Background: Growing Research and Advocacy on Coercion
This compendium report adds to recent policy, research and practice seeking to promote voluntary and coercion-free forms of support, care and treatment (see eg. Barbui et al., 2020; Flynn & Gómez-Carrillo, 2019; Gooding et al., 2020; Hirsch & Steinert, 2019; C. Huber & Schneeberger, 2021; Sashidharan et al., 2019). More recently, the COST (European Cooperation in Science and Technology) funding agency has funded the establishment of a research network, ‘FOSTREN: Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services’ (see : www.fostren.eu).
Some of the prominent existing resources are listed briefly below, which have informed and should be considered complementary to this compendium.
Non-Government Organisations and National Human Rights Institutions
In 2019, Mental Health Europe (MHE) (2019) released a report, Promising practices in prevention, reduction and elimination of coercion across Europe. The following year, the European Network of National Human Rights Institutions (ENNHRI) partnered with MHE to publish a report, Implementing Supported Decision-Making: Developments Across Europe and the Role of National Human Rights Institutions. Both reports include several promising practices that align with this compendium and appear in Part II.
The MHE and ENNHRI reports build upon advocacy by persons with lived experience of mental health conditions and psychosocial disabilities and their representative organisations, who have consistently pointed out the human rights implications of involuntary psychiatric intervention and have advocated for alternatives. (For a collection of such practices, see Gooding et al. 2018, p.201; see also MIA, n.d.; CHRUSP, n.d; Russo & Wallcraft, 2011).
World Health Organisation – QualityRights Toolkit and Good Practice Guidance
The World Health Organisation (WHO) (2020) QualityRights Initiative provides a comprehensive set of resources for improving quality of care and reducing coercive practices. It includes policy and program checklists and training resources, which have been piloted and launched in low-, middle- and high-income countries. The resources are designed for use by a range of actors (service providers, individual healthcare practitioners, national bodies, and so on). Implementation studies have occurred in Gujarat, India, in partnership with the World Psychiatric Association (2020) as a ‘Case Study of Alternatives to Coercion in Mental Health Care’, and an implementation is underway in the Czech Republic (see below).
In addition, in 2021 the WHO has published an important resource titled, Guidance on community mental health services: Promoting person-centred and rights-based approaches. This resource is part of the WHO Guidance and technical packages on community mental health services set of publications (World Health Organization, 2021). The materials include a list of exemplary services from around the world with a focus on non-coercive practices. Specific recommendations and action steps are presented for developing community mental health services that respect human rights and focus on recovery. This comprehensive document is accompanied by a set of seven technical packages focused on specific categories of mental health services and guidance for setting up new services. For more information see:
World Psychiatric Association – Implementing Alternatives to Coercion
In 2020, the World Psychiatric Association (WPA) published a position statement titled, ‘Implementing Alternatives to Coercion: A Key Component of Improving Mental Health Care’ (Rodrigues et al., 2020). The statement includes the following:
…implementing alternatives to coercion is an essential element of the broader transition across the mental health sector toward recovery-oriented systems of care. Recovery-oriented treatment and care require not only respect for human rights and service user involvement, but realisation of rights through sound pathways to non-coercive care. This includes attention to all the important steps along the way – prevention, early intervention, and continuity beyond clinical settings – to provide integrated and personalised care, maximise therapeutic outcomes and promote the rights and recovery of people with mental health conditions and psychosocial disabilities. (Rodrigues et al., 2020) (Emphasis in original)
The position statement was developed internationally, in consultation with national psychiatry associations, and includes a brief list of implementation resources (see World Psychiatric Association, 2020). The statement aimed to recommend ‘action and an optional protocol designed to support [the associations] to engage… in ways that suit their local circumstances’ (Herrman, 2020, p.256).
Council of Europe – Disability Strategy (2017-23)
As noted, the momentum for reducing, preventing and eliminating coercion in mental health settings aligns with the COE Disability Strategy (2017-2023) (Section 3.4), which refers to the importance of supported rather than substituted decision-making. The section ‘Equal recognition before the law’ contains the following:
States are required under the UNCRPD, as far as possible to replace substituted decision-making with systems of supported decision-making. […]
Council of Europe bodies, member States and other relevant stakeholders should seek to:
- a) Support member States in their efforts to improve their legislation, policies and practices with regard to ensuring legal capacity of persons with disabilities.
- b) Identify, collect and disseminate existing good practices on supported decision-making systems and practices that persons with disabilities have available for being able to exercise their legal capacity and have access to choices and rights.
In general, these policy documents and advocacy materials convey high-level agreement on key components of good mental health policy around the globe, from promotion, to prevention, treatment and rehabilitation.
The Question of Elimination
There remain disagreements about the possibility and desirability of eliminating involuntary mental health interventions altogether (see W. Martin & Gurbai, 2019; Pūras & Gooding, 2019; Russo & Wooley, 2020). This compendium report will not engage with these debates, which have been well-covered elsewhere (see e.g. Gill, 2019; Gooding, 2017; Martin & Gurbai, 2019; Russo & Wooley, 2020; Sugiura et al., 2020; Szmukler, 2019). Instead, this compendium seeks to build upon the view that expanding voluntary options for support, and ramping up efforts to reduce and prevent coercion, can help to navigate a way through disagreements about the possibility of eliminating involuntary psychiatric interventions (McSherry, 2014; Ruck Keene, 2019). Focusing on practical examples that have reduced or eliminated the use of coercion can encourage practical action toward achieving the highest quality support for people experiencing mental health crises and psychosocial disability.
- Compendium report : Good practices in the Council of Europe to promote Voluntary Measures in Mental Health Services
- I. Background
- II. Good practices for reducing and preventing coercion in mental health settings in the Council of Europe
- III. Discussion