Seclusion and restraint in mental health care Print this page

In Australia, seclusion and restraint can be legally used in mental health care under some circumstances. All states and territories collect data on the use of seclusion and restraint in public acute mental health hospitals and provide data for national reporting every year.

Data on seclusion are available for over ten years.

• The national seclusion rate has halved over the last decade.
• People in acute hospital care were secluded 10,851 times during 2021–22, a rate of 7 events per 1,000 bed days.
• Seclusion lasted for 6 hours on average, excluding Forensic services (34 hours).
• Forensic services have had the highest rates of seclusion since 2016–17.

Data on restraint have been available for a shorter time than seclusion data.

• There were 16,996 physical restraint events and 1,522 mechanical restraint events during 2021–22, rates are 10 and 1 events per 1,000 bed days respectively.
• Forensic services have the highest rates of mechanical and physical restraint.
• Since data coverage began, the national physical restraint rate has not changed much. Mechanical restraint has a consistently lower rate.

Work towards establishing a national collection for seclusion data began in 2011 (Allan et al. 2017), with restraint data included a few years later. The collection and improvement of data on the use of seclusion and restraint in Australian mental health care is an ongoing initiative. Annual reporting continues through cooperative efforts in the mental health data sector, particularly with the coordinated efforts of state/territory mental health authorities and national government agencies.

Figure 1 shows the number of times seclusion and restraint events were recorded in Australian public hospital mental health care during the last decade and how long seclusion lasted, on average.

Figure SECREST.1: Number of seclusion and restraint events in Australian public hospital mental health care

Services can also be grouped by target population. Seclusion events that occurred in Forensic services had the longest average duration of 34 hours per seclusion event compared with the average of 6 hours (Table SECREST.2).

Figure 2 shows the rates of seclusion and restraint in Australian public hospital mental health care over time.

Figure SECREST.2: Rates of seclusion and restraint over time in Australian public hospital mental health care

National rates

The national seclusion rate has halved since the first year of data collection for all states and territories from 14 per 1,000 bed days during 2009–10 to 7 during 2021–22. Over the last 5 years there has been little change to the national rate.

The national physical restraint rate has stayed about the same since data collection began, remaining between 10 and 12 since 2015–16. The national rate of mechanical restraint is consistently lower than physical restraint and has stayed at 1 during the last few years.  

State and territory rates

Seclusion rates have decreased for all states and territories since the first year of data coverage.

• For 6 of the 8 states and territories, the rate of seclusion has better than halved during this period (since 2008–09 or 2009–10).
• Between 2020–21 and 2021–22, states and territories showed decreases or no change in the rate of seclusion, except Western Australia which reported an increase in the rate of seclusion from 4 to 6 events per 1,000 bed days.

Physical restraint rates decreased from the first year of data coverage for Victoria and Tasmania (since 2015–16).

• All other states and territories showed increases or little change.
• Between 2020–21 and 2021–22, physical restraint rates increased for Western Australia and South Australia while other jurisdictions had decreases or no change.

Mechanical restraint rates have been at 2 events per 1,000 bed days or lower for all states and territories since 2017–18.

• These rates have decreased or had little change from the first year of data coverage.   

Seclusion and restraint data can also be presented by the target population of the service where the event occurred.

Figure 3 shows the rates of seclusion and restraint over time in Australian public hospital mental health care for general, child and adolescent, older person, and forensic target populations.

Figure SECREST.3: Rates of seclusion and restraint over time by target population of Australian public hospital mental health care

General services provide around three-quarters of care (77% of the total number of bed days in 2021–22).

Seclusion and restraint rates show:

• Forensic services had higher rates of seclusion, mechanical restraint and physical restraint than all other groups for the last six years.
• Child and adolescent services usually have higher rates of seclusion and physical restraint than General and Older person services.

During 2021–22, hospitals located in Major cities and Outer regional and remote areas had a higher seclusion rate than Inner regional facilities (7 events per 1,000 bed days compared with 6). This has been a consistent pattern for the last three years. Seclusion in Major cities facilities were longer on average (7 hours) than other areas (Table SECREST.3).

During 2021–22, hospitals located in Major cities had a physical restraint rate of 11 events per 1,000 bed days, which was higher than for other areas. Rates of mechanical restraint were low for all areas (Table SECREST.6).

Seclusion and restraint during a hospital stay can have a negative impact on a person’s recovery.

Some people with mental illness and their carers advocate that restrictive practices do not benefit the consumer and that these interventions infringe on human rights, are anti-therapeutic and compromise the therapeutic relationship between the consumer and the clinician (Melbourne Social Equity Institute 2014; NMHCCF 2021).

Seclusion and restraint in mental health settings can affect everyone involved, including patients, carers and health care staff.

