A Social Work Perspective on Seclusion and Restraint in Australia’s Public Mental Health System

A social work perspective of the nature of seclusion and restraint in Australia’s public mental health systems is presented. The article suggests a theme of seclusion and restraint as a regulatory mechanism despite evidence of harm and even death. The case that the use of seclusion and restraint constitutes a social justice issue as it can be understood as an abuse of human rights and form of torture is established. An incident of a person dying in an Australian mental health facility after being secluded is presented to substantiate this claim. An over focus on individual expressions of violence or risk can be at the expense of understanding the systemic and cultural nature of violence in mental health systems. It is important to understand the nature of, and perhaps to question the presumed necessity of, seclusion and restraint practices to ensure that social workers are not breaching their professional obligations to people who are mental health clients.     

Seclusion & restraint: a historical perspective

(1) The use of restraints in the care of psychiatric patients has been a topic of ethical controversy since the beginning of psychiatric medicine. (2) Enlightenment physicians regarded psychiatric illness as the loss of reason, and many advocated the use of restraints to help violent patients regain the use of reason. (3) John Conolly, a British alienist (a term used for psychiatrists) of the mid 1800s, claimed it was possible to treat psychiatric patients without the use of mechanical restraints, but he made liberal use of seclusion and physical restraint by attendants to manage violent behavior. (4) American alienists expressed misgivings about the use of mechanical and chemical restraint but most were reluctant to relinquish any usable intervention.     

Implementation of comfort rooms to reduce seclusion, restraint use, and acting-out behaviors

The use of seclusion and restraint as methods to control acting-out behaviors by individuals with mental illness continues, despite deaths and other negative outcomes to both the clients themselves and the staff members applying these techniques. Additionally, client-to-client and client-to-staff assaults and self-injurious behaviors can lead to injury or possible fatalities to both parties.Thus, there is a need to find alternative approaches to mitigate or even eliminate some of these behaviors. The use of comfort rooms is one such approach. With the institution of comfort rooms, one small, rural, tertiary mental health hospital demonstrated a reduction in seclusion and restraint use and assaultive behaviors of clients. In addition, 92.9% of the clients who used these rooms found them to be helpful when they experienced increasing levels of distress. With the provision of an area for clients to go voluntarily to self-manage their distress,nurses play a role in promoting autonomy and person-centered care, while reducing environmental stress and potential negative outcomes.     

Perceptions of physical restraint use and barriers to restraint reduction in a long-term care facility

The use of restraints in nursing homes has been curtailed in the United States since the passage of the 1987 federal legislation regulating restraint practices. This study used focus groups with administrators and nursing staff in a skilled nursing facility to examine their views of restraints and perceptions of conditions in the nursing home environment that affect restraint use. Although respondents lacked a shared definition of a "restraint," they did identify contextual factors that in combination with resident characteristics produced situations in which restraint use was justified. Implications of these findings for staff education on restraint reduction are discussed.     

Patient Abuse and Trauma: A Policy Analysis of the Regulation of Seclusion and Restraint in Mental Health Care

Historically, justifications for the seclusion and physical restraint of hospital patients have stereotyped individuals with mental illness as “dangerous” to themselves and others (Huckshorn, 2004a). It can be argued, however, that it is the policies that regulate the use of seclusion and physical and chemical restraints that are dangerous. This article analyzes the Patients’ Rights section of the Hospital Conditions of Participation (CoPs), Part 482 of CFR 42, including sub-sections: e. Standard: Restraint or seclusion; f. Standard: Restraint or seclusion: Staff training requirements; and g. Standard: Death reporting requirements. The set of CoPs regarding Patients’ Rights are analyzed from a value-critical, process-oriented perspective. This article proposes the following six-point framework as uniquely suited to evaluating 42 CFR 428.13: 1) introduction to the background and historical significance of the problem; 2) evaluation of the clarity and measurability of the goals and objectives of the policy; 3) overview of the intended impact of the policy; 4) examination of the value criteria; 5) examination of existing power struggles for those impacted by the policy; and 6) examination of the actual impact of the policy. Results of the policy analysis suggest that the policy does not go far enough to reach its stated goals and objectives in full. In the conclusions, suggestions for further protection of patients’ rights are provided. Examples of alternatives to restraint and seclusion are discussed. Finally, the grave importance of reshaping the culture of mental health care, in terms of life-and-death consequences, is considered.     

