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A prospective study of psychiatry patients' attitudes toward the seclusion room experience
A Prospective Study of Psychiatry Patients’ Attitudes Toward the Seclusion Room ExDerience Lee S. Mann, Ph.D., J.D., Thomas N. Wise, M.D., and Laurel Shay, B.A.
Abstract: The seclusion room is an integral component of kospita1 psychiatry. This study prospecfiuely surveyed 50 pafienfs shortly after each was released from an isolation room in a voluntary general hospital psychiatric unit. Fifty-eight percent of the sample were diagnosed with mood disorders. Previous studies found generally negative attitudes toward seclusion. These data revealed that patients often found seclusion fo be restful and therapeutically helpful. The clinical implications of these data are discussed.
Introduction The seclusion room, an integral feature of hospital psychiatry, allows for isolation and observation of the violent or aggressively suicidal patient. Despite the development of chemical restraints, seclusion is sufficiently common to merit the attention of an American Psychiatric Association Task Force 111. They endorsed its use for control and containment of disturbed and violent behavior. Prior research about seclusion consists of retrospective surveys of primarily schizophrenic patients. Wadeson and Carpenter [2] reported that a cohort of schizophrenic patients had consistently negative perceptions of their seclusion experience. They found that patients who had been placed in seclusion experienced unpleasant delusions and intensely negative affective responses such as terror and fear. They suggested that such intensely negative responses promote sufficiently intense anxiety to provoke and increase both hallucinatory and delusional phenom-
From the Departments of Psychiatry at Fairfax Hospital, Falls Church, Virginia, and Georgetown University School of Medicine, Washington, D.C. Address reprint requests to: Lee S. Mann, Ph.D., 3300 Gallows Road, Falls Church, VA 22046. General Hospital Psychiatry 15, 17i-782, 1993 0 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
ena. Hammill et al. [31 also reported in their study of schizophrenic patients who had been secluded that seclusion was an experience “associated with feelings of helplessness, fear, sadness and anger.” Binder and McCoy [41 reported that patients placed in seclusion believed such treatment was unjustified and feared for their physical safety because of the actual physical layout of the room. Plutchik et al. 151 reported that patients in seclusion were bored, angry, confused, and disgusted. There is little data, however, on the reactions toward isolation of nonschizophrenic patients. This prospective study examines perceptions of the seclusion room experience in a cohort of psychiatric patients with various diagnoses.
Methods The study was conducted on a voluntary psychiatric unit in a not-for-profit community teaching hospital. The unit is comprised of a 36 beds where 34% of all patients are admitted from the emergency room. The average length of stay during the study was 9.7 days. The payer mix of the unit includes 21% Medicare, 33% Medicaid or indigent, and the remainder, private indemnification insurance. Both private attending physicians and psychiatric residents manage patients. The unit includes five seclusion rooms that are contiguous to the nursing station and are architecturally isolated from the rest of the unit. These rooms are constantly monitored with closed-circuit television as well as direct nursing inspection at a minimum of 15-minute intervals. Except for the seclusion rooms, no doors or exits are locked on the unit,
177 ISSN 016~8343/93/$6.00
Figure 1. Patients’ perceptions of the seclusion room.
