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The Journal of Forensic Psychiatry & Psychology
ISSN: 1478-9949 (Print) 1478-9957 (Online) Journal homepage: https://www.tandfonline.com/loi/rjfp20
Least restrictive practice: its role in patient
independence and recovery
Edite Sustere & Emma Tarpey
To cite this article: Edite Sustere & Emma Tarpey (2019): Least restrictive practice: its role in
patient independence and recovery, The Journal of Forensic Psychiatry & Psychology, DOI:
10.1080/14789949.2019.1566489
To link to this article: https://doi.org/10.1080/14789949.2019.1566489
Published online: 20 Jan 2019.
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Least restrictive practice: its role in patient
independence and recovery
Edite Sustere
a
and Emma Tarpey
b
a
Humber Teaching NHS Foundation Trust, Willerby, United Kingdom;
b
Department of
Psychology, Manchester Metropolitan University, Manchester, United Kingdom
ABSTRACT
One of the five overarching principles of the Mental Health Act: Code of Practice is
to provide patients with care and treatment which is least restrictive whilst
encouraging recovery and promoting independence. However, there is limited
research which explores the application of these principles within a medium
secure unit. The aims of the research were to explore what are patient’sexperi-
ences of least restrictive practices and to what extent do they perceive that least
restrictive practices maximise their independence and recovery. Semi-structured
interviews were carried out with 12 male inpatients within a medium secure unit.
Five themes were evident: Positive Changes, Perceived Lack of Transparency,
Social Isolation, Institutionalisation and Normality. It was found that patient’s
perceived that there was lack of shared understanding between staffand patients
of what is considered least restrictive. Patient recovery was promoted through
positive risk-taking, the reduction in the use of seclusion and through the promo-
tion of meaningful activities that resembled life in the community. Nevertheless,
patients perceived that there was a lack of opportunities to socialise with patients
from other wards. Due to the security level of the hospital patients perceived that
independence was not achievable.
ARTICLE HISTORY Received 10 May 2018; Accepted 7 December 2018
KEYWORDS Least restrictive practice; forensic mental health; secure settings; mental health act; recovery
Introduction
Individuals with neuro-developmental or mental disorders who may be at
risk of harm to themselves or others, and whose risk of harm may not be
safely managed within a home, community or hospital setting might require
treatment in secure mental health settings (Department of Health, 2015). In
such settings, relational, physical and procedural security measures are
implemented to ensure safe delivery of care whilst effectively managing
risk (Mezey, Kavuma, Turton, Demetriou, & Wright, 2010). Least restrictive
refers to the process whereby physical, relational and procedural restrictions
are kept to a minimum and only implemented when necessary (Kennedy,
CONTACT Edite Sustere edite.sustere@outlook.com
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY
https://doi.org/10.1080/14789949.2019.1566489
© 2019 Informa UK Limited, trading as Taylor & Francis Group
2002). The Mental Health Act: Code of Practice states that least restrictive
practices (LRPs) should maximise patient independence and promote recov-
ery. However, there is a lack of literature exploring the impact of LRPs on
patient independence and recovery.
The impact of LRPs on patient independence and recovery are important
points of exploration as coercive and restrictive ward practices are the biggest
predictors of violence (Whittington & Richter, 2006). Enforcement of restrictive
practices coupled with a lack of understanding of patient’s experiences may
result in power struggles (Alexander & Bowers, 2004). Often patient-staffcon-
flicts within forensic services are due to what they perceive as unfair restrictions
(Whittington & Richter, 2006) and highly restrictive environments can contri-
bute towards tensions on the ward (Meehan, McIntosh, & Bergen, 2006).
Therefore, it is crucial to consider service user perspectives to help develop
and implement LRPs (Atkinson, 2002). Some of the key elements to recovery are
having meaning, hope and purpose (Drennan & Aldred, 2012). However, living
in a secure hospital, where patients are required to live within a very structured
and compulsory environment, recovery might be difficult to achieve (Mezey
et al., 2010). Individuals are likely to have histories of multiple traumas, com-
plicated emotional and interpersonal needs as well unmet criminogenic needs
(Mann, Matias, & Allen, 2014) therefore, nurses may subconsciously create
restrictions to help manage complex situations and clients (Finnema,
Louwerens, Slooff, & van-den-Bosch, 1996) therefore finding a balance between
recovery and risk management can be difficult (Drennan & Aldred, 2012).
