Long-term seclusion in forensic psychiatry: Bare life,social death,and the role of the nurse

Abstract

Background

The use of seclusion and other restraints in forensic mental health settings are intended to be employed as a last resort and for the shortest time possible to achieve therapeutic effect. And yet, in Canadian forensic hospital settings, patients can remain in seclusion for weeks, months, even years. An ambiguous legal framework across Canadian provinces lacks mechanisms to limit or forbid the long-term seclusion of patients, which we define as any continuous confinement lasting 15 days or longer.

Research objectives

The paper undertakes a critical examination of long-term seclusion practices in forensic hospitals, based on the results of a qualitative study examining nursing practices with ‘difficult’ patients. Agamben’s concepts of homo sacer and bare life and Guenther’s concept of social death provide the framework for this critical examination.

Research design

A qualitative research design was employed, utilizing a critical discourse analysis methodology.

Participants and context

7 nurses working in a high security forensic hospital setting in Canada participated in qualitative interviews.

Ethical considerations

The paradox of custody and caring is central to the considerable ethical challenges nurses face with patients in long-term seclusion.

Findings/results

Integration of study findings with existing (limited) studies of this phenomenon illustrate that, though rare, patients in forensic hospital settings may be subject to lengthy and legally ambiguous periods of seclusion. Nursing practices and interventions are aimed at providing patients temporary reprieve from a state of bare life and to alleviate their social death. However, no mechanisms exist to prevent the use of long-term seclusion.

Conclusions

Long-term seclusion represents a regrettable practice in forensic hospital settings aimed at the management of ‘difficult’ patients but is devoid of therapeutic value or intent. Existing nursing practices can only temporarily relieve patients from this state. More substantive and lasting solutions are proposed, focusing on the role of the nurse.

Introduction

In his 1973-1974 lectures at the Collège de France on the topic of psychiatric power, Michel Foucault ¹ traced the origins of psychiatry through the 18^th and 19^th centuries. The goal throughout focused on ‘the mad person who is to be brought under control’.^1(p7) The specific modalities on how to do so, however, shifted over time. Earlier approaches to the treatment of the ‘mad’ person, described by Foucault as proto-psychiatry, relied upon confinement to dungeons, keeping the ‘mad’ confined in chains. However, in 1792, the physician Philippe Pinel entered the asylum and began to remove the chains from its inhabitants, which Foucault described as a ‘founding scene of psychiatry…the scene of liberation’^1(p28) or what Berlin called ‘the first step to humanizing psychiatry’.^2(p1579) Foucault’s intention in his examination of Pinel’s actions was to interrogate the ‘transformation of a certain relationship of power that was one of violence – the prison, dungeon, chains…[belonging] to the old form of the power of sovereignty – into a relationship of subjection that is a relationship of discipline’.^1(p29) Certainly, this evolution of psychiatric practice, moving from confinement and punishment to more relational approaches can be seen in contemporary practices: a form of progress. But what can be said of modern psychiatric practice when we put the chains back on our patients, when we place them back into these proverbial dungeons?

While the use of seclusion and restraints is intended to occur sparingly and for specific therapeutic purposes in mental health settings, including forensic settings, in some circumstances patients continue to face lengthy confinement. The purpose of this paper is to engage in a necessary critical reflection on the use of long-term seclusion in forensic psychiatry informed by the research of the first author,^3,4 and the clinical experiences of all authors in forensic settings. Here, we indicate that prolonged confinement – in some cases lasting several years – represents a regrettable ongoing practice in these settings. The role of the nurse and the ethical dilemmas in these practices is of specific concern in this examination.

This paper is presented in 4 sections. The first reviews the phenomenon and practice of seclusion and its correlates, and the legalities of such in Canada and beyond. The second presents the first author’s original study of nursing practices with ‘difficult’ patients in a high-security forensic psychiatric setting in Canada, where participants described the use of long-term seclusion. The third introduces Agamben’s ⁵ concepts of homo sacer and bare life, applied to patients subject to long-term seclusion. The fourth section presents Guenther’s ⁶ concept of social death, a product of solitary confinement in correctional settings, in relation to forensic psychiatric patients experiencing long-term seclusion. All four of these sections will then be synthesized in a critical reflection on long-term seclusion, its implications for both patients and nurses, and proposals to minimize or even eliminate its unfortunate use.

