DESIGN IN MENTAL HEALTH CONFERENCE 2019
Reducing the use of restraint and seclusion
Speaking in a session on the use and design of seclusion spaces in contemporary care at May’s Design in Mental Health 2019 conference, Paula Reavey, Professor of Psychology & Mental Health at London South Bank University, and DiMHN Research and Education Workstream lead, and Dr Hamid Alhaj, director of Research for the National Association of Psychiatric Intensive Care Units and Low Secure Units (NAPICU), discussed the increasing drive to reduce the use of restraint and seclusion on psychiatric wards, and a new joint study around the topic.
Speaking first in a joint presentation, Dr Alhaj – a consultant in Psychiatric Intensive Care on the award-winning Endcliffe Ward in Sheffield, and director of Medical Education for Sheffield Health and Social Care NHS Foundation Trust – explained that he would first focus on ‘restrictive interventions in general’ – in terms of definitions of such practice based on current guidance and research. He would then move on to touch on the ‘ENDORSE’ (Impact of the Environment on the Use of De-Escalation, Restraint, and Seclusion on Psychiatric Wards) study. In planning ‘for about a year’, with data collection having recently started ‘following a long NHS ethics application’, the study is a joint initiative between DiMHN, NAPICU, and Sheffield Health and Social Care NHS Foundation Trust. Dr Alhaj explained that Professor Reavey would discuss the study, which will run until August this year, in more detail in the presentation’s second half. He began: “The Mental Health Act defines ‘restrictive interventions’ as ‘the deliberate act on the part of other persons that restrict patients’ movement, liberty, and freedom to act independently’.” He continued: “The Act says such actions should only be taken ‘when there is a danger of harm to the service-user or
patient and others, and that danger cannot be prevented by any other measure’.” Dr Alhaj said he would not ask delegates to ‘rate’ which of the various ‘types’ of restrictive intervention was ‘less or more restrictive’, but hoped all present in the audience would agree that the practice was one to be used ‘only when absolutely necessary’.
Legal aspects and ethical/practical risks Where restrictive interventions were employed, however, it was important to consider both the legal aspects, and the ethical and practical risks. Dr Alhaj said: “We have already heard this morning (earlier in the same session) from Mersey Care’s Dave Riley (the Trust’s Improvement lead for Perfect Care) about his team’s work to reduce restrictive interventions, and the human aspects of all this, and of course ethically, restraint and seclusion don’t sit very comfortably with us in the profession. There are, however, other key considerations.” The Mental Health Act of 2015’s Code of Practice was, he said, clear that staff should not undertake restrictive interventions unless the actions were ‘compliant with human rights’. Meanwhile, the Department of Health’s 2014 document,
Positive and Proactive Care, emphasised that any restrictive actions needed to be ‘the least restrictive option to meet the immediate need’. The NAPICU speaker added: “NICE guidance talks in the same way, and recommends avoiding the use of restrictive intervention unless de-escalation techniques and other strategies (such as medication, as needed) have not been successful, and there is a risk of harm to the service-user or ‘others’.”
Seclusion’s impact studied Dr Alhaj said that while there was some previous study evidence (Bonner et al 2002; Holmes et al 2004) of the detrimental psychological, emotional, and physical effects on patients who had been subject to seclusion in mental healthcare facilities, a more recent study (by Griffiths et al 2018) suggested that (as measured by HoNOS – Health of the Nation Outcome Scales) seclusion, ‘when used very cautiously and properly’, did not necessarily decrease the rate of recovery. He explained: “Overall though, we can conclude that seclusion is at least of questionable therapeutic benefit, and shouldn’t be used routinely.” Turning to systematic reviews, the speaker said it was difficult to ethically undertake a randomised controlled trial where some individuals were allocated to a seclusion facility, and others to a non- seclusion facility. “However,” he said, “the Cochrane Review of 2000 (Seclusion and restraint for people with serious mental illnesses) does talk about seclusion and restrictive interventions generally not having any therapeutic benefits.”
Service-user groups mostly likely to be secluded
The study team will be taking both quantitative and qualitative data. THE NETWORK | JULY 2019
As to the individuals most frequently secluded, evidence suggested that male and younger patients were most prone to it, while female patients tended to be in seclusion for shorter periods. Perhaps unsurprisingly, service-users detained under the Mental Health Act were more likely to be secluded than ‘voluntary’
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