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English Language Page Physical restraint Application of measures of physical restraint — is a necessary element of the internal order of the psychiatric institution. When patients are agitated and therefore can hurt themselves, other patients, or personnel, restraint measures become necessary. According to Federal Law “On Psychiatric Care” (Part 2, Article 30): Measures of physical restraint… are only applied in cases, forms, and for the duration of time that are deemed appropriate by the physician-psychiatrist to prevent actions of an institutionalized individual if other methods in their opinion are considered inadequate… and are resorted to under permanent control of medical personnel. Application of physical restraint measures dramatically restricting the freedom of patient is traumatic to them in any case. It must be resorted to only in cases of emergency and advisably under control of not only physicians and medical personnel who appoint and apply them, but also under that of independent structures, for example representatives of the Patients’ Rights Protection Service or nongovernmental human rights organizations. It is impossible to completely give up restraint measures but the reduction in their application largely depends on the availability of sufficient supplies of medications and adequately selected therapy scheme. According to doctors and nurses today measures of physical restraint are applied much more rarely than before. During the survey of wards of psychiatric institutions restrained patients were not observed practically anywhere. These days, so called soft restraint is used everywhere as a means of stringency — hands and feet of the patient are tied up to the bed with wide fabric belts. If belts are not available, towels are used (as is the case, for example, at the Republican neuro-psychiatric dispensary of the Kalmyk Republic). In some hospitals only patient’s hands are tied up (Republican psychiatric clinic of Mordovia), in others patients are tied not to a bed but to an armchair (Republican psychiatric clinic of the Komi Republic). Russian psychiatry has adopted a policy to give up strait jackets. Nevertheless, some clinics have not given up this practice viewing it as a more effective and humane method of restraining an agitated patient. Strait jackets are still used in the Sverdlovsk regional psychiatric clinic #1, Stavropol territorial psychiatric clinic #2, Khabarovsk territorial and Khabarovsk city psychiatric clinics, and head of the psychiatry department of the Altai republican hospital expressed regret on the account of the fact that strait jackets had been given up. He thinks that they were less traumatic and more humane than bandages and said: “once we had a patient who jumped out of the ward being tied up to his bed.” A nurse of the Republican neuro-psychiatric dispensary of Kabardino-Balkaria reported utilization of such a measure as “camisole.” In the Shadrinsk neuro-psychiatric hospital of the Kurgan region, Nizhniy Novgorod city psychiatric clinic, Republican psychiatric clinic of North Osetia and some other clinics agitated patients are wrapped in wet bed sheets. The same measure is sometimes used in the Bryansk regional children’s psychiatric center (for not more than one hour). In the Votkinsk neuro-psychiatric dispensary of the Udmurt Republic, according to one of its nurses, agitated patients are “held by orderlies.” Only the Bobrovo-Dvorskaya psychiatric clinic of the Belgorod region reported that no measures of physical restraint were used there, only “shots and conversations.” Observation of the principle of voluntarism requires that the choice of measures limiting patient’s freedom be coordinated with them in advance. However in the conditions of Russian psychiatric institutions and the longstanding practice this approach is not used. Undoubtedly, measures of physical restraint in the form of fixation of patients are absolutely necessary in some cases, for example during the intra-venal injection of medications, as well as during some time after that. It is very important however that these measures are applied only in extreme cases and under permanent control of clinical personnel. It is done so practically in all hospitals. Restraint measures are applied only when sanctioned by a physician (only the Sverdlovsk regional psychiatric clinic #1 reported that restraint measures could be sanctioned by the nurse-on-duty), which is specifically reflected in patient’s clinical records. However a detailed description of the patient’s condition is not always provisioned. Usually the clinical record states “psychomotor agitation.” Such practice in fact deprives the patient of the opportunity to appeal actions of doctors and personnel. Restraint measures are applied for terms varying from 15 minutes (Republican neuro-psychiatric dispensary of Adygea, Krasnoyarsk territorial psychiatric clinic #1, and some others) to two hours (Moscow regional psychiatric