In mental health services violence is a current and relevant problem for professionals as well as patients (Staggs 2015). A meta-analysis of 35 international studies including 23,972 inpatients showed that the proportion of patients who committed at least one act of interpersonal violence was 17% (Iozzino et al. 2015). In a recent German study, including 64,367 admissions in psychiatric hospitals, 17,599 aggressive incidents were recorded throughout the year 2019 (Eisele et al. 2021). This study described that 5084 (7.90%) of the admitted patients showed aggressive behavior towards others. Amongst the 1,660 forensic inpatients included in this study, the proportion of aggressive behavior was even higher (20.54%). At least in Germany, data also suggest an increase of violent incidents in psychiatric hospitals over the last ten years (Eisele et al. 2021).
On specialized forensic psychiatric wards there are higher rates of violence compared to general psychiatry (Bowers et al. 2011; Eisele 2021; Ramesh et al. 2020). Violent behaviour includes verbal and physical threats and aggression that may lead to serious injury or death. The risk of these behaviours is significant in forensic settings. This is due to the complex historical and current psychosocial needs of the patient group (Hill et al. 1996). Among other things, the resulting damage includes physical and psychological injuries to fellow patients and staff, diminished therapeutic relationships, lower job-satisfaction of the employees as well as an increase in the number of days of sick leave (Nienhaus et al. 2016; Pekurinen et al. 2017; Roccor et al. 2020; Schablon et al 2018; Zeh et al. 2009).
To manage violent behaviour restraint, seclusion or forced medication are frequently used in psychiatric hospitals as well as in forensic mental health services. However, the use of coercive measures is problematic for patients, staff and organizations. Patients experience coercive measures as dehumanizing, frightening, confusing and at times painful (Hui et al. 2016; Soininen et al. 2016). Moreover, coercive measures such as mechanical restraint or isolation are associated with anxiety and stress for both patients and staff and are widely seen as untherapeutic. These measures, that nowadays are usually used as the last resort to prevent harm, have been found to diminish the therapeutic alliance between staff and patients (Cope and Encandela 2004). Last but not least, both staff and patients might suffer injury using coercive measures (Duxbury et al. 2019).
Therefore it is necessary to intervene before a serious incident occurs. This means, especially in forensic psychiatric settings, staff need to intervene before situations escalate to a level when there seems to be no other choice to using coercive measures to protect themselves as well as the health and lives of their other entrusted patients. For years, de-escalation training programmes for staff to prevent and reduce violent incidents have been adopted in mental health settings. These training programs intend to promote prevention, relational security and the de-escalation of conflicts. Several different deescalation training programmes are already in use. De-escalation training programmes used in psychiatric hospitals are complex and consist of several elements.
A prototypic example of these programs is the “Six Core Strategies for Reduction of Seclusion and Restraint” (6CS). 6CS is a de-escalation training programme which was developed and is commonly used in the US. 6CS consists of 6 topic areas, namely leadership towards organizational change, use of data to inform practice, workforce development, use of restraint and seclusion reduction tools, improve consumer roles in inpatient setting and the consistent use of debriefing techniques (Azeem et al. 2011; Master et al. 2002, Wieman et al. 2016). 6CS seems to be effective in reducing seclusion and restraint of patients in psychiatric settings (Wieman et al. 2016). Team Strategies & Tools to Enhance Performance & Patient Safety (TeamSTEPPS) is another program used in the US to teach nurses about verbal de-escalation in order to reduce patient aggressive behavior. The results of a recent study evaluating the implementation of the TeamSTEPPS educational program are ambiguous. The authors didn’t find a statistically significant difference in the rate of seclusion events before and after implementation of the programme. However, they described that the reduction in seclusion events was clinically significant (pre rate was 5.9%, post rate was 4.4%) (Haefner et al. 2021). A European adaptation of the Six Core Strategies is the REsTRAIN YOURSELF training program that has been evaluated in UK mental health services. It uses a multimodal approach to train staff to reduce the use of coercive measures. The introduction of REsTRAIN YOURSELF was associated with a 22% average reduction in the use of restraint in seven English psychiatric intensive care units over a 13-month period compared to matched wards (Duxbury et al. 2019). Ye et al. examined the effectiveness of a Chinese deescalation training program on reducing physical restraint in psychiatric hospitals (Ye et al. 2021). The program was designed with 5 modules (Communication, Response, Solution-Focused Technique, Care, Environment; CRSCE). CRSCE is a Chinese adaptation of the Six Cores Strategies in the United States and the REsTRAIN YOURSELF program in the United Kingdom. In a small sample (n = 12) Ye et al. found that the intervention reduced the frequency and duration of physical restraints.
A German example is the professional deescalation management program “ProDeMa” (Frank 2019, Weissenberger 2020). The program intends to reduce violent incidents through 7 deescalation levels:
Prevention/Reduction of violence through improvements concerning external framework conditions, e.g. aggression inducing ward rules or process flows
Change of reaction patterns of the staff through change in interpretation and valuation of inpatient violence
Improvement of the staff’s understanding of the etiology of violent behaviour
Training staff in verbal de-escalation techniques
Teaching staff techniques to escape and defend themselves against physical attacks without harming the patient unnecessarily
Techniques to immobilize and restrain patients without doing unnecessary harm to them
Professional post-processing of escalations including inter-collegial first aid.
A recent systematic review of the literature focusing on the efficacy of the measures that have been studied to date for reducing coercion found that complex intervention programs seem to be particularly effective (Hirsch et al. 2019). The review included 84 studies in total. In 42 studies staff training to improve handling of aggression and violence, as well as de-escalating counseling techniques, were evaluated. On the other hand, it was also found that patient outcomes (e.g. length of admissions, rates of incidents) were worse in a group of patients in which a program to reduce coercive measures (Strategies in Crisis Intervention and Prevention, SCIP) was implemented (Lee, Gray, & Gournay, 2012). Further literature reviews about the effectiveness of deescalation training in reducing the use of coercive measures propose that more evidence is needed to evaluate their effectiveness (Price et al. 2015; Gaynes et al. 2017). All in all, the evidence-base for interventions to reduce coercive measures in general mental health services seems to be rather mixed. Given the adverse effects of coercive measures on patients, staff and organizations, it is crucial that more evidence of the efficacy of training programs to implement interventions to reduce coercive measures is collected and analyzed.
Unsurprisingly, in the field of forensic psychiatry, deescalation training for staff is also implemented. Yet, there is even less evidence on its effectiveness. Therefore the systematic review presented here evaluates the current evidence of deescalation training programs in reducing violent incidents in specialized forensic psychiatric settings.