although there is a monitor who is situated at the elevators. Six and one-half percent of the patients on this unit are secluded at some point during the course of their hospital stay. Subjects for the study were consecutively secluded patients from October 1990 through March 1991 who were administered a questionnaire within 48 hours of their release from seclusion. The decision to seclude a patient is made on clinical grounds whereby the attending physician or primary nurse decides that the patient’s ideations or behavior place him/ her at risk for harming oneself or others. A variety of clinical situations merit seclusion such as serious suicidal intent or violent outbursts. Release from isolation is via a weaning process wherein the ideation or behavior that led to the intervention sufficiently diminishes. The only patients excluded from the study were court-ordered, temporary detention cases, patients who were too agitated to follow instructions, 178
or patients with organic conditions that would interfere with their comprehension of the task. The questionnaire was based upon an instrument previously designed to objectively assess patient perceptions of the use of seclusion rooms [61. The data elements included demographic information and past experiences with seclusion. Thirteen yes/ no/unsure questions were asked regarding the physical characteristics of seclusion rooms (e.g., What do you think the room is like?-Dark without light? No one will see you?) see Figure 1. Ten 100mm visual analogue scales evaluated the subject’s perception of the efficacy of such isolation rooms (Fig. 2). Charts were then reviewed to ascertain discharge diagnosis, length of stay, reason for admission to seclusion room, medications, suicidal/ homicidal ideation, utilization of computed tomography (CT) scan, magnetic resonance imaging (MRI) or electroencephalogram CEEG). Also noted were whether the patient had been out on a therapeutic pass prior to seclusion as well as means of admission to the psychiatric unit and to seclusion. Documentation of seclusion room use in the discharge
G \o
going beck into the quiet room
40
50
60
70
80
9’0
100 Fully
30
Agree
20
Totally
10
/ I
Disagree
0
Figure 2. Patients’ attitudes toward seclusion.
quiet room during this haspotelizetion
I wasafraid that I would have to go into the
Imink abut
think it is a good idea to UI tie telcviaion monitor to watch people in the quiet rooms
I
There should be no wch rooms in a psychiatric unit
I was treated like a prisoner while in the quiet mom
; 8 3
C 5.
i
L. S. Mann et al.
Table 1. Demographic
characteristics
of sample according
to sex
Sex
N
Agen
Education (years)
of stay (days)
Hours in quiet room
Number of times in quiet room
Male Female
18 32
30.2 f 10.0 38.4 k 13.4
13.0 f 2.3 13.9 + 2.5
19.1 +- 16.3 22.2 + 21.7
28.4 + 29.3 33.3 + 25.6
2.5 + 3.7 3.3 + 6.2
Hospital length
All numbers are mean 2 SD “p < 0.05
summary was also noted. Statistical performed using SPSS-X 171.
analyses were
Results The sample consisted of 50 patients, 36% male and 64% female. Tables 1 and 2 delineate DSM-III-R patient diagnoses and the demographic characteristics of the sample. The sample diagnostic distribution is similar to the diagnostic distribution for the total population admitted to the unit during the year. The majority of the patients were single (51%), 34% were married, and 14.9% were divorced. Most subjects had a history of suicidal ideation (58%), but only 4% indicated any homicidal ideation. Nearly 54% of patients in the study were admitted to the hospital from the emergency department, and 30 patients were admitted directly to the seclusion room upon admission to the hospital. Twenty-four patients indicated that this had been their first experience in a seclusion room. While in the seclusion room, patients were prescribed the following medications: neuroleptics (N = 33); tricyclic antidepressants (N = 12); benzodiazepines (N = 17); anticonvulsants (N = 11); lithium carbonate (N = 9); and nothing (N = 2). During
Table 2. Distribution of diagnoses study sample
DSM-III-R Axis I diagnoses Depression Dysthymic Bipolar Schizoaffective Schizophrenia Brief psychosis Substance abuse None Total
180
in
N
%
12 5 15 1 8 3 4 2 50
24 10 30 2 16 6 8 4 100
the course of the hospitalization, specialized neurological testing was performed as follows: CT scan (N = 81, EEG (N = 9), and MRI (N = 1). Only three patients refused to take their medications, and 15 patients were classified as noncompliant with the hospital milieu. Seven patients had recently returned from therapeutic passes outside the hospital prior to seclusion placement. Fourteen percent of the patients lived alone, 32% lived with their spouse, 32% lived with their parents, 8% lived with an adult child, 2% lived in a group home, and 2% lived with a roommate. There was missing information on five patients. The disposition of these patients were as follows: 80% went home; 6% went to a drug or alcohol rehabilitation unit; 4% went to live with a friend; and for lo%, there was missing information. Figures 1 and 2 give the individual items in the questionnaire and the subjects’ responses. Males more than females reported the rooms to be stuffy (X2 = 6.0, p < 0.05); patients for whom this was their first time in seclusion also