The terror experienced by those forcibly restrained in a psychiatric ward can have a deep and lasting impact on an already fragile and vulnerable person. From the patient’s perspective, if they don’t die, they certainly never forget a restraint experience.

When I was given treatment that involved being locked up, sedated [chemical restraint] and controlled, it was really like recreating my worst horrors and calling it treatment. Obviously it was about the least helpful thing that could have happened.¹

Australian Patient

Former National Mental Health Commissioner, the late Ms Jackie Crowe, stated in 2015,

There is a lack of evidence internationally to support seclusion and restraint in mental health services. There is strong agreement that it is a human rights issue, that it has no therapeutic value, that it has resulted in emotional and physical harm….²

All Australian states have legislation that prohibit cruelty to animals. Cruelty to an animal in most states3 includes: to abuse, torment or terrify the animal and in Qld and Vic it also includes to worry an animal.4 Penalties for individuals found guilty depend on the state but, as an example, cruelty to an animal in Western Australia carries a maximum penalty of $50,000 and imprisonment for 5 years5. Yet ill-treatment of a psychiatric patient in Western Australia carries a maximum penalty of only $24,000 and imprisonment for 2 years – significantly less than the penalty for being cruel to an animal.

Restraint is criminal and it must be made a criminal offence if performed on a psychiatric patient or someone allegedly mentally ill.

What is Restraint?

Restraint is the intentional restriction of a patient’s voluntary movement. It can be administered in several ways:

• Physical restraint – involves one or more people using force to hold a patient down or prevent their movement.
• Chemical restraint – involves the use of psychiatric drugs to subdue and control.
• Mechanical restraint – involves the application of devices (including belts, harnesses, manacles, sheets and straps) on a person’s body to restrict their movement.⁷

It is well-known within psychiatric circles to have zero therapeutic benefits and instead can greatly increase trauma.⁸

United Nations Says Restraint is Torture

As long ago as 2013, damning comments by the United Nations Special Rapporteur on Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment left no doubt as to the cruelty of restraint:

Furthermore, deprivation of liberty that is based on the grounds of a disability and that inflicts severe pain or suffering falls under the scope of the Convention against Torture. In making such an assessment, factors such as fear and anxiety produced by indefinite detention, the infliction of forced medication or electroshock, the use of restraints and seclusion, the segregation from family and community, should be taken into account.

The mandate has previously declared that there can be no therapeutic justification for the use of solitary confinement and prolonged restraint of persons with disabilities in psychiatric institutions; both prolonged seclusion and restraint constitute torture and ill-treatment. In my 2012 report (A/66/88) I addressed the issue of solitary confinement and stated that its imposition, of any duration, on persons with mental disabilities is cruel, inhuman or degrading treatment.⁹

Mr. Juan E Méndez

In June 2021, The World Health Organization (WHO) released guidelines that lashed out against coercive psychiatric practices, such as restraint, seclusion, forced electroshock and forced detainment and treatment, that it says “are pervasive and are increasingly used in services in countries around the world, despite the lack of evidence that they offer any benefits, and the significant evidence that they lead to physical and psychological harm and even death.” The guidelines point to the United Nations Convention on the Rights of Persons with Disabilities (CRPD) which, in essence, calls for a ban on “forced hospitalization and forced treatment.”

The WHO guidelines highlight the fact that coercive practices such as restraint, seclusion, involuntary commitment and treatment occur because “they are mandated in the national [or state] laws of countries.”

Despite the challenges to changing laws and treatment paradigms, WHO says

…it is important for countries…to eliminate practices that restrict the right to legal capacity, such as involuntary admission and treatment.¹⁰

Restraint Can Cause Death

A NSW Health Policy Directive states, “There have been instances both in Australia and internationally in which young, apparently healthy, people have died suddenly while being held in a physical/manual restraint. The face down position in restraint has been implicated in these deaths.” ¹¹

