Les chambres fermées en psychiatrie: poursuivre le débat pour dépasser les conflits

Constraining measures such as seclusion in a locked room are often used in psychiatry despite the restrictive legislative limits which emphasise the exceptional nature of these measures. In constant tension with various principles of medical ethics, seclusion constitutes a major hindrance to patient rights and liberty, but at the same time, it may arise from a duty to assist or protect the patient or a third party. Within the context of caring for the patient, seclusion in a locked room must be justified by the patient's clinical condition and must aim to attain a therapeutic goal which legitimises its use. Nevertheless, we cannot ignore the conflict of interests between the giver and the receiver of care, nor the controversies among health professionals about this issue. On the patients' side, the locked room is often considered as a punitive measure which intensifies the feelings of rejection and abandonment, producing fear, anxiety and frustration. Seen as a source of suffering, its therapeutic qualities are often unrecognised. On the caregivers' side theoretical, ethical and deontological debates examine the isolation issue with three identified objectives: therapy, security and punishment. At this time, a certain consensus has been established concerning how resorting to confinement should be incorporated within the therapeutic strategy. A list of widely accepted indications and counter-indications has been discussed. Many teams of caregivers include the follow-up of episodes of seclusion within the protocol of care. It has been recognised that the development of the use of alternative measures is necessary, and the patient's voice has finally begun to be heard. Nonetheless, using locked rooms as a tool in caring for patients continues to be difficult and traumatising for patients and a persistent source of uneasiness for caregivers. Certain issues remain unresolved; for example, the evaluation of the expected benefits of seclusion compared to its deleterious effects or the estimation of its efficacy compared to that of alternative measures. Little rigorous scientific research has been carried out attesting to the therapeutic effects of seclusion and calls have been made to eliminate it from hospital services. The debate must continue within the hospital network and outside this network with the participation of patients' associations and the support of political authorities. It is this debate which forces us to envision other, less coercive, measures, thus creating the conditions to reduce seclusion. In this way, the contributions of the various participants in this debate play a part in the establishment of new standards which encourage a culture of care rather than a culture of control and make a partnership possible in caring for the illness that respects patients' rights.