Coercive Treatment in Psychiatry: Clinical, legal and ethical aspects

By John Monahan

Coercion is one of the most fascinating and controversial subjects in psychiatry. It is a highly sensitive, and hotly debated topic in which clinical practice, ethics, the law and public policy converge. This book considers coercion within the healing and ethical framework of therapeutic relationships and partnerships at all levels, and addresses the universal problem of how to balance safety versus autonomy when dealing with psychiatric treatment.

Coercive Treatment in Psychiatry is a much needed contribution to the literature. The first three sections deal with the conceptual and clinical aspects of coercive treatment, the legal aspects and the ethical aspects of coercive treatment. In detail, these sections cover a broad spectrum of issues: coercion in institutions and in the community, coercive treatment and stigma, the definition of best practice standards for coercive treatment, de-escalation of risk situations, recent developments in mental health legislation, mental health care and patients' rights, cross-cultural perspectives on coercive treatment, historical injustice in psychiatry, and paternalism in mental health. The fourth section features users' views on coercive treatment: giving voice to an often-unheeded population. Finally, the book addresses the original topic of coercion and undue influence in decisions to participate in psychiatric research.

This book presents the first comprehensive review of the issue of coercion in psychiatry. With chapters written by the leading experts in the field, many of whom are renowned as clear thinkers and experienced clinicians, it may be seen as a starting point for international discussions and initiatives in this field aiming to minimize coercion.

Highly Commended in the Psychiatry section of the 2012 BMA Book Awards.

• Language: English
• Publisher: Wiley
• Release date: Mar 25, 2011
• ISBN: 9780470978658

Book preview

Section 1

Conceptual and clinical aspects of coercive treatment

Chapter 1

Person-centred Psychiatry Perspectives on Coercion and Cooperation

Juan E. Mezzich

New York University, Mount Sinai School of Medicine, New York, NY, United States

1.1 Introduction

The topic of coercive treatment in psychiatry is both complex and sensitive. It is complex as it involves, inter alia, clinical, public health, ethical and legal issues. And it is sensitive as it deals with delicate aspects of human experience and interpersonal relations. In order to offer a frame of reference to address such complexity and sensitivity, this chapter first summarizes an ongoing initiative on person-centred psychiatry and medicine. It then discusses the place for dialogue, partnership and trust in implementing person-centred care and dealing with the tension between social control and personal autonomy, between coercion and cooperation in health care.

1.2 Psychiatry for the Whole Person

The basic thrust of person-centred clinical care is to place the person in context at the centre of health care. It involves shifting the focus of the field from disease to patient to person [1, 2].

1.2.1 Origins and Early Developments

The roots of person-centred care can be traced back to ancient civilizations both Eastern (e.g. Chinese and Ayurvedic) and Western (principally Hellenistic) which employed a broad concept of health and organized treatments in a personalized manner. Such a broad concept of health (full wellbeing and not only the absence of disease) has been incorporated into the World Health Organization (WHO) definition of health.

In response to disease-based distortions in modern medicine [3], pioneering developments on person-centred perspectives emerged in the twentieth century, illustrated by Tournier's Medicine de la Personne in Switzerland [4], Rogers' person-centred approach focused on open communication and empowerment in the US [5], McWhinney's family medicine movement in the UK and Canada [6], Brera's person-centred medicine programme in Italy [7], and Alanen's need-adaptive assessment and treatment approach in Finland [8]. There has been, as well, increasing recognition of the key role of a collaborative clinician–patient relationship. Tasman pointed out in his American Psychiatric Association presidential address [9] that this relationship must start from the first encounter and represents the fundamental matrix for the whole of care. It must ensure empathetic listening, comprehensive diagnosis beyond symptom checklists, appreciation for symbolic meaning, and effective therapeutic partnerships instead of narrow and reductionistic approaches.

In a related development, recovery-orientated concepts emerged from a coalescence of efforts from both mental health service users and professional groups. On one hand, individuals who suffered and recovered from mental illnesses formed a recovery movement and a national and international community of activists (e.g. [10, 11]) who expressed their criticism against negatively experienced psychiatric treatment, and demanded to be considered active protagonists and partners rather than passive recipients of care. On the other hand, well-known experts in the field of psychosocial rehabilitation (e.g. [12]) have welcomed the statements of service users and the need to attend to their subjective experiences, in contrast to traditional rehabilitation which appeared focused on improving functioning and adaptation and not on the fulfilment of the individual human being. At least since the beginning of the 1990s, many professionals in rehabilitation and other mental health fields, and various service user groups have started substantial collaboration through joint publications and conferences [13].

