|Year : 2020 | Volume
| Issue : 1 | Page : 43-45
Coercion in Mental Health Care – Position Statement of the World Association of Social Psychiatry
Andrew Molodynski1, Jorun Rugkåsa2, Yasser Khazaal3, Arnhild Lauveng4, Rachid Bennegadi5, Marianne Kastrup6, Fernando Lolas7, Roy Abraham Kallivayalil8
1 Department of Psychiatry, Oxford University, Oxford, England, UK
2 Health Services Research Unit, Akershus University Hospital, Nordbyhagen, Norway
3 Department of Addiction Medicine, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
4 National Centre for Knowledge through Experience in Mental Health, Norway
5 World Association of Social Psychiatry, Paris, France
6 National Centre for Transcultural Psychiatry, Copenhagen University Hospital, Copenhagen, Denmark
7 Department of Psychiatry, University of Chile, Santiago, Chile
8 Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, India
|Date of Submission||02-Aug-2019|
|Date of Decision||05-Nov-2019|
|Date of Acceptance||07-Nov-2019|
|Date of Web Publication||21-Mar-2020|
Dr. Andrew Molodynski
Warneford Hospital, Headington, Oxford, OX3 7JX, England
Source of Support: None, Conflict of Interest: None
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.
Keywords: Coercion, mental health care, position statement, World Association of Social Psychiatry
|How to cite this article:|
Molodynski A, Rugkåsa J, Khazaal Y, Lauveng A, Bennegadi R, Kastrup M, Lolas F, Kallivayalil RA. Coercion in Mental Health Care – Position Statement of the World Association of Social Psychiatry. World Soc Psychiatry 2020;2:43-5
|How to cite this URL:|
Molodynski A, Rugkåsa J, Khazaal Y, Lauveng A, Bennegadi R, Kastrup M, Lolas F, Kallivayalil RA. Coercion in Mental Health Care – Position Statement of the World Association of Social Psychiatry. World Soc Psychiatry [serial online] 2020 [cited 2020 Sep 23];2:43-5. Available from: http://www.worldsocpsychiatry.org/text.asp?2020/2/1/43/281132
| Introduction|| |
The World Association of Social Psychiatry (WASP) 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:
- All individuals in a community should have access to the most effective affordable mental health care that is available
- All individuals have the right to receive that care in the least restrictive manner possible
- Individuals have the right to determine their own needs and requirements for treatment as far as is possible
- Where treatment is compelled, this must be done proportionately, humanely, and in accordance with the relevant international conventions
- Countries must give mental health care parity with physical health care and allocate budgets and support accordingly
- High Income Group (HIG) countries must support those in need to develop and improve their mental health services as a global “civic duty.”
| Developments|| |
There is some consensus in the international literature and from the experience of those using and providing services that there are several key specific issues that require action on a global scale. Unsurprisingly, these issues affect us all but differ significantly between countries according to culture, history, and economy.
The increasing use and coverage of legal compulsion
The fact that more countries than ever have legislation scrutinizing and regulating coercive practices is undoubtedly welcome and in time will hopefully provide protection against some of the excesses that exist. As part of this legislative spread, however, there has been an increase both in the powers to compel treatment and in the population who may be subject to them. This is particularly an issue in HIG countries. The clearest example of this is the increasing use of so-called Community Treatment Orders. These are now available in over 75 jurisdictions internationally and continue to be adopted, despite there being no evidence for their effectiveness. Three randomized trials,, and a Cochrane review have failed to demonstrate patient benefit, yet they continue to be introduced and are often enthusiastically embraced by clinicians where available. Inpatient involuntary care is also on the increase and characterized by the increasing use of restrictive measures and locked environments in many countries compared to 20 years ago, with no evidence that this reduces the risk or improves the lives of those subjected to them.
The difference between ratification of key international agreements and practical change
Several key international conventions have been ratified by the majority of countries. Perhaps the highest profile of these recently is the UN Convention on the Rights of Persons with Disabilities. This has been ratified by 174 countries worldwide but in many of those countries, few, (if any), practical steps have been taken to implement any of the key principles, and the experience of people with mental health problems has not changed at all., This includes many HIG countries such as the United Kingdom.