• An involuntarily detained patient at Graylands hospital in Western Australia repeatedly told staff restraining him to let him go and said, “You are going to kill me,” moments before he slumped to the ground and died. A postmortem found significant bruising on his neck and found that death was consistent with cardiac arrhythmia during restraint.¹²
• In a 2017 article in Medical Journal of Australia InSight, Dr Minh Le Cong, who worked for the Royal Flying Doctor Service in Queensland for 15 years, detailed specifics of four of the many restraint deaths that have occurred in Australia. Two of the deaths were linked to the excessive use of the benzodiazepine midazolam as a chemical restraint. The third person who died was given the antipsychotic olanzapine followed by midazolam and the fourth person was physically restrained and given midazolam.¹³
• Former Austin Hospital Director of Mental Health Dr Richard Newton said he would estimate one death in circumstances involving restraint, forced sedation and seclusion each year in Victoria alone.¹⁴

The Lack of Mandatory Reporting

The use of restraint is rife in Australia yet the full extent remains hidden from public scrutiny as reporting of all restraint is not mandatory under most state mental health laws. The use of chemical restraint, in particular, is not addressed adequately – if at all – in the various mental health acts. The Australian Institute of Health and Welfare’s ‘Mental Health Performance Indicators’ for 2021-22, the use of chemical restraint was not reported for any state or territory.¹⁵

…they’re giving them drugs to practically put them in a coma.” I have been hearing about the sedating of patients… just because it makes the clinical staff’s life easier.¹⁶

Dr. Michael Eburn

The 2021-22 online report by the Australian Institute of Health and Welfare (AIHW) reveals there were:

• 16,966 physical restraint events nationally.¹⁷
• 1,522 mechanical restraint events nationally, an increase of 37% compared to the previous year and an increase of 91% compared to 2017/18.¹⁸
• An increase of 11% in the rate of physical restraint applied to children and adolescents compared to 2020-21, and an increase of 36% compared to 2017/18.¹⁹
• A doubling of the rate of mechanical restraint applied to children and adolescents compared to 2020-21.²⁰

Note: These AIHW statistics represent acute mental health services in public hospitals only; data from private mental health facilities are not included.

Restraint is Criminal

The United Nations Committee against Torture recently expressed serious concern about the use of chemical and physical restraints (under the guise of ‘behaviour modification’) in Australian psychiatric institutions. The Committee recommended the repeal of any law or policy that enables the deprivation of liberty and forced medical interventions on persons with intellectual or psychosocial disabilities.²¹

Restraint is criminal and it must be made a criminal offence. It is unacceptable that people in mental health facilities are subjected to this cruel treatment which often worsens their condition. It is unconscionable that those who cause harm or death through the use of restraint are not criminally charged.

Despite the $11.6 billion spent on mental health in Australia in 2020-21, psychiatry is still relying on violence to enforce its will.²² The philosophy behind it is an ingrained mentality from psychiatry’s earliest days of the mental asylums in Bedlam that the mentally ill are somehow lesser people and must be forced into abusive treatments.

There are valid ways to calm and work with traumatised people that preclude the need for harsh and inhumane treatment. Often when patients are treated abruptly, harshly and their opinions ignored, they become more fearful and aggressive.

A 2017 NSW review of restraint and seclusion in mental health facilities report stated:

It is not unusual for staff to raise concerns that staff and consumer safety will be compromised if seclusion and/ or restraint are reduced, but this concern is not supported by the weight of evidence.²³

Psychiatric drugs are known to cause aggression and violence and their role in contributing to violence in psychiatric wards requires a full government investigation in each state to protect both patients and staff. To learn more about how psychiatric drugs can cause violence read, Psychiatric Drugs: Create Violence & Suicide.

After decades of so called “reduction and elimination” of restraint, the harm and deaths continue across Australia. The new Victorian Mental Health and Wellbeing Act 2022 states mental health providers should aim to “eventually eliminate the use of restrictive interventions in mental health treatment.” In addition, the Objectives of the Act state the aim is to eliminate both restraint and seclusion within 10 years. If something causes harm and death, it should be stopped immediately. The Objectives of the Act are not legally enforceable, meaning in 10 years’ time yet another decade could go past and restraint and seclusion may not even be banned at all in Victoria.²⁴

Is there progress on banning restraint?

