By Peter Phalen, a doctoral student in psychology at the University of Indianapolis
CONAKRY, GUINEA – It is possible to walk into Donka Hospital’s psychiatric unit without realizing it.
That alone is enough to differentiate this ward in the capital city of the Republic of Guinea from its counterparts in the United States, where such units typically feature heavy doors that lock behind you after you’ve been buzzed in. Donka feels more like a hospital and a lot less like a prison.
Donka isn’t perfect or even very nice. Like most hospitals in poor countries, it’s underfunded and unsanitary with dirty mattresses and foul-smelling bathrooms.
But when it comes to dealing with the mentally ill, Donka has achieved something few hospitals in the US have done.
There’s been a regular supply of stories done over the years critically examining the practice of chaining the mentally ill in poor countries, such as one by the BBC about Indonesia or this CNN story from the West Bank. These are usually tales of moral outrage, condemnation of these barbaric practices. Yet what’s the difference between a chain and a nylon strap? In the West, we view our ‘chaining’ of the severely mentally ill as a prudent necessity to protect the individual from harming himself or herself.
In Donka, there are no psychiatric isolation rooms and they haven’t used any form of mechanical restraint since 1996, making it one of a small percentage of psychiatric hospitals worldwide to have eliminated them entirely. Ironically, it may have been the absence of restraints that has, over time, contributed to making them unnecessary.
Dr. Siaka Sangaré, chief doctor of the only other mental health clinic in Guinea, describes receiving aggressive mentally ill patients who arrive bound, hand and foot, by their families. The clinic’s first step is to remove these bonds.
“From that moment,” says Sangaré, “the patient trusts and respects us completely.”
Donka is less restrictive in other ways as well. The hospital doors stay open and patients could conceivably walk out of them at any time. This makes people feel less trapped and the hospital staff feel better about their work. “We are not a service for delivering repression,” says Dr. Doukouré Morifodé, psychiatrist at Donka.
Even in the US where they are commonplace, mechanical restraints are controversial. Research has shown that the use of restraints has numerous adverse consequences including psychological distress, high rates of trauma, and a decreased likelihood of utilizing outpatient services. Sometimes there are serious medical consequences. One report finds that hospitals in the US have reported more than two deaths per month related to restraint use since they began keeping track in 1999.
Morifodé argues that his hospital doesn’t need mechanical restraints because they use conflict deescalation techniques and give very aggressive patients high doses of medication (a kind of chemical restraint). But most wards in the United States do both of these and still consider mechanical restraints necessary.
It’s not that Donka selects easier patients. As the country’s only public psychiatric hospital, they are regularly given forensic cases. When I visited they had just admitted a woman with active psychosis after she murdered her children.
There may be other factors that make their job easier. Donka admits a family member with each new patient to accompany them for the duration of their stay. As discussed in a previous post, this practice is workable and unremarkable in Guinea. Even the woman who had just killed her children had her husband with her. The presence of a familiar face helps with stress and conflict mediation.
But it isn’t necessary. Worldwide, there is an increasing recognition that mechanical restraints are ultimately counterproductive and unnecessary. The UK effectively phased them out decades ago, and some hospitals in the United States are following suit. As The Lancet wrote last month in their appeal for the elimination of all forms of restraints: “Psychiatrists, allied professionals, and patients need to send a clear message to governments and the public that the purpose of inpatient care is to help distressed individuals, not to confine them.”
The elimination of restraints requires complex policy changes, and hospitals will need to support each other by sharing their experiences. In some respects, Donka’s setting is unique enough that its techniques aren’t directly transferable to the Western psychiatric environment.
But Guinea’s approach to mental health is a clearly progressive model, and that’s worth recognizing.