Beyond Behaviour Management: Reducing Restrictive Practices Through Psychological Formulation and Human Rights

Safer care asks more than how to stop a behaviour. It asks what is happening for the person, which conditions can change, and whether support protects their rights while creating a life they value.

Author: Arkadiusz Dawidowicz

When behaviour becomes the focus instead of the person

A slammed door or an episode of self-injury can draw attention towards immediate control. Safety matters, but the event is only part of the picture. Pain, communication barriers, sensory overload, fear, trauma, psychiatric illness and an environment with few meaningful opportunities may each warrant assessment. None should be assumed from behaviour alone.

The phrase behaviour that challenges describes difficulties arising in context, rather than a diagnosis or a person's identity. NICE NG11 recommends assessing health, communication and environmental influences. A behaviour may serve several functions, vary across situations, or have no clear communicative intention. Calling everything a message can conceal uncertainty just as readily as calling everything a symptom.

This article develops the practical implications of our discussions of psychological formulation and psychologically informed crisis care: how can services reduce restriction while improving everyday life? “Learning disability” reflects UK policy terminology; “intellectual disability” is common in Irish clinical practice and international research. Autism is distinct, although the two can coexist. Support should reflect individual preferences rather than assumptions about either group.

Understanding restrictive practices

Restrictions extend beyond holding someone physically. They can include mechanical devices, preventing someone leaving a room, locking away possessions, limiting access to shared spaces, or imposing blanket rules about food, visitors and activities. Whether a practice restricts someone depends on its purpose, effect and circumstances; an ordinary safety measure for one person may constrain another's freedom.

Restrictions may prevent immediate harm, yet also create distress, injury, humiliation, lost skills or dependence. Apparently routine rules deserve scrutiny because repetition can make them invisible. The evidence does not support a single universal prevalence: Fitton and Jones's (2020) review found substantial variation across seven cross-sectional studies, with inconsistent definitions and limited attention to environmental factors.

Medication requires particular precision. Treating an assessed illness is different from using a medicine primarily to suppress behaviour. Neither a drug's name nor sedation alone establishes its purpose. Northern Ireland's policy explicitly recognises that an intervention classified as chemical restraint can also have therapeutic benefit; that benefit does not remove the need for scrutiny (Department of Health [NI], 2023).

In a trial involving 86 adults without psychosis, risperidone and haloperidol did not demonstrate superiority over placebo for aggressive behaviour (Tyrer et al., 2008). That finding questions routine prescribing for this purpose; it does not negate treatment for psychosis. NG11 recommends specialist oversight, defined targets and review when antipsychotics are considered for behaviour that challenges. Medication changes require the responsible prescriber.

Psychological formulation beyond diagnosis

A diagnosis can inform treatment and adjustments without explaining why distress occurs in a particular interaction. Biopsychosocial formulation integrates physical health, psychological processes, relationships and wider circumstances into hypotheses that guide support. A clinician-consensus study emphasised personal meaning, strengths and sociocultural influences; agreement among professionals is informative, but is not proof that a formulation is correct (Thrower et al., 2024).

The 4Ps offer one organising framework:

• Predisposing factors: longer-standing influences, such as learning history, communication barriers or previous adversity.
• Precipitating factors: recent changes, such as illness, bereavement, unfamiliar staff or disrupted routines.
• Perpetuating factors: processes maintaining difficulties, perhaps repeated overwhelming demands, isolation or inconsistent responses.
• Protective factors: strengths, trusted relationships, interests, communication resources and supportive environments.

These headings structure enquiry; they are not a validated explanation by themselves. “Predisposing” should not turn disability into a presumed cause. Flinn and colleagues' (2015) systematic review found variable reliability between clinicians' formulations. Transparent reasoning, alternative hypotheses and revision matter more than a polished diagram.

A useful formulation should make its uncertainties visible. If a team proposes that unexpected demands increase distress, it can agree how advance notice and opportunities to decline will be introduced and what changes would support or challenge that account. The person should be able to disagree through their preferred communication. Recording contradictory observations helps prevent a psychological explanation becoming another fixed label, and keeps intervention connected to assessment.

Functional behavioural assessment asks what occurs before and after a clearly described behaviour, and which circumstances may influence it. Foundational experimental research demonstrated that similar-looking self-injury could relate to different environmental conditions (Iwata et al., 1994). This small, historical study supports asking functional questions, rather than extrapolating a treatment effect to today's adult services.

Descriptive observations identify patterns, not necessarily causes. An experimental functional analysis deliberately varies conditions and requires specialist competence, ethical safeguards and risk assessment. Staff should never provoke dangerous behaviour simply to complete an assessment. Functional hypotheses also need medical and psychological context: a pattern around demands does not exclude pain, fear or abuse.

