Formulating an ethical, therapeutic, and safer approach to managing challenging and violent behaviours: a critical review of policy, guidance, law, research, and experience

Violence, aggression, agitation, and other challenging behaviours (“VAAoCB”) remain significant causes for concern across many settings in society. Those working within healthcare (especially mental health and learning disability), criminal justice and security are particularly affected. Hardly a day goes by without reading about VAAoCB with countries around the world managing the problem in different ways. Even within the UK, there is a lack of anything approaching a coherent approach to enhancing the safety of people exhibiting these behaviours or of those who have a legal duty to look after them. Education and training have largely moved away from a robust hands-on approach where staff were taught how to defend themselves to an approach where the safety and interests of the subject appear to take priority. A significant change in legislation was recently brought about following the tragic death of a mental health patient. The Mental Health Units (Use of Force) Act 2018 followed the death of Mr Olaseni Lewis, who died on 4 September 2010 after he was restrained by 11 police officers at a mental health ward in Bethlem Royal Hospital, Beckenham. Given that Mr Lewis was restrained by police officers (and not by hospital staff), and the force used on him was described at his Inquest as “excessive, unreasonable and disproportionate”, it is surprising that the only significant requirement imposed on police officers by the 2018 Act is contained in section 12 and relates to the wearing and operation of body cameras, which is something police officers had been doing for many years. The remainder of the Act relates to the oversight and management of the use of force by hospital staff but says very little about safe or unsafe restraint practises operationally. This is very disappointing and a significant missed opportunity to improve safety especially since the Right Care, Right Person National Partnership Agreement (2023) has been introduced with the aim of minimising police involvement with people with mental ill-health. The natural consequence of this radical change to policing support is that organisations must have clear policies and strategies in place to ensure they have the necessary capability, competence and capacity to deal with incidents of violence and aggression from persons suffering from mental ill-health without needing police assistance. The 2018 Act provided an ideal opportunity to lay down the requirements for hospital staff when managing violence and aggression from mentally unwell patients but failed to do so. Instead, other organisations, and guidance, have imposed prohibitions and restrictions on what staff can do to manage violence and aggression in as safe a manner as possible, although many of these requirements are unworkable and unsafe. This thesis will critically examine the multitude of issues involved in this area and will seek to formulate an ethical, therapeutic, and safer approach to managing challenging and violent behaviours.