Country blog Germany by Tilman Steinert

What is coercion and why does FOSTREN wants to reduce it

Coercion occurs in this context when a person receiving mental health care (i.e. a patient or service user) is compelled through physical force or threat to accept care or treatment against their will. It takes many forms in both community and hospital settings, comprising both legally constituted practices and informal strategies adopted by professionals and family and friends in crisis situations to manage violence, self-harm, suicide attempts, absconding and medication non-compliance. Its use varies widely across Europe. Many countries make extensive use of outpatient commitment, enforced medication and the option of compulsory admission to coercively manage patients in the community. Overt coercive measures within hospitals using physical force include enforced medication (‘rapid tranquillisation’), mechanical restraint and/or seclusion in a locked room.

For many reasons it is imperative at this time to galvanise efforts to reduce these coercive practices. The Council of Europe has recently (June 2019) unanimously adopted a resolution to “immediately start to transition to the abolition of coercive practices in mental health settings”. Coercion often meets the criteria for inhuman or degrading treatment which contravenes the European Convention for the prevention of such acts5. Article 15 of the UN Convention on the Rights of Persons with Disabilities upholds the human right to freedom from torture or cruel, inhuman or degrading treatment or punishment. In terms of international policy objectives, coercion in principle contravenes the objectives of the European Mental Health Action Plan 2013-20207 which stipulates in Objective 2 that people with mental health problems receiving services: “are citizens whose human rights (should be) fully valued, respected and promoted”; and in Objective 4 that they are “entitled to respectful, safe and effective treatment.”  At the social level, coercion is financially costly to health services and wider society. At the individual level, coercion is dangerous and can severely damage the therapeutic relationship between staff and patients.  

Legal background

Use of coercive measures for people with mental illnesses is regulated by three different legal frameworks:

  • Public Law, in case of acute danger to self or others. Public Law is federal, meaning that there are 16 (slightly) different laws
  • Guardianship Law, in case of danger to one’s health (not: danger to others). National Law, valid for the whole country
  • Parents’ Law, for minors. National Law, valid for the whole country.

In several decisions, the Constitutional Court explained that the UN-CRPD (convention on the rights of persons with disabilities) ranks like a national Law the interpretation of which for Germany is due to the Constitutional Court and that existing national laws are not in contradiction to the UN-CRPD.

In Germany, both involuntary commitment in a psychiatric hospital and involuntary treatment require a psychiatric expert review and a judge’s decision after a personal hearing of the patient. Mechanical restraint lasting more than thirty minutes requires a judge’s permission after a hearing at bedside as well. Community treatment orders are not available in the laws.

What is your country’s stand on coercion reduction?

Like in many other countries, substantial efforts have been made in Germany for years to reduce coercion in mental health care within the last three decades:

  • Attempts to introduce a common recording system in psychiatric hospitals
  • Awareness workshops, conferences, congresses
  • World Psychiatric Association’s Congress on Coercive Treatment in Psychiatry held in Dresden, 2007
  • Several working groups for research & practice existing for over 20 years
  • De-escalation techniques have been developed for the German context (e.g., ProDema) and have been broadly implemented
  • Registry for all coercive measures in psychiatric hospitals covering the Federal State of Baden-Wuerttemberg (11 million inhabitants), since 2015
  • Comprehensive national guideline on prevention of coercion of the German Association for Psychiatry, Psychotherapy, and Psychosomatics published in 2018, based on evidence and consensus of 22 psychiatric societies, including patient and relatives’ organisations
  • According to a decision of the Constitutional Court, since 2013 additional judge’s decision and treatment-independent expert review required for coercive treatment (except for emergencies)
  • Since 2018, bedside judge’s decision required for mechanical restraint lasting longer than 30  minutes
  • Complex interventions to reduce coercion in psychiatric hospitals, namely Safewards, 6 core strategies, and “Weddinger Modell” being introduced in many hospitals
  • Development of a guideline for standardized post-coercive review sessions
  • Funding of research projects by the Ministry of Health, “Innovationsfond” (Health Insurance Companies) and others
  • 1:1 supervision during coercive interventions or to avoid such interventions paid extra by health insurances

Like in many other countries, differences between hospitals and Federal States in terms of involuntary admissions and use of freedom-restrictive measures are considerable and cannot solely be explained by different patient populations. The rate of involuntary admissions per 100.000 inhabitants has been reported to be about 10/100.000 by pubic Laws and 7/100.000 by Guadianship Law (Valdes-Stauber 2012). Rates have increased over time, the percentage of involuntary admissions, however, remained rather stable with about 13 %. According to the registry of Baden-Wuerttemberg, the percentage of patients subjected to any kind of coercive intervention was 6,7 % between 2015 and 2017 and dropped to 5.8 % in 2019 after the new legal regulation with judge’s decisions for restraints longer than 30 minutes (Flammer et al.).

