Staff and Institutional Culture

People choose to work in a children's psychiatric hospital for many different reasons. Some genuinely want to help children experiencing serious emotional, behavioural or psychiatric problems. Others are interested in psychiatry, nursing, psychology or child development. For some, it’s a secure government job or simply an available position. There’s also the possibility that a small number of people are attracted to work that gives them considerable authority over vulnerable children.

 

Another issue is how staff can gradually become accustomed to practices and behaviour that would seem unacceptable outside an institution.

 

Institutional control and restrictive practices

Children admitted to psychiatric hospitals are patients living in an environment controlled by adults. Staff can determine when they eat and sleep, where they go, what activities they participate in, when they see their families and, depending on the circumstances, when they can leave. Behaviour that might be regarded differently outside the hospital can instead be interpreted as part of a child's psychiatric or behavioural problems.

 

Staff are also working within the accepted practices of their profession and the institution. If restraint, seclusion or other restrictive practices have been used for years, are supported by colleagues and are described as necessary or therapeutic, they can gradually become accepted as normal procedure.

 

Research into psychiatric inpatient care has found considerable differences in how staff regard coercive practices. Some see restraint and seclusion as emergency measures to prevent immediate harm, while others have regarded them as legitimate ways of controlling behaviour or even as part of treatment. Staff attitudes can therefore influence how readily these measures are used.

 

Intention and experience

This creates an important distinction between intention and experience. A staff member might physically restrain a distressed child because they genuinely believe they are preventing the child from losing control or hurting themselves. Another might use the same restraint because it is the quickest way to obtain compliance. Someone else might react through fear, frustration or anger, while another person could enjoy exercising control over children.

 

Whatever the adult's motivation, the experience for the child could be much the same.

 

Changing views on restraint and seclusion

The World Health Organization now states that restraint and seclusion are not therapeutic interventions and can cause physical injury, psychological trauma and a loss of trust in mental health services. This differs considerably from earlier periods, when restrictive practices could be accepted as legitimate ways of managing psychiatric patients.

 

Becoming desensitised

Institutional environments can also lead to emotional detachment. Staff who repeatedly deal with distressed, frightened, aggressive or traumatised children can become hardened to their behaviour. A frightened or distressed child might increasingly be described as attention-seeking, manipulative, acting out, non-compliant or deliberately troublesome.

 

From understanding to controlling behaviour

The question can gradually change from "Why is this child behaving this way?" to "How do we make this child behave?"

 

This does not excuse violence, abuse or mistreatment. It does, however, help explain how poor practices can become established within an institution without everyone involved, necessarily intending to harm children.

 

It can also create a serious imbalance when children have little authority and their accounts are more easily discounted because the adults are regarded as professionals and the children as psychiatric patients.