It is an unfortunate reality that the use of coercive measures, restrictive interventions or involuntary treatment accompanies treatment for a proportion of individuals affected by mental health disorders. This is one of the most controversial practices in medicine, yet the quantity of research to date on this topic does not match the severity, frequency and importance of the issue. This themed edition of the Irish Journal of Psychological Medicine attempts to address this imbalance by focussing on national and international research on the topic of coercion and mental health legislation. The themed issue examines coercion and involuntary treatment at different levels, from an international comparison of legislation, an epidemiological study of a catchment area, perspectives of stakeholders (family members, general practitioners, mental health staff, tribunal members, police) to the perspectives of affected individuals who have been admitted involuntarily.
Community treatment orders (CTOs)
Cronin et al. compare the Irish Mental Health Act 2001 (MHA2001) to the mental health legislation in four other jurisdictions, specifically England and Wales, Scotland, Victoria (Australia) and Ontario (Canada). This article sets the scene for this themed issue, as it highlights unique aspects of the MHA2001 compared to the other jurisdictions. One of the main differences identified was that in the Republic of Ireland, all involuntary treatment must be provided as an inpatient while the four other jurisdictions have the provision for involuntary treatment with CTOs. In order to consider further whether CTOs should be introduced in the Republic of Ireland, we invited national experts (Prof. Colm McDonald – National University of Ireland, Galway and Prof. Brendan Kelly – Trinity College Dublin) and international experts (Prof. Richard O’Reilly – Western University, Ontario, Canada and Prof. Tom Burns, Oxford University, UK) to debate this important question (pp. 295–303).
Perspectives of stakeholders and those subjected to coercion and involuntary treatment
A central aspect of research on coercion is to understand the perspective of all of the stakeholders involved in the use of coercion and involuntary treatment. A number of studies within this themed issue deliver insights into these perspectives. Georgieva et al. present the perspectives of a broad range of stakeholders including family members, mental health clinicians, tribunal members and police (pp. 223–232). The same research group also describe service users’ experience of mental health tribunals, in which important insights and learnings are delivered (pp. 233–242). The ‘Service users’ perspective of their admission’ was a longitudinal study including involuntarily and voluntarily admitted service users who were followed-up 1 year after discharge (pp. 251–260). One of the key findings of this study was that over one-fifth of voluntarily admitted service users perceived comparable levels of coercion to those admitted involuntarily, some of these individuals were brought to hospital under mental health legislation but subsequently agreed to remain voluntarily in hospital, or they were treated on a secure, locked ward. The study discusses that while it is preferable to treat individuals on a voluntary basis, mental health legislation should be enacted if it is indicated, so as to ensure that the affected individual has access to the rights attributed to them under this legislation, such as an independent assessment, access to legal support and a review by a mental health tribunal.
Alternative models of involving service users in their treatment
Mental health services are moving towards a more collaborative model and rightly involving people in the decisions that affect their own health. Supported decision making and shared decision making are two potential models and as a result, we invited international experts, Dr Magenta Simmons and Dr Piers Gooding from Australia, to explain these models and to highlight their important differences (pp. 275–286). The benefits of integrating these models early in the involvement with mental health services needs to be evaluated. It is possible that episodes of coercion or involuntary treatment could be prevented, particularly repeat episodes, by utilising these models. Riordan describes a proposed model that places greater value on individual autonomy, as opposed to the ‘best interest’ principle (pp. 271–273).
Future directions for research: moving towards interventional studies
The majority of research to date on coercion and involuntary treatment has been descriptive, and while this has been very informative, the focus needs to now move to interventions that could reduce the frequency of this practice. Epidemiological studies can provide insights into the interventions or service designs that could result in a lower rate of involuntary admission or restrictive interventions. Gilhooley et al. describe the trends of involuntary admission rates in a suburban area in Dublin and demonstrate that between 2007 and 2011 the involuntary admission rate was below the national average but subsequently rose to the national average between 2014 and 2015 (pp. 243–249). The results of this study are particularly interesting, as the catchment area examined has a higher than average level of social deprivation and hence, a higher incidence and prevalence of severe mental health disorders would be expected (Kelly et al. Reference Kelly, O’Callaghan, Waddington, Feeney, Browne, Scully, Clarke, Quinn, Mctigue, Morgan, Kinsella and Larkin2010; O’Donoghue et al. Reference O’Donoghue, Roche and Lane2016). Determining the reasons why particular catchment areas have lower than average involuntary admissions rates (or lower than expected rates based on incidence and prevalence data) could help determine what is the optimal service level design to reduce involuntary admissions, such as the development of assertive home-based treatment.
In this themed issue, the findings from a randomised study on a smartphone application to improve service users’ knowledge of their legal rights are presented (pp. 287–293). The rationale behind this study was that it has been repeatedly demonstrated that service users were not aware of their legal rights under mental health legislation (Rooney et al. Reference Rooney, Murphy, Mulvaney, O’Callaghan and Larkin1996; O’Donoghue et al. Reference O’Donoghue, Lyne, Hill, Larkin, Feeney and O’Callaghan2010), which can lead to feelings of disempowerment and a perception of not being involved adequately in the care provided. While the intervention involved in this study was relatively simple, it demonstrates the potential for utilising novel technological interventions in mental health care settings.
Conclusions
The articles in this themed issue have demonstrated that the field is moving forward to a greater understanding of the perspectives of those involved in coercion and involuntary treatment and the factors that are associated with this practice. Ideally, this knowledge could inform future research aimed at preventing or reducing the frequency of this practice. For this high-quality research to be continued, there needs to be adequate funding and support and it is hoped that this issue will inspire clinicians, researchers, funders and policymakers to continue this research into the future.
Conflicts of Interest
Dr B.O’D. has no conflicts of interest to disclose.
Ethical Standards
The author asserts that all procedures contributing to this work comply with the ethical standards of the relevant national and institutional committee on human experimentation with the Helsinki Declaration of 1975, as revised in 2008.
Financial Supports
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
