Does Video Surveillance Help Psychiatric Patients?

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The idea that people are safer if someone is watching has helped to fuel the boom in video surveillance around the world. According to some market estimates, there are more than 60 million security cameras in North America alone.

In psychiatric units, cameras are used to increase safety and security and to monitor patients who may present a suicide risk or require isolation or restraints. But how effective is video surveillance in terms of improving security, what other impacts do cameras have on patients and staff, and what ethical matters should be considered in their use?

“A lot of the discussion of video use in psychiatric settings has focused on practical questions: Do they work? Where should they be used? Less attention has been given to the ethical issues,” said past APA President Paul Appelbaum, M.D. “That’s in contrast to the use of video surveillance in public spaces in society at large, where there’s been a great deal of discussion about the impact on privacy and related issues due to the proliferation of cameras.”

Appelbaum and colleagues reviewed literature on video surveillance, and their findings were published last December in Psychiatric Services. They found a lack of evidence demonstrating effectiveness of video surveillance for increasing security. Yet, Appelbaum pointed out, the data are weak either way, as the few studies on whether cameras improve security have been small. “The absence of evidence is not necessarily evidence of absence,” he said.

“We should always be thinking of whether any intervention, human-based or technological, actually serves the purpose we think it’s going to serve,” said Rebecca Brendel, M.D., J.D., chair of APA’s Committee on Ethics and director of the master’s degree program at the Harvard Medical School Center for Bioethics. “Then, if it doesn’t have clinical utility, we should reconsider its use.”

Creating a Sense of Safety

Charles Dike, M.D., vice chair of the APA Committee on Ethics and an associate professor of psychiatry in the Law and Psychiatry Division at Yale University, has worked on psychiatric units using video surveillance in multiple roles, most recently as the medical director of the Connecticut Department of Mental Health and Addiction Services. The question of the camera’s impact comes up often, he said.

“My overall thoughts are that video surveillance can be very helpful in the right situations, but it should be used with caution in other circumstances,” he said.

In common areas, such as hallways, shared spaces, and treatment rooms, the benefits of video monitoring outweigh the risks, he said, and he has found that patients and staff feel the same.

Patients can be nervous when they enter psychiatric hospitals, he explained, and cameras can help them feel at ease. “Some are worried about other patients with histories of violence,” he said. “There’s a tendency for patients to be really tense and worried about their own safety. But when you know that other people are watching through the cameras, it makes you feel as though you’re not alone. You feel somebody is there to protect you if something were to go wrong.”

Appelbaum cautioned that video surveillance can also create a false sense of security among staff, which in turn could lead to less use of other techniques to ensure safety, such as monitoring and engaging with patients in person.

“Although cameras are often typically installed for the purpose of altering patient behavior, it is possible that one of their major effects may be on staff behavior,” he said.

Not all patients feel comfortable with video surveillance, either. “Patients often have a reduced ability to control their self-presentation, particularly in seclusion or restraint, and adding constant video monitoring can lead to a sense of shame, as aspects of self are exposed that the patient would rather have concealed,” Appelbaum and colleagues wrote.

Giving Patients a Choice

Video surveillance may be helpful to avoid waking patients multiple times during the night when they are being regularly monitored, Appelbaum said.

“When patients are queried, some have said they like the notion of video monitoring so they can sleep without being disturbed, while others don’t. It’s not a universally accepted approach,” he said.

“One of the major consequences of being hospitalized is losing choice. You tend to no longer get to decide what time you wake up, what time your lights have to be out, what time you eat, or how you spend your time during the days. To the extent that they can be given choice, that seems to be a good thing.”

Dike agreed that having a conversation with patients who require monitoring about their preferences can be empowering: “Would they prefer for this to be done through a camera system if available or would they prefer for staff to come in?” But at times, the notion of allowing patients a choice is unrealistic because installing cameras and hiring someone to continuously monitor them can be prohibitively expensive, Dike said, especially for state psychiatric hospitals.

Some patients, he continued, do prefer staff to come in and check on them during the night. “They feel safer,” he said, whereas they’re not always certain that someone is watching them through the camera. However, he continued, some patients would worry about someone coming into their room while they are sleeping, especially those with a history of trauma or of paranoid delusions who would be concerned about their safety.

Considering Importance of Human Interaction

Choice can also play an essential role when monitoring patients who are secluded or restrained.

“These are very difficult, traumatic situations for patients, and it’s important to have staff be there to reassure the patient that everything is going to be OK,” Dike said. “A positive human interaction is important.”

But there are some patients for whom staff presence is agitating, he added. For such patients, video monitoring could be a better option.

In their study, Appelbaum and his colleagues suggest using psychiatric advance directives to ascertain a patient’s preference for monitoring ahead of time if an emergency requires restraint or seclusion.

Increasing technology has allowed patients better access to care, Brendel said. Nevertheless, in times of acute distress, human interaction is hugely important. “We can’t lose the simple act of caring and of a therapeutic presence,” she said. “We can’t replace that, at least not yet.”

At minimum, she said, better data are needed to illustrate in which cases video monitoring effectively improves safety and patients’ well-being. “Or, we should stop doing it, because it would be unethical to do something that is potentially harmful with no counteracting benefits,” she said. ■