Is Victoria on track to eliminate the use of seclusion in mental health?

During the recent Royal Commission into Victoria’s Mental Health System, the mental health system was recognised as being broken – under-resourced, under-staffed, and failing to meet the needs of people with lived and living experience, their families, carers and supporters. 

It found a system intended to respond and support people in need was relying on restrictive approaches that cause harm, and provided a reactive rather than proactive response to people in mental health crises. 

Individuals were falling through gaps across multiple systems when trying to access services, or were simply not able to navigate complex systems that often operated in silos. 

The royal commission’s final report, released in 2021, set out 65 recommendations to transform Victoria’s mental health system, with the Victorian government committing to all. 

In particular, recommendation 54 centred on the elimination of seclusion and restraint in mental health services. The royal commission recommended the government “… act immediately to reduce the use of seclusion and restraint in mental health and wellbeing service delivery, with the aim to eliminate these practices within 10 years”.

Understanding seclusion and restraint in mental healthcare

The Australian Institute of Health and Welfare describes seclusion as “… the confinement of a person at any time of the day or night alone in a room or area from which free exit is prevented”. Restraint is “when a person is held to stop them moving their body” either through physical means by way of arms or hands, or mechanically with the use of straps or belts.

The use of seclusion and restraint is a type of formal coercion that is highly regulated, with its use documented – it’s an intervention legislated by the Mental Health and Wellbeing Act 2022. The act stipulates it can only be used as a last resort to prevent imminent and serious harm to the person being secluded or others, and when less restrictive options have been unsuccessful.

Barriers to eliminating restrictive practices

Anecdotally, the elimination of seclusion and restrictive practices within 10 years was identified as an ambitious target, especially given that direction was not provided to services as to how to achieve it. There also seemed to be a lack of consideration of differences in and between services that impact seclusion rates. These differences were often accounted for by consumer demographics, clinical presentations, organisational culture and service delivery models. 

Other concerns identified relate to service pressure to stop the use of restrictive interventions without viable alternatives, restrictions in the physical environment, workforce constraints, and a lack of education for novice nurses. 

Researchers have also criticised the lack of consideration of the needs of specific populations, such as women, whose complex, gender-specific differences and experiences weren’t addressed by the royal commission, yet require specific attention.

While seclusion aims to protect a person or others from harm, its use is widely known to be an intervention associated with physical and psychological trauma, and in some cases has resulted in death. 

Coercive measures used in mental health services, such as seclusion, have long been associated with human rights concerns. These concerns are primarily related to breaching fundamental human rights that impact on a person’s autonomy and freedom of movement. While the use of seclusion continues to be legislated, it’s likely to remain in use in clinical practice. 

Seclusion use remains high

Victoria is approaching the halfway point – at five years – on the timeframe of seclusion elimination. Despite reductions in seclusion use over time, its use across Victorian mental health services remains high, yet no longer the highest reported rate across the country.

Between 2023-24, the Australian Institute of Health and Welfare (2024) reported five seclusion events per 1000 bed days nationally. General mental health services report six seclusion events per 1000 bed days, nationally. For the same period, Victoria reported five events per 1000 bed days – down from seven events in 2022-23 when it was one of the highest states for seclusion use. This is somewhat promising, but is it enough, and will it be sustained?

In other specialised settings, such as child and adolescent and forensic mental health settings, the rates are higher. For example, child and adolescent services report 12 events per 1000 bed days, while forensic mental health settings report nine events per 1000 bed days. 

But we accept the complex nature of these services and the consumers in which they serve are different to a general mental health service. However, the drive for seclusion elimination remains regardless of the setting. 

Decreasing and working towards elimination of restrictive practices, including seclusion, has been a part of mental health reform over the past decade. Over time, the rate of seclusion in Victoria has decreased dramatically, from 19 events per 1000 bed days in the period 2008-09, noting national data was routinely collected from 2011. 

This is certainly promising and reflects capacity for change. But it begs the question: Is elimination achievable within the next five years to meet the government’s 10-year elimination target? 

Approaches to reduce practices

There are several approaches used currently to reduce the use of restrictive practices, which are reported to have varied success. 

Safewards is an evidence-based model that aims to reduce risk and coercion for consumers and staff in mental health, by identifying factors or “flashpoints” that may result in conflict that results in seclusion, such as crowding, noise or interpersonal conflict. 

Another approach is the Six Core Strategies for Reducing Seclusion and Restraint Use, which similarly aims to reduce the use of seclusion and restraint through targeted strategies across six areas, including leadership, data-informed practice, workforce development, use of seclusion and restraint reduction tools, the roles of consumers, and techniques for debriefing. 

While current seclusion reduction approaches have been found to be somewhat effective, limitations remain, as does the clarity on how mental health services cease seclusion use.

Literature regarding staff perceptions of seclusion use indicates ongoing conflict and the dichotomy between recognising the harms associated with seclusion and subsequently the desire not to use it at all, with how to respond to and perhaps manage behaviour where it does present a risk to the person or other people. 

This is especially important where other, less-restrictive options have been unsuccessful. While studies have recognised that staff do not want to use seclusion, there’s noted fear in relation to the potential elimination of seclusion in the context of safety.

Are services on track to end seclusion?

Health services in Victoria need to continue to work towards elimination in such a way that supports and ensures safety for both consumers and staff, across all mental health settings. 

This is a complex issue, but one that requires ongoing attention to achieve elimination, remove human rights violations and reduce harms for the people mental health services are supporting. Progress towards elimination should be transparent and easily available to the public to ensure and support accountability. 

The next five years are crucial for mental health services to meet the elimination target and deliver mental health services that are free from such formal coercive practices. 

Will Victoria provide a roadmap to the rest of the country as to how the elimination of restrictive interventions will be achieved?