Compulsory Treatment Experiences: A Case for Legal Reform

In the wake of extensive evaluations, new legislative measures concerning mental health in England and Wales are set to be discussed in Westminster. Meanwhile, the Scottish Government has yet to establish a concrete timeline for legal reforms regarding mental health legislation. Given that mental health laws are intricate and often controversial, it is crucial that the limited opportunities for reviewing and updating these laws are backed by the most reliable and comprehensive evidence available. This approach ensures that reforms are not only timely but also effective in addressing the real needs of those affected by mental health issues.

While the legislation that permits non-consensual psychiatric interventions typically necessitates thorough clinical and risk assessments, various other factors can also exert influence over these decisions. Among these factors are the specificities of mental health legislation, the availability of both hospital and community-based services, public attitudes towards mental illness, and demographic variables such as diagnosis, age, gender, race, and ethnicity. Additionally, interactions with the criminal justice system can play a significant role (Aluh et al., 2023; Nathan et al., 2021; Walker et al., 2019; Barnett et al., 2019). Previous discussions on the Mental Elf have highlighted various demographic, economic, social, and clinical risk factors, yet the pathways and mechanisms through which some of these factors contribute to increased rates of involuntary hospitalization are often not well understood.

Research indicates that there are significant disparities in the rates of psychiatric coercion across different countries, although the reasons for these variations remain unclear (Sheridan Rains et al., 2019). Furthermore, it has been observed that many countries have seen an increase in the use of coercive measures in recent years (Mental Welfare Commission for Scotland, 2024; Sheridan Rains et al., 2020; Sheridan Rains et al., 2019), despite evidence suggesting that such measures may not lead to better patient outcomes (Newton Howes, 2010; Department of Health and Social Care, 2018; Scottish Mental Health Law Review, 2022). In contrast, some nations are moving towards reducing or even abolishing psychiatric compulsion, in alignment with the UN Convention on the Rights of Persons with Disabilities (UNCRPD: United Nations, 2017; Committee on the Rights of Persons with Disabilities, 2014a, 2014b).

To effectively enhance mental health legislation and ensure it aligns with ethical and human rights standards, it is essential to incorporate the recent experiences of individuals who have directly faced compulsory treatment, along with insights from their family caregivers. Building on earlier reviews that discussed the experiences of service users and their families regarding compulsory measures, the timely meta-synthesis by Bartl and colleagues brings forward vital qualitative evidence regarding the experiences of service users and carers during assessment and detention processes under mental health laws. This synthesis is crucial for informing future reforms and practices.

Comprehensive Methodology for Researching Mental Health Legislation

As an update to their previously published studies up to 2018, Bartl et al undertook a thorough search across five bibliographic databases and manually screened for published studies that reported qualitative investigations into the experiences of service users or their carers regarding assessment or detention under mental health legislation from January 1, 2018, to March 1, 2023. In total, twenty-four studies were identified, with 16 focused on service users, 3 on carers, and 5 addressing both groups. The project team, which comprised researchers with relevant personal experiences, employed a thematic synthesis approach to analyze and synthesize the gathered data, ensuring a comprehensive understanding of the issues at hand.

Insights from Service Users and Carers on Involuntary Treatment

In-Depth Analysis of Service User Experiences

Most of the published studies exploring service user experiences were conducted across Europe, with three originating from the United States and others from Australia, Nigeria, and South Korea. Sample sizes varied significantly, ranging from 7 to 54 participants, with 13 studies involving 20 or fewer participants. Most studies reported demographic details such as age, gender, and diagnosis, but there was limited reporting on ethnicity. Participants represented a wide range of mental health diagnoses, thus providing a rich background for the findings.

The focus of these studies encompassed various aspects of the involuntary assessment and treatment journey. Key areas of inquiry included experiences related to the assessment and referral processes, police involvement during admission under mental health legislation, and detention in general acute psychiatric or forensic settings. Other critical aspects investigated included experiences of coercion, discharge processes, and the specific experiences of Black ethnic service users in the UK. Common themes identified across these studies included emotional impact, effects on self-esteem, access to information and involvement in care decisions, quality of relationships with healthcare providers, and issues concerning discrimination and inequality of access to services.

