Reducing seclusion and restraint

Dr Nathan Gibson, as Chief Psychiatrist, is not part of either the Health Department or the Mental Health Commission. He is an independent statutory officer with a governance responsibility over any Mental Health Services within the WA community (Mental Health Act 2014). His dual role, and that of his team, is to assist clinicians reach particular standards and uphold the rights of people with mental illness. He provides advice and reports to the Minister for Mental Health.

The Towards Elimination of Restrictive Practice 11th National Forum will be held for the first time in WA on May 4-5, 2017. The forum is jointly hosted by the Chief Psychiatrist (principle sponsor), Department of Health, Mental Health Commission and the WA Association for Mental Health (WAAMH).

What do we know of this topic as it applies to WA? Nathan said it was the Frenchmen Pinel and Pussin who removed iron shackles from the “insane” in Paris around 1800.

“It was earth-shattering stuff. Instead of bleeding and purging, hospital attendants spent time discussing with the patients. Better outcomes ensued,” he said.

Restraint on restraints

Yet 2007 was the year the last straight jacket was removed from Graylands Hospital.

“Why so long? Logic surely says we should just stop restraining or secluding people in mental health hospitals – it’s inhumane. The reality is significantly more complex.”

“When folk are unwell, a small number have strong delusional drives to aggression. Clinical staff may exhaust all talking or other less-restrictive options, and, to prevent acute harm to the patient or others, they use seclusion and restraint. These clinicians are ethical, highly trained professionals (and humane), not gaolers.”

“These challenging clinical situations do not disappear by magically incanting, ‘Stop seclusion and restraint!’.”

But he said some of the evidence around restraint and seclusion is food for thought:

  • Up to 70% of those admitted to a psychiatric hospital have previously experienced serious trauma (emotional, physical, or sexual).
  • Despite preventing harm, seclusion and restraint are often emotionally and physically traumatic for both the patient and staff.
  • What happens when mental health services don’t use it: services often reduce their staff lost-time due to injuries (counterintuitive, but true); most services do not increase staffing; and there are demonstrable higher levels of therapeutic engagement.

“Close to home, WA has seen about a 70% reduction in seclusion rates in mental health units over the past seven years. Services are using strategies involving high level communication skills, the use of ‘chill-out’ rooms, patient-led processes, and programs such as Safewards, to name a few.”

“It remains challenging but we have an ethical responsibility to work towards eliminating restrictive practice.”

Teens with mental health problems

Dr Gordon Shymko is the leading clinician in youth/early episode psychosis and works with the Rockingham Kwinana Mental Health Services in the public state system for the Early Episode Psychosis (EEP) services. These also run out of Bentley Mental Health and Fremantle Mental Health and referrals can be made directly to these services.

However, he has a strong focus on HeadSpace, commonwealth-funded until 2019. HeadSpace services cover mental health, physical health, work and study support and alcohol and other drug services. There are HeadSpace centres in rural areas and urban Perth. It’s Youth Early Psychosis Program (hYEPP) is a specialty program operational since early 2015, of which he is the Clinical Director.

“One of the general principles of HeadSpace centres is that they are a consortium of services that co-locate to provide a ‘one stop shop’ for the young person.”

Access for all

HeadSpace and public sector services are free and people can self-refer, so that both obvious barriers are overcome. Generally lower acuity referrals go to HeadSpace.

“By lower acuity I would include anxiety, depression, stress, school issues, relationship issues, alcohol and drug use, sexual health, etc.”

“There is always some way of receiving support. The after-hours contact for HeadSpace can be accessed daily from 9am until the early hours of the morning. If someone needs urgent contact there is also the Kids Helpline 1800 55 1800 or Lifeline 13 11 14. In WA we also have the 24/7 Mental Health Emergency Response Line (MHERL) at 1300 555 788. Of course clients can self-present to an Emergency Department at any time.”

“The intake criteria for the hYEPP component of headspace are specific and these tend to be more acute clients at ultra-high risk of psychosis or with a first episode psychosis.”

Overall hYEPP is a program that runs for up to five years for 12 to 25 year olds who are either:

  • Experiencing their first episode of psychosis; or
  • Are at ultra-high risk of developing psychosis; who have a family history of psychosis; have a decline in functionality; and/or have transient psychotic symptoms.

Timely access improves outcomes

“The hYEPP services are North and East Metropolitan based and situated in three HeadSpace sites, a ‘hub’ in Joondalup with two ‘spokes’ in Osborne Park and Midland. These services are non-government and are managed by Black Swan Health and Youth Focus.”

The range of services offered within the hYEPP framework includes home-based assessment and care, multi-disciplinary care coordination and medical management, psychological interventions, group programs, family programs, youth participation and peer support. All workers within HeadSpace and hYEPP are trained to deal with drug and alcohol-related issues.

“The ages between 15 and 24 are a crucial time in the development of a young person and this coincides with the peak onset of serious mental illness, including a first episode of psychosis.”

“Psychosis is significant public health issue and has been made all the worse by the near endemic utilisation of substances particularly stimulant-based substances such as methamphetamine.”

