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Alternatives to Compulsory Detention and Treatment and Coercive Practices in Mental Health Settings
Abstract and Figures
Informed consent to medical treatment is generally presumed to be central to the provision of good quality health care. Despite this presumption, legislation exists in many countries that enables the compulsory detention and treatment of people with severe mental health conditions regardless of their wishes. This column discusses global efforts to reduce, prevent and end compulsory detention, treatment and coercive practices in mental health and community settings. It summarises the current state of research, identifying overarching themes in the search for effective non-coercive practices, before focusing on hospital and community-based initiatives.
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... Arguably the hope is, if the voluntary services are sufficiently resourced, there would be no need to initiate the involuntary track even if it is still in place. 15 The examination of China's mental health law reform in this book seeks to provide a detailed and insightful case study to evaluate the above approach. The MHL not only introduced the 'voluntary principle' and narrowing the scope of involuntary detention and treatment but also called for increased attention and resources for the voluntary services. ...
... 13 The generic recognition of human rights under the ICCPR failed to protect persons with mental health issues from nonconsensual human experimentation, because of the long history in which persons with mental health issues have been considered as a 'separate class' with 'lesser rights'. 14 More importantly, these abuses 'have generally not been recognized as violations of human rights even by organizations that are engaged in human rights work', 15 reflecting the deep-rooted marginalisation of persons with mental health issues even within the mainstream human rights community. Additionally, other human rights violations, many of which are still lawful under domestic laws, include arbitrary detention (sometimes for life) without due process of law, forced sterilisation, being chained and caged both at home and in institutions, unmodified electro-convulsive treatment without anaesthesia, and other cruel, inhuman, and degrading treatment. ...
... All health and medical personnel should ensure appropriate consultation that directly engages the person with disabilities. 150 Acknowledging that '[f]orced treatment is a particular problem for persons with psychosocial, intellectual and other cognitive disabilities', the CRPD Committee also requires States Parties to abolish law and policy allowing or perpetrating forced treatment that violates all the rights proscribed by Article 12,15,16 and 17. 151 The position of abolishing involuntary mental health interventions, with other forms of substituted decision-making, has been repeated by the Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities -The right to liberty and security of persons with disabilities. 152 The CRPD Committee has also continued recommending States Parties to do so in its Concluding Observations, among which the recommendation to China is quoted at the beginning of Chapter 1. ...
This book provides an important critique of mental health law and practice in China, with a focus on involuntary detention and treatment.
The work explores China’s mental health law reform regarding treatment decision-making in the new era of the UN Convention on the Rights of Persons with Disabilities (CRPD). It adopts a socio-legal approach, not only by undertaking a comprehensive desk-based analysis of the reforms introduced by China’s Mental Health Law (MHL) but also examining its implementation based on evidence from practice. The book seeks to investigate whether China’s first national MHL takes a step closer to the requirements of the UN Convention on the Rights of Persons with Disabilities on mental health treatment decision-making, and, if not, why not?
The book will be of interest to those working in the areas of mental health law and policy, medical law and disability, human rights law, and Asian Studies.
... Restrictive practices can result in a range of harmful consequences such as physical health problems or physical injury, deterioration of mental health (including the onset of post-traumatic stress disorder), increased length of stay in hospital (Chieze et al., 2019) and in some instances, death (Duxbury et al., 2011;Weiss et al., 1998). Restrictive practices limit human rights, such as physical integrity, autonomy, and liberty of choice or movement (Brown & Tooke, 1992;Gooding & McSherry, 2018). Interventions exist to reduce their use (Bowers et al., 2015;Duxbury et al., 2019) but restrictive practices remain prevalent in adult mental health services across the world (Sashidharan et al., 2019;World Health Organization, 2018). ...
... Thus far, the evidence regarding effective alternatives to restrictive practices (e.g. Bowers et al., 2017;Gooding & McSherry, 2018;Hirsch & Steinert, 2019) has not tended to focus specifically on adult secure services and may be limited therefore in its ability to inform guidelines intended for this highly specialized group of service users. The only review of restrictive practices exclusively in secure mental health settings since the Mental Health Act Code of Practice was amended in 2015 was the review by Hui et al. (2016). ...
