Minimising and eliminating the use of seclusion and restraint in mental health services

Introduction

Seclusion and restraint have long been used as an emergency measure to manage violent behaviour or agitation in mental health settings. The primary aims, when utilised, are to reduce the risk of traumatic experience and/or injury to individuals involved (including the patient, staff, and the patient’s family/whānau) and to ensure the individual is able to make care decisions for themselves and manage their own behaviour. Segregated custody is distinct from seclusion and restraint and is a punitive measure used in detention settings.

Definitions

• Seclusion is the confinement of an individual at any time of the day or night alone in a room or area from which free exit is prevented. 
• Restraint is the restriction of an individual’s freedom of movement by physical, chemical or mechanical means. Here, ‘physical’ means bodily force that controls an individual’s freedom of movement. ‘Chemical’ is often used to describe the use of medication given only to restrict an individual’s movement not to treat a mental illness or physical condition where the individual is unwell and displaying behaviour which makes them dangerous to themselves or others. ‘Mechanical’ means a device that is used to control an individual’s freedom of movement. 
• Segregated custody, also known as solitary confinement or isolation, occurs when a person is confined to a cell in isolation from others, for 22 hours or more a day. Segregated custody in excess of 15 days is considered “prolonged”.[1]

Background

It is now well recognised that the use of seclusion and restraint can be traumatic and may infringe upon the rights of individuals with mental health conditions. Seclusion and restraint are still used in mental health services and in many other areas such as emergency departments, aged care, disability and corrective services in Australia and New Zealand. 

The Australian Institute of Health and Welfare reports that there were 18,690 events of physical restraint and 991 events of mechanical restraint nationally in 2018-19.[2] Overall, data shows that the use of seclusion (in mental health services) seems to be declining.[2] Data on seclusion and restraint have certain limitations as there is no consistency of definitions or data collection methods across jurisdictions.[1] A national approach to data collection may assist with better understanding of the use of seclusion and restraint. 

Publicly available data on rates of restraint is limited in New Zealand. However, the Human Rights Commission (HRC) reported 358 instances of restraint in a 6-month period during September 2019 to February 2020.[3] Publicly available data on seclusion rates shows there were 1527 seclusion events reported in 2017 across mental health inpatient services.[2] However, the Ministry of Health reports that there is a downward trend in the use of seclusion in New Zealand.[4]

Due to the potential trauma (and re-traumatisation) arising from the experience of restraint and seclusion for the individual concerned as well as families and staff, it is important that mental health services in Australia and New Zealand continue to work towards minimising, and where possible eliminating, the use of seclusion and restraint.[5]

Evidence

Seclusion and restraint are generally used with the aim of preventing injury and reducing agitation, but evidence shows that their use can also have negative physical and psychological effects on both the individual and staff.[6]

Continuing to work towards minimising, and where possible eliminating, the use of seclusion and restraint is achievable. It requires leadership, commitment and motivation, and a change in culture underpinned by the recovery model with a focus on workforce and training, prevention and early intervention, good clinical care, and supporting practice change.[7] The well-established Six Core Strategies (the Strategies) were developed with the aim of reducing the use of seclusion and restraint in mental health settings in the United States and internationally.[8] The Strategies were developed using results obtained from extensive literature reviews and feedback from a range of experts who had worked in mental health settings.[8] New Zealand has developed an adaptation of these strategies to reduce the use of restrictive practice suitable for the New Zealand context (please see ‘Further Reading for the Six Core Strategies Checklist, New Zealand adaption).

Alternative models and strategies which move towards minimising, and where possible eliminating, seclusion and restraint are required including proper utilisation of space to promote de-escalation. Such models and strategies balance supporting the autonomy of people with mental health conditions whilst providing access to care and ensuring the safety of the individual, staff and the community. These strategies should include post-incident de-briefing for staff and the individual and provide information which encourages using lessons learned to inform future best practice.[9] To assist with this process and to ensure the needs of people with mental health conditions are met, co-production and design involving people with lived experience should feature strongly in system change. 

