Introduction
Application of restrictive practices (RPs) such as seclusion and restraint within an approved mental health centre (AC) should be ‘humane respectful and for the shortest period’ (National Institute for Health and Care Excellence (NICE), 2015). Strategies to reduce the use of RP have proven effective in ACs (Bowers et al., Reference Bowers, James, Quirk, Simpson, Stewart and Hodsoll2015, Chua et al., Reference Chua, Bellonci and Sorter2021, Celofiga et al., Reference Celofiga, Plesnicar, Koprivsek, Moskon, Benkovic and Kumperscak2022). International best practice recommendations emphasise human rights and consensus-based approaches to achieve further reductions (De Cuyper et al., Reference De Cuyper, Vanlinthout, Vanhoof, Van Achterberg, Opgenhaffen, Nijs, Peeters, Put, Maes and Van Audenhove2023). Nevertheless, in certain settings and in high-risk situations, RPs continue to be used and may be unavoidable (Chieze et al., Reference Chieze, Hurst, Kaiser and Sentissi2019, Perers et al., Reference Perers, Bäckström, Johansson and Rask2022). This paper is the first to compare RP rates in Irish ACs over a five-year period.
The Mental Health Commission (MHC) is the regulator of mental health services in Ireland. It is an independent statutory body established in accordance with the Mental Health Acts 2001–2018 (Mental Health Act) with responsibility for the establishment and maintenance of high standards and good practices in Irish mental health services. The MHC has a duty to enhance the protection of individuals admitted to Irish ACs, including those detained under the Mental Health Act.
A limited number of RP is regulated by the MHC, thus ensuring that ACs adhere to specific rules and codes of practice published by the commission. These include rules on the use of seclusion and a code of practice on the use of physical restraint (Mental Health Commission, 2009a, 2009b).
According to the MHC, physical restraint is “the use of physical force (by one or more persons) for the purpose of preventing the free movement of a resident’s body when he or she poses an immediate threat of serious harm to self or others”. Seclusion means “the placing or leaving of a person in any room alone, at any time, day, or night, with the exit door locked or fastened or held in such a way as to prevent the person from leaving” (Mental Health Commission, 2009a, 2009b).
RPs may only be used when a person poses an immediate threat of serious harm to self or others. Section 69(2) of the Mental Health Act stipulates that the use of seclusion is only permitted in accordance with the rules produced by the MHC, where its use is necessary for the purposes of treatment or to prevent the patient from injuring himself or herself or others. The rules on seclusion, which were applicable to the given period, advise that it must only be “…used in rare and exceptional circumstance and only in the best interests of the patient when he or she poses an immediate threat of serious harm to self or others”. (Mental Health Commission, 2009a). Similarly, the MHC Code of Practice on the Use of Physical Restraint in place during 2018–2022 states that the use of physical restraint should only be used “in rare and exceptional circumstances and only in the best interests of the resident when he or she poses an immediate threat of serious harm to self or others.”
Each AC must report data on its activities, including use of RP, to the MHC on an annual basis. The availability of this database enabled this 5-year analysis.
Method
We examined anonymised data reported to the MHC on RP use within all Irish ACs over a five-year period. The data shown are taken from reports made by ACs to the MHC between 2018 and 2022 inclusive. These are presented for all ACs combined. This RP data refers to all episodes of seclusion and physical restraint used across 26 counties. We recorded total RP numbers and calculated RP rates per 1000 occupied bed days and per 100,000 members of the population. We then compared these data over 5 years from 2018 to 2022.
Results
The total number of admissions to Irish ACs fell by 5% over five years (ranging from 17,000 admissions in 2018 to 16,136 in 2022). Total admission days fell by 18% (from a peak of 895,206 bed days in 2018 to 732,254 bed days in 2022). (See Table 1)
Number of admissions to approved centres and total number of inpatient bed days (by year)
Source: Health Research Board 2018–2022.
The number of ACs using restrictive practices fell from 55 in 2018 to 47 in 2022. The number of approved centres using seclusion did not change substantially over this period (N = 27, range 28–26) (See Table 2).
Number of persons secluded and rate per secluded patient
Source: Mental Health Commission Ireland, Restrictive Practices Activity Reports 2018–2022.
The number of individual residents restrained fell by 21% (from 1207 in 2018 to 1078 in 2022). The total number of physical restraint episodes fell by 48% (from a high of 5665 events in 2018 to 2945 events in 2022). The rate of restraint episodes per 1000 occupied bed days fell from 6.3 per 1000 in 2018 to 4 per 1000 in 2022. The rate of restraint per 100,000 population also fell from 110 in 2018 to 57.2 in 2022. (See Table 3).
