Seclusion in New Zealand
Mental Health Services
APRIL 2004
Published by the
Mental Health Commission
Wellington
2004
ISBN: 0-478-11393-5
II SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
Contents
Foreword from Chair, Mental Health Commission ............................................................................................... v
Comment from Director Mental Health, Ministry of Health .................................................................. vi
CHAPTER ONE: INTRODUCTION ........................................................................................................................................ 1
CHAPTER TWO: WHAT IS SECLUSION? .................................................................................................................... 3
2.1 Theory and rationale ................................................................................................................................................................... 3
2.1.1 Seclusion as therapy ................................................................................................................................................... 3
2.1.2 Seclusion as containment ..................................................................................................................................... 3
2.1.3 Seclusion as punishment ....................................................................................................................................... 3
2.2 Statute and guidelines ............................................................................................................................................................... 4
CHAPTER THREE: WHAT DID THE SECLUSION PROJECT INVOLVE? .................................. 5
CHAPTER FOUR: FINDINGS ....................................................................................................................................................... 7
4.1 The magnitude of seclusion practice ......................................................................................................................... 7
4.2 The consequences of seclusion on people ........................................................................................................... 7
4.3 What factors influence seclusion practice? ........................................................................................................ 8
4.4 Human rights and duty of care issues ................................................................................................................... 10
4.5 Monitoring .......................................................................................................................................................................................... 11
CHAPTER FIVE: CONCLUSION ............................................................................................................................................ 13
CHAPTER SIX: NEXT STEPS .................................................................................................................................................... 15
APPENDICES .............................................................................................................................................................................................. 17
Appendix A: Alty and Mason’s Benevolent-Malevolent Scale Model ........................................ 17
Appendix B: Key Seclusion Documents ........................................................................................................................ 18
Appendix C: Methods and Methodology (including bibliography) ............................................ 19
Appendix D: Resources for the Reduction of Seclusion ............................................................................. 20
CONTENTS III
Acknowledgments
Without the help of many, many people this paper would not have been possible.
The assistance of service users, clinicians, District Health Boards, Mental Health
Commission Advisory and Reference Groups and government agencies is gratefully
acknowledged. A special thanks to Johanna Reidy and Seth Bateman.
IV SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
Foreword
This report on seclusion practice in New Zealand has been a long time in preparation. Through
the process it has attracted great interest from the sector and from service users. The discussions
with service users, families, managers and clinicians generated a wealth of views.
The Commission has taken care to reflect these perspectives and to acknowledge the context in
which seclusion occurs. Factors such as poor ward design, inexperienced staff, failure to share
information across services, unclear policy and guidelines and high levels of acuity undoubtedly
influence the use of seclusion. We have visited District Health Boards where seclusion practice
has been dramatically reduced by an investment in staff training and the introduction of routine
and thorough debriefing after each use of seclusion.
At the same time, we must also acknowledge that seclusion is a form of detention that has human
rights consequences. The rights of those people placed in seclusion must be upheld and this
requires rigorous adherence to legislative protections and the implementation of a thorough and
transparent monitoring system.
The Commission would like to see seclusion eliminated. This has prompted debate and given rise
to concerns about increased use of medication, physical restraint and the criminalisation of service
users who require seclusion facilities.
We accept that a commitment to a substantial reduction in use is an important first step and
believe a strengthened monitoring regime is critical to assessing progress towards that goal. We
acknowledge the willingness of the Ministry to undertake the work required to help ensure seclusion
is substantially reduced.
Jan Dowland
Chair
Mental Health Commission
Wellington
FOREWORD V
Comment from Director Mental Health
Seclusion is one management strategy for mental illness. It offers containment, isolation and
reduction of sensory input. Ideally its efficacy should be measured in terms of a better outcome
for the person than would have occurred had they not been secluded (Fisher 1994) and better
outcomes for other patients, considering the duty of care that each unit has for all within their
jurisdiction.
However, better outcomes are notoriously difficult to measure. ‘Better for whom’ is a pertinent
question. In a practical sense it might be measured in terms of safety and protection or a quieter
environment that is less stimulating and more conducive to recovery.
Sadly, as with all treatments, worthy intentions and aims can fail. Seclusion can and is sometimes
used for the wrong reasons (such as staff pressure) and can be used in the place of more appropriate
and therapeutic interventions (such as engaging with a person and addressing their needs by
explanation and reassurance). Thus it can be a substitute for interpersonal and therapeutic
engagement (which take time and skill) and be symptomatic of poor unit design, lack of space,
lack of options, lack of staff numbers and training. It can also be a reflection of inappropriate staff
gender and ethnic mix.
This Mental Health Commission paper is a serious step to examine the extent of appropriate use,
as well as abuse, of seclusion as a management strategy. It debates how an evidence base can be
established through audit procedures that can be used to inform future policy and practice.
Many clinicians would like to restrict its use to when all other avenues of therapeutic intervention
have been considered inappropriate and when its use can be combined with a ‘debrief’ and
therapeutic feedback as to the reasons for its use.
‘Primum non nocere’ (‘first, do no harm’) is a fundamental obligation for all clinicians. It is in this
regard that seclusion use must only be used as a thoughtful and planned intervention strategy to
improve outcomes for all.
Dr D G Chaplow
Director Mental Health
Ministry of Health
Wellington
VI SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
one
Introduction
“[seclusion] ... [t]he confinement of an individual in a locked room from which they
have no means of egress is widely regarded as one of the most restrictive practices
used in modern psychiatry”1
In June 2001, the Mental Health Commission initiated
a review of seclusion practice in New Zealand mental
health services. The project was instigated because
of concerns expressed by clinicians, service users and
researchers about the legitimacy, therapeutic value
and reported overuse of seclusion.2 Often perceived
as a punishment by service users and traumatising for
all involved, seclusion has been widely debated
around the world.
There are many opinions. Topping-Morris3 stated that
seclusion is ‘anti-therapeutic’, while others suggest it
is a ‘treatment relic of the past’4 and an ‘embarrassing
reality’.5 Those who support seclusion see it as a valid
treatment intervention to control agitation and reduce
sensory stimuli.6
After decades of research and debate, these polarised
views have reached a degree of consensus. Most
would now agree that seclusion is potentially harmful,
contradictory to recovery models of care, and
surrounded by serious ethical and moral issues. A
recently released report in the US, Achieving the
Promise: Transforming Mental Health Care in
America, (July 2003)7 stated that:
...the use of seclusion.. in mental health treatment
settings creates significant risks for adults and
children with psychiatric disabilities. These risks
include serious injury or death, re-traumatizing
people who have a history of trauma, loss of
dignity, and other psychological harm.
Consequently, it is inappropriate to use seclusion
...for the purposes of discipline, coercion, or staff
convenience. (pg. 34)
Furthermore,
Seclusion [is a] safety intervention of last resort...[it
is] not a treatment...In light of the potentially serious
consequences...it is inappropriate to use [this]
intervention instead of providing adequate levels
of staff or active treatment. (pg. 34)
Human rights issues have also been raised where
seclusion practice is seen to sit uneasily with
international human rights principles, although
seclusion itself does not breach current human rights
law.
This report discusses the findings of the Commission’s
two year review of seclusion from human rights, policy
and practice perspectives. It examines the magnitude
of seclusion use in New Zealand, provides an
explanation of that magnitude by explaining the context
of the acute unit, and investigates arguments
surrounding human rights, duty of care, and therapeutic
value.