Insights from Carers on Their Experiences with Involuntary Admissions

Eight of the identified studies focused on the experiences of carers, with participant numbers ranging from 3 to 21, although Bartl’s findings were primarily derived from six of these studies. The research spanned various locations, including Brisbane in Australia, England, Germany, Norway, the Republic of Ireland, South Korea, and Connecticut in the USA, all involving family members caring for individuals experiencing mental health crises. Themes that emerged from these studies included the emotional toll on carers, challenges related to their own health, and the overwhelming sense of responsibility they often felt.

Additionally, these studies highlighted the importance of carer involvement in decision-making processes and care, recognizing their expertise while also addressing issues of confidentiality and power dynamics in relationships with healthcare professionals. Relationships with health providers, family dynamics, and the quality of care received during the admission, detention, and discharge processes were also critical themes, along with the impact of coercive practices on their overall experience.

Key Findings on Compulsory Admission Processes

The updated compilation of studies indicates that the experiences of service users and carers regarding compulsory admission processes are predominantly negative. This negativity is attributed not only to the use of coercive measures—a concern echoed in studies prior to 2018—but now also encompasses issues such as racial discrimination, inequality in access to services, and the inadequacy of community-based care as alternatives to involuntary hospitalization.

Conversely, some reports highlight more positive experiences, which center around collaborative and compassionate approaches taken by healthcare professionals. These positive accounts emphasize the importance of offering choices, including community-based options where feasible, and ensuring that individuals are kept informed throughout the admission process, even in urgent situations. Such practices are not only beneficial but also foster a sense of dignity and respect for the individuals involved.

Strategic Conclusions for Future Mental Health Legislation

It is not surprising that Bartl concluded that enhancing experiences associated with non-consensual interventions can be achieved by increasing the involvement of service users and carers in treatment decisions. This includes providing timely information at crucial stages of the admission process, training key professionals, addressing issues of discrimination, and investing in community alternatives to inpatient care, which are essential for promoting better outcomes.

Assessing the Strengths and Limitations of the Research

The robustness of Bartl’s review is underscored by its methodological rigor, which followed established guidelines, combined with the diverse skill set of the project team. Notably, the inclusion of researchers with lived experiences enriched the analysis, interpretation, and writing of the resulting paper, providing a deeper understanding of the issues at play. However, the authors acknowledge that the involvement of lived experience could have been enhanced by engaging these individuals earlier in the project, especially during the drafting of the review protocol. Additionally, effectively incorporating lived experience as research participants continues to evolve and requires ongoing attention.

The review further emphasizes the significance of understanding the experiences of marginalized ethnic groups and the impact on caregivers. However, it is important to note that there were only a limited number of post-2018 studies related to these groups, indicating a clear need for more focused research in this area. Furthermore, since the review was primarily centered on compulsory admissions, the authors recognized that comparisons with experiences of individuals who were previously voluntary patients could not be adequately made.

Ultimately, this review highlights the fact that mental health compulsion is an experience that is primarily and deeply felt by service users and their caregivers. It reinforces the critical importance of considering their perspectives. Overall, this latest review corroborates, refines, and expands upon existing knowledge regarding the experiences of individuals subjected to mental health compulsion.

Practical Implications for Mental Health Reform

The findings and conclusions drawn from the Bartl review shed light on the often traumatic and adverse experiences encountered by both service users and carers amid psychiatric assessments, admissions, and coercive practices. This builds upon earlier reviews (Akther et al., 2019; Hemmington, 2019; Stuart et al., 2020; Onwumere, 2020). Furthermore, it serves as a reminder that adverse experiences related to mental health coercion can be heightened by additional factors such as racial discrimination and the disparities in access to appropriate support services.

This body of research serves as a crucial evidence base for ongoing mental health law and policy reforms, including the significant changes proposed in the English and Welsh Mental Health Bill 2024, as well as the Scottish Government’s reform initiatives concerning mental health and capacity laws. As previously highlighted, laws informed by lived experiences are not only ethical but also necessary for human rights compliance. There is an imperative to reduce or even eliminate non-consensual psychiatric interventions while developing effective alternatives (United Nations, 2017; Committee on the Rights of Persons with Disabilities, 2014a, 2014b). Achieving these goals would require ensuring that non-discrimination principles and socio-economic, and cultural rights are upheld, facilitating access to such alternatives.

The legal framework plays a pivotal role in promoting enhanced rights and experiences for service users and their caregivers. It can catalyze reductions in psychiatric coercion by mandating timely and appropriate alternatives while fostering a deeper respect for service users’ preferences and autonomy. To effectively implement these changes, a robust system of accountability and monitoring must be established to ensure equality and non-discrimination in accessing support and services, fostering innovative approaches to service delivery (Scottish Mental Health Law Review, 2022), even amidst resource constraints.

