Special section on seclusion and restraint: Consumers' perceptions of negative experiences and "sanctuary harm" in psychiatric settings

Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, United States
Psychiatric Services (Impact Factor: 1.99). 10/2005; 56(9):1134-8. DOI: 10.1176/
Source: PubMed

ABSTRACT Recent studies show a high prevalence of trauma symptoms among people with serious mental illness who are treated in public-sector mental health systems. Unfortunately, growing evidence suggests that many consumers have had traumatic or harmful experiences while being treated in various psychiatric settings. This study explores consumers' perceptions of such harmful inpatient experiences, events that the authors place under the rubric of "sanctuary harm."
The authors conducted semistructured qualitative interviews with 27 randomly selected mental health consumers to hear their descriptions of adverse events that they experienced while receiving psychiatric care. Our analysis of interview transcriptions focused on understanding consumers' narratives of harmful experiences-events that would not meet DSM-IV criteria for trauma but that nevertheless resulted in significant distress.
Eighteen of 27 interviewees described harmful incidents that they had witnessed or experienced directly, many of which evoked strong emotional responses by consumers during their narration. Nearly all incidents described were hospital based and were clustered around two sets of themes. The first set related to the hospital setting, including the fear of physical violence and the arbitrary nature of the rules. The second set related to the narrators' interactions with clinical staff, including depersonalization, lack of fairness, and disrespect.
The findings suggest that many mental health consumers have had a lifetime sanctuary experience that they perceived as harmful. They also offered suggestions for how the mental health service delivery system might reduce the potential for sanctuary harm experiences.

1 Follower
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Mechanical restraint (MR) is a major infringement on the psychiatric patient’s autonomy. MR can cause physical and mental harm but may be necessary, e.g. to avoid putting an individual’s health at risk. The nursing staff is tasked with protecting the life and health of not only the individual patient but also other patients and relatives. A situation can occur in which staff is obligated to use force and occasionally MR, e.g. if a patient is very aggressive, violent, self-destructive or suicidal. Although MR is legal, the European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment concluded, in two reports from 2002, 2008, and 2014 that no medical justification exists for applying instruments of physical restraint to psychiatric patients for days and that doing so amounts to ill treatment. Although the number of MR episodes should be reduced as much as possible, how this goal should be accomplished is quite unclear. Despite the growth in available research in the area decisive evidence is still lacking. No studies have investigated which of the many MR-preventive factors are the most effective in practice, in Denmark and Norway. Therefore, the overall objective of this thesis was to generate knowledge of non-medical MR-prevention. The four studies that contributed to this objective had separate purposes. First, a systematic review of international research papers was conducted to identify evident and effective MR-preventive factors; this review served as a basis for developing a questionnaire examining the degree to which MR-preventive factors have been implemented in psychiatric units and the numbers of MR episodes in those units. Second, a comparative investigation of European countries was conducted to identify a country comparable to Denmark to include in the cross-country questionnaire survey. Third, the collected questionnaire data were analysed to identify the associations between the MR-preventive factors and the number of MR episodes. Finally, the data were analysed to identify if the MR-preventive factors could explain the difference in the number of MR episodes between Denmark and Norway. Three MR-preventive factors were significantly associated with a low frequency of MR episodes in Denmark and Norway: a mandatory review of MR episodes (64% fewer MR episodes), patient involvement (58% fewer MR episodes), and crowding (46% fewer MR episodes). Further, we identified five MR-preventive factors with confounding effects (reducing the difference between countries), which may explain in part why Denmark used 92% more MR compared with Norway. These factors included: staff education (51% of the effect), substitute staff (17% of the effect), work environment (15% of the effect), patient-staff ratio (11% of the effect), and identification of patients’ crisis triggers (10% of the effect). These results have increased our understanding of the ability of specific MR-preventive factors to reduce the number of MR episodes in Denmark and Norway, thereby generating knowledge in the field of MR-prevention. These findings have not been identified via randomised controlled trials (RCTs), and although some biases could be present, the questionnaire was thoroughly developed to include several potential confounders. Furthermore, similar results have been demonstrated in previous international studies. These factors are not likely to have adverse effects on the patients or staff. Rather, the potential positive effects of these factors on the prevention of MR episodes may reflect a general strengthening of the care and treatment environments. Therefore, further investigation into the effects of implementing the following within Danish and Norwegian practices is recommended: mandatory review, patient involvement, less crowding, higher staff education, less substitute staff use, better work environment, increased number of staff per patient, and the identification of the patient’s crisis triggers.
    03/2015, Degree: PhD, Supervisor: Mette Brandt-Christensen
  • [Show abstract] [Hide abstract]
    ABSTRACT: To understand whether and how Family Group Conferencing might contribute to the social embedding of clients with mental illness. Ensuring the social integration of psychiatric clients is a key aspect of community mental health nursing. Family Group Conferencing has potency to create conditions for clients' social embedding and subsequently can prevent coercive measures. A naturalistic qualitative case study on the process of one conference that was part of 41 conferences that had been organized and studied from January 2011-September 2013 in a public mental health care setting in the north of the Netherlands. Semi-structured interviews (N = 20) were conducted with four stakeholder groups (N = 13) involved in a conference on liveability problems in a local neighbourhood wherein a man with schizophrenia resides. To prevent an involuntary admission to a psychiatric ward of a man with schizophrenia, neighbourhood residents requested a family group conference between themselves, the sister of the man and the mental health organization. As a possible conference aggravated psychotic problems, it was decided to organize it without the client. Nine months after the conference, liveability problems in the neighbourhood had been reduced and coercive measures adverted. The conference strengthened the community and resulted in a plan countering liveability problems. The case indicates that social embedding of clients with severe psychiatric problems can be strengthened by Family Group Conferencing and that hence coercive measures can be prevented. A shift is required from working with the individual client to a community driven approach.
    Journal of Advanced Nursing 05/2014; 70(11). DOI:10.1111/jan.12445 · 1.69 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Internationally, seclusion practices continue to be the subject of intense clinical health service and academic scrutiny. Despite extensive efforts to reduce and eliminate this controversial practice, seclusion remains a clinical intervention widely used in contemporary mental health service settings. Early identification of people who are at risk for seclusion and the timely application of alternative evidence-based interventions are critical for reducing incidents of seclusion in real-world practice settings. This retrospective study aimed to determine the relationship between sociodemographic and clinical characteristics, and the use of seclusion for those mental health consumers for whom evidence-based seclusion-reduction initiatives had little impact. A 12-month centred moving average was fitted to seclusion data from a psychiatric inpatient unit over 2 years to determine stabilization in seclusion reduction. The number of consumers admitted was calculated from the point of stabilization for 1 year (n = 469). In this cohort, univariate analysis sought to compare the characteristics of those who were secluded and those who were not. A multivariate logistic regression model was undertaken to associate future seclusion based on significant independent variables. Of those people admitted, 88 (19%) were secluded. The majority of seclusions occurred in the first 5 days (70/88, 79%). Multivariate logistic regression indicated that three variables maintained their independent associative risk of seclusion: (i) age less than 35 years; (ii) assessment of risk of violence to others; and (iii) a history of seclusion. The implications of these findings for nursing practice are discussed.
    International journal of mental health nursing 07/2014; DOI:10.1111/inm.12078 · 2.01 Impact Factor

Preview (2 Sources)

Available from