The frequency and duration of seclusion for women in a secure forensic hospital and their experiences of seclusion - a mixed methods study

<p dir="ltr">Background/Introduction: Seclusion is widely accepted as being associated with negative consequences for the person being secluded and human rights violations. Seclusion use for women in secure forensic hospitals is an under-researched area with much of the research focusing on men, despite increasing numbers of women being incarcerated and requiring forensic mental health care. Women in secure settings are highly vulnerable, and have extensive histories of mental ill health and trauma. Their voices and experiences are often not heard. With more women requiring forensic mental health service input, alongside the need to reduce and safely eradicate the use of seclusion, an understanding of women who may be at higher risk of seclusion is needed in order to better inform sex-specific reduction strategies and address the specific needs of women in secure forensic hospitals. </p><p dir="ltr">Aim: This Doctoral study aimed to explore the use, frequency, and duration of seclusion for women in a secure forensic hospital, and the woman's experience of seclusion. </p><p dir="ltr">Methods: A concurrent mixed methods study design with three components was used to address the study aims. The components included a retrospective and prospective cohort study involving the collection of demographic and clinical characteristics for women admitted during the study timeframes. Where women experienced seclusion, seclusion data were also collected. Women who participated in the prospective study and who experienced seclusion were invited to discuss their experiences of seclusion. Quantitative data were analysed descriptively, with associations between categorical variables measured using chi-squared tests. Logistic regression models were used to determine characteristics associated with seclusion use, negative binomial regression models were used to measure the association between characteristics and the frequency of seclusion, and generalised linear mixed effects models were used to measure the association between characteristics and the duration of seclusion. Qualitative data were analysed thematically. </p><p dir="ltr">Results: The retrospective study had a total of 111 admissions involving 82 individual women, and a total of 232 seclusion events. The prospective study had a total of eight women participate, and a total of three seclusion events, accounted for by two women. Quantitative results found that women who experience seclusion during an admission to a secure forensic hospital are typically single, have child/ren, have a history of trauma, specifically childhood abuse or neglect, and have been diagnosed with a schizophrenia-type disorder and/or a personality disorder. Women with a diagnosis of a schizophrenia-type or a personality disorder and/or a substance use/abuse disorder, previous contact with mental health services, and a history of experiencing more than two different types of trauma are more frequently secluded. Indigenous Australian women and women who have a history of experiencing more than two different types of trauma have shorter seclusion events. </p><p dir="ltr">One woman participated in an interview to discuss her experience of seclusion with the following four themes generated from the data: defensive practice, torture and punishment, an embarrassing and degrading ordeal, and hard lessons. Her experience of seclusion was largely negative; she felt clinicians used seclusion as a punishment and a type of torture. Her experiences were exacerbated by a poorly maintained environment which impacted her ability to communicate effectively with clinicians. </p><p dir="ltr">Conclusion: This is the first study to have solely focused on seclusion use and experience of seclusion for women in a secure forensic hospital. Some research findings reflect the existing literature; however, this study highlights new areas of knowledge that warrant further investigation. The findings reinforce the compounding impacts of trauma and human rights violations in the context of seclusion use for women in secure forensic hospitals. With the increasing numbers of women, especially Indigenous women, in prison and requiring forensic mental health care, targets for seclusion eradication, coupled with the paucity of literature in this area, future research is needed. This study begins to address a gap in current research and provides a basis for future studies that can provide a deeper understanding and evidence to the development of sex-specific interventions and to address the human rights issues and risks for trauma exacerbation associated with seclusion for women in secure forensic settings.</p>