The Contraindications of
Seclusion:
Is There a Proper Role?
James R. P. Ogloff AM
A very long tradition!
Have the patient lie in a moderate and
slightly warm room. The room
should be perfectly quiet, unadorned
by paintings…and the bed should be
firmly fastened down. It should face
away from the entrance to the room so
that the patient will not see those who
enter. In this way the danger of
exciting and aggravating his madness
by letting him see many different faces
would be avoided.
- Soranus of Ephesus (Greek Physician,
2nd Century AD)
and of course Pinel (1745-1826)
“If a madman suddenly experiences an unexpected attack and
arms himself with a log, a stick, or a rock, the director –
always mindful of his maxim to control the insane without
ever permitting them to be hurt – would present himself in
the most determined and threatening manner but without
carrying any kind of weapon, so as to avoid additional
vexation. He speaks with a thundering voice and walks
closer toward the maniac in order to catch his eye. At the
same time, the servants converge on him at a signal, from
behind or sideways, each seizing one of the madman’s limbs,
an arm, a thigh, or a leg. Thus they carry him to his cell
while thwarting his efforts and chain him if he is very
dangerous or merly lock him up….
- Philippe Pinel, Memoir of Madness, 1794
and of course Pinel (1745-1826)
“But one must avoid any unnecessary constraints and use only
enough force to restrain them. Great skill is required to
retain the insane locked in their cells only for the necessary
length of time and only while they are capable of extreme
acts of violence…
“Grant as much freedom as possible to those madmen who
content themselves with mere gesticulations, loud
declamations, and acts of extravagance that hurt no one. To
lock up this kind of madman on the pretext of maintaining
order means to impost needless constraints that provoke his
rebellion and violence and render his madness more inveterate
and often incurable”
- Philippe Pinel, Memoir of Madness, 1794
“I felt terribly distressed because
I was left alone. I felt like the rest
of the world doesn’t even exist
anymore. There’s just me and a
room like a tiny box, and if I
were to look through the
window, ashes would be all I’d
see.”
cited by Keski-Valkama 2010
Topics
• Is seclusion punitive?
• Is seclusion effective?
• Physical impact on patients
• Emotional impact on patients
• Emotional impact on staff
• Physical impact on staff
• Seclusion and suicide
• Is the total elimination of seclusion a possibility?
• Effect of reducing seclusion
• The proper role of seclusion
Seclusion – the sole confinement of the consumer at any
time of the day or night alone in a room, or other
enclosed space, from which free exit is prevented
Restraint – the restriction of an individual’s freedom of
movement by physical, mechanical or emotional means.
“Seclusion remains both a
controversial and common practice
in Australian mental health services,
despite the absence of evidence to
support the effectiveness of its use”
- Happell & Koehn, 2010
“Seclusion is a remnant of the dark days when restrain
was central to the management of mental disorder:
“Seclusion is not a treatment, in any accepted medical
sense. It is a response to violence or immediate
threat of violence, when treatment is insufficient to
counter the threat”
(Maden, 2008)
Is Seclusion Punitive??
• There is evidence to suggest that a proportion of
nurses consider seclusion to have therapeutic
benefits by facilitating a sense of calmness
(Happell & Koehn, 2010)
• “It is important to bear in mind the patient
experience. Most surveys find, not surprisingly,
that seclusion is experienced as unpleasant and
punitive”
(Maden, 2008)
Is Seclusion Punitive??
Queensland research with Aboriginal patients
(Sambrano & Cox, 2013)
• Seclusion was viewed as a negative experience
Participants viewed seclusion negatively:
1. police involvement in psychiatric care;
2. perceptions of being punished and
powerless;
3. occasions of extreme use of force;
4. patient displays resistance
5. power dynamics and dehumanising effects of
seclusion
Is Seclusion Punitive??
Queensland research with Aboriginal patients
(Sambrano & Cox, 2013)
• Aboriginal patients' experience
is that seclusion is consistent
with the discriminatory and
degrading treatment by
governments, police, and
health services that many
Indigenous people have
experienced since colonisation.
Is seclusion effective?
• Very little is known about the efficacy of
seclusion
(Happell & Koehn, 2010)
• Impossible to know ‘what might have been’
• Most research investigates the views and
experiences of patients and members of staff
(primarily nurses) AFTER the incident of
seclusion has taken place
• Often seclusion is followed by restraint and it is
impossible to tease out the effect of seclusion
itself
Physical impact on patients
• Research and clinical experience shows,
convincingly, that the process of secluding
patients can result in them being physically
harmed
• At the extreme end, a small number of patients
died during or after restraint and seclusion
• Positional asphyxia
• Choking
• Neck compression
• Catecholamine rush
Emotional impact on patients
• Patients often experience emotional turmoil as a
result of seclusion
• Many patients interviewed one year following a
seclusion episode still felt bitter at being
secluded
(Wadeson & Carpenter, 1976)
• Those with histories of abuse may experience
the process of seclusion, and seclusion itself, as
a re-enactment of their original trauma
(Gallop, McKay, Guha, & Khan, 1999)
Emotional impact on patients
• Apparent calm does not necessarily imply a
sense of psychic well-being
- Patients who reported feeling calm during
seclusion often simultaneously described
themselves as angry and depressed
(Brown & Tooke, 1992)
Emotional impact on staff
• It is not unusual for staff to feel a degree of
emotional turmoil when secluding a patient.
• At the same time, staff have stated feeling safer
and more secure when a patient is secluded.