The lack of evidence
The overwhelming majority of research into coercion in mental health care, as with most areas of health research, has been conducted in a relatively small group of countries that generally have several characteristics in common: Wealth, managed societies, well-developed health-care systems, and cultures that prioritize the rights of the individual rather than those of the collective. In any branch of scientific inquiry, this would be problematic, but the nature and extent of coercion is so fundamentally influenced by cultural traditions and economy that it renders most of the research utterly irrelevant for the majority of the population. For example, expensive randomized controlled trials of community compulsion are without meaning across whole continents where community services simply do not exist. There are welcome signs of the evidence base beginning to broaden however.
Stigma associated with mental distress generally and coercive treatment, in particular remains a prime concern internationally, and no country or region can say it has successfully eradicated it. Stigma affects an individual's likelihood of presenting for treatment and may lead to longer and more traumatic pathways to care. This in itself can be self-stigmatizing and can contribute to poorer outcomes. On a wider level, stigma can lead to disproportionately small resource allocations to mental health services and a lack of parity of esteem. Currently, there does not appear to be any country that allocates a proportion of resource to mental health care that reflects health use and the overall burden of such conditions. In some countries, it is inappropriately low, such as several in Africa.
Economy and the absence of care
While increasingly developed and assertive services backed by legislation can be experienced as coercive (though the majority view them as supportive and welcome), it is the absence of care which removes choice and is thus most coercive. This, in some countries, may be absolute with no organized mental health or social care on offer. This completely removes the individual's choice to accept treatment and can often then lead to significant “secondary” coercion from families and communities. This is generally borne out of love and a desire to look after a relative who is manifestly unwell and at risk. It often though leads to practices such as tying, shackling, or incarcerating out of desperation in a situation where the chance of improvement is either absent or severely limited.
| Conclusion|| |
In addition to the principles set out above, there is a clear need to support research into coercion in regions of the world outside the traditional “western” HIG countries where most has up to now been generated, as this is irrelevant for much of the world's population and regions where there is most suffering.
The widespread and increasing use of coercion is a stain upon our communities and represents an individual tragedy for those involved. On a global scale, it represents an enormous amount of wasted human potential. The major international mental health organizations such as WASP strongly support the reduction of coercion and the adoption of the aims above as one of the means to do so.
WASP Section on Coercion and WASP Executive Committee, Oxford, July 2019.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Swartz MS, Swanson JW, Wagner HR, Burns BJ, Hiday VA, Borum R, et al.
Can involuntary outpatient commitment reduce hospital recidivism? Findings from a randomized trial with severely mentally ill individuals. Am J Psychiatry 1999;156:1968-75.
Steadman HJ, Gounis K, Dennis D, Hopper K, Roche B, Swartz M, et al.
Assessing the New York City involuntary outpatient commitment pilot program. Psychiatr Serv 2001;52:330-6.
Burns T, Rugkåsa J, Molodynski A, Dawson J, Yeeles K, Vazquez-Montes M, et al.
Community treatment orders for patients with psychosis (OCTET): A randomised controlled trial. Lancet 2013;381:1627-33.
Kisely SR, Campbell LA, O'Reilly R. Compulsory community and involuntary outpatient treatment for people with severe mental disorders. Cochrane Database Syst Rev 2017;3:CD004408.
Huber CG, Schneeberger AR, Kowalinski E, Fröhlich D, von Felten S, Walter M, et al.
Suicide risk and absconding in psychiatric hospitals with and without open door policies: A 15 year, observational study. Lancet Psychiatry 2016;3:842-9.
Turnpenny A, Petri G, Finn A, Beadle-Brown J, Nyman M. Mapping and Understanding Exclusion: Institutional, Coercive and Community-Based Services and Practices across Europe. Brussels: Mental Health Europe; 2017.
Szmukler G. Compulsion and “coercion” in mental health care. World Psychiatry 2015;14:259-61.
Molodynski A, Rugkåsa J, Burns T, editors. Coercion in Community Mental Health Care- International Perspectives. Oxford, United Kingdom: Oxford University Press; 2016.
Raveesh BN, Pathare S, Lepping P, Noorthoorn EO, Gowda GS, Bunders-Aelen JG, et al.
Perceived coercion in persons with mental disorder in India: A cross-sectional study. Indian J Psychiatry 2016;58:S210-20.
Alem A, Manning C. Coercion in community mental health care: African perspectives. In: Molodynski A, Rugkåsa J, Burns T, editors. Coercion in Community Mental Health Care- International Perspectives. Oxford, United Kingdom: Oxford University Press; 2016.