Epidemiology of coercion

There are different forms and degrees of coercion in mental healthcare, some more explicit than others. They comprise a broad range of practices (Szmukler and Applebaum, Reference Szmukler and Appelbaum2008) including treatment pressures, interpersonal leverage, implicit or explicit threats and compulsion i.e. the use of force, usually governed by law, to make a person accept treatment or interventions that have been refused (Szmukler, Reference Szmukler2015). Involuntary treatment may involve imposition of behavioural controls including different forms of restraint (mechanical, physical or pharmacological), forcible seclusion in confined spaces, treatment by administration of medication without the person's consent and restrictive conditions imposed as part of treatment and supervision in the community. Coercion in mental healthcare includes implied or actual threats, the ‘fear that many patients have that non-compliance may lead to the use of compulsion’, described as ‘a coercive shadow’ (Szmukler, Reference Szmukler2015). Coercion in healthcare settings is not limited to mental healthcare but is widely used in care of the elderly, those with intellectual disabilities and children. Coercive practices are also not uncommon in intensive surgical and medical settings. However, no other healthcare setting is as ubiquitous and routinely employed as in mental healthcare.

Despite the ubiquitous nature of coercion in mental healthcare, the epidemiology of coercion is poorly understood. There is little systematic or reliable data on the extent of coercive practices in most countries. This includes the nature and extent of legally authorised sanctions such as involuntary admission, often relied on as a proxy measure for coercive care. Systematic information on more severe and explicit forms of coercion, such as the use of seclusion, forcible segregation and treatment, is more difficult to come by even in high-income countries with well-established mental health systems. When available, the data are often difficult to interpret and compare since they are linked to complex sets of patient-related, environmental and healthcare determinants and critically influenced by the local context (de Jong et al., Reference de Jong, Kamperman, Oorschot, Priebe, Bramer, van de Sande, Van Gool and Mulder2016). The lack of reliable and comparative information on coercive practices is a major barrier to reform and change. While more information, by itself, is unlikely to result in significant changes in clinical practice routinely available systematic data are useful in tracking the extent of coercive care and monitoring the effects of implementing specific, remedial interventions. In England, for example, the recent review of mental health legislation (Department of Health and Social Care, 2018) came about as a result of concern over the rising detention rates, based on national data. In Australia, a nationally reported system of data collection on seclusion and restraint has made it possible to measure the impact of policy directives to reduce coercive interventions across jurisdictions and services (Australian Institute of Health and Welfare, 2019). In Italy, following a national recommendation for the prevention of all mechanical restraint measures in 2010, there was a significant reduction in such practices, for example, a 62% reduction in Emilia-Romagna over the next five years, from 2011 to 2016 (Regione Piemonte, 2017).

Available data indicate considerable variation in rates of involuntary admission between different countries and regions and hospitals in the same country (Weich et al., Reference Weich, McBride, Twigg, Keown, Cyhlarova, Crepaz-Keay, Parsons, Scott and Bhui2014). International comparisons of involuntary admission rates are rare. In Europe, vast differences in involuntary admissions were noted by Salize and Dressing (Reference Salize and Dressing2004) and a further review confirmed a thirty-fold difference in rates of compulsory admission in European countries, from 6/100 000/year in Portugal to 218/100 000 in Finland, with a median of 74/100 000 (De Stefano and Ducci, Reference de Stefano and Ducci2008). The increasing harmonisation of mental healthcare in Europe and similar legislative reforms may have diminished such differences more recently. International variations in involuntary admission rates are unlikely to be the result of differential morbidity or wide disparity in the availability of mental health resources in high-income countries. Differential rates are more likely to be the result of differing legal criteria, variable compliance with agreed policies and standards, professional ethics and attitudes, sociodemographic factors and public perceptions about risk arising from mental illness (Zinkler and Priebe, Reference Zinkler and Priebe2002). However, a recent study that compared annual involuntary hospitalisation rates over a 7-year period in 22 high-income countries (in Europe, Australia and New Zealand) found no relationship between annual involuntary hospital rates and any aspects of legal framework. Higher rates were associated with a large number of psychiatric beds, higher GDP and health care spending per capita although the associations were weak (Rains et al., Reference Rains, Zenina, Dias, Jones, Jeffreys, Branthane-Foster, Lloyd-Evans and Johnson2019). It would appear that the psychiatric detention rate is increasing in most Western countries. For example, in England, in the ten-year period between 2006 and 2017, the use of the Mental Health Act (MHA) increased by 43% (NHS Digital, 2016). Similar trends have been reported in several other European countries, for example, in Scotland, Ireland, Belgium and France (Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018). A consistent and pervasive pattern of human rights violations in psychiatric institutions is also reported across several European countries (WHO, 2018).