clinic #2 (every 30 minutes bandages are gradually relaxed), Republican psychiatric clinic of Buryatia, Kazan city neuro-psychiatric hospital of the Republic of Tatarstan and others). Sometimes the time of application of restraint measures is not specified but every two hours the patient’s condition is checked by a doctor or a nurse. Only 16 psychiatric institutions (17%) reported that they had special journals “On Measures of Physical Restraint when Providing Psychiatric Care” which in compliance with the order of the RF Ministry of Health Care every department of psychiatry must have. Introduction of these journals was targeted at exercising stricter control over the application of restraint measures and is viewed as a means to protect patients’ rights. In the journal of the Krasnoyarsk territorial psychiatric clinic #2 four cases of physical restraint were registered within a period of two months. The Republican psychiatric clinic of Bashkortostan reports that they resort to restraint approximately twice every three months. However, the Kotelnicheskaya psychiatric clinic of the Kirov region reported totally different figures — 100 cases per year to administer procedures, which very likely is a result of the lack of medications (this clinic disposes of only 15% of the required amount of pharmaceuticals). Mid-level clinical personnel are trained to apply restraint measures at certification courses and qualification improvement courses; orderlies are trained in the clinic when being hired. Chief nurses of departments must conduct classes regularly and see to it that patients are not injured. These rules are strictly adhered to in the majority of health care institutions however the significant turnover of the junior-level personnel nullifies the results of training programs. At the same time the level of training of medical nurses is not always sufficient and satisfactory. For instance, a nurse from the neuro-psychiatric department of the Nenetsky autonomous district’s hospital confessed: “I was not specifically trained to use restraint measures, I learned from my own experience only.” In especially dangerous situations clinical personnel resort to external assistance and call for guards or the police. This however also requires physician’s control since police officers are not trained to apply restraint measures to psychiatric patients and act at their own discretion. Representatives of the Moscow regional psychiatric clinic #2 reported that once a group of police officers that was called for assistance handcuffed a patient to a heating radiator. Window bars, lockable departments According to Appendix to Order #92 of the RF Ministry of Health Care of April 11, 1995, windows in psychiatric departments must be designed in such a way so as to make it possible to air the premises on one hand and prevent suicidal attempts, as well as escape on the other hand. The latter is directly related to patients’ safety. This manual requires that windows be made of special unbreakable glass and prohibits installation of window bars. Compliance with the requirements of administration is complicated by the factual lack of financial means; hospitals are not in the position to refurbish their windows. In addition to that, windows of some clinics are not subject to refurbishment at all since the buildings are too old and have to be demolished. As a result, only 30 of the surveyed institutions (32%) had no bars on their windows, the rest of them had kept the bars since the previous times and have no intention of removing them because they are afraid they would not be able to ensure the safety of their patients then. For example, there are no bars on the windows of the Kazan city neuro-psychiatric dispensary but its personnel is sooner dissatisfied with this fact and is of the opinion that bars are absolutely required on the windows of the section that contains agitated patients. Nevertheless, bars on the windows do not result in a smaller number of suicidal attempts and escapes. The latter is much more dependent on the adequacy of therapy and availability of a sufficient number of well-trained personnel. Practically in all of the surveyed psychiatric institutions patients had a possibility to open windows whenever they wanted. The only exception were five clinics (Kaliningrad city psychiatric clinic, Kirov regional psychiatric clinic, Ukhta city psychiatric clinic of the Komi Republic, Chita regional psychiatric clinic #2, Ulyanovsk regional psychiatric clinic #1 named after Karamzin) in which windows are opened by clinical personnel. The Ukhta city psychiatric clinic reported that their premises were aired in strict compliance with an airing schedule and windows were never opened otherwise. In addition, windows of the Kurgan regional psychiatric clinic turned out to be fixed with nails, while window frames of the Nizhniy Novgorod and Yaroslavl regional psychiatric clinics had dried out and require immediate replacement — oftentimes it is impossible to