25 - Seclusion as a Treatment Modality | Manual of Psychiatric Therapeutics: Practical Psychopharmacology and Psychiatry (Little, Browns Paperback Book Series)

Editors: Shader, Richard I.

Title: Manual of Psychiatric Therapeutics, 3rd Edition

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Seclusion as a Treatment Modality

Thomas G. Gutheil

Richard I. Shader

Limiting anyone's freedom is always a serious matter. Although sending a child to his or her room as a time out technique may be common and many children will learn from this type of control, some of these will always feel abandoned and rejected. Restricting the freedom of movement of any patient, particularly a psychiatric patient, is also a serious and almost always controversial decision that should never be taken lightly, even though considerable clinical experience suggests that restricting the amount of space and degree of stimulation available to carefully selected psychiatric patients can play a useful and safety-promoting role in their treatment, either as an adjunct or as an alternative to medication or other behavioral or somatic therapies.

Noting that the use of seclusion has decreased in recent years is important. Many factors are involved, including a changing medicolegal and social climate regarding its use, the availability of increasingly effective medications, a reduction in the number of hospital units with appropriately constructed spaces, and nursing staff changes that result in fewer personnel familiar with its use, as well as rotation practices that reduce the continuity of care. However, paralleling these factors is an increase in overcrowding on some units or admixtures of patients that may put dual diagnosis adolescents alongside frail elderly patients with dementia (situations that may promote the very circumstances that could benefit from the appropriate and judicious use of some forms of seclusion).

Most physicians will not need to prescribe seclusion, but, for those who must do so, this chapter outlines some important considerations. Varying degrees of restriction may be appropriate. The most minor form may be requesting that a patient remain in hospital clothing. More limiting forms include requesting that patients do not leave the ward, asking them to spend increased time in their own rooms, placing them in monitored confinement in a specified section of a ward, and instituting voluntary or forced confinement to a specially designed room (i.e., a quiet or seclusion room). The utility of these treatment strategies depends, in part, on careful and appropriate application and patient selection.

Jurisdictions vary in their criteria and requirements for seclusion, which are generally outlined in statutory law or administrative regulations. At the federal level, the Children's Health Act of 2000 (PL 106-310) established standards for the use of seclusion in all psychiatric facilities that receive federal monies (e.g., Medicare) and in nonmedical community-based facilities for children and youth. Interestingly, these standards are less rigorous than the prototypical set of criteria for the use of seclusion that is outlined at the end of this chapter. Because the use of seclusion continues to occasion forensic and clinical controversy, a brief discussion of the principal legal issues involved is also included.

I. Definition

Seclusion as part of a therapeutic regimen for an inpatient is placement alone in a room especially designed for this purpose. The definition of seclusion does not include the distinction of whether it is involuntary. Indeed, when seclusion is indicated and can be explained to and understood by patients, they should first be asked to comply voluntarily with the therapeutic strategy. Although the door may be unlocked, seclusion usually implies a door that is locked for specified periods of time. The length of time varies according to specific state statutes; a designated time interval is clinically desirable and is usually interposed (e.g., 10 to 20 minutes every 1 to 2 hours) during which the door is opened and appropriate staff patient contact (called breaking seclusion ) is made for clinical observations, feeding, toileting, hygiene, and other medical care, as discussed below. These considerations should be articulated fully in

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hospital or departmental policies, regional guidelines, legislation, or some combination of these.

II. Basic Principles of Seclusion Room Design

The fundamental consideration in designing a seclusion room is to make it safe for the patient (i.e., free from sources of potential self-injury) and from the patient (i.e., sturdy enough to resist destructive abuse). Seamless construction, special paneling, industrial carpeting, or similar materials should be used. When possible, the simple device of high ceilings (out of the reach of the patient) permits the use of standard lighting fixtures and heating and cooling apertures. This type of construction, however, necessitates that patients do not have access to materials such as torn sheets or towels that can be used as ropes. Otherwise, fixtures must be recessed or designed to eliminate sources of danger to the patient such as jagged edges, glass, and electrical wiring. Adequate ventilation is essential; many patients have impaired or potentially impaired thermoregulation (e.g., excited or retarded catatonics, patients on antipsychotic agents with hypothalamic effects or peripheral ₁-adrenergic receptor antagonist properties). Because a padded room is still used for seclusion in some locales, the matter of control of the room's ambient temperature must be monitored and adjusted. Properly designed doors are also an essential feature; for example, doors should be designed to open out and to facilitate rapid entry and exit. Doors should have external hinge pins; safety-glass observation windows that permit a view of the entire room; and key locks, not knob locks. Placement near the nursing station is recommended, and an intercom or closed-circuit television monitoring system may be helpful.

