Mental health services are supposed to avoid locking patients up in isolation - also known as seclusion. But it still happens.
Letitia’s* bedroom is plastered with acrylic artwork. The pieces are decorated with pictures of anchors, butterflies and quotes. One says: “when the world says give up, hope whispers try it one more time”.
There’s a poster of Cool for the Summer popstar Demi Lovato, whose ability to talk about her struggle with bipolar disorder is a source of motivation.
Aged 19, Letitia has been diagnosed with post-traumatic stress disorder and borderline personality disorder.
Much of the art in her room was painted during her stay in Palmerston North Hospital’s mental health unit, Ward 21, where she spent most of 2014.
She was admitted to the ward in March that year, after attempting suicide.
The ward has two parts, she says: an open side with one nurse to about six patients and more freedom. Then there’s the high needs unit - one nurse to every two patients. There, you’re “very limited” - almost constantly under observation, kept away from most activities and objects.
Not that the open side was much better. “Sometimes they had to make room in places that shouldn’t have beds in them. They have these interview rooms where psychiatrists meet with their patients and beds were put in there.
“You can get locked in your room - or worse, strapped to a bed.”
One day she felt herself sinking into depression and went to the nurse station for help but they were too busy filing paperwork, she says. She tried to end her life in the courtyard.
She says she was grabbed, yanked into standing position, her arms twisted behind her back - “they felt like they were going to break” - and taken to the high needs unit.
She claims she was stripped naked by male nurses and put into a suicide gown.
“I was speechless. I was scared. I’d never been in a place like that … I’d visited people but wouldn’t have imagined myself in that situation.”
She was placed in the seclusion room.
“If you were calm they would unlock it. But if you kept smashing things and banging your head against walls it could go for days,” she says.
WATCH Letitia talk about her experience of being placed in seclusion:
Letitia says being locked in seclusion made her feel worse.
“It’s hard to be locked in with your thoughts because it’s like I don’t know what to do and how to sort it out and there’s no one to talk to. It’s kind of boring. There’s nothing to do.”
Seclusion, also known as solitary confinement, is the practice of locking someone in a room. In mental health it is only meant to be used in cases where the patient is at risk to themselves or others.
Since 2009, New Zealand has been trying to reduce and eventually eliminate the practice, with guidelines encouraging the technique of sensory modulation - self-soothing by using items like massage chairs or weighted blankets.
Letitia says understaffing meant high needs patients often missed out on sensory modulation because in order to go to that room they needed to be supervised by two nurses.
Two years ago, the United Nations Working Group on Arbitrary Detention visited New Zealand and expressed concern at how the mental health system was operating.
In a written statement, they said compulsory treatment orders (under the Mental Health Act of 1992) were largely clinical decisions and too difficult to challenge.
Despite the Mental Health Act guaranteeing the right to legal advice for all patients, the group said people undergoing compulsory assessments are often “unrepresented in practice, as they do not have access to legal aid”.
“The Family Court, which makes compulsory treatment orders, is not a specialist court in mental health and seems to have the tendency to heavily rely on medical reports by merely one clinician and one other medical professional, who, in most cases, is a registered nurse.”
Last year judges and lawyers also called for a separate mental health court to avoid the “recycling” of people through the justice system. Over the Tasman, Victoria already allows review of CTOs (Compulsory Treatment Orders) under a specialist Human Rights Tribunal, and provides lawyers and mental health advocates through legal aid programs.
The UN working group also urged authorities to eliminate seclusion entirely.
According to the mental health director’s report released last year, Māori were almost four times more likely to be secluded in adult mental health units than people from other ethnic groups. Of the 763 people secluded in adult mental health services in 2014, 38 percent were Māori.
While the Minister of Health, Jonathan Coleman, points to a 29 percent decrease in seclusion since 2009, mental health professionals say there is not enough funding for the extra resources required to get rid of the practice. Data from OIAs also suggests the decline is not as steady as it was between 2009 and 2013.
Coleman was approached for an interview in relation to the practice of seclusion but could only answer questions via email. When informed about staff complaints around the implementation of the reducing seclusion policy he said in a statement:
“Seclusion continues to decline. The Office of the Director of Mental Health Annual Report 2013 shows that since 2009 the total number of people secluded in adult services nationally decreased by 29 percent. The total number of seclusion hours for people in adult services nationally decreased by 50 percent between 2009 and 2013. Any staff who have concerns about the use of seclusion should raise these with their clinical leader.”
Requests for information on how many instances of seclusion occurred in DHBs in the last year were sent to all 20 DHBs. So far 14 have provided the data requested. Lakes DHB responded, but refused to supply the information requested unless they were paid $1216.
Across the DHBs that provided data, there were 2952 instances of seclusion in the past year.
In 2013, there was a nationwide total of 2637 seclusion “events” according to the Director of Mental Health Annual Report and in 2011 there were 3410.
