alternatives to coercion in mental health settings: a ... · roper, cathy and grey, flick (2018)...

Alternatives to Coercion in Mental Health Settings: A Literature Review

Piers Gooding, Bernadette McSherry, Cath Roper, Flick Grey

Alternatives to Coercion in Mental Health Settings:

A Literature Review

Commissioned by the United Nations Office at Geneva to inform the report

of the United Nations Special Rapporteur on the Rights of Persons

with Disabilities

Piers Gooding

Bernadette McSherry Cath Roper Flick Grey

This literature review is funded by the United Nations Office at Geneva, to inform the report of the United Nations Special Rapporteur for Disability, Ms. Catalina Devandas Aguilar. The mandate of the Special Rapporteur is to recall the universality, indivisibility, interdependence and interrelatedness of all human rights and fundamental freedoms and the need for persons with disabilities to be guaranteed the full enjoyment of these rights and freedoms without discrimination. The information and views contained in this research are not intended as a statement of the Special Rapporteur for Disability, and do not necessarily, or at all, reflect the views held by the Special Rapporteur.

© Melbourne Social Equity Institute, 2018

This work may be reproduced in whole or in part for study or training purposes subject to acknowledgement of the source and is not for commercial use or sale. Reproduction for other purposes or by other organisations requires the written permission of the authors.

Suggested citation: Gooding, Piers; McSherry, Bernadette; Roper, Cathy and Grey, Flick (2018) Alternatives to Coercion in Mental Health Settings: A Literature Review, Melbourne: Melbourne Social Equity Institute, University of Melbourne.

ISBN 978 0 9942709 9 3 First printed October 2018

An electronic version of this document can be obtained from www.socialequity.unimelb.edu.au [email protected]

Table of Contents

Introduction 8Defining ‘Coercion' 9What did the Review Find? 10 Structure of this Literature Review 11

Section One: Background and Methodology 13Background to this Literature Review 13The Convention on the Rights of Persons with Disabilities 13United Nations Bodies 14Changing Policies and Practices 15Terms of Reference for the Literature Review 16Scope of the Review 17Methodology 18Elevating the Perspectives of Persons with Disabilities 21

Section Two: Results of the Literature Review 27

Methods Used in the Studies 28Summarising and Reporting the Results 30Overarching Themes 30 Policies and Practices Promoting Human Rights, Recovery and Trauma-Informed Support 31 National Policies 36 Laws Designed to Reduce, End or Prevent Coercion 36 ‘Peer-Led’ Initiatives and Research 40 Providing Family-based Support when Responding to Crises and Support Needs 43Hospital-based Strategies for Reducing Coercion 47 Reducing Seclusion and Restraint 47 ‘Six Core Strategies to Reduce the Use of Seclusion and Restraint’ 48 Open Door Policies 53 Creating ‘Safewards’, Changing the Physical Environment and Improving Service Culture 57 Emphasising ‘Environmental Factors’ Within Hospitals 59 Examining the Relationship Between Service User Characteristics and Coercion 61 The Number/Ratio of Staff to Service Users, and Staff Characteristics 63 Existence of Registries/Reporting 65 De-Escalation Techniques 66

6

Community’ Based Alternatives to Coercion 67 Residential Programmes for People in Acute Crisis as Alternatives to Hospitalisation 67 Addressing Coercive Practices in Housing and Independent Living Services 77 Community Crisis Resolution and Home Support 78Other Trends in the Literature 82 Advance Planning to Improve Crisis Responses 82 Using Non-Legal Advocacy to Avoid Coercion 85 Reducing Fear of Coercion 87 Culturally Appropriate Pathways Through Mental Health Services 88 Supported Decision-Making 88 Providing Low-medication and/or No-medication Approaches 90

Section Three: Regional Themes 94

Africa 95Asia 98Europe 100Latin America 103Middle East 104North America 104Oceania 105

Section Four: Knowledge Gaps and Future Research Directions 108

Conclusion 116 References 118

Literature Referred to in Background and Methodology 118Literature Cited in Sections Two and Three and Listed in Appendix One 123Major Reviews and Other Notable Literature Listed in Appendix Two 134Appendix One - Literature Selected for Full Review 142Appendix Two – Reviews and Other Notable Materials 193Appendix Three – Practice, Policy and Legal Measures to Help End, Reduce and Prevent Coercion 201

8

IntroductionInformed consent to medical treatment is generally presumed to be cen-tral to the provision of good quality healthcare. Compulsory treatment challenges this presumption. Mental health laws in many countries set out legal criteria enabling the detention and treatment without consent of persons with mental health conditions or psychosocial disabilities in certain circumstances.

There are moves to reduce, end and prevent coercion, at the interna-tional, regional, national and local levels. A Resolution on Mental Health and Human Rights from the United Nations Human Rights Council calls upon States to ‘abandon all practices that fail to respect the rights, will and preferences of all persons, on an equal basis’ with others and to ‘provide mental health services for persons with mental health condi-tions or psychosocial disabilities on the same basis as to those with-out disabilities, including on the basis of free and informed consent’.1

This statement captures an international shift away from coercive prac-tices in mental health settings.

This systematic literature review examines empirical research on efforts to reduce, end and prevent coercion in the mental health context, wheth-er in hospitals in high-income countries, or in family homes and remote communities in rural parts of low- and middle-income countries. We will use the term, ‘persons with mental health conditions or psychosocial disabilities’, as adopted in the aforementioned Human Rights Council Resolution.

We have sought to undertake a comprehensive review of the scholar-ly research drawn from a range of different disciplinary backgrounds and experiences. However the review cannot claim to be exhaustive. For example, time and language limitations prevented a more expansive inquiry. Indeed, we recommend that a more expansive inquiry is required to uncover empirical research and exploratory reports of progressive ef-forts, particularly in non-English-speaking regions. Nevertheless, this re-view encompasses 169 studies from many parts of the world (including 48 reviews and notable grey literature reports), offering valuable insights into the state of research on finding alternatives to reduce, end and pre-vent coercion of people with mental health conditions and psychosocial disabilities.

1 United Nations Human Rights Council, Resolution on Mental Health and Human Rights, UN Doc A/HRC/36/L.25 (2017) 4.

9

Defining ‘Coercion’

It is important to define ‘coercion’ for the purposes of this review. A distinction can be made between ‘coercion’ and ‘compulsion’. The Oxford English Dictionary defines coercion as ‘the action or practice of persuading someone to do something by using force or threats’.2

‘Compulsion’ refers to ‘the action or state of forcing or being forced to do something; constraint’.3 Rather than using the term ‘coercion and compulsion’, the term ‘coercion’ alone will be used in this review to refer to both threats and compulsion or, in other words, the action or practice of persuading in a way that is characterised by the use of force and threats, or forcing someone to do something, in the context of mental health care provision.4

Coercion in mental health settings is commonly associated with powers of civil commitment; that is, compulsory treatment or psychiatric deten-tion, often imposed under the terms of mental health legislation. Civil commitment practices may include compulsory admission, treatment, including medication without consent, involuntary electroconvulsive therapy, seclusion and mechanical/physical/chemical restraint. However, coercion can also occur in nominally ‘voluntary’ service provision. The MacArthur Coercion Study, for example, in a study involving over 1500 adult patients admitted to hospitals in three US jurisdictions over a 10-year period, reported that formal involuntary detention and treatment:

is only a blunt index of whether a patient experienced coercion in being admitted to a mental hospital. A significant minority of legally ‘voluntary’ patients experience coercion, and a significant minority of legally ‘involuntary’ patients believe that they freely chose to be hospitalized.5

Similarly, Fennell discusses the ‘shadow of compulsion’ that voluntary patients may experience:

Detention, forcible treatment without consent, seclusion and restraint are the ultimate mechanisms of clinical power. A person may consent

2 See <https://en.oxforddictionaries.com/definition/coercion>

3 See <https://en.oxforddictionaries.com/definition/compulsion>

4 For a detailed discussion of terms surrounding ‘coercion’ and ‘compulsion’ in mental health services, see George Szmukler, ‘Compulsion and “Coercion” in Mental Health Care’ (2015) 14(3) World Psychiatry 259.

5 John Monahan et al, ‘Coercion in the Provision of Mental Health Services: The MacArthur Studies’ in Joseph P Morrissey and John Monahan (eds), Research in Community and Mental Health, Vol. 10: Coercion in Mental Health Services – Interna-tional Perspectives (Emerald Group Publishing, 1999) 13-30, 27.

10

to treatment or to remain in hospital if they know that they will be compelled in the event of refusal. Compliance in the shadow of compulsion is an important feature of the psychiatric system.6

Coercion also takes place outside hospitals in community based men-tal health services, family homes and disability residential facilities. This may include formal compulsory outpatient psychiatric interventions, but also where individuals are threatened with civil commitment, evic-tion or refusal of other services if they do not comply with proposed interventions.7

In low- and middle-income countries, including those without mental health services per se, coercion may take the form of people being shack-led, caged or detained in homes or communal areas, or in ‘prayer camps’ and other sites in which persons with disabilities are deprived of liberty.8

Finally, coercion may be understood as less visible and explicit than taking particular actions against a person, in the imposition of certain ways of understanding distress (for example, as a curse, or as a purely biomedical or socially constructed phenomenon). However, this report will not engage with these less visible forms of forceful persuasion, and instead concentrate on explicit actions constituting coercion, such as seclusion and restraint, threats, and treatment without consent.

What did the Review Find?

Most of the scholarly literature was quantitative and most of the studies were undertaken by psychiatrists. Most of the studies were discipline

6 Philip Fennell, 'Institutionalising the Community: The Codification of Clinical Authority and the Limits of Rights-Based Approaches' in Bernadette McSherry and Penelope Weller (eds), Rethinking Rights-Based Mental Health Laws (Hart Publishing Ltd, 2010) 13.

7 See generally Tony Zigmond, ‘Pressures to Adhere to Treatment: Observations on “leverage” in English Mental Healthcare’ (2011) 199(2) The British Journal of Psychiatry 90.

8 See, eg, Luh Ketut Suryani, Cokorda Bagus Jaya Lesmana and Niko Tiliopoulos,‘Treat-ing the Untreated: Applying a Community-Based, Culturally Sensitive Psychiatric Intervention to Confined and Physically Restrained Mentally Ill Individuals in Bali, Indonesia’ (2011) 261(2) European Archives of Psychiatry and Clinical Neuroscience S140; Laura Asher et al, ‘“I Cry Every Day and Night, I Have My Son Tied in Chains”: Physical Restraint of People with Schizophrenia in Community Settings in Ethiopia’ (2017) 13 Globalization and Health 47; Harry Minas and Hervita Diatri, ‘Pasung: Physical Restraint and Confinement of the Mentally Ill in the Community’ (2008) 2(1)International Journal of Mental Health Systems 8; Ibrahim Puteh, M Marthoenis and Harry Minas, ‘Aceh Free Pasung: Releasing the Mentally Ill from Physical Restraint’ (2011) 5 International Journal of Mental Health Systems 10.

11

specific – mostly within psychiatry, some within social work, law, psy-chology, and associated disciplines.

A small but significant amount of work was undertaken by persons who had experienced mental health conditions or psychosocial disabilities. Much of the work by this group occurred outside the scholarly literature.9

Formal research typically did not involve persons with psychosocial dis-abilities as either active research participants – for example as interview-ees, survey recipients, and so on – or as lead or co-researchers, though there were several notable exceptions to this general rule.

There are clear geographical gaps in the research. Relatively little re-search could be located from low- and middle-income countries, which is concerning. Overall, research locations are dominated by the United States, the United Kingdom (particularly England), the Netherlands and Northern Europe.

The body of literature had some over-arching themes, namely: the value of recovery-oriented and trauma-informed practices; laws to reduce co-ercive practices; ‘peer-led’ initiatives, family- or social network-directed initiatives; crisis resolution responses in hospitals, respite centres and home-based support; advance planning to improve crisis responses; the use of non-legal ‘advocacy’; supported decision-making; low-medication or no-medication alternatives; and culturally appropriate mental health support.

Perhaps one of the most important emerging themes is that both top-down and local-level leadership is important in order to create and to maintain practices that reduce, prevent and end coercive practices.

Structure of this Literature Review

This review is divided into five sections and three appendices:

• Section One provides the background, terms of reference and methodology.

• Section Two provides the results of the review, including a thematic analysis, which is broadly organised around overarching themes, hospital-based and ‘community’-based initiatives.

• Section Three sets out regional themes.

9 See Appendix Three.

12

• Section Four discusses gaps in research and suggests future research directions.

• Appendix One provides a table of literature used for full review, which summarises the year, region, aim, methods and findings of each study.

• Appendix Two provides a table of literature reviews and other notable materials.

• Appendix Three provides a table of ‘alternatives to coercion in practice’, which are summarised.

It is important to emphasise that the Appendices are the core of this report. The tables in the Appendices are meant for use in future research and should be viewed as an iterative source of materials that can be updated with new materials or existing materials which were not uncov-ered in this literature review. Relevant research and practices are highly likely to be identified that were not captured in our research design. The list of ‘alternatives to coercion in practice’ in Appendix Three, for exam-ple, is not meant to be exhaustive, but instead offers a sample based on the practices identified in the literature search and those most familiar to the authors of this report.

13

Section One: Background and MethodologyBackground to this Literature Review

There are several motivations for finding alternatives to coercive practic-es in mental health settings. Most notably, persons with mental health conditions or psychosocial disabilities themselves have consistently pointed out the human rights implications of involuntary detention and treatment and have advocated for alternatives.

The Convention on the Rights of Persons with Disabilities

The Convention on the Rights of Persons with Disabilities (‘CRPD’)10 has challenged States Parties to improve access to voluntary mental health supports and to reduce, prevent and end involuntary or coercive interventions.

Article 12 of the CRPD deals with equal recognition before the law. Arti-cle 12(2) sets out that ‘persons with disabilities enjoy legal capacity on an equal basis with others in all aspects of life’. The Committee on the Rights of Persons with Disabilities has described legal capacity as the ‘ability to hold rights and duties (legal standing) and to exercise those rights and duties (legal agency)’.11 Article 12(3) requires States Parties to ‘take appropriate measures to provide access by persons with disabilities to the support they may require in exercising their legal capacity’. Such support may include support to make decisions about medical treatment and care.

Article 25 of the CRPD addresses health care and promotes the right of persons with disabilities to the highest attainable standard of health on an equal basis with others, without discrimination on the basis of disa-bility. Article 25(d) requires health care professionals to provide care ‘on the basis of free and informed consent’.

10 Convention on the Rights of Persons with Disabilities, opened for signature 30 March 2007, Doc.A/61/611 (entered into force 3 May 2008) (‘CRPD’).

11 Committee on the Rights of Persons with Disabilities, General Comment No 1: Article 12: Equal Recognition Before the Law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014) and CRPD Committee, Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities: The Right to Liberty and Security of Persons with Disabilities, 14th sess (September 2015) para 13.

14

Articles 12 and 25 intersect in relation to medical treatment without consent.12 They are supplemented by Articles 14, 15 and 17. Article 14, requires governments to ‘ensure that persons with disabilities, on an equal basis with others… [a]re not deprived of their liberty unlawfully or arbitrarily… and that the existence of a disability shall in no case justify a deprivation of liberty’. Additionally, Article 15 provides that ‘[n]o one shall be subjected to torture or to cruel, inhuman or degrading treatment or punishment’ and Article 17 provides that ‘[e]very person with disabil-ities has a right to respect for his or her physical and mental integrity on an equal basis with others’.

United Nations Bodies

Several United Nations bodies have called for the prevention, reduction and ending of coercive practices in mental health settings.

The Committee on the Rights of Persons with Disabilities (the ‘CRPD Committee’) has stated that detention and forced treatment of persons with disabilities on health care grounds violate Article 12 of the CRPD in conjunction with Article 14.13 The Committee produces ‘concluding observations’ that respond to the CRPD-compliance reports of govern-ments and regions which have signed and ratified the CRPD. The Com-mittee has consistently urged States Parties to repeal provisions that al-low for compulsory admission and treatment of persons with disabilities in mental health institutions based on actual or perceived impairments.

This position is supported by the Special Rapporteur on the Rights of Persons with Disabilities, the United Nations Working Group on Arbitrary Detention, and the United Nations High Commissioner on Human Rights.

Some United Nations bodies have declared that certain types of coercive practices can, under some circumstances, help protect human rights and particularly the right to life (Article 10 of the CRPD) of persons with severe mental health conditions. These bodies include the Human Rights Committee14 and the Subcommittee on Prevention of Torture and Other

12 Bernadette McSherry and Lisa Waddington (2017) 'Treat with Care: The Right to Info- rmed Consent for Medical Treatment of Persons with Mental Impairments in Aus-tralia' (2017) 23(1) Australian Journal of Human Rights 109, 111.

13 Committee on the Rights of Persons with Disabilities, General Comment No 1: Article 12: Equal Recognition Before the Law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014) and CRPD Committee, Guidelines on Article 14 of the Convention on the Rights ofPersons with Disabilities: The Right to Liberty and Security of Persons with Disabilities, 14th sess (September 2015) <www.ohchr.org/Documents/HRBodies/CRPD/GC/GuidelinesArticle14.doc>.

14 United Nations Human Rights Committee, General Comment No. 35 - Article 9: Liberty and Security of Person, UN Doc CCPR/C/GC/35 (2014) 6 [19].

15

Cruel, Inhuman or Degrading Treatment or Punishment.15 Other United Nations bodies are less explicit on the legitimacy of forced interventions.16

Irrespective of whether coercion is viewed as a ‘necessary evil’17 in some emergency situations, it is agreed that coercive psychiatric measures restrict human rights and that support should be framed around the 'rights, will and preferences' (Article 12(4) CRPD) of the individual. Thus, numerous United Nations bodies have articulated an urgent need to de-velop alternatives to coercive interventions.

Changing Policies and Practices

International trends in mental health policy and practice have also gen-erated a push to find alternatives to coercive practices.

‘Recovery-oriented’ and ‘trauma-informed’ service delivery for exam-ple, have become prominent in recent years in many parts of the world. Recovery-orientated practice generally focuses on a person’s ability to recover from mental health crises. This approach seeks to avoid what Fisher describes as interventions ‘being done to’ people.18 High priority is placed on respect for self-determination. Support is personalised to the capabilities of each individual.19 Similarly, ‘trauma-informed’ approaches seek to understand the impact of interpersonal violence and victimisation on an individual’s life and development. In Elliott and colleagues’ terms, trauma-informed services are designed to ensure that ‘every interaction [within services] is consistent with the recovery process and reduces

15 United Nations Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment. Approach of the Subcommittee on Prevention of Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment regarding the rights of persons institutionalized and treated medically without informed consent, UN Doc CAT/OP/27/2 (2016) 2 [8].

16 See, United Nations Human Rights Council, Resolution on Mental Health and Human Rights, UN Doc, A/HRC/36/L.25 (2017); D Pūras, Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, UN Doc A/HRC/35/2 (2017); JE Méndez, Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, UN Doc A/HRC/22/53 (2013).

17 Melbourne Social Equity Institute, Seclusion and Restraint Project: Report (University of Melbourne, 2014) 140.

18 Pamela Fisher, ‘Questioning the Ethics of Vulnerability and Informed Consent in Qualitative Studies from a Citizenship and Human Rights Perspective’ (2012) 6 Ethics and Social Welfare 2, 12.

19 See, Patricia Deegan, ‘Recovery as a Journey of the Heart’ (1996) 19(91) Psychosocial Rehabilitation Journal 91; David Pilgrim and Ann McCranie, Recovery and Mental Health: A Critical Sociological Account (Palgrave MacMillan, 2013); Mike Slade, Personal Recovery and Mental Illness: A Guide for Mental Health Professionals (Cambridge University Press, 2009).

16

the possibility of re-traumatization’.20 Hence, trauma-informed services often promote ‘no-force’ forms of care and support.21

This is consistent with findings from other studies focused on the per-spectives of people who have experienced coercion, contributing to a growing body of evidence that coercive practices, such as restraint and seclusion, are harmful.22 Law and policy reforms can contribute to the goal of reducing and eliminating these practices, by regulating their use and improving accountability.23

In summary, efforts are underway at the international, regional, nation-al and local levels to find alternatives to coercive practices. This report contributes to those efforts by reviewing the available research literature in the field.

Terms of Reference for the Literature Review

The authors signed a contract with United Nations Office at Geneva on 10 May 2018 to produce an academic literature review on existing evidence on intervention and strategies to end, reduce and/or prevent coercion in mental health care. The Office commissioned the literature review on non-coercive practices in the context of mental health care to inform the report of the Special Rapporteur on the Rights of Persons with Disabilities, pursuant to the Human Rights Council resolution 35/6.

20 Denise E Elliott et al, ‘Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women’ (2005) 33(4) Journal of Community Psychology 461, 462.

21 See, eg, Robert D Stolorow, Trauma and Human Existence (Routledge, 2007); Maxine Harris and Roger D Fallot, ‘Envisioning a Trauma-Informed Service System: A Vital Paradigm Shift’ (2001) 89 New Directions for Mental Health Services 3.

22 Bradley Foxlewin, What is Happening at the Seclusion Review that Makes a Difference? A Consumer Led Research Study (ACT Mental Health Consumer Network, 2012); Christina Katsakou et al, ‘“Psychiatric Patients” Views on Why their Involuntary Hos-pitalisation was Right or Wrong: A Qualitative Study’ (2012) 47 Social Psychiatry and Psychiatric Epidemiology 1169; Caroline Larue et al, ‘The Experience of Seclusion and Restraint in Psychiatric Settings: Perspectives of Patients’ (2013) 34 Issues in Mental Health Nursing 317; Cynthia Robins et al, ‘Special Section on Seclusion and Restraint: Consumers’ Perceptions of Negative Experiences and “Sanctuary Harm” in Psychiatric Settings’ (2005) 56 Psychiatric Services 1134.

23 See, eg, Australian Department of Health, National Standards for Mental Health Services (Commonwealth of Australia, 2010); Melbourne Social Equity Institute, above n 17, 146.

17

It was agreed that the review should include:

• An overview of practices within and beyond traditional mental health settings;

• A thematic analysis of the literature available across disciplines;

• An identification of survivor/user led interventions; and

• An analysis of gaps and weaknesses in the available literature.

It was also agreed that this literature review should include an analysis of any academic and ‘grey’ literature on interventions and strategies of this kind. ‘Grey’ literature is not formally published and therefore typically not subject to peer review (or external validation) of content. It can take the form of government reports, conference papers, policy documents and web materials. However, there are distinct reasons to include this material, as discussed in the Section on Methodology below.

Scope of the Review

This literature review is guided by the directive from the United Nations Office at Geneva to ‘identify, select and critically evaluate relevant inter-ventions and strategies with the purpose or effect of ending, reducing and/or preventing coercion in mental health care (compulsory admis-sion, involuntary treatment, involuntary medication, seclusion, restraint, etc.).’

According to the Committee on the Rights of Persons with Disabilities ‘[f]orced treatment is a particular problem for persons with psychoso-cial, intellectual and other cognitive disabilities’.24 This review focuses on these groups.

Effort was taken to consider practices, strategies, policy and laws from across low-, middle- and high-income countries. Care was taken to ex-pand the scope of the literature beyond high-income Western countries, in response to concerns by several commentators that some research and commentary concerned with the CRPD casts Western-centric material in

24 Committee on the Rights of Persons with Disabilities, General Comment No 1: Article 12: Equal Recognition Before the Law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014) para 42.

18

universal terms.25 However, due to time and language constraints, we excluded articles which were not available in English (unless the abstract contained sufficient useful information). In our recommendations for fu-ture research, we recommend that this type of systematic review expand to include non-English language resources.

Again, the scope of the review was also limited by time constraints. A more exhaustive study would also draw in material from the bibliogra-phies of each study, would cast a view further back than 1990 and would undertake consultation and peer review from leading representatives in the field, including both academics as well as organisations representing persons with psychosocial disabilities.

Methodology

A literature review is aimed at collecting, analysing and presenting avail-able research in a given field of interest. A range of methodologies can be used, some more systematic and organised than others.26 Scoping reviews use strict, transparent methods for surveying the literature and evaluating the findings. They are particularly useful for surveying a po-tentially large field that has not yet been comprehensively reviewed and for which clarification of concepts is required. A scoping review is there-fore well suited for the purposes of this review.27 This review extends from peer-reviewed articles to ‘grey literature’ and international reports.

Two main questions guided the review:

What laws, policies and/or practices help to reduce and eliminate coercive practices in mental health settings?

What alternative strategies, laws, policies and/or practices exist which promote rights-based support in the mental health context?

For the academic and ‘grey’ literature, a rapid review method (stream-lined literature review) was used. Numerous search strings in multiple

25 See Bhargavi V Davar, ‘Legal Capacity and Civil Political Rights for People with Psychosocial Disabilities’ in Asha Hans (ed), Disability, Gender and the Trajectories of Power (Sage, 2015) 238; Inclusion International, ‘Video: Preparing Feedback to the CRPD Committee on the Draft General Comment on Article 19’ <http://inclusion-international.org/video-preparing-feedback-to-the-crpd-committee-on-the-draft-general-comment-on-article-19/>; Amita Dhanda, ‘Conversations between the Proponents of the New Paradigm of Legal Capacity’ (2017) 13(1) International Journal of Law in Context 87.

26 Hilary Arksey and Lisa O’Malley, ‘Scoping Studies: Towards a Methodological Framework’ (2005) 8(1) International Journal of Social Research Methodology 19.

27 Micah DJ Peters et al, ‘Guidance for Conducting Systematic Scoping Reviews’ (2015) 13(3) International Journal of Evidence-Based Healthcare 141, 141.

19

combinations of the following words were used in keyword fields, or abstract and title fields (where available in each database). The Help section of each database was checked for relevant wildcard operators (typically * or !):

‘mental (health or ill* or disability or impair*)’; ‘coerc* or forced or compulsory or involuntary*’; ‘psychiatr*’; ‘disab*’; ‘disability law’; ‘health care’; ‘alternative*’; ‘healthcare’; ‘health*’; ‘health services’; ‘right to health’; ‘alternative*’; ‘advoca*’: ‘user’; ‘survivor’; ‘crisis respite’; ‘trauma-informed’; ‘recovery’, etc.

Examples of the many individual search strings include:

• ‘human rights’ AND (mental AND (ill* OR health OR disab* OR impair*)) AND (coerci* OR force* OR civil commitment)

• (mental AND (ill* OR health OR disab* OR impair*)) AND (coerci* OR force* OR civil commitment)

• (mental AND (ill* OR disab* OR impair*)) AND (coerci* OR force*) AND (alternative* OR advoca*)

• (mental AND (ill* OR disab* OR impair*)) AND (coerci* OR force*) AND (law OR legislat*)

• (coerc* OR forced OR compulsory OR involuntary) AND (mental (health OR ill*)

• (‘mental health’ OR ‘mental* ill’ OR psychosocial) AND ‘human rights’

• (‘mental health’ OR ‘mental* ill’) AND alternatives

• non-coercive* AND psychiatry

• (alternative* OR voluntary*) AND ‘mental health’

• right* AND ‘mental health’

• advoca* AND ‘mental health’

• right* AND ‘mental health’

• psychiatr* AND voluntary

• psychiatr* AND alternative*

• reduc* AND (seclusion OR restraint) AND (mental (health OR ill* OR disability))

20

For journal articles and similar sources, legal indexing/abstract-ing and full text databases were searched including: University of Melbourne Libraries Catalogue; TROVE – National Library of Australia Catalogue; and Worldcat.

The following research databases were used:

• INFORMIT (which includes AGIS, Health Collection, Health and Society Database);

• EBSCO (which includes Academic Search Complete, CINAHL Complete, MEDLINE, Index to Legal Periodicals);

• PROQUEST (which includes Health and Medical Collection and Psychology Database);

• Science Direct Journals;

• SSRN;

• Google Scholar; and

• LegalTrac.

A limit was placed on the date range for the search, from 1990 onwards and a language filter was applied to focus on Eng-lish-language results.

The materials collected through the systematic review and con-sultation were analysed using thematic content analysis, as well as doctrinal legal analysis.28 Doctrinal legal analysis emphasises identifying a problem of justice (namely, restrictions on rights following coercive intervention) and canvassing alternatives.29 Attention was paid to materials authored by the CRPD Commit-tee, the Human Rights Committee and other treaty bodies, as well as the Special Rapporteurs for the Rights of Persons with Disability, on the Right to Health, on Torture and Other Cruel, In-human or Degrading Treatment or Punishment, and other human rights agencies.

28 Terry Hutchinson and Nigel Duncan, ‘Defining and Describing What We Do: Doctrinal Legal Research’ (2012) 17(1) Deakin Law Review 84, 113.

29 Martha Minow, ‘Archetypal Legal Scholarship – A Field Guide’ (2013) 63(1) Journal of Legal Education 65.

21

Elevating the Perspectives of Persons with Disabilities

The CRPD explicitly directs that persons with disabilities ‘should have the opportunity to be actively involved in decision-making processes about policies and programmes, including those di-rectly concerning them’,30 which would reasonably extend to re-search informing policy and programmes. In addition, the terms of reference required this review to emphasise materials gener-ated by persons with disabilities.

Two authors of this report have expertise with such materials, and themselves draw on their personal experience with mental health services. Ms Flick Grey is a survivor of childhood trauma and has an academic background in sociology, linguistics and mad studies. Ms Cath Roper’s thinking and positioning is influ-enced by multiple experiences of being subject to mental health legislation involving compulsory treatment, detention and restric-tive practices. The list of practices compiled by Ms Grey and Ms Roper – and supplemented by the literature review – are included in Appendix Three. These practices informed the research scope, as discussed shortly.

In addition to the rights-based claims, there are pragmatic rea-sons to emphasise materials produced by users of mental health services, or those who describe themselves as surviving coer-cive measures. Greenhalgh and colleagues have argued that ‘evidence-based medicine’ in general – not simply in the mental health context – carry potential biases that can ‘inadvertently de-value the patient and carer agenda’ due to:

limited patient input to research design, low status given to experience in the hierarchy of evidence, a tendency to conflate patient-centred consulting with use of decision tools, insufficient attention to power imbalances that suppress the patient’s voice, over-emphasis on the clinical consultation, and focus on people who seek and obtain care (rather than the hidden denominator of those that do not seek or cannot access care).31

30 CRPD Preamble para (o), Art 33(3).

31 Trisha Greenhalgh et al, ‘Six “Biases” Against Patients and Carers in Evi-dence-Based Medicine’ (2015) 13(1) BMC Medicine 200, 200.

22

Greenhalgh and colleagues suggest several ways to reduce such ‘biases’,32 which also have application to the growing body of literature aimed at improving the involvement of service users, former service users and persons with psychosocial disabilities in research.33

The devaluing of service user and family perspectives may be acute in mental health research. Beaupert argues that legal and institutional processes devalue the perspective of users and sur-vivors to the extent of compromising their freedom of opinion and expression.34 Russo and Beresford argue that professional researchers in the mental health fields have a ‘longstanding aca-demic habit of avoiding a dialogue with subjects of their interest’ noting that academics tend to conceive of themselves as develop-ing tools and philosophies to help ‘those people’ out there, rather than inviting in and incorporating ‘mad people’s knowledge’.35 Nevertheless, for over two decades at least, service user and survivor researchers have created an evidence-base for change by challenging traditional research assumptions, theories and methods, developing ethical frameworks, and aligning their work to other social movements.36 This has occurred independently of, and in collaboration with a wide range of fellow researchers, including clinical and legal academics, social workers and social scientists.

Emphasising the perspectives of persons with disabilities expand-ed the field of practices considered in this literature search. Russo has argued that there is a general absence of formal research on coercion that is led by people in the ‘user/survivor movement’:

32 Ibid 8-9.

33 See, eg, Angela Sweeney et al, (eds) This is Survivor Research (PCCS Books Ltd, 2008); Alison Faulkner and Phil Thomas, ‘User-Led Research and Evidence-Based Medicine’ (2002) 180(1) The British Journal of Psychiatry 1; Jan Wallcraft, Beate Schrank and Michaela Amering, Handbook of Service User Involvement in Mental Health Research (John Wiley & Sons, 2009).

34 Fleur Beaupert, ‘Freedom of Opinion and Expression: from the Perspective of Psychosocial Disability and Madness’ (2018) 7 Laws 3.

35 Jasna Russo and Peter Beresford, ‘Between Exclusion and Colonisation: Seeking a Place for Mad People’s Knowledge in Academia’ (2015) 30(1) Disability & Society 153, 154.

36 See Angela Sweeney et al, above n 33.

23

Coercion in psychiatry and the fight against forced treatment are two of the main topics in the mental health service user/psychiatric survivor movement worldwide. At the same time, our own user-led or survivor-controlled research in this field is nonexistent.37

There are notable exceptions to this general observation, which we will discuss throughout this review,38 but perhaps more im-portantly for this section of the review, it seems to be the case that most empirical research by persons with mental health con-ditions or psychosocial disabilities does not focus on coercion in a direct sense. Instead, it typically focuses on practices designed to address unmet need—which may, as a secondary effect, work to reduce coercive practices. ‘Unmet need’ here refers to the type of support that is desired but may not be available. The Na-tional User Survivor Network (‘NUSN’) in the United Kingdom, for example, states that its aim is to ‘[m]ake the policy of “getting the right support, at the right time, in the right place, from the right person” a reality’.39 Better meeting people’s support needs, as well as being valuable in and of itself, is likely to help prevent, reduce or end coercive interventions.

Again, this is not to suggest that research into coercion by per-sons with mental health conditions and psychosocial disabilities has not taken place. Indeed, NUSN has published several reports

37 Jasna Russo and Jan Wallcraft, ‘Resisting Variables - Service User/Survivor Perspectives on Researching Coercion’ in Thomas W. Kallert, Juan E. Mezzich and John Monahan (eds.), Coercive Treatment in Psychiatry: Clinical, Legal and Ethical Aspects (John Wiley & Sons, 2011) 213, 213.

38 For legal research and scholarship, see: Tina Minkowitz, ‘The United Nations Convention on the Rights of Persons with Disabilities and the Right to be Free from Non-consensual Psychiatric Interventions’ (2007) 34(2) Syracuse Journal of International Law and Commerce 405; Bhargavi Davar, ‘Legal Frameworks for and against People with Psychosocial Disabilities’ (2012) 47(52) Economic and Political Weekly 123; Elyn Saks, ‘Mental Health Law and the Americans with Disabilities Act: One Consumer’s Journey’ (2016) 4(1) Inclusion 39. For phenomenological, sociological and first person-accounts, see: Erick Fabris and Katie Aubrecht, ‘Chemical Constraint: Experiences of Psychiatric Coercion, Restraint, and Detention as Carceratory Techniques’ in Liat Ben-Moshe, Chris Chapman and Alison C Carey (eds) Disability Incarcerated (New York: Palgrave Macmillan, 2014) 185–99; Erick Fabris, Tranquil Prisons: Chemical Incarceration under Community Treatment Orders (University of Toronto Press, 2011).

39 National Survivor User Network, Manifesto 2017: Our Voice, Our Vision, Our Values (2017) 3 <https://www.nsun.org.uk/our-manifesto>.

24

which explore experiences of coercion40 and has committed to campaigning against ‘abusive practices of forced medication, restraint and seclusion, and stripping’.41 There is also a large international body of first-person accounts of traumatic coer-cive experiences,42 which has added urgency to the search for alternatives. However, researchers who have used mental health services or been subject to coercive interventions tend not to have framed their research around the explicit question, ‘does X practice reduce coercion?’ Instead, researchers tended to ask questions such as the following: ‘how do people experience cur-rent approaches? What alternative responses are preferred, and what are the benefits of these alternatives?’ It is also the case that explicitly testing the impact of a certain practice on rates of coercion often requires considerable resources and professional authority within health systems, which may not be available to service user researchers and representative organisations. Prom-inent practices promoted by user organisations include talking therapies, individual advocacy, mutual aid programs (such as ‘intentional peer support’), peer-run crisis respite houses and non-medication or low-medication approaches, all of which are discussed throughout this report. Again, rarely are these practic-es explicitly tested for their contribution to preventing or reduc-ing coercive interventions—often they are evaluated in terms of the personal benefits to individuals (for example, through hospi-tal diversion, short-term reduction in distress, and self-reported satisfaction). These trends present a challenge when undertaking a formal review of alternatives to coercion in mental healthcare that seeks to elevate the perspectives of persons with mental health conditions and psychosocial disabilities.

40 See, eg, Dorothy Gould, Service Users’ Experiences of Recovery under the 2008 Care Programme Approach: A Research Study (National User Survivor Network, 2012); Dorothy Gould, The Healthy Lives Project Full Report (National User Survivor Network, 2016), 24, 45, 58.

41 National Survivor User Network, above n 39, 11. Aim number 6 of the manifesto is to ‘[c]ampaign to radically reform the Mental Health Act (2007) to make the provisions of the UN Convention on the Rights of Persons with Disability (UNCRPD) a reality for people with lived experience of mental distress, as part of the wider disability community’.

42 See above n 38. See also <http://www.mindfreedom.org/personal-stories/personal-stories/>; <http://psychrights.org/horrors.htm>.

25

As such, Appendices Two and Three contain relevant literature and other materials generated by persons with mental health conditions and psychosocial disabilities that did not fall within the explicit aim to identify empirical studies on alternatives to coercive practices. Appendix Two contains materials that were either non peer reviewed or were peer reviewed but did not fit expressly within the scope. For example, a non peer reviewed report authored by the Users and Survivors of Psychiatry – Ken-ya examines the role of organised and informal peer support in ‘exercising legal capacity in Kenya’.43 There were also service us-er-led initiatives explicitly designed to reduce coercive practices, including Foxlewin’s empirical study, commissioned by the Aus-tralian Capital Territory (ACT) Mental Health Consumer Network.44 Foxlewin’s project examined seclusion reduction interventions at a single Australian hospital, in which seclusion incident rates reportedly fell from 6.9% in 2008/9 to less than 1% in 2010/11. Although this project report is not formally peer reviewed, it is valuable for the added description of a service user-led strategy. It seemed important to acknowledge this type of work and to include relevant grey literature throughout this Review.

To further incorporate practices promoted by persons with men-tal health conditions and psychosocial disabilities and their repre-sentative groups, we included terms during the literature search that reflected these alternatives, such as the terms ‘advocacy’, ‘medication discontinuation’, ‘crisis resolution’ and ‘crisis/respite houses’.45 We will discuss the relevance of each of these cate-gories to different types of coercion in mental healthcare as they arise. Again, Appendix Three contains a list of practices that are commonly presented by organisations representing persons with mental health conditions and psychosocial disabilities, a signifi-cant number of which have not been subject to either formal or informal evaluation.

43 Users and Survivors of Psychiatry – Kenya, The Role Of Peer Support In Exercising Legal Capacity in Kenya (April 2018) <www.uspkenya.org>.

44 Bradley Foxlewin, What Is Happening at the Seclusion Review That Makes a Difference?: A Consumer Led Research Study (ACT Mental Health Consumer Network, 2012).

45 It should also be noted that this approach of undertaking additional searches on particular initiatives was taken to other initiatives, not necessarily service user-led, such as the ‘Six Core Strategies’, uncovering several studies which did not appear in the original search.

26

As a final comment on the importance of involving persons with disabilities in research affecting them, it is noteworthy that coercion in mental health interventions is also used on persons with intellectual and/or developmental disabilities and older persons. A more extensive study would seek to incorporate the views of these individuals and their representative organisations.

27

Section Two: Results of the Literature ReviewAfter an extensive search, 500+ relevant peer-reviewed research studies were identified for review. From these, non-research articles (theoretical papers, reviews, overviews and commentar-ies), articles which were not available in English, duplicates and articles not available in full text (and where a detailed abstract was not available) were excluded. This resulted in a total of 121 empirical research papers included in the review.

Figure 1: Flow chart showing inclusion process

28

Secondary to the research papers, we also identified 48 review papers and other notable materials relevant to this review. ‘Nota-ble materials’ include grey literature, including research papers undertaken by service user organisations, government agencies, and so on. An overview and summary of all the identified review papers and notable materials can be found in Appendix Two. In general, the review papers and notable materials have not been included in the thematic analysis and reporting of results in this report, as they do not contain peer-reviewed primary data. How-ever, we occasionally refer to relevant review papers to supple-ment observations about themes emerging from the empirical studies.

Methods Used in the Studies

The research methods used in the literature can be roughly dis-tinguished between positivist or phenomenological research philosophies.

Positivistic methods are typically deductive, highly structured, include large samples, measurement, and typically adopt quantitative methods of analysis, which allow a range of data to be analysed.46 Researchers in this tradition typically position themselves as detached, neutral and independent and endeavour to undertake value-free research from an objective stance.47

Phenomenological methods consider the way people experience a particular situation or phenomenon. Researchers would typically use qualitative methods, mostly in the form of in-depth conversations and interviews, or data collected through observation. Often, sample sizes are relatively small, often less than 25 participants.48 Data is typically analysed inductively in an attempt to identify themes or make generalisations about a particular phenomenon, and how it is perceived or experienced. Researchers in this tradition typically position themselves as interacting with research

46 See generally, Michael Polanyi, Personal Knowledge: Towards a Post-Critical Philosophy (University of Chicago Press, 1958).

47 Pamela Maykut and Richard Morehouse, Beginning Qualitative Research: A Philosophical and Practical Guide (The Falmer Press, 2002) 15.

48 Ibid 58.

29

subjects; for example, as a participant observer, interviewer, or a focus group facilitator, ‘but also remove[...] him/herself from the situation to rethink the meanings of the experience’.49

The specific methods used in the empirical research papers we reviewed were:

• Case Study: 5

• Mixed Methods: 17

• Qualitative: 26

• Quantitative: 73

Thus, most papers used quantitative methodology, typically com-prising service data and surveys. Overall, sample sizes tended to be small and used convenience sampling (that is, focused on specific services). There were a few national surveys that pro-vide valuable generalisable data. Qualitative studies provided an insight into subjective experiences of participants, and detailed understandings of enablers and barriers to reducing coercive practices in a variety of settings. Often the samples in qualitative studies were small and non-generalisable.

The quantitative studies mostly analysed service data, such as re-ports of seclusion or restraint incidents, rates of restricted leave being imposed, rates of involuntary detention, and so on. Qual-itative studies typically consisted of interviews. Many of these studies had limitations in terms of study design, length of trial periods and settings.

Research involved adults with mental health conditions and psy-chosocial disabilities, both men and women (with only several studies having a gender-focus),50 prisoners or forensic mental

49 Ibid 23.

50 Clive G Long et al, ‘Reducing the Use of Seclusion in a Secure Service for Women’ (2015) 11(2) Journal of Psychiatric Intensive Care 84.

30

health patients,51 children and adolescents,52 older adults,53 and ethnic minorities or migrant groups,54 as well as professionals, typically in clinical settings.

Summarising and Reporting the Results

The thematic analysis is structured as follows. First, we discuss (1) themes and practices that are applicable across hospital and community settings, before focusing on (2) hospital-based and (3) non-hospital measures. We then discuss miscellaneous trends in the literature, including advance planning, supported decision-making and the need for culturally appropriate services.

1. Overarching Themes

This section will discuss overarching approaches to reducing co-ercion before discussing more specific studies based in hospitals and community-based services.

51 Helen Olsson and Ulla-Karin Schön, ‘Reducing Violence in Forensic Care - How Does It Resemble the Domains of a Recovery-Oriented Care?’ (2016) 25(6) Journal of Mental Health 506; Tessa Maguire, R Young and Trish Mar-tin, ‘Seclusion Reduction in a Forensic Mental Health Setting’ 19(2) Journal of Psychiatric and Mental Health Nursing 97.

52 Andrés Martin et al, ‘Reduction of Restraint and Seclusion Through Col-laborative Problem Solving: A Five-Year Prospective Inpatient Study’ (2008) 59(12) Psychiatric Services 1406.

53 Patricia S Mann-Poll et al, ‘Long-Term Impact of a Tailored Seclusion Reduc-tion Program: Evidence for Change?’ (2018) 89(3) Psychiatric Quarterly 733; Elisabeth Gjerberg et al, ‘How to Avoid and Prevent Coercion in Nursing Homes: A Qualitative Study’ (2013) 20(6) Nursing Ethics 632.

54 Marie Louise Norredam et al, ‘Excess Use of Coercive Measures in Psy-chiatry among Migrants Compared with Native Danes.’ (2010) 121(2) Acta Psychiatrica Scandinavica 143; Eric O Noorthoorn et al, ‘Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?’ (2016) 67(12) Psy-chiatric Services 1321; Martin et al, above n 52.

31

Policies and Practices Promoting Human Rights, Recovery and Trauma-Informed Support

Three over-arching themes emerged, which were generally asso-ciated with a shift away from coercive practices. In Watson and colleagues’ terms:

Three frameworks currently used in mental health services – human rights, personal recovery, and trauma-informed – are consistent with a shift away from the use of force.55

These three terms are used in diverse ways to refer to a wide range of policies, practices and law reform efforts. As such, it is difficult to pin-point an evidentiary basis for the causative impact of ‘rights-based’, ‘recovery-oriented’ or ‘trauma-informed’ servic-es, policies and laws on rates of coercion. Each of these catego-ries refer to complex interventions that are often contested and which can be applied in a wide range of national contexts and settings, from low- to high-income countries, in hospitals, respite houses, in-home support services and in efforts to curb coercion in the family home. However, the review findings support Wat-son and colleagues’ general observation that these overarching themes are typically linked to efforts to reduce and end coercive practices. For the purposes of this section we will briefly outline these policy/practice frameworks and highlight several indicative studies. (In-depth consideration of particular studies will occur later in the review in relation to particular practices; for example, respite houses, de-escalation strategies or open door policies).

The basis for human rights approaches to reducing coercion has been described in the Background Section of this report. ‘Human rights’ (and associated terms, such as ‘fundamental’ rights) were explicitly mentioned in the titles, abstracts or keywords of 12

55 Sandy Watson et al, ‘Care without Coercion – Mental Health Rights, Personal Recovery and Trauma-Informed Care’ 49(4) Australian Journal of Social Issues 529.

32

studies.56 This seems a rather low number, and it seems reason-able to suggest that the concept of human rights has not been explicitly used as a framing category in most empirical studies on reducing coercion in mental health settings, though human rights were referred to in the body of several more articles.57 The studies that explicitly refer to human rights tended to do so in relation to: efforts to reduce coercion in low and middle income countries,58 law reform endeavours following the CRPD coming into force (particularly supported decision-making measures in Argentina and the invalidation of some civil commitment powers in Germany),59 and research on self-advocacy by persons with mental health conditions or psychosocial disabilities.60 We will discuss these specific efforts later in the report.

56 Asher et al, above n 8; Francisco J Bariffi and Matthew S Smith, ‘Same Old Game but with Some New Players – Assessing Argentina’s National Mental Health Law in Light of the Rights to Liberty and Legal Capacity under the UN Convention on the Rights of the Persons with Disabilities’ (2013) 31(3) Nordic Journal of Human Rights 325; Paul Cutler, Robert Hayward and Gabriela Tanasan, Supporting User Led Advocacy in Mental Health (Open Society Foundations, 2006); Lili Guan et al, ‘Unlocking Patients with Mental Disorders Who Were in Restraints at Home: A National Follow-Up Study of China’s New Public Mental Health Initiatives’ (2015) 10(4) PLoS ONE e0121425; Jasna Russo and Diana Rose, ‘“But What If Nobody’s Going to Sit down and Have a Real Conversation with You?” Service User/Survivor Perspectives on Human Rights’ (2013) 12(4) Journal of Public Mental Health 184; Sharon Kleintjes, Crick Lund and Leslie Swartz, ‘Organising for Self-Advocacy in Mental Health: Experiences from Seven African Countries’ (2013) 16(3) African Journal of Psychiatry 187; Ragnfrid Eline Kogstad, ‘Protecting Mental Health Clients’ Dignity - The Importance of Legal Control.’ (2009) 32(6) International Journal Of Law and Psychiatry 383; Ellen Meijer et al, ‘Regaining Ownership and Restoring Belongingness: Impact of Family Group Conferences in Coercive Psychiatry’ (2017) 73(8) Journal Of Advanced Nursing 1862; Watson et al, above n 55; Petr Winkler et al, ‘A Blind Spot on the Global Mental Health Map: A Scoping Review of 25 Years’ Development of Mental Health Care for People with Severe Mental Illnesses in Central and Eastern Europe’ (2017) 4(8) The Lancet. Psychiatry 634; Martin Zinkler, ‘Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience’ (2016) 5(1) Laws 15; Sophie Corlett, ‘Policy Watch: A Steady Erosion of Rights.’ (2013) 17(2) Mental Health and Social Inclusion 60.

57 See, eg, Chris Maylea, ‘Minimising Coerciveness in Coercion: A Case Study of Social Work Powers under the Victorian Mental Health Act’ (2017) 70(4) Australian Social Work 465; Diana Rose et al, ‘Service User Perspectives on Coercion and Restraint in Mental Health’ (2017) 14(3) BJPsych International 59; Laura S Shields et al, ‘Unpacking the Psychiatric Advance Directive in Low-Resource Settings: An Exploratory Qualitative Study in Tamil Nadu, India’ (2013) 7 International Journal of Mental Health Systems 29.

58 Guan et al, above n 56; Asher et al, above n 8; Winkler et al, above n 56.

59 Zinkler, above n 56; Bariffi and Smith, above n 56.

60 Kleintjes, Lund and Swartz, above n 56; Cutler, Hayward and Tanasan, above n 56.

33

Recovery-oriented support is prominent in the literature. The term ‘recovery’ appeared in the title, abstract or table of contents of 20 studies,61 and was referred to in the text of several more.62 Leamy and colleagues argue that there are five key themes in the literature on recovery:

• connectedness;

• hope and optimism about the future;

• rebuilding or redefining a positive identity;

61 Lori Ashcraft and William Anthony, ‘Eliminating Seclusion and Restraint in Recovery-Oriented Crisis Services’ (2008) 59(10) Psychiatric Services (Washington, D.C.) 1198; Lori Ashcraft, Michelle Bloss and William A Anthony, ‘Best Practices: The Development and Implementation of “No Force First” as a Best Practice.’ (2012) 63(5) Psychiatric Services (Washington, D.C.) 415; Mary Chambers et al, ‘The Experiences of Detained Mental Health Service Users: Issues of Dignity in Care.’ (2014) 15(1) BMC Medical Ethics 50; Corlett, above n 56; Bevin Croft and Nilüfer Isvan, ‘Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services’ (2015) 66(6) Psychiatric Services 632; Carolyn Doughty and Samson Tse, ‘Can Consumer-Led Mental Health Services Be Equally Effective? An Integrative Review of CLMH Services in High-Income Countries’ (2011) 47(3) Community Mental Health Journal 252; Robert E Drake and Patricia E Deegan, ‘Are Assertive Community Treatment and Recovery Compatible? Commentary on “ACT and Recovery: Integrating Evidence-Based Practice and Recovery Orientation on Assertive Community Treatment Teams”’ (2008) 44(1) Community Mental Health Journal 75; Claire Henderson et al, ‘A Typology of Advance Statements in Mental Health Care’ (2008) 59(1) Psychiatric Services (Washington, D.C.) 63; Matthias Jaeger et al, ‘Patients’ Subjective Perspective on Recovery Orientation on an Acute Psychiatric Unit.’ (2015) 69(3) Nordic Journal Of Psychiatry 188; Kleintjes, Lund and Swartz, above n 56; Renata Kokanović et al, ‘Supported Decision-Making from the Perspectives of Mental Health Service Users, Family Members Supporting Them and Mental Health Practitioners (2018) 52(9) Australian & New Zealand Journal of Psychiatry 826; Harriet P Lefley, ‘Advocacy, Self-Help, and Consumer- Operated Services’ in Alan Tasman et al (eds) Psychiatry (Wiley-Blackwell, 2008) 2083; Long et al, above n 50; Christina Lyons et al, ‘Mental Health Crisis and Respite Services: Service User and Carer Aspirations’ (2009) 16(5) Journal of Psychiatric and Mental Health Nursing 424; Olsson and Schön, above n 51; Sanaz Riahi et al, ‘Implementation of the Six Core Strategies for Restraint Minimization in a Specialized Mental Health Organization’ (2016) 54(10) Journal of Psychosocial Nursing and Mental Health Services 32; Shields et al, above n 57; Watson et al, above n 55; Jennifer P Wisdom et al, ‘The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project’ (2015) 66(8) Psychiatric Services 851; Roberto Mezzina, ‘Community Mental Health Care in Trieste and Beyond: An “Open Door–No Restraint” System of Care for Recovery and Citizenship’ (2014) 202(6) The Journal of Nervous and Mental Disease 440.

62 See, eg, Guan et al, above n 56; Gert Schout et al, ‘The Use of Family Group Conferences in Mental Health: Barriers for Implementation’ (2017) 17(1) Journal of Social Work 52; Mike Slade et al, ‘Alternatives to Standard Acute In-Patient Care in England: Short-Term Clinical Outcomes and Cost-Effectiveness’ (2010) 197(Suppl 53) The British Journal of Psychiatry s14.

34

• pursuing a meaningful life; and

• empowerment through personal responsibility.63

Several practices aimed at reducing coercion drew explicitly from the concept of ‘recovery’. Wisdom and colleagues, for ex-ample, reported that the ‘Positive Alternatives to Restraint and Seclusion’ project of the New York State Office of Mental Health was designed to ‘eliminate the use of [seclusion and restraint] throughout the state’s mental health system of care by creating coercion- and violence-free treatment environments governed by a philosophy of recovery, resiliency, and wellness’.64 The project drew on the ‘Six Core Strategies to Reduce the Use of Seclusion and Restraint’ program, which we will discuss in greater detail shortly. The strategy reportedly resulted in ‘significant decreases in restraint and seclusion episodes per 1,000 client-days’ which included developing ‘ways to facilitate open, respectful two-way communication between management and staff and between staff and youths and greater involvement of youths in program decision making’.65 Riahi and colleagues examine the impact of a Six Core Strategies approach, referring to it explicitly as a ‘recov-ery-oriented’ initiative.66

A ‘trauma-informed’ approach, which again is prominent in the advocacy of organisations for people with psychosocial disabil-ities, was explicitly discussed in only three studies, in which it was positioned as a framing concept for specific efforts to reduce seclusion and restraint.67 Several other studies referred to the traumatising impact of coercive practices.68 ‘Trauma-informed’ approaches involve the recognition of the high prevalence of traumatic experiences in people with mental health issues and

63 Mary Leamy et al, ‘Conceptual Framework for Personal Recovery in Mental Health: Systematic Review and Narrative Synthesis’ (2011) 199(6) The British Journal of Psychiatry 445, 455.

64 Jennifer P Wisdom et al, ‘The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project’ (2015) 66(8) Psychiatric Services 851, 851.

65 Ibid.

66 Riahi et al, above n 61.

67 Muhammad Waqar Azeem et al, ‘Effectiveness of Six Core Strategies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital’ 24(1) Journal of Child and Adolescent Psychiatric Nursing 11.

68 See, eg, Cutler, Hayward and Tanasan, above n 56; Git-Marie Ejneborn Looi, Åsa Engström and Stefan Sävenstedt, ‘A Self-Destructive Care: Self-Reports of People Who Experienced Coercive Measures and Their Suggestions for Alternatives’ (2015) 36(2) Issues in Mental Health Nursing 96; Riahi et al, above n 61; Maylea, above n 57

35

the approach emphasises understanding and responding to the effects of all types of trauma as well as ensuring that practice does not result in re-traumatisation. Azeem and colleagues re-ported on an approach in which a state mental health plan had incorporated trauma-informed care into the Six Core Strategies to Reduce the Use of Seclusion and Restraint discussed below).69 Borckhardt and colleagues also incorporated trauma-informed care into a particular intervention aimed at reducing the rate of seclusion and restraint in an inpatient psychiatric hospital.70 Sev-eral crisis houses, particularly those that are peer-led, place a strong emphasis on addressing histories of trauma in the lives of residents.71 According to the Mental Health Coordinating Council (Australia), there are eight foundational principles of trauma-in-formed care:

• understanding trauma and its impact;

• promoting safety;

• ensuring cultural competence;

• supporting service user control, choice and autonomy;

• sharing power and governance;

• integrating care;

• healing happening in relationships; and

• recovery being possible.72

Given the prominence elsewhere in the mental health-related literature on the importance of trauma-informed support, there appears to be a gap in research explicitly concerned with the impact of trauma-informed approaches to reducing, preventing and ending coercive practices.

69 Azeem et al, above n 67, 11.

70 Jeffrey J Borckardt et al, ‘Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital’ (2011) 62(5) Psychiatric Services 477, 477.

71 See, eg, Alyssum Residential Service, Rochester, Vermont <https://www.alyssum.org/program>.

72 Mental Health Coordinating Council, Trauma Informed Care and Practice: Towards a Cultural Shift in Policy Reform Across Mental Health and Human Services in Australia: A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group (2013) <http://www.mhcc.org.au/media/32045/ticp_awg_position_paper__v_44_final___07_11_13.pdf>.

36

National Policies

Several studies undertook analyses of national practices and policies.73 For example, Noorthoorn and colleagues studied the result of more than 100 reduction projects in 55 hospitals, fol-lowing €35 million in funding from the Dutch government.74 The average yearly nationwide reduction of secluded patients record-ed by this study was about 9%.75 Guan and colleagues studied the result of a national policy in China, referred to as the ‘686’ Program, which was designed to reduce and eliminate incidents of community-based locking away of persons with psychosocial disabilities. Instead, there were concerted efforts made to extend community-based mental health treatment to such persons. The authors report a 92% success rate for those previously detained, as recorded in the year of the empirical research (2012) and sug-gested that the policy sets a useful precedent for low- and mid-dle-income countries.76

Laws Designed to Reduce, End or Prevent Coercion

Six studies examined the impact of legal change on rates of co-ercion in mental health settings. In Germany, in 2011 and 2012, several landmark decisions by Germany’s Constitutional Court and Federal Supreme Court restricted the imposition of invol-untary psychiatric interventions.77 The restriction narrowed the grounds for intervention to ‘life-threatening emergencies’ only.78 The court restrictions were based on Germany’s constitutional obligations as signatories to the CRPD. According to Zinkler, the legal provisions led to ‘examples where clinicians put an even greater emphasis on consensual treatment and did not return to

73 Christoffer Thomsen et al, ‘Risk Factors of Coercion among Psychiatric Inpatients: A Nationwide Register-Based Cohort Study’ (2017) 52(8) Social Psychiatry and Psychiatric Epidemiology 979; Eric O Noorthoorn et al, ‘Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?’ (2016) 67(12) Psychiatric Services 1321; Christopher Toorgard Thomsen et al, ‘Patient-controlled Hospital Admission for Patients with Severe Mental Disorders: A Nationwide Prospective Multicentre Study’ (2018) 137(4) Acta Psychiatrica Scandinavica 355; Martin Zinkler, ‘Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience’ (2016) 5(1) Laws 15; Fleur J Vruwink et al, ‘The Effects of a Nationwide Program to Reduce Seclusion in the Netherlands’ (2012) 12 BMC Psychiatry 231; PS van der Schaaf et al, ‘Impact of the Physical Environment of Psychiatric Wards on the Use of Seclusion’ (2013) 202 The British Journal Of Psychiatry 142.

74 Noorthoorn et al, above n 54.

75 Ibid.

76 Guan et al, above n 56.

77 Federal Constitutional Court (Germany), ‘Press Office - Press Release No 28/2011 of 15 April 2011, Order of 23 March 2011’, 2 BvR 882/09.

78 Ibid.

37

coercive treatment’.79 Flammer and Steinart point to some evi-dence that the legal reform led to a reduction in the use of invol-untary medication, although the study was small-scale.80 Despite the overall reduction, they reported some adverse effects, includ-ing a possible increase in some services of ‘violent incidents’, which potentially increased the use of physical and mechanical restraint.81

Argentina’s National Mental Health Law 2010 (‘NMHL’)82 was the subject of a small qualitative study. The NMHL contains a mech-anism that requires any civil commitment measure to be based on interdisciplinary evaluations that seek to assess not just the person’s mental health condition but the availability of support in his or her life and the harm caused by involuntary interven-tions.83 Bariffi and Smith argue that ‘the evolving practice arising from the interdisciplinary evaluation requirement, suggests that interdisciplinary teams aware of the CRPD may prove effective in promoting the replacement of restrictions with supported deci-sion-making arrangements’.84

The teams consist of psychiatrists, psychologists, lawyers and social workers, who reportedly use the CRPD as a guide in com-municating and reporting to judges, including highlighting a person’s communication needs, considering whether past expe-riences of involuntary treatment have compromised the person’s autonomy and personal development, and looking for gaps that could be remedied with services.85 Aside from Bariffi and Smith’s study, which reports on several cases under the NMHL, there does not appear to be any English-language research on how this

79 Martin Zinkler, ‘Germany without Coercive Treatment in Psychiatry—A 15 Month Real World Experience’ (2016) 5(1) Laws 15.

80 Erich Flammer and Tilman Steinert, ‘Involuntary Medication, Seclusion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013’ (2015) 6 Frontiers in Psychiatry 153.

81 Ibid.

82 Law No 26657, 3 December 2010 [32041] BO 1; ‘Mental Health Regime’, House of Representatives Res D-276/07 (7 March 2007) art 1.

83 Francisco J Bariffi and Matthew S Smith, ‘Same Old Game but with Some New Players – Assessing Argentina’s National Mental Health Law in Light of the Rights to Liberty and Legal Capacity under the UN Convention on the Rights of the Persons with Disabilities’ (2013) 31(03) Nordic Journal of Human Rights 325, 325.

84 Ibid 339.

85 Ibid 340.

38

measure is working in practice, including no indication that data on involuntary hospitalisation is being collected.86

Bruckner and colleagues undertook a study in California, the United States, to examine the impact of California’s Mental Health Services Act 2004 (MHSA) on quarterly rates of ‘72-hour holds’ (N=593,751) and ‘14-day psychiatric hospitalizations’ (N=202,554).87 They examined 28 Californian counties, with over 22 million inhabitants, from 2000-07. They sought to test the hy-pothesis that the incidence of the two types of involuntary treat-ment, 72-hour holds and 14-day psychiatric civil commitments, declined as the service access and quality was improved by the $3.2 billion tax revenue investment associated with the MHSA in California. They reported that the petitions for involuntary 14-day hospitalisations, but not involuntary 72-hour holds, fell below expected values after disbursement of MHSA funds. In these counties, 3,073 fewer involuntary 14-day treatments – ap-proximately 10% below expected levels – could be attributed to disbursement of MHSA funds. They concluded that fewer than expected involuntary 14-day holds for continued hospitalisation may indicate an important shift in service delivery, and argue that MHSA funds may have facilitated the discharge of clients from hospitals by providing enhanced resources and access to a range of less-restrictive community-based treatment alternatives.

Research conducted by the Vermont Department of Mental Health in the United States, is notable with regards to legislative change and a requirement placed on the Vermont government to report on developments aimed at ending and reducing coercive mental health practices. The Department is obliged under state law to report annually ‘regarding the extent to which individuals with a mental health condition or psychiatric disability receive care in the most integrated and least restrictive setting availa-ble’,88 including reporting on the following:

86 See, Bariffi and Smith, above n 83. See also, Ana Laura Aiello, ‘Argentina’ in Lisa Waddington and Anna Lawson, The UN Convention on the Rights of Persons with Disabilities in Practice: A Comparative Analysis of the Role of Courts (Oxford University Press, 2018) Ch 2.

87 Tim A Bruckner et al, ‘Involuntary Civil Commitments After the Implementation of California’s Mental Health Services Act’ (2010) 61(10) Psychiatric Services 1006, 1006.

88 2017 Vermont Statutes, Title 18 – Health, Chapter 174 - Mental Health System of Care, § 7256 Reporting requirements.

39

(6) ways in which patient autonomy and self-determination are maximized within the context of involuntary treatment and medication;

(7) performance measures that demonstrate results and other data on individuals for whom petitions for involuntary medication are filed; and

(8) progress on alternative treatment options across the system of care for individuals seeking to avoid or reduce reliance on medications, including supported withdrawal from medications.89

It is not clear to what extent such reporting requirements impact upon rates of coercion in mental health services.

Eytan and colleagues examined the impact of a law introduced in Switzerland in 2006, in which only certified psychiatrists were authorised to require a compulsory admission, whereas previous-ly, all physicians could do so, including ‘residents’.90 The study, which was based on a single hospital in Switzerland led to a sig-nificant reduction in compulsory admissions, with service users being less likely to be hospitalised on a compulsory basis after the change. The proportion of compulsory admissions increased from 55% in 2001 to 69% in 2005. After the law was introduced, this proportion decreased to 48% in 2007 and remained below 50% thereafter. According to the authors, the results ‘strongly suggest that limiting the right to require compulsory admissions to fully certified psychiatrists can reduce the rate of compulsory versus voluntary admissions’.91 This reform endeavour will not satisfy the high standard of the CRPD Committee, given its di-rective to repeal mental health legislation authorising involuntary interventions. However, this relatively modest study may provide a strategy to reduce rates of involuntary intervention within the general framework of existing law.

In Italy, Mezzina undertook a general review of the available liter-ature on ‘Law 180’, a law which precipitated Italian deinstitution-alisation. Mezzina presents some evidence of the laws impact over 40 years, stating that ‘[m]echanical restraints have been abolished in health and social care, including nursing homes and

89 Ibid (6)-(8).

90 Ariel Eytan et al, ‘Impact of Psychiatrists’ Qualifications on the Rate of Compulsory Admissions’ (2013) 84(1) Psychiatric Quarterly 73, 73.

91 Ibid.

40

general hospitals’.92 He points out that after the law was enacted in 1978, involuntary treatments ‘dropped dramatically’ and ‘have sustained the lowest ratio in Europe (17/100,000 in 2015) and the shortest duration (10 days)’.93 However, it is not clear to which data he is referring when making this claim. Mezzina further notes in relation to rates in the city of Trieste and also the Friu-li-Venezia region that ‘[i]nvoluntary treatments show the lowest rate in Italy, and about 40% of them are managed in [Community Mental Health Centres] with open doors.’94 We will discuss the Trieste model of mental healthcare in Section 2.2 of this report.

‘Peer-Led’ Initiatives and Research

One theme in the literature concerns the wide range of initiatives led by persons with mental health conditions or psychosocial disabilities. These initiatives include self-help organisations and community development groups,95 state-supported service user organisations, independent activist groups, ‘peer-workforces’ in hospitals and other mental health services. These groups appear across low, middle-, and high-income countries. Because of this diversity, this specific section on user-led initiatives will refer to some of the prominent studies on such initiatives, but will dis-cuss them in greater detail when referring to specific practices (such as ‘peer-run crisis centres’ and ‘self-help groups’).

Organisations or groups representing service users, former ser-vice users and others with psychosocial disabilities are inclined to advocate for stronger measures to reduce and end coercion and to aim for more ambitious change in practice, compared to other stakeholder groups, such as clinicians or clinician re-searchers who have led most of the published intervention stud-ies. Often, such organisations stress the need for elimination of seclusion and restraint,96 which has not been the explicit target of any largescale research published study to date. According to Rose and colleagues, in their report on a survey of 65 service

92 Roberto Mezzina, ‘Forty Years of the Law 180: The Aspirations of a Great Reform, Its Successes and Continuing Need’ (2018) 27(4) Epidemiology and Psychiatric Sciences 336.

93 Ibid.

94 Mezzina, above n 92.

95 See, eg, ‘TCI-Asia’ and ‘Club House’ initiatives in Appendix Three.

96 See, eg, World Network of Users and Survivors of Psychiatry, Human Rights Position Paper of the World Network of Users and Survivors of Psychiatry <http://www.wnusp.net/index.php/human-rights-position-paper-of-the-world-network-of-users-and-survivors-of-psychiatry.html>; Balance Aotearoa, ‘Disability Action Plan’ <http://www.balance.org.nz/disability-action-plan>.

41

users in England, ‘[f]rom the perspective of service users, co-ercion and restraint are mostly harmful and must stop being le-gitimised’.97 The material in this review shows little evidence of hospitals involving people with lived experience of mental health issues in planning, oversight or review of strategies to reduce and eliminate coercion in mental health practices, though there are exceptions.98

As noted, most empirical research by persons with psychosocial disabilities does not focus directly on coercion but rather practic-es designed to address unmet need. The Users and Survivors of Psychiatry – Kenya (USPK), for example, examined the role of or-ganised and informal peer support in ‘exercising legal capacity in Kenya’.99 The study focused on 10 peer-support meetings (com-prising users, carers, friends, USPK staff members) with eight additional interviews with service users. The researchers sought to identify concrete examples of decisions taken with the support of peers, which included informal advance directives, representa-tional supports and other practices that the formal literature indi-cates helps to reduce coercive interventions (as discussed later in the report). Other studies, such as Foxlewin’s empirical study, commissioned by the Australian Capital Territory Mental Health Consumer Network, were explicitly aimed at seclusion reduction – again, he reports incidence rates falling from 6.9% in 2008/9 to less than 1% in 2010/11.100

Some empirical studies indicated that certain types of user-led initiatives were not associated with any impact on coercion. For example, Thomsen and colleagues produced evidence indicating that ‘patient-controlled admission’ did not reduce coercion.101 On the other hand, Croft and Isvan compared 139 users of ‘peer res-pite’ with 139 non-users of respite with similar histories of behav-ioural health service use and clinical and demographic character-istics, finding that the odds of using any inpatient or emergency services after the programme start date were approximately 70%

97 Rose et al, above n 57.

98 See, eg, Foxlewin, above n 44.

99 See, eg, Users and Survivors of Psychiatry – Kenya, ‘The Role Of Peer Support In Exercising Legal Capacity In Kenya’ (April 2018) 1 <www.uspkenya.org>.

100 Foxlewin, above n 44.

101 Thomsen et al, ‘Patient-controlled Hospital Admission for Patients with Severe Mental Disorders: A Nationwide Prospective Multicentre Study’, above n 73, 355.

42

lower among respite users than non-respite users.102 (However, the odds reportedly increased with each additional respite day and the association ‘was one of diminishing returns, with negligi-ble decreases predicted beyond 14 respite days’).103 The authors conclude that by reducing the need for inpatient and emergency services for some individuals, peer respites may increase mean-ingful choices for recovery and decrease ‘reliance on costly, co-ercive, and less person-centered modes of service delivery’.104 Other studies concerning user-led initiatives did not directly engage with the issue of coercive treatment, though discussed positive impacts of user-led initiatives that are likely to contrib-ute to the reduction and ending of coercion. Tanenbaum, for ex-ample, undertook qualitative research and argued that user-led organisations helped address the community needs of formerly institutionalised populations, and provided a counter-argument to those who insist that ‘deinstitutionalisation’ and ‘community care’ have failed.105

Many studies sought to include the views of persons with psy-chosocial disabilities.106 It is also true that many studies – both qualitative and quantitative – did not incorporate the views of service users, former service users or others with psychosocial disabilities.

It was not always possible to identify which studies were led by, co-authored by, or co-designed by persons with mental health conditions or psychosocial disabilities. Some people may not self-identify in this way. Others who do may not make a point of

102 Bevin Croft and Nilüfer Isvan, ‘Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services’ (2015) 66(6) Psychiatric Services 632, 632.

103 Ibid, 632.

104 Ibid.

105 Sandra J Tanenbaum, ‘Consumer-Operated Service Organizations: Organizational Characteristics, Community Relationships, and the Potential for Citizenship’ (2012) 48(4) Community Mental Health Journal 397, 397.

106 See, eg, Kolja Heumann, Thomas Bock and Tania M Lincoln, ‘Please Do Something - No Matter What! A Nationwide Online Survey of Mental Health Service Users About the Use of Alternatives to Coercive Measures’ (2017) 44(2) Psychiatrische Praxis 85; Len Bowers et al, ‘Locked Doors: A Survey of Patients, Staff and Visitors.’ (2010) 17(10) Journal of Psychiatric And Mental Health Nursing 873; William A Fisher, ‘Elements of Successful Restraint and Seclusion Reduction Programs and Their Application in a Large, Urban, State Psychiatric Hospital’ (2003) 9(1) Journal of Psychiatric Practice 7; Marvin S Swartz, Jeffrey W Swanson and Michael J Hannon, ‘Does Fear of Coercion Keep People Away from Mental Health Treatment? Evidence from a Survey of Persons with Schizophrenia and Mental Health Professionals.’ (2003) 21(4) Behavioral Sciences & The Law 459.

43

it in the studies they conduct. Four studies, to our knowledge, were led by researchers who had experience using mental health services,107 with several others involved as a co-author.108 One notable initiative is the EURIKHA Project, which is a ‘global us-er-controlled research project looking at the emergence of social movements which privilege the rights and perspectives of people who experience severe mental distress, variedly known around the world as users, survivors, consumers, clients, patients, per-sons with psychosocial disabilities, etc’.109 This relatively new project may provide a useful resource for collating and fostering research on coercive practices that is led by persons with mental health conditions and psychosocial disabilities.

Providing Family-based Support when Responding to Crises and Support Needs

Several studies considered the role of support that was explicitly directed to a person within the context of their family and/or so-cial network. This included both hospital and non-hospital-based crisis resolution.

The Finnish practice of Open Dialogue includes an emphasis on working with a person in their family and/or social network. The practice is presented as an alternative to hospital and is there-fore associated with reduced likelihood of involuntary treatment. Seikkula and colleagues’ small-scale comparative analysis of 45 adults who were given Open Dialogue support compared with 14 service users in typical acute services, indicates that the Open Dialogue approach, ‘like other family therapy programs, seems to produce better outcomes than conventional treatment’.110 We will discuss Open Dialogue later in the report, in relation to Com-munity Crisis Resolution and Home Support, though we note

107 Tanenbaum, above n 105; Foxlewin, above n 44; Russo and Rose, above n 56; Watson et al, above n 55.

108 Barbara Barrett et al, ‘Randomised Controlled Trial of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: Economic Outcomes’ (2013) 8(11) PLoS One e74210; Helen Gilburt et al, ‘The Importance of Relationships in Mental Health Care: A Qualitative Study of Service Users’ Experiences of Psychiatric Hospital Admission in the UK’ (2010) 197(Suppl 53) The British Journal of Psychiatry s26; Graham Thornicroft et al, ‘Clinical Outcomes of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: A Randomised Controlled Trial’ (2013) 381(9878) The Lancet 1634.

109 The Eurikha Project <https://www.eurikha.org/about/>

110 Jaakko Seikkula et al, ‘Open Dialogue Approach: Treatment Principles and Preliminary Results of a Two-Year Follow-Up on First Episode Schizophrenia’ (2003) 5(3) Ethical Human Sciences and Services 163, 164.

44

here that there does not appear to be any empirical research on its impact on rates of coercion. Further, as with all family-based interventions, the benefits may be undermined where family re-lationships are a source of stress and trauma for an individual.

Family Group Conferencing (FGC) was discussed in five stud-ies, all of them from the Netherlands.111 Schout, Meijer and de Jong refer to FCG as a ‘“family-driven” decision-making model and social network strategy’.112 De Jong and Schout describe FGC as follows:

the traditional method of decision making in which the professional is in charge is abandoned; it is the family who determines the agenda. Families often find better solutions than care providers. Family Group Conferences (FGCs) enable families to cope with problems in a manner that is consistent with their own culture, lifestyle and history. Unlike traditional approaches that are often ‘family-centred’, a FGC is ‘family-driven’. In other words, the approach is not aimed at the family, but achieves results through the family. Family Group Conferencing employs the resources within society—the natural resources of the family, friends and neighbours are mobilised.113

De Jong and Schout examined whether FGC is an effective tool to ‘generate social support, to prevent coercion and to promote social integration’, reporting on the ‘steady growth in conferences’ in the Netherlands in recent years.114 They report that an amendment to the Dutch Civil Code designates FGC as ‘good practice’.115 Meijer and colleagues (including de Jong and Schout) followed this proposal with a study involving 41 family

111 Gert Schout, Ellen Meijer and Gideon de Jong, ‘Family Group Conferencing—Its Added Value in Mental Health Care’ (2017) 38(6) Issues in Mental Health Nursing 480; Gert Schout et al, ‘The Use of Family Group Conferences in Mental Health: Barriers for Implementation’ (2017) 17(1) Journal of Social Work 52; Gideon de Jong and Gert Schout, ‘Prevention of Coercion in Public Mental Health Care with Family Group Conferencing’ (2010) 17(9) Journal Of Psychiatric And Mental Health Nursing 846; Gideon de Jong and Gert Schout, ‘Researching the Applicability of Family Group Conferencing in Public Mental Health Care’ (2013) 43(4) British Journal of Social Work 796; Ellen Meijer et al, ‘Regaining Ownership and Restoring Belongingness: Impact of Family Group Conferences in Coercive Psychiatry’ (2017) 73(8) Journal Of Advanced Nursing 1862.

112 Schout, Meijer and de Jong, above n 111, 480.

113 de Jong and Schout, ‘Researching the Applicability of Family Group Conferencing in Public Mental Health Care’, above n 111, 796, 797.

114 Ibid, 796.

115 Ibid.

45

group conferences in three regions.116 Survey and observation data was used to identify the impact of the practice on coercive treatment in adult psychiatry.117 They conclude that family group conferencing ‘seems a promising intervention to reduce coercion in psychiatry’ by helping to ‘regain ownership and restore[] be-longingness’.118 They argue that ‘[i]f mental health professionals take a more active role in the pursuit of a [sic] family group con-ferences and reinforce the plans with their expertise, they can strengthen the impact even further’.119 In the same year, Schout and colleagues examined 17 families/social networks engaged in FCG and sought to identify barriers to applying Family Group Conferences, including identifying when it is not appropriate. 120 They identified the following barriers:

1. (the acute danger in coercion situations, the limited time available, the fear of liability and the culture of control and risk aversion in mental health care;

2. the severity of the mental state of clients leading to difficulties in decision-making and communication;

3. considering a Family Group Conference and involving familial networks as an added value in crisis situation is not part of the thinking and acting of professionals in mental health care;

4. clients and their network (who) are not open to an [sic] Family Group Conference.121

Awareness of the barriers for Family Group Conferences, they ar-gue, can ‘help to keep an open mind for its capacity to strengthen the partnership between clients, familial networks and profession-als’ and ‘can help to effectuate professional and ethical values of social workers in their quest for the least coercive care’.122 Two other Dutch studies, by Boumans and colleagues, examines how the ‘methodical work approach’ could be utilised to reduce se-clusion, which includes an explicit process of involving family

116 Meijer et al, above n 111, 1862.

117 Ibid.

118 Ibid.

119 Ibid.

120 Schout et al, ‘The Use of Family Group Conferences in Mental Health: Barriers for Implementation’ above n 111, 52.

121 Ibid.

122 Ibid.

46

in responding to treatment in acute hospital settings.123 We will discuss this approach in more detail in the Hospital-Based Strat-egies Section of this report.

In low- and middle-income countries, research suggested that family-based interventions were important to address the restraint of persons with mental health conditions and psychosocial dis-abilities in community-settings. Asher and colleagues’ research with adults with schizophrenia, ‘their caregivers, community leaders and primary and community health workers’ in rural Ethi-opia indicated that increasing access to treatment was the most effective way to reduce the incidence of restraint.124 Guan and colleagues conducted a largescale project in China involving a nationwide two-stage follow-up study to measure the effective-ness and sustainability of the ‘unlocking and treatment’ interven-tion and its impact on the ‘well-being of patients’ families’.125 The emphasis on family wellbeing rather than individual wellbeing is notable. The authors reported that over 92% of participants remained free of restraints in 2012 and they argued that ‘[p]rac-tice-based evidence from our study suggests an important model for protecting the human rights of people with mental disorders and keeping them free of restraints […][via] accessible, commu-nity based mental health services with continuity of care’.126 The programme focused on ‘promoting rehabilitation and recovery, family education and support, and making medications contin-uously available’.127 (The 686 Programme is discussed below in the regional analysis concerning Asia). The studies noted here are just a handful of those framed around family intervention, or strong family involvement, though others will be discussed throughout.

123 Christien E Boumans et al, ‘Reduction in the Use of Seclusion by the Methodical Work Approach’ (2014) 23(2) International Journal of Mental Health Nursing 161; Christien E Boumans et al, ‘The Methodical Work Approach and the Reduction in the Use of Seclusion: How Did It Work?’ (2015) 86(1) Psychiatric Quarterly 1.

124 Laura Asher et al, ‘“I Cry Every Day and Night, I Have My Son Tied in Chains”: Physical Restraint of People with Schizophrenia in Community Settings in Ethiopia’ (2017) 13 Globalization and Health 47, 47.

125 Guan et al, above n 56, e0121425.

126 Ibid.

127 Ibid (emphasis added).

47

2. Hospital-based Strategies for Reducing Coercion

The literature on hospital-based practices identifies a number of strategies for reducing coercion such as seclusion reduction/elimination (including ‘Six Core Strategies’ and ‘Safewards’ ap-proaches), open door policies, improving ward culture and staff/patient ratios.

Perhaps one of the most important emerging themes is that both top-down and local-level leadership (that is at the ward level) is important in order to create and to maintain culture change. There is some indication that leadership should include peer in-volvement for ultimate effectiveness.

Reducing Seclusion and Restraint

Seclusion and restraint are interventions currently permitted for use in mental health services and other settings to control or manage a person’s behaviour. Restraint is also used on in-dividuals with mental health issues in prisons, remand centres, emergency departments and by police and emergency transport providers. Seclusion and restraint are generally defined in mental health legislation. The term 'restraint' may encompass physical, mechanical and/or chemical forms of restraint.

A recurring theme in the literature was differences in formal defi-nitions of restraint and no uniform requirements for reporting, which makes it difficult to ascertain whether or not rates of seclu-sion and restraint are falling. However, it is clear that there have been attempts by governments and mental health organisations towards implementing multi-level strategies to reduce the use of seclusion and all forms of restraint. Several studies indicate that many of these practices are effective.

48

Fifty-one studies were concerned with reducing, preventing and ending ‘seclusion’ and/or ‘restraint’ in mental health settings.128 Five of these, from studies in China, Indonesia and Ethiopia, re-lated to restraint in family and communal settings, outside the hospital, which we will discuss later in the report. Many mental health practitioners, service users and family organisations have embraced the aim to prevent and reduce or end seclusion and restraint.

‘Six Core Strategies to Reduce the Use of Seclusion and Restraint’

Six empirical studies examined the implementation and out-comes of the Six Core Strategies to Reduce the Use of Seclusion and Restraint.129 Many of these endeavours reflect the strategies set out in a 2005 document entitled Six Core Strategies to Reduce the Use of Seclusion and Restraint Planning Tool which was re-leased by the National Technical Assistance Center in the United States.130 These strategies are:

1. ‘Leadership towards organizational change’— articulating a philosophy of care that embraces seclusion and restraint reduction;

2. ‘Using data to inform practice’ — using data in an empirical, ‘non-punitive’ way to examine and monitor patterns of seclusion and restraint use;

128 See, eg, Anu Putkonen et al, ‘Cluster-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men With Schizophrenia’ (2013) 64(9) Psychiatric Services 850; Fleur J Vruwink et al, ‘The Effects of a Nationwide Program to Reduce Seclusion in the Netherlands’ (2012) 12(1) BMC Psychiatry 231; PS van der Schaaf et al, ‘Impact of the Physical Environment of Psychiatric Wards on the Use of Seclusion’ (2013) 202 The British Journal of Psychiatry 142; Lori Ashcraft and William Anthony, ‘Eliminating Seclusion and Restraint in Recovery-Oriented Crisis Services’ (2008) 59(10) Psychiatric Services 1198; Eric O Noorthoorn et al, ‘Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?’ (2016) 67(12) Psychiatric Services 1321; Patricia S Mann-Poll et al, ‘Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?’ (2018) 89(3) Psychiatric Quarterly 733.

129 Azeem et al, above n 67; Riahi et al, above n 61; Maguire, Young and Martin, above n 51; Wisdom et al, above n 61; Foxlewin, above n 44; Long et al, above n 50; Dow A Wieman et al, ‘Multisite Study of an Evidence-Based Practice to Reduce Seclusion and Restraint in Psychiatric Inpatient Facilities’ (2014) 65(3) Psychiatric Services 345.

130 National Technical Assistance Center, Six Core Strategies to Reduce the Use of Seclusion and Restraint Planning Tool (Alexandria, VA: National Association of State Mental Health Program Directors, 2005) <https://www.nasmhpd.org/content/six-core-strategies-reduce-seclusion-and-restraint-use>.

49

3. ‘Workforce’ — developing procedures, practices and training that are based on knowledge and principles of mental health recovery;

4. ‘Use of seclusion and restraint reduction tools’ — using assessments and resources to individualise aggression prevention;

5. ‘Consumer roles in inpatient settings’ — including consumers, carers and advocates in seclusion and restraint reduction initiatives; and

6. ‘Debriefing techniques’ — conducting an analysis of why seclusion and restraint occurred and evaluating the impacts of these practices on individuals with lived experience.131

These strategies have been used in services in the United States, Canada, Australia and New Zealand and there have been several studies, with the most tested strategy being that of leadership.132 Much of the literature on this topic deals with the importance of top-down organisational leadership in conjunction with local level leadership (for example, at ward level) in order to create and maintain culture change. It may be that the emphasis on leadership as a strategy for change reflects the fact that a lot of the research in the field is management - rather than service user - driven. Many seclusion reduction projects feature the strategy of staff training and the use of new assessment, review and de-briefing tools. Very few reported projects incorporate consumer/service user roles, as recommended in the Six Core Strategies, with some notable exceptions.133

Six empirical studies in this review, and one notable grey litera-ture study, examined the use of the Six Core Strategies approach and all reported a significant decrease in the use of seclusion and restraint.134 The studies focused upon services for children and young people,135 adult inpatient wards136 and forensic services.137 Aside from the studies involving forensic services, it appears that

131 Ibid, 1-3.

132 Melbourne Social Equity Institute, Seclusion and Restraint Project: Report (University of Melbourne, 2014).


134 Azeem et al, above n 67; Maguire, Young and Martin, above n 51; Riahi et al, above n 61; Wieman et al, above n 129; Wisdom et al, above n 61.