1
Johnson, D. J. (December, 1997) Factors in the Continuance and
Discontinuance of Seclusion in a Special Hospital, Unpublished MSc
Thesis, University of Liverpool. Online Document, Available from:
http://www.fnrh.freeserve.co.uk/docs/report2.pdf.
2
Use of Seclusion in Mental Health Services, Mental Health
Commission (1999)
3
Topping-Morris, B. (1993) Seclusion (RCN Forum for Nursing in a
Continued Environment), Royal College of Nursing, London, cited in
Johnson (1997).
4
Pilette, P. C. (October, 1978) The Tyranny of Seclusion: A Brief Essay,
JPN and Mental Health Services cited in Johnson (1997).
5
Soloff, P. H. (1979) Physical Restraint and the Non-Psychotic Patient:
Clinical and Legal Perspectives, Journal of Clinical Psychiatry, 40 (7)
pp. 302-305.
6
Grigson, J. W. (1984) Beyond Patient Management: The Therapeutic
Use of Seclusion and Restraints, Perspectives in Psychiatric Care, 22
(4), pp. 137-142; also Gutheil, T. G. (1978) Observations on the
Theoretical Bases for Seclusion of the Psychiatric In-Patient,
American Journal of Psychiatry, 135 (3), pp. 325-328.
7
From The President’s New Freedom Commission on Mental Health,
USA.
CHAPTER ONE: INTRODUCTION 1
2 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
two
What is seclusion?
2.1 THEORY AND RATIONALE
In theory, persons requiring seclusion are usually
considered out of control, aggressive and in need of
containment and isolation in a controlled, restrictive
setting under close observation and monitoring by
appropriately qualified and experienced staff. Seclusion
involves:
• Containment – A person is contained within a room
where the door is shut and freedom to exit is decided
by clinical staff.
• Isolation – The person is in a room alone.
• Reduction in sensory input – The room is reasonably
bare, often containing no more than a bed and
sometimes a toilet.
The theoretical rationale for the use of seclusion varies
depending on whether seclusion is viewed as a valid
therapeutic intervention in itself, a method of
containment of a psychiatric emergency, or a form of
punishment that maintains physical and, at times,
psychological control over the secluded person.8
2.1.1 Seclusion as therapy
As a therapy, seclusion is often seen as a ‘treatment’
that ‘improves’ ‘illness’; for,
[c]ontainment limits the environment of the client,
protecting her or him from self-injury or hurting
others. This is said to provide the client with feelings
of safety and reassurance. Isolation removes the
client from personal interactions that may tax the
client’s coping abilities. [Reduction in sensory input]
may calm clients who have escalating psychotic
behaviours. Inherent in these principles is the
assumption that clients are secluded because they
are unable to control their behaviour.9(pg. 37)
Few would argue that the individual components of
seclusion (containment, isolation, and reduction in
sensory input) are not helpful at certain times. The
question is: do all service users who are placed in
seclusion require containment, isolation and a
reduction in sensory input; or do they require only one
or two of these components to improve their condition
or protect others?
2.1.2 Seclusion as containment
Seclusion is often used as a risk management procedure
where potentially violent persons are secluded to
‘decrease opportunities [for them] to do damage to
themselves, others, or the environment’ (pg. 33).10
The validity of the containment rationale rests on the
argument that there is a lack of effective alternatives to
control violent people on the ward and containment
by seclusion is simply the most pragmatic of
interventions. Containment is however only one
component of seclusion, as suggested above. The need
to contain a person may not necessitate the need for
isolation and the reduction of sensory input as well.
2.1.3 Seclusion as punishment
Punishment is an emotive word that ‘conjures up
feelings of abuse, neglect, tyranny and persecution’.11
And although few would condone punishment as an
appropriate justification for seclusion, there are
arguments that suggest punishment may be a legitimate
means to modify behaviour. Tardiff,12 for example,
suggests that seclusionary time out can be therapeutic
if used briefly in behavioural programmes. Of course,
8
Martinez et al (1999) From the other side of the door: Patient views
of seclusion. Journal of Psychosocial Nursing. Vol. 37. No. 3. Also see
Appendix A which details Alty and Mason’s (1994) BenevolentMalevolent Scale Model of various rationales.
9
McBride, S. (August, 1996) Seclusion Versus Empowerment: A
Psychiatric Care Dilemma, The Canadian Nurse, pp. 36-39.
10
Walsh, E. (January-March, 1995) Seclusion and Restraint: What We
Need to Know, Journal of Child and Adolescent Psychiatric Nursing,
pp. 28-40.
11
Johnson, D. J. (1997)
12
Tardiff, K. (Ed) (1984) The Psychiatric Uses of Seclusion and Restraint,
American Psychiatric Press, Wasington D.C.
CHAPTER TWO: WHAT IS SECLUSION? 3
seclusion is supposed to be an emergency procedure
used when people are highly agitated and unable to
control their behaviour. If seclusion worked, from a
behavioural standpoint, one would expect service users
to experience seclusion only once or twice, but this
pattern has not been observed. Multiple seclusion
events are common for extended amounts of time.13
In terms of monitoring and quality assurance, each
hospital or service must keep a register of seclusion
(section 129b). The responsible clinician has the
authority to use seclusion in accordance with the
provisions of the Act and any concerns regarding the
use of seclusion can be referred to the Director of
Mental Health, who can direct District Inspectors to
investigate any concerns.
2.2 STATUTE AND GUIDELINES
In regards to operational guidance, the Ministry of
Health has a Restraint Minimisation and Safe Practice
Standard (2001), which replaces the Procedural
Guidelines for the Use of Seclusion (1995) as the
primary reference document for practice. Seclusion is
defined as a form of restraint and the Standard sets out
twelve outcome measures, one of which deals
specifically with seclusion. Many of the 1995
Procedural Guidelines for seclusion are contained in
the appendices to the Standard.
The Mental Health (Compulsory Assessment and
Treatment) Act 1992 (the Act) requires that every service
user is entitled to the company of others, except in
certain circumstances when they may be placed in
seclusion. The Act also states that seclusion may be
used for the ‘care’ or ‘treatment’ of the service user, or
protection of other persons in the ward (section 71). In
other words, legally, seclusion can be used as a therapy
and as a containment procedure, while it cannot be
used as a form of punishment.
13
Based on findings from the seclusion survey conducted by the
Ministry of Health and the Mental Health Commission (2001).
4 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
three
What did the seclusion project involve?
The Commission’s review of seclusion involved a
variety of components, each adding to our
understanding of seclusion practice in the New Zealand
mental health setting.
3. A review of key policy documents that relate to
seclusion practice.14
4. Consultation with practitioners and site visits to
selected DHBs.
These components were:
1. A survey of all District Health Boards (DHBs)
conducted with the Ministry of Health capturing
data for the 2000/01 financial year.
2. An analysis of the literature on seclusion.
14
A detailed discussion of methods is contained in
Appendix C, which outlines the survey process and
analysis, the literature analysis (including a full list of
references), and the process used for policy analysis,
consultation and site visits.
See Appendix B for a list of these.
CHAPTER THREE: WHAT DID THE SECLUSION PROJECT INVOLVE? 5
6 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
four
Findings
Detailed analysis of the four data components revealed
that seclusion was used widely and often across DHBs.