For genuine improvements in the experiences of service users and caregivers, reformed processes and outcomes must continuously reflect evidence derived from lived experiences. However, as noted by Machin, Nyikavaranda, and Jeynes in their commentary on the Bartl review, the rate at which essential insights from research are translated into practical action remains frustratingly slow.

We cannot afford to delay. Immediate action is crucial to enhance the experience of detention and to explore earlier supportive interventions.

While the pace of legislative reform can often be exasperatingly slow—as is currently observed in both England and Wales, as well as Scotland—there remains a multitude of actions that can be undertaken through policy adjustments and cultural shifts, supported by adequately funded research, to significantly enhance the experiences of service users and carers. Although mental health legislation may sanction non-consensual interventions, it does not imply that their application is necessary or the sole viable option.

Disclosures of Interest

Jill Stavert is a Professor of Mental Health and Capacity Law at Edinburgh Napier University, leading its Centre for Mental Health Practice Policy and Law Research. She served on the executive team of the Scottish Mental Health Law Review (2019-2022) and acted as an expert advisor for the Independent Review of Learning Disability and Autism within the Mental Health Act (2018-2019).

Essential References and Resources

Primary Paper Overview

Bartl, G., Stuart, R., Ahmed, N. et al. A qualitative meta-synthesis of service users’ and carers’ experiences of assessment and involuntary hospital admissions under mental health legislations: a five-year update. BMC Psychiatry 24, 476 (2024). https://doi.org/10.1186/s12888-024-05914-w

Additional References for Further Reading

SF Akther et al (2019) ‘Patients’ experiences of assessment and detention under mental health detention: systematic review and qualitative meta-synthesis’ 5(3) Bjspych Open e37

DO Aluh et al (2023) ‘Beyond patient characteristics: a narrative review of contextual factors influencing involuntary admissions in mental health care’ 11(14) Healthcare 1986

P Barnett et al (2019) ‘Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data’ 6(4) Lancet Psychiatry 305–17

Committee on the Rights of Persons with Disabilities (2014), General Comment No. 1 – Article 12: Equal recognition before the law (adopted 11 April 2014), CRPD/C/GC/1, 19 May

Committee on the Rights of Persons with Disabilities (2014) Statement on Article 14 Convention on the Rights of Persons with Disabilities, Geneva, September

Department of Health and Social Care (2018), Modernising the Mental Health Act Increasing choice, reducing compulsion, December.

J Hemmington (2019) ‘Patients’ experiences of statutory detentions: lessons for reform’ Mental Elf, 30 August

Mental Welfare Commission for Scotland (2024) Mental Health Act Monitoring Report 2023/24, October

J Onwumere (2020) ‘Carers’ experiences of involuntary admission under mental health legislation’ Mental Elf, 4 March

R Nathan et al (2021) ‘Use of acute psychiatric hospitalisation: a study of the factors influencing decisions to arrange acute admission to inpatient mental health facilities’ 12 Frontiers in Psychiatry

G Newton-Howes (2010) ‘Coercion in psychiatric care: where are we now, what do we know, where do we go?’ 34(6) The Psychiatrist 217–20

Scottish Mental Health Law Review (2022), Final Report, September

L Sheridan Rains et al (2019) ‘Variations in patterns of involuntary hospitalisation and in legal frameworks: an international comparative study’ 6(5) Lancet Psychiatry 403–17

L Sheridan Rains et al (2020) ‘Understanding increasing rates of psychiatric hospital detentions in England: development and preliminary testing of an explanatory model’ 6(5) Bjpsych Open

M Stuart et al (2020) ‘Carers’ experiences of involuntary admission under mental health legislation: systematic review and qualitative met-synthesis’ 6(2) Bjpsych Open 1-9

UN General Assembly (Human Rights Council) (2017) Report of the Special Rapporteur on the right of everyone to the enjoyment of the highest attainable standard of physical and mental health, Thirty-fifth session, 6-23 June 2017, 28 March, A/HRC/35/21.

S Walker et al (2019) ‘Clinical and social factors associated with increased risk for involuntary psychiatric hospitalisation: a systematic review, meta-analysis, and narrative synthesis’ 6(12) Lancet Psychiatry 1039–53

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