Sensory approaches in inpatient psychiatric settings: innovative alternatives to seclusion & restraint

The national initiative to decrease the use of seclusion and restraint in psychiatric inpatient settings requires innovative methods to facilitate the processes of consumer self-organization, self-care, and positive change. Sensory-based approaches and multisensory rooms are valuable resources as cultures of care shift to become more responsive and collaborative. This article explores the importance and efficacy of trauma-informed approaches that are sensory supportive, address the individual needs of the person, and strengthen the therapeutic relationship.     

Least to most restrictive interventions. A continuum for mental health care facilities

While this article does not propose to provide answers to the many questions prompted by the new Patient's Rights CoP (1999) or the newly revised JCAHO standards on seclusion and restraint (JCAHO, 2000), a prudent plan of action for any organization serving patients with a behavioral component to their treatment would be to adopt a policy of least restrictive intervention prior to consideration of seclusion and restraint in response to emergency patient care needs. It was the authors' intent to present a representative sample of the available literature and from that to develop a continuum of intervention possibilities ranging from least to most restrictive. In addition, suggestions found in the literature for implementation of least to most restrictive programs have been provided.     

Reducing seclusion restraint in mental health use settings: core strategies for prevention

1. The use of seclusion and restraint (S/R) is traumatizing to consumers and staff, interrupts the therapeutic process, and is not conducive to recovery. 2. Six effective strategies to reduce S/R use have been identified and are low cost, easily replicable, and publicly available. 3. Organizations that wish to reduce S/R use need to embrace a prevention approach, follow the tenets of continuous quality improvement, and develop a reduction plan individualized for that facility. 4. Highly visible, consistent, and effective organizational leadership appears to be the most significant and critical component in any successful S/R reduction initiative.     

Seclusion. The nursing challenge.

The research to date shows that there is not much data to guide nursing decisions about the use of seclusion. The justification for its use is not always as clear as one might hope. Although many patients are secluded for violence against themselves or others, there are others who have not been violent who are secluded. There may be justification for secluding violent patients, but, as indicated earlier, it may reinforce the behavior it is designed to stop. There probably is no justification for secluding patients who make loud noises, refuse to take medication, or refuse to participate in activities. In addition, it is disconcerting that a large percentage of patients are secluded for "escalating agitation," that is, they have not acted violently against themselves or others. What is problematic is that staff are undoubtedly predicting violent behaviors in these patients--predictions that might be erroneous. Thus, there is ample room for injustice to occur. The potential for injustice is even greater if certain patients are singled out for seclusion or if patients are secluded longer than they or the staff think that they need to be, as is indicated in some of the studies to date. Moreover, if unit variables are associated with seclusion activity, this too, may be indicative of decision making at certain times of the day or by certain staff members that may not be in the best interest of the patient. What seems fairly clear is that secluding a patient is a distressing event for staff and is viewed extremely negatively by some patients and as a reward by others.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inpatient psychiatric treatment of the difficult child: Common practices and their ethical implications

This article reviews and discusses the available research literature pertaining to the prevalence of seclusion and restraint procedures in inpatient psychiatric treatment facilities for children and adolescence. The rationales for use, potential effects, and factors found to influence the application of these more extreme clinical interventions are considered. The author suggests that the supposed therapeutic function of these types of practices has not been substantiated and their implementation can vary widely from one setting to another. Results from several studies suggest that clearly defined criteria for use and more observational studies of prevalence and precipitant factors could considerably refine these procedures and reduce potential abuses. The psychopharmacologic approach to the treatment of difficult children is examined as a sophisticated counteraggression strategy which has yet to demonstrate therapeutic efficacy. These clinical procedures, which are utilized in scores of inpatient settings, generate serious ethical questions for the health professional concerned with the legal rights of those minors labeled as deviant members of families or the society at large.     

From the other side of the door: patient views of seclusion

1. Patient participants viewed seclusion as a form of punishment that maintains physical, and at times, psychological control over the secluded person. 2. A seclusion episode should serve a greater function than simply containment or preserving safety. During this period of crisis for the patient, they felt an even greater need for a therapeutic intervention. 3. Environmental, procedural, and attitudinal changes were emphasized by the patients in this study as a means to enhance the therapeutic potential of seclusion.     

Perceptions of seclusion: comparing patient and staff reactions.

