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A seclusion room is a locked room designed to contain the aggressive urges - directed towards the self or other people - of patients hospitalized in psychiatric hospitals or departments.
The use of seclusion in French hospitals has revealed three types of problems: ethical problems in regard to the respect of law and fundamental human rights; clinical problems as to the appropriateness and the therapeutic value of isolation; and finally the practical problems which arise from setting up a specific place for isolation, the establishment of specific procedures conciliating safety measures, clinical needs and the respect of human rights and liberties.
In order to clarify the different problems pertaining to isolation, we will first present you with a survey carried out in 1994-96 with 440 psychiatric nurses working in 28 hospitals throughout France. We will then present you with a prospective study - currently in the process of being validated - with an aim to define precise instructions and the therapeutic effects of isolation.
But first, why consider seclusion as a subject of study?
For two main reasons:
In our society, the confinement of lunatics is part of the moral contract passed in former times between the State and the emerging discipline of Psychiatry. This contract imposed necessary methods of treatment which today still convey profound violence in the collective unconscious of the psychiatric microcosm. Among such types of treatment, we can find forced injections, constraint, ECT and isolation.
Such therapeutic means are at the heart of the dual aspect of treatment which opposes repression to the free will to take part in a therapeutic relationship. A 'taboo' opposition which questions the medical staff on the legitimacy of such practices.
The first bibliographical research which was undertaken revealed that, though many texts describe the history of psychiatric practice in order to denounce it or to praise it, few have raised the legitimacy of such practice.
Finally, the ANDEM experts working on a clinical audit of isolation, showed that no means of reference existed in France.
Such opacity does not mean that nobody has ever reflected upon such practice: many teams have broached the subject during clinical seminars, but this has never led to any written publication.
To conclude, these are the main lines of the motives which lie behind our enterprise.
In 1994, a first survey was carried out with the aim to explore the psychiatric nurses' attitude towards the practice of seclusion.
Based on a series of 20 questions, this survey was carried out in two different steps:
- on a local level, at the hospital of Esquirol, it revealed significant disparities in the practice of seclusion.
This first step led to the establishment of a protocol, a written document in which were noted the different elements of surveillance to be taken into account for each isolated patient.
- A second step involved spreading the investigation to different hospitals in Paris and the provinces. 440 psychiatric nurses working in 228 hospitals answered the questionnaires. Their answers were compared with the 23 elements of criteria defined by ANDEM.
The questionnaire, composed of 30 open or semi-directed questions aimed at describing the psychiatric's nurses' approach to seclusion ( representation, prescription, consensus, practical modalities, information to the patient and the family, instructions and changes in treatment, etc...)
We will only present you with a part of the analysis of answers received.
The principal data resulting from the survey:
Directions: psychiatric nurses find that 3 types of behavior could justify isolation:
* aggressive acts, violence towards others (82%),
* psychomotor restlessness (80%),
* dangerous behavior (73%).
A significant minority of isolation cases were motivated by the risk of suicide (37%).
The average time of isolation is under 7 days, including 15% of cases under 24 hours. Patients are usually isolated within 24 hours of their hospitalization, or during the first week of treatment.
For the psychiatric nurses, the seclusion room appears to fulfil 3 main functions:
* a closed space that incites a respect of physical limits (73%),
* a space to 'rebuild' (69%)
* and a safety sass for the team and other patients (67%).
|
Institutions |
A closed space that incites a respect of physical limits |
A space to "rebuild" |
Safety sass for the team and other patients |
|
Esquirol |
79 % |
72,50 % |
52 % |
|
Sarreguemines |
83 % |
74 % |
71,50 % |
|
St-Venant |
72 % |
52 % |
80 % |
|
La Roche/Yon |
100 % |
100 % |
53 % |
|
Toulouse |
75 % |
35 % |
65 % |
|
Pontorson |
68 % |
49 % |
74 % |
|
Argenteuil |
62,50 % |
100 % |
25 % |
|
Thouars |
75 % |
93,75 % |
62,50 % |
|
Total |
73 % |
69 % |
67 % |
The psychiatric nurses recognize 2 main functions: a safety function and a therapeutic function clearly differentiated according to location.
