(This article was published in the annual report for the Parliamentary Ombudsman as National Preventive Mechanism 2018. The NPM´s 2018 annual report is available here )
From our very first visits to psychiatric hospital departments, the NPM has made worrying findings concerning the use of a measure called ‘shielding’ (a form of segregation). Many patients are subjected to segregation, and the coercive measure may be used for a long time. Segregation often takes place in stripped rooms with little meaningful social contact, strict rules for behaviour, lack of available activities, and unclear treatment plans.
Based on these concerns, the NPM launched a thematic report on the use of segregation in December 2018. The purpose of the thematic report is to provide a summary and elaboration of the NPM’s findings on the use of segregation from its visits to mental healthcare institutions. The findings are assessed on the basis of human rights requirements and standards, and discussed in light of history, research, and public statistics.
What is segregation?
Segregation in Norwegian mental healthcare institu tions entails that the patient is being completely or partly removed from the other patients, reducing human contact to health personell only. Segregation can be implemented against the patient’s will and take place in the patient’s room or in a dedicated segregation unit. A segregation unit is a room with one or more beds separated from the other parts of the department, normally with a door that can be locked. Patients in segregation units can be denied access to communal rooms in the ordinary department, and will normally not be able to have social contact with patients or others in the other parts of the department.
Low threshold for using segregation
Norway is one of the few countries that has a special legal provision on the use of segregation as a coercive measure, distinct from the use of isolation. Segregation can be used both as a control measure to protect the patient or others against aggressive behaviour, and as a treatment measure where the idea is that reduced sensory impressions will calm the patient. The legal threshold for being able to impose segregation as a control measure is clearly lower than for isolation, which requires that the situation is acute. In practice, however, the patients often perceive segregation as being the same as isolation. Using segregation as a compulsory treatment measure is also problematic because there is insufficient knowledge of the effect of the treatment.
Extensive use of segregation
Public figures and surveys indicate that the use of segregation increased significantly in the period 2001–2016. The figures also indicate that some hospitals use segregation more than others, and that some patients are segregated for long periods of time.
The NPM’s visits have also shown that in some hospitals, segregation is an integral part of the treatment regime, for example in that a large proportion of the available beds are located in segregation units. Several of the wards the NPM has visited had a culture characterised by strict boundary setting and correction of undesirable behaviour that could trigger conflicts and segregation measures. The visits also found that inadequate options for engaging in meaningful activities and spending time outdoors can trigger segregation.
Segregation often takes place in undignified conditions
The segregation units in most of the hospitals the NPM has visited have a bare and sterile appearance. Many patients and staff referred to them as being prison-like. The rooms often had no furnishing apart from a bed, and sometimes a table and a chair. In almost all cases, the rooms are painted white with no decoration or pictures on the walls. Many rooms had windows with film that made it completely or partly impossible to look out of.
The bare design of the segregation unit premises is often justified as a security precaution. The NPM believes that such a view of security is problematic as research does not support the notion that a lack of furnishing prevents violence and destruction. On the contrary, research indicates that humane design can contribute to reducing the use of coercion. The hospitals also contended that the patients’ sensory impressions should be limited to help them calm down. However, the patients’ experience indicates that the bare design reinforces the impression of segregation as a form of punishment. The NPM’s visits found that many of the institutions have a low awareness of the potential negative effects of a lack of sensory impressions. Several segregation units also had restraint beds and isolation rooms. This further reinforces the impression of segregation as a form of punishment. Such segregation units generally do not adequately safeguard patients’ dignity.
One important finding is that segregation in many cases clearly resembles isolation. Many patients spend a lot of time alone, often with little contact with the staff. Examples were also found of segregation measures being used for a prolonged period of time. Some patients are segregated for several months or, in exceptional cases, years.
The implementation of segregation is often characterised by strict rules, unclear treatment content, and a lack of opportunity to spend time outdoors every day or participate in adapted activities. The NPM has also found that physically restraining patients by manual control is incorrectly considered as being covered by a segregation decision, and that patients can be held, wrestled to the ground and, in some cases, physically carried into a segregation unit, without an administrative decision being made to that effect.
Furthermore, administrative decisions on the use of segregation were often inadequately documented, without a precise description of why segregation was considered necessary in each individual case.
The thematic report shows that human rights standards set clear limitations on the right to use isolation-like measures in the health care services. The use of segregation, particularly if upheld over long periods of time, in an invasive manner with a low degree of freedom of movement, meaningful human contact and self-determination, can constitute a risk of violation of the prohibition against inhuman and degrading treatment.
Need to focus on alternatives to segregation
The thematic report points out that alternatives are needed to the current segregation practices. In the report, the NPM issues the following recommenda tions to help prevent the risk of inhuman and degrading treatment caused by segregation:
To the national health authorities
› prepare a national overview of the duration of segregation measures. Such an overview should also include information about geographical variations and, in particular, prolonged measures.
Assessment of the legislation
› carry out an assessment of whether the legislation that applies to the use of segregation is in accordance with human rights requirements and standards, both as regards the right to use segregation as a treatment measure and as a control measure. The need for special due process guarantees should also be considered to avoid prolonged segregation.
› consider national professional development projects on segregation, such as projects on humane and safe design of segregation units in mental healthcare institutions, less invasive methods for implementing segregation, and alternatives to segregation.
To health trusts and local hospital departments
Implementation of segregation
› ensure that segregation is not implemented in a way that constitutes isolation, and enable patients to have meaningful social interaction.
› ensure that further restrictions and force during segregation only take place if there is a legal basis and it is strictly necessary and proportionate.
› implement special measures at the local level to avoid prolonged use of segregation.
› implement measures in consultation with patients to prevent the use of segregation, including by developing alternatives to segregation.
Special requirements for staff
› ensure that staff who work in the segregation units meet high ethical awareness requirements relating to the use of force and that they are knowledgeable about how to prevent coercion.
The physical design of segregation premises
› implement measures to ensure that premises that are used for segregation are designed in a humane manner that avoids sensory deprivation. Restraint beds should not be placed in the segregation units.
Due process protection in connection with segregation
› take steps to ensure that decisions on segregation are justified by concrete and independent assessments by the person responsible for the decision.
› Take steps to ensure that a treatment
1- The report is entitled “Skjerming i psykisk helsevern – risiko for umenneskelig behandling” (‘Segregation in mental healthcare – risk of inhumane treatment’). The reports summary and recommendations are available here