To provide context for this critical reflection, we offer definitions and descriptions of long-term seclusion in forensic settings from the Canadian perspective. As noted, policies and practices differ across and within nations, though we expect the content explored here to be applicable in all settings. Following Perryman, ⁷ we define long-term seclusion as any continuous confinement that lasts 15 days or longer. And we consider forensic settings as any forensic psychiatric hospital environment. In Canada, forensic psychiatric hospitals exist at the intersection of the criminal justice and mental health systems. Persons, or, adopting the language common in these settings, patients all have legal restrictions placed upon them for criminal activities. Most patients in these hospitals are those found Not Criminally Responsible on account of Mental Disorder (NCRMD) for crimes committed, unfit to stand trial, or for psychiatric assessment related to court proceedings. These patients are all held involuntarily on account of public safety and for psychiatric treatment. ⁸

Background: Seclusion and its correlates

In clinical practice, seclusion refers to the isolation of a person in a confined and locked space. While the specifics of seclusion may vary across countries and jurisdictions, ⁹ Holmes et al. ¹⁰ and Perryman ⁷ described seclusion rooms in Canadian forensic psychiatric setting as a confined, cold space with a cement floor, a single mattress on the floor, and lights that are on 24 h a day. These conditions may not exist in all jurisdictions, but it is clear that seclusion rooms are a place of uncomfortable isolation. Patients lack both control over the environment and privacy in these spaces, with windows for continuous staff observations, or some spaces featuring surveillance cameras. ¹¹ Hansen et al., ⁹ in their review of seclusion in forensic settings, described these spaces as uncomfortable, claustrophobic, and akin to prison.

Seclusion is viewed as a form of restraint in mental health (including forensic) settings. As Holmes et al. ¹⁰ indicated, in circumstances where patient behaviours – often related to psychiatric diagnoses but exacerbated by the physical environment – place that person and/or others at risk, restrictive measures may be necessary. These measures may include one or more of chemical restraints (sedation), mechanical restraints, and environmental restraint (seclusion). And though the use of restraints should be considered as a last resort, ¹² in forensic settings they often see widespread implementation.^9,10 Mason’s ¹³ assessment of the rationales for seclusion remain relevant today, which he categorized as therapeutic intervention, containment, and punishment. The literature on the use of seclusion (and other restraints) as a last resort and for therapeutic purposes is extensive.^14–17 In these cases, restraints offer short-term maintenance of safety, abatement of psychiatric symptoms, and removal of patients from overstimulating environments. Ongoing assessments by nurses ensure that restraints are used for the shortest time necessary to improve the patient’s safety and wellbeing, and then discontinued. However, despite policies and platitudes suggesting such is the only use of seclusion (and other restraints), in forensic settings particularly, they see more widespread implementation and for longer periods of time.^7,9,10,18 In these settings, seclusion may be used to contain patients who are viewed as unmanageable, or even as punishment for (mis)behaviours.^9,10,13

Of particular concern is the extended use of seclusion. Definitions of what constitutes ‘long-term’ seclusion prove elusive, as most studies focus on recommendations for the shortest time possible, with extended use of seclusion remaining unacknowledged. For our purposes here, we turn to recent work by Perryman, ⁷ whose legal examination of seclusion in Canadian forensic hospitals worked to develop a formal definition. This author contrasted between Canadian prison settings, where strict regulations have been placed on solitary confinement (a synonym for seclusion in these environments) and forensic hospital settings. In Canadian prisons, ‘prolonged’ confinement is anything that lasts longer than 15 consecutive days, which is prohibited. Furthermore, in Canadian prisons, incarcerated persons diagnosed with mental illness(es) cannot – at least according to policy – be placed in solitary confinement at all, with the recognition that doing so would exacerbate their symptoms. Extensive evidence exists linking the development and/or exacerbation of symptoms of mental illness with prolonged seclusion.^6,19–22 It is troubling to acknowledge, based on this evidence, that long-term seclusion (here we adopt this definition of 15 or more consecutive days) is widespread in forensic hospital settings, where all patients ostensibly live with mental illness diagnoses.