characterized the room as stuffy (X2 = 6.5, p < 0.05). Patients with no history of substance abuse more often reported that the seclusion room was like a padded cell (X2 = 8.0, p < 0.05). Patients labeled as noncompliers were less likely to report hearing screams than patients who were more compliant (X2 = 6.1, p < 0.05); noncompliers were less likely to label the seclusion rooms as safe and secure (X2 = 6.7, p < 0.05). Patients without a history of substance abuse were less afraid of seclusion (f = 2.1, p < 0.05), and they were more likely to find the rooms helpful (f = 2.5, p C 0.05). Patients who were placed in seclusion for the first time were more apt to describe such rooms as torture (f = 2.4, p < 0.05). Patients with a history of suicidal ideation were less likely to fear being placed in seclusion again (f = 2.8, p < O.Ol), and were less likely to endorse the fear that when isolated they would never get out (f = 3.9, p < 0.001). Patients were separated into those with a de-
Attitudes Toward the Seclusion Room
pressive disorder (i.e., major depression and dysthymic disorder (N = 16)) and those with other psychoses (i.e., schizophrenia, bipolar manic disorder, and brief reactive psychosis (N = 25)). Patients in the other psychoses group were more likely to state that once you are in a quiet room, it is hard to get out (59% versus 32%, t = 2.4, p < .05). The depressed group expressed more suicidal ideation (81% vs 38%, x2 = 5.6, p < 0.05) and received more EEG studies (38% vs 12%, x2 = 3.7, p < 0.05). Discharge summaries were more likely to mention the quiet room if the patient had a psychosis diagnosis other than depression (70% vs 23%, x2 = 7.2, p < 0.01). Pearson correlations indicated that increased age correlated with thoughts about going back to seclusion (Y = 0.29, p < 0.05). Length of hospital stay correlated with the belief that seclusion rooms should not exist (r = 0.34, p < 0.05). Total hours inside the isolated room correlated positively with several variables: the seclusion room is relaxing (Y = 0.37, p < 0.05); thinking about going back to seclusion (Y = 0.39, p < 0.05); and that no such rooms should exist (r = 0.42, p < 0.05). Finally, the total number of episodes in seclusion correlated with being afraid that one might have to go back into isolation (r = 0.36, p < 0.05). In reviewing patients’ charts, it was noted that 77.1% of the attending psychiatrists properly documented orders for requesting use of seclusion rooms, but only 55% of the attendings mentioned in the discharge summary that their patient had been placed in seclusion.
Discussion Seclusion rooms have been an integral component of institutional psychiatry since antiquity [81. Despite the advent of chemical restraints to contain harmful behaviors, physical isolation continues to be a frequent inpatient strategy. Prior research suggests that patients in general find seclusion to be a negative experience. In contrast, this study suggests that patients may experience the seclusion room as a safe and secure treatment environment due to constant observation. Although most patients reported that the seclusion experience was not restful, they did not indicate that they were treated as a prisoner, and only a small segment believed that there should be no such rooms within a psychiatric unit. The complaints that seclusion was neither quiet nor restful could be due to the actual environmental noise on the ward as well as perceptions influenced by
internal agitation and psychopathology of the individual patient. These data extend our previous research by surveying patients who had just been released from the seclusion room and had the experience freshly in their minds 16,91. Furthermore, the sample was composed of patients with heterogeneous diagnoses, most of whom were not schizophrenic. The data also indicate that patients returning from a therapeutic pass may regress to a level that could require seclusion. This suggests that each patient returning from a pass should have a clinical debriefing. Additionally, it may be helpful to immediately “debrief” any patient who has been in the seclusion room, to elicit discussion of their feelings about seclusion, and to review the reasons that led to their physical isolation. This could prevent premature closure on the experience and provide an opportunity for understanding why such a procedure was utilized. A patient’s inability to accept the explanation for seclusion may predict later complications that could lead to further utilization of such seclusion and restraint. It is important to note that patients who were secluded have an increased length of stay. Such interventions should alert the treatment team that either the illnesses requiring seclusion or the patient’s vulnerability to regress may necessitate additional hospital days. Finally, use of seclusion should be included as a regular component of discharge summaries. In conclusion, patients with nonschizophrenic disorders have ambivalent impressions of their own seclusion and often appear to recognize the need for such intensive observation and environmental restraint. Further work should focus on how to resolve the behavior, ideation, or affects that lead to isolation and further minimize the negative views of those placed in isolation.