Also public health policy developments have been moving in a person- and people-centred direction. In a landmark study [14], the Institute of Medicine in the United States concluded that the American health system was seriously flawed and required a new framework with particular aims and rules, a key one being person-centeredness. Along the same lines, a US Presidential Commission on Mental Health diagnosed a state of disarray in national mental health care and proposed a thorough transformation to be driven by the patient and the community in a recovery orientation manner [15]. Likewise, the World Health Organization European Office [16] held a ministerial event which concluded that integration of mental health services should be organized by the involvement of patients and caregivers; that is, collectively tackling stigma, discrimination and inequality, and empowering and supporting people with mental health problems and their families to be actively engaged in this process; furthermore, recognizing the experience and knowledge of service users and caregivers as an important basis for planning and developing services.

Most recently, the WHO World Health Assembly formulated innovative resolutions for primary health care [17], two pillars of which are people-centred care and health systems responsiveness to human and social aspirations.

1.2.2 Emergence of Person-Centred Psychiatry and Medicine

As elucidated by historians Garrabe and Hoff from the proceedings of the First World Congress of Psychiatry of September 1950 [18], the World Psychiatric Association (WPA) revealed since its inception a keen interest on articulating science and humanism as the seeds of a person-centred psychiatry. But it was only in 2005 that the WPA General Assembly established an Institutional Program on Psychiatry for the Person: from Clinical Care to Public Health (IPPP). This initiative affirmed the whole person in context as the centre and goal of clinical care and health promotion, at both individual and community levels. It pointedly argued for the articulation of the scientific method and humanism to optimize attention to the ill and the positive aspects of a person's health, the integration of all relevant health and social services, and the advancement of pertinent public health policies.

The person-centred approach promotes clinical care of the person (the totality of the person's health, including its ill and positive aspects), for the person (to assist in the fulfilment of the person's life project), by the person (with clinicians extending themselves as full human beings, scientifically grounded and with high ethical aspirations), and with the person (in respectful and empowering collaboration with persons who present for care). The person is conceptualized with its full pluralistic richness and within its life context in line with Ortega y Gasset's dictum I am I and my circumstance. This approach represents a paradigmatic shift from the disease to the person as the main target and centre of medicine and health care [19, 20].

Amongst the key elements of person-centred care are the following: (1) A broad biological, psychological, socio-cultural and spiritual framework. (2) Attention to both ill health and positive health. (3) Person-centred research on the process and outcome of clinician–patient–family communication, diagnosis, clinical care and health promotion. (4) Promotion of and respect for the autonomy, responsibility and dignity of every person involved.

Person-centeredness, in addition to its ethical relevance, may be shown to enhance the effectiveness and outcome of the various aspects of clinical care, from interviewing the person who consults and pertinent family members, to comprehensive diagnosis, and to the various aspects of treatment and health promotion. Illustratively, person-centred diagnosis [21, 22] is primarily aimed at optimizing treatment planning, and involves pointed attention to health status, to experience of health and illness and to contributory agents including risk and protective factors, and it employs descriptive categories, dimensions and narratives, and activates the interaction of clinicians, the patient and family members. A perspective has been articulated recently to integrate conventional disease-centred or nosological diagnosis within a broad, person-centred diagnosis [23].

Person-centred medicine training programmes are emerging in several countries, such as those at Ambrosiana University Medical School in Milan, Italy, Birmingham University in the UK (A. Miles, Medical School Dean, personal information, 1 December 2009), and at Cayetano Heredia Peruvian University in Lima (J. Saavedra, Professor of Psychiatry, personal information, 18 December 2009). Curricula are being developed at the listed medical schools and through the International Network for Person-centered Medicine (INPCM) [24]. Additionally to be noted are Conferences on Psychiatry for the Person in London (co-organized by the WPA Institutional Program on Psychiatry for the Person (IPPP) and the UK Department of Health), October 2007, Paris (co-organized by the WPA IPPP and the Association of WPA French Member Societies) February 2008, and Prague (WPA XIV Congress of Psychiatry), September 2008, and the Geneva Conferences on Person-Centered Medicine in May 2008 and 2009 [25].

