NO Restraint

Day 3
Friday 18 December 2015
THE RIGHT TO
LIBERTY AND
SECURITY
How to avoid restraintrelationship and trust
building
Come evitare la
contenzione
costruzione di relazioni
di fiducia
LIVIA dott.ssa BICEGO
DIRIGENTE INFERMIERISTICA
COMMISSIONE PER
L'ELIMINAZIONE
DELLA CONTENZIONE
AAS1 TRIESTE
Restraint
Restraint causes severe injuries to the patients and death...
considered traumatic but necessary by the majority...
… rules to make safe restraint as much as possible
number of nurses
‘thecniques’ to catch the patients
priority of the parts of the body to immobilize and tie
type of restraint tools to be used
monitoring of breath and cardio-circulatory system...
recommendation to use it as little as possible
only in the ‘necessity status’...
Restraints
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…Restraints and seclusion have no
therapeutic value
they are not a treatment
the causes of death are frequently:
asphyxiation, strangulation, cardiac arrest,
fire or smoke inhalation, drug overdose,
drug interactions and choking…
it would be incumbent upon the state to
protect them from being injured,
traumatized and abused…
TSO
compulsory treatment
‘necessity status’- Art.54
do not oblige at all to the
patient’s restraint
Restraint
A relevant issue.
In spite of the relevant amount of declarations and
denouncements from many countries and
official papers from many international councils,
it still remain active and practiced.
In Italy, in the units for acute patients inside the General
Hospitals – SPDC – the restraint is largely practiced.
In 85% of SPDC in Italy there are restraint tools that have
been used once or more.
Restraint
Seclusion and restraints are imposed on
psychiatric patients for reasons that are
not therapeutic:
to curtail a patient’s movement
to compensate for having inadequate staff
avoid providing appropriate clinical interventions
to force a patient to comply with the staff’s wishes
to impose penalties on patient behaviors….
Toward an open door, no restraint practice
No restraint and open door:
the first step
of
de-institutionalisation
The meaning of closed door
The meaning of restraint
Closed door = prison = guilty
condamned secluded
 Responsibility about detention
careful about risk of escape
 Closed door/ restraint = measure
of seclusion
 Safety measure a ‘right’ and
‘irreplaceable’... by the relatives ...
by the patients...
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The Meaning of open door
The meaning of no restraint
Opened door: you are not guilty
 You have not committed any crime
 You are in hospital and not in jail
 You are here because of your illness
 You as soon as possible come back at
home
 The message is directed also to the family
and the other people
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The Meaning of open door
The meaning of no restraint
Each professional cannot disagree with this
message
Each professional to pursue this fundamental
change of humanisation
Never again
gaoler
inspector
guardian
Restraint
it's illegal
but also
a mark of technical
and organizational
incompetence
The question:
How is possible to make
realistic this change?
The question is realistic,
but not impossible to solve
How is practically possible to get
good therapeutic goals
without restraint
that is considered traumatic
but necessary by the majority?
Key words
Freedom
Dignity
Responsibility
Democracy
Freedom is therapeutic
How to avoid restraint
Relationship and trust building
What do we need?
All we need is ...
All we need is ...
From “treating illness” to a response to tangible
needs
also psychological and subjective needs
Services that promote...
organizations of human services
featured by programs
provided by resources
based on relations
which define the pathways of the “demand” for
mental health as a “circuit”
All we need is ...
Services that promote...
eliminate of any form of stigmatisation
discrimination and exclusion
engage to actively improve full rights of
citizenship for the mentally ill persons
a coherent and unique organisation as a
whole
a strict co-ordination of actions
a links with the other services of community
accessibility and mobility of services and
the ability to respond to a wide variety of
crises and needs
Crisis prevention
Arrive before the crisis...
Continuity of care...
Responding to crisis in the community...
Crisis management is not a special or
separate program
Crisis comes into immediate contact with a
system of resources/options
Intake for problems / not for diagnosis
A low threshold of access
No selection
No waiting list
Avoiding bureaucratic obstacles to accessing
services
Responses quick and flexible
All we need is …
Services that promote...
PARTECIPATION AND EMPOWERMENT
Partecipation to modifications
of a mental health service
All we need is ...
No barriers between operators/users
No to roles/spaces
Reduce the compartmentalisation
Open door, even for compulsory treatments
Share together and live together
Negotiate for everything
Contract everything of acceptance/admission with the
user
Continuous effort to obtain compliance
Be accountable for everything
Care through a relationship based on trust
Inclusion of the user in crisis in both structured and
non-structured activities
Point of reference open 24 hrs
A team that has a contractual relationship with him/her
All we need is ...
Integrated and comprehensive response (social
and medical)
Know individual history, needs and wishes
Ability to “READ” the meaning of
requests and events
Personal Investment/Involvement
Openess To User
“USER Friendly”
… establishing a relationship
More concretely...
Factors who make possible the open door
Factors who make possible no restraint
The ‘human’ factor makes the difference...
an adequate number of professionals
work together without many distinctions of roles (nurses, doctors,
social workers, psychologists, occupational therapists, support
staff...)
the goal of all, all with the same goal:
maintain the ‘open door’
Un'etica condivisa
The professionals must be share the goal
Trained about the therapeutical, ethical, political meaning
Confrontation must be going to the bitter end
NO Restraint
No restraint is a choice of a ‘system as a whole’
In the regulations of MHD of Trieste it has been wrote in
an unequivocal manner, regarding the rights of the
users, that they, among others, have the right to not
receive noxious actions for their own physical integrity
and dignity, specifically by means of whatever
instrument of restraint
there is the principle that not to be restrained...
is a right of mentally ill citizens requiring a therapeutic
treatment
Factors who make possible the open door
When a patient tries to leave and you can not for
his own good ...
negotiations 'to the bitter end'
A firm attitude, welcoming embrace, no violent
tackle by all staff
... They were able to resolve conflicts
Some preliminary questions :
No restraint is a program of a single ward
staff or is shared by leadership and all
professionals?
