Dutch Hospitals Seclude Most Patients

According to a short article in a Dutch newspaper, psychiatric hospitals in the Netherlands seclude more patients than many other countries in Europe. According to the article, other countries’ hospital staff never leave their patients alone, while this is commonplace in Dutch seclusion practices. Indeed, I’ve often read that seclusion is the supervised placement of a person in a separate room, while in my experience, when someone is being secluded, they are never supervised.

This causes obvious risks. In 2008, a man died in an isolation room because he wasn’t being watched. Now I must say that Dutch hospitals rarely have the staffing to supervise patients one-on-one, so in that sense it is not out of unwillingness. But this should obviously change for the sake of patient safety.

Furthermore, I have stated this a million times, but an attitude shift should happen, in which isolation is no longer seen as something that will calm the patient, as is often the case now. Seclusion is often very traumatizing, and should only be used as a last resort to prevent physical harm to people.

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Brandon: One Method of Containment Is Better Than Another?

Over the past few days, I’ve been increasingly concerned with the Brandon case. zarathustra over at Mental Nurse has an interesting perspective from a British point of view. As he writes, mental health practitioners in different countries often criticize each other for their use of different methods of containment of aggressive patients. The Dutch restrain and seclude more, while the British use more rapid tranquilization. I, from a human rights perspective, would condemn all these practises equally, but I, too, realize that you can’t have a person gravely assaulting or killing someone else. It’s a fine line that has to be walked between respecting the patient’s human and civil rights, and protecting people’s safety. From what I’ve heard in Brandon’s case, no-one sees a solution. This is extremely sad.

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Reduced Seclusion in a High Secure Hospital

Seclusion and its reduction is still on my mind, three years after my first and only episode of selcusion. In the most recent issue of the Journal of Psychiatric Intensive Care, seclusion reudction in a high secure hospital was being discussed. It is a very interesting paper, because it is the first study evaluating the reduction of seclusion in such a highly secure setting.

The study authors evaluated the number of seclsusion episodes and adverse incidents (attempted or actual assault) over a five-year period. At the beginning of this period, in 2002, several strategies were implemented to reduce seclusion episodes. These included:

• Use of information and transparancy;
  
• Peer and audit reviews;
  
• Positive risk management and a more recovery-focused treatment;
  
• Increased patient involvement, for example, through the use and advance directives;
  
• Staff training and education;
  
• Enhanced clinical leadership.
  

Some patients also benefited from a medication called clozapine, which is an antipsychotic with independent effects on violence.

Over the five-year period, the number of seclusion episodes decreased by two-thirds. Despite what some earlier studies suggest, there was no increase in adverse incidents within this study period. This signals that maybe an effective reduction of seclusion can be done, if it is a clinical and managerial priority. However, since it was a retrospective study, it is possible that other factors than those mentioned above contributed to the lessening in seclusion episodes.

Reference

Qurashi I, Johnson D, Shaw J, Johnson B (2010), Reduction in the Use of Seclusion in a High Secure Hospital: A Retrospective Analysis. Journal of Psychiatric Intensive Care, 6(2):109-115. DOI:10.1017/S174264640999015X.

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Dutch Autistics Receive Poor Care

According to a report by the Dutch Association for Autism (NVA), autistics often get the wrong care. Staff at residential care facilities don’t often know how to handle autism, hence causing autistics to end up on crisis wards or in isolation rooms. The NVA has been collecting stories from mostly family members of autistics about poor care since 2008. I at one point considered submitting my own story from my former ward, but didn’t since I never ended up in a “real” isolation room.

To me, it is obvious that care staff need more education about how to deal with autistic clients. This of course will not prevent outright abuse, since every adult should know that is wrong, but it will prevent unintended harm done to autistics by staff.

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Victory for Alex Oudman

Last week, the psychiatrist responsible for Alex Oudman’s long-term seclusion, was reprimanded by one of the Dutch regional medical disciplinary boards. Reprimanding is the second lightest sentence, after a warning, but it has a huge impact on doctors. Alex Oudman is a severely autistic man who lived in a mental institution in the northern Netherlands when he was secluded for months at a time in 2008. His family made sure the media was alerted, which even led to questions from MPs and new government policy to reduce the amount of seclusion in Dutch institutions. The family also went to the disciplinary board. I do not know yet whether the psychiatrist will appeal the reprimanding.

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Formal Complaint Filed in Alex Oudman Isolation Case

Alex Oudman is a 50-year-old man with autism. Two years ago, he spent months in an isolation room at two Dutch mental health institutions. Before then, he’d lived for twelve years at a workhome – a sheltered living and working placement for severely autistic people – in Zuidlaren near Groningen. According to the psychiatrist responsible for Mr. Oudman’s seclusion, Alex started showing aggression while at the workhome and was therefore moved to a ward with seclusion facilities. That ward couldn’t handle him, so they sent him to a clinic in Amsterdam where it is said there is lots of expertise in autism. INstead of being observed or treated, Alex was agan secluded for months, until at last his family sent pictures of him to a Dutch TV program.