LRPs should also maximise patient independence (Department of Health,
2015) which is an important component of recovery in mental health along
with self-direction, and ability to determine your own journey of recovery
(Alexander & Bowers, 2004). Restrictions on patient independence within
forensic services make recovery difficult and also maintain feelings of
powerlessness and hopelessness (Livingston, Rossiter, & Verdun-Jones,
2011). Staffmembers should, therefore, facilitate patients understanding of
the rationale behind the restrictions, and apply a flexible and individualised
approach when imposing ward restrictions (Alexander, 2006). However,
professionals might be unsure how to promote healthy independence
whilst managing risk (Jamieson, Taylor, & Gibson, 2006). In Jamieson’s
et al. (2006) study professionals acknowledged that secure services are
created as a place for dependency. This is because these services provide
safety, absence from drugs, therapy and support.
Overall, much of the focus within current literature has been on reducing
the risk of re-offending and little attention has been paid on how ward rules
can increase patient independence and promote recovery (Urheim, Rypdal,
Palmstierna, & Mykletun, 2011). The Good Lives Model (GLM) (Ward &
Brown, 2004) was chosen to interpret the results as it focuses on paying
attention to the individual’s strengths and protective factors. By focusing on
2E. SUSTERE AND E. TARPEY
strengths and risk factors together will create a shared understanding
between the patient and their team of their risks but also safety (Barnao,
Robertson, & Ward, 2010). Therefore, whilst restrictions are still in place,
these are being kept to a minimum and a strength-focused approach is
adapted. It has also shown to improve engagement in treatment and reduce
drop-out rates (Barnao et al., 2010). The GLM model suggests that all human
action, including offending, is considered to be a way of seeking primary
human goods (PHGs) (Ward & Brown, 2004). Research suggests that there
are 11 PHGs: life; knowledge; excellence in play; excellence in work; agency;
inner peace; relatedness; community; spirituality and happiness (Ward &
Brown, 2004). There is a commonality of PHGs; however, the means of
achieving them may be flawed by process of hospitalisation (Ward &
Brown, 2004). GLM is used to support individuals to have ‘a good life’
without re-offending, and to provide purpose and meaning. The following
study aims to apply to the GLM model to review how the PHGs are achieved
within a medium secure service to achieve independence and recovery
using LRPs.
Therefore, this research aims to explore:
●What are patients understanding of LRPs?
●To what extent do patients perceive that LRPs promote their recovery?
●To what extent do patients perceive that LRPs maximise their
independence?
Method
Design
A qualitative research design was employed. The epistemological position of
this research is that of the realist. Patients’experiences were theorised in
a straightforward way because the information provided by the participants
would allow the researcher to articulate experience and meaning (Braun &
Clarke, 2013). The researcher was not trying to theorise any socio-cultural
contexts that may explain individual accounts but instead tried to capture
issues that are important to the participants that the researcher may have
not anticipated (Braun & Clarke, 2013). It was also assumed that patient
experiences of LRPs will change as they progress through their recovery
especially as the concept of LRPs is relatively new. For example, key docu-
ments relating to LRPs date back to 2014 such as Positive and Proactive
Care: Reducing the Need for Restrictive Interventions (2014) and Mental
Health Act 1983: Code of Practice (2015).
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 3
Participants
An opportunity sampling technique was utilised. Posters were displayed on four
medium secure wards and on one low secure ward which are all part of one
National Health Service (NHS) hospital. Participants that volunteered for the study
were provided with a Participant Information Sheet. In total, 12 male participants
over the age of 18 were recruited from four all-male medium secure wards. No
participants from the low secure ward volunteered to participate which may have
affected the results. A semi-structured interview schedule was prepared using
open-ended questions (Appendix 1). Questions were used contextually and
follow-up questions were asked to be responsive to the patient’sdeveloping
account (Braun & Clarke, 2013).
