patients’ perceptions of seclusion: a qualitative investigation

Patients' perceptions of seclusion:a qualitative investigation

Tom Meehan RN BHSc MPH MSocSc GDipDataAnalysis

Senior Lecturer (Queensland University of Technology), Nursing Research

Unit, Wolston Park Hospital, Wacol, Queensland

Cathryn Vermeer EN RPN BNurs (Hons)

Registered Nurse, Integrated Mental Health Unit, Ipswich General Hospital,

Ipswich, Queensland

and Carol Windsor BA (Hons)

Lecturer, School of Nursing, Queensland University of Technology, Red Hill,

Queensland, Australia

Accepted for publication 13 May 1999

MEEHANMEEHAN TT., VERMEERVERMEER CC. && WINDSORWINDSOR C. (2000)C. (2000) Journal of Advanced Nursing 31(2),

370±377

Patients' perceptions of seclusion: a qualitative investigation

Twelve patients receiving acute in-patient psychiatric care in Queensland,

Australia, participated in semi-structured interviews to elicit their perceptions

of seclusion. All respondents had experienced time in seclusion within the 7

days prior to interview. Interviews were audiotaped, transcribed and analysed

using content analysis. Five major themes emerged: use of seclusion, emotional

impact, sensory deprivation, maintaining control and staff±patient interaction.

The prevailing negativity towards seclusion underscores the need for ongoing

critical review of its use. In particular, the relationship between patient

responses to seclusion and the circumstances in which seclusion takes place

requires greater consideration. Interventions such as providing information to

patients about seclusion, increased interaction with patients during seclusion,

attention to privacy and effective debrie®ng following seclusion may help to

reduce the emotional impact of the practice.

Keywords: seclusion, semi-structured interviews, content analysis, patient

perceptions, psychiatric in-patient care, consumer views,

mental health care nursing

INTRODUCTION

Despite advances in our understanding of mental illness,

physical control mechanisms such as seclusion continue

to be required for the management of disturbed patient

behaviour. Indeed, some 20 years ago, Soloff (1979)

claimed that seclusion was an `embarrassing reality' for

psychiatry. While there is no single or agreed de®nition

for the term `seclusion', there is general consensus that it

involves the placement of a patient alone in a locked room

from which he/she cannot freely exit. It has been

suggested that seclusion provides three important

elements: containment, isolation and reduction in sensory

stimuli (Gutheil 1978). It would appear that the `bene®ts'

of seclusion arise from the belief that the disturbed patient

Correspondence: Tom Meehan, Nursing Research Unit,

Wolston Park Hospital, Wacol, Queensland 4076, Australia.

E-mail: [email protected]

Journal of Advanced Nursing, 2000, 31(2), 370±377 Issues and innovations in nursing practice

370 Ó 2000 Blackwell Science Ltd

can feel safe from `persecutors' and other external stimuli

in the isolation of the seclusion room.

A signi®cant number of patients are still forced to spend

time in seclusion. A review of studies conducted in North

America suggests that approximately 20% of patients are

secluded during their time in hospital (Lendemeijer &

Shortridge-Baggett 1997). However, the indications for

using seclusion are less clear and appear to vary from overt

aggression and assault to minor incidents such as non-

compliance with ward routines. Seclusion is also used as a

preventive measure and patients are frequently placed in

seclusion for agitation and threats of violence. While these

patients have not committed an offence, staff justify the use

of seclusion on the grounds that it may prevent the

`progressive disorganization of behaviour which may

culminate in actual violence' (Brown & Tooke 1992 p. 713).

It is clear that the humanitarian, ethical and legal issues

associated with the use of seclusion make it one of the

most controversial patient management strategies avail-

able (Muir-Corchrane 1995). At a practical level, contro-

versy continues over the bene®ts of seclusion for the

patient. While a growing number of patients feel that

seclusion is punitive and has no place in contemporary

psychiatry (Chamberlin 1985), service providers continue

to rely on seclusion in the management of disturbed and

`out of control' patient behaviour (Heyman 1987, Steele

1993). Understanding seclusion from the patient's

perspective may help staff to consider the emotional

impact of the practice on patients, and encourage them to

empathize more closely with the concerns of patients.

Literature review

Research into the use of seclusion has been inspired by a

growth in public and legal criticism of restrictive interven-

tions and controls placed on people with mental illness

(Soloff 1983). Since the earlier work of Gutheil (1978), who

attempted to provide a theoretical basis for the use of

seclusion, many aspects of seclusion have been explored.

