Seclusion in the context of recovery-oriented practice: the perspectives and experiences of psychologists in Ireland

Antaine Stíobhairt (School of Psychology, University College Dublin, Dublin, Ireland and Health Service Executive, Dublin, Ireland)
Nicole Cassidy (Independent Researcher based at Dublin, Ireland)
Niamh Clarke (Community Health Organization 8, Health Service Executive, Dublin, Ireland)
Suzanne Guerin (School of Psychology, University College Dublin, Dublin, Ireland)

Mental Health Review Journal

ISSN: 1361-9322

Article publication date: 25 July 2023

Issue publication date: 1 February 2024

365

Abstract

Purpose

This paper aims to explore the roles of psychologists in seclusion in adult mental health services in Ireland, their perspectives on seclusion and its use in recovery-oriented practice and related professional practice issues.

Design/methodology/approach

A qualitative hermeneutic phenomenological study was conducted from a social constructivist perspective. Semi-structured interviews with 17 psychologists were analysed using reflexive thematic analysis.

Findings

Twenty-four themes were identified, which were clustered into four overarching themes. Participants viewed themselves and psychology in Ireland more broadly as peripheral to seclusion. They believed that seclusion possessed no inherent therapeutic value but viewed it as an uncomfortable and multi-faceted reality. Participants regarded seclusion and recovery as largely inconsistent and difficult to reconcile, and they perceived systemic factors, which had a pervasive negative impact on seclusion and recovery in practice.

Practical implications

The findings highlight the perceived complexity of seclusion and its interface with recovery, and the need to conscientiously balance conflicting priorities that cannot be easily reconciled to ensure ethical practice. The findings suggest psychologists are well-suited to participate in local and national discussions on using seclusion in recovery-oriented practice.

Originality/value

This study offers a unique insight into psychologists’ perceptions of seclusion and considers the implications of these views. Participants’ nuanced views suggest that psychologists can make valuable contributions to local and national discussions on these topics.

Keywords

Citation

Stíobhairt, A., Cassidy, N., Clarke, N. and Guerin, S. (2024), "Seclusion in the context of recovery-oriented practice: the perspectives and experiences of psychologists in Ireland", Mental Health Review Journal, Vol. 29 No. 1, pp. 1-18. https://doi.org/10.1108/MHRJ-08-2022-0058

Publisher

:

Emerald Publishing Limited

Copyright © 2023, Antaine Stíobhairt, Nicole Cassidy, Niamh Clarke and Suzanne Guerin.

License

Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial & non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence may be seen at http://creativecommons.org/licences/by/4.0/legalcode


Introduction

Seclusion is widely classed as a “restrictive” or “coercive” intervention (National Institute for Health and Care Excellence, 2015; Tingleff et al., 2017) and has been defined by the World Health Organisation (WHO; 2012, p. 82) as the “placement of an individual alone in a locked room or secured area from which he or she is physically prevented from leaving”. Seclusion has traditionally been widely used in mental health services throughout the world (Mason, 1994a). The collection and synthesis of prevalence data are challenging (Janssen et al., 2011); however, recent research indicates significant variation across countries. Raboch et al. (2010) reported an overall prevalence of 6% among services users in adult mental health (AMH) settings across ten countries, with the UK accounting for 65% of the cases and Germany, Greece, Lithuania and Poland accounting for none. In Ireland, there were roughly 1,300–2,600 episodes of seclusion among 500–750 residents annually from 2008–2021 (Mental Health Commission, 2022a). Notably, these statistics include a small proportion of cases outside of AMH settings. The number of people secluded remained relatively static over time, but there has been a clear trend towards fewer episodes.

The theoretical basis, functions and implications of seclusion in practice have long been debated in the literature (Gutheil, 1978; Mason, 1994b; Plutchik et al., 1978). While many reasons have traditionally been proposed, many professional bodies and services now only support its use to reduce risk of harm to self and others where less restrictive methods are ineffective [American Psychiatric Nurses Association (APNA), 2018; Mason, 1994b; National Institute for Health and Care Excellence, 2015]. Areas of ongoing concern include the impact on clinical outcomes, as well as effectiveness and harmfulness (McLaughlin et al., 2016; Sailas and Fenton, 2000); paradoxically reducing and increasing the risk of injury (Barnett et al., 2012; Ferleger, 2008; Mohr et al., 2003); and the issue of infringing and upholding human rights (Chavulak and Petrakis, 2017; Janssen et al., 2011). There is also evidence of mostly negative service user experiences (Mellow et al., 2017; Van der Merwe et al., 2013); and ethical issues relating to paternalism, authoritarianism and the potential abusive use of power (Alty, 1994; Muir-Cochrane and Holmes, 2001).

At the same time, seclusion is used in increasingly recovery-oriented AMH services. Recovery-oriented practice has increasingly occupied a central role in AMH policy and practice internationally [Australian Government, 2010; Department of Health (UK), 2011; WHO, 2012]. While there is no international consensus on the principles of recovery-oriented practice, the framework published by the Australian Government (2010) has considerable international support (WHO, 2012). It contains six principles; “uniqueness of the individual”, “real choices”, “attitudes and rights”, “dignity and respect”, “partnership and communication” and “evaluating recovery”.

