Coercive Treatment Research Articles

Adaptación lingüística y conceptual al español de la Escala de experiencia de coerción

IntroductionIssues surrounding coercive measures are an area of concern among mental health clinicians. Their use tends to be seen as unavoidable in the acute patient management in order to prevent harm to the patient or others. They should be used with caution, and only as a last resort. The lack of scientific literature about the effects of coercive interventions is limited, especially regarding patient perceptions. The “Coercion Experience Scale” (CES) is pioneer in the evaluation of the subjective experience of coercive measures. MethodLinguistic and conceptual adaptation process into Spanish of the CES, using translation-back-translation methodology, with semantic and conceptual equivalence rating. ResultsAll items of the final version received a type A (perfect) or B (satisfactory) equivalence assessment. Discussion/conclusionsThe adapted version has good parity with the original version, guaranteeing proper measurement in samples of Spanish-speaking populations.

Recovery-based services in a psychiatric intensive care unit - the consumer perspective.

To describe the implementation of recovery-based practice into a psychiatric intensive care unit, and report change in seclusion rates over the period when these changes were introduced (2011-2013). Recovery-based practices including collaborative care, safety care plans, a comfort room, and debriefing after coercive interventions were introduced. A carer consultant was employed. A restraint and seclusion review committee, chaired by a peer worker, was established. A consumer exit interview was introduced and these data were collected, reviewed by staff and the peer worker and used to improve the ward environment. Rates of seclusion were measured during the period when recovery-based practices were introduced. Consumer feedback indicated that positive aspects of the psychiatric intensive care unit included approachable, helpful staff and completion of a safety care plan. Negative aspects included lack of involvement in decisions about admission and about medications, the non-smoking policy, and being placed in seclusion or restraint. There was a significant reduction in the number of consumers secluded and the total number of seclusions. Recovery principles can be successfully introduced in a psychiatric intensive care unit environment. Introduction of recovery based practice was associated with a reduction in seclusion.

Obstetric Autonomy and Informed Consent

I argue that public officials and health workers ought to respect and protect women’s rights to make risky choices during childbirth. Women’s rights to make treatment decisions ought to be respected even if their decisions expose their unborn children to unnecessary risks, and even if it is wrong to put unborn children at risk. I first defend a presumption of medical autonomy in the context of childbirth. I then draw on women’s birth stories to show that women’s medical autonomy is often ignored during labor. Medical interventions are performed during childbirth without women’s consent. Childbirth is risky and some coercive medical interventions may be understood as attempts to protect children and to prevent mothers from acting impermissibly. However, even if it is wrong to make risky choices during childbirth, women have rights to do wrong in these cases. Therefore, coercive medical interventions are impermissible during childbirth and institutions should adopt specific protections for obstetric autonomy.

Should Supported Decision-Making Replace Substituted Decision-Making? The Convention on the Rights of Persons with Disabilities and Coercive Treatment under Queensland’s Mental Health Act 2000

In 2013, and again in 2014, the UN Committee on the Rights of Persons with Disabilities (CRPD) has recommended that Australia abolish its existing mental health laws which authorise involuntary treatment and detention, and replace them with a regime of supported decision-making. The Australian Law Reform Commission has also recommended the introduction of supported decision-making to replace mental health and guardianship laws. This paper critically evaluates the concepts of autonomy and discrimination and the social model of disability which provide the theoretical underpinning of the CRPD. Focussing on coercive treatment of adults with severe mental illness under Queensland’s Mental Health Act 2000, it then evaluates the advantages and disadvantages of supported decision-making, and concludes that the proposed abolition of involuntary treatment laws is not justified.

Managing and caring for distressed and disturbed service users: the thoughts and feelings experienced by a sample of English mental health nurses.

