• Unambiguously seeking to reduce and prevent coercion

As a general comment, being explicit that coercion is extremely undesirable (even if some view it as being necessary in limited circumstances) and committing to active steps to reduce, prevent and even eliminate coercion, is a necessary pre-condition for success in this area. Such statements of intent are clearly not enough on their own, and mechanisms of accountability are required (see below, Policy and Practice). Yet, making this premise explicit helps to refine the focus of any law, policy or practice toward prevention, reduction and, if indeed it is possible, elimination.

• Topdown and local-level leadership is required

One key theme across the practices was that both top-down and local-level leadership appear important. Without both, it seems difficult to create and maintain culture change toward reducing, ending and preventing coercion, whether in an individual service or initiative, or in the service system as a whole.

• Service user, survivor, peer leadership and involvement

Leadership should include peer involvement at both top- and local-levels, both as a human rights imperative (see CRPD Article 4(3)) but also given there is compelling evidence that the involvement of service users and persons with psychosocial disabilities improves the efficacy of reduction and prevention strategies (Gooding et al., 2018). To this end, governments could promote resourcing for people with lived experience of mental health crises and interventions, including resources for training formalised peer workers, as well as promoting and supporting peer leadership in policy-level work. In addition, the existence of independent, peer-run organisations that operate alongside government mental health services, functioning in a systemic advocacy role, also appears to play a positive role in several of the reduction and prevention initiatives in this compendium.

From a policy perspective, the good practices in the Compendium suggest that coercion-free services or services that greatly reduce coercive measures can be advanced at three interconnected levels:

1. national oversight could include national policies aimed at reducing, preventing and eliminating seclusion and restraint, legislative restrictions, mandates upon governments to collect data, including reporting on ‘progress on alternative treatment options’;
2. organisational culture change would aim to move services toward rights-based, recovery, and trauma-informed care, individual- and family-led supports; and
3. independent, systemic advocacy would be directed at public opinion, politicians, policymakers and service providers to promote the importance of voluntary and coercion-free support (Gooding et al, 2018, p.117).

Some of the most comprehensive systems of reform – such as in East Lille and Trieste – have occurred on the municipal or provincial level. Attention is needed to expanding the lessons of these initiatives to the national and regional levels.

Important work to draw out these lessons is captured in the WHO Good Practice Guidance on Community Based Mental Health Services Promoting Human Rights and Recovery (2021, p.8). The Guidance elaborates on the broad policy proposals noted above, and states that ‘the creation of services free of coercion requires actions on several fronts including’:

1. education of service staff about power differentials, hierarchies and how these can lead to intimidation, fear and loss of trust;
2. helping staff to understand what is considered a coercive practice and the harmful consequences of its use;
3. systematic training for all staff on non-coercive responses to crisis situations including de-escalation strategies and good communication practices;
4. individualized planning with people using the service including crisis plans and advance directives;
5. modifying the physical and social environment to create a welcoming atmosphere including the use of ‘comfort rooms’ and ‘response teams’ to avoid or address and overcome conflictual or otherwise challenging situations;
6. effective means of hearing and responding to complaints and learning from them;
7. systematic debriefing after any use of coercion in an effort to avoid incidents happening in the future; and
8. reflection and change concerning the role of all stakeholders including the justice system, the police, general health care workers and the community at large. (see also World Health Organization, 2019)]

Similarly, the success of hospital-level initiatives listed in this compendium were often grounded in:

• Engagement of and anchoring of the leaders on the ward;
• Active involvement of core, frontline staff so they had a sense of commitment to the practice;
• Engagement and demand from the health authorities;
• Follow up from health authorities and revision of practice;
• Clear leadership of the service;
• Available data (statistics) of own practice and number of admissions/compulsory admissions for personal feedback;
• A culture that is open to learning and trying out new approaches; and
• Stable group of staff.

As a final note, it may be tempting for governments, professional groups, and advocates to direct attention to hospital-based initiatives, given this is where most formal coercive measures take place. However, the good practices in the ‘Community-Based initiatives’, ‘Hybrid’ and ‘Other Initiatives’ Sections highlight the many steps outside the hospital which are needed and can promote the broad aim of creating coercion-free support.

Indeed, the traditional dichotomy of hospital-based care on the one hand, and ‘community’-based care on the other, may be less helpful than a distinction between ‘crisis support’ (which may or may not take place in a hospital) and ‘general support’ (Gooding et al, 2018, p.116). Expanding government and public perceptions of ‘crisis support’ beyond merely the hospital, to instead include a range of options in various settings – the home, respite centres, peer-run drop-in services, mobile support units, family group conferencing arrangements, personal advocacy – can help to reframe the focus away from the institutional environments in which coercive practices traditionally occur.