It is estimated that over a third (38%) of involuntarily admitted patients are subjected to further coercive measures, such as enforced medication, seclusion and restraint within four weeks of admission (Raboch et al., Reference Raboch, Kališová, Nawka, Kitzlerová, Onchev, Karastergiou, Magliano, Dembinskas, Kiejna, Torres-Gonzales and Kjellin2010). As with detention in hospital, large variations in the use of restraint and seclusion are reported, for example, up to a ten-fold difference among hospitals in the same country (Bak and Aggernaes, Reference Bak and Aggernæs2012). These are more likely to be used in secure or forensic mental health settings, against children and adolescents and those with learning difficulty (NSU/MIND, 2015; Care Quality Commission, 2017). People of non-European origin are particularly at risk of coercive interventions in European settings (Kelly et al., Reference Kelly, Emechebe, Anamdi, Duffy, Murphy and Rock2015). In many countries, coercive practices are no longer confined to involuntary hospital admissions; they are becoming increasingly prevalent within community-based care and during ‘voluntary’ admission to hospitals. Although compulsory treatment options in the community, such as Community Treatment Orders, are largely ineffective in preventing re-admission to hospital and restrict patient autonomy (Burns et al., Reference Burns, Rugkåsa, Molodynski, Dawson, Yeeles, Vazquez-Montes, Voysey, Sinclair and Priebe2013) they remain a ‘rapidly expanding form of involuntary treatment in many countries’ (Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018).

We are rightly concerned with evidence-based medicine in psychiatry. It is paradoxical that coercive interventions in mental healthcare continues to be used extensively although there is little evidence they confer any clinical benefits (Sailas and Fenton, Reference Sailas and Fenton2000; Wright, Reference Wright2003). Available research does not suggest they are clinically effective, improve patient safety or result in better clinical or social outcomes (Luciano et al., Reference Luciano, Sampogna, Del Vecchio, Pingani, Palumbo, De Rosa, Catapano and Fiorillo2014; McLaughlin et al., Reference McLaughlin, Giacco and Priebe2016; D'Lima et al., Reference D'Lima, Crawford, Darzi and Archer2017). In contrast, coercive practices are often associated with negative outcomes for patients with significantly adverse impacts on satisfaction and quality of life (Kallert et al., Reference Kallert, Glöckner and Schützwohl2008). While a significant proportion of those subjected involuntary treatment retrospectively acknowledge that such treatment was necessary many have strong negative perceptions about the use of forcible treatment as they wish to be treated with respect rather than being subjected to the professionals' control (Tingleff et al., Reference Tingleff, Bradley, Gildberg, Munksgaard and Hounsgaard2017; Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018). Many of those subjected to involuntary admission do not feel it is justified or beneficial (Katsakou and Priebe, Reference Katsakou and Priebe2006; Priebe et al., Reference Priebe, Frottier, Gaddini, Kilian, Lauber, Martínez-Leal, Munk-Jørgensen, Walsh, Wiersma and Wright2008) and tend to recall their experience as highly distressing and even traumatic (Paksarian et al., Reference Paksarian, Mojtabai, Kotov, Cullen, Nugent and Bromet2014; Rose et al., Reference Rose, Perry, Rae and Good2017; Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018; Akhter et al., Reference Akhter, Molyneaux, Stuart, Johnson, Simpson and Oram2019). Coercive interventions can weaken or damage therapeutic relationships and dissuade people from seeking further treatment thus increasing the risk of non-adherence and involuntary treatment, particularly those with long-term mental health problems (Swartz et al., Reference Swartz, Swanson and Hannon2003; Jaeger et al., Reference Jaeger, Pfiffner, Weiser, Längle, Croissant, Schepp, Kilian, Becker, Eschweiler and Steinert2013; Rose et al., Reference Rose, Perry, Rae and Good2017). It is likely that coercive practices contribute to social stigma against people experiencing mental health problems. The persistent and ubiquitous nature of coercion in mental healthcare suggests that ‘the human rights of users of psychiatry are systematically ignored’ (Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018). This is in sharp contrast to general health care and undermines psychiatry's claim that it is akin to other medical disciplines which, in turn, raises questions about the legitimacy of the current rhetoric around ‘parity of esteem’.

