Content note: This article contains descriptions of psychiatric coercion, restraint, deaths in care, and survivor testimony that some readers may find distressing.
On December 5th the East London NHS Foundation Trust held a conference in collaboration with City St George’s, University of London, and the University of Essex to address this extremely important question. The day was packed with evidence and arguments which deserve much wider dissemination and discussion.
Approximately 1000 people every week are sectioned under the Mental Health Act, according to NHS Digital data, and the rates of psychiatric coercion in the UK are on an upwards trajectory, rising approximately fourfold over a period of just over three decades, as documented in national Mental Health Act statistics. 38% of those sectioned experience further coercive measures during their detention, such as “restraint” (being physically held down and/or chemically tranquilised through forced medication), “seclusion” (being locked in a solitary confinement room) or being forcibly injected with prescribed psychiatric drugs against their will. And beyond these statistics lies a pervasive “informal coercion”, through the threat of these powers being employed.
What are the ethical principles and arguments involved?
The speaker who defined and dissected the arguments for and against psychiatric coercion most clearly was the philosopher Fabian Freyenhagen. He spelled out the fact that coercion is harmful in removing the individual’s rights and causing them distress and damage, such as PTSD. The question is whether this harm is ever the lesser of two evils.
He addressed this question from the perspective of the underlying principles involved, specifically that in society we restrict freedoms in order to prevent greater harms. For instance we set speed limits on the roads in order to save lives. There is always a balance involved in deciding on such laws, e.g. the evidence shows that a lower maximum speed would save even more lives, but safety considerations have been balanced against other factors in setting current speed limits.
Fabian Freyenhagen then introduced the idea of preventing crime through deploying predictive technology and a pre-crime squad with the power to detain people before they actually commit a crime. He illustrated this concept with the fictional example portrayed in the sci-fi movie Minority Report, where the precognitive perceptions of the psychic beings deployed to predict murders were not 100% accurate, leading to an innocent man being targeted for detention. He then argued that our system of psychiatric detention functions, in effect, as a “pre-crime” system.
He then put forward the human-rights-based case against coercion in the context of the Convention on the Rights of Persons with Disabilities (CRPD), an international human rights treaty which the UK ratified in 2009. Article 14 states that “the existence of a disability shall in no case justify a deprivation of liberty” and psychiatric diagnoses (on the basis of which people are detained under the Mental Health Act) are classified as disabilities. A pre-crime detention system would only be compliant with the CRPD if it applied equally to all. As a thought experiment, he suggested that such a system would logically have to involve detaining groups such as intoxicated men, given the strong evidence that this group poses a highly elevated risk of violence to others and of accidental self-injury or death.
As it stands the Mental Health Act is not compliant with the UK’s human rights obligations under the CRPD, as repeatedly stated by the UN Committee on the Rights of Persons with Disabilities, and the proposed changes to mental health legislation do not address this contravention of the Convention.
The other arguments that Fabian Freyenhagen put forward for the abolition of coercion were:
- The coercive powers that professionals hold fundamentally affect the power dynamic between professionals and patients, even when the ‘trump card’ of coercion is not actually played.
- We don’t have any robust evidence that coercion is effective in reducing risk and we have quite a lot of evidence that coercive measures intended to mitigate risk can actually increase risk.
- There is no ethical means to eliminate risk entirely – some degree of risk and harm is inevitable.
- If coercion were not an option then the mental health system would be forced to invest in help and support that people actually want.
- We do not have any accurate ways to predict who is a danger to self or others (around 1 in 500 detained patients go on to seriously harm others, meaning that the vast majority of cases represent false positives, according to epidemiological studies).
- Coercive institutions predictably result in abuse occurring, such as that exposed at Edenfield and Winterbourne.
- Alternatives exist to effectively address risk without infringing rights, such as the mental health system of Trieste in Italy which is based on professionals and patients being equal rightsholders and agreeing negotiated solutions to risk. And also pre-empting risk by providing continuity of care, offering 24/7 community mental health centres accessible to all who want to access them, and working with families and peers.
- Non-coercive alternatives are more cost effective – the system in Trieste is actually one-third less costly to run than the UK approach, even when including the 25% of the mental health budget that Trieste spends on providing housing and employment. Each inpatient bed in the UK costs approximately £200,000 per year, with a bed in a specialist unit costing around £1 million annually, according to NHS and commissioning data.
Fabian Freyenhagen’s conclusion was that psychiatrists should abdicate their social control function, thus placing the responsibility back on wider society to decide how best to address risks, and freeing mental health professionals to concentrate on their function of providing care.
What does research tell us about coercion?
Professor Victoria Bird presented a useful summary of the research evidence regarding coercion in mental health. Involuntary psychiatric admission rates vary widely around the world, with rates within Europe ranging from 6 out of every 100,000 of the population, up to 218 per 100,000. Within the UK the average rate of involuntary admissions is currently 114 per 100,000, but 3.5 times higher for black people than white people, and much higher for children than adults.