III. Theory of Seclusion and Clinical Management of Space

Acutely psychotic or regressed patients may be particularly vulnerable to surprise and the unexpected. Many acutely disturbed patients startle easily, they are confused and terrified by their psychotic distortions, they are fearful of assault, or they are so hyperaroused that they cannot calm themselves or modulate their responses to stimuli in their immediate environment. All these factors can provoke extreme anxiety and distress. A specific and limited space in which to move around may temporarily promote a sense of safety and familiarity. Having a recently admitted patient move in a planned and graduated way from smaller to larger areas of the overall unit may be helpful. A step-wise expansion of territory permits patients to experience a gradual increase in the demands placed on them, to integrate stimuli, to deal with other people, and to master unfamiliar terrain and experiences. Increasing space offers more chances for exploration, interpersonal encounters, and responsibility for one's self-control. When a patient's capacity to integrate stimuli or to contain impulses is impaired or strained, a decrease in the available (external) space may prove therapeutically supportive and may enhance the patient's sense of control. Thus, being moved to a quiet corner, one wing of the ward, a lounge, or his or her own room may calm an agitated patient. Both the decreased stimulation and distance from others may be helpful, as this chapter details later. Patterns of space limitation may range all the way from having patients stay within the grounds of a large hospital complex to secluding them; actual seclusion represents one end point on the continuum of planned space allotment as a clinical treatment.

A. Mechanisms of Action

Seclusion likely operates through its effects on perception, interpersonal relatedness, and behavior.

Perception. Seclusion decreases sensory input in all forms by producing an environment of relative sensory sameness or monotony. This sameness may be particularly helpful when the patient's clinical state or degree of regression has produced a heightened vulnerability to sensory bombardment and distortion; stimulus generalization or overstimulation; or an inability to integrate stimuli, whether from within the body or from without.
Interpersonal relatedness. The effect of seclusion on interpersonal relatedness is to isolate or distance patients temporarily from persons in their perceptual field. The isolation is not total because other patients
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and staff are visible and audible through the door and its observation window. Enough distance is provided, however, to minimize the patient's fears of others, whether from a loss of his or her sense of boundaries or feelings of fusion or from his or her experiences of staff and other patients as sources of persecution, threat, or attack.
Behavior. Compassionate seclusion can prevent out of control patients from harming themselves and others by removing their opportunity for violence and subsequent guilt or embarrassment. In addition, the bareness and absence of objects in the room and the ease with which the patient can be observed closely may reduce his or her self-destructive behavior.

B. Conditions for Which Seclusion May Be Useful

Seclusion is indicated as a treatment for clinical states in which the mechanisms mentioned earlier sensory hyperesthesia, pathologic intensity or distortions in interpersonal relatedness, and pathologic excitement and behavioral dyscontrol apply. These include (a) psychotic disorders (e.g., schizophrenia, especially with catatonic excitement, and bipolar disorder, especially with acute mania in all its forms), (b) acute paranoid reactions (e.g., delusional disorder) and extreme panic, (c) toxic conditions and withdrawal states (e.g., amphetamines, hallucinogens, and phencyclidine psychoses) and deliria of various origins (see section III.F for exceptions), (d) cognitive disorders (e.g., certain forms of dementia that produce difficulty in integration of stimuli, reality perception, or modulation of affects), (e) transient but severe situational disturbances (e.g., a host of circumstances that may evoke overwhelming panic, rage, or self-destructive or outwardly directed assaultiveness on either basis), and (f) acutely suicidal patients for whom seclusion offers temporary freedom from objects that may be put to self-destructive use. Infrequently, a patient may be placed in temporary seclusion solely for the protection of other patients, a use that always requires considerable thought and documentation.