The Wireless will update these statistics as more data becomes available.
During Letitia’s stay, Ward 21 was shaken by the suicides of two patients within three weeks of each other.
“One was in the high needs unit, which is meant to be impossible because there’s only six patients and a few nurses in there. Then a month later a girl died, but she was on the open side.”
An external review of the hospital’s mental health service was prompted as a result of the suicides and listed 44 recommendations.
It said the DHB’s mental health service had a “complacent culture”, a lack of leadership, was under-staffed and had an overcapacity of patients.
“The intensive care area is poorly maintained with an overall air of shabbiness and starkness. Graffiti is evident throughout this area,” it states.
“The unit is built as a 24 bed unit but frequently and in an ad hoc manner goes up to 30 beds. Use of seclusion rooms, meeting rooms and family rooms as bedrooms is inappropriate.”
The review added that the intensive care area was not adequate for six people and the sensory room, “an important resource in a modern inpatient unit, to enhance self-management of distressing symptoms”, was being underused.
It also said the adult inpatient unit would not meet standards for acute mental health units in New Zealand or Australia.
A work programme was established to address the issues.
“The mood was real down,” says Letitia, reflecting on the deaths.
“Patients were checked off a sheet every 30 minutes, doors were taken off the cupboards in their rooms, curtains had to be open at all times, the BBQ tables that people used to move to help escape from the courtyard were bolted to the ground.
I still get suicidal, I’m just aware of how it hurt people. It really destroyed a lot of my family. That’s what stops me now.
The review also criticised the lack of an electronic clinical information system. It made it difficult to tell how and when patients were being monitored. Letitia says during her stay “nurses would check on patients a lot but then that kind of dwindled out and they went back to ‘I’m busy’ because they had to do notetaking on paper and the computer”.
Compulsory treatment has its place, says Letitia, but sometimes it goes too far and doesn’t help patients learn how to look after themselves.
“You’re going to have to learn to make decisions on your own.”
Letitia got out a year ago and she’s no longer under the Mental Health Act, which had meant she was required to be seen by mental health professionals.
“I still get suicidal, I’m just aware of how it hurt people. It really destroyed a lot of my family. That’s what stops me now,” she says.
Richard Barrass, the director of mental health services at MidCentral DHB, says privacy constraints meant he couldn’t speak to specific cases like Letitia’s.
“If we do have any patients with concerns we do have a complaints process and they are investigated at the time,” he says.
“We have quite a good system in place addressing concerns.”
Barrass says he is aware of a period where there was a high number of admissions to the ward and “I’m aware of one event where they stopped using the interview rooms and put furniture and bedding in there.”
The DHB has followed through with many of the recommendations from the external review and he couldn’t directly comment on the review as it involved individuals, he says.
When asked how many of the 44 recommendations had been followed through he responded: “I cannot answer that at this point”.
Will* was taking a nap after a long day at work. His partner answered a knock at the door to find seven policemen - some armed with tasers - staring back. They were wanting Will to come into mental health services for an assessment.
Despite claiming he would go willingly, police handcuffed Will, triggering an old shoulder injury. He struggled to breathe, pleading for police to rearrange the restraints.
“I feared for my safety and was in a fair amount of pain,” he says of the incident two years ago.
“This led to me vomiting all over myself and the back of the car.”
Will had previously been treated by the community forensic mental health team for offenses including possession of marijuana, possession of a police baton, threatening behaviour, and breaching a protection order in 2006.
Sending seven officers to a proposed patient’s home and removing that person from bed and then restraining them in handcuffs is inappropriate ...
He was discharged from mental health care in 2013 but several months later concerns were raised about his well-being, prompting the request for an assessment into Will’s mental state.
He believes he was discriminated against during the process of that assessment because of his past criminal record.
He made an official complaint which was upheld by the district inspector - a lawyer appointed to look after the rights of people under the Mental Health Act.
In the report, seen by The Wireless, the district inspector concluded the way Will was treated by police was a breach of his rights by placing him “face down on the footpath in vomit for approximately half an hour waiting for a police transport van.
“Sending seven officers to a proposed patient’s home and removing that person from bed and then restraining them in handcuffs is inappropriate; especially when the proposed patient has said he would go willingly,” the report says.
A year later, the area’s mental health director apologised.
The report recommended better training for mental health workers tasked with enforcing the Mental Health Act and that junior workers are not placed in situations beyond their level of experience. The case is now before the Mental Health Review Tribunal.
Upon arriving at the hospital’s mental health ward he was placed in seclusion for three-and-a-half days and barred from contacting a lawyer, the Ombudsman or the Human Rights Commission. His complaint regarding lack of legal access was also upheld by the district inspector.
“Seclusion makes you feel completely degraded,” he says.