To the best of the authors’ knowledge, five systematic reviews of staff and service user perspectives on seclusion in AMH services have been published to date (Askew et al., 2020; Happell and Harrow, 2010; Mellow et al., 2017; Stíobhairt et al., 2023; Van der Merwe et al., 2013). Taken together, they indicate mostly negative experiences of seclusion. While staff widely acknowledged these negative experiences and some perceived a risk of abuse, the majority believed that seclusion was necessary, therapeutic and should continue to be used. The ongoing use of seclusion and support for the practice among clinical staff suggests that efforts to minimise or eliminate it may face significant barriers. While it has been argued that seclusion and recovery-oriented practice are incompatible (Ashcraft and Anthony, 2008), the interface between them has received limited attention in the literature. A systematic review by the authors of this paper (Stíobhairt et al., 2023) concluded there was some evidence that staff and service users perceived seclusion as being consistent with aspects of individual recovery principles, but this was contrasted with a larger body of findings indicating a perception that they are in direct opposition.

Most professional participants in studies on seclusion have been psychiatrists and nurses, and no studies have specifically explored the perspectives and experiences of psychologists. In addition, none has specifically explored perspectives on the use of seclusion in the context of recovery-oriented practice, though this was a feature of our recent systematic review (Stíobhairt et al., 2023). Irish legislation on seclusion outlines roles for psychiatry and nursing but not psychology (Mental Health Commission, 2022b); however, AMH services are developing a model of multi-disciplinary shared care in which psychology has been identified as a standard presence on teams (Department of Health and Children, 2006). Seclusion continues to be used in increasingly recovery-oriented AMH services in Ireland (Health Service Executive, 2017). Given the distinct training of psychologists, it is valuable to explore their experiences and perspectives on seclusion and its use in the context of recovery-oriented practice.

This study aims to make an original contribution to clinical psychology while being relevant to other health professions, service user advocacy groups and policy makers by exploring the following research questions:

RQ1.

What roles do psychologists working in Irish AMH services play in the process of seclusion?

RQ2.

What are the perspectives of psychologists on the use of seclusion in AMH services?

RQ3.

How do psychologists understand the use of seclusion in the context of recovery-oriented practice?

RQ4.

What professional practice issues arise in relation to seclusion, particularly as it occurs in the context of recovery-oriented practice?

Methodology

Research design

The design of the present study was qualitative, using a social constructivist paradigm with a relativist ontological epistemological position (Lincoln et al., 2018). The relativist position argues that we can only ever view the world from perspectives and cannot know if the knowledge we have is the only or “right” one (Braun and Clarke, 2013). In line with this approach, knowledge arising from this research is produced, with the researchers playing an active role in the co-reconstruction of knowledge and the meanings made during data analysis. The adoption of a social constructivist paradigm guided the methodology and the methods used to produce the findings.

Participants and sampling

The target population was clinical psychologists and counselling psychologists with experience working in AMH services in Ireland. Recruitment was limited to Ireland primarily to ensure that participants worked in a relatively homogenous social context, and second, due to external constraints on the scale of the research. Participants were eligible for inclusion if they were a qualified clinical or counselling psychologist; they were employed in a basic-, senior- or principal-grade post at the time of participation or previously; they worked at an Irish AMH service in which seclusion was in use at the time of participation or previously; and they worked in that service after the publication of A Vision for Change (Department of Health and Children, 2006).

There is no consensus on appropriate sample sizes for qualitative research, and Baker and Edwards (2012) concluded that the most appropriate number varies based on factors such as the size of the population being studied, the commonality or uniqueness of participants’ experiences and time and resource constraints. A target sample size of 15–20 participants was identified for the present study, and several approaches were adopted to recruit participants. For example, arrangements were made with the national professional body’s divisions of clinical and counselling psychology to highlight the study to their members by email. The team also directly contacted psychologists working in AMH services where permission was secured, and the chairperson of the Heads of Psychological Services Ireland (HPSI) highlighted the study to principal psychology managers by email. Recipients interested in discussing the study further or participating were invited to contact the researchers. Eligibility for inclusion was ascertained through direct correspondence with prospective participants, and interviews were scheduled where appropriate.

A total of 18 participants were recruited; however, only 17 were included in the analysis as one did not meet all the inclusion criteria. Demographic and contextual information about the 17 participants is presented in Table 1. Information about employment grade, geographical location and professional qualification (i.e. counselling or clinical psychology) has been deliberately omitted to protect participant anonymity.

Data collection

Semi-structured interviews were identified as the most appropriate method of data collection, as they enable participants to express their own meanings in relation to the research questions. The researchers developed a topic guide based on the research questions, knowledge of relevant literature, personal experience working in Irish mental health services and the results of a pilot study. The topic guide (which is included as supplementary material) contained four areas of interest, one aligned with each of the research questions. The first author conducted semi-structured, face-to-face interviews with all participants individually (mean length = 52.59 min; SD = 11.21 min). Interviews were recorded using two digital audio recording devices. Care was taken to establish a good rapport with participants and create an atmosphere of ease and open reflection during interviews. The topic guide was followed flexibly and was responsive to the natural flow of participant comments. Follow-up questions were frequently asked to explore issues raised by participants in greater detail. Verbatim transcripts of interviews were produced, and identifiable information (e.g. names, locations, idiosyncrasies relating to a specific service) was replaced with more generic terms or broad descriptors to protect the identity of participants.

Data analysis

Analysis was conducted in line with the reflexive thematic analysis approach outlined by Braun et al. (2019), supplemented with additional guidance from Braun and Clarke (2006, 2012, 2013). This approach consists of a six-phase recursive process. Data were coded using NVivo Version 12 (QSR International, 2018).

Coding was primarily inductive, as the social constructivist paradigm argues that patterns of meaning should be generated inductively rather than deductively (Creswell and Poth, 2018). Regard was given to the research questions during this process to ensure that the knowledge produced addressed these; however, coding was strongly grounded in the content of interviews. Coding was also primarily conducted on a semantic level, where data were coded based on explicit meanings to ensure that the findings were based in the text. Limited coding was also conducted at a latent level where a particular idea or meaning was evident, but comments were not stated explicitly enough to be coded at a semantic level.