Reducing coercion in clinical practice

There is increasing recognition that we need to make mental healthcare more consensual and ensure that the human rights of people with mental health problems are always respected (Szmukler et al., Reference Szmukler, Daw and Callard2014; Pūras, Reference Pūras2017). However, little attention is given within current mental health policies and programmes to reducing coercion in clinical practice despite our commitment to clinical safety. Unfortunately, there is very little research in this area. This is surprising considering the ubiquitous nature of the problem and the negative perceptions of forcible treatment among service users, professionals and the wider public (Salize and Dressing, Reference Salize and Dressing2004). While a number of clinical strategies are considered useful in reducing coercion in mental health, such as ‘front loading’ of services, independent patient advocacy and increased involvement of friends and family (Molodynski, Reference Molodynski2017), large scale, operational or empirical evidence of their effectiveness is lacking.

A systematic review and meta-analysis of interventions to reduce compulsory admissions (de Jong et al., Reference de Jong, Kamperman, Oorschot, Priebe, Bramer, van de Sande, Van Gool and Mulder2016) found only 13 randomised controlled trials (RCTs) in which intention to reduce compulsory admission was the first or secondary outcome measure. This study found that compulsory community treatment, compliance enhancement and integrated treatment had little impact on reducing involuntary admissions. Advanced directives and joint care plans are potentially powerful tools in avoiding non-consensual treatment as they result in service users feeling more in control over their mental health problems and feeling respected and valued as a person. There is some evidence that joint decision making, involving service user and professionals in the context of detailed care planning, could potentially avoid the need for compulsory treatment in the event of a psychiatric crisis (Thornicroft and Henderson, Reference Thornicroft and Henderson2016). Joint crisis plans (JCP) include elements of advanced directives. Unlike advanced directives, the content of which are solely determined by the service user, a JCP is the product of shared decision making between the service user and relevant professionals. A pilot RCT of JCPs for people with psychotic or bipolar disorders found reduced involuntary hospitalisation associated with their use (Henderson et al., Reference Henderson, Flood, Leese, Thornicroft, Sutherby and Szmukler2004) although a subsequent, larger multi-site trial delivered in routine practice failed to replicate this (Thornicroft et al., Reference Thornicroft, Farrelly, Szmukler, Birchwood, Waheed, Flach, Barrett, Byford, Henderson, Sutherby and Lester2013). However, JCPs were found to be associated with a positive effect on service user-rated therapeutic relationships and cost-effectiveness. Yet, the ‘culture of professional dominance in decision making’ may impede effective joint decision making (Newton-Howes and Mullen, Reference Newton-Howes and Mullen2011). Overall, current evidence on the effectiveness of specific interventions to reduce involuntary admissions is limited and there is a pressing need for evidence-based remedies for the ‘rising tide of compulsory admissions’ (Johnson, Reference Johnson2013).

