Best practice recommendations on the application of seclusion and restraint in mental health services: An evidence, human rights and consensus-based approach.

WHAT IS KNOWN ON THE SUBJECT?: Seclusion and restraint still regularly occur within inpatient mental health services. The Council of Europe requires the development of a policy on for instance age limits, techniques and time limits. However, they only define the outer limits of such a policy by indicating when rights are violated. Within these limits, many choices remain open. Staff and service managers lack clarity on safe and humane procedures. Research literature provides limited and contradictory insights on these matters. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: The study resulted in 77 best practice recommendations on the practical application of restraint and seclusion as last resort intervention in inpatient youth and adult mental health services, including forensic facilities. To our knowledge, this is the first study in which the development of recommendations on this topic is not only based on scientific evidence, but also on an analysis of European human rights standards and consensus within and between expert-professionals and experts-by-experience. This approach allowed to develop for the first time recommendations on time limits, asking for second opinion, and registration of seclusion and restraint. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: The 77 recommendations encourage staff to focus on teamwork, safety measures, humane treatment, age and time limits, asking for second opinion, observation, evaluation and registration when applying seclusion and restraint as last resort intervention. The implementation of the best practice recommendations is feasible provided that they are combined with a broad preventive approach and with collaboration between service managers, staff (educators) and experts-by-experience. Under these conditions, the recommendations will improve safety and humane treatment, and reduce harm to both service users and staff. ABSTRACT: INTRODUCTION: Seclusion and restraint still regularly occur within inpatient mental health services. Professionals lack clarity on safe and humane procedures. Nevertheless, a detailed policy on for instance age limits, techniques and time limits is required. AIM: We developed recommendations on the humane and safe application of seclusion, physical intervention and mechanical restraint in inpatient youth and adult mental health services, including forensic facilities. METHOD: After developing a questionnaire based on a rapid scientific literature review and an analysis of human rights sources stemming from the Council of Europe, 60 expert-professionals and 18 experts-by-experience were consulted in Flanders (Belgium) through a Delphi-study. RESULTS: After two rounds, all but one statement reached the consensus-level of 65% in both panels. The study resulted in 77 recommendations on teamwork, communication, materials and techniques, maximum duration, observation, evaluation, registration, second opinion and age limits. DISCUSSION: Combining an evidence, human rights and consensus-based approach allowed for the first time to develop recommendations on time limits, asking for second opinion and registration. IMPLICATIONS FOR PRACTICE: When combined with a preventive approach and collaboration between service managers, staff (educators) and experts-by-experience, the recommendations will improve safety and humane treatment, and reduce harm to service users and staff.

interRAI Subjective Quality of Life Scale for Mental Health and Addiction Settings: A Self-Reported Measure Developed From a Multi-National Study.

Background: Measuring Quality of Life (QoL) in mental health using self-reported items is important for evaluating the quality of service and understanding the person's experience of the care received. Objective: The aim of this research was to develop and validate a self-reported QoL instrument for inpatient and community mental health settings. Methods: Data were collected from diverse research sites in Canada, Belgium, Russia, Finland, Brazil, and Hong Kong, using the 37-item interRAI Quality of Life Survey for Mental Health and Addictions. The survey was administrated to 2,218 participants from inpatient and community mental health settings, assisted living, and the general community. We randomly divided the sample into a training and a test sample (70 and 30%, respectively). We conducted principal component analysis (PCA) and exploratory factor analysis (EFA) using the training sample to identify potential factor structure. Confirmatory factor analysis (CFA) models were then fitted to finalize and externally validate the measurement model using training and test data, respectively. Results: PCA, EFA, and CFA of the training sample collectively suggested a 23-item scale measuring four latent constructs: well-being and hope (8 items), relationship (7 items), support (5 items), and activity (3 items). This model was supported by the CFA of the test sample. The goodness-of-fit statistics root mean square error, comparative fit index and Tucker-Lewis index were 0.03, 1.00, and 0.99, respectively. Estimated Cronbach's alpha based on the test data was 0.92. Raw Cronbach's alpha values for the subscales were 0.86 for well-being and hope, 0.86 for relationship, 0.69 for support, and 0.72 for activity. Conclusions: The interRAI SQoL-MHA scale is a valid instrument to measure QoL in mental health settings. The instrument will support the evaluation of the quality of care and can also be used for future research to produce SQoL-MHA values on a quality adjusted-life-year scale, facilitating the evaluation of various mental health interventions.

Psychometric properties of the multidimensional perfectionism scale of Hewitt in a dutch-speaking sample: associations with the big five personality traits.

We administered the Dutch Multidimensional Perfectionism Scale of Hewitt and Flett (1991, 2004) in a large student sample (N = 959) and performed a confirmatory factor analysis to test the factorial structure proposed by the original authors. The existence of a method factor referring to the negatively keyed items in the questionnaire was investigated by including it in the tested models. Next, we investigated how the 3 perfectionism dimensions are associated with the Five-factor model (FFM) of personality. The 3-factor structure originally observed by the authors was confirmed, at least when a method factor that refers to the negatively keyed items was included in the model. Self-oriented and socially prescribed perfectionism were both distinguished by low extraversion and low emotional stability. Self-oriented perfectionism's positive relationship with both conscientiousness and openness to experience differentiated the 2 perfectionism dimensions from each other. Other-oriented perfectionism was not well-characterized by the Big Five personality traits.

Variability in affective activation predicts non-suicidal self-injury in eating disorders.

We examined whether affective variability can predict non-suicidal self-injury (NSSI) in eating disorders. Affect was represented by valence (positive versus negative) and activation (high versus low). Twenty-one patients with anorexia nervosa-restricting type, 18 patients with anorexia nervosa-binge-purging type and 20 patients with bulimia nervosa reported their momentary affect at nine random times a day during a one week period using a hand-held computer. Affective variability was calculated as the within-person standard deviation of valence and activation over time. Results indicate that patients displaying greater variability in activation and using selective serotonin reuptake inhibitors have a higher probability to engage in lifetime NSSI after adjustment for depression and borderline personality disorder. Neither variability of valence nor mean level of valence and activation had any predictive association with engaging in NSSI. It is suggested that the treatment of NSSI should focus on affect stabilization rather than reducing negative affect.