What kind of research is happening in your country on this topic?

  • Currently, several research groups at the Universities of Ulm, Bochum, Hamburg, Bielefeld and Berlin (Charitè) as well as some community-based or hospital-based initiatives are doing research. Some aspects are (selective literature):
  • PreVCo study (www.prevco.de): RCT on the implementation of the German guidelines for the prevention of coercion on 55 psychiatric wards. Several publications focusing on this study are already available:
    • Steinert T, Bechdolf A, Mahler L, Muche R, Baumgardt J, Bühling-Schindowski F, Cole C, Kampmann M, Sauter D, Vandamme A, Weinmann S, Hirsch S (2020). Implementation of Guidelines on Prevention of Coercion and Violence (PreVCo) in psychiatry: Study protocol of a randomized controlled trial (RCT). Frontiers in Psychiatry, 11, 579176.
    • Bechdolf* A, Bühling-Schindowski* F, Weinmann S,  Baumgardt J,  Kampmann M, Sauter S, Jaeger S, Wal-ter G, Mayer M, Löhr M, Schulz M, Gather J, Ketelsen R, Aßfalg R, Cole C, Vandamme A, Mahler L, Hirsch S, Steinert T. (2021). DGPPN-Pilotstudie zur Umsetzung der aus der S3-Leitlinie „Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsenen“ abgeleiteten Imple-mentierungsempfehlungen. Der Nervenarzt (submitted)
  • Case register studies with different objectives, based on the registry of Baden-Wuerttemberg and hospitals with similar recording standards
    • Flammer E, Steinert T. Involuntary medication, seclusion, and restraint in German psychiatric hospitals after the adoption of legislation in 2013. Front Psychiatry 6:153 (2015)Steinert T, Flammer E. Häufigkeit von Zwangsmaßnahmen als Qualitätsindikator für psychiatrische Kliniken? Nervenarzt 90: 35-39 (2019)
    • Flammer E, Steinert T. Das Fallregister für Zwangsmaßnahmen nach dem baden-württembergischen Psychisch-Kranken-Hilfe-Gesetz: Konzeption und erste Auswertungen. Psychiat Prax 46: 82-89 (2019)
    • Steinert T, Hirsch S, Goebel R, et al. Reduction of coercive measures under routine conditions in psychiatric hospitals 2004-2019: Strong effects in old age psychiatry, much less in general psychiatry. Eur Psychiatry 2020 63(1), e102, 1–7
    • Flammer E, Frank U, Steinert T. Freedom-restrictive measures in forensic psychiatry. Front Psychiatry 11:146 (2020). doi: 10.3389/fpsyt.2020.00146
    • Ketelsen R, Fernando S, Driessen M. Gender-Related Differences Regarding Aggressive Behaviour and Coercive Measures in Psychiatric Inpatients. Psychiatr Prax . 2021 Online ahead of print.
  • Empirical research on complex interventions that aim at reducing coercion, e.g. the implementation of the Safewards Model at Vivantes Hospital Am Urban/Charite in Berlin and the Weddinger Modell at the Department of Psychiatry of the Charité at the St. Hedwig Hospital. Experiences in the implementation and evaluation process are published in German and English language:
    • Baumgardt J, Jäckel D, Helber-Böhlen H, Stiehm N, Morgenstern K, Schöppe E, Voigt A, Mc Cutcheon AK, Velasquez Lecca EE, Löhr M, Schulz M, Bechdolf A, Weinmann S. (2021). Preventing and reducing coercive measures – An evaluation of the implementation of the Safewards Model in two acute locked psychiatric wards in Germany. In Huber, C., Schneeberger, A. R. (Hrsg.), Compulsory Interventions in Psychiatry: an Overview on the Current Situation and Recommendations for Prevention and Adequate Use (S. 155-172). Lausanne: Frontiers Media SA.
    • Baumgardt J, Jäckel D, Helber-Böhlen H, Stiehm N, Morgenstern K, Voigt A, Mc Cutcheon AK, Velasquez Lecca EE, Löhr M, Schulz M, Bechdolf A, Weinmann S. (2020). Sicherheit erhöhen, Konflikte vermeiden, das Miteinander stärken – Zur Implementierung und Evaluation des Safewards-Modells am Vivantes Klinikum Am Urban in Berlin. Neurotransmitter, 31(5), 24-29.
    • Baumgardt J., Helber-Böhlen H., Velasquez Lecca E.E, Bechdolf A., Weinmann S. (2019). Erfahrungen aus der Praxis – Vivantes Klinikum Am Urban – Klinik für Psychiatrie, Psychotherapie und Psychosomatik (Berlin). In M. Löhr, M. Schulz, A. Nienaber (Hrsg.), Safewards – Sicherheit durch Bindung und Milieu (S. 171-179). Psychiatrie-Verlag: Köln.
