A colleague shared an article with me this week which reports that a large proportion of patients experience trauma or traumatic events from psychiatric care in the public setting. The study looked at a sample of 142 randomly selected patients in a day hospital program. It asked them what kinds of experiences they had during their treatment in the public mental health system. The study used the Psychiatric Experiences Questionnaire (PEQ) which was designed to query about experiences specific to psychiatric settings such as aggression, seclusion, restraint, sexual assault, and forced medication. Some interesting results:
-65% had been handcuffed and transported in police cars (an average of 3.4 times!)
-54% reported having been around other patients who were very violent or frightening (an average of 7.2 times!)
-39% witnessed one patient being physically assaulted by another patient
-34% had been put in some kind of restraint (an average of 2.9 times)
-24% had been strip searched (an average of 2.7 times)
This is very disturbing. However I can't say it is surprising. We tend to follow tradition of a variety of practices over time in the psychiatric setting. These practices (seclusion, restraint for example) may or may not be therapeutic. I believe they are carried out to maintain safety (or I want to believe that). But unfortunately we see that in fact they are traumatizing the people we are actually intending to treat!
How do we change this? For example, is it really necessary to strip search patients? Might we either use some other method, or distinguish when or if searching is needed? Aren't wands available to detect weapons? If you aren't a suicide risk must we search for pills, razors and other contraband? Or if we do search people, how can we do it in the most sensitive, private and non-intrusive manner? I do realize that people do attempt to 'smuggle in' a variety of things. But it seems in the majority of cases this is not a problem. I think over 3 years working inpatient, I found only 1 or 2 situations that this happened out of hundreds.
How many of these experiences would be prevented if we turned the system upside down and instead of treating everyone as if they cannot be trusted we actually treated people with a sense of trust? It seems we are attempting to control for the very rare events that occur by controlling everyone and everything (i.e. a patient swallows a staple from the bulletin board, so no staples allowed; or a patient tries to break a light bulb to electrocute themselves so we encase all lights - and end up with a dim environment). You only have to look at research on what is considered 'contraband' on units to see how variable and really ineffective many of these practices are. All patients suffer/are treated as if they are not able to be safe and responsible because a few are unsafe.
As for handcuffing patients, I can't imagine when or why this is really needed. Must we treat people as if they are criminals and cannot be trusted? I have seen patients transported by law enforcement in this way. It is often justified by a concern that the person will jump out of the vehicle and try to escape or kill themselves. Again, how many cases really involve this risk? Don't the vehicles have locks you cannot open? Can't we come up with a better way?
Unfortunately the violence in the setting - patients assaulting one another, staff and patient physical altercations -which judging from this study patients perceive as staff assaulting them - is a major problem. This will not be easily tackled. Maybe culture change is in order.
Recently we have seen the growth of the 'comfort room'. This is a fine idea and way to replace the seclusion room... but why aren't entire units 'comfort units'? Must it only be one room where you can find quiet, privacy, relaxation. Why wouldn't we design the entire unit around this concept? Isn't that truly what our patients need?
I was in Europe recently and in the UK patients now have private rooms. This allows them some space and privacy when needed. What a brilliant idea! If a patient is grossly psychotic and responding to internal stimuli must they be in the middle of the busy day room? Wouldn't we expect this to make them worse and more overstimulated? Is it surprising that others would find them frightening and fear their presence at times?
Of course some will say if we did any of these things all kinds of unsafe mayhem would prevail. I can't say that there would not be risk. We would need to do our job of assessing and therapeutically working with patients very well. Would any of us complain about that?
However I suspect that in many settings unsafe events occur regardless of the rules promulgated on how searches are done, where patients can and can't be, etc. Isn't that how we come up with new rules... and so the cycle goes on.
Maybe we need a better separation of settings in terms of who is safe to be where with what and then a system of procedures that follows this...
It just seems to me that if we had a truly comforting and therapeutic environment we would be starting from a basis of treating people more humanely. From there we might find we are more able to appeal to the healthy aspects of the individual who does have some wish to get better. Maybe those most unsafe and immediately at risk are managed in a 'safer' area - with greater degree of environmental controls (but still comfortable and comforting- not a cell)- this would create a dynamic of wanting to be out in the more comforting less controlled areas... which if managed carefully and therapeutically would encourage patients to be more responsible for keeping themselves safe... And just imagine instead of assigning people to run around and get patients belongings that we keep locked up or simply denying use of (and making them angry and frustrated... which then starts that cycle...), we could spend those extra minutes talking with our patients so we are aware of and in touch with the individual needs of each one. Spending more time on 'controlling things' does result in less time to be therapeutic. I do think we have a lot of work to do in mental health settings. I know a lot of
clinical workers who agree with this and would love to be engaged in redesigning how inpatient mental health care is provided. Why aren't we doing that? If you are, tell me and tell us how you got there and what you are doing?!
If we start by wanting to treat our patients as equal human beings, and respecting their needs, I think we would be moving in the right direction. I sincerely believe that most workers totally agree with this and in the majority of cases follow through on this in their day to day work... The problem is that our unit and organizational cultures do not support this. That is a difficult problem to solve... but one that we desperately need to address.
That study shows how inhumane treatment can really be. Unfortunately it strikes home that it is not uncommon. I encourage you all to review the article (it is not new - although I have never seen or heard of this study previously). You would think this study would have called for a tidal wave of change in how things work in the inpatient psychiatric setting... (as well as all psychiatric settings...) I can't help but think that stereotype and stigma again victimize our most vulnerable patients and that is why there wasn't a tidal wave of action on learning these results.
Here is the reference if you are interested in reviewing the article for yourself...
Frueh, B.C., Knapp, R.G., Cusack, K.J., Grubaugh, A.L., Sauvageot, J.A., Cousins, V.C., Yim, E., Robins, C.S., Monnier, J., Hiers, T.G. (2005). Patients' reports of traumatic or harmful experiences within the psychiatric setting. Psychiatric Services, 56, 1123-1133.
Here is a link - I hope it works! http://www.annafoundation.org/Patients%20rpts%20of%20trauma%20or%20harm%20in%20psychiatric%20setting.pdfh
or try this one...
http://ps.psychiatryonline.org/article.aspx?volume=56&page=1123
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