Trauma-informed care and Positive Behaviour Support

Trauma-informed care attends to how services create safety, predictability, trust and control. It includes explaining actions, seeking permission, recognising distress and supporting meaningful refusal. It does not require assuming that everyone has experienced trauma or asking people to disclose painful experiences before receiving respectful support.

A scoping review found a developing but uneven literature on trauma among adults with intellectual disability (McNally et al., 2021). Behavioural changes can warrant sensitive enquiry, but do not establish a trauma diagnosis. McNally and colleagues subsequently co-produced a residential-care framework with adults and service stakeholders in Northern Ireland (2023). Its local relevance is valuable; development and acceptability are different from demonstrated effectiveness in reducing restraint.

Positive Behaviour Support (PBS) combines behavioural assessment with person-centred values and improvements to quality of life (Gore et al., 2013). A plan might adapt an overwhelming activity, provide reliable communication support, increase access to preferred activities and teach useful skills. Reactive strategies address emerging danger; proactive support changes the conditions in which that danger becomes likely.

Co-production means sharing influence over goals and decisions, using communication methods that make participation possible. A choice between two unwanted activities is limited choice. Harmless stimming, unconventional interests or a preference for solitude should not become targets merely because staff find them unfamiliar. The ethical question is whose wellbeing an intervention serves.

What the trials actually tell us

Hassiotis and colleagues' (2018) cluster randomised trial involved 246 adults across 23 English community intellectual-disability services. PBS training for clinicians, added to usual care, produced no significant improvement in the primary outcome over 12 months: adjusted mean difference −2.14, 95% confidence interval −8.79 to 4.51. Secondary outcomes also showed no treatment effects.

Implementation was problematic: only 33 of 108 possible intervention reports contained all specified elements, and available plans were independently rated as weak. These limitations help interpret the result, but cannot establish that better implementation would have produced benefit. The study provides no basis for promising that training alone changes outcomes.

A different trial randomised 24 supported-accommodation settings to a programme involving practice review, coaching and monitoring alongside access to individual PBS. Behaviour ratings improved more in intervention settings, but quality-of-life scores did not differ significantly (McGill et al., 2018). This supports investigating changes to everyday support while keeping claims specific: fewer behaviours and better lives are related questions, not interchangeable outcomes.

The clinical psychologist's role

A qualified clinical psychologist can integrate assessment findings, develop and test formulations, deliver adapted psychological interventions and consult with teams. UK HCPC standards explicitly include organisational assessment, formulation, consultation and evaluation (HCPC, 2023). These standards apply in Northern Ireland; they should not be presented as the Republic of Ireland's regulatory framework.

Consultation can help a team separate observation from interpretation, recognise conflicting hypotheses and connect each proposed change to an agreed goal. Supervision supports reflection on fear, frustration, power and uncertainty. Psychological expertise contributes to decisions; it does not transfer the responsibilities of prescribers, managers or safeguarding professionals to one clinician.

Medical practitioners investigate physical illness; psychiatry contributes psychiatric assessment and prescribing; speech and language therapy supports communication; occupational therapy considers sensory and participation needs. Nurses, social workers and managers contribute within their roles. Families and advocates bring knowledge and challenge, with appropriate consent and confidentiality. The person's own account remains central.

Support workers contribute detailed observations, implement agreed plans within training, recognise changes and raise concerns. They should not be expected to independently diagnose illness, prescribe treatment or undertake specialist psychological assessments. Collaboration requires an identified lead, clear actions and a review date, rather than a meeting that leaves responsibility diffuse.

Northern Ireland and the Republic of Ireland

Northern Ireland: regional policy and HSC accountability

The Department of Health's 2023 regional policy connects restrictive-practice reduction with prevention, rights, proportionality and organisational governance. HSC Trusts must develop evidence-based, co-produced minimisation strategies with named senior accountability and monitoring. The policy distinguishes these responsibilities from best-practice recommendations for non-statutory providers; it is not itself a new statutory power authorising restraint.

Capacity and deprivation-of-liberty decisions require the applicable Northern Ireland framework. The Mental Capacity Act (NI) 2016 remains partially commenced (Department of Health [NI], n.d.). Neither England and Wales's legislation nor Irish procedures can simply be imported.

Republic of Ireland: HSE provision and HIQA regulation

The HSE funds adult disability residential services delivered by HSE, voluntary and private providers (HSE, 2026). HIQA's Chief Inspector regulates designated disability centres under the Health Act framework. Regulation 7 addresses positive behavioural support and restrictive procedures; these are Irish requirements, distinct from Northern Ireland's regional policy (S.I. No. 367/2013).

