Seclusion and restrain has long been used as the adjunctive therapy to manage disturbed behaviours in psychotic hospital and resident facilities. The use of seclusion is extremely restrictive intervention regulated by Mental Health Act 1986 (New South Wales Government,
2012). In the light of advocate for the person’s rights, privacy, dignity or self-respect for individual with brain- affected illness the practice of seclusion is the current main concern of mental health. According to the prescribed article, this issue was raised again as a main focus of ACT forum reviewing on the achievement of seclusion reduction, the barriers of elimination of this practice and experts’ opinions regarding alternative interventions (Peake,
2013). The negative impact of this practice on health care providers and mental health service recipients has been acknowledged. However, seclusion receives wide support from health care providers, particularly nurses as a necessary behaviour management therapy
(Happell & Koehn, 2010). Many efforts have been made to reduce the use of seclusion but elimination of the practice is still controversial. This essay will discuss the use of seclusion as an intervention of maintaining safety in psychiatric setting and the detrimental impact of the practice on the individuals involved and, at the same time examine on better alternative measures and the opportunities to eliminate the practising of the intervention in different mental health care settings.
Aggression and violence that leads to the consequence of injury to self or other and damaging property are considered as destructive, challenging, behaviours in mental health setting, where zero violence intolerance is prioritized (Meadows et al, 2012). Seclusion is used among other sub-form of wider class of coercive intervention to “compels the patient behave in manner inconsistent with his own” (Paterson, 2012). Technically, the procedure is described by Elder et al (2012) as the involuntary supervised isolation of a patient in a locked, non-stimulating room. Essential materials such as blankets or mattress are provided.
In addition, some settings monitor patient from video screens in nurse’s station, while others nursing staff are outside the seclusion room door for the duration of the seclusion episode.
Functionally, seclusion use is intended to serve two purposes: to interrupt and contain harmful behavior including self-harm and other and damaging property, and to allow time for patient to calm down (Happell & Koehn, 2011). Apparently, the use of this practice, protects the patient or any other person from impeding risks to their health and safety or prevent other potential detrimental consequences, but Evan & Brown, 2013 warn that seclusion can increase aggression in patients may have legal implications and can be expensive.
Seclusion also put negative impact on individuals involved in the practice. In patient’s perspective, it is evidenced that seclusion impinged on their sense of autonomy as well as compromising the ability to trust self and others. They also experienced the intensified feeling of loneliness and isolation (Happell & Koehn, 2011). In the light of upholding the human rights in mental health service, seclusion is deemed to compromise and violate the rights of human. In addition, Peake (2013) reports the use of this practice have negative impact on the trust of patient on health care professionals whom they seek for help in the time of crisis. In staff perspective, they also experience emotional exhaustion or burnout as consumer’s perceived feeling is acknowledged. Mohr (2010) subscribes that in the light of western culture, being clocked in the room during seclusion period confining the human freedom and against self- determination, which, violates human rights At the same time, the support for the calming effect of seclusion on patient by direct care staff is also appreciated
(Happell & Koehn, 2011).
Whilst acknowledging the detrimental impact of seclusion practice on, bilateral aspects, health care providers and mental health service recipients, is clearly expressed, the ACT chief forum Professor Fels admitted the elimination of the seclusion is “not realistic” (Peake, 2013)
The statement is reasonably fit in forensic mental health setting where incidents of challenging behavior are prevalent. This is justified for the use of seclusion as containment measure in the setting where violence is the most common offence committed by mentally disordered offenders (Young & Mart, 2012). The authors also add that the patient with history of violence is more likely aggressive to as response to stimulant.
The justification for seclusion is to manage the aggression and violence with the aim to maintain the safe environment for both staff and patients. The rationale for this practice supported by the research conducted by Maureen et al (2009) that more than 90% of secluded patient is related to their destructive behaviors.
As mentioned above, seclusion and aggressive-violent behaviors presents as a vicious circle, which is important to break the sequence in order to reduce the rate of the use of the practice.
The key for this concern appears to be on the aggression and violence aspect. It is important to understand factors related to destructive behaviors as to de-escalate it. This idea is supported by a research conducted by Vruwink and colleagues, (2012) after conducting comprehensive examination on the determinants of seclusion after aggressions in psychiatric inpatients. It is also the main focus of the work by Maureen et al (2009) who suggest preventative measures of aggressive and violent behaviors. According to the authors, it is categorized into 3 levels. Primary prevention emphasizes on identification of potential disturbed behaviors though patient history taken during admission to formulate the care plan for the individual coined “Personal Safety Care Plan”. Secondary prevention is further development of previous care plan to meet the individual’s specific needs or requests.
Finally, tertiary prevention aims to reduce the negative impact on the seclusion on patient when other alternative interventions exhausting, which is concordant to the policy from New
South Wale Government (Ministry of Health New South Wale, 2012)
Scrutinizing the factors affecting the practice of seclusion in order to have an insight in all aspect of aggression and violence characteristics is a focus of research by Tyrer et al 2012.
The authors also find that these factors including mid age group, male gender, time, seasons, character of diagnosis frequency of mediation administer, have significant relationship with rate of seclusion. This information should be included as indications upon formulating the care plan for psychiatric patient with aim to preventing aggressive and violent. The ideas are also in the favor of the experts in the ACT forum, which emphasize the therapeutic intervention by identifying the triggers
Other alternative measures are also sought out with the aim of seclusion reduction. The use of medication is also a practice in many clinical setting as a containment measure. However, the use of medication against patient consent is consider worse than practice of seclusion in managing challenging behavior due to the violation of the integrity of individual’s body
(Georgieva, 2012). However, according the research result, the author also claims that the patients who refused to take medication experienced longer period of coercive intervention and they also felt more humiliated, stress than the medicated patients. In addition, the author also cautions potential side effect of the use of medicated practice as evidenced by cardiac complication and excessive sedation.
In comparison, seclusion is considered less physical involvement than other coercive intervention but Mohr (2010) also maintained that in the core of western culture, the human right is also violated. The alternative therapy for seclusion is time out was trailed in many hospitals in England, especially in many hospitals with the high rate of seclusion. Time out means asking a patient to stay in a room, usually their bedroom, alone and on a consensual basis, until they have become calm (Bowers et al, 2011). The result was exciting as time out intervention have the same outcome to seclusion with aim to managing destructive behaviors.
In conclusion, in the light of Mental Health Act “treated patient in less restrictive environment” and provide a safe and therapeutic environment for psychiatric in-patients, seclusion is not effective and humane intervention. The attainment of this goal is challenged by disruptive behaviours of patients. The aim of elimination of seclusion or any coercive intervention is challenging matters for mental health organizations as safety issue appears to be conflicted with detrimental impact of the use of the practice on the individual involved.
This practice is in some extend it violates human right, patient mistrust to health professionals where whom they seek for help in crisis situation (Peak, 2013) However, in regard to Occupation Safety Health issue the use of this practice should be maintained as the last resort where other alternative interventions exhausting. The most efficient way to alter the use of this practice is patient focused care by identifying the trigger of potential aggression or violation to de-escalate it. This requires staff to be equipped with better skilled at recognizing and preventing potential trigger. This also gains agreement by expert in the
ACT forum (Peake, 2013)

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