learning disability, are more likely to experience restrictive practices than others.

Olaseni (Seni) Lewis was a young Black man who died following the disproportionate and inappropriate use of force in a mental health ward. After his tragic death, his family tirelessly campaigned for change. This led to the introduction of the Mental Health Units (Use of Force) Act 2018, sometimes known as Seni’s Law. The Act and associated statutory guidance recognise the disproportionate use of restraint on people who share certain protected characteristics under the Equality Act 2010 and seeks to reduce the use of force and ensure accountability for and transparency about the use of force in mental health units.

The Public Sector Equality Duty (PSED) places a duty on public authorities, including mental health services, to consider how to eliminate discrimination and harassment that is based on a person’s protected characteristics. The 9 protected characteristics include sex, race and disability. The Equality and Human Rights Commission (EHRC) has published further technical guidance in the PSED.

Disproportionate use of restrictive practices on certain groups of people must first be recognised within services if it is to be addressed. For example, people with a learning disability and autistic people are more likely to experience environmental restraint in the form of seclusion or segregation than other groups of patients. It is essential that staff are supported to make reasonable adjustments for communication where required and ensure people have access to independent advocacy.

The Restraint Reduction Network’s restraint inequalities toolkit explains how a significant cause of restraint inequality is unconscious bias, which is the influence of the associations people hold outside their conscious awareness and control. What a person thinks unconsciously is often incompatible with their conscious values. Healthcare staff need to recognise they may have unconscious biases and take steps to reduce these.

Under the NHS Standard Contract providers are responsible for implementing actions to reduce racial inequality in their services. From March 2025 this includes the mandatory embedding of NHS England‘s Patient and Carer Race Equality Framework (PCREF) (2023) by all mental health service providers across England. The framework will become part of the CQC’s and the Equality and Human Rights Commission’s inspection processes and will require providers to evidence, for example, their use of restrictive practice data as identified in part 1 of the PCREF. 13 pilot trusts have begun implementing targeted changes, including the culture of care standards for mental health inpatient services as part of the Culture of Care Improvement Programme.

Resources

NHS England: Meeting the needs of autistic adults in mental health services.

NHS England: What are Restrictive Practices (Easy Read)

Reducing the use of restrictive practice through a culture of care

A key factor for reducing the use of restrictive practices in inpatient mental health settings is the right culture in the ward environment. In its work around closed cultures, the CQC identified that the use of restrictive practices in a service should be considered an inherent risk factor. Its policy position statement (2023) states that restrictive practice represents a failure of person-centred planning.

The 12 core commitments of the culture of care standards for mental health services, which were co-produced with patients, identify what is needed to create a positive culture of care and in turn reduce or stop the use of restrictive practices.

Resources

National Collaborating Centre for Mental Health: Reducing restrictive practice: learning from the collaborative.

NHS England: The 15 steps challenge. Quality from a patient’s perspective; a mental health toolkit.

NHS England: Culture of Care Programme

Publication reference: PRN01508