References 1. American Psychiatric Association: Seclusion and restraint (Task Force Report No. 22), 1984 2. Wadeson H, Carpenter WT: Impact of the seclusion room experience. J Nerv Ment Dis 163:318-328,1976 3. Hammill K, McEvoy JP, Koral H, et al: Hospitalized schizophrenic patient views about seclusion. J Clin Psychiatry 50:174-177,1989 4. Binder RL, McCoy SM: A study of patients’ attitudes toward placement in seclusion. Hosp Community Psychiatry 34:1052-1054,1983 5. Plutchik R, Karasu TB, Conte HR, et al: Toward a rationale for the seclusion process. J Nerv Ment Dis 166: 571-579,1978
181
L. S. Mann et al.
6. Wise TN, Mann LS, Murray C, et al: Attitudes of nonsecluded patients toward seclusion rooms. Gen Hosp Psychiatry 10:280-284, 1988 7. SPSS-X Users Guide, 3rd ed. Chicago, SPSS Inc., 1988 8. Soloff PH: Historical notes on seclusion and restraint. In Tardiff K (ed), The Psychiatric Uses of Seclusion and
182
Restraint. Washington, American Psychiatric Assoc, 1984, pp. l-11 9. Wise TN, Mann LS, Leibenluft E, et al: Isolated versus visible seclusion rooms: attitudes of psychiatric patients. Psychiatr Q 60:329-336
Abstract: The seclusion room is an integral component of kospita1 psychiatry. This study prospecfiuely surveyed 50 pafienfs shortly after each was released from an isolation room in a voluntary general hospital psychiatric unit. Fifty-eight percent of the sample were diagnosed with mood disorders. Previous studies found generally negative attitudes toward seclusion. These data revealed that patients often found seclusion fo be restful and therapeutically helpful. The clinical implications of these data are discussed.
Introduction The seclusion room, an integral feature of hospital psychiatry, allows for isolation and observation of the violent or aggressively suicidal patient. Despite the development of chemical restraints, seclusion is sufficiently common to merit the attention of an American Psychiatric Association Task Force 111. They endorsed its use for control and containment of disturbed and violent behavior. Prior research about seclusion consists of retrospective surveys of primarily schizophrenic patients. Wadeson and Carpenter [2] reported that a cohort of schizophrenic patients had consistently negative perceptions of their seclusion experience. They found that patients who had been placed in seclusion experienced unpleasant delusions and intensely negative affective responses such as terror and fear. They suggested that such intensely negative responses promote sufficiently intense anxiety to provoke and increase both hallucinatory and delusional phenom-
From the Departments of Psychiatry at Fairfax Hospital, Falls Church, Virginia, and Georgetown University School of Medicine, Washington, D.C. Address reprint requests to: Lee S. Mann, Ph.D., 3300 Gallows Road, Falls Church, VA 22046. General Hospital Psychiatry 15, 17i-782, 1993 0 1993 Elsevier Science Publishing Co., Inc. 655 Avenue of the Americas, New York, NY 10010
ena. Hammill et al. [31 also reported in their study of schizophrenic patients who had been secluded that seclusion was an experience “associated with feelings of helplessness, fear, sadness and anger.” Binder and McCoy [41 reported that patients placed in seclusion believed such treatment was unjustified and feared for their physical safety because of the actual physical layout of the room. Plutchik et al. 151 reported that patients in seclusion were bored, angry, confused, and disgusted. There is little data, however, on the reactions toward isolation of nonschizophrenic patients. This prospective study examines perceptions of the seclusion room experience in a cohort of psychiatric patients with various diagnoses.