135 Azeem et al, above n 67; Wisdom et al, above n 61.

136 Riahi et al, above n 61; Wieman et al, above n 129.

137 Maguire, Young and Martin, above n 51; Long et al, above n 50.

50

the testing of the Six Core Strategies approach occurred in ser-vices with a mixture of people who are voluntary service users and those subject to involuntary orders.

Two peer-reviewed studies examined adult inpatient services in North America. Riahi and colleagues studied the Six Core Strategies approach in a recovery-oriented, tertiary level mental health care facility in Ontario, Canada. Over a three year period they reported a 19.7% decrease in incidents of seclusion and restraint from 2011/12 to 2013/14, with a 38.9% decrease in the average length of a mechanical restraint or seclusion incident over the 36-month evaluation period.138 Wieman and colleagues undertook a comparative study on the application of the Six Core Strategies across 43 inpatient psychiatric facilities in the Unit-ed States, which had planned to introduce the strategies. They distinguished between five ‘category types’ among services: those that had ‘stabilised’ use of the strategies (N=28), those which continued seeking to implement them (N=7), services which decreased their use of the strategies (N=5), and those that discontinued the use of strategies (N=1), or never implemented them (N=2). They reported that the ‘stabilized group’ reduced the percentage secluded by 17% (p=.002), seclusion hours by 19% (p=.001), and proportion restrained by 30% (p=.03). The re-duction in restraint hours was 55% but non-significant (p=.08). They concluded that the strategy was ‘feasible to implement and effective in diverse facility types’.139 Fidelity over time was non-linear and varied among facilities, and the researchers called on further research on relationships between facility characteristics, fidelity patterns, and outcomes.

Two studies examined the use of the Six Core Strategies in ser-vices for children and young people. Azeem and colleagues examined its application in services for young people (females 276/males 182).140 Their three-year study reported a downward trend in seclusions/restraints among hospitalised youth after im-plementation of National Association of State Mental Health Pro-gram Directors’ Six Core Strategies based on trauma-informed care.141 Wisdom and colleagues evaluated the impact of the Six Core Strategies implemented in three participating residen-tial treatment programmes for ‘children with severe emotional

138 Riahi et al, above n 61, 32.

139 Wieman et al, above n 129, 345.

140 Azeem et al, above n 67, 11.

141 Ibid.

51

disturbances’ in New York, the United States.142 The three par-ticipating mental health treatment facilities demonstrated sig-nificant decreases in restraint and seclusion episodes per 1,000 client-days. Each identified specific activities that contributed to success, including ways to facilitate open, respectful two-way communication between management and staff and between staff and youths and greater involvement of youths in programme decision making.

Two studies on the Six Core Strategies considered forensic mental health services.143 (These were two of only three studies concerning forensic services identified in the review). Maguire, Young and Martin examined the application of the Six Core Strat-egies to a 116-bed forensic hospital in Australia. The research-ers concluded that ‘reducing seclusion in a forensic hospital is a complex undertaking as nurses must provide a safe environment while dealing with volatile patients and may have little alternative at present but to use seclusion after exhausting other interven-tions’.144 In the second study focusing on forensic services, Long and colleagues sought to evaluate efforts, ‘which reflect elements of the six core strategies’, to minimise the use of seclusion ‘in re-sponse to risk behaviours’ among 38 women admitted to the me-dium secure unit of an independent charitable trust in England.145 The intervention reportedly led to a significant reduction in the number of seclusions and risk behaviour post-change, which ‘was complemented by improved staff ratings of institutional be-haviour, increased treatment engagement and a reduction in time spent in medium security’.146 Staff and patients rated the most effective strategies differently, with staff favouring ward train-ing and use of de-escalation techniques as most effective, while patients favoured the ‘Relational Security’ item of ‘increased in-dividual engagement’ and ‘timetabled Behaviour Chain Analysis sessions’.147 Long and colleagues argue that the findings confirm that ‘seclusion can be successfully reduced without an increase in patient violence or alternative coercive strategies’,148 though as with Maguire and colleagues, the researchers stop short of arguing that seclusion can be eliminated.

142 Wisdom et al, above n 61, 851.

143 Maguire, Young and Martin, above n 51; Long et al, above n 50.

144 Maguire, Young and Martin, above n 51, 97.

145 Long et al, above n 50, 85.

146 Ibid.

147 Ibid.

148 Ibid.

52

One noteworthy non-peer reviewed study was led by Foxlewin,149 and is included in Appendix Two. Foxlewin led a service user or ‘consumer’-controlled empirical study, overseen in Australia by the Australian Capital Territory Mental Health Consumer Net-work. The study was aimed at seclusion reduction intervention at the Canberra Hospital Psychiatric Services Unit beginning in 2009 using features of the Six Core Strategies. Foxlewin notes other features of the Six Core Strategies that were employed at Canberra Hospital from 2006- 2009, including the formation of a Seclusion and Restraint Working Group in line with the strategy of Organisational Leadership and the involvement of many key staff investigating reduction possibilities.150 They combined the strat-egies with a strong emphasis on the involvement of consumer workers, or peer-workers, in the hospital. Overall, the programme contributed to a reduction in seclusion incidents from 6.9% in the year 2008/9 to less than 1% in 2010/11.151 It appears that the study occurred in relation to those under compulsory treatment orders. Although this project report is not peer reviewed, it is valuable for the added description of a consumer-led strategy.

Studies suggest that the Six Core Strategies approach can serve to reframe seclusion and restraint as a service failure. (It is per-haps noteworthy that forensic services may be particularly chal-lenging in this respect, given Maguire, Young and Martin’s con-clusion that staff ‘may have little alternative at present but to use seclusion after exhausting other interventions’, though even they report on the effectiveness of the Six Core Strategies in reducing overall restraint and seclusion incidents in their case study).152 Al-though the pool of empirical research uncovered in this review is relatively small, the strategies appear to have diverse application, with success reported in adult, child and adolescent and forensic mental health services.

The empirical research studies and grey literature analysed by the research team also suggest the following interventions may reduce the use of seclusion and restraint, and broader hospi-tal-level coercive practices:


150 Ibid.

151 Ibid.

152 Maguire, Young and Martin, above n 51, 97. For other seemingly effective interventions to reduce coercion in forensic services, see Olsson and Schön, above n 51; Long et al, above n 50.

53

• national oversight;

• organisational culture change through an emphasis on recovery, trauma-informed care and human rights; and

• independent advocacy directed at public opinion, politicians, policymakers and service providers. Future research should focus on mental health care policies targeted at empowering treatment approaches, respecting the patient’s autonomy and promoting reductions of institutional coercion.

One further intervention that does not appear in the Six Core Strategies that shows promise relates to physical changes to the environment, which will be discussed shortly. Borckhardt and colleagues have observed that physical changes to the environ-ment are some of the easiest changes to implement.153

Of the studies that looked at multiple interventions such as the Six Core Strategies, it is not possible to tell which particular fac-tors led to a reduction in seclusion and/or restraint. In some of the literature, there was either no pre-testing or the data was not compared with data from settings that did not undertake inter-ventions. Stewart and colleagues, in their review of methods to reduce seclusion and restraint, reported that the research did not address which programme components were most successful and called for more attention to understanding how interventions work, particularly from the perspective of nursing staff.154

Open Door Policies

Six studies examined locked/unlocked door policies in mental health wards. Again, this section of the report is referring specif-ically to hospital settings.

Huber and colleagues have argued that doors are locked in hos-pitals due to the belief that doing so will prevent absconding, su-icide attempts, and death by suicide.155 However, they argue that ‘there is insufficient evidence that treatment on locked wards can effectively prevent these outcomes’ and their own study indicates

153 Borckardt et al, above n 70.

154 Duncan Stewart et al, ‘A Review of Interventions to Reduce Mechanical Restraint and Seclusion among Adult Psychiatric Inpatients’ (2010) 31(6) Issues in Mental Health Nursing 413.

155 Christian G Huber et al, ‘Suicide Risk and Absconding in Psychiatric Hospitals with and without Open Door Policies: A 15 Year, Observational Study’ (2016) 3(9) The Lancet Psychiatry 842, 842.

54

that ‘locked doors might not be able to prevent suicide and ab-sconding’.156 On the contrary, their study even offered some evi-dence that open wards are associated with a ‘decreased probabil-ity of suicide attempts (OR 0·658, 95% CI 0·504–0·864; p=0·003), absconding with return (0·629, 0·524–0·764; p<0·0001), and ab-sconding without return (0·707, 0·546–0·925; p=0·01), but not completed suicide (0·823, 0·376–1·766; p=0·63)’.157

Bowers and colleagues have reported that locking doors in psy-chiatric wards in England has increased in recent years, but that this has received little attention by researchers.158 Bowers and colleagues conducted a survey in England, receiving responses from a total of 1227 patients, staff and visitors on the practice of door locking in acute psychiatry wards. They identified five factors (adverse effects, staff benefits, patient safety benefits, patient comforts and cold milieu) associated with door locking.159 The researchers did not consider the impact of open door policies on other forms of seclusion and restraint. Instead, they focused on service user, visitor and staff perceptions: service users held more negative views about door locking than staff, including re-porting feeling anger, irritation and depression as a consequence of locked doors, while staff tended to associate locked wards more positively, as did the (relatively few) visitors who responded to the survey.

Another study, by Greenfield and colleagues in the United States, compared the effectiveness of an unlocked, mental health con-sumer-managed, crisis residential programme (CRP) to a locked, inpatient psychiatric facility (LIPF) for adults with severe mental health conditions.160 This randomised trial, involved 393 adults who were subject to involuntary treatment orders. Participants in the CRP reportedly experienced significantly greater improve-ment based on ‘interviewer-rated and self-reported psychopa-thology’ than did participants in the LIPF condition.161 Reported service satisfaction was ‘dramatically higher’ in the CRP condi-tion, leading the researchers to conclude that ‘CRP-style facilities

156 Ibid.

157 Ibid.

158 Bowers et al, above n 106.

159 Ibid.

160 Thomas K Greenfield et al, ‘A Randomized Trial of a Mental Health Consumer-Managed Alternative to Civil Commitment for Acute Psychiatric Crisis’ (2008) 42(1–2) American Journal of Community Psychology 135, 135.

161 Ibid.

55

are a viable alternative to psychiatric hospitalization for many individuals facing civil commitment’.162

A group of German researchers undertook two largescale studies based on data for 349,574 admissions to 21 German psychiatric inpatient hospitals from 1998, to 2012.163 They sought to compare hospitals without locked wards and hospitals with locked wards. They wished to test the hypothesis that locked wards reduced the rates of adverse incidents, like suicides, suicide attempts, and so on. However, Huber and colleagues’ findings indicated that hospitals with an ‘open door policy’ did not have increased numbers of suicide, suicide attempts, and absconding with re-turn, and without return.164 In contrast, treatment on open wards was associated with a decreased probability of suicide attempts, absconding with return, and absconding without return, but not completed suicide.165 In a second study using the same dataset, Schneeberger and colleagues measured the effects of ‘open ver-sus locked door policies’ against rates of ‘aggressive incidents’ and restraint/seclusion.166 The effect of open versus locked door policy was non-significant in all analyses of aggressive behav-iour during treatment. However, ‘[r]estraint or seclusion during treatment was less likely in hospitals with an open door policy’, as was aggressive behaviour.167 Further, ‘bodily harm’ was more likely on open wards than on closed wards.168 It is notable, how-ever, that the study has been criticised on the grounds that the term ‘open door policy’ was classified arbitrarily.169 Nevertheless, several studies support the view that locked doors might not be able to prevent suicide and absconding, and have several down-sides, from a pragmatic and rights-based perspective.

162 Greenfield et al, above n 160, 135.

163 Andres R Schneeberger et al, ‘Aggression and Violence in Psychiatric Hospitals with and without Open Door Policies: A 15-Year Naturalistic Observational Study’ (2017) 95 Journal of Psychiatric Research 189; Huber et al, above n 155.

164 Huber et al, above n 155.

165 Ibid.

166 Schneeberger et al, above n 163, 189.

167 Ibid.

168 Ibid.

169 Thomas Pollmächer and Tilman Steinert, ‘Arbitrary Classification of Hospital Policy Regarding Open and Locked Doors’ (2016) 3(12) The Lancet Psychiatry 1103. Cf. Christian G Huber et al, ‘Arbitrary Classification of Hospital Policy Regarding Open and Locked Doors – Authors’ Reply’ (2016) 3(12) The Lancet Psychiatry 1103.

56

Mezzina reports on the outcomes of an ‘open door… no restraint system of care for recovery and citizenship’ in the city of Trieste, Italy.170 He writes:

Trieste (a city of 236,000 inhabitants in the northeastern region Friuli Venezia Giulia) changed from a clinical model based on treating illness to a wider concept of mental health that looks at the whole person and the social background. The core of the organization is a network of Community Mental Health Centers active 24 hours a day, 7 days a week… with relatively few beds in each of them. The system coordinated by the [Department of Mental Health] also comprises one general hospital psychiatric unit, a network of supported housing facilities and several social enterprises.171

The ‘Trieste Model’ as it is known has been the subject of consid-erable research, though our review did not uncover a large amount of empirical research. This gap may be attributable, at least in part, to methodological challenges in identifying the direct effect of individual measures within complex, system-wide change. In a review paper, Mezzina writes that ‘[i]n Trieste, it has not been possible to evaluate the effectiveness of single interventions (i.e. psychoeducational, rehabilitative, psychotherapeutic) because these are interwoven in its ‘‘whole system’’ approach’.172 Never-theless, there have been several ‘cohort studies on patients with psychosis, family burden studies, research on crisis intervention, user and family member satisfaction, and attitude toward com-munity care’, according to Mezzina, though most appear to be Italian-language studies.173 Mezzina reports that ‘[f]ewer than 10 people per 100,000 of the population receive a [compulsory psy-chiatric treatment order], usually for approximately 7 to 10 days’, which is ‘approximately 1% of all episodes of residential care’.174 Further, ‘most of them are handled by the [Community Mental Health Centres], which have come to take over most [general hospital psychiatric unit] admissions’.175 Mezzina summarises the largely Italian-language evidence base as follows:

170 Mezzina, above n 61, 440.

171 Ibid.

172 Ibid.

173 Ibid.

174 Ibid, 442.

175 Ibid, 442.

57

Crisis management at [Community Mental Health Centers] also proved effective in preventing relapses and chronic courses. A national survey carried out in 13 centers showed that crisis care provided by 24/7 [Community Mental Health Centers] is more effective in crisis resolution and at 2-year follow-up, particularly when related to trusting therapeutic relationships, continuity and flexibility of care, and service comprehensiveness. A 50% reduction occurred in emergency presentation of general hospital casualty for approximately 20 years… Qualitative research particularly highlighted some major social factors connected to services and the connection between recovery, social inclusion, and participatory citizenship. Recent data suggest 75% compliance with antipsychotic medication (n = 587), a situation related to the quality of therapeutic relationship and social network enhancement. User satisfaction with services has been high right from the early years and, more recently, recorded 83% in two [Community Mental Health Centers]

Interestingly, even some forensic services ‘are managed de facto with an open door policy’,176 though evidence on the outcomes and precise nature of such interventions remain limited.177

Creating ‘Safewards’, Changing the Physical Environment and Improving Service Culture

In England, the Safewards model178 has identified aspects of working in psychiatric wards that are known to create potential ‘flashpoints’. This model comprises ten interventions aimed at helping staff manage those flashpoints to reduce conflict. Bow-ers and colleagues proposed six domains of originating factors in the Safewards approach to reducing conflict, restraint and seclu-sion: the staff team, the physical environment, outside hospital, the patient community, patient characteristics and the regulatory framework. The Safewards approach places a strong emphasis on the culture of hospital settings – including staff interactions with patients and family/friends and the physical characteristics

176 Ibid.

177 Roberto Mezzina and Daniela Vidoni, ‘Beyond the Mental Hospital: Crisis Intervention and Continuity of Care in Trieste. A Four Year Follow-Up Study in a Community Mental Health Centre’ (1995) 41(1) International Journal of Social Psychiatry 1.

178 Len Bowers et al, (2014) ‘Safewards: The Empirical Basis of the Model and a Critical Appraisal’, (2014) 21(4) Journal of Psychiatric and Mental Health Nursing 354.

58

of wards. Such service culture was a recurrent theme in several studies.179

The Safewards model was evaluated positively in 2015 with an estimated 15% decrease in conflict and 24% decrease in ‘con-tainment’ across 31 wards in England.180 However, the methodol-ogy used for this evaluation has been criticised.181 An evaluation of a trial of Safewards in the Australian state of Victoria found a reduction in the use of seclusion across the wards that had implemented the approach.182

In a Dutch study, Boumans and colleagues presented four de-tailed case examples and a separate quantitative study to exam-ine how the ‘methodical work approach’ could work to reduce seclusion.183 The ‘methodical work approach’ appears to have provided guidance for the multidisciplinary team, the patient and the family to work together in a systematic and goal-directed way to reduce seclusion. The methodical work approach has five phases: ‘(i) translation of problems into goals; (ii) search for means to realize the goals; (iii) formulation of an individualized plan; (iv) implementation of the plan; and (v) evaluation and re-adjustment’184. The quantitative study compared an experimental ward with 134 adults to a controlled ward with 544 adults, and reported a reduction in the use of seclusion in a ward with a high seclusion rate.185 Compared to control wards within the same hospital, at the ward where the methodical work approach was

179 Len Bowers et al, ‘Correlation between Levels of Conflict and Containment on Acute Psychiatric Wards: The City-128 Study.’ (2013) 64(5) Psychiatric Services 423; Fisher, above n 106; Alice Keski-Valkama et al, ‘A 15-Year National Follow-up: Legislation Is Not Enough to Reduce the Use of Seclusion and Restraint.’ (2007) 42(9) Social Psychiatry And Psychiatric Epidemiology 747; Schout et al, above n 62.

180 Len Bowers et al, ‘Reducing Conflict and Containment Rates on Acute Psychiatric Wards: The Safewards Cluster Randomised Controlled Trial’ (2015) 52(9) International Journal of Nursing Studies 1412, 1422.

181 Feras Ali Mustafa, ‘The Safewards Study Lacks Rigour Despite its Randomised Design’(2015) 52(12) International Journal of Nursing Studies 1906.

182 Justine Fletcher et al, ‘Oucomes of the Victorian Safewards Trial in 13 Wards: Impact on Seclusion Rates and Fidelity Measurement’ (2017) 26(5) International Journal of Mental Health Nursing 461.

183 Boumans et al, ‘Reduction in the Use of Seclusion by the Methodical Work Approach’, above n 123; Boumans et al, ‘The Methodical Work Approach and the Reduction in the Use of Seclusion: How Did It Work?’, above n 123.

184 Ibid.

185 Boumans et al, ‘The Methodical Work Approach and the Reduction in the Use of Seclusion: How Did It Work?’, above n 123, 1.

59

implemented, a more pronounced reduction was achieved in the number of incidents and in the total hours of seclusion.186

Emphasising ‘Environmental Factors’ Within Hospitals

Seven studies explicitly considered environmental factors condu-cive to reducing, eliminating and preventing coercive practices in clinical mental health settings, though many studies concerned with reducing seclusion and restraint, and other coercive practic-es, considered environmental factors in the broad sense of the term.

There is some indication that sensory-based approaches such as the use of sensory modulation rooms can help reduce levels of distress187 thereby preventing the need to use seclusion or restraint. Sensory modulation tools can include the use of au-dio and video equipment, weighted blankets, soft materials and pleasant aromas. These sensory-based approaches are included in some studies of the Six Core Strategies.

Physical design features may play a similar role. Van der Schaaf and colleagues examined the effect of design features on the risk of being secluded, the number of seclusion incidents and the time in seclusion.188 They referred to data on 77 Dutch psychiat-ric hospitals and also a benchmark study on the use of coercive measures in 16 Dutch psychiatric hospitals. Several design fea-tures were associated with rates of seclusion and restraint. The ‘presence of an outdoor space’, ‘special safety measures’ and a large ‘number of patients in the building’ increased the risk of being secluded, while design features such as more ‘total private space per patient’, a higher ‘level of comfort’ and greater ‘visi-bility on the ward’, decreased the risk of being secluded.189 The authors called for a ‘greater focus on the impact of the physical environment on patients’ which they argue ‘can reduce the need for seclusion and restraint’.190

186 Ibid.

187 See generally, Angela Chalmers et al, ‘Establishing Sensory-Based Approaches in Mental Health Inpatient Care: A Multidisciplinary Approach’ (2012) 20(1) Australasian Psychiatry: Bulletin of Royal Australian and New Zealand College of Psychiatrists 35; Tina Champagne and Edward Sayer, The Effects of the Use of the Sensory Room in Psychiatry’ <https://www.ot-innovations.com/wp-content/uploads/2014/09/qi_study_sensory_room.pdf> 13.

188 van der Schaaf et al, above n 73, 142.

189 Ibid.

190 Ibid.

60

Similarly, Borckhardt and colleagues have argued that physical changes to the environment are some of the easiest measures to implement in reducing seclusion and restraint.191 They surveyed changes to the environment that helped reduce the use of se-clusion and restraint by over 82.3% in a state run hospital in the south-eastern United States, which included ‘repainting walls with warm colors, placement of decorative throw rugs and plants, and rearrangement of furniture… along with replacing worn-out furniture and continuing with environmental changes…’.192

Bowers and colleagues investigated wards with the counterin-tuitive combination of ‘low containment and high conflict’. They use the term ‘containment’ to refer to ‘coerced medication, seclusion, manual restraint and other types of containment’.193 The researchers collected cross-sectional data from 136 acute psychiatric wards across England in 2004-2005. Among the var-iables significantly associated with the various ward character-istics, some, such as environmental quality, were changeable, and others – such as social deprivation of the area served – were fixed. High-conflict, low-containment wards had higher rates of male staff and ‘lower-quality environments’ than other wards194 (which somewhat contradicts Van der Schaaf and colleagues’ findings).195 Low-conflict, high-containment wards had higher numbers of beds. High-conflict, high-containment wards utilised more temporary staff as well as more unqualified staff. No overall differences were associated with low-conflict, low-containment wards though the researchers conclude that ‘[w]ards can make positive changes to achieve a low-containment, nonpunitive cul-ture, even when rates of patient conflict are high’.196

Bak and colleagues sought to test the hypothesis that ‘factors of non-medical origin’ may explain the differing number of me-chanical restraint episodes between Denmark and Norway. An earlier study found that mechanical restraint was used twice as frequently in Denmark than Norway. They found that six preven-tive factors confounded the difference in mechanical restraint use between Denmark and Norway, including staff education (- 51%),

191 Jeffrey J Borckardt et al,‘Systematic Investigation of Initiatives to Reduce Seclusion and Restraint in a State Psychiatric Hospital’ (2001) 62(5) Psychiatric Services, 47.

192 Ibid 479.

193 Bowers et al, above n 180, 423.

194 Ibid.

195 See above van der Schaaf et al, above n 73.

196 Bowers et al, above n 180, 423.

61

substitute staff (- 17%), acceptable work environment (- 15%), separation of acutely disturbed patients (13%), patient-staff ratio (- 11%), and the identification of the patient’s crisis triggers (- 10%).197 This research suggests these preventive factors might partially explain the difference in the frequency of mechanical restraint episodes observed in the two countries.198

Examining the Relationship Between Service User Characteristics and Coercion

In contrast to a focus on environmental factors, several studies examined the association between individual service user charac-teristics and coercive measures. These included socio-economic characteristics, ‘the epidemiology of mental disorders’, gender, migrant status, all of which – if they are positively associated with rates of coercion – could be taken into account in efforts to reduce, end and prevent coercive practices.

The findings were mixed, particularly regarding the causation and correlation attributable to service user characteristics. For example, Thomsen and colleagues used nationwide data from Denmark to identify risk factors associated with coercive meas-ures, and reported that ‘clinical characteristics were the foremost predictors of coercion and patients with organic mental disorder [attracting] the highest increased risk of being subjected to a co-ercive measure’ (OR=5.56; 95% CI=5.04, 6.14).199 These findings, they argue, can assist ‘researchers in identifying patients at risk of coercion and thereby help targeting new coercion reduction programs’.200 Similarly, Lay, Nordt and Rössler undertook a study suggesting that the kind and severity of mental illness are the most important risk factors for being subjected to any form of co-ercion, yet nevertheless found that variation in rates of coercion across the six psychiatric hospitals in their study was high, even after accounting for risk factors on the patient level, which sug-gested that centre effects are an important source of variability. However, they argued that ‘effects of the hospital characteristics “size of the hospital”, “length of inpatient stay”, and “work load

197 Jesper Bak et al, ‘Comparing the Effect of Non-Medical Mechanical Restraint Preventive Factors between Psychiatric Units in Denmark and Norway’ (2015) 69(6) Nordic Journal Of Psychiatry 433, 433.

198 Ibid.

199 Christoffer Thomsen et al, ‘Risk Factors of Coercion among Psychiatric Inpatients: A Nationwide Register-Based Cohort Study’ (2017) 52(8) Social Psychiatry and Psychiatric Epidemiology 979, 979.

200 Ibid.

62

of the nursing staff” were only weak (“bed occupancy rate” was not statistically significant)’.201

However, other studies seemed to point in the opposite direc-tion. For example, Siponen and colleagues examined data for all adolescents aged 13–17 from two Finnish districts between the years 1996–2003, and reported that factors other than the characteristics of the adolescents themselves – such as ‘divorc-es, single parent families, social exclusion’ – are associated with use of compulsory interventions.202 Indeed, most studies that considered service user characteristics, also examined socioec-onomic status, and other ‘external’ factors. Even Thomsen and colleagues’ study, noted previously, found evidence indicating that certain socioeconomic variables were associated with an increased risk of coercion, namely: ‘male sex, unemployment, lower social class and immigrants from low and middle income countries (all p<0.001)’.203 Similarly, Janssen and colleagues pro-duced evidence suggesting that ‘more admissions of severely ill patients are related to higher seclusion rates’, and examined patient and background characteristics of 718 secluded patients over 5,097 admissions on 29 different admission wards over sev-en Dutch psychiatric hospitals.204 Seclusion rates, they argued, depended on both patient and ward characteristics. Their evi-dence suggested that differences in seclusion hours between wards could partially be explained by ward size next to patient characteristics. They concluded that the ‘largest deal of the dif-ference between wards in seclusion rates could not be explained by characteristics measured in [their] study’ and concluded that ‘adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion’.205 We will discuss the ratio of staff to service users, and the characteristics of staff, in the next section.

201 Barbara Lay, Carlos Nordt and Wulf Rössler, ‘Variation in Use of Coercive Measures in Psychiatric Hospitals.’ (2011) 26(4) European Psychiatry: The Journal Of The Association Of European Psychiatrists 244, 244.

202 Ulla Siponen et al, 'A Comparison of Two Hospital Districts With Low and High Figures in the Compulsory Care of Minors: An Ecological Study' (2011) 46(8) Social Psychiatry and Psychiatric Epidemiology 661.

203 Ibid.

204 Wim A Janssen et al, ‘Differences in Seclusion Rates between Admission Wards: Does Patient Compilation Explain?’ (2013) 84(1) The Psychiatric Quarterly 39, 39.

205 Ibid.

63

Several studies from the US and England identified higher rates of coercive practices used against minority ethnic groups,206 sug-gesting that targeted efforts to reduce, prevent and end coer-cive practices among these groups should further examine these disproportionate impacts and their underlying causes, including discrimination, lack of culturally responsive services, socio-eco-nomic disadvantage, and so on.

It should be noted that in all studies that use ecological or ob-servational study design cited in this section – that is, a study which uses register data on patient characteristics, services, and socio-economic status – cannot establish causality, even as they identify predictors of coercion. Further, as noted previously, rates of coercion vary greatly between – and even within – countries, suggesting that a focus on service user or patient characteristics is likely to be less important than socio-political factors extrinsic to the person. Salize and Dressing, for example, present evidence showing that rates of ‘involuntary placements’ in the European Union range from 6 per 100,000 in Portugal, to 218 per 100,000 in Finland.207

The Number/Ratio of Staff to Service Users, and Staff Characteristics

The Six Core Strategies and Safewards practices discussed pre-viously include elements of staff training, which should be con-sidered in addition to these specific studies concerning staff-to-service user ratios and staff characteristics.

Several studies considered the staff-to-service-user ratio and its impact on coercive practices. Bak and colleagues found that pa-tient/staff ratio was significant in explaining why Danish hospital units had roughly twice the rates of mechanical restraint than

206 See, eg, Gregory M Smith et al, ‘Pennsylvania State Hospital System’s Seclusion and Restraint Reduction Program’ (2005) 56(9) Psychiatric Services 1115; Barbara Barrett et al, ‘Randomised Controlled Trial of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: Economic Outcomes’ (2013) 8(11) PLoS One e74210; Andrés Martin et al, ‘Reduction of Restraint and Seclusion Through Collaborative Problem Solving: A Five-Year Prospective Inpatient Study’ (2008) 59(12) Psychiatric Services 1406, 1410.

207 Hans Joachim Salize and Harald Dressing,‘Epidemiology of Involuntary Placement of Mentally Ill People Across the European Union’ (2004) 184(2) British Journal of Psychiatry 163.

64

Norwegian hospitals.208 They compared units in which the staff-to-patient ratio was higher than or equal to three-to-one on aver-age with those units where this ratio was lower than three-to-one. According to the authors, the factor explains a large [Δ exp(B) 11%] portion of the difference in mechanical restraint episodes between the two countries.209 The effects of the staff-to-patient ratio were partially supported by other research.210 Most research in this regard finds it difficult to determine what portion of reduc-tion in coercive practices is attributable to added staffing, be-cause several factors often contribute to the effect. Janssen and colleagues reported that seclusion was used more commonly when the number of service users per staff was greater in long-term wards.211 The idea, according to Bak and colleagues, is that staff are better able to interact and co-operate with service users, reduce workplace stress and learn skills in support and commu-nication to create a more ‘recovery oriented environment’.212

However, Bak and colleagues point to some research which indicated that the relative risk of violence increased with more nursing staff, and that increased levels of aggressive incidents were associated with increased staffing. Yet, as Bak and col-leagues observe, these studies did not precisely target mechan-ical restraint or seclusion but instead targeted violence and ag-gression.213 From this, relatively limited and regionally specific evidence (located largely in Scandinavia), staff-to-patient ratios of higher than or equal to three-to-one on average seem to be decisive in rates of seclusion and restraint, even if increased staff may raise other issues.

The composition of staff was considered in some studies. As not-ed, Janssen and colleagues, using the largescale Norwegian-Dan-ish dataset, concluded that ‘ward policy and adequate staffing may, in particular on smaller wards, be key issues in reduction of seclusion’.214 In a previous study led by Janssen, researchers sought to conduct a retrospective analysis of staff characteristics

208 Jesper Bak et al, above n 197, 439; see also Jesper Bak et al, ‘Mechanical Restraint – Which Interventions Prevent Episodes of Mechanical Restraint? – A Systematic Review’ (2012) 48(2) Perspectives in Psychiatric Care 83.

209 Ibid.

210 See, eg, Smith et al, above n 206, 1115.

211 Janssen et al, ‘Differences in Seclusion Rates between Admission Wards: Does Patient Compilation Explain?’, above n 204, 39.

212 Bak et al, above n 197, 439.

213 Ibid, 440.

214 Janssen et al, ‘Differences in Seclusion Rates between Admission Wards: Does Patient Compilation Explain?’, above n 204, 39.

65

from ten wards in four mid-sized general psychiatric hospitals in the Netherlands. The data show that two variables were asso-ciated with seclusion rates: the male–female staff ratio and the variability in team’s work experience. More female and less male nurses in a shift and less variability in team’s work experience predicted an increase in seclusion rates.215 No other studies con-sidered male-female staff ratio, and this modest study remains non-generalisable.

Existence of Registries/Reporting

There was relatively little research on the existence of registries and reporting measures and their contribution to the reduction of coercive practices. As noted, the Six Core Strategies approach promotes the use of data to inform practice, including doing so in an empirical, ‘non-punitive’ way to examine and monitor pat-terns of seclusion and restraint use.216 Janssen and colleagues have discussed important methodological issues in monitoring the use of coercive measures.217 In order to monitor the effects of initiatives at a national and international level to reduce coercion, ‘consensus on definitions of coercive measures, assessment methods and calculation procedures of these coercive measures are required’,218 to which their study involves a literature review and an illustrative case study, using data from a large multicentre study on seclusion patterns in the Netherlands. They argue that:

Coercive measures can be reliably assessed in a standardized and comparable way under the condition of using clear joint definitions. Methodological consensus between researchers and mental health professionals on these definitions is necessary to allow comparisons of seclusion and restraint rates.219

Countries such as the Netherlands, Denmark and Norway, appear to have comprehensive coercion measure data sets. These exem-plary monitoring mechanisms could be considered alongside the

215 Wim A Janssen et al, ‘The Influence of Staffing Levels on the Use of Seclusion’ (2007) 30(2) International Journal of Law and Psychiatry 118, 118.

216 National Technical Assistance Center, above, n 130.

217 Wim A Janssen et al, ‘Methodological Issues in Monitoring the Use of Coercive Measures’ (2011) 34(6) International Journal of Law and Psychiatry 429, 429.

218 Ibid.

219 Ibid.

66

CRPD obligation under Article 31 (statistics and data collection), in which Subsection (1) directs States Parties to:

…undertake to collect appropriate information, including statistical and research data, to enable them to formulate and implement policies to give effect to the present Convention. The process of collecting and maintaining this information shall:

a) Comply with legally established safeguards, including legislation on data protection, to ensure confidentiality and respect for the privacy of persons with disabilities;

b) Comply with internationally accepted norms to protect human rights and fundamental freedoms and ethical principles in the collection and use of statistics.

De-Escalation Techniques

Twelve studies discussed de-escalation techniques in hospital settings, considering either their effectiveness, or the need for staff training in de-escalation techniques.220 Long and colleagues found that staff reported positively on ward training and the use of de-escalation techniques, arguing that it was the most effec-tive factor in their successful reduction of seclusion in a women’s secure unit in England.221 Staff attended weekly one hour training sessions using ward case examples of how to manage disturbed behaviour by ‘non-invasive relational strategies’.222 In India, a study involving 210 psychiatrists and 210 ‘caregivers’ found that these groups perceived staff training in de-escalation techniques to be an urgent need in efforts to reduce coercion in psychiatric hospitals (in addition to ‘early identification of aggressive behav-ior, interventions to reduce aggressiveness, empowering patients [and] improving hospital resources’).223 Gjerberg and colleagues

220 Azeem et al, above n 67; Barbara Lay, Wolfram Kawohl and Wulf Rössler, ‘Outcomes of a Psycho-Education and Monitoring Programme to Prevent Compulsory Admission to Psychiatric Inpatient Care: A Randomised Controlled Trial’ (2018) 48(5) Psychological Medicine 849; Long et al, above n 50; Lyons et al, above n 61; Maguire, Young and Martin, above n 51; Martin et al, above n 52; BN Raveesh et al, ‘Staff and Caregiver Attitude to Coercion in India.’ (2016) 58(Suppl 2) Indian Journal of Psychiatry s221; Shields et al, above n 57; Vruwink et al, above n 73; Wieman et al, above n 129; Zinkler, above n 56; Bak et al, above n 197.

221 Long et al, above n 50.

222 Ibid.

223 Raveesh et al, above n 220, s221.

67

examined what conditions staff in Norwegian services for older persons (one of only two papers concerned with services for older adults) were considered as necessary to succeed in avoiding the use of coercion, and indicated that the nursing home staff usually spent a lot of time trying a wide range of approaches to avoid the use of coercion, including deflecting and persuasive strategies, limiting choices by conscious use of language, different kinds of flexibility and one-to-one care.224 According to the staff, their opportunities to effectively use alternative strategies are greatly affected by the nursing home’s resources, by the organization of care and by individual staff members’ competence.225

A Cochrane review, which assessed research on the effects of de-escalation techniques for managing non-psychosis-induced aggression in adults in care settings, in both staff and service us-ers, concluded that research quality in the field was ‘very low due to high risk of bias and indirectness of the outcome measures’.226 Arguably, a similar uncertainty remains around the effectiveness of de-escalation and the relative efficacy of different techniques in the mental health context. High-quality research on the effec-tiveness of this intervention is therefore needed.

3. ‘Community’ Based Alternatives to Coercion

This section provides an overview of studies concerning non-hos-pital acute and crisis mental health services. Prominent topics in-cluded crisis resolution, respite houses, and home-based support.

Residential Programmes for People in Acute Crisis as Alternatives to Hospitalisation

Community homes for the treatment of people with acute con-ditions or in extreme distress have been established in several places in the world as alternatives to inpatient hospitalisations. Several features are typical of these settings: fewer residents compared to hospital wards; a de-emphasis on medication; and greater contact with staff. The models differ with respect to emphasis on medication and composition of staff. Staff may be predominately those who have used services in the past, or may

224 Gjerberg et al, above n 53.

225 Ibid.

226 Sally Spencer, Paula Johnson and Ian C Smith, ‘De-escalation Techniques for Managing Non-psychosis Induced Aggression in Adults’ in (2018) Issue 7 Cochrane Database of Systemic Reviews Art No: CD012034.

68

be typical mental health professionals, including psychiatrists, psychologists, and so on – or a mixture. The literature tends to indicate that for most people in acute crisis who are eligible for hospitalisation, residential support can be a viable alternative. Some research considers effectiveness, cost, coercive practices within residential programmes, and long-term outcomes.

Most crisis houses offer:

• overnight accommodation

• a small number of beds

• a home-like environment

• intensive treatment.

The different types of residential programmes identified in this review are:

Crisis or Respite Houses Crisis homes offer a smaller scale residential alternative for peo-ple in crisis, sometimes designed for specific groups, including women,227 and minority ethnic groups. Gilburt and colleagues, conducting research in England, proposed that little is known about the ‘preferences and experiences of people with mental illness in relation to residential alternatives to hospital’.228 Forty purposively selected ‘patients in residential alternative servic-es’ were interviewed, who had previously experienced hospital in-patient stays. Interviewees reported an overall preference for residential alternatives, including ‘being safer, having more free-dom and decreased coercion, and having less paternalistic staff compared with traditional in-patient services’.229 Interestingly, respondents identified no substantial difference between their relationships with staff overall and the care provided between the two types of services. The researchers concluded, that al-ternative residential services ‘minimise coercion and maximise freedom, safety and opportunities for peer support’.230

227 Alyssum Residential Service, Rochester, Vermont <https://www.alyssum.org/>.

228 Helen Gilburt et al, ‘Service Users’ Experiences of Residential Alternatives to Standard Acute Wards: Qualitative Study of Similarities and Differences’ (2010) 197(Suppl 53) The British Journal of Psychiatry s26, s26.

229 Ibid.

230 Ibid.

69

Fenton and colleagues examined 119 adults who experienced an ‘illness exacerbation’, and who having accepted voluntary treat-ment were randomly assigned to the acute psychiatric ward of a general hospital or a community-based respite house.231 Case mix data indicated that patients treated in the hospital (N=50) and the alternative (N=69) were comparably ill, and that treatment epi-sode symptom reduction and patient satisfaction were compara-ble for the two settings.232 Psychosocial functioning, satisfaction, and acute care use in the six months following admission were also comparable between the two settings. The authors conclude that for patients who do not require intensive general medical intervention and are willing to accept voluntary treatment, the alternative programme model studied provides outcomes com-parable to those of hospital care.233

Osborn and colleagues compared the experiences of 314 ‘pa-tients in four residential alternatives and four standard services’, considering patient satisfaction, ward atmosphere and perceived coercion ‘using validated measures’.234 They reported that ‘alter-natives to traditional in-patient services’ appear to be associated with a better experience of admission, greater service user satis-faction and less negative experiences.235 They attributed some of these differences to the involuntary nature of admission.

Slade and colleagues examined ‘short-term clinical outcomes and cost data’ for six residential alternatives to acute in-patient care in England, comparing them with six standard in-patient care services.236 All measures indicated improved outcomes for both types of service, with ‘adjusted improvement’ found to be greater for standard services according to most measures, but not ‘Glob-al Assessment of Functioning’ symptoms.237 Admissions to res-idential alternatives were 20.6 days shorter, and hence cheaper (UK£3832 v. £9850). Standard services cost an additional £2939 per unit ‘Health of the Nation Outcome Scales’ improvement, and the authors concluded that there was an ‘absence of clear-cut

231 Wayne S Fenton et al, ‘Randomized Trial of General Hospital and Residential Alternative Care for Patients with Severe and Persistent Mental Illness’ (1998) 155(4) American Journal of Psychiatry 516, 516.

232 Ibid.

233 Ibid.

234 David PJ Osborn et al, ‘Residential Alternatives to Acute In-Patient Care in England: Satisfaction, Ward Atmosphere and Service User Experiences’ (2010) 197(Suppl 53) The British Journal Of Psychiatry s41, s41.

235 Ibid.

236 Slade et al, above n 62, s41.

237 Osborn et al, above n 234, s41.

70

advantage for either type of service’, which highlights the impor-tance of ‘the subjective experience and longer-term costs’.238

Lawlor and colleagues’ research suggests that respite houses may be more likely to be used by particular ethnic groups compared to others.239 In their study of service data related to 287 women admitted to an acute psychiatric inpatient ward or a women’s crisis house in four London boroughs, they found that all groups of ‘black’ patients and ‘white other’ patients were significant-ly more likely to have been compulsorily admitted than ‘white British’ patients, whereas white British patients were more likely than other groups to be admitted to a crisis house.240 (Differenc-es between groups in help-seeking behaviours in a crisis, they concluded, may explain some differences in rates of compulsory admission).241

Soteria is a ‘Therapeutic Community Residence’ for the preven-tion of hospitalisation.242 Soteria facilities were founded in the United States and are small, residential settings for responding to people experiencing psychosis. Similar facilities exist in Swit-zerland, Germany, Sweden, Budapest and Denmark.243 Much of the empirical research that exists on Soteria appears to have been undertaken prior to 1990 (and hence is outside the scope of this review).244 The Soteria Vermont website indicates that it is de-signed for ‘individuals experiencing a distressing extreme state, commonly referred to as psychosis’245 which in the authors’ terms, ‘can be a temporary experience that one works through rather than a chronic mental illness that needs to be managed’.246 Ac-cording to the Vermont Agency of Human Services’ Department of Mental Health, the Soteria House programme opened in 2015

238 Slade et al, above n 62.

239 Caroline Lawlor et al, ‘Ethnic Variations in Pathways to Acute Care and Compulsory Detention for Women Experiencing a Mental Health Crisis.’ (2012) 58(1) The International Journal Of Social Psychiatry 3, 3.

240 Ibid.

241 Ibid.

242 Tim Calton et al, ‘A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia’ (2008) 34(1) Schizophrenia Bulletin 181.

243 Ibid.

244 See generally, ibid.

245 Soteria Website <http://www.pathwaysvermont.org/what-we-do/our-programs/soteria/.

246 Ibid.

71

and ‘includes care from a psychiatrist to support withdrawal from medications’.247

A similar service, Cedar House, was established in Boulder, Colo-rado. It is a 15-bed residence that runs as a therapeutic commu-nity giving responsibility to the ‘guests’ whose stay is no longer than 10-15 days. According to Warner, Cedar House has been running for 30 years in the public system.248 Warner presents some evidence that these alternatives have shown similar or bet-ter outcomes for service users including improved satisfaction and involving demonstrating reduced admissions and re-admis-sion rates. Warner writes:

The county mental health system has found that the facility can accommodate at least half of the catchment area patients in need of acute in-patient care at any point in time, including many patients requiring compulsory treatment. Costing half as much as hospital care (which is purchased by the mental health system at the best price in the marketplace), there has never been any question as to its cost-effectiveness.249

Warner argues that size is an important variable determining the style of working and individualisation of treatment. He describes the variation in size of non-hospital residential alternatives in the United States:

Progress Foundation in San Francisco, which accommodates public-sector patients, has been able to limit the size of each facility to 8–10 residents, but this is unusual and is due to its selection of people who are less severely ill. Cedar House, in Boulder, struck the balance at 15 beds. Venture, in Vancouver, British Columbia, is substantially larger at 20 beds and the operators concede that this leads to a less homelike quality of the environment. Private acute care facilities, such as Balsam House in Boulder, Colorado, and Crossing Place in Washington, DC, each with 8 beds, tend to be smaller, and the higher per capita cost is passed on to consumers and their

247 Department of Mental Health, Agency of Human Services, ‘VERMONT2017 Reforming Vermont’s Mental Health System Report to the Legislature on the Implementation of Act 79’ January 15, 2017, 41 <https://legislature.vermont.gov/assets/Legislative-Reports/2017-ACT-79-Report.pdf>

248 Richard Warner, ‘The Roots of Hospital Alternative Care’ (2010) 197(Suppl 53) British Journal of Psychiatry s4, s4.

249 Ibid.

72

families. Private-sector residential alternatives in the United States that are geared more towards rehabilitation than acute treatment can function well with a larger group size.250

By their nature, respite houses tend to eschew standardisation, making research difficult to undertake.

There appears to be some terminological and conceptual ambi-guity about the range of non-hospital acute and crisis residential services. While some ‘crisis houses’ are very much houses in the typical sense of having three or four bedrooms, of which a small number are available to people in crisis (as with Alyssum), other non-hospital ‘residential alternatives’ have a much great-er number of beds. Slade’s aforementioned study, for example, drew on six alternative-to-hospital residential services which varied from three bed facilities to facilities with 30 beds.251 The English mental health charity, Mind, also points out that ‘crisis houses’ are often mistaken for ‘sanctuary or safe havens’, the latter which refers to crisis support services that do not provide residential support: ‘Sanctuaries and safe havens might be open overnight as a supportive place for you to go for several hours during a crisis, but they don’t usually provide somewhere for you to sleep or live in’.252 Mind’s comments here relate to English services, suggesting the terminological and conceptual variation is even greater at the international level, adding an extra layer of complexity to research into crisis resolution alternatives to acute hospitalisation.

'Peer-run' Crisis or Respite HousesCrisis houses managed and run by service users, former service users and persons with psychosocial disabilities typically have a strong recovery and self-help ethos. Strategies used include: counselling, art, meditation, physical work, massage, skills train-ing and meditation. Croft and Isvan undertook a propensity score matching to create matched pairs of ‘139 users of peer respite and 139 non-users of respite with similar histories of behavioral health service use and clinical and demographic characteris-tics’.253 Their findings suggested that ‘by reducing the need for

250 Ibid s5.

251 Slade et al, above n 62. The makeup of the services are described in an article from the same dataset: Mary E Johnson, ‘Violence and Restraint Reduction Efforts on Inpatient Psychiatric Units’ (2010) 31(3) Issues in Mental Health Nursing 181.

252 See Mind, The Mental Health Charity <www.mind.org.uk>.

253 Croft and Isvan, above n 102, 632.

73

inpatient and emergency services for some individuals, peer res-pites may increase meaningful choices for recovery and decrease the behavioral health system’s reliance on costly, coercive, and less person-centered modes of service delivery’.254 As noted previously, Greenfield and colleagues, compared the effective-ness of an unlocked, mental health service user-managed, crisis residential programme (CRP) to a locked, inpatient psychiatric facility (LIPF) for adults with severe mental health conditions.255 The trial CRP experienced significantly greater improvement based on ‘interviewer-rated and self-reported psychopathology’ than did participants in the LIPF condition. Reported service sat-isfaction was ‘dramatically higher’ in the CRP condition, leading the researchers to conclude that ‘CRP-style facilities are a viable alternative to psychiatric hospitalization for many individuals fac-ing civil commitment’.256

Ostrow, in her (non-peer reviewed) Master’s thesis, examined the growth of peer-run crisis respites ‘operated by trained mental health consumers (i.e. peers)’ in seven of the US states.257 She provides background to the growth of peer-run respites in the United States, a case study for a Massachusetts based-service and recommends effective strategies for their development.258

The Vermont Agency of Human Services’ Department of Mental Health, reported on data collected between 2011-16 on a peer-run crisis house, called Alyssum. Alyssum’s two bed home is a residential crisis respite and hospital diversion service funded by the Vermont Department of Mental Health. According to the Alyssum website: ‘The mission of the corporation is to provide a peer-operated, peer staffed holistic approach to mental well-ness, discovery and recovery for Vermonters who are experienc-ing a mental health crisis’.259 The Vermont Department of Mental Health reported the following:

Alyssum opened its doors in November 2011 and expanded its capacity through additional Act 79 funding. The program offers a peer-developed approach to crisis support for

254 Ibid.

255 Greenfield et al, above n 160.

256 Ibid.

257 Laysha Ostrow, A Case Study of the Peer-Run Crisis Respite Organizing Process in Massachusetts, (Heller School of Social Policy and Management, 2010) 38.

258 Ibid.

259 Alyssum, above n 227.

74

individuals who are seeking an alternative to traditional [drug and alcohol] crisis programs. As one resident stated, ‘Alyssum is a safe haven for me. It works so much better for me than a traditional hospital setting. Being able to talk to peers who have been in my shoes and giving me first hand advice that works for them and try it myself is amazing.’ As of the end of November 2016, Alyssum has had a total of 375 admissions and served 252 individuals (unduplicated). Over this period, Alyssum has had an 86% occupancy rate and an average length of stay of 7 days. Demand for the program has been high—a total of 568 unique individuals have been denied a bed due to full occupancy. 80% of admissions have been for hospital diversion and 20% were for transition from a hospital (step-down). Out of a possible 100% satisfaction rate, guests report 90% satisfaction with the progress made on personal goals while at the program. Upon departure from Alyssum, 84% of guests self-report feeling better, 20% say they feel the same, while 6% say they feel worse. The staff turnover rate at Alyssum is less than 10% annually.260

Alyssum is one of several peer-run crisis centres in Vermont, which were funded after a natural disaster destroyed a psychiat-ric largescale hospital:

Since the evacuation of the Vermont State Hospital in Waterbury at the end of August 2011, after Tropical Storm Irene, the new community capacities for crisis services, hospital diversion and step-down, peer-supported alternatives such as Alyssum (already open) and Soteria House (scheduled to open early in 2015) … are the most important ways in which the redesign of public mental health here in Vermont has emphasized individual choice among a range of options for treatment and support.261

260 Department of Mental Health, Agency of Human Services, VERMONT2017 Reforming Vermont’s Mental Health System, Report to the Legislature on the Implementation of Act 79; January 15, 2017, 38 <https://legislature.vermont.gov/assets/Legislative-Reports/2017-ACT-79-Report.pdf>

261 Department of Mental Health, Agency of Human Services, VERMONT2015 Reforming Vermont’s Mental Health System, Report to the Legislature on the Implementation of Act 114: January 1-November 30, 2014, January 15, 2015, 25 <https://legislature.vermont.gov/assets/Documents/2016/WorkGroups/Senate%20Judiciary/Reports%20and%20Resources/W~Department%20of%20Mental%20Health~The%20Implementating%20of%20Act%20114~1-15-2015.pdf>.

75

A similar ‘intensive residential program’ in Vermont called Hilltop, which has been in operation since 2012, ‘also provides treatment and support using the Soteria model’.262

Crisis Respite Services‘Crisis respite services’ may refer to a combination of non-res-idential settings, including guest houses or supported accom-modation managed and supported by community mental health centre staff,263 visiting centres, as well as home-based services. These may be peer-run, as for example with the Leeds Survi-vor-Led Crisis Service (discussed shortly), or may have more typ-ical, formal professional-aligned staff.

A report by the Social Policy Research Centre at the University of New South Wales in its evaluation of a crisis respite service in South Australia, reported that the service ‘resulted in statistically significant reductions in: Psychological distress; Hospital admis-sions; Time in hospital; Emergency Department visits; A large proportion of the costs were offset by the reductions in hospital-isation and Emergency Department presentations’.264 Rosen and O’Connell provide some evidence to suggest adults who were admitted to a mental health respite programme self-reported a significant improvement in symptom distress (p < 0.05), ‘mental health confidence’ (p < 0.1), and self-esteem (p < 0.05) from admission to discharge.265

In Trieste, Italy, Mezzina and Vidoni followed a sample group of 39 new patients with acute and severe crises at community mental health centers over a four-year period, and reported that ‘voluntary and compulsory hospitalization were avoided in favor of short-term day and night support in the [community mental health centers]’, and there were ‘no suicides, no crimes, no drop-outs’ and ‘[s]ocial adjustment remained unchanged’.266 They ar-gue that ‘mental health services in Trieste are able to cope with acute crises without psychiatric hospitalization’.267

262 Department of Mental Health, Agency of Human Services, above n 260, 41.

263 International Collaboration Mental Health Network, Acute and Crisis Mental Health Services <https://imhcn.org/bibliography/transforming-services/acute-and-crisis-mental-health-services>.

264 Fredrick Zmudzki et al, Evaluation of Crisis Respite Services: Final Report, SPRC Report 06/16 (Social Policy Research Centre, UNSW Australia, 2016) 1.

265 Jonathan Rosen and Maria O’Connell, ‘The Impact of a Mental Health Crisis Respite upon Clients’ Symptom Distress’ (2013) 49(4) Community Mental Health Journal 433.

266 Mezzina and Vidoni, above n 177.

267 Ibid.

76

Sledge and colleagues undertook two largescale studies investi-gating the ‘clinical feasibility and the outcome for patients of a program designed as an alternative to acute hospitalization’, in which a conventional inpatient programme for the ‘urban, poor, severely ill voluntary patients who usually require hospitalization’ was compared with an alternative experimental programme con-sisting of ‘a day hospital linked to a crisis residence’. The authors report that the ‘clinical, functional, social adjustment, quality of life, and satisfaction outcome measures were not statistically dif-ferent for the patients in the two treatment conditions; however, there was a slightly more positive effect of the experimental pro-gram on measures of symptoms, overall functioning, and social functioning’.268 This study does not make it clear whether this resulted in a reduction in participants who were treated and de-tained involuntarily.

Sledge and colleagues’ second study compared ‘service uti-lization and costs for acutely ill psychiatric patients treated in a day hospital/crisis respite program or in a hospital inpatient program’, including following up on outcomes 10 months after discharge.269 The day hospital/crisis respite programme cost less than inpatient hospitalisation (roughly 20% of the total direct costs), although the programmes had roughly equal direct ser-vice staff and capital costs.270 The difference was largely due to operating costs (day hospital/crisis respite operating costs were 51% of inpatient hospital costs). Sledge and colleagues’ study in-dicates that the experimental condition (a combined day hospital/crisis respite community residence) seems to have had the same treatment effectiveness as acute hospital care for urban, poor, acutely ill voluntary patients with severe mental illness.

268 William H Sledge et al, ‘Day Hospital/Crisis Respite Care versus Inpatient Care, Part I: Clinical Outcomes’ (1996) 153(8) The American Journal of Psychiatry 1065, 1065.

269 William H Sledge et al, ‘Day Hospital/Crisis Respite Care versus Inpatient Care, Part II: Service Utilization and Costs’ (1996) 153(8) The American Journal of Psychiatry 1074.

270 Ibid.

77

Host FamiliesSome schemes provide a family support structure for individuals during crisis, or as a form of crisis prevention.271 The Family Care Foundation in Sweden, for example, works with ‘family home living, psychotherapy and family therapy’.272 The staff at Family Care Foundation are psychotherapists, psychologists and social workers, and work with teams consisting of the client, his or her network, the family home, a supervisor and a therapist. No peer-reviewed empirical research on ‘host family’ arrangements appeared in the review.

Addressing Coercive Practices in Housing and Independent Living Services

One socio-legal study considered the use of coercive practices within housing and residential services. Allen analysed legal, policy and research materials and argued that mental health services in the United States appear to be using coercive practices or ‘leveraging’ in some housing services; that is, threatening discontinuation of housing services or eviction if psychiatric intervention is not accepted.273 Allen argues that, within the United States, this practice appears to breach the Americans with Disabilities Act, and according to the author has multiple, negative flow-on effects. Hence, Allen sets out legal avenues for preventing ‘leverage’.274

Richter and Hoffman reviewed randomised and non-randomised controlled trials examining outcomes for people living in ‘inde-pendent settings’ versus ‘institutionalised accommodation’275—the latter in which more coercive practices seem likely to be used. The results of Richter and Allen’s study indicated that ‘In-dependent Housing and Support-settings’ provide at least sim-ilar outcomes to ‘residential care’276 and the authors conclude

271 International Collaboration Mental Health Network, Acute and Crisis Mental Health Services <https://imhcn.org/bibliography/transforming-services/acute-and-crisis-mental-health-services>.

272 The Family Care Foundation, Gothenburg, Sweden <www.familjevardsstiftelsen.se>.

273 Michael Allen, ‘Waking Rip van Winkle: Why Developments in the Last 20 Years Should Teach the Mental Health System Not to Use Housing as a Tool of Coercion.’ (2003) 21(4) Behavioral Sciences & the Law 503, 503.

274 Ibid.

275 Dirk Richter and Holga Hoffmann, ‘Independent Housing and Support for People with Severe Mental Illness: Systematic Review’ (2017) 136(3) Acta Psychiatrica Scandinavica 269, 269.

276 Ibid.

78

by arguing that housing should be based on clients’ preferences rather than service providers sense of their ‘best interests’.277

Some persons with mental health conditions and psychosocial disabilities may refuse any housing attached to mental health services, while others may embrace it. There are even reports of services in Ireland using civil commitment laws to detain home-less people who refuse shelter,278 which may be occurring else-where. ‘Housing First’ policies and programmes are an example of how housing support might be provided in ways that respect a person’s will and preference rather than being based on the co-ercive approach of refusing a person housing support if he or she does not comply with mental health treatment. Under some iter-ations of the Housing First scheme, persons with mental health conditions and psychosocial disabilities who are homeless are supported through intensive case management to move into reg-ular housing, with no requirement that they adhere to treatment plans (even when such treatment is offered).279 Such practices appear likely to reduce instances of coercion in housing services for persons with mental health conditions and psychosocial disa-bilities, though no research has explicitly examined whether this is indeed the case.

Community Crisis Resolution and Home Support

This section discusses non-hospital, non-residential crisis reso-lution and home support on the basis that such settings may reduce the likelihood of coercion. People typically end up in hospital settings or acute psychiatric facilities when they are in extreme crises, which might be exacerbated where there is an absence of ‘step-down’ or alternative, non-hospital crisis resolu-tion services open to people who need various levels of support. Again, better meeting people’s support needs, as well as being valuable in and of itself, is likely to help prevent, reduce or end coercive interventions. Several community-based crisis-interven-tion programmes and services in the review could be broadly categorised as alternatives to coercive practices. These include

277 Ibid.

278 See, eg, Kitty Holland, ‘Services ‘Sectioning’ Homeless People Who Refuse Shelter’ Irish Times (3 March 2018).

279 See, eg, Micah Projects, Housing First: a Foundation for Recovery: Breaking the Cycle of Brisbane’s Housing, Homelessness and Mental Health Challenges (2016) <www.micahprojects.org.au>

79

supports for intensive intervention to address crises and prevent hospital admission for adults280 and children.281

Leeds Survivor Led Crisis Service (LSLCS) was set up in the English city of Leeds in 1999 by a group of service users, initial-ly in partnership with the United Kingdom Government’s Social Services. According to the LSCS website:

The service was set up to be a place of sanctuary, which was an alternative to hospital admission and statutory services for people in acute mental health crisis. The service was established, and continues to be governed and managed, by people with direct experience of mental health problems. We have our own unique perspectives on what it feels like to be in crisis and what helps and does not help. We have developed our service based on this knowledge and experience, while responding to the needs articulated by our visitors and callers.282

Several reports have been authored by LSLCS, which provide some evidence to support its efficacy.283

Hackett and colleagues examine a crisis and home support pro-gramme for the black and minority ethnic community in Shef-field, England, which was aimed at addressing both an over representation of such groups in psychiatric wards and people avoiding mainstream services altogether.284 The Sheffield Crisis Resolution Home Treatment (CRHT) Service created the En-hancing Pathways Into Care (EPIC) project, which initially focused on engagement with the Pakistani community – the largest black and minority ethnic (BME) group in Sheffield. The home treatment service joined with a local Pakistani Muslim Centre, which had existing links with the Pakistani community and provided a range

280 See, eg, Christina Lyons et al, ‘Mental Health Crisis and Respite Services: Service User and Carer Aspirations’ (2009) 16(5) Journal of Psychiatric and Mental Health Nursing 424, 424.

281 Mary E Evans, Roger A Boothroyd and Mary I Armstrong, ‘Development and Implementation of an Experimental Study of the Effectiveness of Intensive In-Home Crisis Services for Children and Their Families’ (1997) 5(2) Journal of Emotional and Behavioral Disorders 93, 93.

282 See Leeds Survivor-Led Crisis Service <https://www.lslcs.org.uk/additional>

283 See Leeds Survivor-Led Crisis Service <https://www.lslcs.org.uk/additional-services/publications/>

284 Rashna Hackett et al, ‘Enhancing Pathways Into Care (EPIC): Community Development Working with the Pakistani Community to Improve Patient Pathways within a Crisis Resolution and Home Treatment Service’ (2009) 21(5) International Review of Psychiatry 465, 465.

80

of social, respite and occupational opportunities. The partnership created an innovative new role: the Pakistani link worker. While there is no direct evidence of a resulting reduction in coercion, the authors reported evidence of positive change including more referrals to the Centre from psychiatric services.285

Johnson and colleagues, again in England, provided some evi-dence that a ‘crisis resolution team’, who assisted 260 residents of the inner London Borough of Islington who were experiencing crises severe enough for hospital admission to be considered, were less likely to be admitted to hospital in the eight weeks after the crisis, though compulsory admission was not significantly reduced.286 A difference of 1.6 points in the mean score on the client satisfaction questionnaire (CSQ-8) was not quite significant (P = 0.07), although it became so after adjustment for baseline characteristics (P = 0.002).287 The authors concluded that crisis resolution teams can reduce hospital admissions in mental health crises and they may also increase satisfaction in patients, but this was an equivocal finding.

The Open Dialogue model is prominent in rights-based debates about crisis support and resolution in people’s homes and com-munities.288 Currently, research on Open Dialogue consists of small-scale studies based in Western Lapland, Finland, which focus on people with first-episode psychosis.289 However, irre-spective of its prominence in some human rights commentary, which positions Open Dialogue as a CRPD-aligned practice, the review did not find any empirical evidence that examines its di-rect impact on rates of coercion. (It is perhaps also noteworthy that Finland has some of the highest rates of formal involuntary psychiatric interventions in the European Union).290 On the other hand, Open Dialogue was designed as a treatment alternative to

285 Ibid.

286 Sonia Johnson et al, ‘Randomised Controlled Trial of Acute Mental Health Care by a Crisis Resolution Team: The North Islington Crisis Study’ (2005) 331(7517) BMJ 599.

287 Ibid.

288 Seikkula et al, above n 110.

289 Jaakko Seikkula et al, above n 110; Niels Buus et al, ‘Adapting and Implementing Open Dialogue in the Scandinavian Countries: A Scoping Review’ (2017) 38(5) Issues in Mental Health Nursing 391; Jukka Aaltonena, Jakko Seikkulaa and Klaus Lehtinen, ‘The Comprehensive Open-Dialogue Approach in Western Lapland: I. The Incidence of Non-Affective Psychosis and Prodromal States’ (2011) 3(3) Psychosis 179.

290 Salize and Dressing, above n 207.

81

hospitalisation.291 In avoiding hospitalisation, there is less likeli-hood – or so it would seem – of formal coercion, including seclu-sion and restraint.

Research on Open Dialogues typically concerns its direct bene-fits to individuals and families. For example, preliminary results of a two-year follow-up found that a group of people with a first-instance diagnosis of schizophrenia who used the approach ‘were hospitalized for fewer days, family meetings were organ-ised more often and neuroleptic medication was used in fewer cases’.292 Seikkula and colleagues reported that participants ex-perienced ‘fewer relapses and less residual psychotic symptoms and their employment status was better than in the (non-partici-pating) Comparison group’.293 Razzaque and Stockman describe ‘peer-supported open dialogue’ as a variant of the Finnish prac-tice, which is being trialled in six National Health Service trusts in the United Kingdom commencing in 2016.294 They describe how a ‘core principle of the approach is the provision of care at the social network level, by staff who have been trained in family, systems and related approaches’.295 Rigorous empirical analysis of Open Dialogue is yet to occur, and its application outside of Finland remains largely untested, although studies are beginning to emerge.296

Evans and colleagues examined demographic data from in-home services for children, highlighting the efficacy of various in-home services as alternatives to hospitalisation for children experiencing serious psychiatric crises.297 However, they did not consider coercion against children and young people, and there is a general absence in literature on preventing coercive practic-es against children and young people.


292 Ibid.

293 Ibid.

294 Russell Razzaque and Tom Stockmann, ‘An Introduction to Peer-Supported Open Dialogue in Mental Healthcare’ (2016) 22(5) BJPsych Advances 348, 348.

295 Ibid.

296 Mary Olson, Jaakko Seikkula and Douglas Ziedonis, The Key Elements of Dialogic Practice in Open Dialogue (The University of Massachusetts, 2014).

297 Evans, Boothroyd and Armstrong, above n 281.

82

4. Other Trends in the Literature

This section notes trends in the literature that cut across hospital and non-hospital settings, yet which are not as overarching as the themes set out in Section 2.1 of this review.

Advance Planning to Improve Crisis Responses

Ten studies explicitly engaged with advance planning.298 Although there is undoubtedly a much larger literature concerning advance planning in mental health services, this review encompassed studies that were particularly aimed at assessing their impact on the use of coercive practices.

‘Joint Crisis Plans’ are a form of advance agreements from the United Kingdom, which are written by an individual in collabora-tion with his or her clinicians, and were considered in 5 studies.299 Joint Crisis Plans were trialled in England and developed in con-sultation with national service user groups, including ‘detailed development work with service users in south London’.300 Each plan is formulated by the patient, ‘care coordinator’, psychiatrist, and a ‘project worker’ and contained contact information, de-tails of mental and physical illnesses, treatments, indicators for relapse, and advance statements of preferences for care in the event of future relapse.

298 Thornicroft et al, above n 108; Graham Thornicroft et al, ‘Randomised Controlled Trial of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: Clinical Outcomes and Implementation’ Abstract 0-90, (2015) 5(Suppl 2) BMJ Supportive & Palliative Care A28; Jeffrey Swanson et al, ‘Psychiatric Advance Directives and Reduction of Coercive Crisis Interventions.’ (2008) 17(3) Journal of Mental Health 255; Alexia Papageorgiou et al, ‘Advance Directives for Patients Compulsorily Admitted to Hospital with Serious Mental Illness. Randomised Controlled Trial’ (2002) 181(6) The British Journal of Psychiatry 513; Barrett et al, above n 91, e74210; Bruce J Winick, ‘Advance Directive Instruments for Those with Mental Illness.’ (1996) 51(1) University Of Miami Law Review 57; Shields et al, above n 57; Claire Henderson et al, ‘Effect of Joint Crisis Plans on Use of Compulsory Treatment in Psychiatry: Single Blind Randomised Controlled Trial’ (2004) 329(7458) BMJ 136; Claire Henderson et al, ‘Views of Service Users and Providers on Joint Crisis Plans’ (2009) 44(5) Social Psychiatry and Psychiatric Epidemiology 369; Claire Henderson et al, ‘Informed, Advance Refusals of Treatment by People with Severe Mental Illness in a Randomised Controlled Trial of Joint Crisis Plans: Demand, Content and Correlates’ (2017) 17(1) BMC Psychiatry 376.

299 C Henderson, et al, ‘Effect of Joint Crisis Plans on Use of Compulsory Treatment in Psychiatry: Single Blind Randomised Controlled Trial’ above n 298, 136.

300 Ibid.

83

In a 2004 study, Henderson and colleagues found that use of compulsory admission or treatment under the Mental Health Act 1983 (England and Wales) was significantly reduced for the group who had Joint Crisis Plans.301 13% (10/80) of the group who had Joint Crisis Plans experienced compulsory admission or treatment compared with 27% (21/80) of the control group (risk ratio 0.48, 95% confidence interval 0.24 to 0.95, P = 0.028).302 Henderson and colleagues’ 2009 study, which consisted of surveys of Joint Crisis Plan recipients and case managers, suggested that partici-pants felt more in control of their mental health problem and that the Plans ‘empower their holders to obtain their preferred care and treatment in a crisis’.303 However, the 2013 follow-up trial was unable to replicate the previous results, although the authors argued ‘that patchy implementation and lack of real commitment are more likely culprits’, and that ‘one meeting between patients and professionals is unlikely to be sufficient to counteract a cul-ture of professional dominance in decision making where this prevails’.304

Barrett and colleagues compared Joint Crisis Plans plus ‘treat-ment as usual’ (TAU) to TAU alone for 569 participants from four English mental health trusts, and found that the addition of Joint Crisis Plans to TAU had ‘no significant effect on compulsory ad-mission.305 They also analysed fiscal cost, and found some evi-dence suggesting a higher probability (80%) of Joint Crisis Plans being the more cost-effective option, particularly amongst the ‘Black ethnic group’.306 Henderson and colleagues’ 2017 trial, compared 221 Joint Crisis Plans with 424 ‘baseline routine care plans’ and aimed to estimate the demand for treatment refusals in such plans, as authorised under the Mental Capacity Act 2005 (England and Wales).307 45% of the Joint Crisis Plans contained a treatment refusal compared to 10 of 424 (2.4%) baseline routine care plans.308 They demonstrated significant demand for writ-ten treatment refusals in line with the Mental Capacity Act 2005

301 Ibid.

302 Ibid.

303 Henderson et al, ‘Views of Service Users and Providers on Joint Crisis Plans’, above n 298, 369.

304 Thornicroft et al, above n 108

305 Barrett et al, above n 81, e74210.

306 Ibid.

307 Henderson et al, ‘Informed, Advance Refusals of Treatment by People with Severe Mental Illness in a Randomised Controlled Trial of Joint Crisis Plans: Demand, Content and Correlates.’, above n 298, 376.

308 Ibid.

84

(England and Wales), which had not previously been elicited by the process of treatment planning. The authors argued that fu-ture treatment/crisis plans should incorporate the opportunity for service users to record a treatment refusal during the drafting of such plans.309

‘Psychiatric advance directives’ and advance statements are a form of statutory advance planning, in which a person makes de-cisions designed to bind oneself or direct others to action in the future, particularly during times of crisis. Swanson and colleagues studied whether the completion of ‘facilitated’ advance planning a ‘Facilitated Psychiatric Advance Directive (F-PAD)’ was associ-ated with reduced frequency of coercive crisis interventions.310 In their study of 130 adults, their quantitative analysis of randomised controlled trial data suggested that F-PAD completion was asso-ciated with lower odds of coercive interventions (adjusted OR = 0.50; 95% CI = 0.26-0.96; p < 0.05).311 They concluded that ‘PADs may be an effective tool for reducing coercive interven-tions around incapacitating mental health crises’.312 Shields and colleagues sought ‘client and carer’ views on psychiatric advance directives in India (making it the only study on advance directives in a low- or middle-income country).313 Most interviewees report-ed being unfamiliar with advance directives and although some clients felt it was important to have a say in treatment wishes, carers expressed ‘concerns about service user capacity to make decisions’.314 The authors conclude that advance directives ‘could potentially mitigate the risks of coercive treatments to persons with severe mental illness’.315 Winick, in his socio-legal analysis of law relevant to living wills and advance directives, particularly case law, argues that advance directive instruments can be a use-ful means of planning for mental illness and of avoiding disputes concerning hospitalisation and treatment.316 However, one study found little observable impact of advance directives on coercion. Papageorgiou and colleagues in their study found users’ advance instruction directives had little observable impact on compulso-ry readmission rates at 12 months.317 In contrast, de Jong and

309 Ibid.

310 Swanson et al, above n 298, 255.

311 Ibid.

312 Ibid.

313 Shields et al, above n 57, 29.

314 Ibid.

315 Ibid.

316 Winick, above n 298.

317 Papageorgiou et al, above n 298.

85

colleagues conducted a systematic literature review on advance statements, including a meta-analyses of all randomised control trials (RCTs), which they argue ‘showed a statistically significant and clinically relevant 23% reduction in compulsory admissions in adult psychiatric patients, whereas the meta-analyses of the RCTs on community treatment orders, compliance enhance-ment, and integrated treatment showed no evidence of such a reduction’.318

Using Non-Legal Advocacy to Avoid Coercion

Some articles considered advocacy to avoid coercion. ‘Advoca-cy’ was referred to in the sense of non-legal advocacy including individual action, but also forms of group and peer advocacy, and systemic advocacy. Cutler, Hayward and Tanasan write:

advocacy enables individuals to have a say in their life and the dimensions that affect their livelihood, whether that be their care, their family, their housing or their work. This is particularly important in mental health, as people experiencing crises may have many of their fundamental rights taken away when they are treated or compulsorily admitted to hospital.319

Interestingly, advocacy was solely discussed with regards to ser-vice user-run organisations, and self-help groups. Kleintjes, Lund and Swartz, in their qualitative study involving 11 members of leadership in mental health self-help organisations across Africa, concluded that self-help organisations provide ‘advocacy to … promote the protection of user’s rights’.320 Tanenbaum, in her study of the directors of 15 consumer-operated service organi-sations (service user led organisations) in the United States ob-served they ‘provide peer support and advocacy training’.321 No empirical evidence in the review was able to indicate the effec-tiveness of non-legal advocacy in causing a reduction in coercive practices, except perhaps Winkler and colleagues’ study of men-tal health policy in Central and Eastern Europe, in which the study respondents suggested that systemic advocacy had been crucial in progressive change away from coercive, institutional prac-tices—change that reportedly occurred ‘because of grassroots

318 Mark H de Jong et al, ‘Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-Analysis’ (2016) 73(7) JAMA Psychiatry 657, 657.

319 Cutler, Hayward and Tanasan, above n 56, 1.

320 Kleintjes, Lund and Swartz, above n 56.

321 Tanenbaum, above n 105.

86

initiatives supported by international organisations, rather than by systematic implementation of government policies’.322

The general absence in the literature on individual advocacy seems significant, given the prominent position given to non-le-gal advocacy in many CRPD debates about coercion in mental health services. The Swedish personligt ombud (or PO) is impor-tant in this regard. In its Handbook for Parliamentarians on the Convention on the Rights of Persons with Disabilities, the Office of the High Commissioner for Human Rights (OHCHR) recommends the ‘PO Skåne’ programme – an iteration of the PO scheme run by persons who had used mental health services – as a form of sup-ported decision-making.323 The Commissioner for Human Rights of the Council of Europe, Nils Muižnieks, writes that ‘recourse to the Personal Ombudsmen system could be a way of limiting coercive practice in psychiatric institutions’.324 According to the Swedish National Board of Health and Welfare, an important func-tion of the PO is to ‘make demands on the public authorities that are responsible for people with serious psychiatric disabilities, to ensure that they are receiving the help and service to which they are entitled’.325 According to the report, this function reduces the number of mental health crises that a person experiences, and leads to savings of up to 17 times the cost of the service itself. Yet, there is an absence of academic research examining the empirical basis for claims about the PO system, which seems like a significant gap in the scholarly literature. Further, despite the PO scheme being presented as a rights-based approach to advocacy for persons with mental health conditions and psy-chosocial disabilities, it is worth noting that Sweden has among the highest rates of formal involuntary psychiatric interventions in the world.326 No English-language materials that examine the

322 Petr Winkler et al, above n 56, 634.

323 Office of the High Commissioner for Human Rights, ‘Chapter Six: From Provisions to Practice: Implementing the Convention, Legal Capacity and Supported Decision-Making’, United Nations Handbook for Parliamentar-ians on the Convention on the Rights of Persons with Disabilities (United Nations, 2007) 89.

324 Swedish National Board of Health and Welfare, A New Profession is Born – Personligt ombud, PO (Västra Aros, Västerås, November 2008) 10 <www.personligtombud.se>.

325 Ibid.

326 Salize and Dressing, above n 207.

87

impacts of the scheme on rates of coercion within mental health settings were identified in the review.

Reducing Fear of Coercion

There is some evidence to suggest that fear of coercion may keep people away from mental health treatment, which may increase risk of coercion. Several studies considered the impact of dissat-isfaction with services, or the result of ‘negative’ encounters with services.327 Some studies identified dissatisfaction of service us-ers with services they have used in the past, as an indicator of the likelihood of treatment refusal. Louk and colleagues provide some evidence indicating that more satisfaction with prior treat-ment seems to ‘reduce the risk of civil detention remarkably’.328 Swartz and colleagues provided some evidence to indicate that involuntary hospitalisation and ‘recent warnings about treatment nonadherence’ were found to be significantly associated with barriers that may inhibit future help seeking, and concluded that ‘mandated treatment may serve as a barrier to treatment, but that ongoing informal pressures to adhere to treatment may also be important barriers to treatment’.329 Informal pressures were examined by Valenti and colleagues in their international study involving 10 countries. They conducted focus groups with mental health professionals regarding their attitudes toward and expe-riences with the use of informal coercion. Despite the different sociocultural contexts, the researchers found that ‘disapproval of informal coercion in theory is often overridden in practice’, which tends to ‘make professionals feel uneasy, and requires more de-bate and guidance’.330

327 Louk FM van der Post et al, ‘Patient Perspectives and the Risk of Compul-sory Admission: The Amsterdam Study of Acute Psychiatry V’ (2014) 60(2) The International Journal of Social Psychiatry 125; Brodie Paterson, Lindsay Bennet and Patrick Bradley, ‘Positive and Proactive Care: Could New Guid-ance Lead to More Problems.’ (2014) 23(17) British Journal of Nursing 939.

328 van der Post et al, above n 327.

329 Marvin S Swartz, Jeffrey W Swanson and Michael J Hannon, ‘Does Fear of Coercion Keep People Away from Mental Health Treatment? Evidence from a Survey of Persons with Schizophrenia and Mental Health Professionals’ (2003) 21(4) Behavioural Sciences & The Law 459.

330 Emanuele Valenti et al, ‘Informal Coercion in Psychiatry: A Focus Group Study of Attitudes and Experiences of Mental Health Professionals in Ten Countries’ (2015) 50(8) Social Psychiatry and Psychiatric Epidemiology 1297, 1297.

88

Culturally Appropriate Pathways Through Mental Health Services

Several studies in high-income Western countries, considered the distinct issues concerning mental health and coercion, or crisis resolution, facing persons with mental health conditions or psychosocial disabilities who are from minority ethnic com-munities. Lawlor and colleagues found that all groups of ‘black’ patients and ‘white other’ patients were significantly more like-ly to have been compulsorily admitted than ‘white British’ pa-tients.331 Differences between groups in help-seeking behaviours in a crisis may contribute to explaining differences in rates of compulsory admission. Smith and others reported in their study that ‘[p]atients from racial or ethnic minority groups had a higher rate and longer duration of seclusion than whites’.332 Barrett and colleagues, in their study of Joint Crisis Plans, reported that ‘the evidence does not support the cost-effectiveness of [Joint Crisis Plans] for White or Asian ethnic groups, there is at least a 90% probability of the JCP intervention being the more cost-effective option in the Black ethnic group’.333 As noted above, Hackett and colleagues examined a crisis and home support programme for the black and minority ethnic community in Sheffield, England, which appeared to drive positive change including more referrals to the Sheffield Crisis Resolution Home Treatment Service from psychiatric services.334 Several examples from grey literature ap-peared, which sought to address culturally-specific needs. The Leeds Survivor-Led Crisis Service, again in England, reports on its partnership with a service that supports people from black and minority ethnic (BME) groups, for which the partnership provides out-of-hours crisis services to people from BME groups in acute mental health crisis. The Manager, Senior Crisis Support Worker and three Crisis Support Workers are all from BME groups.335

Supported Decision-Making

‘Supported decision-making’ is advanced by United Nations bodies as the preferred response for people who are otherwise

331 Lawlor et al, above n 239.

332 Smith et al, above n 206.

333 Barrett et al, above n 81, e74210.

334 Hackett et al, above n 284.

335 See Leeds Survivor-Led Crisis Service <https://www.lslcs.org.uk/additional>.

89

subject to forced psychiatric interventions.336 The OHCHR refers to supported decision-making as simply ‘the process whereby a person with a disability is enabled to make and communicate decisions with respect to personal or legal matters’.337

As noted previously, Bariffi and Smith describe the use of Ar-gentina’s National Mental Health Law 2010 (NMHL) as a means of providing supported decision-making arrangements to people who may otherwise be subject to civil commitment and invol-untary treatment.338 Bariffi and Smith provide several case stud-ies to show how the provision in the NMHL that authorises the provision of a supported decision-making packages, works in practice. One scholarly study conducted empirical research into the possible impact of ‘supported decision-making’ on coercive practices. Kokanović and colleagues conducted interviews with 90 mental health service users, family members supporting them and mental health practitioners.339 The authors conclude that en-abling supported decision-making in clinical practice and policy can be facilitated by (1) support for good communication skills and related attitudes and practices among mental health practi-tioners and removing barriers to their good practice in health and social services and (2) introducing legal supported decision-mak-ing mechanisms.340

Other studies could be broadly categorised as being concerned with supported decision-making and broader ‘support to exercise legal capacity’ in line with Article 12(3) of the CRPD. Consider the PO Skåne’ program, for example, which the OHCHR described as a form of supported decision-making (as discussed in the

336 See, eg, Committee on the Rights of Persons with Disabilities, General Comment No 1: Article 12: Equal Recognition Before the Law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014) 6 [26].

337 UN Office of the High Commissioner for Human Rights, Annual Report of the United Nations High Commissioner for Human Rights and Reports of the Office of the High Commissioner and the Secretary-General: Thematic Study by the Office of the United Nations High Commissioner for Human Rights on Enhancing Awareness and Understanding of the Convention on the Rights of Persons with Disabilities, UN Doc A/HRC/10/48 (26 January 2009) [45].

338 Law No 26657, 3 December 2010 [32041] BO 1; ‘Mental Health Regime’, House of Representatives Res D-276/07 (7 March 2007) art 1.

339 Renata Kokanović et al, ‘Supported Decision-Making from the Perspec-tives of Mental Health Service Users, Family Members Supporting Them and Mental Health Practitioners, Supported Decision-Making from the Perspectives of Mental Health Service Users, Family Members Supporting Them and Mental Health Practitioners’ [2018] Australian & New Zealand Journal of Psychiatry 826.

340 Ibid.

90

previous section).341 In another study, Robertson and Collinson sought to explore outreach workers’ experiences of assisting clients with positive risk-taking,342 which has overlap with the emphasis in supported decision-making on so-called ‘dignity of risk’.343 The authors found different understandings of positive risk-taking at different levels within organisations and a ‘need for better informed, coherent organisational approaches to its practice’.344 Conservative practices were associated with ‘pro-moting coercion and disrupting therapeutic relationships, and so increasing risks over a longer time period’, and the researchers called for more research on creating effective frameworks for as-sisting people with positive risk taking.345

Overall, however, despite the prominence of the concept of sup-ported decision-making in human rights related activity, there were few empirical studies on its application in the mental health context.

Providing Low-medication and/or No-medication Approaches

Organisations representing persons with mental health condi-tions and psychosocial disabilities tend to characterise support with medication discontinuation, or low-medication approaches, as an unmet need. Although discontinuation may not seem at first glance to be an alternative to coercive practice, there is some ev-idence to suggest that many service users chose to keep discon-tinuation a secret from mental health professionals to avoid per-ceived negative consequences such as involuntary treatment.346 Service providers may not wish to assist service users to reduce

341 Office of the High Commissioner for Human Rights, above n 323, 89.

342 John P Robertson and Christine Collinson, ‘Positive Risk Taking: Whose Risk Is It? An Exploration in Community Outreach Teams in Adult Mental Health and Learning Disability Services.’ (2011) 13(2) Health, Risk & Soci-ety 147, 147.

343 Piers Gooding, ‘Supported Decision-Making: A Rights-Based Disability Concept and Its Implications for Mental Health Law’ (2013) 20(3) Psychia-try, Psychology and Law 431, 432 .

344 Robertson and Collinson, above n 342.

345 Ibid.

346 Carmela Salomon, Bridget Hamilton and Stephen Elsom, ‘Experiencing Antipsychotic Discontinuation: Results from a Survey of Australian Con-sumers’ (2014) 21(10) Journal of Psychiatric and Mental Health Nursing 917, 922.

91

or discontinue. A subtly coercive effect can therefore occur which narrows service users’ options for healthcare decision-making.

Studies indicate that discontinuing psychiatric medication is of-ten a complicated and difficult process.347 Salomon, Hamilton and Elsom in their empirical research on 98 service users or former service users in Australia, argued that ‘there may be a need to improve education, monitoring, and support strategies for some people during discontinuation’ and that ‘[s]hifting toward a more collaborative, transparent, and service user-driven approach to discontinuation may help to mitigate some of the negative dis-continuation impacts identified’.348 (They also acknowledge that findings cannot be readily generalised because of sampling con-straints). Ostrow and colleagues, in their sample of 250 service users in the US, argue that ‘[f]uture research should guide health care systems and providers to better support patient choice and self-determination regarding the use and discontinuation of psy-chiatric medication’.349 It seems reasonable to assume that dis-continuation practices, whether formally or informally, are occur-ring worldwide. Groot and van Os have proposed ‘tapering strips’ as a practical solution to help service users discontinue more safely.350 They conducted an observational study on the use of ‘antidepressant tapering strips to help people come off medica-tion more safely’ (n=1194) and concluded that ‘(t)apering strips represent a simple and effective method of achieving a gradual dosage reduction’.351 An international initiative, The Tapering Pro-ject, is promoting the use of Tapering Strips as a way to improve the choice, control and safety of those who take them.352

Cullberg and colleagues, in their study of 253 adults with first episode psychosis in the Swedish Parachute project found some evidence that psychiatric in-patient care was lower as was

347 Ibid; Laysha Ostrow et al, ‘Discontinuing Psychiatric Medications: A Sur-vey of Long-Term Users’ (2017) 68(12) Psychiatric Services 1232.

