Coercion In Mental Health Care Research Articles

Bringing together the World Health Organization's QualityRights initiative and the World Psychiatric Association's programme on implementing alternatives to coercion in mental healthcare: a common goal for action.

Stakeholders worldwide increasingly acknowledge the need to address coercive practices in mental healthcare. Options have been described and evaluated in several countries, as noted recently in major policy documents from the World Health Organization (WHO) and World Psychiatric Association (WPA). The WHO's QualityRights initiative promotes human rights and quality of care for persons with mental health conditions and psychosocial disabilities. A position statement from the WPA calls for implementation of alternatives to coercion in mental healthcare. We describe the engagement of both the WHO and WPA in this work. We discuss their mutual aim to support countries in improving human rights and quality of care, as well as the differences between these two organisations in their stated goals related to coercion in mental healthcare: the WHO's approach to eliminate coercion and the WPA's goal to implement alternatives to coercion. We outline and critically analyse the common ground between the two organisations, which endorse a similar range of rights-based approaches to promoting non-coercive practices in service provision, including early intervention in prevention and care and other policy and practice changes. Advocacy and action based on an agreed need to find practical solutions and advances in this area have the power to build consensus and unify key actors. We conclude that persons with lived experience, families, mental health professionals and policy makers are now coming together in several parts of the world to work toward the common goals of improving quality, promoting human rights and addressing coercion in mental health services.

Contextual factors influencing the use of coercive measures in Portuguese mental health care

The use of coercive measures in mental health care is an important indicator of the quality of care being provided, and non-patient-related factors are increasingly recognized to contribute to their use. The study aimed to explore the perspectives of mental health care professionals who have first-hand experience with the use of coercion on the contextual factors that influence the use of coercion in the Portuguese mental health care. Five focus group discussions were conducted among 23 doctors and 17 nurses from five psychiatric departments in urban and rural regions of Portugal. Discussions were audio recorded, transcribed, and analyzed with the aid of MAXQDA. Four broad themes related to insufficient resources, staff-related factors, inefficient services, and socio-legal factors were derived. Participants highlighted how inadequate structures, staff shortages, staff attitudes, a lack of training, restrictive ward rules, an inefficient organization of services, the mental health legislation, and public attitudes contributed to the use of coercive measures. The COVID-19 pandemic complicated existing shortfalls in the system and increased the use of coercive measures. The study confirms that the use of coercive measures in mental health care is influenced by factors that are independent of patient characteristics. Addressing existing systemic problems is crucial for the successful implementation of interventions to reduce coercion in mental health care.

Implementing alternatives to coercion as a key component of improving mental health care: the WPA contribution

AbstractTo favor the implementation of alternatives to coercive practices, a WPA Taskforce and reference group on Minimizing Coercion in Mental Health Care was created within the WPA 2017-2020 Action Plan. It included several distinguished colleagues from different countries and cultural as well as experiential background, and representatives from patients and carers organizations. Task force members soon realized the presence of a significant diversity of views and experiences among mental health professionals, people with lived experience and their carers. All members agreed that the debate on minimizing versus eliminating coercion could be endless and unfruitful, while the opportunity to concentrate on improving the quality of mental health care in low-, middle- and high-income countries, and implementing alternatives to coercion as a key component of improving mental health care, was instead a shared goal that could make the task of the group feasible and productive. The General Assembly of the WPA in October 2020 approved a Position statement drafted by the Task Force aimed to set a direction and practical starting point for action. This presentation will illustrate contribution provided by the WPA Working Group for Implementing Alternatives to Coercion in Mental Health Care within the current WPA Action Plan (2020-2023).Disclosure of InterestNone Declared

Use of coercion in mental healthcare services in Nigeria: Service providers’ perspective