Now, two years later, the family has filed a formal complaint with the regional medical board in Groningen. They claim the long-term seclusion caused Alex to deteriorate, and that an alternative – placement in an institution for developmentally disabled persons – was available. The psychiatrist contends that Mr. Oudman consented to the isolation. As a psychiatric patient who has had “consensual” seclusion plans, I can tell you that consent doesn’t always mean real consent. Besides, it is said that Alex has the mental capacity of a 6-year-old child, so that makes me wonder even more whether he understands the manipulative language often used to get patients to consent to seclusion.

The medical board will give their opinion in two months. Unfortunately, doctors rarely are disciplined even for worse actions, so I am skeptical that Mr. Oudman and his family will be taken seriously.

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Despite Rules, Restraint and Seclusion Problem Persists in Iowa Schools

In 2008, new regulations took effect in the state of Iowa limiting the use of restraint and seclusion in schools. The regulations determine how and under what circumstances students can be restrained, how long a student can be locked up into a time-out room, and specifically state that seclusion and restraint cannot be used as punishment. Despite these rules, teachers in three school districts have used restraint or seclusion inappropriately. In one case, a student was strapped to a chair because his aides were absent. In another case, someone was physically punished for disruptive behavior.

Disability advocates call for better training of school personnel. Parents want to know the rules, too, so that they can stand up for their children. I agree to both of these, but I also think an attitutde shift is needed, from repression of undesired behavior to individualized intervention. It is shocking, to me, that apparently belting a student to a chair is seen as an appropriate substitute for two aides. Even in unforeseen circumstances – I will assume this was a one-time incident -, this is unacceptable.

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Psychiatric Intensive Care Significantly Reduces Seclusion, Study Finds

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.

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Solitary Confinement in Juvenile Prisons

Via @sesmithwrites on Twitter comes a horrible story of solitary confinement in juvenile prisons. The story provides some testimonies from girls who were put into solitary confinement for silly reasons, and in at least one case subjected to sexual abuse while secluded.

The girls locked up in juvenile prisons have usually not committed major crimes, but are locked up under de guise of rehabilitation. This, to me, should mean that they should be helped to get their lives back on track rather than being retraumatized. It may be that these girls’ offenses warrant time in prison in the United States justice system, so I am not arguing that here, but then at least they deserve to be treated humanely. And it doesn’t matter whether someone is in school, in a hospital, or in prison, solitary confinement should not be used other than to avert immediate physical harm to the person themselves or someone else, if no alternative is available. Therefore, in a few cases of risk to self-harm, the girl might need to be isolated briefly to prevent her from actually injuring herself. However, it makes no sense to isolate someone who has already self-harmed as a means of punishment.

Beyond that, proper mental health services should be available. Most of the people locked up in juvenile prisons have some form of mental health problems. Even if they committed a crime and need to be incarcerated, that doesn’t strip them off the right to proper healthcare. In fact, with proper psychological and psychiatric services, I bet the vast majority of solitary confinement could be avoided. That is, unless the prison staff are unwilling to change their attitudes anyway.

Lastly of course, if seclusion is needed at all, a person’s safety should be of the highest concern, so it is needless to say, but I will repeat it anyway, that abuse is not acceptable. Period. No matter the reason the person ended up in isolation, abuse is unacceptable.

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Seclusion Again and the Need for Individualized Educational Planning

On Twitter, I saw a tiny news clipping about an autistic child pulled out of a New Brunswick school. I didn’t pay much attention even though I was curious why a child being pulled out of school would make the news. Now, Harold L. Doherty of Facing Autism in New Brunswick comments on the story. As I already feared, the child, Jean-Michel, was removed from school because of having been secluded there.

As I have said a million times by now already, seclusion should not be used unless a child poses an immediate, physical threat to themself or someone else and absolutely no alternative can be used. It is not mentioned whether Jean-Michel posed such a threat, but it is likely that he didn’t. Meltdowns can be disturbing, but they don’t need to involve physical aggressiveness. More likely, Jean-Michel was thought to be distressing to the class with his fits.

Jean-Michel himself makes an important point, when he says that you don’t go to an isolation room, you go to the office. Had he not been autistic, that is where he would’ve been sent for disturbing the class, and rightfully so. Why is it that different punishments are used when a disabled child is concerned?

Besides, even if this behavior was so disturbed that a regular office detention would not be an option, have alternative solutions been explored. We do not know this. All we know is that the parents agreed to the seclusion. It is quite possible that no proper educational and behavioral plan was in place, individualized to meet Jean-Michel’s needs.

Harold Doherty goes on to discuss the possibility that some children with disabilities should not be in integrated classrooms. I have mixed thoughts here. On the one hand, special edcuation is not inherently and principly wrong, provided children are given a quality education in line with their needs. Special education as a dustbin for undesirable children, however, is not acceptable. Neither is the currently inevitable connection between special ed and poor academics. This child has Asperger’s Syndrome, which most likely means his academic skills are at or near grade level. If he were pushed into special ed as an alternative for the isolation room or the presumably unsuitable regular classroom, it should’ve been made sure that he got a quality education there.

I don’t have a particular preference of where children with disabilities are educated. Both inclusive and segregated classrooms – provided children are given the opportunity to interact with non-disabled peers – have their advantages. However, it is key that children with disabilities are at all times provided with a quality education in a safe, non-abusive environment.

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