In Canada, forensic hospitals are the jurisdiction of the provinces, as is the regulation of patient seclusion policies. However, as Perryman ⁷ exposed, many Canadian provinces have no laws specifically governing the practice of seclusion at all. In most cases, responsibility for the ordering and maintenance of seclusion is relegated to physicians. In a position statement, the Canadian Psychiatric Association ²³ does not explicitly oppose the use of seclusion, even if not considered therapeutic, in cases where the safety of the patient or others is of concern. They note that seclusion should be used as a last resort and for minimal duration, and defer to local policies for implementation and maintenance. Yet, as noted by Perryman, ⁷ in forensic hospitals in many Canadian provinces such policies do not exist. Furthermore, of the policies that do exist, none specifically forbid the use of indeterminate seclusion. This stands in stark contrast to legislation and policies affecting Canadian prisons. Effectively, the power to place patients in seclusion, and keep them there indefinitely, is left to physicians (typically psychiatrists), with few tangible policy-based or legal safeguards in place. Returning to Foucault’s ¹ description of Pinel’s founding moment of so-called modern psychiatry, wherein the shackles and confinement of madness were removed, what does it say about current practices when patients return to this state?

The unfortunate result of this system of seclusion laws and policies (or lack thereof) is the use of seclusion far beyond what could reasonably be described as therapeutic, and into the realm of what Mason ¹³ described as containment and punishment. In a review by Hansen et al., ⁹ the median duration of seclusion in forensic settings ranged from hours to days. Patients in the study by Holmes et al. ¹⁰ noted that seclusion could be beneficial in some circumstances, such as time alone or decreased stimulation, but extended periods of time in seclusion were detrimental and viewed as punishment. However, reports of significant lengths of time spent in seclusion do exist. Findings by Holmes et al. ¹⁰ described situations where patients were held in seclusion for weeks. Till and Silva ²⁴ provided a case study of a patient in a British forensic setting who had been in seclusion for 1046 days. Perryman described one case in which an individual in a Canadian forensic hospital remained in seclusion for over 3 years, and a forensic hospital in Ontario is currently subject to class action for patient seclusion lasting ‘weeks, months and sometimes years at a time’.^7(p308) The first author of this manuscript worked in a setting where an individual had been kept in seclusion for over a decade. Certainly, no therapeutic value can be derived from such durations of seclusion.

‘Difficult’ patients in forensic psychiatry

Nurses working in forensic hospital settings exist at the intersection of custody and caring, ²⁵ wherein they are tasked with the provision of therapeutic patient care while working in – and maintaining – the restrictive practices of a correctional environment. This paradox, which Holmes ²⁶ described as nurses working as both agents of care and agents of control, is a defining feature of forensic mental health nursing practice. And this paradox is perhaps most apparent in a consideration of long-term seclusion. How do nurses navigate attempts to remain therapeutic to patients placed in circumstances that can only worsen their condition(s)?

To explore this paradox, we refer to the results of the first author’s ³ study of nurses’ work with ‘difficult’ patients in high-security units in a Canadian forensic hospital setting. Nurses were asked to describe the patients they perceived to be most challenging, or ‘difficult’ to work with, and the strategies they employed in their practice to navigate these challenges. Two distinct groups of patients were described. The first was patients described as ‘antisocial’ who refused to cooperate or adhere to institutional rules and expectations – this group has been explored in-depth elsewhere. ⁴ Of note, we described how nursing work with these patients relied heavily on the technologies of disciplinary power.^1,4 The second group, which will be the focus here, were patients described to be living with treatment-resistant psychotic disorders (primarily schizophrenia). Within this patient group, participants described the use of long-term seclusion.

Participants were recruited from two high-security forensic psychiatry units in a large forensic hospital in Western Canada. This hospital consisted of several units of differing mandates and security levels, including the units included here. Patient activities on the high-security units were highly regulated and supervised by forensic nurses, 24 h per day. Seven (n = 7) individuals participated in semi-structured qualitative interviews following a set of seven guiding questions to explore the setting in which they worked, the patients they perceived to be challenging or ‘difficult’ to work with, and the strategies they employed with these patients. The average interview length was 30 min. Due to COVID-19 restrictions, all interviews were conducted via telephone. Interviews were audio recorded and transcribed verbatim by the first author. Participants were either Registered Nurses (RNs) or Registered Psychiatric Nurses (RPNs) who worked full or part-time on either of the two units, or had done so over the past 6 months. These two designations function identically in this setting. Participants included both male and female RNs and RPNs, ranging in age from early 20s to late 50s, and between 2 and 20 years of nursing experience. Specific participant demographics are not reported to maintain confidentiality. Ethics approval was provided by both the authors’ university and the hospital’s health authority review boards. Informed consent was provided by all participants. A discourse analysis methodological framework was employed to explore the power relations extant in the setting, how patient subjectivities were produced, and to interrogate the underlying assumptions of nursing practice.^27–29 Interview transcripts were reviewed multiple times in an iterative process of exploring what participants said, what was left unsaid, and underlying assumptions of statements.