And although it was generally perceived as a negative
intervention by both services users and clinical staff,
its use was influenced by systemic, resourcing,
architectural, management and practice constraints.
4.1 THE MAGNITUDE OF SECLUSION
PRACTICE
Although seclusion varied over time and between
DHBs, all DHBs surveyed used seclusion, with 37% of
service users under the Act experiencing time in a
seclusion room. On average, secluded persons spent
50 hours per month in seclusion. Monthly hours ranged
from 1 to 600 hours, while most seclusion events were
between 8-24 hours in duration. Biographical data
indicates that males and females are secluded at about
the same rate and Māori tend to be secluded more than
others.
4.2 THE CONSEQUENCES OF
SECLUSION ON PEOPLE
The research evidence does not support seclusion as a
treatment or therapy. Rather, seclusion can be seen as
an adjunct to treatment.15 The research literature also
sees seclusion as a containment procedure that can be
psychologically damaging for some people. 16
Qualitative literature indicates that feelings of
helplessness, punishment and depression are
common, 17 as are feelings of anger, frustration,
confusion and fear.18 Martinez et al’s19 quantitative
study confirms these findings as widely applicable.
They found that 76.5% of people felt punished, 63.8%
felt fearful, 64.4% felt worthless, and 54.3% of people
felt a loss of control. These findings contradict the
therapeutic rationale for seclusion that has long been
the primary justification for its use.
Investigations of solitary confinement in prisons20
provides further evidence to challenge the ‘seclusion
as therapy’ argument; for although solitary confinement
is intended primarily as a punishment, the impact on
people is the same as seclusion. Scott and Gandreau,21
for example, found that solitary confinement led to
declining mental functioning, hallucinations and
delusions22, while psychologists at the Maine State
Prison in 1975 argued that excessive time in solitary
confinement caused depression, withdrawal and
psychotic behaviour.23 More recently, Grassian and
Friedman24 (pg.278) stated, ‘the more recent literature
on [solitary confinement] has also nearly uniformly
described or speculated that solitary confinement has
serious psychopathological consequences’. Any form
of solitary confinement then, seclusion included, can
be psychologically damaging for those who experience
it.
15
Exworth, T., Mohan, D., Hindley, N., and Basson, J. (2001) Seclusion:
Punitive or Protective?, The Journal of Forensic Psychiatry, Vol. 12,
No. 2 pp. 423-433
16
Terpstra, T. L., Terpstra, T. L., Pettee, E. J., and Hunter, M. (2001)
Nursing Staff’s Attitude Toward Seclusion, Journal of Psychosocial
Nursing, Vol. 39. No. 5. pp. 21-27.
17
Heyman, E. (1987) Seclusion, Journal of Psychological Nursing and
Mental Health Services, 25 (11), pp. 9-12.
18
Binder, R. L., and McCoy, S. M. (1983) A Study of Patient Attitudes
toward Placement in Seclusion, Hospitals and Community Psychiatry,
34, pp. 1052-1054.
19
Martinez, R. J., Grimm, M., and Adamson, M. (1999) From the Other
Side of the Door: Patient Views of Seclusion, Journal of Psychosocial
Nursing, Vol. 37, No. 3, pp. 13-22.
20
Solitary confinement is defined as containment, isolation and sensory
deprivation. In other words, it is the prison term for seclusion.
21
Scott, M. and Gendreau, P. (1969) Psychological Implications of
Sensory Deprivation in a Maximum Security Prison, Canadian
Psychiatric Journal 337, cited in Benamin, T and Lux, K. (1976-7)
Solitary Confinement as Psychological Punishment, 13 Calif. W. L. R.
265 at pg. 268.
22
M Scott and P Gendreau (1969) Psychological Implications of Sensory
Deprivation in a Maximum Security Prison, Canadian Psychiatric
Journal 337, cited in T Benjamin and K Lux Solitary Confinement as
Psychological Punishment (1976-7) 13 Calif. W. L. R. 265 at pp. 268.
23
D Hasson and J Quinsey (April 10, 1975) unpublished article cited in T
Benjamin and K Lux Solitary Confinement as Psychological
Punishment (1976-7) 13 Calif. W. L. R. 265 at pp. 266-7.
24
Grassian, S. and Friedman, N. (1986) Effects of Sensory Deprivation in
Psychiatric Seclusion and Solitary Confinement, 8 Int’l J.L. and
Psychiatry, 49 at pg. 54.
CHAPTER FOUR: FINDINGS 7
But seclusion also impacts on clinical staff. There are
many reports of staff trauma and unease with seclusion
practice,25 especially where the journey from the open
ward to the seclusion room is fraught with resistance
and physical restraint is necessary along with forced
medication. From a therapeutic standpoint, any form
of coercive practice has the potential to damage the
therapeutic relationship between clinical staff and
service user, for the power differential is highlighted in
these circumstances. The therapeutic mode of care is
replaced by a custodial mode of care.
Perhaps seclusion is best conceived as a safety
mechanism rather than a therapeutic intervention. The
Health and Safety in Employment Act 1992 defines the
right to workplace safety. Section 6 of this Act states
that employers have a duty to ensure the safety of
employees. Furthermore, employers have the duty to
identify and regularly review potential hazards (Section
7), to eliminate a hazard if practicable (Section 8), and
if it is impossible to eliminate the hazard, the employer
must take steps to isolate it from an employee (Section
9). In relation to seclusion, this means seclusion could
be justified in terms of minimising a workplace hazard,
thus legitimating the ‘seclusion as management’
philosophy to some degree. Obviously, a balancing
act is required in terms of service user and staff rights.
No clear indication is given in statute to how this can
be achieved.
Finally, gender and cultural issues create their own
unique set of circumstances in relation to seclusion.
Safety issues are paramount for women, especially in
a mixed sex environment and the de-escalation
intervention process may be different. Women may,
for example, prefer talking therapies.26 Specific issues
also emerge for various cultural groups, where
seclusion may, or may not, be seen as culturally
appropriate. Likewise, the process of how seclusion
occurs may need to take into account cultural
differences. Male staff touching a Muslim woman
would not be appropriate, for example. Also important
are issues for refugees and asylum seekers who may
have had traumatic experiences.
In spite of these evident concerns, seclusion is still
perceived as a ‘necessary evil’ by many clinical staff.
To explore why seclusion is perceived this way, and
why seclusion events in New Zealand mental health
services are reasonably common with long durations,
the context of the acute unit must be understood.
8 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
4.3 WHAT FACTORS INFLUENCE
SECLUSION PRACTICE?
There are a number of factors that influence seclusion
practice, including systemic constraints, resource
limitations, architectural issues, staffing and
management processes, and service user
characteristics. Key factors however are:
• Unclear policy and guidelines – Guideline
documents do not clearly define seclusion or
differentiate it from other practices, such as Night
Safety Orders (the locking of bedroom doors at
night within an acute unit). As a consequence ultra
vires practice is common. The Restraint
Minimisation and Safe Practice Standard (the
Standard) does acknowledge ultra vires seclusion
practice (section 1.3.12 pg. 7) but gives little
guidance on how to clarify the issue, especially in
regards to monitoring.
Also, the Mental Health (Compulsory Assessment
and Treatment) Act 1992 does justify the use of
seclusion as a ‘treatment’. The Standard, however,
indicates that seclusion is a containment procedure
that can be used to manage potentially violent or
destructive behaviour. This discrepancy needs
clarification. If seclusion is a ‘treatment’ then its
rationale becomes one of therapy. If seclusion is a
‘containment’ procedure, then its rationale is one
of management, with no expectation that the
service user will get ‘better’ through the procedure.
