The Use of Seclusion and Mechanical Restraint in Psychiatry - A Persistent Challenge over Time

Coercive measures, such as seclusion and mechanical restraint, have a long history in dealing with mental illness. Both the ethical and legal frameworks for using coercive measures acknowledge that the use of them is, at times, indispensable, but they should only be considered at the last resort, as a safety measure. In this thesis, the use of coercive measures in psychiatry is studied at the level of international and national statistics as well as at the level of the individual patients. The international metaanalysis of published, unpublished and ongoing research regarding the use of coercive measures (mechanical restraint, seclusion, physical restraint) between 2000 and 2008 comprised databases from twelve countries in and beyond Europe. The Finnish nationwide study regarding the use of seclusion and mechanical restraint was conducted in a specific week in 1990, 1991, 1994, 1998 and 2004. The material was collected from two sources: The Survey Data covered all Finnish psychiatric hospitals, and comprised 671 working-age secluded or mechanically restrained patients. The Register Data covered all hospitalised working-age psychiatric inpatients during the study period (N = 28 064). The interview study was composed of the baseline interviews of 106 secluded patients at the two forensic psychiatric hospitals and at the psychiatric inpatient units of two hospital districts in Finland. A follow-up interview was completed by 83 of the participants. The present study indicates that coercive measures are in general use in Western psychiatry, but the type and the quantity vary considerably across countries. Initiatives to curtail the use of coercive measures already exist in a few European countries. Finland stood at the average point on the preliminary international statistics in the use of seclusion and mechanical restraint. Despite the tendency of official policies towards the least restrictive psychiatric treatment in our country during the last two decades, national statistics of the present study indicate, that legislation solely can not change the use of coercive measures. The risk for being secluded had not changed, while the risk for being mechanically restrained decreased slightly, but not linearly, during this timeframe. Furthermore, the duration of mechanical restraint remained the same, and the duration of seclusion increased even three-fold. A rather well-entrenched establishment of seclusion and mechanical restraint seems to prevail in clinical practice. These measures were used mainly among the most clinically disturbed patients. Patient agitation or disorientation with no accompanying signs of actual or threatening violence was the most frequent clinical indication for the use of these measures. Psychiatric patients equate seclusion with prolonged, negative connotations, independent of the type of hospital where the treatment is administered. The only difference detected between the secluded patients in the forensic psychiatric hospitals and the general psychiatric in-patient units was that the forensic patients even more frequently viewed seclusion as a form of punishment. From the viewpoint of the secluded patients, both psychological and physical conditions under which coercive measures are implemented in everyday clinical practice are deficient. Fundamental human considerations demand that the least intrusive practices be achieved and improved upon in order to reduce the use of coercive measures. This thesis indicates that almost no changes toward the reduced use of seclusion and mechanical restraint have taken place over the years, which confirms previous suggestions that deep-rooted treatment traditions and attitudes at least as much as safety requirements or patients` rights determine the use of coercive measures. The shared intention should be to find the best practices to moderate the use of these measures, or when they are really indicated, how they can be implemented in a more benevolent manner. Special attention should be directed toward duration and indications for seclusion and mechanical restraint. Physical conditions and psychological needs of the secluded or mechanically restrained patient must be more scrupulously taken into account.