Background
In Australia, the six states and two territory governments fund and deliver public sector mental health services that provide specialist care for people with severe mental health problems. It is estimated that 2–3 % of Australians (about 600,000 people) have a diagnosis of a severe mental disorder defined as including severe depression, anxiety or psychosis [
1] and that approximately 0.5 % have some form of psychotic disorder, most often diagnosed as schizophrenia [
2]. Each state and territory has mental health legislation that enables the compulsory detention and treatment for those with severe mental health problems providing strict criteria are met [
3].
Seclusion and restraint are interventions currently permitted for use in mental health services and other settings to control or manage a person’s behaviour. Seclusion generally refers to the deliberate confinement of a person, alone, in a room or area that he or she cannot freely exit. Each state and territory regulates the use of seclusion through its mental health legislation [
4]. Rates of seclusion are falling in Australia with 7.8 seclusion events estimated per 1000 bed days in 2014–2015; a decrease from 11.8 in 2010–2011 [
5].
Restraint may encompass the use of bodily force (physical restraint) or a device (mechanical restraint) to control a person’s freedom of movement. It may also refer to the use of medication (chemical restraint) to control a person’s behaviour rather than to treat a mental disorder. Despite the possible adverse effects of physical and mechanical restraint, only mechanical restraint is regulated in every state and territory under mental health legislation [
6]. Physical restraint is regulated under policies and/or mental health legislation in the six states and the Australian Capital Territory, but is not regulated at all in the Northern Territory. The rates of restraint are difficult to estimate in Australia due to differences in reporting requirements across the states and territories and the current lack of national data collection.
Serious concerns about the use of seclusion and mechanical restraint in mental health services have been raised at least since 1993 [
7]. There have been adverse findings by investigators regarding serious injuries resulting from the use of bodily force [
8] as well as concerns raised about deprivations of liberty, interference with personal integrity and loss of dignity. A number of studies have noted adverse consequences for those subjected to seclusion and mechanical restraint [
9,
10] and raised concerns with human rights breaches [
4].
In 2008, the National Mental Health Policy set out that Australian mental health services should adopt a recovery-oriented approach [
11] and there is now a National Framework for Recovery-Oriented Mental Health Services [
12]. In tandem with the recovery movement, an emphasis on human rights is shaping mental health law reform [
13,
14]. The Convention on the Rights of Persons with Disabilities, which Australia has ratified sets out as its first guiding principle in Article 3, ‘[r]espect for inherent dignity, individual autonomy including the freedom to make one’s own choices’. This emphasis on recovery and rights provides an ethical conceptual framework for viewing the use of seclusion and restraint as inherently problematic [
15]. As outlined below, the harmful effects of seclusion and restraint raise issues as to whether recovery-oriented practice and the use of seclusion and restraint are compatible [
16].
Consumers of mental health services (‘consumers’) have expressed strong views about the harm of seclusion and all forms of restraint [
17]. Consumers and their families, friends and other supporters (‘supporters’) have also raised concerns with what has been termed ‘emotional restraint’ whereby consumers feel constrained from expressing their views openly and honestly to staff for fear of the consequences [
18]. Emotional restraint in this sense is about been pressured to comply with behavioural expectations.
Judi Chamberlin has made the point that for those ‘labelled with mental illness…outright prejudice and discrimination…is just as real, and as disabling, as those faced by other devalued groups’ [
19]. While she acknowledges ‘stigma’ is often used in relation to the experiences of consumers, she points out that this word locates the problem as within the individual [
19]. In order to counteract emotional restraint, prejudice and discrimination, it is essential that the perspectives of consumers and their supporters are aired and valued in a system which may be based as much on coercion as care.
This paper reports on the outcomes of ten focus groups in which consumers and their supporters discussed the effects of seclusion and restraint and what consumers and supporters viewed as ‘poor practice’ and its causes leading to the use of these interventions. ‘Poor practice’ is used in this paper as a general term to describe behaviour identified as unacceptable by consumers and their supporters.
Since the late 1990s a number of qualitative interview studies, spread across a range of individual inpatient settings, have been conducted in relation to consumer perspectives on seclusion and mechanical restraint internationally [
20‐
23]. While these have conveyed vivid accounts of consumer experience, the lack of detail about the legal or practice context for the use of seclusion and restraint can limit the opportunity for comparison across jurisdictions. Several other studies have used questionnaires [
24‐
27] and in these studies the samples are also specific to one service, with the exception being one study which compared psychiatric services across New York state [
27]. Studies vary widely in how soon after seclusion or restraint events people are interviewed, ranging from 3 days after to many years later. Despite their diversity, these studies raise many shared concerns.
