JOURNAL ARTICLE

[About the use of seclusion in psychiatry: the patients' point of view]

J Palazzolo
L'Encéphale 2004, 30 (3): 276-84
15235526
In this study of psychiatric inpatients' perceptions of the seclusion-room experience, 67 admitted inpatients were interviewed during 6 Months within 3 days of the experience, and 24 hours after. A 35-items semistructured interview schedule was used to obtain information on six research questions. Subjects' perception of the reasons for their seclusions varied greatly from perceptions of staff members. Findings implied that for some patients seclusion may have been unnecessary, but for others it was beneficial. Subjects who reported out-of-control impulses or pathological intensity of relationships prior to seclusion and who showed positive change in mood, behavior, or thinking toward staff and/or other patients during or after seclusion seem to have benefited from the experience. Seclusion is a common practice in most psychiatric inpatient settings. The reported incidence of seclusion varies from 4% to 66% of admissions to psychia-tric facilities. But seclusion is controversial. Opponents of seclusion have based their arguments on a concern for the rights of mental patients and a dedication to treat patients in the least restrictive environment. Proponents of seclusion have based their arguments on the theoretical benefits of isolation and the reduction of external stimuli. However, little information about the psychiatric patients experience before, during and after seclusion is currently available. The purpose of this exploratory descriptive study is to gather information on psychiatric patients' perceptions of their seclusion-room experiences, their experiences immediately before and after seclusion, and how they thought these experiences affected them or others. Subjects and staff described the reasons for seclusion differently. For example, subjects described situations leading up to seclusion, but staff described aggressive behavior justifying seclusion. Yet, almost all reasons provided by both groups involved subjects' out-of-control impulses or problems in relationships. The physical, behavioral, and emotional responses of patients to seclusion have been the subject of both observation and more formal investigation. In a study of 263 seclusion episodes, Gerlock and Solomons (1983) noted that 83% of the patients evidenced disturbed behavior at the initiation of seclusion and only 23% did so on release. In a study of the use of the quiet room on a children's unit, Joshi et al. (1988) observed that 92% of the patients who were agitated when placed in the quiet room were calm on release and that 79% were able to rejoin group activities. As for nonempirical investigations, Gair et al. (1965) observed no ill effects (such as fear, withdrawal, or disorganization) and an improvement in inner controls as a result of the use of seclusion on a children's unit. Way and Banks (1990) cautioned against the side effects of humiliation, disorientation, and medical complications of restraint and seclusion in the elderly. As previously noted, many re-presentatives of the psychiatric consumer/survivor movement have characterized seclusion as an extraordinarily traumatic intervention. It is therefore important to examine empirical studies of the emotional effects of this intervention on patients. Perhaps the best-known study is that of Wadeson and Carpenter (1976), which involved 62 mostly unmedicated patients on an NIMH research unit with a seclusion rate of 66%. Patients were asked to draw their experiences and feelings connected with their illness and treatment in three art sessions (2 weeks after admission, 2 weeks before discharge, and 1 Year later). Thirty-three percent of the patients drew the seclusion experience. Their art work and their discussions of it revealed negative feelings (fear, estrangement, hostility, retaliation, guilt, paranoia, bitterness) as well as sadomasochistic conflicts and comforting hallucinations (possibly as a response to sensory deprivation). Several other studies have investigated patients' emotional responses to seclusion. Binder and Mac Coy (1983) conducted semistructured interviews with 24 patients who had been secluded. Thirteen of the 24 patients had no idea or a false idea as to why they had been secluded, 22 were unaware that staff checked on them every 15 minutes, and 13 felt that there was nothing good about the experience. Ne-vertheless, half of the 24 patients felt that the intervention had been necessary and about half felt that it would not adversely affect their attitudes toward treatment. Plutchik et al. (1978) investigated the perceptions of seclusion of patients who had or had not been secluded. Patients who had not been secluded felt safer when they saw others being secluded. Patients who had been secluded felt angry when others were secluded and bored and angry while in seclusion, but the majority felt that seclusion helped calm them down. Patients accurately perceived the precipitants of seclusion. Plutchik et al. also looked at staff perceptions. They found that although most staff felt that seclusion was beneficial to patients, professional staff had the most "regrets" about it. Patients accurately estimated and staff significantly underestimated the average duration of seclusion. Joshi et al. (1988) noted that 14% of children who had been secluded on their unit were angry and 17% were sad while they were in seclusion. Sheridan et al. (1990) observed a 2:1 ratio of negative-to-positive attitudes toward seclusion among patients interviewed at a VA hospital. They also noted that patients' attitudes toward initial seclusion had no effect on subsequent seclusion rates. Thus, although it appears to be reasonably well-established that seclusion "works", i.e., it provides an effective means for preventing injury and reducing agitation, it is at least equally well-established that this procedure can have serious deleterious physical and (more often) psychological effects on patients.

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