Restrictive practices are often harmful and many academics, policy-makers and clinicians
agree that their use should be reduced in care settings. Specific focus on secure mental
health services is warranted because restrictive practices are often seen as an integral part
of forensic psychiatry but have received limited research attention relative to other areas of
psychiatric practice. The aim of this scoping review was to map and evaluate recent empirical research that examines the use of restrictive practices, the consequences of using them
and efforts to reduce restrictive practices, in secure mental health settings published since
June 2015. The purpose of this review was to identify limitations and gaps in the literature
in order to inform further research. PsycINFO, Medline, Embase, CINAHL, Scopus and ASSIA
databases were searched for studies published between 2015 and 2020. Following electronic
and manual searches, 36 studies were included. The studies were grouped into four main
areas: 1) Nature of the problem describing the type, incidence, prevalence and scope of
restrictive practices in secure mental health services; 2) Service user perceptions and experiences of restrictive practices; 3) Staff experiences, views and decision making; and 4)
Interventions designed to reduce the use of restrictive practices. Findings support the
notion that restrictive practices have a detrimental impact on the wellbeing of most service
users in adult secure services as well as the staff who use them. Continued efforts to reduce
restrictive practices are needed and the importance of collaborative working cannot be
understated. Implications for future research, clinical practice, policy and best practice guidelines are all discussed.
... Nevertheless, shared decisionmaking defined more broadly as "a formalised process. . .by which clinicians and consumers engage in a collaborative decision-making process for healthcare decisions" [117], has been widely implemented and evaluated in high and middle-income countries across Europe, North America, South America and the Middle East. ...
Coercion of service users/patients when receiving care and treatment has been a serious dilemma for mental health services since at least the 18th century, and the debate about how best to minimise or even eradicate compulsion remains intense. Coercion is now, once again and rightly, at the top of the international policy agenda and the COST Action ‘FOSTREN’ is one example of a renewed commitment by service user advocates, practitioners and researchers to move forward in seriously addressing this problem. The focus of service improvement efforts has moved from pure innovation to practical implementation of effective interventions based on an understanding of the historical, cultural and political realities in which mental health services operate. These realities and their impact on the potential for change vary between countries across Europe and beyond. This article provides a novel overview by focusing on the historical, cultural and political contexts which relate to successful implementation primarily in Europe, North America and Australasia so that policy and practice in these and other regions can be adopted with an awareness of these potentially relevant factors. It also outlines some key aspects of current knowledge about the leading coercion-reduction interventions which might be considered when redesigning mental health services.
... The coercion of people with mental health problems and/or intellectual disabilities (IDs) is highly undesirable as a potential contravention of human rights (UN-CRPD 2006). A global effort to minimise reliance on such practices (WHO 2022) and a willingness to learn from services worldwide have successfully reduced such practices (Gooding and McSherry 2018). ...
A quantitative cross-sectional design was used to systematically examine data derived from the municipality’s coercive decision documents. The study included coercive decisions for people with intellectual disabilities (IDs) (n = 120) from central Norway over a period of one year (2020). The decisions were separated between not altered and altered to less intrusive types. The use of restraint measures can be relevant to prevent harm in some caring to people with IDs and severe behaviour problems. This article has reviewed municipalities’ coercive decisions, identifying the characteristics of cases in which coercive measures were altered to less intrusive practices. Less intrusive coercive measures were correlated to the service’s awareness of what triggers the challenging behaviour, that coercive decisions have an extended description of the person’s life situation, and the person’s opportunity to participate in formalised self-determination. The conclusion of this study shows higher user involvement, which has led to changes in the form of less intrusive measures for the person who is subjected to coercion.
... A distinction may be drawn between direct coercion (e.g., rapid tranquilisation, seclusion, etc.), indirect coercion (e.g., restrictive rules and regulations, a controlling ward atmosphere, etc.), and informal coercion (which patients may refer to as 'pressure'; Franke et al., 2019). Restrictive practices can conflict with individuals' attainment of their human rights, for example, autonomy, physical integrity, and liberty of choice or movement (Gooding & McSherry, 2018). Research has indicated that the more restrictive the environment and approach to care, the higher the levels of depression and suicidal ideation, hostility, disrespect for patients, and perceived lack of institutional transparency. ...