This paper reports the thoughts and feelings experienced by registered mental health nurses caring for distressed and/or disturbed service users in acute inpatient psychiatric settings in England. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; prevailing feelings experienced by nurses were fear, anxiety and vulnerability. To enhance care quality, nurses expressed the need for better communication with service users, and preventing the use of coercive measures and promotion of alternative methods of care and management. The nurses considered that debriefing dialogues following untoward incidents, practice development initiatives, education and training together with clinical supervision could be the way forward. The paper builds on the existing literature in offering clear explanations of nurses' thoughts and feelings when caring for distressed and/or disturbed service users in an English acute, inpatient psychiatric setting. Despite the small sample size and the limitations that it generates, the study findings will be of interest to the wider mental health nursing community. The findings will link to other national and international studies and therefore be valuable for future research studies of this kind. Collectively, they are building up a general picture of the distress, cognitive and emotional dissonance experienced by mental health nurses when using coercive interventions. The findings will help to develop mental health nurse education and enhance practice. High levels of distress and disturbance among service users experiencing acute mental illness is a major problem for mental health nurses (MHNs). The thoughts and feelings experienced by these nurses when caring for service users are of paramount importance as they influence clinical practice and caregiving. Similarly to research by other countries, this paper reports national, qualitative data regarding the thoughts and feelings of English MHNs who care for these service users within acute inpatient psychiatric settings. Data were collected from focus groups in which MHNs working in acute inpatient settings in England participated and analysed using inductive content analysis. Findings highlighted three broad themes: (1) emotional and cognitive dissonance; (2) therapeutic engagement; and (3) organizational management and support. The prevailing thoughts of nurses were of cognitive dissonance and the conflict between benevolence and malevolence if coercive measures were seen as negative rather than positive; the prevailing feelings experienced by nurses were fear, anxiety and vulnerability. Nurses would like better communication with service users, prevention of coercive measures and the use of alternative methods of care and/or management to ensure enhanced care. Participants considered practice development initiatives, education, training, staff and managerial support including debriefing and clinical supervision as the way forward. Despite the small sample size and its limitations, these national data add to the existing literature, and the study findings link to those of other studies both nationally and internationally. Collectively, these studies are building up a general picture of the distress, cognitive and emotional dissonance experienced by MHNs when using coercive interventions. The findings will help to develop MHN education and enhance practice.

Subjective experience of coercion in psychiatric care: a study comparing the attitudes of patients and healthy volunteers towards coercive methods and their justification

Under certain conditions, coercive interventions in psychotic patients can help to regain insight and alleviate symptoms, but can also traumatize subjects. This study explored attitudes towards psychiatric coercive interventions in healthy individuals and persons suffering from schizophrenia, schizoaffective or bipolar disorder. The impact of personal history of coercive treatment on preferences concerning clinical management of patients unable to consent was investigated. Six case vignettes depicting scenarios of ethical dilemmas and demanding decisions in favour of or against coercive interventions were presented to 60 healthy volunteers and 90 patients. Structured interviews focusing on experienced coercion were performed in conjunction with the Coercion Experience Scale and the Admission Experience Survey. Symptom severity, psychosocial functioning and insight into illness were assessed as influencing variables. Student's t tests compared patients' and controls' judgments, followed by regression analyses to define the predictive value of symptoms and measures of coercion on judgments regarding the total patient sample and patients with experience of fixation. Patients and non-psychiatric controls showed no significant difference in their attitudes towards involuntary admission and forced medication. Conversely, patients more than controls significantly disapproved of mechanical restraint. Subjective experience of coercive interventions played an important role for the justification of treatment against an individual's "natural will". Factors influencing judgments on coercion were overall functioning and personal experience of treatment effectiveness and fairness. Qualitative and quantitative aspects of perceived coercion, in addition to insight into illness, predicted judgments of previously fixated patients. Results underline the importance of the quality of practical implementation and care, if coercive interventions cannot be avoided.

Parental Perceptions of the Use of Coercive Measures on Children with Developmental Disabilities.