The intention that lies behind the use of seclusion
could significantly influence its frequency of use.
Seclusion as a therapy would encourage use, as it
‘makes people better’. Seclusion as a containment
procedure, however, should discourage use, as it
takes on a custodial perspective against the
philosophy of nursing care and therapeutic
intervention.
• Overcrowding – Seclusion can be influenced by
high demands on a service, which causes
overcrowding within the acute setting, thus
increasing the likelihood of agitated behaviour
amongst service users.
25
Norris, M. K. and Kennedy, C. W. (1992) How Patients Perceive the
Seclusion Process, Journal of Psychosocial Nursing, 30 (3), p.7.
26
Mental Health Act Commission – Response to Women’s Mental
Health: Into the Mainstream, Strategic Development of Mental
Health Care for Women, December 2002.
seclusion is compromised. Perceived risk can be
increased where clinical staff become more anxious
about managing the ward environment and place
people in seclusion as a risk management
procedure.
Overcrowding also alters the nature of nursing care
by creating an environment that requires extensive
management. Cleary et al (pg. 509)27 suggests:
Recently, claims have been made that psychiatric
nurses do not interact in a therapeutic manner
...The need to maintain ward order, to manage
patients, other staff and the environment, places
pressure on nursing staff who cope by utilising
a custodial model of care thereby creating a
barrier to effective therapeutic interaction.
An overcrowded acute ward can be seen to
encourage the use of seclusion as a containment
procedure, to manage risk and to manage available
resources.
• Poor ward design – A ward that lacks quiet rooms,
personal space, and is not conducive to staff-service
user interaction tends to increase the likelihood of
agitation and hence seclusion. There is an inverse
relationship between a ward environment that
enables easy observation and the level of agitation
by service users. Old psychiatric institutions tended
to have large open spaces, bright lighting and seats
arranged so nurses could easily observe people.
Unfortunately, such spaces are often counter to
therapeutic needs and can increase the degree of
agitation experienced on a ward. Conversely, a
ward environment that has a lot of private space
also demands greater interaction from staff in order
to maintain the necessary level of observation.
Issues of dignity and cultural appropriateness are
also impacted by ward design, which could also
increase the levels of agitation within the ward; the
use of surveillance cameras, and the availability of
toilets and showers for example. These issues are
of particular concern to Māori and Pacific people.
• Low or inflexible staff numbers – Low staff numbers
compromise the care and philosophy of care by
increasing the demand upon nurses to ‘manage’ the
ward environment and thus interact less with service
users. So although Higgins28 suggests that a staffservice user ratio of 1:1.5 was ideal to minimising
seclusion use, staff availability and quality of
interaction may be more important. The tendency
for seclusion to be used least at night when staffservice user ratios are often high supports this
view. 29 Low staff numbers do influence the
availability of staff and the quality of interactions
however.
Low staff numbers can also increase real and
perceived risk on the ward. Real risk can be
increased where regular observation of people in
• Inexperienced staff – Experienced staff are key to
best practice. Considerable skill is required to use
alternative interventions such as de-escalation and
specialling (one-to-one or two-to-one nursing).
Likewise, managing the ward environment and
being able to interpret early signs of agitation can
only be learnt over time.
The interpretation of behaviour by staff is also
culturally bound. Agitation can be displayed
differently depending on the group in question. This
can increase the likelihood of seclusion use as a
risk management procedure. Māori and Pacific
people are most likely to be affected in this regard.
• Poor staff retention – Retaining quality staff is
important because there is a need to ensure
continuity in the care environment. Good care
requires good relationships and communication
between staff and service users and these can only
be built over time. Seclusion often results from
misunderstanding and inaccurate perceptions of
risk. Moreover, staff retention aids the development
of information sharing between the acute unit and
community services as relationships are built
between key personnel.
• Poor information sharing – Seclusion can occur
when appropriate information is not shared with a
service. Information about agitation risk, best
treatment options and so on need to be shared
between community services and acute units. Lack
of information can lead to inappropriate use of
seclusion.
• Service user acuity – Service users who are
extremely agitated and pose serious risks to self and
others leave clinical staff with few alternatives but
to use some form of containment or restraint.
Seclusion rooms may be the only facility available
where such a person can be contained safely. The
evidence points to high levels of acuity amongst
those presenting to acute inpatient units and a view
27
Cleary, M., Edwards, C., and Meehan, T. (n.d.) Factors Influencing
Nurse-Patient Interaction in the Acute Psychiatric Setting: An
Exploratory Investigation, unpublished paper.
28
Higgins, J. (1981) Four Years Experience of an Interim Secure Unit,
British Medical Journal, 292, pp. 889-893.
29
Oldham, J. M., Russakoff, L. M. and Prusnofsky, L. (1983) Seclusion:
Patterns and Milieu, The Journal of Nervous and Mental Disease, 171
(11), pp. 645-650.
CHAPTER FOUR: FINDINGS 9
that seclusion is a necessary tool to manage
profound levels of disturbance and agitation, which
may be drug induced.
Seclusion is supposed to be a ‘last resort’ intervention.
However, in practice the resources, staffing constraints
and the operational environment limit the use of
alternative practices (e.g., quiet lounges, specialling,
time out, confinement without isolation or reduced
sensory input). Seclusion reduces risks and ambiguity
for staff and is a procedure justified by legislation and
policy. Within such an environment, seclusion can
become an all too easy intervention. This raises serious
questions about human rights and the duty of care.
4.4 HUMAN RIGHTS AND DUTY OF
CARE ISSUES
As a form of detention, seclusion practice does require
commentary from a human rights perspective. The
Human Rights Commission’s 1991 report to the Prime
Minister (“Mental Health - Patient Rights and the Public
Interest”) sets out a detailed discussion of the interface
between mental health detention and human rights law.
More recently, the Human Rights Commission, as a
component of the National Action Plan, has looked
again at the issue of detention, which includes issues
relating to seclusion in the mental health setting. That
report is to be submitted to the Prime Minister by the
end of 2004. This brief commentary on human rights
and seclusion is a continuation of a debate initiated
over a decade ago and is part of a growing human
rights discourse in New Zealand.
In 1991, the Human Rights Commission stated:
International instruments on human rights set the
standards by which all people should be permitted
to live. The ideal standards for treatment of mentally
ill people are delineated in a number of them.
Although the Commission acknowledges that
conforming with all the principles laid down in the
instruments is difficult, and providing a service that
satisfies everyone even more so, nevertheless
attempts should be made to meet the criteria
outlined. (pg. 59)
The Mental Health Commission does not suggest that
the seclusion legal framework breaches human rights
law. The Commission does suggest that seclusion
practice sits uneasily with a number of international
agreements to which New Zealand is a signatory. For
example, The Universal Declaration of Human Rights
(Article 5) and the International Covenant on Civil and
10 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
Political Rights (Article 7) both prohibit practices that
can be perceived as torturous, cruel, inhumane or
degrading, whether as a treatment or punishment. New
Zealand was also one of 119 countries to ratify the
Convention Against Torture and other forms of Cruel,
Inhuman and Degrading Treatment (CAT). The CAT
defines torture as:
...any act by which severe pain or suffering, whether
physical or mental, is intentionally inflicted on a
person for such purposes as...punishing him for an
act which he or a third person has committed
...when such pain and suffering is inflicted by or at
the instigation or with the consent or acquiescence
of a public official or other person acting in an
official capacity.30
Section 9 of the New Zealand Bill of Rights Act 1990
and the United Nations Principles for the Protection of
Persons with Mental Illness and for the Improvement
of Mental Health Care (1991) reiterate these statements
on torture, cruel, inhumane and degrading treatment.