A Cochrane Review (Sailas and Fenton, Reference Sailas and Fenton2000) found no controlled evaluations of the value of seclusion or restraint in those with serious mental illness and noted serious adverse effects of such interventions. The review suggested that ‘continuing use of seclusion or restraint must therefore be questioned’ and sought well-designed randomised trials that are generalisable to routine practice. Nearly two decades later, there are still no controlled studies of these coercive practices although they continue to be employed widely in mental healthcare. There is little evidence that prevention or de-escalation of aggressive behaviour in mental health settings, often used in inpatient psychiatric settings, is effective (Gaynes et al., Reference Gaynes, Brown, Lux, Brownley, Van Dorn, Edlund, Coker-Schwimmer, Weber, Sheitman, Zarzar and Viswanathan2017). The value attached to seclusion and restraint, as with the need for involuntary treatment in general, is influenced by beliefs and habits rather than any empirical evidence. This makes it difficult to change these clinical practices (Sailas and Wahlbeck, Reference Sailas and Wahlbeck2005). Local initiatives to reduce coercion in hospital settings can be effective but these tend to be uncontrolled interventions with limited information regarding clinical outcomes, long-term sustainability or the extent to which they are integrated into routine clinical practice. Mostly, such interventions are introduced as ‘alternatives’ or stand-alone programmes rather than part of more generalised or systemic changes in care and treatment. A more recent systematic review of seclusion and restraint reduction programmes since 2010 found some evidence that they may enhance the quality and safety of care but do not reduce the use of coercion (Goulet et al., Reference Goulet, Larue and Dumais2017).

We agree that the use of compulsion in mental healthcare amounts to a ‘system failure’ (Bhugra et al., Reference Bhugra, Tasman, Pathare, Priebe, Smith, Torous, Arbuckle, Langford, Alarcón, Chiu and First2017). It is likely that its persistence is linked to entrenched problems within organisational structures and the culture and ethos of prevailing clinical care (Szmukler, Reference Szmukler2015). This makes it difficult to change such practices (Gaynes et al., Reference Gaynes, Brown, Lux, Brownley, Van Dorn, Edlund, Coker-Schwimmer, Weber, Sheitman, Zarzar and Viswanathan2017). It is clear that individual ‘stand-alone’ programmes or situation-specific training to reduce coercive interventions are not sufficient by themselves. They rarely result in significant changes in the organisational and clinical culture of mental health systems.

A fundamental transformation of mainstream care may be necessary to bring about the required organisational and cultural change. It is suggested that alternatives to forcible psychiatric admissions and coercive care will need to be integrated into ‘whole system’ changes to make mental healthcare more consensual; such as an emphasis on hospitality and support in community mental health centres, community-based crisis intervention and recovery homes, early support, personalised and shared care plans (Mezzina and Vidoni, Reference Mezzina and Vidoni1995; Rosen et al., Reference Rosen, O'Halloran, Mezzina, McQuistion, Sowers, Ranz and Feldman2012). The effectiveness and impact of such innovations will depend on their ability to deal with power dynamics between service users and professionals. Their success will also be dependent on a willingness to manage microsocial stressors and conflicts that trigger or reactivate deviant behaviours. To achieve this, it is important to build therapeutic alliances that respect people's will and preferences, developed in their living environments in the community, that is, on ‘their turf and terms’ (Mezzina et al., Reference Mezzina, Rosen, Amering, Javed, Javed and Fountoulakis2019).

This suggests the need for a profound cultural change. A review by Mezzina (Mezzina et al., Reference Mezzina, Rosen, Amering, Javed, Javed and Fountoulakis2019) identifies several components necessary to preventing and ending coercive care comprising a broad suite of practices, policies and interventions. There should also be ‘top down’ and local-level leadership to create and maintain cultural change in organisations informed by human rights principles, service user involvement and the availability of community-based crisis services. Such a mental health system has the potential to minimise involuntary treatment and foster meaningful alternatives to coercion (Gooding et al., Reference Gooding, McSherry, Roper and Grey2018). These are the same values and principles that more generally underpin effective mental healthcare; equitable access to least restrictive environment, ensuring service users' self-determination and participation in his/her treatment and the involvement of families in decisions concerning assessment and treatment (Mezzina, Reference Mezzina2014, Reference Mezzina2016). This means a fundamental shift in psychiatry's current focus, from patient to citizenship (i.e. being concerned with persons with mental disorders as citizens and not, merely, as patients), guardianship to free will, substituting decision making to supported decision making and shared responsibility. In this way, the social mandate of psychiatry changes, from controlling behaviour to social mediation between stakeholders and the community. The ethos of mental healthcare becomes truly ‘person-centred’ with a ‘rights-based’ approach and vision (Thornicroft et al., Reference Thornicroft, Alem, Dos Santos, Barley, Drake, Gregorio, Hanlon, Ito, Latimer, Law and Mari2010).