Children with developmental disabilities who exhibit challenging behaviour are potentially subject to the use of coercive interventions. The aim of the study was to investigate the prevalence of the use of coercive measures by authorities, according to parents' reports. A postal survey was distributed, as a total population study, to 946 Finnish parents of children with developmental disabilities, between the ages of 5 and 15, and who were entitled to the highest disability allowance. Of the respondents, 54 (22%) answered 'yes' when asked whether their child had been subjected to coercive procedures by authorities. The parents had seldom approved the use of coercive means and often believed that such means had negative effects on their child. To protect the children's rights, the use of coercive measures should be regulated more strictly, and positive intervention strategies should be taught to teachers and nurses.

Legal Briefing: Coerced Treatment and Involuntary Confinement for Contagious Disease

This issue's "Legal Briefing" column covers recent legal developments involving coerced treatment and involuntary confinement for contagious disease. Recent high profile court cases involving measles, tuberculosis, human immunodeficiency virus, and especially Ebola, have thrust this topic back into the bioethics and public spotlights. This has reignited debates over how best to balance individual liberty and public health. For example, the Presidential Commission for the Study of Bioethical Issues has officially requested public comments, held open hearings, and published a 90-page report on "ethical considerations and implications" raised by "U.S. public policies that restrict association or movement (such as quarantine)." Broadly related articles have been published in previous issues of The Journal of Clinical Ethics. We categorize recent legal developments on coerced treatment and involuntary confinement into the following six categories: 1. Most Public Health Confinement Is Voluntary 2. Legal Requirements for Involuntary Confinement 3. New State Laws Authorizing Involuntary Confinement 4. Quarantine Must Be as Least Restrictive as Necessary 5. Isolation Is Justified Only as a Last Resort 6. Coerced Treatment after Persistent Noncompliance.

Treatment Goal: Recovery

Beyond symptom remission, recovery aims at inclusion and social participation of psychiatric patients irrespective of remaining symptoms and disabilities. It thus places a focus on the patients’ individual resources and creativity, which enable them to participate in society. It also places a strong focus on social exclusion and stigmatization, may they result from passive avoidance or active exclusion of subjects with mental disorders. As such, fighting stigma includes a reflection on the role of psychiatry as a health care institution and its everyday practices. We discuss a person-centred approach in psychiatry that aims at inclusion in the life world and community and discuss several steps that facilitate recovery: reduction of coercive treatment by opening the doors of acute wards, rehabilitation via job placement, empowerment in advocacy groups as well as in the supervision of public health policy, hospital settings and treatment, and direct participation of experienced uses in therapeutic teams. With increasing globalization, we also emphasize the necessary intercultural openness of mental health care institutions and the participation of migrants both in devising health care settings as well in therapeutic teams.

Involuntary admission: The case of anorexia nervosa

Involuntary treatment of psychiatric disorders has always been controversial; this is especially true for eating disorders. Patients with anorexia nervosa of life threatening severity frequently refuse psychiatric hospitalization. Ambivalence toward treatment is characteristic of eating disorders and patients are often admitted to inpatient programs under pressure from family and doctors. In this article, we report research on the positive or negative impact of involuntary admission in the treatment of eating disorders, its application and effectiveness as well as the adverse consequences of coercive treatment in eating disorders.A literature review was done. From a total of 134 publications which were retrieved from the literature search, 50 studies were directly relevant to the scope of this review and fulfilled all inclusion criteria.There are trends and arguments for both sides; for and against involuntary treatment in anorexia nervosa. The scientific literature so far is inconclusive, although in the short term, involuntary hospitalization has benefits. This review has also shown that involuntary hospitalization can have adverse long-term consequences for the patient–therapist allegiance.We conclude that in some cases, involuntary treatment can save lives of young patients with anorexia nervosa; however, in other cases, it can break the psychotherapeutic relationship and make the patient abandon treatment. It is the clinician who has to decide for whom and when to approve involuntary treatment or not.

Mental health disabilities and human rights protections.