These include preceding events (Baxter et al. 1989, Swett

1994), characteristics of the secluded patient (Hafner et al.

1989, Swett 1994), staff±patient ratios and the need for

seclusion (Morrison & Lehane 1995), characteristics of the

unit (DeCangas 1993) and alternatives to the use of seclu-

sion (Richmond et al. 1996). While these studies contribute

to a pro®le of seclusion use, they also re¯ect a shift away

from the therapeutic dimension of seclusion.

A considerably smaller body of research has focused on

patient attitudes and perceptions of seclusion. Seclusion

from the patient's perspective appears to invoke a

complex range of feelings which include boredom,

depression, anger, disgust and helplessness (Hammill

1987, Heyman 1987, Norris & Kennedy 1992). In fact,

some patients perceive the practice as a form of torture

and of little therapeutic value (Chamberlin 1985). Others

report that being secluded had bothered them more than

any other experience during their stay in hospital (Binder

& McCoy 1983). Patients interviewed 12 months following

discharge from hospital reported that the experience of

being secluded symbolized their entire mental illness

(Wadeson & Carpenter 1976).

Not all patients perceive seclusion so negatively. Some

patients have expressed bene®ts from the experience, or

have been known to request placement in seclusion (Ray

et al. 1996). Plutchik et al. (1978) found that two-thirds of

patients studied believed that their seclusion experience

improved their behaviour on release. Likewise, in

Heyman's (1987) study, the majority of patients believed

their seclusion experience improved behaviour, was

calming and gave patients a chance to retreat from

`exciting' experiences. However, it is not clear whether

the positive feelings of safety and security relate directly

to seclusion or are an outcome of the constant observation

afforded to these patients.

While most patients believe that seclusion is necessary

to control disturbed behaviour (Hammill 1987), many also

argue that pro-active measures could reduce the need for

seclusion. For example, more staff contact, more recre-

ational activities, training staff in de-escalation and

calming skills, and the use of less restrictive environments

have been suggested (Richardson 1987, Tooke & Brown

1992, Outlaw & Lowery 1994). However, it is clear that

factors operating within the ward environment rather than

the patient's condition at times govern the use of seclusion

(Brown & Tooke 1992). There is an overriding pressure on

staff to ensure that the ward as whole runs smoothly and in

some situations seclusion may be employed for this reason.

In summary, studies of patient attitudes and percep-

tions of seclusion yield con¯icting and inconsistent

results. While most patients reject the use of seclusion,

others perceive bene®ts from its use. The variation in

perceptions may stem from the fact that many of the

studies reported in the literature were undertaken at a

time when patients spent long periods in seclusion

(50 hours or more) and when some patients were also

placed in restraints while in seclusion. 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 experi-

ence. In this study we explore how patients receiving

acute inpatient treatment in a mental health facility

describe and construct meanings about their seclusion

experience.

THE STUDY

Design

The design of the study was informed by the research

objective which was to explore patients' descriptions and

Issues and innovations in nursing practice Perceptions of seclusion

Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(2), 370±377 371

observations of seclusion. In the study wards, the use of

seclusion is controlled by Queensland (Australia) Mental

Health Regulations (1985 p. 3) and de®ned as `con®ne-

ment alone in any locked room during the hours of day'.

Areas of interest included: perceptions of the reasons for

seclusion, feelings while in seclusion, perceptions of staff

impact on the seclusion experience and attitudes to the

seclusion environment. In accordance with this research

focus, a naturalistic, qualitative design was chosen (Morse

& Field 1996).

Setting/sample

The study was conducted at two `open', acute care units

situated on the campus of a large tertiary mental health

facility in Queensland, Australia. While the hospital has a

number of long-stay wards, the study wards provided

acute services for the people of two geographical regions

nearby. A convenience sample of 12 patients (six from

each of the two wards) was identi®ed for the study. To be

included in the sample, participants were required to have

experienced seclusion in the previous 7 days, to be

suf®ciently `settled' to participate, were able to speak

and understand English, and able to provide informed

consent. Seven of the 12 participants were male and the

group ranged in age from 18 to 52 years. The 12 patients in

our sample had spent an average of 3á4 hours in seclusion

during the episodes immediately prior to interview.