shut these windows after the airing. All external doors of departments, as well as doors of all rooms are locked with special psychiatric keys and in many psychiatric institutions patients are unable to independently access any part of the premises, including the recreation room, the only exception being toilet rooms. The open door regime only exists in some sanitarium departments that treat patients with marginal conditions. Contemporary psychiatry tends to take into account the right of patients to freedom of movement. In Russia however independent activity of patients is limited to the maximum possible level to ensure patients’ safety. Prohibition on own clothing and haircut The rights to wear one’s own clothes and have one’s own haircuts that are directly associated with one’s identity can also be restricted to ensure patients’ safety. The decision made in each particular case depends on whether physicians and personnel respect patient’s personality. Unfortunately, sometimes these restrictions do not have an individualized character and are applied to all patients regardless of the specifics of their conditions. As a rule, such practice is used to better accommodate the needs of personnel. For example, all patients regardless of whether or not they have suicidal intentions can be forbidden to wear trousers with waist belts or robes with detachable waist belts. In some psychiatric departments men are forced to have their moustaches and beards shaven which they perceive as an utmost outrage. Note that such indiscriminate approach is justified by the allegedly neglected appearance and one’s inability to maintain their moustache and beard in a due form. All of the monitored clinics denied having prohibitions to wear one’s own clothes and haircuts. Note that absence of the prohibition to wear one’s own clothes is connected with the lack of hospital robes: under the current financial circumstances it is almost impossible to provide each patient with a hospital robe, etc. On one hand the objective difficulties with acquisition of hospital clothes help patients maintain their individualized appearance, on the other hand clinics are not always able to provide their poorer patients with everything they need and the latter find themselves in a more vulnerable position. The right to have and acquire articles of basic necessity The right to have and acquire articles of basic necessity has an exclusive importance for a patient deprived of an opportunity to independently move. It becomes especially important for those who are not visited by their relatives. For such patients the possibility to acquire articles of prime necessity becomes the only method, especially in the situation when clinics oftentimes are capable of providing their patients only with soap. One has to independently acquire beverages, foods, paper, pens, and other articles that they might need. Unfortunately, the majority of psychiatric clinics have no stores or kiosks on their territories that would sell articles of prime necessity. Patients who have the so called free exit, i.e., those who are allowed outside of the clinic’s territory, can buy whatever they need themselves. Those who are not allowed outside the perimeter use assistance of personnel. According to department heads and nurses this procedure is in place in every clinic: social employees or the nurse in charge come up with a list of articles and buy everything that their patients need. In order for a patient who has been staying in the clinic for a long time, who is not visited by relatives, and who has no money, to receive pension benefits they sometimes have the clinic temporarily registered as their domicile. Restriction of visitation, walks, and security of territory The right of patients undergoing therapy or examination at a psychiatric institution to “receive visitors” is one of the rights that can be restricted by recommendation of the attending doctor to protect health or ensure the safety of other people (Part 3, Article 37). The majority of the surveyed psychiatric institutions allow visitation practically every day during certain hours. Restrictions that can be applied in accordance with Federal Law “On Psychiatric Care” are come across rather rarely and are only applied to patients in observation wards whose current condition is aggravated. However there are clinics where the time and conditions of visitation are strictly regulated and significantly restricted. For instance, the Perm city psychiatric clinic and the Votkinsk neuro-psychiatric dispensary of Udmurtia allow visitation only twice a week, and the Krasnodar city psychiatric clinic — only once a week under control. Restriction of visitation, new requirements with respect to visitors can be associated with the enforcement of security measures. For example, the Stavropol territorial psychiatric clinic #2 reported that patients’ relatives were required to produce identification documents due to fear of terrorist attacks and androlepsy. Many hospitals