348 Ibid.

349 Ibid.

350 Peter C Groot and Jim van Os, ‘Antidepressant Tapering Strips to Help People Come off Medication More Safely’ (2018) 10(2) Psychosis 142.

351 Ibid.

352 The Tapering Project <http://www.taperingstrip.org/>. Research at Maas-tricht University is being undertaken into the use of Tapering Strips. See Project Tapering, Maastricht University <https://urc.mumc.maastrichtuni-versity.nl/node/13125>.

92

prescription of neuroleptic medication in project participants.353 Satisfaction with care was generally high in the Parachute group, with access to a small overnight crisis home associated with high-er ‘Global Assessment of Functioning’ scores. The researchers argue that it is possible to successfully treat first episode patients with ‘fewer in-patient days and less neuroleptic medication than is usually recommended, when combined with intensive psycho-social treatment and support’.354 Morrison and colleagues, exam-ined 74 individuals randomly assigned to receive either cognitive therapy plus treatment as usual (n=37), or treatment as usual alone (n=37) in order to examine the feasibility and effectiveness of using cognitive behavioural therapy (CBT) in people with schiz-ophrenia who are not taking medication.355 They provide some evidence indicating that ‘cognitive therapy significantly reduced psychiatric symptoms and seems to be a safe and acceptable al-ternative for people with schizophrenia spectrum disorders who have chosen not to take antipsychotic drugs’, though they call for a larger, definitive trial.356 As previously discussed, the Open Dialogue approach ‘emphasises using fewer neuroleptic medica-tion’, and Seikkula provides some evidence to indicate that the ‘patients in the Open Dialogue in Acute Psychosis (ODAP) group had fewer relapses and less residual psychotic symptoms and their employment status was better than patients in the compar-ison group receiving ‘typical’ treatment.357

Several studies discussed possible correlations between rates of seclusion and physical or mechanical restraint on the one hand, and the use of psychotropics, neuroleptics and so on (forced or otherwise) on the other. Flammer and Steiner, in Germany, re-ported that ‘[r]estriction of involuntary medication [following the 2013 Constitutional Court rulings] was associated with a signif-icant increase in use of mechanical coercive measures and vio-lent incidents’.358 Noorthoorn and colleagues similarly found that

353 Johan Cullberg et al, ‘One-Year Outcome in First Episode Psychosis Pa-tients in the Swedish Parachute Project’ (2002) 106(4) Acta Psychiatrica Scandinavica 276.

354 Ibid. See also Johan Cullberg et al, ‘Treatment Costs and Clinical Outcome for First Episode Schizophrenia Patients: A 3-Year Follow-up of the Swed-ish “Parachute Project” and Two Comparison Groups’ (2006) 114(4) Acta Psychiatrica Scandinavica 274.

355 Anthony P Morrison et al, ‘Cognitive Therapy for People with Schizophre-nia Spectrum Disorders Not Taking Antipsychotic Drugs: A Single-Blind Randomised Controlled Trial’ (2014) 383(9926) The Lancet 1395, 1395.

356 Ibid.


358 Erich Flammer and Tilman Steinert, ‘Association Between Restriction of Involuntary Medication and Frequency of Coercive Measures and Violent Incidents.’ (2016) 67(12) Psychiatric Services 1315.

93

‘[i]n some hospitals where seclusion decreased, use of forced medication increased’ and that in others ‘[s]eclusion decreased significantly, and forced medication increased’.359 However, Hø-jlund and colleagues found that ‘[a] decrease in coercive meas-ures from 2013 to 2016 has not lead to significant increases in the use of antipsychotic medication or benzodiazepines’.360 These mixed outcomes suggest that more research is needed to identi-fy strategies to both reduce and eliminate coercive practices like physical and mechanical restraint, while also ensuring that low-

or no-medication options are available to individuals in crisis.

359 Noorthoorn et al, above n 54.

360 Højlund Mikkel et al, ‘Use of Antipsychotics and Benzodiazepines in Con-nection to Minimising Coercion and Mechanical Restraint in a General Psychiatric Ward’ (2018) 64(3) The International Journal of Social Psychiatry 258.

94

Section Three: Regional ThemesAs can be seen in the table and figure below, most of the re-viewed research was conducted in North America and Western Europe. Overall, research locations are dominated by the United States, the United Kingdom (particularly England), the Neth-erlands and Northern Europe. The regions of Asia, Africa, the Middle East, Eastern and Southern Europe and Latin America remain significantly under-represented. There was one study that encompassed all South American countries.361 Similarly, a single study encompassed seven African countries.362 Hence, the rep-resentation in the table below does not necessarily convey the number of studies undertaken in each region.

Region N* Specific countries

Asia 6 India (2), Indonesia (3), China (1)

Eastern Europe 4 Bulgaria (1), Czech Republic (1), Lithuania (1), Poland (1),

Latin America 15

Argentina (2), Mexico (1), Chile (2); Bolivia (1), Brazil (1), Colombia (1), Ecuador (1), Guyana (1), Paraguay (1), Peru (1), Suriname (1), Uruguay (1), Venezuela (1)

Middle East 0 -

North America 28 United States (25), Canada (3)

Northern Africa 4 Kenya (1), Uganda (1), Ethiopia (1), Ghana (1)

Oceania 7 Australia (7)

Southern Africa 4 Rwanda (1), Tanzania (1), South Africa (1), Zambia (1)

Southern Europe 7 Croatia (1), Italy (3), Greece (1), Spain (2)

Western Europe 81Denmark (10), Finland (5), Germany (7), Iceland (1), Netherlands (15), Norway (9), Sweden (8), Switzerland (6), England (20)

Table 1: Regions in which studies found in the literature review were conducted

361 Christina Larrobla and Neury José Botega, ‘Restructuring Mental Health: A South American Survey’ (2001) 36(5) Social Psychiatry and Psychiatric Epidemiology 256.

362 Kleintjes, Lund and Swartz, above n 56, 187.

95

Figure 2: Regions in which the reviewed research has been conducted

The under-representation of research identified from low- and middle-income countries throughout the world is of concern. This may be partly explained by this review’s bias toward Eng-lish-language material which tends to direct attention to high-in-come countries with majority Anglophone populations (namely, Western Europe and Northern America). Publications in other languages and relevant publications that are not peer-reviewed are available online and elsewhere but were outside the scope of this review.

Africa

Elizabeth Kamundia points out that persons with disabilities in Africa, including those with psychosocial, intellectual and cogni-tive disabilities, typically live with their families against a cultural backdrop of mostly communal ways of life without individualised state-funded support services.363 As such, strategies and prac-tices for creating non-coercive practices differ considerably. The

363 See generally, Elizabeth Kamundia, ‘Choice, Support and Inclusion: Im-plementing Article 19 of the Convention on the Rights of Persons with Disabilities in Kenya’ in African Yearbook on Disability Rights (Pretoria Law Press, 2013) 49.

96

cultural context of communalism with relatively strong social co-hesion, especially in rural areas, seems to be an important foun-dation when talking about ‘alternatives’ in Africa.

Peer support seems to be a key mode of support in Africa that might be broadly termed as a means to prevent coercion in the mental health context, whether through formal mental health services or community-based forms of coercion (for example in family homes or religious camps).364 Kamundia has characterised peer support as culturally appropriate, recovery-focused and community-based.365 Stefan Kleintjes and colleagues, in their qualitative study involving 11 members of leadership in mental health self-help organisations across Africa, concluded that:

Self-help organisations can provide crucial support to [mental health service] users’ recovery in resource poor settings in Af-rica. Support of Ministries, NGOs, DPOs, development agencies and professionals can assist to build organisations’ capacity for sustainable support to members’ recovery.366

The review material – although limited, given the few studies available – suggests that these responses include tools to address coercion, such as informal advance directives and representation agreements, peer support groups to whom local communities and local police may turn to de-escalate crises, informal advoca-cy and information sharing.367

Lack of resources appears to be a pressing issue in low-income African countries, as with low-income countries worldwide. Ash-er and colleagues undertook qualitative research interviewing 35 adults with schizophrenia, ‘their caregivers, community leaders and primary and community health workers’ in rural Ethiopia, in order to better understand the experiences of, and reasons for, restraint of people with schizophrenia in community settings.368 All types of participants cited increasing access to treatment as the most effective way to reduce the incidence of restraint. The

364 Users and Survivors of Psychiatry – Kenya, “The Role Of Peer Support In Exercising Legal Capacity in Kenya (April 2018) <www.uspkenya.org>; Kleintjes, Lund and Swartz, above n 56.

365 Kamundia, above n 363.

366 Kleintjes, Lund and Swartz, above n 56, 187.

367 Users and Survivors of Psychiatry – Kenya, above n 364.

368 Asher et al, above n 8, 47.

97

authors conclude that a scale up of accessible and affordable mental health care may go some way to address the issue of restraint.

Human Rights Watch (in a non-peer reviewed research report) indicated that a Ghanaian coalition of non-governmental groups, including disabled peoples organisations, family groups and mental health professionals, called on the ‘the government of Ghana [to] ensure adequate funding for mental health services in Ghana, as a crucial step to eliminating the widespread practice of shackling and other abuses against people with psychosocial disabilities’.369 The Ghanaian Mental Health Act 2012 includes a provision that requires the Minister responsible for finance to cre-ate a levy to fund mental health services through parliament,370 though Human Rights Watch report that the levy has yet to be established.371

However, it is also clear from this report that more mental health services per se will not lead to a reduction or the elimination of coercive practices. According to the United Nations Special Rapporteur for the Right to Health, Dainius Pūras:

The scaling-up of care must not involve the scaling-up of inappropriate care. For care to comply with the right to health, it must embrace a broad package of integrated and coordinated services for promotion, prevention, treatment, rehabilitation, care and recovery and the rhetoric of “scaling up” must be replaced with mental health actions to “scale across”. That includes mental health services integrated into primary and general health care, which support early identification and intervention, with services designed to support a diverse community.372

369 Human Rights Watch, ‘Ghana: Invest in Mental Health Services to End Shackling’ (9 October 2017) <https://www.hrw.org/news/2017/10/09/ghana-invest-mental-health-services-end-shackling>

370 Mental Health Act 2012 (Ghana) Act 846, s 88.

371 Human Rights Watch, above n 369.

372 Human Rights Council, Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc, 35th sess, A/HRC/35/21 (28 March 2017) [55].

98

More research is needed to identify and address the type of coer-cion facing persons with mental health conditions and psychoso-cial disabilities in Africa, including strategies that are responsive to social and economic conditions, and which go beyond a mere call for more resources for mental health services.

Asia

Studies from India, Indonesia and China appeared in the review but given the low number of studies, few generalisations can be made.

Of the two Indian studies, Shields and colleagues sought ‘client and carer’ views on psychiatric advance directives, as noted pre-viously373 while Raveesh and colleagues examined the attitudes of psychiatrists and caregivers to the use of coercive practices. Regarding the latter, participants recommended ‘early identifi-cation of aggressive behaviour, interventions to reduce aggres-siveness, empowering patients, improving hospital resources [and] staff training in verbal de-escalation techniques’ to prevent coercion.374 They call for ‘standardized operating procedure[s] in the use of coercive measures’; this recommendation is not an al-ternative to coercion per se, though the authors argue that clear regulation would reduce coercion overall.375

Three peer-reviewed studies were undertaken in Indonesia, all concerning the practice of ‘pasung’, that is, the shackling or re-straint of persons with psychosocial disabilities in family homes and communities. All researchers are clinicians and most of the research was action-based, with researchers charting the impact of interventions that aimed to prevent, reduce and end pasung. Minas and Diatri, in their observational study on Samosir Island, argued that the ‘provision of basic community mental health ser-vices, where there were none before, enabled the majority of the people who had been restrained to receive psychiatric treatment and to be released from pasung’.376 Puteh and colleagues sim-ilarly concluded that the ‘development of a community mental health system and the introduction of a health insurance system in Aceh (together with the national health insurance scheme for the poor) has enabled access to free hospital treatment for people

373 Shields et al, above n 57.

374 Raveesh et al, above n 220, s221.

375 Ibid.

376 Minas and Diatri, above n 8.

99

with severe mental disorders, including those who have been in pasung’.377 They argue that it can inform ‘other low and middle-in-come countries where restraint and confinement of the mentally ill is receiving insufficient attention’.378 Suryani and colleagues take a slightly different approach in applying a programme to address pasung; they sought to integrate more culturally-specific forms of support, which they describe as a ‘community-based, culturally sensitive … mental health model’ that assisted all 23 people subject to pasung to show ‘a remarkable recovery within 19 months of treatment’.379

In China, as noted previously, a study by Guan and colleagues was a largescale, national project, involving a nationwide two-stage follow-up study to measure the effectiveness and sus-tainability of the ‘unlocking and treatment’ intervention and its impact on the ‘well-being of patients’ families’.380 (The emphasis on family wellbeing rather than individual wellbeing is notable). Similar to the Indonesian studies, the unlocking process referred to an intervention to free people from deprivations of liberty in family homes or communal spaces (such as villages). 96% of par-ticipants were diagnosed with schizophrenia. Prior to unlocking, their total time locked ranged from two weeks to 28 years, with 32% having been locked multiple times. The authors reported that over 92% of participants remained free of restraints in 2012 and they argued that ‘[p]ractice-based evidence from our study suggests an important model for protecting the human rights of people with mental disorders and keeping them free of restraints […][via] accessible, community based mental health services with continuity of care’.381 China’s ‘686’ Programme may be useful, therefore, for informing efforts in low-resource settings where community locking of persons with psychosocial disabilities is practiced.

Appendix 3 includes reference to ‘Transforming Communities for Inclusion-Asia’ (TCI-Asia), an India-based NGO that describes

377 Ibrahim Puteh, M Marthoenis and Harry Minas, ‘Aceh Free Pasung: Releas-ing the Mentally Ill from Physical Restraint’ (2011) 5 International Journal of Mental Health Systems 10, 10.

378 Ibid.

379 Luh Ketut Suryani, Cokorda Bagus Jaya Lesmana and Niko Tiliopoulos, ‘Treating the Untreated: Applying a Community-Based, Culturally Sensitive Psychiatric Intervention to Confined and Physically Restrained Mentally Ill Individuals in Bali, Indonesia’ (2011) 261(Suppl 2) European Archives of Psychiatry and Clinical Neurosciences 140, s143.

380 Guan et al, above n 56.

381 Ibid.

100

itself as ‘an Asian Alliance of people with psychosocial disabili-ties, and cross disability supporters, focusing on the monitoring and implementation of all human rights for persons with men-tal health problems and psychosocial disabilities’.382 TCI-Asia has contributed to debate about the implications of the CRPD for low- and middle-income countries. They recently reported a growth of psychiatric institutions in Asia, and laws which author-ise non-consensual psychiatric interventions.383 TCI-Asia notes that ‘even though mental health legislations do not exist in many [Asian] countries, and some have [only] recently adopted new coercive mental health laws, mental institutions are coming up quite fast, resulting in the escalation of barriers to inclusion’.384

Clearly, more research is needed regarding both communi-ty-based deprivations of liberty and other coercive practices, as well as research concerning more formal, state-based coercive practices, policies and law.

Europe

Europe contains major economic, cultural and political differ-ences. A spectrum appears to exist between low- and middle-in-come countries with largescale, standalone institutions and min-imal welfare services, as well as high-income countries that are ‘deinstitutionalised’ and have comprehensive welfare systems. These differences have major implications for the nature of men-tal health services, the types of coercion people experience, and the remedies for addressing them.385

English-language studies identified in the review within Europe were mostly conducted in high-income Western countries such as the United Kingdom (particularly England), the Netherlands and Scandinavia (particularly Denmark). This region had a di-verse array of research projects, from quantitative to qualitative, national studies, comparative international studies, case stud-ies and so on. The region has seen concerted efforts to reduce, end and prevent coercive practices in mental health settings.

382 See Transforming Communities for Inclusion – Asia<http://www.interna-tionaldisabilityalliance.org/tci-membership>.

383 Transforming Communities for Inclusion – Asia, Submission to the UNCRPD Monitoring Committee, Day of General Discussion, Article 19 <www.ohchr.org>; see also <www.madinasia.com>.

384 Ibid.

385 Lucie Kalisova et al, ‘Do Patient and Ward-Related Characteristics Influence the Use of Coercive Measures? Results from the EUNOMIA International Study’ (2014) 49(10) Social Psychiatry and Psychiatric Epidemiology 1619.

101

However, it is also noteworthy that the rate of compulsory admis-sions is tending to rise in some parts of Western Europe. In de Jong and colleagues’ terms:

Although recent numbers for most countries are not available, rates in several European countries are tending to rise, albeit for reasons that are largely unknown. In England—where, as in many other countries, many patients have been moved from large institutions into the community—the reduction in the number of mental illness beds has been accompanied by a rise in compulsory admissions. In Western societies, tolerance of deviant behavior by psychiatric patients in the community seems to be decreasing, parallel to an increasing emphasis on autonomy and rights of patients and to strictly defined and regulated coercive measures.386

The Netherlands had a strong representation of research that considered family-directed interventions – particularly Family Group Conferencing, as noted. Scandinavian countries, particu-larly Norway and Denmark tended to include studies which re-ported on robust national data on rates and patterns of coercive practices in mental health settings.

There was only one study identified in the review that focused on Eastern European mental health services, and even that was a European wide study.387 It included ten countries, including Bulgaria, Czech Republic, Lithuania and Poland. In the study, Kalisova and colleagues considered service data for 2,027 invol-untarily admitted patients, who were divided into two groups, the first (N = 770) subject to at least one ‘coercive measure’, the other (N = 1,257) had not received a ‘coercive measure’ during hospi-talisation. (Again, highlighting terminological issues in this field, the authors of this study distinguish ‘coercion’ from ‘involuntary admission’, where other studies include involuntary admission in the definition of coercion). This study sought to identify whether selected patient and ward-related factors are associated with the

386 Mark H de Jong et al, ‘Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-Analysis’ (2016) 73(7) JAMA Psychiatry 657, 658. See, also Alessia de Stefano, Giuseppie Ducci, ‘In-voluntary Admission and Compulsory Treatment in Europe: An Over-view’ (2008) 37(3) International Journal of Mental Health 10; Stefan Priebe et al, ‘Reinstitutionalisation in Mental Health Care: Comparison of Data on Service Provision from Six European Countries’ (2005) 330(7483) BMJ 123; Katrien Schoevaerts et al, ‘An Increase of Compulsory Admissions in Belgium and the Netherlands: An Epidemiological Exploration’ [in Dutch] (2013) 55(1) Tijdschrift Voor Psychiatrie 45.

387 Kalisova et al, above n 385.

102

use of coercive measures. The authors found significant variance of coercive measures in the participating countries. Clinical fac-tors, such as ‘high levels of psychotic symptoms and high levels of perceived coercion at admission were associated with the use of coercive measures’, when controlling for countries’ effect.388 The authors recommend attention to these factors in programmes aimed at reducing the use of coercive measures in psychiatric wards. Activity is clearly underway to reduce coercive practices in Eastern European mental health settings, with ‘grey’ literature materials available in English and regional languages.389 Winkler and colleagues undertook a review of the ‘development of men-tal health-care practice for people with severe mental illnesses’ in Central and Eastern Europe over the past 25 years, drawing on an expert survey in 24 countries. They concluded as follows:

National policies often exist but reforms remain mostly in the realm of aspiration. Services are predominantly based in psychiatric hospitals. Decision making on resource allocation is not transparent, and full economic evaluations of complex interventions and rigorous epidemiological studies are lacking. Stigma seems to be higher than in other European countries, but consideration of human rights and user involvement are increasing. The region has seen respectable development, which happened because of grassroots initiatives supported by international organisations, rather than by systematic implementation of government policies.390

Similarly, there were just two English-language studies con-cerning Southern Europe identified in the review (one of which was the same study that captured the Eastern European coun-tries).391 Again, it is apparent that endeavours are underway to reduce, end and prevent coercive practices in this region.392

Clearly, there is scope for further research in these regions, includ-ing a comprehensive survey of non-English language research, to identify effective measures that reduce coercion in mental health settings.

388 Ibid.

389 See, eg, The EU PERSON Partnership <www.eu-person.com/>; Men-tal Disability Rights Initiative of Serbia <www.mdri-s.org/>; Resource Center for People with Mental Disability<www.zelda.org.lv/en/zelda/pilot-project-of-supported-decision-making>.

390 Winkler et al, above n 56, 634.

391 Kalisova et al, above n 385; Valenti et al, above n 330.

392 See, eg, the ‘Trieste Model’ summarised in Appendix Three.

103

Latin America

There was relatively little English-language research uncovered in the literature review from Latin America. Latin America has un-doubtedly produced research relevant to this review in languages other than English. There are practices in this region aimed at reducing, ending and preventing coercion in mental health set-tings. How this is working in practice, however, is not clear – and there may or may not be research examining outcomes. The work of Barriffi and Smith, for example, describes the possibility of Article 42 of the Argentinian National Mental Health Law being used to promote supported decision-making arrangements as an alternative to civil commitment, but it is essentially a speculative piece of sociolegal research, insofar as it charts a possible legal and policy pathway without evidence of how the law is being applied.393 Evidence of its application is probably now available, though it is not clear if research on the outcomes is underway.

Larrobla and Botega undertook a comparative study, via postal survey to all countries in South America, through ‘health min-istries, national psychiatric associations and key informants’.394 This 2001 study sought to gather information available on the changes in mental health services in South American countries following the ‘social and political upheavals of recent decades’, which included a particular focus on the success or otherwise of deinstitutionalisation.395 The survey results indicate that ‘most’ mental health programmes were implemented during the 1980s and 1990s and aimed at incorporating psychiatric care into prima-ry health care, as well as relocating provision from large hospitals to decentralised services (which is likely to be associated with less coercive environments). However, the authors expressed concern about ‘the availability of adequate human and material resources’, concluding that the transition away from large mental institutions is ‘on the way in South American countries’.396

Latin America countries are clearly taking some steps to move toward the ‘will, preference and rights’ approach. Peru, for ex-ample, has abolished substituted decision-making from its men-tal-health law following recommendations from the Committee

393 Bariffi and Smith, above n 56.

394 Larrobla and Botega, above n 361, 256.

395 Ibid.

396 Ibid.

104

on the Rights of Persons with Disabilities in 2012.397 (There re-main several caveats, including that the new legislation on mental health, which is part of the general health legislation, established an exception for ‘drug addicts’ and ‘emergency situations’). Again, English-language scholarly research on many of these de-velopments is not currently available.

Middle East

No materials were found on alternatives to coercion in mental health settings in the Middle East, indicating an urgent need for further research, including a comprehensive review of non-Eng-lish research.

North America

The Six Core Strategies approach to reducing seclusion and re-straint is prominent in North America, which is perhaps unsur-prising given its origins in the United States.398 The United States was also the source of several noteworthy, largescale studies, involving high participant numbers. For example, Ashcraft and colleagues conducted two studies, one involving service data on 14,500 adults per year for a four-year period, and another involv-ing 12,346 adults.399 Greenfield and colleagues’ study is novel insofar as it involved quantitative methods and a randomised trial comparing the effectiveness of an unlocked, mental health con-sumer-managed, crisis residential programme to a locked, inpa-tient psychiatric facility for adults with severe mental health con-ditions.400 In contrast, the vast majority of research concerning user/peer/consumer-led support services is qualitative – which is perhaps unsurprising, given the basis of phenomenological research in human experience. The Vermont Governments quan-titative data on peer-run crisis centres, which was identified for inclusion in Appendix Three, is also unique in this respect (see previous discussion of respite houses). Research on crisis respite

397 International Disability Alliance, IDA Report on First Follow up Mission to Peru: Monitoring Implementation of the CRPD Committee’s Recommendations <www.internationaldisabilityalliance.org/ida-follow-up-peru-oct2015>.

398 See, eg, Azeem et al, above n 67; Riahi et al, above n 61; Wisdom et al, above n 61; Janice L LeBel et al, ‘Multinational Experiences in Reducing and Preventing the Use of Restraint and Seclusion’ (2014) 52(11) Journal of Psychosocial Nursing and Mental Health Services 22.

399 Ashcraft and Anthony, above n 61; Ashcraft, Bloss and Anthony, above n 61.

400 Greenfield et al, above n 160.

105

houses, including those that are ‘peer-run’, appear to be more prominent in research emanating from the United States.401

Only three studies were identified that examined Canadian men-tal health care, which seems a relatively small number, though there are likely to be a range of non-English resources in Franco-phone Canada relevant to this review, and much grey literature produced by civil society and federal, provincial and state gov-ernments across both Canada and the US. The Canadian studies that were identified were mostly case studies involving individual services that were able to trial seclusion and restraint reduction strategies.

Oceania

Oceania is a geographic region comprising Melanesia, Micro-nesia, Polynesia and Australasia. All studies uncovered for this literature review came from Australia – five in total – suggesting a need for further research in this region.

Australia was the source of several novel studies, including the only study concerning sensory-based approaches within the en-vironment of a psychiatric inpatient unit, which provided some evidence for a ‘significant reduction in patient distress levels, as per consumer and clinician ratings’.402 Australia was also home to one of two studies identified in this review concerning ‘sup-ported decision-making’, with Kokanović and colleagues provid-ing some evidence to suggest that supported decision-making in mental health settings could better ‘facilitate the participation of mental health service users and their family supporters’ in health-care decisions, though no empirical evidence was provided to show impact on rates of coercion.403 Australia was also the loca-tion of the only study explicitly concerned with the role of social workers in imposing coercive practices on persons with men-tal health conditions or psychosocial disabilities. Maylea’s case study considers the legislative powers granted to social workers in the mental health context, and argues that there may be ways for social workers to use these powers in a potentially less coer-cive approach than that taken by police or paramedics who are also empowered under mental health legislation.404 Another novel

401 Croft and Isvan, above n 61; Rosen and O’Connell, above n 265; Sledge et al, above n 268; Sledge et al, above n 269; Fenton et al, above n 231.

402 Chalmers et al, above n 187, 35.

403 Renata Kokanović et al, above n 339.

404 Maylea, above n 57.

106

study was led by self-identifying mental health service users, or ‘consumer’ researchers, who examined the text of the National Standards for Mental Health Services 2010 as well as the public text of speakers’ notes regarding lived experience from the Care Without Coercion Conference 2010.405 They used three different frameworks currently utilised in mental health services (human rights, personal recovery, and trauma-informed) and ‘identified the use of force in many aspects of policy’, suggesting instead ‘pathways to apply the frameworks in national policy [to][…] bring about freedom from violence; support for decision making; access and choice about community and inpatient options; safe-ty and risk management; and greater understanding of current policy frameworks through engagement with people with lived experience about the options and impact of support processes that exclude the use of force’.406

There is evidence that measures to address coercion in the men-tal health context are occurring in Pacific Island countries407 and New Zealand.408 The Pacific Disability Forum Sustainable Devel-opment Goals/CRPD Monitoring Report 2018, for example, notes that ‘[s]ome resources are still used to fund services in education and mental health that are not aimed at inclusion and participa-tion and should be reallocated towards inclusive programs’ yet highlights positive measures, such as the Kingdom of Tonga’s first National Disability Inclusive Health Plan 2016-2020. This is designed to strengthen access to health care, rehabilitation and mental health services for people with disabilities in Tonga.409 More research is needed to identify positive actions being taken in Pacific Island countries and New Zealand (and indeed, Austral-ia) to reduce, prevent and end coercive practices in the mental health context, including among Indigenous communities. On this latter point, it is noteworthy that the Family Group Confer-ence approach discussed earlier in the report, was developed from Māori approaches to family law disputes, and that several

405 Watson et al, above n 55, 529.

406 Ibid.

407 See, eg, Pacific Disability Forum, Pacific Disability Forum SDG-CRPD Mon-itoring Report 2018, 15 <http://www.pacificdisability.org/What-We-Do/Re-search/FINAL_SDG-Report_Exec-Summary_2018.aspx>; Bhargavi Davar, ‘From ‘User Survivor’ to ‘Person with Psychosocial Disability’: Why We Are ‘TCI Asia’’ (blog) <https://madinasia.org/2018/07/from-user-survivor-to-person-with-psychosocial-disability-why-we-are-tci-asia>

408 See, eg, Te Pou, Reducing Seclusion and Restraint <www.tepou.co.nz/initiatives/reducing-seclusion-and-restraint/102>; Kāhui Tū Kaha (<www.kahuitukaha.co.nz>

409 Pacific Disability Forum, above n 407.

107

crisis respite services in New Zealand draw from Māori cultural traditions.410 Yet, empirical, scholarly research was not readily available, at least within the scope of this review.

410 See Renee Thørnblad et al, ‘Family Group Conferences: From Maori Culture to Decision-Making Model in Work with Late Modern Families in Norway’ (2016) 19(6) European Journal of Social Work 992; see also ‘Crisis Respite House’ in Appendix Three.

108

Section Four: Knowledge Gaps and Future Research DirectionsThere are several gaps and limitations in the literature reviewed. This section sets out some of the major gaps and limitations that need to be acknowledged and addressed through future research.

More Research Led by or Actively Involving Persons with Psychosocial Disabilities

Most research in this area is conducted by academic psychi-atrists, typically in the form of quantitative research based on service data. Governments and research institutions could take steps to ensure persons with mental health conditions or psycho-social disabilities are able to contribute to research in this field. Standards could be set to measure the extent to which service user organisations can influence national mental health research agendas. National research funds could require service user in-volvement and ethical research guidelines on mental health re-search could better promote the importance of research conduct-ed with the active input or coproduced with persons with mental health conditions and disabilities themselves. Thomas and Cahill have argued in relation to compulsion and psychiatry that action research is likely to be the most suitable method:

The participatory nature of action research engages research subjects actively in the research processes of deciding the research questions, design, and implementation. It is more ‘democratic’ than positivistic research and thus capable of taking different interests into account.411

More Mixed Methods Research that Incorporates Both Natural and Social Sciences

Although there are clear benefits to quantitative research, par-ticularly in undertaking largescale research such as national sur-veys, it is also important to gain the benefits of phenomenological

411 Philip Thomas and Anne B Cahill, ‘Compulsion and Psychiatry—the Role of Advance Statements’ (2004) 329(7458) BMJ 122, 123.

109

research, given that many of the practices for preventing, ending or reducing coercive practices are complex social interventions. The complexity of these interventions can have an impact upon the effectiveness of quantitative methods, including randomised control trials, in which variable confounding factors can make replication difficult.412 The outcomes of such studies depend on multiple contextual factors relating to the intervention itself, but also on how it is researched and by whom.413 Advance planning, peer support, respite services, trauma-informed approaches, family and social network responsiveness, are complex social in-terventions. Each occurs in a complex web of formal and informal relationships. Multiple contested ideas and values are at play. It is perhaps noteworthy that ‘organisational culture’ was identified as an important site for addressing the use of coercion in sever-al studies in this review,414 particularly regarding the Safewards strategy for reducing coercive practices in clinical mental health settings.415 Yet, social science disciplines that tend to focus on organisational culture and human behaviour, such as sociology, anthropology and behavioural psychology, were almost entirely absent among the studies.

Regarding psychiatric research, Kleinman has called for a ‘rebal-ancing of academic psychiatry’, arguing that academic psychia-trists should pursue social, clinical and community studies within a humanistic frame.416 (Kleinman takes particular issue with the over-investment in academic psychiatry into the ‘narrowest of biological research’).417 He argues that ties between psychiatry, public health and social sciences need to be strengthened, to which might be added – as per the previous recommendation – the active contribution of service users and former service users in research aimed at preventing, ending and reducing coercion in mental health services. This is not to suggest that exempla-ry studies did not appear. Some studies both adopted mixed methods and included service user researchers and participatory

412 See, eg, Thornicroft et al, above n 108.

413 See, eg, Diana Rose et al, ‘Patients’ Perspectives on Electroconvulsive Therapy: Systematic Review’ (2003) 326(7403) BMJ 1363.

414 Bowers et al, above n 179; Fisher, above n 106; Keski-Valkama et al, above n 179; Schout et al, above n 111.

415 See Len Bowers, ‘Safewards: A New Model of Conflict and Containment on Psychiatric Wards’ (2014) 21(6) Journal of Psychiatric and Mental Health Nursing 499.

416 Arthur Kleinman, ‘Rebalancing Academic Psychiatry: Why It Needs to Hap-pen – and Soon’ (2012) 201(6) The British Journal of Psychiatry 421, 421.

417 Ibid.

110

practices.418 Nor is it to suggest that purely quantitative or qual-itative research, or studies undertaken in a single discipline, are necessarily inappropriate. The point here is that mixed methods were used in a minority of studies, despite the apparent value of interdisciplinary research in examining the complex causes of and ways to address coercive practices.

Research Explicitly Premised on the Aim to Reduce, End and Prevent Coercion

Within the literature examined in this review, relatively few stud-ies were explicitly designed with the aim of reducing, ending and preventing coercion. Expanding the scope beyond the review, it was notable that there was a relatively vast literature on ‘percep-tions of coercion’, which did not seek alternatives or to undertake action research designed to reduce or end coercion. Although some studies concerning service user perceptions could be used to identify the most egregious forms of coercion, or hidden forms of coercion, which could become a focal point for efforts to ame-liorate harm, most did not appear to have such an instrumental purpose. A more defined research field may be needed that is unambiguously premised on the need to prevent, reduce and end coercive interventions in mental health settings. Presupposing that coercion is undesirable – even if some view it as necessary – helps to refine the focus to effective steps toward prevention, reduction and elimination.

More Research Examining the Impact of Trauma-Informed Support on Reducing and Eliminating Coercion

Given the importance given to trauma-informed support else-where in the mental health-related literature on human rights and mental health, there appears to be a gap in research explicitly concerned with the impact of trauma-informed approaches on reducing, preventing and ending coercive practices. The prom-ising research concerning the Six Core Strategies for Restraint Minimisation,419 provides a strong starting point for further re-search along these lines.

418 Greenfield et al, above n 160; Henderson et al, ‘Informed, Advance Re-fusals of Treatment by People with Severe Mental Illness in a Randomised Controlled Trial of Joint Crisis Plans: Demand, Content and Correlates’, above n 298.

419 Azeem et al, above n 67.

111

Greater Alliances between Academics and Service User Organisations, Policymakers and Service Providers

Internationally, there are examples of service providers, profes-sionals, policymakers, as well as persons with psychosocial disa-bilities and their representative organisations putting ‘alternatives to coercion’ into action. Many of these practices are likely, even if indirectly, to help prevent, reduce or end coercive interventions. Yet, many of them have not been subject to academic research. Hence, many of the practices that appear in Appendix Three have not been subject to peer-reviewed research despite having been in operation, in some cases, for many years. There are pragmatic benefits for scholarly researchers to engage with existing pro-grammes, including the relatively low cost of undertaking re-search into existing good practices (compared to creating and trialling new practices, for example through costly randomised control trials). There are examples of governments, United Na-tions bodies and other non-academic bodies, examining the ef-ficacy of various programmes; as is the case, for example, with the Commissioner for Human Rights of the Council of Europe’s information gathering on the Swedish Welfare Personligt ombud scheme, or the research into Soteria House by Vermont’s Depart-ment of Mental Health.420 In both instances, fruitful collaboration could have occurred with academic researchers to improve the quality and validation of reported efficacy.

A Comprehensive Review of Non-English Materials

Future research is needed outside the English-speaking world. Dhanda has argued that literature surveys ‘need to expand their materials to search across languages and economic status, along with privileging survivor narratives’.421 As noted, this review did not uncover English-language academic research concerning the Middle East, the Pacific, many parts of Asia, much of Africa, Central America, and so on. Efforts are undoubtedly underway in these places to reduce, prevent or end coercion, and there may be researchers seeking to pursue and record them. An exhaus-tive global review would seek to capture these efforts, particu-larly by expanding the scope to non-English resources and data-bases that may not be commonly available. Some high-income

420 See Appendix Three.

421 Amita Dhanda, ‘Conversations between the Proponents of the New Para-digm of Legal Capacity’ (2017) 13(1) International Journal of Law in Context 87, 89.

112

countries outside the English-speaking world warrant attention, even as the gap in research in low- and middle-income countries is more pressing. Legal and policy developments in Germany, for example, warrant in-depth consideration.422

More Focus on Reducing and Eliminating Coercion for Older Persons and Other Marginalised Groups in the Mental Health Context

Coercion is likely to be occurring in homes for older persons, worldwide. This is likely to include coercive mental health prac-tices. This review did not explicitly focus on strategies to reduce or eliminate coercive practices in these settings, even as some of the strategies cited throughout may work to this end. Gjerberg and colleagues, who did focus explicitly on reducing coercion in nursing homes, have argued that ‘[i]n many Western countries, studies have demonstrated extensive use of coercion in nursing homes, especially towards patients suffering from dementia’.423 Although this may sit outside a strict definition of mental health settings, there are clear intersections. First, some strategies con-cerning staffing, training, resourcing and so on may be applicable across elder care and mental health settings. Second, the distinc-tion between older persons and persons with mental health con-ditions or psychosocial disabilities is not always neat. Many older persons also have mental health conditions, and many persons with psychosocial disabilities become older persons and receive care services. More research is needed to examine alternatives to coercive practices in support settings specifically designed for older persons, including a systematic review of existing material.

People with intellectual and/or developmental disabilities also experience coercion in mental health settings, perhaps even at higher rates than others. Yet, there was no research uncovered in this review that directly concerned these groups. More research is needed to examine instances of coercion experienced by these individuals in mental health settings, and measures that can re-duce, prevent and end the use of coercion against them.

422 See above, Section ‘Laws Designed to Reduce, End or Prevent Coercion’, fn 77.

423 Elisabeth Gjerberg et al, ‘How to Avoid and Prevent Coercion in Nursing Homes: A Qualitative Study’ (2013) 20(6) Nursing Ethics 632, 632.

113

More Research on Organisational Cultural Change

Organisational cultural change was an important component of efforts to reduce coercive practices in hospital settings. There is some literature assessing the organisational social context424 and organisational factors in burnout and work attitudes in men-tal health services,425 but there is relatively little research on ef-fective ways to change ward culture, or management culture. Social psychological theories of group processes and intergroup behaviour could shine a light on how best to change organisa-tional culture. Organisational climate generally refers to shared attitudes and perceptions of the work environment.426 Stressful climates characterised by high workloads may lead to coercive practices, but research measuring this and on how this could be changed would be of benefit. There was also relatively little re-search on the type of informal coercion people may experience in ‘community-based’ services; for example, housing services that use coercion, but this could logically extend to the work of social workers, occupational therapists, and other professionals.

More Research on Reducing Deprivations of Liberty in Communal and Family Settings in Low- and Middle-Income Countries

It seems reasonable to infer that coercion is occurring in low- and middle-income countries against persons with mental health conditions and psychosocial disabilities quite outside of any formal mental health services. According to Davar, non-West-ern, low- and middle-income countries such as India, tend to be more concerned with developing inclusive and community-based mental health support in more communal social contexts, which provide access or freedom to resources needed for good mental health (that is, promoting social and economic rights) rather than

424 Charles Glisson et al, ‘Assessing the Organizational Social Context (OSC) of Mental Health Services: Implications for Research and Practice’ (2008) 35(1-2) Administration and Policy in Mental Health and Mental Health Ser-vices Research 98; Gregory A Aarons and Angelina C Sawitzky, ‘Organiza-tional Culture and Climate and Mental Health Provider Attitudes Toward Evidence-Based Practice’ (2006) 3(1) Psychological Services 61.

425 Gregory A Aarons and Angelina C Sawitzky, ‘Organizational Climate Par-tially Mediates the Effect of Culture on Work Attitudes and Staff Turnover in Mental Health Services’ (2006) 33(3) Administration and Policy in Mental Health and Mental Health Services Research 289; Amy E Green et al, ‘The Roles of Individual and Organizational Factors in Burnout Among Com-munity-Based Mental Health Service Proviers’ (2014) 11(1) Psychological Services 41.

426 Amy E Green, above n 425, 42.

114

resisting State intrusion (that is, civil and political rights).427 Davar writes of the socio-economic minority of people in India taking part in and affected by debates about mental health law reform and institutionalisation in recent years:

even these intense debates… are relevant only to the middle and upper classes in urban areas, especially non-resident Indians looking for the ideal mental institutions for ageing parents, sisters or other siblings and dependents. This may constitute around 7% of the Indian population. For the remaining 93% of the population in rural areas, inner city slums, mountainous terrains, and other far-flung regions of the country, where the social fabric is still intact, and where there is no doctor or asylum, this will have no relevance.428

It is striking therefore that there was only a handful of studies aimed at preventing, reducing, and ending coercive practices against persons with mental health conditions and psychosocial disabilities in these parts of the world. More research is needed, therefore, on reducing coercive practices in communal and fam-ily settings in low- and middle-income countries.

Establishing a Framework for Gathering Empirical Evidence

A final comment is that any examination of how existing laws and policies are working requires consideration of available em-pirical evidence. Irrespective of the ideological issues at stake in debates about coercion, evidence is crucial to assessing the efficacy of steps to reduce and end coercive practices.

Some conceptual clarity may also be needed to generate reliable and valid data. Shared understandings and definitions may be needed. The term ‘coercion’ is not necessarily used uniformly in research in this field. Some studies, for example, distinguished between ‘compulsion’, ‘leverage’, ‘treatment pressures’, ‘con-flict’ and ‘containment’. The field could benefit from establish-ing an agreed upon vocabulary, or a global agenda for research.

427 Bhargavi Davar, ‘Legal Capacity and Civil Political Rights for People with Psychosocial Disabilities’ in A Hans (ed), Disability, Gender and the Trajec-tories of Power (Sage, 2015) ch 11.

428 Bhargavi Davar, ‘Legal Frameworks for and against People with Psychoso-cial Disabilities’ (2012) 47(52) Economic and Political Weekly 123, 130.

115

While there is a significant body of literature on the types of coer-cion that exist, and measures for their reduction and elimination, Szmukler has argued that ‘substantial work is still needed to de-velop a useful vocabulary of “coercion” and related concepts’.429

429 Szmukler, above n 4, 259.

116

ConclusionTo summarise, this systematic scoping review uncovered a com-plex and heterogenous body of literature. While we acknowl-edge time and language limitations, this review has identified themes and clarified concepts relating to alternatives to coercion in mental health settings. More importantly, the findings are gen-erally positive. Efforts to reduce, prevent and end coercion ap-pear effective in most studies, notwithstanding limitations in the research. A broad suite of practices, policies and interventions exist, which can be implemented at local, national and regional levels. A policy ‘charter’ or ‘framework’ could collate these find-ings, outlining the broad package of alternatives that have been introduced and tested elsewhere, or which warrant further inves-tigation. No single country or national region has implemented the broad range of measures outlined in this review. This invites consideration of what might happen if countries or regions did so.

Another important theme in the research is that both top-down and local-level leadership are important in order to create and maintain culture change toward reducing, ending and preventing coercion. There is some indication that leadership should include peer involvement for ultimate effectiveness, for which a human rights imperative also exists.430

Another important theme is the need for new community-based crisis services, hospital diversion and step-down supports. Tradi-tionally, mental health policy has been organised in many parts of the world into two categories of support: hospital- or commu-nity-based care. The hospital is typically presented as a site for acute treatment while the ‘community’ is presented as a site for non-urgent support and prevention. However, the findings of this review suggest that a more constructive and accurate distinction might be between ‘crisis resolution’ and ‘general support’.

‘Crisis resolution’ could – and should – include hospital-based support, but could also include crisis respite houses, intensive home-based support, and residential programmes. ‘General sup-port’ could include the range of non-urgent community-based services that currently exist to help prevent emergencies and assist people to live full lives; for example, by using independent

430 CRPD, Article 4(3).

117

advocacy, housing support and personal assistance. In other words, ‘getting the right support, at the right time, in the right place, from the right person’431 is likely to have the one of the greatest impacts in reducing all forms of coercion in the context of mental health care. An effective suite of options for crisis res-olution and general support will also require resources.

The empirical research studies and grey literature analysed by the research team also suggest the following interventions are likely to reduce coercion:

• national oversight (for example, national policies aimed at reducing and eliminating seclusion and restraint, legislation that restricts the use of involuntary treatment, mandates upon governments to collect data, including reporting on ‘progress on alternative treatment options’);432

• organisational culture change through an emphasis on recovery, trauma-informed care, individual- and family-led supports, and human rights; and

• independent advocacy directed at public opinion, politicians, policymakers and service providers.

Future research should focus on mental health care policies targeted at support and treatment that respect people’s dignity and autonomy as well as promoting reductions of institutional coercion.

431 National Survivor User Network, Manifesto 2017: Our Voice, Our Vision, Our Values <https://www.nsun.org.uk/our-manifesto>.

432 2017 Vermont Statutes, Title 18 – Health, Chapter 174 - Mental Health System of Care, § 7256 Reporting requirements (8).

118

ReferencesLiterature Referred to in Background and MethodologyArksey, Hilary and O’Malley, Lisa, ‘Scoping Studies: Towards a Method-ological Framework’ (2005) 8(1) International Journal of Social Research Methodology 19-32.

Asher, Laura; Fekadu, Abebaw; Teferra, Solomon; De Silva, Mary; Pathare, Soumitra and Hanlon, Charlotte, ‘“I Cry Every Day and Night, I Have My Son Tied in Chains”: Physical Restraint of People with Schizo-phrenia in Community Settings in Ethiopia’ (2017) 13 Globalization and Health 47, DOI: 10.1186/s12992-017-0273-1.

Beaupert, Fleur, ‘Freedom of Opinion and Expression: from the Per-spective of Psychosocial Disability and Madness’ (2018) 7 Laws 3, DOI: 10.3390/laws7010003.

Boumans, Christien E; Walvoort, Serge JW; Egger Jos IM and Hutsche-maekers, Giel JM, ‘The Methodical Work Approach and the Reduction in the Use of Seclusion: How Did It Work?’ (2015) 86(1) Psychiatric Quarterly 1-17.

Committee on the Rights of Persons with Disabilities, Consideration of reports submitted by States parties under article 35 of the Convention: concluding observations of the Committee on the Rights of Persons with Disabilities: Spain, UN Doc CRPD/C/ESP/CO/1 (19 October 2011).

Committee on the Rights of Persons with Disabilities, General Comment No 1: Article 12: Equal Recognition Before the Law, 11th sess, UN Doc CRPD/C/GC/1 (19 May 2014).

Committee on the Rights of Persons with Disabilities, Guidelines on Article 14 of the Convention on the Rights of Persons with Disabilities: The Right to Liberty and Security of Persons with Disabilities, 14th sess (September 2015).

Davar, Bhargavi, ‘Legal Capacity and Civil Political Rights for People with Psychosocial Disabilities’ in Hans, Asha, (ed), Disability, Gender and the Trajectories of Power (London: Sage, 2015) 238-257.

Davar, Bhargavi, ‘Legal Frameworks for and against People with Psy-chosocial Disabilities’ (2012) 47(52) Economic and Political Weekly 123-131.

Deegan, Patricia, ‘Recovery as a Journey of the Heart’ (1996) 19(3) Psychosocial Rehabilitation Journal 91-97.

Dhanda, Amita, ‘Conversations between the Proponents of the New Paradigm of Legal Capacity’ (2017) 13(1) International Journal of Law in Context 87-95.

Duryani, Luh Ketut; Lesmana, Cokorda Bagus Jaya and Tiliopoulos, Niko, ‘Treating the Untreated: Applying a Community-Based, Culturally Sensitive Psychiatric Intervention to Confined and Physically Restrained Mentally Ill Individuals in Bali, Indonesia’ (2011) 261 (Suppl 2) European Archives of Psychiatry and Clinical Neuroscience S140-144.

119

Elliott, Denise E; Bjelajac, Paula; Fallot, Roger D; Markoff, Laurie S and Glover Reed, Beth ‘Trauma-Informed or Trauma-Denied: Principles and Implementation of Trauma-Informed Services for Women’ (2005) 33(4) Journal of Community Psychology 461-477.

Fabris, Erik, Tranquil Prisons: Chemical Incarceration under Community Treatment Orders (Toronto: University of Toronto Press, 2011).

Fabris, Erik and Aubrecht, Katie, ‘Chemical Constraint: Experiences of Psychiatric Coercion, Restraint, and Detention as Carceratory Tech-niques’ in Ben-Moshe, Liat; Chapman, Chris and Carey, Allison C, (eds), Disability Incarcerated (Palgrave Macmillan, 2014) 185-199.

Faulkner, Alison and Thomas, Phil, ‘User-Led Research and Evi-dence-Based Medicine’ (2002) 180(1) The British Journal of Psychiatry 1-3.

Fisher, Pamela, ‘Questioning the Ethics of Vulnerability and Informed Consent in Qualitative Studies from a Citizenship and Human Rights Perspective’ (2012) 6(1) Ethics and Social Welfare 2-17.

Fennell, Philip, ‘Institutionalising the Community: The Codification of Clinical Authority and the Limits of Rights-Based Approaches’ in Ber-nadette McSherry and Penelope Weller (eds), Rethinking Rights-Based Mental Health Laws (Oxford: Hart Publishing Ltd, 2010) 13-49.

Foxlewin, Bradley, What is Happening at the Seclusion Review that Makes a Difference? A Consumer Led Research Study (Canberra: ACT Mental Health Consumer Network, 2012).

Greenhalgh, Trisha; Snow, Rosamund; Ryan, Sara; Rees, Sian and Salisbury, Helen, ‘Six “Biases” Against Patients and Carers in Evi-dence-Based Medicine’ (2015) 13(1) BMC Medicine 200, DOI: 10.1186/s12916-015-0437-x.

Gould, Dorothy, Service Users’ Experiences of Recovery under the 2008 Care Programme Approach; A Research Study (London: National User Survivor Network, 2012) <https://www.nsun.org.uk/>.

Gould, Dorothy, The Healthy Lives Project Full Report (London: National User Survivor Network, 2016) <https://www.nsun.org.uk/>.

Harris, Maxine and Fallot, Roger D, ‘Envisioning a Trauma-Informed Service System: A Vital Paradigm Shift’ (2001) 89 New Directions for Mental Health Services 3-22.

Happell, Brenda; Gordon, Sarah E; Bocking, Julia and Pla-tania-Phung, Chris, ‘“Chipping Away”: Non-Consumer Research-er Perspectives on Barriers to Collaborating with Consumers in Mental Health Research’ (2018) Journal of Mental Health 1-7 DOI: 10.1080/09638237.2018.1466051

Hutchinson, Terry and Duncan, Nigel, ‘Defining and Describing What We Do: Doctrinal Legal Research’ (2012) 17(1) Deakin Law Review 84-119.

Inclusion International, Video: Preparing Feedback to the CRPD Commit-tee on the Draft General Comment on Article 19 (25 May 2017) <http:// inclusion-international.org/video-preparing-feedback-to-the-crpd-committee-on-the-draft-general-comment-on-article-19/>.

120

Katsakou, Christina; Rose, Diana; Amos, Tim; Bowers, Len; McCabe, Rosemary; Oliver, Danielle; Wykes, Til and Priebe, Stefan, ‘Psychiatric patients’ views on why their involuntary hospitalisation was right or wrong: a qualitative study’ (2012) 47(7) Social Psychiatry and Psychiatric Epidemiology 1169-1179.

Larue, Caroline; Dumais, Alexandre; Boyer, Richard; Goulet, Ma-rie-Hélène; Bonin, Jean-Pierre and Baba, Nathalia, ‘The Experience of Seclusion and Restraint in Psychiatric Settings: Perspectives of Pa-tients’ (2013) 34(5) Issues in Mental Health Nursing 317-324.

MacArthur Research Network on Mental Health and Law, MacArthur Coercion Study: Executive Summary (February 2001), <http://www.macarthur.virginia.edu/coercion.html>.

Maykut, Pamela and Morehouse, Richard, Beginning Qualitative Re-search: A Philosophical and Practical Guide (London: The Falmer Press, 2002).

McSherry, Bernadette and Waddington, Lisa, ‘Treat with Care: The Right to Informed Consent for Medical Treatment of Persons with Men-tal Impairments in Australia’ (2017) 23(1) Australian Journal of Human Rights 109-129.

Mental Disability Advocacy Center, The Right to Legal Capacity in Ken-ya: “I Felt like an Animal Going to a Slaughter and I Had No Choice” Yusuf’s Story (Mental Disability Advocacy Center, 2014).

Minas, Harry and Diatri, Hervita, ‘Pasung: Physical Restraint and Con-finement of the Mentally Ill in the Community’ (2008) 2(1) International Journal of Mental Health Systems 8, DOI: 10.1186/1752-4458-2-8.

Minkowitz, Tina, ‘The United Nations Convention on the Rights of Persons with Disabilities and the Right to be Free from Non-consensual Psychiatric Interventions’ (2007) 34(2) Syracuse Journal of International Law and Commerce 405-428.

Minow, Martha, ‘Archetypal Legal Scholarship: A Field Guide’ (2013) 63(1) Journal of Legal Education 65-69.

Monahan, John; Lidz, Charles; Hoge, Stephen K; Mulvey, Edward P; Eisenberg, Marlene M; Roth, Loren H; Gardner, William P and Ben-nett, Nancy, ‘Coercion In the Provision of Mental Health Services: The MacArthur Studies’ in Morrissey, Joseph P and Monahan, John (eds) Research In Community and Mental Health, Vol 10: Coercion In Mental Health Services - International Perspectives (Bingley, UK: Emerald Group Publishing Limited, 1999), 13-30.

National Survivor User Network, Manifesto 2017: Our Voice, Our Vision, Our Values (London: National Survivor User Network, 2017) <https://www.nsun.org.uk/our-manifesto>.

Office of the High Commissioner for Human Rights, “Dignity Must Prevail” – An Appeal to Do Away with Non-consensual Psychiatric Treat-ment World Mental Health Day – Saturday 10 October 2015 (8 October 2015) <https://www.ohchr.org/EN/NewsEvents/Pages/DisplayNews.aspx?NewsID=16583>.

121

Office of the High Commissioner for Human Rights, ‘Chapter Six: From Provisions to Practice: Implementing the Convention, Legal Capacity and Supported Decision-Making’, United Nations Handbook for Parlia-mentarians on the Convention on the Rights of Persons with Disabilities (Geneva: United Nations, 2007) 77-91, <http://archive.ipu.org/PDF/publications/disabilities-e.pdf>

Office of the High Commissioner for Human Rights, Annual Report of the United Nations Hiah Commissioner for Human Rights and Reports of the Office of the High Commission and the Secretary-General: Thematic Study by the Office of the United Nations High Commissioner for Human Rights on Enhancing Awareness and Understanding of the Convention on the Rights of Persons with Disabilities UN Doc A/HRC/10/48 (26 January 2009).

Peters, Micah; Godfrey, Christina; Khalil, Hanan; McInerney, Patricia; Parker, Deborah and Soares, Cassia Baldini, ‘Guidance for Conducting Systematic Scoping Reviews’ (2015) 13(3) International Journal of Evidence-Based Healthcare 141-146.

Pilgrim, David and McCranie, Ann, Recovery and Mental Health: A Critical Sociological Account (London: Palgrave MacMillan, 2013).

Polanyi, Michael, Personal Knowledge: Towards a Post-Critical Philoso-phy (Chicago: University of Chicago Press, 1958).

Pūras, Dainius, Report of the Special Rapporteur on the Right of Every-one to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health, UN Doc A/HRC/35/21 (28 March 2017).

Puteh, Ibrahim; Marthoenis, M and Minas, Harry, ‘Aceh Free Pasung: Releasing the Mentally Ill from Physical Restraint’ (2011) 5 International Journal of Mental Health Systems 10, 10.1186/1752-4458-5-10.

Robins, Cynthia; Sauvageot, Julie A: Cusack, KJ; Suffoletta-Maierle, Samantha and Frueh, B Christopher, ‘Special Section on Seclusion and Restraint: Consumers’ Perceptions of Negative Experiences and “Sanc-tuary Harm” in Psychiatric Settings’ (2005) 56(9) Psychiatric Services 1134-1138.

Russo, Jasna and Beresford, Peter, ‘Between Exclusion and Colonisa-tion: Seeking a Place for Mad People’s Knowledge in Academia’ (2015) 30(1) Disability & Society 153-157.

Russo, Jasna, ‘The Importance of User Controlled Research on Coercion’ (2007) 7 (Suppl 1) BMC Psychiatry s59, DOI: 10.1186/1471-244X-7-S1-S59.

Russo, Jasna and Wallcraft, Jan, ‘Resisting Variables - Service User/Survivor Perspectives on Researching Coercion’ In Kallert, Thomas W; Mezzich, Juan E and Monahan, John (eds) Coercive Treatment in Psy-chiatry: Clinical, Legal and Ethical Aspects (West Sussex: John Wiley & Sons, 2011) 213-234.

Saks, Elyn, ‘Mental Health Law and the Americans with Disabilities Act: One Consumer’s Journey’ (2016) 4(1) Inclusion 39-45.

Slade, Mike, Personal Recovery and Mental Illness: A Guide for Mental Health Professionals (Cambridge: Cambridge University Press, 2009).

122

Stolorow, Robert D, Trauma and Human Existence (London: Routledge, 2007).

Sweeney, Angela; Beresford, Peter; Faulkner, Alison; Sweeney, Angela; Rose, Diana and Mary Nettle, (eds) This is Survivor Research (Ross-on-Wye: PCCS Books Ltd, 2008).

Szmukler, George, ‘Treatment Pressures, Leverage, Coercion and Com-pulsion in Mental Health Care’ (2008) 17(3) Journal of Mental Health 233-244.

Szmukler, George and Rose, Diana, ‘Strengthening Self-Determination of Persons with Mental Illness’ in Clausen, Jens and Levy, Neil (eds), Handbook of Neuroethics (Springer, 2015) 879-895.

Users and Survivors of Psychiatry - Kenya, The Role of Peer Support in Exercising Legal Capacity in Kenya (April 2018) <www.uspkenya.org>.

Wallcraft, Jan; Schrank, Beate and Amering, Michaela, Handbook of Service User Involvement in Mental Health Research (Chichester: John Wiley & Sons, 2009.)

Zigmond, Tony, ‘Pressures to Adhere to Treatment: Observations on “leverage” in English Mental Healthcare’ (2011) 199(2) The British Journal of Psychiatry: The Journal of Mental Science 90-91.

123

Literature Cited in Sections Two and Three and Listed in Appendix OneAagaard, Jørgen; Tuszewski, Bartosz and Kølbæk, Pernille, ‘Does Assertive Community Treatment Reduce the Use of Compulsory Admis-sions?’ (2017) 31(6) Archives of Psychiatric Nursing 641-646.

Aarons, Gregory A and Sawitzky, Angelina C, ‘Organizational Climate Partially Mediates the Effect of Culture on Work Attitudes and Staff Turnover in Mental Health Services (2006) 33(3) Administration and Policy in Mental Health and Mental Health Services Research 289-301.

Aarons, Gregory A and Sawitzky, Angelina C, ‘Organizational Cul-ture and Climate and Mental Health Provider Attitudes Toward Evi-dence-Based Practice’ (2006) 3(1) Psychological Services 61-72.

Aaltonen, Jukka; Seikkulaa, Jaakko and Lehtinen, Ville, ‘The Compre-hensive Open-Dialogue Approach In Western Lapland: I. The Incidence of Non-Affective Psychosis and Prodromal States’ (2011) 3(3) Psychosis 179-191.

Aiello, Ana Laura, ‘Argentina’ in Waddington, Lisa and Lawson, Anna, The UN Convention on the Rights of Persons with Disabilities in Practice: A Comparative Analysis of the Role of Courts (Oxford: Oxford University Press, 2018) Ch 2.

Allen, Michael, ‘Waking Rip van Winkle: Why Developments in the Last 20 Years Should Teach the Mental Health System Not to Use Housing as a Tool of Coercion’ (2003) 21(4) Behavioral Sciences & the Law 503-521.

Andersen, Kjeld and Nielsen, Bent, ‘Coercion in Psychiatry: The Impor-tance of Extramural Factors’ (2016) 70(8) Nordic Journal of Psychiatry 606-610.

Ashcraft, Lori and Anthony, William, ‘Eliminating Seclusion and Re-straint in Recovery-Oriented Crisis Services’ (2008) 59(10) Psychiatric Services 1198-1202.

Ashcraft, Lori; Bloss, Michelle and Anthony, William A, ‘Best Practices: The Development and Implementation of “No Force First” as a Best Practice’ (2012) 63(5) Psychiatric Services 415-417.

Asher, Laura; Fekadu, Abebaw; Teferra, Solomon; De Silva, Mary; Pathare, Soumitra and Hanlon, Charlotte, ‘“I Cry Every Day and Night, I Have My Son Tied in Chains”: Physical Restraint of People with Schiz-ophrenia in Community Settings in Ethiopia’ (2017) 13(1) Globalization and Health 47, DOI: 10.1186/s12992-017-0273-1.

Azeem, Muhammad Waqar; Aujla, Akashdeep; Rammerth, Michelle; Binsfeld, Gary and Jones, Robert B, ‘Effectiveness of Six Core Strat-egies Based on Trauma Informed Care in Reducing Seclusions and Restraints at a Child and Adolescent Psychiatric Hospital’ 24(1) Journal of Child and Adolescent Psychiatric Nursing 11-15.

Bak, Jesper; Zoffmann, Vibeke; Sestoft, Dorte Maria; Almvik Roger and Mette Brandt-Christensen, ‘Mechanical Restraint in Psychiatry: Preven-tive Factors in Theory and Practice. A Danish-Norwegian Association Study’ (2014) 50(3) Perspectives in Psychiatric Care 155-166.

124

Bak, Jesper; Zoffmann, Vibeke; Sestoft, Dorte Maria; Almvik, Roger; Brandt-Christensen, Mette and Siersma, Volkert Dirk, ‘Comparing the Effect of Non-Medical Mechanical Restraint Preventive Factors be-tween Psychiatric Units in Denmark and Norway’ (2015) 69(6) Nordic Journal of Psychiatry 433-443.

Bariffi, Francisco J and Smith, Matthew S, ‘Same Old Game but with Some New Players – Assessing Argentina’s National Mental Health Law in Light of the Rights to Liberty and Legal Capacity under the UN Convention on the Rights of the Persons with Disabilities’ (2013) 31(3) Nordic Journal of Human Rights 325-342.

Barrett, Barbara; Waheed, Waquas; Farrelly, Simone; Birchwood, Max; Dunn, Graham; Flach, Clare; Henderson, Claire; Leese, Morven; Lester, Helen; Marshall, Max; Rose, Diana; Sutherby, Kim; Szmukler, George; Thornicroft, Graham and Byford, Sarah, ‘Randomised Controlled Trial of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: Economic Outcomes’ (2013) 8(11) PLoS One e74210, DOI: 10.1371/journal.pone.0074210.

Bola, John R; Lehtinen, Klaus; Cullberg, Johan and Ciompi, Luc, ‘Psy-chosocial Treatment, Antipsychotic Postponement, and Low-Dose Medication Strategies in First-Episode Psychosis: A Review of the Literature’ (2009) 1(1) Psychosis: Psychological, Social and Integrative Approaches 4-18.

Borckardt, Jeffrey J; Madan, Alok; Grubaugh, Anouk L; Danielson, Carla Kmett; Pelic, Christopher G; Hardesty, Susan J; Hanson, Rochelle; Herbert, Joan; Cooney, Harriet; Benson Anna and Frueh, B Christopher, ‘Systematic Investigation of Initiatives to Reduce Seclusion and Re-straint in a State Psychiatric Hospital’ (2011) 62(5) Psychiatric Services 477-483.

Boumans, Christien E; Egger, Jos IM; Souren, Pierre M and Hutsche-maekers, Giel JM, ‘Reduction in the Use of Seclusion by the Methodi-cal Work Approach’ (2014) 23(2) International Journal of Mental Health Nursing 161-170.

Boumans, Christien E; Walvoort, Serge JW; Egger, Jos IM and Hut-schemaekers, Giel JM,‘The Methodical Work Approach and the Reduc-tion in the Use of Seclusion: How Did It Work?’ (2015) 86(1) Psychiatric Quarterly 1-17.

Bowers, Len; Haglund, Kristina; Muir-Cochrane, Eimear; Nijman, Henk; Simpson, Alan and Van De Merwe, Marie, ‘Locked Doors: A Survey of Patients, Staff and Visitors’ (2010) 17(10) Journal of Psychiatric and Mental Health Nursing 873-880.

Bowers, Len; Stewart, Duncan; Papadopoulos, Chris and DeSanto Ien-naco, Joanne, ‘Correlation between Levels of Conflict and Containment on Acute Psychiatric Wards: The City-128 Study’ (2013) 64(5) Psychiat-ric Services 423-430.

Bowers, Len; James, Karen; Quirk, Alan; Simpson, Alan; Stewart, Duncan and Hodsoll, John, ‘Reducing Conflict and Containment Rates on Acute Psychiatric Wards: The Safewards Cluster Randomised Controlled Trial’ (2015) 52(9) International Journal of Nursing Studies 1412-1422.

125

Bruckner, Tim A; Yoon, Jangho; Brown, Timothy T and Adams, Neal, ‘Involuntary Civil Commitments After the Implementation of Califor-nia’s Mental Health Services Act’ (2010) 61(10) Psychiatric Services 1006-1011.

Buus, Niels; Bikic, Aida; Jacobsen, Elise Kragh: Mueller-Nielsen, Klaus; Aagaard, Jorgen and Blach, Camilla, ‘Adapting and Implementing Open Dialogue in the Scandinavian Countries: A Scoping Review’ (2017) 38(5) Issues in Mental Health Nursing 391-401.

Chalmers, Angela; Harrison, Sophie; Mollison, Kade; Molloy, Noel and Gray, Kelly M, ‘Establishing Sensory-Based Approaches in Mental Health Inpatient Care: A Multidisciplinary Approach’ (2012) 20(1) Australasian Psychiatry 35-39.

Chambers, Mary; Gallagher, Ann; Borschmann, Rohan; Gillard, Steve; Turner, Kati and Kantaris, Xenya, ‘The Experiences of Detained Mental Health Service Users: Issues of Dignity in Care’ (2014) 15(1) BMC Medical Ethics 50, DOI: 10.1186/1472-6939-15-50.

Corlett, Sophie, ‘Policy Watch: A Steady Erosion of Rights’ (2013) 17(2) Mental Health and Social Inclusion 60-63.

Croft, Bevin and Isvan, Nilüfer, ‘Impact of the 2nd Story Peer Respite Program on Use of Inpatient and Emergency Services’ (2015) 66(6) Psychiatric Services 632-637.

Cullberg, Johan; Levander, Sten; Holmqvist, Ragnhild; Mattsson, Maria and Wieselgren, Ing-Marie, ‘One-Year Outcome in First Episode Psy-chosis Patients in the Swedish Parachute Project’ (2002) 106(4) Acta Psychiatrica Scandinavica 276-285.

Cullberg, Johan; Mattsson, Maria; Levander Sten; Holmqvist, R; Toms-mark, Lars; Elingfors, Christine and Wieselgren, Ing-Marie, ‘Treatment Costs and Clinical Outcome for First Episode Schizophrenia Patients: A 3-Year Follow-up of the Swedish “Parachute Project” and Two Compari-son Groups’ (2006) 114(4) Acta Psychiatrica Scandinavica 274-281.

Currier, Joseph M; Stefurak, Tres; Carroll, Timothy D and Shatto, Erynne H, ‘Applying Trauma-Informed Care to Community-Based Men-tal Health Services for Military Veterans’ (2017) 13(1) Best Practices in Mental Health 47-65.

Cutler, Paul; Hayward, Robert and Tanasan, Gabriel, Supporting User Led Advocacy in Mental Health (Open Society Founda-tions, 2006) <https://www.opensocietyfoundations.org/reports/supporting-user-led-advocacy-mental-health>.

de Jong, Gideon and Schout, Gert, ‘Prevention of Coercion in Public Mental Health Care with Family Group Conferencing’ (2010) 17(9) Journal of Psychiatric and Mental Health Nursing 846-848.

de Jong, Gideon and Schout, Gert, ‘Researching the Applicability of Family Group Conferencing in Public Mental Health Care’ (2013) 43(4) British Journal of Social Work 796-802.

126

de Jong, Mark H; Kamperman, Astrid M; Oorschot, Margreet; Priebe, Stefan; Bramer, Wichor; van de Sande, Roland; Van Gool, Arthur R and Mulder, Cornelis L, ‘Interventions to Reduce Compulsory Psychiatric Admissions: A Systematic Review and Meta-Analysis’ (2016) 73(7) JAMA Psychiatry 657-664.

de Stefano, Alessia and Ducci, Giuseppe, ‘Involuntary Admission and Compulsory Treatment In Europe: An Overview’ (2008) 37(3) Interna-tional Journal of Mental Health 10-21.

Drake, Robert E and Deegan, Patricia, ‘Are Assertive Community Treat-ment and Recovery Compatible? Commentary on “ACT and Recovery: Integrating Evidence-Based Practice and Recovery Orientation on As-sertive Community Treatment Teams”’ (2008) 44(1) Community Mental Health Journal 75-77.

Ejneborn Looi, Git-Marie; Engström, Åsa and Sävenstedt, Stefan, ‘A Self-Destructive Care: Self-Reports of People Who Experienced Co-ercive Measures and Their Suggestions for Alternatives’ (2015) 36(2) Issues in Mental Health Nursing 96-103.

Evans, Mary E; Boothroyd, Roger A and Armstrong, Mary I, ‘Develop-ment and Implementation of an Experimental Study of the Effective-ness of Intensive In-Home Crisis Services for Children and Their Fami-lies’ (1997) 5(2) Journal of Emotional and Behavioral Disorders 93-105.

Eytan, Ariel; Chatton, Anne; Safran, Edith and Khazaal, Yasser, ‘Impact of Psychiatrists’ Qualifications on the Rate of Compulsory Admissions’ (2013) 84(1) Psychiatric Quarterly 73-80.

Fenton, Wayne S; Mosher, Loren R; Herrell, James M and Blyler, Crys-tal R, ‘Randomized Trial of General Hospital and Residential Alternative Care for Patients with Severe and Persistent Mental Illness’ (1998) 155(4) American Journal of Psychiatry 516-522.

Fisher, William A, ‘Elements of Successful Restraint and Seclusion Reduction Programs and Their Application in a Large, Urban, State Psychiatric Hospital’ (2003) 9(1) Journal of Psychiatric Practice 7-15.

Flammer, Erich and Steinert, Tilman, ‘Involuntary Medication, Seclu-sion, and Restraint in German Psychiatric Hospitals after the Adoption of Legislation in 2013’ (2015) 6 Frontiers in Psychiatry 153, DOI: 10.3389/fpsyt.2015.00153.

Flammer, Erich and Steinert, Tilman, ‘Association Between Restriction of Involuntary Medication and Frequency of Coercive Measures and Violent Incidents’ (2016) 67(12) Psychiatric Services 1315-1320.

Fletcher, Justine; Spittal, Matthew; Brophy, Lisa; Tibble, Holly; Kinner, Stuart, Elsom, Stephen and Hamilton, Bridget, ‘Oucomes of the Victori-an Safewards Trial in 13 Wards: Impact on Seclusion Rates and Fidelity Measurement’ (2017) 26(5) International Journal of Mental Health Nursing 461-471.

Gilburt, Helen; Slade, Mike; Rose, Diana; Lloyd-Evans, Brynmor; Johnson, Sonia and Osborn, David PJ, ‘Service Users’ Experiences of Residential Alternatives to Standard Acute Wards: Qualitative Study of Similarities and Differences’ (2010) 197 (Suppl 53) The British Journal of Psychiatry s26-s31.

127

Gjerberg, Elisabeth; Hem, Marit Helene; Førde, Reidun and Pedersen, Reidar, ‘How to Avoid and Prevent Coercion in Nursing Homes: A Qualitative Study’ (2013) 20(6) Nursing Ethics 632-644.

Glisson, Charles; Landsverk, John; Schoenwald, Sonja; Kelleher, Kelly; Eaton Hoagwood, Kimberley; Mayberg, Stephen and Green, Philip, ‘Assessing the Organizational Social Context (OSC) of Mental Health Services: Implications for Research and Practice’ (2008) 35(1-2) Ad-ministration and Policy in Mental Health and Mental Health Services Research 98-113.

Gooding, Piers, ‘Supported Decision-Making: A Rights-Based Disability Concept and Its Implications for Mental Health Law’ (2013) 20(3) Psy-chiatry, Psychology and Law 431-451.

Goulet, Marie-Hélène; Larue, Caroline and Ashley, J Lemieux, ‘A Pilot Study of “Post-seclusion and/or Restraint Review” Intervention with Patients and Staff in a Mental Health Setting’ (2018) 54(2) Perspectives in Psychiatric Care 212

Greenfield, Thomas K; Stoneking, Beth C; Humphreys, Keith; Sundby, Evan and Bond, Jason, ‘A Randomized Trial of a Mental Health Con-sumer-Managed Alternative to Civil Commitment for Acute Psychiatric Crisis’ (2008) 42(1-2) American Journal of Community Psychology 135-144.

Groot, Peter, and van Os, Jim, ‘Antidepressant Tapering Strips to Help People Come off Medication More Safely’ (2018) 10(2) Psychosis 142-145.

Guan, Lili; Liu, Jin; Wu, Xia; Chen, Da-Fang; Wang, Xun; Ma, Ning; Wang, Yan; Good, Byron J; Ma, Hong; Yu, Xin; DelVecchio Good, Mary-Jo, ‘Unlocking Patients with Mental Disorders Who Were in Restraints at Home: A National Follow-Up Study of China’s New Public Mental Health Initiatives’ (2015) 10(4) PLoS ONE e0121425, DOI: 10.1371/jour-nal.pone.0121425

Hackett, Rashna; Nicholson, Jo; Mullins, Simon; Farrington, Tony; Ward, Sharon; Pritchard, Gareth; Miller, Elizabeth and Mahmood, Nayla, ‘Enhancing Pathways into Care (EPIC): Community Development Work-ing with the Pakistani Community to Improve Patient Pathways within a Crisis Resolution and Home Treatment Service’ (2009) 21(5) Internation-al Review of Psychiatry 465-471.

Haycock, Joel; Finkelman, David and Presskreischer, Helene, ‘Medi-ating the Gap: Thinking about Alternatives to the Current Practice of Civil Commitment Symposium: Therapeutic Jurisprudence: From Idea to Application’ (1993) 20(2) New England Journal on Criminal and Civil Confinement 265-289.

Henderson, Claire; Farrelly, Simone; Flach, Clare; Borschmann, Rohan; Birchwood, Max; Thornicroft, Graham; Waheed, Waquas and Szmukler, George, ‘Informed, Advance Refusals of Treatment by People with Severe Mental Illness in a Randomised Controlled Trial of Joint Crisis Plans: Demand, Content and Correlates’ (2017) 17(1) BMC Psychiatry 376, DOI: 10.1186/s12888-017-1542-5.

128

Henderson, Claire; Flood, Chris; Leese, Morven; Thornicroft, Graham; Sutherby, Kim and Szmukler, George, ‘Effect of Joint Crisis Plans on Use of Compulsory Treatment in Psychiatry: Single Blind Ran-domised Controlled Trial’ (2004) 329(7458) BMJ 136, DOI: 10.1136/bmj.38155.585046.63.

Henderson, Claire; Flood, Chris; Leese, Morven; Thornicroft, Graham; Sutherby, Kim and Szmukler, George, ‘Views of Service Users and Providers on Joint Crisis Plans’ (2009) 44(5) Social Psychiatry and Psy-chiatric Epidemiology 369-376.

Heumann, Kolja; Bock, Thomas and Lincoln, Tania M, ‘Bitte macht (irgend)was! Eine bundesweite Online-Befragung Psychiatrieerfahren-er zum Einsatz milderer Maßnahmen zur Vermeidung von Zwang-smaßnahmen [Please Do Something - No Matter What! A Nationwide Online Survey of Mental Health Service Users About the Use of Alterna-tives to Coercive Measures]’ (2017) 44(2) Psychiatrische Praxis 85-92.

Højlund, Mikkel; Høgh, Lene; Bojesen, Anders Bo; Munk-Jørgensen, Povl and Stenager, Elsebeth, ‘Use of Antipsychotics and Benzodiaze-pines in Connection to Minimising Coercion and Mechanical Restraint in a General Psychiatric Ward’ (2018) 64(3) The International Journal of Social Psychiatry 258-265.

Høyer, Georg; Kjellin, Lars; Engberg, Marianne; Kaltiala-Heinod, Rit-takerttu; Nilstune, Tore; Sigurjónsdóttir, Maria and Syse, Aslak, ‘Pater-nalism and Autonomy: A Presentation of a Nordic Study on the Use of Coercion in the Mental Health Care System’ (2002) 25 International Journal of Law and Psychiatry 93-108.

Huber, Christian G; Schneeberger, Andrew R; Kowalinski, Eva; Fröhlich, Daniela; von Felten, Stefanie; Walter, Marc; Zinkler, Martin; Beine, Karl; Heinz, Andreas; Borgwardt, Stefan and Lang, Undine E, ‘Suicide Risk and Absconding in Psychiatric Hospitals with and without Open Door Policies: A 15 Year, Observational Study’ (2016) 3(9) The Lancet Psychia-try 842-849.

Huber, Christian G; Schneeberger, Andrew R; Kowalinski, Eva; Fröhlich, Daniela; von Felten, Stefanie; Walter, Marc; Zinkler, Martin; Beine, Karl; Heinz, Andreas; Borgwardt, Stefan and Lang, Undine E, ‘Arbitrary Classification of Hospital Policy Regarding Open and Locked Doors - Authors’ Reply’ (2016) 3 (12) The Lancet Psychiatry 1103-1104.

Human Rights Council, Report of the Special Rapporteur on the Right of Everyone to the Enjoyment of the Highest Attainable Standard of Phys-ical and Mental Health, UN Doc, 35th Sess, A/HRC/35/21 (28 March 2017).

Hustoft, Kjetil; Larsen, Tor Ketil; Brønnick, Kolbjørn; Joa, Inge; Johan-nessen, Jan Olav and Ruud, Torleif, ‘Voluntary or Involuntary Acute Psychiatric Hospitalization in Norway: A 24h Follow up Study’ (2018) 56 International Journal of Law and Psychiatry 27-34.

Husum, Tonje Lossius; Bjørngaard, Johan Håkon; Finset, Arnstein and Ruud, Torleif, ‘A Cross-Sectional Prospective Study of Seclusion, Re-straint and Involuntary Medication in Acute Psychiatric Wards: Patient, Staff and Ward Characteristics’ (2010) 10(1) BMC Health Services Research 89, DOI: 10.1186/1472-6963-10-89.

129

International Disability Alliance, IDA Report on First Follow Up Mis-sion to Peru: Monitoring Implementation of the CRPD Committee’s Recommendations <http://www.internationaldisabilityalliance.org/ida-follow-up-peru-oct2015>.

Jaeger, Matthias; Ketteler, Daniel, Rabenschlag, Franziska and Theodor-idou, Anastasia, ‘Informal Coercion in Acute Inpatient Setting – Knowl-edge and Attitudes Held by Mental Health Professionals’ (2014) 220(3) Psychiatry Research 1007-1011.

Jaeger, Matthias; Konrad, Albrecht; Rueegg, Sebastian and Raben-schlag, Franziska, ‘Patients’ Subjective Perspective on Recovery Ori-entation on an Acute Psychiatric Unit’ (2015) 69(3) Nordic Journal of Psychiatry 188-195.

Janssen, Wim A; Noorthoorn, Eric O; Van Linge, Roland and Lende-meijer, Bert, ‘The Influence of Staffing Levels on the Use of Seclusion’ (2007) 30(2) International Journal of Law and Psychiatry 118-126.

Janssen, Wim A; van de Sande, Roland; Noorthoorn, Eric O; Nijman, Henk L; Bowers, Len; Mulder, Cornelis L; Smit, Annet; Widdershoven, Guy A and Steinert Tilman, ‘Methodological Issues in Monitoring the Use of Coercive Measures’ (2011) 34(6) International Journal of Law and Psychiatry 429-438.

Janssen, Wim A; Noorthoorn, Eric O; Nijman, Henk; Bowers, Len; Hoogendoorn, Adriaan W; Smit, Annet and Widdershoven, Guy A, ‘Dif-ferences in Seclusion Rates between Admission Wards: Does Patient Compilation Explain?’ (2013) 84(1) The Psychiatric Quarterly 39-52.

Jendreyschak, Jasmin; Illes, Franciska; Hoffman, Knut; Holtmann, Martin; Haas, Claus-Rüdiger; Burchard, Falk; Emons, Barbara; Schaub, Markus; Armgart, Carina; Schnieder, Hildegard; Juckel, Georg and Haussleiter, Ida, ‘Voluntary versus Involuntary Hospital Admission in Child and Adolescent Psychiatry: A German Sample’ (2014) 23(3) European Child & Adolescent Psychiatry 151-161.

Johnson, Sonia; Nolan, Fiona; Pilling, Stephen; Sandor, An-drew; Hoult, John I; McKenzie, Nigel; White, Ian R; Thompson, Marie and Bebbington, Paul, ‘Randomised Controlled Trial of Acute Mental Health Care by a Crisis Resolution Team: The North Islington Crisis Study’ (2005) 331(7517) BMJ 599-603.

Kalisova, Lucie; Raboch, Jiri; Nawka, Alexander; Sampogna, Gaia; Ci-hal, Libor; Kallert, Thomas W; Onchev, Gerogi; Karastergiou, Anastasia; del Vecchio, Valeria; Kiejna, Andrzej; Adamowski, Tomasz; Torres-Gon-zales, Francisco; Cervilla, Jorge A; Priebe, Stefan; Giacco, Domenic; Kjellin, Lars; Dembinskas, Algirdas and Fiorilloet, Andrea, ‘Do Patient and Ward-Related Characteristics Influence the Use of Coercive Meas-ures? Results from the EUNOMIA International Study’ (2014) 49(10) Social Psychiatry and Psychiatric Epidemiology 1619-1629.

Kallert, Thomas Wilhelm, ‘Coercion in Psychiatry’ (2008) 21(5) Current Opinion in Psychiatry 485-489.

130

Kamundia, Elizabeth, ‘Choice, Support and Inclusion: Implementing Ar-ticle 19 of the Convention on the Rights of Persons with Disabilities’ in African Yearbook on Disability Rights (Pretoria Law Press, 2013) 49-72, <http://www.adry.up.ac.za/images/adry/volume1_2013/adry_2013_1_chapter3.pdf>.

Keski-Valkama, Alice; Sailas, Eila; Eronen, Markku, Koivisto, Anna-Mai-ja; Lonnqvist, Jouku and Kaltiala-Heino, Rittakerttu, ‘A 15-Year National Follow-up: Legislation Is Not Enough to Reduce the Use of Seclusion and Restraint’ (2007) 42(9) Social Psychiatry and Psychiatric Epidemiolo-gy 747-752.

Kisely, Steve, ‘Involvement of Patients in Planning Their Future Treat-ment May Reduce Compulsory Admissions to Hospital’ (2017) 20(1) Evidence-Based Mental Health 26, DOI: 10.1136/eb-2016-102530.

Kleintjes, Sharon; Lund, Crick and Swartz, Leslie, ‘Organising for Self-Advocacy in Mental Health: Experiences from Seven African Coun-tries’ (2013) 16(3) African Journal of Psychiatry 187-195.

Kleinman, Arthur, ‘Rebalancing Academic Psychiatry: Why It Needs to Happen - and Soon’ (2012) 201(6) The British Journal of Psychiatry 421-422.

Kogstad, Ragnfrid Eline, ‘Protecting Mental Health Clients’ Dignity - the Importance of Legal Control’ (2009) 32(6) International Journal of Law and Psychiatry 383-391.

Kokanović, Renata; Brophy, Lisa; McSherry, Bernadette; Flore, Jacin-the; Moeller-Saxone, Kristen and Herrman, Helen, ‘Supported Deci-sion-Making from the Perspectives of Mental Health Service Users, Family Members Supporting Them and Mental Health practitioners’ (2018) 52(9) Australian and New Zealand Journal of Psychiatry 826-239.

Kontio, Raija; Välimäki, Maritta; Putkonen, Hanna; Kuosmanen, Lauri; Scott, anne and Joffe, Grigori, ‘Patient Restrictions: Are There Ethical Alternatives to Seclusion and Restraint?’ (2010) 17(1) Nursing Ethics 65-76.

Larrobla, Cristina and Botega, Neury José, ‘Restructuring Mental Health: A South American Survey’ (2001) 36(5) Social Psychiatry and Psychiatric Epidemiology 256-259.

Lawlor, Caroline; Johnson, Sonia; Cole, Laura and Howard, Louise M, ‘Ethnic Variations in Pathways to Acute Care and Compulsory Deten-tion for Women Experiencing a Mental Health Crisis’ (2012) 58(1) The International Journal of Social Psychiatry 3-15.

Lay, Barbara; Nordt, Carlos and Rössler, Wulf, ‘Variation in Use of Coer-cive Measures in Psychiatric Hospitals’ (2011) 26(4) European Psychia-try: The Journal of The Association of European Psychiatrists 244-251.

Lay, Barbara; Drack, Thekler; Bleiker, Marco; Lengler, Silke; Blank, Christina and Rössler, Wulf, ‘Preventing Compulsory Admission to Psychiatric Inpatient Care through Psycho-Education and Cri-sis Focused Monitoring’ (2012) 12 BMC Psychiatry 136, DOI: 10.1186/1471-244X-12-136.

