8(D). Practical measures to reduce coercion
When Philippe Pinel threw open the doors at the Salpetriere and the York Retreat,83 it became apparent that even those with significant levels of distress and agitated behaviour could be effectively cared for without recourse to physical restraint or restriction of liberty. Coercion has long been associated with psychiatric practice, particularly in institutional settings. Reports on the earliest facilities often revealed shocking practices. At the same time, it has been demonstrated over many years that mental health care can be humane, person-centred and cost-effective. Taking action in this respect is not only desirable but is now required under international human rights law.
Philippe Pinel Image by: Julien Léopold Boilly
At the end of the 17th century, the Salpêtrière in Paris was used to house four categories of women: ‘bad’ adolescents, prostitutes, criminals and the ‘insane’. By the early 19th century it had become an asylum used to warehouse people with mental health issues, the vast majority kept in chains. When social reformer Philippe Pinel (1745-1826) visited, he was reportedly so shocked at the scene that he called for the women to be unchained and released. Along with other reformers including Jean-Baptiste Pussin (1745–1811), Pinel is seen as one of first who attempted to humanise psychiatry in Europe.
At the same period, William Tuke (1732–1819), founded the York Retreat in northern England for 30 patients. At this new institution, he believed that the focus must be on developing the ‘morality’ of patients, placing an emphasis on the minimisation of restraints.
Adapted, in part, from: Ivan Berlin, ‘The Salpêtrière Hospital: From Confining the Poor to Freeing the Insane’, (American Journal of Psychiatry, 2003, 160:1579-1579).
There has been a steady move towards community support services and the closure of large psychiatric and social care institutions in many countries over the last sixty years. This has meant that hospital stays have shortened and become more ‘acute’ in many countries, and units have become smaller and more focused on the goal of getting people back into their own homes, with support, as quickly as possible. This move into the community has occurred at different rates. Many countries still concentrate their mental health services in large institutions with little community services.84
Research in the field is challenging and robust evidence hard to come by. However, a growing evidence base exists suggesting that coercion itself is not associated with improved clinical outcomes and negatively impacts upon the individual’s experience of care,85 perspectives which were also repeatedly stated by patients in those institutions visited. Reflecting the move towards a more human rights-compliant approach to psychiatry, a growing medical consensus exists that treatment within institutions must be carried out in the least restrictive manner possible.
International practice varies significantly and there is no single measure which can fully minimise coercion. This is the case in all countries. For example, there have recently been concerns regarding the use of “face down restraint” in UK National Health Service (NHS) hospitals and injuries and fatalities associated with this.86 In the USA and some Scandinavian countries practices such as strapping continue to be used and in low-income countries people in distress may simply be chained to a tree.87
The evidence on reducing coercion in psychiatric settings points to a number of interventions which may reduce coercion. If applied in a systemic manner, they can reduce overall levels of abuse and ill-treatment associated with cage beds, restraints and seclusion. These interventions are summarised briefly below. It must also be noted that such interventions cannot replace broader structural changes required, including securing the right to community living for everyone with mental health issues, as required by international law.
83 D.H. Tuke, ‘Retrospective glance at the early history of the retreat, York; its origins and influence’, (British Journal of Psychiatry 38: 1892, 333-359).
84 World Health Organization, Mental Health Atlas 2005, (Geneva: World Health Organization, 2005).
85 Tulla Wallsten, Lars Kjellin and Leif Lindström, ‘Short-term outcome of inpatient psychiatric care - impact of coercion and treatment characteristics’, (Social psychiatry and psychiatric epidemiology, 2006, Vol.41(12), pp.975-80).
86 Mark Easton, ‘Excessive’ use of face-down restraint in mental health hospitals, (BBC, 10 June 2013), available online at: http://www.bbc.co.uk/news/uk-22955917 (last accessed: 15.06.2014).
87 Mental Disability Advocacy Center, Human rights and mental health services in Zambia, (Budapest: MDAC, 2014).