Procedure
All of the interested participants were assessed as having the capacity to consent
to participation by the Multi-Disciplinary Team (MDT) and the researcher. Patients
were then approached by the researcher and invited for an interview. Interviews
were audio-recorded to ensure that the richness of the data was captured. When
each interview ended, the recording was stopped and the researcher de-briefed
each participant taking into account their presentation and well-being.
Analysis
The epistemological position of this research was that of the realist. This
means that patient’s experiences were theorised in a straightforward way
because it was assumed that the information provided by the participants
would allow the researcher to articulate experience and meaning (Braun &
Clarke, 2013). The data was analysed using guidelines produced by Braun
and Clarke (2006). The themes were identified using an inductive approach.
This meant that the themes were strongly related to the data and not driven
by a specific pre-existing coding frame or theoretical interest. Instead, the
analysis was data-driven to fully explore patient’s experiences of LRP (Braun
& Clarke, 2006). The themes were analysed at a semantic level. In this
instance, codes were semantic features which were assessed as meaningful.
Codes were identified and matched up with all the relevant data extracts to
evidence those codes. The codes were then analysed to see how they may
be combined and sorted into potential themes.
Ethics
The research project was assessed and approved by the Health and Research
Authority (HRA) and the local Research and Ethics Committee (REC).
4E. SUSTERE AND E. TARPEY
Results and discussion
Five themes were identified and interpreted using the GLM model:
Theme 1: positive changes
Several positive changes were observed by patients in regards to LRPs.
Participants thought that staffsupported patients to have more responsi-
bility by engaging in positive risk taking. In addition, patients reported that
seclusion was rarely used. These results are further explored in sub-themes
Compassionate Care and Seclusion as Last Resort.
Sub-theme 1: compassionate care
Staffmembers were perceived as responsive to patient’s needs and
adopted a non-judgmental approach when patients experienced a crisis.
When patients self-harmed staffhelped patients to express how they felt
rather than imposing restrictions through the removal of risk items or
seclusion.
“. . .like if you was self-harming. . .you get things locked up in your bedroom then
you could lose it for a week. . .now they give me half an hour to calm me self
down and give me some pen and paper and that way. . .I could draw how
I feel. . .”(P1)
This individual was offered alternative support strategies to minimise their
emotional stress, which is likely to help the patient develop more adaptive
ways of coping.
“I mean every staffthey do their hardest to go out of their way just to help
patients. . . as soon as you actually see that the staffjust wanna give you a hand
it’s great I mean we do need a hand sometimes. . .”(P2)
Participants spoke about the positive changes they noticed since the intro-
duction and implementation of LRPs. The key to effective balance between
treatment and security was the therapeutic relationship between staffand
patients. In addition, positive risk-taking had a significant impact on partici-
pants independence by promoting responsibility and personal choice.
“. . .when I first come it was tight. . .it’s like we was in the army or something. . .I
prefer all the risks that they took with me. . .for me to have more
responsibility. . .”(P4)
Sub-theme 2: seclusion as last resort
Patients reported previously being restrained and taken to seclusion for
minor incidents. However, patients reported that now seclusion was used
as last resort when managing aggressive behaviour. Instead, early interven-
tion and de-escalation strategies were utilised.
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 5
“. . .if you told a member of sta ffto fuck offor go away. . .they’d all bother ya
knock you down and. . .make you go down to seclusion but now they don’t take
ya unless it’s necessary. . .”(P4)
“. . .the main thing really good in least restrictive that first option isn’t to restrain
somebody but in the past it always has been. . .when I first come here. . .you could
get taken offthe ward for swearing. . .”(P5)
Theme 2: perceived lack of transparency
Patients perceived that there was lack of transparency between staffand
patients regarding what is considered least restrictive. Similarly, patients
were not always given reasons behind denied requests and the outcomes
of meetings.
“. . .it’s the front line staffwho need to be education in what is considered to be
least restrictive and what’s not because. . .we don’t know what we can and can’t
do. . . a lot of the time we haven’t got a clue what’s going on we rely on our staff
to know what’s happening. . .”(P6)
In this study, patients perceived that staffwere not always aware of what is
considered LRP. Patients reported that staffdid not always communicate ward
related LRPs to them. It is essential that staffmembers and patients are
provided with appropriate support, education and guidance on LRPs.
