An international perspective on the use of coercive measures

Abstract

Coercive interventions of many kinds are the oldest problem of psychiatric institutions and still today are considered as necessary in seemingly all countries in the management of dangerous behaviour against self or others. Though a huge variety of coercive interventions has been in use, basically there are only four different types: therapy by coercion (typically by antipsychotics), use of therapeutic measures without primary therapeutic purpose (e.g. chemical restraint), separation (e.g. seclusion) and mechanical restriction (e.g. restraint by belts). Traditions still determine preferences in the use of coercive interventions. Interventions being considered as least restrictive in some European countries and frequently used there are considered as inhuman and inacceptable in other countries. Seclusion is banned in Denmark, mechanical restraint in the UK and parts of Switzerland, net beds are used in parts of Austria and Eastern European countries but are strongly disapproved in most other countries; involuntary medication is used as a last resort in some countries and as first choice in others. In recent years, epidemiological data and evidence from randomised controlled trials and studies with patient interviews have become increasingly available. Results allow an empirical approach to the claim of the ‘least restrictive intervention’. A ban of one kind of measure seems to lead to an increase of others and which is least restrictive is dependent on individual patient preferences and the context of action. Country comparisons yield valuable insight into the consequences of traditions and attitudes if they are different in the respective countries.