There is very little evidence for the effectiveness of coercive practices in preventing the harms they are intended to address, or in positively impacting outcomes for patients. Epidemiology shows that while Italy uses psychiatric detention at approximately one-tenth of the rate of the UK its suicide rate is around half that in the UK. Restraint, seclusion and forced treatment are linked to longer inpatient admissions. And the only factor that reliably predicts the likelihood of a patient being readmitted as a psychiatric inpatient is how satisfied they were with their previous admission, with those who felt positively about their experience significantly less likely to end up being readmitted.
The OCTET randomised controlled trial of Community Treatment Orders versus Section 17 leave showed that CTOs were unsuccessful in their intended purpose of reducing inpatient readmissions and produced no benefits in outcomes. The only country where any positive outcomes have been demonstrated from community treatment orders is in the USA, where very little community mental health provision or support is otherwise available without coercion.
There is little evidence available from randomised controlled trials into coercion because academic ethics committees will not normally approve such studies. And relatively small cohort studies such as those on the non-coercive Finnish practice of Open Dialogue tend to be dismissed by policy makers and mental health leaders as insufficiently robust evidence, despite the dramatically improved outcomes they show over standard coercive practices.
The human cost of coercion
Behind the statistics are thousands of human lives, impacted profoundly and too often destroyed by psychiatric coercion. In contrast to the Medical Director of the East London Foundation Trust who opened his presentation with a long list of infamous mental health patients and the violent crimes they committed, community activist Malik Gul presented photos of some of the patients killed by coercive practices in the mental health system, who never made media headlines in the same way.
Professor Brendan Stone of the University of Sheffield, and the University of Lived Experience, described his own experience of forced injections as “chemical rape”, in his own words, and vividly narrated the moment when he feared he was about to be murdered during the restraint, as the staff pinning him down exerted such force that he struggled to breathe. (Thankfully after fleeing the country by ferry and sleeping rough in Belgium he eventually regained his mental stability, once he had secure housing and no more worries about having enough to eat.)
We heard further powerful personal testimony from Sidney Millin whose nascent career in journalism was cut short by the effects of extreme and prolonged sleep deprivation from having to work long hours as a security guard to support his family while simultaneously studying full-time, consequently ending up sectioned and diagnosed as “bipolar”, leading to decades spent in the mental health system experiencing further coercion. Another survivor of multiple involuntary admissions described the inhumanity of psychiatric wards, and the fact that she would rather die than ever be sent back to one. And yet she raised the point that she feels that one of those admissions, to a private psychiatric facility, did actually save her from dying of self-starvation.
The time allotted for discussion after each session allowed for others with lived experience to contribute. For instance I was able to make the point that although every entry on my extensive psychiatric records warns that I have a “history of violence when unwell”, in fact I have a history of attempted self-defence when threatened with imminent violence from a policeman (under section 136), triggering the trauma of having ended up bruised black and blue from struggling against the six men who forced me into the metal cage inside their van during my previous experience of this form of what I experienced as legalised kidnapping, and (in my own sleep-deprived state) being triggered into an instinctive fight/flight reaction. Yet mental health professionals treated me as if I was someone who might well go around randomly attacking people if they didn’t have me locked up and drugged.
Bringing about change…
Some presentations addressed the distinct but related question of how the use of coercion can be reduced. Research shows that when staff within our current coercive system behave in more human ways and avoid actions that escalate situations then rates of coercion can be significantly reduced. However I felt compelled to question whether employing what could be described as “Good Cop” persuasion techniques to get people to stay peacefully imprisoned, and passively accept drugs that they don’t want to take, is really the best way forward — especially when such techniques rely on the ever-present threat of violence, in a way that is analogous to how abusive men sometimes act kindly towards their partners, thus more easily maintaining control while simultaneously protecting their own positive self-image.
Another way forward that was discussed is providing services that patients actually want to use — with one such proposed project being a new network of Neighbourhood Mental Health Centres, intended to shift more resources into community provision. (Currently the ratio of spending on each inpatient compared to each outpatient is 30 to 1, rising to 100:1 in Child and Adolescent Mental Health.) This project is also intended to address the current fragmented structure of community services that have “a team for everything and a place for no-one”, with rejection rates for referrals ranging from 50% to 92%. However a representative from the voluntary sector, who had been involved in the project, raised strong concerns that this was more top-down medical-model provision, with charities that represent and engage local communities cut before the centres have even got off the ground.
Many speakers emphasised that harmful coercive practices were not the fault of the individuals working in the system, but a social worker raised the powerful point that, “We ARE the system”, and that all those who work within the current coercive system bear responsibility for helping to bring such harms to an end.
But perhaps the most positive calls for change were for communities to proactively provide compassionate non-coercive care through the voluntary sector, rather than simply wait for change within a state system that is sustained by self-interest. And for conversations about psychiatric coercion, human rights and effective mental health care to belong to society as a whole rather than remain the preserve of professionals.