No Woman is an Island
The New Zealand Health and Disability Services Standards define seclusion as it relates to the Mental Health (Compulsory Assessment and Treatment) Act 1992 “where a consumer is placed alone in a room or area, at any time and for any duration, from which they cannot freely exit”. To me, the definition is clear enough.
Seclusion Starts
A period of seclusion starts when the patient enters the conditions of seclusion. In Te Whare Ahuru the place where Kate is currently being held, those conditions are present in the Acute Inpatient Unit (AIU) called ‘Rangimarie’. I don’t know who names these places but to me, nothing seems further from the spirit of its meaning in Maori, ‘Peaceful Place’ given the ‘treatment’ that is dispensed to Kate from its less than idyllic setting.
The seclusion period is deemed to have ended when the patient leaves the conditions of seclusion without the expectation of return, and in any case, if the patient has been out of seclusion for more than one hour.”
Preferred Alternative Interventions
Interestingly, the same Standards call for preferred alternative interventions to have been used in a timely manner to prevent or minimise the use of seclusion until all other practical options have been considered or tried. So it got me thinking, did Kate’s Te Whare Ahuru case management team consider any? Wouldn’t we all like to know! We can’t of course for ‘privacy’ reasons.
I’d also be curious to know if their individual service delivery plan for Kate identified proactive alternative interventions to ensure that seclusion was only used where it was required, followed an assessment and that it could be fully justified. As an observer to my friend’s predicament I wouldn’t consider this an unreasonable line of questioning since all those matters form the basis for an approved rule of thumb.
Aside from meeting requirements of legislation, practices of seclusion also need to ensure patient rights and that current standards and relevant professional codes of practice are met throughout the process. I have some serious reservations about whether Kate’s patient rights have been fulfilled. Just so we’re clear about how I mean that, here in New Zealand:
Patients have the right to:
* Always be treated with respect
* Not be discriminated against, pressured or taken advantage of
* Services that promote dignified and independent lives
* Be treated with care and skill and receive correctly administered treatment
* Medical staff who listen to you and communicate clearly
* An interpreter if required
* A clear explanation of your medical condition and the types of treatment available
* An honest description of the risks and costs as well as the benefits of proposed treatment
* Ask questions and receive competent answers
* Make their own decisions
* Change their mind if you have already said yes or no to a course of treatment
* Refuse to participate in teaching or research
* Have a support person present at most times
* Register a complaint
A Snapshot: New Zealand Human Rights
“The inappropriate use of seclusion was identified as an issue which needed to be actioned in the New Zealand Action Plan for Human Rights to ensure current practice met human rights standards for the care and safety of mental health service users.”
A BIGGER picture:The International Human Rights Framework
The contemporary international human rights framework has its origins in the Universal Declaration of Human Rights adopted by the General Assembly in 1948. When a country ratifies one of these treaties it accepts that it will be bound by the terms of the treaty and guarantees its delivery domestically. In ratifying a treaty, therefore, a country recognises the international law and accepts a legal obligation to respect, promote and fulfil the rights in that treaty.
The two major treaties in this context, are the International Covenant on Civil and Political Rights (ICCPR) and the International Covenant on Economic Social and Cultural Rights (ICESCR). Together with the Universal Declaration these two treaties make up the International Bill of Rights. New Zealand ratified both treaties in 1972.
Now “although neither refers specifically to the rights of people with mental illness, they emphasise that rights (such as the right not to be subjected to cruel and degrading treatment, the right to be treated with humanity and dignity and the right to the highest attainable standard of physical and mental health) apply equally to all people without discrimination.
Initiatives relevant to Seclusion
Two international initiatives that are relevant to the issue of seclusion are the International Convention on the Protection and Promotion of the Rights and Dignity of Persons with Disabilities (the Convention on the Rights of Persons with Disabilities) which became part of international law in May 2008 and the Optional Protocol to the Convention against Torture (OPCAT) which came into force in 2006.
The OPCAT convention establishes an international inspection system for places of detention (including mental health facilities). New Zealand ratified OPCAT following enactment of the Crimes of Torture Amendment Bill. The Bill created a system of National Preventive Mechanisms for the purpose of carrying out regular inspections of detention facilities. The Human Rights Commission (as the Central Preventive Mechanism) has a co-ordinating role.
An IMAX picture view: United Nations Principles for the Protection of People with Mental Illness and for the Improvement of Mental Health Care (the UN Principles)
The United Nations Principles were the “first step in providing a global set of minimum standards for protecting persons with mental illness and improving mental health care.” The UN Principles emphasise the importance of quality treatment, that preserves and enhances personal autonomy. They also stress the concept of the least restrictive intervention. That is, there is a presumption that any intervention will be the least intrusive option available.
The UN Principles do not define seclusion. They do however address the circumstances under which seclusion is administered. Principle 11.11 states that ‘physical restraint or involuntary seclusion of a patient shall not be employed except in accordance with officially approved procedures of the mental health facility and when it is the only means available to prevent immediate or imminent harm to the patient or others’.
The UN Principles do not specifically define the appropriate length of time that a person can be placed in seclusion. Instead, it is stated the seclusion time should not extend beyond what is ‘strictly necessary’. They also state that all instances of physical restraint must be recorded and that any patient who is secluded must be kept under humane conditions and supervised regularly by qualified members of staff.”
If all that’s so, it begs the question doesn’t it, is making a person sleep on a mattress on a floor really necessary? For the record, Kate has graduated to having a bed. She’s in an area with 4-6 other patients. Many of those patients have acute mental problems. But for me, the question remains, why is she still in seclusion?
