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.     

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.     

Nursing staff's attitudes toward seclusion & restraint

1. Staff preferred to treat patients as they themselves wanted to be treated. 2. More than one third of respondents did not view seclusion and restraint use as a time for a therapeutic intervention. 3. If staff are practicing from their belief patterns, they will choose interventions to avoid use of seclusion and restraint. 4. The majority of respondents preferred using medication to treat out-of-control behavior because they considered it less restrictive.     

Personality, Negative Interactions, and Mental Health

Research suggests that an individual's personality traits may mediate the relationship between social support and mental health. This study uses two national data sets to test a conceptual model that integrates personality, social support, negative interactions, and psychological distress. Results suggest that, beyond the influence of personality, social support is negatively associated with psychological distress, and negative interactions are positively associated with such distress. The findings also suggest that personality has direct and indirect effects, through social support and negative interactions, on psychological distress. Findings specify how positive and negative facets of relationships and personality influence mental health outcomes.     

Family therapist comfort with and willingness to discuss client sexuality

Limited empirical information exists on whether or not marriage and family therapists are having sexuality-related discussions with their clients. When helping professionals ignore client sexuality, the potential for unintended negative outcomes increases. The researchers surveyed 175 clinical members of the American Association for Marriage and Family Therapy to assess how their clinical training and education, their perceived sexual knowledge, and their comfort with sexual material influenced their willingness to engage in sexuality-related discussions with their clients. The results indicate that sexuality education and supervision experiences are the cornerstone for a therapist's base level of comfort. It is through sexuality education and supervision that sex knowledge is acquired and comfort levels are increased. Once comfort with sexual discussions increases, then therapists are more likely to engage in sexuality discussions with their clients.     

Moral Incongruence and Pornography Use: A Critical Review and Integration

Internet pornography use (IPU) remains a controversial topic within sexual behavior research fields. Whereas some people report feeling dysregulated in their use of pornography, mental health and medical communities are divided as to whether IPU can be addictive. The present review sought to examine this issue more closely, with a focus on how variables other than pornography use, such as moral disapproval and moral incongruence (i.e., feeling as if one’s behaviors and one’s values about those behaviors are misaligned), might specifically contribute to self-perceived problems around pornography use. Through an examination of recent literature, the present work reviews evidence that moral incongruence about IPU is a common phenomenon and that it is associated with outcomes relevant to current debates about pornography addiction. Specifically, moral incongruence regarding IPU appears to be associated with greater distress about IPU, greater psychological distress in general, greater reports of problems related to IPU, and greater reports of perceived addiction to IPU. The implications of this body of evidence for both clinical and research communities are discussed, and future directions for research are considered.     

A Comparative Study of Arm‐Restraint Methodology: Differential Effects of Mother and Stranger Restrainers on Infants' Distress Reactivity at 6 and 9 Months of Age

This study examined both differential patterns and the stability of infants' (N = 70) distress reactivity across mother and stranger arm‐restraint conditions when infants were 6 and 9 months of age. Reactivity measures included observational variables for the rise, intensity, and duration of infant distress as well as motor activities associated with escape behaviors. Correlation analyses revealed that infant behaviors during arm restraint were modestly stable across conditions and over time; however, mean comparisons also showed that infants' distress responses appear to be sensitive to protocol parameters (whether restrainer is mother or stranger). At 6 months of age, infants cried more during maternal restraint than with strangers and exhibited escape behaviors more frequently with mothers. Findings further indicate that infants' distress reactivity undergoes developmental alterations from 6 to 9 months of age, with infants crying more quickly, reaching peak intensity of distress faster, and displaying more distress at 9 months compared to 6 months. These changes in infants' reactivity were particularly accentuated during maternal compared to stranger restraint conditions at 9 months of age.     

Civil war, social integration and mental health in Croatia

Research has shown that social relationships are generally beneficial for mental health (Thoits 1995). However, few scholars have examined this association after the occurrence of a significant shock to the social system as a whole. The purpose of this article is to examine the relationship between social integration and war-related distress in Croatia immediately following the recent civil war. Does social integration decrease war-related distress? Does social integration buffer the effect of traumatic events on war-related distress? We analyze these questions using nationally representative survey data collected in Croatia in 1996. Results suggest that social integration has both positive and negative direct effects on distress. Being a member of informal organizations, such as sports clubs, and participating in social activities are beneficial for mental health. On the other hand, being a member of some formal organizations, such as church organizations and unions, is detrimental to mental health. There is little support for the idea that social integration buffers the effect of traumatic events on distress. Only one of thirty-six possible interactions is significant and supports the buffer hypothesis. Frequent participation in social activities buffers the effect of experiencing violence on war-related distress. Also, some forms of social integration appear to aggravate the effect of traumatic events on war-related distress. In sum, social integration does affect war-related distress after a system shock, but in complex and sometimes unexpected ways.     

