Letter

Ratings of Coercive Interventions by Inpatients and Staff in Germany: Reply

In Reply: We thank Dr. Bergk and his colleagues for their comments on our article. We agree that this is a complex area that requires subtle and sophisticated research methods to establish findings that can be used with confidence to shape practice. As we stated in the article, the findings can serve as a benchmark against which other samples can be compared, and we are gratified that similar relative ratings have been found in Germany, confirming the low level of acceptability of mechanical restraint.

We cannot agree that experience of a coercive measure increases approval by patients. Our results showed that for the more severe containment methods (seclusion and manual restraint), experience was associated with less approval; however, for less severe methods (constant special observation), experience was associated with greater approval. Only for staff was experience associated with more positive ratings. We do, however, think that the work of Dr. Bergk and his colleagues highlights what might be a very important factor influencing patients' attitudes toward their experience of inpatient psychiatric care as a whole—that is, their first experiences of coercive measures.

We believe that questionnaires surveying general attitudes toward coercive measures have a role as long as other factors—for example, exposure to specific coercive measures—are factored into the conclusions. Although each person's experience during each incident is unique, it is important to ascertain general views by using structured tools so that comparisons between groups can be made. The design of a study, controlled or otherwise, seems to us irrelevant to the issue of accurate measurement of attitudes. Furthermore, although these findings from England and Germany cannot resolve ethical debates, they can inform the discussion and enable, among other things, the collective voice of service users to be heard.

Thus, although we do not expect our evidence to settle an ethical judgment, it does pose a challenge to countries in which mechanical restraint is used. For how is it that psychiatric practice in the United Kingdom does without mechanical restraint at all, without any apparent negative consequences and without high use of seclusion?