All models and strategies should recognise the role of cultural bias and institutional racism in the use of seclusion and restraint. For example, the Takarangi Competency Framework may be helpful to inform best practice in providing care for Māori, in order to reduce the use of seclusion.[10, 11] Culturally specific considerations are key to reducing the frequency and impact of seclusion and restraint for Māori in all settings. In conjunction with cultural workers and whanau, 6 key principles have been highlighted as key for changing current practices of seclusion and restrain affecting Māori. These are: actively upholding the obligations and ethics of Te Tiriti o Waitangi, embedding culturally safe practice (Tikanga-based approaches), whānau-centred and relationship-based care, Māori-led de-escalation and prevention strategies, restorative and reflective learning, and aligning practice with Māori aspirations for Oranga (Wellbeing).[12] Policy changes need to be deliberate and prioritise redressing systemic issues and recognising and advancing cultural and relation changes through shared understanding. Data in New Zealand also highlights Pasifika experience high levels of seclusion events.[3] 

There are situations where it is appropriate to use restraint and/or seclusion but only as a safety measure of last resort where all other interventions have been tried or considered and excluded. For example, the use of physical restraint may be used to manage immediate risk to staff, the individual and other people due to aggressive behaviour as a result of acute distress, and consent may be impossible (please see ‘Further Reading’ for Guidelines for Safe Care for Patients Sedated in Health Care Facilities for Acute Behavioural Disturbance).[13] 

Seclusion and restraint should only be used within approved protocols by properly trained professional staff in an appropriate environment for safe management of the individual. The aim is to reduce the use of these interventions and the adverse events that accompany them through supporting recovery and trauma-informed practice principles. People who have been traumatised by the use of seclusion and restraint are less likely to utilise mental health services even when required. Ensuring that any use of seclusion and restraint is undertaken in a manner which acknowledges individuals and their circumstances as much as possible, is crucial. In addition, the use of seclusion and restraint is not a substitute for inadequate resources (such as lack of trained staff). They should never be used as a method of punishment.

Use of seclusion and restraint requires a balance of professional and legal obligations to care and protect the individual, as well as the individual’s family/ whānau and the wider community.[14] Family and whānau should be involved in supporting those who experience seclusion and restraint, especially for Aboriginal and Torres Strait Islander peoples, Māori and Pasifika.[4]

Places of detention

The use of restrictive practices involving individuals with mental illness also occurs in places of detention where health services are provided, such as correctional centres and immigration detention. Whilst justice and security agencies usually hold direct responsibility for such practices, health services are often required to work in partnership with these agencies to ensure the health and safety of individuals with mental health conditions detained under these conditions. Psychiatrists therefore have a leadership role in advocating for the human rights and just treatment of individuals in places of detention. 

Prolonged segregation, regardless of the rationale behind its use, may amount to an act of torture and other cruel, inhuman or degrading treatment or punishment. [15] Australia and Aotearoa New Zealand are both signatories to the Optional Protocol to the Convention Against Torture and the Convention of the Rights of the Child, which prohibit states from engaging in practices which amount to torture or inhumane treatment.[16, 17] The RANZCP opposes the use of the professional knowledge and skills of psychiatrists in ways intended to cause harm.

Individuals with severe mental illness were 2.25 times more likely to be placed in segregated custody than other detainees, and having any mental health condition was associated with a 170% increased chance of receiving extended segregation.[18] Segregated custody is also known to cause and worsen psychiatric conditions in incarcerated individuals and increase the risk of adverse outcomes.[19] It can lead to psychiatric complications even in people without pre-existing mental illness. Research indicates such psychiatric effects include perceptual distortions, panic attacks, mood disturbances, impaired concentration and memory, intrusive obsessional thoughts, paranoia and impulsivity.[20] Detainment in conditions of segregation is also an empirical risk factor preceding deaths by suicide in custody.[21] 

Placement in segregated custody restricts opportunities for detained individuals to participate in otherwise available therapeutic programs, impeding recovery from mental illness. The restrictive nature of segregation limits access for mental health clinicians to assess people with mental health conditions, compromises the potential benefits of psychiatric care and treatment, and can prevent and delay access to dedicated mental health treatment areas and services. 

The RANZCP also acknowledges the clinical constraints and ethical obligations faced by psychiatrists who provide care to individuals experiencing the detrimental impacts of segregation. This may be a significant source of moral distress, which has considerable impacts on staff health and wellbeing. Psychiatrists should be free to advocate for their own wellbeing, and that of their patients, including by arguing against, and refusing to participate in, the use of segregated custody without fear of retribution in the workplace.