The person-centred medicine academic programmes and events listed above pointedly involve also research activities. These include both conceptual explorations [1, 26] as well as the presentation of empirical research on topics such as clinical communication [27, 28] and Person-Centred Integrative Diagnosis [21, 22].

1.3 The WPA Dresden conference – reviewing coercion and cooperation

A key element of the above outlined initiative is to promote a psychiatry and medicine with the person; that is, the affirmation of the personhood of the patient and the commitment to work in respectful and collaborative partnership with the person who consults. This includes, first, work with individuals highlighting the ethical underpinnings of this effort. It also encompasses work with patient groups including those critical of psychiatry.

It is on these grounds that the WPA Thematic Conference held in Dresden on 6–8 June 2007 represented a crucial opening for dialogue. The conference had an intriguing and sensitive overall topic, Coercive Treatment in Psychiatry: A Comprehensive Review. Professor John Monahan, Scientific Committee chair, anticipated on his invitation letter that

while the fissures in this area run so deep and are so long-standing that achieving consensus is unlikely, our aspiration is that this historic meeting will sharpen moral issues, clarify political viewpoints, identify evidence-based practices, and share cutting-edge data on one of the most contested topics of our time.

In fact, as reported by Professor Thomas Kallert, Organizing Committee chair, the Conference succeeded in attracting participants from 36 different countries, with virtually all world experts on this field attending and speaking at it, all leading to an absolutely top-quality scientific programme.

But there was, additionally, a surprising event that marked the Dresden Conference indelibly for all its organizational and individual participants. Many of the user groups critical of psychiatry (but not all), which traditionally would be expected to protest outside, decided to come in and engage in a discussion of serious concerns. This opening had a crucial value for global psychiatry as this substantially broadened the range of its patients/users interlocutors which also encompass groups (including self-help groups) with which psychiatric organizations have been interacting for a long time.

In a historic encounter on 6 June, requested formally and with the endorsement of the WHO by Mind Freedom International, the European Network of (ex-)Users and Survivors of Psychiatry and world networks of current and past users of psychiatric services (ENUSP, World Network of Users and Survivors of Psychiatry WNUSP), the president and other top leaders of the WPA met with four representatives of the user organizations. The encounter, originally scheduled to last one hour, spontaneously extended to three. A range of issues were discussed, and possibilities for continuing the dialogue in congresses and other settings were explored. As reported by David Oaks [29], Director of Mind Freedom International, ‘This conversation was different than usual. Yes, once more, the proof will be in the results. But all involved felt they were heard and respected in this discussion’.

During the following day, the WPA Executive Committee temporarily suspended its official business meeting in order to attend the keynote lecture by Ms Dorothea Buck on ‘70 Years of Coercion in German Psychiatric Institutions, Experienced and Witnessed’. On the basis of her personal history, she challenged a psychiatry that neglects communication with patients, and demanded a paradigm shift based on the wealth of patients' experiences. After her lecture, the WPA president offered a thank-you speech for Ms Buck's articulate and moving lecture, and greeted her in the company of all present members of the WPA Executive Committee and the session chair (see Figure 1.1).

Figure 1.1 Seated Ms D. Buck; standing (left to right): Professors H. Herrman, S. Tyano, M. Amering, J. E. Mezzich, M. Jorge, J. Cox and P. Ruiz at the WPA Thematic Conference, Dresden, 7 June 2007.

At an immediately ensuing press conference, representatives of the WPA, Council of Europe, and user organizations sitting at the main table held a lively exchange of questions, answers and comments with press representatives and the general audience (Figure 1.2). The issues experienced globally by service users, the patterns and diversity of their organizations, and prospective opportunities for continuing the Dresden dialogue and for user participation in activities of global and national psychiatry activities were broadly discussed.

Figure 1.2 (Left to right): Professor T. Kallert (conference organizer), Dr V. Pimenoff (Council of Europe representative), Mr P. Lehmann (author and German User Network representative), Professor J. E. Mezzich (president of the WPA and of the conference), Mr D. Oaks (Mind Freedom International Director) and Professor J. Cox (WPA Secretary General), seated at the press conference of the WPA Thematic Conference in Dresden, 7 June 2007.

