Toward a System Based on Support Only
Several UN bodies, including the High Commissioner for Human Rights, have pushed for a complete ban on all forceful interventions in mental health care based on the UN Convention on the Rights of Persons with Disabilities (CRPD) (United Nations 2013, 2014, 2017a, 2017b, 2018b). The Committee on the Rights of Persons with Disabilities called for states to “abolish policies and legislative provisions that allow or perpetrate forced treatment” (United Nations 2014), arguing that it is an “ongoing violation found in mental health laws across the globe, despite empirical evidence indicating its lack of effectiveness and the views of people using mental health systems who have experienced deep pain and trauma as a result of forced treatment.”
In its General Comment No. 1, the UN Committee on the Rights of Persons with Disabilities infers a prohibition on all types of substituted decision-making from Article 12 of the Convention (Equal recognition before the law). Traditionally, healthcare providers, legal guardians, or family members are involved in substituted decision-making. Persons with disabilities should now be assisted in making their own decisions to the extent that they choose to be supported (United Nations 2014)[1].
Denial of legal ability to persons with disabilities and their detention in institutions against their will, either without their agreement or with the consent of a substitute decision-maker, is seen as an ongoing problem by the Committee. “This conduct amounts to unjust coercion and is in violation of the Convention’s paragraphs 12 and 14. States parties must cease from such practises and create a mechanism to investigate incidents in which people with disabilities have been placed in a residential environment without their express agreement.”
Forms of coercion and restraint
Coercion and restraint in mental health practice has a long and frankly dark, history, restraint can involve:
- Physical restraint: manually holding a person to prevent or restrict movement.
- Mechanical restraint: the use of devices such as straps belts cage, beds etc to prevent it subdues movement
- Chemical or pharmacological restraint: the use of sedatives drugs to control or subdues behaviour.
- Seclusion: confinement in a room or elected area from which a person cannot freely exit.
This can be done through threatening consequences for non-compliance such as forceable readmission to the hospital or any other way of disregarding the expressed wishes of the person receiving treatment.
A recent discussion of a shift in mental health treatment away from coercion and toward a system based only on support as a possible scenario for the future of mental health care, with an emphasis on service users playing a major role in service design, development, and delivery. While there was no further indication of what such services would look like or what they would do, this scenario serves as the foundation for our paper: rather than discussing the rationale for or against coercion in mental health care, this paper will outline what coercion-free mental health care could look like and how mental health services might interact with other agents in specific situations.
The basic principles of a psychosocial support system that follows this interpretation of the Convention are solidarity and respect for self-determination. Solidarity means support from informal and institutional parts of society that aims for full participation in society. Depending on the extent of the disability, this may be informal support and counselling in minor impairments or wide-ranging and intensive support in severe impairments. Respect for self-determination involves the freedom of choice in the uptake of support, irrespective of the type or extent of the disability. Offering certain kinds of institutional care (supported housing, social firms, hospital care) will not suffice in this new system of assistance since many persons with psychosocial disabilities find existing types of assistance ineffective or unsuitable for their requirements. The goal will be to create assistance methods that are useful and successful for as many service users as possible.
The preferences of those service users who have rejected traditional mental health care and become victims of coercive care such as imprisonment in mental health facilities, isolation, constraint, and coercive treatment are particularly important. The system’s capacity to meet these people’s expectations will determine how effective their aid is. A person with a psychosocial handicap may refuse to be diagnosed with a specific psychiatric diagnosis or may completely reject the idea of mental illness. Even Nevertheless, in a moment of despair and homelessness, this person would not forego societal solidarity and support. The support team will then talk with the person about what type of help they can provide.
Any form of assistance will be reliant on the individual’s willingness to accept a specific intervention. Even if the person declines the provided assistance, mental health and social services cannot abandon their responsibility to assist them; instead, they must seek other assistance. This may necessitate new kinds of communication to elicit will and preferences, as well as more personalised support.
Alternative use of coercion and restraint
In 2017, Mental Health Europe (MHE) took a stand on Article 12 of the United Nations Convention on the Rights of Persons with Disabilities (UN CRPD), supporting the transition of all mental health services and legislation to completely consensual practises free of coercion and decision-making by proxy. After two years, a report on promising approaches in the prevention, reduction, and eradication of coercion in Europe is published[2].
- ITALY used Psychiatric units of general hospitals SPDCs (Servizi Psichiatrici di Diagnosi e Cura)
- FINLAND used Open Dialogue to Acute Psychosis
- United Kingdom used The NO Force First Initiative.[3]
Need for reducing or eliminating coercion and restraint
The use of coercion and restraint is embedded within the culture and procedures of mental health and community services. However, it does not go unchallenged. In 2019, the former UN special rapporteur on the right to physical and mental health made the grounds breaking proposal of a rights first approach to counter the increasing reliance on forced treatment worldwide.
Actions will include:
- Focus on service users
- Build capacity of staff & public officials
- Improve communication with users
- Physical environment matters
- Ensure interagency collaboration
- Monitor the use of coercion
Police Custody and Mental Illness
Most jurisdictions enable the authorities to take someone from a public area to a mental facility without their consent. Because the removal is based on the presumption of mental illness, this practice discriminates against people who are suspected of having a mental disease. As a result, the law treats people who are suspected of having a mental condition differently from other people. The person must see a doctor or another mental health professional in the community or at a hospital if they are suspected of having a mental illness. The conclusion of the evaluation could result in a hospital stay.
These actions can be followed as long as the person agrees to see a doctor or be taken to the hospital. Equality before the law (Article 12 of the Convention) states that a person with a suspected or confirmed mental disorder has the same legal rights as everyone else. Only if the usual criteria for police custody (those not connected to mental illness) are met can the person be taken into custody. If the general grounds for continued detention are met, the case could be decided by a judge, just like any other case.
Conclusion
Changing national and international systems for the sake of health is a difficult endeavour. International human rights instruments and agencies work to define basic human rights and freedoms that everyone in the world should enjoy, as well as to monitor governments’ compliance with such rights. It is the CRPD in this case, which clarifies that the application of existing human rights demands the abolition of coercive practises in psychiatry and the replacement of supported decision making. Despite almost a decade of work in the direction established by the CRPD, progress on such reform has been gradual. When looking at the international environment, examples of CRPD-compliant services can be identified, albeit in governments that still allow coercion.
Nonetheless, it appears that these cases have benefited from the creation of deliberate training, care system design, and founding principles that are consistent with the CRPD. These not only function but are also claimed to be producing positive effects for people with psychosocial disabilities, which appear to be sustained over time. As a result, there is an international legal convention as well as practical examples of how supported decision-making and non-coercive practice might be implemented. Individual clinicians and patients cannot bring about change on their own. As this study points out, progress toward a socio-political atmosphere that allows for non-coercive psychiatric practice is critical and must be aided.
[1] United Nations. 2014. Committee on the Rights of Persons with Disabilities. Eleventh Session. General Comment No. 1. Article 12: Equal Recognition before the Law. CRPD/C/GC/1. New York: United Nations
[2] https://mhe-sme.org/wp-content/uploads/2019/01/Coercion-Report.pdf
[3] https://www.mhe-sme.org/wp-content/uploads/2021/06/Short-Guide-on-Alternatives-to-Coercion.pdf