Good practices towards zero coercion in mental health
When we talk about the rights of people with mental health problems, one of the aspects to address is the problems of violence, coercion and mistreatment that, in some countries, can occur even before reaching a mental health care service, for example, at home, in a police station or in an emergency department of a general hospital.
The QualityRights training initiative, promoted by the World Health Organization (WHO), includes valuable information to understand what we are talking about and demonstrates that another way of doing things is possible. In addition to theoretical information, the WHO is offering a series of training webinars worldwide aimed at sharing best practices on different topics from around the globe.
The first of these training sessions focused on showcasing best practices aimed at zero coercion . These are practices in mental health services based on respect for the rights enshrined in the Convention on the Rights of Persons with Disabilities (CRPD), such as the right to make one's own decisions. This right also includes deciding whether and where to receive help.
Understanding the basics
Violence is understood as the intentional use of physical force or power (threatened or actual) that causes or has a high probability of causing injury, death, psychological harm, or deprivation. Coercion can be understood as any action or practice that is not in accordance with a person's will (without their informed consent) to force them to behave or refrain from behaving in a certain way. These are two overlapping terms. Both are perceived as violent when carried out coercively. Furthermore, a certain degree of violence is frequently required to implement coercion.
Violence and coercion can be very obvious or very subtle. For example, the following are clear cases of coercion:
- Isolation and the use of restrictive measures, including physical restraint with the hands, mechanical restraint, or the use of medication to control a person's behavior.
- Forced hospitalization in social and mental health services, and forced treatment.
- Forced treatment in the community.
- Violence and economic coercion (controlling a person's resources to force them to act against their will).
- Sterilization, contraception, or miscarriage.
But it is also:
- To induce a person to think that their actions will have negative consequences or that action will be taken against them or they will be denied certain things if they do not accept treatment.
- Giving a person medication without their consent.
Acts of violence and coercion can include physical, psychological, or verbal abuse; sexual violence and abuse; and neglect. It is also important to note that various intersectional factors can increase the risk of violence, coercion, and abuse both within and outside of mental health services.
According to global data collected during the formation of the WHO:
- Women and girls experience high rates of violence and sexual assault, including in mental health institutions, and women and girls with psychosocial disabilities are at higher risk of violence both in the domestic and community contexts.
- Transgender people may experience high rates of violence, harassment, and mistreatment, including when accessing health services and in the context of mental health services.
- The use of restrictive measures such as restraint may vary depending on gender in the services.
Proposals for measures that respect rights
The WHO webinar presented two cases that, in the words of the event's moderator, Javeed Sukhera , director responsible for Psychiatry at the Institute of Living at Hartford Hospital (USA), "are examples not only of how we can advance in practice in some of these challenges, but also of how we can consider ourselves part of this community of professionals, of people who want to change things, knowing and recognizing that none of us who try to do it in our environment are destined to do it alone."
One of the cases is that presented by Martin Zinkler , head of the mental health service department at the Bremen General Hospital (Germany), although his presentation is about his previous position as medical director at the Heidenheim Clinic (Germany).
Zinkler acknowledges that the measures implemented in Heidenheim have not yet achieved a zero-coercion scenario, but that the results of the practices carried out have changed the figures and there is a clear direction. These best practices include:
- An open-door policy is in place, with ward doors open from 8 a.m. to 8 p.m. "And that also includes people who are involuntarily admitted, because Germany, like most countries, has a mental health law with legal provisions that allow people to be kept in a hospital setting," explains Zinkler. In cases of acute crisis, they establish individual support with any member of staff (not just nurses, but any professional working in the ward).
- The use of open dialogue , in which the people being served decide what they want to talk about and schedules and places for future meetings are agreed upon.
- The support they offer regarding people's legal capacity . "People detained under the Mental Health Act are also helped. They cannot leave the facility, but what we do is support them in the appeals process against this decision, which will lead to a court hearing within three days. We also help them draft advance directives or, even better, joint crisis plans," explains the German psychiatrist and psychotherapist.
- Offering options when choosing the type of treatment: “For severe cases, in Heidenheim, day hospital and home treatment are offered without delay. You might think that’s how it should be, but unfortunately, in many places in Germany and elsewhere, the hospital is the only place you can go for acute crises. All other services have waiting lists, delays, and preparatory appointments, so many of them don’t work in severe cases. The transformation in Heidenheim for acute cases involved making it possible to choose between three support settings: day hospital and home treatment,” says Zinkler. Home treatment and day hospital can be options to avoid involuntary hospitalization, and medication is an optional, but not mandatory, part of the treatment, even in cases of acute psychosis.
- Eliminating financial incentives for hospital treatment is a key factor, particularly relevant to the German system. Traditionally, hospital services are the most expensive, but this also means that health insurance pays more for hospital treatment than for other types of treatment. Consequently, most mental health services favor hospitalization. According to Zinkler, this can be overcome with a regional mental health budget, essentially a population-based payment system, which eliminates the incentive to keep beds occupied. This was implemented in Heidenheim in 2017, resulting in a reduction of bed occupancy from 95% to 60%.
The second case presented in this WHO webinar focuses on the Gerstein Crisis Centre (Canada) , with the presentation made by Susan Davis , executive director, and Kaola Baird , peer-to-peer social worker.
The Gerstein Crisis Center is a 24/7 community-based mental health crisis center established in 1989 by Dr. Reva Gerstein and Pat Capponi, a lived experience person and activist. The goal was to provide an alternative resource where people could turn to support themselves and maintain their dignity during a crisis. They offer mobile teams and short-term residential beds, with a highly person-centered professional team. At least 30% of their board members are people with lived experience in mental health, and they are also involved in other aspects of the center's structure. The center operates on a model where individuals can come and go, stay, or return to the community. They have barrier-free access to all parts of the center and can benefit from a service based on consent, equity, and respect for their dignity, autonomy, and lived experience.
As Davis explains, “We strongly advocate for a model where immediate intervention in mental health crises is provided by a mental health professional, not the police . There are many reasons for this, including that it gives people better access to the social and mental health services they may need. It also allows them to get help sooner instead of waiting, which is what many people do because they try to avoid coercion and interaction with the police. Making it readily available, easily accessible, and not a barrier allows people to access that help sooner. It reduces stigma and coercive approaches to care, and much of that police or criminal justice involvement is undoubtedly unnecessary.”
The Gerstein Center, together with Human Rights Watch, has developed the document Community Support as a Response to Mental Health and Human Rights Crises , which describes its work in depth.
Kaola Bird, a peer-to -peer social worker and former user of the Gerstein Crisis Center, brings the perspective of the person receiving support to the discussion: “I think it all comes down to communication and personal interaction. It’s not that complicated, it’s not that hard to understand. Having people in the community who can meet with you, talk to you. Access is easy, you can have a conversation in a familiar setting. For example, like I did, you call the crisis line and a couple of workers come and meet you in a place you’re both familiar with, comfortable in, close to home. You sit and chat like you would with a friend or maybe a family member, and that builds trust. You can maintain your dignity because you’re treated with respect. You’re in control and you can communicate what you need. They can make suggestions and you can work together on a plan. So I would say that personal interaction and easy access to the community are key.”
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