1.4 Evolving Developments for Enhancing Cooperation

The current volume on Coercive Treatment in Psychiatry represents a principal follow-up of the 2007 Dresden Conference. Many of its speakers, including multidisciplinary scholars and users, are present again through its pages. The topics covered comprise a comprehensive clinical, public health, ethics and legal review of the volume's complex and sensitive theme. As a group they encompass both intellectual and experiential, scientific and humanistic perspectives. They can be conceived, therefore, as representing a person-centred approach.

Some steps have been undertaken in the years that followed Dresden in terms of invitations to user and family representatives to speak at person-centred conferences in Paris (February 2008), Prague (September 2008) and Geneva (May of 2008, 2009 and 2010). Joint studies involving users, families and professionals are evolving as well [13, 30]. The room for further collaborative work, however, is ample indeed.

Additionally, one can list some recent innovative developments that may contribute directly or indirectly to addressing usefully and helpfully the tension between coercion and cooperation. They refer in various degrees to clinical care and public health.

One such development is the ongoing preparation of a Person-Centred Integrative Diagnosis model undertaken by the INPCM [24]. This comprehensive diagnosis model covers both ill health, through a nosological diagnosis component based on the WHO International Classification of Diseases, and positive health (self-awareness, resilience, sense of control and transcendence, resources, well-being), attends to the person's experience and values as well as to risk and protective health factors, employs categories, dimensions and narratives as descriptive instruments, and engages the patient, family and clinicians in partnerships for shared diagnostic understanding and shared commitment to care [22]. Extending the practical prospects for person-centred diagnosis, a number of national and regional developments incorporating such approaches are being developed in Europe [31] and Latin America [32].

Based on the resolutions of the WHO [17] World Health Assembly promoting people-centred primary health care, the WHO and the INPCM are planning the Fourth Geneva Conference on Person-Centered Medicine for 2–4 May 2011, which will include presentation of an evolving study on the systematic conceptualization and measurement of person- and people-centred care. This may open new horizons for addressing control–cooperation issues in a diversity of countries.

Applicable to all aspects of health care are research and development efforts towards enhancing clinical communication. They facilitate direct acquaintance, fluid exchange of information, and presentation of helpful intentions and attitudes [27, 33]. As such, they can powerfully foster empathy and trust, crucial elements of person-centred care and relevant to understanding and addressing usefully the tension between coercion and cooperation.

1.5 Concluding Remarks

We have briefly reviewed broad historical and contemporary perspectives on person-centred care, and global psychiatry and medicine's evolving scientific and humanistic response to them. A renewed commitment to the clinician–patient relationship appears crucial, as well as building an effective dialogue with service users and families, respecting the diversity of their perspectives. Let's take advantage of the Dresden opening and developments that followed to find creative paths to jointly address specific coercion–cooperation issues and cultivate a shared commitment to promote health in individuals and communities across the world.

References

1. Mezzich, J.E., Snaedal, J., van Weel, C. and Heath, I. (eds) (2010) Introduction to conceptual explorations on person-centered medicine. International Journal of Integrated Care, 10 (Supplement), e022.

2. Christodoulou, G.N., Fulford, K.M.W. and Mezzich, J.E. (2007) Conceptual bases of psychiatry for the person. International Psychiatry, 5(1), 1–3.

3. Heath, I. (2005) Promotion of disease and corrosion of medicine. Canadian Family Physician, 51, 1320–1322.

4. Tournier, P. (1940) Medicine de la Personne. Delachaux et Niestle, Neuchâtel.

5. Rogers, C.R. (1961) On becoming a Person: A Therapist's View of Psychotherapy, Houghton Mifflin, Boston.

6. McWhinney, I.R. (1989) A Textbook of Family Medicine, Oxford University Press, Oxford.

7. Brera, G.R. (1992) Epistemological aspects of medical science. Medicine and Mind, 7, 5–12.

8. Alanen, Y.O. (1997) Schizophrenia: Its Origins and Need-adaptive Treatment, Karnak, London.

9. Tasman, A. (2000) Presidential Address: The doctor-patient relationship. American Journal of Psychiatry, 157, 1763–1768.

