Patients subject to high levels of coercion: staff's understanding.

Measures to keep staff and patients safe (containment) frequently involve coercion. A small proportion of patients is subject to a large proportion of containment use. To reduce the use of containment, we need a better understanding of the circumstances in which it is used and the understandings of patients and staff. Two sweeps were made of all the wards, spread over four hospital sites, in one large London mental health organization to identify patients who had been subject to high levels of containment in the previous two weeks. Data were then extracted from their case notes about their past history, current problem behaviours, and how they were understood by the patients involved and the staff. Nurses and consultant psychiatrists were interviewed to supplement the information from the case records. Twenty-six heterogeneous patients were identified, with many ages, genders, diagnoses, and psychiatric specialities represented. The main problem behaviours giving rise to containment use were violence and self-harm. The roots of the problem behaviours were to be found in severe psychiatric symptoms, cognitive difficulties, personality traits, and the implementation of the internal structure of the ward by staff. Staff's range and depth of understandings was limited and did not include functional analysis, defence mechanisms, specific cognitive assessment, and other potential frameworks. There is a need for more in-depth assessment and understanding of patients' problems, which may lead to additional ways to reduce containment use.