Several members of the research team were involved in the analysis process, with the aim of enhancing trustworthiness. Recognising the potential impact of the researchers, it is important to note that at the time the study was conducted, the lead author was a clinical psychologist in training, and one co-author was a principal psychology manager in the health services. Balancing the potential for these roles to influence interpretation of the data, the analysis was conducted by the lead author with support from the two remaining authors, who were not clinical psychologists. One of these had significant experience of qualitative research, and both supported the lead author to reflect on his interpretation of the data by shadowing the coding and theme development process and contributing to meetings held during the analysis process. Rather than attempt to reach consensus in a positivist manner, the purpose of their involvement was to support reflection on possible assumptions during the development of a diverse range of codes and themes in Phases 1–4. The first author then completed the remaining phases to finalise the themes, continuing the process of reflexion based on the input of the other members of the research team.

Ethical considerations

Each stage of the study was conducted in line with the Psychological Society of Ireland’s Code of Professional Ethics (2019), with local research ethics reviews conducted in four health service regions.

Results

In total, 24 themes were identified within the data. They were clustered as four overarching themes, each of which addressed one of the research questions (see Figure 1). The figure represents the relationships between the themes, with the experience of psychologists of being on the periphery in relation to this issue contrasted with the influence of wider systemic issues that were at play. Between these positions, the interrelated themes of participants’ discomfort with seclusion and the challenges evident in the interaction of seclusion and recovery are represented as practices influence each other. In the sections below, the overarching themes and component themes for each of the four research questions are discussed in turn, supported by illustrative quotes. Additional supporting quotes are provided in the supplementary materials.

What roles do psychologists working in Irish adult mental health services play in the process of seclusion?

For this research question, five themes clustered under the overarching theme of the peripheral role of psychologists in seclusion, which represented participants’ reports that neither they as individual practitioners nor psychology as a professional discipline was routinely involved in decisions in relation to seclusion, as evident in the following quote:

I loathe to generalise but in the different roles that I’ve occupied I’ve had opportunities to go around the country a bit and to visit mental health staff in different parts of the unit, or different parts of the country. And my, I would argue that what I described is the most common scenario. That psychology remains peripheral.

Many of the psychologists had limited experience of seclusion. While some participants described regular exposure to seclusion, most viewed themselves as having no input in the moment where seclusion is used. As one participant reported, “You’d passively observe. Like you’d be aware of it […] It would be something that happens, I suppose, without my, without my input”. For some, exposure occurred by incidentally observing the practice or hearing discussions among nursing staff. While indirect exposure was gained by attending individual care planning (ICP) and multi-disciplinary team (MDT) meetings, participants noted that they rarely worked with service users who had been secluded (“in my experience the cohort of patients who ultimately end up needing seclusion are not the cohort of patients for whom psychological intervention is generally sought”).

In line with their limited exposure, participants spoke about having no personal involvement in frontline roles associated with seclusion, resulting in the theme no frontline role for psychology. The psychologists had never had any role in decisions to initiate, monitor or discontinue seclusion, nor had they been invited to have such roles, with one participant reporting:

I have never been there, involved at a decision-making level when it has been initiated. I always come in after the, the event basically. I’ve never, nobody has ever consulted me on whether this should be initiated as an intervention say.

Many participants only became aware of seclusion when it was already underway or after it was discontinued (“things tend to happen rather quickly. So, because the team meetings happen once a week there, someone might be in and out of seclusion”). Only two participants recalled a single instance each in which they accompanied consultant psychiatrists to review the need for seclusion; however, in these instances, the final decision lay with the consultant psychiatrist. All but one of the participants reported that they had no role in formal debriefings after events.

In contrast to the absence of frontline roles, participants noted that they had some involvement in non-acute activities associated with seclusion, resulting in the theme ancillary roles for psychology (not given, but taken). The majority reported that they attended weekly ICP and MDT meetings where seclusion was discussed to varying degrees. At these meetings, the psychologists described themselves as often encouraging staff to reflect on their practice and consider more holistic formulations to understand events, service user perspectives and the meaning of behaviour, as evident in the following quote, “I suppose oftentimes trying to advocate that look when people are, you know when, when behaviours are becoming riskier […] most of the time people are distressed and confused and they’re frightened”.

While many felt that their input was not actually sought, participants noted that their input was limited due to the perceived dominance of consultant psychiatrists (“it’s very limited, and still it’s more the consultant who has really something to say and we can try to have a word, but it’s quite difficult to really get involved”). Some participants described other infrequent roles, including contributing to audits of compliance with procedures, organisational policies and coaching nurses in relation to positive behaviour support.

Some psychologists expanded on their statements about the limited degree to which seclusion featured in their work and expressed the view of seclusion as a peripheral topic for psychology in Ireland. Some participants were struck by the limited degree to which seclusion arose in their work despite regularly spending time in inpatient services. Others also experienced limited discussion on the topic among psychologists in Ireland and within their training (“I don’t remember ever getting any training or, when I was doing my PhD, you know the clinical training and all, I don’t remember anyone talking about seclusion either”).

Although seclusion was seen as a peripheral topic for psychology in Ireland at present, many psychologists spoke at length about meaningful contributions they felt the profession could and should make, resulting in the theme potential roles for psychology. Most participants were reluctant to have any direct involvement in the physical act of seclusion itself or in sanctioning it, both at a personal level and a professional level. They described being uncomfortable with the practice, and they did not see direct involvement as being “part of the psychologist’s role”. They were concerned that this would compromise their therapeutic relationships with service users, as evident in the following quote:

I would have concerns that that would jeopardise my ability to work as a psychologist because what I want to do with the people I work with here is meet them in a safe space and have them feel safe enough to talk about their biggest worries, their vulnerabilities, their opinions.