Participants described patients with legal statuses of NCRMD living with ‘treatment resistant’ psychotic disorders, such as schizophrenia, as spending lengthy durations both in the hospital and in seclusion. Though patients spending lengthy periods in seclusion was noted as rare, these were the patients that participants described as ‘difficult’ and were the focus of their experiences. Describing this patient population, Participant 7 stated ‘they have been here for the longest time ever, and we give them every single medication that is available and they’re not responding’. Despite these reported exhausted attempts at psychopharmacological intervention, these patients were described as both unpredictable and dangerous. Participant 4 stated ‘you know… just sporadically, spontaneously without any provocation be hitting someone’. This aggressiveness was explained by Participant 6, who added ‘there’s no way for us to figure – they don’t escalate – you know, it’s very random, there’s no rhyme or reason’. Describing one of these patients, Participant 5 succinctly summarized ‘I was quite afraid of him’. Participants described patients living with psychotic disorders that do not ‘respond’ to medications, who remain ‘floridly psychotic’ (Participant 6) and, as a result, are unpredictable in their acts of aggression and violence.

As a result of these behaviours, participants described the necessity to ‘manage’ these patients. To them, available treatment options had failed. Circumstances such as sufficient staffing levels to attempt alternatives are not always adequate. There was no discussion of potential recovery or patient progress, simply a necessity to manage their unpredictability. Seclusion, particularly long-term seclusion, was described as a method for ‘managing’ these patients – akin to Mason’s ¹³ concept of patient containment. With long-term seclusion becoming the baseline ‘treatment’ for this group of patients, the nursing focus shifted to ‘quality of life’ interventions, aimed at interrupting their near-constant confinement. Participant 6 described these approaches aimed to ‘give them some freedom instead of maintaining them in seclusion all the time…different measures of providing them a level of freedom in terms of quality of life’. Participants described ‘care plans’ for these patients, wherein nurses assess the patient’s suitability to be taken out of seclusion and onto the unit or outside the hospital. Patients are then placed in shackles and brought out under heavy supervision. Participant 6 described this process:

Imagine a belt going around your waist, and then it’s got these little…cuffs that – they’re very careful, you know we’re very careful in how we apply them and how much pressure they’re put on and they’re checked regularly…and so these individuals are allowed out on constant [observations], so they’re being monitored constantly with staff at stand-by on the unit to socialize with other patients, to watch television and so on. And that’s improved their quality of life.

These brief releases from seclusion were described by Participant 3 as ‘whatever we can give him. Like the most that we can within the circumstances of everything, right?’ Participants described these measures as a necessary ‘balance’ between safety (of unit staff, the patient, and co-patients) and patient quality of life.

Such scenarios present highly challenging dilemmas in nursing practice. Participants acknowledged the harms of long-term seclusion but recognized that without it, these select patients had potential to be aggressive or even violent, jeopardizing the safety of unit staff and other patients. Temporary release from seclusion only occurred with use of mechanical restraints, under heavy staff supervision. Though, due to staffing issues, this is not always possible. Describing this phenomenon, Participant 5 stated ‘I find that hard. It makes me sad to see him, you know, to have the shackles on. He seems more used to it. I’m not used to it’. The paradox of custody and caring is fundamentally presented here; nurses are forced to do both simultaneously. The ‘caring’ that occurs takes the form of temporary reprieves from seclusion, accompanied with a sense of resignation that this is the best they can do.

Agamben: The state of exception

We can envision the trajectory in which long-term seclusion develops. A patient detained in a forensic setting living with a psychotic disorder’s symptoms result in aggressive or violent behaviour. Nurses and other professions work to de-escalate or contain these behaviours, but these efforts fail. The patient is placed in seclusion for safety purposes. Perhaps they are sedated. This emergent behaviour must be managed. Nurses attempt to release the patient from seclusion, but the aggressive or violent behaviours continue. Antipsychotic medications are administered, but the symptoms do not subside. Further attempts to terminate seclusion only result in more acts of aggression. Different – or combinations of – antipsychotics are trialed without success. Nurses develop plans to trial patients out of seclusion, but the aggression continues. Eventually the patient becomes ‘treatment resistant’ and efforts at recovery shift to those of management. Seclusion becomes the rule.