Although seclusion is not legally sanctioned in New
Zealand as a punishment, it is clearly perceived as a
punishment by many service users and the potential
harm is the same regardless of whether seclusion is
used for therapy, containment or punishment.
The term ‘torture’ is however debatable and rests on
the interpretation of the phrase ‘severe pain or suffering’
in the CAT. Case law in the UK has concluded that
solitary confinement in itself is not torture but the
conditions of the confinement may lend themselves to
cruel and inhumane treatment; for example, where
persons are placed in a room that lacks sanitation.31
Individual responses to such conditions may vary, so
whereas unsanitary conditions are tolerable for some,
they may be intolerable, cruel and inhumane for others.
What can be said, then, is that in rare cases seclusion
places some people at risk of cruel, inhumane and
degrading treatment, which can lead to significant
psychological harm.
In regards to the duty of care, staff within inpatient units
have an obligation to protect all service users from
potential harm. This is particularly pertinent where
service users are committed under the Act and deprived
of their liberty. The environment of the acute unit, or
any other mental health facility, should be therapeutic
not custodial.
30
Dec 10 1984, GA Res 39/46, U.N. GAOR 39th Session Supp No 51 at
197, UN Doc E/CN 4/1984/72 (1984), Article 1.
31
Foley, K. (2000) Solitary Confinement: A Violation of International
Law?, e-valuate, Vol. 3, Online Document, Available at:
www.law.ecel.uwa.edu/elawjournal.
4.5 MONITORING
Seclusion incidents are recorded in a register that can
be scrutinised by District Inspectors (required under
section 129b of the Act). The Standard also requires
that a specific form be used, and that 10 minute and
two-hourly observations are made and noted. It is up
to the discretion of District Inspectors as to the
frequency of seclusion monitoring. No central
monitoring of seclusion currently occurs.
As mentioned above, although guideline documents
acknowledge that ‘practices similar to seclusion occur
in many health and disability settings...[including] night
safety orders... “time out” and isolating consumers for
the protection of themselves and/or others’ (The
Standard, pg. 7), these practices do not receive the same
level of scrutiny as seclusion proper. It is up to each
individual service to develop policies and procedures
to ensure these practices are used appropriately.
32
‘Critical Incidents’ are now referred to as ‘Reportable Events’ by the
Ministry of Health.
33
Guidelines for Reporting and Review of Incidents in Mental Health
Services: Revised Version (December 1995), Ministry of Health.
Also, given the research evidence sees seclusion as
potentially psychologically damaging, seclusion events
should therefore be classified as ‘critical incidents’.32
Critical incidents are defined as an ‘event that is
physically, psychologically, spiritually or culturally
harmful or potentially harmful to a client or other
person’ (pg. 2).33 This reclassification would add an
additional layer of quality assurance and add robustness
to the monitoring of seclusion practice.
For the potential impact seclusion can have on a person
there do not appear to be sufficient checks and balances
in place to encourage best practice. Evidence does
suggest, however, that close monitoring may provide
an incentive for this to occur.
CHAPTER FOUR: FINDINGS 11
12 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
five
Conclusion
Over the last three decades, researchers, clinicians and
service users have put forward a range of views on
seclusion. These views are the product of research,
clinical practice and personal testimony. And as diverse
as these views are, a consensus is now emerging that
questions the legitimacy of seclusion practice in the
modern mental health setting. As a therapeutic
intervention, seclusion was portrayed as solitude – calm,
serene and contemplative. Evidence now suggests that
seclusion poses significant risks to service users,
including death, re-traumatisation, loss of dignity and
other psychological harm. As a punishment, seclusion
has been portrayed as remedial, although this rationale
is not sanctioned under New Zealand law.
Seclusion as a containment procedure requires more
careful examination. This rationale is sanctioned in
statute34 and is justified by quite reasonable arguments.
Containment is seen as a mechanism to protect the
service user and others from harm, and until better
alternatives arise, containing people in seclusion rooms
is perceived as a ‘necessary evil’. Questions can be asked
regarding the degree of restriction imposed by seclusion,
though. Does seclusion impose an unnecessary degree
of restriction on people where least restrictive practice
is the most desirable model of care? In other words, does
containment of a person also necessitate the need for
isolation and reduced sensory input? Seclusion appears
to be an all-or-nothing approach and consequently the
degree of restriction may pose unjustifiable infringements
on rights, freedoms and privileges.
Finally, as a form of detention, seclusion requires human
rights considerations. It is important to note that there is
no evidence that seclusion practice breaches New
Zealand human rights law. Seclusion practice does sit
uneasily with international human rights instruments
however. Human rights considerations can be seen to
add a layer of protection in seclusion practice.
These things considered, the issue at hand appears not
to be a question concerning the appropriateness of
seclusion practice, but rather how extreme violence, or
the risk of extreme violence, can be managed within a
psychiatric acute ward? If this is the true problem, then
the focus changes. All factors that relate to violence
should come under scrutiny, this includes the origin of
violence, ways to divert, predict and prevent its
occurrence.35 Our examination of the acute ward context
gives some insight into factors that may influence
agitation on the ward. Outside of the ward, crisis
prevention strategies such as greater access to support
workers, psychotherapy, alternative treatments, peer
support and recovery education options may prevent
crises from occurring.36 Minimising the pressure on acute
wards by building community capacity and intersectoral
cooperation could also resolve many of the systemic
issues that influence ward agitation and violence.
The Commission would like to see a significant reduction
in seclusion use and its eventual eradication. The
pathway towards eradication would require several years
of development work including research, staff training
programmes, which would promote ways to prevent
seclusion and identify humane alternatives, and a
strengthened monitoring regime. The last of these is of
utmost importance for it would allow the measurement
of progress towards eradication. Redefining seclusion
as a ‘critical incident’ or ‘reportable event’ would add
to a strengthened monitoring programme.
It is noteworthy that under the existing Restraint
Minimisation and Safe Practice Standard (2001) least
restrictive practice is a requirement, and demonstrated
competence focusing on de-escalation skills and the
minimisation and elimination of restraint is emphasised.
The Commission supports these requirements
wholeheartedly, but sees stringent monitoring as the
most useful tool to encourage best practice and clarify
the pathway towards eradication.
34
The Mental Health (Compulsory Treatment and Assessment) Act 1992.
35
Alty, A. and Mason, T. (1994) Seclusion and Mental Health: A Break
with the Past, London, Chapman and Hall.
36
O’Hagan, M. (2003) Force in Mental Health Services: International
User/Survivor Perspectives, Incite, Vol. 2, No. 1, pp. 3-14.
CHAPTER FIVE: CONCLUSION 13
14 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
CHAPTER
six
Next Steps
The Minister of Health Hon Annette King, the Ministry
of Health and the Mental Health Commission agree
that this review of seclusion in mental health services
is the beginning of a path forward, which will enable
us to understand seclusion better and substantially
reduce its use.
