title: Innovation and pragmatism required to reduce seclusion practices.
abstract: Seclusion may be harmful and traumatic to patients, detrimental to therapeutic relationships, and can result in physical injury to staff. Further, strategies to reduce seclusion have been identified as a potential method of improving cost-effectiveness of psychiatric services. However, developing alternative strategies to seclusion can be difficult. Interventions to reduce seclusion do not lend themselves to evaluation using randomized controlled trials (RCTs), though comprehensive literature reviews have demonstrated considerable non-RCT evidence for interventions to reduce seclusion in psychiatric facilities. In the UK, a recent 5-year evaluation of seclusion practice in a high secure UK hospital revealed reduced rates of seclusion without an increase in adverse incidents. To assess the effect of a novel intervention strategy for reduction of long-term segregation on a high secure, high dependency forensic psychiatry ward in the UK, we introduced a pilot program involving stratified levels of seclusion ("long-term segregation"), multidisciplinary feedback and information sharing, and a bespoke occupational therapy program. Reduced seclusion was demonstrated and staff feedback was mainly positive, indicating increased dynamism and empowerment on the ward. A more structured, stratified approach to seclusion, incorporating multidisciplinary team-working, senior administrative involvement, dynamic risk assessment, and bespoke occupational therapy may lead to a more effective model of reducing seclusion in high secure hospitals and other psychiatric settings. While lacking an evidence base at the level of RCTs, innovative, pragmatic strategies are likely to have an impact at a clinical level and should guide future practice and research.
authors: Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry and South London and Maudsley Foundation Trust, London, UK.
authors: John
authors: J
authors: Tully
authors: High Dependency Service, Broadmoor Hospital, Crowthorne, UK.
authors: Leo
authors: L
authors: McSweeney
authors: High Dependency Service, Broadmoor Hospital, Crowthorne, UK.
authors: Katie-Lynn
authors: KL
authors: Harfield
authors: High Dependency Service, Broadmoor Hospital, Crowthorne, UK.
authors: Cindie
authors: C
authors: Castle
authors: High Dependency Service, Broadmoor Hospital, Crowthorne, UK.
authors: Mrigendra
authors: M
authors: Das
mesh_terms: D019317:Evidence-Based Medicine; D005555:Forensic Psychiatry; D006778:Hospitals, Psychiatric; D006801:Humans; D001523:Mental Disorders / Q000628:therapy*; D009788:Occupational Therapy; D010348:Patient Care Team; D010356:Patient Isolation; D010817:Physician-Patient Relations; D010865:Pilot Projects; D006113:United Kingdom
keywords: Information sharing; multidisciplinary feedback; nonpharmacological interventions; occupational therapy; relational security; staff education; supervised confinement