Data collection

Data were collected through individual interviews with

the 12 participants. A semi-structured and thematically

organized interview schedule was devised on the basis of

previous studies, and with the intent to broaden our

understanding of the interactional processes involved in

seclusion. All interviews were conducted by one of the

authors (CV) who had previously worked as a nurse in

both study wards and was therefore known to many of the

participants. It must be acknowledged that people with

mental illness are a disempowered group and may there-

fore be reluctant to voice opinion or criticism about the

services they receive (El-Guebaly et al. 1983). Thus, a

known and trusted interviewer may improve the richness

of data obtained from clients in a mental health setting. In

their study of people with mental illness living in a hostel,

Norman & Parker (1990 p. 1042) recognized the impor-

tance of `the interviewer being well known and accepted

by the residents if rich and valid information is to emerge'.

Data analysis

All interviews were audio-taped and transcribed for data

analysis. Transcripts were checked for errors against the

taped version of each interview to ensure accurate and

authentic reproductions of participants' accounts. The

interviews were subsequently analysed using a process

which is broadly termed `meaning categorization' (Kvale

1996). The method permits data analysis to move beyond

simple description (Silverman 1997). Themes considered

signi®cant in each individual interview were identi®ed and

coded to facilitate the development of categories. Credibility

of data analysis involved all members of the research team

reaching agreement on the ®nal categorizations. The ®nal

step in the data analysis was the movement from broad

categories to some general statements or themes which

re¯ected the patients' experience of seclusion.

RESULTS

Data analysis produced ®ve recurrent themes which have

implications for nursing practice. These included: use of

seclusion, emotional impact, sensory deprivation, main-

taining control and staff±patient interaction. There has

been no attempt to rank these themes by order of impor-

tance.

Theme 1: use of seclusion

While the participants interviewed acknowledged a role

for seclusion in dealing with aggressive, violent and

destructive behaviours, most felt that they had been

secluded inappropriately. For example, there was a

perception that patients were generally inadequately

informed of ward rules, and as a result were at risk of

being secluded for rule transgression:

¼ they never told me anything. I was dumped into this ward and

expected to know how everything worked and who everyone was

and how and why they were there. I left for a few hours to do

things at home and when I came back they [staff] locked me up.

For the majority of participants, there was similarly a

lack of information about expected length of time in

seclusion and behaviours that would result in release. The

perceived arbitrary nature of decisions over time of release

reinforced a view that the seclusion period was of more

bene®t to the staff than the patient:

They [staff] never speci®ed any time limit that I should be in

there. When day staff came back on I was let out, there was no

reason that I was let out then and not six hours before, it was just

convenient for them [staff] and that's wrong.

All participants commented on the use of force in the

seclusion process and most described this experience as

unjusti®able. Force was applied in placing patients in

seclusion, in removing patient's clothing and personal

belongings, and when administering medication:

I was hauled back here and placed in seclusion¼ ®ve policemen

to drag me out of the house, even though I was offering no

T. Meehan et al.

372 Ó 2000 Blackwell Science Ltd, Journal of Advanced Nursing, 31(2), 370±377

resistance¼ and then I was stripped and placed in seclusion¼Yes. Quite barbaric is what I thought of it.

These experiences gave rise to an association being

made between seclusion and punishment. Five respon-

dents described seclusion as equivalent to a `prison', `jail',

`lock up' or `watch house':

I felt like a prisoner¼ Yeah, but I've never been in prison. I've got

no criminal record at all.

The process of `stripping away' an individual's identity

is what Goffman (1961) refers to as a shared characteristic

of the `total institution', whether an asylum or prison. The

removal of all personal property and clothing and the

wearing of a `uniform' (specially designed night attire) is

barely distinguishable from the procedure of a person

entering jail. Furthermore, if seclusion is viewed by

patients as an act of punishment, the nurse becomes the

perpetrator of the punishment and is consequently feared

by the patient (Bernstein et al. 1991). The process of

seclusion, if conceived in this way, must carry little

therapeutic value.

Not all patients were critical of their experiences. Some

patients saw seclusion as a safe environment where they

could gain control over their actions:

I'm glad they put me in seclusion away from everybody else¼ it

made me settle down a bit¼ there's nothing really that good about

it, it's just to sort of protect yourself and protect other people in

ward.

These same respondents viewed their seclusion

episodes as a necessary safety measure, as one noted:

I suppose I had a razor blade in my pocket of my pants, had two or

three I think. ¼ I suppose I probably would've used it if they

hadn't taken my clothes off, from me.