10. Chamberlin, J. (1979) On Our Own: Patient-controlled Alternatives to the Mental Health System, McGraw-Hill, New York.

11. Deegan, P. (1992) The independent living movement and people with psychiatric disabilities: taking back control over our own lives. Psychosocial Rehabilitation Journal, 15, 3–19.

12. Anthony, W. (1993) Recovery from mental illness. The guiding vision of the mental health service system in the 1990s. Psychosocial Rehabilitation Journal, 16, 11–23.

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14. Institute of Medicine (2001) Crossing the Quality Chasm: A New Health System for the 21st Century, National Academies Press, Washington, DC.

15. New Freedom Commission on Mental Health (2003) Achieving the Promise: Transforming Mental Health Care in America. Final Report. DHHS Pub. No. SMA-03-3832, US Department of Health and Human Services, Rockville, MD.

16. World Health Organization European Office (2005) Mental Health Action Plan for Europe: Facing the Challenges, Building Solutions. WHO European Ministerial Conference on Mental Health. Helsinki, Finland, 12–15 January 2005. EUR/04/5047810/7, WHO Regional Office for Europe, Copenhagen

17. World Health Organization (2009) Resolution WHA62.12. Primary health care, including health system strengthening, in Sixty-Second World Health Assembly, Geneva, 18–22 May 2009: Resolutions and Decisions. WHA62/2009/REC/1, World Health Organization, Geneva, pp. 16–19.

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21. Mezzich, J.E. and Salloum, I.M. (2009) Towards a person-centered integrative diagnosis, in Psychiatric Diagnosis: Challenges and Prospects (eds I.M. Salloum and J.E. Mezzich), John Wiley & Sons, Ltd, Chichester, p. 297.

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23. Mezzich, J.E. (2010) New developments on classification and diagnostic systems. Canadian Journal of Psychiatry, 55(11), 689–691

24. Mezzich, J.E., Snaedal, J., van Weel, C. and Heath, I. (2009) The International Network for Person-centered Medicine: background and first steps. World Medical Journal, 55, 104–107.

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27. Finset, A. (2010) Emotions, narratives and empathy in clinical communication. International Journal of Integrated Care, 10 (Supplement), e020.

28. Zwaanswijk, M., Tates, K., van Dulmen, S. et al. (2007) Young patients', parents' and survivors' communication preferences in paediatric oncology: Results of online focus groups. BMC Pediatrics, 7, 35.

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32. Otero, A., Saavedra, J.E., Mezzich, J.E. and Salloum, I.M. (2010) La Guia Latinoamericana de Diagnostico Psiquiatrico (GLADP) y su Revision. Revista de la Asociación Psiquiátrica de América Latina, in press.

33. Shiryaev, O.U., Gayvoronskaya, E.B. and Shapovalov, D.L. (2008) Separate Aspects of Psychology and Pedagogy. Voronezh N. N. Burdenko State Medical Academy, Voronezh, Russia.

Chapter 2

Coercive Treatment and Stigma – is there a Link?

Wolfgang Gaebel and Harald Zäske

Heinrich-Heine University, Department of Psychiatry and Psychotherapy, Medical Faculty, Düsseldorf, Germany

2.1 Introduction

Involuntary admissions as well as coercive measures such as seclusion, (physical) restraint and forced medication are immanent elements of psychiatric care; nevertheless they are fundamental encroachments of human rights. In the following, the term ‘coercive measures’ will be used as an umbrella term for involuntary admissions and placements, and coercive treatments such as seclusion, restraint or forced medication.

In this chapter, the relationship between coercive measures and the stigma of mental illness will be discussed. The stigma of mental illness incriminates those suffering from mental illness, aggravating the course of the illness, hampering social functions and offending against equal opportunities [1–4].

As coercive measures are ‘understudied issues’ themselves [5], it is not surprising that their relationship to the stigma of mental illness is not yet well studied, as demonstrated by a retrieval of the PUBMED database (www.ncbi.nlm.nih.gov/pubmed): the search ‘stigma AND mental illness’ results in 1798 hits, whereas the search ‘stigma AND (coercion OR coercive OR involuntary)’ reveals only 58 hits (retrieval from the 22nd February 2010). Thus literature on this topic is scarce, but nevertheless, some valuable findings will be presented here.