131

Lay, Barbara; Blank, Christina; Lengler, Silke; Drack, Thekler; Bleiker, Marco and Rössler, Wulf, ‘Preventing Compulsory Admission to Psychi-atric Inpatient Care Using Psycho-Education and Monitoring: Feasibility and Outcomes after 12 Months’ (2015) 265(3) European Archives of Psychiatry and Clinical Neuroscience 209-217.

Lay, Barbara; Kawohl, Wolfram and Rössler, Wulf, ‘Outcomes of a Psycho-Education and Monitoring Programme to Prevent Compulsory Admission to Psychiatric Inpatient Care: A Randomised Controlled Trial’ (2018) 48(5) Psychological Medicine 849-860.

Leamy, Mary; Bird, Victoria; Le Boutillier, Clair; Williams, Julie and Mike Slade, ‘Conceptual Framework for Personal Recovery in Mental Health: Systematic Review and Narrative Synthesis’ (2011) 199(6) The British Journal of Psychiatry 445-452.

Lefley, Harriet P, ‘Advocacy, Self-Help, and Consumer-Operated Servic-es’ in Tasman, Allan; Kay, Jerald; Lieberman, Jeffrey A; First, Michael B and Maj, Mario, (eds), Psychiatry, 3rd ed (Chichester: Wiley-Blackwell, 2008) Chapter 98.

Lewis, Maureen; Taylor, Karin and Parks, Joyce, ‘Crisis Prevention Man-agement: A Program to Reduce the Use of Seclusion and Restraint in an Inpatient Mental Health Setting’ (2009) 30(3) Issues in Mental Health Nursing 159-164.

Lindgren, Ingrid; Hogstedt, Margareta Falk and Cullberg, Johan, ‘Out-patient vs. Comprehensive First-Episode Psychosis Services, a 5-Year Follow-up of Soteria Nacka’ (2006) 60(5) Nordic Journal of Psychiatry 405-409.

Long, Clive G; West, Rachel; Afford, Matthew and Collins, Lesley, ‘Reducing the Use of Seclusion in a Secure Service for Women’ (2015) 11(2) Journal of Psychiatric Intensive Care 84-94.

Lyons, Christina; Hopley, Paul; Burton, Christopher R and Horrocks, Janice, ‘Mental Health Crisis and Respite Services: Service User and Carer Aspirations’ (2009) 16(5) Journal of Psychiatric and Mental Health Nursing 424-433.

Maguire, Tessa; Young, R and Martin, Trish, ‘Seclusion Reduction in a Forensic Mental Health Setting’ (2011) 19(2) Journal of Psychiatric and Mental Health Nursing 97-106.

Mann-Poll, Patricia S; Smit, Annet; Noorthoorn, Eric O; Janssen, Wim A; Koekkoek, Bauke and Hutschemaekers, Giel JM, ‘Long-Term Impact of a Tailored Seclusion Reduction Program: Evidence for Change?’ (2018) 89(3) Psychiatric Quarterly 733-746.

Martin, Andrés; Krieg, Heidi; Esposito, Frank; Stubbe, Dorothy and Cardona, Laurie, ‘Reduction of Restraint and Seclusion Through Col-laborative Problem Solving: A Five-Year Prospective Inpatient Study’ (2008) 59(12) Psychiatric Services 1406-1412.

Maylea, Chris, ‘Minimising Coerciveness in Coercion: A Case Study of Social Work Powers under the Victorian Mental Health Act’ (2017) 70(4) Australian Social Work 465-476.

132

Meijer, Ellen; Schout, Gert; de Jong, Gideon and Abma, Tineke, ‘Re-gaining Ownership and Restoring Belongingness: Impact of Family Group Conferences in Coercive Psychiatry’ (2017) 73(8) Journal of Advanced Nursing 1862-1872.

Melbourne Social Equity Institute, Seclusion and Restraint Project: Re-port (Melbourne: University of Melbourne, 2014) <https://socialequity.unimelb.edu.au/__data/assets/pdf_file/0017/2004722/Seclusion-and-Re-straint-report.PDF>.

Mental Health Coordinating Council, Trauma Informed Care and Prac-tice: Towards a Cultural Shift in Policy Reform Across Mental Health and Human services In Australia: A National Strategic Direction, Position Paper and Recommendations of the National Trauma-Informed Care and Practice Advisory Working Group (2013) <https://www.mhcc.org.au/wp-content/uploads/2018/05/ticp_awg_position_paper__v_44_fi-nal___07_11_13-1.pdf>.

Mezzina, Roberto and Vidoni, Daniela, ‘Beyond the Mental Hospital: Cri-sis Intervention and Continuity of Care in Trieste. A Four Year Follow-Up Study in a Community Mental Health Centre’ (1995) 41(1) International Journal of Social Psychiatry 1-20.

Minas, Harry and Hervita Diatri, ‘Pasung: Physical Restraint and Con-finement of the Mentally Ill in the Community’ (2008) 2(1) International Journal of Mental Health Systems 8, DOI: 10.1186/1752-4458-2-8.

Morrison, Anthony P; Turkington, Douglas; Pyle, Melissa; Spencer, Helen; Brabban, Alison; Dunn, Graham; Christodoulides, Tom; Dudley, Rob; Chapman, Nicola; Callcott, Pauline; Grace, Tim; Lumley, Victoria; Drage, Laura; Tully, Sarah; Irving, Kerry; Cummings, Anna; Byrne, Rory; Davies, Linda M and Hutton, Paul, ‘Cognitive Therapy for People with Schizophrenia Spectrum Disorders Not Taking Antipsychotic Drugs: A Single-Blind Randomised Controlled Trial’ (2014) 383(9926) Lancet 1395-1403.

Mustafa, Feras Ali, ‘The Safewards Study Lacks Vigour Despite Its Ran-domised Design’ (2015) 52(12) International Journal of Nursing Studies 461-471.

Noorthoorn, Eric O; Voskes, Yolande; Janssen, Wim A; Mulder, Cor-nelis L; van de Sande, Roland; Nijman, Henk L; Smit, Annet; Hoogen-doorn, Adriaan W; Bousardt, Annelea and Widdershoven, Guy AM, ‘Seclusion Reduction in Dutch Mental Health Care: Did Hospitals Meet Goals?’ (2016) 67(12) Psychiatric Services 1321-1327.

Norredam, Marie Louise; Garcia-Lopez, Ana Maria; Keiding Niels; Krasnik Allan, ‘Excess Use of Coercive Measures in Psychiatry among Migrants Compared with Native Danes’ (2010) 121(2) Acta Psychiatrica Scandinavica 143-151.

Norvoll, Reidun; Hem, Marit Helene and Pedersen, Reidar, ‘The Role of Ethics in Reducing and Improving the Quality of Coercion in Mental Health Care’ (2017) 29(1) HEC Forum: An Interdisciplinary Journal On Hospitals’ Ethical And Legal Issues 59-74.

133

Nyttingnes, Olav; Ruud, Torleif and Rugkåsa, Jorun, ‘“It’s Unbelievably Humiliating”-Patients’ Expressions of Negative Effects of Coercion in Mental Health Care’ (2016) 49 (Part A) International Journal of Law and Psychiatry 147-153.

Olson, Mary; Seikkula, Jaakko and Ziedonis, Dougls The key elements of dialogic practice in Open Dialogue. (Worcester, MA: The University of Massachusetts Medical School, 2014).

Olsson, Helen and Schön, Ulla-Karin, ‘Reducing Violence in Forensic Care - How Does It Resemble the Domains of a Recovery-Oriented Care?’ (2016) 25(6) Journal of Mental Health 506-511.

Osborn, David PJ; Lloyd-Evans, Brynmor; Johnson, Sonia; Gilburt, Helen; Byford, Sarah; Leese, Morven and Slade, Mike; ‘Residential Alternatives to Acute In-Patient Care in England: Satisfaction, Ward Atmosphere and Service User Experiences’ (2010) 197 (Suppl 53) The British Journal of Psychiatry s41-s45.

Ostrow, Laysha, A Case Study of the Peer-Run Crisis Respite Organizing Process in Massachusetts (Waltham, MA: Heller School for Social Policy and Management, 2010) <https://www.ncmhr.org/downloads/Ostrow_Groundhogs-case-study.pdf>

Ostrow, Laysha; Jessell, Lauren; Hurd, Manton; Darrow, Sabrina and Cohen, David, ‘Discontinuing Psychiatric Medications: A Survey of Long-Term Users’ (2017) 68(12) Psychiatric Services 1231-1238.

Pacific Disability Forum, Pacific Disability Forum SDG-CRPS Monitoring Report 2018 <http://www.pacificdisability.org/What-We-Do/Research/FINAL_SDG-Report_Exec-Summary_2018.aspx>

Papageorgiou, Alexia; King, Michael; Janmohamed, Anis; Davidson, Oliver and Dawson, John, ‘Advance Directives for Patients Compulsorily Admitted to Hospital with Serious Mental Illness. Randomised Con-trolled Trial’ (2002) 181(6) The British Journal of Psychiatry 513-519.

Paterson, Brodie; Bennet Lindsay and Bradley, Patrick ‘Positive and Proactive Care: Could New Guidance Lead to More Problems?’ (2014) 23(17) British Journal of Nursing 939-941.

Pollmächer, Thomas and Steinert, Tilman, ‘Arbitrary Classification of Hospital Policy Regarding Open and Locked Doors’ (2016) 3(12) The Lancet Psychiatry 1103-1103.

Poulsen, Henrik Day, ‘The Prevalence of Extralegal Deprivation of Liber-ty in a Psychiatric Hospital Population’ (2002) 25(1) International Journal of Law and Psychiatry 29-36.

Priebe, Stefan; Badesconyi, Alli; Fioritti, Angelo; Hansson, Lars; Kilian, Reinhold; Torres-Gonzales, Francisco; Turner, Trevor and Wiersma, Durk, ‘Reinstitutionalisation In Mental Health Care: Comparison of Data on Service Provision from Six European Countries’ (2005) 330(7483) BMJ 123-126.

Putkonen, Anu; Kuivalainen, Satu; Louheranta, Olavi; Repo-Tijhonen, Eila; Ryynänen, Olli-Pekka; Kautiainen, Hannu and Tiihonen, Jari, ‘Clus-ter-Randomized Controlled Trial of Reducing Seclusion and Restraint in Secured Care of Men with Schizophrenia’ (2013) 64(9) Psychiatric Services 850-855.

134

Puteh, Ibrahim; Marthoenis, M and Minas, Harry, ‘Aceh Free Pasung: Releasing the Mentally Ill from Physical Restraint’ (2011) 5 International Journal of Mental Health Systems 10, 10.1186/1752-4458-5-10.

Quirk, Alan; Lelliott, Paul; Audini, Bernard and Buston, Katie, ‘Non-Clin-ical and Extra-Legal Influences on Decisions about Compulsory Ad-mission to Psychiatric Hospital’ (2003) 12(2) Journal of Mental Health 119-130.

Raveesh, BN; Pathare, Soumitra; Noorthoorn, Eric O; Gowda, Guru S; Lepping, Peter, and Bunders-Aelen, Joske, ‘Staff and Caregiver Attitude to Coercion in India’ (2016) 58 (Suppl 2) Indian Journal of Psychiatry s221-s220.

Razzaque, Russell and Stockmann, Tom, ‘An Introduction to Peer-Sup-ported Open Dialogue In Mental Healthcare’ (2016) 22(5) British Journal Psych Advances 348-356.

Riahi, Sanaz; Dawe, Ian C; Stuckey, Melanie I and Klassen, Philip E, ‘Implementation of the Six Core Strategies for Restraint Minimization in a Specialized Mental Health Organization’ (2016) 54(10) Journal of Psychosocial Nursing and Mental Health Services 32-39.

Robertson, John P and Collinson, Christine, ‘Positive Risk Taking: Whose Risk Is It? An Exploration in Community Outreach Teams in Adult Mental Health and Learning Disability Services’ (2011) 13(2) Health, Risk & Society 147-164.

Rosen, Jonathan and O’Connell, Maria, ‘The Impact of a Mental Health Crisis Respite upon Clients’ Symptom Distress’ (2013) 49(4) Community Mental Health Journal 433-437.

Russo, Jasna and Rose, Diana, ‘“But What If Nobody’s Going to Sit down and Have a Real Conversation with You?” Service User/Survivor Perspectives on Human Rights’ (2013) 12(4) Journal of Public Mental Health 184-192.

Salize, Hans Joachim and Dressing, Harald, ‘Epidemiology of Invol-untary Placement of Mentally Ill People across the European Union’ (2004) 184(2) British Journal of Psychiatry 163-168.

Salomon, Carmela: Hamilton, Bridget and Elsom, Stephen, ‘Experienc-ing Antipsychotic Discontinuation: Results from a Survey of Australian Consumers’ (2014) 21(10) Journal of Psychiatric and Mental Health Nursing 917-923.

Schneeberger, Andres Ricardo; Kowalinski, Eva; Frohlich, Daniela; Schroder, Katrin; von Felten, Stefanie; Zinkler, Martin; Beine, Karl H; Heinz, Andreas; Borgwardt, Stefan; Lang, Undine E; Bux, Donald A and Huber, Christian G, ‘Aggression and Violence in Psychiatric Hospitals with and without Open Door Policies: A 15-Year Naturalistic Observa-tional Study’ (2017) 95 Journal of Psychiatric Research 189-195.

Schoevaerts, Katrien; Bruffaerts, Ronny; Mulder, Cornelis L and Vandenberghe, Joris, ‘An Increase of Compusory Admissions in Bel-gium and the Netherlands: An Epidemiological Exploration’ (2013) 55(1) Tijdschrift Voor Psychiatrie 45-55.

135

Schout, Gert; Meijer, Ellen and de Jong, Gideon, ‘Family Group Confer-encing—Its Added Value in Mental Health Care’ (2017) 38(6) Issues in Mental Health Nursing 480-485.

Schout, Gert; Van Dijk, Marjolein; Meijer, Ellen; Landeweer, Elleke and de Jong, Gideon, ‘The Use of Family Group Conferences in Mental Health: Barriers for Implementation’ (2017) 17(1) Journal of Social Work 52-70.

Segal, Steven P; Laurie Theresa A and Segal, Matthew J, ‘Factors in the Use of Coercive Retention in Civil Commitment Evaluations in Psychiat-ric Emergency Services’ (2001) 52(4) Psychiatric Services 514-520.

Seikkula, Jaakko; Alakare, Birgitta; Aaltonen, Jukka; Holma, Juha; Rasinkangas, Anu and Lehtinen, Ville, ‘Open Dialogue Approach: Treatment Principles and Preliminary Results of a Two-Year Follow-Up on First Episode Schizophrenia’ (2003) 5(3) Ethical Human Sciences and Services 163-182.

Shields, Laura S; Pathare, Soumitra; van Zelst, Selina DM; Dijkkamp, Sophie; Narasimhan, Lakshmi and Bunders, Joske G F, ‘Unpacking the Psychiatric Advance Directive in Low-Resource Settings: An Explorato-ry Qualitative Study in Tamil Nadu, India’ (2013) 7 International Journal of Mental Health Systems 29, DOI: 10.1186/1752-4458-7-29.

Siponen, Ulla; Välimäki, Maritta and Kaltiala-Heino, Riittakerttu ‘A Comparison of Two Hospital Districts with Low and High Figures in the Compulsory Care of Minors: An Ecological Study’ (2011) 46(8) Social Psychiatry and Psychiatric Epidemiology 661-670.

Slade, Mike; Byford, Sarah; Barrett, Barbara; Lloyd-Evans, Bryn; Gilburt, Helen; Osborn, Dominic; Phillip J; Sinner, Rachel; Leese, Morven; Thornicroft, Graham and Johnson, Sonia, ‘Alternatives to Standard Acute In-Patient Care in England: Short-Term Clinical Outcomes and Cost-Effectiveness’ (2010) 197 (Suppl 53) The British Journal of Psychia-try s14-s19.

Sledge, William H; Tebes, Jacob; Wolff, Nancy and Helminiak, Thom-as W, ‘Day Hospital/Crisis Respite Care versus Inpatient Care, Part I: Clinical Outcomes’ (1996) 153(8) The American Journal of Psychiatry 1065-1073.

Sledge, William H; Tebes, Jacob; Wolff, Nancy and Helminiak, Thomas W, ‘Day Hospital/Crisis Respite Care versus Inpatient Care, Part II: Service Utilization and Costs’ (1996) 153(8) The American Journal of Psychiatry 1074-1083.

Smith, Gregory M; Davis, Robert H; Bixler, Edward O; Lin, Hung-Mo; Altenor, Aidan; Altenor, Roberta J; Hardentstine, Bonnie D and Kopchik, George A, ‘Pennsylvania State Hospital System’s Seclusion and Re-straint Reduction Program’ (2005) 56(9) Psychiatric Services 1115-1122.

Spencer, Sally; Johnson, Paula and Smith, Ian C, ‘De‐escalation techniques for managing non‐psychosis induced aggression in adults’ (2018) Issue 7 Cochrane Database of Systematic Reviews Art No: CD012034. DOI: 10.1002/14651858.CD012034.pub2.

136

Suryani, Luh Ketut; Lesmana, Cokorda Bagus Jaya and Tiliopoulos, Niko, ‘Treating the Untreated: Applying a Community-Based, Culturally Sensitive Psychiatric Intervention to Confined and Physically Restrained Mentally Ill Individuals in Bali, Indonesia’ (2011) 261 (Suppl 2) European Archives of Psychiatry and Clinical Neu-roscience s140-s144.

Swanson, Jeffrey; Swartz, Marvin S; Elbogen, Eric B; Van Dorn, Richard A; Wag-ner, H Ryan; Moser, Lorna A; Wilder, Christine and Gilbert, Allison R, ‘Psychiatric Advance Directives and Reduction of Coercive Crisis Interventions’ (2008) 17(3) Journal of Mental Health 255-267.

Swartz, Marvin S; Swanson, Jeffrey W and Hannon, Michael J, ‘Does Fear of Coercion Keep People Away from Mental Health Treatment? Evidence from a Sur-vey of Persons with Schizophrenia and Mental Health Professionals’ (2003) 21(4) Behavioral Sciences & the Law 459-472.

Tanenbaum, Sandra J, ‘Consumer-Operated Service Organizations: Organizational Characteristics, Community Relationships, and the Potential for Citizenship’ (2012) 48(4) Community Mental Health Journal 397-406.

Te Pou, Reducing Seclusion and Restraint <https://www.tepou.co.nz/initiatives/reducing-seclusion-and-restraint/102>.

Thomas, Philip and Cahill, Anne B, ‘Compulsion and Psychiatry - The role of Ad-vance Statements’ (2004) 329(7458) BMJ 122-123.

Thomsen, Christoffer Toorgard; Benros, Michael Eriksen; Hastrup, Lene Halling; Andersen, Per Kragh; Giacco, Domenico and Nordentoft, Merete, ‘Patient-con-trolled Hospital Admission for Patients with Severe Mental Disorders: A Nation-wide Prospective Multicentre Study’ (2018) 137(4) Acta Psychiatrica Scandinavica 355-363.

Thomsen, Christoffer; Starkopf, Liis; Hastrup, Lene Halling; Andersen, Per Kragh; Nordentoft, Merete and Benros Michael Eriksen, ‘Risk Factors of Coercion among Psychiatric Inpatients: A Nationwide Register-Based Cohort Study’ (2017) 52(8) Social Psychiatry and Psychiatric Epidemiology 979-987.

Thørnblad, Renee; Strandbu, Astrid; Holtan, Amy and Jenssen, Toril, ‘ Family Group Conferences: from Maori Culture to Decision-Making Model in Work with Late Modern Families in Norway’ (2016) 19(6) European Journal of Social Work 992-1003.

Thornicroft, Graham; Farrelly, Simone; Szmukler, George; Birchwood, Max; Wa-heed, Waquas; Flach, Clare; Barrett, Barbara; Byford, Sarah; Henderson, Claire; Sutherby, Kim; Lester, Helen; Rose, Diana; Dunn, Graham; Leese, Morven and Marshall, Max, ‘Clinical Outcomes of Joint Crisis Plans to Reduce Compulsory Treatment for People with Psychosis: A Randomised Controlled Trial’ (2013) 381(9878) The Lancet 1634-1641.

Thornicroft, Graham; Farrelly, Simone; Szmukler, George; Birchwood, Max; Wa-heed, Waquas; Flach, Clare; Barrett, Barbara; Byford, Sarah; Henderson, Claire; Sutherby, Kim; Lester, Helen; Rose, Diana; Dunn, Graham; Leese, Morven and Marshall, Max, ‘Randomised Controlled Trial of Joint Crisis Plans to Reduce Com-pulsory Treatment for People with Psychosis: Clinical Outcomes and Implementa-tion’, Abstract 0-90, (2015) 5 (Suppl 2) BMJ Supportive & Palliative Care A28.

Transforming Communities for Inclusion - Asia, Submission to the UN CRPD Mon-itoring Committee, Day of General Discussion, Art 19 < https://www.ohchr.org/EN/HRBodies/CRPD/Pages/CallDGDtoliveindependently.aspx>

137

Valenti, Emanuele; Banks, Ciara; Calcedo-Barba, Alfredo; Bensimon, Ce´cile M; Hoffmann, Karin-Maria; Pelto-Piri, Veikko; Jurin, Tanja; Ma´rquez Mendoza, Octavio; Mundt, Adrian P; Rugka˚sa, Jorun; Tubini, Jacopo and Priebe, Stefan, ‘Informal Coercion in Psychiatry: A Focus Group Study of Attitudes and Experiences of Mental Health Profes-sionals in Ten Countries’ (2015) 50(8) Social Psychiatry and Psychiatric Epidemiology 1297-1308.

van der Post, Louk FM; Peen, Jaap; Visch, Irene; Mulder, Cornelis L; Beekman, Aartjan TF and Dekker, Jack JM, ‘Patient Perspectives and the Risk of Compulsory Admission: The Amsterdam Study of Acute Psychiatry V’ (2014) 60(2) The International Journal of Social Psychiatry 125-133.

van der Schaaf, PS; Dusseldorp, Elise; Keuning FM; Janssen, Wim A and Noorthoorn, Eric O, ‘Impact of the Physical Environment of Psychi-atric Wards on the Use of Seclusion’ (2013) 202 The British Journal of Psychiatry 142-149.

Vruwink, Fleur J; Mulder, Cornelis L; Noorthoorn, Eric O; Uitenbroek, Daan and Nijman, Henk L I, ‘The Effects of a Nationwide Program to Reduce Seclusion in the Netherlands’ (2012) 12(1) BMC Psychiatry 231-234, DOI: 10.1186/1471-244X-12-231.

Wanchek, Tanya Nicole and Bonnie, Richard J, ‘Use of Longer Periods of Temporary Detention to Reduce Mental Health Civil Commitments’ (2012) 63 Psychiatric Services 643-648.

Warner, Richard, ‘The Roots of Hospital Alternative Care’ (2010) 197 (Suppl 53) The British Journal of Psychiatry s4-s5.

Watson, Sandy; Thorburn, Kath; Everett, Michelle and Fisher, Karen Raewyn, ‘Care without Coercion – Mental Health Rights, Personal Recovery and Trauma-Informed Care’ 49(4) Australian Journal of Social Issues 529-549.

Wieman, Dow A; Camacho-Gonsalves, Teresita, Huckshorn, Kevin Ann and Leff, Stephen, ‘Multisite Study of an Evidence-Based Practice to Reduce Seclusion and Restraint in Psychiatric Inpatient Facilities’ (2014) 65(3) Psychiatric Services 345-351.

Winick, Bruce J, ‘Advance Directive Instruments for Those with Mental Illness’ (1996) 51(1) University of Miami Law Review 57-95.

Wisdom, Jennifer P; Wenger, David; Robertson, David; Van Bramer, Jayne and Sederer, Lloyd I, ‘The New York State Office of Mental Health Positive Alternatives to Restraint and Seclusion (PARS) Project’ (2015) 66(8) Psychiatric Services 851-856.

Zinkler, Martin, ‘Germany without Coercive Treatment in Psychiatry - A 15 Month Real World Experience’ (2016) 5(1) Laws 15, DOI: 10.3390/laws5010015.

Zmudzki, Fredrick; Griffiths, Andrew; Bates, Shona; Katz, Ilan and Kayess, Rosemary, Evaluation of Crisis Respite Services: Final Report, SPRC Report 06/16 (Sydney: Social Policy Research Centre, UNSW Australia, 2016).

138

Major Reviews and Other Notable Literature Listed in Appendix Two Bak, Jesper; Brandt-Christensen, Mette; Sestoft, Dorte Maria and Zoffmann, Vibeke, ‘Mechanical Restraint - Which Interventions Prevent Episodes of Mechanical Restraint? - A Systematic Review’ (2012) 48(2)

Perspectives in Psychiatric Care 83-94.

Bola, John R; Lehtinen, Klaus; Cullberg, Johan and Ciompi, Luc, ‘Psy-chosocial Treatment, Antipsychotic Postponement, and Low-Dose Medication Strategies in First-Episode Psychosis: A Review of the Literature’ (2009) 1(1) Psychosis: Psychological, Social and Integrative Approaches 4-18.

Bowers, Len; Alexander, J; Bilgin, H; Botha, M; Dack, Charlotte; James, Karen; Jarrett, M; Jeffery, D; Nijman, Henk; Owiti, JA; Pap-adopoulos, Chris; Ross, Jamie; Wright, Steve and Stewart, Duncan, ‘Safewards: The Empirical Basis of the Model and a Critical Appraisal’ (2014) 21(4) Journal of Psychiatric and Mental Health Nursing 354-364.

Bowers, Len, ‘Safewards: A New Model of Conflict and Containment on Psychiatric Wards’ (2014) 21(6) Journal of Psychiatric and Mental Health Nursing 499–508.

Burns, Tom; Knapp, Martin; Catty, Jocelyn; Healey, Andrew; Henderson, J; Watt, Hilary and Wright, Christine, ‘Home Treatment for Mental Health Problems: A Systematic Review’ (2001) 5(15) Health Technology Assessment 1-139.

Buus, Niels; Bikic, Aida; Jacobsen, Elise Kragh; Müller-Nielsen, Klaus; Aagaard, Jørgen and Camilla Rossen, Camilla Blach, ‘Adapting and Implementing Open Dialogue in the Scandinavian Countries: A Scoping Review’ (2017) 38(5) Issues in Mental Health Nursing 391-401.

Calton, Tim; Ferriter, Michael; Huband, Nick and Spandler, Helen ‘A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed with Schizophrenia’ (2008) 34(1) Schizophrenia Bulletin 181-192.

Champagne, Tina and Sayer, Edward, The Effects of the Use of the Sen-sory Room in Psychiatry <https://www.ot-innovations.com/wp-content/uploads/2014/09/qi_study_sensory_room.pdf>.

Champagne, Tina and Stromberg, Nan, ‘Sensory Approaches in Inpa-tient Psychiatric Settings: Innovative Alternatives to Seclusion & Re-straint’ (2004) 42(9) Journal of Psychosocial Nursing and Mental Health Services 34-44.

Danzer, Graham and Rieger, Sarah M, ‘Improving Medication Ad-herence for Severely Mentally Ill Adults by Decreasing Coercion and Increasing Cooperation’ (2016) 80(1) Bulletin of The Menninger Clinic 30-48.

139

Department of Mental Health, Agency of Human Services Vermont, Vermont2018: Reforming Vermont’s Mental Health System Report to the Legislature on the Implementation of Act 79, Vermont Government, January 15, 2018, <http://mentalhealth.vermont.gov/sites/dmh/files/documents/reports/2018_ACT_79_Report.pdf<http://mentalhealth.vermont.gov/sites/dmh/files/documents/reports/2018_ACT_79_Report.pdf>

Doughty, Carolyn and Tse, Samson, ‘Can Consumer-Led Mental Health Services Be Equally Effective? An Integrative Review of CLMH Servic-es in High-Income Countries’ (2011) 47(3) Community Mental Health Journal 252-266.

Evans, Elizabeth; Howlett, Sophie; Kremser, Thea; Simpson, Jim; Kayess, Rosemary and Trollor, Julian N, ‘Service Development for Intellectual Disability Mental Health: A Human Rights Approach’ (2012) 56(11) Journal of Intellectual Disability Research 1098-1109.

Ford, Skye-Blue; Bowyer, Terry and Morgan, Phil, ‘The Experience of Compulsory Treatment: The Implications for Recovery-Orientated Prac-tice?’ (2015) 19(3) Mental Health and Social Inclusion 126-132.

Foxlewin, Bradley, What is Happening at the Seclusion Review that Makes a Difference? A Consumer Led Research Study (Canberra: ACT Mental Health Consumer Network, 2012).

Gaskin, Cadeyrn J; Elsom, Stephen J and Happell, Brenda, ‘Inter-ventions for Reducing the Use of Seclusion in Psychiatric Facilities: Review of the Literature’ (2007) 191(4) The British Journal of Psychiatry 298-303.

Hem, Marit Helene; Gjerberg, Elisabeth; Husum, Tonje Lossius and Pedersen, Reidar, ‘Ethical Challenges When Using Coercion in Mental Healthcare: A Systematic Literature Review.’ (2018) 25(1) Nursing Ethics 92-110.

Henderson, Claire; Farrelly, Simone; Flach, Clare; Borschmann, Rohan; Birchwood, Max; Thornicroft, Graham; Waheed, Waquas and Szmukler, George, ‘Informed, Advance Refusals of Treatment by People with Severe Mental Illness In a Randomised Controlled Trial of Joint Crisis Plans: Demand, Content and Correlates’ 17(1) BMC Psychiatry 376, DOI: 10.1186/s12888-017-1542-1545.

Henderson, Claire; Flood, Chris; Leese, Morven; Thornicroft, Graham; Sutherby, Kim and Szmukler, George, ‘Effect of Joint Crisis Plans on Use of Compulsory Treatment in Psychiatry: Single Blind Randomised Controlled Trial’ (2004) 329(7458) BMJ 136-140.

Henderson, Claire; Flood, Chris; Leese, Morven; Thornicroft, Graham; Sutherby, Kim and Szmukler, George, ‘Views of Service Users and Providers on Joint Crisis Plans’ (2009) 44(5) Social Psychiatry and Psy-chiatric Epidemiology 369-376.

Henderson, Claire; Swanson, Jeffrey W; Szmukler, George; Thornicroft, Graham and Zinkler, Martin, ‘A Typology of Advance Statements in Mental Health Care’ (2008) 59(1) Psychiatric Services 63-71.

140

Human Rights Watch, ‘Ghana: Invest in Mental Health Services to End Shackling’ (9 October 2017) < https://www.hrw.org/news/2017/10/09/ghana-invest-mental-health-services-end-shackling>.

Janssen, Wim A; van de Sande, Roland; Noorthoorn, Eric O; Nijman, Henk L; Bowers, Len; Mulder, Cornelis L; Smit, Annet; Widdershoven, Guy A and Steinert, Tilman, ‘Methodological Issues in Monitoring the Use of Coercive Measures’ (2011) 34(6) International Journal of Law and Psychiatry 429-438.

Johnson, Mary E, ‘Violence and Restraint Reduction Efforts on Inpatient Psychiatric Units’ (2010) 31(3) Issues in Mental Health Nursing 181-197.

Kallert, Thomas Wilhelm, ‘Coercion in Psychiatry’ (2008) 21(5) Current Opinion in Psychiatry 485-489.

Kisely, Steve R and Campbell Leslie A, Compulsory Community and Involuntary Outpatient Treatment for People with Severe Mental Disorders (2014) 12 Cochrane Database of Systematic Reviews, DOI: 10.1002/14651858.CD004408.pub4.

Klag, Stefanie, O’Callaghan, Frances and Creed, Peter, ‘The Use of Le-gal Coercion in the Treatment of Substance Abusers: An Overview and Critical Analysis of Thirty Years of Research.’ (2005) 40(12) Substance Use & Misuse 1777-1795.

LeBel, Janice L; Duxbury, Joy; Putkonen, Anu; Sprague, Titia; Rae, Carolyn and Sharoe, Joanne, et al, ‘Multinational Experiences in Reduc-ing and Preventing the Use of Restraint and Seclusion’ (2014) 52(11) Journal of Psychosocial Nursing and Mental Health Services 22-29.

Mead, Shery and Filson, Beth, ‘Mutuality and Shared Power as an Alternative to Coercion and Force’ (2017) 21(3) Mental Health & Social Inclusion 144-152.

Mezzina, Roberto, ‘Community Mental Health Care in Trieste and Be-yond: An “Open Door–No Restraint” System of Care for Recovery and Citizenship’ (2014) 202(6) The Journal of Nervous and Mental Disease 440-445.

Mezzina, Roberto, ‘Forty Years of the Law 180: The Aspirations of a Great Reform, Its Successes and Continuing Need’ (2018) 27(4) Epide-miology and Psychiatric Sciences 336-345.

Möhler, Ralph; Richter, Tanja, Köpke, Sascha and Meye,r Gabriel, ‘In-terventions for Preventing and Reducing the Use of Physical Restraints in Long-Term Geriatric Care’ (2011) Issue 2 The Cochrane Database of Systematic Reviews CD007546.

Olfson, Mark, ‘Review: Limited Evidence to Support Specialist Mental Health Services as Alternatives to Inpatient Care for Young People with Severe Mental Health Disorders’ (2009) 12(4) Evidence-Based Mental Health 117-117.

Richter, Dirk and Hoffmann, Holga, ‘Independent Housing and Support for People with Severe Mental Illness: Systematic Review’ (2017) 136(3) Acta Psychiatrica Scandinavica 269-279.

141

Rose, Diana; Perry, Emma; Rae, Sarah and Good, Naomi, ‘Service User Perspectives on Coercion and Restraint in Mental Health’ (2017) 14(3) BJPsych International 59-61.

Rosen Alan, Mueser, Kim T and Teesson Maree, ‘Assertive Community Treatment -- Issues from Scientific and Clinical Literature with Impli-cations for Practice’ (2007) 44(6) Journal of Rehabilitation Research & Development 813-826.

Scanlan, Justin Newton, ‘Interventions to Reduce the Use of Seclusion and Restraint in Inpatient Psychiatric Settings: What We Know So Far: A Review of the Literature’ (2010) 56(4) The International Journal of Social Psychiatry 412-423.

Stastny, Peter and Lehmann, Peter, (eds), Alternatives Beyond Psychiatry (Berlin: Peter Lehmann Publishing, 2007).

Stewart, Duncan; Van der Merwe, Marie; Bowers Len; Simpson, Alan and Jones Julia, ‘A Review of Interventions to Reduce Mechanical Re-straint and Seclusion among Adult Psychiatric Inpatients’ (2010) 31(6) Issues in Mental Health Nursing 413-424.

Swedish National Board of Health and Welfare, A New Profession is Born – Personligt ombud, PO (Västra Aros, Västerås, November 2008) <www.personligtombud.se>.

Van Dorn, Richard A; Scheyett, Anna; Swanson, Jeffrey J and Swartz, Marvin S, ‘Psychiatric Advance Directives and Social Workers: An Integrative Review’ (2010) 55(2) Social Work 157-167.

Users and Survivors of Psychiatry – Kenya, The Role of Peer Support in Exercising Legal Capacity in Kenya (April 2018) <www.uspkenya.org>.

Winkler, Petr; Krupchanka, Dzmitry; Roberts, Tessa; Kondratova, Lucie; Machů, Vendula; Höschl, Cyril; Sartorius, Norman; Van Voren, Robert; Aizberg, Oleg; Bitter, Istvan; Cerga-Pashoja, Arlinda; Deljkovic, Azra; Fanaj, Naim; Germanavicius, Arunas; Hinkov, Hristo; Hovsepyan, Aram; Ismayilov, Fuad N; Ivezic, Sladana Strkalj; Jarema, Marek; Jordanova, Vesna; Kukić, Selma; Makhashvili, Nino; Šarotar, Brigita Novak; Plev-achuk, Oksana; Smirnova, Daria; Voinescu, Bogdan Ioan; Vrublevska, Jelena and Thornicroft, Graham, ‘A Blind Spot on the Global Mental Health Map: A Scoping Review of 25 Years’ Development of Mental Health Care for People with Severe Mental Illnesses in Central and Eastern Europe’ (2017) 4(8) The Lancet Psychiatry 634-642.

142

App

endi

x O

ne -

Lite

ratu

re S

elec

ted

for F

ull R

evie

w

AU

TH

OR

YE

AR

RE

GIO

N/

CO

UN

TR

YP

OP

ULA

TIO

N

SA

MP

LE

AIM

TY

PE

OF

ST

UD

YM

AIN

FIN

DIN

GS

Aag

aard

, J;

Tusz

ewsk

i, B

; K

ølb

æk,

P20

17D

enm

ark

240

men

an

d w

omen

sta

rtin

g

as r

ecip

ien

ts

of A

sser

tive

Com

mu

nity

Tr

eatm

ent

du

rin

g

a fiv

e-ye

ar

per

iod

.

To s

ee w

het

her

A

sser

tive

Com

mu

nity

Tr

eatm

ent

(AC

T)

may

hav

e th

e q

ual

ity t

o re

du

ce

the

use

of

seve

ral

typ

es o

f co

erci

on

incl

ud

ing

com

pu

lsor

y ad

mis

sion

s.

Qu

antit

ativ

e -

anal

ysis

of

serv

ice

dat

a fr

om t

he

Dan

ish

Nat

ion

al C

ase

Reg

iste

r at

th

ree

psy

chia

tric

h

osp

itals

.

An

ass

ertiv

e ap

pro

ach

ap

pea

rs t

o re

du

ce h

osp

ita-

lisat

ion

incl

ud

ing

som

e in

volu

nta

ry a

dm

issi

ons.

AC

T is

pre

fera

ble

fro

m b

oth

tea

m a

nd

pat

ien

t p

ersp

ectiv

es.

The

rese

arch

ers

reco

mm

end

rev

isio

n o

f th

e cr

iteri

on o

f ‘s

ever

e m

enta

l illn

ess’

to

faci

litat

e A

CT

to b

e of

fere

d t

o a

larg

er g

rou

p o

f p

atie

nts

. In

ad

diti

on, t

he

rese

arch

ers

reco

mm

end

th

at t

he

intr

odu

ctio

n o

f C

risi

s In

terv

entio

n Te

ams

shou

ld b

e co

nsi

der

ed a

nd

allo

cate

d t

o p

sych

iatr

ic

emer

gen

cy r

oom

s.

Alle

n, M

2003

Un

ited

Sta

tes

N/A

To s

um

mar

ise

the

reas

ons

wh

y h

ousi

ng

fo

r p

eop

le w

ith

psy

chia

tric

dia

gn

osis

sh

ould

be

pro

vid

ed f

ree

of t

he

use

of

coer

cion

.

Qu

alita

tive

- an

alys

is o

f le

gal

, pol

icy

doc

um

ents

an

d r

esea

rch

rep

orts

.

Men

tal h

ealth

ser

vice

s ap

pea

r to

be

usi

ng

coe

rciv

e p

ract

ices

or

‘leve

rag

ing

’ w

ith h

ousi

ng

. Th

at is

, th

reat

enin

g d

isco

ntin

uat

ion

of

hou

sin

g s

ervi

ces

or

evic

tion

if p

sych

iatr

ic in

terv

entio

n is

not

acc

epte

d.

This

pra

ctic

e ap

pea

rs t

o b

reac

h t

he

Am

eric

ans

with

D

isab

ilitie

s A

ct, a

nd

acc

ord

ing

to

the

auth

or h

as m

ulti

ple

, n

egat

ive

flow

-on

eff

ects

.

An

der

sen

, K;

Nie

lsen

, B20

16D

enm

ark

235

men

an

d w

omen

ad

mitt

ed

to a

clo

sed

war

d d

uri

ng

20

11-2

013

wer

e ra

nd

omly

se

lect

ed.

To id

entif

y p

ossi

ble

ex

tern

al (

extr

amu

ral)

fact

ors

that

may

in

crea

se t

he

risk

of

coe

rcio

n d

uri

ng

ad

mis

sion

to

a cl

osed

p

sych

iatr

ic w

ard

.

Qu

antit

ativ

e -

retr

osp

ectiv

e an

alys

is o

f ca

se

rep

ort

dat

a.

66 p

eop

le (

28%

of

the

sam

ple

) w

ere

sub

ject

to

coer

cion

. Th

e tim

e of

for

ced

pro

ced

ure

s w

as p

red

omin

atel

y d

uri

ng

th

e fir

st h

ours

aft

er a

dm

issi

on. T

he

risk

of

forc

ed

mea

sure

s b

ein

g a

pp

lied

was

sig

-nifi

can

tly h

igh

er if

p

atie

nts

wer

e in

volu

nta

rily

ad

mitt

ed (

OR

= 6

.4 (

3.4-

11.9

)), o

r w

ere

acu

tely

into

xica

ted

by

sub

stan

ces

at t

he

time

of a

dm

issi

on (

OR

= 3

.7 (

1.7-

8.2)

). T

he

rese

arch

ers

reco

mm

end

th

at e

xtra

mu

ral f

acto

rs s

hou

ld

be

con

sid

ered

wh

en s

eeki

ng

to

red

uce

coe

rcio

n, a

nd

sug

ges

t b

ette

r in

teg

rate

d e

ffor

ts b

etw

een

men

tal h

ealth

an

d s

ub

stan

ce a

bu

se s

ervi

ces

as a

way

to

red

uce

co

erci

on.

143

Ash

craf

t,

L; A

nth

ony,

W20

08U

nite

d S

tate

s

Ser

vice

dat

a on

14

,500

ad

ults

per

ye

ar f

or a

fou

r-ye

ar p

erio

d (

incl

. 4,

600

bro

ug

ht

to s

ervi

ce

invo

lun

tari

ly)

To e

valu

ate

a p

olic

y to

elim

inat

e p

hys

ical

an

d m

ech

anic

al

rest

rain

t an

d e

valu

ate

the

succ

ess

of t

he

pro

gra

mm

e at

tw

o cr

isis

cen

tres

in t

he

Un

ited

Sta

tes.

Qu

antit

ativ

e -

anal

ysis

of

case

re

por

t d

ata.

Exi

stin

g r

ecor

ds

ind

icat

ed t

hat

ove

r a

58-m

onth

fol

low

-u

p p

erio

d (

Jan

uar

y 20

00 t

o O

ctob

er 2

004)

, th

e la

rger

cr

isis

cen

tre

took

ten

mon

ths

un

til a

mon

th r

egis

tere

d ze

ro s

eclu

sion

s an

d 3

1 m

onth

s u

ntil

a m

onth

rec

ord

ed

zero

res

trai

nts

. Th

e sm

alle

r cr

isis

cen

tre

ach

ieve

d t

hes

e sa

me

goa

ls in

tw

o m

onth

s an

d 1

5 m

onth

s, r

esp

ectiv

ely.

Ash

craf

t, L

; Blo

ss,

M; A

nth

ony,

WA

2012

Un

ited

Sta

tes

12,3

46 a

du

lts

wh

o u

sed

a

men

tal h

ealth

cr

isis

cen

tre

over

a t

wo

year

p

erio

d.

To e

valu

ate

the

succ

ess

of t

he

‘No

Forc

e Fi

rst’

ap

pro

ach

dev

elop

ed b

y R

ecov

ery

Inn

o-va

tion

s an

d e

valu

ate

the

succ

ess

of t

he

pro

g-

ram

me

in r

edu

cin

g

chem

ical

res

trai

nt

at

a cr

isis

cen

tre

in t

he

Un

ited

Sta

tes.

Qu

antit

ativ

e -

anal

ysis

of

case

rep

ort

dat

a (b

efor

e an

d a

fter

in

trod

uct

ion

of

‘No

Forc

e Fi

rst’

).

At

the

cris

is c

entr

e, c

hem

ical

res

trai

nt

was

use

d f

or

56 o

f 12

,346

peo

ple

ser

ved

ove

r th

e tw

o-ye

ar p

erio

d (0

.45%

). T

he

per

cen

tag

e of

ser

vice

rec

ipie

nts

wh

o re

ceiv

ed c

hem

ical

res

trai

nt

in a

ny

mon

th r

ang

ed f

rom

0%

to

1.27

%. F

or r

oug

h c

omp

arat

ive

pu

rpos

es, d

ata

wer

e ob

tain

ed f

rom

sta

te r

ecor

ds

on t

he

use

of

rest

rain

ts

by

com

par

able

pro

gra

ms:

ch

emic

al r

estr

ain

ts w

ere

use

d fo

r 3.

9% o

f in

div

idu

als

serv

ed s

tate

wid

e.

Ash

er, L

; et

al

2017

Eth

iop

ia

35 a

du

lts w

ith

sch

izop

hre

nia

, ‘t

hei

r ca

reg

iver

s,

com

mu

nity

le

ader

s an

d p

rim

ary

and

com

mu

nity

h

ealth

wor

kers

’ in

ru

ral E

thio

pia

.

To u

nd

erst

and

th

e ex

per

ien

ces

of,

and

rea

son

s fo

r, re

stra

int

of p

eop

le

with

sch

izop

hre

nia

in

com

mu

nity

set

ting

s in

ru

ral E

thio

pia

in o

rder

to

dev

elop

con

stru

ctiv

e an

d s

cala

ble

in

terv

entio

ns.

Qu

alita

tive

- in

-dep

th

inte

rvie

ws

and

5 fo

cus

gro

up

dis

cuss

ion

s w

ith t

hem

atic

an

alys

is.

Mos

t of

th

e p

artic

ipan

ts w

ith s

chiz

oph

ren

ia a

nd

th

eir

care

giv

ers

had

per

son

al e

xper

ien

ce o

f th

e p

ract

ice

of r

estr

ain

t. T

he

mai

n e

xpla

nat

ion

s g

iven

for

res

trai

nt

wer

e to

pro

tect

th

e in

div

idu

al o

r th

e co

mm

un

ity, a

nd

to f

acili

tate

tra

nsp

orta

tion

to

hea

lth f

acili

ties.

Th

ese

reas

ons

wer

e u

nd

erp

inn

ed b

y a

lack

of

care

op

tion

s,

and

th

e co

nse

qu

ent

hea

vy f

amily

res

pon

sib

ility

an

d a

se

nse

of

pow

erle

ssn

ess

amon

gst

car

egiv

ers.

All

typ

es o

f p

artic

ipan

ts c

ited

incr

easi

ng

acc

ess

to t

reat

men

t as

th

e m

ost

effe

ctiv

e w

ay t

o re

du

ce t

he

inci

den

ce o

f re

stra

int.

Th

e au

thor

s co

ncl

ud

e th

at a

sca

le u

p o

f ac

cess

ible

an

d af

ford

able

men

tal h

ealth

car

e m

ay g

o so

me

way

to

add

ress

th

e is

sue

of r

estr

ain

t.

144

Aze

em, M

; et

al

2011

Un

ited

Sta

tes

458

you

th

(fem

ales

276

/m

ales

182

)

To d

eter

min

e th

e ef

fect

iven

ess

of s

ix

core

str

ateg

ies

bas

ed

on t

rau

ma-

info

rmed

ca

re in

red

uci

ng

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t w

ith

hos

pita

lised

you

th

bet

wee

n J

uly

200

4 an

d M

arch

200

7.

Qu

antit

ativ

e –

anal

ysis

of

case

re

por

t d

ata

and

dem

ogra

ph

ics,

in

clu

din

g

age,

gen

der

, et

hn

icity

, n

um

ber

of

adm

issi

ons,

ty

pe

of

adm

issi

ons,

le

ng

th o

f st

ay,

psy

chia

tric

d

iag

nos

is,

nu

mb

er o

f se

clu

sion

s, a

nd

rest

rain

ts

Sev

enty

-nin

e p

atie

nts

or

17.2

% (

fem

ales

44/

mal

es 3

5)

‘req

uir

ed’

278

secl

usi

ons/

rest

rain

ts (

159

secl

usi

ons/

119

rest

rain

ts),

with

ave

rag

e n

um

ber

of

epis

odes

3.5

/pat

ien

t (r

ang

e 1–

28).

Th

irty

-sev

en c

hild

ren

an

d a

dol

esce

nts

p

lace

d in

sec

lusi

on a

nd

/or

rest

rain

ts h

ad t

hre

e or

mor

e ep

isod

es. I

n t

he

first

six

mon

ths

of s

tud

y, t

he

nu

mb

er o

f se

clu

sion

s/re

stra

ints

ep

isod

es w

ere

93 (

73 s

eclu

sion

s/20

re

stra

ints

), in

volv

ing

22

child

ren

an

d a

dol

esce

nts

(f

emal

es 1

1/m

ales

11)

. Com

par

ativ

ely,

in t

he

final

six

m

onth

s of

th

e st

ud

y fo

llow

ing

th

e tr

ain

ing

pro

gra

m,

ther

e w

ere

31 e

pis

odes

(6

secl

usi

ons/

25 r

estr

ain

ts)

invo

lvin

g 1

1 ch

ildre

n a

nd

ad

oles

cen

ts (

7 fe

mal

es/4

m

ales

). T

he

maj

or d

iag

nos

es o

f th

e yo

uth

pla

ced

in

secl

usi

on a

nd

/or

rest

rain

t w

ere

dis

rup

tive

beh

avio

ur

dis

ord

ers

(61%

) an

d m

ood

dis

ord

ers

(52%

). T

his

stu

dy

show

s a

dow

nw

ard

tre

nd

in s

eclu

sion

s/re

stra

ints

am

ong

h

osp

italis

ed y

outh

aft

er im

ple

men

tatio

n o

f N

atio

nal

A

ssoc

iatio

n o

f S

tate

Men

tal H

ealth

Pro

gra

m D

irec

tors

’ S

ix C

ore

Str

ateg

ies

bas

ed o

n t

rau

ma-

info

rmed

car

e.

Bak

, J; Z

offm

ann

, V

; Ses

toft

, DM

; A

lmvi

k, R

; Bra

nd

t-C

hri

sten

sen

, M

2014

Den

mar

k,

Nor

way

Su

rvey

dat

a fr

om

all p

sy-c

hia

tric

h

os-p

ital u

nits

in

Den

mar

k (8

7)

and

Nor

way

(96

) th

at t

reat

ed a

du

lt in

pat

ien

ts.

To e

xam

ine

how

p

oten

tial m

ech

anic

al

rest

rain

t p

reve

ntiv

e fa

ctor

s in

hos

pita

ls

are

asso

ciat

ed w

ith

the

freq

uen

cy o

f m

ech

anic

al r

estr

ain

t ep

isod

es.

Qu

antit

ativ

e -

cros

s-se

ctio

nal

su

rvey

of

psy

chia

tric

u

nits

.

Thre

e m

ech

anic

al r

estr

ain

t p

reve

ntiv

e fa

ctor

s w

ere

sig

nifi

can

tly a

ssoc

iate

d w

ith lo

w r

ates

of

mec

han

ical

re

stra

int

use

: ‘m

and

ator

y re

view

’ (e

xp[B

]=.3

6, p

<

.01)

, ‘p

atie

nt

invo

lvem

ent’

(ex

p[B

]=.4

2, p

< .0

1), a

nd

‘no

crow

din

g’

(exp

[B]=

.54,

p <

.01)

. Non

e of

th

e th

ree

rest

rain

t p

reve

ntiv

e fa

ctor

s p

rese

nte

d a

ny

adve

rse

effe

cts.

Au

thor

s re

com

men

d im

ple

men

ting

th

e m

easu

res.

Bak

, J; Z

offm

ann

, V

; Ses

toft

, D

M; A

lmvi

k,

R; S

iers

ma,

V

D; B

ran

dt-

Ch

rist

ense

n, M

2015

Den

mar

k,

Nor

way

Su

rvey

dat

a fr

om

all p

sych

iatr

ic

hos

pita

l un

its in

D

enm

ark

(87)

an

d N

orw

ay (

96)

that

tre

ated

ad

ult

inp

atie

nts

.

To t

est

the

hyp

oth

esis

th

at ‘

fact

ors

of n

on-

med

ical

ori

gin

’ m

ay

exp

lain

th

e d

iffer

ing

n

um

ber

of

mec

han

ical

re

stra

int

(MR

) ep

i-so

des

bet

wee

n D

en-

mar

k an

d N

orw

ay. A

n ea

rlie

r st

ud

y fo

un

d M

R w

as u

sed

tw

ice

as

freq

uen

tly in

Den

mar

k th

an N

orw

ay.

Qu

antit

ativ

e –

cros

s-se

ctio

nal

su

rvey

of

psy

chia

tric

u

nits

.

Six

MR

pre

ven

tive

fact

ors

con

fou

nd

ed [

∆ex

p(B

)>

10%

] th

e d

iffer

ence

in M

R u

se b

etw

een

Den

mar

k an

d N

orw

ay, i

ncl

ud

ing

sta

ff e

du

catio

n (

- 51

%),

su

bst

itute

st

aff

(- 1

7%),

acc

epta

ble

wor

k en

viro

nm

ent

(- 1

5%),

se

par

atio

n o

f ac

ute

ly d

istu

rbed

pat

ien

ts (

13%

), p

atie

nt-

staf

f ra

tio (

- 11

%),

an

d t

he

iden

tifica

tion

of

the

pat

ien

t’s

cris

is t

rig

ger

s (-

10%

). R

esea

rch

ers

sug

ges

t th

ese

pre

ven

tive

fact

ors

mig

ht

par

tially

exp

lain

th

e d

iffer

ence

in

th

e fr

equ

ency

of

MR

ep

isod

es o

bse

rved

in t

he

two

cou

ntr

ies.

Non

e of

th

e si

x M

R p

reve

ntiv

e fa

ctor

s p

rese

nts

an

y ad

vers

e ef

fect

s.

145

Bar

iffi, F

J; S

mith

, M

S20

13A

rgen

tina

N/A

To a

nal

yse

leg

al

and

pol

icy

mat

eria

ls

con

cern

ing

Arg

entin

a’s

Nat

iona

l Men

tal H

ealth

La

w (

NM

HL)

, an

d d

eter

min

e w

het

her

its

‘su

pp

orte

d d

ecis

ion

-m

akin

g’

mea

sure

s m

ay

imp

rove

com

plia

nce

w

ith t

he

Con

vent

ion

on

the

Rig

hts

of P

erso

ns

with

Dis

abili

ties

(CR

PD

) an

d r

edu

ce in

volu

nta

ry

inte

rven

tion

s.

Qu

alita

tive

- an

alys

is o

f ca

se la

w, p

olic

y d

ocu

men

ts

and

res

earc

h re

por

ts.

The

NM

HL

esta

blis

hes

th

resh

old

s fo

r d

epri

vin

g p

erso

ns

with

dis

abili

ties

of t

hei

r lib

erty

an

d f

or r

estr

ictin

g t

hei

r ex

erci

se o

f le

gal

cap

acity

th

at a

re in

con

sist

ent

with

th

e C

RP

D. H

owev

er, d

esp

ite t

he

NM

HL’

s si

gn

ifica

nt

shor

tcom

ing

s, it

has

th

e p

oten

tial t

o co

ntr

ibu

te b

oth

to in

crea

sed

au

ton

omy

for

use

rs o

f th

e m

enta

l hea

lth

syst

em a

nd

als

o to

less

res

tric

tive

leg

al c

apac

ity

rest

rict

ion

s. T

he

auth

ors

con

clu

de

that

wh

ile t

he

NM

HL

is in

con

sist

ent

with

th

e C

RP

D, i

t m

ay s

till h

elp

pro

mot

e a

shift

aw

ay f

rom

invo

lun

tary

com

mitm

ents

an

d le

gal

ca

pac

ity r

estr

ictio

ns

if its

imp

lem

enta

tion

res

ults

in t

he

dis

sem

inat

ion

of

‘bet

ter’

pra

ctic

es t

hat

hav

e em

erg

ed

thu

s fa

r.

Bar

rett

, B;

Wah

eed

, W;

Farr

elly

, S;

Bir

chw

ood

, M;

Du

nn

, G; F

lach

, C

; Hen

der

son

, C;

Lees

e, M

; Hel

en

L; M

arsh

all,

M;

Ros

e, D

; Kim

S

; Szm

ukl

er, G

; Th

orn

icro

ft, G

; B

yfor

d, S

2013

En

gla

nd

569

par

ticip

ants

w

ere

chos

en

from

fou

r E

ng

lish

men

tal h

ealth

tr

ust

s.

To t

est

the

effe

ctiv

enes

s of

‘Jo

int

Cri

sis

Pla

ns’

(JC

P),

a

form

of

(non

-sta

tuto

ry)

adva

nce

pla

nn

ing

, in

red

uci

ng

rat

es o

f co

mp

uls

ory

trea

tmen

t.

They

com

par

ed J

CP

p

lus

trea

tmen

t as

usu

al

(TA

U)

to T

AU

alo

ne

for

pat

ien

ts a

ged

ove

r 16

, with

at

leas

t on

e p

sych

iatr

ic h

osp

ital

adm

issi

on in

th

e p

revi

ous

two

year

s.

Qu

antit

ativ

e –

econ

omic

ev

alu

atio

n w

ithin

a

mu

lti-c

entr

e ra

nd

omis

ed

con

trol

tri

al.

The

add

ition

of

JCP

s to

TA

U h

ad n

o si

gn

ifica

nt

effe

ct

on c

omp

uls

ory

adm

issi

ons

or t

otal

soc

ieta

l cos

t p

er

par

ticip

ant

over

18-

mon

ths

follo

w-u

p. F

rom

th

e se

rvic

e co

st p

ersp

ectiv

e, h

owev

er, e

vid

ence

su

gg

ests

a h

igh

er

pro

bab

ility

(80

%)

of J

CP

s b

ein

g t

he

mor

e co

st-e

ffec

tive

optio

n. E

xplo

ratio

n b

y et

hn

ic g

rou

p h

igh

ligh

ts d

istin

ct

pat

tern

s of

cos

ts a

nd

eff

ects

. Wh

ilst

the

evid

ence

doe

s n

ot s

up

por

t th

e co

st-e

ffec

tiven

ess

of J

CP

s fo

r W

hite

or

Asi

an e

thn

ic g

rou

ps,

th

ere

is a

t le

ast

a 90

% p

rob

abili

ty

of t

he

JCP

inte

rven

tion

bei

ng

th

e m

ore

cost

-eff

ectiv

e op

tion

in t

he

Bla

ck e

thn

ic g

rou

p. T

he

rese

arch

ers

arg

ue

that

th

e re

sults

by

eth

nic

gro

up

are

su

ffici

ently

str

ikin

g

to w

arra

nt

furt

her

inve

stig

atio

n in

to t

he

pot

entia

l for

p

atie

nt

gai

n f

rom

JC

Ps

amon

g B

lack

pat

ien

t g

rou

ps.

146

Bor

ckar

dt,

J; e

t al

2011

Un

ited

Sta

tes

Part

icip

ants

wer

e p

atie

nts

an

d s

taff

in

an

inp

atie

nt

psy

chia

tric

h

osp

ital,

for

a to

tal o

f 89

,783

p

atie

nt-

day

s ov

er

a 3.

5-ye

ar p

erio

d fr

om J

anu

ary

200

5 th

rou

gh

Jun

e 20

08.

To u

se a

n e

xper

imen

tal

des

ign

to

exam

ine

the

effe

ct o

f sy

stem

atic

im

ple

men

tatio

n of

beh

avio

ura

l in

terv

entio

ns

on t

he

rate

of

secl

usi

on a

nd

rest

rain

t in

an

inp

atie

nt

psy

chia

tric

hos

pita

l.

Qu

antit

ativ

e –

a va

rian

t of

th

e m

ulti

ple

b

asel

ine

des

ign

. E

ach

of

five

inp

atie

nt

un

its

was

ran

dom

ly

assi

gn

ed t

o im

ple

men

t th

e in

terv

entio

n co

mp

onen

ts in

a

diff

eren

t or

der

, an

d e

ach

un

it se

rved

as

its

own

con

trol

.

A s

ign

ifica

nt

red

uct

ion

of

82.3

% (

p=

.008

) in

th

e ra

te

of s

eclu

sion

an

d r

estr

ain

t w

as o

bse

rved

bet

wee

n t

he

bas

elin

e p

has

e (J

anu

ary

200

5 th

rou

gh

Feb

ruar

y 20

06)

and

th

e fo

llow

-up

, pos

tinte

rven

tion

ph

ase

(Ap

ril 2

008

thro

ug

h J

un

e 20

08).

Aft

er c

ontr

ol f

or il

lnes

s se

veri

ty

and

non

spec

ific

effe

cts

asso

ciat

ed w

ith a

n o

bse

rvat

ion

-on

ly p

has

e, c

han

ges

to

the

ph

ysic

al e

nvi

ron

men

t w

ere

un

iqu

ely

asso

ciat

ed w

ith a

sig

nifi

can

t re

du

ctio

n in

rat

e of

sec

lusi

on a

nd

res

trai

nt

du

rin

g t

he

inte

rven

tion

rol

lou

t p

erio

d. T

hes

e d

ata

sug

ges

t th

at s

ub

stan

tial r

edu

ctio

ns

in u

se o

f se

clu

sion

an

d r

estr

ain

t ar

e p

ossi

ble

in in

pat

ien

t p

sych

iatr

ic s

ettin

gs

and

th

at c

han

ges

to

the

ph

ysic

al

char

acte

rist

ics

of t

he

ther

apeu

tic e

nvi

ron

men

t m

ay h

ave

a si

gn

ifica

nt

effe

ct o

n t

he

use

of

secl

usi

on a

nd

res

trai

nt.

Bou

man

s,

CE

; Wal

voor

t,

SJ;

Eg

ger

, JI;

Hu

tsch

emae

kers

, G

J

2015

Net

her

lan

ds

4 d

etai

led

cas

e ex

amp

les,

in

volv

ing

4

adu

lts in

th

e S

outh

Eas

t of

th

e N

eth

erla

nd

s.

To e

xam

ine

how

th

e ‘m

eth

odic

al w

ork

app

roac

h’

wor

ked

to

red

uce

sec

lusi

on, b

y p

rovi

din

g a

det

aile

d ca

se s

tud

y. T

he

stu

dy

com

ple

men

ted

a

qu

antit

ativ

e st

ud

y on

th

e ap

pro

ach

(see

bel

ow),

wh

ich

rep

orte

dly

led

to

a re

du

ctio

n in

th

e u

se

of s

eclu

sion

in a

war

d w

ith a

hig

h s

eclu

sion

ra

te.

Cas

e S

tud

y -

the

team

of

th

is w

ard

imp

lem

ente

d th

e m

eth

odic

al

wor

k ap

pro

ach

.

The

‘met

hod

ical

wor

k ap

pro

ach

’, w

hic

h h

as b

een

adop

ted

larg

ely

in D

utc

h a

nd

Fle

mis

h s

ettin

gs,

ap

pea

rs

to h

ave

pro

vid

ed g

uid

ance

for

th

e m

ulti

dis

cip

linar

y te

am, t

he

pat

ien

t an

d t

he

fam

ily t

o w

ork

tog

eth

er in

a

syst

emat

ic a

nd

goa

l-d

irec

ted

way

to

red

uce

sec

lusi

on.

Posi

tive

chan

ges

wer

e re

por

ted

in t

he

team

pro

cess

: in

crea

sed

inte

rdis

cip

linar

y co

llab

orat

ion

, tea

m c

ohes

ion

, an

d ‘

pro

fess

ion

aliz

atio

n’. I

t is

arg

ued

th

at t

he

imp

licit

or n

on-s

pec

ific

effe

cts

of a

n in

terv

entio

n t

o p

reve

nt

secl

usi

on m

ay c

onst

itute

a m

ajor

con

trib

utio

n t

o th

e re

sults

an

d t

her

efor

e m

erit

furt

her

res

earc

h. T

his

stu

dy

follo

ws

from

a s

tud

y to

tes

t w

het

her

red

uct

ion

s in

rat

es

of s

eclu

sion

occ

ur

(see

bel

ow).

147

Bou

man

s,

CE

; Wal

voor

t,

SJ;

Eg

ger

, JI;

Sou

rren

, P;

Hu

tsch

emae

kers

, G

J

2014

Net

her

lan

ds

134

adu

lts

adm

itted

to

an

exp

erim

enta

l w

ard

an

d 5

44

adu

lts in

con

trol

w

ard

s fo

r th

e in

ten

sive

tr

eatm

ent

of

adu

lts w

ith

psy

chos

is a

nd

sub

stan

ce u

se

dis

ord

ers

in t

he

Sou

th-E

ast

of t

he

Net

her

lan

ds.

To t

est

effe

ctiv

enes

s of

an

inte

rven

tion

, th

e ‘m

eth

odic

al w

ork

app

roac

h’,

des

ign

ed

to r

edu

ce s

eclu

sion

. Th

is is

a ‘

syst

emat

ic,

tran

spar

ent

and

goa

l-d

irec

ted

way

’ of

w

orki

ng

, ch

arac

teri

sed

by

‘an

em

ph

asis

on

cycl

ic e

valu

atio

n a

nd

read

just

men

t of

th

e w

orki

ng

pro

cess

’.

Qu

antit

ativ

e –

anal

ysis

of

case

rep

ort

dat

a (b

efor

e an

d a

fter

in

trod

uct

ion

of

the

met

hod

ical

w

ork

app

roac

h).

The

met

hod

ical

wor

k ap

pro

ach

has

five

ph

ases

: (i)

tran

slat

ion

of

pro

ble

ms

into

goa

ls; (

ii) s

earc

h f

or m

ean

s to

rea

lise

the

goa

ls; (

iii)

form

ula

tion

of

an in

div

idu

alis

ed

pla

n; (

iv)

imp

lem

enta

tion

of

the

pla

n; a

nd

(v)

eva

luat

ion

and

rea

dju

stm

ent.

Com

par

ed t

o co

ntr

ol w

ard

s w

ithin

th

e sa

me

hos

pita

l, at

th

e w

ard

wh

ere

the

met

hod

ical

w

ork

app

roac

h w

as im

ple

men

ted

, a m

ore

pro

nou

nce

d re

du

ctio

n w

as a

chie

ved

in t

he

nu

mb

er o

f in

cid

ents

an

d in

th

e to

tal h

ours

of

secl

usi

on. T

he

auth

ors

con

clu

de

that

th

e m

eth

odic

al w

ork

app

roac

h c

an c

ontr

ibu

te t

o a

red

uct

ion

in t

he

use

of

secl

usi

on.

Bow

ers,

L;

Hag

lun

d, K

; M

uir-

Coc

hra

ne,

E

; Nijm

an, H

; S

imp

son

, A; V

an

Der

Mer

we,

M

2010

En

gla

nd

A t

otal

of

1227

re

spon

ses

wer

e ob

tain

ed, w

ith

the

hig

hes

t n

um

ber

com

ing

fr

om s

taff

, an

d th

e sm

alle

st f

rom

vi

sito

rs.

To s

urv

ey t

he

bel

iefs

an

d a

ttitu

des

of

pat

ien

ts, s

taff

an

d vi

sito

rs t

o th

e p

ract

ice

of d

oor

lock

ing

in a

cute

p

sych

iatr

y. L

ocki

ng

d

oors

in p

sych

iatr

ic

war

ds

has

incr

ease

d in

th

e U

K in

rec

ent

year

s, b

ut

has

rec

eive

d lit

tle a

tten

tion

by

rese

arch

ers.

Qu

antit

ativ

e –

cros

s-se

ctio

nal

q

ues

tion

nai

re

of s

taff

, pat

ien

ts

and

vis

itors

at

psy

chia

tric

u

nits

.

An

alys

is id

entifi

ed fi

ve f

acto

rs (

adve

rse

effe

cts,

sta

ff

ben

efits

, pat

ien

t sa

fety

ben

efits

, pat

ien

t co

mfo

rts

and

cold

mili

eu).

Pat

ien

ts w

ere

mor

e n

egat

ive

abou

t d

oor

lock

ing

th

an t

he

staf

f, an

d m

ore

likel

y to

exp

ress

su

ch

neg

ativ

e ju

dg

men

ts if

th

ey w

ere

resi

din

g in

a lo

cked

w

ard

. For

sta

ff, b

ein

g o

n a

lock

ed w

ard

was

ass

ocia

ted

with

mor

e p

ositi

ve ju

dg

men

ts a

bou

t th

e p

ract

ice.

Th

ere

wer

e si

gn

ifica

nt

age,

gen

der

an

d e

thn

icity

eff

ects

for

st

aff

only

. Pat

ien

ts r

egis

tere

d m

ore

ang

er, i

rrita

tion

an

d d

epre

ssio

n a

s a

con

seq

uen

ce o

f lo

cked

doo

rs t

han

sta

ff

or v

isito

rs t

hou

gh

t th

ey e

xper

ien

ced

.

148

Bow

ers,

L;

Ste

war

t, D

; Pa

pad

opou

los,

C;

Ien

nac

o, J

D

2013

En

gla

nd

Sec

ond

ary

anal

ysis

of

cros

s-se

ctio

nal

d

ata

colle

cted

fr

om 1

36 a

cute

p

sych

iatr

ic w

ard

s ac

ross

En

gla

nd

in 2

004-

200

5.

This

stu

dy

inve

stig

ated

w

ard

s w

ith t

he

cou

nte

rin

tuiti

ve

com

bin

atio

n o

f ‘lo

w

con

tain

men

t an

d h

igh

con

flict

’ or

‘h

igh

con

tain

men

t an

d lo

w

con

flict

’.

Qu

antit

ativ

e –

seco

nd

ary

anal

ysis

of

cros

s-se

ctio

nal

se

rvic

e d

ata

colle

cted

fro

m

136

psy

chia

tric

w

ard

s.

Saf

e, c

alm

inp

atie

nt

psy

chia

tric

war

ds

that

are

con

du

cive

to

pos

itive

th

erap

eutic

car

e h

ave

thou

gh

t to

hav

e lo

wer

ra

tes

of c

oerc

ed m

edic

atio

n, s

eclu

sion

, man

ual

res

trai

nt

and

oth

er t

ypes

of

con

tain

men

t, a

nd

, usu

ally

, rat

es

of c

onfli

ct -

for

exa

mp

le, a

gg

ress

ion

, su

bst

ance

use

, an

d a

bsc

ond

ing

- a

re a

lso

low

. Som

etim

es, h

owev

er,

war

ds

mai

nta

in lo

w r

ates

of

con

tain

men

t ev

en w

hen

co

nfli

ct r

ates

are

hig

h. T

his

stu

dy

wan

ted

to

un

der

stan

d th

ese

anom

alie

s. T

he

rese

arch

ers

crea

ted

a t

ypol

ogy

of d

iffer

ent

war

d c

har

acte

rist

ics

(e.g

. hig

h/lo

w c

onfli

ct,

hig

h/lo

w c

onta

inm

ent,

soc

io-e

con

omic

dis

adva

nta

ge

in t

he

area

). A

mon

g t

he

vari

able

s si

gn

ifica

ntly

as

soci

ated

with

th

e va

riou

s ty

pol

ogie

s, s

ome,

su

ch a

s en

viro

nm

enta

l qu

ality

, wer

e ch

ang

eab

le, a

nd

oth

ers

- su

ch a

s so

cial

dep

riva

tion

of

the

area

ser

ved

- w

ere

fixed

. Hig

h-c

onfli

ct, l

ow-c

onta

inm

ent

war

ds

had

hig

her

ra

tes

of m

ale

staf

f an

d lo

wer

-qu

ality

en

viro

nm

ents

th

an

oth

er w

ard

s. L

ow-c

onfli

ct, h

igh

-con

tain

men

t w

ard

s h

ad

hig

her

nu

mb

ers

of b

eds.

Hig

h-c

onfli

ct, h

igh

-con

tain

men

t w

ard

s u

tilis

ed m

ore

tem

por

ary

staf

f as

wel

l as

mor

e u

nq

ual

ified

sta

ff. N

o ov

eral

l diff

eren

ces

wer

e as

soci

ated

w

ith lo

w-c

onfli

ct, l

ow-c

onta

inm

ent

war

ds.

War

ds

can

mak

e p

ositi

ve c

han

ges

to

ach

ieve

a lo

w-c

onta

inm

ent,

n

onp

un

itive

cu

lture

, eve

n w

hen

rat

es o

f p

atie

nt

con

flict

ar

e h

igh.

Bow

ers,

L; e

t al

2015

En

gla

nd

Sta

ff a

nd

pat

ien

ts

in 3

1 ra

nd

omly

ch

osen

war

ds

at 1

5 ra

nd

omly

ch

osen

hos

pita

ls.

To t

est

the

effic

acy

of

the

Saf

ewar

ds

mod

el in

re

du

cin

g t

he

freq

uen

cy

of ‘

con

flict

’ an

d ‘c

onta

inm

ent’

.

A p

rag

mat

ic

clu

ster

ran

-d

omis

ed

con

trol

led

tri

al

with

psy

chia

tric

h

osp

itals

an

d w

ard

s as

th

e u

nits

of

ran

dom

isat

ion

. Th

e m

ain

outc

omes

w

ere

rate

s of

co

nfli

ct a

nd

con

tain

men

t.

The

Saf

ewar

ds

mod

el e

nab

led

th

e id

entifi

catio

n o

f te

n in

terv

entio

ns

to r

edu

ce t

he

freq

uen

cy o

f b

oth

. For

sh

ifts

with

con

flict

or

con

tain

men

t in

cid

ents

, th

e ex

per

imen

tal

con

diti

on r

edu

ced

th

e ra

te o

f co

nfli

ct e

ven

ts b

y 15

%

(95%

CI 5

.6–2

3.7%

) re

lativ

e to

th

e co

ntr

ol in

terv

entio

n.

The

rate

of

con

tain

men

t ev

ents

for

th

e ex

per

imen

tal

inte

rven

tion

was

red

uce

d b

y 26

.4%

(95

% C

I 9.9

–34.

3%).

Sim

ple

inte

rven

tion

s ai

min

g t

o im

pro

ve s

taff

re

latio

nsh

ips

with

pat

ien

ts c

an r

edu

ce t

he

freq

uen

cy o

f co

nfli

ct a

nd

con

tain

men

t.

149

Bru

ckn

er, T

A;

Yoon

, J; B

row

n,

TT; A

dam

s, N

2010

Un

ited

Sta

tes

Qu

arte

rly

cou

nts

of

invo

lun

tary

72

-hou

r h

old

s (N

=59

3,75

1)

and

14-

day

p

sych

iatr

ic

hos

pita

l-is

atio

ns

(N=

202,

554)

for

28

Cal

iforn

ian

cou

ntie

s, w

ith

over

22

mill

ion

inh

abita

nts

, fro

m

2000

-07.

To t

est

the

hyp

oth

esis

th

at t

he

inci

den

ce

of t

wo

typ

es o

f in

volu

nta

ry t

reat

men

t,

72-h

our

hol

ds

and

14-d

ay p

sych

iatr

ic

civi

l com

mitm

ents

, d

eclin

es a

s th

e se

rvic

e ac

cess

an

d q

ual

ity is

im

pro

ved

by

the

$3.2

b

illio

n t

ax r

even

ue

inve

stm

ent

asso

ciat

ed

with

th

e M

enta

l Hea

lth

Ser

vice

s A

ct (

MH

SA

) in

C

alifo

rnia

.

Qu

antit

ativ

e -

anal

ysis

of

case

rep

ort

dat

a (b

efor

e an

d a

fter

in

trod

uct

ion

of t

he

Act

). A

fix

ed-e

ffec

ts

reg

ress

ion

app

roac

h ad

just

ed f

or

tem

por

al

pat

tern

s in

tr

eatm

ent.

The

pet

ition

s fo

r in

volu

nta

ry 1

4-d

ay h

osp

italis

atio

ns,

b

ut

not

invo

lun

tary

72-

hou

r h

old

s, f

ell b

elow

exp

ecte

d va

lues

aft

er d

isb

urs

emen

t of

MH

SA

fu

nd

s. In

th

ese

cou

ntie

s, 3

,073

few

er in

volu

nta

ry 1

4-d

ay t

reat

men

ts-

-ap

pro

xim

atel

y 10

% b

elow

exp

ecte

d le

vels

--co

uld

be

attr

ibu

ted

to

dis

bu

rsem

ent

of M

HS

A f

un

ds.

Res

ults

re

mai

ned

rob

ust

to

alte

rnat

ive

reg

ress

ion

sp

ecifi

catio

ns.

Th

e re

sear

cher

s co

ncl

ud

e th

at f

ewer

th

an e

xpec

ted

invo

lun

tary

14-

day

hol

ds

for

con

tinu

ed h

osp

italis

atio

n m

ay in

dic

ate

an im

por

tan

t sh

ift in

ser

vice

del

iver

y.

MH

SA

fu

nd

s m

ay h

ave

faci

litat

ed t

he

dis

char

ge

of

clie

nts

fro

m t

he

hos

pita

l by

pro

vid

ing

en

han

ced

reso

urc

es a

nd

acc

ess

to a

ran

ge

of le

ss-r

estr

ictiv

e co

mm

un

ity-b

ased

tre

atm

ent

alte

rnat

ives

.

Ch

alm

ers,

A;

Har

riso

n, S

; M

ollis

on, K

; M

ollo

y, N

; Gra

y, K

2012

Au

stra

lia

Cas

e st

ud

y:

imp

lem

enta

tion

of p

ract

ice

in a

29

-bed

acu

te

adu

lt p

sych

iatr

ic

inp

atie

nt

un

it in

Vic

tori

a,

Au

stra

lia.

To r

eflec

t u

pon

th

e im

ple

men

tatio

n of

sen

sory

-bas

ed

app

roac

hes

with

in

the

envi

ron

men

t of

a p

sych

iatr

ic

inp

atie

nt

un

it. A

va

riet

y of

sen

sory

-b

ased

pri

nci

ple

s w

ere

pla

nn

ed, d

evel

oped

an

d im

ple

men

ted

ove

r a

3-ye

ar p

erio

d.

Cas

e S

tud

y –

An

alys

is o

f ca

se r

epor

t d

ata

and

des

crip

tive

stat

istic

s.

Pre

limin

ary

dat

a re

gar

din

g s

enso

ry r

oom

use

an

d ac

ute

aro

usa

l rat

ing

s w

ithin

th

e h

igh

-dep

end

ency

are

a w

ere

anal

ysed

. It

show

ed a

sig

nifi

can

t re

du

ctio

n in

p

atie

nt

dis

tres

s le

vels

, as

per

con

sum

er a

nd

clin

icia

n ra

ting

s. T

he

maj

ority

of

sen

sory

roo

m s

essi

ons

wer

e co

nd

uct

ed b

y n

urs

ing

sta

ff. A

sig

nifi

can

t re

du

ctio

n w

as

also

fou

nd

for

‘acu

te a

rou

sal r

atin

gs’

, ‘p

re t

o p

ost’

, for

th

e ‘H

DU

en

gag

emen

t p

rog

ram

’. S

ever

al is

sues

wer

e u

nco

vere

d t

hro

ug

hou

t im

ple

men

tatio

n o

f th

e se

nso

ry-

bas

ed s

trat

egie

s. F

ind

ing

s in

dic

ate

the

imp

orta

nce

of

cultu

ral c

han

ge,

com

par

ed w

ith s

imp

ly a

n e

nvi

ron

men

tal

chan

ge,

giv

ing

all

staf

f an

d c

onsu

mer

s th

e co

nfid

ence

to

util

ise

a va

riet

y of

sen

sory

-bas

ed m

eth

ods

du

rin

g

times

of

nee

d. F

urt

her

Au

stra

lian

res

earc

h is

req

uir

ed

to e

xplo

re t

he

pos

itive

con

trib

utio

n s

enso

ry m

odu

latio

n ca

n p

oten

tially

mak

e ac

ross

th

e sp

ectr

um

of

psy

chia

tric

se

ttin

gs.

150

Ch

amb

ers,

M;

Gal

lag

her

, A;

Bor

sch

man

n, R

; G

illar

d, S

; Tu

rner

, K

; Kan

tari

s, X

2014

En

gla

nd

19 a

du

lt se

rvic

e u

sers

det

ain

ed

un

der

men

tal

hea

lth le

gis

latio

n.

This

pap

er r

epor

ts

on t

he

exp

erie

nce

s of

19

adu

lts d

etai

ned

u

nd

er m

enta

l hea

lth

leg

isla

tion

. Th

ese

serv

ice

use

rs h

ad

exp

erie

nce

d c

oerc

ive

inte

rven

tion

s an

d t

hey

g

ave

thei

r ac

cou

nt

of

how

th

ey c

onsi

der

ed

thei

r d

ign

ity t

o b

e p

rote

cted

(or

not

),

and

th

eir

sen

se o

f se

lf b

ein

g r

esp

ecte

d (

or

not

).

Qu

alita

tive

– in

-d

epth

inte

rvie

ws

with

th

emat

ic

anal

ysis

.

The

serv

ice

use

rs c

onsi

der

ed t

hei

r d

ign

ity a

nd

res

pec

t co

mp

rom

ised

by

1) n

ot b

ein

g ‘

hea

rd’

by

staf

f m

emb

ers,

2)

a la

ck o

f in

volv

emen

t in

dec

isio

n-m

akin

g r

egar

din

g

thei

r ca

re, 3

) a

lack

of

info

rmat

ion

ab

out

thei

r tr

eatm

ent

pla

ns

par

ticu

larl

y m

edic

atio

n, 4

) la

ck o

f ac

cess

to

mor

e ta

lkin

g t

her

apie

s an

d t

her

apeu

tic e

ng

agem

ent,

an

d 5)

th

e p

hys

ical

set

ting

/en

viro

nm

ent

and

lack

of

dai

ly

activ

ities

to

alle

viat

e th

eir

bor

edom

. Dig

nity

an

d r

esp

ect

are

imp

orta

nt

valu

es in

rec

over

y an

d p

ract

ition

ers

nee

d tim

e to

en

gag

e w

ith s

ervi

ce u

ser

nar

rativ

es a

nd

to

refle

ct

on t

he

eth

ics

of t

hei

r p

ract

ice.

Res

pec

ting

th

e d

ign

ity o

f ot

her

s is

a k

ey e

lem

ent

of t

he

cod

e of

con

du

ct f

or h

ealth

p

rofe

ssio

nal

s. O

ften

fro

m t

he

serv

ice

use

r p

ersp

ectiv

e th

is is

ign

ored

.

Cor

lett

, S20

13E

ng

lan

dN

/A

This

pap

er a

ims

to

revi

ew r

ecen

t tr

end

s in

det

entio

n u

nd

er t

he

Men

tal H

ealth

Act

198

3 in

En

gla

nd

an

d t

he

rela

tion

ship

to

tren

ds

in a

cces

s to

men

tal

hea

lth s

ervi

ces.

Qu

alita

tive

– p

olic

y re

sear

ch

revi

ew b

ased

on

Car

e Q

ual

ity

Com

mis

sion

, w

hic

h m

onito

rs

the

Men

tal

Hea

lth A

ct a

nd

reg

ula

tes

hea

lth

and

soc

ial c

are.

The

pap

er s

ug

ges

ts t

hat

a s

tead

y in

crea

se in

coe

rcio

n is

rel

ated

to

tigh

ten

ing

acc

ess

to m

enta

l hea

lth

care

an

d t

hat

th

ese

form

a t

oxic

rel

atio

nsh

ip t

hat

u

nd

erm

ines

peo

ple

’s m

enta

l hea

lth, r

ecov

ery

and

rig

hts

. Th

ese

tren

ds

mig

ht

be

reve

rsed

by

a co

mb

inat

ion

of

rig

hts

-bas

ed m

easu

res,

sh

ared

dec

isio

n-m

akin

g a

nd

com

mis

sion

ing

a b

ette

r le

vel a

nd

mix

of

men

tal h

ealth

se

rvic

es. T

he

pap

er u

pd

ates

an

d d

iscu

sses

kn

owle

dg

e on

tre

nd

s an

d c

ites

rece

nt

evid

ence

fro

m t

he

Car

e Q

ual

ity C

omm

issi

on a

nd

fro

m M

ind

.

151

Cro

ft, B

; Isv

an, N

2015

Un

ited

Sta

tes

278

adu

lt se

rvic

e u

sers

. Th

is

anal

ysis

use

d p

rop

ensi

ty s

core

m

atch

ing

to

crea

te m

atch

ed

pai

rs o

f 13

9 u

sers

of

pee

r re

spite

an

d 13

9 n

on-u

sers

of

res

pite

with

si

mila

r h

isto

ries

of

beh

avio

ura

l h

ealth

ser

vice

u

se a

nd

clin

ical

an

d d

emog

rap

hic

ch

arac

teri

stic

s.

This

stu

dy

exam

ined

th

e re

latio

nsh

ip

bet

wee

n p

eer

resp

ite

and

use

of

inp

atie

nt

and

em

erg

ency

se

rvic

es a

mon

g a

du

lts

rece

ivin

g p

ub

licly

fu

nd

ed b

ehav

iou

ral

hea

lth s

ervi

ces.

By

pro

vid

ing

a s

afe

and

su

pp

ortiv

e sp

ace

for

ind

ivid

ual

s ex

per

ien

cin

g o

r at

ri

sk o

f ex

per

ien

cin

g a

m

enta

l hea

lth c

risi

s,

a p

eer

resp

ite m

ay

red

uce

th

e n

eed

for

trad

ition

al c

risi

s in

terv

entio

ns.

Qu

antit

ativ

e -

anal

ysis

of

case

re

por

t d

ata.

A

tw

o-st

age

reg

ress

ion

mod

el fi

rst

pre

dic

ted

th

e lik

elih

ood

of

inp

atie

nt

or

emer

gen

cy

serv

ice

use

af

ter

the

pee

r re

spite

sta

rt

dat

e an

d t

hen

p

red

icte

d h

ours

of

inp

atie

nt

and

em

erg

ency

se

rvic

e u

se

amon

g 8

9 in

div

idu

als

wh

o u

sed

an

y in

pat

ien

t or

em

erg

ency

se

rvic

es.