The Royal Commission into Aged Care Quality and Safety led to the 2019 and following 2021 amendments of the Quality of Care Principles made under the Aged Care Act. The 2021 amendments specify that Aged Care Providers who receive payment from the Commonwealth Government for their residents must now obtain consent from the elderly person they are proposing to restrain, or their representative, before applying either chemical or physical restraint (unless it is an emergency).²⁵

We need full and complete transparency on the use of restraint. Considering the trauma restraint produces, a ban on restraint with criminal fines and prison terms for its use, is called for. Only in this way can patient’s rights be restored, with real compassion and human rights brought to fruition.

What can you do?

There are no bans anywhere in Australia’s state mental health acts to prevent the use of restraint, not even on children, pregnant women or the elderly. While this is being addressed, at least in the event that restraint results in death or physical damage, any psychiatric staff member who applied the restraint, the psychiatrist who authorised it including the Chief Psychiatrist for the state or territory if they also approved it, should be made criminally responsible under the law.

Add your voice to the call for the ban of restraint:

• Contact your local Member of Parliament, Health Minister and Mental Health Minister and ask them to make changes to your state’s mental health act so that restraint is made illegal with criminal fines and prison terms for its use if performed on a psychiatric patient or someone allegedly mentally ill. Ask others to do the same.

To find the contact details for your local Member of Parliament and Health Minister:

ACT: https://www.parliament.act.gov.au/members/members-of-the-assembly
NSW: https://www.parliament.nsw.gov.au/members/pages/all-members.aspx
NT: https://parliament.nt.gov.au/members/by-name
Qld: https://www.parliament.qld.gov.au/members/current/list
SA: https://www.parliament.sa.gov.au/en/Members/Members-Home
Tas: https://www.parliament.tas.gov.au/legislative-council/members and https://www.parliament.tas.gov.au/house-of-assembly/members
Vic: https://www.parliament.vic.gov.au/about/people-in-parliament/members-search/list-all-members
WA: http://www.parliament.wa.gov.au/parliament/memblist.nsf/wallmembers

To learn more about restraint read CCHR’s booklet, Deadly Restraints online or contact CCHR Australia for a free copy.