In the first section, coercive measures concerning epidemiological and legal issues will be discussed. Most available empirical data concern involuntary admissions, presumably because they are far easier to assess than data about coercive treatments. For example, in Germany involuntary admissions are threefold regulated: the ‘protective’ placement according to the German Civil Code, Section 1906; placements because of a threat of public safety or to oneself according to Federal State laws, such as the Gesetz über Hilfen und Schutzmaßnahmen bei psychischen Krankheiten (Psych-KG) from North Rhine-Westphalia [law on aids and protection measures in the case of mental illness: Mental Health Act], and placements in the context of penal imprisoning (StGB [criminal code]). Coercive treatments usually comprise seclusion, medication and physical restraint. In Germany, the legal prerequisites are defined in the FamFG (Gesetz über das Verfahren in Familiensachen und in den Angelegenheiten der freiwilligen Gerichtsbarkeit [law on the procedure of family matters and of matters of voluntary jurisdiction]). Thus physical restraint is allowed only in the case of averting a danger, and if other effective measures are not available. A judicial approval is obligatory (post hoc, if necessary), as well as the duty of documentation.

In Section 2.2, we will focus on the question of which attributes are characteristic for involuntarily admitted patients, and discuss the comparability of data from different countries. Furthermore, legal regulations and long-term trends will be considered.

In Section 2.3, stigma will be discussed as a contributing factor in coercive measures. Stigmatizing attitudes towards people with mental illness such as negative stereotypes and high social distance are related to a positive attitude towards coercive measures. The question is, whether these attitudes also affect the evaluations of psychiatrists as well as the decisions of judges concerning coercive placements and treatments, respectively.

Further topics to be discussed in Sections 2.4 and 2.5 are illness-related behaviour that might facilitate coercive measures and consequences of coercive measures. These are to be differentiated into subjective consequences (e.g. perceived coercion, traumata) and objective consequences (e.g. loss of custody of own children, job loss).

Finally, in Sections 2.6 and 2.7, strategies to fight against stigma and discrimination due to mental illness are presented and discussed regarding their impact on the prevention and practice of coercive measures. Hence a global human rights perspective on these issues is important to ensure long-term achievements in the fight against the stigma and to minimize negative consequences of coercive measures against people with mental illness.

2.2 Coercive Treatment – Epidemiology and International Comparisons

Before starting the discussion about the relation between stigma and coercive measures, it seems helpful to elaborate what is covered by the term ‘coercive measures’. The complexity of this issue might be a reason for the low number of empirical studies in this domain. In general, causes for involuntary admissions and coercive treatment comprise several issues which can be subsumed under two conditions (see Table 2.1): someone endangers himself, or someone endangers other people. For example, suicidal intentions potentially endanger oneself, as well as under-nourishment, manic episodes or disorientation. Obviously, the mental state itself is not a reason for coercive admissions but only the resulting potential danger he or she is exposed to. The same applies for endangerment of other people, as in the case of homicide-suicide incidents, or (being delusional or not) threats of violence.

Table 2.1 Causes for involuntary admissions and coercive treatment.

Characteristics of patients who are involuntarily admitted into a hospital have been described in a case study by Längle et al. [6]. According to their German sample (N = 47), involuntary admissions predominantly concern persons with a diagnosis of schizophrenia and happen usually outside of the regular working hours. Further characteristics such as sex, age, living situation or nationality do not correlate with involuntary admissions. However, validity of these results is limited due to the small sample and, of much more importance, the fact that the situation of Germany is not representative for other countries, neither in the European Union. Numbers of involuntary placements in European Union member states differ significantly; furthermore differences in developmental trends can be observed between some of these states [7]. Thus an absolute increase of involuntary placements between 1990 and 2000 has been recorded in some of the analysed countries (Austria, Finland, Sweden, as well as Germany and France), but in other countries the numbers remained rather constant (Denmark, Ireland, Luxemburg and England).