However, as 10 of the respondents felt undeserving of

seclusion, a number of alternatives to being locked in a

room were identi®ed. These included the use of close

observation (one-to-one nursing), intensive care units,

`time out' programmes, appropriate medication and

improved communication and openness of staff towards

patient's concerns:

¼ Well if I had been put on cat red [close observation], I might

have read a nice book or¼ tried to talk to somebody to try and lift

my mood, but because I was in there with nothing and nobody

there was nothing to lift [my] mood.

Theme 2: emotional impact

Statements relating to emotional responses were charac-

teristically negative. Participants reported feeling angry

before, during and after the seclusion episode and this

anger was directed primarily at the staff involved. For

some, the source of anger was the lack of opportunity to

discuss or defend actions prior to being placed in seclu-

sion. For others, as noted, the anger was associated with

physical interventions related to the seclusion process.

Regardless of the cause, anger usually gave way to a sense

of powerlessness in a system that took complete control:

The only thing I remember is when they ®rst put me in there and I

was just screaming and kicking and yelling because I didn't want

a needle and then I remembered just bursting into tears and I

think I cried myself to sleep.

Powerlessness has long been a feature associated with

mental illness. Many aspects of hospitalization reinforce

such feelings of powerlessness for patients including the

forced removal and detainment associated with some

hospital admissions. Indeed, evidence contained in many

reports suggests that the humiliation and helplessness of

incarceration is more likely to be recalled than details of

the incidents necessitating hospitalization and physical

restraint (Hat®eld & Le¯ey 1993). The following comment

by one participant re¯ects the sense of powerlessness

shared by many of the participants:

¼ I was feeling very low, I couldn't have felt any lower I thought,

until they put me in seclusion and then I realized you could go

lower. But by then there was nothing I could do about it. They

even take away your option to change the circumstances to try

and lift your mood.

Disempowerment in the form of the humiliation of

being stripped of clothes and personal property was a

particular concern for the female participants:

It's humiliating, having male staff seeing me naked and you've got

to face them ¼ Yeah, there was females there too, but they don't

care if there's male staff there watching while you're naked,

couldn't care less.

A further manifestation of disempowerment was the

sense of fear; fear of con®ned spaces, of injections and of

medication. Moreover, the fear did not readily dissipate

upon release from the seclusion room. This was evident in

the concern expressed for other patients who were

observed being taken to seclusion:

I feel like crying for them because I know how awful it is. But I

hold it in, I don't want to be emotionally attached to anyone here

because I know¼ that at any given time someone could get

plucked out of the environment.

Other researchers have found that patients who were

secluded continued to feel vulnerable and fearful about

the experience for up to 1 year (Wadeson & Carpenter

1976) and even 2 years (Ray et al. 1996) following admis-

sion to a psychiatric facility. This raises concerns about

the level of support a patient receives when released from

seclusion and whether this support is suf®cient and/or

effective in assisting people to come to terms with their

seclusion experience.



Theme 3: sensory deprivation

Seclusion has been associated with sensory deprivation,

solitary con®nement and isolation (Bernstein et al. 1991).

Indeed, early experiments into the effects of sensory

deprivation found that participants experience extreme

boredom, restlessness and irritability, as well as dramatic

mood swings (Bernstein et al. 1991). Clearly, the partici-

pants involved in our study had similar experiences.

The social isolation and physical characteristics of the

seclusion room combined to infringe on any sense of

reality and made some patients feel they were `going mad'

or `losing control':

You get very depressed when you are in there a long time¼ you

are completely isolated and you start to go mad because you

cannot talk to anyone.

Respondents recalled a heightened awareness of

sounds, dif®culty in judging time, dysfunctional thought

patterns and feelings of losing control. Many of the

participants commented on the noise coming from the

fan in the ceiling of the seclusion room. This seemed to

overwhelm a number of participants and acted as a cue for

hallucinatory and delusional experiences:

¼. the silence starts to drive you mad except for that blowing

sound [fan in the ceiling] so you start talking to yourself, trying to

keep yourself, you know, sane.

A related factor was the level of boredom resulting from

isolation and monotonous surroundings. An under-

stimulating environment is an acknowledged and signi®-

cant cause of stress (Bernstein et al. 1991). While not

speci®cally asked, participants offered a range of possi-

bilities for improving the seclusion room to alleviate

boredom and increase comfort:

I reckon they should have paintings on the walls or on the roof or

something. ¼.I don't know, anything to keep your mind occu-

pied¼ I think it was worse for me in a way because I was so bored¼.

