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Seclusion and restraint in psychiatric hospitals must end today

16 May 2017

The community is genuinely shocked and appalled by the CCTV footage of the mistreatment and subsequent death of Miriam Merten at the acute mental health facility at Lismore Hospital. 

On Friday, our Prime Minister was asked if he was sufficiently affected to take immediate action as he had done in response to the video footage of the mistreatment of young people in the Don Dale Centre in the Northern Territory. The responsibility for immediate and effective action does not sit with the Prime Minister. It lies squarely with NSW Health.

So today is the day to stop passing the buck and have our NSW Health Minister, the chief executives of our Local Health Districts and our senior medical and nursing leadership take immediate action to cease the common practices of seclusion and restraint in acute psychiatric facilities.

Importantly, these practices have no therapeutic value. They are psychologically and physically traumatic. They can end these practices today by direct instruction to those who implement these actions.

These practices have no therapeutic value. They are psychologically and physically traumatic.
Professor Ian Hickie AM, Brain and Mind Centre, University of Sydney

Very few people in this acute situation pose a major risk to the public, most are in the chaotic and disorganised state so graphically depicted in the Miriam Merten video. Others are young people, at times including children, who are being hospitalised for the first time.

The practices of seclusion and restraint simply perpetuate the stigma and public fear that surround mental health. They communicate the message that if you need acute psychiatric care, you'll simply be "locked up", not treated with respect or dignity, or worse, punished.

This makes it even harder to move mental health care to where it should be located in the 21st century, namely, in alternatives to hospitalisation. These include early intervention services, "step-up" and "step-down" facilities in residential settings and active co-ordinated programs to prevent re-hospitalisation

The "cell-block" physical environments used for seclusion and restraint have their origins in prisons, are custodial and have no genuine place in modern health care. The processes of seclusion, isolation from family and peers and physical restraint are terrifying for those involved. Typically, they are happening to people who are already fearful, agitated and struggling to keep a hold on reality. The end result is often psychologically devastating.

Most importantly, clear and safe alternatives exist now – and are used on a daily basis throughout other parts of our NSW Public Hospital system. These include intensive care, emergency departments and general hospital wards. In those settings, we rely on highly trained medical and nursing staff, working on a consistent and highly responsive one-to-one basis. The person in crisis is never left alone and we use the appropriate levels of medicine to reduce agitation or induce sedation.

Clear and safe alternatives exist now – and are used on a daily basis throughout other parts of our NSW Public Hospital system.
Professor Ian Hickie AM, Brain and Mind Centre, University of Sydney

The NSW Government response is to label this new incident as a "one-off" and order yet another internal inquiry (though not through its own commission). Sadly, this tragedy is but one of many that have been recorded over the last two decades in Australia. In 2005, I participated in the inquiry led by the Human Rights and Equal Opportunities Commission, resulting in the report "Not for Service: Experiences of Injustice and Despair in Mental Health Care in Australia". 

In 2005, in response to the disturbing findings, all Australian health ministers committed to reducing and then ceasing seclusion and restraint. They agreed to much more rigorous monitoring and public reporting of the implementation of that agreement. Today, that reporting is still not accurate, transparent or easily available to the public or health care providers. Each hospital should be able to compare itself with like-facilities and every family should know the practices at their local hospital before they bring their relatives to care.

In 2012, the new National Mental Health Commission took up the issue of reducing and preferably ending seclusion and restraint as a matter of public urgency. It was influenced most by the people and families, and frustrated by the glacial rate of change at the state level. In the same year, the O'Farrell Government in NSW established its own NSW Mental Health Commission with independent and experienced lawyer, John Feneley, as its head. As with the national commission, this was a direct response to the lack of public confidence in previous departmental reporting of public safety or major person-focused improvements in care.

What is now crystal clear after a decade of political commitment is that we are still failing on a daily basis to meet our basic health and human rights obligations. Nationally, since 2005, we have only seen a 30 per cent decline in seclusion and restraint. The very considered approach, so loved by health systems, and now rolled out again by NSW Health in response to this tragedy, does not deliver.

We do not need another inquiry – unless it intends to overturn the 2005 agreement and recommend that we continue these 19th and 20th century non-therapeutic and harmful practices. If you could choose, would you present to a hospital that still uses seclusion and restraint as a standard intervention?

Professor Ian Hickie is co-director of the University of Sydney's Brain and Mind Centre and a commissioner on the National Mental Health Commission. This article was originally published in The Sydney Morning Herald.

Dan Gaffney

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