Additionally, if set in relation to the countries' population numbers, the rate of involuntary placements differs substantially between these countries (Figure 2.1); with the lowest figures in Portugal (6 per 100 000) and France (11), and the highest figures in Finland (215), Austria and Germany (both 175). A rather similar distribution appears for the percentage of involuntary placements in relation to all inpatient episodes in these countries (Figure 2.1). The authors discuss three explanations for these findings [7] : first, no operational descriptions for the basic judicial definitions are available. Second, in different countries, different concepts and definitions of involuntary placement (with different historical backgrounds of national legal systems and mental health care systems) exist. And third, the rate of patients whose status changed during hospitalization from voluntary to involuntary placement was not included in most countries.

Figure 2.1 Rates of involuntary placements in European Union countries. Numbers refer to the years 1998, 1999 or 2000. Adapted from [7]

Regarding the situation in Germany, some further interesting findings arise concerning the epidemiology of involuntary admissions: in a catchment area in Berlin, the ratio between the number of involuntary admissions and the rate of total admissions has been found to be constant over a period of 15 years (approximately 13% between 1988 and 2003; [8]). For Germany, Salize and Dressing provide rather constant ratios between 1993 (13.5%) and 1999 (15.9%) [7]. In other European countries, the ratio is also relatively constant over time, although on different levels (between 4.5 in Denmark and 20 in Finland). Nevertheless, for Germany, a constant rise of absolute numbers of admissions in total, and of involuntary admissions, has been recorded in the 1990s (probably due to a higher patient turnover because of shorter length of hospital stays; see [8]). Hence the ratio seems to be unaffected by the development of regulations to reduce involuntary admissions and treatments since the 1970s in Germany: the (ongoing) transition process toward a decentralized, community-orientated mental health care system [9]; further development of laws regulating involuntary placement and treatment on federal and state level (e.g. German Civil Code and Mental Health Acts); implementation of hospital inspection commissions as governmental control systems; and the development of guidelines and recommendations in the German Association for Psychiatry and Psychotherapy (DGPPN).

On the European level, legal regulations also seem not to affect numbers of involuntary placements (per 100 000 inhabitants) or involuntary placement rates (percentage of all inpatient cases; [10]). Both numbers and rates differ substantially between 12 analysed European countries, but the differences are not closely related to the legal practices in these countries such as, for example, whether dangerousness is used explicitly as a criterion for involuntary placement or not (as is the case in Italy, Spain or Sweden), or whether countries have detailed legal regulations for involuntary placements, as in Austria, Denmark, Germany, the Netherlands and Sweden. The Austrian example will elucidate this finding: in 1991, the Civil Commitment law (Unterbringungsgesetz) was implemented in Austria, which includes restrictive rules for involuntary admissions, namely that two psychiatrists must assess the patient and that provision of legal assistance is mandatory [11]. Despite these strict regulations, a high and increasing rate of involuntary admissions is found in Austria [10]. Moreover, in countries with very low rates of involuntary placements, legal regulations may differ substantially, for example in Portugal (only about 3% of all admissions are involuntary) with a restrictive judicial system vs. Denmark (with a rate of 4–5%), where the regulations are more treatment orientated and no judicial approval is needed [10]. As Schanda states [11], intended changes and improvements through laws (or their reforms, respectively) and real effects of their practical implementation may show high discrepancies, at least in the field of mental health care.

In sum, no stringent correlation between the kind of detailed legal regulations and rates of involuntary admissions can be observed across Europe. Nevertheless, such regulations are necessary to provide a reliable mental health care system, ensuring predictability of legal decisions in a constitutional state. Now the question arises, what other factors might influence the practice of involuntary psychiatric hospital admissions and coercive treatments in psychiatry? In terms of decision-making, a multitude of medical, social, cultural and psychological factors bear on the decision of whether to apply coercive measures. From an international point of view, the related decision-making process varies between countries: mostly, the psychiatrist is expert witness, counselling the judge who decides about the admission, but in some countries (e.g. in Denmark) the psychiatrist himself decides about involuntary admissions.