In this paper, we present an account of the nature of relational security and the need for robust, comprehensive and consistent implementation within secure and forensic mental health settings in England and Wales. Within this, we review and critique the See Think Act framework of relational security and consider how it may be further developed. We conclude by making a series of evidence-based recommendations for improving the quality of relational security as it is deployed within secure and forensic mental health settings.
... A distinction may be drawn between direct coercion (e.g., rapid tranquilisation, seclusion etc.) indirect coercion (e.g., restrictive rules and regulations, a controlling ward atmosphere, etc.), and informal coercion (which patients may refer to as "pressure") (97). Restrictive practises can conflict with individuals' attainment of their human rights, for example autonomy, physical integrity, and liberty of choice or movement (98). Research has indicated that the more restrictive the environment and approach to care, the higher the levels of depression and suicidal ideation, hostility, disrespect for patients, and perceived lack of institutional transparency. ...
This evidence-based opinion piece explores the totalising risk averse nature of secure and forensic mental health services and associated iatrogenic harms in England and Wales. Drawing on the research literature I consider the various influences, both external and internal which impact on the provision of such services and how both the therapeutic alliance and recovery potential for patients may be improved. Especial attention is paid to the deployment of restrictive practise, practitioner attitudes, the potential for non-thinking, and how these may impact on decision-making and the care and treatment of mentally disordered offenders.
... (Szmukler, 2020, p. 233) In 2018, the UN Special Rapporteur for the Rights of Persons with Disabilities commissioned a systematic literature review of efforts to reduce, prevent, and eliminate "coercion" in mental healthcare (hereafter the "Coercion Review"). The Coercion Review, of which I was a contributing author, was published as a standalone report (Gooding et al., 2018) and a peer-reviewed summary (Gooding et al., 2020), and it appears to be the largest survey of its kind. The findings, perhaps surprisingly for such a controversial field, were quite straightforward: various efforts have been made to prevent and reduce coercion worldwide and for the most part they seem effective. ...
... A better question is whether detention is appropriate for the needs of a particular patient. Mental health legislation is almost always discussed as coercive and restrictive, 8 and it is indeed that. 9 But it is enabling too, allowing those who need mental health care to receive it when they are most in need. ...
... A better question is whether detention is appropriate for the needs of a particular patient. Mental health legislation is almost always discussed as coercive and restrictive, 8 and it is indeed that. 9 But it is enabling too, allowing those who need mental health care to receive it when they are most in need. ...
Background
Following the Independent Mental Health Act review, there is increasing focus on this coercive part of mental health services and a call for service user views to be central to proposed changes. Although there are numerous studies into being detained in hospital, there is a lack of data exploring the service user experiences of the assessment process.
Aim
To explore the subjective experience of being assessed under the Mental Health Act (MHA).
Method
10 participants were interviewed about their recent assessment experience and the transcribed interviews were analysed using framework approach.
Results
The overarching theme of person centred care emerged from these interviews with interconnecting sub themes: 1) information and options; 2) “the barrage of three”; 3) “sit down and listen”; and 4) service user voice.
Conclusion
As one of the first studies into service user experiences of MHA assessments, this exploratory study indicates that there is lack of person centeredness. The Independent Mental Health Act review has set a challenge for treating person as individual and increasing rights and involvement of service users. This study suggests service user’s experiences do not yet meet this aspiration and they want to discuss these experiences and have their voices heard.
PURPOSE: Whilst formal coercion in psychiatry is regulated by legislation, other interventions that are often referred to as informal coercion are less regulated. It remains unclear to what extent these interventions are, and how they are used, in mental healthcare. This paper aims to identify the attitudes and experiences of mental health professionals towards the use of informal coercion across countries with differing sociocultural contexts.
METHOD: Focus groups with mental health professionals were conducted in ten countries with different sociocultural contexts (Canada, Chile, Croatia, Germany, Italy, Mexico, Norway, Spain, Sweden, United Kingdom).