By contrast, participants believed they had expertise in formulation and understanding behaviour and psychological experiences that enabled them to make wider contributions that aim to understand individual seclusion events, reduce its use and reduce the negative impact on staff and service users. They highlighted potential work with frontline staff, service users, within MDTs and at an organisational level reviewing systems and contributing to policies.

Taken together, the themes in this section converge to indicate that the topic of seclusion is most often a minor feature in the work of individual psychologists and within psychology in Ireland more broadly, resulting in the overarching theme of the peripheral role of psychologists in seclusion. The psychologists played no frontline roles and wished for this to remain the case. Despite feeling somewhat removed from the practice, many of the participants believed that psychology could and should make meaningful contributions at a wider level. As a result, they asserted some ancillary roles to influence practice indirectly where possible.

What are the perspectives of psychologists on the use of seclusion in adult mental health services?

Moving beyond the role of psychology and psychologists in seclusion, the second question examined participants’ perspectives on the use of seclusion in Irish mental health services. Seven themes clustered under one overarching theme of seclusion as an uncomfortable reality, in addressing this research question.

The psychologists spoke at length about their understanding of the functions of seclusion, which were captured in the theme multiple functions, but primarily safety. While participants believed that seclusion could be used in several ways, most perceived that its primary function was managing acute and significant risk of harm to oneself or others where other methods are ineffective. As one participant reported, “I think it’s just really something that can be used when there’s a crisis and that just because you can’t really do any different”. Many participants added that safety was the primary or sole function within their service (“from my experience it’s been for everyone that’s ever used, that I’ve known of, it’s been for safety for themselves and other people, as an absolute last option”). Some psychologists also referred to other functions, most notably, a common perception among some staff and service users that seclusion could be or was being used as punishment or coercion, as evident in the following quote, “I see it as punishment, as prison, and that’s exactly what all my clients who have had this used, that, they’re in prison”. There was also a belief that seclusion served to de-escalate situations and emotions and bring relief to staff and other service users, but that seclusion was not always limited to situations in which there was a significant and immediate risk of harm to oneself or others.

The psychologists unanimously expressed the view that there was no therapeutic value to seclusion. They widely acknowledged that there may be a “benefit” to containing risk and reducing harm, but that seclusion was not therapeutic in its own right:

If someone is potentially dangerous and at a risk to themselves and other people, I believe seclusion is a practical backstop to managing risk. But I do not think that it has any necessary therapeutic benefit, any more so than handcuffs or whatever, you know.

When explicitly asked whether they could conceive of any theoretical argument to justify seclusion, some cautioned against actively trying to justify a practice with a theory where this is not actually the basis of it in reality. This was captured by one participant who reported:

I think it’s still better to see that sometimes rarely it’s a thing that you can’t avoid. Even if it has no therapeutic value, rather than starting to justify it with some theories and trying to see the therapeutic aspect of it, because then you can go on a slipping road. Is it really something therapeutic?

Many psychologists expanded on the functions of seclusion and absence of therapeutic value by referring to a range of concerns they had with the practice, resulting in the theme seclusion as a problematic practice. Many participants expressed the view that seclusion was an archaic practice that was at odds with modern conceptions of “care” in mental health (“you don’t really treat the patient as a patient anymore. It’s not really a hospital anymore. It’s not really a carer anymore. It’s not really a patient anymore”). Some noted that the subjectivity of judgements about when to initiate and discontinue seclusion was also problematic. Seclusion was viewed as a limited attempt to address a difficulty, as it simply managed behaviour rather than maintaining a human connection and addressing a person’s distress or the underlying need. They also expressed a strong desire for changes to be made to the procedures surrounding all stages of seclusion and the appearance of the room itself (“I almost like wish the room […] wish the room had a better, wasn’t such like a horrible place”).

Expanding on this, the psychologists spoke at length about the lived experience of seclusion for service users and staff, resulting in the theme of seclusion as a unique but harmful experience for most. All the psychologists believed that service users most often experienced seclusion as an aversive experience that negatively affected their well-being and trust for staff (“I’d imagine it could bring up things around trust, feeling very out of control, confused, helplessness, being overwhelmed”). Seclusion was also widely considered distressing for staff and other service users that may witness it. Many of the psychologists emphasised that the experience of seclusion was also unique to individuals, and therefore subject to individual meaning-making and factors relating to their presentations and histories (“It is an individual thing, ‘cause each person will experience it differently and their own histories and the meaning they make, like ‘why am I here?’”). By contrast, some participants perceived that seclusion could be considered a positive experience by a minority of service users, or that they may come to agree with being secluded in hindsight, as is evident in the following quote, “she came back to her typical presentation, so this is a real crisis piece. And I think she was quite grateful actually that, you know, she had been kept safe and hadn’t, like, really damaged herself or someone else”.

In reflecting on the experience of seclusion, psychologists spoke about the relational impact of seclusion. The majority of participants believed that it could have a range of negative short- and long-term effects, including limiting service users’ ability to trust staff (“so it’s a real challenge to, how cared for someone can feel and how trusting they can be of a team, and it can affect things going forward”). Some psychologists believed that service users often did not associate them with seclusion, and it therefore did not impact their therapeutic relationship directly. Notably, however, the majority believed that it did or could affect this indirectly, due to reduced engagement and mistrust of services in general, as noted by one participant, “there’s ghosts in the background that people carry with them into the therapeutic relationship with psychology, if they’ve ever had an experience of seclusion all the way through”. The participants also expressed concern that staff may become desensitised or detach from the lived-experience to manage their personal distress, resulting in seclusion being normalised, as evident in the following quote, “the first time you do it is quite difficult and distressing I would imagine, if you’re in any ways reflective. But after a period of time that can become very normal, this kind of what we do, you know”.

