Abstract
Introduction
Seclusion and restraints are involuntary measures that restrict the mobility of patients, and are only to be used when there is an imminent risk. Restraints (mechanical or chemical) may be used alongside seclusion, which involves confining a patient to a space that they cannot leave from. 1 One study found that reported rates of restrictive practices across nine countries were highly variable, poorly documented, and diversely measured. 2
Over the last decade, Canadian provinces have tried to reduce the use of seclusion. These attempts have been well-intentioned and sometimes successful. Ontario Shores reported a 90% reduction in restraint and seclusion hours using evidence-based interventions (e.g., Six Core Strategies) that have reduced violent incidents involving staff.3,4 After BC introduced mandatory standards, the Forensic Psychiatric Hospital cut seclusion days by 27% and violent incidents by 90%. 5
Across the country, however, progress has been fragmented. From 2016 to 2021, the annual incidence of seclusion in a Quebec mental health hospital rose 205%. 6 Seclusion continues to appear in coroner's reports, lawsuits, and media exposes. Further, class actions in Ontario have alleged patients have endured prolonged, harmful “solitary confinement” under the guise of care. These are symptoms of wider system issues: our systems of governance, infrastructure, and clinical oversight are not keeping pace with modern mental health care.
A patient-centred, government-monitored model would make every episode transparent, time-limited, and accountable, restoring seclusion to what it was intended to be: a last resort governed by compassion and clinical skill.
The Problem Isn’t Just Practice, It's Systemic
Canada still lacks a coherent legal framework for seclusion. Only Ontario implies statutory authority; most provinces rely on patchworks of hospital policies that attract little external scrutiny. 7 Seclusion in its current form is no longer acceptable. Evidence suggests restrictive practices increase trauma risk and physical and/or psychological harm. 8 We must adopt a national, patient-centred, accountable approach with consistent standards. There are successful examples that we can learn from and emulate.
Learning From International Models: Ireland's Path Forward
One example is Ireland, who has shown that national leadership drives change. Their Mental Health Commission introduced centralised oversight, reporting requirements, strict seclusion room standards, and regular medical reviews. From 2018 to 2022, the total number of seclusion episodes fell 24% and the total number of physical restraint episodes fell 48%. Compliance with seclusion rules rose from 33% to 83%, and compliance with restraint rules rose from 19% to 82% reflecting accountability and adherence to best practice. 9
Canada should move in the same direction but this will require leadership and new approaches to accountability.
Towards a Patient-Centred Model of Seclusion
We do not need to eliminate seclusion altogether as there are circumstances where it remains clinically necessary. However, practices must preserve dignity, promote safety, be non-traumatising, and follow modern psychiatric principles.
We are proposing six changes to help achieve this:
Rethinking the Physical Design of Seclusion Spaces
Seclusion rooms should not resemble solitary confinement cells. They should be safe, humane, purpose-built spaces engineered to withstand high-force impacts, with no ligature points and exposed wiring. They should also have ensuite toilets and showers with externally facing windows. There should be controls for lighting, temperature, and ventilation with full-height observation panels of safety glass facing staff stations that can always be monitored.
Specifications can draw from BC's 124-page Secure Rooms Standards and Guidelines which is still the most detailed blueprint in Canada. 1
Real-Time Monitoring: In-Person and CCTV
During seclusion patients must not be left alone, physically or emotionally. A dual-monitoring system and a CCTV system with centralised monitoring would significantly reduce harm and ensure timely intervention. There should be distance monitoring of vital signs, which is a significant safety advantage if a patient is unwell, reluctant to engage with staff, or if staff safety is a concern.
Clinical Governance and Documentation
Every episode of seclusion should be documented meticulously in a detailed standardised format, including:
Clear justification of imminent risk. Time-limited orders with regular mandatory in-person re-evaluation by a psychiatrist at least daily. Real-time monitoring of vital signs, mental status, and distress levels every 5 to 15 minutes. Minimum staff-to-patient ratios during seclusion. Explicit prohibition on simultaneous use of mechanical restraint unless a physician authorises it in writing, with a time-limited order (<30 minutes, renewable only after a fresh assessment). Mandatory post-event debriefs with the patient (or substitute decision maker) and care team within 24 hours, recorded in the chart, and sent to a provincial oversight body. Ireland specifies including questions on the patient's experience, any resulting trauma, and offers family or carer involvement. Reporting guidelines during seclusion including:
Review of seclusion every 4 hours by a physician and daily reviews by a senior physician. Extended seclusion beyond 2 hours will trigger automatic notification to a clinical director. If it exceeds 4 hours, a full interdisciplinary review should be mandatory.
Each facility provides an annual public report of aggregate data on seclusion and restraint and serious incident summaries on their website.
Training and Staff Support
Frontline staff must be trained in trauma-informed care, verbal crisis de-escalation, risk reduction techniques and the early identification of agitation and distress. Psychological support for staff should be available, if needed.
National Standards
Monitoring these changes can no longer just be left up to individual institutions. Canada needs a national set of standards that would incorporate many of the elements outlined above and would be mandatory for each province and territory. Adherence would be overseen by a specific Provincial body, which would function with the same level of transparency and independence that governs corrections, policing, and other high-risk domains. It would have the authority to enforce design and practice standards for all provinces these would include:
Physical design standards. Seclusion justification documentation. Ways to monitor seclusion. A standard process for investigating adverse events or prolonged seclusion episodes. Real-time reporting of the use of seclusion to the central body.
This body would also:
Publish annual seclusion rates by facility, population group and outcome (injury, duration, complaints). Issue improvement notices to facilities not meeting these standards. This mirrors Ireland's MHC model with the power to trigger external reviews and deal with recalcitrant institutions or physicians.
These standards would be monitored during hospital accreditation visits, and infrastructure funding could then be tied to compliance. Hospitals seeking capital grants would have to demonstrate that their seclusion suites meet the new physical-design standard and that total seclusion hours have decreased year over year.
Legislative Reform and Public Accountability/Reporting
Provinces must embed clear definitions and limitations around seclusion in their Mental Health Acts. Patients are entitled to know their rights, and clinicians need legislative clarity. Standard reporting of seclusion and restraints may help address their differential use within Canada.
Why Act Now?
As a country, we pride ourselves on a compassionate, equitable health care system. But seclusion used improperly undermines that vision. Patchy oversight has consequences that no modern health-care system should tolerate including preventable deaths, multi-million-dollar lawsuits, public trust eroded by secrecy, and most importantly traumatised patients and staff.
Ireland's progress shows that robust regulation and redesign can halve restrictive practices in 5 years. Canada can do the same if federal and provincial leaders, accreditation bodies, and clinician-advocates seize this moment. The tools are there. The evidence exists. What we need now is resolve.
Key Points
In a true patient-centred system we need to be aware of the often-traumatising impact seclusion can have. Despite some successes in reducing seclusion in Canada, progress has been inconsistent, with high-profile incidents exposing serious safety and accountability concerns, and the need for a cohesive national framework.
Seclusion is a last resort intervention to prevent imminent harm and should never be used for punishment or staffing convenience.
Other countries have demonstrated that centralised oversight, standardised reporting, and improved facility design can significantly reduce the use of seclusion within a patient-centred, dignity-preserving approach.
Footnotes
Contributors
Gary Chaimowitz, Nick Kates & Mary Davoren.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