RESULTS: Five common themes were identified: (a) a belief that informal coercion is effective; (b) an often uncomfortable feeling using it; (c) an explicit as well as (d) implicit dissonance between attitudes and practice-with wider use of informal coercion than is thought right in theory; (e) a link to principles of paternalism and responsibility versus respect for the patient's autonomy.
CONCLUSIONS: A disapproval of informal coercion in theory is often overridden in practice. This dissonance occurs across different sociocultural contexts, tends to make professionals feel uneasy, and requires more debate and guidance.
1 Objective
The purpose of the study was to determine the effectiveness of six core strategies based on trauma informed care in reducing the use of seclusion and restraints with hospitalized youth.
2 Methods
The hospital staff received training inMarch 2005 in six core strategies that are based on trauma informed care. Medical records were reviewed for youth admitted between July 2004 andMarch 2007. Data were collected on demographics, including age, gender, ethnicity,number of admissions, type of admissions, length of stay, psychiatric diagnosis, number of seclusions, and restraints.
3 Results
Four hundred fifty‐eight youth (females 276/males 182) were admitted between July 2004 and March 2007. Seventy‐nine patients or 17.2% (females 44/males 35) required 278 seclusions/restraints (159 seclusions/119 restraints),with average number of episodes 3.5/patient (range 1–28). Thirty‐seven children and adolescents placed in seclusion and/or restraints had three or more episodes. In the first six months of study, the number of seclusions/restraints episodes were 93 (73 seclusions/20 restraints), involving 22 children and adolescents (females 11/males 11). Comparatively, in final six months of study following the training program, there were 31 episodes (6 seclusions/25 restraints) involving 11 children and adolescents (females 7/males 4). The major diagnoses of the youth placed in seclusion and/or restraints were disruptive behavior disorders (61%) and mood disorders (52%).
4 Conclusions
This study shows downward trend in seclusions/restraints among hospitalized youth after implementation of National Association of State Mental Health ProgramDirectors six core strategies based on trauma informed care.
Antidepressants are commonly prescribed for many mental disorders, including psychosis. Withdrawal effects, resulting from inappropriately short duration of tapering or lack of flexibility in prescribing gradual reduction, are common. An observational study was conducted of the use of “tapering strips”, which allow gradual dosage reduction and minimise the potential for withdrawal effects. A tapering strip consists of antidepressant medication, packaged in a roll of small daily pouches, each with the same or slightly lower dose than the one before it. Strips come in series covering 28 days. Of 1194 users of tapering strips, 895 (75%) wished to discontinue their antidepressant medication. In these 895, median length of antidepressant use was 2–5 years (IQR: 1–2 years– > 10 years). Nearly two-thirds (62%) had unsuccessfully attempted withdrawal before (median = 2 times before, IQR 1–3). Almost all of these (97%) had experienced some degree of withdrawal, with 49% experiencing severe withdrawal (7 on a scale of 1–7, IQR 6–7). The most common medications were paroxetine (n = 423, 47%) and venlafaxine (n = 386, 43%). Of the 895 wishing to discontinue, 636 (71%) succeeded in tapering their antidepressant medication completely, using a median of 2 tapering strips (IQR 1–3) over a median of 56 days (IQR = 28–84). Tapering strips represent a simple and effective method of achieving a gradual dosage reduction.
International comparative studies show that Dutch seclusion rates are relatively high. Therefore, several programs to change this practice were developed and implemented. The purpose of this study was to examine the impact of a seclusion reduction program over a long time frame, from 2004 until 2013. Three phases could be identified; the phase of development and implementation of the program (2004–2007), the project phase (2008–2010) and the consolidation phase (2011–2013). Five inpatient wards of a mental health institute were monitored. Each ward had one or more seclusion rooms. Primary outcome were the number and the duration of seclusion incidents. Involuntary medication was monitored as well to rule out substitution of one coercive measure by another. Case mix correction for patient characteristics was done by a multi-level logistic regression analysis with patient characteristics as predictors and hours seclusion per admission hours as outcome. Seclusion use reduced significantly during the project phase, both in number (−73%) and duration (−80%) and was not substituted by the use of enforced medication. Patient compilation as analyzed by the multi- level regression seemed not to confound the findings. Findings show a slight increase in number and seclusion days over the last year of monitoring. Whether this should be interpreted as a continuous or temporary trend remains unclear and is subject for further investigation.