Reducing secure care – rethinking service delivery

Calls for a paradigm shift in psychiatry are as old as psychiatry itself. While this is a worthy objective, it is unlikely to happen any time soon (WHO, 2013). In the meantime, it is incumbent upon us to work towards reducing coercion in mental health services worldwide, in its totality and a whole phenomenon. The most obvious and entrenched form of coercive care in high-income countries is in the field of forensic psychiatry. Since the 1990s forensic psychiatry has burgeoned as part of mainstream mental healthcare in most of Western Europe, an unintended consequence of the deinstitutionalisation process (Jansman-Hart et al., Reference Jansman-Hart, Seto, Crocker, Nicholls and Côté2011). The substantial reduction in the number of psychiatric hospital beds following the closure of mental hospitals was accompanied by an increase in the prison population as well as forensic beds and inconsistent changes in the availability of protective housing, including residential care (Chow and Priebe, Reference Chow and Priebe2016). In England, there are currently 7000 to 8000 secure care (forensic) beds. This includes over 750 beds in three high security hospitals, 3500 beds in medium secure care and a similar number in low-secure care (‘locked rehabilitation’ units) (National Mental Health Development Unit, 2010). Increasing demand for forensic services has also been noted in other countries in Western Europe (Salize et al., Reference Salize, Lepping and Dressing2005).

Forensic psychiatric practice is not uniform or consistent. Admission criteria to secure care vary widely between countries and within same jurisdictions, dependent on a range of factors from the severity of the offending behaviour to the absence of alternative provisions. People tend to stay in these facilities for a long time, not necessarily because of clinical needs (Duke et al., Reference Duke, Furtado, Guo and Völlm2018). According to some estimates, a significant proportion of patients in secure settings in the UK, between 20 and 60%, do not need such a high level of security (Shaw et al., Reference Shaw, Davies and Morey2001). This form of psychiatric care is extremely expensive. Medium secure units in England, for example, cost £1.2 billion in 2009/10 and, on average, £ 175 000 per patient per annum. This amounts to 1% of the entire NHS expenditure, corresponding to 18.9% of all public expenditure on adult mental healthcare (National Mental Health Development Unit, 2010). These are also extremely restrictive forms of care. Most of those detained in forensic hospitals live in circumstances that amount to being under ‘suspended citizenship’, that is, their full rights as citizens are either limited or compromised as result of their detention. Decisions regarding treatment and discharge from secure services are determined primarily by presumed risk rather than healthcare needs. Secure services offer little in the way of psychosocial rehabilitation or recovery focused care which is inevitable given the high levels of restrictions under which patients are managed. Often these services are remote and disconnected from community resources and services.

Despite the significant investment in the secure care sector its continuing expansion within current models of service delivery, there is a surprising lack of basic information and outcomes about the quality and effectiveness of forensic care provisions in most countries (Shaw et al., Reference Shaw, Davies and Morey2001). Domains such as quality of life, social function and psychosocial adjustment, which are relevant to those who use the services, are rarely addressed in forensic mental health research (Fitzpatrick et al., Reference Fitzpatrick, Chambers, Burns, Doll, Fazel, Jenkinson, Kaur, Knapp, Sutton and Yiend2010). Policies and programmes in relation to secure care do not address the extent to which human rights of service users are routinely compromised in such settings. Available research suggests that the long-term outcome of treatment of mentally disordered offenders (the main client group in forensic psychiatry) is generally poor (Davies et al., Reference Davies, Clarke, Hollin and Duggan2007). As with involuntary treatment in general, there is hardly any evidence-base for forensic psychiatric interventions including the central tenets of secure care i.e. risk prediction and management.