Based on the perceived issues and concerns highlighted by psychologists, the theme seclusion experienced as ethically and morally challenging was identified. Participants spoke about the experience of witnessing seclusion and described feeling uncomfortable or personally distressed by this. As one participant reported, “sitting down to, kind of, brainstorm this [interview], words that were coming to mind was ‘barbaric’, you know, it doesn’t sit well”. Some psychologists noted that, although such practices were officially sanctioned, they found them difficult to accept on a personal level. The participants highlighted the power imbalance in staff–service user relationships and perceived that seclusion could be or was sometimes being used inappropriately (“one has to be careful that a theoretical background doesn’t just become a way of justifying inappropriate behaviour that’s actually driven by another agenda”). These concerns focused on the threshold for risk that is applied when considering seclusion and the extent to which alternatives have been exhausted before it is used.

Despite disagreement with seclusion in many respects, many psychologists believed that there was a limited place for seclusion in services as they stand at present but only as a last resort and under exceptional circumstances – this was captured in the theme of seclusion as a necessary evil at present. The participants believed that exposure to aggressive behaviour can be very distressing for other service users, as evident in the following quote, “it can be extremely threatening, extremely threatening and terrifying for other patients on acute psychiatric wards to share space with, with fellow patients who are extremely agitated, aggressive and combatant and acutely psychotic”. They also noted that at times, there was a reality of significant risk of harm and even death associated with inpatient services. Based on this perception, they referred to the need to manage conflicting priorities and referred to concepts such as “triage” and a “hierarchy of needs”. As is evident in the following quote, participants believed a range of strategies would likely be used to manage significant risks in the absence of seclusion;

A number of things could happen. A, people wouldn’t be admitted that maybe need to be admitted and they would, as I said, they’d end up in other places like police stations or acute general hospitals which are not appropriate. B, the rates of I.M. medications, you know the intra-muscular medications, would go up, significantly.

These themes suggest that psychologists frequently viewed the use of seclusion in AMH services as a complex and multi-faceted issue. The overarching theme seclusion as an uncomfortable reality was based on the synthesis of these seven themes. None of the psychologists believed that seclusion possessed any inherent therapeutic value. Rather, it was widely viewed as a problematic practice that was associated with a range of adverse outcomes. Despite their reservations, many believed that the risk of harm in inpatient services meant that seclusion addresses a genuine need that exists in inpatient services, as they currently function and are structured.

How do psychologists understand the use of seclusion in the context of recovery-oriented practice?

This question moved the study beyond the consideration of seclusion in isolation, to examine its relationship with recovery-oriented practice in AMH services. Five themes clustered under one overarching theme in relation to this research question, which highlighted the challenges evident where these two principles and practices intersect.

The psychologists unanimously perceived that the concept of seclusion and the principles of recovery-oriented practice were greatly at odds, with many describing them as opposites that disqualify one another. The theme seclusion and recovery as opposing practices is illustrated by the following quote:

When you talk about all those things, and the respect and the dignity and up-skilling, there’s none of those compatible with seclusion […] there’s nothing dignified about being placed in a seclusion room. Especially if you’re taken there by force […] that’s not up-skilling a person, it’s taking the power off them. It’s taking their agency away.

Many participants believed recovery principles were effectively suspended during seclusion or that the practice itself may hinder a service user’s recovery, compromising a service’s ability to fully work in a recovery-oriented manner. More fundamentally, some psychologists argued that symptom reduction was not synonymous with recovery, which they believed comprised more personal and profound changes than simply changing behaviour.

While acknowledging the incongruence between seclusion and recovery, the theme seclusion as a turning point towards recovery reflected the view that seclusion could conceivably support the recovery process. Some participants believed that in certain situations, seclusion could prevent further deterioration and contribute to a more positive mental state or calmer environment, as reflected by this participant:

And that’s the dilemma […] out of necessity you will infringe the rights and the recovery principles of the individual, but the argument is that if you don’t do it, you might enter a spiral of negativity where you can never get to where you want to go.

Many participants expanded on the relationship between seclusion and recovery, highlighting that there are multiple priorities in inpatient services, reflected in the theme balancing conflicting needs. Participants noted that the needs of secluded service users, other service users, staff and organisations cannot be easily reconciled in relation to seclusion. Some participants noted that safety was a pre-requisite for recovery (“I mean it doesn’t fit really very well, but on a really practical level I suppose someone can’t have recovery if they’re injured or if someone else is injured”) and emphasised a resulting need for nuanced views of seclusion that were realistic rather than idealistic.

In acknowledging the need to balance conflicting priorities, psychologists’ views reflected partial reconciliation of seclusion and recovery. Some participants noted that concerns about seclusion were primarily related to the context in which it occurs, rather than the practice in and of itself (e.g. “it’s not the intervention is the concern for me, it’s how and when it’s used and that’s where policy comes in”). They referred to “when” and “why” it is used and the “philosophy that guides the behaviour”. The psychologists believed that seclusion and recovery could be partially reconciled by involving service users, their supporters and MDT members in collaborative decision-making. Some other participants also recommended that the physical characteristics of seclusion rooms should be reviewed to make them more than “just a containment space”, but a space that is soothing.

Many psychologists also showed empathy for burdened staff, who they believed faced increasingly challenging roles due to developments such as the regulation of seclusion and emphasis on recovery. While largely supporting recent developments, they perceived that the increased responsibility to satisfy conflicting priorities and accountability for one’s actions has made the roles of nurses and psychiatrists more stressful and difficult to fulfil, as evident in the following quote; “the more measures you put in place to protect the dignity and the human rights and keeping the patient central, the more stressful it is for the staff to actually perform a reasonable balancing act”.