A person’s experience of seclusion or restraint can vary. Research in this area identifies a range of factors that can impact a person’s experience and long term effects on mental health care. Common ones are physical environment and the extent of consumer and carer engagement in the service.

The hospital’s physical environment can be a key component of the impact of seclusion and restraint.

Access to basic necessities such as food, warmth and the ability to go to the bathroom change a person’s physical comfort through the experience and potentially lessen trauma. Providing mental stimulation has also been suggested to lessen mental distress.

Based on the experience of consumers and staff (provided in group discussions, surveys and other methods), researchers have noted that the physical environment of a service (such as its design and layout of indoor and outdoor spaces) could be a factor in preventing seclusion and restraint from occurring. If a person is able to separate themselves from stressful environments when required, the need for a seclusion or restraint event is lessened. 

Having the opportunity to access support from staff and family members throughout a person’s hospitalisation and in crisis situations, may also help in this regard.

Meaningful consumer engagement in service design and delivery can reduce the use and impact of seclusion and restraint.

Researchers and people with lived experience have described multiple ways for services and consumers to engage to improve service delivery and reduce seclusion and restraint. This can include:

• integrating the perspectives of people with lived experience in service planning
• including the consumer in decisions regarding their treatment
• having strategies in place for consumers at greater risk of becoming secluded or restrained
• use of reflective practice where consumers and staff are brought together to discuss an event of seclusion or restraint and create plans to avoid repeated use
• training with clinical and non-clinical staff (such as security personnel).

Figure 4 shows the rates of seclusion, mechanical restraint and physical restraint for Australian public hospital mental health care.

During 2021–22, the highest rates by hospital were 24 for seclusion, 14 for mechanical restraint and 80 for physical restraint. Of the 135 hospitals:

• 60% had a rate of zero for mechanical restraint (81 hospitals)
• 13% had a rate of zero for seclusion (17 hospitals)
• 7% had a rate of zero for physical restraint (9 hospitals).

Figure SECREST.4: Rates of seclusion and restraint for individual Australian public hospital mental health care

All Australian states and territories have legislation and associated regulations on the rights and treatment of people with mental illness in health care. Legislation varies between states and territories but all include criteria for when and where seclusion and restraint may be used.

Seclusion and/or restraint in health services can be used to provide safety and containment at times when this is considered necessary to protect patients, health service staff and others. However, use of these practices can also be distressing for the consumer, support people, representatives, other patients, staff and visitors. Wherever possible, alternative ways of managing a consumer’s behaviour should be used instead of seclusion and restraint.

“…Seclusion and restraint should only be used in accordance with approved protocols and best practice by properly trained professional staff in an appropriate environment…” (RANZCP 2021). More information about seclusion and restraint for Australian and New Zealand mental health legislation is on the RANZCP website (RANZCP 2017a, 2017b).

Seclusion and restraint are examples of restrictive practices in a care setting. A restrictive practice is any practice or intervention that restricts a person’s rights, including their freedom to move (Australian Government 2014; SQPSC 2016).

Minimising the use of seclusion and restraint in mental health services is a key focus across multiple sectors—including consumers, carers, governments and services. The National Mental Health Consumer and Carer Forum maintains that seclusion and restraint and other restrictive practices are avoidable and preventable (NMHCCF 2021). The Royal Australian and New Zealand College of Psychiatrists acknowledges in its position statement that seclusion and restraint should only be used “…as a safety measure of last resort where all other interventions…” were considered (RANZCP 2021).

Another example of a restrictive practice is involuntary treatment. This is the compulsory assessment or treatment of people in mental health services without the person's consent being given. This can also be legally approved under certain conditions. More information about this is in the Involuntary treatment report.

Rates of seclusion and restraint are included in the Key Performance Indicators for Australian Public Mental Health Services. These indicators contribute to measuring the performance and progress of mental health services in Australia. The indicators are also reported on the Performance indicators monitoring page. Refer to the data source section for more information.

It is a policy priority in Australian mental health care to work towards eliminating seclusion (CHC 2017; National Mental Health Working Group 2005 as cited in NMHPSC 2013). This has been supported by changes to legislation, policy and clinical practice as well as:

• former national mental health committees, including the Safety Quality Partnership Standing Committee and Mental Health Information Strategy Standing Committee (Allan et al. 2017, SQPSC 2017)
• the Towards Eliminating Restrictive Practices (TERP) Forum, supported by all governments to share results, best practice and change to remove seclusion and restraint practices in mental health
• the National Mental Health Commission’s Statement on seclusion and restraint in mental health, which called for leadership including “…national monitoring and reporting on seclusion and restraint across jurisdictions and services” (NMHC 2015).

Rates are a way to calculate how often something happens in relation to something else. An example is the number of mental health-related prescriptions that are given for every 1,000 people.

In this report, rates are used to describe how often seclusion and restraint happen in Australian public hospital mental health services against a set number of days that a patient (or patients) used a bed in a service or group of services. This is known as patient days or bed days. This report uses statements to report the number of seclusion or restraint events for every 1,000 bed days.