Aft

er t

he

auth

ors

con

trol

led

for

rel

evan

t co

vari

ates

, th

e od

ds

of u

sin

g a

ny

inp

atie

nt

or e

mer

gen

cy s

ervi

ces

afte

r th

e p

rog

ram

me

star

t d

ate

wer

e ap

pro

xim

atel

y 70

% lo

wer

am

ong

res

pite

use

rs t

han

non

resp

ite u

sers

, al

thou

gh

th

e od

ds

incr

ease

d w

ith e

ach

ad

diti

onal

re

spite

day

. Am

ong

ind

ivid

ual

s w

ho

use

d a

ny

inp

atie

nt

or e

mer

gen

cy s

ervi

ces,

a lo

ng

er s

tay

in r

esp

ite w

as

asso

ciat

ed w

ith f

ewer

hou

rs o

f in

pat

ien

t an

d e

mer

gen

cy

serv

ice

use

. How

ever

, th

e as

soci

atio

n w

as o

ne

of

dim

inis

hin

g r

etu

rns,

with

neg

ligib

le d

ecre

ases

pre

dic

ted

bey

ond

14

resp

ite d

ays.

By

red

uci

ng

th

e n

eed

for

in

pat

ien

t an

d e

mer

gen

cy s

ervi

ces

for

som

e in

div

idu

als,

p

eer

resp

ites

may

incr

ease

mea

nin

gfu

l ch

oice

s fo

r re

cove

ry a

nd

dec

reas

e th

e b

ehav

iou

ral h

ealth

sys

tem

’s

relia

nce

on

cos

tly, c

oerc

ive,

an

d le

ss p

erso

n-c

entr

eed

mod

es o

f se

rvic

e d

eliv

ery.

Cu

llber

g, J

; Le

van

der

, S;

Hol

mq

vist

, R;

Mat

tsso

n, M

; W

iese

lgre

n, I

-M

2002

Sw

eden

253

adu

lts w

ith

first

ep

isod

e p

sych

osis

(F

EP

) fr

om a

ca

tch

men

t w

ith a

p

opu

latio

n o

f 1.

5 m

illio

n.

To e

valu

ate

one-

year

ou

tcom

es in

firs

t ep

isod

e p

sych

osis

p

atie

nts

in t

he

Sw

edis

h Pa

rach

ute

pro

ject

. R

esea

rch

par

ticip

ants

w

ere

aske

d t

o p

artic

ipat

e in

th

is

5-ye

ar p

roje

ct.

Qu

antit

ativ

e -

anal

ysis

of

case

re

por

t d

ata,

u

sin

g h

isto

rica

l (c

ontr

ol (

n=

71))

an

d p

rosp

ectiv

e (e

xper

imen

tal

(n=

64))

p

opu

latio

ns.

A t

otal

of

175

pat

ien

ts (

69%

) w

ere

follo

wed

up

th

rou

gh

the

first

yea

r of

tre

atm

ent.

Glo

bal

Ass

essm

ent

of

Fun

ctio

nin

g (

GA

F) v

alu

es w

ere

sig

nifi

can

tly h

igh

er

than

in t

he

his

tori

cal c

omp

aris

on g

rou

p b

ut

sim

ilar

to

the

pro

spec

tive

gro

up

. Psy

chia

tric

in-p

atie

nt

care

was

lo

wer

as

was

pre

scri

ptio

n o

f n

euro

lep

tic m

edic

atio

n.

Sat

isfa

ctio

n w

ith c

are

was

gen

eral

ly h

igh

in t

he

Para

chu

te g

rou

p. A

cces

s to

a s

mal

l ove

rnig

ht

cris

is

hom

e w

as a

ssoc

iate

d w

ith h

igh

er G

AF.

Th

e re

sear

cher

s ar

gu

ed t

hat

it is

pos

sib

le t

o su

cces

sfu

lly t

reat

FE

P

pat

ien

ts w

ith f

ewer

in-p

atie

nt

day

s an

d le

ss n

euro

lep

tic

med

icat

ion

th

an is

usu

ally

rec

omm

end

ed, w

hen

co

mb

ined

with

inte

nsi

ve p

sych

osoc

ial t

reat

men

t an

d su

pp

ort.

152

Cu

llber

g, J

; M

atts

son

, M;

Leva

nd

er, S

; H

olm

qvi

st, R

; To

msm

ark,

L;

Elin

gfo

rs, C

; W

iese

lgre

n, I

-M

2006

Sw

eden

61 c

onse

cutiv

e fir

st e

pis

ode

sch

izop

hre

nia

p

atie

nts

wer

e fo

llow

ed o

ver

3 ye

ars,

an

d co

mp

ared

to

66

serv

ice

use

rs

from

‘tr

eatm

ent

as u

sual

’ an

d h

igh

qu

ality

se

rvic

e g

rou

ps.

To u

nd

erta

ke a

th

ree-

year

fol

low

-u

p o

f th

e S

wed

ish

‘Par

ach

ute

Pro

ject

’,

wh

ich

use

s ‘n

eed

-sp

ecifi

c tr

eatm

ents

’,

con

sid

erin

g t

reat

men

t co

sts

and

clin

ical

ou

tcom

es f

or fi

rst

epis

ode

sch

izop

hre

nia

p

atie

nts

.

Qu

antit

ativ

e –

anal

ysis

of

case

rep

ort

dat

a co

mp

arin

g

Para

chu

te

Pro

ject

gro

up

with

‘tr

eatm

ent

as u

sual

’ (n

=41

) an

d p

rosp

ectiv

e g

rou

p f

rom

a

hig

h q

ual

ity

psy

chia

tric

ce

ntr

e (n

= 2

5).

Sym

pto

mat

ic a

nd

fu

nct

ion

al o

utc

ome

was

sig

nifi

can

tly

bet

ter

com

par

ed w

ith t

he

His

tori

cal g

rou

p a

nd

eq

ual

w

ith t

he

Pro

spec

tive

gro

up

. Du

rin

g t

he

first

yea

r, th

e d

irec

t co

sts

for

in-

and

ou

t-p

atie

nt

care

per

pat

ien

t in

th

e Pa

rach

ute

pro

ject

wer

e le

ss t

han

hal

f of

th

ose

in t

he

Pro

spec

tive

gro

up

. Th

e re

sear

cher

s co

ncl

ud

e th

at t

he

evid

ence

su

pp

orts

th

e fe

asib

ility

, clin

ical

ly

and

eco

nom

ical

ly, o

f a

larg

esca

le a

pp

licat

ion

of

‘nee

d-

spec

ific

trea

tmen

ts’

for

first

ep

isod

e p

sych

otic

pat

ien

ts.

De

Jon

g, G

; S

chou

t, G

G20

13N

eth

erla

nd

sN

/A

The

aim

of

the

stu

dy

is

to a

nsw

er t

he

qu

estio

n of

wh

eth

er F

amily

G

rou

p C

onfe

ren

cin

g

(FG

C)

is a

n e

ffec

tive

tool

to

gen

erat

e so

cial

su

pp

ort,

to

pre

ven

t co

erci

on a

nd

to p

rom

ote

soci

al

inte

gra

tion

in p

ub

lic

men

tal h

ealth

car

e (P

MH

C).

Qu

alita

tive

– p

olic

y an

alys

is,

and

stu

dy

des

ign

.

The

pap

er m

erel

y se

ts o

ut

the

pro

pos

ed s

tud

y, w

hic

h is

re

por

ted

up

on in

th

e 20

17 p

aper

by

the

sam

e au

thor

s,

led

by

Sch

out

(see

bel

ow).

Th

e p

aper

ske

tch

es t

he

con

text

for

usi

ng

FG

C in

th

e N

eth

erla

nd

s, in

wh

ich

ther

e h

as b

een

a s

tead

y g

row

th in

con

fere

nce

s b

ein

g

org

anis

ed e

ach

yea

r. A

n a

men

dm

ent

in t

he

Du

tch

Civ

il C

ode

des

ign

ates

FG

C a

s g

ood

pra

ctic

e. C

lien

ts in

PM

HC

of

ten

hav

e a

limite

d n

etw

ork.

Th

e au

thor

s p

rop

osed

th

at

they

will

res

earc

h t

he

app

licab

ility

of

FGC

s in

PM

HC

ove

r th

e fo

llow

ing

tw

o ye

ars

by

eval

uat

ing

for

ty c

ase

stu

die

s.

Eva

ns,

M;

Boo

thro

yd, R

; A

rmst

ron

g, M

1997

Un

ited

Sta

tes

Dem

ogra

ph

ic

dat

a ar

e re

por

ted

on t

he

238

child

ren

an

d fa

mili

es w

ho

rece

ived

th

e fu

ll co

urs

e of

in-

hom

e se

rvic

es

du

rin

g t

he

26-m

onth

stu

dy

per

iod

.

This

art

icle

des

crib

es

a 3-

year

res

earc

h d

emon

stra

tion

pro

ject

. Th

is p

roje

ct, w

hic

h w

as c

ond

uct

ed in

th

e B

ron

x, N

ew

York

, exa

min

ed t

he

effic

acy

of 3

mod

els

of in

ten

sive

in-h

ome

serv

ices

as

alte

rnat

ives

to

hos

pita

lisat

ion

for

ch

ildre

n e

xper

ien

cin

g

seri

ous

psy

chia

tric

cr

ises

.

Mix

ed M

eth

ods

– A

nal

ysis

of

case

rep

ort

dat

a an

d d

escr

iptiv

e st

atis

tics.

The

thre

e m

odel

s w

ere

char

acte

rise

d a

s ‘a

ltern

ativ

es

to h

osp

italiz

atio

n’. T

he

first

, Hom

e-B

ased

Cri

sis

Inte

rven

tion

(H

BC

I), w

as m

odel

led

on

th

e H

omeb

uild

ers

mod

el o

f fa

mily

pre

serv

atio

n; t

he

seco

nd

, En

han

ced

HB

CI (

HB

CI+

), a

dd

ed r

esp

ite c

are,

flex

ible

ser

vice

m

oney

, par

ent

advo

cate

an

d s

up

por

t se

rvic

es, a

nd

add

ition

al s

taff

tra

inin

g in

cu

ltura

l com

pet

ence

an

d vi

olen

ce m

anag

emen

t. C

risi

s C

ase

Man

agem

ent,

th

e th

ird

mod

el, u

sed

cas

e m

anag

ers

to a

sses

s ch

ild a

nd

fam

ily n

eed

s an

d li

nk

them

to

serv

ices

, as

wel

l as

resp

ite c

are

and

flex

ible

mon

ey. T

he

app

aren

t b

enefi

ts

and

lim

itatio

ns

of e

ach

mod

el is

pre

sen

ted

alo

ng

with

su

pp

ortin

g e

vid

ence

.

153

Eyt

an, A

; Ch

atto

n,

A; S

afra

n, E

; K

haz

aal,

Y20

13S

witz

er-

lan

d

This

sea

rch

retr

ieve

d d

ata

on a

tot

al o

f 2,

227

hos

pita

l-is

atio

ns

for

1,58

4 p

atie

nts

in a

si

ng

le h

osp

ital

in G

enev

a,

Sw

itzer

lan

d.

From

Oct

ober

20

06, o

nly

cer

tified

p

sych

iatr

ists

wer

e au

thor

ised

to

req

uir

e a

com

pu

lsor

y ad

mis

sion

to

th

is f

acili

ty, w

hile

b

efor

e al

l ph

ysic

ian

s w

ere,

incl

ud

ing

re

sid

ents

. Th

is s

tud

y so

ug

ht

to a

sses

s th

e im

pac

t of

th

is

chan

ge

of p

roce

du

re

on t

he

pro

por

tion

of c

omp

uls

ory

adm

issi

ons.

Qu

antit

ativ

e -

anal

ysis

of

case

rep

ort

dat

a (b

efor

e/af

ter

new

re

qu

irem

ent)

. All

med

ical

rec

ord

s of

pat

ien

ts

adm

itted

re

spec

tivel

y 4

mon

ths

bef

ore

and

4

mon

th a

fter

th

e im

ple

men

tatio

n of

th

e p

roce

du

re w

ere

retr

osp

ectiv

ely

anal

ysed

.

The

over

all p

rop

ortio

ns

of c

omp

uls

ory

and

vol

un

tary

ad

mis

sion

s w

ere

63.9

% a

nd

36.

1 %

res

pec

tivel

y.

The

aver

age

len

gth

of

stay

was

32

day

s (S

D ±

64.

4).

Du

rin

g t

he

stu

dy

per

iod

, 25%

of

pat

ien

ts e

xper

ien

ced

two

hos

pita

lisat

ion

s or

mor

e. C

omp

ared

with

th

e p

erio

d b

efor

e O

ctob

er 2

006,

pat

ien

ts h

osp

italis

ed f

rom

O

ctob

er 2

006

up

wer

e le

ss li

kely

to

be

hos

pita

lised

on

a co

mp

uls

ory

bas

is (

OR

= 0

.745

, 95

% C

I: 0.

596-

0.93

0).

Fact

ors

asso

ciat

ed w

ith in

volu

nta

ry a

dm

issi

on w

ere

you

ng

ag

e (2

0 ye

ars

or le

ss),

fem

ale

gen

der

, a d

iag

nos

is

of p

sych

otic

dis

ord

er a

nd

bei

ng

hos

pita

lised

for

th

e fir

st t

ime.

Th

e au

thor

s ar

gu

e th

at t

hei

r re

sults

‘st

ron

gly

su

gg

est

that

lim

itin

g t

he

rig

ht

to r

equ

ire

com

pu

lsor

y ad

mis

sion

s to

fu

lly c

ertifi

ed p

sych

iatr

ists

can

red

uce

th

e ra

te o

f co

mp

uls

ory

vers

us

volu

nta

ry a

dm

issi

ons’

.

Fen

ton

, WS

; M

osh

er, L

R;

Her

rell,

JM

; B

lyle

r, C

R

1998

Un

ited

Sta

tes

185

adu

lts w

ho

exp

erie

nce

d an

‘ill

nes

s ex

acer

bat

ion’

an

d w

ere

will

ing

to

acc

ept

volu

nta

ry

trea

tmen

t w

ere

ran

dom

ly

assi

gn

ed t

o th

e ac

ute

psy

chia

tric

w

ard

of

a g

ener

al

hos

pita

l or

a co

mm

un

ity

resi

den

tial

alte

rnat

ive.

The

auth

ors

rep

ort

a p

rosp

ectiv

e ra

nd

omis

ed t

rial

to

tes

t th

e cl

inic

al

effe

ctiv

enes

s of

a

mod

el o

f ac

ute

re

sid

entia

l alte

rnat

ive

trea

tmen

t fo

r p

atie

nts

w

ith p

ersi

sten

t m

enta

l ill

nes

s re

qu

irin

g

hos

pita

l-le

vel c

are.

Qu

antit

ativ

e –

econ

omic

ev

alu

atio

n w

ithin

a

du

al-c

entr

e ra

nd

omis

ed

con

trol

tri

al.

The

auth

ors

rep

ort

that

of

185

pat

ien

ts, 1

19 (

64%

) w

ere

succ

essf

ully

pla

ced

at

thei

r as

sig

ned

tre

atm

ent

site

. Cas

e m

ix d

ata

ind

icat

ed t

hat

pat

ien

ts t

reat

ed in

th

e h

osp

ital (

N=

50)

and

th

e al

tern

ativ

e (N

=69

) w

ere

com

par

ably

ill.

Trea

tmen

t ep

isod

e sy

mp

tom

red

uct

ion

and

pat

ien

t sa

tisfa

ctio

n w

ere

com

par

able

for

th

e tw

o se

ttin

gs.

Nin

e (1

3%)

of 6

9 p

atie

nts

ran

dom

ly a

ssig

ned

to

th

e al

tern

ativ

e re

qu

ired

tra

nsf

er t

o a

hos

pita

l un

it; t

wo

(4%

) of

50

pat

ien

ts r

and

omly

ass

ign

ed t

o th

e h

osp

ital

cou

ld n

ot b

e st

abili

sed

an

d r

equ

ired

tra

nsf

er t

o an

oth

er

faci

lity.

Psy

chos

ocia

l fu

nct

ion

ing

, sat

isfa

ctio

n, a

nd

acu

te

care

use

in t

he

6 m

onth

s fo

llow

ing

ad

mis

sion

wer

e co

mp

arab

le f

or p

atie

nts

tre

ated

in t

he

two

sett

ing

s an

d d

id n

ot d

iffer

sig

nifi

can

tly f

rom

fu

nct

ion

ing

bef

ore

the

acu

te e

pis

ode.

Hos

pita

lisat

ion

is a

fre

qu

ent

and

hig

h-

cost

con

seq

uen

ce o

f se

vere

men

tal i

llnes

s. T

he

auth

ors

con

clu

de

that

for

pat

ien

ts w

ho

do

not

req

uir

e in

ten

sive

g

ener

al m

edic

al in

terv

entio

n a

nd

are

will

ing

to

acce

pt

volu

nta

ry t

reat

men

t, t

he

alte

rnat

ive

pro

gra

mm

e m

odel

st

ud

ied

pro

vid

es o

utc

omes

com

par

able

to

thos

e of

h

osp

ital c

are.

154

Fish

er, W

A20

03U

nite

d S

tate

s

N=

260

adu

lts

over

all.

148

adu

lt se

rvic

e u

sers

, 54%

of

wh

om h

ad b

een

rest

rain

ed o

r se

clu

ded

; 112

st

aff

(ab

out

15%

of

th

e in

pat

ien

t cl

inic

al s

taff

at

the

time)

, 47%

of

wh

om w

ere

par

a-p

rofe

ssio

nal

s.

This

art

icle

des

crib

es

elem

ents

ass

ocia

ted

in t

he

liter

atu

re w

ith

succ

essf

ul r

edu

ctio

n of

sec

lusi

on a

nd

rest

rain

t, a

nd

look

s at

th

eir

app

licat

ion

in

a su

cces

sfu

l res

trai

nt

red

uct

ion

pro

gra

mm

e at

Cre

edm

oor

Psy

chia

tric

Cen

ter,

a la

rge,

urb

an, s

tate

-op

erat

ed p

sych

iatr

ic

hos

pita

l.

Mix

ed M

eth

ods

– d

ata

incl

ud

ed

rate

s of

res

-tr

ain

t an

d se

clu

sion

bu

t al

so s

urv

eys

gat

her

ing

sta

ff

know

led

ge,

ev

alu

atio

n of

tra

inin

g

pro

gra

mm

es,

and

info

rmat

ion

abou

t st

aff

and

rec

ipie

nt

attit

ud

es a

nd

actio

ns.

The

esse

ntia

l ele

men

ts o

f su

ch p

rog

ram

mes

are

hig

h le

vel a

dm

inis

trat

ive

end

orse

men

t, p

artic

ipat

ion

by

reci

pie

nts

of

men

tal h

ealth

ser

vice

s, c

ultu

re c

han

ge,

tr

ain

ing

, dat

a an

alys

is, a

nd

ind

ivid

ual

ised

tre

atm

ent.

Th

ese

elem

ents

wer

e ap

plie

d s

ucc

essf

ully

to

a re

stra

int

red

uct

ion

pro

gra

mm

e at

Cre

edm

oor

Psy

chia

tric

Cen

ter,

a la

rge,

urb

an, s

tate

-op

erat

ed p

sych

iatr

ic h

osp

ital t

hat

re

du

ced

its

com

bin

ed r

estr

ain

t an

d s

eclu

sion

rat

e b

y 67

% o

ver

a p

erio

d o

f 2

year

s.

Flam

mer

, E;

Ste

iner

t, T

2016

Ger

man

y

2,07

1 ad

ults

d

iag

nos

ed

with

psy

chot

ic

dis

ord

ers

and

at le

ast

one

adm

issi

on d

uri

ng

at

leas

t on

e of

th

e th

ree

time

per

iod

s w

ere

incl

ud

ed, f

or a

to

tal o

f 3,

482

adm

issi

ons.

In o

ne

Ger

man

sta

te,

‘invo

lun

tary

med

icat

ion

of p

sych

iatr

ic

inp

atie

nts

was

ille

gal

d

uri

ng

eig

ht

mon

ths

from

Ju

ly 2

012

un

til

Feb

ruar

y 20

13’.

Th

e au

thor

s ex

amin

ed

wh

eth

er t

he

nu

mb

er

and

du

ratio

n o

f m

ech

anic

al c

oerc

ive

mea

sure

s (s

eclu

sion

an

d r

estr

ain

t) a

nd

th

e n

um

ber

an

d s

ever

ity

of v

iole

nt

inci

den

ts

chan

ged

in t

his

per

iod

.

Qu

antit

ativ

e –

A

cros

s-se

ctio

nal

an

alys

is w

as

con

du

cted

of

adm

issi

on-

rela

ted

rou

tine

dat

a co

llect

ed

in s

even

p

sych

iatr

ic

hos

pita

ls.

Dat

a w

as c

olle

cted

in t

hre

e tim

e p

erio

ds

(per

iod

1, J

uly

20

11-F

ebru

ary

2012

; per

iod

2, J

uly

201

2-Fe

bru

ary

2013

; an

d p

erio

d 3

, Ju

ly 2

013-

Feb

ruar

y 20

14).

Th

e m

ean

nu

mb

er o

f m

ech

anic

al c

oerc

ive

mea

sure

s an

d v

iole

nt

inci

den

ts p

er a

dm

issi

on in

crea

sed

sig

nifi

can

tly d

uri

ng

p

erio

d 2

, wh

en in

volu

nta

ry m

edic

atio

n w

as n

ot p

ossi

ble

, an

d d

ecre

ased

sig

nifi

can

tly d

uri

ng

per

iod

3. T

hey

als

o d

iffer

ed s

ign

ifica

ntly

bet

wee

n p

erio

ds

1 an

d 3

. Th

e p

erce

nta

ge

of a

dm

issi

ons

invo

lvin

g s

eclu

sion

incr

ease

d d

uri

ng

per

iod

2 s

ign

ifica

ntly

an

d w

as s

ign

ifica

ntly

d

iffer

ent

du

rin

g p

erio

d 1

com

par

ed w

ith p

erio

d 3

. Th

e se

veri

ty o

f ill

nes

s an

d t

he

len

gth

of

hos

pita

lizsa

tion

did

n

ot c

han

ge

over

th

e th

ree

per

iod

s. T

he

auth

ors

not

e th

at

‘[r]

estr

ictio

n o

f in

volu

nta

ry m

edic

atio

n w

as a

ssoc

iate

d w

ith a

sig

nifi

can

t in

crea

se in

use

of

mec

han

ical

coe

rciv

e m

easu

res

and

vio

len

t in

cid

ents

’.

155

Flet

cher

, J;

Sp

ittal

, M;

Bro

ph

y, L

; et

al20

17A

ust

ralia

13 w

ard

s op

ted

into

a 1

2-w

eek

tria

l to

imp

lem

ent

Saf

ewar

ds

and

1-ye

ar f

ollo

w u

p.

The

com

par

ison

g

rou

p w

as a

ll ot

her

war

ds

(n =

31)

with

se

clu

sion

fa

cilit

ies

in t

he

juri

sdic

tion

.

To a

sses

s th

e im

pac

t of

imp

lem

entin

g

Saf

ewar

ds

on s

eclu

sion

in

Vic

tori

an in

pat

ien

t m

enta

l hea

lth s

ervi

ces

in A

ust

ralia

.

Qu

antit

ativ

e -

bef

ore-

and

-aft

er

des

ign

, with

a

com

par

ison

g

rou

p m

atch

ed

for

serv

ice

typ

e, u

sin

g

man

dat

orily

re

por

ted

ser

vice

d

ata.

Sec

lusi

on r

ates

wer

e re

du

ced

by

36%

in S

afew

ard

s tr

ial w

ard

s b

y th

e 12

-mon

th f

ollo

w-u

p p

erio

d (

inci

den

ce

rate

rat

ios

(IR

R)

= 0

.64,

) b

ut

in t

he

com

par

ison

war

ds

secl

usi

on r

ates

did

not

diff

er f

rom

bas

elin

e to

pos

t-tr

ial (

IRR

= 1

.17)

or

to f

ollo

w-u

p p

erio

d (

IRR

= 1

.35)

. Fi

del

ity a

nal

ysis

rev

eale

d a

tra

ject

ory

of in

crea

sed

use

of

Saf

ewar

ds

inte

rven

tion

s af

ter

the

tria

l ph

ase

to f

ollo

w

up

. Th

e fin

din

gs

sug

ges

t th

at S

afew

ard

s is

ap

pro

pri

ate

for

pra

ctic

e ch

ang

e in

Vic

tori

an in

pat

ien

t m

enta

l hea

lth

serv

ices

mor

e b

road

ly t

han

ad

ult

acu

te w

ard

s, a

nd

is

effe

ctiv

e in

red

uci

ng

th

e u

se o

f se

clu

sion

.

Gilb

urt

, H; S

lad

e,

M; R

ose,

D;

Lloy

d-E

van

s,

B; J

ohn

son

, S;

Osb

orn

, Dav

id P

J

2010

En

gla

nd

40 a

du

lts li

vin

g

in r

esid

entia

l al

tern

ativ

e se

rvic

es w

ho

had

pre

viou

sly

exp

erie

nce

d h

osp

ital i

n-

pat

ien

t st

ays.

To e

xplo

re p

atie

nts

’ su

bje

ctiv

e ex

per

ien

ces

of t

rad

ition

al h

osp

ital

serv

ices

an

d r

esid

entia

l al

tern

ativ

es t

o h

osp

ital.

To a

dd

ress

g

ap in

res

earc

h o

n th

e ‘p

refe

ren

ces

and

exp

erie

nce

s of

p

eop

le w

ith m

enta

l ill

nes

s in

rel

atio

n t

o re

sid

entia

l alte

rnat

ives

to

hos

pita

l’.

Qu

alita

tive

– p

urp

osiv

e sa

mp

ling

, th

emat

ic

anal

ysis

of

inte

rvie

w d

ata.

Patie

nts

rep

orte

d a

n o

vera

ll p

refe

ren

ce f

or r

esid

entia

l al

tern

ativ

es. T

hes

e w

ere

iden

tified

as

trea

ting

pat

ien

ts

with

low

er le

vels

of

dis

turb

ance

, bei

ng

saf

er, h

avin

g

mor

e fr

eed

om a

nd

dec

reas

ed c

oerc

ion

, an

d h

avin

g le

ss

pat

ern

alis

tic s

taff

com

par

ed w

ith t

rad

ition

al in

-pat

ien

t se

rvic

es. H

owev

er, p

atie

nts

iden

tified

no

sub

stan

tial

diff

eren

ce b

etw

een

th

eir

rela

tion

ship

s w

ith s

taff

ove

rall

and

th

e ca

re p

rovi

ded

bet

wee

n t

he

two

typ

es o

f se

rvic

es. T

he

auth

ors

con

clu

de

that

‘fo

r p

atie

nts

wh

o h

ave

acu

te m

enta

l illn

ess

bu

t lo

wer

leve

ls o

f d

istu

rban

ce,

resi

den

tial a

ltern

ativ

es o

ffer

a p

refe

rab

le e

nvi

ron

men

t to

tra

diti

onal

hos

pita

l ser

vice

s: t

hey

min

imis

e co

erci

on

and

max

imis

e fr

eed

om, s

afet

y an

d o

pp

ortu

niti

es f

or p

eer

sup

por

t’.

Gou

let,

MH

; La

rue,

C; A

shle

y,

JL20

18C

anad

a

Acu

te a

du

lt p

sych

iatr

ic c

are

un

it sp

ecia

lised

in

firs

t-ep

isod

e p

sych

oses

with

27

bed

s.

To d

evel

op a

nd

eval

uat

e a

‘pos

t-se

clu

sion

an

d/o

r re

stra

int

revi

ew’

(PS

RR

) in

terv

entio

n im

ple

men

ted

in a

n ac

ute

psy

chia

tric

car

e u

nit.

Cas

e st

ud

y d

esig

n,

qu

alita

tive

in

nat

ure

, with

an

ad

ded

q

uan

titat

ive

com

pon

ent.

Nu

rses

rep

orte

d t

hat

th

ey w

ere

able

to

exp

lore

th

e p

atie

nt’

s fe

elin

gs

du

rin

g t

he

PS

RR

inte

rven

tion

with

p

atie

nts

, wh

ich

led

to

rest

orat

ion

of

the

ther

apeu

tic

rela

tion

ship

. PS

RR

with

th

e tr

eatm

ent

team

was

p

erce

ived

as

a le

arn

ing

op

por

tun

ity, w

hic

h a

llow

ed

the

ther

apeu

tic in

terv

entio

n t

o im

pro

ve. B

oth

th

e u

se

of s

eclu

sion

an

d t

he

time

spen

t in

sec

lusi

on w

ere

sig

nifi

can

tly r

edu

ced

6 m

onth

s af

ter

the

imp

lem

enta

tion

of P

SR

R in

terv

entio

n.

Res

ults

su

gg

est

the

effic

acy

of

PS

RR

in o

verc

omin

g t

he

dis

com

fort

per

ceiv

ed b

y b

oth

staf

f an

d p

atie

nt

and

, in

th

e m

ean

time,

in r

edu

cin

g t

he

nee

d f

or c

oerc

ive

pro

ced

ure

s. S

yste

mat

ic P

SR

R c

ould

p

erm

it to

imp

rove

th

e q

ual

ity o

f ca

re a

nd

th

e sa

fety

of

agg

ress

iven

ess

man

agem

ent.

156

Gje

rber

g, E

; Hem

, M

H; F

ørd

e, R

; Pe

der

sen

, R20

13N

orw

ay

11 in

ter-

dis

cip

linar

y fo

cus

gro

up

inte

rvie

ws

con

sist

ing

of

nu

rses

, au

xilia

ry

nu

rses

an

d s

ome

mem

ber

s of

sta

ff

with

out

form

al

qu

alifi

catio

ns,

(N

=

60)

.

This

art

icle

exa

min

es

wh

at k

ind

s of

st

rate

gie

s or

alte

rnat

ive

inte

rven

tion

s n

urs

ing

st

aff

in N

orw

ay u

sed

wh

en p

atie

nts

res

ist

care

an

d t

reat

men

t an

d w

hat

con

diti

ons

the

staf

f co

nsi

der

ed a

s n

eces

sary

to

succ

eed

in a

void

ing

th

e u

se o

f co

erci

on.

Qu

alita

tive

–in

ter-

dis

cip

linar

y fo

cus

gro

up

inte

rvie

ws

with

n

urs

ing

hom

e st

aff.

In m

any

Wes

tern

cou

ntr

ies,

stu

die

s h

ave

dem

onst

rate

d ex

ten

sive

use

of

coer

cion

in n

urs

ing

hom

es, e

spec

ially

to

war

ds

pat

ien

ts s

uff

erin

g f

rom

dem

entia

. Th

e st

ud

y in

dic

ated

th

at t

he

nu

rsin

g h

ome

staf

f u

sual

ly s

pen

t a

lot

of t

ime

tryi

ng

a w

ide

ran

ge

of a

pp

roac

hes

to

avoi

d th

e u

se o

f co

erci

on. T

he

mos

t co

mm

on s

trat

egie

s w

ere

defl

ectin

g a

nd

per

suas

ive

stra

teg

ies,

lim

itin

g c

hoi

ces

by

con

scio

us

use

of

lan

gu

age,

diff

eren

t ki

nd

s of

flex

ibili

ty

and

on

e-to

-on

e ca

re. A

ccor

din

g t

o th

e st

aff,

thei

r op

por

tun

ities

to

use

alte

rnat

ive

stra

teg

ies

effe

ctiv

ely

are

gre

atly

aff

ecte

d b

y th

e n

urs

ing

hom

e’s

reso

urc

es, b

y th

e or

gan

isat

ion

of

care

an

d b

y th

e st

aff’s

com

pet

ence

.

Gre

enfie

ld, T

K;

Sto

nek

ing

, BC

; H

um

ph

reys

, K;

Su

nd

by,

E; B

ond

, J

2008

Un

ited

Sta

tes

393

adu

lts,

‘civ

illy

com

mitt

ted

’.

This

exp

erim

ent

com

par

ed t

he

effe

ctiv

enes

s of

an

un

lock

ed, m

enta

l h

ealth

con

sum

er-

man

aged

, cri

sis

resi

den

tial p

rog

ram

me

(CR

P)

to a

lock

ed,

inp

atie

nt

psy

chia

tric

fa

cilit

y (L

IPF)

for

ad

ults

ci

villy

com

mitt

ed f

or

seve

re p

sych

iatr

ic

pro

ble

ms.

Mix

ed m

eth

ods

– ra

nd

omis

ed

con

trol

tri

al

with

eco

nom

ic

eval

uat

ion

and

inte

rvie

ws

with

th

emat

ic

anal

ysis

.

Follo

win

g s

cree

nin

g a

nd

info

rmed

con

sen

t, p

artic

ipan

ts

wer

e ra

nd

omis

ed t

o th

e C

RP

or

the

LIP

F an

d in

terv

iew

ed a

t b

asel

ine

and

at

30-d

ay, 6

-mon

th, a

nd

1-ye

ar p

ost

adm

issi

on. O

utc

omes

wer

e co

sts,

leve

l of

fu

nct

ion

ing

, psy

chia

tric

sym

pto

ms,

sel

f-es

teem

, en

rich

men

t, a

nd

ser

vice

sat

isfa

ctio

n. T

reat

men

t ou

tcom

es w

ere

com

par

ed u

sin

g h

iera

rch

ical

lin

ear

mod

els.

Par

ticip

ants

in t

he

CR

P e

xper

ien

ced

sig

nifi

can

tly

gre

ater

imp

rove

men

t on

inte

rvie

wer

-rat

ed a

nd

sel

f-re

por

ted

psy

chop

ath

olog

y th

an d

id p

artic

ipan

ts in

th

e LI

PF

con

diti

on; s

ervi

ce s

atis

fact

ion

was

dra

mat

ical

ly

hig

her

in t

he

CR

P c

ond

ition

. CR

P-st

yle

faci

litie

s ar

e a

viab

le a

ltern

ativ

e to

psy

chia

tric

hos

pita

lisat

ion

for

man

y in

div

idu

als

faci

ng

civ

il co

mm

itmen

t.

Gro

ot, P

; va

n O

s J

2018

Net

her

lan

ds

1194

ad

ult

use

rs

of t

aper

ing

str

ips

To o

bse

rve

the

use

of

‘tap

erin

g s

trip

s’, w

hic

h al

low

gra

du

al d

osag

e re

du

ctio

n a

nd

min

imis

e th

e p

oten

tial f

or

with

dra

wal

eff

ects

. A

tap

erin

g s

trip

con

sist

s of

an

tidep

ress

ant

med

icat

ion

, pac

kag

ed

in a

rol

l of

smal

l dai

ly

pou

ches

, eac

h w

ith t

he

sam

e or

slig

htly

low

er

dos

e th

an t

he

one

bef

ore

it.

Qu

antit

ativ

e –

obse

rvat

ion

al

and

su

rvey

st

ud

y of

119

4 u

sers

.

Of

1194

use

rs o

f ta

per

ing

str

ips,

895

(75

%)

wis

hed

to

dis

con

tinu

e th

eir

antid

epre

ssan

t m

edic

atio

n. I

n t

hes

e 89

5, m

edia

n le

ng

th o

f an

tidep

ress

ant

use

was

2–5

ye

ars

(IQ

R: 1

–2 y

ears

– >

10

year

s). N

earl

y tw

o-th

ird

s (6

2%)

had

un

succ

essf

ully

att

emp

ted

with

dra

wal

bef

ore

(med

ian

= 2

tim

es b

efor

e, IQ

R 1

–3).

Alm

ost

all o

f th

ese

(97%

) h

ad e

xper

ien

ced

som

e d

egre

e of

with

dra

wal

, w

ith 4

9% e

xper

ien

cin

g s

ever

e w

ithd

raw

al (

7 on

a s

cale

of

1–7

, IQ

R 6

–7).

Tap

erin

g s

trip

s re

pre

sen

t a

sim

ple

an

d e

ffec

tive

met

hod

of

ach

ievi

ng

a g

rad

ual

dos

age

red

uct

ion

.

157

Gu

an, L

; et

al20

15C

hin

a

266

pat

ien

ts

fou

nd

in

rest

rain

ts in

th

eir

fam

ily h

omes

fr

om 2

005

acro

ss C

hin

a w

ere

recr

uite

d in

S

tag

e O

ne

of t

he

stu

dy

in 2

009.

In

2012

, 230

of

the

266

case

s w

ere

re-i

nte

rvie

wed

(t

he

Sta

ge

Two

stu

dy)

.

To im

ple

men

t a

nat

ion

wid

e tw

o-st

age

follo

w-u

p st

ud

y to

mea

sure

th

e ef

fect

iven

ess

and

su

stai

nab

ility

of

the

‘un

lock

ing

an

d tr

eatm

ent’

inte

rven

tion

and

its

imp

act

on t

he

wel

l-b

ein

g o

f p

atie

nts

’ fa

mili

es. O

utc

ome

mea

sure

s in

clu

ded

th

e p

atie

nt

med

icat

ion

adh

eren

ce a

nd

soc

ial

fun

ctio

nin

g, f

amily

b

urd

en r

atin

gs,

an

d re

lock

ing

rat

e.

Mix

ed m

eth

ods

– tw

o-st

age

follo

w-u

p s

tud

y,

inte

rvie

ws

pre

-pos

t in

terv

entio

n,

outc

ome

test

s

96%

of

pat

ien

ts w

ere

dia

gn

osed

with

sch

izop

hre

nia

. P

rior

to

un

lock

ing

, th

eir

tota

l tim

e lo

cked

ran

ged

fro

m

two

wee

ks t

o 28

yea

rs, w

ith 3

2% h

avin

g b

een

lock

ed

mu

ltip

le t

imes

. Th

e n

um

ber

of

per

son

s re

gu

larl

y ta

kin

g

med

icin

es in

crea

sed

fro

m o

ne

per

son

at

the

time

of

un

lock

ing

to

74%

in 2

009

and

76%

in 2

012.

Pre

-pos

t te

sts

show

ed s

ust

ain

ed im

pro

vem

ent

in p

atie

nt

soci

al

fun

ctio

nin

g a

nd

sig

nifi

can

t re

du

ctio

ns

in f

amily

bu

rden

. O

ver

92%

of

pat

ien

ts r

emai

ned

fre

e of

res

trai

nts

in 2

012.

Th

e au

thor

s re

por

t th

at ‘

Pra

ctic

e-b

ased

evi

den

ce f

rom

ou

r st

ud

y su

gg

ests

an

imp

orta

nt

mod

el f

or p

rote

ctin

g

the

hu

man

rig

hts

of

peo

ple

with

men

tal d

isor

der

s an

d k

eep

ing

th

em f

ree

of r

estr

ain

ts c

an b

e ac

hie

ved

by

pro

vid

ing

acc

essi

ble

, com

mu

nity

bas

ed m

enta

l h

ealth

ser

vice

s w

ith c

ontin

uity

of

care

. Ch

ina’

s “6

86”

Pro

gra

mm

e ca

n in

form

sim

ilar

effo

rts

in lo

w-r

esou

rce

sett

ing

s w

her

e co

mm

un

ity lo

ckin

g o

f p

atie

nts

is

pra

ctic

ed.’

Hac

kett

, R;

Nic

hol

son

, J;

Mu

llin

s, S

; Fa

rrin

gto

n,

T; W

ard

, S;

Pri

tch

ard

, G;

Mill

er, E

; M

ahm

ood

, N

2009

En

gla

nd

Acc

ess

dat

a w

as

anal

ysed

for

200

-30

0 ad

ults

.

The

pro

ject

aim

ed t

o em

pow

er t

he

Paki

stan

i co

mm

un

ity t

o se

ek

men

tal h

ealth

su

pp

ort

earl

ier

with

in t

hei

r ow

n co

mm

un

ity, b

uild

up

tru

st in

mai

nst

ream

se

rvic

es a

nd

en

han

ce

the

clin

ical

pat

hw

ays

with

in s

ervi

ces

to

pro

vid

e m

ore

cultu

rally

ap

pro

pri

ate

care

.

Mix

ed m

eth

ods

– q

ual

itativ

e re

por

t fr

om ‘

link

wor

ker’

(se

e M

ain

Fin

din

gs)

an

d q

uan

titat

ive

serv

ice

dat

a on

ac

cess

rat

es.

Bla

ck a

nd

Min

ority

Eth

nic

(B

ME

) co

mm

un

ities

rec

eive

d

iffer

ent

pat

hw

ays

into

men

tal h

ealth

car

e w

ith B

ME

se

rvic

e u

sers

oft

en p

rese

ntin

g in

cri

sis.

Th

e S

hef

field

C

risi

s R

esol

utio

n H

ome

Trea

tmen

t jo

ined

with

th

e lo

cal

Paki

stan

i Mu

slim

Cen

tre

(PM

C)

to w

ork

in p

artn

ersh

ip.

The

PM

C h

ad e

xist

ing

lin

ks w

ith t

he

Paki

stan

i co

mm

un

ity a

nd

pro

vid

ed a

ran

ge

of s

ocia

l, re

spite

an

d oc

cup

atio

nal

op

por

tun

ities

. Th

e p

artn

ersh

ip c

reat

ed a

n in

nov

ativ

e n

ew r

ole:

th

e Pa

kist

ani l

ink

wor

ker.

The

EP

IC

par

tner

ship

str

eng

then

ed t

he

PM

C’s

influ

ence

an

d r

aise

d aw

aren

ess

of m

enta

l hea

lth is

sues

in t

he

com

mu

nity

. Th

rou

gh

inte

gra

tion

of

the

link

wor

ker

with

in t

he

ever

yday

pra

ctic

e of

clin

icia

ns,

pat

hw

ays

of c

are

show

ed

evid

ence

of

pos

itive

ch

ang

e in

clu

din

g m

ore

refe

rral

s to

th

e P

MC

fro

m p

sych

iatr

ic s

ervi

ces.

Th

e E

PIC

pro

ject

p

ilote

d a

mod

el o

f p

artn

ersh

ip w

orki

ng

th

at is

eff

ectiv

e an

d t

ran

sfer

able

.

158

Hay

cock

, J;

Fin

kelm

an, D

; P

ress

krei

sch

er, H

1993

Un

ited

Sta

tes

N/A

– s

ocio

leg

al

anal

ysis

of

law

an

d a

ltern

ativ

e le

gal

pat

hw

ays

To r

evie

w t

he

stat

ute

s,

reg

ula

tion

s an

d ca

se la

w g

over

nin

g

civi

l com

mitm

ent

in

Mas

sach

use

tts,

rev

iew

th

e p

ract

ice

of c

ivil

com

mitm

ent

in t

his

U

S s

tate

an

d c

onsi

der

w

het

her

th

e p

roce

ss

of m

edia

tion

cou

ld

pro

vid

e an

alte

rnat

ive

to c

ivil

com

mitm

ent.

Qu

alita

tive

– an

alys

is o

f ex

istin

g la

ws,

an

d e

xplo

ratio

n of

alte

rnat

ive

leg

al p

ath

way

s to

civ

il co

mm

itmen

t.

The

auth

ors

arg

ue

that

th

e p

roce

ss o

f m

edia

tion

mig

ht

bet

ter

fit t

he

ther

apeu

tic o

bje

ctiv

es t

hat

un

der

lie

clin

ical

par

ticip

atio

n in

th

e ci

vil c

omm

itmen

t p

roce

ss.

They

arg

ue

that

‘N

o am

oun

t of

tin

keri

ng

fro

m a

rig

hts

-b

ased

ag

end

a w

ith c

omm

itmen

t cr

iteri

a is

like

ly t

o co

rrec

t th

e fa

ilure

s of

ou

r cu

rren

t sy

stem

’. T

hey

not

e:

‘how

med

iate

d a

gre

emen

ts b

etw

een

clin

icia

ns

and

pat

ien

ts w

ould

wor

k ca

nn

ot b

e ex

hau

stiv

ely

des

crib

ed

in a

dva

nce

of

exp

erim

entin

g w

ith s

uch

an

alte

rnat

ive.

S

ome

of t

hat

exp

erim

enta

tion

nee

d n

ot w

ait

on t

he

full

imp

lem

enta

tion

of

a m

edia

tion

mod

el. E

ven

with

out

inst

itutin

g a

fu

ll-b

low

n m

edia

tion

pro

cess

, som

e of

ou

r su

gg

estio

ns

cou

ld b

e in

corp

orat

ed in

to c

urr

ent

civi

l co

mm

itmen

t p

roce

du

res.

’

Hen

der

son

, C;

Farr

elly

, S; F

lach

, C

; Bor

sch

man

n,

R; B

irch

woo

d,

M; T

hor

nic

roft

, G

; Wah

eed

, W;

Szm

ukl

er, G

2017

En

gla

nd

an

d W

ales

221

Join

t C

risi

s P

lan

s, w

hic

h a

re

pla

ns

form

ula

ted

by

serv

ice

use

rs a

nd

th

eir

clin

ical

tea

m

with

invo

lvem

ent

from

an

ext

ern

al

faci

litat

or,

com

par

ed t

o 42

4 ‘b

asel

ine

rou

tine

care

pla

ns’

.

The

auth

ors

aim

ed t

o es

timat

e th

e d

eman

d fo

r an

info

rmed

ad

van

ce t

reat

men

t re

fusa

l un

der

th

e M

enta

l Cap

acity

Act

20

05 (

En

gla

nd

an

d W

ales

) w

ithin

a s

amp

le

of s

ervi

ce u

sers

wh

o h

ad h

ad a

rec

ent

hos

pita

l ad

mis

sion

, an

d t

o ex

amin

e th

e re

latio

nsh

ip b

etw

een

refu

sals

an

d s

ervi

ce

use

r ch

arac

teri

stic

s.

Mix

ed m

eth

ods

– co

nte

nt

anal

ysis

of

Join

t C

risi

s P

lan

s,

and

rou

tine

care

p

lan

s in

su

b-

sam

ple

s fr

om

a m

ulti

-cen

tre

ran

dom

ised

co

ntr

olle

d t

rial

of

Joi

nt

Cri

sis

Pla

ns

(plu

s ro

utin

e m

enta

l h

ealth

car

e)

vers

us

rou

tine

care

alo

ne

(CR

IMS

ON

) in

E

ng

lan

d.

99 o

f 22

1 (4

5%)

of t

he

Join

t C

risi

s P

lan

s co

nta

ined

a

trea

tmen

t re

fusa

l com

par

ed t

o 10

of

424

(2.4

%)

bas

elin

e ro

utin

e ca

re p

lan

s. N

o Jo

int

Cri

sis

Pla

ns

reco

rded

d

isag

reem

ent

with

ref

usa

ls o

n t

he

par

t of

clin

icia

ns.

A

mon

g t

hos

e w

ith c

omp

lete

d J

oin

t C

risi

s P

lan

s,

adju

sted

an

alys

es in

dic

ated

a s

ign

ifica

nt

asso

ciat

ion

bet

wee

n t

reat

men

t re

fusa

ls a

nd

per

ceiv

ed c

oerc

ion

at b

asel

ine

(od

ds

ratio

= 1

.21,

95%

CI 1

.02-

1.43

), b

ut

not

with

bas

elin

e w

orki

ng

alli

ance

or

a p

ast

his

tory

of

invo

lun

tary

ad

mis

sion

. Th

ey d

emon

stra

ted

sig

nifi

can

t d

eman

d f

or w

ritt

en t

reat

men

t re

fusa

ls in

lin

e w

ith t

he

Men

tal C

apac

ity A

ct 2

005,

wh

ich

had

not

pre

viou

sly

bee

n e

licite

d b

y th

e p

roce

ss o

f tr

eatm

ent

pla

nn

ing

. Fu

ture

tre

atm

ent/

cris

is p

lan

s sh

ould

inco

rpor

ate

the

opp

ortu

nity

for

ser

vice

use

rs t

o re

cord

a t

reat

men

t re

fusa

l du

rin

g t

he

dra

ftin

g o

f su

ch p

lan

s

159

Hen

der

son

, C;

et a

l 20

04E

ng

lan

d

160

peo

ple

with

an

op

erat

ion

al

dia

gn

osis

of

psy

chot

ic

illn

ess

or n

on-

psy

chot

ic b

ipol

ar

dis

ord

er w

ho

had

exp

erie

nce

d a

hos

pita

l ad

mis

sion

with

in

the

pre

viou

s tw

o ye

ars.

To in

vest

igat

e w

het

her

a

form

of

adva

nce

ag

reem

ent

for

peo

ple

with

sev

ere

men

tal i

llnes

s ca

n re

du

ce t

he

use

of

inp

atie

nt

serv

ices

an

d co

mp

uls

ory

adm

issi

on

or t

reat

men

t.

Qu

antit

ativ

e:

Sin

gle

blin

d ra

nd

omis

ed

con

trol

led

tria

l, w

ith

ran

dom

isat

ion

of in

div

idu

al

pat

ien

ts. T

he

inve

stig

ator

w

as b

lind

to

allo

catio

n.

Use

of

the

Men

tal H

ealth

Act

was

sig

nifi

can

tly r

edu

ced

for

the

inte

rven

tion

gro

up

, 13%

(10

/80)

of

wh

om

exp

erie

nce

d c

omp

uls

ory

adm

issi

on o

r tr

eatm

ent

com

par

ed w

ith 2

7% (

21/8

0) o

f th

e co

ntr

ol g

rou

p (

risk

ra

tio 0

.48,

95%

con

fiden

ce in

terv

al 0

.24

to 0

.95,

P =

0.

028)

. Th

e au

thor

s co

ncl

ud

ed t

hat

th

e u

se o

f Jo

int

Cri

sis

Pla

ns

red

uce

d c

omp

uls

ory

adm

issi

ons

and

trea

tmen

t in

pat

ien

ts w

ith s

ever

e m

enta

l illn

ess.

Th

e re

du

ctio

n in

ove

rall

adm

issi

on w

as le

ss. A

ccor

din

g t

o th

e au

thor

s ‘[

t]h

is is

th

e fir

st s

tru

ctu

red

clin

ical

inte

rven

tion

that

see

ms

to r

edu

ce c

omp

uls

ory

adm

issi

on a

nd

trea

tmen

t in

men

tal h

ealth

ser

vice

s.’

Hen

der

son

, C;

Floo

d, C

; Lee

se,

M; T

hor

nic

roft

, G

; Su

ther

by,

K;

Szm

ukl

er, G

2009

En

gla

nd

62 a

du

lts w

ho

rece

ived

a J

oin

t C

risi

s P

lan

.

To r

epor

t p

artic

ipan

ts’

and

cas

e m

anag

ers’

u

se o

f an

d v

iew

s on

th

e va

lue

of J

oin

t C

risi

s P

lan

s (J

CP

s), s

how

n to

red

uce

com

pu

lsor

y h

osp

italis

atio

n a

nd

viol

ence

.

Mix

ed m

eth

ods

– q

ual

itativ

e re

sear

ch in

th

e fo

rm o

f q

ues

tion

nai

res.

Inte

rven

tion

gro

up

par

ticip

ants

wer

e in

terv

iew

ed o

n re

ceip

t of

th

e JC

P, o

n h

osp

italis

atio

n, a

nd

at

15-m

onth

fo

llow

-up

s; c

ase

man

ager

s w

ere

inte

rvie

wed

at

15

mon

ths.

46-

96%

of

JCP

hol

der

s (N

= 4

4) r

esp

ond

ed

pos

itive

ly t

o q

ues

tion

s co

nce

rnin

g t

he

valu

e of

th

e JC

P

at im

med

iate

fol

low

up

. At

15 m

onth

s th

e p

rop

ortio

ns

of p

ositi

ve r

esp

onse

s to

th

e d

iffer

ent

qu

estio

ns

was

14-

82%

(N

= 5

0). T

hir

ty-n

ine

to e

igh

ty-fi

ve p

er c

ent

of c

ase

man

ager

s (N

= 2

8) r

esp

ond

ed p

ositi

vely

at

15 m

onth

s.

Com

par

ing

th

e to

tal s

core

s of

par

ticip

ants

wh

o h

ad

com

ple

ted

bot

h t

he

initi

al a

nd

fol

low

up

qu

estio

nn

aire

s sh

owed

a s

hift

in r

esp

onse

s, f

rom

pos

itive

to

no

chan

ge,

fr

om t

he

imm

edia

te f

ollo

w u

p t

o 15

mon

ths

(mea

ns

6.1

vs. 8

.3, d

iffer

ence

2.2

, 95%

CI 0

.8, 3

.7, P

= 0

.003

) w

her

e a

hig

her

sco

re in

dic

ates

less

pos

itive

vie

ws.

Th

e tw

o ite

ms

that

rec

eive

d h

igh

est

end

orse

men

t al

so s

how

ed

leas

t sh

ift o

ver

time,

i.e.

wh

eth

er t

he

par

ticip

ant

wou

ld

reco

mm

end

th

e JC

P t

o ot

her

s (9

0% in

itial

vs.

82%

at

15

mon

ths)

an

d w

het

her

th

ey f

elt

mor

e in

con

trol

of

thei

r m

enta

l hea

lth p

rob

lem

as

a re

sult

(71%

at

initi

al v

s. 5

6%

at 1

5 m

onth

s). C

ase

man

ager

s at

15

mon

ths

wer

e m

ore

pos

itive

th

an s

ervi

ce u

sers

, with

tot

al s

core

mea

ns

of 5

vs

. 7.8

(d

iffer

ence

-2.

8, 9

5% C

I -4.

5, -

1.2,

P =

0.0

02).

160

Heu

man

n, K

; B

ock,

T; L

inco

ln,

TM20

17G

erm

any

83 s

ervi

ce u

sers

In r

ecen

t ye

ars

the

leg

al b

asis

in G

erm

any

for

the

use

of

coer

cive

m

easu

res

in p

sych

iatr

y h

as c

han

ged

, yet

th

ere

is n

o re

gu

latio

n o

f th

e ty

pe

or a

mou

nt

of ‘

mild

er m

easu

res’

, w

hic

h m

ust

now

be

use

d. T

he

auth

ors

inve

stig

ated

wh

ich

and

how

man

y ‘m

ilder

m

easu

res’

wer

e ex

per

ien

ced

by

serv

ice

use

rs b

efor

e co

erci

on

was

use

d a

nd

wh

ich

mea

sure

s th

ey v

alu

e as

pot

entia

lly h

elp

ful t

o av

oid

it.

Qu

antit

ativ

e –

onlin

e su

rvey

of

83

serv

ice

use

rs. T

hei

r ex

per

ien

ce

with

21

mild

er

mea

sure

s an

d th

eir

eval

uat

ion

of w

het

her

th

e m

easu

res

wer

e h

elp

ful w

ere

asse

ssed

by

self-

rep

ortin

g.

On

ave

rag

e, p

artic

ipan

ts r

epor

ted

5.4

exp

erie

nce

d m

ilder

m

easu

res.

Th

e m

ost

freq

uen

t re

ason

pro

vid

ed f

or w

hy

mea

sure

s fa

iled

wer

e st

ruct

ura

l fac

tors

, fol

low

ed b

y st

aff

beh

avio

ur,

and

rea

son

s ca

use

d b

y th

e p

artic

ipan

ts

them

selv

es. T

he

only

mild

er m

easu

re r

ated

by

less

th

an

50 %

as

pot

entia

lly h

elp

ful i

n a

void

ing

coe

rciv

e m

easu

res

was

bei

ng

per

suad

ed t

o ta

ke m

edic

atio

n. A

lthou

gh

man

y m

ilder

mea

sure

s ar

e p

erce

ived

as

pot

entia

lly

hel

pfu

l, on

ly f

ew s

eem

to

be

mad

e u

se o

f in

rou

tine

clin

ical

pra

ctic

e. T

he

auth

ors

con

clu

de

that

in o

rder

to

pre

ven

t co

erci

on s

taff

mem

ber

s sh

ould

ap

ply

a w

ider

ra

ng

e of

mild

er m

easu

res.

Høj

lun

d M

; Høg

h L;

Boj

esen

, A;

Mu

nk-

Jørg

ense

n P

; Ste

nag

er E

2018

Den

mar

k

Dat

a fr

om 1

01

adm

issi

ons

afte

r im

ple

men

tatio

n of

inte

rven

tion

s w

ere

com

par

ed

with

dat

a fr

om

85 a

dm

issi

ons

in a

his

tori

cal

refe

ren

ce c

ohor

t.

To q

uan

tify

and

com

par

e th

e u

se o

f an

tipsy

chot

ic a

nd

anxi

olyt

ic m

edic

atio

ns

in c

onn

ectio

n w

ith t

he

imp

lem

enta

tion

of

a p

rog

ram

me

to r

edu

ce

coer

cion

an

d r

estr

ain

t.

Mix

ed m

eth

ods

– q

uan

titat

ive

anal

ysis

of

serv

ice

dat

a co

mb

ined

with

ob

serv

atio

nal

st

ud

y in

a

gen

eral

p

sych

iatr

ic

war

d.

Mea

n d

efin

ed d

aily

dos

es o

f an

tipsy

chot

ics,

b

enzo

dia

zep

ines

or

the

tota

l am

oun

t of

bot

h s

how

ed

no

diff

eren

ce b

efor

e an

d a

fter

imp

lem

enta

tion

of

the

pro

gra

mm

e. T

he

dat

a sh

owed

th

at n

eith

er t

otal

dos

e of

an

tipsy

chot

ics

(ad

just

ed ‐

: .0

5, 9

5% c

onfid

ence

inte

rval

(C

I): −

0.20

to

0.31

), t

otal

dos

e of

ben

zod

iaze

pin

es

(ad

just

ed ‐

: −.1

3, 9

5%C

I: −

.42

to 0

.16)

nor

tot

al a

mou

nt

of b

oth

dru

gs

(ad

just

ed ‐

: .00

, 95%

CI:

−.2

6 to

0.2

1)

incr

ease

d a

fter

imp

lem

enta

tion

. A d

ecre

ase

in c

oerc

ive

mea

sure

s fr

om 2

013

to 2

016

has

not

lead

to

sig

nifi

can

t in

crea

ses

in t

he

use

of

antip

sych

otic

med

icat

ion

or b

enzo

dia

zep

ines

. Th

e in

terv

entio

ns

are

use

ful i

n es

tab

lish

ing

res

trai

nt-

free

war

ds,

an

d c

aref

ul m

onito

rin

g

of t

he

psy

chop

har

mac

olog

ical

tre

atm

ent

is im

por

tan

t fo

r p

atie

nt

safe

ty.

161

Høy

er, G

; Kje

llin

, L;

En

gb

erg

, M;

Kal

tiala

-Hei

no,

R

; Nils

tun

, T;

Sig

urj

ónsd

óttir

, M

; Sys

e, A

2002

Den

mar

k,

Fin

lan

d,

Icel

and

, N

orw

ay,

and

Sw

eden

(N

orth

ern

Eu

rop

e)

Not

sta

ted

Stu

dy

calle

d ‘P

ater

nal

ism

an

d A

uto

nom

y—A

Nor

dic

S

tud

y on

th

e U

se o

f C

oerc

ion

in t

he

Men

tal

Hea

lth C

are

Sys

tem

,’ is

a

join

t st

ud

y in

volv

ing

al

l th

e fiv

e N

ord

ic

cou

ntr

ies

(Den

mar

k,

Fin

lan

d, I

cela

nd

, N

orw

ay, a

nd

Sw

eden

).

Mix

ed m

eth

ods

- te

xtu

al a

nal

ysis

an

d in

terv

iew

s w

ith e

thic

ists

, la

wye

rs, a

nd

ph

ysic

ian

s,

‘cor

e in

terv

iew

’ w

ith s

ervi

ce

use

rs, d

ata

from

m

edic

al r

ecor

ds

and

rel

ated

d

ocu

men

ts

Pre

limin

ary

dat

a fr

om a

ll N

ord

ic c

oun

trie

s su

gg

est

that

per

ceiv

ed c

oerc

ion

ten

ds

to b

e a

‘dic

hot

omiz

ed

ph

enom

enon

’, m

easu

red

bot

h b

y th

e ‘M

PC

S’

and

the

‘Coe

rcio

n L

add

er’,

an

d t

his

dic

hot

omiz

ed p

atte

rn

rem

ain

s ev

en w

hen

for

mal

ly v

olu

nta

rily

an

d in

volu

nta

rily

ad

mitt

ed p

atie

nts

are

stu

die

d s

epar

atel

y. T

he

auth

ors

rep

ort

bei

ng

‘u

nab

le t

o p

rod

uce

a g

ood

exp

lan

atio

n fo

r th

e b

imod

al d

istr

ibu

tion

of

per

ceiv

ed c

oerc

ion’

an

d ra

ise

‘qu

estio

ns

abou

t fla

ws

in t

he

inst

rum

ents

use

d t

o m

easu

re p

erce

ived

coe

rcio

n’ a

nd

‘if

per

ceiv

ed c

oerc

ion

real

ly is

a d

ich

otom

ized

ph

enom

enon

an

d, i

n t

his

way

, m

ore

rese

mb

les

the

con

cep

t of

“in

teg

rity

.”’

Hu

ber

, CG

; S

chn

eeb

erg

er,

AR

; Kow

alin

ski,

E; F

röh

lich

, D

; Fel

ten

, S

von

; Wal

ter,

M; Z

inkl

er, M

; B

ein

e, K

; Hei

nz,

A

; Bor

gw

ard

t, S

; La

ng

, UE

2016

Ger

man

y

349

574

adm

issi

ons

to 2

1 G

erm

an

psy

chia

tric

in

pat

ien

t h

osp

itals

fro

m

Jan

1, 1

998,

to

Dec

31,

201

2.

To c

omp

are

hos

pita

ls

with

out

lock

ed w

ard

s an

d h

osp

itals

with

lo

cked

war

ds

and

to

esta

blis

h w

het

her

h

osp

ital t

ype

has

an

eff

ect

on t

hes

e ou

tcom

es.

Qu

antit

ativ

e –

nat

ura

listic

ob

serv

atio

nal

st

ud

y w

ith

linea

r m

ixed

-ef

fect

s m

odel

s to

an

alys

e th

e d

ata.

Patie

nts

at

risk

are

oft

en a

dm

itted

to

lock

ed w

ard

s in

p

sych

iatr

ic h

osp

itals

to

pre

ven

t ab

scon

din

g, s

uic

ide

atte

mp

ts, a

nd

dea

th b

y su

icid

e. H

owev

er, t

her

e is

in-

suffi

cien

t ev

iden

ce t

hat

tre

atm

ent

on lo

cked

war

ds

can

effe

ctiv

ely

pre

ven

t th

ese

outc

omes

. In

th

e 14

5 73

8 p

rop

-en

sity

sco

re-m

atch

ed c

ases

, su

icid

e (O

R 1

·326

, 95%

CI

0·80

3–2·

113;

p=

0·24

), s

uic

ide

atte

mp

ts (

1·0

57, 0

·787

–1·

412;

p=

0·71

), a

nd

ab

scon

din

g w

ith r

etu

rn (

1·28

8,

0·87

4–1·

929;

p=

0·21

) an

d w

ithou

t re

turn

(1·

090,

0·7

22–

1·65

9; p

=0·

69)

wer

e n

ot in

crea

sed

in h

osp

itals

with

an

open

doo

r p

olic

y. C

omp

ared

with

tre

atm

ent

on lo

cked

w

ard

s, t

reat

men

t on

op

en w

ard

s w

as a

ssoc

iate

d w

ith

a d

ecre

ased

pro

bab

ility

of

suic

ide

atte

mp

ts (

OR

0·6

58,

95%

CI 0

·504

–0·8

64; p

=0·

003)

, ab

scon

din

g w

ith r

etu

rn

(0·6

29, 0

·524

–0·7

64; p

<0·

0001

), a

nd

ab

scon

din

g w

ithou

t re

turn

(0·

707,

0·5

46–0

·925

; p=

0·01

), b

ut

not

com

ple

ted

suic

ide

(0·8

23, 0

·376

–1·7

66; p

=0·

63).

Loc

k-ed

doo

rs

mig

ht

not

be

able

to

pre

ven

t su

icid

e an

d a

bsc

ond

ing

.

162

Hu

stof

t, K

; La

rsen

, TK

; B

røn

nic

k, K

; Joa

, I;

Joh

ann

esse

n,

JO; R

uu

d, T

2018

Nor

way

3338

pat

ien

ts

refe

rred

for

ad

mis

sion

in 2

0 N

orw

egia

n a

cute

p

sych

iatr

ic u

nits

ac

ross

3 m

onth

s in

200

5–06

(a

bou

t 75

% o

f n

atio

nal

acu

te

un

its).

The

aim

of

this

stu

dy

was

to

inve

stig

ate

the

exte

nt

to

wh

ich

Invo

lun

tari

ly

Hos

pita

lised

(I

H)

pat

ien

ts

wer

e co

nve

rted

to

a V

olu

nta

ry

Hos

pita

lisat

ion

(VH

), a

nd

to

iden

tify

pre

dic

tive

fact

ors

lead

ing

to

this

co

nve

rsio

n.

Qu

antit

ativ

e –

anal

ysis

of

ser

vice

d

ata

usi

ng

g

ener

aliz

ed

linea

r m

ixed

m

odel

ling

.

The

inci

den

t of

con

vers

ion

fro

m in

volu

nta

rily

hos

-p

italis

atio

n (

IH)

to v

olu

nta

ry h

osp

italis

atio

n (

VH

) w

as

anal

ysed

. Ou

t of

333

8 p

atie

nts

ref

erre

d f

or a

dm

issi

on,

1468

wer

e IH

(44

%)

and

187

0 w

ere

VH

. Aft

er r

e-ev

alu

atio

n, 1

148

(78.

2%)

rem

ain

ed o

n in

volu

nta

ry

hos

-pita

lisat

ion

, wh

ile 3

20 p

atie

nts

(21

.8%

) w

ere

con

vert

ed t

o vo

lun

tary

hos

pita

lisat

ion

. Th

e p

re-

dic

tors

of

con

vers

ion

fro

m in

volu

nta

ry t

o vo

lun

tary

h

osp

italis

atio

n a

fter

re-

eval

uat

ion

of

a sp

ecia

list

incl

ud

ed

pat

ien

ts w

antin

g a

dm

issi

on, b

ette

r sc

ores

on

Glo

bal

A

sses

smen

t of

Sym

pto

m s

cale

, few

er h

allu

cin

atio

ns

and

del

usi

ons

and

hig

her

alc

ohol

inta

ke. T

he

24h

re-

eval

uat

ion

per

iod

for

pat

ien

ts r

efer

red

for

invo

lun

tary

h

osp

italis

atio

n, a

s st

ipu

late

d b

y th

e N

orw

egia

n M

enta

l H

ealth

Car

e A

ct, a

pp

eare

d t

o g

ive

adeq

uat

e op

por

tun

ity

to r

edu

ce u

nn

eces

sary

invo

lun

tary

hos

pita

lisat

ion

, wh

ile

safe

gu

ard

ing

th

e p

atie

nt’

s ri

gh

t to

VH

.

Hu

sum

, TL;

B

jørn

gaa

rd, J

H;

Fin

set,

A; R

uu

d, T

2010

Nor

way

The

stu

dy

incl

ud

es d

ata

from

32

acu

te

psy

chia

tric

w

ard

s an

d 1

214

invo

lun

tari

ly

adm

itted

p

erso

ns.

This

stu

dy

inve

stig

ates

to

wh

at e

xten

t u

se o

f se

clu

sion

, res

trai

nt

and

invo

lun

tary

med

icat

ion

for

invo

lun

tary

ad

mitt

ed p

atie

nts

in

Nor

weg

ian

acu

te

psy

chia

tric

war

ds

is a

ssoc

iate

d w

ith

pat

ien

t, s

taff

an

d w

ard

char

acte

rist

ics.

Qu

antit

ativ

e –

mu

ltile

vel

log

istic

re

gre

ssio

n u

sin

g S

tata

was

ap

plie

d w

ith

serv

ice

dat

a fr

om p

atie

nts

th

at w

ere

linke

d to

dat

a ab

out

war

ds.

The

tota

l nu

mb

er o

f in

volu

nta

ry a

dm

itted

pat

ien

ts

was

121

4 (3

5% o

f to

tal s

amp

le).

Th

e p

erce

nta

ge

of

pat

ien

ts w

ho

wer

e ex

pos

ed t

o co

erci

ve m

easu

res

ran

ged

fro

m 0

-88%

acr

oss

war

ds.

Of

the

invo

lun

tary

ad

mitt

ed p

atie

nts

, 424

(35

%)

had

bee

n s

eclu

ded

, 117

(1

0%)

had

bee

n r

estr

ain

ed a

nd

113

(9%

) h

ad r

ecei

ved

invo

lun

tary

dep

ot m

edic

atio

n a

t d

isch

arg

e. D

ata

from

10

16 p

atie

nts

cou

ld b

e lin

ked

in t

he

mu

ltile

vel a

nal

ysis

. Th

e au

thor

s co

ncl

ud

e th

at t

he

sub

stan

tial b

etw

een

-w

ard

var

ian

ce, e

ven

wh

en a

dju

stin

g f

or p

atie

nts

’ in

div

idu

al p

sych

opat

hol

ogy,

ind

icat

es t

hat

war

d f

acto

rs

influ

ence

th

e u

se o

f se

clu

sion

, res

trai

nt

and

invo

lun

tary

m

edic

atio

n a

nd

th

at s

ome

war

ds

hav

e th

e p

oten

tial f

or

qu

ality

imp

rove

men

t. T

hey

con

clu

de

that

inte

rven

tion

s to

red

uce

th

e u

se o

f se

clu

sion

, res

trai

nt

and

invo

lun

tary

m

edic

atio

n s

hou

ld t

ake

into

acc

oun

t or

gan

isat

ion

al a

nd

envi

ron

men

tal f

acto

rs.

163

Jaeg

er, M

; K

ette

ler,

D;

Rab

ensc

hla

g, F

; Th

eod

orid

ou, A

2014

Sw

itzer

lan

d39

men

tal h

ealth

p

rofe

ssio

nal

s.

This

pilo

t st

ud

y ai

med

at

inve

stig

atin

g

how

men

tal h

ealth

p

rofe

ssio

nal

s on

acu

te

psy

chia

tric

war

ds

reco

gn

ise

diff

eren

t le

vels

of

form

al a

nd

info

rmal

coe

rcio

ns

and

trea

tmen

t p

ress

ure

s as

wel

l as

thei

r at

titu

de

tow

ard

s th

ese

inte

rven

tion

s.

Mix

ed m

eth

ods

– cr

oss-

sect

ion

al

surv

ey u

sin

g a

q

ues

tion

nai

re

that

con

sist

ed

of 1

5 vi

gn

ette

s d

escr

ibin

g

typ

ical

clin

ical

si

tuat

ion

s on

fiv

e d

iffer

ent

stag

es o

f th

e co

ntin

uu

m o

f co

erci

on.

Low

leve

ls o

f co

erci

on a

re r

ecog

nis

ed a

deq

uat

ely

wh

ile

hig

her

leve

ls a

re g

ross

ly u

nd

eres

timat

ed. T

he

deg

ree

of

coer

cion

inh

eren

t to

inte

rven

tion

s co

mp

risi

ng

per

suas

ion

and

leve

rag

e w

as u

nd

eres

timat

ed b

y p

rofe

ssio

nal

s w

ith

a p

ositi

ve a

ttitu

de

and

ove

rest

imat

ed b

y th

ose

with

a

neg

ativ

e at

titu

de

tow

ard

s th

e re

spec

tive

inte

rven

tion

s.

No

asso

ciat

ion

s of

th

e ab

ility

to

reco

gn

ise

diff

eren

t le

vels

of

coer

cion

with

war

d o

r st

aff

rela

ted

var

iab

les

wer

e fo

un

d. H

igh

er k

now

led

ge

on a

mb

igu

ous

vari

atio

ns

of c

oerc

ive

inte

rven

tion

s se

ems

to f

oste

r m

ore

bal

ance

d re

flect

ion

s ab

out

thei

r et

hic

al im

plic

atio

ns.

Th

e au

thor

s co

ncl

ud

e th

at ‘

(a)d

van

ced

un

der

stan

din

g o

f in

fluen

cin

g

fact

ors

of p

rofe

ssio

nal

s‐ a

ttitu

des

tow

ard

s co

erci

on

cou

ld le

ad t

o im

pro

ved

tra

inin

g o

f p

rofe

ssio

nal

s in

u

tiliz

ing

inte

rven

tion

s to

en

han

ce t

reat

men

t ad

her

ence

in

an in

form

ed a

nd

eth

ical

way

’.

Jaeg

er, M

; K

onra

d, A

; R

uee

gg

, S;

Rab

ensc

hla

g, F

2015

Sw

itzer

lan

d

63 s

ervi

ce u

sers

of

an

acu

te

psy

chia

tric

un

it in

Sw

itzer

lan

d.

This

nat

ura

listic

ob

serv

atio

nal

stu

dy

seek

s to

eva

luat

e th

e su

bje

ctiv

e p

ersp

ectiv

e an

d fu

nct

ion

al o

utc

ome

of in

pat

ien

ts b

efor

e an

d a

fter

str

uct

ura

l al

tera

tion

s. T

he

chan

ges

mad

e w

ere

the

intr

odu

ctio

n o

f tr

eatm

ent

con

fere

nce

s an

d c

onjo

int

trea

tmen

t p

lan

nin

g, r

edu

ctio

n o

f th

e to

tal t

ime

spen

t on

re

por

ts a

bou

t p

atie

nts

(in

th

eir

abse

nce

), a

nd

reco

very

-ori

ente

d s

taff

tr

ain

ing

on

an

acu

te

psy

chia

tric

un

it.

Mix

ed m

eth

ods

– in

terv

iew

an

d s

urv

eyin

g.

Du

rin

g 1

yea

r (2

011/

2012

) el

igib

le p

atie

nts

on

th

e st

ud

y u

nit

wer

e in

terv

iew

ed

on a

vol

un

tary

b

asis

usi

ng

es

tab

lish

ed

inst

rum

ents

to

asse

ss s

ever

al

reco

very

-re

leva

nt

asp

ects

.

Two

diff

eren

t sa

mp

les

(bef

ore

and

aft

er t

he

pro

ject

; n =

34

an

d n

= 2

9) w

ere

com

par

ed w

ith r

egar

d t

o su

bje

ctiv

e p

aram

eter

s (e

.g. p

atie

nts

’ at

titu

des

tow

ard

rec

over

y,

qu

ality

of

life,

per

ceiv

ed c

oerc

ion

, tre

atm

ent

satis

fact

ion

, an

d h

ope)

, clin

ical

an

d s

ocio

-dem

ogra

ph

ic b

asic

dat

a, a

s w

ell a

s th

e fu

nct

ion

al o

utc

ome

acco

rdin

g t

o th

e H

ealth

of

th

e N

atio

n O

utc

ome

Sca

les

(HoN

OS

). S

ome

pat

ien

t at

titu

des

tow

ard

s re

cove

ry a

nd

th

eir

self-

asse

ssm

ent

of t

he

reco

very

pro

cess

imp

rove

d d

uri

ng

th

e st

ud

y.

Oth

er s

ub

ject

ive

par

amet

ers

rem

ain

ed s

tab

le b

etw

een

sam

ple

s. F

un

ctio

nal

ou

tcom

e w

as b

ette

r in

su

bje

cts

wh

o w

ere

trea

ted

aft

er t

he

imp

lem

enta

tion

of

the

new

co

nce

pt.

Th

e le

ng

th o

f st

ay r

emai

ned

un

chan

ged

. Th

e im

ple

men

tatio

n o

f re

cove

ry-o

rien

ted

str

uct

ure

s an

d p

rovi

din

g t

he

nec

essa

ry t

heo

retic

al u

nd

erp

inn

ing

on

an

acu

te p

sych

iatr

ic u

nit

is f

easi

ble

an

d c

an h

ave

an im

pac

t on

att

itud

es a

nd

kn

owle

dg

e of

per

son

al r

ecov

ery.

164

Jan

ssen

, WA

; N

oort

hoo

rn,

EO

; Nijm

an,

HLI

; Bow

ers,

L;

Hoo

gen

doo

rn,

AW

; Sm

it, A

; W

idd

ersh

oven

, G

AM

2013

Net

her

lan

ds

718

per

son

s w

ho

had

bee

n se

clu

ded

ove

r 5,

097

adm

issi

ons

on 2

9 d

iffer

ent

adm

issi

on w

ard

s ov

er s

even

Du

tch

psy

chia

tric

h

osp

itals

.

To t

est

the

hyp

oth

esis

th

at d

iffer

ence

in

secl

usi

on fi

gu

res

bet

wee

n w

ard

s m

ay p

red

omin

antly

b

e ex

pla

ined

by

diff

eren

ces

in p

atie

nt

char

acte

rist

ics,

as

thes

e ar

e ex

pec

ted

to

hav

e a

larg

e im

pac

t on

th

ese

secl

usi

on

rate

s. N

urs

es a

nd

war

d m

anag

ers

ten

d t

o h

old

this

vie

w, a

ssu

min

g

mor

e ad

mis

sion

s of

se

vere

ly il

l pat

ien

ts

are

rela

ted

to

hig

her

se

clu

sion

rat

es.

Mix

ed m

eth

ods

– d

escr

iptiv

e an

alys

is o

f se

rvic

e d

ata,

ex

plo

rin

g

rela

tion

ship

b

etw

een

pat

ien

t an

d w

ard

char

acte

rist

ics

and

th

e w

ard

s’

nu

mb

er o

f se

clu

sion

hou

rs

per

1,0

00

adm

issi

on

hou

rs.

The

extr

eme

gro

up

an

alys

is s

how

ed t

hat

sec

lusi

on r

ates

d

epen

ded

on

bot

h p

atie

nt

and

war

d c

har

acte

rist

ics.

A

mu

ltiva

riat

e an

d m

ulti

leve

l an

alys

es r

evea

led

th

at

diff

eren

ces

in s

eclu

sion

hou

rs b

etw

een

war

ds

cou

ld

par

tially

be

exp

lain

ed b

y w

ard

siz

e n

ext

to p

atie

nt

char

acte

rist

ics.

How

ever

, th

e la

rges

t d

eal o

f th

e d

iffer

ence

bet

wee

n w

ard

s in

sec

lusi

on r

ates

cou

ld n

ot

be

exp

lain

ed b

y ch

arac

teri

stic

s m

easu

red

in t

his

stu

dy.

Th

e au

thor

s co

ncl

ud

ed w

ard

pol

icy

and

ad

equ

ate

staf

fing

may

, par

ticu

larl

y on

sm

alle

r w

ard

s, b

e ke

y is

sues

in

red

uct

ion

of

secl

usi

on.

Jan

ssen

, WA

; va

n d

e S

and

e,

R; N

oort

hoo

rn,

EO

; Nijm

an,

HLI

; Bow

ers,

L;

Mu

lder

, CL;

Sm

it,

A; W

idd

ersh

oven

, G

AM

; Ste

iner

t, T

2011

Net

her

lan

ds

Sec

lusi

on a

nd

rest

rain

t d

ata

from

31,

594

adm

issi

ons

for

20,9

34 p

atie

nts

. 12

Du

tch

men

tal

hea

lth in

stitu

tes,

co

mp

risi

ng

37

hos

pita

ls a

nd

227

w

ard

s co

nta

inin

g

6812

bed

s.

The

aim

of

this

art

icle

is

to id

entif

y p

rob

lem

s in

d

efin

ing

an

d r

ecor

din

g

coer

cive

mea

sure

s.

The

stu

dy

con

trib

ute

s to

th

e d

evel

opm

ent

of

con

sist

ent

com

par

able

m

easu

rem

ents

d

efin

ition

s an

d p

rovi

des

re

com

men

dat

ion

s fo

r m

ean

ing

ful d

ata-

anal

yses

illu

stra

ting

th

e re

leva

nce

of

the

pro

pos

ed f

ram

ewor

k.

Mix

ed m

eth

ods

– lit

erat

ure

was

re

view

ed t

o id

entif

y va

riou

s d

efin

ition

s an

d ca

lcu

latio

n m

odal

ities

use

d to

mea

sure

co

erci

ve

mea

sure

s in

p

sych

iatr

ic

inp

atie

nt

care

.

Con

sid

erab

le v

aria

tion

in w

ard

an

d p

atie

nt

char

act-

eris

tics

was

iden

tified

in t

his

stu

dy.

Th

e ch

ance

to

be

exp

osed

to

secl

usi

on p

er c

apita

inh

abita

nts

of

the

inst

itute

’s c

atch

men

t ar

eas

vari

ed b

etw

een

0.3

1 an

d 1.

6 p

er 1

00.0

00. T

he

nu

mb

er o

f se

clu

sion

inci

den

ts

per

100

0 ad

mis

sion

s va

ried

bet

wee

n 7

9 u

p t

o 74

5.

The

auth

ors

con

clu

de

that

coe

rciv

e m

easu

res

can

be

relia

bly

ass

esse

d in

a s

tan

dar

dis

ed a

nd

com

par

able

w

ay u

nd

er t

he

con

diti

on o

f u

sin

g c

lear

join

t d

efin

ition

s.

Met

hod

olog

ical

con

sen

sus

bet

wee

n r

esea

rch

ers

and

men

tal h

ealth

pro

fess

ion

als

on t

hes

e d

efin

ition

s is

ne-

cess

ary

to a

llow

com

par

ison

s of

sec

lusi

on a

nd

res

trai

nt

rate

s. T

he

stu

dy

con

trib

ute

s to

th

e d

evel

opm

ent

of

inte

rnat

ion

al s

tan

dar

ds

on g

ath

erin

g c

oerc

ion

rel

ated

d

ata

and

th

e co

nsi

sten

t ca

lcu

latio

n o

f re

leva

nt

outc

ome

par

amet

ers.

165

Joh

nso

n, S

; N

olan

, F; P

illin

g,

S; S

and

or,

A; H

oult,

J;

McK

enzi

e,

N; W

hite

, IR

; Th

omp

son

, M;

Beb

bin

gto

n, P

200

5E

ng

lan

d

260

resi

den

ts

of t

he

inn

er

Lon

don

Bor

oug

h of

Islin

gto

n w

ho

wer

e ex

per

ien

cin

g

cris

es s

ever

e en

oug

h f

or

hos

pita

l ad

mis

sion

to

be

con

sid

ered

.

To e

valu

ate

the

effe

ctiv

enes

s of

a c

risi

s re

solu

tion

tea

m.

Qu

antit

ativ

e –

ran

dom

ised

co

ntr

ol t

rial

, ex

amin

ing

se

rvic

e u

sers

’ sa

tisfa

ctio

n.

Patie

nts

in t

he

exp

erim

enta

l gro

up

wer

e le

ss li

kely

to

be

adm

itted

to

hos

pita

l in

th

e ei

gh

t w

eeks

aft

er t

he

cris

is

(od

ds

ratio

0.1

9, 9

5% c

onfid

ence

inte

rval

0.1

1 to

0.3

2),

thou

gh

com

pu

lsor

y ad

mis

sion

was

not

sig

nifi

can

tly

red

uce

d. A

diff

eren

ce o

f 1.

6 p

oin

ts in

th

e m

ean

sco

re

on t

he

clie

nt

satis

fact

ion

qu

estio

nn

aire

(C

SQ

-8)

was

n

ot q

uite

sig

nifi

can

t (P

= 0

.07)

, alth

oug

h it

bec

ame

so

afte

r ad

just

men

t fo

r b

asel

ine

char

acte

rist

ics

(P =

0.0

02).

C

risi

s re

solu

tion

tea

ms

can

red

uce

hos

pita

l ad

mis

sion

s in

men

tal h

ealth

cri

ses.

Th

ey m

ay a

lso

incr

ease

sat

-is

fact

ion

in p

atie

nts

, bu

t th

is w

as a

n e

qu

ivoc

al fi

nd

ing

.

Kal

isov

a, L

; et

al20

14

Bu

lgar

ia,

Cze

ch

Rep

ub

lic,

Ger

man

y,

Gre

ece,

It

aly,

Li

thu

ania

, Po

lan

d,

Sp

ain

, S

wed

en a

nd

En

gla

nd

.

Invo

lun

tari

ly

adm

itted

pat

ien

ts

(N =

2,0

27)

div

ided

into

tw

o g

rou

ps,

th

e fir

st (

N =

770

) su

bje

ct t

o at

leas

t on

e co

erci

ve

mea

sure

, th

e ot

her

(N

= 1

,257

) h

ad n

ot r

ecei

ved

a co

erci

ve

mea

sure

du

rin

g

hos

pita

lisat

ion

.

This

stu

dy

aim

s to

id

entif

y w

het

her

se

lect

ed p

atie

nt

and

war

d-r

elat

ed f

acto

rs

are

asso

ciat

ed w

ith

the

use

of

coer

cive

m

easu

res.

Mix

ed m

eth

ods

– d

escr

iptiv

e d

ata,

incl

ud

ing

p

atie

nts

’ so

cio-

dem

ogra

ph

ic

and

clin

ical

ch

arac

teri

stic

s an

d c

entr

e-re

late

d ch

arac

teri

stic

s.

Test

ed in

a

mu

ltiva

riat

e lo

gis

tic

reg

ress

ion

mod

el,

con

trol

led

for

cou

ntr

ies’

ef

fect

.