Methods The study was conducted on a voluntary psychiatric unit in a not-for-profit community teaching hospital. The unit is comprised of a 36 beds where 34% of all patients are admitted from the emergency room. The average length of stay during the study was 9.7 days. The payer mix of the unit includes 21% Medicare, 33% Medicaid or indigent, and the remainder, private indemnification insurance. Both private attending physicians and psychiatric residents manage patients. The unit includes five seclusion rooms that are contiguous to the nursing station and are architecturally isolated from the rest of the unit. These rooms are constantly monitored with closed-circuit television as well as direct nursing inspection at a minimum of 15-minute intervals. Except for the seclusion rooms, no doors or exits are locked on the unit,
177 ISSN 016~8343/93/$6.00
Figure 1. Patients’ perceptions of the seclusion room.
although there is a monitor who is situated at the elevators. Six and one-half percent of the patients on this unit are secluded at some point during the course of their hospital stay. Subjects for the study were consecutively secluded patients from October 1990 through March 1991 who were administered a questionnaire within 48 hours of their release from seclusion. The decision to seclude a patient is made on clinical grounds whereby the attending physician or primary nurse decides that the patient’s ideations or behavior place him/ her at risk for harming oneself or others. A variety of clinical situations merit seclusion such as serious suicidal intent or violent outbursts. Release from isolation is via a weaning process wherein the ideation or behavior that led to the intervention sufficiently diminishes. The only patients excluded from the study were court-ordered, temporary detention cases, patients who were too agitated to follow instructions, 178
or patients with organic conditions that would interfere with their comprehension of the task. The questionnaire was based upon an instrument previously designed to objectively assess patient perceptions of the use of seclusion rooms [61. The data elements included demographic information and past experiences with seclusion. Thirteen yes/ no/unsure questions were asked regarding the physical characteristics of seclusion rooms (e.g., What do you think the room is like?-Dark without light? No one will see you?) see Figure 1. Ten 100mm visual analogue scales evaluated the subject’s perception of the efficacy of such isolation rooms (Fig. 2). Charts were then reviewed to ascertain discharge diagnosis, length of stay, reason for admission to seclusion room, medications, suicidal/ homicidal ideation, utilization of computed tomography (CT) scan, magnetic resonance imaging (MRI) or electroencephalogram CEEG). Also noted were whether the patient had been out on a therapeutic pass prior to seclusion as well as means of admission to the psychiatric unit and to seclusion. Documentation of seclusion room use in the discharge
G \o
going beck into the quiet room
40
50
60
70
80
9’0
100 Fully
30
Agree
20
Totally
10
/ I
Disagree
0
Figure 2. Patients’ attitudes toward seclusion.
quiet room during this haspotelizetion
I wasafraid that I would have to go into the
Imink abut
think it is a good idea to UI tie telcviaion monitor to watch people in the quiet rooms
I
There should be no wch rooms in a psychiatric unit
I was treated like a prisoner while in the quiet mom
; 8 3
C 5.
i
L. S. Mann et al.
Table 1. Demographic
characteristics
of sample according
to sex
Sex
N
Agen
Education (years)
of stay (days)
Hours in quiet room
Number of times in quiet room
Male Female
18 32
30.2 f 10.0 38.4 k 13.4
13.0 f 2.3 13.9 + 2.5
19.1 +- 16.3 22.2 + 21.7
28.4 + 29.3 33.3 + 25.6
2.5 + 3.7 3.3 + 6.2
Hospital length
All numbers are mean 2 SD “p < 0.05
summary was also noted. Statistical performed using SPSS-X 171.
