A survey by the Institute for Research and Documentation in Health Economics (Irdes) analyzes the strong disparities in the use of isolation and mechanical restraint in French psychiatric establishments.
A first study showed that each year, a third of people hospitalized without their consent in psychiatry are placed in solitary confinement, and that more than a quarter are also subjected to mechanical restraint, with strong variations between establishments. This second part is based on the quantitative analysis of 204 establishments providing psychiatric care without consent and on a qualitative ethnographic study of four establishments historically characterized by low use of isolation and restraint, in order to identify the factors associated with these variations.
A finding of strong disparities
The Irdes study, which combines a quantitative (204 establishments) and qualitative (4 low-use sites) approach, first reveals very notable differences between establishments. These massive differences in practice cannot be explained solely by the pathology of the patients. Some establishments never use restraint (9% of the sample). “The analysis of the use of isolation and restraint within the 204 establishments included in the quantitative approach highlights the extent of variations between care providers. It also identifies establishments that do not use restraint (9% of them) while all, except one, use isolation. Concerning restraint, the high rates sometimes observed (up to 100% in three establishments) must be interpreted in light of the denominator chosen. In certain cases, they reflect a systematic practice of restraining people placed in solitary confinement, even though the use of solitary confinement remains low and may only be used when restraint is deemed necessary.detail the authors.
“The variations observed are not only linked to the specificities of individual clinical situations: a significant part depends on the establishments themselves, in particular”
The study highlights the typical profile associated with a higher risk of coercive measure, through different criteria:
- The demographic profile : Young men.
- Le diagnostic : Psychotic disorders, manic episodes or certain developmental disorders (autism, intellectual disability).
- Entry mode : Admissions via emergencies or long-term hospitalizations.
- Legal status : Prisoners are more often isolated (for security reasons), but less often restrained than average.
It also shows that internal organization plays a crucial role in the use or not of these practices, starting with staffing: the authors note in particular that the use of restraint decreases when the ratio of nurses per patient is higher. They also point out the type of structure: isolation is thus more frequent in establishments specializing in psychiatry than in university hospital centers (CHU) or multidisciplinary hospitals. Finally, they questioned the place of territories in these differences in practices but, surprisingly, no correlation was found between the use of these measures and social precariousness or the prevalence of disorders in the geographical area served.
“Another institutional lever often mentioned by professionals to reduce isolation and restraint
is the implementation of a policy of opening the units, which has the effect of reducing the level of tension within them.”
What levers can be used to reduce coercion?
Establishments that succeed in limiting these practices share common characteristics, finally note the authors of this study. These differences are partly due to the culture and values of the healthcare teams. The use of coercion is thus less systematic when the establishment promotes a “counter-culture of risk” where freedom of movement is established as a principle. “For example, it was surprising to see that the notion of “therapeutic escape” was mentioned in the four sites surveyed. This implies that the possibility of circulating, or even experiencing unauthorized exit, is part of the therapeutic process,” note the authors. Along the same lines, the ethical positioning of healthcare teams counts in these differences, when doctors and management are collectively committed to prohibiting or limiting these practices. The authors also highlight the stability of teams: cohesive, stable and available teams promote a bond of trust which allows tensions to be defused through discussion rather than by force. “In the ethnographic study, the existence of a link with caregivers was also repeatedly cited as a means of defusing tensions”confide the authors. Finally, the openness of care units plays an important role in the low use of coercion, as well as an offer of regular activities for patients.”
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