To provide a theoretical framework for this phenomenon, we draw upon the work of Italian philosopher Giorgio Agamben, specifically his text Homo Sacer: Sovereign Power and Bare Life, ⁵ originally written in 1995. Agamben’s work is wide-ranging; here, we will focus on his concepts of homo sacer, bare life, and the state of exception. These concepts facilitate critical examination of the phenomenon of long-term seclusion, and the state to which those persons subject to this confinement are reduced.

Following the Greeks, Agamben ⁵ illustrated that two terms could be used to describe ‘life’ as we currently understand it. The first, zoē, describes the basic fact of living, and could be used to describe humans and animals alike. In contrast, bios is what Agamben described as a ‘living animal with the additional capacity for political existence’.^5(p7) Human beings may occupy either of these definitions; not all humans have the right to exist in a state of bios. This contrasting pair of states (zoē/bios), Agamben claimed, is characterized by bare life and political existence, exclusion and inclusion. However, in the modern Western world, both of these statuses exist within the political realm. Agamben points to the concentration camp as emblematic of this situation; those who exist as zoē:

Were lacking almost all the rights and expectations that we customarily attribute to human existence, and yet were still biologically alive, they came to be situated in a limit zone between life and death, inside and outside, in which they were no longer anything but bare life (emphasis added).^5(p159)

This state of bare life, to which the person is reduced to simple biological function and not entitled to the joys and freedoms of political existence, accurately describes the state of the forensic patient in long-term seclusion. Basic needs are provided, such as food, hygiene, and clothing (though at times these may even be challenging to provide). But beyond these basic needs, little is provided. Even departure from the space of confinement is mediated with additional restraints. As Agamben noted, such is a life devoid of value.

A specific term was used to describe these individuals reduced to this state of bare life: homo sacer. Perhaps confusingly, Agamben described homo sacer (or sacred man) as one ‘who may be killed and yet not sacrificed’.^5(p8) This homo sacer is simultaneously excluded from political existence while still existing within it. Banishment is the act in which homo sacer is produced. As Agamben elaborated:

He who has been banned is not, in fact, simply set outside the law and made indifferent to it but rather abandoned by it, that is, exposed and threatened on the threshold in which life and law, outside and inside, become indistinguishable.^5(p29)

Such an individual may be killed without punishment, but because of their exclusion from the political community, they may not be religiously sacrificed. ³⁰ Again, this concept of homo sacer accurately reflects the status of the forensic patient in long-term seclusion. And while these persons may not be literally killed, as Agamben suggests, we argue that they are instead subject to a social death, with those responsible free from punishment.

So here, in long-term seclusion of forensic patients, we have persons no longer entitled to the joys, freedoms, and agency of bios, but are instead reduced to zoē, to a state of bare life. This person is homo sacer – one who has been banished, who exists in an ambiguous legal state, wherein they very much exist outside of the law, but have been placed in that state by the sovereign (in this case, the physician), who belongs to the law. This is what Agamben described as the state of exception. The circumstances in which homo sacer is placed outside the law – effectively, in which the law is suspended – typically begin in an emergency. As Foth described, these are ‘periods when sovereign states rationalise the suspension or modification of law in the name of national security’.^27(p17) In the case of long-term seclusion, however, it is not some political sovereign suspending the rights of citizens, but the physician – as sovereign – who suspends the rights of patients in the name of hospital security. Indeed, as Agamben explored, in Nazi Germany’s eugenics program targeting mentally ill persons, ‘a sovereign decision on bare life comes to be displaced from strictly political motivations and areas to a more ambiguous terrain in which the physician and the sovereign seem to exchange roles’.^5(p143) The opening vignette of this manuscript, wherein the physician refutes sovereign power and removes psychiatric patients from their shackles is now reversed.

Echoing the legally ambiguous circumstances in which the state of exception produces homo sacer, ⁵ Perryman’s ⁷ exploration of the inconsistent legal framework in which seclusion is implemented and maintained in Canadian forensic hospitals highlights this ambiguous legal space in which physicians exercise this sovereign power. Here, we return to our conceptualization in which long-term seclusion develops. The patient, now deemed treatment-resistant, requires extended seclusion to maintain the safety of the hospital unit. This lengthy seclusion is deemed an exceptional circumstance, forced upon the staff by an unruly and untreatable patient. But, as Agamben described, in the state of exception the emergency becomes the rule. Normal order is suspended – in these cases, indefinitely. And as Perryman ⁷ described, unlike Canadian prisons, there are no legal frameworks preventing this normalization of long-term seclusion in forensic hospitals.

