Seclusion and restraint in mental health care Print this page

• Seclusion is when a person is locked alone in a room and cannot leave by themselves. The national seclusion rate (events per 1,000 bed days) halved from 14 in 2009–10 to 6 in 2022–23. This is real change in how services used seclusion. 
• Mechanical restraint is when items are used on a person’s body to stop them moving freely, such as belts or straps. Mechanical restraint is relatively low, with a national rate of 2 events per 1,000 bed days in 2015–16 and 1 in 2022–23. 
• Physical restraint is when staff use their hands or body to stop a person moving freely. The physical restraint rate has been essentially steady between 10 to 12 events per 1,000 bed days since 2015–16. Refer to Table 1.

In Australia there are legal and regulatory frameworks which govern the use of seclusion and restraint 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 10 years.

• The national seclusion rate has more than halved over the last decade. 
• People in acute hospital care were secluded 9,964 times during 2022–23, a rate of 6 events per 1,000 bed days. 
• Seclusion lasted for 6 hours on average, excluding Forensic services.
• Duration of seclusion for Forensic services is calculated separately. In 2022–23 seclusion in Forensic services lasted for 43 hours on average.

Data on restraint are available for over 5 years.

• There were 16,452 physical restraint events and 1,127 mechanical restraint events during 2022–23, rates are 10 and 1 events per 1,000 bed days respectively. 
• Since data coverage began, the national physical restraint rate has been essentially steady. Mechanical restraint has a consistently lower rate. 

Data are also reported under the Mental health performance indicators. 

• Child and adolescent services have the highest seclusion rate with a rate of 12 events per 1,000 bed days.
• Forensic services have the highest rates of mechanical restraint. Child and adolescent services have the highest rate of physical restraint. 

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 1.1 shows the number of times seclusion and restraint events were recorded in Australian public hospital mental health care during the last decade.

• Data on seclusion are available since 2009–10. Nationally during 2022–23, there were 9,964 seclusion events with a rate of 6 events per 1,000 bed days.
• Data on restraint are available since 2015–16.   Nationally there were 16,452 physical restraint events and 1,127 mechanical restraint events during 2022–23, rates are 10 and 1 events per 1,000 bed days respectively. 

Figure 1.2 shows how long seclusion lasted, in average hours, in Australian public mental health care during the last decade.

• Nationally during 2022–23, seclusion lasted for 6 hours on average, excluding Forensic services.

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.

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 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).

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.

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 makes 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.

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-, 2023; Quality Statement. Previous years' data quality statements are also accessible in METEOR.

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. 

Askew L, Fisher P and Beazley P (2019) ‘What are adult psychiatric inpatients’ experience of seclusion: a systematic review of qualitative studies’, Journal of Psychiatric and Mental Health Nursing, 26:274–285, doi: 10.1111/jpm.12537

Brophy LM, Roper CE, Hamilton BE, Tellez JJ and McSherry BM (2016a) ‘Consumers’ and their supporters’ perspectives on barriers and strategies to reducing seclusion and restraint in mental health settings’, Australian Health Review, 40 (6): 599–604, doi: 10.1071/AH15128

Brophy LM, Roper CE, Hamilton BE, Tellez JJ and McSherry BM (2016b) ‘Consumers and their supporters’ perspectives on poor practice and the use of seclusion and restraint in mental health settings: results from Australian focus groups’, International Journal of Mental Health Systems, 10 (6), doi: 10.1186/s13033-016-0038-x

Foxlewin B (2012) What is happening at the Seclusion Review that makes a difference? – a consumer led research study, ACT Mental Health Consumer Network, accessed 19 August 2022.

Hansen A, Hazelton M, Rosina R and Inder K (2022) ‘What do we know about the experience of seclusion in a forensic setting? An integrative literature review’, International Journal of Mental Health Nursing, 31: 1109–1124, doi: 10.1111/inm.13002

Hawsawi T, Power T, Zugai J and Jackson D (2020) ‘Nurses’ and consumers’ shared experiences of seclusion and restraint: a qualitative literature review’, International Journal of Mental Health Nursing, 29 (5):831–845, doi: 10.1111/inm.12716

Muir-Cochrane E, O’Kane D and Oster C (2018) ‘Fear and blame in mental health nurses’ accounts of restrictive practices: implications for the elimination of seclusion and restraint’, International Journal of Mental Health Nursing, 27: 1511–1521, doi: 10.1111/inm.12451

NSW Health (2017) Review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities, NSW Health, New South Wales Government, accessed 19 August 2022.

NMHCCF (National Mental Health Consumer and Carer Forum) (2021) Restrictive Practices in Australian Mental Health Services, NMHCCF, accessed 15 December 2022.

Allan J, Hanson G, Schroder N, O’Mahony A, Foster R & Sara G (2017) 'Six years of national mental health seclusion data: the Australian experience', Australasian Psychiatry, 25(3):277–281, doi:10.1177/1039856217700298.

Australian Government (2014) National Framework for Reducing and Eliminating the Use of Restrictive Practices in the Disability Service Sector (the ‘National Framework’), accessed 31 August 2021.

Australian Government (2022) The National Mental Health and Suicide Prevention Agreement, accessed 2 March 2023.

CHC (COAG [Council of Australian Governments] Health Council) (2017) The Fifth National Mental Health and Suicide Prevention Plan, Department of Health, Canberra.

Gee A, Harris M, Burgess P, and Thomson J (2022) Use of a clinical outcomes national data collection in measuring performance of mental health services. 12th Health Services Research Conference, 30 Nov–2 Dec 2022, Sydney Australia.

Melbourne Social Equity Institute (2014) Seclusion and Restraint Project: Overview, University of Melbourne, Melbourne.

NMHC (National Mental Health Commission) (2015) Statement on seclusion and restraint in mental health, NMHC, Sydney, accessed December 2020.

NMHCCF (National Mental Health Consumer & Carer Forum) (2020) Restrictive Practices in Australian Mental Health Services, NMHCCF website, Canberra, accessed 7 February 2023.

NMHPSC (National Mental Health Performance Subcommittee) (2013) Key Performance Indicators for Australian Public Mental Health Services, 3^rd edn, NMHPSC, Australian Health Ministers Advisory Council’s Mental Health Drug and Alcohol Principal Committee (MHDAPC).

RANZCP (Royal Australian and New Zealand College of Psychiatrists) (2017a) Restraint – mental health legislation , RANZCP, Melbourne, accessed 15 February 2022.

RANZCP (2017b) Seclusion – mental health legislation, RANZCP, Melbourne, accessed 15 February 2022.

RANZCP (2021) Position Statement 61: Minimising and, where possible, eliminating the use of seclusion and restraint in people with mental illness, RANZCP, Melbourne, accessed 2 February 2022.

Sallway R, Gee A, and Thomson J (2022) The impact of making seclusion and restraint data visible: Innovation, collaboration and change in mental health care. 12th Health Services Research Conference, 30 Nov–2 Dec 2022, Sydney Australia.

SQPSC (Safety and Quality Partnership Standing Committee) (2016) National Principles for Communicating about Restrictive Practices with Consumers and Carers, NMHC, accessed 31 August 2021.

SQPSC (2017) Use of restraint in Australian specialised mental health hospital services: Discussion paper on the development of a national data collection.