The Mental Health Commission is to ask the Ministry
of Health and Standards New Zealand to redefine
seclusion in current guideline documents, ensuring that
all practice that embodies confinement, isolation and
a reduction in sensory input is acknowledged as
seclusion.
The Ministry of Health is developing an auditable
requirement for each District Health Board to establish
a debriefing system which provides that each seclusion
event is followed by a formal debriefing of staff and
the person secluded, and a formal report is prepared
for file and the relevant District Inspector for his/her
consideration.
By June 2006 the Ministry of Health will capture detailed
data surrounding seclusion events as part of the Mental
Health Information National Collection (MHINC).
To enable the progress towards significant reduction in
seclusion use to be monitored, the Commission is to
request the Ministry to include rates of seclusion use in
DHB service profiles.
Collaborative work will be undertaken between the
Mental Health Commission, the Human Rights
Commission and the Health and Disability
Commissioner to clarify the human rights issues around
the use of seclusion.
These initiatives will make a substantial contribution to
a unified understanding of what seclusion is and the
establishment of a stringent monitoring regime to enable
information on seclusion to be compared and
benchmarked. As a result, we will be able to assess our
progress toward the reduction and the eventual
eradication of seclusion.
CHAPTER SIX: NEXT STEPS 15
16 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
APPENDIX
A
Alty and Mason’s (1994)
Benevolent-Malevolent Scale Model
S E C L U S I O N
BENEVOLENT
Relationship formation
Maturation
Mastering of Space
Isolation
Decrease in Sensory Input
THERAPY
Protection of Milieu
Place where Other Therapies Applied
Emergency Medication
Facilitates Diagnosis
MALEVOLENT
Social Control
BENEVOLENT
Safety of Self
Safety of Others
Safety of Property
Internal/External Control
Repression of Aggression
CONTAINMENT
No Other Alternative
Mitigating Staff Anxiety
Elective Seclusion
MALEVOLENT
Durations of Seclusion
BENEVOLENT
Paternalism
Behaviour Modification
Ethological Model
Institutional Control
PUNISHMENT
Sensory Deprivation
MALEVOLENT
Revenge/Sadism
APPENDICES 17
APPENDIX
B
Key Seclusion Documents
Key documents that relate to seclusion and its operation
are:
• Guidelines for Effective Consumer Participation in
Mental Health Services (1995)
• Guidelines to the Mental Health (Compulsory
Assessment and Treatment) Act 1992 (1995)
• Guidelines for Cultural Assessment in Mental Health
Services (1995)
• Guidelines for Reducing Violence in Mental Health
Services (1994)
• Guidelines for Clinical Risk Assessment and
Management in Mental Health Services (1998)
• Restraint Minimization and Safe Practice (Feb 2001)
• Procedural Guidelines for the Use of Seclusion
(Revised Edition) (1995)
18 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
• Guidelines for Reporting and Review of Incidents
in Mental Health Services: Revised Version
(December 1995)
• Guidelines for Discharge Planning for People with
Mental Illness (1993)
The ordering for these documents is not random. They
are organised to match the process of a consumer
moving through an acute unit and back into the
community. These documents provide an overview of
processes, procedures and approaches within mental
health services. The important point is that seclusion
is not an isolated process, and as such, the procedural
guidelines for seclusion (or the Restraint Minimisation
and Safe Practice Standard) should not be considered
the only relevant guide document.
The Ministry of Health has been updating these
documents. The Restraint Minimisation and Safe
Practice Standard, for example, replaces the Procedural
Guidelines for the Use of Seclusion.
APPENDIX
C
Methods and Methodology
1. SURVEY
Process
The Mental Health Commission and the Ministry of
Health conducted a joint survey of all DHBs starting in
June 2001. The Commission was responsible for the
development of the survey and the data analysis. The
Ministry was responsible for sending out the survey
and collecting the returns.
The survey had four sections relating to the
management of seclusion – admissions statistics,
information on service users who were placed in
seclusion, and general feedback from the service about
seclusion and the survey itself. From this information,
a spreadsheet database was developed with quantitative
analysis identifying key trends, such as the level of
seclusion in New Zealand, both at national and regional
levels; the biographical make-up of people who were
secluded; duration in seclusion; details of the acute
ward environment; and information on the
management of seclusion.
Issues
The survey process was constrained by a number of
factors. The most significant of these was that more
than one version of the survey questionnaire was sent
out to DHBs. Of those who filled out the survey,
approximately half filled out version 1, while the other
half filled out version 3. While both versions had the
same general format and schemata, there were
fundamental differences in the way the data was
categorised.
Section 3, for example, which related to information
on service users that have been in seclusion, was a
concern. Version 1 categorised the data in terms of
individual service users, their biographical categories,
and the amount of time spent in seclusion per month.
Version 1 allowed for an analysis of full biographical
statistics per service user, and the hours that each
person had spent in seclusion on a monthly basis.
Version 3 categorised each individual episode of
seclusion by category of hours spent in seclusion and
biographical categories, but there was no way of
knowing which person (e.g. Māori, aged 31, male) had
been put in seclusion and for how long. This not only
made it difficult to compare accurately between survey
versions, due to the incongruity of format, but it also
made it difficult to get the individual service user
profiles from those services that had answered survey
version 3.
2. LITERATURE ANALYSIS
Aspects of constant comparative analysis and metasynthesis were used to formulate the findings of this
report. Meta-synthesis is a means whereby “scholars
[can] find ways to apprehend and re-present different
representations to achieve fuller knowing”
(Sandelowski, 1993:3). It has been justified by Jensen
and Allen (1996) in the following way:
Although informative, isolated studies in and of
themselves, like the pieces of a jigsaw puzzle, do
not contribute significantly to our full understanding
of the phenomenon of interest. In order to advance
knowledge and influence practice, a synthesis of
representations is essential. This synthesis of findings
across studies is a type of secondary analysis
particular to qualitative research, which provides a
powerful approach to theory development.
(Proquest electronic document)
Meta-synthesis is significantly different than reviewing
the literature. A literature review attempts to cover the
range of work done on a particular area (e.g., seclusion).
The more work that is covered, the more thorough the
literature review is perceived to be. Also, within
literature reviews methodologies are commented on
to show the strengths or weaknesses of certain research
approaches. Literature reviews typically describe the
research domain.
APPENDICES 19
By contrast, our approach conceptualises the literature
by seeing the literature as data able to be merged or
synthesised to achieve a higher level of understanding.
This approach is not too dissimilar to the Hegelian
approach to theory development (thesis + anti-thesis =
synthesis). Essentially, a research article may be broken
down into component parts through a process of
qualitative coding. Similar and dissimilar codes are
compared constantly. Codes are refined through an
iterative process of moving between data and our
emergent synthesis. Eventually, codes and the concepts
they represent are positioned logically into a suggested
model of the phenomenon under study.
Data Selection
There are a number of issues relating to sampling. The
boundaries of the study must be clearly defined. In our
study, the boundaries can be seen as ‘inappropriate
use’ and ‘overuse’ of seclusion as indicated in the
Mental Health Commission’s seclusion discussion
document (Use of Seclusion in New Zealand Mental
Health Services, 1999). This defines the issue under
study. The sampling of literature was also based on a
clear definition of seclusion. We suggested that
seclusion is comprised of three key components:
containment, isolation and reduction in sensory input.
Theoretical sampling was used to guide the ongoing
selection of data and refine theory development. This
approach is fundamentally different from random
sampling, the normative sampling technique.