Yeah, I'd like to see a seclusion room with nice pretty things in,

not things that you can get out and hurt yourself with or smash

anything, but even just paintings on the walls to relax you or a

nice quilt to look at, because there's nothing to look at but the

walls and that fan and the window, but unless you're on cat red

you just staring at another wall.

Theme 4: maintaining control

Despite a lack of control and choice during seclusion,

patients adopted a number of strategies to assist them in

coping with their restricted environment and to remain

rational:

¼ you start talking to yourself, trying to keep yourself, you know,

sane and then they think you're mad because you're talking to

yourself but it's just that you can't stand the silence anymore, you

just start saying things just to hear something.

Although one patient demonstrated disordered

thinking, the importance of some sense of control was

manifest:

I just paced around, sung to myself, talked to myself, did all these

stupid little things that you do when you've got nothing else to do

and you can't go no where else.

Participants were also acutely aware of what they

considered were the unspoken `rules' of seclusion. They

were of the view that any display of behaviour that might

be interpreted by staff as aggressive would result in the

prolongation of the seclusion episode:

I just became so distressed that I didn't speak and stopped talking

and just stopped moving and just thought maybe if I just keep still

enough they'd come in eventually and let me out and by the time I

was out I didn't dare talk to anyone or do anything, you know,

cause I was frightened I'd go back in.

It may be that those who realized the importance of

compliance (or how to play the seclusion `game') obtained

release from seclusion earlier than others. This is a tenet

central to the work of Szasz (1958 p. 509), who de®ned

mental health as `the ability to play whatever the game of

social living might consist of and to play it well¼ to refuse

to play, or to play badly means that the person is mentally

ill'. For the participants in this study, there was a

perception that if the seclusion `game' was played appro-

priately and patients remained calm and non-aggressive,

they would be considered mentally well and not in need

of the seclusion room.

In a variation on the `game' theme, one patient claimed

that she knew how to `annoy' staff to the extent that she

would be placed in seclusion and thereby have the

occasion for a `nap' during the day. The reasons why

patients in acute psychiatric units cannot have access to

their bedrooms during the day needs to be explored more

fully.

Theme 5: staff±patient interaction

The level of interaction with staff during and following

the seclusion experience was a major source of dissatis-

faction for all participants. The dominant view was that

more effective communication about seclusion, and

speci®c input about behaviours that may warrant its use,

would act as a preventative measure:

¼. if they had said right from the beginning you are not allowed

to go down there or you'll end up in seclusion, and seclusion is da

da da, I would have done everything differently.

Participants also highlighted the importance of staff

interaction during their time in seclusion. It would appear

T. Meehan et al.


that while staff observe patients in seclusion at least every

15 minutes (according to the policy in the study wards),

they do not always communicate with them:

I couldn't speak to anyone for all that time, when I really needed

to talk to someone. It was horri®c.

A perceived lack of support following seclusion was

also of concern. Participants wanted an opportunity to

discuss and `off-load' emotions immediately after release

from seclusion. It was implied that, despite an institu-

tional policy which recommends defusing following

seclusion episodes, effective post-seclusion debrie®ng

does not always occur. Some participants were unable to

articulate reasons for their seclusion episodes:

I don't understand why they felt the need to put me there. I still

don't understand that, and no one will discuss it with me. They

could have sat me down and explained why I'd been through all

that hell.

There was also the sense that, once in seclusion,

participants lose claim to any individuality or rights. This

point was re¯ected in the following statements:

They don't understand the pain I went through in that 12 hours,

they've got no idea.

They could have asked me what I wanted on my sandwich before

they had given me promite.

DISCUSSION

The ®ndings reported here form part of a larger study

which was designed to explore staff and patient percep-

tions of seclusion. The information presented in this

paper represents the patients' descriptions and observa-

tions of seclusion. The ®ndings are limited by a lack of

previous studies in an Australian context to the extent that

we are unable to draw analytical comparisons. Moreover,

the ®ndings are derived from data obtained from a

convenience sample of 12 patients in the acute psychiatric

setting and therefore may not be representative of patients

in other environments. Interviews with patients are also

inherently problematic, particularly where patients are

asked to comment directly on staff and treatment. None-

theless, the responses in this research suggest that the

participants did discuss freely their concerns regarding

the care they received and that they were prepared to

address critically some staff-related issues. Indeed, many

of the participants expressed a sense of relief to the

interviewer and appreciated the opportunity to tell their

stories.