HIQA's safeguarding guidance, version 2.1 (May 2025), describes rights-focused practice, proactive support, oversight of restrictions, attention to residents' views and learning from records and incidents. It explains how compliance is assessed; guidance, regulation and evidence of effectiveness perform different functions. This remit should not be generalised to every HSE contact or all mental-health settings.

Ireland's Decision Support Service guidance emphasises presumed capacity, practicable decision support, specific decisions at specific times, and the person's will and preferences (2023). Disagreement or an apparently unwise choice is not sufficient evidence of incapacity. Safeguarding and autonomy need joint consideration, with necessity, proportionality and lawful authority examined for any proposed restriction.

From individual support to organisational improvement

A restrictive practice can persist because it has become normal within a team. Reflective supervision should make it possible to ask whether routines serve the person, how staff anxiety affects decisions and whether reasonable alternatives have been resourced. Supportive reflection must sit alongside accountability for harmful practice and proper safeguarding responses.

Reviews of restraint-reduction programmes describe promising changes, but varied intervention packages and study designs limit certainty about which components cause improvement (Gaskin et al., 2013; Sturmey, 2018). Leaders need to provide time, stable staffing, coaching and consistent review. Attendance at training is an implementation input, not evidence that care improved.

Evaluation should combine measures agreed with the person:

• Quality of life and autonomy: meaningful activities, relationships, access to ordinary places, privacy and choices actually honoured.
• Safety and restriction: intervention frequency, duration and type, injuries and distress, including whether one restriction has replaced another.
• Emotional wellbeing: the person's report, adapted where needed, alongside carefully interpreted observations.
• Fidelity: whether agreed support is delivered in practice, not simply whether a plan exists.

Observational research associates skilled active support with better outcomes for people with severe disabilities and complex needs; association alone cannot establish causality (Beadle-Brown et al., 2016). A quiet service may still leave people isolated. Use consistent definitions, repeated observations and appropriate denominators, such as episodes per occupied bed-day, while reporting individuals' experiences rather than relying only on averages.

Incident learning should include accessible follow-up with the person and staff, examination of antecedents and responses, and changes to the plan. An initial rise in reported restrictions may reflect better recording. Before-and-after improvement may reflect staffing or case-mix changes; evaluation should state these limitations rather than claim causation.

Managers can review whose restrictions are renewed automatically, whether night and temporary staff can use the plan, and whether residents can access independent advocacy. Review meetings should include the restrictions' cumulative impact across a whole day. A sequence of individually described safety rules may leave very little freedom overall. This is an ethical and quality-improvement question as well as a question about the last recorded incident.

Ireland's community-living reform provides a wider context (National Disability Authority, n.d.). A systematic review associated moving from institutions to community settings with improved quality of life, while identifying evidence gaps (McCarron et al., 2019). Moving address alone cannot ensure that everyday routines offer real choice.

Clinical illustration: an entirely fictional example

This invented illustration is not a real case and is not based on an identifiable person.

Leonie, an autistic adult with an intellectual disability, pushes chairs away during a crowded afternoon craft group. Staff begin keeping the activity cupboard locked throughout the day. She loses access to materials she enjoys using independently, while distress continues around group sessions.

With Leonie's involvement through photographs, gestures and supported conversation, the team reviews health, communication, sensory conditions and incident records. A psychologist helps formulate competing explanations: unpredictable invitations, noise and difficulty declining may interact. Medical review remains necessary; observations do not establish a single cause.

Leonie selects a quieter space and a reliable way to indicate “later”. Staff offer advance information, support access to chosen materials and practise recognising refusal. The multidisciplinary team reviews the cupboard restriction through applicable governance procedures and agrees a monitored, proportionate plan to restore access safely, rather than withdrawing safeguards without assessment.

The hypothetical evaluation examines participation, choices honoured, distress, safety and restriction, alongside staff delivery of the plan. If distress persists, the formulation is revised. The illustration shows a reasoning process, not evidence that this combination will work for everyone.

Support that expands a person's life

Reducing restriction requires more than reducing recorded incidents. It means examining environments, relationships, opportunities and professional power, while responding competently to genuine danger. Article 19 of the UN disability-rights convention places choice and community inclusion at the centre (United Nations, 2006). Formulation can help teams connect those principles to practical decisions, provided hypotheses remain open to challenge. Effective support should be judged by the safety, freedom, dignity and quality of life it enables.

Educational information, not personalised clinical or legal advice. Clinical, safeguarding and capacity decisions require appropriate professional assessment and the applicable local framework. Sources checked on 25 October 2026.

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