At risk of appearing overzealous or unnecessarily strident in our presentation of long-term seclusion, we offer Agamben’s ⁵ framework of the concentration camp as emblematic of this phenomenon, and implication of nurses in these cases. Foth’s^30,31 examination of nurses working in Nazi Germany, and their involvement in the euthanasia of mental patients, illustrates how a critical examination of nursing calls into question what is often considered the essence of nursing practice: care. To Agamben, the concentration camp comes to represent the nomos of a political space. It can be manifest in many ways and is born out of the state of exception. In describing the camp as paradigm, he described a state ‘in which the norm becomes indistinguishable from the exception. The camp is thus the structure in which the state of exception – the possibility of deciding on which founds sovereign power – is realized normally’.^5(p170) The patient is reduced to a normalized state of zoē, a state of bare life indistinguishable, as Agamben offered, from beasts. As the authors have observed, it is difficult to view a patient in a state of long-term seclusion and not come to this conclusion. Indeed, studies in Canadian settings have illustrated that patients in seclusion report feeling like they had been treated like animals.^7,10 The nurses interviewed in the study had normalized this use of long-term seclusion. Instead of questioning its use on a fundamental level, they instead worked to find ways to alleviate the suffering of patients, to at least temporarily move patients away from a state of bare life. While this may represent nursing care, this care cannot be separated from the broader context in which it exists.

Social death

Before drawing broader conclusions and nursing implications, we will attempt to illustrate the profound effect long-term seclusion can have on a person. Studies examining long-term seclusion in forensic hospitals from the patient’s perspective are effectively non-existent. So instead, we draw upon Lisa Guenther’s ⁶ critical phenomenology of solitary confinement, and her concept of social death, which we link to Agamben’s ⁵ assertion that homo sacer may be killed (in this case, socially), but not sacrificed. Guenther’s ⁶ work, though primarily derived from accounts of incarcerated persons in the United States, where prolonged solitary confinement is common practice in prisons, permits parallel consideration of the experiences of forensic hospital patients in long-term seclusion. Such an examination, even if speculative in this case, is necessary to consider just how significantly this phenomenon can compromise the mental (and physical) wellbeing of persons.

The opening statement of Guenther’s text suggests ‘there are many ways to destroy a person, but one of the simplest and most devastating is through prolonged solitary confinement’.^6(p11) Guenther described the typical logistics of solitary confinement in American prisons: upwards of 23 h per day spent in confinement, exiting of a cell via shackles and under officer escort, and limited to no social contact beyond these custodial engagements. Any supposed efforts at rehabilitation are abandoned to a focus on control. She added ‘the prisoner has become a risk to be managed, a resistance to be eliminated, and an organism to be fed, maintained, and prevented from taking its own life’.^6(p138) This reduction of a person to a state of bare life, to be managed but not rehabilitated, is paralleled in the treatment of long-term seclusion patients in forensic hospitals. Indeed, the conditions of solitary confinement mirror those of long-term seclusion: extreme solitude, minimal time outside the cell, and highly restraint-mediated interactions with staff.

How a patient in a forensic hospital experiences long-term seclusion has not been explored in the literature. But we can extrapolate from Guenther’s work, which draws on the experiences of persons held in solitary confinement in prisons. As this author described, these are accounts derived from memoirs, or interviews with psychologists and other researchers. And tragically, but unsurprisingly, ‘countless others have left no record of their experiences’.^6(p14) Homo sacer – the person in this state – has been banished; their experiences left inconsequential. Guenther, citing Grassian, ¹⁹ outlined what has been described as SHU syndrome, named after Secure Housing Units – solitary confinement units in American supermax prisons. There are six components to SHU syndrome: ‘(1) hyperresponsivity to external stimuli; (2) perceptual distortions, illusions, and hallucinations; (3) panic attacks; (4) difficulties with thinking concentration, and memory; (5) intrusive obsessional thoughts; and (6) overt paranoia’.^6(p145) Certainly, we can recognize these components as identical to the symptoms of psychotic disorders. And as Guenther and others^19–22 have noted, extended periods of seclusion can not only exacerbate the symptoms of a diagnosed mental illness, but they can also produce these symptoms in those without a prior diagnosis. Furthermore, humans, as social beings, are reduced to a state in which meaningful engagement with others is severed. Guenther continued, stating ‘prolonged isolation cuts prisoners off from this network of social, cognitive, perceptual, affective, and even ontological support, turning prisoners’ capacity for meaning, and for meaningful relationships, against itself to the point of incapacitation’.^6(p146) Any relationality with others, be it with correctional officers or, in forensic hospitals, nurses, is a forced relationality. It is a relationship that is not entered into consensually, and it is one that does not permit either solitude or interaction on the patient’s own terms.