Around the world, reports regularly expose persistent and systemic human rights violations of patients in mental health services and facilities, and of those who are unable to access needed supports. A number of factors contribute - political will; the range and quality of services available; public and professional attitudes to mental health; stigma; health professionals' training and expertise; and available resources. This paper examines one of the main determinants, the legal framework. This sets the parameters for mental health policies and services and for applicable human rights norms and standards that can be realized in practice. We provide an overview of international human rights instruments in relation to mental health disabilities, and of the major human rights violations in this area. Key implications for mental health law reform are drawn with a particular focus on discrimination and coercive interventions. The major challenges posed by the UN Convention on the Rights of Persons with Disabilities (2006) are examined. Current mental health laws, to greater or lesser degrees, fail to meet the newly required standards. We discuss reforms based on 'generic law' and 'legal capacity' principles that seek to meet those standards. We outline some emergent and promising examples of reform. The role of civil society and the importance of the standing of those with mental health disabilities in this process is noted.

Migratory Phenomenons, Bioethics and Vaccinations

The evolution of the HIV following migratory phenomenons is reported in an interesting study carried on for 15 years. Polymerase Chain Reaction (PCR) is a technique in molecular biology that amplifies a specific region of deoxyribonucleic acid (DNA), and has been useful in the molecular characterization of viruses as poxviruses. In many countries, such as Italy,the vaccinations are included in the so-called sanitary obliged not coercive treatments. This means that the obligation is anticipated for all the subjects belonging to one determined range of age to undergo some vaccinations, but these are not subministrated by force in case of refusal. The legitimacy of the obligatory vaccination against the smallpox, with all the risks connected, stated that such “risks were too much reduced to be seriously taken in consideration for the benefits produced on the collectivity”. To ratify this obligation brings, however, to the reimbursement of the incidental damages produced by the vaccination. Nevertheless, mass vaccination against smallpox continues to be a leading initiative in western countries to guard against bioterrorist attack.

Modalités et enjeux du traitement sous contrainte auprès des toxicomanes

This article is exploring different forms of constraint that are exerted in the field of drug addiction treatment. The objective of this article is to establish benchmarks and to stimulate reflection about the ethical and clinical implications of those constraints in the field of drug addiction treatment. This article is presenting a critical review of different forms of constraint that can be exerted in Canada in regard to the treatment of drug addiction. In the first section of the article, a definition of therapeutic intervention is proposed, that includes the dimension of power, which justifies the importance of considering the coercive aspects of treatment. The second section, which represents the core section of the paper, is devoted to the presentation of different levels of constraint that can be distinguished in regard to drug addicts who are under treatment. Three levels of constraint are exposed: judicial constraint, institutional constraint and relational constraint. The coercive aspect of treatment can then be recognized as a combination of all tree levels of constraint. Judicial constraint refers to any form of constraint in which the court or the judge is imposing or recommending treatment. This particular level of constraint can take different forms, such as therapeutic remands, conditions of a probation order, conditions of a conditional sentence of imprisonment, and coercive treatment such as the ones provided through drug courts. Institutional constraint refers to any form of constraint exerted within any institutional setting, such as correctional facilities and programs offered in community. Correctional facilities being limited by their own specific mission, it might have a major impact on the way the objectives of treatment are defined. Those limitations can then be considered as a form of constraint, in which drug users don't have much space to express their personal needs. Finally, relational constraint refers to any form of constraint in which the drug addict might be coerced to treatment under the pressure of people from the immediate environment, such as members of family, friends or employers. Even if this form of constraint is not as obvious as the ones exerted by court and correctional facilities, it has to be considered by practitioners who are evaluating the motivation of drug addicts under treatment. Considering the diversity of constraints that are exerted on drug addicts who are under treatment, it appears that we should be always aware of the ethical and clinical challenges facing practitioners every day. The recognition of those constraints can also help to understand how important it is to consider the institutional and social context in which treatment is being provided.

