Violence and aggression: short-term management in mental health, health and community settings

Observation

Observation means that a member of the care team will watch you carefully for a period of time. They will stay in contact with you during that time. The care team should only use observation after they have talked to you and tried to calm you down using other methods.

How closely you are watched, and how long for, depends on how high your risk of becoming violent is.

If your risk of becoming violent or aggressive is low, you should be checked once every 30 to 60 minutes. If your risk is a bit higher you should be checked more often – once every 15 to 30 minutes.

If your risk of becoming violent or aggressive is high, you should be watched all the time by a member of the care team, who should stay close to you (within arm's length). If your risk is very high, two or three members of the care team should watch you all the time, and one member of the care team should stay close to you (within arm's length).

If your observation is handed over to other members of the care team, you should be included in their handover discussions if possible.

The care team should understand that being under observation can be upsetting and make you feel isolated from other people. They should use the least amount of observation possible and take into account your views, your current mental state, and any medications you are taking and their effects. If you agree, they should tell your carer that you're having observation, and explain the reasons to them.

Manual restraint

Manual restraint is a way of physically holding you so that you can't hurt yourself or another person. If you're under 18, you should be manually restrained by a member of the care team who is the same sex as you, if possible.

You should not be lowered to the floor during manual restraint, but if this is unavoidable you should be lowered on your back with your face up. You shouldn't be held in any way that makes it hard for you to see, hear, speak or breathe, or affects your blood circulation. This means that the person holding you shouldn't press on your rib cage, neck or abdomen, or cover your eyes, ears, nose or mouth.

You should be held for as short a time as possible and not usually for more than 10 minutes. Your dignity and safety should be protected as much as possible.

If you're physically unwell, disabled, pregnant or obese, manual restraint should be done with extra care.

After manual restraint your physical and mental wellbeing should be checked for as long as needed.

Mechanical restraint

Mechanical restraint uses equipment such as handcuffs or restraining belts to limit a person's movement. It should only be used in a high‑secure psychiatric hospital to stop or prevent extreme violence or injury. Mechanical restraint may also be used when service users are being transferred from a medium‑secure psychiatric hospital to a high‑secure psychiatric hospital. (Medium‑secure and high‑secure psychiatric hospitals have high levels of security for people with severe mental health problems who are at high risk of harming themselves or other people.)

For young people under 18 mechanical restraint should only be used in special circumstances such as during transfer from a medium‑secure to a high‑secure psychiatric hospital, and only if the young person is 13 or older. Mechanical restraint shouldn't be used at all in children under 13.

Rapid tranquillisation

You may be given an injection of medication to calm you down quickly. This is called rapid tranquillisation. Rapid tranquillisation is always given by injection rather than as a tablet or pill.

NICE recommends two types of medication for rapid tranquillisation:

If you need an injection to calm you down and you're 18 or over, you should be given lorazepam on its own if:

If the injection doesn't calm you down enough, you may be given a second injection. The second injection may be the same type of medication as the first, or it may be the other type.

If you're under 18 you should only be given lorazepam on its own. Your physical and emotional wellbeing should be checked constantly when you have lorazepam. Using lorazepam for people aged under 18 is known as 'off‑label' use. The care team should tell you or your parent or carer this, and explain what it means for you. There is more information about 'off‑label use' below.

Seclusion

Seclusion means that you are taken to a room and not allowed to leave until the seclusion ends. The room may be locked if you're 18 or over. You should be secluded for as short a time as possible.

You should be able to keep your clothing and any personal items with you, if you wish, unless they might be a risk to yourself or others.

The room you're secluded in should allow the care team to see you clearly. It should be at a comfortable temperature with enough fresh air, and there should be toilet and washing facilities.

If you're under 18 the room shouldn't be locked, even if it's your own bedroom.

What should happen after a restrictive intervention

You should be offered a chance to talk about why the restrictive intervention was used with a member of the care team, an advocate (an independent person who represents your views) or a carer. You should also be invited to write down what you think about what happened in the notes made by the care team.

If you saw or heard violence or aggression from another service user that led to them having a restrictive intervention, you should be given a chance to talk about it with the care team.