Taken together, these themes illustrate the overarching theme the problematic interface of seclusion and recovery. Participants perceived that seclusion and recovery have a complex and problematic relationship, with the practice unanimously seen as greatly at odds with the concept of recovery. Seclusion suspended or even hindered recovery, though it could act as a turning point towards recovery in some cases. Participants recognised the reality of conflicting priorities that are not easily reconciled and the challenges faced by staff with direct roles.

What professional practice issues arise in relation to seclusion, particularly as it occurs in the context of recovery-oriented practice?

The final research question provided for perhaps a broader consideration of the context for seclusion and how it relates to recovery in AMH settings. Seven themes were clustered under an overarching theme, reflecting the pervasive impact of systemic factors on seclusion and recovery.

The theme impact of organisational and environmental factors incorporated the positive and negative contextual influences described by participants. Positive influences included the regulation and training mandated by the Mental Health Commission in Ireland, while negative influences included the physical design of inpatient units and atmosphere within them. Some participants added that inpatient environments often lacked basic facilities that enable service users to regulate their emotions and soothe themselves, such as access to outdoor spaces and quiet spaces [“anything over in that building, would seem like contrary to that idea of like, that you want to bring a person into a place of (soothing)”]. Some psychologists believed that systemic factors such as national and local culture, training, limited reflective practice, dominance of the medical model and limited continuity of care between in- and outpatient services all contributed to the need for seclusion. Some also stated that the ability of services to meet service users’ needs and deal with conflict was dynamic and subject to change, rather than being static.

In reflecting on the impact of systemic factors in relation to seclusion, the theme recovery-oriented practice – still a way to go reflects the view that fundamental changes are required for the system to be recovery-orientated. Some psychologists perceived that recovery was largely an adjunct concept within mental health services at present, rather than being a core part of their philosophy, as evident in the following quote:

Most mental health services systems still operate on the basis that our job is to manage risk and to treat mental illness which is largely seen as a biological illness. And they add recovery-oriented on to their, kind of, policy documents as “but we’re also trying to be nice”.

Some participants noted power imbalances between services and service users, and the perception that services revert to paternalistic practices such as seclusion under challenging circumstances, were greatly at odds with recovery.

Relating to the impact of systemic factors, many psychologists perceived decisions about seclusion – and decisions within inpatient services more broadly – to be largely dominated by psychiatry and nursing, resulting in the theme multi-disciplinary shared care – still a way to go. Psychologists believed that trusting relationships and shared responsibility were important for multi-disciplinary work. By contrast, however, they perceived that there were inherent hierarchies in inpatient services, as evident in the following quote, “there’s layers of the team to the concentric circles. And I think a lot of time psychologists and to a greater extent social workers and occupational therapists believe that they’re on the periphery and that”. While a small number of psychologists described positive experiences of collaboration in MDTs, most described tension arising from conflicting biomedical and psychosocial perspectives; beliefs about the roles and remit of disciplines; and reluctance to cooperate or work in an inter-disciplinary manner.

The finding that there was typically limited reflection on seclusion represents the view evident among most participants that there was limited meaningful discussion of seclusion within their services. While a small number of participants described open reflection on recent seclusion episodes, most felt that discussions were brief and primarily administrative rather than reflective. Many of the participants perceived that there was limited appetite for more meaningful reflection on seclusion practices, and the format and timing of meetings did not facilitate this. As one participant described, “those discussions and those reviews really, in my experience, did not really take place in any meaningful way, it was more of a kind of an admin exercise”.

In expanding on their experience of inter-personal dynamics, the psychologists spoke about their ability to influence practice in relation to seclusion and more broadly within inpatient services. The theme psychology’s voice often unheard and not valued reflected participants’ limited sense of their influence in relation to seclusion. Only a small number of participants reported that their input on seclusion was actively sought, and they had opportunities to influence practice (“the nurses here are very receptive […] generally speaking yes there's a warm environment, I don’t feel restrained in saying anything in that meeting”). By contrast, many noted that their views were rarely or never sought and opportunities to be heard were often limited or perceived as not valued or unwelcome. As one participant described, “It’s a struggle despite repeated attempts to vocalise opinions, and clinical opinions, […] it’s a constant struggle to have that voice heard”.

Building on this, many psychologists described the perceived impact of not being co-located. Not being co-located precluded psychology from having greater involvement with seclusion as they were present for only limited periods or discrete pieces of work. Psychologists perceived a need to be available and build relationships with other staff. Some of these issues are evident in the following quote:

If you wanted a psychologist to be involved in the decision of seclusion, he would have to be available at the right time, which is any time, to make that decision. But in order to make someone available you need a dedicated member of staff to be there.

The final theme in relation to this question, inpatient psychology role experienced as challenging, reflects the systemic issues noted. Some psychologists experienced difficulties due to the dominance of a biomedical model, and they noted that it was challenging to advocate a more psychosocial and recovery-oriented perspective (“It’s a challenge on a daily basis, to advocate for a recovery model and for […] more psycho-social focus of the work, yes it’s a challenge in my experience, yeah, constantly”). Challenges included inter-personal dynamics and negative responses from others. In response, they had limited their concerns or efforts in relation to seclusion, or had been tempted to do so, as they saw this as one area in which they had little power to bring change. One participant stated that “probably a lot of psychologists want just to have the peace and avoid any conflict and wouldn’t say anything. And so, it gives a false […] It can give a false impression that there is a psychologist involved”.

