Seclusion: Do We Need It? What Should It Look Like?
In the first of our new DIMHN interactive workshops, a group of over 50 industry professionals, experts by experience, clinicians and stakeholders gathered to share their thoughts and experience on the topic of ‘seclusion rooms’ within mental health facilities.
Facilitated by DIMHN Board member, Trudi Beswick, alongside Ben Sutcliffe and Dr Louise Joy-Johnson from Caudwell Children, the interactive sessions stimulated a productive and enlightening debate on this sensitive topic.
We would particularly like to thank our experts by experience, Nick Smith and David Parkin, for their invaluable contributions and our facilitators; Katherine Lazenby, Lianne Knotts, Jen Aspinall, Alessandro Caruso, Garry Charlton, Paula Reavey, Steven Brown, Karen Howell, Matthew Speight, Andrew Arnold, Alexandru Senciuc, Ian Tearle and John Plum.
Topic 1: Do We Need It?
The first topic for discussion was the fundamental question of whether the use of seclusion in modern mental health services was still required and/or appropriate.
Much debate was had regarding the recognised best practice within mental health services and the recent review by the Care Quality Commission into the use restraint, seclusion and segregation in care services for people with a mental health condition, a learning disability or autistic people.
The original ‘Out of sight – who cares?’ report has recently been reviewed and found that, despite the report’s recommendations to the contrary, restrictive interventions were used too often and for too many people.
Within the group a consensus towards the use of appropriate language was reached and specifically that the term seclusion too often inferred a punitive approach and held negative connotations, whereas a more therapeutic methodology may use labels such as ‘calming’ or ‘safe’.
In addition to the labels used for such spaces, where they are used, was the discussion regarding the steps or journey that a person may go on before the need for the use of a defined space.
Once again the group highlighted the need for inpatient services to adopt a therapeutic approach and for any kind of seclusion to be the last step on a de-escalation journey, during which people are provided with the necessary support and empowered to self-regulate any heightened emotions or challenging behaviours.
In summary, across the group, it was recognised that there is still be a requirement for designated areas designed to assist in keeping staff and people experiencing mental ill health safe, but that the nature of the spaces and the process employed prior to their use has moved on from the stereotyped image of an empty, padded, secure room.
Topic 2: What Should It Look Like?
If safe/calming environments still need to ultimately achieve the same objective (to keep staff and patients safe), but need to rapidly and drastically progress from the padded cells of the mental health facilities of old; then what design considerations must we undertake to ensure the therapeutic support and recovery of service users in today’s mental health facilities.
Honest accounts of time spent within inpatient facilities and the use of restricted practices from the experts by experience within the group helped to shape the debate and re-consider some of the design approaches some professionals had become used to.
It quickly emerged that a simple ‘low stimuli’ approach was not always appropriate and that distraction could often serve as an important tool to aid self-regulation during times of distress. Author, artist and mental health campaigner, David Parkin, explained that it was during his most manic episodes that he found art and creativity as a method of managing his mental health but was forced to use the sparse materials he could find while in seclusion.
Despite the unanimous sentiment that restricting all sensory input did not offer the therapeutic environments that modern mental health facilities needed, it was also recognised among the group that for effective de-escalation and self-regulation that designated spaces could neither be high-stimulus areas as they would not suit all service users either.
Therefore, modern personalisation and adaptation approaches were recommended to offer users the agency to change the environment to suit their needs and interact with it in the way that aided their wellbeing the most. Included in the suggestions were digital interactive screens to offer optional distraction and sensory stimulation, as well as adjustable lighting and temperature controls.
Also discussed and agreed to be an important consideration for any de-escalation journey or safe space was the access to outdoor spaces and natural daylight. Where possible it was agreed that within any mental health facility that the availability of access to outdoor spaces and, where possible, elements of natural landscaping (grass, trees, plants) had been evidenced to provide good results for self-regulation in users of all ages.
With such wide-ranging opinion, experience and interest in this topic it was evident that innovation in the use of seclusion rooms as part of wider restrictive practices within mental health facilities is something stakeholders want to see.
While varying degrees of abolishment and modernisation were being called for from within the group, it was universally agreed that the stereotypical perception of seclusion should be a thing of the past.
Experience and evidence from within the group all pointed towards the use of personalisation and adaptation, which not only applies to specific spaces or environments but also to the policy and practice leading to the need or use of the designated spaces in the first place.
With personal safety for all parties a residual priority, it was agreed that moments of extreme distress would still require environments designed with safety in mind; but that a therapeutic approach to the design and to the method of de-escalation would inevitably result in a better outcome for everyone involved.
Further dynamic workshops on key topics within the industry are planned across the country for 2023. To stay in touch and find out when future workshops are scheduled visit: https://dimhn.org/active-projects/stakeholder-engagement/