The

freq

uen

cy o

f co

erci

ve m

easu

res

vari

ed s

ign

ifica

ntly

ac

ross

cou

ntr

ies,

bei

ng

hig

her

in P

olan

d, I

taly

an

d G

reec

e. T

hos

e w

ho

rece

ived

coe

rciv

e m

easu

res

wer

e m

ore

ofte

n m

ale

and

dia

gn

osed

with

psy

chot

ic

dis

ord

er (

F20-

F29)

. Acc

ord

ing

to

the

reg

ress

ion

mod

el,

pat

ien

ts w

ith h

igh

er le

vels

of

psy

chot

ic a

nd

hos

tility

sy

mp

tom

s, a

nd

of

per

ceiv

ed c

oerc

ion

had

a h

igh

er r

isk

to b

e co

erce

d a

t ad

mis

sion

. Con

trol

ling

for

cou

ntr

ies’

ef

fect

, th

e ri

sk o

f b

ein

g c

oerc

ed w

as h

igh

er in

Pol

and

. Pa

tien

ts’

soci

odem

ogra

ph

ic c

har

acte

rist

ics

and

war

d-r

elat

ed f

acto

rs w

ere

not

iden

tifyi

ng

as

pos

sib

le

pre

dic

tors

bec

ause

th

ey d

id n

ot e

nte

r th

e m

odel

. Th

e u

se o

f co

erci

ve m

easu

res

vari

ed s

ign

ifica

ntly

in

the

par

ticip

atin

g c

oun

trie

s. C

linic

al f

acto

rs, s

uch

as

hig

h le

vels

of

psy

chot

ic s

ymp

tom

s an

d h

igh

leve

ls o

f p

erce

ived

coe

rcio

n a

t ad

mis

sion

wer

e as

soci

ated

with

th

e u

se o

f co

erci

ve m

easu

res,

wh

en c

ontr

ollin

g f

or

cou

ntr

ies’

eff

ect.

Th

ese

fact

ors

shou

ld b

e ta

ken

into

co

nsi

der

atio

n b

y p

rog

ram

mes

aim

ed a

t re

du

cin

g t

he

use

of

coe

rciv

e m

easu

res

in p

sych

iatr

ic w

ard

s.

166

Kes

ki-V

alka

ma,

A;

Sai

las,

E; E

ron

en,

M; K

oivi

sto,

A-M

; Lö

nn

qvi

st, J

; K

altia

la-H

ein

o, R

2007

Fin

lan

dN

atio

nal

su

rvey

of

psy

chia

tric

h

osp

itals

To e

valu

ate

the

nat

ion

wid

e tr

end

s in

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t w

ere

inve

stig

ated

in

Fin

lan

d o

ver

a 15

-ye

ar s

pan

wh

ich

was

ch

arac

teri

sed

by

leg

isla

tive

chan

ges

ai

min

g t

o cl

arify

an

d re

stri

ct t

he

use

of

thes

e m

easu

res.

Qu

antit

ativ

e –

stru

ctu

red

pos

tal s

urv

ey

of F

inn

ish

psy

chia

tric

h

osp

itals

, usi

ng

d

ata

from

th

e N

atio

nal

H

osp

ital

Dis

char

ge

Reg

iste

r.

The

tota

l nu

mb

er o

f th

e se

clu

ded

an

d r

estr

ain

ed p

atie

nts

d

eclin

ed a

s d

id t

he

nu

mb

er o

f al

l in

pat

ien

ts d

uri

ng

th

e st

ud

y w

eeks

, bu

t th

e ri

sk o

f b

ein

g s

eclu

ded

or

rest

rain

ed

rem

ain

ed t

he

sam

e ov

er t

ime

wh

en c

omp

ared

to

the

first

stu

dy

year

. Th

e d

ura

tion

of

the

rest

rain

t in

cid

ents

d

id n

ot c

han

ge,

bu

t th

e d

ura

tion

of

secl

usi

on in

crea

sed

. Th

e au

thor

s co

ncl

ud

e th

at le

gis

lativ

e ch

ang

es s

olel

y ca

nn

ot r

edu

ce t

he

use

of

secl

usi

on a

nd

res

trai

nt

or

chan

ge

the

pre

vaili

ng

tre

atm

ent

cultu

res

con

nec

ted

with

th

ese

mea

sure

s, a

nd

arg

ue

that

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t sh

ould

be

vig

ilan

tly m

onito

red

an

d e

thic

al

qu

estio

ns

shou

ld b

e u

nd

er c

ontin

uou

s sc

rutin

y.

Kle

intje

s, S

; Lu

nd

, C

; Sw

artz

, L20

13

Gh

ana,

K

enya

, R

wan

da,

S

outh

A

fric

a,

Tan

zan

ia,

Ug

and

a an

d Za

mb

ia

11 m

emb

ers

of le

ader

ship

in

men

tal

hea

lth s

elf-

hel

p or

gan

isat

ion

s (in

clu

din

g

care

rs).

This

pap

er r

epor

ts o

n ov

erar

chin

g s

trat

egie

s w

hic

h s

up

por

ted

th

e es

tab

lish

men

t an

d su

stai

nab

ility

of

nin

e m

enta

l hea

lth s

elf-

hel

p or

gan

isat

ion

s in

sev

en

Afr

ican

cou

ntr

ies.

Qu

alita

tive

– in

terv

iew

s w

ith t

hem

atic

an

alys

is.

The

inte

rvie

ws

sug

ges

t th

at s

elf-

hel

p o

rgan

isat

ion

s ca

n p

rovi

de

cru

cial

su

pp

ort

to u

sers

’ re

cove

ry in

res

ourc

e-p

oor

sett

ing

s in

Afr

ica.

Su

pp

ort

of m

inis

trie

s, N

GO

s,

DP

Os,

dev

elop

men

t ag

enci

es a

nd

pro

fess

ion

als

can

assi

st t

o b

uild

org

anis

atio

ns’

cap

acity

for

su

stai

nab

le

sup

por

t to

mem

ber

s’ r

ecov

ery.

Org

anis

atio

ns’

wor

k in

clu

de

advo

cacy

to

des

tigm

atis

e m

enta

l dis

ord

ers

and

pro

mot

e th

e p

rote

ctio

n o

f u

ser’

s ri

gh

ts, a

ctiv

ities

to

imp

rove

acc

ess

to h

ealth

car

e an

d t

o in

com

e g

ener

atio

n an

d s

ocia

l su

pp

ort,

par

ticip

atio

n in

leg

isla

tive

and

pol

icy

refo

rm, a

nd

cap

acity

bu

ildin

g o

f m

emb

ers.

Kog

stad

, RE

2009

Nor

way

335

adu

lt se

rvic

e u

sers

To in

vest

igat

e vi

olat

ion

s of

dig

nity

co

nsi

der

ed f

rom

th

e cl

ien

ts’

poi

nts

of

view

, an

d t

o su

gg

est

actio

ns

that

may

en

sure

th

at

pra

ctic

e is

bro

ug

ht

in

line

with

hu

man

rig

hts

va

lues

.

Qu

alita

tive

– in

terv

iew

s w

ith t

hem

atic

co

nte

nt

anal

ysis

.

The

auth

ors

con

clu

de

that

‘[m

]en

tal h

ealth

clie

nts

ex

per

ien

ce in

frin

gem

ents

th

at c

ann

ot b

e ex

pla

ined

w

ithou

t re

fere

nce

to

thei

r st

atu

s as

clie

nts

in a

sys

tem

w

hic

h, b

ased

on

jud

gm

ents

fro

m m

edic

al e

xper

ts,

has

a le

giti

mat

e ri

gh

t to

ign

ore

clie

nts

’ vo

ices

as

wel

l as

th

eir

fun

dam

enta

l hu

man

rig

hts

’. T

hey

arg

ue

that

‘r

ecom

men

dat

ion

s an

d p

ract

ices

sh

ould

be

har

mon

ized

w

ith t

he

new

UN

Con

ven

tion

on

th

e R

igh

ts o

f Pe

rson

s w

ith D

isab

ilitie

s (2

006)

’.

167

Kon

tio, R

; V

älim

äki,

M;

Pu

tkon

en, H

; K

uos

man

en, L

; S

cott

, A; J

offe

, G

2010

Fin

lan

d22

nu

rses

an

d 5

p

hys

icia

ns

To e

xplo

re n

urs

es’

and

ph

ysic

ian

s’

per

cep

tion

s of

wh

at

actu

ally

hap

pen

s w

hen

an

ag

gre

ssiv

e b

ehav

iou

r ep

isod

e oc

curs

on

th

e w

ard

and

wh

at a

ltern

ativ

es

to s

eclu

sion

an

d re

stra

int

are

actu

ally

in

use

as

nor

mal

sta

nd

ard

pra

ctic

e in

acu

te

psy

chia

tric

car

e.

Qu

alita

tive

– fo

cus

gro

up

inte

rvie

w

with

th

emat

ic

con

ten

t an

alys

is.

The

par

ticip

ants

bel

ieve

d t

hat

th

e d

ecis

ion

-mak

ing

p

roce

ss f

or m

anag

ing

pat

ien

ts’

agg

ress

ive

beh

avio

ur

con

tain

s so

me

in-b

uilt

eth

ical

dile

mm

as. T

hey

th

oug

ht

that

pat

ien

ts’

sub

ject

ive

per

spec

tive

rece

ived

litt

le

atte

ntio

n. N

ever

thel

ess,

th

e st

aff

pro

pos

ed a

nd

ap

pea

red

to u

se a

nu

mb

er o

f al

tern

ativ

es t

o m

inim

ise

or r

epla

ce

the

use

of

secl

usi

on a

nd

res

trai

nt.

Th

e au

thor

s co

ncl

ud

e th

at ‘

[m]e

dic

al a

nd

nu

rsin

g s

taff

nee

d t

o b

e en

cou

rag

ed

and

tau

gh

t to

: (1)

tu

ne

in m

ore

dee

ply

to

reas

ons

for

pat

ien

ts’

agg

ress

ive

beh

avio

ur;

an

d (

2) u

se a

ltern

ativ

es

to s

eclu

sion

an

d r

estr

ain

t in

ord

er t

o h

um

aniz

e p

atie

nt

care

to

a g

reat

er e

xten

t.’

Kok

anov

ić, R

; et

al20

18A

ust

ralia

90 m

enta

l hea

lth

serv

ice

use

rs

wh

o re

por

ted

dia

gn

oses

of

sch

izop

hre

nia

, p

sych

osis

, b

ipol

ar d

isor

der

an

d s

ever

e d

epre

ssio

n;

fam

ily m

emb

ers

sup

por

ting

th

em a

nd

men

tal h

ealth

p

ract

ition

ers.

The

stu

dy

aim

s to

ex

plo

re f

rom

sev

eral

p

ersp

ectiv

es t

he

bar

rier

s an

d f

acili

tato

rs

to s

up

por

ted

dec

isio

n-

mak

ing

in a

n A

ust

ralia

n co

nte

xt. S

up

por

ted

dec

isio

n-m

akin

g w

as

con

sid

ered

in t

erm

s of

inte

rper

son

al

exp

erie

nce

s an

d le

gal

su

pp

orte

d d

ecis

ion

-m

akin

g m

ech

anis

ms.

Qu

alita

tive

– in

terv

iew

dat

a w

as a

nal

ysed

th

emat

ical

ly

acro

ss a

ll p

artic

ipan

ts.

Neg

ativ

e in

terp

erso

nal

exp

erie

nce

s in

th

e m

enta

l hea

lth

care

sys

tem

un

der

min

ed in

volv

emen

t in

dec

isio

n-

mak

ing

for

peo

ple

with

psy

chia

tric

dia

gn

oses

an

d fa

mily

car

ers.

Men

tal h

ealth

pra

ctiti

oner

s n

oted

th

eir

own

dis

emp

ower

men

t in

ser

vice

sys

tem

s as

bar

rier

s to

g

ood

su

pp

orte

d d

ecis

ion

-mak

ing

pra

ctic

es. A

ll g

rou

ps

not

ed t

he

influ

ence

of

pre

vaili

ng

att

itud

es t

owar

ds

men

tal h

ealth

ser

vice

use

rs a

nd

th

e as

soci

ated

stig

ma

and

dis

crim

inat

ion

th

at e

xist

in s

ervi

ces

and

th

e b

road

er

com

mu

nity

. Th

ey r

epor

ted

th

at le

gal

su

pp

orte

d d

ecis

ion

-m

akin

g m

ech

anis

ms

faci

litat

e th

e p

artic

ipat

ion

of

men

tal

hea

lth s

ervi

ce u

sers

an

d t

hei

r fa

mily

su

pp

orte

rs in

su

pp

orte

d d

ecis

ion

-mak

ing

. Th

e au

thor

s co

ncl

ud

e th

at

enab

ling

su

pp

orte

d d

ecis

ion

-mak

ing

in c

linic

al p

ract

ice

and

pol

icy

can

be

faci

litat

ed b

y (1

) su

pp

ort

for

goo

d co

mm

un

icat

ion

ski

lls a

nd

rel

ated

att

itud

es a

nd

pra

ctic

es

amon

g m

enta

l hea

lth p

ract

ition

ers

and

rem

ovin

g b

arri

ers

to t

hei

r g

ood

pra

ctic

e in

hea

lth a

nd

soc

ial s

ervi

ces

and

(2)

intr

odu

cin

g le

gal

su

pp

orte

d d

ecis

ion

-mak

ing

m

ech

anis

ms.

168

Larr

obla

, C;

Bot

ega,

NJ

2001

Sou

th

Am

eric

a:

Arg

entin

a,

Bol

ivia

, B

razi

l, C

hile

, C

olom

bia

, E

cuad

or,

Gu

yan

a,

Para

gu

ay,

Peru

, S

uri

nam

e,

Uru

gu

ay,

and

Ven

ezu

ela

A p

osta

l su

rvey

w

as c

ond

uct

ed

of a

ll S

outh

A

mer

ican

co

un

trie

s (h

ealth

m

inis

trie

s,

nat

ion

al

psy

chia

tric

as

soci

atio

ns

and

key

info

rman

ts).

This

stu

dy

aim

s to

g

ath

er in

form

atio

n av

aila

ble

on

th

e ch

ang

es in

men

tal

hea

lth s

ervi

ces

in

Sou

th A

mer

ican

co

un

trie

s fo

llow

ing

th

e ‘s

ocia

l an

d p

oliti

cal

up

hea

vals

of

rece

nt

dec

ades

’.

Qu

antit

ativ

e –

pos

tal s

urv

ey

to a

sses

s th

e d

evel

opm

ent

of

men

tal h

ealth

p

rog

ram

mes

an

d t

he

org

anis

atio

n of

alte

rnat

ive

psy

chia

tric

car

e ce

ntr

es s

uch

as

the

psy

chia

tric

u

nits

in g

ener

al

hos

pita

ls

(PU

GH

).

The

surv

ey r

esu

lts in

dic

ate

that

mos

t of

th

e m

enta

l h

ealth

pro

gra

mm

es w

ere

imp

lem

ente

d d

uri

ng

th

e 19

80s

and

199

0s, a

nd

aim

ed a

t in

corp

orat

ing

psy

chia

tric

car

e in

to p

rim

ary

hea

lth c

are,

as

wel

l as

relo

catin

g p

rovi

sion

fr

om la

rge

hos

pita

ls t

o d

ecen

tral

ised

ser

vice

s (w

hic

h is

like

ly t

o b

e st

ron

gly

ass

ocia

ted

with

less

coe

rciv

e re

spon

ses)

. Mos

t of

th

e co

un

trie

s su

rvey

ed h

ave

less

th

an 0

.5 p

sych

iatr

ic b

eds

per

100

0 in

hab

itan

ts. T

his

ch

ang

e re

flect

s a

ten

den

cy t

o re

du

ce t

he

tota

l nu

mb

er

of p

sych

iatr

ic b

eds

and

incr

ease

th

e n

um

ber

of

PU

GH

. O

ver

the

last

10

year

s th

is in

crea

se w

as s

ign

ifica

nt

in

som

e co

un

trie

s (5

0-75

%),

bu

t w

as n

ot r

eflec

ted

in t

he

avai

lab

ility

of

adeq

uat

e h

um

an a

nd

mat

eria

l res

ourc

es. A

tr

ansi

tion

fro

m a

sys

tem

bas

ed o

n la

rge

men

tal h

osp

itals

to

alte

rnat

ive

serv

ice

pro

visi

on is

on

th

e w

ay in

Sou

th

Am

eric

an c

oun

trie

s. In

ten

sive

eff

orts

hav

e to

be

mad

e to

col

lect

an

d d

isse

min

ate

info

rmat

ion

, as

wel

l as

to

mon

itor

the

dev

elop

men

t an

d o

utc

ome

of t

he

men

tal

hea

lth p

rog

ram

mes

in t

hes

e co

un

trie

s.

Law

lor,

C;

Joh

nso

n, S

; Col

e,

L; H

owar

d, L

M20

12E

ng

lan

d

287

wom

en

adm

itted

to

an

acu

te p

sych

iatr

ic

inp

atie

nt

war

d or

a w

omen

’s

cris

is h

ouse

in

fou

r Lo

nd

on

bor

oug

hs

du

rin

g

a 12

-wee

k p

erio

d w

ere

incl

ud

ed.

To e

xplo

re e

thn

ic

vari

atio

ns

in

com

pu

lsor

y d

eten

tion

s of

wom

en, a

nd

to

exp

lore

th

e p

oten

tial

role

of

imm

edia

te

pat

hw

ays

to a

dm

issi

on

and

clin

icia

n-r

ated

re

ason

s fo

r ad

mis

sion

as

med

iato

rs o

f th

ese

diff

eren

ces.

Qu

antit

ativ

e –

des

crip

tive

dat

a d

raw

n f

rom

h

ealth

ser

vice

s.

287

wom

en f

rom

Wh

ite B

ritis

h, W

hite

Oth

er, B

ack

Car

ibb

ean

, Bla

ck A

fric

an a

nd

bla

ck o

ther

gro

up

s w

ere

incl

ud

ed. A

dju

stin

g f

or s

ocia

l an

d c

linic

al c

har

acte

rist

ics,

al

l gro

up

s of

Bla

ck p

atie

nts

an

d W

hite

oth

er p

atie

nts

w

ere

sig

nifi

can

tly m

ore

likel

y to

hav

e b

een

com

pu

lsor

ily

adm

itted

th

an W

hite

Bri

tish

pat

ien

ts; W

hite

Bri

tish

pat

ien

ts w

ere

mor

e lik

ely

than

oth

er g

rou

ps

to b

e ad

mitt

ed t

o a

cris

is h

ouse

an

d m

ore

likel

y th

an a

ll th

e B

lack

gro

up

s to

be

adm

itted

bec

ause

of

per

ceiv

ed

suic

ide

risk

. Im

med

iate

pat

hw

ays

to c

are

diff

ered

: Wh

ite

Oth

er, B

lack

Afr

ican

an

d B

lack

Oth

er g

rou

ps

wer

e le

ss

likel

y to

hav

e re

ferr

ed t

hem

selv

es in

a c

risi

s an

d m

ore

likel

y to

hav

e b

een

in c

onta

ct w

ith t

he

pol

ice.

Wh

en

adju

stm

ent

was

mad

e fo

r d

iffer

ence

s in

pat

hw

ays

to

care

, th

e et

hn

ic d

iffer

ence

s in

com

pu

lsor

y ad

mis

sion

w

ere

con

sid

erab

ly r

edu

ced

. Th

ere

are

mar

ked

eth

nic

in

equ

ities

not

on

ly b

etw

een

Wh

ite B

ritis

h a

nd

Bla

ck

wom

en, b

ut

also

bet

wee

n W

hite

Bri

tish

an

d W

hite

Oth

er

wom

en in

exp

erie

nce

s of

acu

te a

dm

issi

on. D

iffer

ence

s b

etw

een

gro

up

s in

hel

p-s

eeki

ng

beh

avio

urs

in a

cri

sis

may

con

trib

ute

to

exp

lain

ing

diff

eren

ces

in r

ates

of

com

pu

lsor

y ad

mis

sion

.

169

Lay,

B; N

ord

t, C

; R

össl

er, W

2011

Sw

itzer

lan

d96

89 in

pat

ien

ts

from

th

e ye

ar

2007

ag

ed 1

8-70

.

This

stu

dy

add

ress

es

thre

e co

erci

ve

mea

sure

s an

d t

he

role

of

pre

dic

tive

fact

ors

at b

oth

pat

ien

t an

d in

stitu

tion

al le

vels

.

Qu

antit

ativ

e –

use

d ‘g

ener

aliz

ed

estim

atin

g

equ

atio

n’

mod

els

to

anal

yse

vari

atio

n in

rat

es b

etw

een

psy

chia

tric

h

osp

itals

.

The

auth

ors

rep

ort

qu

otas

of

24.8

% in

volu

nta

ry

adm

issi

ons,

6.4

% s

eclu

sion

/res

trai

nt

and

4.2

%

coer

ced

med

icat

ion

. Res

ults

su

gg

est

that

th

e ki

nd

an

d se

veri

ty o

f m

enta

l illn

ess

are

the

mos

t im

por

tan

t ri

sk

fact

ors

for

bei

ng

su

bje

cted

to

any

form

of

coer

cion

. V

aria

tion

acr

oss

the

six

psy

chia

tric

hos

pita

ls w

as h

igh

, ev

en a

fter

acc

oun

ting

for

ris

k fa

ctor

s on

th

e p

atie

nt

leve

l su

gg

estin

g t

hat

cen

tre

effe

cts

are

an im

por

tan

t so

urc

e of

var

iab

ility

. How

ever

, eff

ects

of

the

hos

pita

l ch

arac

teri

stic

s ‘s

ize

of t

he

hos

pita

l’, ‘

len

gth

of

inp

atie

nt

stay

’, a

nd

‘w

ork

load

of

the

nu

rsin

g s

taff

’ w

ere

only

w

eak

(‘b

ed o

ccu

pan

cy r

ate’

was

not

sta

tistic

ally

si

gn

ifica

nt)

.

Lay,

B; B

lan

k, C

; Le

ng

ler,

S; D

rack

, T;

Ble

iker

, M;

Rös

sler

, W

2015

Sw

itzer

lan

d

238

inp

atie

nts

w

ho

had

at

leas

t on

e co

mp

uls

ory

adm

issi

on d

uri

ng

th

e p

ast

24

mon

ths.

The

aim

of

this

stu

dy

was

to

eval

uat

e an

inte

rven

tion

pro

gra

mm

e fo

r p

eop

le

with

sev

ere

men

tal

illn

ess

that

tar

get

s th

e re

du

ctio

n in

co

mp

uls

ory

psy

chia

tric

ad

mis

sion

s. In

th

e cu

rren

t st

ud

y, t

he

rese

arch

ers

exam

ine

the

feas

ibili

ty o

f re

tain

ing

pat

ien

ts in

th

is p

rog

ram

me

and

com

par

e ou

tcom

es

over

th

e fir

st 1

2 m

onth

s to

th

ose

afte

r tr

eatm

ent

as u

sual

(T

AU

).

Qu

antit

ativ

e –

ran

dom

ised

co

ntr

olle

d in

terv

entio

n st

ud

y co

nd

uct

ed

curr

ently

at

fou

r p

sych

iatr

ic

hos

pita

ls in

th

e C

anto

n o

f Zu

rich

.

Part

icip

ants

wer

e as

sig

ned

at

ran

dom

to

the

inte

rven

tion

or t

o th

e TA

U g

rou

p. T

he

inte

rven

tion

pro

gra

mm

e co

nsi

sts

of in

div

idu

alis

ed p

sych

o-ed

uca

tion

foc

usi

ng

on

beh

avio

urs

pri

or t

o ill

nes

s-re

late

d c

risi

s, c

risi

s ca

rds

and

, af

ter

dis

char

ge

from

th

e p

sych

iatr

ic h

osp

ital,

a 24

-mon

th

pre

ven

tive

mon

itori

ng

. In

tot

al, 2

38 (

of 7

56 a

pp

roac

hed

) in

pat

ien

ts w

ere

incl

ud

ed in

th

e tr

ial.

Aft

er 1

2 m

onth

s,

80 (

67.2

%)

in t

he

inte

rven

tion

gro

up

an

d 1

02 (

85.7

%)

in t

he

TAU

gro

up

wer

e st

ill p

artic

ipat

ing

in t

he

tria

l. O

f th

ese,

22.

5 %

in t

he

inte

rven

tion

gro

up

(35

.3 %

TA

U)

had

bee

n c

omp

uls

orily

rea

dm

itted

to

psy

chia

try;

res

ults

su

gg

est

a si

gn

ifica

ntly

low

er n

um

ber

of

com

pu

lsor

y re

adm

issi

ons

per

pat

ien

t (0

.3 in

terv

entio

n; 0

.7 T

AU

).

This

inte

rim

an

alys

is s

ug

ges

ts b

enefi

cial

eff

ects

of

this

in

terv

entio

n f

or t

arg

eted

psy

chia

tric

pat

ien

ts.

170

Lay,

B; K

awoh

l, W

; Rös

sler

, W

2018

Sw

itzer

lan

d

238

inp

atie

nts

w

ho

had

at

leas

t on

e co

mp

uls

ory

adm

issi

on d

uri

ng

th

e p

ast

24

mon

ths.

The

aim

of

this

stu

dy

was

to

eval

uat

e an

inte

rven

tion

pro

gra

mm

e fo

r p

eop

le

with

sev

ere

men

tal

illn

ess

that

tar

get

s th

e re

du

ctio

n in

co

mp

uls

ory

psy

chia

tric

ad

mis

sion

s. In

th

e cu

rren

t st

ud

y, t

he

rese

arch

ers

exam

ine

the

feas

ibili

ty o

f re

tain

ing

pat

ien

ts in

th

is p

rog

ram

me

and

com

par

e ou

tcom

es

over

th

e 24

mon

ths

to

thos

e af

ter

trea

tmen

t as

usu

al (

TAU

).

Qu

antit

ativ

e –

ran

dom

ised

co

ntr

olle

d in

terv

entio

n st

ud

y co

nd

uct

ed

curr

ently

at

fou

r p

sych

iatr

ic

hos

pita

ls in

th

e C

anto

n o

f Zu

rich

.

Few

er p

artic

ipan

ts w

ho

com

ple

ted

th

e 24

-mon

th

pro

gra

mm

e w

ere

com

pu

lsor

ily r

ead

mitt

ed t

o p

sych

iatr

y (2

8%),

com

par

ed w

ith t

hos

e re

ceiv

ing

TA

U (

43%

).

Like

wis

e, t

he

nu

mb

er o

f co

mp

uls

ory

read

mis

sion

s p

er p

atie

nt

was

sig

nifi

can

tly lo

wer

(0.

6 v.

1.0

) an

d in

volu

nta

ry e

pis

odes

wer

e sh

orte

r (1

5 v.

31

day

s),

com

par

ed w

ith T

AU

. A n

egat

ive

bin

omia

l reg

ress

ion

mod

el s

how

ed a

sig

nifi

can

t in

terv

entio

n e

ffec

t (R

R 0

.6;

95%

con

fiden

ce in

terv

al 0

.3–0

.9);

fu

rth

er f

acto

rs li

nke

d to

th

e ri

sk o

f co

mp

uls

ory

read

mis

sion

wer

e th

e n

um

ber

of

com

pu

lsor

y ad

mis

sion

s in

th

e p

atie

nt’

s h

isto

ry (

RR

2.

8), t

he

dia

gn

osis

of

a p

erso

nal

ity d

isor

der

(R

R 2

.8),

or

a p

sych

otic

dis

ord

er (

RR

1.9

). D

rop

outs

(37

% in

terv

entio

n g

rou

p; 2

2% T

AU

) w

ere

char

acte

rise

d b

y a

hig

h n

um

ber

of

com

pu

lsor

y ad

mis

sion

s p

rior

to

the

tria

l, yo

un

ger

ag

e an

d f

orei

gn

nat

ion

ality

. Th

is s

tud

y su

gg

ests

th

at t

his

in

terv

entio

n is

a f

easi

ble

an

d v

alu

able

op

tion

to

pre

ven

t co

mp

uls

ory

re-h

osp

italis

atio

n in

a ‘

hig

h-r

isk

gro

up

of p

eop

le w

ith s

ever

e m

enta

l hea

lth p

rob

lem

s, s

ocia

l d

isab

ilitie

s, a

nd

a h

isto

ry o

f h

osp

italis

atio

ns’

.

Lew

is, M

; Tay

lor,

K; P

arks

, J20

09U

nite

d S

tate

s

A 9

00-b

ed

tert

iary

car

e ac

adem

ic

med

ical

cen

tre

loca

ted

in a

n u

rban

, soc

io-

econ

omic

ally

d

istr

esse

d a

rea.

A g

rou

p o

f d

irec

t ca

re

psy

chia

tric

nu

rses

in

a la

rge

urb

an

teac

hin

g h

osp

ital

crea

ted

an

evi

den

ced

-b

ased

per

form

ance

im

pro

vem

ent

pro

gra

mm

e th

at

resu

lted

in a

dec

reas

e in

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t.

Qu

antit

ativ

e –

serv

ice

dat

a (b

efor

e/af

ter

inte

rven

tion

).

No

add

ition

al f

un

ds

wer

e re

qu

ired

to

dev

elop

th

is

pro

gra

m. T

he

pu

blic

hea

lth p

reve

ntio

n m

odel

was

th

e fr

amew

ork

util

ised

. Ear

ly r

esu

lts s

how

a 7

5% r

edu

ctio

n in

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t w

ith n

o in

crea

se in

p

atie

nt

or s

taff

inju

ries

sin

ce it

s im

ple

men

tatio

n.

Lin

dg

ren

, I; F

alk

Hog

sted

t, M

; C

ullb

erg

, J20

06S

wed

en

24 fi

rst-

epis

ode

psy

chos

is

pat

ien

ts

dia

gn

osed

b

etw

een

199

0-92

an

d 3

2 b

etw

een

1993

-96.

The

aim

of

the

pre

sen

t st

ud

y w

as t

o fo

llow

th

e p

atie

nts

in t

he

two

gro

up

s fo

r 5

year

s, c

omp

arin

g t

he

outc

ome.

Qu

antit

ativ

e an

alys

is u

sin

g

Sot

eria

Nac

ka

reco

very

sca

le.

The

resu

lts s

how

ed t

hat

eas

ily a

cces

sib

le n

eed

-ad

apte

d tr

eatm

ent

with

inte

gra

ted

ove

rnig

ht

care

mig

ht

be

adva

nta

geo

us

for

first

-ep

isod

e p

sych

otic

pat

ien

ts. T

he

du

ratio

n o

f u

ntr

eate

d p

sych

osis

was

sh

orte

r an

d t

he

outc

ome

bet

ter

171

Lon

g, C

G; W

est,

R

; Aff

ord

, M;

Col

lins,

L; D

olle

y,

O

2015

En

gla

nd

38 w

omen

ad

mitt

ed t

o th

e m

ediu

m

secu

re u

nit

of

an in

dep

end

ent

char

itab

le t

rust

.

Aim

s of

th

e st

ud

y ar

e to

ass

ess

the

effe

ctiv

enes

s of

in

terv

entio

ns

des

ign

ed

to m

inim

ise

the

use

of

secl

usi

on in

res

pon

se

to r

isk

beh

avio

urs

by

com

par

ing

mat

ched

p

atie

nts

bef

ore

and

afte

r ch

ang

e.

Qu

antit

ativ

e an

alys

is

of s

tud

y in

terv

entio

ns

to

red

uce

th

e u

se

of s

eclu

sion

.

A s

ign

ifica

nt

dec

line

in b

oth

th

e n

um

ber

of

secl

usi

ons

and

ris

k b

ehav

iou

r p

ost-

chan

ge

was

com

ple

men

ted

by

imp

rove

d s

taff

rat

ing

s of

inst

itutio

nal

beh

avio

ur,

incr

ease

d t

reat

men

t en

gag

emen

t an

d a

red

uct

ion

in t

ime

spen

t in

med

ium

sec

uri

ty. S

taff

an

d p

atie

nts

d

iffer

ed in

ter

ms

of t

hei

r ra

ting

s of

th

e m

ost

effe

ctiv

e st

rate

gie

s in

trod

uce

d. P

atie

nts

fav

oure

d t

he

Rel

atio

nal

S

ecu

rity

item

of

incr

ease

d in

div

idu

al e

ng

agem

ent

and

timet

able

d B

ehav

iou

r C

hai

n A

nal

ysis

ses

sion

s. S

taff

vi

ewed

on

war

d t

rain

ing

an

d u

se o

f d

e-es

cala

tion

tech

niq

ues

as

mos

t ef

fect

ive.

Fin

din

gs

con

firm

res

ults

fr

om m

ixed

gen

der

for

ensi

c m

enta

l hea

lth s

amp

les

that

sec

lusi

on c

an b

e su

cces

sfu

lly r

edu

ced

with

out

an in

crea

se in

pat

ien

t vi

olen

ce o

r al

tern

ativ

e co

erci

ve

stra

teg

ies.

Looi

, G-M

E;

En

gst

röm

, Å;

Säv

enst

edt,

S20

15S

wed

enTo

tal o

f 19

sel

f-re

por

ts

The

aim

of

this

stu

dy

was

to

des

crib

e h

ow

peo

ple

wh

o se

lf-h

arm

p

erce

ive

alte

rnat

ives

to

coe

rciv

e m

easu

res

in r

elat

ion

to

actu

al

exp

erie

nce

s of

p

sych

iatr

ic c

are.

Qu

alita

tive

-con

ten

t an

alys

is o

f se

lf-re

por

ts.

The

rese

arch

ers

cam

e u

p w

ith t

hre

e th

emes

fro

m t

he

liter

atu

re: ‘

a w

ish

for

un

der

stan

din

g in

stea

d o

f n

egle

ct;

a w

ish

for

mu

tual

rel

atio

n in

stea

d o

f d

istr

ust

; a w

ish

for

p

rofe

ssio

nal

ism

inst

ead

of

a co

un

terp

rod

uct

ive

care

’.

They

arg

ue

that

if t

he

care

giv

ers

can

un

der

stan

d a

nd

colla

bor

ate

with

th

e p

atie

nt,

th

ere

is s

eld

om a

ny

nee

d fo

r co

erci

ve m

easu

res.

[O

nly

ab

stra

ct a

vaila

ble

]

Lyon

s, C

; Hop

ley,

P

; Bu

rton

, CR

; H

orro

cks,

J20

09E

ng

lan

d

Post

al

qu

estio

nn

aire

s an

d 2

4 g

rou

p m

eetin

gs

with

se

rvic

e u

sers

an

d ca

rers

To g

ain

an

un

der

stan

din

g o

f h

ow u

sers

an

d c

arer

s d

efin

e a

cris

is a

nd

wh

at r

ang

e of

cri

sis

serv

ices

, res

ourc

es a

nd

inte

rven

tion

s se

rvic

e u

sers

an

d c

arer

s th

oug

ht

wou

ld h

elp

avoi

d u

nn

eces

sary

h

osp

ital a

dm

issi

on.

Qu

antit

ativ

e an

alys

is o

f q

ues

tion

nai

res

and

gro

up

mee

ting

s.

Ther

e is

em

erg

ing

evi

den

ce t

hat

cri

sis

reso

lutio

n s

ervi

ces

can

pro

vid

e al

tern

ativ

es t

o h

osp

ital a

dm

issi

on, r

edu

cin

g

dem

and

on

inp

atie

nt

bed

s. T

he

auth

ors

con

clu

de

that

ex

pre

ssed

pre

fere

nce

s of

ser

vice

use

rs a

nd

car

ers

for

pre

-em

ptiv

e se

rvic

es t

hat

are

del

iver

ed fl

exib

ly w

ill

pre

sen

t a

chal

len

ge

for

serv

ice

com

mis

sion

ers

and

pro

vid

ers,

par

ticu

larl

y w

her

e st

rin

gen

t ac

cess

cri

teri

a ar

e u

sed

. Hom

e-b

ased

pre

-em

ptiv

e se

rvic

es t

hat

red

uce

th

e n

eed

for

un

nec

essa

ry h

osp

ital t

reat

men

t m

ay a

void

p

rog

ress

ion

to

soci

al e

xclu

sion

of

serv

ice

use

rs.

172

Mag

uir

e, T

; Yo

un

g, R

; Mar

tin,

T 20

11A

ust

ralia

Fore

nsi

c h

osp

ital

with

116

bed

s,

pro

vid

ing

acu

te,

reh

abili

tatio

n a

nd

con

tinu

ing

car

e p

rog

ram

mes

for

m

en a

nd

wom

en.

To p

rese

nt

a p

roje

ct

that

was

un

der

take

n a

t an

Au

stra

lian

for

ensi

c m

enta

l hea

lth h

osp

ital

to r

edu

ce s

eclu

sion

. Th

ese

initi

ativ

es a

re

bas

ed o

n t

he

Six

Cor

e S

trat

egie

s th

at h

ave

bee

n s

ucc

essf

ully

use

d in

Nor

th A

mer

ica

to

red

uce

sec

lusi

on.

Qu

antit

ativ

e –

serv

ice

dat

a fo

llow

ing

in

terv

entio

n.

The

freq

uen

cy a

nd

du

ratio

n o

f se

clu

sion

eve

nts

wer

e re

du

ced

bu

t th

ere

was

less

red

uct

ion

in t

he

nu

mb

er

of p

atie

nts

th

at w

ere

secl

ud

ed. A

t th

is t

ime,

sec

lusi

on

may

be

nec

essa

ry f

or t

he

gen

eral

saf

ety

of t

he

un

it. It

is

pos

sib

le t

hat

th

e st

rate

gie

s w

ere

succ

essf

ully

su

pp

orte

d b

y th

e id

entifi

ed o

pp

ortu

niti

es t

o re

du

ce t

he

freq

uen

cy

and

du

ratio

n o

f se

clu

sion

bu

t th

e ch

alle

ng

es w

ere

sig

nifi

can

tly p

ower

ful i

n t

he

earl

y p

erio

d o

f ad

mis

sion

to

pro

mp

t th

e n

eed

for

sec

lusi

on. R

edu

cin

g s

eclu

sion

in

a fo

ren

sic

hos

pita

l is

a co

mp

lex

un

der

taki

ng

as

nu

rses

m

ust

pro

vid

e a

safe

en

viro

nm

ent

wh

ile d

ealin

g w

ith

vola

tile

pat

ien

ts a

nd

may

hav

e lit

tle a

ltern

ativ

e at

pre

sen

t b

ut

to u

se s

eclu

sion

aft

er e

xhau

stin

g o

ther

inte

rven

tion

s.

Man

n-P

oll,

PS

; Sm

it, A

; N

oort

hoo

rn, E

O;

Jan

ssen

, WA

; K

oekk

oek,

B;

Hu

tsch

emae

kers

, G

JM

2018

Net

her

lan

ds

Five

inp

atie

nt

war

ds

par

ticip

ated

: th

ree

adm

issi

on

war

ds

for

adu

lts,

one

adm

issi

on

war

d f

or e

lder

ly

and

on

e w

ard

pro

vid

ing

lon

g-

stay

res

iden

t ca

re

to a

du

lt p

atie

nts

.

The

pu

rpos

e of

th

is

stu

dy

was

to

exam

ine

the

imp

act

of a

se

clu

sion

red

uct

ion

pro

gra

mm

e ov

er a

lon

g

time

fram

e, f

rom

200

4 u

ntil

201

3.

Qu

antit

ativ

e an

alys

is o

f g

over

nm

ent

dat

a.

This

stu

dy

show

s a

sig

nifi

can

t re

du

ctio

n in

nu

mb

er

and

du

ratio

n o

f se

clu

sion

inci

den

ts o

ver

a lo

ng

tim

e fr

ame.

Org

anis

atio

nal

lead

ersh

ip a

nd

a t

ailo

red

pac

kag

e of

inte

rven

tion

s to

red

uce

sec

lusi

on w

ere

use

d a

s ke

y el

emen

ts. H

owev

er, r

edu

cin

g t

he

use

of

secl

usi

on

rem

ain

s ch

alle

ng

ing

an

d r

equ

ires

tim

e, g

rou

nd

ing

in

the

org

anis

atio

n a

nd

con

tinu

ous

org

anis

atio

nal

an

d p

rofe

ssio

nal

aw

aren

ess.

173

Mar

tin, A

; et

al20

08U

nite

d S

tate

s

The

inp

atie

nt

serv

ice

had

a

bed

cap

acity

of

15; d

uri

ng

th

e fiv

e-ye

ar in

terv

al

of t

he

stu

dy,

th

e u

nit

had

an

ave

rag

e of

19

8 ad

mis

sion

s p

er y

ear,

a b

ed

occu

pan

cy o

f 92

%, a

nd

a

len

gth

of

stay

of

29 d

ays.

To d

escr

ibe

chan

ges

in

use

of

rest

rain

t an

d se

clu

sion

in a

ch

ild

psy

chia

tric

inp

atie

nt

sett

ing

aft

er t

he

imp

lem

enta

tion

of

the

colla

bor

ativ

e p

rob

lem

-so

lvin

g (

CP

S)

mod

el o

f ca

re.

Qu

antit

ativ

e –

serv

ice

dat

a se

clu

sion

an

d r

estr

ain

t in

cid

ents

, se

rvic

e u

ser

dem

ogra

ph

ics.

Du

rin

g t

his

five

-yea

r p

erio

d, a

nd

aft

er t

he

com

ple

te

imp

lem

enta

tion

of

the

CP

S m

odel

by

earl

y 20

06, t

her

e w

as a

mar

ked

red

uct

ion

in t

he

use

of

rest

rain

ts (

from

26

3 to

sev

en e

ven

ts p

er y

ear,

rep

rese

ntin

g a

37.

6-fo

ld r

edu

ctio

n, s

lop

e B

=-.

696)

an

d s

eclu

sion

(fr

om

432

to 1

33 e

ven

ts p

er y

ear,

rep

rese

ntin

g a

3.2

-fol

d re

du

ctio

n, B

=-.

423)

. Th

e m

ean

du

ratio

n o

f re

stra

ints

d

ecre

ased

fro

m 4

1±8

to 1

8±20

min

ute

s p

er e

pis

ode,

yi

eld

ing

cu

mu

lativ

e u

nitw

ide

rest

rain

t u

se t

hat

dro

pp

ed

from

16±

10 t

o .3

±.5

hou

rs p

er m

onth

(a

45.5

-fol

d re

du

ctio

n, B

=-.

674)

. Th

e m

ean

du

ratio

n o

f se

clu

sion

d

ecre

ased

fro

m 2

7±5

to 2

1±5

min

ute

s p

er e

pis

ode,

yi

eld

ing

cu

mu

lativ

e u

nitw

ide

secl

usi

on u

se t

hat

dro

pp

ed

from

15±

6 to

7±

6 h

ours

per

mon

th, a

2.2

-fol

d r

edu

ctio

n (p

for

tre

nd

<.0

1 or

bet

ter

for

all s

lop

es).

Str

ong

rac

ial

diff

eren

ces

emer

ged

. Bla

ck c

hild

ren

wer

e m

ore

than

fo

ur

times

as

likel

y to

be

rest

rain

ed o

r se

clu

ded

as

thei

r w

hite

pee

rs; H

isp

anic

ch

ildre

n w

ere

50%

mor

e lik

ely

than

wh

ites

to b

e re

stra

ined

or

secl

ud

ed, a

lthou

gh

th

e d

iffer

ence

was

sta

tistic

ally

sig

nifi

can

t on

ly f

or s

eclu

sion

.

May

lea,

C20

17A

ust

ralia

N/A

(C

ase

stu

dy)

This

pap

er c

onsi

der

s a

case

stu

dy

of t

he

pow

ers

giv

en t

o so

cial

wor

kers

by

the

Vic

tori

an M

enta

l Hea

lth

Act

201

4

Cas

e st

ud

y –

qu

alita

tive

in

nat

ure

, doc

trin

al

leg

al a

nal

ysis

.

This

pap

er o

utli

nes

th

e co

erci

ve p

ower

s av

aila

ble

to

soci

al w

orke

rs u

nd

er t

he

Men

tal H

ealth

Act

201

4 (V

ic),

ar

gu

ing

th

at u

sin

g t

hes

e p

ower

s m

ay b

e le

ss r

estr

ictiv

e th

an n

ot u

sin

g t

hem

. Th

e u

se o

f co

erci

on is

pro

ble

mat

ic

in s

ocia

l wor

k p

ract

ice,

bu

t th

e ex

erci

se o

f th

ese

pow

ers

by

soci

al w

orke

rs, r

ath

er t

han

by

pol

ice

or p

aram

edic

s,

has

th

e p

oten

tial t

o b

e a

less

coe

rciv

e ap

pro

ach

. Th

e au

thor

arg

ues

th

at if

soc

ial w

orke

rs a

re u

nco

mfo

rtab

le

with

exe

rcis

ing

th

ese

pow

ers

them

selv

es, t

his

mig

ht

rais

e th

e q

ues

tion

of

wh

eth

er t

hey

sh

ould

be

exer

cise

d at

all.

Mei

jer,

E; S

chou

t,

G; d

e Jo

ng

, G;

Ab

ma,

T20

17N

eth

erla

nd

s

41 f

amily

gro

up

con

fere

nce

s w

ere

stu

die

d in

th

ree

reg

ion

s.

This

stu

dy

exam

ined

th

e im

pac

t of

fam

ily

gro

up

con

fere

nce

s on

co

erci

ve t

reat

men

t in

ad

ult

psy

chia

try.

Mix

ed m

eth

ods

– su

rvey

an

d ob

serv

atio

nal

d

ata,

use

d to

eva

luat

e ou

tcom

es o

f fa

mily

gro

up

con

fere

nce

s.

Fam

ily g

rou

p c

onfe

ren

ces

seem

s a

pro

mis

ing

in

terv

entio

n t

o re

du

ce c

oerc

ion

in p

sych

iatr

y. It

hel

ps

to r

egai

n o

wn

ersh

ip a

nd

res

tore

s b

elon

gin

gn

ess.

If

men

tal h

ealth

pro

fess

ion

als

take

a m

ore

activ

e ro

le in

th

e p

urs

uit

of f

amily

gro

up

con

fere

nce

s an

d r

ein

forc

e th

e p

lan

s w

ith t

hei

r ex

per

tise,

th

ey c

an s

tren

gth

en t

he

imp

act

even

fu

rth

er.

174

Mez

zin

a, R

; V

idon

i, D

1995

Ital

y

39 n

ew p

atie

nts

w

ith ‘a

cute

an

d se

vere

cri

ses’

in

a 4-

year

fol

low

-u

p s

tud

y at

th

e co

mm

un

ity

men

tal h

ealth

ce

nte

r in

Tri

este

(C

MH

C).

To a

sses

s th

e im

pac

t of

th

e Tr

iest

e m

odel

of

men

tal h

ealth

ser

vice

d

eliv

ery;

par

ticu

larl

y ‘m

ulti

-dis

cip

linar

y in

terv

entio

ns

emp

loyi

ng

a w

ide

ran

ge

of r

esp

onse

s to

th

e ex

iste

ntia

l an

d so

cial

nee

ds

aris

ing

d

uri

ng

a c

risi

s’.

Mix

ed m

eth

ods

– se

rvic

e d

ata

anal

ysis

.

Acc

ord

ing

to

the

auth

ors,

th

e ev

alu

atio

n in

dic

ates

: ‘1)

a

gen

eral

ly g

ood

ou

tcom

e of

th

e in

itial

cri

sis;

2)

a lo

w

rela

pse

rat

e; 3

) a

ten

den

cy t

owar

ds

favo

ura

ble

lon

g-t

erm

ou

tcom

es’.

Fu

rth

er:

‘In

ter

ms

of p

ract

ice,

vol

un

tary

an

d c

omp

uls

ory

hos

pita

lizat

ion

wer

e av

oid

ed in

fav

or o

f sh

ort-

term

d

ay a

nd

nig

ht

sup

por

t in

th

e C

MH

C. T

her

e w

ere

no

suic

ides

, no

crim

es, n

o d

rop

-ou

ts. S

ocia

l ad

just

men

t re

mai

ned

un

chan

ged

. Th

e st

ud

y d

emon

stra

tes

that

th

e m

enta

l hea

lth s

ervi

ces

in T

ries

te a

re a

ble

to

cop

e w

ith

acu

te c

rise

s w

ithou

t p

sych

iatr

ic h

osp

italiz

atio

n.’

Min

as, H

; D

iatr

i, H

2008

Ind

ones

ia

Cro

ss-s

ectio

nal

ob

serv

atio

nal

re

sear

ch in

a

nat

ura

l set

ting

, ca

rrie

d o

ut

du

rin

g a

six

-m

onth

per

iod

of

wor

kin

g a

s th

e on

ly p

sych

iatr

ist

in a

rem

ote

dis

tric

t

To in

vest

igat

e th

e n

atu

re o

f ‘P

asun

g’

– re

stra

int

and

con

finem

ent

by

fam

ilies

– t

he

clin

ical

ch

arac

teri

stic

s of

p

eop

le r

estr

ain

ed,

and

th

e re

ason

s g

iven

by

fam

ilies

an

d c

omm

un

ities

for

ap

ply

ing

su

ch r

estr

ain

t.

Qu

alita

tive

anal

ysis

of

obse

rvat

ion

al

dat

a

Ph

ysic

al r

estr

ain

t an

d c

onfin

emen

t (‘

pasu

ng’)

by

fam

ilies

of

peo

ple

with

men

tal i

llnes

s is

kn

own

to

occu

r in

man

y p

arts

of

the

wor

ld b

ut

has

att

ract

ed li

mite

d in

vest

igat

ion

. Th

is p

relim

inar

y ob

serv

atio

nal

stu

dy

was

car

ried

ou

t on

S

amos

ir Is

lan

d in

Su

mat

ra, I

nd

ones

ia. T

he

pro

visi

on o

f b

asic

com

mu

nity

men

tal h

ealth

ser

vice

s, w

her

e th

ere

wer

e n

one

bef

ore,

en

able

d t

he

maj

ority

of

the

peo

ple

w

ho

had

bee

n r

estr

ain

ed t

o re

ceiv

e p

sych

iatr

ic t

reat

men

t an

d t

o b

e re

leas

ed f

rom

‘pa

sung

’.

Mor

riso

n, A

P; e

t al

2014

Un

ited

Kin

gd

om

(cou

ntr

y n

ot

spec

ified

)

74 in

div

idu

als

wer

e ra

nd

omly

as

sig

ned

to

rece

ive

eith

er

cog

niti

ve t

her

apy

plu

s tr

eatm

ent

as u

sual

(n

=37

),

or t

reat

men

t as

usu

al a

lon

e (n

=37

).

To e

xam

ine

the

feas

ibili

ty a

nd

effe

ctiv

enes

s of

usi

ng

co

gn

itive

beh

avio

ura

l th

erap

y (C

BT)

in p

eop

le

with

sch

izop

hre

nia

w

ho

are

not

tak

ing

m

edic

atio

n.

Qu

antit

ativ

e -

a si

ng

le-b

lind

ran

dom

ised

co

ntr

olle

d tr

ial a

t tw

o U

K

cen

tres

bet

wee

n Fe

b 1

5, 2

010,

an

d M

ay 3

0,

2013

.

Mea

n P

AN

SS

tot

al s

core

s w

ere

con

sist

ently

low

er in

th

e co

gn

itive

th

erap

y g

rou

p t

han

in t

he

trea

tmen

t as

usu

al

gro

up

, with

an

est

imat

ed b

etw

een

-gro

up

eff

ect

size

of

-6.

52 (

95%

CI -

10.7

9 to

-2.

25; p

=0.

003)

. Cog

niti

ve

ther

apy

sig

nifi

can

tly r

edu

ced

psy

chia

tric

sym

pto

ms

and

see

ms

to b

e a

safe

an

d a

ccep

tab

le a

ltern

ativ

e fo

r p

eop

le w

ith s

chiz

oph

ren

ia s

pec

tru

m d

isor

der

s w

ho

hav

e ch

osen

not

to

take

an

tipsy

chot

ic d

rug

s. E

vid

ence

-bas

ed

trea

tmen

ts s

hou

ld b

e av

aila

ble

to

thes

e in

div

idu

als.

A

larg

er, d

efin

itive

tri

al is

nee

ded

.

175

Noo

rth

oorn

, E

O; V

oske

s, Y

; Ja

nss

en, W

A;

Mu

lder

, CL;

van

d

e S

and

e, R

; N

ijman

, HLI

; Sm

it,

A; H

oog

end

oorn

, A

W; B

ousa

rdt,

A;

Wid

der

shov

en,

GA

M

2016

Net

her

lan

ds

Dat

a (2

008

to

2013

) w

ere

from

a n

atio

nal

re

gis

ter

In 2

006,

a g

oal o

f re

du

cin

g s

eclu

sion

in

Du

tch

hos

pita

ls b

y at

le

ast

10%

eac

h y

ear

was

set

. Mor

e th

an 1

00

red

uct

ion

pro

ject

s in

55

hos

pita

ls h

ave

bee

n co

nd

uct

ed, w

ith €

35

mill

ion

in f

un

din

g. T

his

st

ud

y ev

alu

ated

th

e re

sults

.

Qu

antit

ativ

e an

alys

is o

f g

over

nm

ent

dat

a

Hos

pita

l par

ticip

atio

n in

th

e re

gis

ter

ran

ged

fro

m e

igh

t in

20

08 t

o 66

in 2

013,

an

d a

dm

issi

ons

ran

ged

fro

m 1

1,30

0 to

113

,290

. Th

e av

erag

e ye

arly

nat

ion

wid

e re

du

ctio

n of

sec

lud

ed p

atie

nts

was

ab

out

9%. R

edu

ctio

n w

as

ach

ieve

d in

hal

f of

th

e h

osp

itals

. Som

e h

osp

itals

saw

in

crea

sed

rat

es. I

n s

ome

hos

pita

ls w

her

e se

clu

sion

d

ecre

ased

, use

of

forc

ed m

edic

atio

n in

crea

sed

. Hig

her

se

clu

sion

rat

es w

ere

asso

ciat

ed w

ith p

sych

otic

an

d b

ipol

ar d

isor

der

s, m

ale

gen

der

, an

d s

ever

al w

ard

typ

es.

Sec

lusi

on d

ecre

ased

sig

nifi

can

tly, a

nd

for

ced

med

icat

ion

incr

ease

d. R

ates

var

ied

wid

ely

bet

wee

n h

osp

itals

. For

m

any

hos

pita

ls, m

ore

effo

rts

to r

edu

ce s

eclu

sion

are

n

eed

ed.

Nor

red

am, M

; G

arci

a-Lo

pez

, A

; Kei

din

g, N

; K

rasn

ik, A

2010

Den

mar

k

Sam

ple

of

6476

in

div

idu

als

with

p

sych

iatr

ic in

-p

atie

nt

con

tact

fr

om a

tot

al

coh

ort

of 3

12,

300

per

son

s

To in

vest

igat

e d

iffer

ence

s in

ris

k of

co

mp

uls

ory

adm

issi

on

and

oth

er c

oerc

ive

mea

sure

s in

psy

chia

tric

em

erg

enci

es a

mon

g

refu

gee

s an

d im

mig

ran

ts c

omp

ared

w

ith t

hat

am

ong

nat

ive

Dan

es.

Qu

antit

ativ

e an

alys

is o

f g

over

nm

ent

dat

a

Coe

rciv

e m

easu

res

in p

sych

iatr

y ar

e m

ore

likel

y to

be

exp

erie

nce

d b

y m

igra

nts

th

an b

y n

ativ

e D

anes

.

Nor

voll,

R; H

em,

MH

; Ped

erse

n, R

2017

Nor

way

Sev

en s

emi-

stru

ctu

red

tele

ph

one

inte

rvie

ws

with

ke

y in

form

ants

in

char

ge

of ‘

cen

tral

d

evel

opm

ent

pro

ject

s an

d q

ual

ity-a

ssu

ran

ce

wor

k in

men

tal

hea

lth s

ervi

ces

in

Nor

way

’.

This

art

icle

aim

s to

in

crea

se u

nd

erst

and

ing

of

how

eth

ics

can

con

trib

ute

to

red

uci

ng

co

erci

ve p

ract

ices

an

d im

pro

vin

g t

hei

r q

ual

ity

thro

ug

h a

qu

alita

tive

stu

dy

of k

ey in

form

ants

fr

om d

evel

opm

ent

pro

ject

s an

d f

acili

ties

in

Nor

way

th

at u

se li

ttle

co

erci

on.

Qu

alita

tive

anal

ysis

of

sem

i-st

ruct

ure

d te

lep

hon

e in

terv

iew

s

This

stu

dy

ind

icat

es t

hat

eth

ics

can

con

trib

ute

si

gn

ifica

ntly

to

dev

elop

men

t p

roje

cts

and

qu

ality

as

sura

nce

ab

out

coer

cion

by

offe

rin

g m

ore

syst

emat

ic w

ays

of d

ealin

g w

ith m

oral

con

cern

s.

The

inte

rrel

ated

nes

s of

org

anis

atio

nal

en

viro

nm

ents

, p

rofe

ssio

nal

asp

ects

an

d m

oral

issu

es u

nd

erlin

es t

he

nee

d f

or in

teg

rate

d a

nd

pro

cess

ori

ente

d e

thic

s. F

urt

her

st

ud

ies

are

nee

ded

to

inve

stig

ate

how

sys

tem

atic

use

of

vari

ous

kin

ds

of c

linic

al e

thic

s su

pp

ort

cou

ld c

ontr

ibu

te

to d

evel

opm

ent

wor

k on

coe

rcio

n.

176

Ols

son

, H; S

chön

, U

-K20

16S

wed

en

13 ‘

key

care

w

orke

rs’

at

a m

axim

um

-se

curi

ty f

oren

sic

psy

chia

tric

h

osp

ital.

To d

eter

min

e w

hat

re

sou

rces

for

ensi

c st

aff

use

to

avoi

d o

r p

reve

nt

viol

ent

situ

atio

ns,

an

d to

exp

lore

how

th

ese

pra

ctic

es r

esem

ble

th

e d

omai

ns

of r

ecov

ery-

orie

nte

d c

are.

Qu

alita

tive

anal

ysis

of

in-d

epth

in

terv

iew

tex

ts

with

th

emat

ic

anal

ysis

.

Sta

ff p

reve

nt

viol

ent

situ

atio

ns

usi

ng

tac

it kn

owle

dg

e an

d e

xper

ien

ce, a

nd

th

rou

gh

a s

har

ed c

olle

gia

l re

spon

sib

ility

. Sta

ff s

afeg

uar

d p

atie

nts

, en

cou

rag

e p

atie

nt

par

ticip

atio

n, a

nd

pro

vid

e st

aff

con

sist

ency

. Th

e re

sults

hav

e im

plic

atio

ns

for

fore

nsi

c ca

re a

s w

ell a

s p

sych

iatr

y re

gar

din

g t

he

pro

cess

of

mak

ing

rec

over

y a

real

ity f

or p

atie

nts

in t

he

fore

nsi

c ca

re s

ettin

g.

Osb

orn

, D;

Lloy

d-E

van

s,

B; J

ohn

son

, S;

Gilb

urt

, H; B

yfor

d,

S; L

eese

, M;

Sla

de,

M

2010

En

gla

nd

Exp

erie

nce

of

314

pat

ien

ts in

fo

ur

resi

den

tial

alte

rnat

ives

an

d fo

ur

stan

dar

d se

rvic

es w

ere

com

par

ed.

To c

omp

are

pat

ien

t sa

tisfa

ctio

n, w

ard

atm

osp

her

e an

d p

erce

ived

coe

rcio

n in

th

e tw

o ty

pes

of

serv

ice,

usi

ng

val

idat

ed

mea

sure

s.

Qu

antit

ativ

e an

alys

is o

f d

ata

colle

cted

u

sin

g: t

he

Clie

nt

Sat

isfa

ctio

n Q

ues

tion

nai

re,

the

Ser

vice

S

atis

fact

ion

Sca

le -

R

esid

entia

l fo

rm, e

tc.

‘Alte

rnat

ives

to

trad

ition

al in

-pat

ien

t se

rvic

es’

app

ear

to

be

asso

ciat

ed w

ith a

bet

ter

exp

erie

nce

of

adm

issi

on.

Com

mu

nity

alte

rnat

ives

wer

e as

soci

ated

with

gre

ater

se

rvic

e u

ser

satis

fact

ion

an

d le

ss n

egat

ive

exp

erie

nce

s.

Som

e b

ut

not

all

of t

hes

e d

iffer

ence

s w

ere

exp

lain

ed

by

diff

eren

ces

in t

he

two

pop

ula

tion

s, p

artic

ula

rly

in

invo

lun

tary

ad

mis

sion

.

Ost

row

, L20

10U

nite

d S

tate

sN

/A

To p

rese

nt

a ca

se s

tud

y of

Gro

un

dh

ogs’

(a

gro

up

of

con

sum

ers

in M

assa

chu

sett

s)

org

anis

ing

str

ateg

ies,

in

ten

ded

to

info

rm

con

sum

er g

rou

ps

in o

ther

sta

tes

and

cou

ntie

s th

at a

re

inte

rest

ed in

pee

r-ru

n cr

isis

res

pite

s (P

RC

Rs)

.

Cas

e st

ud

y –

qu

alita

tive

in

nat

ure

.

This

bri

ef r

epor

ts t

he

org

anis

ing

str

ateg

ies

of t

he

Mas

sach

use

tts

gro

up

, Gro

un

dh

ogs,

th

at h

as o

rgan

ised

fo

r p

eer-

run

cri

sis

resp

ites

(PR

CR

). T

he

anal

ysis

an

d op

tion

s im

par

ted

her

e ca

n b

e u

sefu

l for

con

sum

ers

in o

ther

sta

tes

and

cou

ntie

s em

bar

kin

g o

n a

sim

ilar

mis

sion

. Th

e au

thor

s w

rite

: ‘If

we

are

to b

e su

cces

sfu

l as

a m

ovem

ent

in b

rin

gin

g a

bou

t re

cove

ry-o

rien

ted

, co

nsu

mer

-dri

ven

sys

tem

s, w

e n

eed

to

be

effe

ctiv

e or

gan

izer

s of

pol

icy

chan

ge

and

ser

vice

inn

ovat

ion

. Th

e ex

per

ien

ce o

f G

rou

nd

hog

s in

Mas

sach

use

tts

is

info

rmat

ive

for

mod

els

of c

omm

un

ity a

nd

con

sum

er

org

aniz

ing

.’ [N

ot p

eer

revi

ewed

]

177

Pap

ageo

rgio

u,

A; K

ing

, M;

Jan

moh

amed

, A

; Dav

idso

n, O

; D

awso

n, J

2002

En

gla

nd

156

in-p

atie

nts

ab

out

to b

e d

isch

arg

ed f

rom

co

mp

uls

ory

trea

tmen

t u

nd

er

the

Men

tal H

ealth

A

ct p

artic

ipat

ed.

To e

valu

ate

wh

eth

er

use

of

adva

nce

d

irec

tives

by

pat

ien

ts

with

men

tal i

llnes

s le

ads

to lo

wer

rat

es

of c

omp

uls

ory

read

mis

sion

to

hos

pita

l.

Qu

antit

ativ

e an

alys

is o

f in

-p

atie

nts

’ u

sual

p

sych

iatr

ic

care

with

usu

al

care

plu

s th

e co

mp

letio

n o

f an

ad

van

ce

dir

ectiv

e.

Fift

een

pat

ien

ts (

19%

) in

th

e in

terv

entio

n g

rou

p a

nd

16

(21%

) in

th

e co

ntr

ol g

rou

p w

ere

read

mitt

ed c

omp

uls

orily

w

ithin

1 y

ear

of d

isch

arg

e. T

her

e w

as n

o d

iffer

ence

in

the

nu

mb

ers

of c

omp

uls

ory

read

mis

sion

s, n

um

ber

s of

p

atie

nts

rea

dm

itted

vol

un

tari

ly, d

ays

spen

t in

hos

pita

l or

sat

isfa

ctio

n w

ith p

sych

iatr

ic s

ervi

ces.

Th

ere

was

no

diff

eren

ce in

th

e n

um

ber

s of

com

pu

lsor

y re

adm

issi

ons,

n

um

ber

s of

pat

ien

ts r

ead

mitt

ed v

olu

nta

rily

, day

s sp

ent

in

hos

pita

l or

satis

fact

ion

with

psy

chia

tric

ser

vice

s. U

sers

’ ad

van

ce in

stru

ctio

n d

irec

tives

had

litt

le o

bse

rvab

le

imp

act

on t

he

outc

ome

of c

are

at 1

2 m

onth

s.

Pate

rson

, B;

Ben

net

, L;

Bra

dle

y, P

2014

Net

her

lan

ds

Ran

dom

sam

ple

of

252

fro

m t

he

2,68

2 p

atie

nts

co

nse

cutiv

ely

com

ing

into

co

nta

ct w

ith

two

psy

chia

tric

em

erg

ency

te

ams

in

Am

ster

dam

.

Aim

is t

o st

ud

y th

e lin

ks b

etw

een

op

inio

ns

abou

t p

rior

psy

chia

tric

tr

eatm

ent,

insi

gh

t,

serv

ice

eng

agem

ent

and

th

e ri

sk o

f (n

ew)

civi

l det

entio

ns.

Qu

antit

ativ

e an

alys

is o

f p

atie

nt

soci

o-d

emog

rap

hic

an

d c

linic

al

char

acte

rist

ics,

an

d in

form

atio

n ab

out

pri

or

invo

lun

tary

ad

mis

sion

s.

Mor

e sa

tisfa

ctio

n w

ith p

rior

tre

atm

ent

seem

s to

red

uce

th

e ri

sk o

f ci

vil d

eten

tion

rem

arka

bly

. Low

leve

ls o

f sa

tisfa

ctio

n s

eem

to

be

mai

nly

dep

end

ent

on a

his

tory

of

pre

viou

s in

volu

nta

ry a

dm

issi

on. T

hes

e fin

din

gs

seem

to

op

en u

p a

new

per

spec

tive

for

dim

inis

hin

g t

he

risk

of

(new

) ci

vil d

eten

tion

by

tryi

ng

to

enh

ance

sat

isfa

ctio

n w

ith t

reat

men

t, e

spec

ially

for

pat

ien

ts u

nd

er d

eten

tion

.

Pou

lsen

, HD

2002

Den

mar

k

472

adm

issi

ons

to a

ll p

sych

iatr

ic

war

ds

at

one

hos

pita

l w

ere

sele

cted

ra

nd

omly

by

sele

ctin

g e

very

fif

th a

dm

issi

on.

To in

vest

igat

e th

e p

reva

len

ce o

f ‘e

xtra

-le

gal

dep

riva

tion

of

liber

ty’

- re

stri

ctio

ns

in

leav

ing

a p

sych

iatr

ic

war

d o

ther

th

an a

fo

rmal

in

volu

nta

ry

com

mitm

ent

of

det

entio

n –

in a

h

osp

ital p

opu

latio

n.

Qu

antit

ativ

e –

surv

ey o

f la

rge

sam

ple

of

psy

chia

tric

ad

mis

sion

d

ata

(sta

ff

mu

st r

ecor

d im

pos

ition

of

rest

rict

ed le

ave)

.

Ext

ra-l

egal

dep

riva

tion

of

liber

ty s

eem

s to

be

a co

mm

on

ph

enom

enon

at

the

psy

chia

tric

war

d a

lso

amon

g

pat

ien

ts a

dm

itted

vol

un

tari

ly. R

easo

ns

for

usi

ng

th

is t

ype

of c

oerc

ion

are

pro

bab

ly c

omp

lex,

bu

t it

seem

s to

be

mos

t co

mm

on a

mon

g s

ever

ely

ill p

atie

nts

.

178

Pu

tkon

en, A

; K

uiv

alai

nen

, S;

Lou

her

anta

, O;

Rep

o-Ti

ihon

en, E

; R

yyn

änen

, O-P

; K

autia

inen

, H;

Tiih

onen

, J

2013

Fin

lan

d

13 w

ard

s of

a

secu

red

nat

ion

al

psy

chia

tric

h

osp

ital i

n Fi

nla

nd

.

To s

tud

y w

het

her

se

clu

sion

an

d r

estr

ain

t co

uld

be

pre

ven

ted

in t

he

psy

chia

tric

ca

re o

f p

erso

ns

with

sc

hiz

oph

ren

ia w

ithou

t an

incr

ease

of

viol

ence

.

Qu

antit

ativ

e –

ran

dom

ised

co

ntr

olle

d t

rial

, co

mp

arin

g

mon

thly

in

cid

ence

rat

e ra

tios

(IR

Rs)

of

coer

cion

an

d vi

olen

ce.

The

pro

por

tion

of

pat

ien

t-d

ays

with

sec

lusi

on, r

estr

ain

t,

or r

oom

ob

serv

atio

n d

eclin

ed f

rom

30%

to

15%

fo

r in

terv

entio

n w

ard

s (I

RR

=.8

8, 9

5% c

onfid

ence

in

terv

al [

CI]

=.8

6-.9

0, p

<.0

01)

vers

us

from

25%

to

19%

fo

r co

ntr

ol w

ard

s (I

RR

=.9

7, C

I=.9

3-1.

01, p

=.0

56).

S

eclu

sion

-res

trai

nt

time

dec

reas

ed f

rom

110

to

56 h

ours

p

er 1

00 p

atie

nt-

day

s fo

r in

terv

entio

n w

ard

s (I

RR

=.8

5,

CI=

.78-

.92,

p<

.001

) b

ut

incr

ease

d f

rom

133

to

150

hou

rs f

or c

ontr

ol w

ard

s (I

RR

=1.

09, C

I=.9

4-1.

25, p

=.2

4).

Sec

lusi

on a

nd

res

trai

nt

wer

e p

reve

nte

d w

ithou

t an

in

crea

se o

f vi

olen

ce in

war

ds

for

men

with

sch

izop

hre

nia

an

d v

iole

nt

beh

avio

ur.

A s

imila

r re

du

ctio

n m

ay a

lso

be

feas

ible

un

der

less

ext

rem

e ci

rcu

mst

ance

s.

Pu

teh

, I;

Mar

thoe

nis

, M;

Min

as, H

2011

Ind

ones

ia

59 ‘

form

er e

x-p

asu

ng

pat

ien

ts

wer

e ex

amin

ed’.

Th

e m

ajor

ity

(88.

1%)

wer

e m

en, a

ged

18

to

68 y

ears

.

To r

epor

t th

e fin

din

gs

of a

pre

limin

ary

inve

stig

atio

n o

f th

e d

emog

rap

hic

an

d cl

inic

al c

har

acte

rist

ics

of p

atie

nts

wh

o h

ave

bee

n a

dm

itted

to

the

Ban

da

Ace

h M

enta

l H

osp

ital a

s p

art

of

the

Ace

h Fr

ee P

asun

g p

rog

ram

.

Qu

alita

tive

– cr

oss-

sect

ion

al

des

crip

tive

stu

dy

con

du

cted

at

the

Ban

da

Ace

h M

enta

l Hos

pita

l.

Ph

ysic

al r

estr

ain

t an

d c

onfin

emen

t of

th

e m

enta

lly il

l (c

alle

d ‘

pasu

ng’

in In

don

esia

) is

com

mon

in A

ceh

. Th

e au

thor

s re

por

t th

at ‘

dev

elop

men

t of

a c

omm

un

ity m

enta

l h

ealth

sys

tem

an

d t

he

intr

odu

ctio

n o

f a

hea

lth in

sura

nce

sy

stem

in A

ceh

(to

get

her

with

th

e n

atio

nal

hea

lth

insu

ran

ce s

chem

e fo

r th

e p

oor)

has

en

able

d a

cces

s to

fr

ee h

osp

ital t

reat

men

t fo

r p

eop

le w

ith s

ever

e m

enta

l d

isor

der

s, in

clu

din

g t

hos

e w

ho

hav

e b

een

in p

asun

g.’

Furt

her

, ‘Th

e d

emog

rap

hic

an

d c

linic

al c

har

acte

rist

ics

of t

his

gro

up

of

ex-p

asu

ng

pat

ien

ts a

re b

road

ly s

imila

r to

th

ose

rep

orte

d in

pre

viou

s st

ud

ies.

Th

e A

ceh

Free

Pa

sung

pro

gra

mm

e is

an

imp

orta

nt

men

tal h

ealth

an

d h

um

an r

igh

ts in

itiat

ive

that

can

ser

ve t

o in

form

si

mila

r ef

fort

s in

oth

er p

arts

of

Ind

ones

ia a

nd

oth

er

low

an

d m

idd

le-i

nco

me

cou

ntr

ies

wh

ere

rest

rain

t an

d co

nfin

emen

t of

th

e m

enta

lly il

l is

rece

ivin

g in

suffi

cien

t at

ten

tion’

.

Rav

eesh

, BN

; Pa

thar

e, S

; N

oort

hoo

rn,

EO

; Gow

da,

G

S; L

epp

ing

, P;

Bu

nd

ers-

Ael

en,

JGF

2016

Ind

ia

A t

otal

of

210

psy

chia

tris

ts a

nd

210

care

giv

ers

par

ticip

ated

in

the

stu

dy.

The

obje

ctiv

e of

th

is

stu

dy

was

to

asse

ss

attit

ud

es o

f In

dia

n p

sych

iatr

ists

an

d ca

reg

iver

s to

war

d co

erci

on.

Qu

antit

ativ

e an

alys

is o

f a

15-i

tem

q

ues

tion

nai

re

Car

egiv

ers

and

psy

chia

tris

ts f

elt

that

th

e la

ck

of r

esou

rces

is o

ne

of t

he

reas

ons

for

coer

cion

. Fu

rth

erm

ore,

th

ey f

elt

that

th

e n

eed

on

ear

ly

iden

tifica

tion

of

agg

ress

ive

beh

avio

ur,

inte

rven

tion

s to

re

du

ce a

gg

ress

iven

ess,

em

pow

erin

g p

atie

nts

, im

pro

vin

g

hos

pita

l res

ourc

es, s

taff

tra

inin

g in

ver

bal

de-

esca

latio

n te

chn

iqu

es is

ess

entia

l. Th

ere

is a

n u

rgen

t n

eed

in t

he

stan

dar

dis

ed o

per

atin

g p

roce

du

re in

th

e u

se o

f co

erci

ve

mea

sure

s in

Ind

ian

men

tal h

ealth

set

ting

s.

179

Ria

hi,

S; e

t al

20

16C

anad

a

326-

bed

, ter

tiary

le

vel,

spec

ialis

ed

men

tal h

ealth

ca

re f

acili

ty in

O

nta

rio,

Can

ada.

To e

valu

ate

the

Six

C

ore

Str

ateg

ies

for

Res

trai

nt

Min

imis

atio

n at

a r

ecov

ery-

orie

nte

d,

tert

iary

leve

l men

tal

hea

lth c

are

faci

lity

and

its e

ffec

t on

mec

han

ical

re

stra

int

and

sec

lusi

on

inci

den

ts.

Qu

antit

ativ

e –

serv

ice

dat

a,

retr

osp

ectiv

e re

view

exa

min

es

rest

rain

t p

ract

ices

.

Str

ateg

ies

wer

e im

ple

men

ted

in a

sta

ged

man

ner

ac

ross

3 y

ears

. Th

e to

tal n

um

ber

of

mec

han

ical

re

stra

int

and

sec

lusi

on in

cid

ents

dec

reas

ed b

y 19

.7%

fr

om 2

011/

12 t

o 20

13/1

4. C

oncu

rren

tly, t

he

aver

age

len

gth

of

a m

ech

anic

al r

estr

ain

t or

sec

lusi

on in

cid

ent

dec

reas

ed 3

8.9%

ove

r th

e 36

-mon

th e

valu

atio

n p

erio

d.

Imp

lem

enta

tion

of

the

Six

Cor

e S

trat

egie

s fo

r R

estr

ain

t M

inim

isat

ion

eff

ectiv

ely

dec

reas

ed t

he

nu

mb

er a

nd

len

gth

of

mec

han

ical

res

trai

nt

and

sec

lusi

on in

cid

ents

in

a sp

ecia

lised

men

tal h

ealth

car

e fa

cilit

y.

Rob

erts

on, J

P;

Col

linso

n, C

2011

En

gla

nd

Two

gro

up

s of

st

aff

wor

kin

g in

lo

cal c

omm

un

ity

outr

each

tea

ms

in a

du

lt m

enta

l h

ealth

an

d le

arn

ing

dis

abili

ty

serv

ices

in a

m

idla

nd

s ci

ty.

To u

nd

erta

ke a

n ex

plo

ratio

n in

to

outr

each

wor

kers

’ ex

per

ien

ces

of

assi

stin

g c

lien

ts w

ith

pos

itive

ris

k-ta

kin

g

(PR

T), i

ncl

ud

ing

d

imen

sion

s of

ris

k st

aff

face

, an

d f

acto

rs

influ

enci

ng

th

eir

risk

ap

pro

ach

es.

Qu

alita

tive

anal

ysis

of

inte

rvie

w

tran

scri

pts

.

The

stu

dy

hig

hlig

hte

d d

iffer

ent

un

der

stan

din

gs

of

pos

itive

ris

k-ta

kin

g P

RT

at d

iffer

ent

leve

ls w

ithin

or

gan

isat

ion

s an

d a

nee

d f

or b

ette

r in

form

ed, c

oher

ent

org

anis

atio

nal

ap

pro

ach

es t

o its

pra

ctic

e. In

terp

erso

nal

tr

ust

rel

ies

up

on s

uch

org

anis

atio

nal

coh

eren

ce; w

ithou

t it

som

e st

aff

may

see

th

emse

lves

as

gam

blin

g w

hen

u

nd

erta

kin

g P

RT,

wh

erea

s ot

her

s m

ay r

etre

at in

to

con

serv

ativ

e in

terv

entio

ns.

Su

ch c

onse

rvat

ive

pra

ctic

es

wer

e p

erce

ived

as

pot

entia

lly d

ang

erou

s, p

rom

otin

g

coer

cion

an

d d

isru

ptin

g t

her

apeu

tic r

elat

ion

ship

s, a

nd

so in

crea

sin

g r

isks

ove

r a

lon

ger

tim

e p

erio

d. R

esea

rch

is n

eed

ed in

to t

he

use

of

syst

ems

failu

re a

nal

ysis

an

d ri

sk a

sses

smen

t to

ols

to h

igh

ligh

t h

ow P

RT

can

gen

erat

e su

cces

sfu

l ou

tcom

es.

Ros

en, J

; O

’con

nel

l, M

2013

Un

ited

Sta

tes

14 a

du

lts

adm

itted

to

a m

enta

l hea

lth

resp

ite p

rog

ram

.

To e

xam

ine

clie

nts

wh

o w

ere

adm

itted

to

a m

enta

l hea

lth r

esp

ite

pro

gra

mm

e in

th

e fir

st 3

mon

ths

of 2

011

in o

rder

to

iden

tify

the

abili

ty o

f th

e p

rog

ram

me

to r

edu

ce

sym

pto

m d

istr

ess

and

to

exp

lore

rel

ated

p

sych

osoc

ial f

acto

rs.

Qu

antit

ativ

e an

alys

is o

f en

try

and

exi

t q

ues

tion

nai

res.

Mea

sure

s of

sym

pto

m d

istr

ess,

men

tal h

ealth

co

nfid

ence

, an

d s

elf-

este

em a

ll im

pro

ved

sig

nifi

can

tly

over

tim

e sp

ent

in t

he

resp

ite p

rog

ram

. How

ever

, th

e im

med

iate

imp

act

of t

he

resp

ite p

rog

ram

me

on e

xter

nal

in

dic

ator

s of

fu

nct

ion

ing

wer

e n

ot o

bse

rved

. A c

omm

on

defi

niti

on f

or p

urp

ose

and

imp

lem

enta

tion

of

resp

ite

is la

ckin

g, a

nd

a b

ette

r u

nd

erst

and

ing

of

thes

e d

etai

ls

cou

ld im

pro

ve c

urr

ent

pro

gra

mm

es a

s w

ell a

s d

efin

e a

stru

ctu

re f

or n

ewly

cre

ated

on

es.

180

Ru

sso,

J; R

ose,

D20

13E

uro

pe

Stu

dy

invo

lved

on

e fo

cus

gro

up

in e

ach

of 1

5 E

uro

pea

n co

un

trie

s an

d ex

ten

ded

to

a to

tal o

f 11

6 p

artic

ipan

ts.

The

pu

rpos

e of

th

is p

aper

is t

o d

iscu

ss h

um

an

rig

hts

ass

essm

ent

and

mon

itori

ng

in

psy

chia

tric

inst

itutio

ns

from

th

e p

ersp

ectiv

es

of t

hos

e w

hos

e ri

gh

ts

are

at s

take

.

Qu

alita

tive

anal

ysis

of

focu

s g

rou

p d

ata.

Pap

er h

igh

ligh

ts h

um

an r

igh

ts is

sues

wh

ich

are

not

re

adily

vis

ible

an

d t

her

efor

e le

ss li

kely

to

be

cap

ture

d in

inst

itutio

nal

mon

itori

ng

vis

its. K

ey is

sues

incl

ud

e th

e la

ck o

f in

tera

ctio

n a

nd

gen

eral

hu

man

ity o

f st

aff,

rece

ipt

of u

nh

elp

ful t

reat

men

t, w

ides

pre

ad r

elia

nce

on

psy

chot

rop

ic d

rug

s as

th

e so

le t

reat

men

t an

d t

he

over

all i

mp

act

of p

sych

iatr

ic e

xper

ien

ce o

n a

per

son’

s b

iog

rap

hy.

Sal

omon

, C

Ham

ilton

, B;

Els

om, S

2014

Au

stra

lia

98 A

ust

ralia

n co

nsu

mer

s in

volv

ed w

ith

par

ticip

atin

g

org

anis

atio

ns

com

ple

ted

an

anon

ymou

s su

rvey

d

etai

ling

pas

t an

tipsy

chot

ic

dis

con

tinu

atio

n at

tem

pts

.

To g

ain

an

un

der

stan

din

g o

f co

nsu

mer

exp

erie

nce

s of

an

tipsy

chot

ic

dis

con

tinu

atio

n. T

his

st

ud

y w

as d

esig

ned

to

incr

ease

un

der

stan

din

g

of a

ntip

sych

otic

d

isco

ntin

uat

ion

from

con

sum

er

per

spec

tives

.

Qu

antit

ativ

e –

surv

ey.

Of

the

88 p

artic

ipan

ts w

ho

rep

orte

d a

t le

ast

one

dis

con

tinu

atio

n a

ttem

pt,

ove

r h

alf

(n =

47,

54.

7%)

rep

orte

d s

top

pin

g w

ithou

t cl

inic

ian

kn

owle

dg

e or

su

pp

ort.

Th

is g

rou

p w

as 3

5% (

con

fiden

ce in

terv

al

15.4

–54.

6%)

mor

e lik

ely

to s

top

ab

rup

tly t

han

th

ose

(n =

41,

45.

3%)

stop

pin

g w

ith c

linic

ian

su

pp

ort

(P =

0.

002)

. On

ly 1

0 p

artic

ipan

ts (

23.3

%)

reca

lled

bei

ng

giv

en

info

rmat

ion

ab

out

dis

con

tinu

atio

n s

ymp

tom

s ot

her

th

an r

elap

se; h

owev

er, 6

8 p

artic

ipan

ts (

78.2

%)

rep

orte

d ex

per

ien

cin

g a

ran

ge

of d

isco

ntin

uat

ion

sym

pto

ms

incl

ud

ing

ph

ysic

al, c

ogn

itive

, em

otio

nal

, psy

chot

ic

or s

leep

-rel

ated

dis

turb

ance

s. F

ind

ing

s ca

nn

ot b

e re

adily

gen

eral

ised

bec

ause

of

sam

plin

g c

onst

rain

ts.

How

ever

, th

e si

gn

ifica

nt

nu

mb

er o

f p

artic

ipan

ts w

ho

rep

orte

d d

isco

ntin

uat

ion

sym

pto

ms,

in a

dd

ition

to

psy

chos

is, i

s co

nsi

sten

t w

ith p

revi

ous

rese

arch

. Th

is

stu

dy

pro

vid

es n

ew in

sig

ht

into

con

sum

er m

otiv

atio

ns

for

dis

con

tinu

atio

n a

nd

pos

sib

le p

rob

lem

s in

clin

ical

co

mm

un

icat

ion

th

at m

ay c

ontr

ibu

te t

o fr

equ

ent

non

-col

lab

orat

ive

dis

con

tinu

atio

n a

ttem

pts

. Men

tal

hea

lth n

urs

es, w

ho

pla

y a

piv

otal

rol

e in

med

icat

ion

com

mu

nic

atio

n e

ven

ts, m

ay b

enefi

t fr

om in

crea

sed

awar

enes

s of

con

sum

er p

ersp

ectiv

es o

n t

his

top

ic.

181

Sch

nee

ber

ger

, A

R; K

owal

insk

i, E

; Frö

hlic

h, D

; S

chrö

der

, K; v

on

Felte

n, S

; Zin

kler

, M

; Bei

ne,

KH

; H

ein

z, A

nd

reas

; B

org

war

dt,

S;

Lan

g, U

E; B

ux,

D

A; H

ub

er, C

G

2017

Ger

man

y

Sec

lusi

on o

r re

stra

int

dat

a in

21

Ger

man

h

osp

itals

.

To e

xam

ine

the

effe

cts

of o

pen

vs.

lock

ed d

oor

pol

icie

s on

ag

gre

ssiv

e in

cid

ents

wh

ich

rem

ain

un

clea

r.

Qu

antit

ativ

e an

alys

is o

f h

osp

ital d

ata.

N

atu

ralis

tic

obse

rvat

ion

al

des

ign

an

d an

alys

is o

f th

e oc

curr

ence

of

ag

gre

ssiv

e b

ehav

iou

r.

Res

trai

nt

or s

eclu

sion

du

rin

g t

reat

men

t w

as le

ss

likel

y in

hos

pita

ls w

ith a

n o

pen

doo

r p

olic

y. O

n o

pen

w

ard

s, a

ny

agg

ress

ive

beh

avio

r an

d r

estr

ain

t or

se

clu

sion

wer

e le

ss li

kely

, wh

erea

s b

odily

har

m w

as

mor

e lik

ely

than

on

clo

sed

war

ds.