Furthermore, if a patient was told ‘no’in response to a request they were
not always provided reasons as to why their requests could not be completed.
“you’re just told you can’t you’re not told why you can’t. . .it’s just petty can’tdoit
somebody made a decision and you can’tdoit”(P7)
“depends on the person suppose who you’ve asked some staffmight tell you why
and be honest with you upfront and other staffmight not. . .”(P8)
Similarly, patients reported that they were not always kept up to date
regarding developing policies and ward rules.
“. . .they seem to have meetings about meetings. . .you go to one person and they
say oh that things gone to so and so and the next time you see them again ask
oh patient council are dealing with it now. . .they don’t always relate what’s
happened to other people. . .”(P5)
Consequently, lack of information is unlikely to help patients become more
independent and promote their recovery.
Theme 3: social isolation
Patients wished to have increased freedom of movement across the hospi-
tal. Although meeting at certain social events was helpful, it was recognised
that there was still some isolation within the hospital.
6E. SUSTERE AND E. TARPEY
“. . .one of the other restrictive practices has been a big thing about. . .keeping
patients segregated so for example. . .if patients from [WARD] were at the shop
and patients from [WARD] came down it was a big massive issue. . .by not letting
patients mix nobody knows each other and it’s all very difficult...”(P6)
“. . .you can’t mix with them because they got learning disabilities you can’t mix
with them because they’ve got erm severe mental illness. . .it.. .stigmatises even in
the place. . . they must feel you know how are we different to them.. .it must play
on their minds”(P5)
Allowing patients to engage in activities that facilitate meeting new people
is likely to promote the development of healthy peer relationships. However,
social isolation was also observed in an individual ward. Talking in groups on
corridors and walking down other patient’s corridors was not allowed,
although patients did not understand why this was the case.
“. . .talking in corridors. . .you’re not allowed to yet we live together. ..”(P7)
“. . .it’s just a little place it’s just depressing. . .if we go on the other side of the
corridor they tell ya come back the other way. . .we should be allowed to go in
each other’s rooms. . .it’s nice just to chill out in someone’s room and just have
a nice game”(P9)
Theme 4: institutionalisation
Patients reported that independence was minimal within a medium secure
unit.
“. . .you can’t be independent when you’re here. . .they’ve got a system they’ve got
to stick to they’ve got the cleaner to clean up they’ve got the cooks to cook the
food you’ve got the room you get to eat your food in you don’t get independent”
(P10)
“they do everything for us don’t they you only do a few bits. . .”(P11)
Although some degree of control within forensic settings is inevitable,
especially in the context of risk management, participants felt like they did
not have much control over the decisions made regarding risk management
within the hospital. There was some evidence of hopelessness and just
accepting that this is how things were. Consequently, this decreased
patient’s perceived independence. These perceptions were based on the
security level of the hospital.
“. . .if you was asking me in another environment I’m sure the answers would be
different but within this environment in terms of the level of security indepen-
dence is minimum. . .”(P6)
“. . .they’ve got to make it safe so they won’t be able to make it independent will
they”(P7)
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 7
Theme 5: normality
LRPs helped patients to achieve a sense of normality when they were
offered opportunities to engage in activities which reflected life in the
community.
“. . .I learnt to live by myself which was one of the bonuses of being in here and
progressing and with the OT cooking sessions. ..which shows we are really getting
prepared to go out in the community. . .”(P8)
Patients engaged in meaningful activities offered by the hospital which
were likely to help them achieve the PHG of Happiness. For example,
patients utilised community leave to engage in hobbies and activities
which they found meaningful.
“. . .going to cinema. . .I’ve been like going to football matches and stufflike that
which is good. . .least restrictive is good in that sense case giving people that
freedom. . .to do normal things. . .”(P5)
Therefore, these are positive findings in terms of how LRPs have promoted
and maximised patient independence and recovery. In addition, self-
medication and having a bedroom key increased sense responsibility and
control.
“. . .now people can lock their own bedroom. . .just like if you had a key to your
house. . .now majority of patients can actually give themselves their own medica-
tion people got control. . .”(P5)
Implementing practices that reflect life in the community also further max-
imised participants recovery. Participants who were provided with opportu-
nities to practice skills within a framework of LRPs spoke much more
positively of their idea of recovery and experiences of living within
a secure environment.