Number of episodes of physical restraint including restraint rate per 100,000 population and restraint rate per 1000 occupied bed days (by year)
The total number of residents secluded fell by 18% (from 760 in 2018 to 620 in 2022). The total number of seclusion episodes fell by 24% (from 1799 in 2018 to 1364 in 2022). There was a fall of 5% in the rate of seclusion per 1000 occupied bed days (from 2 per 1000 in 2018 to 1.9 per 1000 in 2022) and a fall of 30% in the seclusion rate per 100,000 population (from 37.8 in 2018 to 26.5 in 2022). (See Table 4). The rate of seclusion per secluded resident has risen by 9.5 %. (from 2.4 episodes per secluded patient to 2.63 in 2022). (See Table 2).
Number of episodes of seclusion, including seclusion rate per 100,000 population and seclusion rate per 1000 occupied bed days (by year)
The mean (SD) age of residents secluded within Irish ACs remained static at 45 (1) years. Secluded residents were marginally younger at 36 (2) years compared to residents who were restrained 41 (1) years. (See Table 5). The gender profile of residents admitted to Irish ACs remained equipoised throughout five years, and while males and females were physically restrained in almost equal measures, males remained twice as likely to experience an episode of seclusion compared to females admitted to an Irish AC. (See Table 6).
Profile of persons secluded and physically restrained compared to the overall inpatient population: mean age (in years)
Source: Mental Health Commission, Restrictive Practices Activity Reports 2018–2022; Health Research Board 2018–2022.
Profile of persons secluded and physically restrained compared to the overall inpatient population: gender
Source: Mental Health Commission, Restrictive Practices Activity Reports 2018–2022; Health Research Board 2018–2022.
The duration of RP episodes did not change substantially over the period. Most episodes of restraint remain of short duration (58.9% of restraints in 2022 were for less than 5 minutes), and the proportion of lengthy restraints (> 30 minutes) has fallen from 1.1% in 2018 to 0.3% in 2022. (See Table 7). The duration of seclusion episodes has remained static. In 2022, 22% of seclusions persisted for less than 4 hours, but 7% were for more than 72 hours. (See Table 8).
Duration of physical restraint episodes (by year) 1
Source: Mental Health Commission Ireland, Restrictive Practices Activity Reports 2018–2022.
1 In some instances, the percentages do not add up to 100% due to rounding.
Duration of seclusion episodes
Source: Mental Health Commission Ireland, Restrictive Practices Activity Reports 2018–2022.
The total number of restrictive practice episodes (calculated by combining episodes of restraint with episodes of seclusion) fell from 7464 restrictive practice events in 2018 to 4309 in 2022. The rate of restrictive practices per 1000 occupied bed days fell by 29% (from 8.3 in 2018 to 5.9 in 2022). The rate of restrictive practices per 100,000 population fell by 47% (from 156.8 in 2018 to 83.7 in 2022). (See Table 9).
Total number of restrictive practice (RP) episodes (physical restraint and seclusion), including rate per 100,000 population and rate per 1000 bed days (by year)
Discussion
RPs such as seclusion and physical restraint have been a feature of psychiatric practice since its very beginning (Abderhalden et al., Reference Abderhalden, Hahn, Bonner, Galeazzi, ed. and Whittington2006). In modern times, the negative physical and psychological consequences for those subjected to RP have been acknowledged (Chieze et al., Reference Chieze, Hurst, Kaiser and Sentissi2019). RPs are recognised as being inconsistent with principles ensuring human rights (World Health Organisation, 2019).
Although RPs are never therapeutic in themselves, they may be justified in an emergency, such as where serious threat to life arises because of mental illness. Following extensive consultation with experts and stakeholders, the MHC published a strategy for RP reduction in Irish Mental Health Services (Mental Health Commission, 2014). MHC rules and code of practice on RPs were published in 2009 and more recently revised (Mental Health Commission, 2022b). Our data suggest that application of these standards in Irish ACs correlates with a reduction in RP.
Comparing the rates of RPs with those in other jurisdictions
Comparison of RP rates across centres and across nations remains problematic. There have been calls for a common set of international measures so that finer comparisons within and between countries can be made (Savage et al., Reference Savage, Lepping, Newton-Howes, Arnold, Staggs, Kisely, Hasegawa, Reid and Noorthoom2024). The types and definitions of reported coercive practices vary considerably. For example, some jurisdictions do not differentiate “restraint” into physical restraint and mechanical restraint. Additionally, there are discrepancies in how rates are reported, with countries and states measuring rates of RPs per 1,000 occupied bed days and/or rates per 100,000 population, for example. The MHC has been called to address some of these difficulties in its publications (Duffy Reference Duffy2023). In this analysis, we have presented the data as total numbers of RP events experienced in the total numbers of residents. At the same time, we have calculated the rates of RP per 1000 bed days and per 100,000 population. (See Tables 10–12)
We have not calculated the rates of RP per region or per CHO. We cannot rule out the possibility that reduction in seclusion and, or restraint is associated with the emergence of other effects, such as the use of chemical restraint.
