Workplace violence and insecurity might make psychiatric staff more accepting of coercion

A study examining attitudes of German psychiatric staff towards coercion in psychiatry found that older individuals, those working in forensic psychiatry, those with greater feelings of insecurity, those more frequently exposed to physical violence, and those with a greater emotional burden from verbal violence tended to hold less critical attitudes towards coercive measures. Those who used coercive measures more often also tended to be less critical towards them. The paper was published in Comprehensive Psychiatry.

Coercive measures in psychiatry are interventions used without a patient’s consent when clinicians believe they are necessary to prevent serious harm or allow essential treatment to take place. They can include involuntary hospitalization, physical restraint, seclusion, forced medication, and, in some circumstances, other forms of compulsory treatment.

Such measures are most commonly considered when a person experiencing a severe mental health crisis poses an immediate danger to themselves or others. They may also be used when a person is unable to make informed treatment decisions and failure to provide care could result in serious deterioration or harm.

Because coercive interventions restrict fundamental rights such as personal liberty and bodily autonomy, their use raises important ethical and legal questions. Modern psychiatric practice considers them measures of last resort rather than routine methods of managing difficult behavior. Less restrictive approaches, including verbal de-escalation, supportive environments, and voluntary treatment, are typically preferred. Psychiatric guidelines state that these less restrictive approaches should be attempted whenever circumstances permit.

Study author Klara Czernin and her colleagues investigated the factors associated with attitudes towards coercive measures in psychiatry among psychiatric staff. They considered factors such as feelings of insecurity, frequency of violent events, use of coercive measures, and emotional burden due to workplace violence. They also wanted to study potential interactions between these factors.

This study was a part of the wider AttCo project, an online anonymous survey of psychiatric staff across all federal states in Germany conducted between March and June 2023. Participants were 1585 members of psychiatric staff from 16 German federal states. Their average age was 42 years and, on average, they had 13 years of work experience. Women made up 65% of the participants. Additionally, 64% worked in adult psychiatry, and 79% in inpatient settings.

The survey asked for participants’ sociodemographic data including their workplace setting, specialization, and professional group affiliation. It also contained assessments of feelings of insecurity and experiences of violence in the workplace, support measures after experiencing violence, and the frequency of applied or observed coercive measures (assessed using 0-to-100 rating scales). Participants’ attitudes towards coercion were assessed using the German version of the Staff Attitude to Coercion Scale.

Results showed that 70% of participants had experienced verbal assault during the past 6 months, with 19% reporting that they experienced them at least once a week. The most frequent forms of support in cases of verbal assault were team debriefings and individual debriefings. Psychological counseling was relatively rare (11% reported it). Twenty-seven percent reported that no support measures were offered.

Twenty-six percent of participants reported that they were affected by a physical assault, with 2% stating that physical assaults happened at least once a week. Support measures were the same as with verbal assaults, but somewhat more frequently applied.

Seventy-nine percent of participants reported that they observed coercive measures in the past 6 months, and 26% reported that they observed them at least once a week. Forty-seven percent had applied coercive measures, and 9% reported applying them at least once a week.

Further analyses revealed that older participants, those working in forensic psychiatry, those with greater feelings of insecurity, those experiencing more frequent physical violence, those with a greater emotional burden from verbal violence, and those using coercive measures more frequently tended to be less critical towards coercion. In contrast, those with more years of work experience and a greater emotional burden from witnessing coercive measures tended to have more critical attitudes.

“Subjective staff characteristics such as work experience, exposure to violence and emotional burden influence staff attitudes to coercion considerably. Notably, the use of coercive measures and the burden due to coercion constitute important influences on staff perspectives. Improving violence prevention and de-escalation strategies, integrating emotions and self-perceptions into debriefings, and providing individualized support for staff following distressing incidents might help reduce feelings of insecurity,” study authors concluded.

The study sheds light on the attitudes German psychiatry staff members have toward the use of coercion in psychiatry. However, it should be noted that the design of the study does not allow any causal inferences to be drawn from the results. Additionally, all data came from self-reports, leaving room for reporting bias to have affected the results. This possibility is particularly important given that the use of coercion is a sensitive topic, potentially motivating some participants to give socially desirable answers.

The paper, “Staff attitudes towards coercion in psychiatry: The role of violence, emotional burden, and insecurity – Evidence from a nationwide study using multiple regression and moderation analyses,” was authored by Klara Czernin, Anna Oster, Lieselotte Mahler, and Josef Severin Baumgartner.