24 NORWEGIAN PARLIAMENTARY OMBUDSMAN National Preventive Mechanism ANNUAL REPORT 2017 Isolation-like segregation in mental health care A key finding from the visits carried out in 2017 was that a number of mental health care institutions practised extensive segregation of patients. Patients were often segregated in unsuitable premises, with very limited opportunity for human contact and activity. The Ombudsman expressed concern on several occasions that this measure, in practice, resembled isolation. What is segregation? Segregation is restriction of patients’ freedom of movement and self-determination that exceeds the level otherwise defined for compulsory mental health care. A segregation measure is, in part, considered a treatment measure and, in part, a measure to shield other patients. Segregation is regulated in Section 4-3 of the Mental Health Care Act, and means that the patient is kept completely or partly segregated from other patients and from personnel who do not take part in the examination, treatment and care of the patient. Segregation can take place in the patient's own room or in a special segregation unit. The responsible mental health professional can decide to segregate a patient for treatment purposes or out of consideration for other patients. Norway is one of the few countries that uses segregation as a form of treatment, which is in principle distinct from isolation.1 Isolation is defined in the Mental Health Care Act as a coercive measure where the patient is detained behind a locked or closed door without a staff member present, while segregation requires close follow-up by the health personnel present. A systematic review of literature in 2015 concluded that there was little knowledge of the effect of segregation in Norway.2 Patient studies indicate that the coercive elements of segregation are stronger than and are perceived as being more isolation-like than treatment purposes would indicate.3 Human rights standards and Norwegian legislative amendments As segregation entails further restriction of patients' already limited freedom of movement and self-determination, it constitutes an encroachment on patients’ right to privacy pursuant to Article 8 of the European Convention on Human Rights (ECHR). Segregation must therefore have a legal basis, and it must be necessary and proportionate in each case. In cases 1 In Denmark, Section 18 d-f of the Psychiatry Act gives institutions the right to practise individual segregation and lock doors in the unit. Announcement No 1160 of 29 September 2015 regarding the act on use of force in psychiatric care (the Psychiatry Act). 2 Norvoll, R., Ruud, T., Hynnekleiv, T. (2015). Skjerming i akuttpsykiatrien ('Segregation in emergency psychiatry’). The Journal of the Norwegian Medical Association, 135, pages 35–39. 3 See note above.