allow visitation only under control of a representative of the clinical personnel — a nurse, a social employee, or an orderly (Kursk regional psychiatric clinic, Lipetsk regional neuro-psychiatric hospital, Penza regional psychiatric clinic, Kuznetsk city psychiatric clinic of the Penza region, Magadan regional neuro-psychiatric dispensary, etc.). The Central Moscow regional psychiatric clinic #1 allows visitation only by relatives, no friends are allowed. To visit a patient of the Republican psychiatric clinic of Buryatia one needs to obtain authorization of the department head: “We speak with the visitor and then make a decision.” Even if such practice has been introduced for the benefit of the patients this nevertheless can restrict their right to visitation, especially considering that patients’ opinions are never taken into account. In some of the clinics this situation can be recognized as satisfactory since their chief physicians have no doubts that patients’ right to visitation must be observed: “Even if the person is in a poor condition nobody has the right to forbid them to see their relatives.” The Khabarovsk city psychiatric clinic named after Professor Galant also always allows visitation: “We do not let in only drunk and aggressive people.” Visitation is never forbidden at the Oryol regional psychiatric clinic, the psychiatric department of the Altai republican hospital, the neuro-psychiatric department of the Nenetsky district hospital, and the Chukotka district neuro-psychiatric dispensary. The right to walks can be restricted not only due to patient’s condition, but also due to other circumstances, oftentimes very trivial, such as for example, lack of upper clothes and footwear (Astrakhan regional psychiatric clinic, Vladimir regional psychiatric clinic #4, Vologda regional psychiatric clinic, Republican psychiatric clinic of Bashkortostan, and some others). This situation is complicated in winter due to the limited amount of warm clothing and footwear. For example, patients of the Belgorod regional psychiatric clinic take turns going out for walks in winter due to the deficit of warm clothing and footwear. Patients of the Moscow regional psychiatric clinic #2, Tver regional psychiatric clinic #1, Republican neuro-psychiatric dispensary of Buryatia and the psychiatric department of the district hospital of the Komi-Permyatsky autonomous district practically do not go out for walks in winter. In addition, lack of funds prevents the majority of clinics from acquiring new upper clothing that meets modern standards of aesthetics and they keep using telogreika (warm and cheap working clothes) and shapeless jerseys, as well as felt and high boots wearing which is humiliating for many a patient. Sometimes patients are not able to implement their right to walks only because there are not enough personnel to accompany them outside their departments (Moscow regional psychiatric clinic #2). Some head physicians referred to insufficient isolation of territory as another reason accounting for the restriction of the right to walks: the lack of dependable fences and guards leads to escapes and absences without leave. The security problem is indeed important where there are patients admitted against their will. A special regime is established for them that entails additional control measures and a variety of restrictions. For the rest of the patients walking areas surrounded by fences, high fences around the territory and security guards serve as just another repressive measure restricting their freedom. Only 30 of the surveyed clinics had no fences. Note that in the majority of cases this was accounted for by the fact that the old fences had dilapidated and the clinics had no money to erect new ones. Head physicians are of the opinion that this factor complicates patients’ walks in view of the junior-level personnel deficit. 74 out of 93 clinics (80%) had security guards, however in many cases their work is confined to checking passes during the night time. In six of the monitored clinics guards require passes to enter the clinic’s territory. At the same time the work of security guards consumes significant amounts of budget funds which is very taxing for clinics in the conditions of scarce funding. Complications with telephone communications Patients’ right to use telephone provided for by the law is currently not supported by the existing possibilities. Telephone communication in hospitals and departments is limited, there are not enough telephones, and payphones are practically non-existent. This results in the fact that the right to use telephone which according to the law may be restricted at the recommendation of the attending doctor in many clinics has turned into the right whose implementation requires special authorization. Due to insufficient development of the telephone communication network clinics resort to a variety of methods to observe the right of patients to use telephone at least to a minimum degree. It is logical that