An unpalatable reality in the age of improving care

New Zealand Herald
November 06, 2007
By Chris Barton

It happens more often than you’d think. A person arrives at a mental health unit in a psychotic state and is immediately put into a seclusion room.

Mental health consumer adviser Vicki Burnett tells the story of patient A. “When psychotic, she thought she was on fire and her hands were on fire. Put into a seclusion room, all the walls appeared to her to be on fire. I can’t think of anything worse or more terrifying.”

Why, asks Burnett, when someone is struggling with reality, lock them into a stark empty space with nothing to anchor them to the real world? “That’s not low stimulus, it’s worse than low stimulus because there is nothing – there is no reality.”

The sticking point for this story is getting a photo of a seclusion room. No one is keen to provide an image of this unpalatable reality that harks back to the days of the padded cell. Locking people up in solitary confinement is not a good look for enlightened, recovery-based mental health services in the 21st century.

We can get a description. “A seclusion room is a bare room with a plastic mattress on the floor and a disposable potty that’s made out the same stuff that egg cartons are,” says Burnett.

We know, too, the effect of being put in seclusion. Anne Helm, a member of the Confidential Forum for Former In-Patients of Psychiatric Hospitals, says: “If you are in a seclusion cell you have feelings of worthlessness, of loss of dignity and, at the very time when you are most fragile, you are removed from any human contact. It’s counterproductive to what people generally need.”

For the first time, we also know just how much this outmoded practice is still being used in mental health units around the country today.

Data just made public by the office of the director of mental health shows that 477 people were locked in seclusion rooms during the last quarter of last year. The bulk (383) were in adult mental health units, 59 were in forensic (crime related) services and 18 in child and young persons facilities. Data for those over the age of 65 was incomplete, but it appears most mental health units for the elderly do not have seclusion rooms.

Maori are more often secluded than other ethnic groups, accounting for 186 of the 477 locked up. Most stays (82 per cent) were shorter than one day. The longest recorded was 30 days.

There were 1514 seclusions in adult services during the quarter, indicating the same people are secluded multiple times – about four times on average. There is a wide variation in the data from district health boards (DHB). Tairawhiti (Gisborne), Canterbury and Bay of Plenty had the highest incidence of locking people up, and Auckland, Waitemata and Capital and Coast were among the lowest.

“Seclusion is a worry to us,” says the mental health director for the Ministry of Health, Dr David Chaplow. “We want it to start trending down and we want to really minimise, possibly even extinguish, the use of seclusion.”

The worry for the ministry is unavoidable evidence that the practice has no therapeutic purpose and that its continued use may breach fundamental human rights – and expose mental health services, already tainted by a legacy of inhumane practices, to further compensation claims.

Chaplow says the latest statistics are one of the steps in setting a benchmark for acceptable practice. At present, the use of seclusion is allowed under the Mental Health Act for the “care” or “treatment” of the service user, or protection of other users in the ward. It’s operation is outlined in the ministry’s Restraint Minimisation and Safe Practice Standard (2001), which is about to be updated.

With only three months of reporting, not too much can be read into the wide variation of figures by district. Tairawhiti, for example, which has the highest number of seclusion events (120 for the quarter) is a six-bed unit with two seclusion rooms.

Its statistics have been looked at by the mental health district inspector, who has reported that the use of seclusion in each of the cases was justified.

But Chaplow says that when the full figures for last year come out such discrepancies will be weighed against the wider picture. “If we do have DHBs wildly out of step, we’ll be saying to them they had better have a look at this.”

He points to reasons for the variations, including data being skewed by one or two difficult patients, demographic differences, ward design, staff training and differences in seclusion practices.

“In the past, it would not be uncommon for people to be secluded as a type of punishment. We are rigorously combating that in our training.”

Burnett is not so sure the message is getting through. “I think seclusion rooms are a threat to people and I think they are used as a threat: ‘If you don’t settle down we’ll have to put you into seclusion.”‘

She argues that it’s not necessary to lock someone in a room to reduce stimuli and says the ministry shouldn’t be approving any new buildings that have seclusion rooms.

Although the ministry wants the use of seclusion minimised in mental health services, many – including the Mental Health Foundation, the Mental Health Commission and the Mental Health Advocacy Coalition – want its routine practice eradicated. “We would like to see it become unacceptable as a norm to use seclusion – and if it is used, there has to be a thorough justification and explanation,” says Judi Clements, chief executive of the Mental Health Foundation. Clements says that, aside from seclusion, other statistics in the director’s report raise concerns, such as that 224 patients were treated with electroconvulsive therapy (ECT) last year and that 17 per cent of the treatments given did not have consent.

Seventy per cent of the recipients were women, most aged in the 64 to 84 age age group.