“Evidence shows that early intervention can change the course of the illness, generating greater personal, social and economic benefits than intervention at any other time in their lifespan. However it can also take long periods of time and patience before one sees significant shifts in alcohol and drug use behaviours.”

Keeping Mental Health Clinically Relevant

In 2015, formation of the Mental Health Clinical Reference Group (MHCRG) was designed to provide the Health Department with broad-based expert clinical opinion and policy advice around statewide mental health services. The 16-member group draws on people from a range or clinical disciplines (including doctors, nurses and the allied health professions), care settings (rural and metropolitan, inpatient and community) and areas of practice (such as youth mental health, forensics and older adults).

Dr Bradleigh.Hayhow is chair of the Clinical Reference Group and clearly wants to ensure that psychiatrists like himself get involved so that any polices are clinically relevant and can be appropriately implemented. His involvement with the group was initially peripheral as a representative of the South Metropolitan Health Service.

“I still spend most of my time working as a front line clinician but it has certainly been a privilege to work with such a talented group of clinical leaders and such a receptive group of policy-makers.”

Policy and implementation

“Each member is empowered to consult broadly within their own professional networks. Obviously the view of clinicians is that clinical perspectives matter, especially in relation to policy feasibility and implementation at the clinical coalface; after all, policy is only as successful as its implementation.”

In this way clinically astute advice reaches the Health Department and working clinicians get involved in the strategic management of their services. This duality of function is built-in to the group’s terms of reference.

“It is really this bilateral capacity that makes the group so valuable. This is to the great mutual benefit not only of policy-makers and clinicians, but more importantly to the patients.”

No doubt his special interests in neuropsychiatry and adult eating disorders provide some personal insights.

Links have been established with the Mental Health Commission (MHC) and the independent Office of the Chief Psychiatrist (OCP). This liaison with the OCP has been particularly useful and exciting with the implementation of the new Mental Health Act.

“Mental Health has become diverse so building workable relationships in this work space are important – public sector clinicians remain key players in the delivery of good mental health care to Western Australians.”

Treating Older Patients

One of the struggles Dr Helen McGowan faces in her role as Clinical Director of the Older Adult Mental Health Program (OAMHP) for North Metropolitan Health Service has nothing to do with funding or lack of resources. While every health service can do with more of both, she believes many older people are held back from effective mental health treatment by their thinking and the thinking of those around them.

Many older people, their families even their medical practitioners fall into the ageist trap that reinforces a therapeutic nihilism and she thinks that view needs to be challenged.

“We can’t cure dementia but we’re very good at alleviating distress for patients and their families. We get great results for older people who suffer from anxiety, depression or psychosis. I think sometimes the nihilism associated with treating dementia spills over into a pessimistic view of likely outcomes for other mental health conditions in the elderly,” Helen said.

“There is an ageist view that goes something like this: “If I had peripheral vascular disease and needed an amputation, and my wife died last year, I’d be depressed too…but there’s not much anyone is able to do about this.’”

“I would counter that with the evidence which shows a lot of people in exactly these types of situations come through these scenarios well with good treatment care and support and regain a good quality of life. The OAMHP has the specialist skills and the resources that can help.”

The OAMHP works in multidisciplinary teams that are clinically led by sub-specialty trained psychiatrists. The program runs outpatient clinics, community in-reach services, and inpatient services at three sites – at Shenton Park, Joondalup and Osborne Park with 56 inpatient beds across Osborne Park and Shenton Park and eight hospital-in-the-home beds and sees about 800 people a year and an additional 400 elderly people when consulted by other specialty staff at SCGH).

Helen said about 50% of referrals related to Behavioural and Psychological Symptoms of Dementia (BPSD) and of that group, 60% came from residential aged care and the rest from the community. The other half of referrals were for functional psychiatric illnesses associated with people getting older often triggered by a deterioration or change in their physical health or psycho-social circumstances. There are also those with a range of neuro-psychiatric issues that commonly present in the older population, such as Parkinson’s disease

Referral process is detailed on the website (see below) and Helen says the triage officers working business hours are adept at streamlining urgent cases which can often been seen within two days and other referrals between one to two weeks.

Helen stresses communication channels between the program and the referring GP are always open. If a GP has a question, a phone call can often answer it.

“We operate very much on a consultation model. We’re not here to take over, we’re here to support patients, families and their GPs with specialty skills that can add value and improve quality of life. If circumstances allow, we prefer not to prescribe psychotropic medications but rather advise the GP on what medications and actions are needed so the GP remains case manager where possible. If risks escalate, that’s when we will do more assertive management with the aim of handing over to GP as soon as possible,” she said.

Helen says OAMHP is developing a relationship with Dementia Advisory Service (DAS) a commonwealth initiative which is run nationally by Hammond Care. It is anticipated that DAS will be another pathway for patients and family if dementia behaviours become difficult to manage.

“We are trying hard to develop a ‘no wrong door approach’ which is why we are working on this collaboration. This is a complex space with a lot of different service providers and it can be confusing for doctors and their patients and families – we’re hoping to simply the process a bit. If you refer to either OAMHP or DAS for people who have BPSD, those referrals will be followed up appropriately.”


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