The entrenchment of the secure care sector within mental health is indicative of a trend towards greater convergence of public protection functions and treatment of mental disorders in many high-income countries (Rutherford, Reference Rutherford2010). For example, there is increasing overlap of legislation (in the criminal justice system and mental healthcare), professional practices and patient/offender management although there are fundamental distinctions between mental health services and criminal justice. There is a danger that such convergence will increase the stigma attached to offenders and those with mental health problems and adversely affect their resettlement and reintegration into society. The primary purpose of mental health services is the provision of care and treatment for people with mental health problems and not public protection or managing criminal recidivism. According to Rutherford (Reference Rutherford2010), it is vital therefore that the lines between prisons and hospitals do not become overly blurred. Prisons should never become a substitute for hospitals, and hospitals should not be designed, managed or function like prisons. It is unethical and anti-therapeutic to combine long-term psychiatric care and forcible detention for the purpose of public protection. Unfortunately, the primary purpose of secure units has become risk management and public protection rather than treatment of mental illness. This has meant the introduction of increasing sanctions and punitive interventions within mental healthcare based on risk profiling rather than as an aide to treatment or to facilitate recovery. If psychiatry wants to position itself as a truly medical discipline, our primary objective should remain the care and treatment of people with mental health problems.

We believe that dismantling the current apparatus of forensic mental healthcare will go a long way towards making psychiatry less coercive and more akin to other healthcare disciplines. Recent experience from Italy shows that this is possible. In the last six years all forensic psychiatric hospitals in Italy have been closed through the creation of new care pathways involving small-scale and high-intensity therapeutic facilities (Residenze per la Esecuzione della Misura di Sicurezza, REMS) as part of local community mental health services (Barbui and Saraceno, Reference Barbui and Saraceno2015; De Ambrogi, Reference De Ambrogi2017). This integration of ‘forensic care’ within general mental healthcare has allowed the adoption of a rehabilitation model to help and support people with long-term mental health problems and a criminal history (or otherwise considered as ‘socially dangerous’) instead of their long-term containment for public protection. Italy now relies on fewer secure psychiatric beds (1/100 000) compared to most other European countries (Mezzina, Reference Mezzina2018).

Reducing coercion through legislation and policies

Although mental health laws are thought necessary for protecting the rights of people with mental disorders in just under a third of the countries (31%) worldwide have legislation fully implemented. These are mostly high-income countries (WHO, 2014). The availability of mental health legislation does not prevent psychiatric abuse or reduce coercion. For example, maltreatment and violence towards people with mental health problems are reported in countries with well-established mental health legislation and well-resourced mental health systems.

The two most common grounds for authorising involuntary admission of people with mental disorders in most jurisdictions are ‘serious likelihood of immediate or imminent danger’ and ‘the need for treatment’ (WHO, 2005). For example, in 12 European member states, dangerousness/safety criteria are still the main conditions for justifying involuntary placement, while in Italy and Spain involuntary treatment is based on ‘need for treatment’ with no specific reference to classification of danger with regard to risk levels or thresholds (FRA, 2012). The need for treatment should be connected to the right to health and healthcare. This is highlighted in a number of international covenants and standards and is included in the promotion and protection of all human rights including the right to personal, social, economic, cultural and political development. However, ensuring that these needs are protected or facilitated through mental health legislation remain ‘controversial topics in the field of mental health’ as coercive interventions ‘impinge on personal liberty and the right to choose, and they carry the risk of abuse for political, social and other reasons’ (WHO, 2005). Current laws embedded in the criminal justice system in many countries regarding ‘fitness to plead’ and ‘fitness to stand trial’ also have serious implications for persons with cognitive disabilities. Such laws can result in the denial of equal access to justice, such as fair trial, liberty, legal capacity and equal recognition before the law and may result in long-term psychiatric care and forcible detention.

