[Patients' perception of seclusion in psychiatry: ethical perspectives].

OBJECTIVE: Although seclusion is legally sanctioned in France, its use remains controversial, and debate continues over ethical and therapeutic aspects of the practice. Seclusion continues to be widely used in the management of disturbed behaviour in hospitalized patients. Although recent studies serve to strengthen the link between the use of seclusion and negative patient responses, they are limited in extending our understanding of the seclusion experience. The objective of this work was two-fold: to examine the perceptions and experiences of patients about their seclusion experience and then suggest ways of improving the use of seclusion in relation to an ethical perspective.

METHOD: We conducted face-to-face semi-structured interviews with inpatients in a French Public Psychiatric Hospital, 3 weeks after their seclusion. They were conducted until no new ideas emerged in the content analysis, comprising 30 patients. Interviews were conducted using an interview guide by a physician. Specific attention was paid to their perceptions of seclusion. This guide was based on the concepts of medical ethics (autonomy, beneficence, non-malfeasance). Interviews were retranscribed and content analysis was performed by two of the authors who were skilled in textual analysis. Data analysis was performed using SPSS 15.0 software.

RESULTS: Autonomy was challenged by 50% of interviewed patients. For 70% of patients, there was a lack of information and explanation during the seclusion on therapeutics, practices, procedures, expected length of time in seclusion and behaviours. This can contribute to perception of this process as punishment expressed by the patients. The dominant view of patients was that more effective communication about seclusion was needed. A majority of patients perceived the beneficence of the health professionals even if most of them did not express a benefit from this experience: only 26% believed that seclusion made them calm down and 36% that seclusion helped them to feel and behave better. The level and the quality of the relationship with staff during and following the seclusion experience was a major source of satisfaction for patients and can counter-balance their negative perception of seclusion. The non-malfeasance was questioned by patients. The therapeutic value of seclusion was not recognized by a majority of them. Seclusion from the patient's perspective appears to invoke a complex range of feelings that include helplessness (76%), anger (60%), humiliation (60%), depression (50%), and fear (63%). For 60% of patients, the act of placing them in seclusion had a profound negative impact. Seventy-six percent of them considered that seclusion could be prevented.

CONCLUSION: Despite advances in our knowledge and understanding of mental illness, seclusion continues, and is likely to continue, as a treatment option for a number of patients. In our study, a certain number of trends were observed. Globally, there is some tension concerning ethical principles. Attention to the specific needs of patients while in seclusion may serve to reduce the punitive connotations linked to the practice. What is needed is a permanent ethical reevaluation of seclusion. For this purpose, healthcare professional staffs may be useful for a truly ethical reflection. The aim is to recognize the patient as the agent of his/her own empowerment through appropriate information. This approach should not only provide the patient with the opportunity to understand why the seclusion occurred, but also some means for overcoming the negative effects of the procedure.