The ethical quandary of employing force or restraint in mental health care encapsulates a profound societal challenge: how to balance the imperative for humane treatment with the necessity of care. This tension between protecting individual rights and ensuring the well-being of patients and caregivers fuels a vigorous debate and underscores the critical demand for innovative approaches in psychiatric interventions. These approaches must champion dignity and compassion at their core. As we explore this critical issue, it becomes evident that there are concerted efforts underway to transform psychiatric care, illuminating the nuanced interplay between ethical principles and the practicalities of providing mental health treatment.
In an effort to refine psychiatric care practices, a significant study detailed in The Lancet Regional Health – Europe and led by Professor Tilman Steinert from Ulm University, set out to examine the implementation of guidelines designed to mitigate the use of coercive measures in 55 psychiatric in-patient units across Germany. This ambitious research initiative stood out for its comprehensive approach and the employment of external consultants to facilitate guideline implementation, resulting in nuanced findings that enrich our understanding of clinical practices in psychiatric care.
Reflecting on the study’s objectives, Professor Steinert shared, “The major result of the PreVCo study was that we could not show that the intervention aiming at improving guideline adherence had a significant impact on the primary outcome measure, the frequency of coercive measures used in the participating wards.” However, the main reason for this negative finding was that the median number of coercive measures used decreased by 45 % from baseline until the end of the intervention period on the intervention wards, but also by 28 % on waiting list wards. This was probably due to observer effects, while in the same time, during the COVID-19 pandemic, the use of coercion increased in psychiatric hospitals in Germany. Despite the challenging goal of reducing coercive measures, the study marked significant strides in other areas of psychiatric care practices.
A noteworthy success of the research was the marked improvement in guideline adherence among the intervention wards, as measured by the PreVCo Rating Tool. “Team performance in terms of guideline implementation was significantly better in the intervention group after a year,” Professor Steinert observed. This outcome signals a positive shift towards structured interventions and showcases the potential of external consultants in driving such transformative changes in clinical practices.
This study also stands as a testament to the ongoing journey towards more ethical, patient-centered psychiatric care. The insights gleaned from this research provide a solid foundation for future explorations, emphasizing the necessity of continuous innovation in the quest to minimize coercion in psychiatric care. Professor Steinert aptly concludes, “Further research from adequately powered robust RCTs is necessary to identify effective interventions to reduce the use of coercion in psychiatric hospitals.” This call to action underscores the commitment to advancing patient care and upholding the dignity and rights of individuals in psychiatric settings. Overall, the research led by Professor Tilman Steinert and his team, while navigating the complexities of implementing change within psychiatric care practices, contributes valuable insights into the efforts to reduce coercion. Its findings and the advancements in guideline adherence serve as a beacon for future research, paving the way for further improvements in psychiatric care that respect the rights and dignity of all patients.
JOURNAL REFERENCE
Steinert, T., et al. (2023). Implementation of guidelines on prevention of coercion and violence (PreVCo) in psychiatry: a multicentre randomised controlled trial. The Lancet Regional Health – Europe, 35, 100770.
DOI: https://doi.org/10.1016/j.lanepe.2023.100770.
ABOUT THE AUTHORS
Tilman Steinert is Professor of Psychiatry and Psychotherapy at the University of Ulm in Germany and Director of the Weissenau Psychiatric Clinic at the Südwürttemberg Psychiatric Centers. He is a member of the European Violence in Psychiatry Research Group and of the European FOSTREN Network for Research on the use of coercion in psychiatry. He has been conducting research on violence and coercion since the early 1990s and has published over 200 articles in peer-reviewed journals (see pubmed.ncbi.nlm.nih.gov/?term=steinert+t&sort=date) and several books, and serves as a reviewer for many psychiatric journals and funding agencies. He has also served as an expert witness for the German Federal Constitutional Court on issues of ethics and coercion. His main research interests are the epidemiology and subjective experience of coercion, ethics in psychiatry, violence, borderline personality disorder, and schizophrenia.
Sophie Hirsch is senior psychiatrist at the Department of Psychiatry and Psychotherapy in Biberach/Germany. She studied medicine and economics in Tuebingen and Hagen/Germany and attended advanced training as a specialist in psychiatry at the Centre for Psychiatry South Wuerttemberg and in neuro-oncology at the University Hospital of Eberhard-Karls-University and Hertie Institute for Clinical Brain Research in Tuebingen. She is a board member of the European Violence in Psychiatry Research Group (EViPRG) and member of the European FOSTREN Network for Research on the use of coercion in psychiatry. She was involved in the development of German clinical practice guidelines on prevention of coercion and aggressive behavior in mental healthcare and a nationwide, multicenter RCT for the implementation of the guidelines on wards in clinical routine.
Lieselotte Mahler is Director of the Psychiatric Department of the Clinics in the Theodor-Wenzel-Werk in Berlin. She is the head of the social psychiatry and health services research group of the Department of Psychiatry and Neurosciences at Charité Berlin and has been conducting research on reduction of coercion in acute psychiatry for over 10 years. Lieselotte Mahler has published numerous articles in peer-reviewed journals (see https://pubmed.ncbi.nlm.nih.gov/?term=lieselotte+mahler) and several books. In particular, she has developed the ‘Weddinger Modell’, a recovery-oriented psychiatric concept that leads to a significant reduction in coercive measures, as well as a standardized guideline for post-coercive review sessions with patients, which has been well evaluated in terms of reducing the negative consequences of coercion.
Dorothea Sauter is a nurse and health scientist, MSc. She is currently head of nursing development at the LWL-Klinikum Münster. She is president of the German Society for Psychiatric Nursing, first editor of the German core textbook for psychiatric nursing and co-editor of the transfer journal “Psychiatrische Pflege”. As a nurse, nurse manager, teacher and researcher, as well as a consultant and expert, she has dealt with the reduction of coercive measures and the implementation of complex interventions in many different ways.
