Putting a stop to coercive practices in mental healthcare

The United Nations is investigating the use of coercion in mental health services around the world 

The United Nations is investigating the use of coercion in mental health services around the world

Coercion was a constant feature of psychiatric care in the past and is still used in some contexts today.

Less visible forms of coercion can include the imposition of certain ways of understanding mental illness, seeing it for example as a purely biomedical construct. Picture: Alamy

In Britain it may be less overt and brutal than in countries where straps and shackles remain key weapons in the armoury of the ‘carer’. But even in more enlightened systems, coercive practices remain, raising questions of law, ethics and human rights.

A team from the Melbourne Social Equity Institute, part of the University of Melbourne, Australia, has been undertaking a systematic review of practices worldwide that seek to ‘reduce, prevent and end’ coercion in mental health services. Its report was published in October 2018.

Alternatives to Coercion in Mental Health Settings: A Literature Review was commissioned by the United Nations (UN) to inform the work of the UN special rapporteur on the rights of people with disabilities.

In many places and in certain circumstances, laws enable people with mental health conditions to be detained and treated without their consent. But there has been a shift away from coercive practices at international, national and local levels. For example, the UN Human Rights Council calls on states to provide mental health services ‘on the basis of free and informed consent’.

What exactly is ‘coercion’ in mental healthcare?

The report’s authors define it as the action or practice of persuading ‘in a way characterised by the use of force and threats, or forcing someone to do something’.

Obvious examples include compulsory admission, electroconvulsive therapy, and seclusion and restraint by mechanical, physical or chemical means.

But coercion can also occur in ‘voluntary’ service provision. Research quoted in the report talks of the ‘shadow of compulsion’ that falls on some voluntary patients and argues that coercion takes place in family homes as well as hospitals.

And although the authors of the study focus on explicit forms of coercion, they acknowledge less visible forms that include the imposition of certain ways of understanding mental illness – seeing it as a curse, for example, or a purely biomedical construct.

Finding alternatives

To compile their report, the authors analysed empirical research drawn from international sources but written in English that offered insight into alternatives to coercion.

Two questions guided the work:

  • What laws, policies or practices help to reduce and eliminate coercion?
  • What existing alternative laws, policies or practices promote rights-based support in the mental health context?

Various themes emerged from the literature review, including:

  • The value of recovery-orientated and trauma-informed practices.
  • Laws to reduce or end coercive practices.
  • Peer-led initiatives.
  • Crisis-resolution responses.
  • Culturally appropriate mental health support.

Coercive practices in Germany

Several landmark decisions in German courts in 2011 and 2012 led to restrictions on involuntary psychiatric interventions, limiting their use to ‘life-threatening emergencies’ only. As a result, clinicians placed even greater emphasis on consensual treatment. There was also some evidence of a reduction in the use of medications without consent. But there were also adverse effects, such as an apparent increase in violent incidents.

Each of the themes is unpacked in the report with reference to approaches drawn from around the world. For example, legal intervention in Germany (see Box).

Featuring heavily in the report are the six core strategies to reduce the use of seclusion and restraint. Developed in the US, the strategies focus on:

  • Leadership toward organisational change.
  • Use of data to inform practice.
  • Workforce development.
  • Use of prevention tools.
  • Consumer roles in inpatient settings.
  • Debriefing techniques.

The review found several studies that examined the use of the six core strategies, all of which reported a significant decrease in the use of seclusion and restraint when the strategies were implemented.

The Safewards model

The Safewards model, familiar to many UK nurses, is also prominent in the report. Safewards proposes interventions to manage flashpoints in mental health units and reduce conflicts.

A study by Len Bowers, former professor of psychiatric nursing at the King’s College London Institute of Psychiatry, Psychology and Neuroscience and the driving force behind Safewards, which is referenced in the report, found the model brought an estimated 15% reduction in conflict when implemented in 31 wards in England.

But what does the weight of international evidence mean in relation to the daily practice of mental health nurses in the UK?

Lecturer in mental health nursing at the University of Manchester Owen Price, whose research interests include the reduction of restrictive practices, says there is great value in considering the approaches taken by other countries.

‘We’re a multicultural society. We need to find out more about the international context, particularly culturally sensitive trauma-informed care.’

Dr Price welcomes the report’s emphasis on service user involvement in research, pointing out that two of its authors draw on their own experiences of mental health services. 

Six core strategies in action

One of the studies considered by the Melbourne Social Equity Institute review examined the implementation in a forensic unit in England of elements of the six core strategies for reducing seclusion and restraint. A significant reduction in seclusion and risk behaviour was reported, complemented by an increase in engagement with treatment. The authors of the study say that seclusion can be reduced without a rise in patient violence or ‘alternative coercive strategies’.

‘But an important issue that is consistent across studies is the divergence between service user and clinician perspectives in relation to what’s realistically achievable in terms of reduction.

Ethical considerations

‘There seems to be a consistent message that service users consider coercion to be unacceptable ethically and that the target should be to completely eliminate coercive interventions.’

He adds: ‘Obviously that view is not always shared by clinicians, so I think the answer is more collaborative research to try to understand the gap in perspectives.’

He cites the work of Eimear Muir-Cochrane at Flinders University, Adelaide, South Australia, who is head of a major project investigating barriers to the elimination of seclusion and restraint.

‘Hopefully, Professor Muir-Cochrane and her team will draw out what some of the key issues are in terms of getting service user and staff views on this more aligned,’ Dr Price says.

Modifying practice

‘And I think one of the things that comes across really clearly in the report is that people need to start looking inwardly at what they can do to change their own behaviour and the environment to prevent unsafe incidents, rather than looking at aspects of the patient, such as diagnosis, gender or age.

‘Those features may be significant in terms of risk but they are perhaps given more credence than they should at the expense of other, modifiable areas of practice.’

The report itself makes a number of suggestions about where the focus of future research should lie, including stronger alliances between academics, service users, policy makers and service providers.

The authors conclude optimistically, saying their review findings are ‘generally positive’.

‘Efforts to reduce, prevent and end coercion appear effective in most studies, notwithstanding limitations in the research.’

Find out more

Alternatives to Coercion in Mental Health Settings: A Literature Review

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