Hos

pita

ls w

ith o

pen

d

oor

pol

icie

s d

id n

ot d

iffer

fro

m h

osp

itals

with

lock

ed

war

ds

reg

ard

ing

diff

eren

t fo

rms

of a

gg

ress

ion

. Oth

er

rest

rict

ive

inte

rven

tion

s u

sed

to

con

trol

ag

gre

ssio

n w

ere

sig

nifi

can

tly r

edu

ced

in o

pen

set

ting

s. O

pen

war

ds

seem

to

hav

e a

pos

itive

eff

ect

on r

edu

cin

g a

gg

ress

ion

. Fu

ture

res

earc

h s

hou

ld f

ocu

s on

men

tal h

ealth

car

e p

olic

ies

targ

eted

at

emp

ower

ing

tre

atm

ent

app

roac

hes

, re

spec

ting

th

e p

atie

nt’

s au

ton

omy

and

pro

mot

ing

re

du

ctio

ns

of in

stitu

tion

al c

oerc

ion

.

Sch

out,

G; v

an

Dijk

, M; M

eije

r, E

; La

nd

ewee

r, E

; de

Jon

g, G

2017

Net

her

lan

ds

Two

case

ex

amp

les

of

fam

ilies

/soc

ial

net

wor

ks.

To a

dd

ress

th

e q

ues

tion

wh

at F

amily

G

rou

p C

onfe

ren

cin

g

(FC

G)

add

s to

th

e ex

istin

g m

eth

ods

to

red

uce

coe

rcio

n in

m

enta

l hea

lth c

are

and

pro

mot

e in

clu

sion

.

Qu

alita

tive

anal

ysis

of

eval

uat

ion

stu

dy

dat

a

Res

earc

h in

dic

ates

th

at t

her

e ar

e g

rou

nd

s fo

r a

wid

er

app

licat

ion

of

FGC

in m

enta

l hea

lth, e

ven

ou

tsid

e th

e fr

amew

ork

of c

oerc

ive

care

. Stu

dy

obse

rved

th

at c

lien

ts

and

/or

thei

r so

cial

net

wor

k w

ere

not

alw

ays

able

to

par

ticip

ate

in a

con

fere

nce

, let

alo

ne

to b

rin

g in

en

oug

h se

lf-d

irec

tion

; so

that

du

rin

g t

he

pri

vate

tim

e a

pla

n co

uld

be

esta

blis

hed

.

182

Sch

out,

G; e

t al

20

17N

eth

erla

nd

s

17 f

amili

es/

soci

al n

etw

orks

en

gag

ed in

fa

mily

gro

up

con

fere

nci

ng

.

To id

entif

y b

arri

ers

to

app

lyin

g F

amily

Gro

up

Con

fere

nce

s. ‘A

n an

swer

to

this

qu

estio

n p

rovi

des

insi

gh

ts

reg

ard

ing

situ

atio

ns

in

wh

ich

Fam

ily G

rou

p C

onfe

ren

ces

may

(n

ot)

be

use

ful’.

Qu

alita

tive

– 17

ca

se s

tud

ies

The

follo

win

g b

arri

ers

emer

ged

: ‘(1

) th

e ac

ute

dan

ger

in

coer

cion

situ

atio

ns,

th

e lim

ited

tim

e av

aila

ble

, th

e fe

ar

of li

abili

ty a

nd

th

e cu

lture

of

con

trol

an

d r

isk

aver

sion

in

men

tal h

ealth

car

e; (

2) t

he

seve

rity

of

the

men

tal

stat

e of

clie

nts

lead

ing

to

diffi

culti

es in

dec

isio

n-m

akin

g

and

com

mu

nic

atio

n; (

3) c

onsi

der

ing

a F

amily

Gro

up

Con

fere

nce

an

d in

volv

ing

fam

ilial

net

wor

ks a

s an

ad

ded

va

lue

in c

risi

s si

tuat

ion

is n

ot p

art

of t

he

thin

kin

g a

nd

actin

g o

f p

rofe

ssio

nal

s in

men

tal h

ealth

car

e; (

4) c

lien

ts

and

th

eir

net

wor

k (w

ho)

are

not

op

en t

o an

Fam

ily G

rou

p C

onfe

ren

ce.’

Aw

aren

ess

of t

he

bar

rier

s fo

r Fa

mily

Gro

up

Con

fere

nce

s ca

n ‘

hel

p t

o ke

ep a

n o

pen

min

d f

or it

s ca

pac

ity t

o st

ren

gth

en t

he

par

tner

ship

bet

wee

n c

lien

ts,

fam

ilial

net

wor

ks a

nd

pro

fess

ion

als’

an

d ‘

can

hel

p t

o ef

fect

uat

e p

rofe

ssio

nal

an

d e

thic

al v

alu

es o

f so

cial

w

orke

rs in

th

eir

qu

est

for

the

leas

t co

erci

ve c

are’

.

Sei

kku

la, J

2003

Fin

lan

d

Dat

a fr

om 6

9 se

rvic

e u

sers

, of

wh

om 4

5 w

ho

wer

e g

iven

Op

en

Dia

log

ue

sup

por

t w

ere

com

par

ed

with

14

serv

ice

use

rs in

typ

ical

ac

ute

ser

vice

s.

To e

valu

ate

the

Op

en D

ialo

gu

e (O

D)

app

roac

h t

hat

aim

s to

tr

eat

psy

chot

ic p

atie

nts

in

th

eir

hom

e.

Qu

antit

ativ

e an

alys

is o

f g

over

nm

ent

pat

ien

t d

ata

As

par

t of

th

e N

eed

-Ad

apte

d F

inn

ish

mod

el, t

he

Op

en

Dia

log

ue

(OD

) ap

pro

ach

aim

s to

tre

at p

sych

otic

pat

ien

ts

in t

hei

r h

ome.

Tre

atm

ent

invo

lves

th

e p

atie

nt’

s so

cial

n

etw

ork,

sta

rts

with

in 2

4 h

ours

of

initi

al c

onta

ct, a

nd

resp

onsi

bili

ty f

or t

he

entir

e tr

eatm

ent

rest

s w

ith t

he

sam

e te

am in

inp

atie

nt

and

ou

tpat

ien

t se

ttin

gs.

Pat

ien

ts

in t

he

Op

en D

ialo

gu

e in

Acu

te P

sych

osis

(O

DA

P)

gro

up

had

few

er r

elap

ses

and

less

res

idu

al p

sych

otic

sy

mp

tom

s an

d t

hei

r em

plo

ymen

t st

atu

s w

as b

ette

r th

an

pat

ien

ts in

th

e co

mp

aris

on g

rou

p. T

he

OD

ap

pro

ach

, lik

e ot

her

fam

ily t

her

apy

pro

gra

mm

es, s

eem

s to

pro

du

ce

bet

ter

outc

omes

th

an c

onve

ntio

nal

tre

atm

ent.

OD

em

ph

asis

es u

sin

g f

ewer

neu

role

ptic

med

icat

ion

.

183

Sh

ield

s, L

S; e

t al

2013

Ind

ia

N =

51.

Clie

nts

(n

= 3

9) a

nd

car

ers

(n =

12)

see

kin

g

men

tal h

ealth

tr

eatm

ent

at

outp

atie

nt

clin

ics

in u

rban

an

d r

ura

l se

ttin

gs.

To e

xplo

re t

he

feas

ibili

ty a

nd

util

ity

of p

sych

iatr

ic a

dva

nce

d

irec

tives

(PA

Ds)

in

Ind

ia, w

ith a

foc

us

on

the

nee

d f

or in

div

idu

al

con

trol

ove

r d

ecis

ion

mak

ing

an

d b

arri

ers

to im

ple

men

tatio

n, b

y ex

plo

rin

g v

iew

s of

its

cen

tral

sta

keh

old

ers,

se

rvic

e u

sers

an

d ca

rers

.

Qu

alita

tive

– in

terv

iew

s w

ith t

hem

atic

an

alys

is.

Clie

nts

en

gag

ed in

a n

um

ber

of

form

s of

dec

isio

n-

mak

ing

(p

assi

ve, a

ctiv

e, a

nd

col

lab

orat

ive)

dep

end

ing

on

the

situ

atio

n a

nd

dec

isio

n a

t h

and

, an

d h

ad h

igh

leve

ls

of s

elf-

effic

acy.

Mos

t cl

ien

ts a

nd

car

ers

wer

e u

nfa

mili

ar

with

PA

Ds,

an

d w

hile

som

e cl

ien

ts f

elt

it is

imp

orta

nt

to h

ave

a sa

y in

tre

atm

ent

wis

hes

, car

ers

exp

ress

ed

con

cern

s ab

out

serv

ice

use

r ca

pac

ity t

o m

ake

dec

isio

ns.

A

fter

com

ple

ting

PA

Ds,

clie

nts

rep

orte

d a

n in

crea

se in

se

lf-ef

ficac

y an

d a

n in

crea

sed

des

ire

to m

ake

dec

isio

ns.

Th

e au

thor

s co

ncl

ud

e th

at ‘

PAD

s co

uld

pot

entia

lly

miti

gat

e th

e ri

sks

of c

oerc

ive

trea

tmen

ts t

o p

erso

ns

with

se

vere

men

tal i

llnes

s.’

Sip

onen

, U;

Väl

imäk

i, M

; K

aivo

soja

, M;

Mar

ttu

nen

, M;

Kal

tiala

-Hei

no,

R

2011

Fin

lan

d

Dat

a fo

r al

l ad

oles

cen

ts a

ged

13

–17

from

tw

o Fi

nn

ish

dis

tric

ts

bet

wee

n y

ears

19

96–2

003.

The

aim

of

the

stu

dy

was

to

exp

lore

fe

atu

res

asso

ciat

ed

with

com

pu

lsor

y in

terv

entio

n o

f ad

oles

cen

ts a

t th

e re

gio

nal

leve

l by

com

par

ing

tw

o h

osp

ital d

istr

icts

cle

arly

d

iffer

ing

in t

his

reg

ard

.

Qu

antit

ativ

e an

alys

is o

f g

over

nm

ent

hos

pita

l d

isch

arg

e d

ata.

Fact

ors

oth

er t

han

th

e ch

arac

teri

stic

s of

th

e ad

oles

cen

ts

them

selv

es –

su

ch a

s ‘d

ivor

ces,

sin

gle

par

ent

fam

ilies

, soc

ial e

xclu

sion

’ –

are

asso

ciat

ed w

ith u

se o

f co

mp

uls

ory

care

, alth

oug

h a

n e

colo

gic

al s

tud

y d

esig

n ca

nn

ot e

stab

lish

cau

salit

y.

Sla

de,

M; e

t al

2010

En

gla

nd

Ad

mis

sion

co

st d

ata

wer

e co

llect

ed f

or

six

alte

rnat

ive

serv

ices

an

d si

x st

and

ard

serv

ices

.

To e

xplo

re s

hor

t-te

rm

outc

omes

an

d c

osts

of

adm

issi

on t

o al

tern

ativ

e an

d s

tan

dar

d s

ervi

ces,

an

d a

dd

ress

th

e g

ap in

res

earc

h o

n ou

tcom

es f

ollo

win

g

adm

issi

on t

o re

sid

entia

l al

tern

ativ

es t

o st

and

ard

in-p

atie

nt

men

tal h

ealth

se

rvic

es w

hic

h a

re

un

der

rese

arch

ed.

Qu

antit

ativ

e -

Hea

lth o

f th

e N

atio

n O

utc

ome

Sca

les

(HoN

OS

),

Thre

shol

d A

sses

smen

t G

rid

(TA

G),

G

lob

al

Ass

essm

ent

of F

un

ctio

nin

g

(GA

F).

All

outc

omes

imp

rove

d d

uri

ng

ad

mis

sion

for

bot

h t

ypes

of

ser

vice

(n

= 4

33).

Ad

just

ed im

pro

vem

ent

was

gre

ater

fo

r st

and

ard

ser

vice

s in

sco

res

on H

oNO

S (

diff

eren

ce

1.99

, 95%

CI 1

.12–

2.86

), T

AG

(d

iffer

ence

1.4

0, 9

5% C

I 0.

39–2

.51)

an

d G

AF

fun

ctio

nin

g (

diff

eren

ce 4

.15,

95%

C

I 1.0

8–7.

22)

bu

t n

ot G

AF

sym

pto

ms.

Ad

mis

sion

s to

al

tern

ativ

es w

ere

20.6

day

s sh

orte

r, an

d h

ence

ch

eap

er

(UK

£383

2 v.

£98

50).

Sta

nd

ard

ser

vice

s co

st a

n a

dd

ition

al

£293

9 p

er u

nit

HoN

OS

imp

rove

men

t. T

he

abse

nce

of

clea

r-cu

t ad

van

tag

e fo

r ei

ther

typ

e of

ser

vice

hig

hlig

hts

th

e im

por

tan

ce o

f th

e su

bje

ctiv

e ex

per

ien

ce a

nd

lon

ger

-te

rm c

osts

.

184

Sle

dg

e, W

H;

Teb

es, J

; Rak

feld

t,

J; D

avid

son

, L;

et a

l

1996

Un

ited

Sta

tes

197

pat

ien

ts

wer

e en

rolle

d in

th

e 2-

year

re

sear

ch

pro

gra

mm

e an

d fo

llow

ed f

or 1

0 m

onth

s.

To in

vest

igat

e th

e cl

inic

al f

easi

bili

ty

and

th

e ou

tcom

e fo

r p

atie

nts

of

a p

rog

ram

me

des

ign

ed

as a

n a

ltern

ativ

e to

ac

ute

hos

pita

lisat

ion

.

Qu

antit

ativ

e an

alys

is o

f ra

nd

om-d

esig

n st

ud

y d

ata.

The

clin

ical

, fu

nct

ion

al, s

ocia

l ad

just

men

t, q

ual

ity o

f lif

e, a

nd

sat

isfa

ctio

n o

utc

ome

mea

sure

s w

ere

not

st

atis

tical

ly d

iffer

ent

for

the

pat

ien

ts in

th

e tw

o tr

eatm

ent

con

diti

ons;

how

ever

, th

ere

was

a s

ligh

tly m

ore

pos

itive

ef

fect

of

the

exp

erim

enta

l pro

gra

mm

e on

mea

sure

s of

sy

mp

tom

s, o

vera

ll fu

nct

ion

ing

, an

d s

ocia

l fu

nct

ion

ing

. Th

e ex

per

imen

tal c

ond

ition

, a c

omb

ined

day

hos

pita

l/cr

isis

res

pite

com

mu

nity

res

iden

ce, s

eem

s to

hav

e h

ad

the

sam

e tr

eatm

ent

effe

ctiv

enes

s as

acu

te h

osp

ital c

are

for

urb

an, p

oor,

acu

tely

ill v

olu

nta

ry p

atie

nts

with

sev

ere

men

tal i

llnes

s.

Sle

dg

e, W

H;

Teb

es, J

; Wol

ff, N

; H

elm

inia

k, T

W19

96U

nite

d S

tate

s

197

pat

ien

ts

wer

e en

rolle

d in

th

e 2-

year

re

sear

ch

pro

gra

mm

e an

d fo

llow

ed f

or 1

0 m

onth

s.

To c

omp

are

serv

ice

use

an

d c

osts

for

ac

ute

ly il

l psy

chia

tric

p

atie

nts

tre

ated

in

a d

ay h

osp

ital/c

risi

s re

spite

pro

gra

mm

e or

in

a h

osp

ital i

np

atie

nt

pro

gra

m.

Qu

antit

ativ

e an

alys

is o

f d

ata

colle

cted

fo

r d

evel

opin

g

serv

ice

use

p

rofil

es a

nd

estim

ates

of

per

-un

it co

sts.

On

ave

rag

e, t

he

day

hos

pita

l/cri

sis

resp

ite p

rog

ram

me

cost

less

th

an in

pat

ien

t h

osp

italis

atio

n. T

he

aver

age

savi

ng

per

pat

ien

t w

as +

7,10

0, o

r ro

ug

hly

20%

of

the

tota

l dir

ect

cost

s. T

her

e w

ere

no

sig

nifi

can

t d

iffer

ence

s b

etw

een

pro

gra

mm

es in

ser

vice

util

isat

ion

or

cost

s d

uri

ng

th

e fo

llow

-up

ph

ase.

Th

e p

rog

ram

mes

wer

e eq

ual

ly e

ffec

tive,

bu

t d

ay h

osp

ital/c

risi

s re

spite

tre

atm

ent

was

less

exp

ensi

ve f

or s

ome

pat

ien

ts. P

oten

tial c

ost

savi

ng

s ar

e h

igh

er f

or n

onp

sych

otic

pat

ien

ts. C

ost

diff

eren

ces

bet

wee

n t

he

pro

gra

mm

es a

re d

rive

n b

y th

e h

osp

ital’s

rel

ativ

ely

hig

her

ove

rhea

d c

osts

. Th

e ro

ug

hly

eq

ual

exp

end

iture

s fo

r d

irec

t se

rvic

e st

aff

cost

s in

th

e tw

o p

rog

ram

mes

may

be

an im

por

tan

t cl

ue

for

un

der

stan

din

g w

hy

thes

e p

rog

ram

mes

pro

vid

ed e

qu

ally

ef

fect

ive

acu

te c

are.

Sm

ith, G

; et

al

200

5U

nite

d S

tate

s

Rec

ord

s of

p

atie

nts

old

er

than

18

year

s w

ho

wer

e ci

villy

co

mm

itted

to

one

of t

he

nin

e st

ate

hos

pita

ls

in P

enn

sylv

ania

w

ere

incl

ud

ed in

th

e an

alys

es.

To e

xam

ine

the

use

of

sec

lusi

on a

nd

mec

han

ical

res

trai

nt

from

199

0 to

200

0 an

d th

e ra

te o

f st

aff

inju

ries

fr

om p

atie

nt

assa

ults

fr

om 1

998

to 2

000

in a

st

ate

hos

pita

l sys

tem

, d

uri

ng

a p

erio

d o

f in

terv

entio

n t

o re

du

ce

rate

s.

Qu

antit

ativ

e an

alys

is o

f d

ata

colle

cted

p

re/p

ost

inte

rven

tion

.

The

rate

an

d d

ura

tion

of

secl

usi

on a

nd

mec

han

ical

re

stra

int

dec

reas

ed d

ram

atic

ally

du

rin

g t

his

per

iod

; fr

om 4

.2 t

o 0.

3 ep

isod

es p

er 1

,000

pat

ien

t-d

ays.

Th

e av

erag

e d

ura

tion

of

secl

usi

on d

ecre

ased

fro

m 1

0.8

to

1.3

hou

rs. T

he

rate

of

rest

rain

t d

ecre

ased

fro

m 3

.5 t

o 1.

2 ep

isod

es p

er 1

,000

pat

ien

t-d

ays.

Th

e av

erag

e d

ura

tion

of

rest

rain

t d

ecre

ased

fro

m 1

1.9

to 1

.9 h

ours

. Pat

ien

ts f

rom

ra

cial

or

eth

nic

min

ority

gro

up

s h

ad a

hig

her

rat

e an

d lo

ng

er d

ura

tion

of

secl

usi

on t

han

wh

ites.

Man

y fa

ctor

s co

ntr

ibu

ted

to

the

succ

ess

of t

his

eff

ort,

incl

ud

ing

ad

voca

cy e

ffor

ts, s

tate

pol

icy

chan

ge,

imp

rove

d p

atie

nt-

staf

f ra

tios,

res

pon

se t

eam

s, a

nd

sec

ond

-gen

erat

ion

antip

sych

otic

s.

185

Su

ryan

i, L;

et

al20

11In

don

esia

404,

591

peo

ple

cl

inic

ally

in

terv

iew

ed,

of w

hic

h 8

95

per

son

s w

ith

men

tal h

ealth

co

nd

ition

s w

ere

iden

tified

. 23

exp

erie

nce

d p

hys

ical

res

trai

nt/

con

finem

ent.

This

stu

dy

iden

tified

, m

app

ed a

nd

tre

ated

th

e cl

inic

al f

eatu

res

of m

enta

lly il

l peo

ple

, w

ho

had

bee

n is

olat

ed

and

res

trai

ned

by

fam

ily a

nd

com

mu

nity

m

emb

ers

as a

res

ult

of

a fu

nct

ion

al f

ailu

re o

f th

e tr

aditi

onal

med

ical

, h

osp

ital-

bas

ed m

enta

l h

ealth

mod

el c

urr

ently

p

ract

iced

in In

don

esia

.

Qu

antit

ativ

e –

10-m

onth

ep

idem

iolo

gic

al

pop

ula

tion

surv

ey

carr

ied

ou

t in

K

aran

gas

em

reg

ency

of

Bal

i, In

don

esia

.

Du

ratio

n o

f re

stra

int

ran

ged

fro

m 3

mon

ths

to 3

0 ye

ars

(mea

n =

8.1

yea

rs, S

D =

8.3

yea

rs).

Acc

ord

ing

to

th

e au

thor

s, ‘

Thro

ug

h t

he

app

licat

ion

of

a h

olis

tic

inte

rven

tion

mod

el, a

ll p

atie

nts

exh

ibite

d a

rem

arka

ble

re

cove

ry w

ithin

19

mon

ths

of t

reat

men

t.’

They

con

clu

de

that

‘th

e d

evel

opm

ent

of a

com

mu

nity

-bas

ed, c

ultu

rally

se

nsi

tive

and

res

pec

tfu

l men

tal h

ealth

mod

el c

an s

erve

as

an

op

timu

m p

rom

oter

of

pos

itive

men

tal h

ealth

ou

tcom

es’.

Sw

anso

n, J

; S

war

tz, M

; E

lbog

en, E

; R

ich

ard

Van

Dor

n;

Wag

ner

, R; M

oser

LA

; Wild

er C

; G

ilber

t A

R

2008

Un

ited

Sta

tes

A t

otal

of

239

pat

ien

ts w

ere

assi

gn

ed t

o b

e of

fere

d ‘f

acili

tate

d’

adva

nce

p

lan

nin

g; a

bou

t 60

% c

omp

lete

d p

lan

nin

g.

This

stu

dy

exam

ined

w

het

her

com

ple

tion

of

a Fa

cilit

ated

Psy

chia

tric

A

dva

nce

Dir

ectiv

e (F

-PA

D)

was

ass

ocia

ted

with

red

uce

d fr

equ

ency

of

coer

cive

cr

isis

inte

rven

tion

s.

Qu

antit

ativ

e an

alys

is o

f ra

nd

omis

ed

con

trol

led

tri

al

dat

a.

F-PA

D c

omp

letio

n w

as a

ssoc

iate

d w

ith lo

wer

od

ds

of

coer

cive

inte

rven

tion

s (a

dju

sted

OR

= 0

.50;

95%

CI =

0.

26-0

.96;

p <

0.0

5). P

AD

s m

ay b

e an

eff

ectiv

e to

ol f

or

red

uci

ng

coe

rciv

e in

terv

entio

ns

arou

nd

inca

pac

itatin

g

men

tal h

ealth

cri

ses.

Les

s co

erci

on s

hou

ld le

ad t

o g

reat

er a

uto

nom

y an

d s

elf-

det

erm

inat

ion

for

peo

ple

with

se

vere

men

tal i

llnes

s.

186

Sw

artz

, MS

; S

wan

son

, JW

; H

ann

on, M

J20

03U

nite

d S

tate

s

Su

rvey

ed 8

5 m

enta

l hea

lth

pro

fess

ion

als,

an

d 1

04

ind

ivid

ual

s w

ith

sch

izop

hre

nia

sp

ectr

um

co

nd

ition

s.

To e

xam

ine

wh

at

exte

nt

do

exp

erie

nce

s w

ith d

iffer

ent

form

s of

co

erci

on a

nd

pre

ssu

res

to a

dh

ere

to t

reat

men

t cr

eate

bar

rier

s th

at

may

inh

ibit

futu

re h

elp

seek

ing

for

men

tal

hea

lth p

rob

lem

s.

Qu

antit

ativ

e an

alys

is o

f su

rvey

dat

a.

Of

the

clin

icia

ns,

78%

rep

orte

d t

hat

ove

rall

they

th

oug

ht

leg

al p

ress

ure

s m

ade

thei

r p

atie

nts

with

sch

izop

hre

nia

m

ore

likel

y to

sta

y in

tre

atm

ent.

Reg

ard

ing

invo

lun

tary

ou

tpat

ien

t co

mm

itmen

t, 8

1% o

f cl

inic

ian

s d

isag

reed

w

ith t

he

pre

mis

e th

at m

and

ated

com

mu

nity

tre

atm

ent

det

ers

per

son

s w

ith s

chiz

oph

ren

ia f

rom

see

kin

g

volu

nta

ry t

reat

men

t in

th

e fu

ture

. Of

the

con

sum

er

sam

ple

, 63%

rep

orte

d a

life

time

his

tory

of

invo

lun

tary

h

osp

italis

atio

n, w

hile

36%

rep

orte

d f

ear

of c

oerc

ed

trea

tmen

t as

a b

arri

er t

o se

ekin

g h

elp

for

a m

enta

l h

ealth

pro

ble

m-t

erm

ed h

ere

‘man

dat

ed t

reat

men

t-re

late

d b

arri

ers

to c

are.

’ In

mu

ltiva

riab

le a

nal

yses

, on

ly

invo

lun

tary

hos

pita

lisat

ion

an

d r

ecen

t w

arn

ing

s ab

out

trea

tmen

t n

onad

her

ence

wer

e fo

un

d t

o b

e si

gn

ifica

ntly

as

soci

ated

with

bar

rier

s th

at m

ay in

hib

it fu

ture

hel

p se

ekin

g. T

hes

e re

sults

su

gg

est

that

man

dat

ed t

reat

men

t m

ay s

erve

as

a b

arri

er t

o tr

eatm

ent,

bu

t th

at o

ng

oin

g

info

rmal

pre

ssu

res

to a

dh

ere

to t

reat

men

t m

ay a

lso

be

imp

orta

nt

bar

rier

s to

tre

atm

ent.

Tan

enb

aum

, SJ

2012

Un

ited

Sta

tes

Su

rvey

of

dir

ecto

rs o

f 15

con

sum

er-

oper

ated

ser

vice

or

gan

isat

ion

s (s

ervi

ce u

ser

led

org

anis

atio

n)

and

fol

low

up

inte

rvie

w w

ith 6

d

irec

tors

.

This

stu

dy

exam

ines

th

e op

erat

ion

of

con

sum

er-o

per

ated

se

rvic

e or

gan

isat

ion

s in

on

e U

S s

tate

, an

d a

rgu

es t

hes

e or

gan

isat

ion

s, w

hic

h ar

e n

ew f

ollo

win

g

‘dei

nst

itutio

nal

isat

ion’

, ar

e ov

erlo

oked

by

pro

pon

ents

of

bri

ng

ing

b

ack

larg

esca

le

psy

chia

tric

hos

pita

ls.

Mix

ed m

eth

ods

– q

uan

titat

ive

anal

ysis

of

mai

l su

rvey

, w

ith f

ollo

w u

p q

uan

titat

ive

tele

ph

one

inte

rvie

ws.

Con

sum

er-o

per

ated

ser

vice

org

anis

atio

ns

(CO

SO

s)

emer

ge

as m

ore

self-

gov

ern

ing

an

d c

omm

un

ity-b

ased

th

an r

equ

ired

by

cert

ifica

tion

req

uir

emen

ts a

nd

as

dev

elop

ing

inte

rnal

ly a

nd

ext

ern

ally

in t

and

em. C

OS

Os

are

not

on

ly a

dju

nct

or

alte

rnat

ive

serv

ice

pro

vid

ers,

b

ut

also

civ

ic a

ssoc

iatio

ns

and

loci

for

th

e ex

pre

ssio

n o

f ci

tizen

ship

by

men

tally

ill p

eop

le. T

he

auth

ors

arg

ue

that

‘C

OS

O m

emb

ersh

ip c

onsi

sts

of

ser

iou

sly

men

tally

ill

peo

ple

(in

var

iou

s s

tag

es o

f r

ecov

ery)

, an

d

CO

SO

ser

vice

s a

nd

lin

kag

es w

ith o

ther

com

mu

nity

g

rou

ps

pro

vid

e th

e e

lem

ents

of

hos

pita

l ca

re t

hat

co

mm

un

ity-b

ased

clin

ical

pro

vid

ers

can

not

: fo

od,

shel

ter,

rec

reat

ion

, an

d s

ocia

liza-

tion

.’ F

urt

her

mor

e

bec

ause

CO

SO

s a

re n

ot c

onte

nt

to

rep

lace

th

e

hos

pita

l b

ut

als

o p

artic

ipat

e in

th

e r

ecov

ery

mov

emen

t, t

hey

pro

vid

e p

eer

su

pp

ort

an

d a

dvo

cacy

tr

ain

ing

an

d,

per

hap

s m

ost

imp

orta

ntly

, in

sist

on

se

lf-g

over

nan

ce a

nd

oth

er f

orm

s o

f c

itize

nsh

ip.

187

Thom

sen

, CT;

B

enro

s, M

E;

Mal

tese

n, T

; H

astr

up

, LH

; A

nd

erse

n, P

K;

Gia

cco,

D;

Nor

den

toft

, M

2018

Den

mar

k

Clin

ical

dat

a ob

tain

ed f

rom

re

cip

ien

ts o

f p

atie

nt-

con

trol

led

adm

issi

on in

all

the

five

reg

ion

s in

Den

mar

k w

her

e p

atie

nt-

con

trol

led

adm

issi

on is

av

aila

ble

.

To a

sses

s w

het

her

im

ple

men

ting

pat

ien

t-co

ntr

olle

d a

dm

issi

on

(PC

A)

can

red

uce

co

erci

on a

nd

imp

rove

ot

her

clin

ical

ou

tcom

es

for

psy

chia

tric

in-

pat

ien

ts.

Qu

antit

ativ

e an

alys

is

of p

atie

nt-

con

trol

led

adm

issi

on d

ata.

Imp

lem

entin

g p

atie

nt-

con

trol

led

ad

mis

sion

(P

CA

) d

id

not

red

uce

coe

rcio

n, s

ervi

ce u

se o

r se

lf-h

arm

beh

avio

ur

wh

en c

omp

ared

with

tre

atm

ent

as u

sual

(TA

U).

In a

p

aire

d d

esig

n, t

he

outc

omes

of

PC

A p

atie

nts

du

rin

g

the

year

aft

er s

ign

ing

a c

ontr

act

wer

e co

mp

ared

with

th

e ye

ar b

efor

e. T

he

PC

A g

rou

p h

ad m

ore

in-p

atie

nt

bed

day

s (m

ean

diff

eren

ce =

28.

4; 9

5% C

I: 21

.3; 3

5.5)

an

d m

ore

med

icat

ion

use

(P

< 0

.000

1) t

han

th

e TA

U

gro

up

. Bef

ore

and

aft

er a

nal

yses

sh

owed

red

uct

ion

in c

oerc

ion

(P

= 0

.000

1) a

nd

in-p

atie

nt

bed

day

s (P

=

0.00

03).

Ben

efici

al e

ffec

ts o

f P

CA

wer

e ob

serv

ed o

nly

in

the

bef

ore

and

aft

er P

CA

com

par

ison

s. F

urt

her

res

earc

h sh

ould

inve

stig

ate

wh

eth

er P

CA

aff

ects

oth

er o

utc

omes

to

bet

ter

esta

blis

h it

s cl

inic

al v

alu

e.

Thom

sen

, C;

Sta

rkop

f, L;

H

astr

up

, LH

; A

nd

erse

n, P

K;

Nor

den

toft

, M;

Ben

ros,

ME

2017

Den

mar

k

Stu

dy

pop

ula

tion

incl

ud

ed a

ll in

div

idu

als

aged

18

–63

year

s w

ith

a p

sych

iatr

ic

inp

atie

nt

adm

issi

on d

uri

ng

Ja

nu

ary

1, 1

999–

Dec

emb

er 3

1,

2014

To id

entif

y ri

sk f

acto

rs

asso

ciat

ed w

ith

coer

cive

mea

sure

s,

to b

ette

r id

entif

yin

g

pos

sib

le c

ause

s of

(an

d h

ence

rem

edie

s to

) co

erci

on.

Qu

antit

ativ

e an

alys

is o

f p

sych

iatr

ic

inp

atie

nt

adm

issi

on d

ata.

Clin

ical

ch

arac

teri

stic

s w

ere

the

fore

mos

t p

red

icto

rs

of c

oerc

ion

an

d p

atie

nts

with

org

anic

men

tal d

isor

der

h

ad t

he

hig

hes

t in

crea

sed

ris

k of

bei

ng

su

bje

cted

to

a co

erci

ve m

easu

re (

OR

=5.

56; 9

5% C

I=5.

04, 6

.14)

. Th

e ri

sk o

f co

erci

on w

as t

he

hig

hes

t in

th

e fir

st a

dm

issi

on

and

dec

reas

ed w

ith t

he

nu

mb

er o

f ad

mis

sion

s (a

ll p

<0.

001)

. Th

e fo

llow

ing

soc

ioec

onom

ic v

aria

ble

s w

ere

asso

ciat

ed w

ith a

n in

crea

sed

ris

k of

coe

rcio

n: m

ale

sex,

un

emp

loym

ent,

low

er s

ocia

l cla

ss a

nd

imm

igra

nts

fr

om lo

w a

nd

mid

dle

inco

me

cou

ntr

ies

(all

p<

0.00

1).

Ear

ly r

etir

emen

t an

d s

ocia

l rel

atio

ns,

su

ch a

s b

ein

g

mar

ried

an

d h

avin

g c

hild

ren

, red

uce

d t

he

risk

of

bei

ng

su

bje

cted

to

coer

cive

mea

sure

(al

l p<

0.0

5). T

hes

e fin

din

gs

can

ass

ist

rese

arch

ers

in id

entif

yin

g p

atie

nts

at

risk

of

coer

cion

an

d t

her

eby

hel

p t

arg

etin

g n

ew c

oerc

ion

red

uct

ion

pro

gra

mm

es.

188

Thor

nic

roft

, G;

et a

l20

13E

ng

lan

d

569

par

ticip

ants

w

ere

ran

dom

ly

assi

gn

ed (

285

to

the

inte

rven

tion

gro

up

an

d 2

84

to t

he

con

trol

g

rou

p)

To a

sses

s w

het

her

th

e ad

diti

onal

use

of

Joi

nt

Cri

sis

Pla

ns

imp

rove

d p

atie

nt

outc

omes

com

par

ed

with

tre

atm

ent

as u

sual

fo

r p

eop

le w

ith s

ever

e m

enta

l illn

ess.

Qu

antit

ativ

e an

alys

is o

f C

RIM

SO

N

(Cri

sis

Imp

act:

S

ub

ject

ive

and

Ob

ject

ive

coer

cion

an

d eN

gag

emen

t)

ran

dom

ised

co

ntr

olle

d t

rial

d

ata.

The

find

ing

s ar

e in

con

sist

ent

with

tw

o ea

rlie

r Jo

int

Cri

sis

Pla

ns

(JC

P)

stu

die

s, a

nd

sh

ow t

hat

th

e JC

P is

not

si

gn

ifica

ntly

mor

e ef

fect

ive

than

tre

atm

ent

as u

sual

. Th

ere

is e

vid

ence

to

sug

ges

t th

e JC

Ps

wer

e n

ot f

ully

im

ple

men

ted

in a

ll st

ud

y si

tes,

an

d w

ere

com

bin

ed w

ith

rou

tine

clin

ical

rev

iew

mee

ting

s w

hic

h d

id n

ot a

ctiv

ely

inco

rpor

ate

pat

ien

ts’

pre

fere

nce

s. T

he

stu

dy

ther

efor

e ra

ises

imp

orta

nt

qu

estio

ns

abou

t im

ple

men

ting

new

in

terv

entio

ns

in r

outin

e cl

inic

al p

ract

ice.

Val

enti,

E; e

t al

2015

Inte

r-n

atio

nal

: C

anad

a,

Ch

ile,

Cro

atia

, G

erm

any,

It

aly,

M

exic

o,

Nor

way

, S

pai

n,

Sw

eden

, U

nite

d K

ing

dom

.

Focu

s g

rou

ps

with

men

tal

hea

lth

pro

fess

ion

als

wer

e co

nd

uct

ed

in t

en c

oun

trie

s.

This

pap

er a

ims

to

iden

tify

the

attit

ud

es

and

exp

erie

nce

s of

men

tal h

ealth

p

rofe

ssio

nal

s to

war

ds

the

use

of

info

rmal

co

erci

on a

cros

s co

un

trie

s w

ith d

iffer

ing

so

cioc

ultu

ral c

onte

xts.

Qu

alita

tive

anal

ysis

of

focu

s g

rou

p in

terv

iew

s in

te

n c

oun

trie

s w

ith d

iffer

ent

soci

ocu

ltura

l co

nte

xts.

A d

isap

pro

val o

f in

form

al c

oerc

ion

in t

heo

ry is

of

ten

ove

rrid

den

in p

ract

ice.

Th

is d

isso

nan

ce o

ccu

rs

acro

ss d

iffer

ent

soci

ocu

ltura

l con

text

s, t

end

s to

mak

e p

rofe

ssio

nal

s fe

el u

nea

sy, a

nd

req

uir

es m

ore

deb

ate

and

gu

idan

ce.

van

der

Pos

t,

Lou

k FM

; Pee

n, J

; V

isch

, I; M

uld

er,

CL;

Bee

kman

, A

TF; D

ekke

r, JJ

M

2014

Net

her

lan

ds

Ran

dom

sam

ple

of

252

fro

m t

he

2,68

2 p

atie

nts

co

nse

cutiv

ely

com

ing

into

co

nta

ct w

ith

two

psy

chia

tric

em

erg

ency

te

ams

in

Am

ster

dam

.

Aim

is t

o st

ud

y th

e lin

ks b

etw

een

op

inio

ns

abou

t p

rior

psy

chia

tric

tr

eatm

ent,

insi

gh

t,

serv

ice

eng

agem

ent

and

th

e ri

sk o

f (n

ew)

civi

l det

entio

ns.

Qu

antit

ativ

e an

alys

is

of s

ocio

-d

emog

rap

hic

an

d c

linic

al

char

acte

rist

ics

and

info

rmat

ion

abou

t p

rior

in

volu

nta

ry

adm

issi

ons.

Mor

e sa

tisfa

ctio

n w

ith p

rior

tre

atm

ent

seem

s to

red

uce

th

e ri

sk o

f ci

vil d

eten

tion

rem

arka

bly

. Low

leve

ls o

f sa

tisfa

ctio

n s

eem

to

be

mai

nly

dep

end

ent

on a

his

tory

of

pre

viou

s in

volu

nta

ry a

dm

issi

on. T

hes

e fin

din

gs

seem

to

op

en u

p a

new

per

spec

tive

for

dim

inis

hin

g t

he

risk

of

(new

) ci

vil d

eten

tion

by

tryi

ng

to

enh

ance

sat

isfa

ctio

n w

ith t

reat

men

t, e

spec

ially

for

pat

ien

ts u

nd

er d

eten

tion

.

189

van

der

Sch

aaf,

PS

; Du

ssel

dor

p,

E; K

eun

ing

, FM

; Ja

nss

en, W

A;

Noo

rth

oorn

, EO

2013

Net

her

lan

ds

Ser

vice

dat

a on

77

Du

tch

psy

chia

tric

h

osp

itals

an

d al

so a

ben

chm

ark

stu

dy

on t

he

use

of

coer

cive

m

easu

res

in 1

6 D

utc

h p

sych

iatr

ic

hos

pita

ls.

To e

xplo

re t

he

effe

ct o

f d

esig

n f

eatu

res

on t

he

risk

of

bei

ng

sec

lud

ed,

the

nu

mb

er o

f se

clu

sion

inci

den

ts a

nd

the

time

in s

eclu

sion

, fo

r p

atie

nts

ad

mitt

ed

to lo

cked

war

ds

for

inte

nsi

ve p

sych

iatr

ic

care

.

Qu

antit

ativ

e an

alys

is b

y co

mb

inin

g d

ata

of b

uild

ing

q

ual

ity a

nd

safe

ty w

ith d

ata

on f

req

uen

cy

and

typ

e of

coe

rciv

e m

easu

res.

A n

um

ber

of

des

ign

fea

ture

s h

ad a

n e

ffec

t on

th

e u

se o

f se

clu

sion

an

d r

estr

ain

t. T

he

stu

dy

hig

hlig

hte

d th

e n

eed

for

a g

reat

er f

ocu

s on

th

e im

pac

t of

th

e p

hys

ical

en

viro

nm

ent

on p

atie

nts

, as,

alo

ng

with

oth

er

inte

rven

tion

s, t

his

can

red

uce

th

e n

eed

for

sec

lusi

on a

nd

rest

rain

t.

Vru

win

k, F

J;

Mu

lder

, CL;

N

oort

hoo

rn, E

O;

Uite

nb

roek

, D;

Nijm

an, H

LI

2012

Net

her

lan

ds

Du

tch

hos

pita

ls

that

rec

eive

d a

gov

ern

men

t g

ran

t p

rog

ram

, w

hic

h in

200

6 (s

tart

of

pro

gra

m)

nu

mb

ered

34

and

by

2009

(e

nd

of

pro

gra

m)

nu

mb

ered

42.

To e

stab

lish

wh

eth

er

the

nu

mb

ers

of

bot

h s

eclu

sion

an

d in

volu

nta

ry m

edic

atio

n ch

ang

ed s

ign

ifica

ntly

af

ter

the

star

t of

th

is

nat

ion

al p

rog

ram

me

des

ign

ed t

o re

du

ce

secl

usi

on in

Du

tch

hos

pita

ls.

Qu

antit

ativ

e an

alys

is

(usi

ng

Poi

sson

re

gre

ssio

n to

est

imat

e d

iffer

ence

in

log

it sl

opes

) of

Du

tch

Hea

lth C

are

Insp

ecto

rate

d

ata

for

secl

usi

on a

nd

invo

lun

tary

m

edic

atio

n.

Aft

er t

he

star

t of

th

e n

atio

nw

ide

pro

gra

mm

e th

e n

um

ber

of

secl

usi

ons

fell,

an

d a

lthou

gh

sig

nifi

can

tly

chan

gin

g, t

he

red

uct

ion

was

mod

est

and

fai

led

to

mee

t th

e ob

ject

ive

of a

10%

an

nu

al d

ecre

ase.

Th

e n

um

ber

of

invo

lun

tary

med

icat

ion

s d

id n

ot c

han

ge;

inst

ead

, aft

er

corr

ectio

n f

or t

he

nu

mb

er o

f in

volu

nta

ry h

osp

italis

atio

ns,

it

incr

ease

d.

190

Wan

chek

, TN

; B

onn

ie, R

J20

12U

nite

d S

tate

s

500

Med

icai

d re

cip

ien

ts w

ho

had

a m

enta

l h

ealth

dia

gn

osis

an

d a

t le

ast

one

tem

por

ary

det

entio

n o

rder

(T

DO

).

This

stu

dy

exam

ined

w

het

her

len

gth

enin

g

the

hol

din

g p

erio

d fo

r an

ind

ivid

ual

ex

per

ien

cin

g a

men

tal

hea

lth c

risi

s u

nd

er a

te

mp

orar

y d

eten

tion

ord

er (

TDO

) ca

n r

edu

ce

the

nu

mb

er a

nd

len

gth

of

pos

t-TD

O in

volu

nta

ry

hos

pita

l com

mitm

ents

.

Qu

antit

ativ

e an

alys

is o

f d

ata

from

Vir

gin

ia

Cou

rt S

yste

m

and

Vir

gin

ia

Med

icar

e cl

aim

s d

atab

ase.

Lon

ger

TD

O p

erio

ds

wer

e co

rrel

ated

with

an

incr

ease

d p

rob

abili

ty o

f a

dis

mis

sal o

f th

e co

mm

itmen

t p

etiti

on

rath

er t

han

hos

pita

lisat

ion

aft

er a

TD

O. A

mon

g

ind

ivid

ual

s w

ho

wer

e h

osp

italis

ed, l

ong

er T

DO

per

iod

s w

ere

corr

elat

ed w

ith a

n in

crea

sed

like

lihoo

d o

f vo

lun

tary

h

osp

italis

atio

n, r

ath

er t

han

invo

lun

tary

com

mitm

ent,

an

d s

hor

ter

hos

pita

lisat

ion

s, a

lthou

gh

th

e n

et c

are

time

(TD

O p

erio

d p

lus

pos

t-TD

O h

osp

italis

atio

n)

incr

ease

d fo

r in

div

idu

als

wh

ose

TDO

len

gth

was

gre

ater

th

an 2

4 h

ours

.

Wat

son

, S;

Thor

bu

rn, K

; E

vere

tt, M

; Fis

her

, K

R

2014

Au

stra

liaN

/A

To a

pp

ly t

hre

e d

iffer

ent

fram

ewor

ks c

urr

ently

u

sed

in m

enta

l hea

lth

serv

ices

(h

um

an r

igh

ts,

per

son

al r

ecov

ery,

an

d tr

aum

a-in

form

ed)

to

the

text

of

the

Nat

iona

l S

tand

ard

s fo

r M

enta

l H

ealth

Ser

vice

s 20

10

as w

ell a

s th

e p

ub

lic

text

of

spea

kers

’ n

otes

reg

ard

ing

live

d ex

per

ien

ce f

rom

th

e C

are

With

out

Coe

rcio

n C

onfe

ren

ce 2

010

Qu

alita

tive

anal

ysis

of

bot

h a

key

nat

ion

al

pol

icy

doc

um

ent

as w

ell a

s p

ub

lic t

ext

from

sp

eake

rs

of a

nat

ion

al

con

fere

nce

.

The

anal

ysis

sou

gh

t to

an

alys

e th

e d

egre

e to

wh

ich

nat

ion

al p

olic

y d

ocu

men

ts r

eflec

t a

shift

sig

nal

led

in t

he

thre

e fr

amew

orks

. Th

e au

thor

s id

entifi

ed t

he

use

of

forc

e in

man

y as

pec

ts o

f p

olic

y. T

he

auth

ors

sug

ges

t p

ath

way

s to

ap

ply

th

e fr

amew

orks

in n

atio

nal

pol

icy,

wh

ich

they

arg

ue

wou

ld b

rin

g a

bou

t fr

eed

om f

rom

vio

len

ce;

sup

por

t fo

r d

ecis

ion

mak

ing

; acc

ess

and

ch

oice

ab

out

com

mu

nity

an

d in

pat

ien

t op

tion

s; s

afet

y an

d r

isk

man

agem

ent;

an

d g

reat

er u

nd

erst

and

ing

of

curr

ent

pol

icy

fram

ewor

ks t

hro

ug

h e

ng

agem

ent

with

peo

ple

w

ith li

ved

exp

erie

nce

ab

out

the

optio

ns

and

imp

act

of

sup

por

t p

roce

sses

th

at e

xclu

de

the

use

of

forc

e.

191

Wie

man

, D; e

t al

20

14U

nite

d S

tate

s

Ser

vice

dat

a fo

r 43

inp

atie

nt

psy

chia

tric

fa

cilit

ies

To e

xam

ine

imp

lem

enta

tion

an

d ou

tcom

es o

f th

e S

ix

Cor

e S

trat

egie

s fo

r R

edu

ctio

n o

f S

eclu

sion

an

d R

estr

ain

t (6

CS

) in

43

inp

atie

nt

psy

chia

tric

fa

cilit

ies.

Fac

ilitie

s w

ere

clas

sifie

d in

to fi

ve

imp

lem

enta

tion

typ

es:

stab

ilise

d (

N=

28),

co

ntin

ued

(N

=7)

, d

ecre

ased

(N

=5)

, d

isco

ntin

ued

(N

=1)

, or

nev

er im

ple

men

ted

(N=

2).

Qu

antit

ativ

e –

a p

roto

typ

e In

ven

tory

of

Sec

lusi

on

and

Res

trai

nt

Red

uct

ion

Inte

rven

tion

s (I

SR

RI)

‘tr

acke

d fid

elity

’ ov

er

time.

Ove

rall,

th

e st

abili

sed

gro

up

red

uce

d t

he

per

cen

tag

e se

clu

ded

by

17%

(p

=.0

02),

sec

lusi

on h

ours

by

19%

(p

=.0

01),

an

d p

rop

ortio

n r

estr

ain

ed b

y 30

% (

p=

.03)

. Th

e re

du

ctio

n in

res

trai

nt

hou

rs w

as 5

5% b

ut

non

sig

nifi

can

t (p

=.0

8). I

nd

ivid

ual

fac

ility

eff

ect

size

s va

ried

; som

e ra

tes

incr

ease

d f

or s

ome

faci

litie

s. T

he

dos

e-ef

fect

hyp

oth

esis

w

as s

up

por

ted

for

tw

o ou

tcom

es, s

eclu

sion

hou

rs a

nd

per

cen

tag

e re

stra

ined

. Th

e or

der

of

imp

lem

enta

tion

gro

up

eff

ects

in r

elat

ion

to

each

ou

tcom

e va

ried

u

np

red

icta

bly

. Th

e 6C

S w

as f

easi

ble

to

imp

lem

ent

and

effe

ctiv

e in

div

erse

fac

ility

typ

es. F

idel

ity o

ver

time

was

n

onlin

ear

and

var

ied

am

ong

fac

ilitie

s. F

urt

her

res

earc

h on

rel

atio

nsh

ips

bet

wee

n f

acili

ty c

har

acte

rist

ics,

fid

elity

p

atte

rns,

an

d o

utc

omes

is n

eed

ed.

Win

ick,

BJ

1996

Un

ited

Sta

tes

N/A

Art

icle

an

alys

es h

ow

livin

g w

ills

and

oth

er

adva

nce

dir

ectiv

e in

stru

men

ts m

ay b

e u

sed

in m

enta

l hea

lth

con

text

s.

Qu

alita

tive

anal

ysis

of

law

rel

evan

t to

livi

ng

will

s an

d a

dva

nce

d

irec

tives

, p

artic

ula

rly

case

la

w.

Ad

van

ce d

irec

tive

inst

rum

ents

can

be

a u

sefu

l mea

ns

of p

lan

nin

g f

or m

enta

l illn

ess

and

of

avoi

din

g d

isp

ute

s co

nce

rnin

g h

osp

italis

atio

n a

nd

tre

atm

ent.

Th

e av

oid

ance

of

hea

rin

gs,

eith

er ju

dic

ial o

r ad

min

istr

ativ

e, t

o re

solv

e th

ese

con

trov

ersi

es w

ould

pro

du

ce c

onsi

der

able

fis

cal a

nd

ad

min

istr

ativ

e sa

vin

gs.

It a

lso

cou

ld p

reve

nt

div

ersi

on o

f sc

arce

clin

ical

res

ourc

es f

rom

tre

atm

ent

to

dis

pu

te r

esol

utio

n. I

n a

dd

ition

, it

wou

ld a

void

th

e p

atie

nt

dis

satis

fact

ion

th

at r

esu

lts w

hen

pat

ien

ts lo

se s

uch

h

eari

ng

s an

d t

hat

som

etim

es p

rod

uce

s a

psy

chol

ogic

al

reac

tan

ce t

hat

un

der

min

es t

he

chan

ces

for

succ

essf

ul

trea

tmen

t.

192

Wis

dom

, JP

; W

eng

er, D

; R

ober

tson

, D;

Van

Bra

mer

, J;

Sed

erer

, LI

2015

Un

ited

Sta

tes

Thre

e p

artic

ipat

ing

m

enta

l hea

lth

trea

tmen

t ce

ntr

es t

hat

ad

opte

d t

he

Six

C

ore

Str

ateg

ies

pro

gra

m.

To e

valu

ate

the

Posi

tive

Alte

rnat

ives

to

Res

trai

nt

and

Sec

lusi

on

pro

ject

of

the

New

Yor

k S

tate

Offi

ce o

f M

enta

l H

ealth

(O

MH

).

Qu

antit

ativ

e –

serv

ice

dat

a fr

om s

tate

-op

erat

ed

and

lice

nse

d in

pat

ien

t an

d re

sid

entia

l tr

eatm

ent

pro

gra

mm

es

for

‘ch

ildre

n w

ith s

ever

e em

otio

nal

d

istu

rban

ces’

.

The

thre

e p

artic

ipat

ing

men

tal h

ealth

tre

atm

ent

faci

litie

s d

emon

stra

ted

sig

nifi

can

t d

ecre

ases

in r

estr

ain

t an

d s

eclu

sion

ep

isod

es p

er 1

,000

clie

nt-

day

s. E

ach

iden

tified

sp

ecifi

c ac

tiviti

es t

hat

con

trib

ute

d t

o su

cces

s,

incl

ud

ing

way

s to

fac

ilita

te o

pen

, res

pec

tfu

l tw

o-w

ay

com

mu

nic

atio

n b

etw

een

man

agem

ent

and

sta

ff a

nd

bet

wee

n s

taff

an

d y

outh

s an

d g

reat

er in

volv

emen

t of

yo

uth

s in

pro

gra

mm

e d

ecis

ion

mak

ing

.

Zin

kler

, M20

16G

erm

any

Ser

vice

dat

a on

a n

etw

ork

of B

avar

ian

hos

pita

ls

To r

evie

w d

ata

on

the

use

of

coer

cion

, ag

ain

st d

ata

on t

he

use

of

coe

rciv

e tr

eatm

ent

in a

gro

up

of

Bav

aria

n h

osp

itals

sin

ce

2014

. Ad

diti

onal

ly,

det

aile

d d

ata

from

on

e in

stitu

tion

with

an

un

com

mon

ap

pro

ach

to v

iole

nce

an

d co

erci

on is

pre

sen

ted

.

Qu

antit

ativ

e d

ata

anal

ysis

of

use

of

coer

cion

in

net

wor

k of

p

sych

iatr

ic

hos

pita

ls

In a

15-

mon

th p

erio

d s

tart

ing

in 2

014,

Ger

man

y’s

Con

stitu

tion

al C

ourt

an

d F

eder

al S

up

rem

e C

ourt

re

stri

cted

invo

lun

tary

tre

atm

ent

‘in a

ll b

ut

life-

thre

aten

ing

em

erg

enci

es’

in r

esp

onse

to

the

CR

PD

. Nat

ion

al a

nd

loca

l dat

a su

gg

ests

th

at g

ivin

g u

p c

oerc

ive

med

icat

ion

is

not

str

aig

htf

orw

ard

an

d p

rob

lem

s ar

ise

wh

en o

ne

form

of

coe

rciv

e tr

eatm

ent

(coe

rciv

e m

edic

atio

n)

is s

top

ped

b

ut

oth

er f

orm

s of

coe

rcio

n (

rest

rain

t) a

nd

vio

len

ce in

p

sych

iatr

ic in

stitu

tion

s in

crea

se. T

he

auth

or w

rite

s th

at

‘[d

]ata

fro

m a

… lo

cal m

enta

l hea

lth s

ervi

ce s

ug

ges

t th

at

the

use

of

coer

cive

med

icat

ion

cou

ld b

e m

ade

obso

lete

.’

193

App

endi

x Tw

o –

Rev

iew

s an

d O

ther

Not

able

Mat

eria

ls

AU

TH

OR

YE

AR

TIT

LES

UM

MA

RY

Bak

, J; B

rand

t-C

hris

tens

en, M

; S

esto

ft, D

M;

Zoff

man

n, V

2012

Mec

hani

cal r

estr

aint

--w

hich

in

terv

entio

ns p

reve

nt e

piso

des

of m

echa

nica

l res

trai

nt?

- a

syst

emat

ic r

evie

w

This

rev

iew

iden

tifies

inte

rven

tions

pre

vent

ing

mec

hani

cal r

estr

aint

s, e

ncom

pass

ing

inte

rnat

iona

l re

sear

ch p

aper

s de

alin

g w

ith m

echa

nica

l res

trai

nt. T

he r

evie

w c

ombi

nes

qual

itativ

e an

d qu

antit

ativ

e re

sear

ch in

a n

ew w

ay, d

escr

ibin

g t

he q

ualit

y of

evi

denc

e an

d th

e ef

fect

of

inte

rven

tion.

The

aut

hors

su

gg

est

‘cog

nitiv

e m

ilieu

the

rapy

’, ‘c

ombi

ned

inte

rven

tions

’, an

d ‘p

atie

nt-c

ente

red

care

’ wer

e th

e th

ree

inte

rven

tions

mos

t lik

ely

to r

educ

e th

e nu

mbe

r of

mec

hani

cal r

estr

aint

s, y

et r

ue t

he la

ck o

f hi

gh-

qual

ity

and

effe

ctiv

e in

terv

entio

n st

udie

s.

Bol

a, J

R;

Leht

inen

, K;

Cul

lber

g, J

; C

iom

pi, L

2009

Psy

chos

ocia

l tre

atm

ent,

an

tipsy

chot

ic p

ostp

onem

ent,

an

d lo

w-d

ose

med

icat

ion

stra

teg

ies

in fi

rst-

epis

ode

psyc

hosi

s: a

rev

iew

of

the

liter

atur

e

This

rev

iew

inve

stig

ates

the

eff

ects

of

acut

e ps

ycho

soci

al t

reat

men

ts u

sing

med

icat

ion

post

pone

men

t pr

otoc

ols

for

early

epi

sode

sch

izop

hren

ia. F

ive

stud

ies

wer

e in

clud

ed in

the

rev

iew

(n=

261

patie

nts)

; on

e w

as a

ran

dom

ised

con

trol

led

tria

l (R

CT)

, thr

ee w

ere

quas

i-exp

erim

enta

l stu

dies

and

one

was

a

case

-con

trol

stu

dy. F

ollo

w-u

p ra

nged

fro

m t

wo

to fi

ve y

ears

(whe

re r

epor

ted)

. Tw

en27

% t

o 43

% o

f ps

ycho

-soc

ially

tre

ated

pat

ient

s w

ere

not

rece

ivin

g a

ntip

sych

otic

s at

tw

o or

thr

ee-y

ear

follo

w-u

p.:

Initi

al p

sych

osoc

ial t

reat

men

t co

mbi

ned

with

tim

e-lim

ited

post

pone

men

t of

ant

ipsy

chot

ic m

edic

atio

ns

may

fac

ilita

te a

red

uctio

n in

long

-ter

m m

edic

atio

n de

pend

ence

and

the

dis

crim

inat

ion

of s

imila

r (b

ut

‘pat

hoph

ysio

log

ical

ly d

iffer

ent’

) dia

gno

stic

ent

ities

for

pat

ient

s w

ith fi

rst-

epis

ode

psyc

hosi

s.

Bow

ers,

L20

14S

afew

ards

: a n

ew m

odel

of

confl

ict

and

cont

ainm

ent

on

psyc

hiat

ric w

ards

In E

ngla

nd, t

he S

afew

ards

mod

el h

as b

een

deve

lope

d w

hich

iden

tifies

asp

ects

of

wor

king

in p

sych

iatr

ic

war

ds t

hat

are

know

n to

cre

ate

pote

ntia

l ‘fla

shpo

ints

’. Th

e m

odel

invo

lves

ten

inte

rven

tions

aim

ed a

t he

lpin

g s

taff

man

age

thos

e fla

shpo

ints

to

redu

ce c

onfli

ct.

Bur

ns, T

; et

al20

01H

ome

trea

tmen

t fo

r m

enta

l he

alth

pro

blem

s: a

sys

tem

atic

re

view

This

rev

iew

inve

stig

ates

the

eff

ectiv

enes

s of

‘hom

e tr

eatm

ent’

for

men

tal h

ealth

pro

blem

s in

ter

ms

of h

ospi

talis

atio

n an

d co

st-e

ffec

tiven

ess.

The

aut

hors

find

tha

t th

e ev

iden

ce b

ase

for

hom

e tr

eatm

ent

com

pare

d w

ith o

ther

com

mun

ity-b

ased

ser

vice

s is

not

str

ong

, alth

oug

h it

does

sho

w t

hat

hom

e tr

eatm

ent

redu

ces

days

spe

nt in

hos

pita

l com

pare

d w

ith in

patie

nt t

reat

men

t.

Buu

s, N

; et

al20

17

Ada

ptin

g a

nd Im

plem

entin

g

Ope

n D

ialo

gue

in t

he

Sca

ndin

avia

n C

ount

ries:

A

Sco

ping

Rev

iew

This

sco

ping

rev

iew

1) i

dent

ified

the

ran

ge

and

natu

re o

f lit

erat

ure

on t

he a

dopt

ion

of O

pen

Dia

log

ue in

S

cand

inav

ia in

pla

ces

othe

r th

an t

he o

rigin

al s

ites

in F

inla

nd (3

3 pu

blic

atio

ns),

and

2) s

umm

aris

es t

his

liter

atur

e. M

ost

stud

ies

in t

his

scop

ing

rev

iew

wer

e pu

blis

hed

as ‘g

rey’

lite

ratu

re a

nd m

ost

gra

pple

d w

ith h

ow t

o im

plem

ent

Ope

n D

ialo

gue

fai

thfu

lly. I

n th

e S

cand

inav

ian

rese

arch

con

text

, Ope

n D

ialo

gue

w

as m

ainl

y de

scrib

ed a

s a

prom

isin

g a

nd f

avou

rabl

e ap

proa

ch t

o m

enta

l hea

lth c

are.

194

Cal

ton,

T; F

errit

er,

M; H

uban

d, N

; S

pand

ler,

H20

08

A S

yste

mat

ic R

evie

w o

f th

e S

oter

ia P

arad

igm

for

the

Tr

eatm

ent

of P

eopl

e D

iag

nose

d W

ith S

chiz

ophr

enia

Sum

mar

ises

the

find

ing

s fr

om a

ll co

ntro

lled

tria

ls t

hat

have

ass

esse

d th

e ef

ficac

y of

the

Sot

eria

pa

radi

gm

for

the

tre

atm

ent

of p

eopl

e di

agno

sed

with

sch

izop

hren

ia s

pect

rum

dis

orde

rs. T

he s

tudi

es

incl

uded

in t

his

revi

ew s

ugg

est

that

the

Sot

eria

par

adig

m y

ield

s eq

ual,

and

in c

erta

in s

peci

fic a

reas

, be

tter

res

ults

in t

he t

reat

men

t of

peo

ple

diag

nose

d w

ith fi

rst-

or

seco

nd-e

piso

de s

chiz

ophr

enia

spe

ctru

m

diso

rder

s (a

chie

ving

thi

s w

ith c

onsi

dera

bly

low

er u

se o

f m

edic

atio

n) w

hen

com

pare

d w

ith c

onve

ntio

nal,

med

icat

ion-

base

d ap

proa

ches

. Fur

ther

res

earc

h is

urg

ently

req

uire

d to

eva

luat

e th

is a

ppro

ach

mor

e rig

orou

sly

beca

use

it m

ay o

ffer

an

alte

rnat

ive

trea

tmen

t fo

r pe

ople

dia

gno

sed

with

sch

izop

hren

ia

spec

trum

dis

orde

rs.

Cha

mpa

gne

, T;

Say

er, E

2004

The

Eff

ects

of

the

Use

of

the

Sen

sory

Roo

m in

Psy

chia

try

This

is n

ot a

pee

r re

view

ed a

rtic

le. A

ccor

ding

to

the

auth

ors,

47

serv

ice

user

s ra

ngin

g in

ag

e fr

om 1

7 to

93

yea

rs p

artic

ipat

ed in

thi

s st

udy

in a

sin

gle

24

bed

lock

ed p

sych

iatr

ic u

nit.

The

aim

was

to

eval

uate

the

re

sults

of

the

use

of m

ulti-

sens

ory

room

s, m

odel

ed a

fter

exi

stin

g s

ourc

es. S

urve

ys o

f cl

ient

s an

d ca

se

repo

rt d

ata

was

ana

lyse

d. T

he r

esea

rche

rs r

epor

t th

at ‘t

his

clie

nt-c

ente

red

qual

ity im

prov

emen

t st

udy’

in

dica

ted

that

the

use

of

the

‘mul

ti-se

nsor

y ro

om’ o

n an

in-p

atie

nt p

sych

iatr

ic u

nit,

with

ado

lesc

ent

and

adul

t cl

ient

s, h

ad ‘p

ositi

ve e

ffec

ts’ o

n 98

% o

f th

ose

who

par

ticip

ated

. Th

e re

sear

cher

s co

nclu

de t

hat

the

‘app

ropr

iate

use

of

the

mul

ti-se

nsor

y en

viro

nmen

t pr

ovid

es

expe

rient

ial a

nd a

ltern

ativ

e op

port

uniti

es f

or d

e-es

cala

tion

empo

wer

men

t, c

hoic

e, in

crea

sing

aw

aren

ess,

an

d sk

ill d

evel

opm

ent’

. [N

ot p

eer

revi

ewed

]1

Cha

mpa

gne

, T;

Str

ombe

rg, N

2004

Sen

sory

App

roac

hes

in In

patie

nt

Psy

chia

tric

Set

ting

s: In

nova

tive

Alte

rnat

ives

to

Sec

lusi

on &

R

estr

aint

This

art

icle

exp

lore

s th

e ‘im

port

ance

and

effi

cacy

of

trau

ma-

info

rmed

app

roac

hes

that

are

sen

sory

su

ppor

tive,

add

ress

the

indi

vidu

al n

eeds

of

the

pers

on, a

nd s

tren

gth

en t

he t

hera

peut

ic r

elat

ions

hip’

. It

disc

usse

s a

Uni

ted

Sta

tes-

wid

e in

itiat

ive

to d

ecre

ase

the

use

of s

eclu

sion

and

res

trai

nt in

psy

chia

tric

in

patie

nt s

ettin

gs,

whi

ch t

hey

arg

ue r

equi

res

inno

vativ

e m

etho

ds t

o fa

cilit

ate

the

proc

esse

s of

con

sum

er

self-

org

anis

atio

n, s

elf-

care

, and

pos

itive

cha

nge.

The

aut

hors

arg

ue t

hat

sens

ory-

base

d ap

proa

ches

and

m

ultis

enso

ry r

oom

s ar

e va

luab

le r

esou

rces

as

cultu

res

of c

are

shift

to

beco

me

mor

e re

spon

sive

and

co

llabo

rativ

e.

Dan

zer,

G; R

ieg

er,

S20

16

Impr

ovin

g m

edic

atio

n ad

here

nce

for

seve

rely

men

tally

ill a

dults

by d

ecre

asin

g c

oerc

ion

and

incr

easi

ng c

oope

ratio

n

This

lite

ratu

re r

evie

w s

ugg

ests

bes

t pr

actic

e st

rate

gie

s fo

r ‘h

elpi

ng in

volu

ntar

y m

enta

lly il

l pat

ient

s g

row

into

vol

unta

ry c

onsu

mer

s of

med

icat

ion’

. ‘B

est

prac

tice’

str

ateg

ies

incl

uded

dec

reas

ing

usa

ge

of c

oerc

ive

tact

ics,

hel

ping

pat

ient

s co

pe w

ith m

edic

atio

n si

de e

ffec

ts, a

nd e

mph

asis

ing

the

nec

essi

ty

of f

amily

invo

lvem

ent.

The

aut

hors

con

clud

e w

ith a

rev

iew

of

the

limita

tions

of

arg

uing

for

invo

lunt

ary

hosp

italis

atio

n an

d tr

eatm

ent

as r

esto

ring

pat

ient

aut

onom

y, a

long

with

impl

icat

ions

for

fut

ure

prac

tice

focu

sing

on

incr

easi

ng t

he m

edic

atio

n ad

here

nce

of s

ever

ely

men

tally

ill p

opul

atio

ns.

Dep

artm

ent

of

Men

tal H

ealth

, A

gen

cy o

f H

uman

Ser

vice

s V

erm

ont

2018

2018

Ref

orm

ing

Ver

mon

t’s

Men

tal H

ealth

Sys

tem

Rep

ort

to t

he L

egis

latu

re o

n th

e Im

plem

enta

tion

of A

ct 7

9

Und

er V

erm

ont

law

, the

Dep

artm

ent

of M

enta

l Hea

lth m

ust

repo

rt a

nnua

lly o

n or

bef

ore

Janu

ary

15 t

o th

e st

ate’

s S

enat

e C

omm

ittee

on

Hea

lth a

nd W

elfa

re a

nd t

he H

ouse

Com

mitt

ee o

n H

uman

Ser

vice

s re

gar

ding

the

ext

ent

to w

hich

indi

vidu

als

with

a m

enta

l hea

lth c

ondi

tion

or p

sych

iatr

ic d

isab

ility

rec

eive

ca

re in

the

mos

t in

teg

rate

d an

d le

ast

rest

rictiv

e se

ttin

g a

vaila

ble.

195

Dou

ght

y, C

; Tse

, S

20

11

Can

Con

sum

er-L

ed M

enta

l H

ealth

Ser

vice

s B

e E

qual

ly

Eff

ectiv

e? A

n In

teg

rativ

e R

evie

w

of C

LMH

Ser

vice

s in

Hig

h-In

com

e C

ount

ries

This

stu

dy e

xam

ined

the

evi

denc

e fr

om c

ontr

olle

d st

udie

s fo

r th

e ef

fect

iven

ess

of c

onsu

mer

-led

men

tal

heal

th s

ervi

ces.

Fol

low

ing

an

exte

nsiv

e se

arch

of

mat

eria

l pub

lishe

d in

Eng

lish

from

198

0, p

rede

fined

in

clus

ion

crite

ria w

ere

syst

emat

ical

ly a

pplie

d to

res

earc

h ar

ticle

s th

at c

ompa

red

a co

nsum

er-le

d m

enta

l he

alth

ser

vice

to

a tr

aditi

onal

men

tal h

ealth

ser

vice

. A t

otal

of

29 e

ligib

le s

tudi

es w

ere

appr

aise

d; a

ll of

th

em w

ere

cond

ucte

d in

hig

h-in

com

e co

untr

ies.

Ove

rall

cons

umer

-led

serv

ices

rep

orte

d eq

ually

pos

itive

ou

tcom

es f

or t

heir

clie

nts

as t

radi

tiona

l ser

vice

s, p

artic

ular

ly f

or p

ract

ical

out

com

es s

uch

as e

mpl

oym

ent

or li

ving

arr

ang

emen

ts, a

nd in

red

ucin

g h

ospi

talis

atio

ns a

nd t

hus

the

cost

of

serv

ices

. Des

pite

gro

win

g

evid

ence

of

effe

ctiv

enes

s, b

arrie

rs s

uch

as u

nder

fund

ing

con

tinue

to

limit

the

use

and

eval

uatio

n of

co

nsum

er-le

d se

rvic

es.

Eva

ns, E

; et

al20

12

Ser

vice

Dev

elop

men

t fo

r In

telle

ctua

l Dis

abili

ty M

enta

l H

ealth

: A H

uman

Rig

hts

App

roac

h

Peop

le w

ith in

telle

ctua

l dis

abili

ty (I

D) e

xper

ienc

e hi

ghe

r ra

tes

of m

ajor

men

tal d

isor

ders

tha

n th

eir

non-

ID p

eers

, but

in m

any

coun

trie

s ha

ve d

ifficu

lty a

cces

sing

app

ropr

iate

men

tal h

ealth

ser

vice

s. T

his

pape

r re

view

s th

e cu

rren

t st

ate

of m

enta

l hea

lth s

ervi

ces

for

peop

le w

ith ID

usi

ng A

ustr

alia

as

a ca

se e

xam

ple,

an

d cr

itica

lly a

ppra

ises

whe

ther

suc

h se

rvic

es c

urre

ntly

mee

t th

e st

anda

rds

set

by t

he C

onve

ntio

n on

the

R

ight

s of

Per

sons

with

Dis

abili

ties.

The

rev

iew

hig

hlig

hted

a n

umbe

r of

issu

es t

o be

add

ress

ed t

o m

eet

the

men

tal h

ealth

nee

ds o

f pe

ople

with

ID t

o en

sure

tha

t th

eir

hum

an r

ight

s ar

e up

held

like

tho

se o

f al

l ot

her

citiz

ens.

Ford

, S; e

t al

2015

The

expe

rienc

e of

com

puls

ory

trea

tmen

t: t

he im

plic

atio

ns f

or

reco

very

-orie

ntat

ed p

ract

ice?

This

pap

er p

rovi

des

a lit

erat

ure

revi

ew e

xplo

ring

pat

ient

s’ e

xper

ienc

es o

f co

mpu

lsor

y de

tent

ion,

an

d is

pre

sent

ed h

ere

alon

gsi

de a

live

d-ex

perie

nce

com

men

tary

. Thi

s le

ads

into

a d

iscu

ssio

n of

the

im

plic

atio

ns f

or p

ract

ice.

The

re a

re t

hree

key

the

mes

iden

tified

: peo

ple’

s vi

ews

on t

he ju

stifi

catio

n of

th

eir

com

puls

ory

dete

ntio

n; t

he p

ower

imba

lanc

e be

twee

n pa

tient

s an

d st

aff;

and

the

lack

of

info

rmat

ion

or c

hoic

e. T

he li

ved-

expe

rienc

e co

mm

enta

ry a

dds

wei

ght

to

thes

e fin

ding

s by

citi

ng p

erso

nal

exam

ples

and

mak

ing

sug

ges

tions

for

impr

ovin

g s

ervi

ces.

The

dis

cuss

ion

cent

res

on t

he p

oten

tial o

f co

-pro

duct

ion

betw

een

peop

le w

ho a

cces

s se

rvic

es, t

heir

supp

orte

rs, a

nd p

rofe

ssio

nals

to

impr

ove

trea

tmen

t fo

r pe

ople

who

may

nee

d co

mpu

lsor

y de

tent

ion.

The

pap

er a

lso

rais

es q

uest

ions

on

whe

ther

cu

rren

t le

gis

latio

n an

d se

rvic

e pr

ovis

ion

can

effe

ctiv

ely

deliv

er r

ecov

ery-

orie

ntat

ed p

ract

ice.

Foxl

ewin

, B20

12

Wha

t is

Hap

peni

ng a

t th

e S

eclu

sion

Rev

iew

tha

t M

akes

a

Diff

eren

ce?

A C

onsu

mer

Led

R

esea

rch

Stu

dy

This

em

piric

al s

tudy

, und

erta

ken

by t

he A

CT

Men

tal H

ealth

Con

sum

er N

etw

ork,

was

aim

ed a

t se

clus

ion

redu

ctio

n in

terv

entio

n at

the

Can

berr

a H

ospi

tal P

sych

iatr

ic S

ervi

ces

Uni

t be

gin

ning

in 2

009.

Fea

ture

s of

the

Six

Cor

e S

trat

egie

s w

ere

empl

oyed

at

the

hosp

ital.

The

repo

rt s

tate

s th

at ‘t

he li

ved

expe

rienc

e of

bot

h co

nsum

ers

and

clin

icia

ns [w

as] t

he c

entr

al d

river

for

cul

tura

l cha

nge

in r

elat

ion

to s

eclu

sion

re

duct

ion’

. The

pro

ject

rep

ort

iden

tifies

tha

t us

e of

sec

lusi

on w

as d

eclin

ing

prio

r to

the

rev

iew

(fro

m

8.5%

of

patie

nts

adm

itted

in 2

007/

8 to

6.9

% in

200

8/9)

, but

tha

t th

ese

mee

ting

s dr

ove

secl

usio

n to

be

clas

sifie

d as

a r

are

even

t (t

o le

ss t

han

1% in

201

0/11

). S

eclu

sion

cam

e to

be

view

ed b

y th

e or

gan

isat

ion

as a

ser

vice

fai

lure

. Alth

oug

h th

is p

roje

ct r

epor

t is

not

pee

r re

view

ed, i

t is

val

uabl

e fo

r th

e ad

ded

desc

riptio

n of

a c

onsu

mer

-led

stra

teg

y. [N

ot p

eer

revi

ewed

]

196

Gas

kin,

C; E

lsom

S

; Hap

pell,

B

2007

Inte

rven

tions

for

Red

ucin

g t

he

Use

of

Sec

lusi

on in

Psy

chia

tric

Fa

cilit

ies:

Rev

iew

of

the

Lite

ratu

re

The

auth

ors

seek

em

piric

ally

sup

port

ed in

terv

entio

ns t

hat

allo

w r

educ

tion

in t

he u

se o

f se

clus

ion

in

psyc

hiat

ric f

acili

ties,

by

revi

ewin

g E

nglis

h-la

ngua

ge,

pee

r-re

view

ed li

tera

ture

on

inte

rven

tions

tha

t al

low

re

duct

ion

in t

he u

se o

f se

clus

ion.

Inte

rven

tions

iden

tified

incl

ude

stat

e po

licy

and

reg

ulat

ion

chan

ges

, le

ader

ship

, exa

min

atio

ns o

f th

e pr

actic

e co

ntex

ts, s

taff

inte

gra

tion,

tre

atm

ent

plan

impr

ovem

ent,

in

crea

sed

staf

f to

pat

ient

rat

ios,

mon

itorin

g s

eclu

sion

epi

sode

s, p

sych

iatr

ic e

mer

gen

cy r

espo

nse

team

s,

staf

f ed

ucat

ion,

mon

itorin

g o

f pa

tient

s, p

harm

acol

ogic

al in

terv

entio

ns, t

reat

ing

pat

ient

s as

act

ive

part

icip

ants

in s

eclu

sion

red

uctio

n in

terv

entio

ns, c

hang

ing

the

the

rape

utic

env

ironm

ent,

cha

ngin

g

the

faci

lity

envi

ronm

ent,

ado

ptin

g a

fac

ility

foc

us, a

nd im

prov

ing

sta

ff s

afet

y an

d w

elfa

re. T

he a

utho

rs

reco

mm

end

impl

emen

ting

sev

eral

inte

rven

tions

at

any

one

time.

Hem

, MH

; et

al20

18E

thic

al c

halle

nges

whe

n us

ing

co

erci

on in

men

tal h

ealth

care

: A

syst

emat

ic li

tera

ture

rev

iew

A s

yste

mat

ic r

evie

w o

f sc

ient

ific

liter

atur

e co

ncer

ning

eth

ics

and

coer

cion

in m

enta

l hea

lth s

ettin

gs.

A

tota

l of

22 s

tudi

es w

ere

incl

uded

. The

res

earc

hers

fou

nd a

lack

of

liter

atur

e ex

plic

itly

addr

essi

ng e

thic

al

chal

leng

es r

elat

ed t

o th

e us

e of

coe

rcio

n in

men

tal h

ealth

care

and

arg

ue t

hat

a m

ore

refin

ed a

nd r

ich

lang

uag

e de

scrib

ing

eth

ical

cha

lleng

e co

uld

impr

ove

clin

icia

ns a

bilit

y to

pre

vent

coe

rcio

n an

d th

e ac

com

pany

ing

‘mor

al d

istr

ess’

.

Hen

ders

on, C

; S

wan

son,

JW

; S

zmuk

ler,

G;

Thor

nicr

oft,

G;

Zink

ler,

M

2008

A t

ypol

ogy

of a

dvan

ce

stat

emen

ts in

men

tal h

ealth

car

e

This

art

icle

rev

iew

s th

e lit

erat

ure

in E

nglis

h an

d G

erm

an t

o de

velo

p a

com

para

tive

typo

log

y of

adv

ance

st

atem

ents

: joi

nt c

risis

pla

ns, c

risis

car

ds, t

reat

men

t pl

ans,

wel

lnes

s re

cove

ry a

ctio

n pl

ans,

and

ps

ychi

atric

adv

ance

dire

ctiv

es (w

ith a

nd w

ithou

t fo

rmal

fac

ilita

tion)

. The

fea

ture

s th

at d

istin

gui

sh t

hem

ar

e th

e ex

tent

to

whi

ch t

hey

are

leg

ally

bin

ding

, whe

ther

hea

lth c

are

prov

ider

s ar

e in

volv

ed in

the

ir pr

oduc

tion,

and

whe

ther

an

inde

pend

ent

faci

litat

or a

ssis

ts in

the

ir pr

oduc

tion.

Hum

an R

ight

s W

atch

2017

Gha

na: I

nves

t in

Men

tal H

ealth

S

ervi

ces

to E

nd S

hack

ling

A r

epor

t by

a c

oalit

ion

calli

ng o

n th

e g

over

nmen

t of

Gha

na t

o en

sure

ade

quat

e fu

ndin

g f

or m

enta

l he

alth

ser

vice

s in

Gha

na, a

s a

cruc

ial s

tep

to e

limin

atin

g t

he w

ides

prea

d pr

actic

e of

sha

cklin

g a

nd o

ther

ab

uses

ag

ains

t pe

ople

with

psy

chos

ocia

l dis

abili

ties.

The

coa

litio

n of

non

-gov

ernm

enta

l gro

ups

incl

udes

M

indF

reed

om G

hana

, Men

tal H

ealth

Soc

iety

of

Gha

na, B

asic

Nee

ds G

hana

, Law

and

Dev

elop

men

t A

ssoc

iate

s, H

uman

Rig

hts

Adv

ocac

y C

ente

r, C

hris

tian

Hea

lth A

ssoc

iatio

n of

Gha

na, H

uman

Rig

hts

Wat

ch, C

BM

, Dis

abili

ty R

ight

s A

dvoc

acy

Fund

, Ant

i-Tor

ture

Initi

ativ

e, a

nd f

orm

er U

nite

d N

atio

ns S

peci

al

Rap

port

eur

on T

ortu

re J

uan

Men

dez.

Jans

sen,

WA

; et

al

2011

Met

hodo

log

ical

Issu

es in

M

onito

ring

the

Use

of

Coe

rciv

e M

easu

res

This

pap

er r

evie

ws

rele

vant

lite

ratu

re t

o id

entif

y va

rious

defi

nitio

ns o

f co

erci

on, a

nd c

alcu

latio

n m

odal

ities

use

d to

mea

sure

coe

rciv

e m

easu

res

in p

sych

iatr

ic in

patie

nt c

are.

The

aut

hors

cal

cula

te

figur

es o

n th

e co

erci

ve m

easu

res

in a

sta

ndar

dise

d w

ay. T

o ill

ustr

ate

how

res

earc

h in

clin

ical

pra

ctic

e on

coe

rciv

e m

easu

res

can

be c

ondu

cted

, dat

a fr

om a

larg

e m

ultic

ente

r st

udy

on s

eclu

sion

pat

tern

s in

the

Net

herla

nds

wer

e us

ed. T

hey

conc

lude

tha

t co

erci

ve m

easu

res

can

be r

elia

bly

asse

ssed

in a

st

anda

rdis

ed a

nd c

ompa

rabl

e w

ay u

nder

the

con

ditio

n of

usi

ng c

lear

join

t de

finiti

ons.

Met

hodo

log

ical

co

nsen

sus

betw

een

rese

arch

ers

and

men

tal h

ealth

pro

fess

iona

ls o

n th

ese

defin

ition

s is

nec

essa

ry t

o al

low

com

paris

ons

of s

eclu

sion

and

res

trai

nt r

ates

.

197

John

son,

M

2010

Vio

lenc

e an

d R

estr

aint

Red

uctio

n E

ffor

ts o

n In

patie

nt P

sych

iatr

ic

Uni

ts

This

pap

er p

rese

nts

an in

teg

rativ

e re

view

of

rese

arch

and

qua

lity

impr

ovem

ent

proj

ects

tha

t ai

med

to

redu

ce a

gg

ress

ion/

viol

ence

or

rest

rain

t/se

clus

ion

thro

ugh

the

use

of a

n ed

ucat

iona

l pro

gra

m. F

orty

-six

pa

pers

are

incl

uded

in t

his

revi

ew. T

his

pape

r pr

esen

ts s

umm

arie

s an

d co

mpa

rison

s of

the

res

earc

h de

sig

ns, t

he c

onte

nt a

nd le

ngth

of

prog

ram

mes

, and

the

out

com

es o

f th

ese

prog

ram

mes

. Fro

m t

hese

su

mm

arie

s, t

rend

s in

rel

atio

n to

des

ign,

con

tent

, and

out

com

es a

re id

entifi

ed, a

nd r

ecom

men

datio

ns f

or

clin

icia

ns a

nd r

esea

rche

rs a

re g

iven

.

de J

ong

, G;

Sch

out,

G20

10P

reve

ntio

n of

coe

rcio

n in

pub

licm

enta

l hea

lth c

are

with

fam

ilyg

roup

con

fere

ncin

g

This

edi

toria

l sum

mar

ises

res

earc

h in

a r

evie

w o

f ev

iden

ce f

or t

he u

se o

f Fa

mily

Gro

up C

onfe

renc

ing

in

pub

lic m

enta

l hea

lth s

ervi

ces.

The

aut

hors

rep

ort

little

in t

he w

ay o

f em

piric

al e

vide

nce.

The

sam

e au

thor

s re

port

the

ir ow

n em

piric

al fi

ndin

gs

on t

he p

ract

ice

in 2

013

(see

App

endi

x O

ne).

de J

ong

, MH

; et

al

2016

Inte

rven

tions

to

Red

uce

Com

puls

ory

Psy

chia

tric

A

dmis

sion

s: A

Sys

tem

atic

R

evie

w a

nd M

eta-

Ana

lysi

s

The

met

a-an

alys

is o

f th

e ra

ndom

ised

con

trol

led

tria

ls (R

CTs

) on

adva

nce

stat

emen

ts s

how

ed a

st

atis

tical

ly s

igni

fican

t an

d cl

inic

ally

rel

evan

t 23

% r

educ

tion

in c

ompu

lsor

y ad

mis

sion

s in

adu

lt ps

ychi

atric

pat

ient

s, w

here

as t

he m

eta-

anal

yses

of

the

RC

Ts o

n co

mm

unity

tre

atm

ent

orde

rs,

com

plia

nce

enha

ncem

ent,

and

inte

gra

ted

trea

tmen

t sh

owed

no

evid

ence

of

such

a r

educ

tion.

In

othe

r w

ords

, adv

ance

sta

tem

ents

app

ear

to r

educ

e th

e oc

curr

ence

of

com

puls

ory

adm

issi

ons

by

appr

oxim

atel

y on

e-qu

arte

r, w

hile

com

mun

ity t

reat

men

t or

ders

, med

icat

ion

com

plia

nce

enha

ncem

ent,

an

d in

teg

rate

d tr

eatm

ent

mea

sure

s w

ere

inef

fect

ive

in r

educ

ing

com

puls

ory

adm

issi

ons.

To

date

, onl

y 13

RC

Ts h

ave

used

com

puls

ory

adm

issi

ons

as t

heir

prim

ary

or s

econ

dary

out

com

e m

easu

re. T

his

dem

onst

rate

s th

e ne

ed f

or m

ore

rese

arch

in t

his

field

.

