Humanizing Mental Healthcare by Reducing Coercive Practices

A review of the literature demonstrates that coercive practices lack empirical support and violate human rights.

Ashley Bobak, MS
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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.

“Love, Dignity, Justice” by ANDR3W A is licensed under CC BY-ND 2.0

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.

 

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Sashidharan, S. P., Mezzina, R., & Puras, D. (2019). Reducing coercion in mental healthcare. Epidemiology and Psychiatric Sciences, 1-8. (Link)

12 COMMENTS

  1. “Coercive practices”, as they are called, have a different term for other contexts, and that different term is tyranny. If we’re going to criticize “coercive practices”, maybe we should be criticizing the entire system that has produced them, perfected them, excuses them, and apologizes for them. Antipsychiatry, as I see it, is pro-freedom, pro-democracy, and anti-tyranny. Why reform a system that should never have arisen in the first place when you can do away with it. More simply put, wrong is wrong, and “coercive practices” are not merely “dehumanizing”, they are wrong. Talk “reducing coercive practices” and you’ve already justified them. No, let’s not talk reform. Let’s abolish involuntary hospitalization and involuntary drugging. Tyranny is unjustified in all instances and under all circumstances. Limited tyranny has had its day, but let’s make sure that day is finally over by putting it to sleep once and for all.

  2. So it is all coercive, its just being done via duplicity and deception.

    This is why I say:

    1. Eliminate Psychiatry and prosecute the practitioners in International Court.

    2. Stop our government from being able to license or fund or promote Psychotherapy, Life Coaching, Recovery, or Religion.

    • As far as protecting the public we already have the penal system. This is understood to be punishment so it’s limited to an acceptable degree. But because psychiatry pretends to be medicine instead of a punitive system they get away with all kinds of BS the legal system never could.

      Such as denial of due process. Cruel and unusual punishments. Extended, indefinite imprisonments based solely on the whim of the warden. And treating harmless eccentrics, those with TBI, and unhappy loners exactly the same way as violent criminals.

  3. The fact that people have to be coerced into receiving “care” should tell us all we need to know about the quality of that “care” and what people think of it.

    The fact that coercive practices have been designed into the “care” system and codified into the law of the land reveals that it isn’t about “care” but rather about control.

  4. How can the authors write that we need to “ensure that the human rights of people with mental health problems are always respected.”. Surely they would be aware that along with the status of “patient” comes a removal of human rights? They simply don’t have any, at all. This is why police will simply do absolutely nothing for a “patient” as they are fully aware that it would need to be approved by their doctor first. And when it is the doctor committing the offences against the “patient”? Sorry, not in the public interest.
    So how can you respect something that doesn’t exist? Meh, anyway I need to go feed my Unicorn. Human rights and mental patients waaaahahahaha Were heading in the other direction in my country. Euthanasia Bill here we come. Want to talk about the coercive practices that might come into play there? Nope, need to keep the public out of that debate altogether. They just wouldn’t understand.
    Not that we haven’t been shown police beating and pepper spraying a man whilst asking “Do you like that?” Before delivering him to his doctor. Perhaps next time he will be a little more cooperative and attend his appointments with his master.