This study set out to investigate the relative effectiveness of four types of coercive interventions used by the mental health services, and the relative psychological and physical burdens these interventions imposed on patients. The study, which used structured and validated assessment tools completed by trained staff at two time points, also sought to assess the patient’s perspective through interviews conducted after the coercive event.
By using change scores, it is possible to identify improvement or deterioration in mental state after the implementation of a coercive intervention. It is noticeable that mental health (GAF) and behavior (SDAS, PANSS) improved in all four groups irrespective of the measure to which they had been exposed. While it is possible for reductions in conflict behaviors such as aggression (SDAS) and uncooperativeness (PANSS) to reflect submission to the authority and power of the staff that acts coercively, more notable were the improvements in wellbeing (GAF) and insight. Nevertheless all such ratings are at risk of contamination, as they were completed by staff who were not blind to the allocated intervention, and who were likely to have an investment in reporting improvements. It is also possible that there would have been equal or even better improvements in wellbeing and insight if the coercive interventions had not been used. Only a controlled research design would be able to establish this relationship, which is difficult to apply when violent behavior needs to be managed.
Although testing in both the univariate and multivariate analyses did not enable us to find any significant differences in effectiveness between the coercive interventions, there were differences between the groups with regard to the change scores for psychological functioning (change scores for GAF and insight into the illness) and reduction of imminent danger (change scores for aggression and uncooperativeness) (see Table
). This suggests that differences in effectiveness might become significant with a larger sample.
Our study raises a number of key issues. Firstly, it provides evidence that, when all else fails and a patient’s preference has not been previously recorded, involuntary medication should be the treatment of choice if a coercive intervention is unavoidable. In the first instance, the patient’s unequivocal consent to the oral route of administration is recommended, not only because oral administration is experienced as less coercive [27
] but also because it manages acute agitation just as effectively as an intramuscular formulation [28
When seclusion was not part of the coercive intervention, patients in our study who received medication alone experienced less isolation. After controlling for the effect of other variables, involuntary medication emerged as significantly associated with lower burden in more aspects of CES (i.e. overall CES, humiliation, and physically adverse events) than seclusion with or without restraint was. Medicated patients also reported substantially less global strain than patients who had been secluded only.
Conversely, we found that, as reported earlier [29
], subjecting the patient to a combination of seclusion and mechanical restraint is highly aversive and should be the least preferred option. As 9% of our sample was subjected to this highly intrusive intervention, it is by no means uncommon – and, given the availability of the less intrusive interventions examined here, could also be said to risk contravening the well-established principle of proportionality. If seclusion episodes were combined with mechanical restraint, they were more than twice as long as seclusion alone or seclusion combined with medication. Although the restraint group sample was small (n
11), there is no evidence that, in terms of aggression and psychological functioning, the restrained group were more disturbed than the secluded and medicated group at the onset of the intervention.
Further, combining seclusion with mechanical restraint was not significantly more effective in improving psychological functioning or reducing aggression than the rest of the restrictive measures were. However, all three other types of intervention as measured by some of the CES’s subscales were associated with lower burden; this further indicates the psychological costs to the patient of being restrained and secluded. These findings are in line with the recommendation of the Council of Europe as stated in the White Paper: “seclusion and mechanical or other means of restraint for prolonged periods should be resorted to only in exceptional cases” [3
By the same token, there is evidence that the combination of coercive interventions should be avoided – regardless of the types being combined. The principle of proportionality indicates that, because combined interventions were not more effective, single interventions should be used – and our findings indicate that these single interventions should preferably consist of medication.
It is also clear that different groups of patients react differently to the coercive situation. This variation amongst gender and age groups in terms of attitudes to coercive measures has been observed elsewhere [10
]. Our own study produced evidence that women and younger people reported that they had experienced coercive interventions as more burdensome – something staff should be aware of when deciding on implementing coercive interventions. This higher reported burden may of course reflect a willingness to report feelings of vulnerability, but it may also reflect not just women’s lower average tolerance thresholds for painful stimuli [30
], but also, as a socially influenced gender-based characteristic, their greater emotional responsiveness [31
]. While no decision to coerce should be taken lightly in this context, it seems that decisions to coerce women should be considered particularly carefully.
At the start of the coercive interventions, nursing staff should also use as little pressure as possible, because it may increase patients’ feelings of fear and coercion during the intervention. This may aggravate their condition: previous research has provided strong evidence that anxiety is related to the occurrence of persecutory delusions [32
], paranoia and hallucinations [33
]. Such interventions may thus end up counteracting the main therapeutic goal of psychiatric admission, which is to reduce symptoms and bizarre behaviours – although in this study we have also noted the general improvement in psychological functioning brought about by the coercive intervention(s).
In addition to this, increased perceived coercion might lead a patient to disengage from psychiatric services. It can also seriously damage the therapeutic relationship [34
]. In order to facilitate effective communication and aid the patients’ recovery, patients should be encouraged to participate and negotiate in decision-making on their own care [35
]. Increased feelings of coercion, humiliation, physically adverse effects and fear can also cause serious long-lasting adverse effects like retraumatization [36
] and PTSD.
While this is the first study yielding evidence that involuntary medication is less distressing for patients than seclusion or restraint by exploring actual coercive experiences, we must acknowledge a number of limitations. Firstly, 40% of the coerced patients refused to fill in the CES or were discharged before debriefing. Although a response rate of 60% has been described as good in an acute setting with difficult-to-recruit patients [37
], the non-respondents were significantly less cooperative and had lower GAF, so it is possible that the most seriously ill and traumatized patients were unable to participate, or refused to, making the CES scores here an underestimate of the real burden.
Secondly, patients were interviewed by the nursing staff and not by an independent researcher. Again, it is therefore possible that patients underreported the intensity of their experience to avoid challenging the staff.
Thirdly, a randomized clinical design and a larger sample size would clearly be preferable for establishing the effectiveness of these interventions [38
]. But such a design is extremely difficult to implement for this particular question, and samples are difficult to recruit. Although patients were not randomly allocated to the interventions groups and patients’ condition differed significantly between some of the groups at the start of the coercive interventions, we controlled for these baseline differences in the analyses.
Fourthly, the setting here in a single Dutch mental health unit makes widespread generalizability to other services and national policy contexts difficult.
Fifthly, we could not subdivide patients according to whether they received oral or intramuscular medication because of the small sample size.
Finally, we should add that the scope of our study was limited to the coercive measures that are used most often in the Netherlands, and that we did not evaluate the effects of other restrictive interventions such as physical restraint, continuous observation, or time-out. Ideally, the next step in this field would be an international multi-centre study conducted in way that assessed differences in a broader range of coercive practices and patients’ responses.