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Articles   |    
Subjective Distress After Seclusion or Mechanical Restraint: One-Year Follow-Up of a Randomized Controlled Study
Tilman Steinert, Prof. Dr. med.; Michael Birk, Dr. med.; Erich Flammer; Jan Bergk, Dr. med.
Psychiatric Services 2013; doi: 10.1176/appi.ps.201200315
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Dr. Steinert, Dr. Birk, and Mr. Flammer are affiliated with the Department of Research and Education, and Dr. Bergk is with the Department of Psychotherapy, Centres for Psychiatry Suedwuerttemberg, University of Ulm, Ravensburg, Germany. Dr. Steinert is also with Weissenau Psychiatric Hospital, University of Ulm, Postfach 2044, Ravensburg D 88190, Germany (e-mail: tilman.steinert@zfp-weissenau.de).

Copyright © 2013 by the American Psychiatric Association


Objective  Patients who participated in a randomized controlled trial comparing subjective distress and traumatic impact after seclusion or mechanical restraint were interviewed about the coercive measure about one year later.

Methods  Between May and December 2006, patients were interviewed about one year after experiencing seclusion or mechanical restraint as an inpatient. Items from the Coercion Experience Scale (CES) were used in the original and the follow-up studies to assess distress on a 5-point scale, with higher scores indicating greater distress. Patients were also asked about subjective feelings about the coercive measure and completed the Impact of Event Scale–Revised (IES-R) to assess symptoms of posttraumatic stress disorder (PTSD).

Results  Sixty (59%) of the 102 patients in the original sample were included for follow-up. Although the original study found no differences between patients who experienced seclusion or mechanical restraint, the follow-up study found significantly higher mean scores for CES items among patients who had experienced mechanical restraint (2.5 and 3.7, respectively, p<.001). IES-R scores did not differ significantly. IES-R scores for two patients who experienced mechanical restraint and one who experienced seclusion indicated probable PTSD. Patients reported experiencing a wide range of negative feelings during the measure, most frequently helplessness, tension, fear, and rage. However, 58% reported some positive effects. Contact with staff was most helpful in alleviating distress during the coercive measure.

Conclusions  Contrary to the original study, the follow-up study suggested that seclusion might be a less restrictive alternative for most patients. The incidence of PTSD seemed lower than expected.

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Table 1CES scores among patients who experienced seclusion or mechanical restraint, by original or one-year follow-up studya
Table Footer Note

a CES, Coercion Experience Scale

Table Footer Note

b Possible scores range from 1, little, to 5, extreme.

Table Footer Note

c Possible scores range from 1 to 5, with 1 indicating partly agreeable, partly disagreeable; 2, moderately disagreeable; 3, disagreeable; 4, very disagreeable; and 5, extremely disagreeable (“the worst I ever experienced”).