Background There is increasing advocacy to reduce coercive practices in mental healthcare. Little research has been done on the topic in developing countries. Aims To explore what mental health professionals in Nigeria think about coercion, why it is used, and what contextual factors influence its use in mental healthcare services. Methods Semi-structured interviews were carried out with 16 doctors and 14 nurses from two psychiatric hospitals in two regions of Nigeria. The audio-recorded interviews were analyzed thematically with the aid of MAXQDA software. Results Three broad categories relating to the perception of, reasons for, and barriers/facilitators to the use of coercion were derived. Coercion was viewed as being for the best interests of patients, a means to an end, and effective for achieving desired outcomes. Safety was both a reason to use a coercive measure and a deterrent to using specific coercive measures thought to be unsafe. The socio-cultural context, obsolete mental health legislation, staff shortages, and attitudes were factors influencing the use of coercion in mental healthcare. Conclusion Coercion was perceived to be ultimately beneficial in mental health practice. There is need for a new mental health legislation and more resources for mental health care in Nigeria to address the problem of coercion.

A qualitative integrative analysis of service users' and service providers' perspectives on ways to reduce coercion in mental health care.

The movement to develop and implement non-coercive alternatives in the provision of mental health care is gaining momentum globally. To strengthen the basis of potential interventions that will be contextually relevant, and to complement the body of literature which is largely from high-income settings, the current study sought to explore the suggestions of service users and providers in Nigeria on how to reduce the use of coercive measures in mental health settings. Semi-structured interviews with 30 mental health professionals and four focus group discussions among 30 service users from two psychiatric hospitals in Nigeria were conducted. The data were analyzed thematically with the aid of MAXQDA. The suggestions proposed by service users and mental health professionals were within the broad themes of communication, policies and legislation, and increased resources. Service users felt that improved communication, home consultations, non-legal advocates and clear rules and legislation would reduce the use of coercion, while service providers suggested increased public mental health literacy, better interpersonal relationships with patients, increased resources for mental health care, more research on the topic and regulation of coercive measures. Many of the suggestions from this study reinforce strategies already in place to decrease coercion in other settings. However, additional recommendations that are relevant to the study setting, such as enhancing public mental health literacy, mental health legislation reform and increasing access to mental health services, deserve further consideration.

Experiences and perceptions of coercive practices in mental health care among service users in Nigeria: a qualitative study

BackgroundPeople with mental health problems are more vulnerable to a broad range of coercive practices and human rights abuses. There is a global campaign to eliminate, or at the very least decrease, the use of coercion in mental health care. The use of coercion in psychiatric hospitals in developing countries is poorly documented. The primary aim of this study was to explore service users’ perceptions and experiences of coercion in psychiatric hospitals in Nigeria.MethodsFour focus group discussions were carried out among 30 service users on admission in two major psychiatric hospitals in Nigeria. The audio recordings were transcribed verbatim and then analyzed thematically with the aid of MAXQDA software.ResultsThe Focus group participants included 19 males and 11 females with a mean age of 34.67 ± 9.54. Schizophrenia was the most common diagnosis (40%, n = 12) and had a secondary school education (60%, n = 18). The focus group participants perceived coercion to be a necessary evil in severe cases but anti-therapeutic to their own recovery, an extension of stigma and a vicious cycle of abuse. The experience of involuntary admission revolved mainly around deception, maltreatment, and disdain. Participants in both study sites narrated experiences of being flogged for refusing medication. Mechanical restraint with chains was a common experience for reasons including refusing medications, to prevent absconding and in other cases, punitively. The use of chains was viewed by participants as dehumanizing and excruciatingly painful.ConclusionThe experiences of coercion by participants in this study confirm that human rights violations occur in large psychiatric hospitals and underscore the need for mental health services reform. The use of coercion in this context reflects agelong underinvestment in the mental health care system in the country and obsolete mental health legislation that does not protect the rights of people with mental health problems. The study findings highlight an urgent need to address issues of human rights violations in psychiatric hospitals in the country.