Recently published analysis (Te Pou, 2022) demonstrates that Ireland is below average in terms of its use of seclusion in adult inpatient units; it ranked fourth lowest in the use of seclusion per 10,000 occupied bed days out of nine jurisdictions during 2022. Ireland’s seclusion rate was lower than New Zealand, Australia, England, Northern Ireland, and Sweden, and higher than the Netherlands, Wales, and Scotland.
In terms of physical restraint, the rate of RP per 1,000 occupied bed days is lower than in comparable jurisdictions (England and Australia). Ireland had a restraint rate per 1,000 occupied bed days of 4 in 2022 and 4.8 in 2021. In contrast, England reported 17 restraints per 1,000 occupied bed days in August 2021 (Care Quality Commission, 2021), while Australia published a rate of 10 physical restraint events per 1,000 bed days in 2022/2023 (Australian Institute of Health and Welfare, 2024).
The question remains whether the fall in RP as identified is a real effect or simply an artefact of a reduction in the numbers of admissions, along with a fall in the numbers of bed days and a fall in the numbers of centres using RP? The years of the pandemic also intervened, and it is possible that clinical behaviours mandatory during that period also had some effect.
Nevertheless, there are several reasons to conclude that the level of RP use has fallen. The first prosecution under the Mental Health Act occurred in early 2019 on foot of an inspection in 2018. The registered proprietor was convicted of failing to ensure adherence to the regulations comply with the rules governing the use of seclusion and mechanical means of bodily restraint (The Irish Times 2019). While the rules and code governing RPs during the subsequent five-year period remained static, the numbers of centres achieving full compliance with these standards rose substantially. Compliance with the rules and code in centres using seclusion rose from 33% in 2018 to 83% in 2022 and in centres using restraint from 19% in 2018 to 82% in 2022 (Mental Health Commission, 2023b).
Along with more effective regulation, improved training on human rights and initiatives aimed at improving the quality of care in Irish ACs may also have had a positive effect.
Number of persons physically restrained and rate per restrained patient (by year)
Source: Mental Health Commission Ireland, Restrictive Practices Activity Reports 2018–2022.
Profile of persons physically restrained (by age group) 1
Source: Mental Health Commission, Restrictive Practices Activity Reports 2018–2022.
1 In some instances, the percentages do not add up to 100% due to rounding.
Source: Mental Health Commission, Restrictive Practices Activity Reports 2018–2022.
1 In some instances, the percentages do not add up to 100% due to rounding.
2 Calculations based on the 2016 Census population of 4,761,865 (2018-2021 inclusive) and on the 2022 Census population of 5,149,139 (2022).
3 Rate: The average number of times a person was physically restrained has reduced from 4.7 episodes per restrained patient in 2018, to 2.7 episodes per restrained patient in 2022.
Consequences of the use of RPs
The MHC has considered the consequences of the use of RPs, such as seclusion and physical restraint. In 2022, it conducted a public consultation (Mental Health Commission, 2022b) on the use of such interventions, including with people who had direct experience of being subjected to seclusion and/or physical restraint in an Irish AC. The MHC also commissioned in-depth evidence review (Mental Health Commission, 2022c) to inform the review of the code of practice on the use of physical restraint and the rules governing seclusion and mechanical means of bodily restraint in inpatient mental health services.
The results of the MHC’s public consultation with service users who had experience of RPs were revealing. There was general agreement that the trauma experienced because of seclusion or restraint had a subsequent negative impact on their recovery. During consultation service, users described feeling ‘controlled’, ‘abused’, ‘frightened’, ‘anxious’, ‘angry’, ‘helpless’, ‘disempowered’, ‘humiliated’, ‘vulnerable’, and ‘disrespected’, when seclusion or restraint was used. “It [seclusion] was traumatising for me. People should be offered counselling afterwards…you are still in shock at what happened to you”. Another service-user described: “If in life you find yourself in a distressing situation, you need to talk to someone…instead you are locked up…seems like a punishment rather than a treatment and that is a long way from being person-centred.” The use of seclusion or restraint was reported as leading to a “lack of trust” and a “…change in dynamics…you now feel threatened by the staff that are supposed to be taking care of you…you think these people have absolute power over you”. One service user described: “There is a huge power imbalance when you are being restrained and going forward…dealing with the staff who restrained you.” One service user spoke of their experience of lengthy seclusion (three weeks): “It felt lonely and isolated in the seclusion room …I missed social interaction…staff should communicate with the person in seclusion…through a closed door…so they know that they aren’t forgotten about”. Another commented: “When you are in seclusion there is nothing to read or see…You’re just alone with your thoughts…this isn’t the best thing [for me] …it’s important to be able to speak to someone you can trust when in [seclusion]…maybe have some sort of communication device so you can talk to a family member or advocate…that would ground you and calm you.” Another service user detailed how she was “…put in a gown in a padded cell so there is no way to harm yourself. Heavy, woolly thing - horrible. You don’t feel like a person in that environment…it is dehumanising, rights are taken” (Mental Health Commission, 2022b).
