A review of the literature, published in Epidemiology and Psychiatric Sciences, examines the effectiveness of coercive practices in mental healthcare. The review indicates that coercive practices are not only ineffective, but unethical, anti-therapeutic, and violate human rights. The authors suggest steps that can be taken to reduce coercive practices in mental healthcare but ultimately arrive at the conclusion that a paradigm shift in the field of psychiatry is required for large-scale changes to be made.
“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. However, little attention is given within current mental health policies and programs to reducing coercion in clinical practice despite our commitment to clinical safety,” write the authors, led by Dr. S.P. Sashidharan, a professor and researcher at the University of Glasgow.
Coercive practices are used internationally in mental healthcare, yet they remain under-researched. In addition, the available research suggests that they are detrimental to the health, wellbeing, and human rights of mental health clients. Coercive treatment broadly consists of involuntary and forcible treatment, which includes practices such as seclusion, physical restraint, and the forcible administration of medication. Such practices are not confined to mental healthcare but are also used in general healthcare, particularly in the treatment of the elderly, children, and individuals diagnosed with intellectual disabilities.
Despite the pervasive use of coercive practices in treatment, there remains a lack of systematic and reliable data on coercive practices both nationally and internationally. Yet, available research suggests that such practices elicit the opposite effect of what is intended. Although coercive practices are used in the service of keeping the client and others safe, research demonstrates that clients who are subjected to such treatment experience high levels of distress, even traumatization, as a result of such experiences. The authors note:
“. . . coercive practices are often associated with negative outcomes for patients with significantly adverse impacts on satisfaction and quality of life.”
While research identifying potential clinical remedies to coercive treatment is scarce, the research that is available suggests that clinical practices that involve loved ones of the client, client advocacy, and the use of advanced directives and joint care plans all contribute to the reduction of coercive practices in treatment.
In order for practices such as joint care plans, wherein the client and professionals collaborate in the process of treatment planning, to be utilized across psychiatric institutions, a major shift will need to occur regarding how treating professionals view their clients – not as dangerous or lacking the agency to engage in their own treatment, but instead as competent, capable, and worthy of dignity and respect.
Although coercive care is used across mental health and general healthcare settings, it is most prevalent in forensic psychiatry in high-income countries. In order to reduce coercive treatment as a whole, the authors suggest that forensic psychiatry itself needs to be completely restructured into treatment based on rehabilitation, as opposed to its current focus on public protection. Italy provides one example of how such a restructuring lends itself to positive outcomes – rather than indefinitely confining those with mental health issues and criminal histories, Italy has moved toward rehabilitating these individuals, which has resulted in the reduction in reliance on secure psychiatric beds.
Further, while legislative changes will likely not impact the use of coercive care in clinical practice, it can allow for increased protection of rights for those in treatment. Unfortunately, despite current mental health laws being described by the UN Convention of Rights of People with Disabilities (UNCRPD) as being, “fundamentally discriminatory and inconsistent with human rights principles,” there remains a lack of action by the field of psychiatry to make changes in mental health legislation.
There are organizations advocating for the upholding of human rights in mental healthcare. Dr. Sashidharan and his colleagues highlight the QualityRights initiative of the World Health Organization (WHO) as being an entity that promotes the maintenance of human rights across several countries through the use of assessment, training, and measures of treatment quality in mental health facilities.
The review of the literature outlined by the authors clearly indicates that coercive practices are harmful and detrimental to individuals, providing a strong argument to reduce the use of these practices in mental healthcare. Although a major overhaul of the field of psychiatry is required in order to significantly reduce these practices, changes in legislation and in the field of forensic psychiatry can pave the way for a shift in the psychiatric paradigm.
Sashidharan, S. P., Mezzina, R., & Puras, D. (2019). Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences, 1-8. (Link)