A tripartite relationship theory of voice hearing: a grounded theory study

ABSTRACT Background Some people receiving mental healthcare experience distress related to voice hearing and the available support. Some practitioners lack knowledge and confidence in providing this support. Furthermore, coercion in mental healthcare can negatively affect voice hearer-practitioner relationships. Previous research investigating mental health distress, including voice hearing, has largely emphasised an individual-centric perspective. Less is known about voice hearers’ and practitioners’ relational experiences within mental healthcare contexts and how this might influence voice hearing. Methods This was a qualitative study that utilised a constructivist Grounded Theory methodology to explore the experiences of voice hearers (n = 15), through semi-structured interviews, and practitioners (n = 18) through focus group discussions (n = 3). Results A tripartite relationship theory situates experiences of voice hearing within a mental healthcare context, mediated through a tripartite voice hearer – voice – practitioner relationship. This consists of five themes: Level of agency; Interpersonal dynamic; Who’s making sense; Medication: helping or hindering; and Personal bully. Discussion This paper presents a novel theory, grounded in voice hearers’ and practitioners’ experiences. This expands on current knowledge about voice hearing by situating voice hearing experiences within relational and clinical contexts.

Nigeria's mental health and substance abuse bill 2019: Analysis of its compliance with the United Nations convention on the rights of persons with disabilities

Countries are struggling with reconciling their national mental health legislation with the CRPD approach, which stresses equality as the focal point of legislation, policies, and practices that affect people with disabilities. Several failed attempts have been made over the last two decades to update Nigeria's obsolete mental health legislation. The most recent attempt is the Mental Health and Substance abuse Bill 2019, which aims to protect the rights of people with mental health needs. It addresses many areas neglected by previous bills, such as non-discrimination of people with mental and substance use problems in the exercise of their civil, political, economic, social, full employment, religious, educational, and cultural rights. It categorically prohibits the use of seclusion in the treatment of people with mental health problems, makes provision for service users to be members of the Mental health review tribunal and allows for the protection of privacy and confidentiality of information about people with mental health problems. While keeping to most of WHO's recommendations for mental health legislation, the bill diverges from the CRPD's recommendations by allowing forced admission and treatment based on mental capacity, substitute decision-making by legal representatives or closest relatives, and non-prohibition of coercive practices. The bill does not make provisions for advance directives and is silent on informed consent to participate in research. Despite the bill's deficiencies, it would be a significant step forward for the country, whose current mental health legislation is the Lunacy Act of 1958. Although the CRPD has left it unclear how countries, especially low resource countries, should go about creating a workable legal framework, it is clear that all countries are expected to join the current global effort to eliminate, or at least reduce to the barest minimum, the use of coercion in mental health care. We expect that future revisions of this bill will examine its limitations in light of Nigeria's socio-cultural context.

Effect of Psychiatric Advance Directives Facilitated by Peer Workers on Compulsory Admission Among People With Mental Illness

Reducing the use of coercion in mental health care is crucial from a human rights and public health perspective. Psychiatric advance directives (PADs) are promising tools that may reduce compulsory admissions. Assessments of PADs have included facilitation by health care agents but not facilitation by peer workers. To determine the efficacy of PADs facilitated by peer workers (PW-PAD) in people with mental disorders. A multicenter randomized clinical trial was conducted in 7 French mental health facilities. Adults with a DSM-5 diagnosis of schizophrenia, bipolar I disorder, or schizoaffective disorder who had a compulsory admission in the past 12 months and the capacity to consent were enrolled between January 2019 and June 2020 and followed up for 12 months. The PW-PAD group was invited to fill out a PAD form and meet a peer worker who was trained to assist in completing and sharing the form with relatives and psychiatrists. The primary outcome was the rate of compulsory admission at 12 months after randomization. The overall psychiatric admission rate, therapeutic alliance, quality of life, mental health symptoms, empowerment, and recovery outcomes were also investigated. Among 394 allocated participants (median age, 39 years; 39.3% female; 45% with schizophrenia, 36% bipolar I disorder, and 19% schizoaffective disorder), 196 were assigned to the PW-PAD group and 198 to the control group. In the PW-PAD group, 27.0% had compulsory admissions compared with 39.9% in the control group (risk difference, -0.13; 95% CI, -0.22 to -0.04; P = .007). No significant differences were found in the rate of overall admissions, therapeutic alliance score, and quality of life. Participants in the PW-PAD group exhibited fewer symptoms (effect size, -0.20; 95% CI, -0.40 to 0.00), greater empowerment (effect size, 0.30; 95% CI, 0.10 to 0.50), and a higher recovery score (effect size, 0.44; 95% CI, 0.24 to 0.65), compared with those in the control group. Peer worker-facilitated PADs are effective in decreasing compulsory hospital admissions and increasing some mental health outcomes (self-perceived symptoms, empowerment, and recovery). Involving peer workers in the completion of PADs supports the current shift of mental health care from substitute decision-making to supported decision-making. ClinicalTrials.gov Identifier: NCT03630822.

