Nobody in their right mind would consider ‘punishment’ as a means of treating patients in psychiatry of today – or so you might think. Punishment was a part of treatment in the history of behavioural modification. To be 100% clear no contributor at this website thinks that punishment should be brought back into psychiatry or behavioural modification.
Aromatic ammonia was used effectively to reduce self-injurious behaviour in two studies. In the first, hair-pulling was decreased with a 3-second ammonia contingency, but long-term maintenance was challenging. The second study successfully eliminated hand-biting using response-duration ammonia, with effects lasting up to a year. These studies confirm the effectiveness of aromatic ammonia for different self-injurious behaviours, extend its use to natural settings with non-professionals as therapists, highlight the need for varying ammonia durations, and emphasise the importance of actively planning for long-term maintenance – summarised from Altman 1978 et al in Behaviour Modification and Research.
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Punishment. Little disagreement surfaces around the belief that punishment is the most effective method of reducing self-injurious behaviour. Considerable disagreement arises over what kinds of punishments are ethically and morally justified – Simpson 1981, University of Kansas (out of publication – not available on the net)
History is replete with other similar examples.
A question today is, “Has punishment actually left the practice of modern psychiatry?” The first problem with the question is that ‘psychiatry’ is being widely air-brushed out of descriptions in services in slow motion over the last 20 years (not everybody would agree, of course). How would I know? In certain EPRs – one cannot make an entry under the discipline ‘psychiatry’, but if one is a psychologist that’s fine; it comes under ‘psychology’.
Perhaps an alternative question is “Has punishment left the modern practice of mental health services?” That should open a ‘Pandora’s box’ – and why not? I have met many inpatients in the last 30 years – and more concentrated into the last 15 years – who have said, “I feel punished” or “You all are punishing me“. [This comes up only in my memory, so I wasn’t doing an audit over 30 years.] Their faces bore the features of people who felt punished. Some felt “tortured“. My explanations to them that we were doing no such thing, made little difference to how they felt. I think they were referring to situations where their freedoms were seriously restricted by law, or in other situations where therapeutic hands-on restraint were well justified. Patients who required seclusion – rare in my experience, were more likely to feel punished.
Restrictions on liberties even for patients who were detained, that were outside of the law were observed.
Baroness Hollins (former President of RCPsych from 2005 to 2008) heart was broken (Nov 2023), when she said, “People who, in some hospital settings, are experiencing what we considered to be poor, punitive or even abusive care, which only adds to their trauma.“
Punishment happens though via the legal system (courts and prison)- as it does not stop as a legal concept – when prisoners are transferred, usually into medium secure facilities and above.
In Special Hospitals patients were subject to lock up at night in their cells (aka rooms). It was called ‘Night time confinement’ (NC). Reasearch findings by Braham et al found “… that NC had no adverse effects and incidents of self harm, other incidents and seclusion hours dropped by a third during this period. This was contrary to staff expectations.” In their analysis they said, “This evaluation suggests that NC can contribute to providing an efficient and effective secure mental health service.” [Yes – they made other moderating comments]
The UK government distinguished NC from seclusion in Direction 34 of their Guidance on the High Security Psychiatric Services 2019.
George Szmukler, Emeritus Professor of Psychiatry and Society at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK, said “Night-time confinement is an unacceptable hospital practice” in BJPsych Bulletin 2019 Feb; 43(1): 35–37.
Perhaps cautious not to appear to be locking horns with your government(s), Baroness Hollins continued to work away at the “Oversight Panel’s solitary confinement code of practice framework“.
