The use of seclusion is a highly emotionally charged issue. It is argued that the use of seclusion is often in the best interest of a person receiving services, but it is not always clear under what circumstances that is the case. This blog entry argues that there is a need for additional criteria and best practices to provide additional guidance on the appropriate use of seclusion.
What is seclusion? The definition of seclusion may vary slightly depending on the setting, population and regulatory authority but essentially it is defined as the involuntary placement of an individual who is receiving services alone, in a room or an area from which the person is physically prevented from leaving. This discussion and the definition must differentiate from locked wards, as well as confinement in juvenile justice and criminal justice settings or in parental homes where children are sent to their rooms (generally not locked). This discussion also excludes the use of seclusion for reasons such as detoxification due to substance abuse or medical issues. When there are substance abuse or medical issues, the use of seclusion must be directed by clinically qualified professionals.
The use of seclusion is restricted to certain types of residential settings, when other less restrictive techniques have been considered, and it has been determined that the less restrictive techniques would not succeed in reducing or eliminating behaviors that are self injurious or dangerous to others. It is routinely mandated that it shall not be used for punishment or convenience of staff. In many regulations it is required that the person be under continuous observation during the period of seclusion, although remote monitoring is frequently allowed.
In looking at actual incidents in which seclusion was used, it is questionable to what degree, if at all, the last criteria is complied with or even if there is consensus on what that criteria means in practice.
When Should Seclusion Be Used? It is difficult to clearly identify situations in which seclusion is in fact necessary. There have been numerous instances when seclusion has been used to intervene when individuals were involved in self harm. In one setting a person receiving services was unsuccessful in attempting suicide by hanging. When found by staff the individual was cut down and then placed in seclusion. It is difficult to ascertain the clinical justification for that intervention. In fact in any situation when the individual is involved in self injurious behavior, the use of seclusion should be prohibited since they may continue to self harm in seclusion.
Justification for seclusion often occurs when the individual exhibits continuous and persistent aggressive behaviors towards others. However in situations where that occurs with a specific person or targets a specific number of individuals, it is less restrictive to separate individuals rather than to use seclusion. Additionally from a clinical perspective, there is a need to help the individual identify what goal is being met by the behavior and to teach the individual alternative techniques such as the use of a voluntary “time out” to self manage and de-escalate. This goal is the goal of Positive Behavior Supports taught in the Mandt System.
Research involving individuals with a mental illness who have been placed in solitary confinement in criminal justice systems indicate that this may be contraindicated and in fact may exacerbate psychotic symptoms. There is not similar research on the use of seclusion in health and human service settings but the similarity of the interventions (despite the variance in time) argues for the need for further investigation on the impact of seclusion used with individuals who have cognitive issues and in many instances have been traumatized due to abuse or neglect. While it may be argued that solitary confinement is more long term, when individuals are in crisis and out of control, their perception of time is distorted and therefore the impact of seclusion is not clear.
There are a number of issues that warrant clarification and further examination to develop best practices.
The use of the term “locked” in the definition is questionable. Seclusion feels the same to the individual regardless of whether or not the door is locked, there is a physical barrier or simply due to threats or coercion by staff. The definition should clarify that seclusion occurs any time the person is placed in an area involuntarily and egress is prevented rather than being limited to a locked room.
Monitoring is crucial for an individual in crisis and the use of remote monitoring equipment raises questions about its effectiveness. An advantage to using a remote device is that the monitor can engage in other activities simultaneously. If that is the case, how closely is the monitoring and how quickly could the monitor move to where the individual is secluded to intervene if necessary? Remote monitoring should never be used with individuals in seclusion.
Seclusion is used when there is a risk of harm to others. Arguably as soon as the individual is placed in seclusion, the risk of harm to others is eliminated. That being the case, how is it determined when the individual should be released? Too often individuals remain in seclusion for hours and in some cases days. The justification is that the individual has not yet calmed down and become compliant. However it is unlikely that any individual will calm down when they are locked in a room against their will instead they exhaust. Instead it is more likely that the individual remains in seclusion for an extended period to punish the individual and/or give staff a break.
Whenever seclusion is used, the team should review the entire incident (not just beginning when the “aggressive behavior” occurred) looking at precipitating events to determine the antecedent and if other responses by the staff might have de-escalated the situation. The review should also involve objective examination of whether or not there were any less intrusive interventions that might have been effective.
If the individual does in fact meet the criteria for seclusion for hours at a time staff should be concerned about what is happening to the individual’s heart! There are medical issues of concern such as rhabdomyolsis (the breakdown of muscle cells resulting from strenuous exertion) or catecholamine (a neurotransmitter released by the adrenal gland during stress) discussed in Medical Risk Chapter of the RCT events.
Prior to the use of any emergency intervention individuals receiving services should receive both a medical and psychological examination to determine if there are contraindications to the use of specific interventions and the length of time that seclusion might be used for a particular individual taking into account the individual’s trauma history.
Staff often react emotionally (rather than respond) to the behavior of the individual without weighing the risks and benefits and considering the entire range of interventions available. Data from the Child Welfare League of America and the Texas Department of Mental Health (2003) indicate staff injuries occur at approximately twice the rate of individuals receiving services when emergency interventions are used. Physically moving an individual who is aggressive into seclusion creates risk for not only the individual receiving services but even more so the staff involved, particularly when they are attempting to remove themselves from the seclusion room.
The risk to both the individual and staff should be carefully and objectively weighed in determining if there are other less invasive interventions that might keep everyone safe.
There is a dire need for additional guidance and direction to ensure when seclusion is necessary may re-traumatize or harming individuals in their care. If seclusion is permitted in any setting, additional regulatory requirements and/or best practices must be developed on a federal and/or state level to provide guidance to staff that often have difficulty with objectivity in dealing individuals who exhibit challenging behaviors.
SAMHSA has published Treatment Improvement Protocols that provide clinically directed Best Practice recommendations. The TIP for Detoxificaiton and Substance Abuse Treatment has excellent guidance on the use of seclusion and restraint, and can be downloaded at http://www.ncbi.nlm.nih.gov/books/NBK64115/pdf/TOC.pdf
Aaryce Hayes – COO The Mandt System