Coercion in psychiatry - is seclusion ethical?
Cheryl Pui-Yan Au B Med Sci* |

*Medical student, The University of Sydney

**Patient’s name has been altered for confidentiality purposes

A clinical scenario

C

ooper** is a 22 year old male with a three year history of paranoid schizophrenia on a background of chronic cannabis use. He has had a history of trouble with the law for aggression/violence. He is on a community treatment order (CTO) but has been non-compliant with his medication. His sister contacted the acute crisis team when he became verbally and physically aggressive towards her. On presentation to the Acute Psychiatric Unit, Cooper was very agitated and tried to assault staff members. He was then physically restrained by four staff members and secluded in the isolation room.
In my article, I will be exploring whether it is justified to use coercive measures in psychiatry, specifically the involuntary use of seclusion. Seclusion can be defined as “locking a patient alone in a room for protection of the patient and his environment, in order to control problem behaviour, and to enable nursing and treatment” (1).
Is it acceptable if patients are a danger to others or to themselves, and if seclusion creates a therapeutic climate (e.g. patient becomes calm and gains access to repressed memories due to decreased sensory stimulation)? Or is an appeal to respect autonomy and/or human dignity a sufficient reason to reject coercive measures?

Ethical Issues

Autonomy
In medical ethics, there have been several attacks against a central role for autonomy.
Firstly, autonomy is just one of the many moral considerations, and it has been argued that respect for autonomy should not override other moral values such as beneficence and dependency (2).  Secondly, the concept of autonomy itself is broader and is relational (3). Complete self-sufficiency and independence, free from controlling factors, does not exist. In addition, autonomy as a moral capacity can only be developed in relation to others, i.e. it cannot be seen in isolation from other people and relationships.

From these arguments, seclusion cannot be dismissed simply on the idea of autonomy. Other moral principles as well as the relational context of autonomy need to be considered. Perhaps it can be argued that to prevent destructive behaviour to self and/or others, coercive measures may be necessary to foster or regain autonomy (3). If seclusion is viewed as an intervention for attaining autonomy instead of threatening autonomy, then we have lost one reason for eliminating seclusion completely. However, this does not mean that seclusion does not raise many issues related to autonomy.

Human dignity
Violation of human dignity is often used as an argument against seclusion (4, 5). But what exactly is human dignity? There are at least two conceptions of dignity (6):

  1. “Inherent dignity”: a universal and inalienable moral quality of every human being which cannot be earned/taken away
  2. “Individualistic dignity”: dignity that is tied to personal goals and social circumstances, which can be enhanced/robbed depending on events outside the control of the persons involved.

Can seclusion be regarded as a violation of inherent dignity? Although this characteristic of humans cannot be taken away from the patient, we can act in a way that is not in accordance with it and thus violate it.

In relation to “individualistic dignity”, Nordenfelt proposes the concept of “the dignity of identity” (7).  He states that we can be humiliated by and our autonomy restricted in many ways, but this does not just entail feelings of worthlessness or of humiliation. He argues that intrusion in the private sphere is a violation of a person’s integrity and this encompasses a change in the person’s identity and thereby his dignity. In light of this, it can be argued that seclusion should not be used.
Conversely, a study about patients’ perceptions of the concept of dignity in a psychiatric setting showed that “encountering competent and committed staff”, “being confirmed”, “being looked upon as like anyone else”, “being helped to reduce the shame” and “being understood”, are conditions associated with respect for dignity (8). If seclusion measures were enacted by competent staff, with confirmation and understanding and in a way that reduces the shame, is human dignity violated in this sense?

Effects of seclusion: promoting wellbeing?
The definition of seclusion implies that it is used with good intention – i.e. to protect the patient and his environment and to create a therapeutic situation. This view of seclusion is based on doing good and avoiding harm, or additional harm.
Indications for seclusion (and restraint) are (9):

  1. “To prevent imminent harm to the patient and/or others
  2. To prevent serious disruption of the treatment program or significant damage to the physical environment
  3. To assist in treatment as part of ongoing behaviour therapy
  4. To decreased the stimulation the patient receives”

Even though there is observational evidence about the positive effects of seclusion, there is a lack of controlled studies to evaluate the value of seclusion/restraint in patients with serious mental illness (10). Furthermore, negative effects have been published, including substantial deleterious physical and psychological effects on both patient and staff (11).