Why do we use rates?

Using only the number of events shows how much an event has happened. Without context, this number does not help us to draw any further conclusions. However, if we measure the number of events in relation to something else, like a period of time, we can determine how often it occurs. This also allows us to compare different groups, as we can measure each group in the same way.

An example

Using rates means that a large mental health service can be assessed in the same way as a smaller service and we can better compare their performance. Here is an example with two hypothetical services.

Service A reports more seclusion events than Service B (100 vs 50). Using these numbers alone, it appears that Service A uses seclusion more than Service B. However Service A is a larger service with more bed days, showing it has more service activity than Service B (10,950 vs 4,015). If we convert the number of seclusion events to a rate, we can see that Service A actually uses seclusion less often than Service B compared to the amount of activity the service provides (9 vs 12).

By assessing the activity of the two services against the same measurement (a rate), their activity can be compared despite the difference in size.

Direct comparisons between states and territories and over time should be made with caution for the following reasons.

• States and territories have different policies, regulations and legal criteria for the use of seclusion and restraint.
• States and territories have different systems in place for collecting data. Even though the data specifications provide some national compatibility there may be differences in counting and recording practices. These are noted in the General and Specific information tabs of the data download. It is expected that data quality will continue to improve over time, but these improvements also mean that year to year data methodologies may differ.
• High numbers of events for a few individuals can have a disproportional effect on the overall rates. For example, the increases in the state-wide Tasmanian seclusion rate between 2012–13 and 2013–14, for the ACT from 2017–18 to 2019–20, for SA in 2017–18 and 2018–19, and for WA in 2018–19, are due to a small number of clients having an above average number of seclusion events.

Data for smaller jurisdictions should be interpreted with caution as small changes in the number of seclusion or restraint events can have a marked impact on their overall rate. Further data quality information is in the data source section. 

Target population represents the age group that the mental health service is intended to serve, not the age of individual patients.  

Forensic services provide services largely for people whose health condition has led them to commit, or be suspected of committing, a criminal offence or make it likely that they will reoffend without adequate treatment or containment. The average duration of a seclusion event is reported excluding Forensic services, as forensic seclusion events are typically of longer duration, and substantially skew the overall duration average.

National Seclusion and Restraint Database

Seclusion and restraint data reported in this section are from the National Seclusion and Restraint Database (NSRD). Data are supplied by each Australian state and territory, under the Mental health Seclusion and Restraint National Best Endeavours Data Set (SECREST NBEDS) agreement. Historical data are available from 2008–09 for seclusion and 2015–16 for restraint. Data on the use of seclusion and restraint by hospital were reported for the first time in December 2018. Public reporting enables services to review their individual results against other states and territories, national rates and like services, thereby supporting service reform and quality improvement agendas.

Although seclusion and restraint may occur across a range of mental health service settings, the scope of the NSRD and SECREST NBEDS is hospital units that provide specialised mental health care. Only acute units are included, which provide short-term care. This service setting has been the focus of many associated quality improvement initiatives, including data collection and reporting developments.

Data Quality Statements are published annually on METEOR. Statements provide information on the institutional environment, timeliness, accessibility, interpretability, relevance, accuracy and coherence. Refer to the National Seclusion and Restraint Database; Mental health seclusion and restraint NBEDS 2015-, 2022; Quality Statement. Previous years' data quality statements are also accessible in METEOR.

National indicator set

Data from the National Seclusion and Restraint Database are also used for the Key Performance Indicators for Australian Public Mental Health Services (KPIs). These include the indicators KPI 15 Seclusion rate and KPI 16 Restraint rate draw on the National Seclusion and Restraint Database for reporting.

The original KPI set was released in 2005, with the aim to measure and improve the performance of public mental health services. The indicators have been revised over time through the former National Mental Health Performance Subcommittee (NMHPSC) of the former Mental Health Information Strategy Standing Committee (MHISSC), to drive and incorporate improvements made to data sources, jurisdictional implementation and results of nation-wide projects (NMHPSC 2013).

Rate of seclusion was added to the national KPI set in 2011 (NMHPSC 2013) and rate of restraint was added in 2018. Both indicators fall under the priority area of safety in mental health services, in which reducing the use of seclusion and restraint is considered a key aspect (CHC 2017; National Mental Health Working Group 2005 as cited in NMHPSC 2013).

In 2022 the new National Mental Health and Suicide Prevention Agreement and Bilateral Agreements were signed by the Australian Government and state and territory governments. While performance indicators for these agreements have not yet been established, seclusion and restraint are listed as priority data and Indicators for Development in the National Agreement (Australian Government 2022). Seclusion and restraint rates as measured in the KPIs will continue to be reported until indicators for the new National Agreement become available.

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