Theoretical sampling is used to discover concepts and
their properties, and to reveal interconnections in a
theory. Random sampling is used to “obtain accurate
evidence on distributions of people among categories
to be used in descriptions or verifications” (Glaser and
Strauss, 1967:62-3). Given this distinction, sample size
is less relevant for our purposes. Our aim is to suggest
theory and to verify it only within the confines of the
study itself.
Constraint Composition Analysis
Constraint composition analysis is a useful way of
understanding the imperfections in research. It states
that constraints are built into all researches; these
accumulate over the course of a study and eventually
lead to a problem being resolved (Haig, 1987 in Yee,
2001). Constraints can take many forms; time is a good
example of a constraint. The less time one has the more
innovative one must become to complete the project.
Lack of specific data is another common constraint.
20 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
The dearth of New Zealand-based research on
seclusion was a clear limitation of this study. Constraint
composition analysis allows us to understand research
in a real world context and shows us how research
limitations can shape a research report.
Credibility
The term credibility is used in qualitative research more
often than validity because the latter is bundled with
meanings associated with quantitative (or positivistic)
work. Jensen and Allen (1996) describe credibility as
an inherent component of rigour when they write:
...rigor is essential to achieve credible and consistent
descriptions of the phenomenon. The general
themes of credibility, auditability, and fittingness
persist as criteria for scientific rigor. The truth value
of qualitative account synthesis would reside in the
discovery of human phenomena or experiences as
they are lived and perceived by subjects, rather than
in the verification of a prior conceptions of those
experience. Thus, a meta-synthesis is rooted in the
original data and is credible when it re-presents such
faithful descriptions or interpretations of a human
experience that the people having that experience
would immediately recognize it from those
descriptions or interpretations as their own.
Consequently, achieving credible interpretations is
fostered if original studies provide exemplars.
[Our study] meets the criterion of fittingness when
the findings can fit into contexts outside the studies
and when the findings are grounded in the life
experience studied and reflect their typical and
atypical elements. Furthermore, an interpretive
synthesis is auditable when the same or comparable
conclusions can be achieved, given the data.
Findings are internally validated through the quotes
of the studies’ participants and the metaphors used
to describe these experiences and externally
validated through comparisons with theoretical
literature. Lastly, confirmability is achieved when
auditability, truth value, and applicability are
achieved.
(Proquest electronic document)
Other Methodological Issues
4. CONSULTATION AND SITE VISITS
Questions must be asked regarding the comparability
of research literature that adopt different methods and
underlying philosophies. How comparable can these
studies be? Can they be synthesised at all? The answer
to this question is partially answered in the above
section on credibility, where any study that captures
human experience should be recognisable to people
in the field. If a synthesised study captures a
recognisable process, then the methodological or
philosophical differences between studies becomes
irrelevant. In essence, if the social world is seen as
integrated and seamless by ordinary people, then a
theory that is equally so is credible.
Throughout the seclusion project, consultation and
advice was taken from a variety of groups. In particular,
the Mental Health Commission’s clinical and service
user reference groups commented on significant parts
of the project. An external service user advisor also
contributed to the project and an external academic
peer reviewer assessed the literature analysis.
3. POLICY ANALYSIS
Key policy documents relating to seclusion were
collected. These included service policy, DHB policy
and the guiding documents from central government
(e.g., Restraint Minimisation and Safe Practice Standard,
and others listed in Appendix B). DHB and service
policies were compared to central government
guideline documents to identify similarities, differences,
and the findings from the literature analysis were
utilised to identify the degree of relevance to operation.
Site visits were conducted after the survey, literature
and policy analyses were complete. From this
information, four DHBs were selected to test our
findings and ground our analysis. The selection criteria
included geographical variation, demographic profile
variation, and the magnitude of seclusion. Letters were
written to the CEOs of each selected DHB and following
acceptance of our visit, seclusion data on each specific
DHB and letters of introduction were sent to relevant
mental health services. Site visits included one-to-one
discussion with service managers, clinical staff and
consumer advisors. Open forums were held in one
DHB. A tour through acute wards was also requested,
which included an examination of seclusion areas.
Notes were taken during each session and these were
analysed using qualitative methods against our
emergent framework developed from the literature and
policy analysis, survey findings and a priori
consultations.
APPENDICES 21
5. BIBLIOGRAPHY
Alty, A. and Mason, T. (1994) Seclusion and Mental Health: A Break with the Past, London, Chapman
and Hall.
An Executive Briefing on Adult Acute Inpatient Care for People with Mental Health Problems (Briefing
16), Sainsbury Centre for Mental Health (2003)
Binder, R. L., and McCoy, S. M. (1983) A Study of Patient Attitudes toward Placement in Seclusion,
Hospitals and Community Psychiatry, 34, pp. 1052-1054.
Blueprint for Mental Health Services in New Zealand: How Things Need to Be, (1998) Mental Health
Commission.
Burney, C. (1952) Solitary Confinement, New York, Conrad-McGann. Chamberlin, J. (1985) An Expatient’s Response to Soliday, The Journal of Nervous and Mental Disease, Vol. 173, pp. 289-290.
Cleary, M., Edwards, C., and Meehan, T. (n.d.) Factors Influencing Nurse-Patient Interaction in the
Acute Psychiatric Setting: An Exploratory Investigation, unpublished paper.
Criteria for the Design and Refurbishment of Psychiatric Acute and Intensive Care Facilities: A
Statement from the Ministry of Health, Ministry of Health (2002)
de Cangas, J. P. C. (July-September, 1993) Nursing Staff and Unit Characteristics: Do They Affect the
Use of Seclusion? Perspectives in Psychiatric Care, Vol. 29, No. 3, pp. 15-21.
Dreikurs, R. and Gren, L. (1968) A New Approach to Discipline: Logical Consequences, New York,
Hawthorne.
Flaherty, J. A., and Meagher, R. (1980) Measuring Racial Bias in Inpatient Treatment, American
Journal of Psychiatry, Vol. 137, No. 6, pp. 679-682.
Friasse, P. (1973) Temporal Isolation, Activity, Rhythms and Time Estimation, in Rasmussen, J. (ed.),
Man in Isolation and Confinement, Chicago, Adeline.
Glaser, B. G. (1978) Theoretical Sensitivity: Advances in the Methodology of Grounded Theory,
California, Sociology Press.
Glaser, B. G. and Strauss, A. L. (1967) The Discovery of Grounded Theory: Strategies for Qualitative
Research, Chicago, Aldine Publishers.
Goffman, E. (1961) Asylums: Essays on the Social Situation of Mental Patients and Other Inmates,
New York, Doubleday Anchor.
Guidelines for Reducing Violence in Mental Health Services, Ministry of Health, (1994)
Gulak, M. (July, 1991) Architectural Guidelines for State Psychiatric Hospitals, Hospital and
Community Psychiatry, Vol. 42, No. 7, pp. 705-707.
Gutheil, T. G. (1978) Observations on the theoretical basis for seclusion of the psychiatric inpatient.
American Journal of Psychiatry, 135, pp. 325-328.
Hermit website – www.artsima.org/mythology/slide13 accessed 11 May 2002.
Heyman, E. (1987) Seclusion, Journal of Psychological Nursing and Mental Health Services, 25 (11),
pp. 9-12.
Jackson, M. (1983) Prison and Isolation: Solitary Confinement in Canada, Toronto, University of
Toronto Press.