this inevitably results in difficulties for both patients and personnel. The Ulyanovsk regional psychiatric clinic named after Karamzin has a telephone only in its administrative building where a patient can be admitted only if accompanied by a personnel representative, in the Republican psychiatric clinic of North Osetia one can make a call only from the admission room, patients of the Voronezh regional psychiatric clinic, Moscow regional psychiatric clinic #2 and Nizhnii Novgorod regional psychiatric clinic #1 who need to call home have to be escorted to the local postal office. In all of these cases authorization of the attending doctor is required. Telephone communication being not an issue for the clinic in general, patients of the Republican psychiatric clinic of Udmurtia may use the telephone only when authorized by a doctor. Patients of the Republican neuro-psychiatric dispensary of Adygea are allowed to use the telephone only in cases of emergency at the personal request of the patient. In some clinics there are schedules according to which the telephone may be used. For example, there is only one telephone in the corridor of the Ukhta city psychiatric clinic (Komi Republic) and it is used in accordance with the following strict schedule: from 16:00 to 17:00 — men, from 19:00 to 20:00 — women. The Oryol regional psychiatric clinic also has a telephone usage schedule, patients of the Moscow psychiatric clinic #13 may only use telephone is they have signed up for it having put their name in a special list one day in advance, patients of the Kurgan regional psychiatric clinic and the Khabarovsk territorial and city hospitals are allowed to use the phone only after 16:00. Three psychiatric institutions — Rostov regional psychiatric clinic (Kovalyovka settlement), Tula city psychiatric clinic and the neuro-psychiatric department of the Nenetsky district hospital — have no telephone communication at all. Only 10 out of the 93 monitored clinics (11%) dispose of free payphones for patients, and only two of them (Volgograd regional psychiatric clinic #2 and the Republican psychiatric clinic of Khakassia) have these payphones located directly in the departments and patients can call without additional requests or authorizations. At the Irkutsk regional neuro-psychiatric dispensary, Novokuznetsk city psychiatric clinic #12 of the Kemerovo region, Lipetsk regional neuro-psychiatric hospital, Central Moscow psychiatric clinic #1, Sverdlovsk regional psychiatric clinic #1 and the Yaroslavl regional psychiatric clinic “Afonino” payphones are installed on staircase landings or in foyers downstairs where patients are not allowed to on their own, and at the Kirov regional psychiatric clinic named after Bekhterev and Smolensk municipal neuro-psychiatric hospital — in administrative buildings. Yaroslavl regional psychiatric clinic had allocated funds for installation of payphones for patients but the local telephone company — Yartelekom — refused to install payphones in the psychiatric clinic due to the fear that servicing them would be too complicated. The Kotelnicheskaya psychiatric clinic of the Kirov region and Krasnodar territorial psychiatric clinic dispose of payphones which patients may use if they have pay cards, but they are also located outside departments and each call must be authorized. Clinics do not have enough funding to cover long-distance calls therefore patients are recommended to buy telephone pay cards, even though in some rare cases exceptions are made. For example, patients of the Perm regional psychiatric clinic are allowed to make one long-distance call at clinic’s expense — to inform of their stay, while patients of the St. Petersburg psychiatric clinic #1 are allowed to make two long-distance calls — at times of admission and discharge. For some patients wireless phones could be a way out but they are not allowed in the majority of clinics: physicians are afraid they will not be able to ensure their preservation and therefore have the patients submit their wireless phones to their relatives or give them up for keeping in a safe. Wireless phones are allowed only at the Central Moscow regional psychiatric clinic #1, Sverdlovsk regional psychiatric clinic #1, and Khabarovsk territorial and city hospitals. In addition to the above there are also limitations associated with the condition of the patient. Here, just like with the restriction of visitation, everything depends on the head physician and head of the department. Some of them allow their patients to call regardless of their condition while others take care of patients’ relatives and forbid any calls for as long as the patient is in a poor condition. Doctors have the right to do this by law. Censorship of correspondence and complaints The law reserves the right of the patient of a psychiatric institution to “submit uncensored complaints and petitions to bodies of representative and executive power, prosecution authorities, courts, and attorneys” (Part 2, Article 37), as