Seclusion, or the use of locked, closely monitored containment, is widely used in psychiatric practice and is legally sanctioned. Involving humanitarian, ethical, and legal issues, seclusion poses dilemmas and raises questions for health-care professionals. Among those defending the practice, some would argue that it is used reluctantly and only as a last resort, whereas others consider it to be a positive therapeutic treatment modality, whether used alone or in conjunction with other treatments. Opponents of seclusion disagree, considering seclusion to be punitive, arbitrary, and geared toward serving the needs of other patients and staff. Although professionals have interpreted seclusion differently with regard to its function, efficacy, and impact, the vast majority of patients view it negatively. Wadeson and Carpenter (1976) found that individuals interviewed 1 year after seclusion still felt bitter about the experience; for many, that experience symbolized their entire psychiatric illness.     

Problem Gambling Within a Chinese Speaking Community

The purpose of this study was to obtain preliminary data on pathological gambling rates within a metropolitan Chinese community to determine if more costly extensive epidemiological surveys were justified. Two thousand survey questionnaires were distributed to parents through children attending a local Chinese speaking school. A response rate of 27.4% was obtained. Over a quarter of respondents were born overseas in either Mainland China or Hong Kong. Results indicated that gambling was not a popular activity with 60.0% of respondents stating that they never gambled. Of those who gambled, a third of respondents identified lotto as the preferred form. Using a Chinese translation version of the SOGS and a cut-off score of 10, a prevalence estimate of 2.9% for pathological gambling was found with males showing a higher rate (4.3%) as compared to females (1.6%). Respondents reporting a prior history of gambling in their country of origin were more likely to be classified as probable pathological gamblers. Despite the use of a sample of convenience, changes to the wording of two items in the Chinese translation of the SOGS and the possibility of false positive cases in the present study, it is concluded that further research into problem gambling in this community should be undertaken.     

How do people perceive urban trees? Assessing likes and dislikes in relation to the trees of a city

Cities are systems that include natural and human-created components. When a city grows without proper planning, it tends to have low environmental quality. If improving environmental quality is intended, people’s opinion should be taken into account for a better acceptance of urban management decisions. In this study, we assessed people’s perception of trees by conducting a survey with a controlled sample of citizens from the city of Morelia (west-central Mexico). Citizens liked both native and exotic tree species and rejected mainly exotic ones. Preference for trees were related to tree attributes; such as size. Trees that dropped leaves or tended to fall were not liked. The most-mentioned tree-related benefits were oxygen supply and shade; the most mentioned tree-related damages were accidents and infrastructure damage. The majority of respondents preferred trees near houses to increase tree density. Also, most respondents preferred trees in green areas as well as close to their houses, as they consider that trees provide oxygen. The majority of the respondents thought more trees were needed in the city. In general, our results show that although people perceive that trees in urban areas can cause damages, they often show more interest for the benefits related to trees and consider there should be more trees in cities. We strongly suggest the development of studies that broaden our knowledge of citizen preferences in relation to urban vegetation, and that further policy making takes their perception into account when considering creating new urban green areas, regardless of their type or size.     

Physical Restraints:

In spite of the increasing recognition of the physical and mental problems encountered as a result of using physical restraints, their use has markedly increased over the years. The ultimate form of abuse, restraint related deaths, has only recently come to light. The popular press began to investigate and report on deaths, but there has been little recognition of the potential lethal dangers of restraint use in the professional literature. Health professionals, particularly nurses, walk the thorny path of choosing ethical dilemmas, such as freedom vs. best interests, where safety and sanctity of life often become the overriding concerns when caring for confused elders. Faced with an increasingly litigious society, nurses feel they must tie down the elderly to prevent lawsuits. However, several reviews of lawsuits indicate that, rarely, are suits entered for a lack of restraining and when they are, other abridgements of care standards can be found to support the plaintiffs claim. The future should see an increasing number of legal cases brought for abridgement of human rights. A more informed public can be expected to seek redress when there is a lack of keeping with the spirit of the new OBRA regulations and incidents occur in the presence of restraint use.     

Discrepancies in Perceived Organizational Control: their Incidence and Importance in Local Churches*

The effects of discrepancies between preferred and perceived control among church members are investigated in terms of amount and distribution of control. For each dimension of control, three categories of respondents are identified: those who preferred a greater amount or wider distribution of control than they perceived to exist within their churches (deficit); those whose preferred and perceived control scores were identical (balance); and those who preferred a lesser amount or more concentrated distribution of control in their churches than they perceived to exist (surplus). For both amount and distribution of control, a perceived deficit is more common than a surplus. Respondents experiencing discrepancies in either direction are more dissatisfied and alienated than those with a balance in desired and perceived organizational control. A deficit is associated with more dissatisfaction (but not necessarily more alienation) than a surplus. Subsample comparisons show these findings hold for both officers and non-officers. Regression analyses show that discrepancies regarding organizational control are important even after other aspects of control have been introduced.     