It was necessary to check the percentage of medical prescription.
|
Establishments |
|
|
|
Esquirol |
60,50 % |
39,50 % |
|
Sarreguemines |
95,50 % |
4,50 % |
|
St-Venant |
2 % |
98 % |
|
La Roche/Yon |
73 % |
27 % |
|
Toulouse |
58 % |
42 % |
|
Pontorson |
70 % |
30 % |
|
Argenteuil |
87,50 % |
12,50 % |
|
Thouars |
12,50 % |
87,50 % |
|
Total |
56 % |
43 % |
In every second case, the patient was isolated without any medical prescription.
3 conclusions may be drawn:
- All this confirms what we mentioned about the opposition between the safety aspect and the therapeutic aspect of isolation. When the safety aspect prevails, isolation is not prescribed by a doctor.
- when protocols are used by the team, seclusion often results from a doctor's decision (70,50%).
- This also applies when functional units remain open. (73%)
A statistical exception does exist in the Unit for Difficult Patients (Unité de Malades Difficiles) in Sarreguemines. The government rule of October.14.1986 which regulates such units, stipulates that patients are admitted accordingly with adapted intensive therapy procedures and specific safety measures. This would tend to show that only a text regulating isolation would institute respect for such basic legal requirements.
|
|
|
|
|
Esquirol |
83 % |
17 % |
|
Sarreguemines |
74 % |
24 % |
|
St-Venant |
56 % |
44 % |
|
La Roche/Yon |
94 % |
6 % |
|
Toulouse |
40 % |
60 % |
|
Pontorson |
64 % |
26 % |
|
Argenteuil |
75 % |
25 % |
|
Thouars |
62,50 % |
35,50 % |
|
Total |
75 % |
24 % |
The isolation room only seems to be an exceptional source of conflict between the different members of a team. We can note that such consensus is rarer in sectors where isolation is used as a safety measure.
The conformity of hospitalization regulations with isolation.
The French law of June 27, 1990 sets forth that any person who agrees to be hospitalized for mental disturbance, benefits from the same rights and status of a patient hospitalized in a general medical service. That is to say the patient cannot be held against his/her will and even less be confined in isolation.
|
|
|
|
|
Esquirol |
30 % |
50 % |
|
Sarreguemines |
1 % |
99 % |
|
St-Venant |
0 |
80 % |
|
La Roche/Yon |
67 % |
33 % |
|
Toulouse |
0 |
75 % |
|
Pontorson |
15 % |
60 % |
|
Argenteuil |
12 % |
78 % |
|
Thouars |
0 |
80 % |
|
Total |
13 % |
75 % |
It is clear that on this point the law is not respected, with the exception again of the special unit in Sarreguemines, which does not take in patients coming of their free will, and the hospital of la Roche-sur-Yon.
|
Institutions |
Protocol |
|
slip |
of surveillance |
|
Esquirol |
43 % |
56 % |
67 % |
61 % |
|
Sarreguemines |
69 % |
66 % |
11 % |
51 % |
|
St-Venant |
27 % |
56 % |
13 % |
36 % |
|
La Roche/Yon |
80 % |
73 % |
20 % |
80 % |
|
Toulouse |
43 % |
57 % |
29 % |
40 % |
|
Pontorson |
81 % |
88 % |
34 % |
61 % |
|
Argenteuil |
100 % |
87,50 % |
37,50 % |
50 % |
|
Thouars |
31 % |
37,50 % |
6 % |
44 % |
|
Total |
53 % |
60 % |
26 % |
60 % |
It involves the written modalities of isolation (organization of surveillance and transmission of the different elements of surveillance)
Statistically, every second case of isolation is not supported by a written document. This figure is certainly overestimated, some nurses specifying in the questionnaire that they use a non-written protocol. We estimate, according to the number of favourable answers to the question 'Individual control card' that about 26% of nurses use a written protocol.
In the departments where isolation is first and foremost a safety measure, no written document exists, as opposed to departments where therapeutic isolation prevails.
A psychiatric follow-up often implies working with the family. The situation is less simple than it appears to be. No text solves the question of choice between informing the family and respecting professional secrecy.
|
|
|
|
|
Esquirol |
19 % |
69 % |
|
Sarreguemines |
6 % |
92 % |
|
St-Venant |
5 % |
95 % |
|
La Roche/Yon |
67 % |
33 % |
|
Toulouse |
15 % |
85 % |
|
Pontorson |
27 % |
42 % |
|
Argenteuil |
75 % |
25 % |
|
Thouars |
62,50 % |
31 % |
|
Total |
23 % |
70 % |
Families are usually not informed. (70%)
The nurses answers appear to be very scattered as if each one had hesitated on replying according to local practice or to what he/she thought was expected to be done.
