3(D). Reducing coercion
The Czech authorities have voluntarily signed up to a range of human rights obligations. They must, under law, adopt a human rights approach to the mental health system. This is even more the case since ratifiying the UN Convention on the Rights of Persons with Disabilities (CRPD) in 2009. In policy terms the government must take an active approach to reducing coercion, and rolling out a system of community-based services. Ending the most egregious forms of coercion in psychiatric institutions is an immediate task.
Although the international law impetus is established, there is strong opposition on the ground. MDAC found that many mental health professionals did not believe that psychiatric care was possible without coercion. This finding signals a role for government to carry out targeted training; to convene meetings where people who take different views can discuss their standpoints and find common ground; to set specific clinical quality standards and to establish a robust enforcement mechanism for clinicians who, after training and warning, opt to abuse their patients.
The report notes several promising practices. At Prague Bohnice Psychiatric Hospital where all but one cage bed had been removed, a doctor told MDAC that he does not miss the cage beds. In a cage bed-free era, doctors pay more attention to patients, he said. They talk to them every day: “The wards are smaller and more specified, the supervision is more intensive”. His commitment to a more personal and humane way of practising psychiatry shows that change is possible.
In order to scale up such change, the report offers practical ideas for reducing coercion in psychiatric hospitals, and these flow from emerging practice internationally. A combination of the following clinical practices can lead to less reliance on coercion:
- rapid clinical assessment;
- observation procedures;
- advance directives;
- independent advocacy;
- involving people with mental health issues in their own treatment decisions.
These ideas can and should be quickly implemented. Alongside them, the more fundamental shifts required by international human rights law must also be rolled out.
