Alone in a living hell

MENTAL health leaders and former patients want to end seclusion.

Julie Dempsey

JULIE Dempsey has been to a place from which some have never returned.

Governments call it "seclusion", though this may conjure a misleading flavour of a restful holiday getaway.

Dempsey experienced seclusion several times while on psychiatric wards, when the delusions of her mental illness made her fear "dissection" at the hand of "aliens" - the nurses - prompting her, naturally, to attempt to leave.

At this point, a group of nurses and sometimes security staff would appear and grab her, carry her into a small bare cell, force her on a mattress on her stomach, strip her, put her into pyjamas and forcibly sedate her with injections in her buttock.

"And I'm terrified of (the injection)," she says, "because I think they're injecting something into me that's going to harm me, so I'm pleading with them not to do it".

Then, "with the voices, petrified of what is going on in my head", Dempsey would be left alone in the seclusion cell.

Cath Roper's experience of seclusion echoes Dempsey's. Australia's first "consumer academic" - an academic with personal experience of the mental health system - Roper recalls "the violence involved ... and the feeling of utter neglect, when you're screaming to be let out and you are terrified and nobody comes".

The official line of most states on seclusion and its fellow "restrictive practices" - physical restraint and the forced injection of sedatives - is that they are occasional measures of last resort used to stop distressed or aggressive patients perpetrating violence against themselves or others.

But seclusion, restraint and forced sedation are in widespread use throughout Australia, despite warnings that most of their use is avoidable and that they are causing deaths and high rates of physical and mental harm to consumers and medical staff.

The trauma of her experiences left Dempsey with permanent post-traumatic symptoms. She can't sleep with her bedroom door shut. She panics if she finds herself in spaces she can't easily get out of. And despite suffering from the "horrible" episodes of her illness, Dempsey, like many others who described seclusion experiences to The Australian, would do anything rather than return to hospital.

"Seclusion is manifestly harmful to the people who experience it - almost invariably," says Austin Health director of mental health Richard Newton, who has driven reductions in seclusion rates to near zero in two Melbourne hospitals.

"If you are distressed, angry, fearful, worried that people are out to get you or are trying to hurt you, and responding to that in an agitated way, and if that leads to you being essentially manhandled by a group of strangers into a room, often injected without your consent ... and then left in there on your own ... it is devastating."

Increasingly, researchers are uncovering injuries, deaths and lasting mental harm associated with coercive psychiatric practices; they have even coined terms - "sanctuary harm" and "sanctuary trauma" - to describe the findings.

A unique study at Melbourne's The Alfred hospital found 47 per cent of patients interviewed about their seclusion reported levels of distress as high as those found in post-traumatic stress disorder. Despite design limitations acknowledged by the researchers, University of Melbourne senior lecturer Bridget Hamilton agrees lasting trauma occurs at high rates, describing it as occurring "more commonly than not".

Given that thousands of people are secluded each year in Australia - 1584 in Victoria alone during 2011-12 - the research paints a picture of mental trauma occurring on a huge scale.

Of particular concern to experts is that a high proportion of people on psychiatric wards - one study estimates 90 per cent - already have histories of trauma, including physical and sexual assault, and that coercive practices may not be only traumatising but retraumatising vulnerable people.

"Many (consumers) over the years have likened their seclusion experience to their past abuse," says National Mental Health Consumer and Carer consumer representative Isabell Collins. "Some have said to me that it was just like a past rape - and that it brought it all back".

Concern about these impacts has now been reflected at the international level. The UN special rapporteur on torture determined recently that "any" use of seclusion in psychiatric settings is "cruel, inhuman or degrading treatment".

Large numbers of medical staff also suffer mental trauma, researchers say, as a result of carrying out the coercive psychiatric ward practices.

Hamilton, who drove a large reduction in seclusion at St Vincent's Hospital Melbourne, says seclusion is "traumatising for everyone involved". The distress it causes the nurses, she says, "definitely" forms part of the reason nurses have post-traumatic stress disorder rates as high as those found in emergency services personnel.

It's not hard to see a cycle happening. Responding as traumatised people do, Hamilton says, staff will "avoid, and then react in a visceral gut reaction". If secluded consumers perceive they have been "acted against unfairly," says senior forensic psychologist James Ogloff, "then they may retaliate and the staff feel they have to respond, and then you do get that cycle".

Roper and Dempsey at least lived to describe their experiences. Not everyone has.

As recently as March, seclusion and restraint procedures were the subject of coronial criticism, such as that delivered in the cases of Justin Fraser and Adam White, both of whom died after being held on the floor by staff trying to move them into seclusion rooms.

