Response

Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} critique Hollins’s^{Reference Hollins2} conceptual definitions of long-term segregation (LTS) and seclusion, and findings on their effects on autistic people and/or people with intellectual disability. We refute all their arguments because they minimise and negate the current situation, and reassert that enforced isolation is a harmful, rights-restricting practice that has no place in contemporary mental healthcare.

Enforced isolation breaches disabled people’s human rights and is prohibited in many countries. Solitary confinement in prisons is the most punitive and harmful intervention bar the death penalty. The law is clear – restrictive interventions must be justified, proportionate, least restrictive and humane. However, the Hollins report^{Reference Hollins2} is just the latest of multiple national reports to unequivocally demonstrate this is simply not the case.^{Reference Hollins2,3} Tromans et al’s^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} assertion that ‘enforced isolation cannot always be avoided’ is indicative of organisational cultures that support and excuse its use as a ‘last resort’, often consequent to staff perceptions of disability, resulting in its greater prevalence.^{Reference De Benedictis, Dumais, Sieu, Mailhot, Létourneau and Tran4,Reference Webber, Richardson and Lambrick5}

The phenomenon of enforced isolation and terminology

Hollins^{Reference Hollins2} found that LTS was difficult to quantify. Staff often use it unknowingly, under less pejorative descriptors, such as ‘care away from others’ (CAFO), ‘living alone’ and ‘long-term seclusion’, without adequate safeguards or reduction strategies. However, regardless of the term used, people’s experience was of enforced isolation from meaningful human contact, which is consistent with the definition and experience associated with the term ‘solitary confinement’. Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} reject this term, arguing that regular contact with healthcare professionals constitutes meaningful human contact. Yet, Hollins^{Reference Hollins2} found that direct, meaningful social, emotional and sensory contact was severely moderated and/or denied. For example, communication was frequently obstructed by doors or glass and mediated through hatches or electronic devices. These factors, among others, acted as barriers to safe and therapeutic emotional connection for people who were distressed.

Tromans et al’s^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} suggestion that Hollins^{Reference Hollins2} includes bespoke single-occupancy housing, where a person has agency and control over when they leave and who enters their space, as enforced isolation is misleading. Clearly, this does not meet the definition of ‘enforced’. However, the report^{Reference Hollins2} does include hospital-based bespoke, single-occupancy accommodation where force is enacted to maintain isolation, recognising that these settings are vulnerable to becoming closed cultures, warranting greater supportive oversight.

Hollins’s^{Reference Hollins2} assertion that isolation has no therapeutic benefit is evidence-based, and the suggestion that social contact is crucial to normal human development is hardly contentious. The report’s findings are in keeping with consistent robust evidence spanning decades and sectors.^{Reference Haney, Lobel and Smith6} Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} criticise Hollins’s methodology, in which independent chairs (mainly psychiatrists) of multidisciplinary panels reviewed 191 episodes of LTS in depth, troublingly dismissing their carefully documented encounters and the experiences of the people involved.

Isolation is not a therapeutic alternative to inappropriate in-patient wards

Autistic people and people with intellectual disability do not sit outside of core human values and characteristics. The anecdotes offered by Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} – that ‘certain patients’ escalate their behaviour to sabotage reintegration because they prefer solitude – do not account for normal, human traumatic reactions to isolation, attempts to ward off its harmful effects, or the impact of power differentials between patients and carers and health professionals. Reactions to isolation are known to include perceptual distortions, paranoia, psychosis, sensory hypersensitivity, anxiety, depression, self-injury, action-oriented coping and insomnia.^{Reference Haney, Lobel and Smith6}

Ward environments may be difficult for some, but Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} perpetuate the outdated stereotype that autistic people prefer their own company and like enforced isolation because it is less stimulating. Solitary confinement is not solitude.^{Reference Haney, Lobel and Smith6} Any potential benefits^{Reference Chieze, Hurst, Kaiser and Sentissi7} come at a high physical and psychological cost and should not need to be realised through forcible isolation. Isolation is simply not legally justifiable on this basis. Additionally, even in the best cases of enforced isolation (where people were better able to control their social and sensory environment), the absence of normal, direct social and emotional connection had deleterious effects.^{Reference Hollins2} Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} cite Chieze et al’s^{Reference Chieze, Hurst, Kaiser and Sentissi7} systematic review of 14 studies involving enforced isolation, yet this overwhelmingly details its adverse consequences, including high rates of post-traumatic stress disorder. Chieze et al,^{Reference Chieze, Hurst, Kaiser and Sentissi7} like Hollins,^{Reference Hollins2} suggested that enforced isolation should be avoided and therapeutic relationships prioritised.

The need to rethink and un-think as professionals

A further challenge by Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} is that LTS is not experienced punitively. However, people are often isolated because they are perceived as having a behavioural disturbance and being at a sustained risk of harm, which may be understood as a constant feature of their presentation – Hollins^{Reference Hollins2} found that many patients attributed such enforced isolation to their distress, which communicated procedurally and sensorially their experience of being deserving of a cold and objectless space (Fig. 1).

Fig. 1

An autistic person’s graphic representation of ‘deserving’ their time in what they call solitary confinement. The person is under review by Independent Care (Education) and Treatment Reviews.

Claims are made by Tromans et al^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} about patients’ experiences as if their testimonies is not to be trusted. This ‘othering’ of people who have experienced solitary confinement – suggesting they like having their neurobiological needs for connection frustrated – and that it is therapeutic is arguably inhumane and constitutes epistemic violence. Like trauma, solitary confinement is not located in how others understand the event, but how it is experienced by the person – the inside-out perspective.^{Reference Bradley, Korossy, Branford, Gangadharan, Barrett and Alexander8} Our social and biological imperative is connection, and enforcing isolation on any human is fundamentally traumatising. Systemic change is required to end LTS, and co-produced/co-delivered psychiatric curricula, particularly in the context of trauma- and neurodiversity-informed care, could support relational safety and reduction of restraint.^{Reference Bradley, Korossy, Branford, Gangadharan, Barrett and Alexander8,Reference Quinn, Wood, Lodge and Hollins9} However, a framework of intensive support comprising consistent and collaborative practice leadership is essential, while listening to, learning from and understanding patients is foregrounded.^{Reference Quinn, Wood, Lodge and Hollins9}

In conclusion, we are alarmed by the tone, content and defensiveness of Tromans et al ’s paper^{Reference Tromans, Sawhney, Odiyoor, de Villiers, McCarthy and Boer1} and are deeply concerned about what it signifies for the care of current and future patients. We reiterate the urgent need to work collectively and constructively towards ending human rights abuses and improving support for people who are highly distressed.