Why I No Longer Believe in Seclusion
One of my most viewed and controversial TikTok videos concerns the use of seclusion in inpatient psychiatry. In that video, I argue that I see little place for seclusion in modern mental health care.
I do not hold this view lightly.
Over the last decade, I have encountered seclusion from multiple perspectives: as a psychiatric patient, as a healthcare assistant implementing restrictive interventions, as a control and restraint tutor teaching the legal framework surrounding seclusion and segregation, and later as a researcher and returning member of ward staff.
Taken together, those experiences have left me increasingly unconvinced that seclusion consistently achieves the purposes for which it is intended.
In theory, seclusion is a last-resort intervention used to manage severe behavioural disturbance and reduce immediate risk to others. In practice, I frequently observed something more complicated.
What struck me most was not the existence of seclusion itself, but the gap between policy and practice.
When I returned to inpatient psychiatry in 2024, I was disappointed by some of what I observed. Patients who had damaged property or behaved aggressively towards staff were sometimes directed towards seclusion as though it were an expected consequence of their behaviour. Conversations among staff occasionally suggested that prolonged periods in seclusion were anticipated long before any formal review had taken place.
I also observed patients remaining in seclusion while engaging in behaviours that appeared to indicate significant distress, including self-injurious behaviour. My expectation had been that such situations would trigger immediate therapeutic intervention. What I often saw instead was a system struggling to respond effectively once a patient was behind a locked door.
Another change surprised me.
When I first worked in inpatient services in 2015 and 2016, planned interventions typically involved relatively small teams. Communication and de-escalation remained central to the approach, even when restraint became necessary.
By 2024, the scale of some interventions appeared to have increased significantly. Wards routinely requested additional staff from neighbouring units before entering seclusion areas. In some cases, so many staff were present that movement within the area became difficult. Whether intended or not, the visual impact of these large groups struck me as potentially intimidating for already distressed patients.
Watching twenty people physically contain a single individual, I found myself wondering how this had become normal practice.
The core problem, as I see it, is that seclusion often appears poorly suited to de-escalation.
Once a patient is inside a seclusion room, meaningful communication becomes difficult. Doors cannot be opened casually. Staff require support to enter safely. Conversations are often reduced to brief exchanges through reinforced barriers. The intervention creates physical separation at precisely the moment when communication may be most needed.
In practice, this can create a troubling cycle. Distress leads to seclusion. Seclusion limits communication. Reduced communication makes it harder to resolve distress. The result can be prolonged confinement without obvious progress towards recovery.
I repeatedly observed patients remaining in seclusion long after the immediate crisis appeared to have passed. Meals were delivered. The room was cleaned. Patients were engaged by staff. Yet seclusion sometimes continued for days.
This raised a question for me.
If seclusion is intended primarily as a short-term response to immediate risk, what exactly justifies its continuation once that risk has subsided?
My interpretation was often that seclusion had drifted away from its stated purpose. Rather than functioning solely as a measure to manage severe and immediate risk to others, it sometimes appeared to operate as a means of securing compliance or managing behaviour that staff felt unable to address in other ways.
I also encountered situations earlier in my career where patients were secluded primarily because of self-harm risks, despite posing little obvious danger to other people. Whether these decisions were clinically justified in the circumstances, I cannot say. What concerned me was how frequently seclusion seemed to be employed in ways that sat uneasily alongside the legal and policy frameworks I had been taught.
This led me to a broader conclusion.
The problem is not necessarily individual staff members. Most inpatient staff work under extraordinary pressure. They are exposed to violence, distress, trauma, and chronic understaffing. Many receive limited supervision and inadequate organisational support.
Under those conditions, restrictive interventions can begin to feel inevitable.
Much of the criticism I have received for expressing these views has come from inpatient staff. Patients, by contrast, often seem to understand immediately what I am describing. Staff frequently respond by pointing to the most extreme examples of violence and behavioural disturbance. Such cases certainly exist, and they are challenging.
The question, however, is whether those exceptional cases justify the routine use of a practice that may be ineffective, traumatising, and difficult to reconcile with therapeutic aims.
As a healthcare assistant, I believed there was a better way.
As a restraint tutor, I became frustrated by how difficult it was to persuade people that seclusion should genuinely be a last resort.
After ten years spent working, researching, and reflecting on mental health services, I have become increasingly convinced that many behavioural crises are fundamentally crises of communication and relationship.
Patients are often frightened, confused, detached from reality, or struggling with histories of trauma. Staff, meanwhile, are stretched across multiple competing demands and frequently lack the time needed to build meaningful therapeutic relationships.
In such environments, behaviour is managed and contained rather than understood.
My own experiences as a patient reinforced this view.
During my first admission, I was restrained and rapidly tranquillised following verbal aggression and repeated attempts to abscond. During a later admission, I was struck not by the intensity of the intervention but by the relative absence of therapeutic engagement. Many patients received very little meaningful clinical contact. Some were left alone with frightening beliefs and experiences until they eventually reached a crisis point.
When those crises occurred, restrictive interventions often followed.
It seemed to me that attention was directed towards managing the consequences rather than addressing the conditions that had produced them.
This is why I no longer believe seclusion should occupy the central place it currently holds within many inpatient services.
My objection is not primarily moral, although there are moral questions worth asking. Nor is it ideological.
Rather, I have become unconvinced that seclusion consistently achieves what it is supposed to achieve.
There are alternatives. Models such as Safewards have demonstrated that better communication, stronger therapeutic relationships, improved staff training, and carefully designed ward environments can reduce conflict and restrictive interventions significantly.
The challenge is not a lack of evidence.
The challenge is culture.
Restrictive practices become embedded within organisations. Staff inherit them, learn them, and eventually stop questioning them. Under pressure, these practices begin to feel normal and necessary.
My hope is that inpatient psychiatry continues moving towards approaches that place communication, trauma awareness, therapeutic relationships, and human understanding at the centre of care.
If we are serious about helping people through periods of extreme distress, we should be asking not how to confine them more effectively, but how to understand them better.
I discuss my experience of inpatient psychiatry, both as a patient and staff, on my YouTube channel and in my book Androids DO Dream.