As noted in a recent review [
28], consumer experiences of physical restraint and seclusion are reported as overwhelmingly negative, associated with immediate escalation of distress, and intense feelings such as despair, shame, terror and rage [
29]. Patients reported feeling: frightened, anxious, angry, helpless, humiliated and vulnerable, re-traumatised by the experience [
23]; abandoned, deserted, excluded and rejected [
20]. Harms were experienced before, during and after the incidents [
30]. Other detailed impacts include: a sense of injustice [
21], and of being punished and powerless [
22]. A significant subset of participants reported experiences strongly suggestive of poor practice in the use of seclusion and restraint, such as patronising communication, physical harassment and insulting communication [
32] and extreme use of force [
22]. In one US study, participants reported a sense of being both punished and abandoned by staff, particularly in relation to ‘non-professional’ (security/attendant) staff [
33].
A small number of studies, or a minority of consumer participants within studies, report positive views, such as: that seclusion provided an opportunity for meditation [
33]; or that the use of restraint had a calming effect [
23]. In one Canadian study, patients reported on comfort and safety of seclusion rooms and the meeting of their physical needs [
26].
The negative effects experienced overall can obscure differences in experiences, between people and settings. In this regard, it may be that there are important differences between poor and better practices, and the associated impacts may differ.
There is a dearth of literature dealing with the perspectives of supporters on the topic of seclusion and restraint. Recent studies explore ‘carer’ views about coercion in community settings [
16,
34]. These studies raise concerns about the nature and experience of social control and the lack of human responsiveness to emerging crises that are later managed via acts of coercion.
In summary, there is a gap in the literature pertaining to a broad range of consumers’ and their supporters’ perspectives on the use of seclusion and restraint. Most of the studies concerning consumers outlined above have been conducted within a single jurisdiction and mainly from a single site. There is also a lack of studies concerning supporters’ perspectives. As indicated above, despite the growing emphasis on recovery and rights, this gap may be the result of a system that reflects societal and organisational power dynamics [
15].
To fill this gap, as part of a larger study conducted by the Melbourne Social Equity Institute at the University of Melbourne and funded by Australia’s National Mental Health Commission, five focus groups for consumers and five focus groups for supporters were conducted in Melbourne, Shepparton, Perth, Brisbane and Sydney. This paper focuses on the discussions concerning the effects of seclusion and restraint on consumers and supporters and what the participants thought was poor practice in this regard and what contributed to it.
Discussion
The themes presented in this paper are based on the questions used in the focus groups to guide discussion and the themes that emerged in the data analysis, which used a general inductive approach [
36]. The responses suggest that many participants attended the focus groups in order to express their concerns about poor practice in mental health settings as well as raise concerns about the use of restraints in emergency departments and by the police.
The traumatic impact of seclusion and restraint represents one of the major themes that were apparent across the focus group discussions. Participants identified seclusion and restraint as nontherapeutic, anti-recovery and an abuse of human rights. The traumatic effects of these practices are long-standing and not limited to an acute or inpatient setting. Participants also recognised specific challenges for Indigenous and culturally and linguistically diverse populations. The findings indicate the need for further, specific investigation into the use of seclusion and restraint involving minority and marginalised groups.
Participants gave a number of examples of poor practice, including the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of contributing factors to poor practice identified revolving around organisational culture, the physical environment, under-resourced mental health services and fear and ‘stigma’. The latter term was used by participants rather than ‘prejudice’ or ‘discrimination’, but stigma in common parlance could be interpreted as meaning unwarranted negative attitudes as well as the societal codification of such attitudes, rather than locating the problem within the individual as Chamberlin has defined this term [
19].
These findings suggest that groups of consumers and their supporters across Australia share similar concerns about the harm caused by the use of seclusion and restraint. The harms identified were viewed as being caused by the intrinsic effects of excessive force, isolation and the breaching of human rights, particularly in relation to the loss of dignity. Such harms were viewed as longstanding for consumers and for supporters and usually (re)traumatising. Participants also raised concerns about the lack communication and interaction in mental health services alongside practices of ‘othering’, paired with stigma and fear. Only one participant expressed the view that seclusion and restraint was a ‘necessary evil’.
These findings indicate that consumers and supporters view ‘poor practice’ as indicative of a system which expects and condones mental health practioners to use seclusion and restraint to manage behaviour, despite consumers experiencing such practices in an overwhelmingly negative way. This suggests that it is institutional cultures and norms that require addressing [
15].
The focus groups were deliberately small and based on participants opting into participate. This means that the generalisability of the findings is limited. There were both ethical and financial constraints on the project that limited the potential for more targeted purposive sampling. However, a broad range of participants did attend, the discussions were lengthy and fruitful and a safe environment for the discussion of such potentially sensitive issues was achieved. This was particularly supported by having a co-facilitator who shared the participants’ lived experience.