While the use of belts and straps to mechanically restrain hospital patients has declined across the country, in regional areas it's the opposite story.
The rate at which patients in public mental health wards are being either held down or tied down has increased sharply outside of the major cities over the past five years, according to figures published by the Australian Institute of Health and Welfare (AIHW).
In inner regional areas, the use of mechanical restraint (per 1,000 bed days) went up more than 22 per cent*, while in the cities, it went down almost 10 per cent*.
In outer regional and remote areas, the use of physical restraint (ie staff holding patients down) was up by almost 24 per cent, compared to 2.7 per cent in the major cities*.
The reason for this, experts say, is the documented shortage of staff in regional health care, and particularly in mental health services.
As a result, people who are in distress and seeking help can feel "punished" for interacting with the mental health system.
'I was wanting to co-operate with them'
This is exactly what happened to Aeon Walker, 29, who sought help from staff at a Victorian hospital earlier this year.
While in the hospital, Aeon believed they had been possessed by demons, and, as the hallucinations worsened, they yelled out for help.
"The yelling was being perceived as being aggressive, when it was me calling out for help and wanting help from them," Aeon said.
"I wasn't moving from the bed, I wasn't trying to run, I was wanting to co-operate with them."
Aeon said five "big, strong people" wearing masks and blue gloves, to comply with COVID-19 procedures, picked them up and dragged them to another bed where they were physically restrained by velcro straps.
For Aeon, this confirmed that they had, in fact, been possessed by demons.
"At the time I was freaking out, thinking that I must be getting restrained because I'm getting possessed by demons."
"Why else would I be restrained unless I was not being me."
Aeon claims the hospital staff made no effort to communicate why they were being restrained or what medication they had been injected with.
Call to phase out 'restrictive practices'
Victorian Mental Illness Awareness Council CEO Craig Wallace says there's a workforce shortage across the mental health care system — and rural and regional areas have an extra tough time attracting and retaining staff.
"It may mean that people who are in distress and seeking support aren't getting help within a hospital setting as quickly as they would like or as much as they would like."
"And this can lead to further deterioration in their health, which may lead to instances where staff feel that it's necessary to use those restrictive practices."
Mr Wallace said any use of restrictive intervention should be eliminated as quickly as possible.
There are generally four kinds of restrictive intervention: using devices like belts, harnesses, sheets, and straps to restrict a patient's freedom of movement (mechanical restraint); having a healthcare worker hold down a patient (physical restraint); sedating (chemical restraint); and confining a patient in a room or some other area on their own (seclusion).
Over the past five years, rates of seclusion have fallen in inner regional areas, stayed about constant in major cities, and increased slightly in outer regional and remote areas, according to the AIHW.
The use of seclusion and restraint can be harmful to mental health system users and may mean they don't access support in future, Mr Wallace said.
"We can have a mental health system where service users don't feel punished for going through a really hard time in their life."
Most mental health workers didn't want to use these methods, he added.
"We do know that staff don't go into mental health nursing, for example, because they want to restrain people."
"They go because they want to help them and support them in their recovery in their mental health journey."
Useful as a last resort: Mental health care nurse
Nick Howson, a mental health nurse in Western Sydney, agreed that hospitals needed more staff to attend to mental healthcare patients.
"Patients in these mental health care settings are not like patients that you have in a medical or surgical ward."
The initial conversation can take up to an hour, he said.
"And when you're [doing that] for six people, when you're only there for eight hours and you still have to have a break and document things, time becomes really tight," he said.
Each state and territory have different mental health-related legislation that outlines when restrictive practises can be used.
These may include assessments and authorisation by a psychologist or senior nurse.
But in some jurisdictions a nurse can use these interventions without other approvals or assessments if they think the person may harm themselves or others.
Mr Howson said it was used as a last resort to mitigate the risk of the patient hurting somebody and then ending up charged with assault.
"It's easier and better for the individual if they spend a brief couple of hours in a seclusion room in a mental health facility with medication and support and observation on site than seriously injure somebody and end up in jail."
Mr Howson said that in his seven years in mental health care he's seen seclusion go from a regular to an irregular occurrence.
"Which has been a fantastic change," he said.
But he said that the use of seclusion should not be banned outright.
"Occasionally, we do still need to use it unfortunately."
'A breach of human rights'
But mental health and human rights advocate Simon Katterl questioned the argument that restraints and seclusion were only ever used as a last resort, or that phasing out these methods would endanger staff and patients.
"I can totally empathise with folks out on the front line there who feel like this stuff is the only option."
"But there's actually lots of other places in Australia and lots of other places overseas where they dramatically reduce this stuff, the use of force, and maintain safety for people at the same time."
He said the use of restrictive practices caused "profound trauma" and was a breach of basic human rights.
"You can't provide mental health care by traumatising people."
Despite the AIHW figures, it was unclear how often restrictive interventions were being used around the country, Mr Katterl said.
Each state and territory has a different process for patients to make complaints and some methods, like chemical restraint, often go unmeasured.
Victoria had the best system, but it was still flawed, he said.
Earlier this year, under freedom of information laws, Mr Katterl obtained the complaint reports from the state's statutory complaints body.
They showed that in seven years Victoria's Mental Health Complaints Commissioner received more than 12,000 complaints but did not issue a single compliance notice.
Commissioner Treasure Jennings said the body has received 68 complaints relating to restraint or seclusion so far this financial year.
"When consumers and carers complain to the MHCC, we work to ensure they are heard by the service, that the service provide an explanation or apology for their experiences where appropriate, assess whether legislative requirements were met and if any necessary improvements should be recommended," she said.
"Some complaints lead to a service entering into an enforceable undertaking with the MHCC where they agree to implement service improvements as a result of the outcome."
The MHCC also makes recommendations to services. In 2020-21, it made 80 such recommendations as a result of complaints.
*The period referenced is four years from 2016-17 to 2020-21
Editor’s note: 10/11/2022: Since this article was published, the ABC has updated it to include the relevant timeframe for the statistics quoted. The ABC has also removed an image which was not an accurate depiction of modern medical restraint used in Australia.