well as conduct correspondence without censorship (Part 3, Article 37). Monitoring of personal correspondence may be introduced by recommendation of the attending doctor in the interests of health and safety of other individuals. According to survey results 44 clinics (47%) strictly follow the law and do not peruse correspondence of their patients. In 14 clinics (15%) all incoming and outgoing correspondence of patients is monitored. A nurse of the Tver regional psychiatric clinic #1 reported that the clinic maintained a journal used to register correspondence and the administration had the staff read all patients’ letters, especially complaints. Some clinics censor only the outgoing correspondence. Among them are the Krasnoyarsk territorial psychiatric clinic #1 (“we send them out if they are not delirious”), the Republican psychiatric clinic of Karelia (“we attach all absurd complaints addressed to higher-level instances to patients’ clinical records”), the Republican psychiatric clinic of the Komi Republic (“we do not send out gibberish, we try to avoid overloading the post with abracadabra”), Tula city psychiatric clinic (“we do not send out clear absurdities”), Khabarovsk territorial psychiatric clinic (“correspondence is practically not censored, but if a patient writes gibberish addressed to Putin, who needs this?”) etc. Thus the ban on censorship of patients’ correspondence accounted for by the law is violated. Acting in the interests of patients clinical staff should have helped the patient write a relevant complain instead of taking it out of the flow of outgoing correspondence and attaching it to patient’s clinical record. Other clinics (Orenburg regional psychiatric clinic #2, Rostov regional psychiatric clinic (Kovalyovka settlement), Ulyanovsk regional psychiatric clinic named after Karamzin, Stavropol territorial psychiatric clinic #2) on the contrary prefer to censor the incoming correspondence to protect the peace of mind of the patient. “What if they receive unpleasant news from home? We peruse and let them read only neutral letters.” Subscription to newspapers and magazines which is a paid service (Part 4, Article 37) has lost its importance in view of the fact that patients not longer stay in psychiatric institutions for extended periods of time. However when patients stay in the hospital for several months/years implementation of this right becomes important. In practice very few psychiatric institutions are capable of provisioning their patients with periodicals. At least only five psychiatric institutions (Bobrovo-Dvorskaya psychiatric clinic of the Belgorod region, Bryansk regional psychiatric clinic #3, Kotelnicheskaya psychiatric clinic of the Kirov region, Kirov regional psychiatric clinic named after Bekhterev, Republican psychiatric clinic of Karelia) answered the question of whether or not patients subscribe to newspapers and magazines in the positive. Acting frequently in the interests of patients but in essence neutralizing possible negative consequences of patients’ correspondence in advance doctors’ actions sometimes become excessive and unjustified which results in indiscriminate restrictions of the right of patients to privacy of personal correspondence. Right to solitude Existing conditions in psychiatric institutions are such that the natural and necessary right to solitude does not even actualize itself in the mentality of personnel and many of the patients. It should be born in mind however that the number of psychiatric patients for whom implementation of this right is a necessity is insignificant. It is those patients whose mental conditions are accompanied with a tendency to solitude. Among them are first and foremost patients with various kinds of depression syndromes, relationship ideas, paranoid delirium, regardless of the nosologic diagnosis. In addition, important are typological peculiarities of the person, i.e., specific qualities of the patients who are naturally prone to solitude. For them living in a multi-bed ward, in a common room, in fact in any place of a regular department is an additional hard tax. Active involvement of all patients of this category in various group events, the “collective approach” that does not consider individual peculiarities of patients — is one of the indicative examples when the notion of high standard is turned or rather degraded into a template. At the same time certain individualization is possible even in the conditions of crowdedness. According to the rules of organization of psychiatric institutions approved by the RF Ministry of Health Care, each department must have several one or two-bed wards which could be used for patients prone to solitude. Such wards are not to be found practically anywhere, and where they do exist they are used for different purposes. Thus, implementation of the right to solitude in Russian psychiatric institutions is extremely complicated and in fact is not possible. |
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