Short summary

The Council of Europe has put forward that member states take steps toward total abolition of coercive measure in mental health care. This is a noble aspiration but it may conflict with previous European Council statements and with what could be considered a realistic and reasonable step forward in the foreseeable future. FOSTREN is a European network of mental health practitioners and researchers specifically dedicated to exchanging knowledge on reducing the use of coercive measures in psychiat

Rationale

Coercion in health care can be defined as measures applied against the patient's will (please see, e.g., Chieze et al., 2021)(1). Hence it overrides some fundamental patient rights like the liberty of movement and use of coercion therefore requires ethical (and legal) justifications (1). It is widely agreed that, if anything, coercion can be only legitimate in exceptional circumstances, when infringement of a patient's right to self-determination is the only means to fulfill more important values and goals like safety of the patient self or of others. In a recent literature review, Chieze et al. only found a minority of authors arguing in favor of an absolute ban on the use of medical coercion. This minority argued that coercion violates fundamental rights and principles, including dignity, integrity, autonomy, beneficence, and non-maleficence. The majority of studies stipulated that coercion can be used in certain circumstances. The values usually put forward in the literature to justify the occasional use of coercion is protection from violence, promotion of the patient's well-being, and justice (1).

Outside the scientific forum as well, it is a common viewpoint that coercion in some instances may be legitimate to protect the life of a patient or others. Apart from anti-psychiatry movements in the 1970s predominantly, focus therefore has been on minimizing coercive measure use while safeguarding patients' legal rights and right to reasonable treatment, rather than on simply abolishing all coercion. This is mirrored also in one of the most well acknowledged documents in European soft law, the Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine (Oviedo convention) where, in Article 7, the necessity for sometimes using coercive measures in the mentally ill is recognized ("Article 7 - Protection of persons who have a mental disorder. Subject to protective conditions prescribed by law, including supervisory, control and appeal procedures, a person who has a mental disorder of a serious nature may be subjected, without his or her consent, to an intervention aimed at treating his or her mental disorder only where, without such treatment, serious harm is likely to result to his or her health"). One will note that, despite being a widely held argument for legitimizing coercion in exceptional cases, the safety of others is not a criterion in the Oviedo Convention. According to the United Nations' Convention on the Rights of Persons with Disabilities (CRPD), Article 3, a general principle of the convention is "Respect for inherent dignity, individual autonomy including the freedom to make one's own choices" and, for example, according to Article 14, states parties shall ensure that persons with disabilities, on an equal basis with others "Enjoy the right to liberty and security of person." In 2019, the WHO QualityRights group released resources seeking to making mental health practices come up to the CRPD (2).

A major goal is reducing coercive practices and for example a 'Freedom from coercion, violence and abuse' section maintains the negative impact of coercive measures on individuals and makes suggestions for reducing (rather than abolishing) these practices, emphasizing the role of communication and training and paying consideration to the alternatives to coercive measure use (3).

More recently, the Parliamentary Assembly of the European Council issued a Resolution 2291 (2019) that "urges the member States to immediately start to transition to the abolition of coercive practices in mental health settings". This approach to psychiatric coercive measures is very remarkable. The wish to decrease coercion in mental health to the very least possible presumably would be advocated by most patients, patient organizations, mental health staff, and others. As mentioned above, however, it has been a common conception that coercion in some instances may be legitimate at least to protect the patient's life.

Among the reasons for claiming abolition of all coercive practices in psychiatry, Resolution 2291 argues that measures constitute "arbitrary deprivations of liberty". Furthermore, it is argued that there is a "lack of empirical evidence regarding both the association between mental health conditions and violence, and the effectiveness of coercive measures in preventing self-harm or harm to others". From a distance, Resolution 2291 may appear to conflict with the Oviedo Convention as well as with the predominant opinion expressed in the literature that coercive measure use should be limited as far possible but in some instances may be justified or even mandatory with reference to fundamental human rights and ethical principles. Furthermore, critics of the new Council of Europe initiatives might for example express worries as to how reasonable mental healthcare for the most seriously ill can be ensured in mental health services with no power to temporarily make decisions on the mentally incapacitated and how to avoid, e.g., the development of informal coercion ('below the radar') practices with little or no patient right guarantees. Questions like the latter currently seem to lack a clear answer. It could be claimed that such an 'abolitionist' objective is a clear and measurable goal (instead of "reduction") and it is 'good' to communicate. On the other hand, the objective disagrees with current legal frameworks and their underlying reasoning (i.e. psychiatry and other medical specialties being responsible to prevent harm to self or others by people who lack mental capacity due to a mental disorder)). Also, the objective could be claimed to be unrealistic, because coercion seems indispensable also in somatic medicine. Moreover, it implies that staff applying coercive practices violate human rights and act immorally (and consequently well-educated professionals will be reluctant to work in acute psychiatric services).

FOSTREN (Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services) is a multidisciplinary network of mental health care practitioners and researchers established in order to specifically focus on reducing the degree to which mental health services use coercion in hospital and community mental health services. It is funded from 2020 to 2024 by the European Cooperation on Science and Technology (COST) scheme. The FOSTREN network constitutes a good resource consisting of topic experts to test the question of whether it is feasible/desirable or not and thus to feed into the wider debate on this topic beyond FOSTREN.

AIM: In a collaborative survey across European countries, we want to investigate if the complete abolition of coercion is considered a reasonable objective by FOSTREN members. Furthermore, we want to explore FOSTREN members' views on what are the most important hindrances to decreasing coercive measure use in current mental health care practices.

Description of the cohort

This is a European survey distributed among FOSTREN members across participating countries. The proposed survey instrument is attached. Survey participants are questioned if they think the complete abolition of coercive practices in mental health settings is an achievable goal at some point in the future, and, if so, when it would be possible to abolish all coercion. In addition, participants are questioned about what are the most important hindrances to decreasing coercive measure use in current mental health care practices. Information will be obtained about respondents' gender and age, experience with mental health care practice (years), research experience in mental health, country of residence. All individuals registered as a FOSTREN member on a specified date in 2022 (current n=145) will be eligible to participate. Questionnaires will be distributed through e-mail addresses of FOSTREN members (currently n=145) via a link to a web-based platform (REDCap; Research Electronic Data Capture ©). Data will be analyzed mainly with descriptive methods comparing responses across various key variables (e.g. country, profession/role). Furthermore, sub-analyses will be conducted to investigate variations among respondent groups regarding, e.g., agreement with a total abolition of coercive measure use according to countryregion (Western, Central, Southern Europe etc., always avoiding too small groups for reasons of data privacy), profession, role etc. A small pilot study with 4 or 5 people outside our team will be conducted to test the feasibility of the questionnaire and the distribution / data capture procedures.

Data and biological material

Survey study

Collaborating researchers and departments

Retspsykiatrisk Forskningsenhed Middelfart; Leeds University and Ulm University