“recovery means to me. ..to manage being able to manage your problems and living
in the community without re-offending and so looking after yourself.. .”(P8)
Implementation of LRPs helped patients to develop those skills which are
more likely to help patients feel prepared for discharge into the community
to achieve a happy life.
Discussion
This research aimed to explore the patient’s understanding of LRPs and
whether LRPs promote patient independence and recovery. Five themes
were identified (1). Positive Changes with sub-themes Compassionate Care
and Seclusion as Last Resort, (2). Perceived Lack of Transparency, (3). Social
Isolation, (4). Institutionalisation and (5). Normality.
8E. SUSTERE AND E. TARPEY
The guidance for commissioners of forensic mental health services
emphasises that ‘The application of security measures should aim to promote
a safe and therapeutic environment, whilst pro-actively encouraging indepen-
dence and recovery. . .’(Joint Commissioning Panel for Mental Health, 2013).
However, there is a lack of measures available which highlight whether
independence and recovery are actually promoted. Therefore, the following
study has applied the Good Lives Model to review what is patient under-
standing of LRPs and how primary human goods (primarily independence
and recovery) are achieved within a medium secure service using the least
restrictive approach.
The first theme of Positive Changes reflected the cultural change which
had occurred since a greater focus was brought onto the principles of LRPs.
Staffmembers were observed to present as compassionate and engage in
positive risk-taking, which promoted the patient’s sense of responsibility
and independence. Receiving support and being able to make choices are
all important characteristics which positively affect treatment engagement,
and likeliness to maintain engagement as demonstrated by the GLM (Mason
et al., 2012). The GLM suggests that individuals have a desire for personal
choice and independence. This is referred to as primary human good of
Excellence in Agency (Ward & Brown, 2004). In this study, professionals were
perceived as more understanding and non-judgmental whilst focusing on
rehabilitation; possessing characteristics which promote patient indepen-
dence, self-reliance and recovery (Alexander, 2006). Similarly, positive risk
taking in mental health promotes patient’s personal growth, autonomy and
success (Robinson, 2007).
Second sub-theme Seclusion as Last Resort reflected the reduced use of
seclusion. Seclusion is a controversial management strategy of aggressive
and disrupted behaviour (Alexander, 2006). Patients reported that previously
they could be transferred to seclusion for minor incidents such as swearing
and arguing, however, patients stated that now seclusion was last resort.
Reduced seclusion is likely to increase patient inner peace (freedom from
emotional turmoil and stress) as suggested by GLM. Inner Peace refers to the
individual’s ability to have an understanding and awareness of their emo-
tions and how to achieve emotional balance through adaptive strategies
(Ward & Brown, 2004). In this study, a patient was trying to achieve emo-
tional turmoil through self-harming, and effective preventive interventions
were actively applied, such as verbal de-escalation and drawings as a way of
expressing emotion. Although seclusion may not always be avoidable, it is
essential that it is done in a therapeutic manner by providing patients with
a clear explanation for their seclusion, and are provided with enough
opportunities to interact with professionals during their seclusion (Keski-
Valkama, Koivisto, Eronen, & Kaltiala-Heino, 2010). Indeed, early intervention,
engaging the patients and evidence-based risk assessments are all positive
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 9
strategies used to reduce violence and aggression (Maguire, Young, &
Martin, 2012).
In contrast, Theme 2: Perceived Lack of Transparency demonstrated that
patients were dependant on staffknowledge however, there was a lack of
understanding what is considered LRP. Detailed knowledge is essential to
maintain a therapeutic alliance between staffand patients (Dimond et al.,
2011). Rae (1993) argues that secure units apply a custodial culture in order
to protect against staffanxiety and fear. This is maintained through lack of
training and education of staff. If staffmembers feel confident in supporting
patients, they are more likely to apply LRPs, rather than resulting to restric-
tive practices of just saying ‘no’without providing a reason (Maguire et al.,
2012; Arif et al., 2016). Patients may feel sensitive, rejected, criticised and
confused about the restriction, even when that was not the professional’s
intention (Alexander, 2006). Components that increase staffsafety and con-
fidence were colleague’s knowledge, experience and ability. Staffwelcome
policies and training which ensures a skilful and experienced workforce
(Martin & Daffern, 2006).
