Whether or not seclusion has a place within the treatment of the mentally disordered is one of the longest running debates in the history of mental health care, and it is likely to continue. Controversial deaths in mental health facilities and their subsequent inquiries will further fuel speculation as to how best to manage challenging behaviour. This chapter provides an overview of the history of seclusion, its value or otherwise, its alternatives and the necessary supporting policies for its use. It also offers a practical framework within which seclusion may be considered in the context of psychiatric intensive care units (PICUs).

Absconding from mental health inpatient facilities is a long-standing and significant issue. Absconding is a core admission criterion for transfer to the psychiatric intensive care unit (PICU).

Psychiatric intensive care units (PICUs) are an important provision but are significantly under-provided internationally. Law, funding and stigma all have significant influence on mental health service provision and the consequent lack of access to appropriate treatment. Whilst this varies from country to country, there are themes throughout which can be applied everywhere. Improving legal frameworks, providing more resources, educating the population and working more closely with patients will be key to creating a truly global approach to severe mental illness. PICUs are a key element in providing safe, effective care for the most unwell people. Practices such as shackling need to end and mental health care in all countries around the world must be brought front and centre in the twenty-first century, having spent so long in the shadows.

Virtually all societies have found the need for containment and control of behaviour by physical means. The first words in any discussion about restraint must include the methods of avoiding the need for its use wherever possible. De-escalation, negotiation, meaningful activity programmes and the development of trusting relationships are the necessary first steps. This chapter focuses on the activity of restraint, assuming that due attention has already been paid to the methods of avoiding the need for its use.