Taken together, the seven themes reflect the overarching theme of the pervasive impact of systemic factors on seclusion and recovery. A range of factors had a negative impact on clinical practice, including the physical environment, a limited multi-disciplinary shared care approach, limited recovery-oriented practice in reality and limited meaningful reflection on seclusion practices. The participants also typically felt that psychology had limited power to bring change in relation to seclusion and found their inpatient roles challenging as a result.

Discussion

This study provides an important insight into the perspectives and experiences of psychologists working in clinical settings where seclusion is used. Despite seclusion being only a minor feature of their work, the psychologists expressed well-developed and nuanced views on its use in the context of recovery-oriented practice. These were influenced by their understanding of psychological theory and systemic processes within and beyond inpatients units. The psychologists perceived a lack of discussion about seclusion within psychology in Ireland or within professional training programmes, which contributes to the status of seclusion as a peripheral topic in Irish psychology. There is an opportunity to apply psychological theory and skills to an area of need and for services to benefit from this. This opportunity is largely yet to be seized by either Irish psychology or services but will likely become increasingly apparent as Irish AMH services continue to adopt an ethos of recovery-oriented practice and a model of collaborative multi-disciplinary shared care.

While many viewed the experience of seclusion and the impact of this as being unique to individuals, they believed that it was typically an adverse experience associated with negative outcomes for both service users and staff. This perspective is consistent with notable position statements [APNA, 2018; National Alliance on Mental Illness (USA), 2016]. Systematic reviews by Van der Merwe et al. (2013) and Happell and Harrow (2010) found that many staff in the included studies were nurses and psychiatrists who believed that seclusion was therapeutic. They perceived that a low stimulus environment allowed service users to deescalate and thought them to respect physical limits and modify their behaviour. While the psychologists in this study discussed these effects, they cited multiple practical and theoretic issues that led them to believe that seclusion had no intrinsic therapeutic value. All the participants were uncomfortable with seclusion but saw a limited place for it in inpatient services as they are currently structured and function, primarily due to a perceived significant risk of harm and even death.

These findings raise important questions for those who perceive that seclusion is therapeutic:

  • If we change structure and functioning of inpatient services, how often would we still “need” seclusion?

  • How much of the perceived therapeutic benefit would be left?

These findings support the focus that multi-component approaches to reducing seclusion and other restrictive practices frequently place on the role of contextual factors in contributing to their use (Goulet et al., 2017). The psychologists frequently believed that seclusion and recovery were in direct opposition, in line with statements from notable organisations [e.g. Department of Health and Human Services (USA), 2005; WHO, 2017]. They believed that changes should be made to every stage of the procedure, seclusion rooms and inpatient environments to address practical and conceptual issues with seclusion in its own right and to partially reconcile it with recovery. They perceived there were various conflicting priorities in inpatient services that could not be easily reconciled, and that there was a need to be realistic rather than idealistic. This position is consistent with our recent systematic review (Stíobhairt et al., 2023), where it was reported that staff and service user perceptions of seclusion in relation to recovery highlight paradoxical needs relating to care, control and conflicting rights. The review concluded that they occur both within and across various levels of social systems and include the various needs of secluded individuals, other service users, staff, the mental health system and society more broadly. They note that the various needs are dynamic rather than static over time and need to be satisfied under imperfect and challenging circumstances, and result in ethical dilemmas in clinical practice. Although some authors have argued that seclusion should be completely eliminated due to its inconsistency with recovery (LeBel and Huckshorn, 2006; Sharfstein, 2008), the views of the psychologists interviewed – based on services as they currently stand – are more in line with those who advocate the minimisation of seclusion as a goal [Mental Health Commission, 2014; National Institute for Health and Care Excellence, 2015; APNA, 2018; National Alliance on Mental Illness (USA), 2016].

While participants identified various changes to partially reconcile seclusion and recovery, they believed multiple barriers existed. Systemic factors included the physical environment of inpatient services; limited multi-disciplinary shared care and recovery-oriented practice; a weak voice for psychology; limited reflection on seclusion; and systemic incentives to prioritise risk management over recovery. While some psychologists perceived openness to their input in relation to seclusion at ICP and MDT meetings, most perceived that further systemic factors contributed to limited roles and influence for psychology in these forums, including their limited presence and availability in inpatient units; inter-disciplinary power hierarchies; the dominance of a biomedical model; limited openness or opportunity for meaningful reflection; and a limited value or welcome for psychology’s input. As a result, the psychologists often experienced their inpatient work as both personally and professionally challenging. One result of this was to reduce or consider reducing the expression of one’s concerns about seclusion. While understandable, this could inadvertently reinforce the peripheral role of psychology in relation to seclusion and service managers should consider addressing the contributing factors for the benefit of service users.

Strengths and limitations

This study possesses several strengths and limitations. It is positioned to make a unique contribution to the academic literature, as no studies to date have actively explored the perspectives of psychologists on the use of seclusion in AMH settings or in the context of recovery-oriented practice. The findings have relevance to clinical psychology and other groups reflecting on the shift towards least restrictive and recovery-oriented practice in mental health services. The pilot study provided a valuable opportunity to assess and revise the methods used. The participants were perceived as being open and honest during interviews. As such, the data collected are perceived to accurately reflect the perspectives and experiences of the participants. Multiple steps were taken throughout the research process to promote trustworthiness, as defined by Lincoln and Guba (1985). Prolonged engagement with the data, coding of several transcripts by multiple authors and meetings to reflect on the variety of codes and candidate themes identified supported good reflexive practice and promoted credibility.

Contextual information was provided about the participants and their working arrangements in AMH services to promote transferability. Although the omission of contextual information such as the employment grade, geographical location, professional qualification and ethnic background is important to ensure participant anonymity, it may limit the ability of readers and other researchers to judge the transferability of the findings to other settings. While this study aimed to provide an authentic representation of the views of the participants recruited, it is possible that the themes and overarching themes identified would be somewhat different if all the psychologists were based in inpatient services full-time. However, the proportion of time spent by the participants in inpatient services is likely broadly representative of psychologists nationally in Ireland.