Implementing Alternatives to Coercion in Mental Health Care

Abstract BodyThe use of coercive measures in Medicine represents a controversial issue. Even when they comply with all rules and procedures and are enacted with the intention to address the health needs of the patient, and/or protect the patient and/or others, they always represent an infringement of fundamental personal rights and require strong ethical justification.In Psychiatry the debate around coercive measures has led to a theoretical impasse, as the attempt to solve an ethical dilemma may expose mental health care to other ethical challenges and questions of competing rights. At the same time, the ongoing debate has contributed to raise the awareness that coercive practices are over-used, and mental health care is in need of a profound transformation towards recovery-oriented systems of care.The implementation and dissemination of alternatives to coercive practices is an essential component of such transformation. Relevant research has provided tools and documented successful practices, and initiatives aimed at making these resources available and adapted to different contexts are being promoted by international organizations, professional associations and associations of users and carers.1The profound transformation of current mental health care towards recovery-oriented systems of care requires resources and shared goals among the different stakeholders. Integrated and personalised care pathways, respect of human rights, shared decision making, and involvement of users and carers are essential components of this transformation.DisclosureNo significant relationships.

Current State of Research on Coercion in Mental Health: Umbrella Review Protocol.

In recent years, international organizations, professionals, and representatives of mental health service users have expressed the need to regulate, limit, and even eliminate coercive measures in psychiatric treatment. The main objective of the current review is to provide a comprehensive synthesis of existing evidence on coercion in mental health care through a protocol for an umbrella review of systematic reviews. This protocol was designed according to the Joanna Briggs Institute guide for methodological development, conduct, and reporting of umbrella reviews. To minimize bias in the process, two independent reviewers selected the studies to be included, extracted, and synthesized; analyzed the data; and assessed risk of bias of each review. The review protocol was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guidelines. This review offers a comprehensive compilation of systematic reviews on coercion developed to date. Coercion causes adverse physical and psychological effects and is an emotional stressor for individuals with psychiatric diagnoses and health care workers. Characterization of coercion across care settings, its impact on clinical outcomes, the perception of those involved, and how coercion could be reduced will also be discussed. [Journal of Psychosocial Nursing and Mental Health Services, 60(10), 49-55.].

Influence of mental health professionals’ attitudes and personality traits on decision‐making around coercion: Results from an experimental quantitative survey using case vignettes

Research on coercion in mental healthcare has recently shifted to the investigation of subjective aspects, both on the side of the people with mental disorders affected and the staff members involved. In this context, the role of personality traits and attitudes of staff members in decision-making around coercion is increasingly being assessed. This study aimed to examine the role of staff attitudes towards coercion and staff members' personality traits in decision-making around coercion in an experimental setting. We assessed the attitudes towards coercion and (general) personality traits of mental health professionals in psychiatric hospitals with a quantitative survey. Furthermore, we developed case vignettes representing cases in a 'grey zone' and included them in the survey to assess staff members' decisions about coercion in specific situations. A general approving attitude towards coercion significantly influenced decisions around coercion in individual cases-resulting in a more likely approval of applying coercion in the cases described in the vignettes. Personality traits did not seem to be relevant in this regard. Strategies to reduce coercion in mental healthcare institutions should focus more on the role of staff attitudes and encourage staff members to reflect on them critically.

