Trauma, trust and the use of seclusion

Between the ages of 18 and 26, I was hospitalized ten different times while in my hometown of Halifax, Nova Scotia. During those hospital stays, I was seen as being depressed, anxious, hypo-manic, and even stoic.  No one ever thought I was angry or confrontational, because I knew better.

It’s not that I wasn’t angry; I was furious. I was furious about the lack of recommended therapy compared to the abundance of prescribed medications. I was furious about the loss of my dignity and autonomy. I was enraged about the reductionist approach that stripped away my personhood, transforming what once was a bright young woman into a collection of pathologies.

However, far more than I was angry, I was afraid. I was afraid of what would be done with me or what would be taken away from me if I gave that anger a voice. I did not want my passes taken away, my visitors restricted, or to incite hostility from the staff, because they were the ones with the power. More than anything I feared being placed in “therapeutic quiet” (TQ), also known as seclusion.

This fear did not go away when I left the hospital; it is something I still carry with me. I will apologize profusely for things I know are not my fault and I rarely raise my voice.  If someone ever screams at me directly, I lose my ability to speak and I shake. When I’m in the presence of an enraged person, I try to remain still, lest I make myself a target. This is my reality even though I have never been placed in seclusion.

I spent the last several weeks in clinical training for my new job as peer support specialist at Ontario Shores. Throughout the training, we were repeatedly reminded that “seclusion and restraints are only used when every other means has been exhausted. We never use these measures for punishment only for safety”. To me, this was revolutionary and hearing it filled me with emotion. I felt hope that maybe things have changed but I also felt a gut wrenching sadness for all the people I have witnessed being ostracized and punished over the years.

I have seen people placed in seclusion for such offenses as being loud, knocking on the partition at the nurses’ station, asking too many questions, asking for a Tylenol, crying loudly, spitting in the hallway, and being upset that they cannot go outside. I have seen some exceptional nurses in my time and I did see verbal de-escalation techniques used effectively on several occasions, but I also saw confused people agitated by overwhelmed staff.

I kept revisiting one particular incidence throughout my clinical training. During my last hospital stay, a man was brought to my unit who spoke English as a second language and who seemed to be suffering from psychosis. He was clearly agitated and confused, but he was not violent. I was not afraid of him, but I was certainly afraid for him.

Between the language barrier and his illness, he really didn’t seem to understand where he was. Within minutes of his arrival, he began asking the nurses where he was and why he could not go outside to have a cigarette. Instead of offering him comfort he was generally just ignored or would have an answer like ‘CALM DOWN’ barked back at him.

As this unfolded before me I could tell where the interaction was going wrong. However, at this point in my hospital career I knew better than to have an opinion and opted for self-preservation. The more this man’s concerns were minimized or ignored, the more loudly he would ask questions.  The staff called security.

He was sitting immobile in a chair when several security guards swept onto the unit. He was not yelling, he was not acting threatening, but clearly the decision had already been made to place him in seclusion. After being asked to move and not responding, two guards took his arms, forced him face down on the ground, and held him there. He asked them what he did wrong. 

This situation could have been avoided with proper use of de-escalation techniques and possibly a PRN. Unless someone is actively violent they should not be put in seclusion or restraints because it is traumatizing for the person, for other patients, and for the staff.

How could someone who hasn’t spent time in seclusion be traumatized by it? It has a lot to do with powerlessness. In his book ‘The Boy Who was Raised as a Dog’ Dr. Bruce Perry states: “… Trauma at its core is an experience of utter powerlessness, and loss of control, recovery requires the patient to be in charge.” When you are a patient and this kind of incident occurs you don’t have the option of walking away because the doors are locked. You don’t have the option of speaking out because the same people who are acting as oppressors are also your caretakers. My room was directly adjacent to the seclusion room, so I listened to this man howl, cry, bang the walls, and beg to be let out for hours. I felt totally powerless because I was unable to protect him, and I feared the same thing would happen to me.

Having seclusion used as a punishment is not conducive to recovery. It creates an environment of fear, and I cannot think of a situation where fear has ever brought out the best in anyone. It also erodes trust, particularly trust in staff and their recommendations for treatment. Clients who adhere to their treatment plans because of fear instead of trust do not continue that behavior upon discharge. We need to promote autonomy not paternalism. We need to heal trauma not exacerbate it. We need to respect our client’s rights if we expect them to trust us.