The end result of these experiences is what Guenther described as social death. This is a state in which the person is deprived of social relations. The author offered the following definition:

Social death is the effect of a (social) practice in which a person…is excluded, dominated, or humiliated to the point of becoming dead to the rest of society. Although such people are physically alive, their lives no longer bear a social meaning; they no longer count as lives that matter.^6(p20)

The forensic hospital patient who languishes in long-term seclusion remains physically alive, but reduced to a state of bare life – that of homo sacer. And as Agamben stated, homo sacer is one who can be killed without consequence, in these cases a social death. Trapped in a legally ambiguous state, ⁷ with no tangible mechanisms signalling an end-point to their confinement, it is all but impossible to conclude that these are persons whose lives do not, in fact, matter.

The role of the nurse and the path forward

We write this manuscript from a place of grief. It is difficult to acknowledge that persons living with mental illnesses can be reduced to such a state. It is difficult to acknowledge that these persons’ seemingly perpetually declining mental state can be anything but iatrogenic. And it is difficult to acknowledge that nurses may be part of this. We doubt that any nurse has entered the profession wanting to be part of an apparatus that causes such harm. And yet we are placed in these seemingly impossible situations in which we must attempt to balance the safety of others with the destruction of our patients.

The first author of this manuscript recalls working on a unit wherein a patient had been locked in seclusion for over a decade. This patient, deemed ‘treatment resistant’, had been reduced to such a state of bare life that they no longer paid any attention to personal hygiene. This author recalls accompanying a psychiatrist to speak with this patient. To do so, conversation occurred through a small, locked meal slot, or sallyport, in the heavy steel door. To open this small orifice into the patient’s seclusion room was to unleash an overwhelmingly unpleasant, malodorous miasma. The psychiatrist was struck by this foul stench and said to themself, ‘my god, what have we done to this man?’ This statement is an acknowledgement that we were responsible for this patient’s state. Nurses, too, were part of this.

Thomas Foth^30,31 performed the difficult work of examining the roles that nurses played in the euthanasia of psychiatric patients in Nazi Germany. His examinations fundamentally question the seemingly essential nature of care in nursing practice. This concept of care must be placed within a broader political and social framework to recognize that nursing practice was not one of simple barbarism. In the present examination of long-term seclusion, we must consider the broader context in which nursing practice and care are delivered. Nurses are placed in a seemingly impossible position, attempting to provide some semblance of care to their patients within the highly restrictive and custodial forensic hospital environment. The realities of patient violence, personal safety, legal circumstances, and a highly inflexible physical environment restrict the actions and interventions nurses may employ. The introduction of zero-tolerance policies in forensic settings, which position patients as the primary source of violence, may contribute to an increased reliance on seclusion not for therapeutic means but for patient management and even punishment.^13,32,33 However, contrary to Foth’s examination of nursing practices in Nazi Germany, where ‘the life the nurses killed was, to them, considered to be no life at all’,^30(p21) the participants in our study refused to do so. Like us, these participants grieved the bare life to which their patients had been reduced. And as Foth, quoting Butler, ³⁴ acknowledged, ‘grievability is a presupposition for the life that matters’.^30(p21)

The state of bare life to which patients in long-term seclusion are reduced produces a form of social death. ⁶ These patients have been (socially) killed in a legally ambiguous state of exception, absent a legal framework prohibiting this treatment. While the (at least symbolic) removal of shackles ostensibly heralded a more humane approach to psychiatry, as Foucault ¹ noted, it simply shifted the operation of power to other coercive forms, such as disciplinary and pastoral power.^26,35 Patients are still subject to coercion, but these forms do not reduce patients to a state of bare life and social death. For those in long-term seclusion, they have been abandoned, returned to the shackles from which they were once (historically) freed – the operation of sovereign power. In this state of seclusion, existing symptoms of mental illness are exacerbated, others newly produced. It is difficult to imagine a dramatic shift in forensic practice where nurses simply refuse to participate in long-term seclusion; as we have explored elsewhere, ⁴ this is a highly disciplinary space in which nurses and their practices are also deeply embroiled. Acts of resistance are more subtle. As our study indicated, nurses engage in acts of resistance against this terminal relegation of long-term seclusion patients to a state of bare life. They found opportunities to engage with patients, to bring them out of seclusion in attempts to provide ‘quality of life’ interventions aimed at at-least temporary respite from this state of bare life. They worked against the social death of their patients.

