Within any country, different economic and social groups may experience mental health services (and all services) differently. People from lower income groups, women, men, children and young people, older persons, LGTBI+, migrants, refugees and asylum seekers, ethnic minorities, and so on, are all likely to experience coercive measures differently.
Demographic matters were only generally noted in submissions for this report in relation to the broader population to which a particular service operated. For example, the Belgian TANDEMplus program serves a part of Brussels with high numbers of migrants, people living in small houses and/or public housing, and populations with higher rates of unemployment and drug use. Other studies noted similar socio-economic disadvantage in the areas in which services operated (such as the Norwegian restraint-reduction program at Lovisenberg diaconal hospital, Clinic for Mental Health).
However, none of the practices appear to have been explicitly designed for specific sub-populations.
None of the practices/initiatives/programs appear to include an explicit focus on the role of gender, and the different experiences and needs of women and men.
Some programs noted differential outcomes along gender lines. For example, the Six Core Strategies program in Andalusia, Spain, has produced findings that of those who were subject to mechanical restraint, 65% were male and 35% female. This pattern remained over the 3-year implementation of the program, even as the program led to a 15% drop in restraint overall. However, these gendered dynamics do not appear to have been further analysed in the resources currently available, and cannot be said to reveal much about the importance of gender regarding alternatives to coercion as a whole.
There appear to be only a handful of empirical studies in the broader literature concerning reduction and prevention of coercion that explicitly considers differences according to gender (see eg Long et al., 2015). According to studies by Clive Long and colleagues ( 2015), gender has a significant impact on how coercion is experienced. These impacts are likely to occur in combination with other socio-economic characteristics. For example, in the UK, Black-British men are overrepresented in involuntary psychiatric interventions (Gajwani et al., 2016). Another study from the UK, found that there are ‘marked ethnic inequities’ between white British women and black British women, but also between white British and ‘white other’ women in experiences of acute admission, including in how coercion is applied (Lawlor et al, 2012). Further research may be required to consider more broadly the important gender dimensions of efforts to reduce and prevent coercion.
Racial and Ethnic Minorities
None of the initiatives in the compendium included an explicit consideration of the experience of racial and ethnic minorities—although, as with the gender dynamic, this consideration may be occurring on the ground at the level of the service or community organisation itself. One submission noted the higher numbers of migrant groups in an area in which a practice took place (TANDEMplus) but this observation did not form a core part of the practice itself.
As noted, the broader literature indicates that ethnic minorities or migrant groups tend to experience mental health services, and indeed coercive practices, differently compared to others (see eg, Lawlor et al., 2012; Norredam et al., 2010). The 2019 review of the UK Mental Health Act 1983 (England and Wales), for example, reported that between 2017-18 ‘there were 289 detentions per 100,000 population for the black or black British group, compared to 72 for the white group’ and that ‘[community treatment order] rates for the black or black British group were over eight times greater than for those in the white group’ (Legraien, 2018).
Economic characteristics may explain some of the ethnic differences discussed in the literature. However, at least in the UK, according to Phoebe Barnett and colleagues (Barnett et al., 2019, p.314), identifying socioeconomic and clinical moderators by ethnic group and involuntary status is difficult because such information is ‘infrequently reported, preventing meaningful investigation’; it is possible that similar issues of poor data quality occur across Europe. Some ethnic or cultural groups have established or lobbied for their own services, such as Sharing Voices Bradford in the UK, a support programme particularly for Black British and migrant people in mental health crisis, particularly those facing social exclusion, isolation and discrimination (Gooding et al., 2018, p.206).
There is evidence to suggest that older persons are experiencing involuntary interventions in mental health contexts at higher rates compared to others (Gooding, 2018 p.112). None of the practices in this compendium appeared to explicitly address this group, at least in the submission materials, although the East Lille Citizen Psychiatry model appeared to include specific outreach programs for older people. Further, some supplementary research identified the explicit focus on older persons by one service – the Greek Mobile Mental Health Units – which tended to serve older people in remote and rural areas in Greece (Peritogiannis et al., 2017).
Other Demographic Issues
Several studies in the broader literature have focused on specific groups, such as prisoners or persons held in forensic mental health facilities (see e.g., Maguire et al., 2012; Olsson & Schön, 2016), children and adolescents (see e.g., Martin et al., 2008), and older adults (see e.g., Gjerberg et al., 2013; Mann-Poll et al., 2018), though there was nothing of this nature in the submission materials. There are also likely to be significant differences comparing low-income/high-income, young/older, people with intellectual and cognitive disabilities, rural/urban, and so on.
There have been calls for further cross-national study on demographic characteristics of people who experience involuntary psychiatric interventions (Curley et al., 2016, p.53).
- 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