\u201cVoluntary in quotation marks\u201d: a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users

Background Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. This phenomenon is also commonly referred to as informal coercion or treatment pressure. Empirical studies indicated that psychological pressure is common in mental healthcare services. No generally accepted definition of psychological pressure is available to date. A first conceptual analysis of psychological pressure focused on staff communication to promote treatment adherence and distinguished between persuasion, interpersonal leverage, inducements and threats.AimThe aim of this study was to develop a conceptual model of psychological pressure based on the perspectives of service users.MethodsData were collected by means of semi-structured interviews. The sample consisted of 14 mental health service users with a self-reported psychiatric diagnosis and prior experience with coercion in mental healthcare. We used theoretical sampling and contacted participants via mental healthcare services and self-help groups to ensure a variety of attitudes toward the mental healthcare system in the sample. The study was conducted in Germany from October 2019 to January 2020. Data were analyzed according to grounded theory methodology.Results The study indicated that psychological pressure is used not only to improve service users’ adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties’ understanding of mental disorder.ConclusionsThe results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services.

The WPA programme on implementing alternatives to coercion

Abstract BodyThe call for alternatives to coercion in mental health care is growing both within the profession and among people with lived experience of coercion in mental healthcare. There is widespread agreement that coercive practices are over-used. Considerable work is warranted across the mental health sector and in communities and governments to ensure that people living with mental disorders and psychosocial disabilities uniformly have access to high-quality care and support that meet their needs and respect their personhood and human rights. The question of whether coercive interventions can ever be justified as part of mental health treatment, to protect rights holders’ own interests or on other grounds, is highly contested. WPA issued a Position Statement and Call to Action in 2020: Implementing Alternatives to Coercion: A Key Component of Improving Mental Health Care after extensive consultation and review. The purpose is (1) to recognize the substantive role of psychiatry in implementing alternatives to coercion in mental health care and (2) to support action in this regard, essential to improving mental health treatment and care in all countries. The Statement recognises the diversity of views and experiences among mental health professionals, people with lived experience and their families and carers. This initial step is the beginning of a longer-term process, which requires continued engagement with WPA member societies, people with lived experience, families and other partners to encourage and support the implementation of alternatives to coercion in mental health care. https://www.wpanet.org/alternatives-to-coercionDisclosureNo significant relationships.

Intégration des droits humains dans la pratique du personnel infirmier faisant usage de coercition en santé mentale : recension systématique des écrits et méta-ethnographie

Introduction and background : The last decade has seen a steady and rising use of coercion in mental health care, as well as an increase in the number of forms it takes. The application of these measures frequently relies on the work of nurses, but few studies have analyzed the human rights issues raised by these practices.Aim : To produce a qualitative synthesis of how human rights are integrated into the practice of nurses who use coercion in mental health care.Methodology : A systematic review of qualitative scientific literature published between 2008 and 2018 was conducted and supplemented by a meta-ethnographic analysis.Results : The analysis of the forty-six selected studies revealed four distinct themes : coercion in mental health care as a socio-legal object, issues of recognition of human rights in mental health care, role conflict experienced by nurses, and the conceptualization of coercion as a necessary evil or a critical incident.Discussion and conclusion : Further research is needed to understand the specifics of the continuum of support and control that characterizes the coercive work of psychiatric nurses.

Coercion in Mental Health Care – Position Statement of the World Association of Social Psychiatry

The World Association of Social Psychiatry working party on coercion in mental health care recently released a set of guiding principles and standards, developed from the research and collaboration of members alongside issues highlighted in the literature and raised by service user and human rights groups. These principles are set out below and are designed to be applicable in all countries.