C. When to Seclude a Patient

Seclusion should be instituted as (a) an elective (patient-requested) measure to provide calm, quiet time for reflection; (b) a planned measure to head off a developing crisis when the patient's typical pattern is known or can be anticipated; (c) an adjunct to other treatments, such as medication, particularly for the dangerously aggressive patient; or (d) an alternative when other interventions have not been effective. Though the clinical effects may be quite similar, legal statutes or mental health regulations tend to distinguish involuntary from voluntary seclusion. Involuntary seclusion is usually sanctioned by law in cases of emergency, which are defined in one state, for example, as the occurrence of, or serious threat of, extreme violence, personal injury, or attempted suicide. In certain instances, such as toxic states, both secluding and restraining patients may be necessary and helpful.

D. How to Seclude a Patient

Seclusion should preferably be initiated only after the ordering physician has evaluated the patient and has discussed other treatment options with involved staff. In an emergency, if the physician cannot see the patient immediately, the ordering physician should see the patient no more than 1 hour after the order is carried out. The patient should be conveyed to the seclusion room in a manner that permits maximum safety for the patient, other patients, and staff. This method may involve merely a staff escort of one or more persons, or it may entail a five-person face-down carry, with one person to each limb and another holding the head and managing doors. When the patient is in seclusion, he or she should be searched, and potentially hazardous articles, such as pocketknives, matches, belts, and sharp objects, should be removed. If medically indicated, the appropriate medications should be administered, giving careful attention to the seclusion room context (e.g., hydration, thermoregulation). Secluded patients should be told that they are being placed in the room for their own protection (or for the protection of others when this is

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the indication), that they will be observed frequently and regularly and will be given time for necessities such as toileting and eating, and that they will be released when their self-control makes this possible. Such information may provide some reassurance against abandonment feelings.

E. Continuation of Seclusion

As an emergency situation, seclusion requires extremely careful monitoring. The patient must be observed at regular intervals. Seclusion must be broken regularly (e.g., 10 to 20 minutes out of every 1 to 2 hours) to allow for feeding; conversation (if it is not too stimulating to the patient); bathing; toileting (usually every 4 hours); medication; monitoring of vital signs; medical procedures; drawing of blood; and, most important, clinical assessment of the patient's condition to determine the need for continuing or terminating seclusion. In addition, patients should be checked through an observation window at designated intervals, usually every 15 minutes, but surveillance should occur more frequently or even constantly if it is required by a patient's clinical condition. Because staff may be in danger when seclusion is broken, adequate staffing patterns must be ensured. Staff must be alert to potential dangers, and they must be trained to deal with them.

F. Termination of Seclusion

Because no absolute clinical assessment criteria are available for determining when to terminate seclusion, the responsible physician must rely on his or her judgment and experience and on consultation with other treatment team members. The most important indicator for ending seclusion is a worsening of the patient's clinical state in response to seclusion. Though ill effects are relatively rare in practice, seclusion may communicate to the patient, despite reassurances, a sense of being unwanted, abandoned, or isolated that may vitiate its calming effect. Some patients (e.g., those with cognitive disorders or toxic deliria) may need the reassurance of having a familiar person close by. Their disorganization may derive in part from feelings of isolation or from sensory deprivation, and seclusion may worsen their agitation rather than help it, a phenomenon similar to that seen in some patients with black patch psychosis after cataract surgery or in some elderly patients who sundown. On occasion, worsening may also result from inadequate or inappropriate concomitant pharmacotherapy or from staff whose fear of the patient prevents them from establishing reassuring contact. Unfortunately, no obvious way for predicting the outcome of seclusion is available, short of a brief trial.

Seclusion should be terminated as soon as it has produced its desired effects. In most instances, seclusion and the appropriate medication can calm a patient sufficiently to avert or arrest an emergency or an upsurge in symptoms. At that point, the patient should return to a larger environment. A common first step is to open the door with adequate numbers of staff in attendance and then to begin increasing the number and duration of forays out of the seclusion room. The return (a) should be discussed and negotiated with the patient to maintain or reestablish the treatment alliance; (b) should be graduated to allow the patient to acclimate to gradually increasing levels of stimulation, spatial expansion, and responsibility for self-control; (c) should be monitored to assess the need for additional treatment that might include a return to seclusion for additional periods; and (d) should include a debriefing of the patient to elicit his or her responses to the intervention and to answer any questions.