References

1. “Warning on restraint tactics in mental health care,” ABC Radio, AM Program, 5 Jan.2016
2. Margaret Scheikowski, AAP, “Call to reform mental health practices,” The Australian, 29 May 2015.
3. NSW Prevention of Cruelty to Animals Act 1979. As at 23 September 2020. p10. https://www.legislation.nsw.gov.au/view/html/inforce/current/act-1979-200; Qld Animal Care and Protection Act 2001 Current as at 1 July 2016. P21. https://www.legislation.qld.gov.au/view/pdf/2016-07-01/act-2001-064 ; ACT Animal Welfare Act 1992 A1992-45. Republication No 31. Effective: 10 April 2020. p5 in pdf. https://www.legislation.act.gov.au/a/1992-45 : TAS Animal Welfare Act 1993 Version 1 July 2019. Sec 8.(2)(a) https://www.legislation.tas.gov.au/view/html/inforce/current/act-1993-063 : VIC Prevention of Cruelty to Animals Act 1986 p17 https://content.legislation.vic.gov.au/sites/default/files/08febf3f-607b-3f8f-b3df-92028dee2fc1_86-46aa095%20authorised.pdf
4. VIC Prevention of Cruelty to Animals Act 1986 p17 https://content.legislation.vic.gov.au/sites/default/files/08febf3f-607b-3f8f-b3df-92028dee2fc1_86-46aa095%20authorised.pdf : Qld Animal Care and Protection Act 2001 Current as at 1 July 2016.P21. https://www.legislation.qld.gov.au/view/pdf/2016-07-01/act-2001-064
5. Western Australia Animal Welfare Act 2002. As at 22 Feb 2019. Sec 19.(1) Animal Welfare Act 2002 (available from www.legislation.wa.gov.au).
6. Section 253. Western Australia Mental Health Act 2014. As at 01 Dec 2018 Version 01-g0-02 Published on www.legislation.wa.gov.au https://www.legislation.wa.gov.au/legislation/statutes.nsf/main_mrtitle_13534_homepage.html
7. “National Principles to Support the Goal of Eliminating Mechanical and Physical Restraints in Mental Health Services,” Australian Health Ministers Advisory Project, 15 Dec. 2016. http://www.apha.org.au/wp-content/uploads/2017/05/Att-A-Nat-Principles-mechanical_physical-_restraint-2.pdf
8. “Minimising the use of seclusion and restraint in people with mental illness,” RANZCP, Position Statement 61, Feb.2016. https://www.ranzcp.org/News-policy/Policy-submissions-reports/Document-library/Minimising-the-use-of-seclusion-and-restraint-in-p
9. UN Human Rights Council, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, 1 February 2013, A/HRC/22/53
10. “Guidance on Community Mental Health Services: Promoting Person-Centered and Rights-Based Approaches,” World Health Organization, 10 June 2021, pages 4,6,7,8. https://www.who.int/publications/i/item/9789240025707 (to download report).
11. “Aggression, Seclusion & Restraint in Mental Health Facilities – Guideline Focused Upon Older People,” NSW Government Guideline GL2012-005, p 3. https://www1.health.nsw.gov.au/pds/ActivePDSDocuments/GL2012_005.pdf
12. “’Misadventure’ as psychiatric patient died,” WA Today, 22 Nov.2011 https://www.watoday.com.au/national/western-australia/misadventure-as-psychiatric-patient-died-20111122-1nsoc.html
13. Minh Le Cong, “Chemical restraint or lethal injection?” MJA InSight, 6 March 2017. https://www.doctorportal.com.au/mjainsight/2017/8/chemical-restraint-or-lethal-injection/
14. Joel Magarey, “Deaths, injuries, trauma the fallout from psychiatric practices,” The Australian, 26 July 2013. https://www.theaustralian.com.au/news/health-science/deaths-injuries-trauma-the-fallout-from-psychiatric-practices/news-story/1e1be5ae62150c5fa23a8424ddf7ddbf?sv=73a16caf5355f8475c6d8b2718e55896;
15. “Mental Health Performance Indicators.” Australian Institute of Health and Welfare web report, last updated July 2023. https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
16. “Revealed: mental health patients being intubated.” NT News, 21 March 2023
17. Table SECREST.4: Restraint in public hospital acute mental health hospital services, states and territories, 2015-16 to 2021-22. Row 7 – Number of physical restraint events. Column I. https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
18. Table SECREST.4: Restraint in public hospital acute mental health hospital services, states and territories, 2015-16 to 2021-22. Row 6 – Number of mechanical restraint events. Columns E, H and I. https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
19. Table SECREST.5: Restraint rates in public hospital acute mental health services, by target population, 2015–16 to 2021–22. Row 7 – Rate of mechanical restraint, Child and adolescent. Columns E, H and I. https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
20. Table SECREST.5: Restraint rates in public hospital acute mental health services, by target population, 2015–16 to 2021–22. Row 12 – Rate of physical restraint, Child and adolescent. Columns H and I. https://www.aihw.gov.au/mental-health/topic-areas/seclusion-and-restraint
21. “Committee against Torture: Concluding observations on the sixth periodic report of Australia,” United Nations Convention against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment, 5 December 2022
22. “Expenditure on mental health-related services,” web report last updated April 2023. https://www.aihw.gov.au/mental-health/topic-areas/expenditure
23. “Review of seclusion, restraint and observation of consumers with a mental illness in NSW Health facilities, NSW Government, December 2017, p.II. https://www.health.nsw.gov.au/mentalhealth/reviews/seclusionprevention/Pages/about.aspx
24. Mental Health and Wellbeing Act 2022, Part 3.7—Restrictive interventions, S.125, 1 September 2023. https://www.legislation.vic.gov.au/as-made/acts/mental-health-and-wellbeing-act-2022
25. Quality of Care Principles 2014, made under section 96-1 of the Aged Care Act 1997, Compilation date: 1 September 2021, s15FA. See also the following in the Aged Care Act 1997: Chapter 7, Division 96- Miscellaneous, 96-1, Division 54- Quality of care, 54-1, Division 23A- Introduction, 23A-1 & 23B-, Division 41-Introduction, 41-1.