- The use of coercion, forceful actions deployed against the will of a person, is a controversial practice in health care, especially mental health care.
- A number of interventions, such as forced medication, are considered to be a violation of human rights, creating the need to explore the potential to replace them with alternative practices.
- Professor Richard Whittington at St Olav’s Hospital Trondheim and the Norwegian University of Science and Technology is Chair of the FOSTREN project, a collaboration of European researchers, experts by experience, and clinicians aiming to understand how to minimise coercion in mental health services.
- Together, they are gaining a deeper understanding of coercion in hospitals and communities across Europe. They aim to develop new guidance and initiatives that move away from reliance on coercion.
Coercion in mental health care is the use of force to make a service user do something or stop doing something without their consent in order to prevent harmful behaviour towards themselves or others (harm minimisation). It can also be implemented to make them comply with their prescribed treatment. Examples of coercion include involuntary admission to hospital, mechanical restraint, seclusion or isolation, and forced medication. Although such practices are considered undesirable and only to be used as a last resort, there is evidence that the use of coercion in mental health services varies widely across Europe and is often poorly documented.
Recent research has shown that over 40% of service users and 90% of staff in mental health institutions have been involved in at least one episode of coercion such as rapid tranquillisation and patient isolation. Some of these practices are considered inhumane and degrading by both the relevant European convention (European Convention for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment) and the World Health Organization, with both organisations having previously called for its reduction, if not for its complete elimination in health care practices. Besides the fact that such practices can be dangerous and traumatising for the patient, they can also severely damage the clinician–patient therapeutic relationship. More widely, they can become financially costly for health care services and by extension for society itself.
Bringing together leading researchers, pioneering mental health service users, and innovative practitioners from all over Europe has promoted the exchange of new ideas and the development of new practices.
Professor Richard Whittington at St Olav’s Hospital Trondheim / Norwegian University of Science and Technology is Chair of the FOSTREN network (Fostering and Strengthening Approaches to Reducing Coercion in European Mental Health Services). FOSTREN has more than 200 members, including researchers, experts by experience, and clinicians, with the shared aim of addressing the issue of coercion in hospitals and communities across Europe.
Together, they are investigating coercion practices across Europe, working to get a better understanding of the reasons for it. With the help of new scientific research, the network is exploring alternative ways of working with people in distress and developing new standards of practice that may help to transform mental health services. Professor Whittington explains, ‘FOSTREN members have met regularly over the past four years to develop guidance on implementing coercion-free best-practice methods. Operating through five working groups, our network has both research and capacity-building objectives which we hope will contribute to best practice in this area.’
What are the challenges?
The FOSTREN network has several questions to answer: How can the stakeholders fully understand coercion and its implications? Mental health care practices, including coercive ones, can vary vastly from country to country, while there are also substantial differences in policy-making regarding which coercive methods are acceptable or not in different countries.
On top of this, any current scientific efforts towards improving our understanding of coercion are very fragmented, with most studies running locally and focusing on specific aspects of the problem. How should we deal with this diversity? By which criteria are we going to evaluate various alternatives to coercion interventions? Which alternative interventions actually work? Finally, when the most promising alternative practices are identified, how can they be highlighted in national policies and how can mental health services proceed with implementing them? The key challenge is translating research evidence into clinical practice and implementing the evidence in sustainable ways.
Building a European network
The first step for FOSTREN has been to build a multidisciplinary network of European mental health researchers and practitioners. Bringing together leading researchers, pioneering mental health service users, and innovative practitioners from all over Europe has promoted the exchange of new ideas and the development of new models to help pick and advise on the implementation of best practices in routine mental health care.
Funding, training, and support has been offered to network participants with particular focus on those from under-represented groups, including women and researchers from countries with fewer resources. Career development opportunities have also been offered for the participants, with an aim to enhance their abilities and aspirations.
Research, outcomes, and implementation
A particular need is the design and conduct of high-quality studies to advance knowledge in this area, including clinical trials, surveys, and systematic reviews with international relevance. For these studies to be successful, they must be designed in a way that allows for the great variety of coercive practices across Europe, the differences in the health care systems, and significant social and cultural differences to be taken into account.
FOSTREN aims to create a new wave of innovation in mental health services and develop novel approaches to this longstanding and neglected challenge in mental health care.
The design of these studies should be based on findings from multinational studies in a wide variety of disciplines including psychology, sociology, nursing, and psychiatry, with the aim of bringing the different branches of knowledge together and achieving a more comprehensive understanding of coercion minimisation in health care. The network is also expected to summarise current knowledge on the most effective alternative practices, identify the ones they consider the most likely to succeed, and advise on implementing them locally in both hospital and community settings. They therefore need research on the most effective ways to utilise advancements in the field of implementation science when trying to ensure these alternatives are adopted in everyday practice.
Spreading the word
The network is also co-ordinating their efforts to spread the word and make sure that decision-makers around Europe are aware of how the new methods could be implemented on a broader scale across different countries and disciplines. Such initiatives and recommendations must of course take into consideration the discrepancy in funding for mental health services between European countries. The team will therefore tailor recommendations for each case and communicate these new ideas to mental health policy-makers and practitioners to help improve patient care and experience.
FOSTREN ultimately aims to create a new wave of innovation in mental health services and develop novel approaches to this longstanding and neglected challenge in mental health care. The outputs will be made public to enable faster implementation of positive results. A website has been launched that serves as a point of information on the current work of the network such as study results, published papers, webinars, and policy statements. Promotional videos explaining the goals of the network and study results will also be available on the website and on social media. In the longer term, it is hoped that these actions will contribute to the development of European mental health care guidelines and recommendations that will help minimise coercion and enable better collaborative care in mental health services across Europe.