Listening to Words,Hearing Feelings: Links Between Eating Disorders and Alexithymia

Research suggests that eating disorders often involve difficulty with affect regulation and processing of emotions. Studies also show that many individuals with these difficulties suffer from alexithymia, or an impaired ability to use language to tolerate or process emotions. Many clients with eating disorders are highly verbal, able to talk about feelings and even have good insight into the causes of their behaviors. Yet their verbal and cognitive strengths may disguise their inability to use thoughts to manage their emotions. Such clients often have a lifelong experience of appearing more capable and competent than they feel. Self-criticism and negative self-image concretized in a negative body image are part of their eating disorder. Therapeutic exploration can increase anxiety and self-criticism, aggravating feelings of inadequacy and the concomitant need for self-soothing. Techniques that focus on affect regulation have been shown to be effective, yet a psychodynamic approach can be an important tool in such an integrative practice. In this article, clinical material and theory will illustrate some of the ways that incorporating an understanding of alexithymia into the work can enhance the use of both psychodynamic exploration of meaning and also tools to manage affect and change behavior.     

Subjective distress from trauma in older clients with severe mental illness

There is little research on older persons with severe mental illness (SMI) who have experienced trauma. We conducted an exploratory study with 174 community mental health clients with SMI who were 50 years of age or older (range 50–87; mean age 58) to examine the relationship between subjective distress related to six common traumas and post-traumatic stress symptoms while controlling for gender and other key psychiatric symptoms. With regression analysis, we found that of the six common traumas, only distress from unexpected loss of a loved one was significant. That factor accounted for the most variance in post-traumatic stress symptoms than all other factors in the model including gender, psychiatric symptoms of SMI, and other trauma. Gender and symptoms of psychosis were also significant in the model. Unexpected losses, particularly in older persons with SMI, can cause considerable emotional distress and could be related to post-traumatic stress symptoms. Practitioners should be vigilant in regularly screening older people with SMI for recent loss of loved ones and be prepared to address their distress with grief/bereavement counseling.     

Reciprocity Counseling: Practice and Research*

This paper reviews the literature on reciprocity counseling. Evidence is presented for the usefulness of reciprocity counseling with young, well educated, white clients with slight to moderate marital distress. Research into the effectiveness of several components of reciprocity counseling including contracting, problem solving training and feedback is reviewed. Findings suggest that contracting alone is an important positive influence in increasing couples' reciprocating reinforcement. The impact of problem solving training is unclear. Sex of the therapist may influence husband and wife outcomes in problem solving training differentially. Couples' performance of problem-solving behavior appears to be under the control of other as yet unspecified variables. Feedback as a single treatment has unpredictable and sometimes negative results. Therefore use of feedback alone or without careful supervision appears questionable at this time. Issues raised for further research include use of token economies for more severely distressed couples, use of multiple therapists, and the development of a classification scheme for the severity of marital distress.     

Examination of the Role of Therapeutic Alliance,Treatment Dose,and Treatment Completion in the Effectiveness of The Seven Challenges

Adolescent alcohol and illicit drug (AOD) use is a major public health concern. This longitudinal study examines the effectiveness of The Seven Challenges in reducing adolescent substance use and mental health problems, as well as the process by which it is effective. Participants were 89 adolescents (72 male, 17 female) enrolled in a 3 month intensive outpatient adolescent substance abuse treatment program using The Seven Challenges and who provided self-report data at pre- and post-treatment. Results indicated that The Seven Challenges was effective at increasing the number of days refrained from using AOD, reducing use of tetrahydrocannabinol (THC) and other drugs, and reducing substance use problems and internal mental distress. Results also indicated that The Seven Challenges drug counselors effectively established and maintained therapeutic alliance but this seems to not play a role in the effectiveness of The Seven Challenges. Both treatment dose and completion played a role in the effectiveness of The Seven Challenges; they were both positively related to post-treatment days refrained from AOD use, and negatively related to days of THC use, substance use problems, and internal mental distress. However, the strength of the influence of treatment completion was stronger when treatment dose was low than when it was high. Despite a small sample and other limitations, findings add to existing literature that suggests that The Seven Challenges is an effective substance abuse treatment for adolescents. Furthermore, findings suggest that adolescent substance abuse treatment should focus on clients meeting pre-determined program goals as well as on dose.     

Sexual Debut and Mental Health Among South Korean Adolescents

Numerous studies have demonstrated the negative influence of sexual debut during adolescence on mental health outcomes. This article contributes to this literature by investigating whether sexual debut has negative effects on mental health among South Korean adolescents and whether the timing of adolescent sexual debut matters. Drawing on longitudinal data from a nationally representative survey, we first predicted mental health outcomes at one year after high school graduation using first sexual intercourse that had occurred before the outcomes were measured. In a second statistical model, adolescent sexual debut was defined as first coitus that had occurred before high school graduation. Sexual debut was associated with an increase in problematic aggressive behaviors for both genders. In contrast, only girls experienced a rise in depressive symptoms after becoming sexually active. For girls, having sex before high school graduation was correlated with worse mental health outcomes to the extent that sexual debut even enhanced the risk of suicidal ideation. We concluded that the negative effects of sexual activity among South Korean adolescents are attributable mainly to the sexually conservative atmosphere and gendered sexuality in that country.     

