The administration of medication to mental health consumers against their wishes is equivalent to the overpowering of them by physical force. To many consumers it is much worse, with very significant side effects. But the issue of chemical restraint, however it was justified, was carefully avoided. The Forum did not receive data on the rates of use of chemical restraint at all, from any state or territory. It was not counted at all.
However, the strident voice of Justice Action and our distribution of "Mad In Australia", ensured exposure of the issue. It is clear that involuntary medication is as critical an issue as physical restraint, but much more insidious. If the consumer is being overpowered then the motivation is irrelevant. The question as to whether the patient wants the medication or not should be recorded. It is dishonest to say that only the psychiatrist’s motivation is relevant, and if called "treatment" is acceptable.
The National Seclusion & Restraint Forum was initiated by the Australian Health Ministers’ Advisory Council (AHMAC) in its 2005 publication, National Safety Priorities in Mental Health: A National Plan for Reducing Harm, which endorsed Australia’s first national plan on safety improvements in the mental health area, including the reduction of and, where possible, the elimination of restraint and seclusion practices on patients in mental health facilities. This 9th Forum brought together key figures in mental health from around Australia who presented ideas and findings on ways to create violence-free and coercion-free mental health treatment environments through the reduction of seclusion and restraint. However, the issue of reducing chemical restraint was mostly avoided.
The Forum became the platform at which five years of data regarding seclusion was released by Associate Professor John Allan of the NSW Ministry of Health. The data showed a significant reduction in national rates of seclusion from 15.6 events per 1,000 bed days in 2008-2009 to 10.6 in 2011-12. While there is evidence of a reduction in national seclusion rates, data involving the rate of involuntary medication given - and whether this has increased - is non-existent. This leaves open the possibility that the national seclusion data is reflective of chemical restraint being used in place of seclusion, rather than an improvement in the mental health system.
The various issues raised by key speakers, such as Alan Fels, aligned with the goals of the National Mental Health Seclusion and Restraint Project (‘the Beacon Project’), which was implemented between 2007-2009 to develop and apply international “policies, guidelines and staff training based on good practice” in the Australian mental health environment. The annual National Mental Health Seclusion and Restraint Forums maintain the efforts of the Beacon Project.
Webcasts of the topics, raised in the Forum, can be viewed at: http://webcast.gigtv.com.au/Mediasite/Catalog/catalogs/NSR2013
We have outlined some particular areas of interest from the forum below;
Reducing Trauma in Mental Health Services
According to Beverly Raphael, during her address at the 9th Annual National Seclusion and Restraint Reduction Forum, trauma needs to be taken into account in management and in specifically understanding and responding to behaviour and distress. Models of trauma-informed care involve ensuring a sensitivity to trauma and in avoiding practices which can lead to re-traumatisation. To achieve this, it is essential to know the trauma history of a patient as often trauma, particularly child trauma, is linked to the onset of mental health disorders. Raphael gives evidence that two-thirds of people presenting to mental health services will have experienced childhood trauma, often with histories of physical or sexual abuse, chronic neglect, protracted emotional abuse, witnessing domestic violence or are victims themselves, or interpersonal violence. Because of this, a thorough assessment of a patient’s trauma history is vital in providing effective treatment, as well as, addressing their current strengths, difficulties, and current functioning. It has further been suggested that, whenever possible, family/carers of clients should be included in the therapeutic process.
Certified Peer Specialists
Gary Parker, Executive Director of Kansas Consumer Advisory Council for Adult Mental Health, describes the benefit of implementing Certified Peer Specialists into the mental health system as not only helping to establish recovery goals, but also in developing a relationship of trust with the consumer. The employment of a peer workforce has been shown to reduce seclusion and restraint within acute adult mental health inpatient units. The implementation of peer workers would ensure there is interaction and dialogue with consumers. “Sharing stories of both positive and negative experiences helps to break down the barriers and belief systems that are perpetuated within mental health models of care”. Certified Peer Specialists in America work similarly to this. A Certified Peer Specialist is a person, with a lived experience of mental illness, who shares their stories with people being served in the mental health setting. It is because of this that they are able to create a human connection with the consumer.