The ®ndings suggest that the act of placing a patient in

seclusion had a profound negative impact which persisted

for some time following the experience. Only two of the 12

participants in our study acknowledged any therapeutic

value from spending time in seclusion. This seems to

contradict the work of Gutheil (1978) which suggests that

the bene®ts of seclusion are derived from the isolation of

the seclusion room which provides the patient with relief

from perceived `persecutors' and sensory overload.

Perhaps it is the way in which seclusion is implemented,

rather than the time spent alone in a locked room, that

generates the negativity associated with seclusion.

The overriding issue in this study was the perceived

lack of communication between staff and patients. This

factor underpinned most of the anxieties expressed during

the interviews. Perceptions relating to punishment, aban-

donment, fear, isolation and depression were acute in

situations where participants felt under-informed about

the seclusion process. This does not suggest that the staff

involved withhold information from patients. Rather, it

raises the issue of what constitutes an `informed' state for

patients. Patients noted that they were not informed about

the behaviours that would result in the use of seclusion,

and the amount of time they were likely to spend in

seclusion. This lack of clarity about the seclusion process

was reinforced by perceived inconsistencies in the way

seclusion was implemented. For example, time of release

from seclusion did not appear to be associated with clear

goal attainment. This is contrary to generally accepted

predetermined indicators for the release of a patient from

seclusion (Tardiff 1984).

Lack of interaction with staff while in seclusion was

also raised by participants as a source of considerable

frustration which contributed to a feeling of abandonment.

A number of authors argue that the presence of a staff

member is bene®cial to the secluded patient in countering

the potentially harmful effects of social isolation (Rich-

mond et al. 1996). However, dif®culties arise in deter-

mining when the presence of a staff member may not be

bene®cial to a secluded patient, and in identifying situ-

ations which might compromise the safety of the staff

member.

Many of the participants described speci®c psychiatric

symptoms similar to those experienced by prison

inmates in solitary con®nement (Grassian 1983). These

included perceptual disturbances such as hypersensitivity

to external stimuli and hallucinations, which, in turn,

were associated with feelings of anxiety and fear. While

the frequency and intensity of these symptoms varied,

they are of clinical signi®cance and worthy of future

investigation. Indeed, if sensory and social isolation

produces negative clinical manifestations or feelings, the

therapeutic value of the practice must be questioned.

The participants appeared to embrace the opportunity

to discuss their seclusion experiences which supports the

role of debrie®ng in the post-seclusion phase. Debrie®ng

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 proce-

dure (Norris & Kennedy 1992). Moreover, debrie®ng could



provide an opportunity for staff to negotiate a treatment

plan with the patient; one which may result in the use of

less restrictive measures during the remainder of the

patient's stay in hospital.

While this study acknowledges the need for the

ongoing use of seclusion, it does raise concerns about

the appropriate use of the practice. The participants

advocated less restrictive alternatives to seclusion and

strategies to improve seclusion outcomes. These

included constant observation, use of a psychiatric

intensive care unit, a `time out' programme, the provi-

sion of appropriate medication and an opportunity to

negotiate with staff. However, the use of these alterna-

tive management strategies gives rise to a range of

therapeutic, safety and economic factors. As Alty &

Mason (1994) argue, the contradictions between the

concepts of force and care (or safety and therapy), and

the emotive issues they evoke, means that a situation of

`openness' about seclusion is possibly not attainable.

Nonetheless, the ®ndings do reinforce a need for

ongoing critical analysis of the practice of seclusion

and of aspects of the individual care that is offered to

those requiring seclusion.

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.

This ongoing need for seclusion results from the complex

interaction between patient, staff and environmental

factors. However, if the use of seclusion is to be

proclaimed (at all) therapeutic, practices and procedures

that contribute to perceptions of this process as punish-

ment need to be reviewed. Attention to the speci®c needs

of patients while in seclusion may serve to reduce the

punitive connotations linked to the practice. Moreover,

increased interaction with patients while in seclusion,

and following release from seclusion, may help both

patients and staff to understand and give meaning to one

of the most controversial and restrictive practices used in

the treatment of people with mental illness.

Acknowledgements

This study was funded by a seeding grant from the School

of Nursing at Queensland University of Technology,

Brisbane.

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