Thus, if we want to practice evidence-based medicine, it can be argued seclusion should only continue to be used in the context of randomised trials, in which the effects of seclusion in extreme circumstances are explored and compared to other measures such as forced drug treatment (which may be even more harmful) (12). The design of such studies will no doubt be fraught with ethical dilemmas. Even cohort studies investigating methods to control severe and violent behavioural disturbances in psychiatric patients are problematic, since the comparison/control group receiving less or no intervention may pose physical risks to staff and/or other patients. Nevertheless, if there is a lack of evidence of positive effects of seclusion, perhaps it should stimulate us to find alternative methods of dealing with extreme circumstances of aggressive behaviour.

The patient’s perspective

Many studies have explored patients' experiences of seclusion/restraint. While there are some contradictory findings, the predominant emotions expressed by patients include fear, helplessness, confusion and humiliation (13). Many do not know the reason for their seclusion and view the act as punishment and/or violation of their autonomy (14). A recent study suggested that providing patients with meaningful activities, planning beforehand, documenting the patients' wishes, and making patient-staff agreements can result in reduced use of seclusion/restraint and thus a more positive patient experience (15). However, this is contingent on patients playing a more active role in their management and clinical staff seeking and eliciting patients' thoughts, suggestions and preferences "in advance".

Conclusion

In Cooper’s case, the indication for seclusion/restraint was to prevent imminent harm to himself and to staff members. As outlined in my article, coercive measures cannot be dismissed or accepted based on autonomy or human dignity principles alone. More research on whether coercive measures are beneficent is needed to complete the argument, but as long as there is no strong evidence for positive effects of seclusion and the fact that deleterious effects have been described, coercive measures should be used with caution and perhaps reduction encouraged. Certainly from the patient's perspective, seclusion/restraint is undesirable and measures to reduce the need for restrictions as well as alternatives should be continually evaluated and developed.

References

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  2. Beauchamp T, Childress J. Principles of biomedical ethics. 5th edition. Oxford UP 2001.
  3. Verkerk M. A care perspective on coercion and autonomy. Bioethics. 1999;13:359-68.
  4. Curie C. SAMHSA’s commitment to eliminating the use of seclusion and restraint. Psychiatr Serv. 2005;56:1139-40.
  5. Muir-Cochrane E, Holmes C. Legal and ethical aspects of seclusion: an Australian perspective. J Psychiatr Mental Health Nurs. 2001;8:501-6.
  6. Pullman D. Human dignity and the ethics and aesthetics of pain and suffering. Theor Med Bioeth. 2002; 23:75-94.
  7. Nordenfelt L. The varieties of dignity. Health Care Anal. 2004;12:69-81.
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  9. Gutheil T, Tardiff K. Indications and contraindications for seclusion and restraint. In: Tardiff K, ed. The Psychiatric uses of seclusion and restraint. Washington DC: American Psychiatric Press. 1984:19-34.
  10. Sailas E, Fenton M. Seclusion and restraint for people with serious mental illness. Cochrane Database Syst Rev. 2000;C001163.
  11. Fisher W. Restraint and seclusion: a review of the literature. Am J Psychiatry. 1994;151:1584-91.
  12. Prinsen E, van Delden J. Can we justify eliminating coercive measures in psychiatry? J Med Ethics. 2009;35:69-73.
  13. Hoekstra T, Lendemeijer H, Jansen M. Seclusion: The inside story. J Psych Ment Health Nurs 2004; 11(3): 276-83.
  14. Meehan T, Bergen H, Fjeldsoe K. Staff and patient perceptions of seclusion: Has anything changed? J Adv Nurs. 2004; 47(1):33-8.
  15. Keski-Valkama A, Koivisto A, Eronen M, Kaltiala-Heino R. Forensic and general psychiatric patients' views of seclusion: A comparison study. J Forensic Psychiatr. 2010;21(3):446-61.
  16. Kontio R, Joffe G, Putkonen H, Kuosmanen L, Hane K, Holi M, et al. Seclusion and restraint in psychiatry: Patients' experiences and practical suggestions on how to improve practices and use alternatives. Perspect Psychiatr C 2012; 48:16-24.