How is acceptance of the brain disease model of addiction related to Australians’ attitudes towards addicted individuals and treatments for addiction?

BackgroundWe investigated whether beliefs about addiction being a ‘disease’ or ‘brain disease’, and holding certain beliefs about addiction aetiology, are associated with public views about addicted persons and support for different types of treatment, coerced treatment and punishment for addiction.MethodsData were collected as part of the 2012 Queensland Social Survey, a computer assisted telephone interview of 1263 residents of Queensland, Australia. Participants were presented with scenarios of two addicted males, one who was addicted to heroin and the other addicted to alcohol. Participants were then asked a series of questions for both characters.ResultsThere was widespread support for all treatment modalities (alcohol: 80.8-98.0%, heroin: 89.9-97.2%). There was less support for coerced treatment for alcohol than heroin addiction (alcohol: 41%, heroin: 71%, χ2 = 273.90, p < 0.001). Being 35 years of age or older (alcohol: OR = 0.58 (0.37-0.91), heroin: OR = 0.49 (0.28-0.85)) and having 15 or more years of education (alcohol: OR = 0.60 (0.44-0.81), heroin: 0.55 (0.40-0.75)) predicted less support for coerced treatment. 31.7% of respondents agreed heroin use should be punished by imprisonment and being 35 years of age or older (OR = 0.51 (0.33-0.80)) predicted lack of support. The sample agreed that an alcohol or heroin dependent person would suffer career damage (alcohol: 96.2%, heroin: 98.9%), marriage breakdown (alcohol: 92.2%, heroin: 97.3%) and get in trouble with the law (alcohol: 92.3%, heroin: 98.9%). Respondents expressed more comfort with encountering alcohol rather than heroin addicted persons in the workplace or at a dinner party. Beliefs that addiction was a ‘brain disease’ or a ‘disease’ did not predict any of these attitudes. Beliefs about addiction aetiology were inconsistent predictors of outcomes measured.ConclusionsAge and educational attainment were the most consistent predictors of stigmatising beliefs and beliefs about coercion and punishment. Beliefs that addiction is a ‘disease’ or a ‘brain disease’ were not associated with an overall reduction in beliefs about stigma, coercion or punishment. Beliefs in different causes of addiction were not consistent predictors of beliefs about stigma, coercion or punishment.

Interpretations of legal criteria for involuntary psychiatric admission: a qualitative analysis

BackgroundThe use of involuntary admission in psychiatry may be necessary to enable treatment and prevent harm, yet remains controversial. Mental health laws in high-income countries typically permit coercive treatment of persons with mental disorders to restore health or prevent future harm. Criteria intended to regulate practice leave scope for discretion. The values and beliefs of staff may become a determinating factor for decisions. Previous research has only to a limited degree addressed how legal criteria for involuntary psychiatric admission are interpreted by clinical decision-makers. We examined clinicians’ interpretations of criteria for involuntary admission under the Norwegian Mental Health Care Act. This act applies a status approach, whereby involuntary admission can be used at the presence of mental disorder and need for treatment or perceived risk to the patient or others. Further, best interest assessments carry a large justificatory burden and open for a range of extra-legislative factors to be considered.MethodsDeductive thematic analysis was used. Three ideal types of attitudes-to-coercion were developed, denoted paternalistic, deliberative and interpretive. Semi-structured, in-depth interviews with 10 Norwegian clinicians with experience from admissions to psychiatric care were carried out. Data was fit into the preconceived analytical frame. We hypothesised that the data would mirror the recent shift from paternalism towards a more human rights focused approach in modern mental health care.ResultsThe paternalistic perspective was, however, clearly expressed in the data. Involuntary admission was considered to be in the patient’s best interest, and patients suffering from serious mental disorder were assumed to lack decision-making capacity. In addition to assessment of need, outcome effectiveness and risk of harm, extra-legislative factors such as patients’ functioning, experience, resistance, networks, and follow-up options were told to influence decisions. Variation in how these multiple factors were taken into consideration was found. Some of the participants’ statements could be attributed to the deliberative perspective, most of which concerned participants’ beliefs about an ideal decision-making situation.ConclusionsOur data suggest how a deliberative-oriented ideal of reasoning about legal criteria for involuntary admission lapses into paternalism in clinical decision-making. Supplementary professional guidelines should be developed.