Recommendations

The RANZCP recommends the following actions for implementation by governments and all organisations which provide mental health services in order to work towards minimising, and where possible, working towards eliminating the use of seclusion and restraint:

• Ensure all mental health services have appropriate policies, resources and frameworks aimed at minimising, working towards eliminating, the use of seclusion and restraint and a culture which uses seclusion and restraint only as a last resort.[14] 
• Ensure people with lived experience of mental health conditions are involved in designing policies, frameworks and spaces for best methods to minimise the use of seclusion and restraint in mental health services.
• Provide consistency of definitions and data across jurisdictions to allow for more accurate data collection on the use of seclusion and restraint in Australia and New Zealand.[22]
• Establish long-term research programs into resources, models and strategies which work towards minimising, and where possible, eliminating the use of seclusion and restraint.[14] 
• Strengthen cultural approaches that are effective at reducing seclusion and restraint among Aboriginal and Torres Strait Islander peoples, Māori and Pasifika, such as the involvement of family/whanau.[23]
• Ensure individuals and staff who have been exposed to seclusion and restraint are provided with appropriate trauma-informed post-incident debriefing.
• All post-incident debriefing should utilise a lessons-learnt approach to inform future best practice.[9]
• Psychiatrists do not authorise segregated custody for any detained person.
• Young people in places of detention should be excluded from segregated custody of any duration; and prolonged segregated custody as a means of punishment should be eliminated for all detained individuals.
• All jurisdictional governments and detention facilities comply with their obligations under the Optional Protocol to the Convention against Torture and Other Cruel, Inhumane or Degrading Treatment or Punishment and the Convention on the Rights of the Child.

References

1. United Nations Standard Minimum Rules for the Treatment of Prisoners (the Nelson Mandela Rules), 70/175 (2015).
2. Australian institute of Health and Welfare. Mental health services in Australia 2019 [Available from: https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/medicare-subsidised-mental-health-specific-services.
3. Shalev S, Commission NHR. Time for a paradigm shift: A follow up review of seclusion and restraint practices in New Zealand. New Zealand Human Rights Commission; 2020 2021.
4. Ministry of Health. Office of the Director of Mental Health and Addiction Services. Wellington, New Zealand: Ministry of Health; 2019.
5. Cusack P, Cusack F, McAndrew S, McKeown M, Duxbury J. An integrative review exploring the physical and psychological harm inherent in using restraint in mental health inpatient settings. International Journal of Mental Health Nursing. 2018;27:1162-76.
6. World Health Organisation. Freedom from coercion, violence and abuse, WHO QualityRights core training: mental health and social services. Course Guide. Geneva: World Health Organisation; 2019.
7. Wright M. Review of seclusion, restraint and observation of consumer with a mental illness in NSW Health facilities. 2017 December 2017.
8. Te Pou. Six Core Strategies checklist, New Zealand adaption. 2013.
9. Master K, Huckshorn K. The Role of the Psychiatrist in Seclusion and Restraint. Psychiatric Services. 2020.
10. Shalev S. Thinking outside the box? A review of seclusion and restraint practices in New Zealand. Auckland, New Zealand: Human Rights Commission; 2017.
11. Matua Raki. Takarangi Competency Framework: Matua Raki; n.d [Available from: https://www.matuaraki.org.nz/initiatives/takarangi-competency-framework/159.
12. Wharewera-Mika JP, Cooper EP, Wiki NR, Field TR, Haitana J, Toko M, et al. Strategies to reduce the use of seclusion with tāngata whai i te ora (Māori mental health service users). (1447-0349 (Electronic)).
13. National Institute for Health and Care Excellence. Violence and aggression: short-term management in mental health, health and community ettings United Kingdom: NICE; 2015.
14. Bhugra D, Tasman A, Pathare S, Priebe S, Smith S, al e. The WPA-Lancet Psychiatry Commission on the Future of Psychiatry The lancet Psychiatry Commission. 2017;4:775-818.
15. Report on the visit of the Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment to the Republic of Paraguay, CAT/OP/PRY/1 (2010).
16. Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment, A/RES/57/199 (2002).
17. Convention on the Rights of the Child, 44/25 (1989).
18. Siennick SE, Mayra P, M. BJ, and Mears DP. Revisiting and Unpacking the Mental Illness and Solitary Confinement Relationship. Justice Quarterly. 2022;39(4):772-801.
19. Enggist S, Møller L, Galea G, Udesen C. Prisons and health. Copenhagen: World Health Organization. Regional Office for Europe; 2014 2014.
20. Grassian S. Psychiatric effects of solitary confinement. Wash UJL & Pol'y. 2006;22:325.
21. Zhong S, Senior M, Yu R, Perry A, Hawton K, Shaw J, Fazel S. Risk factors for suicide in prisons: a systematic review and meta-analysis. (2468-2667 (Electronic)).
22. National Mental Health Commission. A case for change: Position paper on seclusion, restraint and restrictive practices in mental health services. 2015 May 2015.
23. Te Pou o te Whakaaro Nui. Reducing and eliminating seclusion in mental health inpatient services: An evidence review for the Health Quality and Safety Commission New Zealand. Auckland, New Zealand: Te Pou o te Whakaaro Nui; 2018.

Disclaimer: This information is intended to provide general guidance to practitioners and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.