IV. Misuses of Seclusion

Seclusion is a valuable addition to the therapeutic armamentarium, but it is subject to misuse. PL 106-310 requires that seclusion should only be used to ensure the patient's safety. In the authors' opinion, seclusion is misused when it is used in the following ways:

As punishment for bad behavior (as a child is sent to his or her room).
As an aversive stimulus in the context of an involuntarily imposed behavior modification paradigm.

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As an intervention for a patient who is obnoxious, pestering, irritating, insulting, or provocative when this behavior is voluntary and is not due, for example, to the intrusive, irritable clinical escalation that can occur in mania.
As an expression of milieu countertransference. Seclusion as a treatment is meant to benefit the patient and, indirectly, other patients, and it is not for the unconscious or conscious needs of staff. Protection from this contingency typically is achieved by peer assessment, consultation, supervision, and legal safeguards.
As a procedure unaccompanied by planned close observation and monitoring. This misuse of seclusion may represent clinical abandonment or neglect of the patient.

Seclusion should not be used as a substitute for staff attention; it must be prescribed in concert with attention.

V. Adverse or Unwanted Effects of Seclusion

Almost no lasting unwanted effects specific to seclusion are observed when it is appropriately prescribed and monitored. As was noted earlier, seclusion can temporarily worsen certain clinical states as a result of sensory deprivation, but, except for the transient grudges that sometimes develop over seclusion, this is not a serious problem. Self-injury is always possible, but patients who are not placed in seclusion may just as easily harm themselves. Improper use of seclusion or an improperly designed or monitored room can result in injuries, exhaustion states, dehydration, pneumonia, and death. Careful search procedures are essential to protect against hazards from objects taken into seclusion by patients or smuggled in by others.

In addition to physical and emotional dangers to patients, the use of seclusion can cause splitting or lack of cohesion among staff. Ample time must be given for staff to air their views and to review carefully the issues concerning a particular patient. Unresolved differences among staff can be communicated to patients and may potentially increase their turmoil. At times, providing other patients with an opportunity to voice their fears and other feelings about seclusion (e.g., in a ward community meeting) may also be helpful.

VI. Forensic Aspects of Seclusion

Forensic problems around seclusion rest on three interrelated factors.

A. Confusion Between the Proper Use and Abuse of Seclusion

If seclusion is used to approximate the solitary confinement of a prison, no therapeutic goal for the patient is served, and the patient is, in effect, imprisoned without due process. Attorneys not uncommonly view this abuse of seclusion as if it represents all uses of seclusion. Some accept the concept of seclusion as equivalent to a public health quarantine.

B. The View of Seclusion as Punitive, Without Therapeutic Effect or Clinical Justification

This view draws its force from the ignorance of many attorneys of clinical psychiatry, that perhaps is coupled with an antiillness bias from reading the works of certain authors such as Thomas Szasz, an author frequently represented in law school curricula.

C. A Clouded View of the Custodial Versus Treatment Role of Psychiatric Inpatient Care for Some Patients

Many attorneys contend that patients have the right to receive treatment and, increasingly, the right to refuse it, and yet the hospital is not free to discharge the treatment-refusing or uncooperative involuntary patient. No parallel exists to the disciplinary code of school systems, which permits detention in the principal's office or expulsion from school to prevent harm to others. Furthermore, physicians may feel compromised in their responsibility, ability, and freedom to treat when legal authorities see the behavior in question not as the result of illness but as freedom of expression by the patient.

Seclusion, in some instances, may represent the least restrictive alternative currently sought by some jurists because it usually permits brief placement in the seclusion room, followed by return to an open ward, instead of more restrictive alternatives such as transfer to a closed-door high-security

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facility. An exception would be an unremittingly assaultive patient who does not respond to short-term interventions. In such cases, transfer to a secure facility is often less restrictive, because such a patient's clinical condition might require long-term seclusion in the average inpatient setting, whereas in a secure facility with structured programs, trained personnel, and adequate physical design, the patient might be able to leave his or her room or walk around a courtyard. In addition, seclusion may be safer for some specific patients in both the short and long term than the two alternative approaches to the same symptoms medication or electroconvulsive therapy (see Chapter 24) a fact often overlooked by legal authorities.

