Delivering security-focused mental healthcare

It is widely accepted that the level of security appropriate for an individual patient should match the risk posed to self and/or others — visitors, staff and the general public. Security can be defined as the state of being or feeling secure — free from harm, danger, doubt, anxiety and fear.

The risk and level required must be assessed continuously by clinicians, with the help of the wider multi-disciplinary teams. In healthcare, the security focus is on: Ensuring safety against paranoid behaviours

Preventing patients from accessing staff ’s personal information or other details Preventing access to restricted substances/ items regarded as contraband In Zimbabwe, there are four categories of secure care settings: A, B, C and D. Each requires a different security level.

High security is necessary only for those patients who pose a grave and immediate danger to others.

Treatment or care should be provided in secure hospitals with a full range of therapeutic and recreational facilities within a perimeter fence. Security arrangements should be capable of keeping even the most determined absconder under control.

Patients suited to medium security settings present a serious but less immediate danger to others. They have the potential to abscond and even harm themselves.

Low security is necessary for patients who present less serious physical danger to others. The security measures are intended to impede rather than prevent abscondment. Greater reliance is on staffing arrangements and less on physical security measures.

Security is a survival discipline with two components:

◆ Elimination and reduction of risks to an organisation

Protection of people and utilities, as well as peace of mind

To achieve the ultimate safe care environment, three components must be provided: physical security, procedural security and relational/therapeutic security.

Physical security refers to measures that prevent access to a facility. It can be as simple as a locked door or as elaborate as multiple layers of armed guarded posts and includes control of items brought in or taken out of the secure perimeter wall.

Procedural security involves policies and procedures. Relational security relies entirely on staff developing constructive and professional working relationships with their colleagues and therapeutic relationships with the patients.

There must be a commitment to the provision of therapeutic activity and recognition of each patient’s needs.

Team members must be confident of each other’s support in the event of a problem. Patients are not always in the wrong and there will be times when they raise valid points.

However, team members must stick together and any differences addressed at forums away from the patients.

Relational security should be a continuous process, through which staff can highlight any security threats and support each other at work. This calls for the establishment of an intelligence centre, where events are analysed and possible links established to prevent serious security breaches.

Awareness on the therapeutic importance of environmental security, relational security and procedural security is valuable in drafting safe treatment plans for patients and in the organisation and management of all secure mental health services.

Relational security is by far the most important element in the maintenance of the therapeutic progress of patients and in ensuring that the whole security system works.

Many staff members struggle to strike a balance between maintaining therapeutic relationships and the safety of the environment due to the nature of the job.

If it becomes necessary to restrain your

patient for their safety and that of others, this may damage any relationship that has been formed.

All aspects of security — searching, escorting, contraband, use of handcuffs, observation, patrolling and out-of-bounds areas, working relationships and so on — must be emphasised from the induction stages to ensure the staff understand what their responsibilities are before they enter these environments.

It is important for security training to be standardised across the country to minimise confusion in definition, interpretation and implementation.

Types of security threats

Overt threats: escape, abscondment, assault, group disorder/riot, hostage and other threats to physical safety.

Covert threats: smuggling/trafficking of contraband, accessing of sensitive information, bullying and intimidation, manipulation, conditioning, grooming, conning and splitting of staff, thus weakening relational security.