By searching media reports alone, mainly of coronial inquiries, The Australian found 13 deaths linked to the practices nationally in the past 10 years, but Newton thinks the death rate is much higher, estimating around one such death a year in Victoria alone.

Short of death, the number of physical injuries associated with the practices appear to be as overwhelming as the estimates of psychological harm. Newton says physical injuries, including minor injuries, occur in about 20 per cent of restraint procedures - of which there are several thousand nationally each year.

A series of West Australian hospital incident report summaries obtained by The Australian provides a disturbing snapshot of the more serious injuries or adverse effects. Many patients suffer acute biological system collapses after forcible injections. Then there are the bones broken, mainly patients' arms, including one case of a paraplegic patient sustaining a broken arm during "restraint". Some staff also sustained broken bones.

Research documenting all this damage and death is darkly welcome to many consumers, but Collins brands the procedures it exposes "gruesome and abusive".

"To (impose seclusion and restraint) on somebody already in emotional distress," she says, "could only ever be described as cruel and inhumane."

Consumers and advocates such as Collins pose a troubling question: six years after a national mental health seclusion and restraint project, eight years after health ministers committed to "reducing use of, and where possible eliminating, restraint and seclusion" and 22 years after Australia acceded to the global convention against torture and cruel, inhumane or degrading treatment, why are seclusion and restraint still flourishing in so many Australian hospitals?

The answer is not, it seems, because they work so well. As an answer to aggression and violence, "seclusion", Ogloff says, "backfires". The community "might believe that if you increase seclusion, aggression goes down, but it just doesn't work like that".

In fact one set of hospital injury data seen by The Australian shows reductions in injuries of about 80 per cent in association with reductions of seclusion of about 90 per cent. "Assaultative behaviour," Newton says, "reduces once you reduce restraint and seclusion, and ... most of the actual physical assaults occur during seclusion and restraint episodes themselves".

Nor does seclusion appear to continue because it's too hard to significantly reduce or eliminate. Among success stories adding to those of Newton at the Austin and Peninsula hospitals and Hamilton at St Vincent's, the Canberra Hospital - in an initiative driven in no small part by consumers - reduced seclusion by 88 per cent over one year after including consumer representatives in seclusion incident review meetings.

"Advance directives" that guide nurses as to how to treat consumers in acute distress, comfortable and relaxing "quiet rooms" for voluntary "time out" and spacious ward design that encourage nurses out of nurse stations are also being worked towards.

The seclusion and restraint reduction approach most emphasised by experts, however, is that of medical staff paying higher quality and earlier attention to patient expressions of concern - to pick up potential conflict before it "snowballs" - and staff training in and use of verbal "de-escalation" skills.

It's impossible to reason with a crazy person, though, right? Australia's most senior psychiatrists stress this community perception is wrong. NSW chief psychiatrist John Allan, chairman of the key intergovernmental committee driving seclusion and restraint reduction, says while people on drugs such as ice can get out of control, "with psychotic people you can talk to them and you can do lots of stuff with them; de-escalation works".

Less than impressed with departmental efforts, Collins, a former nurse, offers her own, more disturbing theory on why "such ... horrible practices" continue. "Probably the main reason is because ... (they) can." Though seclusion and restraint are used "regularly" without legal justification, Collins says, "no state or territory has an independent body to facilitate the laying of charges, and the mental health acts are not strong enough to facilitate accountability".

Meanwhile, Australian College of Mental Health Nurses chief executive Kim Ryan says a shortage of mental health nurses means inexperienced nurses "may end up using seclusion and restraint in not the most appropriate way".

University of Melbourne professor of youth mental health and former Australian of the year Pat McGorry calls for state governments to be held to account for their "disinvestment by stealth" in mental health.

Many consumers advocate the removal of many or all coercive elements of hospital-based mental health treatment and their replacement with innovative home and community-based systems of treatment, such as the successful Open Dialogue approach used in Finland.

Roper wants services to be trauma-informed and ethical in focus, asking "what are the costs (consumers) are incurring and we (hospital staff) are incurring when we do this?".

Allan proposes a "coercive treatments index" which would measure "the consumer experience ... the experience people have of all that kind of coercion".

For Hamilton the broadest meaning of moving away from coercive practices lies in reducing the "misunderstanding in the wider social conscience that this (coercive practice) is necessary or that this person is somehow not a human being at this moment".

Bradley Foxlewin, one of the consumers who drove the ACT's success in reducing seclusion - now a NSW Mental Health Commission deputy commissioner - says the ACT experience shows "that the impossible can occur ... so long as you listen to our stories".