Estranged relations: coercion and care in narratives of supported decision-making in mental healthcare

Supported decision-making has become popular among policymakers and mental health advocates as a means of reducing coercion in mental healthcare. Nevertheless, users of psychiatric services often seem equivocal about the...

Reducing coercion in mental healthcare.

To examine the extent and nature of coercive practices in mental healthcare and to consider the ethical, human rights challenges facing the current clinical practices in this area. We consider the epidemiology of coercion in mental health and appraise the efficacy of attempts to reduce coercion and make specific recommendations for making mental healthcare less coercive and more consensual. We identified references through searches of MEDLINE, EMBASE, PsycINFO and CINAHL Plus. Search was limited to articles published from January 1980 to May 2018. Searches were carried out using the terms mental health (admission or detain* or detention or coercion) and treatment (forcible or involuntary or seclusion or restraint). Articles published during this period were further identified through searches in the authors' personal files and Google Scholar. Articles resulting from searches and relevant references cited in those articles were reviewed. Articles and reviews of non-psychiatric population, children under 16 years, and those pertaining exclusively to people with dementia were excluded. Coercion in its various guises is embedded in mental healthcare. There is very little research in this area and the absence of systematic and routinely collected data is a major barrier to research as well as understanding the nature of coercion and attempts to address this problem. Examples of good practice in this area are limited and there is hardly any evidence pertaining to the generalisability or sustainability of individual programmes. Based on the review, we make specific recommendations to reduce coercive care. Our contention is that this will require more than legislative tinkering and will necessitate a fundamental change in the culture of psychiatry. In particular, we must ensure that clinical practice never compromises people's human rights. It is ethically, clinically and legally necessary to address the problem of coercion and make mental healthcare more consensual. All forms of coercive practices are inconsistent with human rights-based mental healthcare. This is global challenge that requires urgent action.

Rates of use of community treatment orders in Australia

ObjectivesThe variable and changing rates of use of involuntary community treatment orders (CTOs) in the treatment of people living with mental illness are not well-documented or well understood. This new study sought to determine contemporary rates of use in Australia, where local jurisdictions were previously shown to have varied and shifting rates of use that were high by world standards. MethodsAustralian state and territory mental health review tribunals, health departments, and/or offices of the chief psychiatrist were surveyed for the most recent published annual data on the total number of individual people placed on a CTO and/or the total number of CTOs made. FindingsContemporary rates of CTO use in Australia range from 40.0 per 100,000 population (in Western Australia) to 112.5 per 100,000 (in South Australia). Since the last national survey, the rates of people subject to CTOs fell into in two jurisdictions (Victoria and Western Australia). However, rates of CTOs made were higher than previous figures in all jurisdictions reporting data. Use of CTOs in Australia varies considerably within and between jurisdictions. ConclusionsAustralian jurisdictions continue to use CTOs at high and varying rates, despite unresolved questions about their role and impact. Transparency and accountability around their use would be improved by regular and nationally uniform public reporting of CTO data. Further research into how and why CTOs are used may also provide opportunities to respond to factors driving their use and thereby reduce the use of coercion in mental health care.

Family Members' Existential and Moral Dilemmas With Coercion in Mental Healthcare.

Coercion in mental healthcare does not only affect the patient, but also the patient's families. Using data from interviews with 36 family members of adult and adolescent people with mental health problems and coercion experiences, the present narrative study explores family members' existential and moral dilemmas regarding coercion and the factors influencing these dilemmas. Four major themes are identified: the ambiguity of coercion; struggling to stay connected and establishing collaboration; worries and distress regarding compulsory care; and dilemmas regarding initiating coercion. Subsequently, coercion can reduce, but also add burden for the family by creating strains on family relations, dilemmas, (moral) distress, and retrospective regrets; this is reinforced by the lack of information or involvement and low-quality care. Subsequently, it is a moral obligation to develop more responsive health services and professionals who provide more guidance and balanced information to increase the possibilities for voluntary alternatives and informed decision making.