Does the staff work contemporarily inside
the structure and the community?
Are there connections with other health
structures?
Are there relations with the police or other
safety agencies?
Factors who make possible the open door
Keeping promises
Understand the needs
Meet demands
Meet the needs
It is better the small size
A protocol with emergency ward, Police or other safety
agencies
organisation of the staff
ability and competence
an adequate number of people to be present at work
a daily planning
one or more internal meetings
knows and analyze each personal, familiar, clinical history...
Factors who make possible the open door
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Daily meetings with the patients
discussion about the single programs
... and also about the open door...
explaining the meaning of it
searching for collaboration of all patients
Factors who make possible the open door
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If some difficulties are going on or a patient escaped, the staff
should be discuss the event also in meeting with patients
Analyzing why and how
to normalize the situation
collective plan to prevent similar events
a staff person - alone or with some patient as volunteer- stay
near the door
the accident can occur
the accident cannot be avoided by means of closing
doors
Open door and no restraint
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a ‘closed door’ represents a ‘relational’ and ‘therapeutic’
barrier
reinforces the sterotype of danger
doesn’t recognize
makes damage to the rights of patients
is a mark of bad professional skill
an intelligent organisation of the staff and of daily work in the
ward
some changes in the system reduction of the size of wards
working in and outside the institution
agreements and protocols with other agencies
Responsibility
directly involving the patients in decision
good professional skill
recognizes the rights of patient
Restraint
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education and training of professionals
general vision of its own mission, technical
competence, ethics
proper availability of resources
organization model of services
a whole of intervention procedures on
crisis states
NO Restraint
In the Health Agency whose MHD of Trieste is part, the
issue of restraint is considered very important also
out of psychiatry
A lot of researches, meetings and professional training
have been organized (with prevalence of nurses)
about it.
In 2006 a research in all rest houses of province was
carried out , aimed to know the relevance of restraint
among the institutionalized elderly
and to purpose alternatives
ITALY today...
DOCUMENTO BIOETICA 2006
RACCOMANDAZIONI ALLE REGIONI 2009
STOP OPG 2014
DOCUMENTO BIOETICA 2015...
Restraint
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Approaching the problem in this way is the result of the
heritage from Franco Basaglia
A tradition of respect of the rights and values of the human
being
TODAY is coherent and aligned with all national and
international declarations against the practices destroying the
human dignity.
The global approach to the person in her historical dimension
(psychological, social, biological)
Ethical principles of health profession not consistent with
restraint.
The professionals in mental health must not be ‘ prison guards’,
or experts in the ‘restraining art’
Dati
2015...
TSO 2015 - Giornate di accoglienza e/o ricovero in TSO
nel DSM
TSO 2015 - Giornate di accoglienza e/o ricovero in TSO
nel DSM
TSO - Trend nel DSM dell'ASS1 negli anni 2011 - 2015
Serie storica 1996 - 2015 – Persone e giornate in TSO
Serie storica 1996 - 2015 – Luoghi dei TSO
Serie storica 1996 - 2015 – Tasso giornate e persone/100.000
residenti
THE FREEDOM
IS THERAPEUTIC !
Serve un paradigma centrato sulla relazione e
sull'accoglienza dell'altro e non sulla
prestazione
The paradigm of illness is broken in favor of that
of the person.
La forza dell'alleanza terapeutica
Relazione instancabile
Negoziazione ad oltranza
Nessuna pregressa esperienza negativa per
favorire il riaggancio
Eliminare il pessimismo terapeutico
Attenzione ai luoghi
Introdurre la possibilità, la guaribilità,la visione del
Come fare?
Non rimuovere mai la soggettività
Restituire e riconoscere il valore degli atti
Lotta alla pandemia di stigma e pregiudizio
Con questo documento le Regioni intendono migliorare la qualità delle cure nell’ambito
psichiatrico.
Raccomandazioni alle Regioni: modificare conoscenze, atteggiamenti, risorse,
gestione, organizzazione per portare a valore zero il numero delle contenzioni.
1:Monitorare a livello regionale il fenomeno
2:Monitorare a livello regionale i comportamenti violenti
3: Formazione di tutti i soggetti coinvolti, sanitari e non, per arrestare i fenomeni di
escalation.
4:Definire e garantire standard di struttura e di processo
5:Valutare l’impatto delle iniziative di informazione, di formazione e di appropriatezza
organizzativa
6:Promuovere pratiche di verifica e miglioramento della qualità
7:Trasparenza delle strutture di cura (accessibilità, vivibilità, accoglienza, informare
sulle procedure e garanzie, facilitare la comunicazione con l’esterno)
The Mission of MHD
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The MHD shall operate for the elimination of any form of
stigmatisation, discrimination and exclusion concerning the
mentally ill persons.
The MHD is engaged to actively improve full rights of citizenship
for the mentally ill persons.
The MHD shall ensure that the community mental health services
of the LHC have a coherent and unique organisation as a whole,
through a strict co-ordination of actions and links with the other
services of LHC, particularly with general health districts and
emphasizing the relationships with the Community and its
institutions.