Steinert  T;  Lepping  P;  Bernhardsgrütter  R  et al:  Incidence of seclusion and restraint in psychiatric hospitals: a literature review and survey of international trends.  Social Psychiatry and Psychiatric Epidemiology 45:889–897, 2010
[CrossRef] | [PubMed]
Appelbaum  PS:  Least restrictive alternative revisited: Olmstead’s uncertain mandate for community-based care.  Psychiatric Services 50:1271–1272, 1280, 1999
Kingdon  D;  Jones  R;  Lönnqvist  J:  Protecting the human rights of people with mental disorder: new recommendations emerging from the Council of Europe.  British Journal of Psychiatry 185:277–279, 2004
[CrossRef] | [PubMed]
Improving the Mental Health of the Population: Towards a Strategy on Mental Health for the European Union. Brussels, Commission of the European Communities, 2005. Available at ec.europa.eu/health/ph_determinants/life_style/mental/green_paper/mental_gp_en.pdf
White Paper on the Protection of the Human Rights and Dignity of People Suffering From Mental Disorders, Especially Those Placed as Involuntary Patients in a Psychiatric Establishment. Strasbourg, France, Council of Europe, 2000. Available at www.ijic.org/docs/psychiatry.pdf
Steenfeldt-Foss  OW:  Ethical principles in psychiatry: the Declarations of Hawaii and Madrid; in  Ethics in Psychiatry . Edited by Helmchen  H;  Sartorius  N.  Heidelberg,  Germany,  Springer, 2010
Guideline: Therapeutic Measures for Aggressive Behavior in Psychiatry and Psychotherapy [in German]. Darmstadt, Steinkopff, 2009
Whittington  R;  Bowers  L;  Nolan  P  et al:  Approval ratings of inpatient coercive interventions in a national sample of mental health service users and staff in England.  Psychiatric Services 60:792–798, 2009
[CrossRef] | [PubMed]
Bergk  J;  Flammer  E;  Steinert  T:  Ratings of coercive interventions by inpatients and staff in Germany (ltr).  Psychiatric Services 60:1401–1402, 2009
[CrossRef] | [PubMed]
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
[CrossRef] | [PubMed]
Georgieva  I;  Mulder  CL;  Whittington  R:  Evaluation of behavioral changes and subjective distress after exposure to coercive inpatient interventions.  BMC Psychiatry 12:54, 2012
[CrossRef] | [PubMed]
Bergk  J;  Flammer  E;  Steinert  T:  Coercion Experience Scale (CES)—validation of a questionnaire on coercive measures.  BMC Psychiatry 10:5, 2010
[CrossRef] | [PubMed]
Frueh  BC;  Knapp  RG;  Cusack  KJ  et al:  Patients’ reports of traumatic or harmful experiences within the psychiatric setting.  Psychiatric Services 56:1123–1133, 2005
[CrossRef] | [PubMed]
Meyer  H;  Taiminen  T;  Vuori  T  et al:  Posttraumatic stress disorder symptoms related to psychosis and acute involuntary hospitalization in schizophrenic and delusional patients.  Journal of Nervous and Mental Disease 187:343–352, 1999
[CrossRef] | [PubMed]
Shaw  K;  McFarlane  A;  Bookless  C  et al:  The aetiology of postpsychotic posttraumatic stress disorder following a psychotic episode.  Journal of Traumatic Stress 15:39–47, 2002
[CrossRef] | [PubMed]
Steinert  T;  Bergbauer  G;  Schmid  P  et al:  Seclusion and restraint in patients with schizophrenia: clinical and biographical correlates.  Journal of Nervous and Mental Disease 195:492–496, 2007
[CrossRef] | [PubMed]
Weiss  DS;  Marmar  CR:  The Impact of Event Scale–Revised; in  Assessing Psychological Trauma and PTSD . Edited by Wilson  JP;  Keane  TM.  New York,  Guilford, 1996
Maercker  A;  Schützwohl  M:  Evaluation of mental consequences of traumatic stress: the Impact of Event Scale–Revised Version[in German].  Diagnostica 44:130–141, 1998
Bowers  L;  van der Werf  B;  Vokkolainen  A  et al:  International variation in containment measures for disturbed psychiatric inpatients: a comparative questionnaire survey.  International Journal of Nursing Studies 44:357–364, 2007
[CrossRef] | [PubMed]
Roe  D;  Weishut  DJ;  Jaglom  M  et al:  Patients’ and staff members’ attitudes about the rights of hospitalized psychiatric patients.  Psychiatric Services 53:87–91, 2002
[CrossRef] | [PubMed]
Veltkamp  E;  Nijman  H;  Stolker  JJ  et al:  Patients’ preferences for seclusion or forced medication in acute psychiatric emergency in the Netherlands.  Psychiatric Services 59:209–211, 2008
[CrossRef] | [PubMed]
Längle  G;  Renner  G;  Günthner  A  et al:  Psychiatric commitment: patients’ perspectives.  Medicine and Law 22:29–53, 2003
Haglund  K;  Von Knorring  L;  Von Essen  L:  Forced medication in psychiatric care: patient experiences and nurse perceptions.  Journal of Psychiatric and Mental Health Nursing 10:65–72, 2003
[CrossRef] | [PubMed]
Katsakou  C;  Rose  D;  Amos  T  et al:  Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: a qualitative study.  Social Psychiatry and Psychiatric Epidemiology 47:1169–1179, 2012
[CrossRef] | [PubMed]
Sailas  E;  Fenton  M:  Seclusion and restraint for people with serious mental illnesses.  Cochrane Database of Systematic Reviews 2:CD001163, 2000
Mason  T:  Seclusion theory reviewed—a benevolent or malevolent intervention? Medicine, Science, and the Law 33:95–102, 1993
Steinert  T:  After 200 years of psychiatry: are mechanical restraints in Germany still inevitable [in German]  ? Psychiatrische Praxis 38:348–351, 2011
[CrossRef] | [PubMed]
Kessler  RC;  Sonnega  A;  Bromet  E  et al:  Posttraumatic stress disorder in the National Comorbidity Survey.  Archives of General Psychiatry 52:1048–1060, 1995
[CrossRef] | [PubMed]
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