22 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
Jensen, L. A. and Allen, M. N. (November, 1996) Meta-Synthesis of Qualitative Research Findings,
Qualitative Health Research, [Electronic Document] Proquest Database, University of Waikato.
Kalogjera, I. J., Bedi, A., Watson, W. N., and Meyer, A. D. (1989) Impact of Therapeutic Management
on Use of Seclusion and Restraint with Disruptive Adolescent Inpatients, Hospital and Community
Psychiatry, Vol. 40, No. 3, March, pp. 280-285.
Lapsley, H (2003) Mental Health Sector Systems Approach to Recovery, Unpublished Mental Health
Commission Discussion Document.
Learning from Each Other: Success Stories and Ideas for Reducing Restraint/Seclusion in Behavioral
Health, American Psychiatric Association, American Psychiatric Nurses Association, National Association
of Psychiatric Health Systems (2003).
Available at http://www.psych.org/clin_res/LearningfromEachOther.pdf.
MacKenzie, H. (2002) An Evaluation Framework for Mental Illness Anti-Discrimination, unpublished
report prepared for the Mental Health Commission.
Martinez, R. J., Grimm, M., and Adamson, M. (1999) From the Other Side of the Door: Patient Views of
Seclusion, Journal of Psychosocial Nursing, Vol. 37, No. 3, pp. 13-22.
Mason, T. (1997) An Ethnomethodological Analysis of the Use of Seclusion, Journal of Advanced Nursing,
Vol. 26, pp. 780-789.
Mason, T. and Whittington, R. (November, 1995) Seclusion: Te Use of a Stress Model to Appraise the
Problem, Nursing Times, Vol. 91, No. 48, pp. 31-33.
McBride, S. (August, 1996) Seclusion Versus Empowerment: A Psychiatric Care Dilemma, The Canadian
Nurse, pp. 36-39.
McConnell, S. (1981) A History of English Prison Administration 1750-1877 (Vol. 1), Routledge, London.
Meehan, T., Winsor, C., and Vermeer, C. (2000) Patients’ Perceptions of Seclusion: A Qualitative
Investigation, Journal of Advanced Nursing, Vol. 31, No. 2, pp. 370-377.
Melossi, D. (1991) The Establishment of Modern Prison Practice in Continental Europe, in Munce, J. and
Starkes, R. (eds.) Imprisonment: European Perspectives, London, Harvester Wheatsheaf.
Mental Health Commission (1998), The Blueprint for Mental Health Services, Wellington, Mental Health
Commission.
Morrison, P. (1990) A Multidimensional Scalogram Analysis of the Use of Seclusion in Acute Psychiatric
Settings, Journal of Advanced Nursing, Vol. 15, pp. 59-66.
Morrison, P. and Lehane, M. (1995) Staffing Levels and Seclusion Use, Journal of Advanced Nursing,
Vol. 22, pp. 1193-1202.
Muir-Cochrane, E. (1996) An Investigation into Nurses’ Perceptions of Secluding Patients on Closed
Psychiatric Wards, Journal of Advanced Nursing, Vol. 23, pp. 555-563.
Nearman, S. (1975) Suggestions of the Devil, New York, Doubleday.
Niebuhr, G. (30 October, 2001) A City Dweller Chooses Hermit Life, New York Times.
Night Safety Procedures, Ministry of Health (June 1995)
Norris, M. and Kennedy, C. (1992) The View from Within: How Patients Perceive the Seclusion Process,
Journal of Psychosocial Nursing and Mental Health Services, Vol. 30, No. 3, pp. 7-13.
APPENDICES 23
O’Hagan, M. (2003) Force in Mental Health Services: International User/Survivor Perspectives, Incite,
Vol. 2, No. 1, pp. 3-14.
Onions, C. T. (1967) The Shorter Oxford English Dictionary (3rd ed), Oxford, Clarendon Press.
Procedural Guidelines to the Use of Seclusion, Ministry of Health (1995)
Pugh, R. (1968) Imprisonment in Medieval England, Cambridge, Cambridge University Press.
Sandelowski, M (1993) Rigor or Rigor Mortis: The Problem of Rigor in Qualitative Research Revisited,
Advances in Nursing Science, Vol. 16, No. 2, pp. 1-8.
Schwartz, B. (1993) The Social Psychology of Privacy, in Glaser, B. G. (ed.), Examples of Grounded
Theory: A Reader, California, Sociology Press, pp. 360-379.
Soliday, S. M. (1985) A Comparison of Patient and Staff Attitudes toward Seclusion, Journal of Nervous
and Mental Disease, Vol. 173, No. 5, pp. 282-286.
Standards New Zealand (February, 2001) Restraint Minimization and Safe Practice, Wellington, Ministry
of Health.
Standards on Restraint Minimisation and Seclusion, Ministry of Health (2001)
Time out website www.gosin/com/timeout.htm accessed 18 May 2002
Topping-Morris, B. (August, 1994) Seclusion: Examining the Nurse’s Role, Nursing Standard Vol. 8, No.
49, pp. 35-37.
Tse, S. (In press, 2004) Use of Recovery Approach to Support Chinese Immigrants Recovering from
Mental Illness: A New Zealand Perspective. American Journal of Psychiatric Rehabilitation, 7 (1).
Walsh, E. (January-March, 1995) Seclusion and Restraint: What We Need to Know, Journal of Child and
Adolescent Psychiatric Nursing, pp. 28-40.
Yee, B. (2001) Enhancing Security: A Grounded Theory of Chinese Survival in New Zealand, Unpublished
PhD Dissertation, University of Canterbury.
Yee, B. (2003) Coping with Insecurity: Everyday Experiences of Chinese New Zealanders, in Unfolding
History, Evolving Identity: The Chinese in New Zealand, Edited by Manying Ip, Auckland, Auckland
University Press, pp. 215-235.
Yee B, and Bateman S (2003). Seclusion: The Views of Service Users. Incite, Vol. 2 (2) pp. 3-10.
Zubek, J.P. (1973) Behavioural and Psychological Effects of Prolonged Sensory and Perceptual Deprivation,
in Rasmussen, J. (ed.), Man in Isolation and Confinement. Chicago, Adeline.
24 SECLUSION IN NEW ZEALAND MENTAL HEALTH SERVICES
APPENDIX
D
Resources for the Reduction of Seclusion
A Toolkit for Reducing/Eliminating the Use of Seclusion and Restraint in Psychiatric Inpatient
Settings, available from Professor Judith Cook, Mental Health Services Research Program,
Department of Psychiatry, University of Illinois at Chicago.
Leading the Way Toward a Seclusion and Restraint-Free Environment – Pennsylvania’s Seclusion
and Restraint Reduction Initiative, Harrisburg Office of Mental Health and Substance Abuse
Services, 2000.
Learning from each other – Success Stories and Ideas for Reducing Restraint/Seclusion in
Behavioural Health, American Psychiatric Association, American Psychiatric Nurses
Association, National Association of Psychiatric Health Systems (2003), available from http://
omni.ac.uk/whatsnew/detail/17011971.html
Reducing Staff Injuries and Violence in A Forensic Psychiatric Setting, Archives of Psychiatric
Nursing, Vol. XVI, No. 3 (June) 2002 pp. 108-117, Morrison, E., Morman, G., Bonner, G.,
Taylor, C., Abraham, I., and Lathan, L.
APPENDICES 25