Some clinicians believe that using restraints (see Chapter 26) is a less restrictive alternative than seclusion, in part because the restrained patient can have closer and more human contact. In the authors' clinical experience, the feeling of being physically restrained is more troubling to some patients than is seclusion. The use of restraints carries its own hazards, such as aspiration and exhaustion. The main indications for restraints are probably limited to awakening from a delirium, constant self-destructive acts, or potential injury to staff during necessary clinical activities such as taking vital signs (see Chapter 26).

As this chapter was being put into its final form (2002), the Health Care Financing Administration promulgated an Interim Final Rule (HCFA-3018-IFC) on seclusion and restraint. This rule contains stronger provisions than the Children's Health Act; it permits seclusion or restraint only under emergency conditions and when other interventions have failed to be effective. As the reader can imagine, the proposed rule is being vigorously debated. Among the arguments against the rule is that, given current staffing and funding levels and the composition of many patient cohorts, its adoption could force the closure of some clinical settings.

VII. A Prototypical Set of Principles for Clinicians

The following factors or principles are offered as guidelines to the therapeutic use of seclusion.

All personnel working with patients in seclusion must receive careful orientation about the medical, legal, and ethical issues involved before they are assigned to patient care duties.
Patients should always be asked to enter seclusion voluntarily before they are involuntarily secluded.
As soon as possible, a responsible member of the patient's family, if one can be found, should be told of the symptoms requiring seclusion. Any questions should be answered to permit families to exercise their right to seek treatment elsewhere (at present, many families view seclusion only in negative terms). On the other hand, confidentiality and right to privacy issues must also be considered.
The decision to seclude should be documented by a clearly written order on the physician's order sheet. This order may be signed by the ordering physician, and it should include both the date and the time. The ordering physician should preferably see the patient before seclusion is initiated or within 1 hour if he or she cannot be immediately present.
The option of telephone orders should only be considered rarely. Telephone orders should be used only in extreme emergencies, and they should be countersigned in person by the ordering physician within a specified time interval (e.g., 30 minutes or long enough to permit the physician time to evaluate the patient's condition before signing). No more than 1 hour should be acceptable for this delay. An American Psychiatric Association Task Force report (see Additional Reading) recommends that the patient be seen within 1 hour of entering seclusion but allows up to 3 hours to adjust for physician availability.
Whenever possible, the need to seclude should be anticipated and discussed with the patient and staff as part of a total treatment program. The conditions
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and symptoms to be treated by seclusion should be documented clearly in the patient's treatment plan. This point is controversial because many hospitals and some jurisdictions believe that standing orders for as needed seclusion are always improper.
While in formal seclusion, the patient should be seen by a physician at least two to three times per 8-hour shift.
A single seclusion order should have a defined duration of applicability (e.g., a maximum of 8 hours). The physician making the assessment must then write new orders with documentation of the patient's condition and including reasons for continuation.
A physician must evaluate the patient to end seclusion and to assess the consequences of seclusion and its termination.
Progress notes should document all incidents of seclusion; their positive and unwanted consequences; and the reason(s) for seclusion, including a description of the target symptoms and behaviors.
Any patient who requires two or more seclusion episodes in a week should be reviewed formally (e.g., at a team or ward conference) by the responsible physician; at least one other physician, preferably a physician from another service who is knowledgeable about the benefits and risks of seclusion; and the nursing service. This discussion should include review of alternative treatment, including transfer to another ward or facility. Many hospitals require that patients in continuous seclusion be evaluated by the hospital's chief medical officer (or his or her designee) after 72 hours and before further seclusion orders can be written.
Hospital seclusion must be subjected to regular review by the medical staff, utilization review personnel, quality assurance staff, other standard-setting groups within the hospital, and relevant external bodies.
Any death during seclusion or within 24 hours after the termination of seclusion must be reported to the appropriate agencies.

ADDITIONAL READING

Binder RL. The use of seclusion on an inpatient crisis intervention unit. Hosp Commun Psychiatry 1979;30:266 269.

Binder RL, McCoy SM. A study of patients' attitudes toward placement in seclusion. Hosp Commun Psychiatry 1983;34:1052 1054.

