Yesterday, I stumbled upon an interesting paper in the International Journal of Social Psychiatry. The study, carried out in South Africa, aimed to examine the experiences psychiatric patients had with seclusion, restraint and sedation, and the perceptions these service users had of these procedures.
Mental health patients were recruited to interview 43 other mental patients about their experiences of containment. The authors say that it may be a disadvantage that patients were used as interviewers, but I think it is a good point of this study. Diagnostic information about the interviewees was not collected, but I consider this also an advantage. After all, it doesn’t matter what diagnosis may or may not have contributed to the behavior that led to your containment, and that diagnosis is far less likely to influence mental health providers’ attitudes than the fact that you have a diagnosis at all.
There were several problems with the use of restraitn, seclusion and sedation. First, seclusion was perceived to be primarily used as punishment rather than as a therapeutic intervention. One interviewee described being put in seclusion when they asked for PRN medication, for example. The conditions in seclusion rooms were also rather bad. For example, windows were broken, linen was dirty, and there were insufficient baqsic facilities.
On the other hand, sedation was seen as relatively humane, although most people despised haloperidol (a powerful antipsychotic with potentially serious side effects) as a sedative. I turn out not to have invented the word “shut up pill”, as an Afrikaans equivalent of it was used as a nick name for haloperidol.
Restraint was seen as one of the most abusive and least helpful interventions. Only six of the 43 interviewees had experienced this, of which only two found it helpful or necessary.
In general, patients saw containment as an infringement of their human rights. They were not content with the information provided by staff, and would want to have a choice of containment method. They also highlighted incidents of verbal and physical abuse. Furthermore, patients were inadequately re-oriented after containment and were not enabled to discuss their experiences. Lastly, a number of patients indicated isolation from family and friends. A problem here may be not so much the containment as the fact that patients from rural areas were transported to the city for psychiatric treatment.
A number of recommendations for implementation by mental hospitals are provided, including:
- Service users should be educated about their rights as contained in relevant mental health care legislation;
- All health care service providers, and in particular security personnel, should be adequately trained regarding the management of persons who are mentally ill and the assistance of service users in an emergency situation;
- Caregivers and family members of service users should be trained to detect early indicators of relapses and respond appropriately to prevent emergencies;
- Treatment should be administered as far as possible at a local health care facility so that service users can maintain contact with their support systems;
- Service providers should be trained to prevent distress by responding appropriately to early indicators;
- Debriefing and reorientating of the service user after intervention should be done;
- A caregiver or relative should be allowed to stay with the service user while they’re being transported to a health care facility and/or being sedated, secluded or restrained;
- Service providers should maintain communication about procedures to be administered and treatment options with service users even though they might appear disoriented;
- Service users should be encouraged to discuss with service providers the containment procedures they experience as most effective and least distressing;
- Service providers should be given training opportunities for the provision of care within a human rights framework;
- The culture of the health care setting needs to be changed. Administrative and therapeutic staff need to see a restraint-free environment and empowered patients as desirable and achievable;
- Service providers need to be given the therapeutic tools to manage violence-prone patients differently;
- Team work with common goals and ongoing communication will promote the safety of the service users;
- Trends in care need to be monitored and mental health service providers must be willing to engage with these and learn new techniques in consultation with service users.
Of course, given the limited resources available in the South African health system, it is quite hard to implement all of these changes. However, it would be highly desirable if mental hospitals all over the world took effort to implement them.
Mayers P, Keet N, Winklr G, Flisher AJ (2010), Mental Health Service Users’ Perceptions and Experiences of Sedation, Seclusion and Restraint. International Journal of Social Psychiatry, 56(1):60-73. DOI: 10.1177/0020764008098293.