On 3 December 2010, Argentina enacted the National Mental Health Law (NMHL), two years after ratifying the United Nations Convention on the Rights of Persons with Disabilities (CRPD). By allowing extrajudicial involuntary commitments for up to three days and legal capacity restrictions upon recommendation by an interdisciplinary team, the NMHL establishes thresholds for depriving persons with disabilities of their liberty and for restricting their exercise of legal capacity that are inconsistent with the CRPD. However, despite the NMHL's significant shortcomings, it has the potential to contribute both to increased autonomy for users of the mental health system and also to less restrictive legal capacity restrictions. The authors conclude that while the NMHL is inconsistent with the CRPD, it may still help promote a shift away from involuntary commitments and legal capacity restrictions if its implementation results in the dissemination of "better" practices that have emerged thus far.
Background:
Aggression occurs frequently within health and social care settings. It can result in injury to patients and staff and can adversely affect staff performance and well-being. De-escalation is a widely used and recommended intervention for managing aggression, but the efficacy of the intervention as a whole and the specific techniques that comprise it are unclear.
Objectives:
To assess the effects of de-escalation techniques for managing non-psychosis-induced aggression in adults in care settings, in both staff and service users.
Search methods:
We searched CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and 14 other databases in September 2017, plus three trials registers in October 2017. We also checked references, and contacted study authors and authorities in the field to identify additional published and unpublished studies.
Selection criteria:
We included randomised controlled trials (RCTs) and quasi-RCTs comparing de-escalation techniques with standard practice or alternative techniques for managing aggressive behaviour in adult care settings. We excluded studies in which participants had psychosis.
Data collection and analysis:
We used the standard methodological procedures expected by Cochrane.
Main results:
This review includes just one cluster-randomised study of 306 older people with dementia and an average age of 86 years, conducted across 16 nursing homes in France. The study did not measure any of our primary or secondary outcomes but did measure behavioural change using three measurement scales: the Cohen-Mansfield Agitation Inventory (CMAI; 29-item scale), the Neuropsychiatric Inventory (NPI; 12-item scale), and the Observation Scale (OS; 25-item scale). For the CMAI, the study reports a Global score (29 items rated on a seven-point scale (1 = never occurs to 7 = occurs several times an hour) and summed to give a total score ranging from 29 to 203) and mean scores (evaluable items (rated on the same 7-point scale) divided by the theoretical total number of items) for the following four domains: Physically Non-Aggressive Behaviour, such as pacing (13 items); Verbally Non-Aggressive Behaviour, such as repetition (four items); Physically Aggressive Behaviour, such as hitting (nine items); and Verbally Aggressive Behaviour, such as swearing (three items). Four of the five CMAI scales improved in the intervention group (Global: change mean difference (MD) -5.69 points, 95% confidence interval (CI) -9.59 to -1.79; Physically Non-Aggressive: change MD -0.32 points, 95% CI -0.49 to -0.15; Verbally Non-Aggressive: change MD -0.44 points, 95% CI -0.69 to -0.19; and Verbally Aggressive: change MD -0.16 points, 95% CI -0.31 to -0.01). There was no difference in change scores on the Physically Aggressive scale (MD -0.08 points, 95% CI -0.37 to 0.21). Using GRADE guidelines, we rated the quality of this evidence as very low due to high risk of bias and indirectness of the outcome measures. There were no differences in NPI or OS change scores between groups by the end of the study.We also identified one ongoing study.
Authors' conclusions:
The limited evidence means that uncertainty remains around the effectiveness of de-escalation and the relative efficacy of different techniques. High-quality research on the effectiveness of this intervention is therefore urgently needed.
Background:
Supporting the decision-making of mental health service users fulfils professional, ethical and moral obligations of mental health practitioners. It may also aid personal recovery. Previous research on the effectiveness of supported decision-making interventions is limited.