“We need to keep asking, what place does compulsion have in an environment that is moving towards a more enlightened approach towards people with mental illness?” says Clements.

Being forced to accept assessment and intervention against their will is a common complaint among mental health service users, and seclusion – forced restraint and imprisonment – is a prime example.

Psychiatrist David Codyre, also a member of the Mental Health Advocacy Coalition, agrees. He sees no evidence that seclusion is of any benefit and much confirmation from consumers that it is harmful and a significant breach of human rights. “It is no longer sustainable to say this is a necessary evil,” says Codyre. “It’s an unnecessary evil in the vast majority of cases.”

Codyre says studies show that when staff work in ways that minimise confrontation and maximise reassurance and engagement, the need to use seclusion as an intervention reduces dramatically.

Importantly, when staff work to reduce the use of seclusion, the level of violence in in-patient units, and particularly assaults on staff, reduces in a parallel line. “While seclusion was viewed as a way to keep everyone safe, what it actually was doing was increasing levels of trauma and violence for everyone involved .”

Consumer advocate Burnett sees the use of seclusion as poor nursing practice. “In nearly all instances it could have been avoided by better engagement with the person before that was necessary.”

But not everyone is convinced that it’s possible to totally eradicate seclusion. “That’s a good aim to have – whether it’s realistic I’m not entirely sure,” says Nigel Fairley, Capital and Coast DHB director of area mental health services, a DHB which is among the lowest users of seclusion practices. “The problem with that aim is that it does not recognise that, in some circumstances, there is a therapeutic value for the use of seclusion in that it provides the person a low stimulus environment, which is important at that point in time in their mental health issue.” He sees seclusion as a compulsory time out to deal with risky situations – a last, but legitimate, resort.

One who is determined to see seclusion completely removed is Karla Bergquist, the manager of district mental health services for the Waitemata District Health Board.

“We’re supposed to be providing services for people who have experienced trauma that are supportive and caring and therapeutic,” Bergquist says. “I don’t think that seclusion and restraint fit into those categories.”

The DHB has introduced “trauma informed care” projects, where staff use debriefing and analysis of each incidence of restraint and seclusion to understand why they happened and what could be done differently.

Bergquist says studies show that while initially there may be a small increase in the use of psychotropic medication – sometimes called the chemical straitjacket – when seclusion is removed it’s not a lasting effect. “When you’ve had an option that has been available to you for a very long period of time it’s hard to imagine what life would be like without it.” As to staff reaction to her ideas, “A lot of people say ‘You’re off your head’, but we’ve also got a group who are really passionate about moving towards that goal.”

Helm sees seclusion as part of our institutional legacy and no longer appropriate as a response to distress in the light of what is now call recovery-based practice. “It’s basically used as a behavioural management tool in controlling very complex environments.”

Like most, Helm agrees there are instances – such as for those in drug-induced psychosis – when restraint will be required. But seclusion is usually the result of impaired judgment by overworked, over-stressed staffing regimes where room for more appropriate responses is not possible.

“Solitary confinement might be perceived as therapeutic by the staff, when the recipient is seen as calm and contemplative. Mostly, that’s just the trauma of confinement. It breaks the spirit and sometimes results in long held fears which means the service user doesn’t want to use the service again.”

Big guy Mark tells his side of story

Mark, at the time 28, describes his experience of being put into seclusion in an Auckland mental health unit for three days.

I was diagnosed bipolar schizoaffective. At the time I wasn’t aware I had problems. I thought what I was going through was natural – that it was a spiritual awakening when you start hearing voices. I got hospitalised in February 2003. I had no clue about why I was there. I wanted to escape and one night I did. I took off out the door, jumped the fence and was away.

I got caught and put into the acute service. In the ward I was wrestled to the floor and given an injection to calm me down. I was afraid for my life. I thought they were going to do something to me. I spent the next few days locked up in a daze – you don’t know what time it is. All I recall is waking up and going back to sleep again. Sometimes there would be food and water. It was a lock-up room. It felt like being chucked into prison without a conviction – without any reason for why I was there.

I remember the smell of urine. The room wasn’t cleaned often. The walls were yellowish brown. My bed was just a flat pillow on the floor. They would come and give me another injection. There was nothing to look at all day – except out the window in the door which had a view of the corridor. There was no other window. The lights were on 24/7. The only person I saw was the one who brought the tray in and took away the waste. It’s something you shelve – try to forget about. I felt helpless and kept thinking I had done something wrong to be locked up. It felt like I was being punished for something I had no control over.

At the end of it, in the review, the staff told me the main problem was they thought I would be violent and psychotic and basically because I’m a big guy, they thought it was better to keep me monitored. I was in there for three days. My parents cried when they saw me – they thought going to hospital was the only and best choice for me. They didn’t realise anything like this would have occurred.

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