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

BackgroundThe 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 objectivesThe 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 designA qualitative research design was employed, utilizing a critical discourse analysis methodology.Participants and context7 nurses working in a high security forensic hospital setting in Canada participated in qualitative interviews.Ethical considerationsThe paradox of custody and caring is central to the considerable ethical challenges nurses face with patients in long-term seclusion.Findings/resultsIntegration 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.ConclusionsLong-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.