In the Netherlands, seclusion is the main form of coercive management of dangerous people with mental illness. I have always opposed this, and argued that more individualiz\ed treatment could significantly reduce the need for seclusion. Now, in the current issue of the Journal of Psychiatric Intensive Care, this hypothesis was tested in one newly-built unit in Halsteren, North Brabant.
The patients all had a history of seclusion and long-term admission at different psychiatric units. All were thought to be a serious threat to themselves and others, and were committed to the PICU through our equivalent of the Mental Health Act. Most had a diagnosis of borderline personality disorder.
The new psychiatric intensive care unit (PICU) has four beds. Its multidisciplinary team consists of nursing staff, an occupational therapist, a social worker and a psychiatrist. The staff:patient ratio during the day is 1:2, which allows for the close observation of patient behavior.
The treatment philosophy of the unit incorporates aspects of mentalization-based treatment and attachment theory. Both are effective for treating borderline personality disorder. Further, the staff approach clients in a non-coeercive way, calling onto each patient’s autonomy as much as possible.
The study unfortunately did not evaluate clinical outcomes, although the authors say that most patients imporved. However, with regards to seclusion, the rate dropped dramatically, from 40% of one’s hospital stay before the patients were moved to the PICU to 0.5% while at the PICU. This is astonishing and promising to me. The one bad thing is that of course such intensive treatment is very expensive – more expensive than a seclusion room -, so I do hope this unit survives the healthcare budget cuts.
Reference
Deorgieva I, De Haan G, Smith W, Mulder CL (2010), Successful Reduction of Seclusion in a Newly Developed Psychiatric Intensive Care Unit. Journal of Psychiatric Intensive Care, 6(1):31-38. DOI: 10.1017/S1742646409990082.
I know your new system works well with good effects on the patient after discharge. If they decompensate at a later time they will want this same type of unit.
All your patients could benefit from a version of this type of approach. In some of our psychiatric hospitals, it is done by consistant assignment of certain staff to work with the clients. The ratio is lower, 2-3 patients per staff. But the ability to deal with problems patients feel are valid, go a long way toward trusting in the staff to keep them safe, which is their biggest fear. Patients need to know what they have to say, no matter the topic, someone will listen. They will be heard, and hopefully something will be done. I know that cannot always happen, but by explaining why to the patient goes a long way in teaching them consideration for others as well as themselves. A tool they need to be able to succeed outside the hospital confines of professional staff there all the time to help them reason things out and find solutions.
The second thing they need is proper teaching about any medicines they are on, and the ability to talk to knowledgeble staff about their concerns, problems with it and even their worries. The kind of knowledge they need is basic, and can be taught by any Registered Nurse or Licensed Practical Nurse. And yes it gives the Nurses on the unit more work, but more blessings when they see these people come in agan, not as badly decompensated and willing to help themselves to get back what they once had.
This time around they still need the information, but examples of the behavior that caused admission, and how they could have reacted differently, and maintained themselves in the community.
Sorry for the long response, but it is what I learned in 22 years of psychiatric nursing here in the US. I also know from first hand treatment I received when I needed help. All the staff were commited to helping become selfsufficient again and plan for disharge. Patients felt the staff’s support an belief in each patient’s ability to take back their life and learn to thrive in the community, and not in residential psychiatric care institutions. It can be done, if the staff will change their ways and meet patient needs. Cass
Helpful links for psych nurses: Go to you tube: Search for video titled: “Behaviorally Fragile Autistics” and “Looking Back at Severe Autism”. This will take you to channels that show a case of severe autism with self injury that has baffled experts over the years.