In summary, the evidence reviews (Mental Health Commission, 2022c) found evidence that restrictive practices can cause deleterious physical and psychological consequences (Chieze et al., Reference Chieze, Hurst, Kaiser and Sentissi2019) for those subjected to them. Eight themes from the integrative review by Cusack et al (Reference Cusack, Cusack, McAndrew, McKeown and Duxbury2018) summarise the negative impact of physical restraint upon those subjected to it: Trauma/retraumatisation due to the incident itself or retraumatised due to past trauma, distress, fear, feeling ignored, control, power, and dehumanising. Fear, anxiety, post-traumatic stress disorder, powerlessness, abandonment, distrustfulness or loneliness, punishment, maltreatment, anger, rage, resentment, depression, impotence, sadness, humiliation, degradation, shame, loss of freedom, and coercion. Similar findings were also identified by Aguilera-Serrano et al. (Reference Aguilera-Serrano, Guzman-Parra, Garcia-Sanchez, Moreno-Küstner and Mayoral-Cleries2018) in 24 of the 26 papers in their systematic review.
The emotional impact of seclusion in 10 of 11 papers examined in the evidence review was identified as negative. This included intense effect, emotional impact, emotional experiences, loneliness, autonomy, fear, anger, frustration, powerlessness, and sadness. The environmental experience of seclusion and the process of being placed in seclusion (disrobing and the locking of the door) were described as frightening, humiliating, and dehumanising and resulted in sensory deprivation and problems relating to lack of access to meet basic needs. The seclusion experience can also result in or exacerbate symptoms such as agitation, hallucinations, delusions, and the effects of sensory deprivation (Mellow et al., Reference Mellow, Tickle and Rennoldson2017).
Future research
There is a need for examination of whether efforts to reduce or eliminate the use of RPs in Irish inpatient mental health units have proven successful (particular in the period post January 2023 when the MHC introduced revised rules and codes of practice and a requirement of mandatory reporting of each use of RP within three working days). The MHC-commissioned evidence review identified a dearth of research on the physical risks associated with physical restraint and the impact of the use of restraint/seclusion on older people and in children/adolescents. This paper has focused on the use of seclusion and physical restraint. Additional research that looks at the use of other forms of restrictive practices in approved centres in Ireland would be welcomed.
Conclusion
International policy and best practice is increasingly focused on a human rights approach to care and treatment, and several jurisdictions are introducing measures to reduce or eliminate restrictive practices from their mental health services, having regard to the evidence that shows the harmful physical and psychological consequences of RPs.
The data presented in this paper suggest that a substantial reduction in RP has occurred in Irish ACs, and this is to be welcomed. Further progress is expected with increased emphasis on a human rights approach to Irish acute mental healthcare.
Evidence of this momentum is to be found in the MHC’s introduction of revised rules governing the use of seclusion and a revised code of practice on the use of physical restraint, which came into effect on 1 January 2023. The regulator now requires that each approved centre recognises the inherent rights of a person to personal dignity and freedom in accordance with national and international human rights instruments and legislation. It also requires that every approved centre that uses, or permits the use of, seclusion/physical restraint develops and implements a reduction policy that clearly documents how the approved centre aims to reduce, or where possible eliminate, the use of seclusion/physical restraint within the approved centre. Furthermore, the MHC has made training in trauma-informed care and human rights (including the legal principles of restrictive interventions) mandatory for staff.
Henceforth, every episode of seclusion/physical restraint will be reported to the MHC within three working days, and the regulator will actively follow up with the service in relation to the use of these RPs.
RP data will be analysed and published with a greater focus on national and international best practice.
Financial support
None.
Competing interests
None.
Ethical standards
The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. The authors assert that the local ethics committee has determined that ethical approval for publication of this service evaluation was not required by their local ethics committee.
Open access