While honourable, these interventions are insufficient to undo the iatrogenic effects of long-term seclusion. They can only provide brief respite from a place of bare life. And they cannot undo the social death of their patients. As Guenther ⁶ noted in defining social death, relationality remains nonconsensual for these patients. They cannot choose when and how they engage with others. These engagements are instead imposed upon them, dictated by nurses’ schedules and a patient’s ‘suitability’ to be removed from seclusion, and maintain another form of restraint through the use of shackles. We applaud these efforts by nurses and their acts of resistance, but also recognize that meaningful, long-lasting change requires more dramatic steps.

What is instead necessary are measures that both question and challenge the use of seclusion altogether, especially long-term seclusion. As noted, seclusion (as environmental restraint) is indicated as an intervention of last resort.^12,14–17 As Holmes and colleagues ¹⁰ observed, from a patient perspective, there are some circumstances in which short-term seclusion may be therapeutic, such as providing a sense of safety or to de-escalate from states of agitation. However, most view seclusion as a negative experience – one of boredom, loneliness, or perceived punishment. ³⁵ Indeed, seclusion as punishment can exacerbate the (mis)behaviours of patients and lead to more extreme episodes of aggression and violence that are subsequently used to justify continued seclusion. ³⁶ Nurses should be aware of the limited circumstances in which short-term seclusion may be therapeutic, and avoid its use in all other situations. And we hope that our theoretical interrogations of seclusion here – the exposition of seclusion producing a state of bare life and social death – will provide an understanding of just how devastating this experience may be to patients. Additionally, an awareness of how long-term seclusion becomes normalized can present nurses an opportunity for critical reflection and prevention. ³⁷

In addition to nursing practice measures aimed at the prevention of long-term seclusion, legal and policy-based approaches present opportunities to limit or even eliminate its use. Perryman ⁷ outlined three administrative approaches. The first is to declare the use of seclusion as unconstitutional, mobilizing similar arguments as those used to limit the use of solitary confinement in Canadian prisons. Such an approach, Perryman concedes, would be both complex and challenging to pursue. The second approach is to bring about class and/or individual actions against the hospitals that place patients in long-term seclusion. Such actions, Perryman ⁷ indicated, can affect institutional changes in practices. Both of these approaches, the author recognized, are complex, lengthy, and expensive to pursue. The third approach is to present complaints to medical professional regulators, including psychiatrists (and potentially nurses), which may act as a deterrent against future use of long-term seclusion. In addition, these revelations on the use of long-term seclusion should force the Canadian Psychiatric Association to reconsider its position statement on the use of seclusion. ²³ Are psychiatrists, in fact, undoing the historic progress made by Pinel by effectively placing their patients back into dungeons?

Conclusion

The use of seclusion as a form of restraint presents unfortunate and challenging ethical dilemmas for nurses working in forensic mental health settings. Burdened by the paradox of custody and caring, nurses are tasked with the management of potentially aggressive and violent patients in a highly disciplinary and restrictive environment, while also working to provide therapeutic interventions. While the short-term use of seclusion may prove therapeutic in limited situations, we are forced to acknowledge that seclusion may also be used as a tool of patient management, even punishment. Our critical examination here identifies the circumstances in which seclusion becomes the norm and identifies the ambiguous legal framework in which long-term seclusion is permitted. By illustrating the devastating effects of long-term seclusion on patients, including the production of a state of bare life and social death, we aim to provide nurses with a framework for critical reflection on practices that may lead to its implementation. And though more radical approaches such as the refusal to participate in the use of seclusion may not be realistic to practicing nurses, consideration of acts of resistance to minimize its use and identify the circumstances that produce long-term seclusion is of use to nurses. While the interventions of nurses in our study are admirable and work to address the effects of long-term seclusion, we ask how we can avoid getting to this stage at all. ¹⁷ And certainly this is a topic that warrants further examination. Our analysis here is based upon details from two qualitative studies,^3,4,10 personal experience, and limited legal cases. ⁷ Future studies could examine how widespread long-term seclusion use is across Canada (and beyond) to better understand the magnitude of this most unfortunate phenomenon. Furthermore, a better understanding of the persons subject to long-term seclusion is warranted; details such as mental health diagnoses, race, and gender may provide additional insight into this practice and further opportunity to eliminate its use.