A Consultant Psychiatrist in CAMHS shares an account, reflecting over a 2year period, of how a secure hospital inpatient service empowered a very mentally unwell young adolescent autistic male, and the staff looking after them, to fracture the shackles set through the use of seclusion.

Seclusion is a necessary but not a common intervention utilised in secure psychiatric hospitals to help safeguard a patient to prevent any imminent risk of violence towards staff and fellow peers of the said unit. Seclusion is defined by the Mental Health Act Code of Practice as “the supervised confinement and isolation of a patient, away from other patients, in an area from which the patient is prevented from leaving, where it is of immediate necessity for the purpose of the containment of severe behavioural disturbance which is likely to cause harm to others.” (1) 

There have been long-held concerns about the use of restrictive practices within various institutions in the country such as psychiatric hospitals. This prompted a request from the Secretary of State for Health and Social Care for the Care Quality Commission to investigate such restrictive practices. This review found that most people that they interviewed had a learning disability and/or autism. (2) It was also found that patients had very diverse needs and that some areas of good practice to help end the need for this level of restriction included understanding their unique needs, ensuring that they were provided with meaningful activities and therapeutic activities. In this story, we wish to share some of the more out of box thinking that we utilised as a healthcare team to help the young person in question safely progress out of seclusion, which eventually led to the need for this level of restriction to end.  

On the outset of the journey with the young person in question, very little was known about their active needs other than them having the diagnosis of Autism made in the community. It was recognised early in the admission that the young person suffered with sensory difficulties, had challenges in being able to express their emotions and of not being able to effectively interpret social cues. Traditional ways in being able to conduct these important assessments were constrained due to the young person presenting with very profound levels of violence towards healthcare staff. A greater reliance was placed on specialist nursing and multi-disciplinary therapeutic observations to determine how the environment impacted on their wellbeing. Positive risks were taken to trial various interventions like testing out sour sweets, aromatherapy as well as the use of a comfortable safety pod to help the young person engage in physical health assessments and basic hygiene care. 

As anyone should expect, our mental health hospital offered a multidisciplinary approach to help support the young person’s mental health needs. These ranged from daily medical and nursing reviews, weekly speech and language therapy intervention, at least weekly psychologist input, daily sensory interventions, and daily access to full time education from the on-site school. The latter was a tremendous achievement given that the young person not accessing education in the community. Creation of a personalised, structured timetable, with due to consideration of their communication, sensory and zones of regulation needs proved to be a very helpful intervention to help organise their day. Independent oversight of the young person’s general and social welfare through near to daily input from both the on-site social worker and visits from various external professionals were offered. The care delivered was also subject to external scrutiny by NHS England through the Care, Education and Treatment Review (CETR) process. (3)

Numerous attempts were made to provide time out of seclusion for the young person, which sadly led to numerous staff members become severely hurt. This did not deter the team to continue to provide a holistic caring approach towards the young person. Outside of the box thinking to aid the young person’s wellbeing, over time, allowed both the young person and staff to develop trust and the therapeutic relationship with one another again. These interventions included sessions of animal therapy such as regularly bringing in a therapy dog, a Leonberger by breed, to see the young person, hiring an “animal man” who brought more exotic animals in and, on some occasions a group of lambs for the young person to socialise with. The young person has also taken many photos with these animals during their time out seclusion, photos of which they continue to cherish. In addition, the young person was always involved in the ward celebrations with staff holding bespoke events for them e.g. religious festivals, sporting events like the Fifa World CupTM and Halloween etc. Adaptations were made to allow the young person to engage in the Duke of Edinburgh’s Award and the team are proud to report that this young person achieved their Bronze Award. It is this kind of approach, armed with the additional clinical interventions for their severe mental health illness, that helped to build trust and rapport, which aided to develop a sense of safety and predictability to enable them to gradually arise outside of the seclusion environment. The team are pleased to report that the young person has since come out of seclusion several months ago and they have not since returned to this restrictive environment.
 

Conclusion:

It is hoped that this story provides you with an understanding of the journey experienced by a young adolescent male with very complex mental health needs in a secure hospital and help you to recognise the transformative power of holistic care, tailored interventions and outside of the box thinking can have in empowering them in their recovery. This journey was a powerful one and the clinical team have benefited and learnt a lot from this. This journey shows the power of compassionate care and how personalised interventions can nurture growth in young people with autism by breaking down barriers.