Reforming mental health legislation may help in decriminalising those with mental health problems and can further protect the rights of those subject to such legislation but revising the law on involuntary treatment by itself is unlikely to change current patterns of coercive care (Care Quality Commission, 2018). This is because changes in legislation alone seldom affect prevailing clinical practices and institutional processes related to the treatment and management of people with mental health problems. For example, attempts at reforming existing mental health legislation in many high-income countries have so far failed to halt or reverse the inexorable increase in the trends of increasing psychiatric detention and continued reliance on coercive care. In England, there has been a 43% increase in psychiatric detentions since 2007 following changes to the 1983 Act (Care Quality Commission, 2018). By contrast, in Finland and Germany, there was a decrease in compulsory admission rates following changes in legislation (Turnpenny et al., Reference Turnpenny, Petri, Finn, Beadle-Brown and Nyman2018). The implementation of Law 180 that closed all psychiatric hospitals in Italy was also followed by a substantial reduction in involuntary treatment rates, currently at 16/100,000, one of the lowest in Europe (Starace et al., Reference Starace, Baccari and Mungai2018).

According to the UN Convention of Rights of People with Disabilities (UNCRPD), current mental health laws are fundamentally discriminatory and inconsistent with the human rights principles (Pūras, Reference Pūras2017). In the wake of the UNCRPD and the increase in coercive care (and discriminatory practice) in many high-income countries it is argued that mental health laws are no longer ‘fit for purpose’ (Szmukler and Kelly, Reference Szmukler and Kelly2016). It is, therefore, unsurprising that international organisations, service users, politicians and legal experts are all calling for the reappraisal of current mental health legislation and, in particular, abandoning laws applicable only to those considered to have psychosocial disability. What is striking in this context is the lack of any commitment from the psychiatric profession, so far, to address this challenge.

The European Parliament Resolution of 2006 declared that ‘the use of force is counterproductive’, as is compulsory medication. A Parliamentary Assembly Recommendation of the Council of Europe in 2016 concluded that ‘any legal instrument that maintains a link between involuntary measures and disability will be discriminatory and thus violate the CRPD’ (Council of Europe, 2016). Instead, it recommended that the Committee of Ministers ‘instruct the Committee on Bioethics to focus its work on promoting alternatives to involuntary measures in psychiatry, including by devising measures to increase the involvement of persons with psychosocial disabilities in decisions affecting their health.’

International experiences

The QualityRights initiative of the WHO has been at the forefront of ensuring human-rights compliant mental healthcare in several countries. This is a systematised programme that includes assessment, training and quality improvement measures that focus on the human rights in mental health and social care facilities (Funk and Drew, Reference Funk and Drew2017). Forced confinement and the use of physical restraints of people with severe mental health problems within family settings are an endemic problem in several sub-Saharan Africa and Asian countries (Human Rights Watch, 2015, 2016, 2017). In Indonesia, for example, it is estimated that 19 000 people with mental illness are physically restrained in the community. Through a systematic programme, Bebas Pasung (free from restraints), involving the provision of community-based mental health services alongside intensive education campaigns, it has been possible to free people from restraints (pasung) (Puteh et al., Reference Puteh, Marthoenis and Minas2011). The chain free initiative in Somalia, supported by the WHO, aims to reduce the number of people restrained in community settings and in hospital through increasing access to mental healthcare (WHO, 2010). In China, a national mental health programme, the ‘686 program’, provides a package of interventions including ‘unlocking’ by a team of mental health professionals, admission to a psychiatric hospital and community follow up for those restrained in the community. The initial results indicate that 92% of patients remained restraint-free after 7 years (Guan et al., Reference Guan, Liu, Wu, Chen, Wang, Ma, Wang, Good, Ma, Yu and Good2015). However, in most of these countries the successful reduction in community-based coercion is not replicated in hospital settings. More often than not, pasung is re-imposed following admission to hospital, under the medical guise of psychiatric treatment. It is important that programmes such as Bebas Pasung and the Chinese 686 initiatives are not confined to the community and are extended to mental healthcare facilities where compulsion, restraint and seclusion remain the norm.