Moral case deliberation about coercion in psychiatry. Dilemmas, value and implementation

To identify moral dilemmas regarding coercion and restraint among professionals working at a psychiatric ward, to get insight in the value of Moral Case Deliberation meetings about these dilemmas, and in the implementation of such meetings. Qualitative explorative study with interviews, focus group and participant observation. Professionals experience dilemmas related to closing the ward (freedom versus safety), coercive treatment (freedom versus health), and camera surveillance (privacy versus safety). The introduction of Moral Case Deliberation contributes to changes concerning quality of treatment, professionalism of healthcare providers, and cooperation in the treatment team. The implementation of Moral Case Deliberation depends on an atmosphere of trust, expertise of the facilitator, and active involvement of a local coordinator. Bottlenecks for implementation include the availability of physicians, time-pressure and intervals between meetings. Moral Case Deliberation fosters quality of treatment and moral competence of professionals in dealing with ethical dilemmas in psychiatric practice. Continuity of Moral Case Deliberation meetings motivates the participants and provides the opportunity to learn and practice ethical skills.

The Swedish Drug Problem: Conceptual understanding and Problem Handling, 1839-2011

Aim To analyse the Swedish drug question by examining dominant concepts used to portray the problem in the years 1839-2011. Theoretically, we understand these concepts as ideological tools that shape the political initiatives and administrative efforts to deal with the problem. The study is based on two kinds of source material: articles in medical journals from the years 1839-1964 and public reports on vagrancy, the alcohol problem, mental health and the drug problem from the years 1882-2011. Findings During the nineteenth century and the first part of the twentieth century the drug problem remained an individual problem handled by doctors. When the Swedish drug problem was established as a political question from the 1960s on, it also came to disengage itself from the medical frame of understanding. Medically oriented descriptions of “dependence” and “addiction” have appeared adequate or attractive when, for example, the socially motivated coercive treatment solution has been discredited (as in the 1970s), when there has been a desire to connect with an internationally accepted terminology (as in the 1990s) or when a new organisational model with a stronger professional support has been on the agenda (as in the 2010s). But otherwise the social problem description has called for concepts that have more or less explicitly dissociated themselves from speculations in physiological or psychological predispositions for substance abuse.

P.1.k.009 Epidemiology of involuntary hospitalization of schizophrenic patients attended at home