Poor information sharing may mean that patients are unable to achieve
primary human good of Knowledge. Knowledge refers to the individual’s
desire to understand themselves and their environment (Ward & Brown,
2004). Patients are more likely to be aggressive when they think that ward
restrictions are imposed in a punitive manner (Alexander & Bowers, 2004).
Genuinely engaging patients in the construction and evaluation of ward
restrictions mat facilitate independence and improve patient-staffcommu-
nication (Alexander, 2006).
Literature suggests that positive social relationships can have a significant
impact on the patient’s recovery (Nijdam-Jones, Livingston, Verdun-Jones, &
Brink, 2015). Social cohesion has been the centre of government policies
within mental health services, for example, No Health without Mental Health
(DoH, 2011). However, in Theme 3: Social Isolation, patients perceived that
there was little opportunity for creating positive, social relationships with
their peers either on the ward or generally across the hospital. Patients felt
that certain restrictions on the ward, such as not going near other patient’s
bedrooms and lack of freedom of movement across the hospital meant
there was little opportunity for social cohesion. This means that their pri-
mary goods of Friendship and Community are unmet. These primary human
goods relate to the desire to establish bonds with others and relate to being
part of a group and being connected to others (Ward & Brown, 2004). These
findings are consistent with previous literature where patients felt there
were restrictions on their social environments, meaning that there was little
opportunity for empowerment and recovery (Morris, Cox., & Ward, 2016). If
patients are restricted from achieving these goods through pro-social
means, they are more likely to engage in unhelpful activities to seek
10 E. SUSTERE AND E. TARPEY
belonging elsewhere. Patients might form antisocial networks within hospi-
tal perimeters to achieve a sense of relatedness and community.
The Social Bonding Theory suggests that human morality is dependant to
what extent an individual is able to bond with society and others, therefore,
adopting society’s morals (Hirschi, 2002). The development of healthy and pro-
social relationships within the hospital may make the individual feel more
socially equipped to develop healthy relationships once in the community.
Relationships formed on psychiatric wards are likely to predict relationships on
the outside or their absence (Ward & Brown, 2004). Similarly, social cohesion
and support from fellow patients are seen as essential foundations for effective
rehabilitation (Bressington, Stewart, Beer, & MacInnes, 2011). Therefore, pro-
moting social inclusion within a medium secure unit is likely to benefitthe
patient’s recovery, the services and society (CSIP, 2007).
Independence was perceived as a minimum within secure services which
was reflected within Theme 4: Institutionalisation. There were certain pro-
cedures in place which, in the eyes of the patient, could not be changed
because of the security level. Similar findings have been found by previous
research, where the level of security and restrictions had a significant effect
on patient’s freedom and independence (Milsom, Freesone, Duller, Bouman,
& Taylor, 2014). It is important to take into the account contextual factors
which might affect the patient, such as ward practices and routines to avoid
individuals feeling like they’re being fitted into the hospital’s existing pro-
cesses (Barnao, Ward, & Robertson, 2015). According to GLM, by promoting
patient’s goals and supporting them with skills to achieve these goals are
likely to restore independence (Barnao et al., 2015). However, early onset of
mental illness can affect the development of certain skills, such as indepen-
dent living. In addition, previously learnt skills may be temporarily affected
(Barnao et al., 2010).
Although some degree of control is inevitable, especially in the
context of risk management, it is important that clinicians remain mind-
ful of the effects of this on the patient (Alexander, 2006). For example,
some patients may just accept the ward rules which means they might
be susceptible to institutionalisation. Patients might be afraid to express
their feelings because this might be seen as a sign of deterioration in
mental health (Alexander, 2006). Nevertheless, patients are not always
included in the design, planning or delivery of forensic services
(National Survivor User Network, 2011). It is essential that services
involvepatientsasmuchaspossibleastheyhavedirectexperience
and knowledge of being part of forensic services, therefore, their exper-
tise is invaluable.