analyses were
Results The sample consisted of 50 patients, 36% male and 64% female. Tables 1 and 2 delineate DSM-III-R patient diagnoses and the demographic characteristics of the sample. The sample diagnostic distribution is similar to the diagnostic distribution for the total population admitted to the unit during the year. The majority of the patients were single (51%), 34% were married, and 14.9% were divorced. Most subjects had a history of suicidal ideation (58%), but only 4% indicated any homicidal ideation. Nearly 54% of patients in the study were admitted to the hospital from the emergency department, and 30 patients were admitted directly to the seclusion room upon admission to the hospital. Twenty-four patients indicated that this had been their first experience in a seclusion room. While in the seclusion room, patients were prescribed the following medications: neuroleptics (N = 33); tricyclic antidepressants (N = 12); benzodiazepines (N = 17); anticonvulsants (N = 11); lithium carbonate (N = 9); and nothing (N = 2). During
Table 2. Distribution of diagnoses study sample
DSM-III-R Axis I diagnoses Depression Dysthymic Bipolar Schizoaffective Schizophrenia Brief psychosis Substance abuse None Total
180
in
N
%
12 5 15 1 8 3 4 2 50
24 10 30 2 16 6 8 4 100
the course of the hospitalization, specialized neurological testing was performed as follows: CT scan (N = 81, EEG (N = 9), and MRI (N = 1). Only three patients refused to take their medications, and 15 patients were classified as noncompliant with the hospital milieu. Seven patients had recently returned from therapeutic passes outside the hospital prior to seclusion placement. Fourteen percent of the patients lived alone, 32% lived with their spouse, 32% lived with their parents, 8% lived with an adult child, 2% lived in a group home, and 2% lived with a roommate. There was missing information on five patients. The disposition of these patients were as follows: 80% went home; 6% went to a drug or alcohol rehabilitation unit; 4% went to live with a friend; and for lo%, there was missing information. Figures 1 and 2 give the individual items in the questionnaire and the subjects’ responses. Males more than females reported the rooms to be stuffy (X2 = 6.0, p < 0.05); patients for whom this was their first time in seclusion also characterized the room as stuffy (X2 = 6.5, p < 0.05). Patients with no history of substance abuse more often reported that the seclusion room was like a padded cell (X2 = 8.0, p < 0.05). Patients labeled as noncompliers were less likely to report hearing screams than patients who were more compliant (X2 = 6.1, p < 0.05); noncompliers were less likely to label the seclusion rooms as safe and secure (X2 = 6.7, p < 0.05). Patients without a history of substance abuse were less afraid of seclusion (f = 2.1, p < 0.05), and they were more likely to find the rooms helpful (f = 2.5, p C 0.05). Patients who were placed in seclusion for the first time were more apt to describe such rooms as torture (f = 2.4, p < 0.05). Patients with a history of suicidal ideation were less likely to fear being placed in seclusion again (f = 2.8, p < O.Ol), and were less likely to endorse the fear that when isolated they would never get out (f = 3.9, p < 0.001). Patients were separated into those with a de-
Attitudes Toward the Seclusion Room
pressive disorder (i.e., major depression and dysthymic disorder (N = 16)) and those with other psychoses (i.e., schizophrenia, bipolar manic disorder, and brief reactive psychosis (N = 25)). Patients in the other psychoses group were more likely to state that once you are in a quiet room, it is hard to get out (59% versus 32%, t = 2.4, p < .05). The depressed group expressed more suicidal ideation (81% vs 38%, x2 = 5.6, p < 0.05) and received more EEG studies (38% vs 12%, x2 = 3.7, p < 0.05). Discharge summaries were more likely to mention the quiet room if the patient had a psychosis diagnosis other than depression (70% vs 23%, x2 = 7.2, p < 0.01). Pearson correlations indicated that increased age correlated with thoughts about going back to seclusion (Y = 0.29, p < 0.05). Length of hospital stay correlated with the belief that seclusion rooms should not exist (r = 0.34, p < 0.05). Total hours inside the isolated room correlated positively with several variables: the seclusion room is relaxing (Y = 0.37, p < 0.05); thinking about going back to seclusion (Y = 0.39, p < 0.05); and that no such rooms should exist (r = 0.42, p < 0.05). Finally, the total number of episodes in seclusion correlated with being afraid that one might have to go back into isolation (r = 0.36, p < 0.05). In reviewing patients’ charts, it was noted that 77.1% of the attending psychiatrists properly documented orders for requesting use of seclusion rooms, but only 55% of the attendings mentioned in the discharge summary that their patient had been placed in seclusion.