However, independent of the question of legal responsibility, diverse objectives and attitudes might play a role for those who are involved in the decision: intentions such as the prevention of self-harm and care for the patients might play a role as well as paternalistic attitudes (which are somewhat double-edged: on the one hand, they express an attentive attitude towards patients; on the other hand they might result in the unintended suppression of the patients' self-empowering resources). A second cluster of influencing factors relates to the perceived dangerousness of the concerned patient to himself (the evaluation of the seriousness of suicidal intentions is one of the most important diagnostic tasks) as well as to others (influencing factors such as public safety concerns and current political sentiments are important, especially in the second case). A third point concerns the symptom severity of a mental disorder. Even though, legally, the severity of symptoms is not the decisive cause for a decision for involuntary admittance, physicians might be influenced in their decision-making, because the patients' communicative behaviour is influenced by their symptoms, at least in some cases. Beyond these clinical, societal and attitudinal factors, we assume that the prevailing stigma against individuals with mental disorders affects the practice of coercive measures. This issue will be examined in the following section.

2.3 Stigma as a Contributing Factor in Coercive Measures

A persistent stigmatizing myth about psychiatry is that in psychiatric hospitals people are commonly treated against their will (if treated at all). The negative picture of psychiatric institutions is underpinned by scientific debates on the arbitrariness of psychiatric diagnoses, for example in the framework of the ‘Rosenhan experiment’ (for a current contribution to this topic, see [12]) and a common theme in mass media representations, as for example in the melodramatic movie One Flew Over The Cuckoo's Nest (1975), representing psychiatric hospitals as authoritarian and oppressive systems. Moreover, the stigma of mental illness is far more complex, and concerns also illness-specific prejudices, lay theories of the genesis of mental disorders, and attitudes towards psychiatric treatment settings and institutions. Such attitudes and cognitions can be found in the general public and in specific groups, for example in persons who work in psychiatric institutions (mental health professionals). We will show that some of these attitudes towards coercive measures correlate with attitudes directly associated with the stigma of mental illness.

As demonstrated in a British representative survey, stigmatizing attitudes in the population are differentiated concerning different mental illnesses ([13]; see Figure 2.2). Hence, negative attitudes such as perceived dangerousness and unpredictability relate predominantly to persons suffering from schizophrenia and substance or drug abuse disorders. Hence up to 75% of interviewees endorse negative statements about persons with schizophrenia. An overall lower frequency (approximately 40–50%) of negative attitudes in the population is found in mental disorders such as depression, anxiety disorders and eating disorders.

Figure 2.2 Public opinions on different mental illnesses. UK: representative household survey (1998; N = 1737; illnesses were presented with labels). Adapted from [13]

The stereotype that people with severe mental illness are dangerous is a crucial issue for stigma research, not only because of its high prevalence (more than 70% of the British population think that persons with schizophrenia or with alcohol or drug addictions are dangerous), but in particular because of its associated implications. As Lauber and colleagues have shown [14], stigmatizing attitudes towards people with mental illness in terms of negative stereotypes (with assumed dangerousness being a key stereotype) and the acceptance of coercive measures (namely compulsory admissions) correlate significantly which each other. Thus one central message of antistigma programmes is to set the alleged dangerousness of people with a severe mental illness, especially schizophrenia, into a more realistic context, that persons with schizophrenia are not more dangerous than the average population (if they are professionally treated), and that the increased risk (for persons not adequately treated, and for those having an additional diagnosis of substance abuse) of being violent or having a related criminal record is comparable with that of young male adolescents, compared to the average. Additionally, persons with a severe mental illness are more often victims of violent assaults than offenders (see [15]).

Before continuing to report further empirical data, a methodological issue needs to be clarified. A general obstacle in psychiatric stigma research is to measure it. Direct observation of stigmatizing behaviour is methodologically complicated; hence proxy measures are used to assess the tendency to stigmatize in the sense of a behavioural intention. A commonly used stigma proxy is the adapted concept of social distance that was originally developed to assess attitudes towards ethnic minorities [16]. Several predictors or correlates of social distance towards people with mental illness, especially to those suffering from schizophrenia, are reported in the research literature. Apparently, the most prevalent one is the above-reported stereotype of dangerousness, which is closely associated with further negative stereotypes such as eeriness and unpredictability [17]. Further correlates of social distance are the kind of symptoms and the course of illness, perceived strangeness and impaired social skills (e.g. [18]), ascribed responsibility and lack of personal contact (e.g. [19]), and lack of knowledge about a mental illness (e.g. [20]). Two correlates of social distance will be discussed in more detail: lay theories on the genesis of mental disorders, and attitudes towards psychiatric treatment