Whether a protocol is established or not in the functional unit, and whether it recommends or not the warning of the family appears to be of no relevance.
As a paradox, open functional units are more likely to inform the family and do not express the same reserve.
As for the information of the patient: an explanation of reasons justifying isolation seems to be the rule (88%). However, nothing can enable us to appreciate the nature of information given to the patient.
|
|
|
|
|
Esquirol |
74 % |
26 % |
|
Sarreguemines |
0 |
100 % |
|
St-Venant |
12 % |
88 % |
|
La Roche/Yon |
7 % |
83 % |
|
Toulouse |
0 |
87 % |
|
Pontorson |
80 % |
16 % |
|
Argenteuil |
37,50 % |
25 % |
|
Thouars |
100 % |
0 |
|
Total |
42 % |
55 % |
Only 42% of questioned nurses admitted to having bound patients. A very rare practice in the Paris area, it is less so in the provinces.
Protocols are mute as to the use of constraint. Who prescribes it, what means are used etc...?
The decision to bind the patient is taken by a doctor or by the nursing team. The team uses constraint braces (76%), bands(42%), belts (31%) or sheets (23%).
The principal information resulting from this survey is:
1) The blatant absence of agreement as to the practice of isolation.
2) A great difference between departments where the notion of therapy prevails and others where the notion of safety seems to dominate.
3) Arbitrary practice which goes against professional ethics manifests itself in the absence of written and formal documents complying with basic legal requirements.
4) The impossibility of referring to instructions other than 'safety measure' and to question them.
5) The inability of evaluating the therapeutic aspect of isolation.
On a local level, at the hospital Esquirol, this survey led to the appearance of a protocol which would follow the patient in isolation. Our wish to further develop our survey led us to set up a prospective study which is currently being validated.
Methodology:
- We began with 2 hypotheses on the instructions and the therapeutic effects of isolation:
In de facto situations, reference to suspected acting-out or previous behavior on the part of the patient tends to guide the treatment (here isolation) rather than semiology. Instructions are therefore based on vague clinical grounds.
Also, as behavior tends to mask psychopathology, the therapeutic effects of isolation are rarely discussed.
The tool. :
Assuming that behavior cannot be dissociated from psychic dynamics, we propose an accurate questionnaire for the practitioner and the nursing staff on the existing links between psychic content and acting-out.
In order to achieve this, the starting questionnaire will enable the practitioner to define instructions for isolation. It offers a comprehensive scan of semiology which could be linked to possible instructions for isolation.
Then open or semi directed questions will be submitted daily to the team during the period of isolation and will follow its evolution.
A last card will question the therapist on the nature of the therapeutic effects achieved by the isolation of the patient.
The means:
The study will take place at the hospital Esquirol, from September 1998 for a period of 6 months, in an establishment of 350 patients, mainly psychotic, and therefore hospitalized on a full time basis.
To summarize, our first survey has enabled us to establish that isolation is only a form of treatment in the sectors where the isolation room is considered as a 'reconstruction' space. When the 'safety' aspect prevails, no guaranty exists for the patient. The sectors where the notion of reconstruction prevails have often established a protocol of isolation. What differs in the sectors where the therapeutic aspect dominates, is the importance given to the written and formal application of a basic legal requirement.
That the attitude adopted by institutions in regards to the law conditions the modalities of isolation can only question the medical staff. This question is even more founded when isolation is essentially justified by the limits to oppose to aggressive behavior whether self-directed or towards others.
It is therefore necessary to require the most objective clinical criteria enabling to foresee whether a patient can tolerate isolation or not. How can one assess if the measure has achieved its aim? What could such clinical criteria be? One would have to take into account the institutional system of relationships between medical staff and patients. Must the prescription be based on pathology, on the nature of acting-out, on its significance, on the level of regression, on the themes appearing in delirium, on the importance of fragmentation anxiety, on the patient's tolerance to frustration, on his ability to maintain a differentiated relationship?
One thing is to observe that isolation can have paradoxical effects, another is to be able to do without it. Isolation is valued in terms of profit vs. risk. Can we hesitate between an aggravation of the symptoms of an agitated patient likely to become violent and the physical safety of other patients ?