Economic distress and mental health: The role of family coping resources and behaviors

Relationships among economic distress, family coping resources and behaviors, and mental health are examined among a sample of 203 married men and 207 married women. Economic distress is negatively associated with mental health. Although family coping resources are lower among those experiencing economic distress and are generally positively related to mental health, their role as mediators of relationships between economic distress and mental health is limited. Economic distress is positively related to family coping behaviors. However, these behaviors do not have positive relationships with mental health and do not counteract the effects of economic distress on mental health. Some coping resources and behaviors have buffering effects on relationships between economic distress and mental health while others have exacerbating effects.This article is a revision of a paper presented at the annual meeting of the American Sociological Association, August, 1986. The research was supported by grant 84–164 from the Office of Program Evaluation and Research, Ohio Department of Mental Health. Additional support was provided by the Office of Computing Activities, University of Dayton.Patricia Voydanoff is Director of the Center for the Study of Family Development, University of Dayton. Dr. Voydanoff holds a Ph.D. in Sociology from Wayne State University. Her research interests include work and family life and coping with economic distress.Brenda W. Donnelly is a Research Associate at the Center for the Study of Family Development, University of Dayton. Dr. Donnelly received her Ph.D. from the University of Delaware. She is currently conducting research on adolescent childbearing and religion and family life.     

Girls Most of the Time,Boys Some of the Time: Gender Differences in Toddlers' Use of Maternal Proximity and Comfort Seeking

How children experience, express, and regulate distress has important implications for adjustment. Factors influencing individual differences in these aspects of affective behavior include temperament, context of situation, and parents, to name a few. Gender differences in the expression of affective behaviors have also been implicated in past research. However, differences are not always found, especially before preschool ages. This study examined the presence of gender differences and moderating influences of gender on the expression of distress and mother‐oriented behaviors (e.g., comfort seeking and proximity to mother) in 24‐month‐old toddlers during a series of situations designed to elicit either fear or frustration. Girls were more likely to seek contact from mother and stay in closer proximity to her compared to boys even after controlling for distress. However, the association between distress and contact seeking or proximity was significant for boys but not for girls. The discussion focuses on implications for biological and socialization effects of sex‐typed behavior and consequences for adjustment.     

Disruption in Parental Co-habitation and its Effects on Short-Term,Medium-Term,and Long-Term Outcomes of Adolescents

In this paper the relationships between a disruption in parental co-habitation and various categories of adolescent outcomes over multiple time horizons are explored. Using data from the National Longitudinal Study of Adolescent Health (Add Health), we estimated the effects of a change from living with both parents to just one, on academic and employment outcomes, the likelihood to indulge in risky behaviors, mental health outcomes and body mass index measures, from less than 1 year to over 14 years after the change. Propensity score matching methods were used to control for individual characteristics and pre-existing differences in the family environment that may increase the chances of separation, and the results are compared to those obtained using ordinary least squares or probit methods. Results showed evidence of adverse effects of living with one parent in the short term, medium term and long term. Adolescents living with one parent had lower academic achievement in all term lengths, poor mental health in the short to medium term, and were more likely to engage in risky behaviors in the medium to long term.     

The moderating effects of culture on peer deviance and alcohol use among high-risk African-American Adolescents

African-American adolescents have lower rates of alcohol consumption than White youth. However, African-American youth suffer disproportionately more adverse social, mental, and physical health outcomes related to alcohol use. Affiliating with negative peers is a risk factor for alcohol initiation and consumption. Cultural variables have shown moderating effects against other risk factors for African-American youth and therefore were the focus of this study. Specifically, we tested whether three culturally-relevant variables, Africentric beliefs, religiosity, and ethnic identity were promotive or protective for alcohol initiation and use within the context of negative peer affiliations. The sample consisted of 114 at-risk African-American adolescents whose ages ranged from 13 to 20. Participants were administered a questionnaire with measures of alcohol initiation and use, peer risk behaviors, ethnic identity, Africentric beliefs, religiosity, and demographic items. Peer risk behaviors accounted for significant percentages of the variance in age of alcohol initiation, lifetime use, and current and heavy alcohol use after adjusting for age and gender. Cultural variables showed both promotive and protective effects. Africentric beliefs were promotive of delayed alcohol initiation, whereas both Africentrism and religiosity moderated peer risk behaviors effect on alcohol initiation. Africentric beliefs were also inversely related to lifetime alcohol use revealing a promotive effect. Moreover, there were significant protective effects of ethnic identity and religiosity on heavy alcohol consumption. One implication of these findings is that prevention programs that infuse cultural values and practices such as Africentrism, ethnic identity, and religiosity may delay alcohol initiation and reduce use especially for youth with high risk peers.     

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.