Reduction of Seclusion Episodes Within Psychiatric Services
Reduction of seclusion episodes within psychiatric services has been a goal for many years (Tilley and Chambers 2005). There still continues to be a healthy debate on the subject. In this literature review there will be an exploration of issues regarding the subject. For the purpose of this search, Medline, PsychInfo, CINAL and PsyTri databases were utilized. Also, archive journal articles located within the Hillmorten research library. Throughout the majority of the literature reviewed, both physical and chemical restraint were themes. For this review they have been excluded.
More than 200 years have passed since French psychiatrist Philippe Pinel embarked on the course of unchaining the mental patients of La Salpetrière and Bicêtre. Today we are still using seclusion regularly in practice within psychiatry, despite supposed advances within the discipline (Busch 2005).
As will be explained in this literature search, the use of seclusion is increasingly controversial. Patients continue to present as violently psychotic and are a risk to themselves and others. Conversely seclusion can be fatal. As outlined in the report by the Health and Disability Commissioner on the case 02 HDC08692 (2000), in this case patient Mr D died in seclusion after Clopixol Acuphase.
Removing seclusion from the from the clinicians’ toolbox may be seen by some as radical. It evokes strong emotions within the profession, it challenges long-held beliefs and focuses on the legal and ethical issues underpinning seclusion.
Seclusion is the supervised confinement of patients in a cell or room, which may or may not be locked for the protection of the patient and others from significant harm (Department of Health and Welsh Office 1999). This can be carried out with, or without the patient’s consent, but should be considered as a last resort and for the least amount of time.
In psychiatric practice, seclusion is an intervention used to treat and manage disruptive and violent behaviour (Sailas and Wahlbeck 2005). Seclusion remains a controversial issue and its value has been much debated. It has been described by some as a valid therapeutic intervention in itself, to others, a method of containment in a psychiatric emergency and still others, a punishment (Sailas and Wahlbeck 2005).
In recent years new legislation recommendations, professional guidelines and several court cases have highlighted the need to control the use of seclusion and other coercive measures used in psychiatry, eg, timeout and chemical restraint. What is evident throughout is the message that caution when applying seclusion is necessary. These guidelines and recommendations in themselves can affect the use of seclusion (Sailas and Wahlbeck 2005).
The council of Europe state that the benefits of utilizing seclusion should be in proportion to the risks entailed. Further to this it should be used in exceptional cases, that is, after exhausting all other means of remedying the situation, and closely supervised by a doctor. The European Committee for the Prevention of Torture and Inhumane or Degrading Treatment of Punishment, considers seclusion as a matter of particular concern given the potential for abuse and mismanagement (WHO 1996).
The issue of seclusion when seen in this light poses many legal and ethical problems. Muir-Cochrane and Holmes (2001) address this. They highlight the focus of international mental health law in this area, and the complex ethical issues arising from this. This has led to a move towards provision of care for the disturbed psychiatric patient within the least restrictive environment.
This can be seen, though, as legitimising current practices, although more closely monitoring them.
This status quo can be seen as a pragmatic answer to risk management within a system which is often too understaffed to deal with situations any other way. This is usually due to financial constraints (LeBel and Goldstein 2005). Others are constantly amazed that such controls still exist in today’s nursing, which is driven by humanism, individualism and the therapeutic nurse-patient relationship (Muir-Cochrane and Holmes 2001).
Seclusion as a therapeutic intervention was outlined over 30 years ago (Guthell cited in Muir-Cochrane and Holmes 2001). The main drive of the argument was to diminish sensory input or reduction of distress caused by interpersonal interactions, but the seclusion room itself is generally seen as having no therapeutic value. Further to this, comparisons have been drawn to solitary confinement (Muir-Cochrane and Holmes 2001).
This view has been challenged and the therapeutic dimension of seclusion is no longer used as the thrust to seclude (Lendemeijer and Shortridge-Baggett cited in Muir-Cochrane and Holmes 2001). This has recently been replaced by the idea of using seclusion as frontline management of out of control, aggressive or disturbed behaviour (Muir-Cochrane and Holmes 2001).
Other reviews of literature appear to back this view. The consensus is that seclusion is effective in preventing self-injurous behaviours, reducing violence and lessening agitation (Fisher 1994). All this is unsubstantiated, however, as no theoretical rationale for seclusion backed by thorough research as yet exists (Cochrane Foundation cited in Muir-Cochrane and Holmes 2001). This is further compounded as there is little discussion of the ethical and legal status of seclusion (Muir-Cochrane and Holmes 2001).
Muir-Cochrane and Holmes (2001), see this issue as an interaction of four elements. They are morality/ethics, pragmatics, legislation and professionalism. It is seen that seclusion uniquely and effectively removes all social contact. Within Australian legal literature this is seen as having implications for a persons human rights. It is considered humiliating and can lead to loss of dignity by those undergoing the experience (Robins et al 2005). They were also viewed by clients as both harmful and traumatic experiences and were associated with psychological distress at a level that met the DSM IV criteria for trauma (Frueh et al 2005). This leads the author to push for treatments that are more curative and supportive rather than dis-empowering and punitive.
Current focus on human rights in Britain paves the way for clients increasingly to seek the legal recourse. This said Britain’s legal situation on seclusion is contradictory. This ambiguity stems from the legal use of seclusion. The Mental Health Act of England and Wales (HMSO 1983) and the Code of Practice associated with the Act contradict one another. The Act outlines seclusion as a medical treatment. Whereas the Code of Practice states it is not, going further to point out that it is contra-indicated in suicidal and self-injurous individuals (Muir-Cochrane and Holmes 2001). This has led to inconsistencies in policy provision nationally and this is reflected in both the USA and Australia (Muir-Cochrane and Holmes 2001).
