In 2018, an expert group of the German Association for Psychiatry, Psychotherapy and Psychosomatics (DGPPN) published guidelines on how to deal with ‘coercion and violence’ in adult psychiatric services in Germany. The DGPPN is the largest scientific medical association focussing on mental health in Germany. The Guidelines are titled, Prevention of Coercion: Prevention and Therapy of Aggressive Behavior in Adults [S3 Leitlinie: Verhinderung von Zwang: Prävention und Therapie aggressiven Verhaltens bei Erwachsene]. (hereafter ‘the Guidelines’)

 Guidelines

The Guidelines, in part, aim to prevent and reduce coercive measures that occur in response to aggressive behaviour in adults. (They do not address the issue of coercive measures against people who are self-harming and/or who do not act violently). The Guidelines are premised on the view that some forms of coercion in mental health settings are unavoidable in some cases, which requires that ‘human rights and dignity must be respected and legal rules strictly followed’ in accordance with standard principles of least restrictive and best interests interventions (Submission 3C).

The guidelines concern healthcare settings; particularly psychiatric wards and ‘community-based mental health services’. The Guidelines include training and education of staff, and information for service users and those subject to involuntary interventions, their relatives as well as for policy makers.

The expert group behind the Guidelines was interdisciplinary and consisted of service users, family members, health professionals including physicians, psychologists, nurses and caregivers, as well as scientists and legal experts. Tilman Steinert and colleagues (2020) summarise the content of the Guidelines as follows:

Measures which were effective in clinical trials were staff educational programs and regular training of the employees, enrichment of the ward environment, structured risk assessment and early interventions [e.g., Brøset Violence Checklist], individualized treatment planning, especially advanced care planning for patients who already experienced violence and coercion, as well as debriefing techniques. Interventions were especially helpful if they were combined with each other, incorporated organizational changes and were endorsed by the management of the clinic. Therefore, several complex interventions consisting of different measures were developed in the past few years, e.g., internationally Six Core Strategies and Safewards and in Germany Weddinger Modell. While the Six Core Strategies include top-down-elements focusing on the organization of a psychiatric ward or clinic, Safewards emphasizes the communication among patients and staff on a specific ward. The Weddinger Modell, developed in 2010 in Berlin, Germany, is an innovative model of psychiatric care focusing on recovery, participation, supported decision-making and the prevention of coercive measures on psychiatric wards.

 12 recommendations from the Guidelines

After the publication of the Guidelines, an expert group convened and derived 12 recommendations from the Guidelines. The recommendations were established via a consensus and rating method involving 23 external expert groups comprising of service users, family members and professionals. The recommendations were adopted in November 2018 by the DGPPN and are listed below.

12 recommendations to implement the DGPPN Guidelines:

1. Implement a standardised recording of coercive measures and aggressive incidents with the possibility of regular evaluation at ward level.
2. Implement internal standards adapted to the guidelines regarding the indication, initiation, review, documentation, and debriefing of coercive measures, or review existing standards, as appropriate.
3. Hold a monthly team meeting, chaired by the department or ward manager, to analyze data on coercive measures and aggressive incidents and discuss the background.
4. Implement a training plan for all employees with patient contact in de-escalation/aggression management and ensure that all employees receive training at least once every two years.
5. Ensure that any coercive measures restricting or depriving freedom (restraint, seclusion) are accompanied by continuous observation and personal care.
6. Ensure that debriefings after coercive measures with the affected patients take place and are documented.
7. Employ or involve peers on the ward.
8. Create an action plan for the aggression-reducing design of the spatial environment on the ward and review it annually.
9. Introduce a risk assessment with the Brøset Violence Checklist (BVC) or another instrument for all patients at risk according to clinical assessment and make sure that clinical consequences result. For scores above BVC 2, e.g., the patient is contacted for de-escalation within half an hour, usually by at least two persons.
10. During debriefing after a coercive measure, recommend all patients to draw up a joint crisis plan for the prevention of future coercion.
11. Introduce measures to ensure guideline-based pharmacotherapy [based on the guideline with regard to aggressive behavior, but also the disorder-specific other guidelines (“guideline-based treatment of the underlying disease”)], and, e.g., monthly random check or hold regular meetings during rounds.
12. Introduce complex interventions for reducing coercion that can be operationalised into individual modules (e.g., Safewards, Weddinger Model, Six Core Strategies).

The recommendations are not, strictly speaking, evidence-based; research is required to establish their feasibility and efficacy in reducing coercion.

As a first step, Steinert and colleagues tested whether these recommendations are feasible in a pilot study. Once feasibility was established, a randomised control trial was undertaken described as the Implementation of Guidelines on Prevention of Coercion and Violence in Psychiatry (the PreVCo study) which included 52 psychiatric admission wards, and is ongoing at the time of writing (Steinert et al., 2020). Management at each psychiatric ward will be invited to choose three of the recommended interventions that appeared most relevant and desirable to their service. A randomised controlled trial will be conducted ‘stratified by the amount of coercive measures and implemented aspects of the guidelines’ (Steinert et al., 2020, p.3).

Steinert and colleagues (2020, p.3) note that ‘[t]here is good evidence for all 12 individual elements and a high consensus among 23 expert groups, including professionals, patients, and their relatives who were involved in the development of the guidelines.’ The recommendations were only established by the expert groups if the recommendation was measurable in terms of the degree of implementation. Reportedly, all psychiatric hospitals in Germany are likely to have implemented at least some interventions or strategies to reduce coercion but Steinert and colleagues report that ‘no clinic has fully implemented all recommendations suggested in the guidelines’ (Steinert et al., 2020 p.2).

The Guidelines and recommendations have been disseminated in several ways, including via:

• free nline access to the guidelines;
• the creatin of a short, practice-oriented version of the guideline and distribution of free copies to all psychiatrists in Germany;
• publicatins regarding the Guidelines in scientific journals;
• training f implementation consultants;
• funding f scientific implementation by DGPPN and government/public funding bodies.

The recommendations incorporated the ‘Weddinger Modell’, which refers to a ‘recovery-oriented care concept’ for improving acute psychiatric care, that appears to have had a tangible impact in smallscale trials on reducing a person’s chances of being subject to mechanical restraints and seclusion (Czernin et al., 2020 p.242). (The Weddinger Modell is discussed in this report at p.44).

Finally, the Guidelines are ‘S3 guidelines’, indicating that they hold the ‘highest methodological quality of guidelines developed in Germany’, and that ‘they are evidence and consensus based taking into account all available scientific literature and the opinion of acknowledged specialists in the field’ (Steinert et al., 2020 p.2). This process encompassed 4 systematic reviews and a formalised consensus process, assisted by a working group of scientific medical societies (the ‘AWMF’). In this case, 22 societies in the field consented to the Guidelines, and one patient organisation did not. A comprehensive methods-report is available (in German) on the creation of the Guidelines (see Bechdolf et al, 2019).