Alternatives to coercion in mental health care: WPA Position Statement and Call to Action

The WPA wishes to spur progress worldwide in implementing alternatives to coercion in mental health care. Agreement is widespread among psychiatrists, other health practitioners and people with lived experience and their families that coercive practices are over‐used1, 2, and that implementing alternatives is essential to improving standards of mental health care.

In October 2020, the WPA General Assembly adopted a Position Statement and Call for Action to begin this work ³ . Action is needed in all countries, involving health services, communities, service users and their organizations, and governments, to ensure that people living with mental disorders and psychosocial disabilities have access to high‐quality care and support that meet their needs and respect their rights.

These rights are set out in the United Nations Convention on the Rights of Persons with Disabilities2, 4. They include rights to: equality and non‐discrimination; equal recognition before the law; freedom from torture, inhuman or degrading treatment; respect for physical and mental integrity of the person; and respect for home and the family.

The term “coercion” describes forceful action, involuntary treatment, or threats undertaken in the course of providing treatment or addressing perceived harm that a person poses to his/her own self or others due to a mental health condition. Coercive practices include formal detention, treatment without consent (or “compulsory treatment”), seclusion and restraint, including the use of mechanical devices, person‐to‐person restraint, or psychotropic drugs for the primary purpose of controlling movement (“chemical restraint”) ⁴ .

The question of whether coercive interventions can ever be justified in psychiatric treatment and mental health care, to protect rights holders’ own interests or on other grounds, is highly debated5, 6. The WPA Position Statement recognizes the diversity of views and experiences among psychiatrists, other health practitioners, people with lived experience, and their families and carers. Developed in consultation with WPA Member Societies and service user advocates, the Statement sets a direction and gives a practical starting point for action, even while recognizing the importance of the seemingly intractable question of competing rights (sometimes referred to as the “Geneva impasse”)7, 8.

The WPA Call for Action takes a pragmatic approach. There is a large and growing evidence base ⁴ on implementing effective alternatives to coercion in health settings across low‐, middle‐ and high‐income countries. Many of the changes promote the rights and recovery of service users and the transition towards recovery‐oriented systems of care, for example: service user involvement, attention to early intervention, integrated and personalized care, continuity beyond clinical settings and support for full participation in community life9, 10, 11.

Failing to make these changes exposes people with lived experience and their informal and professional carers to continued risk of harm, heightened when stigma and discrimination prompt fear and exclusion through sensationalized media coverage and politicization of efforts to stop coercive practices. Social, cultural and economic barriers of all types exist in countries. Patterns of practice and awareness of coercion, quality of training, attitudes toward care, service resources, the types of facilities, and the laws under which they operate can all act as facilitators or barriers ⁴ .

Given the evidence that alternatives to coercion are achievable, improve care and avoid harm, the WPA calls on psychiatrists and all care providers, community groups and policy‐makers to: a) consider the evidence base on alternatives to coercion (such as Safewards, Six Core Strategies, Open Door Policies, and the World Health Organization's QualityRights Initiative) ⁴ , and learn from the experiences of those who have generated change; b) identify alternatives that are feasible to implement; and c) take active steps with partners to develop and implement evidence‐based alternatives. Working with all stakeholders is exemplified by WPA's recommendations on working with service users and family carers ¹² , now incorporated in the WPA Code of Ethics ¹³ .

The Call for Action encourages WPA Member Societies and partners to decide on priority actions for their own countries. They can choose from 15 recommendations across several arenas: treatment and care; policy and legislation; service culture and attitudes; and research programs. For example, psychiatrists can have a strong influence on attitudes, practice and training in health services. They often have significant roles in persuading policy‐makers to give priority and resources to implement alternatives to coercion, to regard these changes as indicators of health service performance and to establish public databases relevant to measuring these. They can explain the need to intervene early in an episode of ill health to avoid situations in which coercion is perceived as necessary.

Psychiatrists are important in generating political will, developing evidence‐informed policy, and sharing experiences with colleagues in other settings; and ensuring that service users and their families and carers are involved centrally in decisions about care, research, evaluation and policy‐making. The testimony of persons who have experienced coercive practices and their families, and the advocacy of services users’ and family movements are essential. The united voices are key to governments, researchers and funders giving priority to development and testing of alternatives to coercion in a wide range of settings, including those with vastly different access to resources1, 2.

The WPA plans to continue the work through engagement with its Member Societies and the other partners involved in developing the Position Statement as well as wider national and international communities. Translation of the Statement into several languages is in progress or planned. We can aim through a sustained effort that gathers pace and size over time to implement evidence‐based alternatives to coercion, improve standards of mental health care, and promote lasting change fundamental to the lives and health of service users and their families and the practice of psychiatry everywhere.