In Australian mental health law, seclusion was first seen as an impingement on an individual’s liberty and freedom by the Victorian Mental Health Act (Victoria Government 1986). It outlines that, although seclusion is not unlawful, it places constraints on its’ use. Namely, when the situation necessitates an individual, or individuals, protection from immediate, or imminent, risk to their health and safety. However, they also advocate seclusion to prevent patients from absconding, but no direct link is made here to state that this would be to protect the individual, or individuals, from harm.
More recently, the World Health Organisation’s mental health care law has attempted to address this legal and ethical problem; by compiling ten basic principals (WHO 1996). This underlines the client’s right to be cared for in the least restrictive environment. This document has been formulated by investigating 45 countries’ mental health laws. It outlines the need for clear rationale for the use of seclusion. Furthermore, this is to be used as a last resort, once all other options have been exhausted.
With an eye on the more practical application of “deemed necessary seclusion”, the WHO directs that appropriately qualified health professionals should prescribe the seclusion event, then, that subsequent regular observations, assessment of mental state and documentation is required, and importantly, with the focus of assessing the necessity of continuing the event.
More radically, the WHO (1996) suggests the removal of all isolation rooms and a ban on introducing new facilities. This in conjunction with mandatory re-training of all staff involved in the process of using alternatives to seclusion (Muir-Cochrane and Holmes 2001).
This ideal must be interpreted pragmatically and ethically within a clinical setting. As already stated, clinical staff are split when the discussion of seclusion arises. The consensus is that the needs of the individual must be weighed against the needs of the others present at that time. In other words the greatest good for the greatest number (Mills cited in Muir-Cochrane and Holmes 2001). That is, the right of the individual to the least restrictive environment, when displaying behaviours that could cause harm to others or themselves (Muir-Cochrane and Holmes 2001).
It is these safety needs and ethical considerations for the individual and the group that comes down to duty of care, and clinical judgement. The idea of staff imposing external control for clients who are unable to maintain their own boundaries. This area is most problematic ethically, as in the literature review, there is noted opportunity for misuse of seclusion. For example, several countries report the more frequent use of seclusion for black patients compared to white. (Sallah (1992), Donat (2005), Busch (2005), Frueh et al (2005)).
This highlights that although staff believe that a patient may be harmful or violent, seclusion must be used with caution. This prediction of violent behaviour is problematic and decisions made could be as a result of transference from staff involved. This would lead to seclusion not ethically justified (Frueh et al 2005).
The complicated nature of involving seclusion, within legal and ethical boundaries will continue to present staff with complex judgement calls. It will also continue to split staff teams as to the desired outcome depending where they sit with the argument. What is felt by researching this topic is that continuing to challenge the status quo is essential. Through challenging attitudes and looking at the client as a human being with intrinsic rights, change to the least restrictive environment could be achievable.
References:
Busch, AB. (2005) Special Section on Seclusion and Restraint. Psychiatric Services,a Journal of the American Psychiaric Association. 9, 1104.
Donat, DC. (2005) Encouraging Alternatives to Seclusion, Restraint, and Reliance on PRN Drugs in a Public Psychiatric Hospital. Psychiatric Services, A Journal of the American Psychiaric Association. 9, 1105-1108.
Fisher, WA.(1994) Restraint and seclution: a review of the literature. American Journal of Psychiatry.151 (11) 1584-1591.
Frueh, BC. Knapp, RG. Cusack, KJ. Gurbaugh, AL. Sauvageot, JA. Cousins, VC. Yim, E. Robins, CS. Monnier, J. Hiers, TG. (2005) Patients’ Reports of Traumatic or Harmful Experiences Within the Psychiatric Setting. Psychiatric Services, A Journal of the American Psychiatric Association. 9, 1123-1133.
Health and Disability Commissioner.(2002), A Report by the Health and Disability Commissioner, Case 02HDC08692: http://www.hdc.org.nz/files/hdc/opinions/02hdc08692.pdf.
LeBel, J. Goldstein, R. (2005) The Economic Cost of Using Restraint and the Value Added by Restraint reduction or Elimination. Psychiatric Services, A Journal of the American Psychiatric Association. 9, 1109-1114.
Muir-Cochrane, C.Holmes,CA(2001) Legal and ethical aspects of seclusion: an Australian perspective. Journal of Psychiatric and Mental Health Nursing, 8,501-506.
Robins, CS. Sauvageot, JA. Cusack, KJ. Suffoletta-Maierle, S. Frueh, BC. (2005) Consumers, perspectives of Negative Experiences and “ Sanctuary Harm”.in Psychiatric Settings. Psychiatric Services, A Journal of the American Psychiatric Association. 9, 1134-1138.
Sallah, D. (1992) Points of view. Nursing Standard 6 (12) 43.
Sailas, E. Wahlbeck, K. (2005) Restraint and seclution in psychiatric inpatient wards. Current Opinion in Psychiatry. 18, 555-559.
Tilley, S. Chambers, M. (2005) Review of seclusion policies in high secure hospitals and medium secure units in England, Scotland and Wales. Journal of Psychiatric and mental Health Nursing. 12, 380-382.
Victoria Government. (1986) Victorian Mental Health Act 1986. Published at: http;//www.austlii.edu/au/legis/vic/.
WHO (1996)World Health Organisation Mental Health Care Law: Ten Basic Principles. World Health Organisation, Geneva: http://www.who.intrnational/msa/mhn/mnd/legal/htm
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