“There’s no running water, no toilet, they take your clothes off you and give you a bucket to use as a toilet. They kick your food across the floor like you’re an unwanted dog. They had a huge clock behind the perspex window and you look at it every 20 seconds. Times goes slow. You begin to feel like you want to die.
“The only thing in the room except for the shit bucket is a hard, dirty mattress on the floor with a couple of blankets. Every time the room gets entered there’s like 7 or 8 of them and they treat you like you’re a disease. I can’t see it helping in a huge percentage of cases it’s used in. Very violent inmates, yes, but 95 percent of mental health cases, no.”
Those working in the sector find themselves torn between the push from higher-ups for a reduction in seclusion and the lack of resources to pull off such a feat.
Andy* is an inpatient mental health nurse and duly authorised officer - meaning he is empowered to enforce compulsory treatment for patients like Will.
He says in today’s climate seclusion appears “archaic, almost barbaric” but the government is not following through with alternatives. Nurses simply don’t have resources to cope with the change, especially with patients who are acutely unwell, addicted to substances like methamphetamine or hallucinating.
“The vast majority of nurses are doing the best they can with limited resources at their disposal. I’ve seen nurses attacked, hair pulled out, punched. Nurses in tears dealing with verbal abuse.
“On top of the constant stress of dealing with violence and aggression, inpatient nurses are now being told the seclusion rooms will be decommissioned one room at a time - and within the next couple of years seclusion is to be abolished nationwide,” he says.
One room at the DHB he works at was decommissioned but then reinstated as there was no alternative plan.
“We’d had a couple of months where our seclusion stats were down and management were aware of the push to decrease seclusion in the future, so they decommissioned a room, putting a sign on it to say it was no longer a seclusion room.”
But as soon as two patients arrived needing seclusion, the sign disappeared off the door. Since then, Andy says, the seclusion room is commonly used - but there is talk again of getting rid of it permanently.
To force treatment upon someone against their will is a decision that cannot be taken lightly. However, sometimes it is necessary. Often people that are really unwell - psychotic, manic, severely depressed - have little insight into their behaviour.
“Nurses are very anxious about this, again, they haven’t been informed of any alternative to seclusion at all. This absolutely needs to happen, but what is the alternative for these extremely risky patients?”
There are three registered nurses on during the day and two at night. With no seclusion there would need to be at least two more permanent nurses around the clock, Andy says.
“It’s already challenging to find staff as it is. And where is the extra funding coming from?”
Section 71 of the Mental Health Act states seclusion should never be used for discipline, staff convenience or as a substitute for adequate staffing levels.
Andy says he often faces an “ethical dilemma” when assessing someone and sectioning them under the Mental Health Act.
“To force treatment upon someone against their will is a decision that cannot be taken lightly. However, sometimes it is necessary. Often people that are really unwell - psychotic, manic, severely depressed - have little insight into their behaviour.”
For the families of those placed in seclusion there is also doubt about how much it helps.
A mother, Jane*, says four years ago her daughter (34) had a psychotic break after suffering from schizophrenia all her life.
Her daughter was admitted to a mental health unit and spent her first 48 hours in seclusion.
“Mattress on the floor, no windows, nothing. It appeared that it didn’t bother my daughter as she was so unwell but from a mother’s perspective it was heart-breaking.”
A year later, she was readmitted under the Mental Health Act in a “step-down” area while the normal mental health ward was being renovated.
I think things are still not right with our treatment of people with mental health.
“One particular day she’d been asking staff if they could walk with her down to the petrol station to get some smokes. She’d been asking for 12 hours. All the staff said ‘yes, when I’m not busy’ but no one ever took her down.
“She jumped out of a two story building that night, under darkness, to go and get smokes herself. So the story goes. The ward rang me and told me the police had been called and they were searching for her, she couldn’t be found all night and I thought she’d killed herself.
“It was only to buy a packet of smokes and she was found walking along the motorway the next day. She was coming home, she told me.”
Now her daughter works part-time and lives with Jane. She is seen occasionally by the community mental health team.
“I think things are still not right with our treatment of people with mental health,” says Jane.
“Why does everything have to become acute for something to happen? People with mental illness, in my experience, do not recognise when they are unwell and will not seek help. It is up to the family but what about the people who don’t have anyone?”
* Letitia is referred to by first name only to help with the chance of getting jobs in the google-able future.
** Some names have been changed to protect privacy
If you need to talk to someone about your own mental health, try these helplines. If it is an emergency, call 111.
Lifeline - 0800 543 354
Depression Helpline - 0800 111 757
Healthline - 0800 611 116
Samaritans - 0800 726 666
Suicide Crisis Helpline (aimed at those in distress, or those who are concerned about the wellbeing of someone else) - 0508 828 865 (0508 TAUTOKO)
Youthline - 0800 376 633, free text 234 or email firstname.lastname@example.org