Introduction: The involuntary placement and involuntary treatment of mentally ill patients are central issues in mental health care. Their massive impact upon the liberty and freedom of the persons concerned have made them a topic of controversial legal and ethical debates for more than 100 years. Coercive treatment in psychiatry, including the admission to a psychiatric hospital, remains an understudied issue [1]. The only replicated finding in this highly sensitive area is the significant cross-national variation concerning aspects such as provisions in mental health legislations and rates of involuntary admissions to psychiatric hospitals [2]. Objectives: The purpose of this study is to examine the impact of clinical and contextual characteristics on the decision to perform compulsory admission in psychiatric units in patients with diagnostic of schizophrenia who were attended and treated by a mobile home-care unit in the area of Barcelona (Multidisciplinary Team Support Specialist, EMSE in its Spanish acronym). Methods: We performed a cross-sectional retrospective study of the medical records of 362 patients with diagnosis of schizophrenia according to DSM-IV criteria who were attended at home by a mobile home-care unit in Barcelona. We collected the following data; age, number of visits done by EMSE at home, presence of violent behavior (evaluated with AVAT scale), awareness of disease (evaluated with SUMD scale), functionality of the patient (evaluated with WHO scale), global severity of disease (evaluated with GEP scale), clinical impression (evaluated with CGI scale), score in GAF scale, score in Positive PANSS scale, score in Negative PANSS scale and score in General PANSS scale. The sample was divided in two groups according to if patients were compulsory hospitalized or not. Results: We found more aggressiveness in the group of patients in which we decide to do compulsory hospitalization (mean AVAT score 4.87 Vs 2.99, p = 0.033). We also observed in patients compulsorily admitted to hospital worse awareness of disease (mean SUMD score 12.9 Vs 10.6, p = 0.008), major global severity of disease (mean GEP score 16.55 Vs 12.51, p = 0.047), worse clinical impression (mean CGI score 5.34 Vs 4.41, p< 0.001) and lower score in GAF scale (30.63 Vs 43.36, p< 0.001). Regarding to psychopathology we found higher score in positive PANSS scale in patients compulsorily admitted (29.44 Vs 22.54, p = 0.002), but we haven’t found statistically significant differences in negative PANSS score nor general PANSS score. Conclusions: As previously seen in the literature [3], in our study we observed that the decision to perform an involuntary admission is related with a worse awareness of disease, lower score at GAF scale and more aggressiveness in schizophrenic patients. In our sample we also observed that the decision to perform an involuntary admission is related with major severity of disease, a worse clinical impression and with higher positive psychotic symptoms.

The use of coercive interventions in mental health care in Germany and the Netherlands. A comparison of the developments in two neighboring countries.

In this review, we compare the use of coercion in mental health care in Germany and in the Netherlands. Legal frameworks and published data on involuntary commitment, involuntary medication, seclusion, and restraint are highlighted as well as the role of guidelines, training, and attitudes held by psychiatrists and the public. Legal procedures regulating involuntary admission and commitment are rather similar, and so is the percentage of involuntary admissions and the rate per 100,000 inhabitants. However, opposing trends can be observed in the use of coercive interventions during treatment, which in both countries are considered as a last resort after all other alternative approaches have failed. In the Netherlands, for a long time seclusion has been considered as preferred intervention while the use of medication by force was widely disapproved as being unnecessarily invasive. However, after increasing evidence showed that number and duration of seclusions as well as the number of aggressive incidents per admission were considerably higher than in other European countries, attitudes changed within recent years. A national program with spending of 15 million € was launched to reduce the use of seclusion, while the use of medication was facilitated. A legislation is scheduled, which will allow also outpatient coercive treatment. In Germany, the latter was never legalized. While coercive treatment in Germany was rather common for involuntarily committed patients and mechanical restraint was preferred to seclusion in most hospital as a containment measure, the decisions of the Constitutional Court in 2011 had a high impact on legislation, attitudes, and clinical practice. Though since 2013 coercive medication is approvable again under strict conditions, it is now widely perceived as very invasive and last resort. There is evidence that this change of attitudes lead to a considerable increase of the use of seclusion and restraint for some patients.

Developing a capacity test for compulsion in mental health law

&lt;p&gt;Concepts of mental capacity are taking on an increased importance in the mental health law of the United Kingdom. For England and Wales, the proposal to introduce a threshold requirement of ‘impaired decision-making’ into the criteria for detention under sections 2 and 3 of the Mental Health Act 1983 was the first amendment to be voted upon in the House of Lords’ reading of the Mental Health Bill. Despite its emphatic (and whipped) resistance to this amendment, Government lost the vote by a wide margin, although it seems possible, at the time of writing, that the Government will seek to overturn their defeat in the Commons.&lt;/p&gt;&lt;p&gt;It is therefore timely to re-examine the role of such capacity tests in mental health legislation dealing with detention and treatment. This paper describes as yet unresolved definitional questions that must be encountered when concepts of mental capacity operate as a threshold for coercive psychiatric detention and/or treatment.&lt;/p&gt;