Aims:
The study aims to explore from several perspectives the barriers and facilitators to supported decision-making in an Australian context. Supported decision-making was considered in terms of interpersonal experiences and legal supported decision-making mechanisms.
Methods:
In all, 90 narrative interviews about experiences of supported decision-making were conducted and analysed. Participants were mental health service users who reported diagnoses of schizophrenia, psychosis, bipolar disorder and severe depression; family members supporting them and mental health practitioners, including psychiatrists. The data were analysed thematically across all participants.
Results:
Negative interpersonal experiences in the mental health care system undermined involvement in decision-making for people with psychiatric diagnoses and family carers. Mental health practitioners noted their own disempowerment in service systems as barriers to good supported decision-making practices. All groups noted the influence of prevailing attitudes towards mental health service users and the associated stigma and discrimination that exist in services and the broader community. They believed that legal supported decision-making mechanisms facilitate the participation of mental health service user and their family supporters in supported decision-making.
Conclusions:
Enabling supported decision-making in clinical practice and policy can be facilitated by (1) support for good communication skills and related attitudes and practices among mental health practitioners and removing barriers to their good practice in health and social services and (2) introducing legal supported decision-making mechanisms.
Background: Collaboration between researchers who have lived experience of mental illness and services (consumer researchers) and mental health researchers without (other mental health researchers) is an emergent development in research. Inclusion of consumer perspectives is crucial to ensuring the ethics, relevancy and validity of mental health research; yet widespread and embedded consumer collaboration of this nature is known to be impeded by attitudinal and organisational factors. Limited research describes consumer researchers’ experiences of barriers. Other mental health researchers are key players in the co-production process yet there is also a paucity of research reporting their views on barriers to collaborating with consumers.
Aims: To explore other researchers’ views and experiences on partnering with consumer mental health researchers in Australia and New Zealand.
Methods: Exploratory qualitative design. Eleven semi-structured interviews were conducted with mental health researchers. Interviews were recorded, transcribed and thematically analysed.
Results: Four themes concerning barriers to collaborating with consumers (hierarchies, status quo, not understanding, paternalism), and one theme on addressing the barriers (constantly chipping away) were identified.
Conclusions: It is suggested that multifaceted strategies for advancing collaboration with consumers are most effective. It is imperative to attend to several barriers simultaneously to redress the inherent power disparity.
Aim
Italy pioneered deinstitutionalisation over the past 60 years and enforced a famous mental health (MH) reform law in 1978. Deinstitutionalisation has been completed with the very closure of all psychiatric hospitals over two decades.
Methods
After 40 years of implementation, this article presents the main achievements and challenges of the Italian MH reform law, including its long-term effect and impact in Italy and abroad.
Results
The Legislation of 1978 was based on the discovery of rights as a key tool in mental healthcare. At the climax of crisis of psychiatric hospitals as total institutions in this country, through the new community-based system of care, it has fostered the lowest rate of involuntary care and gave back the full citizenship to people with MH disorders. This act was also part of a social movement for expanding civil and social rights, and a promise of a true paradigm shift not only in psychiatry, but also in the way of providing an adequate welfare community for all citizens. According to the WHO, the Italian city of Trieste, together with its region, is a practical example of how the Italian movement achieved deinstitutionalisation, intended as a complex process resulting in the gradual relocation of the economic and human resources and subsequent creation of 24 h services together with the development of social inclusion programmes.
Conclusions
Even if the great principles of the Italian reform law were anticipatory (e.g., the UN Convention on Rights of Persons with Disabilities – CRPD), the law application has been poorly provided with resources and did not follow those avant-garde experiences as models. Limitations are evident today especially at the organisational levels, such as services capable to take up the challenge and transforming the field, left free from the imprint of total institutions. These endemic critical aspects concerning to implementation policies, together with the financial crisis of the Italian healthcare system, must be taken into consideration for a re-launch of this historical law. The rights-based approach opened by the Law 180 should now take into consideration the new legal situation caused by the CRPD worldwide in the area of individuals’ human rights, especially about the issue of legal capacity and related involuntary care.