To promote dependability, the study was conducted in a systematised, consistent and exhaustive manner with clear epistemological and ontological positions. The analysis was conducted in line with the reflexive thematic analysis approach outlined by Braun et al. (2019), which was supplemented with additional guidance from Braun and Clarke (2006, 2012, 2013). To promote confirmability and create an audit trail, a selection of quotes supporting the findings is included in the Results section, and additional examples are provided in a supplementary table.

Conclusion

The psychologists interviewed viewed seclusion as a problematic practice in AMH services. They viewed the interface of seclusion and recovery as problematic and believed that various systemic factors negatively impacted both seclusion and recovery in practice. The findings indicate topics of focus for the development of clinical practice, governance and future research. There is a need for reflective practice in relation to seclusion and the impact on an individual’s recovery. Judgements about the value, need for and impact of seclusion should not be based on behaviour alone. They should consider the function of behaviour, the role of meaning-making in shaping the lived-experience and the active contribution of staff and social systems to situations. Even where the seclusion is deemed necessary by some, the findings highlight opportunities to amend procedures and practices to partially reconcile seclusion and recovery, such as redesigning seclusion rooms to make them actively soothing, rather than primarily containment spaces. This study represents only a small contribution to the understudied interface of seclusion and recovery. There is a need for research that directly explores the views of service users and other health professionals on this interface.

The findings stress the need to openly acknowledge the reality of conflicting needs and priorities in relation to seclusion and recovery in AMH services. Several of these, including care, control and conflicting rights, are paradoxical and cannot be easily reconciled. They can exist within and across various levels of social systems and include the various needs of secluded individuals, other service users, staff, the mental health system and society more broadly. They are not static over time but are dynamic. They need to be addressed under imperfect and challenging circumstances, resulting in ethical dilemmas in clinical practice. The current findings suggest that, in the absence of changes to the way AMH services are structured and function, calls for the complete elimination of seclusion and strict adherence to a recovery model may be somewhat idealistic for particular settings.

There is a clear need for nuanced understanding and efforts to conscientiously balance conflicting priorities as best as possible in any given moment to ensure ethical practice, rather than consistently prioritising some needs to the detriment of others. Care must be taken to avoid polarised stances based on overly simplified narratives that may ultimately be detrimental to service user outcomes. Oversimplified narratives put future clinical practice at risk of having different but equally problematic limitations, leading to calls for yet another ideological revision. The nuanced viewed expressed by psychologists in the current study suggests that they are well-suited to participate in local and national discussions on the complexities of using seclusion in recovery-oriented practice.

Figures

RQs, overarching themes and the associated themes

Figure 1

RQs, overarching themes and the associated themes

Demographic characteristics of the sample (N = 17)

Demographic characteristic n (%) Demographic characteristic n (%)
Age in years Time in service in which seclusion was used*
30–40 9 (53.94) 0–5 years 8 (47.06)
40–50 6 (35.29) 5–10 years 5 (29.41)
50–60 2 (11.76) 10–15 years 4 (23.53)
Gender Time in inpatient AMH units (most relevant role)
Male 6 (35.29) 1 day per week 2 (11.76)
Female 11 (64.71) 2.5 days per week 3 (17.65)
3 days per week 1 (5.88)
Years since obtaining professional qualifications* 5 days per week 2 (11.76)
0–5 3 (17.65)
5–10 7 (41.18) Other bespoke activities
10–15 4 (23.53) ICP/MDT** meetings; appointments with service
users in the community; facilitating groups
9 (52.94)
15–20 2 (11.76)
25+ 1 (5.88)
Notes:

*Whole-time equivalents; **Individual care planning/multi-disciplinary team meetings

Source: Table by authors

Supplementary material

Supplementary material for this article can be found online.

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Acknowledgements

The lead author was funded to complete doctoral training in clinical psychology by the Health Service Executive.

Corresponding author

Suzanne Guerin can be contacted at: suzanne.guerin@ucd.ie

About the authors

Antaine Stíobhairt is based at the School of Psychology, University College Dublin, Dublin, Ireland and Health Service Executive, Dublin, Ireland. He completed a bachelor’s degree in psychology at the National University of Ireland Maynooth and a master’s in human cognitive neuropsychology at the University of Edinburgh. He completed his doctorate in clinical psychology at University College Dublin in 2020, funded by the Health Service Executive. Antaine currently works as a Clinical Psychologist with the Health Service Executive.

Nicole Cassidy is an Independent Researcher based at Dublin, Ireland. She completed a bachelor’s degree in psychology at University College Dublin and a master’s degree in clinical neuropsychology at the University of Groningen. She is currently working as a Project Worker with Merchants Quay Ireland.

Dr Niamh Clarke is based at Community Health Organization 8, Health Service Executive, Dublin, Ireland. Dr Niamh Clarke is Principal Psychologist Manager with the Health Service Executive, Ireland. She also an expert member on the Midlands Regional Ethic committee. Niamh has many research interests, including infant mental health, clinical supervision and positive psychology. Niamh is the recipient of the Irish Medical Times National Health Care Award and the National Health Service Excellence Award.

Suzanne Guerin is based at the School of Psychology, University College Dublin, Dublin, Ireland. Professor Suzanne Guerin is a Professor of Research Design and Analysis at the UCD School of Psychology, where she serves as the Head of School. Suzanne’s research interests lie in health services research, and she is involved in studies of intellectual disability, palliative care and childhood chronic illness.

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