Individualised Crisis Plan
What has been further suggested by the Victorian Government in their document on Seclusion & Restraint Prevention Tools is an individualised crisis plan, designed to develop a therapeutic relationship between the consumer and mental health workers. The focus is on dialogue, a “thoughtful conversation about what works, what helps and what doesn’t when a problem is emerging”. The document draws on a quote by Ben Franklin, “you involve me and I will learn”, as central to the development of a successful individualised crisis plan. The plan reflects the belief that if you involve the people you are working with, there is an opportunity to empower the consumer and reduce risk and trauma to them. This idea is central to Justice Action’s ‘Mad in Australia” report, which involves ensuring patients make informed decisions concerning their health. Mad in Australia promotes the understanding that directing greater attention to the area of the patient voice is an essential means of resolving issues within the current Mental Health System. This can be achieved through;
1) Consumer advocates at point of prescription
2) Information and explanation about side effects which may occur every time a prescription is administered- consumers can be advised to ask certain key questions.
Seclusion can generally be defined as the deliberate and sole isolation of a person who has been confined in a room that has been locked from the outside. While seclusion may protect the safety of other patients, it can be distressing for the patient, family members, and other immediate people involved. It can also further exacerbate underlying mental health issues. Seclusion, therefore, should be used as a last resort where possible or minimised in favour of other less restrictive control measures.
Data regarding seclusion rates have allowed comparisons to be made between the States and Territories. For instance, there has been an average annual reduction of 11.3% in the number of seclusion events nationally, from 15.5 seclusion events per 1,000 bed days from 2008-2009 to 9.6 seclusion events per 1,000 bed days from 2012-2013. Seclusion rates have fallen in most jurisdictions, with the Australian Capital Territory (ACT) leading the front with an average annual reduction of 49.1% over the 5 year period, followed by Western Australia with a 21.0% average annual reduction. Tasmania, however, reported a 6.5% increase in seclusion rates over the same period.
Of particular concern has been the relatively high rates of seclusion in child and adolescent acute mental health facilities. For instance, in 2012-2013, there were 14.5 seclusion events per 1,000 bed days compared to 10.3 for general units. However, many child and adolescent mental health units are included in the mixed category, referring to combinations of older people, forensic, general, youth, child and adolescent services, and as such, may reflect the disparity.
The definition of restraint is defined by the Mental Health Act 2000 and the National Safety Priorities in Mental Health: A National Plan for Reducing Harm. Restraint refers to the restrictive intervention that relies on external controls to limit the movement or behaviour of a person. Restraint can be classed into physical, mechanical, and chemical restraint.
Physical restraint refers to the use of physical force to prevent a person from placing themselves in a dangerous situation or harming themselves and others.
Mechanical restraint refers to the restraint of a person by the use of a mechanical appliance (including belt, harness, manacle, sheet, strap, and handcuffs), preventing the free movement of the person’s body or a limb of the person. Restraint comes with a large number of adverse risks, including asphyxiation or choking of the person, bruising, circulatory problems, dehydration, injury from physical and/or mechanical restraint, psychological distress, and in some circumstances, death.
Chemical Restraint occurs when medication limits the movement and behaviour of the person. “Mad in Australia” analyses the use of involuntary medication and says that it could be an option to avoid the risk of serious harm to the person or others, but social support is usually much better. The culture of the mental health industry has permitted a false division between treatment and sedation, allowing forced medication to be cloaked as treatment and not as restraint.
The NSW Health Policy Directive gives guidance to the sedation practices and clearly outlines the circumstances in which sedation may be used on a patient. The policy directive states that these “chemical restraints” can only be used in “extreme circumstances when other forms of management of a least restrictive nature have been proven unsuccessful”. However the policy does not accurately separate sedation from treatment , thereby leaving an opportunity for the abuse by those in authority over mental health patients.
While the problems surrounding physical, and mechanical restraint were addressed at the forum, issues surrounding chemical restraint were not given the attention they deserve. Research has shown that social alternatives to chemical restraints are much more effective at treating the mentally ill without breaching individual liberties and therefore should be brought to public attention.
The purpose of the Forum was to call for national action in reducing the use of and, where possible, eliminating restraint and seclusion. The implementation of therapeutic practices that empower consumers within mental health facilities is essential. This includes informed consent regarding treatment options, greater accessibility to alternatives of restraint, and the use of the least restrictive methods to enable a patient's recovery. Seclusion and restraint can be violent, stressful and humiliating and its reduction is essential in order to ensure the human rights of mental health patients are met.