    • Baumgardt J, Jäckel D, Helber-Böhlen H, Stiehm N, Morgenstern K, Schöppe E, Voigt A, Mc Cutcheon AK, Velasquez Lecca EE, Löhr M, Schulz M, Bechdolf A, Weinmann S. (2020). Making Psychiatric Wards More Peaceful Places: Evaluating the Implementation of the Safewards Model in Acute Psychiatry Us-ing a Pre–Post Mixed-Method Study Design. SAGE Research Methods Cases: Medicine and Health. DOI: 10.4135/9781529726411
    • Baumgardt J*, Jäckel D*, Helber-Böhlen H, Stiehm N, Morgenstern K, Schöppe E, Voigt A, Mc Cutcheon AK, Velasquez Lecca EE, Löhr M, Schulz M, Bechdolf A, Weinmann S. (2019). Preventing and reducing coercive measures – An evaluation of the implementation of the Safewards Model in two acute locked psychiatric wards in Germany. Front Psychiatry, 10:340.
    • Cole, C., Vandamme, A., Bermpohl, F., Czernin, K., Wullschleger, A., & Mahler, L. (2020). Correlates of Seclusion and Restraint of Patients Admitted to Psychiatric Inpatient Treatment via a German Emergency Room. Journal of Psychiatric Research, 130, 201-206.
    • Czernin, K., Bermpohl, F., Heinz, A., Wullschleger, A. & Mahler, L. (2020). Auswirkungen der Etablierung des psychiatrischen Behandlungskonzeptes „Weddinger Modell“ auf mechanische Zwangsmaßnahmen. Psychiatrische Praxis, 47, 242-248.
    • Oster, A., Cole, C., & Mahler, L. (in press). The Weddinger Modell: A systematic review of the research findings to date and experiences from clinical practice. Medical Research Archives.
    • Wullschleger, A., Vandamme, A., Mielau, J., Renner, L., Bermpohl, F., Heinz, A., Montag, C., & Mahler, L. (2020). Effect of standardized post-coercion review session on symptoms of PTSD: results of a randomized controlled trial. European Archives of Psychiatry and Clinical Neuroscience. Doi: 10.1007/s00406-020-01215-x
    • Wullschleger, A., Vandamme, A., Ried, J., Pluta, M., Montag, C. & Mahler, L. (2019). Standardisierte Nachbesprechung von Zwangsmaßnahmen auf psychiatrischen Akutstationen: Ergebnisse einer Pilotstudie.  Psychiatrische Praxis, 46, 128-134.
  • Research on coercive treatment
  • Ethical issues
    • Steinert T. Ethics of coercive treatment and misuse of psychiatry. Psychiatr Serv 68: 291-294 (2017)
  • RCTs
    • Bergk J, Einsiedler B, Flammer E et al. A Randomized Controlled Comparison of Seclusion and Mechanical Restraint in Inpatient Settings.  Psychiatric Services 62:1310-1317 (2011)
    • Steinert T, Birk M, Flammer E, et al. Subjective distress after seclusion or mechanical restraint: one-year follow-up of a randomized controlled study. Psychiatr Serv 64; 1012-1017 (2013)

    Why are you in the network? What would you like to achieve with it?

We joined FOSTREN because we wanted to share our experiences and to enlarge our perspectives in research and clinical practice. We are particularly interested in how people in other countries manage implementation of evidence-based interventions successfully and what their experiences are with different types of coercive measures. Moreover, we would like to gain knowledge on different ethical views and legal regulations. A thrilling objective would be to establish multi-centre multi-country empirical research projects.

    Is there anything else that you want to share with us?

We wonder whether it makes sense to claim the complete abolition of coercive practices as it has been done by several renowned international organisations. Without doubt, it is very important to increase efforts to avoid coercion. However, according to medical ethics and legal regulations, in some cases coercion can be inevitable to protect patients and others from harm or death in case of impaired mental capacity. In such cases, the use of coercion is not a violation of human rights but a legal obligation. Therefore, blaming all kinds of coercion in psychiatric services as a violation of human rights discriminates against the professionals working in these services, putting them on a level with torturers. We need them urgently to keep the quality of our services, particularly for the most severely mentally ill people.