• Patients’ attribute a high degree of anger,
annoyance, and punitive intent to nurses when
being restrained and secluded
(Brown & Tooke, 1992)
Physical impact on staff
• On occasion staff members are injured during
the seclusion process or by a secluded patient
• An investigation into inpatient aggression
revealed that of 32 acts of physical aggression
toward staff in acute wards at Thomas Embling
Hospital, 20 occurred in the context of restraint
or seclusion
(Daffern, Mayer, & Martin, 2003)
Physical impact on staff
• Nursing staff were more frequently the victims of
aggression than other staff
• partly due to their large numbers and because
of the reliance on nursing staff to restrain and
seclude aggressive patients
(Daffern, Mayer, & Martin, 2003)
• Most injuries toward nurses occurred during the
holding stage of restraining patients
(Moyo & Robinson, 2012)
Seclusion and suicide
• Suicidal individuals respond poorly to seclusion;
an alternative is 1:1 nursing care
(Horsfall & Clearly, 2003)
• A degree of hopelessness is almost always
present among suicidal patients; since seclusion
contributes to feelings of hopelessness, it may
inadvertently escalate the risk of suicide among
some patients
Is there currently an overuse of seclusion?
• Seclusion rates have been generally going down
in the past few years
• Nonetheless, seclusion is still seen as an option
• Finnish study showed
that the most
common reason for
seclusion was
agitation/disorientatio
n of the patient
without any actual
evidence of violence
or property damage
(Kalitana-Heino, 203)
Swinburne
Is the total elimination of
seclusion a possibility?
SCIENCE | TECHNOLOGY | INNOVATION | BUSINESS | DESIGN
Is the total elimination of seclusion a
possibility?
No. (Liberman, 2006)
“the assumption that
seclusion and restraint can
be ultimately eliminated from
psychiatric practice to
‘improve the quality of
people’s lives’, is laudable in
idealism but lacking in clinical
reality.”
SCIENCE | TECHNOLOGY | INNOVATION | BUSINESS | DESIGN
Swinburne
Is the total elimination of seclusion a
possibility?
No. (Liberman, 2006)
“the assumption that
seclusion and restraint can
be ultimately eliminated from
psychiatric practice to
‘improve the quality of
people’s lives’, is laudable in
idealism but lacking in clinical
reality.”
SCIENCE | TECHNOLOGY | INNOVATION | BUSINESS | DESIGN
Swinburne
Yes. (LeBel & Huckshon, 2006)
“Pennsylvania has eliminated
restraint and seclusion all
together at two state
hospitals and eliminated
seclusion”
How does reducing seclusion affect nursing staff
members’ confidence in managing aggressive
patients?
• Research at Thomas Embling Hospital revealed
a significant reduction in seclusion
 with NO decline in staff confidence in
handling aggression
 no indication that the environment became
less sage for either staff or patients.
 No change in staff or patient perception of
therapeutic climate despite a reduction in
seclusion
(Ching, Daffern, Martin, & Thomas, Daffern, Mayer, &
Martin, 2010)
The proper role of seclusion in contemporary mental
health care
• The culture surrounding the use of seclusion must
change, and it has been changing
• Seclusion must be used sparingly, following strict
protocols and procedures
• When used appropriately, seclusion should not be
seen as a ‘therapeutic failure’
 of either the staff or consumer!
When can restrictive interventions be used?
Mental Health Act 2014
Restrictive interventions may only be used on
a person after all reasonable and less
restrictive options have been tried or
considered and have been found to be
unsuitable (s. 105).
Restrictive interventions may only be used if it
is ‘necessary to prevent imminent and
serious harm to the person or to another
person’ (s. 110 and s. 113).
Best practice
Engagement with consumers and carers
• The use of restrictive interventions needs to reflect
trauma-informed care principles.
• Experiences of trauma are common among
consumers and the use of restrictive
interventions has the potential to be experienced
as a traumatic event and/or trigger previous
traumatic experiences.
• Responses may be extreme and may include
symptoms such as flashbacks, hallucinations,
dissociation, aggression, self-injury and
depression.
• Advance statements and safety plans should be
used to ensure care is trauma-informed. Carers can
provide valuable insights to assist mental health staff
in this regard.
Best practice
Engagement with consumers and carers
• There is a greater chance of avoiding the use of
restrictive interventions when there is the full and
informed inclusion of consumers and carers in
discussions about the use of restrictive interventions.
• Every effort must be made to routinely provide
information sensitively to consumers and carers
about the use of restrictive interventions.
• It is important for staff to listen, and respond to
consumer and carer concerns about the use of
restrictive interventions.
Best practice
Engagement with consumers and carers
• While it is appropriate to provide information
about these interventions to carers in general
terms, it is only where the consumer
consents to the disclosure of specific
planning involving the potential use of a
restrictive intervention, that the details can
be discussed with carers.
Staff training and education
Training must develop:
• Proficiency in the use of ‘evidence based’
preventative strategies (such as de-escalation
techniques and the use of sensory modulation)
to ensure restrictive interventions are used
minimally.
• Proficiency in using approved techniques.
• An awareness of the consumer experiences of
compulsory treatment and restrictive
interventions.
• An understanding of the causes of aggressive or
threatening behaviour.
Staff training and education
Training must develop:
• An awareness of the impact of staff behaviours
and attitudes on consumers.
• Proficiency in undertaking observation and
monitoring techniques.
• Proficiency in recognising signs of physical
distress during the use of restrictive
interventions.
• Proficiency in responding to escalating
emergency responses and basic life support
skills (CPR).
• An understanding of how medication can be
used to prevent and support a person who is
acutely agitated.