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

The existential dimension of the experience of seclusion: a qualitative study among former psychiatric inpatients

BACKGROUND

Seclusion is a coercive measure - temporary confinement in an almost empty, non-stimulating room in a closed psychiatric admission ward to prevent (further) urgent danger due to a mental disorder. Although there is observational research about patients' behaviors during separation (e.g. hitting walls or doors, sleeping, or praying), research into the subjective and existential dimension of the experience of seclusion in psychiatry is rare.

AIM

Aim of the current study is to describe and analyze - using the theoretical lenses of Yalom (1980) and Jaspers (1919) - how clients experience their involuntary stay in a seclusion room in a closed psychiatric clinic in existential terms.

METHODS

A qualitative study was carried out among former clients (N = 10) who were asked, in retrospect, about their existential concerns in the seclusion room. In the thematic analysis, the main, deductive codes were theory based (Yalom, Jaspers), composed of subcodes that were inductively derived from the interviews.

RESULTS

The respondents affirmed the ultimate existential concerns about death (e.g. sensing to be dead already), lack of freedom (e.g. loss of agency), isolation (e.g. interpersonal, not able to speak, feeling an object) and meaninglessness. With respect to the latter, the respondents reported a rich variety of spiritual experiences (both negative, such as knowing to be in hell, as positive, hearing/imagining a comforting voice or noticing/imagining a scenery of nature in the room).

DISCUSSION

Although some experiences and behaviors may conflate with symptoms of psychosis, the participants generally expressed a relief about the ability to talk about their experiences. Sharing and discussing the existential experiences fits into the paradigm of psychiatric recovery and personalized care. Their intensity was obvious and might have warranted additional support by a chaplain or spiritual counselor in mental health care settings.

Effects of Seclusion and Restraint in Adult Psychiatry: A Systematic Review

Background: Determining the clinical effects of coercion is a difficult challenge, raising ethical, legal, and methodological questions. Despite limited scientific evidence on effectiveness, coercive measures are frequently used, especially in psychiatry. This systematic review aims to search for effects of seclusion and restraint on psychiatric inpatients with wider inclusion of outcomes and study designs than former reviews. Methods: A systematic search was conducted following PRISMA guidelines, primarily through Pubmed, Embase, and CENTRAL. Interventional and prospective observational studies on effects of seclusion and restraint on psychiatric inpatients were included. Main search keywords were restraint, seclusion, psychiatry, effect, harm, efficiency, efficacy, effectiveness, and quality of life. Results: Thirty-five articles were included, out of 6,854 records. Studies on the effects of seclusion and restraint in adult psychiatry comprise a wide range of outcomes and designs. The identified literature provides some evidence that seclusion and restraint have deleterious physical or psychological consequences. Estimation of post-traumatic stress disorder incidence after intervention varies from 25% to 47% and, thus, is not negligible, especially for patients with past traumatic experiences. Subjective perception has high interindividual variability, mostly associated with negative emotions. Effectiveness and adverse effects of seclusion and restraint seem to be similar. Compared to other coercive measures (notably forced medication), seclusion seems to be better accepted, while restraint seems to be less tolerated, possibly because of the perception of seclusion as "non-invasive." Therapeutic interaction appears to have a positive influence on coercion perception. Conclusion: Heterogeneity of the included studies limited drawing clear conclusions, but the main results identified show negative effects of seclusion and restraint. These interventions should be used with caution and as a last resort. Patients' preferences should be taken into account when deciding to apply these measures. The therapeutic relationship could be a focus for improvement of effects and subjective perception of coercion. In terms of methodology, studying coercive measures remains difficult but, in the context of current research on coercion reduction, is needed to provide workable baseline data and potential targets for interventions. Well-conducted prospective cohort studies could be more feasible than randomized controlled trials for interventional studies.

Exploring patterns of seclusion use in Australian mental health services

Seclusion has remained a common practice in mental health services. In Australia, recent mental health policy has reflected a desire to reduce (and, if possible, eliminate) the use of seclusion. The collection and analysis of data on the use of seclusion have been identified as an important component of the success of reduction initiatives. A cross-sectional design was used in the collection of inpatient unit data on seclusions that occurred in 11 mental health services in Australia over a 6-month period. During this time, there were 4,337 episodes of care. One or more seclusions occurred in 6.8% of episodes of care, with consumers being secluded, on average, 2.32 times and with 44% of them having been secluded more than once. The average length of the seclusions was 2 hours 52 minutes, with 51.4% of seclusions being less than 2 hours. These rates were lower than those reported in previous research studies. The practice of seclusion occurred more commonly on the first 2 days following admission, on weekdays than weekends, and between the hours of 9:00 a.m. and midnight. An understanding of seclusion data can provide fundamental information from which strategies to reduce seclusion can be developed.

[Psychiatric medication as restraint: between autonomy and protection, is there place for a legal framework?]

The use of chemical restraint has been regulated for the past ten years in Quebec. However, clinical, ethical and legal issues, sometimes contradictory, have not really been considered during the legislative process leading to consolidation in its current form. The author supports that, because of the absence of consent and the effects of medication, a specific legal framework to the use of medication is necessary in a context of unplanned intervention to protect both patients and medical staff. This framework would prescribe good practice, take into account the non-medical aspects of consent to care and formalize the practice as an exception to the rule. In addition, the symbolism of law, through which social solidarity can be expressed, must not be underestimated.