Discussion Seclusion rooms have been an integral component of institutional psychiatry since antiquity [81. Despite the advent of chemical restraints to contain harmful behaviors, physical isolation continues to be a frequent inpatient strategy. Prior research suggests that patients in general find seclusion to be a negative experience. In contrast, this study suggests that patients may experience the seclusion room as a safe and secure treatment environment due to constant observation. Although most patients reported that the seclusion experience was not restful, they did not indicate that they were treated as a prisoner, and only a small segment believed that there should be no such rooms within a psychiatric unit. The complaints that seclusion was neither quiet nor restful could be due to the actual environmental noise on the ward as well as perceptions influenced by
internal agitation and psychopathology of the individual patient. These data extend our previous research by surveying patients who had just been released from the seclusion room and had the experience freshly in their minds 16,91. Furthermore, the sample was composed of patients with heterogeneous diagnoses, most of whom were not schizophrenic. The data also indicate that patients returning from a therapeutic pass may regress to a level that could require seclusion. This suggests that each patient returning from a pass should have a clinical debriefing. Additionally, it may be helpful to immediately “debrief” any patient who has been in the seclusion room, to elicit discussion of their feelings about seclusion, and to review the reasons that led to their physical isolation. This could prevent premature closure on the experience and provide an opportunity for understanding why such a procedure was utilized. A patient’s inability to accept the explanation for seclusion may predict later complications that could lead to further utilization of such seclusion and restraint. It is important to note that patients who were secluded have an increased length of stay. Such interventions should alert the treatment team that either the illnesses requiring seclusion or the patient’s vulnerability to regress may necessitate additional hospital days. Finally, use of seclusion should be included as a regular component of discharge summaries. In conclusion, patients with nonschizophrenic disorders have ambivalent impressions of their own seclusion and often appear to recognize the need for such intensive observation and environmental restraint. Further work should focus on how to resolve the behavior, ideation, or affects that lead to isolation and further minimize the negative views of those placed in isolation.
References 1. American Psychiatric Association: Seclusion and restraint (Task Force Report No. 22), 1984 2. Wadeson H, Carpenter WT: Impact of the seclusion room experience. J Nerv Ment Dis 163:318-328,1976 3. Hammill K, McEvoy JP, Koral H, et al: Hospitalized schizophrenic patient views about seclusion. J Clin Psychiatry 50:174-177,1989 4. Binder RL, McCoy SM: A study of patients’ attitudes toward placement in seclusion. Hosp Community Psychiatry 34:1052-1054,1983 5. Plutchik R, Karasu TB, Conte HR, et al: Toward a rationale for the seclusion process. J Nerv Ment Dis 166: 571-579,1978
181
L. S. Mann et al.
6. Wise TN, Mann LS, Murray C, et al: Attitudes of nonsecluded patients toward seclusion rooms. Gen Hosp Psychiatry 10:280-284, 1988 7. SPSS-X Users Guide, 3rd ed. Chicago, SPSS Inc., 1988 8. Soloff PH: Historical notes on seclusion and restraint. In Tardiff K (ed), The Psychiatric Uses of Seclusion and
182
Restraint. Washington, American Psychiatric Assoc, 1984, pp. l-11 9. Wise TN, Mann LS, Leibenluft E, et al: Isolated versus visible seclusion rooms: attitudes of psychiatric patients. Psychiatr Q 60:329-336