Patients reported that LRPs helped them achieve a sense of normality
when offered opportunities to engage in activities which reflect life in the
community. For example, leave to the community helped patients to regain
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 11
control and develop independence. Indeed, recovery can be much more
than just about mental illness, it is about overcoming challenges, being able
to work, study, love and live with a sense of meaning and purpose (Ward &
Brown, 2004). According to GLM, some individuals use mental health ser-
vices as a means of achieving their primary human goods until more
normalised ways of achieving them can be used (Barnao et al., 2010).
Indeed, the GLM encourages adapting treatment which will help patients
learn skills which can be utilised to achieve their goals. However, if this not
achieved, patients may result in controlling, dominating or abusing others
to establish control (Ward & Brown, 2004). A focus on the patient’s
strength’s is likely to increase motivation and satisfaction of the ward
(McMurran & Ward, 2004).
Conclusion
According to the participants, there was still a lack of shared understand-
ing between staffand patients around what is considered LRP.
Inconsistent responses, lack of communication and feelings of uncertainty
behind some of the staffdecisions affected participant’s understanding of
what are LRP within the hospital. Therefore, staffshould work with
patients to facilitate understanding of the reasons behind some of the
restrictions and involve patients in the decision-making of the hospitals
practices wherever possible.
Overall, patients perceived that positive risk-taking, engaging in activities
that reflect life in the community and seclusion being used as last resort are all
examples of how LRPs have had a positive impact on patient recovery.
Independence was seen as a minimum due to the physical and procedural
processes of the hospital rather than relational security. Therefore, it is impor-
tant to remain mindful of the effects of risk management and avoid making
patients feel like they are being ‘fitted’into existing processes.
Limitations
Consultation with patients at the design and implementation stages of the
research may have better-represented patient’s voices. This research was
completed as part of a Master’s degree qualification, therefore, one profes-
sional carried out the entire research. It is also possible that as the
researcher works within the hospital it may have had an impact on the
data. Participants may have felt hesitant to share their views about restric-
tive practices although there was a good balance of positive and negative
views. The length of admission at the hospital was not recorded therefore,
this was likely to have an influence on the results as patient experiences of
LRPs are likely to change as they progress through their recovery. Patients at
12 E. SUSTERE AND E. TARPEY
higher risk of violence may be subject to increase relational, procedural and
physical security, therefore, their perceptions of the ward may be different
to other patients (de Vries, Brazil, Tonkin and Bullten, 2016). The research is
explorative and the findings contribute to a new understanding of the
literature. However, not all medium secure units are identical. There may
be differences in discharge pathways as well as differences in the therapeu-
tic environment. Nevertheless, it is hoped that due to resemblances in the
environments and similarities in treatments available the themes are applic-
able to other forensic settings. The findings only reflect patient’s views and
might not necessarily reflect the services practices although, these findings
are consistent with previous research where entrenched practices within’
closed institutions have been evident (Carr & Harvers, 2012).
Acknowledgments
We would like to thank Humber Teaching NHS Foundation Trust for allowing us to
carry out the research.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
No funding was sought for the following research project.
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Appendix 1:
Sample questions used for semi-structured interview
●In your own words, could you please tell me what the term ‘least restrictive
practice’means to you? (If the participant is unable to answer the question,
provide definition and information).
●Could you tell me more about your personal experience of ‘least restrictive
practice’within the hospital that you are in?
THE JOURNAL OF FORENSIC PSYCHIATRY & PSYCHOLOGY 15
●What impact do you think ‘least restrictive practices’have had on your care?
●According to the Mental Health Act, 1983 ‘least restrictive practices’are
designed to maximise and promote your independence. Thinking about inde-
pendence, what does independence mean to you?
●How do you think ‘least restrictive practices’implemented within your care
maximise your independence?
●How do you think these practices could be further improved to maximise and
promote your independence?
●According to the Mental Health Act 1983 ‘least restrictive practices’are also
designed to maximise and promote your recovery. What does recovery mean
to you?
●How do you think ‘least restrictive practices’implemented within your care
maximise and promote your recovery?
●How do you think ‘least restrictive practices’could be further improved to
maximise and promote your recovery?
16 E. SUSTERE AND E. TARPEY