Kal

lert

, TW

2008

Coe

rcio

n in

psy

chia

try

The

auth

or g

athe

rs r

evie

ws

on ‘i

nvol

unta

ry h

ospi

tal a

dmis

sion

’ and

dis

ting

uish

es s

ever

al a

reas

of

conc

ern,

incl

udin

g ‘c

oerc

ion

and

the

law

’, th

e ‘p

atie

nt’s

per

spec

tive’

, ‘fa

mily

bur

den

of c

oerc

ion’

‘o

utpa

tient

com

mitm

ent’

, ‘co

erci

on in

spe

cial

(hea

lthca

re) s

ettin

gs

and

patie

nt s

ubg

roup

s’ a

nd a

rgue

s fo

r fu

rthe

r cl

inic

al a

nd r

esea

rch

initi

ativ

es in

the

se a

reas

.

Kha

zaal

, Y; e

t al

20

14

Psy

chia

tric

Adv

ance

Dire

ctiv

es,

a Po

ssib

le W

ay t

o O

verc

ome

Coe

rcio

n an

d P

rom

ote

Em

pow

erm

ent

This

rev

iew

con

side

rs s

tudi

es c

ompl

eted

to

asse

ss t

he im

pact

of

adva

nce

dire

ctiv

es o

n se

rvic

e us

e an

d co

erci

on. T

heir

resu

lts g

ive

a m

ixed

pic

ture

but

dire

ctiv

es n

ever

thel

ess

have

the

pot

entia

l to

supp

ort

the

empo

wer

men

t pr

oces

s, m

inim

ise

expe

rienc

ed c

oerc

ion,

and

impr

ove

copi

ng s

trat

egie

s. F

urth

er s

tudi

es

on t

he d

iffer

ent

proc

esse

s of

fac

ilita

tion

invo

lved

and

on

diff

eren

t po

pula

tions

are

nee

ded.

Kis

ely,

S;

Cam

pbel

l L20

14

Com

puls

ory

com

mun

ity a

nd

invo

lunt

ary

outp

atie

nt t

reat

men

t fo

r pe

ople

with

sev

ere

men

tal

diso

rder

s

The

auth

ors

revi

ewed

all

rele

vant

ran

dom

ised

con

trol

led

clin

ical

tria

ls (R

CTs

) of

com

puls

ory

com

mun

ity

trea

tmen

t co

mpa

red

with

sta

ndar

d ca

re f

or p

eopl

e w

ith s

erio

us m

enta

l illn

ess

(mai

nly

schi

zoph

reni

a an

d sc

hizo

phre

nia-

like

diso

rder

s, b

ipol

ar d

isor

der,

or d

epre

ssio

n w

ith p

sych

otic

fea

ture

s). T

hey

conc

lude

tha

t C

CT

resu

lts in

no

sig

nific

ant

diff

eren

ce in

ser

vice

use

, soc

ial f

unct

ioni

ng o

r qu

ality

of

life

com

pare

d w

ith

stan

dard

vol

unta

ry c

are.

Kla

g, S

; O

’Cal

lag

han,

F;

Cre

ed, P

20

05

The

Use

of

Leg

al C

oerc

ion

in t

he

Trea

tmen

t of

Sub

stan

ce A

buse

rs:

An

Ove

rvie

w a

nd C

ritic

al A

naly

sis

of T

hirt

y Ye

ars

of R

esea

rch

Sur

veys

thr

ee d

ecad

es o

f re

sear

ch in

to t

he e

ffec

tiven

ess

of c

ompu

lsor

y tr

eatm

ent

for

peop

le a

ffec

ted

by s

ubst

ance

abu

se, c

oncl

udin

g t

hat

the

liter

atur

e yi

elds

a m

ixed

, inc

onsi

sten

t, a

nd in

conc

lusi

ve

patt

ern

of r

esul

ts, c

allin

g in

to q

uest

ion

the

evid

ence

-bas

ed c

laim

s m

ade

by n

umer

ous

rese

arch

ers

that

co

mpu

lsor

y tr

eatm

ent

is e

ffec

tive

in t

he r

ehab

ilita

tion

of s

ubst

ance

use

rs. T

he p

rese

nt p

aper

pro

vide

s an

ove

rvie

w o

f th

e ke

y is

sues

con

cern

ing

the

use

and

effi

cacy

of

leg

al c

oerc

ion

in t

he r

ehab

ilita

tion

of

subs

tanc

e us

ers,

incl

udin

g a

crit

ique

of

the

rese

arch

bas

e an

d re

com

men

datio

ns f

or f

utur

e re

sear

ch.

198

LeB

el, J

L; e

t al

2014

Mul

tinat

iona

l Exp

erie

nces

in

Red

ucin

g a

nd P

reve

ntin

g t

he U

se

of R

estr

aint

and

Sec

lusi

on

This

pap

er r

evie

ws

prel

imin

ary

findi

ngs

of s

ome

of t

he in

tern

atio

nal e

ffor

ts t

o re

duce

sec

lusi

on a

nd

rest

rain

t in

men

tal h

ealth

set

ting

s, In

clud

ing

the

Six

Cor

e S

trat

egie

s to

Pre

vent

Con

flict

, Vio

lenc

e an

d th

e U

se o

f S

eclu

sion

and

Res

trai

nt, a

nd s

o on

, inc

ludi

ng a

s im

plem

ente

d in

U.S

. sta

tes

and

coun

trie

s in

clud

ing

Fin

land

, Aus

tral

ia, a

nd t

he U

nite

d K

ing

dom

.

Mea

d, S

; Fils

on,

B20

17M

utua

lity

and

Sha

red

Pow

er a

s an

Alte

rnat

ive

to C

oerc

ion

and

Forc

e

The

purp

ose

of t

his

pape

r is

to

dem

onst

rate

how

mut

ualit

y an

d sh

ared

pow

er in

rel

atio

nshi

p ca

n av

oid

coer

cion

and

for

ce in

men

tal h

ealth

tre

atm

ent.

The

aut

hors

not

e th

at ‘[

t]hi

s is

not

a r

esea

rch

desi

gn.

It

is r

athe

r an

opi

nion

pie

ce w

ith e

xten

sive

exa

mpl

es o

f th

e ap

proa

ch. T

he a

utho

rs h

ave

foun

d th

at u

sing

th

ese

proc

esse

s ca

n en

able

con

nect

ion;

the

key

to

rela

tions

hip

build

ing

.’

Mez

zina

, R20

18Fo

rty

year

s of

the

Law

180

: the

as

pira

tions

of

a g

reat

ref

orm

, its

su

cces

ses

and

cont

inui

ng n

eed

This

stu

dy s

eeks

to

eval

uate

the

impa

ct –

the

‘mai

n ac

hiev

emen

ts a

nd c

halle

nges

’ – o

f ‘L

aw 1

80’ o

n It

alia

n m

enta

l hea

lth s

ervi

ces,

incl

udin

g in

eff

orts

to

redu

ce c

oerc

ive

prac

tices

, in

Ital

y. M

ezzi

na a

rgue

s th

at ‘e

ven

if th

e g

reat

prin

cipl

es o

f th

e It

alia

n re

form

law

wer

e an

ticip

ator

y (e

.g.,

the

UN

Con

vent

ion

on R

ight

s of

Per

sons

with

Dis

abili

ties

– C

RP

D),

the

law

app

licat

ion

has

been

poo

rly p

rovi

ded

with

re

sour

ces

and

did

not

follo

w t

hose

ava

nt-g

arde

exp

erie

nces

as

mod

els.

’ Fur

ther

‘[l]i

mita

tions

are

evi

dent

to

day

espe

cial

ly a

t th

e or

gan

isat

iona

l lev

els,

suc

h as

ser

vice

s ca

pabl

e to

tak

e up

the

cha

lleng

e an

d tr

ansf

orm

ing

the

fiel

d, le

ft f

ree

from

the

impr

int

of t

otal

inst

itutio

ns’.

Fina

lly, ‘

[t]h

e rig

hts-

base

d ap

proa

ch

open

ed b

y th

e La

w 1

80 s

houl

d no

w t

ake

into

con

side

ratio

n th

e ne

w le

gal

situ

atio

n ca

used

by

the

CR

PD

w

orld

wid

e in

the

are

a of

indi

vidu

als’

hum

an r

ight

s, e

spec

ially

abo

ut t

he is

sue

of le

gal

cap

acity

and

re

late

d in

volu

ntar

y ca

re’ (

336)

.

Mez

zina

, R20

14

Com

mun

ity M

enta

l Hea

lth

Car

e in

Trie

ste

and

Bey

ond

- A

n ‘‘

Ope

n D

oor—

No

Res

trai

nt’’

S

yste

m o

f C

are

for

Rec

over

y an

d C

itize

nshi

p

This

stu

dy p

rovi

des

an o

verv

iew

of

seve

ral I

talia

n-la

ngua

ge

stud

ies

and

com

bine

s th

em w

ith s

ervi

ce d

ata

for

the

men

tal h

ealth

ser

vice

s of

Trie

ste,

Ital

y. T

he T

riest

e M

odel

is d

efine

d as

the

‘who

le s

yste

m, w

hole

co

mm

unity

, rec

over

y-or

ient

ed’ a

ppro

ach.

Mez

zina

rep

orts

‘low

rat

es o

f ho

spita

lizat

ion,

low

com

puls

ory

trea

tmen

t ra

tes,

eff

ectiv

e jo

b pl

acem

ent,

a lo

w n

umbe

r of

for

ensi

c pa

tient

s, a

nd a

dec

reas

ing

(30%

) su

icid

e ra

te d

urin

g t

he la

st 1

5 ye

ars’

(p.4

40).

Furt

her,

‘Few

er t

han

10 p

eopl

e pe

r 10

0,00

0 of

the

po

pula

tion

rece

ive

a C

PTO

, usu

ally

for

app

roxi

mat

ely

7 to

10

days

’ (p.

442)

.

Möh

ler,

R; e

t al

20

11

Inte

rven

tions

for

Pre

vent

ing

and

R

educ

ing

the

Use

of

Phy

sica

l R

estr

aint

s in

Lon

g-T

erm

Ger

iatr

ic

Car

e

This

rev

iew

aim

s to

eva

luat

e th

e ef

fect

iven

ess

of in

terv

entio

ns t

o pr

even

t an

d re

duce

the

use

of

phys

ical

re

stra

ints

in o

lder

peo

ple

who

req

uire

long

-ter

m n

ursi

ng c

are

(eith

er in

com

mun

ity n

ursi

ng c

are

or in

re

side

ntia

l car

e fa

cilit

ies)

. The

y co

nclu

de t

hat

ther

e is

insu

ffici

ent

evid

ence

sup

port

ing

the

eff

ectiv

enes

s of

edu

catio

nal i

nter

vent

ions

tar

get

ing

nur

sing

sta

ff f

or p

reve

ntin

g o

r re

duci

ng t

he u

se o

f ph

ysic

al

rest

rain

ts in

ger

iatr

ic lo

ng-t

erm

car

e.

Olfs

on, M

2009

Rev

iew

: Lim

ited

Evi

denc

e to

S

uppo

rt S

peci

alis

t M

enta

l Hea

lth

Ser

vice

s as

Alte

rnat

ives

to

Inpa

tient

Car

e fo

r Yo

ung

Peo

ple

with

Sev

ere

Men

tal H

ealth

D

isor

ders

Incl

usio

n cr

iteria

invo

lved

ran

dom

ised

con

trol

led

tria

ls, w

ell d

esig

ned

cont

rolle

d be

fore

-aft

er s

tudi

es

and

inte

rrup

ted

time

serie

s co

mpa

ring

inpa

tient

car

e fo

r yo

ung

peo

ple

with

one

or

mor

e al

tern

ativ

e sp

ecia

list

men

tal h

ealth

ser

vice

s (b

eyon

d no

rmal

out

patie

nt p

rovi

sion

); on

ly s

tudi

es in

you

ng p

eopl

e ag

ed 5

-18

year

s w

ith a

ser

ious

men

tal h

ealth

pro

blem

req

uirin

g m

ore

than

gen

eric

out

patie

nt s

ervi

ces.

Th

ere

is li

mite

d ev

iden

ce t

o su

ppor

t sp

ecia

list

men

tal h

ealth

ser

vice

s as

alte

rnat

ives

to

inpa

tient

car

e fo

r yo

ung

peo

ple

with

sev

ere

men

tal h

ealth

dis

orde

rs.

199

Ric

hter

, D;

Hof

fman

n, H

2017

Inde

pend

ent

Hou

sing

and

S

uppo

rt f

or P

eopl

e w

ith S

ever

e M

enta

l Illn

ess:

Sys

tem

atic

R

evie

w’

Sys

tem

atic

rev

iew

of

Ran

dom

ised

and

Non

-Ran

dom

ised

Con

trol

led

Tria

ls o

f pu

blic

atio

ns t

hat

anal

yse

the

outc

omes

of

livin

g in

inde

pend

ent

sett

ing

s ve

rsus

inst

itutio

nalis

ed a

ccom

mod

atio

n. T

he r

esul

ts

indi

cate

tha

t In

depe

nden

t H

ousi

ng a

nd S

uppo

rt-s

ettin

gs

prov

ide

at le

ast

sim

ilar

outc

omes

tha

n re

side

ntia

l car

e. T

he a

utho

rs p

ropo

se t

hat

clie

nts’

pre

fere

nces

sho

uld

dete

rmin

e th

e ch

oice

of

hous

ing

se

ttin

g.

Ros

en A

; Mue

ser

KT;

Tee

sson

M20

07

Ass

ertiv

e co

mm

unity

tre

atm

ent

-- is

sues

fro

m s

cien

tific

and

clin

ical

lite

ratu

re w

ith

impl

icat

ions

for

pra

ctic

e

This

rev

iew

des

crib

es A

sser

tive

Com

mun

ity T

reat

men

t (A

CT)

, an

inte

gra

l com

pone

nt o

f th

e ca

re o

f pe

rson

s w

ith s

ever

e m

enta

l illn

ess.

Dra

win

g o

n re

sear

ch f

rom

Nor

th A

mer

ica,

Aus

tral

asia

, and

Brit

ain,

w

e su

mm

aris

e th

e cu

rren

t ev

iden

ce b

ase

for

AC

T an

d ex

amin

e th

e tr

ends

and

issu

es t

hat

may

aff

ect

prac

tice.

Str

ong

evi

denc

e su

ppor

ts t

he fi

delit

y st

anda

rdis

atio

n, e

ffica

cy, e

ffec

tiven

ess,

and

cos

t-ef

fect

iven

ess

of A

CT

mod

els

in p

sych

iatr

y. Y

et, s

igni

fican

t m

etho

dolo

gic

al p

robl

ems

and

issu

es a

ffec

t im

plem

enta

tion.

The

evi

denc

e in

dica

tes

that

the

AC

T m

odel

is o

ne o

f th

e m

ost

effe

ctiv

e sy

stem

atic

m

odel

s fo

r or

gan

isin

g c

linic

al a

nd f

unct

iona

l int

erve

ntio

ns in

psy

chia

try.

Eff

ectiv

e sy

stem

s ba

sed

on t

he

AC

T m

odel

mee

t m

ore

AC

T fid

elity

crit

eria

; are

oft

en n

onco

erci

ve; d

o no

t re

ly o

n co

mpu

lsor

y or

ders

; m

ay r

ely

on a

wid

er r

ang

e of

inte

rven

tions

tha

n ju

st m

edic

atio

n ad

here

nce,

incl

udin

g v

ocat

iona

l and

su

bsta

nce

abus

e re

habi

litat

ion;

con

tain

oth

er e

vide

nce-

base

d in

terv

entio

ns a

nd m

ore

mob

ile in

viv

o in

terv

entio

ns; i

nvol

ve in

divi

dual

and

tea

m c

ase

man

agem

ent;

may

invo

lve

cons

umer

s as

dire

ct s

ervi

ce

prov

ider

s; a

nd h

ave

an in

terd

isci

plin

ary

wor

kfor

ce a

nd s

uppo

rt s

truc

ture

with

in t

he t

eam

, pro

vidi

ng

som

e pr

otec

tion

from

wor

k-re

late

d st

ress

or

burn

out.

Sta

stsn

y, P

; Le

hman

n, P

(eds

)20

07A

ltern

ativ

es B

eyon

d P

sych

iatr

y

A c

olle

ctio

n of

art

icle

s su

bmitt

ed b

y 61

aut

hors

fro

m v

ario

us b

ackg

roun

ds, i

nclu

ding

soc

ial w

ork,

cl

inic

al p

sych

olog

y, p

sych

iatr

y, p

sych

othe

rapy

, law

and

tea

chin

g. T

he a

utho

rs e

valu

ate

glo

bal m

enta

l he

alth

pra

ctic

es a

nd s

eek

way

s to

mov

e ‘b

eyon

d’ p

sych

iatr

y to

new

‘pos

sibi

litie

s of

sel

f-he

lp f

or

indi

vidu

als

expe

rienc

ing

mad

ness

, and

str

ateg

ies

tow

ard

impl

emen

ting

hum

ane

trea

tmen

t’. [

Not

pee

r re

view

ed]

Van

Dor

n R

A;

Sch

eyet

t A

; S

wan

son

JW;

Sw

artz

MS

2010

Psy

chia

tric

adv

ance

dire

ctiv

es

and

soci

al w

orke

rs: a

n in

teg

rativ

e re

view

.

This

art

icle

rev

iew

s re

sear

ch in

the

soc

ial w

ork

trad

ition

on

the

clin

ical

and

leg

al h

isto

ry o

f ps

ychi

atric

ad

vanc

e di

rect

ives

and

em

piric

al e

vide

nce

for

thei

r im

plem

enta

tion

and

effe

ctiv

enes

s. D

espi

te w

hat

shou

ld b

e an

inhe

rent

inte

rest

in a

dvan

ce d

irect

ives

and

the

fac

t th

at la

ws

auth

oris

ing

psy

chia

tric

ad

vanc

e di

rect

ives

hav

e pr

olife

rate

d in

the

pas

t de

cade

, the

re is

litt

le t

heor

etic

al o

r em

piric

al r

esea

rch

on t

hem

in t

he s

ocia

l wor

k lit

erat

ure.

Ste

war

t, D

; Van

de

r M

erw

e,

MV

; Bow

ers,

L;

Sim

pson

, A;

Jone

s, J

2010

A R

evie

w o

f In

terv

entio

ns t

o R

educ

e M

echa

nica

l Res

trai

nt

and

Sec

lusi

on a

mon

g A

dult

Psy

chia

tric

Inpa

tient

s

This

rev

iew

exa

min

es t

he n

atur

e an

d ef

fect

iven

ess

of in

terv

entio

ns t

o re

duce

the

use

of

mec

hani

cal

rest

rain

t an

d se

clus

ion

amon

g a

dult

psyc

hiat

ric in

patie

nts.

Thi

rty-

six

post

-196

0 em

piric

al s

tudi

es w

ere

iden

tified

. Mos

t st

udie

s re

port

ed r

educ

ed le

vels

of

mec

hani

cal r

estr

aint

and

/or

secl

usio

n, b

ut t

he

stan

dard

of

evid

ence

was

poo

r. Th

e re

sear

ch d

id n

ot a

ddre

ss w

hich

pro

gra

mm

e co

mpo

nent

s w

ere

mos

t su

cces

sful

. The

aut

hors

arg

ue t

hat

mor

e at

tent

ion

shou

ld b

e pa

id t

o un

ders

tand

ing

how

inte

rven

tions

w

ork,

par

ticul

arly

fro

m t

he p

ersp

ectiv

e of

nur

sing

sta

ff, a

n is

sue

that

is la

rgel

y ov

erlo

oked

.

200

Sca

nlan

, JN

2010

Inte

rven

tions

to

redu

ce t

he u

se

of s

eclu

sion

and

res

trai

nt in

in

patie

nt p

sych

iatr

ic s

ettin

gs:

w

hat

we

know

so

far

a re

view

of

the

liter

atur

e

This

pap

er a

naly

ses

evid

ence

ava

ilabl

e fr

om e

valu

atio

ns o

f si

ngle

sec

lusi

on a

nd/o

r re

stra

int

redu

ctio

n pr

ogra

mm

es. A

tot

al o

f 29

pap

ers

wer

e in

clud

ed in

the

rev

iew

. Sev

en k

ey s

trat

egy

type

s th

at e

mer

ged

fr

om t

he a

naly

sis

are

outli

ned:

(i) p

olic

y ch

ang

e/le

ader

ship

; (ii)

ext

erna

l rev

iew

/deb

riefin

g; (

iii) d

ata

use;

(iv

) tra

inin

g; (

v) c

onsu

mer

/fam

ily in

volv

emen

t; (v

i) in

crea

se in

sta

ff r

atio

/cris

is r

espo

nse

team

s; a

nd (v

ii)

prog

ram

me

elem

ents

/cha

nges

. The

res

earc

hers

rec

omm

end

furt

her

syst

emat

ic r

esea

rch

to m

ore

fully

un

ders

tand

whi

ch e

lem

ents

of

succ

essf

ul p

rog

ram

mes

are

the

mos

t po

wer

ful i

n re

duci

ng in

cide

nts

of

secl

usio

n an

d re

stra

int.

Sw

edis

h N

atio

nal

Boa

rd o

f H

ealth

an

d W

elfa

re20

08A

New

Pro

fess

ion

is B

orn

– Pe

rson

ligt

ombu

d, P

O

This

rep

ort

by t

he S

wed

ish

Nat

iona

l Boa

rd o

f H

ealth

and

Wel

fare

exa

min

es t

he P

erso

nlig

t om

bud

sche

me,

off

erin

g s

ome

prel

imin

ary

serv

ice

data

on

the

prac

tice,

incl

udin

g fi

scal

ana

lysi

s an

d ca

se

stud

ies

to il

lust

rate

how

the

sch

eme

is w

orki

ng in

pra

ctic

e.

Use

rs a

nd

Sur

vivo

rs o

f P

sych

iatr

y –

Ken

ya (U

SP

KA

) 20

18Th

e R

ole

of P

eer

Sup

port

In

Exe

rcis

ing

Leg

al C

apac

ity In

K

enya

This

stu

dy c

once

rned

10

peer

-sup

port

mee

ting

s. P

artic

ipan

ts a

t th

e m

eetin

gs

incl

ude

user

s, c

arer

s,

frie

nds,

US

PK

sta

ff m

embe

rs. E

ight

add

ition

al in

terv

iew

s w

ere

cond

ucte

d w

ith s

ervi

ce u

sers

. The

stu

dy

aim

ed t

o ex

amin

e th

e ro

leof

pee

r su

ppor

t am

ong

use

rs a

nd s

urvi

vors

in ‘e

xerc

isin

g le

gal

cap

acity

’ in

Ken

ya. T

he k

inds

of

deci

sion

s ad

dres

sed

thro

ugh

peer

sup

port

are

tra

cked

with

con

cret

e ex

ampl

es o

f de

cisi

ons

take

n w

ith t

he s

uppo

rt o

f pe

ers,

and

incl

ude

info

rmal

adv

ance

dire

ctiv

es, r

epre

sent

atio

nal

supp

orts

and

oth

er p

ract

ices

tha

t th

e fo

rmal

lite

ratu

re in

dica

tes

help

s to

red

uce

coer

cive

inte

rven

tions

. [N

ot p

eer

revi

ewed

]

Win

kler

, P; e

t al

2017

A B

lind

Spo

t on

the

Glo

bal

Men

tal H

ealth

Map

: A S

copi

ng

Rev

iew

of

25 Y

ears

’ Dev

elop

men

t of

Men

tal H

ealth

Car

e fo

r Pe

ople

w

ith S

ever

e M

enta

l Illn

esse

s in

C

entr

al a

nd E

aste

rn E

urop

e

This

pap

er a

naly

ses

the

deve

lopm

ent

of m

enta

l hea

lth-c

are

prac

tice

for

peop

le w

ith s

ever

e m

enta

l ill

ness

es in

thi

s re

gio

n. A

sco

ping

rev

iew

was

com

plem

ente

d by

an

expe

rt s

urve

y in

24

coun

trie

s.

Men

tal h

ealth

-car

e pr

actic

e in

the

reg

ion

diff

ers

gre

atly

acr

oss

as w

ell a

s w

ithin

indi

vidu

al c

ount

ries.

N

atio

nal p

olic

ies

ofte

n ex

ist

but

refo

rms

rem

ain

mos

tly in

the

rea

lm o

f as

pira

tion.

Ser

vice

s ar

e pr

edom

inan

tly b

ased

in p

sych

iatr

ic h

ospi

tals

. Dec

isio

n m

akin

g o

n re

sour

ce a

lloca

tion

is n

ot t

rans

pare

nt,

and

full

econ

omic

eva

luat

ions

of

com

plex

inte

rven

tions

and

rig

orou

s ep

idem

iolo

gic

al s

tudi

es a

re la

ckin

g.

Stig

ma

seem

s to

be

hig

her

than

in o

ther

Eur

opea

n co

untr

ies,

but

con

side

ratio

n of

hum

an r

ight

s an

d us

er in

volv

emen

t ar

e in

crea

sing

. The

reg

ion

has

seen

res

pect

able

dev

elop

men

t, w

hich

hap

pene

d be

caus

e of

gra

ssro

ots

initi

ativ

es s

uppo

rted

by

inte

rnat

iona

l org

anis

atio

ns, r

athe

r th

an b

y sy

stem

atic

im

plem

enta

tion

of g

over

nmen

t po

licie

s.

Zmud

zki,

F;

Grif

fiths

, A;

Bat

es, S

; Kat

z, I;

K

ayes

s, R

2016

Eva

luat

ion

of C

risis

Res

pite

S

ervi

ces:

Fin

al R

epor

t (S

PR

C

Rep

ort

06/1

6)

This

is t

he fi

nal r

epor

t of

the

eva

luat

ion

of t

he C

risis

Res

pite

Ser

vice

s (C

RS

). Th

e pr

ogra

mm

e is

fun

ded

and

man

aged

by

SA

Hea

lth a

nd d

eliv

ered

in p

artn

ersh

ip w

ith N

eam

i Nat

iona

l. Th

e ev

alua

tion

team

fr

om t

he S

ocia

l Pol

icy

Res

earc

h C

entr

e (S

PR

C) a

t U

NS

W A

ustr

alia

(the

Uni

vers

ity o

f N

ew S

outh

Wal

es)

cond

ucte

d th

e ev

alua

tion

in c

olla

bora

tion

with

Épo

que

Con

sulti

ng. T

he o

vera

ll ai

m o

f th

is r

esea

rch

is

to b

uild

a s

tron

g e

vide

nce

base

for

the

pro

visi

on o

f be

st p

ract

ice

and

impr

oved

pol

icy

in t

he d

eliv

ery

of

reco

very

-orie

nted

sub

-acu

te c

risis

res

pite

ser

vice

s in

Sou

th A

ustr

alia

.

201

App

endi

x Th

ree

– Pr

actic

e, P

olic

y an

d Le

gal M

easu

res

to H

elp

End,

Red

uce

and

Prev

ent C

oerc

ion

The

follo

win

g is

a b

rief

list

of

pra

ctic

es, s

trat

egie

s, p

olic

ies,

leg

isla

tive

chan

ges

an

d s

o on

, wh

ich

wer

e ci

ted

in t

he

form

al a

nd

gre

y lit

erat

ure

. Rat

her

th

an

eval

uat

ing

evi

den

ce f

or o

r ag

ain

st t

hei

r ef

ficac

y in

red

uci

ng

coe

rcio

n, t

his

list

su

mm

aris

es p

rom

inen

t m

easu

res

and

ap

pro

ach

es.

NA

ME

RE

GIO

NS

UM

MA

RY

Ad

van

ce

Pla

nn

ing

Inte

rnat

iona

l

Adv

ance

pla

nnin

g c

an h

elp

resp

ect

the

will

and

pre

fere

nce

of a

per

son

durin

g c

rises

, and

can

min

imis

e ch

ang

es o

f co

erci

ve

inte

rven

tion.

The

y al

low

for

fre

ely

mad

e de

cisi

ons

desi

gne

d to

bin

d on

esel

f or

dire

ct o

ther

s to

act

ion

in t

he f

utur

e, p

artic

ular

ly

durin

g t

imes

of

cris

is. D

ecis

ions

may

con

cern

tre

atm

ent

pref

eren

ces

or o

ther

info

rmat

ion

(for

exa

mpl

e, in

stru

ctio

ns f

or w

ho t

o co

ntac

t or

not

to

cont

act

or w

ho t

o ap

poin

t as

a f

orm

al s

uppo

rter

). A

dvan

ce p

lann

ing

cou

ld t

ake

stat

utor

y fo

rm (a

s fo

r ex

ampl

e w

ith t

he C

anad

ian

prov

ince

of

Brit

ish

Col

umbi

a’s

Rep

rese

ntat

ion

Agr

eem

ent

Act

199

6, In

dia’

s M

enta

l Hea

lthca

re A

ct 2

017,

an

d in

man

y ot

her

coun

trie

s) b

ut c

an a

lso

take

non

-sta

tuto

ry f

orm

s, in

the

for

m o

f cr

isis

pla

nnin

g f

or in

divi

dual

s w

ith in

form

al

supp

orte

rs a

nd m

enta

l hea

lth p

rofe

ssio

nals

(suc

h as

Joi

nt C

risis

Pla

nnin

g),

or in

form

al a

rran

gem

ents

bet

wee

n fa

mily

and

pee

rs.

Ber

liner

K

rise

nd

ien

stG

erm

any

Ber

lin k

risen

dien

st ‘C

risis

Hou

se’ p

rovi

des

assi

stan

ce f

or is

sues

incl

udin

g ‘p

sych

osoc

ial c

rises

and

acu

te m

enta

l and

psy

chia

tric

em

erg

enci

es’ f

ree

of c

harg

e av

aila

ble

year

rou

nd.2

Peop

le in

nee

d of

ass

ista

nce

can

be h

elpe

d pe

rson

ally

, by

phon

e, a

nd in

ex

trem

e si

tuat

ions

on

site

at

nine

Ber

lin lo

catio

ns w

ithou

t an

app

oint

men

t. T

he c

onsu

ltatio

n ca

n al

so b

e ca

rrie

d ou

t an

onym

ousl

y up

on r

eque

st. T

he s

ervi

ce p

rom

otes

the

use

of

‘tria

log

ue’ b

etw

een

staf

f, cl

ient

s an

d fa

mili

es.

Cri

sis

Car

ds

Eng

land

A f

orm

of

adva

nce

plan

ning

, the

cris

is-c

ard

is t

he s

ize

of a

cre

dit

card

whi

ch d

etai

ls w

hat

shou

ld h

appe

n in

the

eve

nt t

hat

a pe

rson

has

a p

sych

iatr

ic c

risis

. It

was

con

ceiv

ed a

s an

adv

ocac

y to

ol t

o en

sure

a p

erso

n m

aint

aine

d co

ntro

l ove

r th

eir

pote

ntia

l fu

ture

tre

atm

ent

thus

pro

mot

ing

aut

onom

ous

choi

ce a

nd w

ith t

he in

tent

of

redu

cing

com

puls

ory

inte

rven

tions

.3 A

rev

iew

of

cris

is

card

s fo

und

no in

form

atio

n on

the

ir ef

fect

s du

ring

men

tal h

ealth

em

erg

enci

es.4

Clu

b H

ou

seIn

tern

atio

nally

Clu

bhou

se In

tern

atio

nal h

elps

sta

rt a

nd g

row

Clu

bhou

ses

glo

bally

. In

cont

rast

to

trad

ition

al d

ay-t

reat

men

t an

d ot

her

day

prog

ram

me

mod

els,

Clu

bhou

se p

artic

ipan

ts a

re c

alle

d ‘m

embe

rs’ (

as o

ppos

ed t

o ‘p

atie

nts’

or

‘clie

nts’

) and

the

re is

a f

ocus

on

mem

bers

str

eng

ths

and

abili

ties,

not

the

ir ill

ness

. It

is n

ot a

clin

ical

pro

gra

m, m

eani

ng t

here

are

no

ther

apis

ts o

r ps

ychi

atris

ts

on s

taff.

All

part

icip

atio

n in

a c

lubh

ouse

is s

tric

tly o

n a

volu

ntar

y ba

sis.

Fiv

e C

lubh

ouse

s in

Mai

nlan

d C

hina

are

reg

iste

red

as

mem

bers

of

Clu

bhou

se In

tern

atio

nal,

with

five

mor

e re

port

edly

und

erg

oing

acc

redi

tatio

n.5

Fam

ily G

rou

p

Co

nfe

ren

cin

gN

ethe

rland

s,

Aus

tral

ia

Fam

ily G

roup

Con

fere

ncin

g is

a v

olun

tary

con

sulta

tion

proc

ess,

ada

pted

fro

m a

Mao

ri-le

d pr

oces

s fo

r re

solv

ing

fam

ily c

ourt

di

sput

es, i

n w

hich

an

inde

pend

ent

co-o

rdin

ator

fac

ilita

tes

a se

ries

of d

iscu

ssio

ns b

etw

een

an in

divi

dual

and

her

or

his

key

soci

al

netw

ork.

The

indi

vidu

al s

elec

ts f

riend

s an

d/or

fam

ily, o

r pr

ofes

sion

als,

to

disc

uss

issu

es o

f co

ncer

n an

d se

ek s

olut

ions

, inc

ludi

ng

com

posi

ng a

pla

n w

hich

set

s ou

t th

e st

eps

to b

e ta

ken.

The

rol

e of

the

co-

ordi

nato

r is

to

thin

k ‘w

ith’ t

he g

roup

, and

hel

p re

mov

e ba

rrie

rs t

o pa

rtic

ipat

ion

and

seek

con

sens

us. C

linic

ians

may

hav

e a

back

gro

und

supp

ort

role

, or

coul

d ha

ve r

oles

in f

acili

tatin

g

any

outc

omes

of

deci

sion

s th

at in

volv

e cl

inic

al c

are.

6

202

Hea

rin

g V

oic

es

Net

wo

rks

Inte

rnat

iona

l

Hea

ring

Voi

ces

Gro

ups

(HV

G) a

re b

ased

on

the

idea

tha

t m

embe

rs c

an s

hare

suc

cess

ful s

trat

egie

s w

ith e

ach

othe

r in

a m

utua

lly

safe

spa

ce. H

VG

are

an

inte

rnat

iona

l phe

nom

enon

. A r

evie

w e

valu

ated

the

evi

denc

e fo

r H

earin

g V

oice

s G

roup

s (H

VG

) and

the

m

echa

nism

s of

cha

nge

for

succ

essf

ul in

terv

entio

ns. C

BT

was

the

onl

y ap

proa

ch w

ith e

vide

nce

from

wel

l-con

trol

led

stud

ies.

H

owev

er, s

ever

al e

vide

nce-

base

d tr

eatm

ents

sha

re ‘k

ey in

gre

dien

ts’ w

hich

evi

denc

e su

gg

ests

hel

p re

duce

dis

tres

s. S

ucce

ssfu

l g

roup

s su

pply

a s

afe

cont

ext

for

part

icip

ants

to

shar

e ex

perie

nces

, and

ena

ble

diss

emin

atio

n of

str

ateg

ies

for

copi

ng w

ith v

oice

s as

wel

l as

cons

ider

ing

alte

rnat

ive

belie

fs a

bout

voi

ces.

7

Info

rmal

S

afeg

uar

din

g

and

Cit

izen

V

olu

nte

erin

g

Aus

tral

ia

The

Wes

tern

Aus

tral

ian

Men

tal H

ealth

Com

mis

sion

(WA

MH

C) h

as u

nder

take

n sy

stem

ic r

efor

m e

ffor

ts t

o im

plem

ent

a ‘s

elf-

dire

cted

app

roac

h’ t

o m

enta

l hea

lth s

ervi

ce p

rovi

sion

, whi

ch in

clud

es e

ffor

ts t

o fo

ster

‘inf

orm

al o

r na

tura

l, in

tent

iona

l saf

egua

rd

arra

ngem

ents

’.8 In

form

al s

afeg

uard

s m

ight

incl

ude

long

stay

inpa

tient

s be

ing

pai

red

with

citi

zen

volu

ntee

rs w

ho a

gre

e to

ass

ist

a pe

rson

in a

tra

nsiti

on t

o in

depe

nden

t liv

ing

. Sim

ilar

info

rmal

saf

egua

rdin

g a

ppro

ache

s ar

e lik

ely

to a

ppea

r w

orld

wid

e. (S

ee, f

or

exam

ple,

Jen

ner’

s A

dmis

sion

Pre

vent

ing

Str

ateg

y be

low

).

Info

rmal

Pee

r S

up

po

rt in

H

osp

ital

s an

d

Ser

vice

s

Inte

rnat

iona

l

Muc

h ha

s be

en w

ritte

n on

the

rol

e of

info

rmal

pee

r su

ppor

t, in

clud

ing

am

ong

inpa

tient

s. Q

uirk

and

col

leag

ues

arg

ue t

hat

patie

nts

rout

inel

y ta

ke a

n ac

tive

role

in m

akin

g a

saf

e en

viro

nmen

t fo

r th

emse

lves

in p

art

beca

use

they

can

not

rely

on

staf

f to

do

this

for

th

em, a

nd r

ecom

men

d th

at m

enta

l hea

lth p

rofe

ssio

nals

con

side

r ho

w t

o bu

ild u

pon

wha

t pa

tient

s ar

e al

read

y do

ing

to

max

imis

e w

ard

safe

ty.9

Inte

nti

on

al P

eer

Su

pp

ort

Uni

ted

Sta

tes,

Ja

pan,

New

Ze

alan

d,

Aus

tral

ia,

Eng

land

‘Int

entio

nal P

eer

Sup

port

’ (IP

S) w

as d

evel

oped

by

She

ry M

ead

as a

n al

tern

ativ

e to

tra

ditio

nal p

eer

supp

ort

prac

tices

with

in

men

tal h

ealth

ser

vice

s. IP

S o

ffer

s th

e op

port

unity

to

find

and

crea

te n

ew m

eani

ng t

hrou

gh

rela

tions

hips

and

con

vers

atio

ns

that

lead

to

new

way

s of

und

erst

andi

ng c

risis

. It

prov

ides

a le

ns t

hrou

gh

whi

ch t

o ad

dres

s th

ese

issu

es b

y ta

lkin

g v

ery

over

tly

abou

t po

wer

, who

has

it, w

ho d

oes

not

and

to n

egot

iate

how

it c

an b

e sh

ared

. Suc

h re

latio

nshi

ps a

re m

ore

proa

ctiv

e, b

uild

ing

m

utua

lity,

and

sha

red

mea

ning

mak

ing

. Mut

ualit

y an

d sh

ared

pow

er a

re p

ut f

orw

ard

as a

ltern

ativ

es t

o co

erci

on a

nd f

orce

.10 I

PS

ha

s be

en a

dvan

ced

by t

he C

entr

e fo

r th

e H

uman

Rig

hts

of U

sers

and

Sur

vivo

rs o

f P

sych

iatr

y as

a f

orm

of

supp

ort

in li

ne w

ith

the

CR

PD

.11 T

here

is c

urre

ntly

no

peer

-rev

iew

ed e

mpi

rical

res

earc

h in

to In

tent

iona

l Pee

r S

uppo

rt; h

owev

er, t

his

prac

tice

may

be

usef

ul in

ope

ratio

nalis

ing

ele

men

ts o

f rig

hts-

base

d C

RP

D w

hich

hel

p pr

even

t co

erci

ve in

terv

entio

ns.12

Jen

ner

’s

Ad

mis

sio

n

Pre

ven

tin

g

Str

ateg

y

Net

herla

nds

A D

utch

psy

chia

tris

t Ja

cobu

s A

dria

nus

Jenn

er d

evel

oped

an

appr

oach

whe

re h

e w

orke

d cl

osel

y to

get

her

with

the

peo

ple

who

w

ould

be

invo

lved

dire

ctly

with

the

per

son

in c

risis

.13 A

dmis

sion

Pre

vent

ing

Str

ateg

ies

(‘O

pnam

e V

oork

omen

de S

trat

egie

ën’)

in

volv

ed f

amily

mem

bers

and

sig

nific

ant

othe

rs b

eing

see

n as

aux

iliar

y fo

rces

, as

reso

urce

s in

ove

rcom

ing

a c

risis

. He

reg

arde

d th

em a

s re

sour

ces

who

cou

ld a

ssis

t th

e pe

rson

to

get

thr

oug

h a

psyc

hiat

ric c

risis

with

out

bein

g c

ompu

lsor

ily a

dmitt

ed, c

allin

g

them

‘gua

rdia

n an

gel

s’ o

r ‘b

odyg

uard

s’. A

n un

derp

inni

ng id

ea o

f th

is a

ppro

ach

was

tha

t cr

isis

was

vie

wed

as

an o

ppor

tuni

ty f

or

gro

wth

. Th

ese

prac

tices

wou

ld g

o on

to

info

rm D

utch

eff

orts

with

Fam

ily G

roup

Con

fere

ncin

g.14

Car

ina

Hak

anss

on

, Fa

mily

Car

e Fo

un

dat

ion

Sw

eden

Car

ina

Håk

anss

on is

the

co-

foun

der

of t

he F

amily

Car

e Fo

unda

tion

in S

wed

en. T

he F

ound

atio

n is

loca

ted

in G

othe

nbur

g, a

nd

wor

ks w

ith ‘f

amily

hom

e liv

ing

, psy

chot

hera

py a

nd f

amily

the

rapy

in t

he a

bsen

ce o

f ps

ychi

atric

dia

gno

ses

and

man

ual’.

15 P

eopl

e w

ho a

re e

xper

ienc

ing

men

tal h

ealth

cris

es a

re e

ssen

tially

pla

ced

in a

fam

ily h

ome,

oft

en in

the

cou

ntry

side

, whe

re t

hey

are

giv

en

wor

k ro

les

and

offe

red

ong

oing

sup

port

in w

hat

the

web

site

des

crib

es a

s a

‘fam

ily h

ome

livin

g in

a t

hera

peut

ic c

onte

xt’.

The

staf

f at

Fam

ily C

are

Foun

datio

n ar

e ps

ycho

ther

apis

ts, p

sych

olog

ists

and

soc

ial w

orke

rs. T

he w

orke

rs w

ork

tog

ethe

r in

tea

ms

cons

istin

g o

f th

e cl

ient

, his

or

her

netw

ork,

the

fam

ily h

ome,

a s

uper

viso

r an

d a

ther

apis

t.

203

Leed

s, ‘

Leed

s S

urv

ivo

r-Le

d

Cri

sis

Ser

vice

’ E

ngla

nd

The

Leed

s S

urvi

vor-

Led

Cris

is S

ervi

ce (L

SLC

S) i

s a

men

tal h

ealth

cha

rity

base

d in

Lee

ds. T

hey

prov

ide

out-

of-h

ours

sup

port

to

peop

le in

acu

te m

enta

l hea

lth c

risis

with

the

aim

of

redu

cing

hos

pita

l adm

issi

ons,

A&

E v

isits

, and

use

of

stat

utor

y cr

isis

ser

vice

s.

LSLC

S w

as f

ound

ed in

199

9 by

a g

roup

of

cam

paig

ning

men

tal h

ealth

ser

vice

use

rs, w

ho w

ante

d a

non-

med

ical

, non

-dia

gno

stic

ap

proa

ch t

o pe

ople

in c

risis

out

side

of

a cl

inic

al e

nviro

nmen

t. L

SLC

S h

as a

lso

part

nere

d w

ith T

ouch

ston

e S

uppo

rt C

entr

e in

H

areh

ills,

whi

ch h

as e

xper

ienc

e of

sup

port

ing

peo

ple

from

Bla

ck a

nd m

inor

ity e

thni

c (B

ME

) gro

ups.

The

ser

vice

pro

vide

s ou

t-of

-ho

urs

cris

is s

ervi

ces

to p

eopl

e fr

om B

ME

gro

ups

in a

cute

men

tal h

ealth

cris

is a

nd is

sta

ffed

by

a M

anag

er, S

enio

r C

risis

Sup

port

W

orke

r an

d th

ree

Cris

is S

uppo

rt W

orke

rs w

ho a

re a

ll fr

om B

ME

gro

ups.

Loca

l Are

a C

o-

Ord

inat

ion

Eng

land

, A

ustr

alia

and

N

ew Z

eala

nd

‘Loc

al A

rea

Co-

ordi

natio

n’ in

volv

es s

uppo

rtin

g is

olat

ed p

eopl

e w

ith a

ran

ge

of n

eeds

, inc

ludi

ng m

enta

l hea

lth s

uppo

rt n

eeds

, to

avo

id r

elyi

ng s

olel

y on

hea

lth a

nd s

ocia

l car

e se

rvic

es f

or s

ocia

l con

tact

. Thi

s pr

actic

e in

volv

es c

omm

unity

wor

kers

bas

ed

in p

artic

ular

nei

ghb

ourh

oods

who

se r

ole

is t

o bu

ild r

elat

ions

hips

, ide

ntify

pro

blem

s, a

nd h

elp

conn

ect

peop

le t

o co

mm

unity

as

soci

atio

ns, e

xist

ing

ser

vice

s, b

usin

esse

s an

d co

mm

unity

org

anis

atio

ns (r

athe

r th

an c

ong

reg

ated

, dis

abili

ty-s

peci

fic s

ervi

ces)

. Th

ere

does

not

app

ear

to b

e ev

iden

ce s

ugg

estin

g L

ocal

Are

a C

o-or

dina

tion

redu

ces

the

likel

ihoo

d of

coe

rcio

n, t

houg

h it

is

gen

eral

ly a

gre

ed t

o co

nstit

ute

a pr

even

tativ

e m

easu

re.

Med

icat

ion

D

isco

nti

nu

atio

n In

tern

atio

nal

Ser

vice

use

r or

gan

isat

ions

ten

d to

pre

sent

sup

port

with

med

icat

ion

disc

ontin

uatio

n as

an

unm

et n

eed.

Of

the

few

stu

dies

on

the

topi

c th

at d

o ex

ist,

sev

eral

indi

cate

tha

t di

scon

tinui

ng p

sych

iatr

ic m

edic

atio

n is

oft

en a

com

plic

ated

and

diffi

cult

proc

ess.

16

It s

eem

s re

ason

able

to

assu

me

that

dis

cont

inua

tion

prac

tices

, whe

ther

for

mal

ly o

r in

form

ally

, are

occ

urrin

g w

orld

wid

e. P

eter

G

root

and

Jim

van

Os

have

pro

pose

d ‘t

aper

ing

str

ips’

as

a pr

actic

al s

olut

ion

to h

elp

serv

ice

user

s di

scon

tinue

mor

e sa

fely

. Th

ey c

ondu

cted

an

obse

rvat

iona

l stu

dy o

n th

e us

e of

‘ant

idep

ress

ant

tape

ring

str

ips

to h

elp

peop

le c

ome

off

med

icat

ion

mor

e sa

fely

’ (n=

1194

), an

d co

nclu

ded

that

‘(t)

aper

ing

str

ips

repr

esen

t a

sim

ple

and

effe

ctiv

e m

etho

d of

ach

ievi

ng a

gra

dual

dos

age

redu

ctio

n’.17

An

inte

rnat

iona

l ini

tiativ

e, T

he T

aper

ing

Pro

ject

, is

prom

otin

g t

he u

se o

f Ta

perin

g S

trip

s as

a w

ay t

o im

prov

e th

e ch

oice

, con

trol

and

saf

ety

of t

hose

who

tak

e th

em.18

Op

en D

ialo

gu

eS

wed

en,

Eng

land

The

‘Ope

n D

ialo

gue

App

roac

h to

Acu

te P

sych

osis

’ is

a pr

actic

e de

velo

ped

in F

inla

nd in

whi

ch c

are

deci

sion

s ar

e m

ade

in t

he

pres

ence

of

the

indi

vidu

al a

nd h

is o

r he

r w

ider

net

wor

ks. P

sych

othe

rape

utic

app

roac

hes

are

take

n w

ith t

he a

im o

f de

velo

ping

di

alog

ue b

etw

een

the

pers

on a

nd t

heir

supp

ort

syst

em a

s a

ther

apeu

tic in

terv

entio

n. S

ervi

ce p

rovi

ders

aim

to

faci

litat

e re

gul

ar

‘net

wor

k m

eetin

gs’

bet

wee

n th

e pe

rson

and

his

/her

imm

edia

te n

etw

ork

of f

riend

s, c

arer

s an

d fa

mily

, and

sev

eral

con

sist

ently

at

tend

ing

mem

bers

of

the

clin

ical

tea

m. A

str

ong

em

phas

is is

pla

ced

on e

qual

hea

ring

of

all v

oice

s an

d pe

rspe

ctiv

es a

s bo

th a

m

eans

and

an

obje

ctiv

e of

tre

atm

ent

in it

self.

19

Para

chu

te

Pro

gra

m U

nite

d S

tate

s

Est

ablis

hed

in e

arly

201

3 by

the

New

Yor

k D

epar

tmen

t of

Hea

lth a

nd M

enta

l Hyg

iene

(DH

MH

), th

e Pa

rach

ute

prog

ram

me

uses

th

e O

pen

Dia

log

ue a

nd In

tent

iona

l Pee

r S

uppo

rt a

ppro

ache

s, a

gai

n to

res

pond

to

cris

es a

nd a

void

hos

pita

lisat

ion.

A t

eam

of

ther

apis

ts, s

ocia

l wor

kers

and

pee

r w

orke

rs w

ork

with

ser

vice

use

rs a

nd t

heir

fam

ilies

, enc

oura

gin

g t

hem

to

defin

e an

d w

ork

tow

ards

rec

over

y. R

epor

tedl

y, t

he a

ppro

ach

‘rej

ects

hie

rarc

hy, e

ncou

rag

ing

equ

al a

nd o

pen

dial

ogue

bet

wee

n ev

eryo

ne in

the

g

roup

’. It

is le

ss a

bout

get

ting

‘bet

ter’

and

mor

e ab

out

lear

ning

to

dwel

l alo

ngsi

de a

nd m

anag

e ac

ute

dist

ress

.

204

Peer

Su

pp

ort

Inte

rnat

iona

l

‘Pee

r su

ppor

t’, i

n w

hich

per

sons

with

psy

chos

ocia

l dis

abili

ties

prov

ide

supp

ort

to o

ne a

noth

er c

an t

ake

man

y fo

rms.

As

note

d pr

evio

usly

, it

can

be in

form

al (o

n w

ards

, in

inst

itutio

ns o

r in

the

com

mun

ity),

or f

orm

al (w

here

ser

vice

use

r co

nsul

tant

s as

sist

in

hos

pita

ls, o

r re

spite

hou

ses

are

run

by p

eopl

e w

ho e

xper

ienc

ed m

enta

l hea

lth c

rises

). R

egar

ding

the

latt

er, J

ulie

Rep

per

and

Tim

Car

ter

unde

rtoo

k a

met

a-an

alys

is o

f st

udie

s on

pee

r su

ppor

t w

orke

rs m

ore

gen

eral

ly, a

nd r

epor

ted

that

the

y ‘c

an le

ad t

o a

redu

ctio

n in

adm

issi

ons

amon

g t

hose

with

who

m t

hey

wor

k’, a

nd t

hat

‘ass

ocia

ted

impr

ovem

ents

hav

e be

en r

epor

ted

on

num

erou

s is

sues

tha

t ca

n im

pact

on

the

lives

of

peop

le w

ith m

enta

l hea

lth p

robl

ems’

. With

suf

ficie

nt t

rain

ing

, sup

ervi

sion

and

m

anag

emen

t, t

hey

arg

ue, t

his

coho

rt h

as t

he ‘p

oten

tial t

o dr

ive

thro

ugh

reco

very

-foc

used

cha

nges

in s

ervi

ces’

.2 0 T

here

is a

lso

muc

h w

ritte

n on

the

ben

efit

of p

eer

supp

ort

in lo

w-

and

mid

dle-

inco

me

coun

trie

s, in

clud

ing

in t

he a

bsen

ce o

f fo

rmal

men

tal

heal

th s

ervi

ces.

Pers

on

ligt

om

bu

d (

or

PO

) S

chem

e,

Sw

eden

Sw

eden

The

pers

onlig

t om

bud

(or

PO

) sys

tem

em

erg

ed a

fter

adv

ocat

es f

elt

that

exi

stin

g le

gal

cap

acity

sys

tem

s di

d no

t m

eet

the

need

s of

man

y pe

ople

with

psy

chos

ocia

l dis

abili

ties.

A P

O h

olds

an

inde

pend

ent

posi

tion

in a

mun

icip

ality

’s s

ocia

l ser

vice

s. T

he

‘ass

ista

nts’

or

‘adv

ocat

es’ a

re s

tatu

toril

y ap

poin

ted

to a

ssis

t a

pers

on t

o m

ake

leg

al d

ecis

ions

in a

fac

ilita

tive

rath

er t

han

coer

cive

fa

shio

n.21

Mun

icip

aliti

es m

ay r

un t

he P

O s

ervi

ce o

r su

b-co

ntra

ct t

hem

to

non-

gov

ernm

enta

l org

anis

atio

ns. T

he C

omm

issi

oner

for

H

uman

Rig

hts

of t

he C

ounc

il of

Eur

ope,

Nils

Mui

žnie

ks, r

epor

ted

that

in 2

013

a ne

w r

egul

atio

n es

tabl

ishe

d pe

rman

ent

fund

ing

fo

r th

e P

O s

yste

m in

the

reg

ular

wel

fare

sys

tem

.22 A

s of

201

4, a

ccor

ding

to

Mui

žnie

ks, 3

10 P

Os

prov

ided

sup

port

to

mor

e th

an

6,00

0 in

divi

dual

s an

d 24

5 m

unic

ipal

ities

(84

% o

f al

l mun

icip

aliti

es in

Sw

eden

) inc

lude

d P

Os

in t

heir

soci

al s

ervi

ce s

yste

m.23

In

its

Han

dbo

ok fo

r Pa

rliam

enta

rians

on

the

Con

vent

ion

on t

he R

ight

s of

Per

sons

with

Dis

abili

ties,

the

OH

CH

R r

ecom

men

d th

e ‘P

O S

kåne

’ pro

gra

mm

e –

an it

erat

ion

of t

he P

O p

rog

ram

me

run

by p

erso

ns w

ith p

sych

osoc

ial d

isab

ilitie

s –

as a

n ap

prop

riate

su

ppor

ted

deci

sion

-mak

ing

sta

tuto

ry m

echa

nism

.24 M

uižn

ieks

writ

es t

hat

‘rec

ours

e to

the

Per

sona

l Om

buds

men

sys

tem

cou

ld

be a

way

of

limiti

ng c

oerc

ive

prac

tice

in p

sych

iatr

ic in

stitu

tions

’, al

thou

gh

such

em

piric

al e

vide

nce

does

not

app

ear

to e

xist

at

pres

ent.

Rec

ove

ry C

amp

an

d W

ork

ing

fo

r R

ecove

ry

Eng

land

, S

cotla

nd,

Aus

tral

ia

Ron

Col

eman

and

Kar

en T

aylo

r ar

e se

rvic

e us

er a

dvoc

ates

who

run

a s

erie

s of

pra

ctic

es a

nd e

vent

s di

rect

ed t

owar

d R

ecov

ery.

Th

e R

ecov

ery

Cam

p is

a r

esid

entia

l sum

mer

cam

p th

at is

hel

d in

Sco

tland

and

Eng

land

, and

has

bee

n ru

nnin

g s

ince

201

5.25

Rec

ove

ry

Mo

del

s

Inte

rnat

iona

l (m

ostly

Eng

lish-

spea

king

hi

gh-

inco

me

coun

trie

s)

‘Rec

over

y’-o

rient

ed m

enta

l hea

lth p

olic

y an

d pr

actic

e ai

ms

to e

nhan

ce t

he a

gen

cy o

f a

pers

on a

nd t

o av

oid

wha

t Pa

mel

a Fi

sher

de

scrib

es a

s in

terv

entio

ns ‘b

eing

don

e to

’ peo

ple.

26 It

is t

he s

ubje

ct o

f an

ext

ensi

ve li

tera

ture

, is

unde

rsto

od in

div

erse

way

s,

and

has

influ

ence

d m

enta

l hea

lth s

ervi

ces

inte

rnat

iona

lly. R

ecov

ery

is g

over

nmen

t po

licy

in E

nglis

h-sp

eaki

ng c

ount

ries

such

as

Aus

tral

ia, C

anad

a, N

ew Z

eala

nd, S

cotla

nd, I

rela

nd, N

orth

ern

Irel

and,

the

Uni

ted

Sta

tes

and

Eng

land

.

Red

uci

ng

an

d

Elim

inat

ing

S

eclu

sio

n a

nd

R

estr

ain

t

Inte

rnat

iona

l

As

this

rep

ort

has

deta

iled,

the

re a

re m

ultip

le p

rog

ram

mes

, pra

ctic

es a

nd p

olic

y-m

easu

res

desi

gne

d to

red

uce

and

elim

inat

e th

e us

e of

sec

lusi

on a

nd r

estr

aint

in m

enta

l hea

lth s

ettin

gs.

The

se in

clud

e: S

ix C

ore

Str

ateg

ies

and

Saf

ewar

ds (s

ee b

elow

).27 T

he

appr

oach

es in

clud

e se

clus

ion

room

s, im

prov

emen

ts t

o w

ard

phys

ical

env

ironm

ents

, hav

ing

mor

e op

port

uniti

es f

or s

uppo

rt a

nd

conn

ectio

n, a

nd g

reat

er a

cces

s to

pee

r w

orke

rs, f

amily

and

oth

er in

form

al s

uppo

rt.

205

‘Rep

rese

nta

tio

n

Ag

reem

ents

’,

No

min

ated

Pe

rso

ns

Sch

emes

, et

c.

Inte

rnat

iona

l

Ther

e ar

e m

ultip

le f

orm

s of

rep

rese

ntat

ion

agre

emen

ts. M

ost

adva

nce

plan

ning

mea

sure

s w

ill in

clud

e a

form

of

repr

esen

tatio

n ag

reem

ent,

in w

hich

a p

erso

n is

nom

inat

ed b

y th

e pl

anee

, to

assi

st in

som

e w

ay d

urin

g a

fut

ure

cris

is. O

ne le

gis

lativ

e fo

rm

of r

epre

sent

atio

n ag

reem

ent

that

is o

ften

pro

mot

ed a

s be

ing

clo

sely

in li

ne w

ith t

he C

RP

D is

the

Can

adia

n pr

ovin

ce o

f B

ritis

h C

olum

bia’

s R

epre

sent

atio

n A

gree

men

t A

ct 1

996,

whi

ch p

rovi

des

an e

xam

ple

of s

tatu

tory

adv

ance

pla

nnin

g a

nd r

epre

sent

atio

n ag

reem

ents

.28 P

ower

s of

att

orne

y m

ay a

lso

prov

ide

a si

mpl

e le

gal

ave

nue

for

appo

intin

g a

rep

rese

ntat

ive

on c

erta

in d

ecis

ions

. O

ther

s, s

uch

as J

oint

Cris

is P

lann

ing

, and

info

rmal

rep

rese

ntat

ion

agre

emen

ts a

mon

g u

sers

and

prio

r us

ers

of s

ervi

ces,

are

di

scus

sed

in t

his

repo

rt.

Res

pit

e H

ou

ses

Inte

rnat

iona

l

Ther

e ar

e m

any

type

s of

res

pite

hou

ses.

The

ter

m t

ypic

ally

ref

ers

to n

on-h

ospi

tal e

nviro

nmen

ts t

o w

hich

peo

ple

can

go

for

shor

t pe

riods

of

time

whe

n th

ey a

re e

xper

ienc

ing

men

tal h

ealth

cris

es. L

aysh

a O

stro

w h

as w

ritte

n of

‘pee

r-ru

n cr

isis

res

pite

s’, a

nd

dist

ing

uish

es w

ithin

thi

s ca

teg

ory

betw

een

‘hyb

rid’ a

nd ‘p

eer-

run’

mod

els.

‘Hyb

rid’ m

odel

s re

fer

to r

espi

tes

unde

r th

e au

spic

es

of a

non

-pee

r-ru

n or

gan

isat

ion,

but

whe

re t

he r

espi

te u

nder

its

cont

rol h

as a

dire

ctor

and

sta

ff w

ho a

re p

eers

. ‘P

ure

peer

-run

’, fo

r O

stro

w, r

espi

tes

are

thos

e in

whi

ch ‘p

eers

sta

ff, o

pera

te, a

nd o

vers

ee t

he r

espi

te a

t al

l lev

els’

. Thi

s ce

ntre

wou

ld b

e a

stan

d-al

one

prog

ram

me

in a

res

iden

tial n

eig

hbou

rhoo

d th

at is

not

att

ache

d to

a ‘t

radi

tiona

l pro

vide

r, an

d ha

s no

ons

ite o

r co

ntra

ctua

l po

tent

ial t

o of

fer

psyc

hiat

ric o

r m

edic

al s

ervi

ces.

’29 T

here

are

als

o ex

ampl

es o

f re

spite

hou

ses

that

are

not

pee

r-ru

n, a

nd w

hich

m

ay b

e at

tach

ed t

o cl

inic

al m

enta

l hea

lth s

ervi

ces,

and

whi

ch o

ffer

a ‘s

tep

dow

n’ f

rom

hos

pita

ls. S

ome

exam

ples

of

cris

is r

espi

te

hous

es a

re:

- S

oter

ia H

ouse

(see

bel

ow)

- W

este

rn M

assa

chus

etts

Rec

over

y an

d Le

arni

ng C

entr

e (s

ee b

elow

)-

Aw

hi R

ito –

Mat

erna

l Cris

is R

espi

te (N

Z) (a

mat

erna

l cris

is r

espi

te s

ervi

ce f

or m

othe

rs a

nd t

heir

babi

es)30

- Th

e B

erlin

Run

away

Hou

se (s

ee b

elow

).A

sm

all n

umbe

r of

suc

h pr

ogra

mm

es o

pera

te t

hrou

gho

ut t

he w

orld

, inc

ludi

ng 2

1+ in

the

Uni

ted

Sta

tes

of A

mer

ica.

31

Saf

ewar

ds

Pola

nd, N

orw

ay,

Aus

tral

ia,

Eng

land

, S

cotla

nd,

Irel

and,

Can

ada,

G

erm

any,

D

enm

ark

Saf

ewar

ds is

a s

erie

s of

str

ateg

ies

amou

ntin

g t

o a

syst

ems

appr

oach

aim

ing

to

chan

ge

cultu

re a

roun

d ‘fl

ashp

oint

s’ t

hat

can

lead

to

sec

lusi

on a

nd r

estr

aint

in in

patie

nt u

nits

. O

rigin

atin

g in

the

UK

, the

Mod

el d

epic

ts s

ix d

omai

ns o

f or

igin

atin

g f

acto

rs: t

he s

taff

te

am, t

he p

hysi

cal e

nviro

nmen

t, o

utsi

de h

ospi

tal,

the

patie

nt c

omm

unity

, pat

ient

cha

ract

eris

tics

and

the

reg

ulat

ory

fram

ewor

k.

Thes

e do

mai

ns g

ive

risk

to fl

ashp

oint

s, w

hich

hav

e th

e ca

paci

ty t

o tr

igg

er c

onfli

ct a

nd/o

r co

ntai

nmen

t. S

taff

inte

rven

tions

can

m

odify

the

se p

roce

sses

by

redu

cing

the

con

flict

-orig

inat

ing

fac

tors

, pre

vent

ing

flas

hpoi

nts

from

aris

ing

, cut

ting

the

link

bet

wee

n fla

shpo

int

and

confl

ict,

cho

osin

g n

ot t

o us

e co

ntai

nmen

t, a

nd e

nsur

ing

tha

t co

ntai

nmen

t us

e do

es n

ot le

ad t

o fu

rthe

r co

nflic

t.

The

mod

el is

use

d to

dev

ise

stra

teg

ies

for

prom

otin

g t

he s

afet

y of

pat

ient

s an

d st

aff.32

Sh

ared

Dec

isio

n-

Mak

ing

Can

ada,

E

ngla

nd,

Ger

man

y, t

he

Net

herla

nds,

U

nite

d S

tate

s,

Peru

, Wal

es,

Aus

tral

ia, I

taly

, an

d S

audi

A

rabi

a

Sha

red

deci

sion

-mak

ing

is a

for

mal

ised

pro

cess

in m

enta

l hea

lth s

ervi

ce b

y w

hich

clin

icia

ns a

nd c

onsu

mer

s en

gag

e in

a

colla

bora

tive

deci

sion

-mak

ing

pro

cess

for

hea

lthca

re d

ecis

ions

. It

is p

rem

ised

on

the

idea

tha

t op

timal

dec

isio

n-m

akin

g o

ccur

s w

hen

a de

cisi

on is

info

rmed

by

the

mos

t re

leva

nt e

vide

nce

and

the

serv

ice

user

’s p

erso

nal p

refe

renc

es a

nd v

alue

s.33

206

Sh

arin

g V

oic

es

Bra

dfo

rd E

ngla

nd

Sha

ring

Voi

ces

Bra

dfor

d is

a s

uppo

rt p

rog

ram

me

part

icul

arly

for

Bla

ck B

ritis

h an

d m

igra

nt p

eopl

e in

men

tal h

ealth

cris

is,

part

icul

arly

tho

se f

acin

g s

ocia

l exc

lusi

on, i

sola

tion

and

disc

rimin

atio

n. S

harin

g V

oice

s is

mor

e of

a c

omm

unity

dev

elop

men

t m

enta

l hea

lth p

roje

ct t

han

a tr

aditi

onal

ser

vice

, foc

usin

g o

n de

velo

ping

and

rai

sing

aw

aren

ess

of m

enta

l hea

lth w

ellb

eing

am

ong

st m

arg

inal

ised

Bla

ck a

nd m

igra

nt c

omm

uniti

es (w

ho a

re o

ver-

repr

esen

ted

amon

g t

hose

fac

ing

for

ced

psyc

hiat

ric

inte

rven

tions

). Th

e se

rvic

e w

as r

epor

tedl

y es

tabl

ishe

d on

the

bas

is t

hat

‘an

indi

vidu

al’s

men

tal h

ealth

exp

erie

nces

oft

en a

rise

from

issu

es a

roun

d: p

over

ty, r

acis

m, u

nem

ploy

men

t, lo

nelin

ess,

fam

ily c

onfli

cts,

rel

atio

nshi

p di

fficu

lties

and

can

not

be m

erel

y un

ders

tood

thr

oug

h bi

olog

ical

ter

ms

alon

e’ a

nd e

mph

asis

es ‘l

iste

ning

to

peop

le’s

ow

n ex

plan

atio

n an

d he

lpin

g t

hem

find

the

ir so

lutio

ns t

o pr

oble

ms’

.34

So

teri

a H

ou

se

Sw

eden

, Fi

nlan

d,

Ger

man

y,

Sw

itzer

land

, H

ung

ary

and

the

Uni

ted

Sta

tes

The

Sot

eria

mod

el is

a t

ype

of r

espi

te h

ouse

(see

abo

ve).

It w

as f

ound

ed in

Cal

iforn

ia, U

nite

d S

tate

s, a

s an

alte

rnat

ive

com

mun

ity-

base

d, n

on-m

edic

al a

ppro

ach

to t

radi

tiona

l hos

pita

lisat

ion

for

peop

le d

iag

nose

d w

ith s

chiz

ophr

enia

.35 T

he a

ppro

ach

cons

ists

of

a sm

all,

com

mun

ity-b

ased

, res

iden

tial t

reat

men

t en

viro

nmen

t w

ith s

tron

g u

se o

f pe

er a

nd a

llied

-pro

fess

iona

l sta

ffing

rat

her

than

cl

inic

al s

taff.

Sot

eria

Hou

se r

epor

tedl

y fo

cus

on e

mpo

wer

men

t, p

eer

supp

ort,

soc

ial n

etw

orks

, and

mut

ual r

espo

nsib

ility

. It

tend

s to

invo

lve

min

imal

use

of

psyc

hotr

opic

med

icat

ion

base

d on

per

sona

l cho

ice

of e

ach

resi

dent

. Acc

ordi

ng t

o th

e D

epar

tmen

t of

M

enta

l Hea

lth V

erm

ont,

‘fur

ther

ana

lysi

s m

ay b

e w

arra

nted

to

asse

ss h

ow V

erm

ont’s

fut

ure

supp

ort

and

impl

emen

tatio

n of

the

S

oter

ia m

odel

can

red

uce

the

need

for

invo

lunt

ary

med

icat

ion

for

indi

vidu

als

expe

rienc

ing

a p

sych

iatr

ic c

risis

’.36

TC

I-A

sia

– C

om

mu

nit

y D

evel

op

men

t

Sou

th A

sia,

E

ast

Asi

a,

Sou

th E

ast

Asi

a an

d th

e Pa

cific

Tran

sfor

min

g C

omm

uniti

es f

or In

clus

ion

of P

erso

ns w

ith P

sych

osoc

ial D

isab

ilitie

s, A

sia,

is a

n A

sian

alli

ance

of

peop

le w

ho

self-

iden

tify

as p

eopl

e w

ith p

sych

osoc

ial d

isab

ilitie

s, t

heir

org

anis

atio

ns a

nd t

heir

‘cro

ss-d

isab

ility

’ sup

port

ers.

TC

I Asi

a is

an

inde

pend

ent,

reg

iona

l Dis

able

d Pe

ople

’s O

rgan

isat

ion

(DP

O) f

ocus

sing

on

the

mon

itorin

g a

nd im

plem

enta

tion

of a

ll hu

man

rig

hts

for

pers

ons

with

men

tal h

ealth

pro

blem

s an

d ps

ycho

soci

al d

isab

ilitie

s. T

CI-

Asi

a es

sent

ially

und

erta

kes

com

mun

ity d

evel

opm

ent

wor

k, f

acili

tatin

g m

ulti-

stak

ehol

der

dial

ogue

s, t

echn

ical

inpu

ts t

o g

over

nmen

ts, c

apac

ity b

uild

ing

and

tra

inin

gs

on t

he C

RP

D a

nd

incl

usio

n, a

nd t

hrou

gh

the

‘em

pow

erm

ent

of e

mer

gin

g le

ader

s an

d na

tiona

l DP

O’. 3

7

The

Inst

itu

te f

or

the

Dev

elo

pm

ent

of

Hu

man

Art

s (I

DH

A)

Uni

ted

Sta

tes

Acc

ordi

ng t

o V

aler

ie C

anad

y, ‘(

t)he

Inst

itute

for

the

Dev

elop

men

t of

Hum

an A

rts

(IDH

A) i

s de

fined

as

a le

arni

ng c

omm

unity

th

at a

dvan

ces

holis

tic, d

emoc

ratic

and

tra

nsfo

rmat

ive

men

tal h

ealth

pra

ctic

es. S

he w

rites

, ‘[t

]he

trai

ning

initi

ativ

e fo

cuse

s on

com

mun

ity-b

ased

, rec

over

y-or

ient

ed a

nd p

eer-

driv

en a

ltern

ativ

es…

’.38 T

he ID

HA

is lo

cate

d in

New

Yor

k C

ity. T

he w

ebsi

te

desc

ribes

the

gro

up a

s co

nsis

ting

of:

‘men

tal h

ealth

wor

kers

, clin

icia

ns, p

sych

iatr

ists

, cur

rent

and

prio

r us

ers

of m

enta

l hea

lth

serv

ices

, adv

ocat

es, a

rtis

ts, a

nd s

urvi

vors

of

trau

ma

and

adve

rsity

.’39

207

The

Ru

naw

ay

Ho

use

, B

erlin

Ger

man

y

The

co-o

rdin

ator

s of

the

Weg

lauf

haus

‘Vill

a S

töck

le’ (

or R

unaw

ay H

ouse

) des

crib

e it

as ‘a

n an

ti-ps

ychi

atric

orie

nted

cris

is f

acili

ty

in B

erlin

’.40 It

is p

ositi

oned

as

a cr

isis

cen

tre

for

‘hom

eles

s ex

-use

rs o

f ps

ychi

atry

’. R

esid

ents

rep

orte

dly

have

the

‘opp

ortu

nity

to

live

thr

oug

h th

eir

cris

is w

ithou

t ps

ychi

atric

tre

atm

ent

and

to w

ithdr

aw g

radu

ally

fro

m p

sych

iatr

ic d

rug

s w

ith s

uppo

rt a

nd

inte

nsiv

e co

unse

lling

.’41

Trau

ma-

Info

rmed

In

tern

atio

nal

Ther

e ar

e m

any

mod

els

of ‘t

raum

a-in

form

ed’ s

ervi

ces,

whi

ch r

efer

to

serv

ices

des

igne

d in

rec

ogni

tion

of t

he im

pact

of

inte

rper

sona

l vio

lenc

e an

d vi

ctim

isat

ion

on a

n in

divi

dual

’s li

fe a

nd d

evel

opm

ent.

Max

ine

Har

ris a

nd R

oger

Fal

lot

have

poi

nted

to

evid

ence

sug

ges

ting

mos

t m

enta

l hea

lth a

nd w

elfa

re r

ecip

ient

s ha

ve s

urvi

ved

phys

ical

or

sexu

al v

iole

nce,

and

arg

ue t

hat

curr

ent

‘[s]

yste

ms

serv

e su

rviv

ors

of c

hild

hood

tra

uma

with

out

trea

ting

the

m f

or t

he c

onse

quen

ces

of t

hat

trau

ma;

mor

e si

gni

fican

t,

syst

ems

serv

e in

divi

dual

s w

ithou

t ev

en b

eing

aw

are

of t

he t

raum

a th

at o

ccur

red’

.42 T

raum

a-in

form

ed s

ervi

ces

arg

uabl

y re

duce

the

lik

elih

ood

of c

oerc

ive

prac

tices

by

resp

ondi

ng w

ith g

reat

er u

nder

stan

ding

to

indi

vidu

als

in c

risis

, and

by

desi

gni

ng s

ervi

ces

that

av

oid

repl

icat

ing

the

har

m a

lread

y ca

used

to

serv

ice

user

s.

Trie

ste

Mo

del

Ital

y

Acc

ordi

ng t

o th

e W

orld

Hea

lth O

rgan

izat

ion

(WH

O),

the

‘Trie

ste

mod

el’ o

f pu

blic

psy

chia

try

is o

ne o

f th

e m

ost

prog

ress

ive

in

the

wor

ld. I

t w

as in

Trie

ste,

Ital

y, in

the

197

0s t

hat

the

radi

cal p

sych

iatr

ist,

Fra

nco

Bas

aglia

, sou

ght

to

crea

te a

n an

ti-in

stitu

tiona

l, de

moc

ratic

app

roac

h to

sup

port

ing

peo

ple

with

men

tal h

ealth

con

ditio

ns a

nd p

sych

osoc

ial d

isab

ilitie

s. T

he m

odel

has

a s

tron

g

focu

s on

citi

zens

hip

and

soci

al in

clus

ion.

43

Tria

log

ue

Pola

nd, F

renc

h-sp

eaki

ng

Sw

itzer

land

, G

erm

any,

Fr

ance

, and

Ir

elan

d

In t

rialo

gue

gro

ups

user

s, c

arer

s an

d fr

iend

s an

d m

enta

l hea

lth w

orke

rs m

eet

reg

ular

ly in

an

open

for

um t

hat

is lo

cate

d on

‘n

eutr

al t

erra

in’ –

out

side

any

the

rape

utic

, fam

ilial

or

inst

itutio

nal c

onte

xt –

with

the

aim

of

disc

ussi

ng t

he e

xper

ienc

es a

nd

cons

eque

nces

of

men

tal h

ealth

pro

blem

s an

d w

ays

forw

ard.

Tria

log

ues

offe

r ne

w p

ossi

bilit

ies

for

gai

ning

kno

wle

dge

and

insi

ght

s an

d de

velo

ping

new

way

s of

com

mun

icat

ing

bey

ond

role

ste

reot

ypes

.44 A

sim

ilar

mod

el w

as u

sed

in F

oxle

win

’s s

eclu

sion

re

duct

ion

pilo

t st

udy

(see

App

endi

x Tw

o).

Afi

ya, W

este

rn

Mas

sach

use

tts

Res

pit

e an

d

Lear

nin

g C

ente

r

Uni

ted

Sta

tes

A p

eer-

run

cris

is r

espi

te c

entr

e, a

ccor

ding

to

the

Afiy

a w

ebsi

te, ‘

is lo

cate

d in

a r

esid

entia

l nei

ghb

ourh

ood

in N

orth

ampt

on,

Mas

sach

uset

ts a

nd is

cen

tral

to

a va

riety

of

com

mun

ity r

esou

rces

’. It

is a

vaila

ble

to a

dults

exp

erie

ncin

g d

istr

ess

who

‘fee

l the

y w

ould

ben

efit

from

bei

ng in

a s

hort

-ter

m, 2

4-ho

ur p

eer-

supp

orte

d en

viro

nmen

t w

ith o

ther

s w

ho h

ave

“bee

n th

ere”

’ – o

ther

s w

ho

‘iden

tify

as h

avin

g li

ved

expe

rienc

e th

at m

ay in

clud

e ex

trem

e em

otio

nal o

r al

tere

d st

ates

, psy

chia

tric

dia

gno

ses,

tra

uma

hist

orie

s,

livin

g w

ithou

t a

hom

e, n

avig

atin

g t

he m

enta

l hea

lth a

nd o

ther

pub

lic s

yste

ms,

add

ictio

ns a

nd m

ore’

.45

208

Appendix Endnotes1. ‘Not peer reviewed’ is meant in the strict sense of subjecting an author’s

scholarly work, research, or ideas to the scrutiny of others who are ex-perts in the same field and are independent to the study, at a stage before a paper is published in a journal or as a book. However, other forms of peer review in the broader sense may have been included in the few ‘non-peer reviewed’ studies listed here. Bradley Foxlewin’s study, for example (see below), was conducted using an advisory group consisting of fellow service users who monitored and guided the study. A similar process guided the report authored by the Users and Survivors of Psychiatry – Kenya (see below).

2. Berliner Krisendienst, Berlin, Germany <www.berliner-krisendienst.de/en/>.

3. Claire Henderson et al, ‘A Typology of Advance Statements in Mental Health Care’ (2008) 59(1) Psychiatric Services (Washington, D.C.) 63.

4. Kim Sutherby and George Szmukler, ‘Crisis Cards and Self-Help Crisis Initiatives’ (1998) 22(1) Psychiatric Bulletin 4.

5. Clubhouse International, ‘Clubhouse Stories’ <https://clubhouse-intl.org/hopeclubhousestory/>.

6. Gert Schout, Ellen Meijer and Gideon de Jong, ‘Family Group Conferenc-ing—Its Added Value in Mental Health Care’ (2017) 38(6) Issues in Mental Health Nursing 480.

7. Anna Ruddle, Oliver Mason and Til Wykes, ‘A Review of Hearing Voices Groups: Evidence and Mechanisms of Change’ (2011) 31(5) Clinical psy-chology review 757.

8. Government of Western Australia, Mental Health Commission, Draft Safeguards Framework for Individualised Support and Funding (May 2013) 2 <www.mentalhealth.wa.gov.au>.

9. Alan Quirk, Paul Lelliott and Clive Seale, ‘Risk Management by Patients on Psychiatric Wards in London: An Ethnographic Study’ (2005) 7(1) Health, Risk & Society 85.

10. Shery Mead and Beth Filson, ‘Mutuality and shared power as an alterna-tive to coercion and force’ (2017) 21(3) Mental Health and Social Inclusion 144.

11. See Center for the Human Rights of Users and Survivors of Psychiatry, ‘Good Practices’, n.d. <www.chrusp.org>.

12. Sherry Mead, David Hilton and Laurie Curtis, ‘Peer Support: A Theoretical Perspective’ (2001) 25(2) Psychiatric Rehabilitation Journal 134.

13. Jacobus Jenner, Opnamevoorkómende strategieën in de praktijk van de so-ciale psychiatrie (Erasmus University Rotterdam, 1984) <http://hdl.handle.net/1765/38522>.

14. See Gert Schout, Ellen Meijer and Gideon de Jong, ‘Family Group Conferencing— Its Added Value in Mental Health Care’ (2017) 38(6) Issues in Mental Health Nursing 480.

15. Familjevårdsstiftelsen, Gothenburg, Sweden <www.familjevardsstiftelsen.se>

209

16. Carmela Salomon, Bridget Hamilton and Stephen Elsom, ‘Experiencing Antipsychotic Discontinuation: Results from a Survey of Australian Con sumers’ (2014) 21(10) Journal of Psychiatric and Mental Health Nursing 917; Laysha Ostrow et al, ‘Discontinuing Psychiatric Medications: A Sur vey of Long-Term Users’ (2017) 68(12) Psychiatric Services 1232.

17. Peter C Groot and Jim van Os, ‘Antidepressant Tapering Strips to Help People Come off Medication More Safely’ (2018) 10(2) Psychosis 142.

18. Tapering Strip Project, Maastricht, The Netherlands <www.tapering-strip.org>. Research at Maastricht University is being undertaken into the use of Tapering Strips. See ‘Project Tapering’ (website), Maastricht University <https://urc.mumc.maastrichtuniversity.nl/node/13125>.

19. Lisa Wood and Russell Razzaque, Open Dialogue in psycho-sis: a systematic review of current evidence (PROSPERO, 2014) <http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42014013139>

20. Julie Repper and Tim Carter, ‘A Review of the Literature on Peer Support in Mental Health Services’ (2011) 20(4) Journal of Mental Health 392.

21. Leslie Salzman, ‘Guardianship for Persons with Mental Illness – A Legal and Appropriate Alternative?’ (2011) 4 St. Louis University Journal of Health Law and Policy 279.

22. Council of Europe: Commissioner for Human Rights, Report by Nils Muižnieks Commissioner for Human Rights of the Council of Europe Following His Visit to Sweden, 16 October 2018, CommDH(2018)4 paras [76]-[78].

23. Ibid.

24. Office of the High Commissioner for Human Rights, ‘Chapter Six: From Provisions to Practice: Implementing the Convention, Legal Capacity and Supported Decision-Making’, United Nations Hand-book for Parliamentarians on the Convention on the Rights of Persons with Disabilities (Geneva, 2007) 89.

25. Working to Recovery, Isle of Lewis, United Kingdom <www.work-ingtorecovery.co.uk>.

26. Pamela Fisher, ‘Questioning the Ethics of Vulnerability and Informed Consent in Qualitative Studies from a Citizenship and Human Rights Perspective’ (2012) 6(1) Ethics and Social Welfare 2, 12.

27. For a full list of these approaches, see Melbourne Social Equity Institute, ‘Literature Review’. in Melbourne Social Equity Institute, Seclusion and Restraint Project: Report (Melbourne: University of Melbourne, 2014) <https://socialequity.unimelb.edu.au/__data/as-sets/pdf_file/0017/2004722/Seclusion-and-Restraint-report.PDF>.

28. Representation Agreement Act R.S.B.C. 1996 c 405, ss 2(a), 8.

29. Laysha Ostrow, ‘A Case Study of the Peer-Run Crisis Respite Organ-izing Process in Massachusetts’, Heller School for Social Policy and Management, Master of Public Policy Capstone, 2010.

210

30. Kāhui Tū Kaha, Auckland, New Zealand <http://kahuitukaha.co.nz/>

31. See ‘Directory of Peer-Run Crisis Services’, National Empowerment Center Website <https://power2u.org/directory-of-peer-respites/>

32. Len Bowers, ‘Safewards: A New Model of Conflict and Containment on Psychiatric Wards’ (2014) 21(6) Journal of Psychiatric and Mental Health Nursing 499.

33. Patricia Deegan, ‘A Web Application to Support Recovery and Shared Decision Making in Psychiatric Medication Clinics’ (2010) 34(1) Psychiatric Rehabilitation Journal 23.

34. Sharing Voices, Bradford, United Kingdom <www.sharingvoices.net>

35. Tim Calton et al, ‘A Systematic Review of the Soteria Paradigm for the Treatment of People Diagnosed With Schizophrenia’ (2008) 34(1) Schizophrenia Bulletin 181; Pesach Lichtenberg, ‘From the Closed Ward to Soteria: A Professional and Personal Journey’ (2017) 9(4) Psychosis 369; Ingrid Lindgren, Margareta Falk Hogstedt and Johan Cullberg, ‘Outpatient vs. Comprehensive First-Episode Psychosis Services, a 5-Year Follow-up of Soteria Nacka’ (2006) 60(5) Nordic Journal of Psychiatry 405.

36. Department of Mental Health, Vermont Reforming Vermont’s Mental Health System Report to the Legislature on the Implementation of Act 82, Section 5: Involuntary Treatment and Medication Review, 15 December 2017

37. Transforming Communities for Inclusion – Asia Pacific, Pune, India <http://www.tci-asia.org>.

38. Valerie Canady, ‘Learning Community Promotes Holistic, Trans-formative Practices’ Mental Health Weekly - Wiley Online Library (24 October 2017).

39. Institute for the Development of Human Arts, New York City, United States <www.idha-nyc.org>.

40. Weglaufhaus "Villa Stöckle", Berlin, Germany <www.weglaufhaus.de>.

41. Ibid.

42. Denise E Elliott et al, ‘Trauma-Informed or Trauma-Denied: Princip-les and Implementation of Trauma-Informed Services for Women’ (2005) 33(4) Journal of Community Psychology 461, 462.

43. The Trieste Mental Health Department, English language website, Trieste, Italy <www.triestesalutementale.it/english/mhd_depart-ment.htm>.

44. Mental Health Trialogue Ireland, Dublin, Ireland <http://trialogue.co/>.

45. Afiya, Massachusetts, United States <http://www.westernmassrlc.org/afiya>.

214

socialequity.unimelb.edu.au

+61 3 9035 4738

facebook.com/MSEIatUniMelb

twitter.com/MSEI_UniMelb

[email protected]

Contact the Melbourne Social Equity Institute