Socioeconomic and ecological perceptions and barriers to urban tree distribution and reforestation programs

Tree planting and reforestation initiatives in urban and peri-urban areas often use tree distribution or “giveaway” programs as a strategy to increase tree cover and subsequent benefits. However, the effectiveness of these programs in terms of increasing overall tree cover and providing benefits to low-income and disadvantaged communities has been little studied. We assess these programs by exploring community participation in, and barriers to, an urban tree distribution program in Fort Lauderdale, United States and the role socioeconomic background and tree functional types have on participation. We use a mixed-methods approach, panel data, choice experiments, and econometrics to quantitatively analyze respondent’s ranking of program options. High income, White respondents had the highest level of awareness and participation while low income, African Americans (AA) had the lowest level. Monetary rebates were perceived as positive and significant as the compensation value increased to US$8.00 - $12.00. Fruit-bearing and native tree functional types were more preferred than flowering or shade trees. Latinos, AA, and high income respondents preferred fruit trees, while White, high income preferred native trees. Overall, low income respondents perceived the greatest barriers towards participation. 20% of Broward County residents who participated in the survey were aware of the tree giveaway programs and 13% had previously participated. Findings indicate an adaptive governance mismatch between program objectives to equitably increase city tree cover via planting shade trees versus individual’s knowledge and preference for other tree types and functions. Results can be used for developing and evaluating reforestation initiatives to equitably increase tree cover and improve the governance of urban ecosystems.     

Reply to Sloan

Abstract

While previous studies have used trust in the government as an exogenous variable to measure political protest and other forms of social unrest, we treat it as a dependent variable. Thus, we attempt to identify variables that affect trust in government, and we also distinguish between those variables that transcend race and those that differentially affect black and white respondents. Using data from the 1987 General Social Survey, we regress trust in the government on a variety of demographic and ideological measures. Results show that political apathy and belief that the government is unresponsive to the needs of the people lead to low levels of trust, regardless of the respondent's race. However, ideological variables such as political and religious views display different patterns for black and white respondents. While these variables do not affect black respondents' attitudes toward the government, they have a strong effect for white respondents. Implications of this study are discussed.     

Stimulant Medication Use,Misuse, and Abuse in an Undergraduate and Graduate Student Sample

In this study, the authors investigated the characteristics of use, misuse, and abuse of stimulant medication (primarily methylphenidate and variants) among students at a northeastern US university. Researchers sent an invitation to take an Internet survey to student e-mail addresses and passed 150 paper surveys in undergraduate classes, analyzing 1,025 (975 electronically) returned surveys. Sixteen percent of respondents reported abusing or misusing stimulant medication. Ninety-six percent of respondents who specified a medication preferred to abuse or misuse Ritalin. Men and women reported similar use patterns. Most respondents who abused or misused stimulant medication swallowed pills; 40% used intranasally. Reasons for abusing or misusing stimulant medication included improving attention, partying, reducing hyperactivity, and improving grades. Consistent with previous studies, results suggest that abuse of stimulant medication is a concern on college campuses. The results point to various reasons for and methods of abusing and misusing stimulant medication that may direct future research, prevention, and intervention.     

Stimulant medication use, misuse, and abuse in an undergraduate and graduate student sample

In this study, the authors investigated the characteristics of use, misuse, and abuse of stimulant medication (primarily methylphenidate and variants) among students at a northeastern US university. Researchers sent an invitation to take an Internet survey to student e-mail addresses and passed 150 paper surveys in undergraduate classes, analyzing 1,025 (975 electronically) returned surveys. Sixteen percent of respondents reported abusing or misusing stimulant medication. Ninety-six percent of respondents who specified a medication preferred to abuse or misuse Ritalin. Men and women reported similar use patterns. Most respondents who abused or misused stimulant medication swallowed pills; 40% used intranasally. Reasons for abusing or misusing stimulant medication included improving attention, partying, reducing hyperactivity, and improving grades. Consistent with previous studies, results suggest that abuse of stimulant medication is a concern on college campuses. The results point to various reasons for and methods of abusing and misusing stimulant medication that may direct future research, prevention, and intervention.