Chamberlin J. An ex-patient's response to Soliday. J Nerv Ment Dis 1985;173:288 289.

Convertino K, Pinto RP, Fiester AR. Use of inpatient seclusion at a community mental health center. Hosp Commun Psychiatry 1980;31:848 850.

Curie CG. Use of restraints, seclusion, and exclusion in state mental hospitals. Pennsylvania Department of Public Welfare, Mental Health, and Substance Abuse Services Bulletin. OMHSAS-99-01. Harrisburg, PA: Pennsylvania Department of Public Welfare, Mental Health, and Substance Abuse Services, 1999.

Curran WJ. Law-medicine notes. The management of psychiatric patients: courts, patients' representatives, and the refusal of treatment. N Engl J Med 1980;302:1297 1299.

Department of Health and Human Services, Health Care Financing Administration. Medicare and Medicaid Programs: hospital conditions of participation: patients' rights: Interim Final Rule. 42 CFR 482. Federal Register 1999;64:36069 36089.

Fitzgerald RG, Long I. Seclusion in the treatment and management of severely disturbed manic and depressed patients. Perspect Psychiatr Care 1973;11:59 64.

Guirguis EG. Management of disturbed patients: an alternative to the use of mechanical restraints. J Clin Psychiatry 1978;39:295 303.

Gutheil TG. Observations on the theoretical bases for seclusion of the psychiatric inpatient. Am J Psychiatry 1978;135:325 328.

Gutheil TG. Restraint versus treatment: seclusion as discussed in the Boston state hospital case. Am J Psychiatry 1980;137:718 719.

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Hammill K, McEvoy JP, Koral H, et al. Hospitalized schizophrenic patient views about seclusion. J Clin Psychiatry 1989;50:174 177.

Jensen K. Comments on Dr. Stanley M. Soliday's A comparison of patient and staff attitudes toward seclusion. J Nerv Ment Dis 1985;173:290 291.

Mallya AR, Roos PD, Roebuck-Colgan K. Restraint, seclusion, and clozapine. J Clin Psychiatry 1992;53:395 397.

Mattson MR, Sacks MH. Seclusion: uses and complications. Am J Psychiatry 1978;135:1210 1213.

Ng B, Kumar S, Ranclaud M, et al. Ward crowding and incidents of violence on an acute psychiatric inpatient unit. Psychiatr Serv 2001;52:521 525.

Oldham JM, Russakoff LM, Prusnofsky L. Seclusion: patterns and milieu. J Nerv Ment Dis 1983;171:645 650.

Plutchik R, Karasu TB, Conte HR, et al. Toward a rationale for the seclusion process. J Nerv Ment Dis 1978;166:571 579.

Ramchandani D, Akhtar S, Helfrich J. Seclusion of psychiatric inpatients. Int J Soc Psychiatry 1981;27:225 231.

Schwab PJ, Lahmeyer CB. The uses of seclusion on a general hospital psychiatric unit. J Clin Psychiatry 1979;40:228 231.

Soliday SM. A comparison of patient and staff attitudes toward seclusion. J Nerv Ment Dis 1985;173:282 286.

Soloff PH, Gutheil TG, Wexler DB. Seclusion and restraint in 1985: a review and update. Hosp Commun Psychiatry 1985;36:652 657.

Soloff PH, Turner SM. Patterns of seclusion: a prospective study. J Nerv Ment Dis 1981;169:37 44.

Steel E. Seclusion and restraint practices: a review and analysis. Alexandria, VA: National Mental Health Association, 1999.

Tardiff K, ed. The psychiatric uses of seclusion and restraint. Task Force Report No. 22. Washington, D.C.: American Psychiatric Press, 1984.

Tardiff K. Concise guide to assessment & management of violent patients. Washington, D.C.: American Psychiatric Press, 1989.

Wadeson H, Carpenter WT. Impact of the seclusion room experience. J Nerv Ment Dis 1976;163:318 328.

Wells DA. Use of seclusion on a university hospital psychiatric floor. Arch Gen Psychiatry 1972;26:410 413.

Whaley MS, Ramirez LF. The use of seclusion rooms and physical restraints in the treatment of psychiatric patients. J Psychiatr Nurs Ment Health Serv 1980;18:13 16.