This paper reports research that was undertaken in Belgium. The research is concerned with the experiences of people who have been subject to compulsory mental health legislation and admitted to hospital against their will (Verbeke et al, 2019).

Coercion and power in psychiatry is a hugely important area, but one that is surprisingly under-researched. The focus has been on trends in the use of compulsory powers with relatively little work on the experiences of either those who have been subject to these powers or those who exercise them. I should make it clear that I am not trying to establish any equivalence between the two areas.

In addition, it is important to note that I have worked as an approved social worker so have carried out assessments under the MHA and detained people against their will.

Use of the Mental Health Act

It is important to place this research in context. There will be differences between mental health systems, but I would argue that there will be significant overlaps when examining service users experiences of being subject to compulsory powers.

There have been increasing concerns about the rise in the use of the Mental Health Act (MHA) in England and Wales. This was one of the justifications for the Wessely Review of the MHA which reported in December last year.

• In 2015/16, there were 63,662 detentions under the MHA. This represented an increase of 9% from the 2014/15 figure of 58,399. This is quite a staggering statistic.
• A longer perspective shows that the 15/16 increase was part of an upward trend in the use of the MHA. In 2005/06, there were 43,361 detentions. This means that there has been a 50% increase in the use of the MHA over a ten year period.
• If these trends continue the 2025/26 will see nearly 100,000 admissions under the MHA. The reforms outlined in the Wessely Review are designed to reverse this.
• On 31 March 2016, 5,954 patients were detained in private hospitals. This represents 30% of all detained patients. This is the highest percentage since 2006, when 17% of patients were detained in private hospitals.
• There has been a particularly significant increase in the use of Section 3, following an initial admission under Section 2. In 2015/16, there were 12,462 such incidences. This represents an increase of over 80% on the previous four years.
• There were 4,361 Community Treatment Orders (CTOs) issued in 2015/16. This was a decrease of 4% compared with the 4,564 issued in 2014/15.
• There were 2,294 recalls to hospital in 2015/16, a slight fall compared with 2014/15.
• Keown et al (2018) in their analysis of trends in the use of the MHA concluded that, paradoxically, community care had led to significant rises in the use of compulsory powers.

Methods

Language is clearly important, particularly in this field as it reflects underlying power relationships. None of the terms used (patient, former patient, service user or expert by experience) are totally satisfactory. The paper uses the term ex-patients in the title. In outlining the research, the authors state that it is based on interviews with twelve people who had experience of  “psychiatric hospitalisations”. The participants were four men and eight women aged between 29-58. They had been admitted to hospital between two and twenty-four times.

The interviews took place between March 2016 and January 2017. Six of the participants are described as having a “degree in mental health care” (psychologist, social worker, or nurse). Four of the participants had worked in a psychiatric centre prior to their own hospitalisation. At the time of the interview, six participants worked as peer counsellors in a psychiatric clinic and one as a paid social worker in a psychiatric clinic.

The research was based in Flanders and all the participants were Dutch speakers. The study used interpretative phenomenological analysis (IPA). IPA seeks to develop an understanding of how an individual makes sense of experiences (Smith, 2011). It is thus, a dynamic and generative rather than simply descriptive one.

Results

• The use of coercion led to the participants experiencing feelings of anxiety, distress, anger, trauma and the loss of autonomy.
• The participants emphasised that coercion can and does take several forms. Compulsory admission is one and perhaps the most obvious. Participants reported other forms of coercion as including seclusion, involuntary treatment, diagnostic labelling, involuntary medication, pressure to take medication, rules and daily routines.
• The study highlights that ultimately coercion is based on the relational interaction between staff and patients. The participants outlined the way that staff saw them as “the sick patient”. There was a clear divide between patients and staff, which the authors term “segregation”.

The authors concluded that:

This segregation caused a form of de-subjectivation: participants felt that important aspects of their subjectivity was neglected and experienced professionals as de-subjectivated. In this dynamic patients felt that power resides within the interactions between patients and mental health workers. (page 91)

The study does highlight ways forward. As the authors note, this meant some interventions which were previously regarded as coercion were experienced in a different way. This was the result of a change in staff attitudes and approach. Examples of this included being able to develop longer term working relationships with staff and being able to discuss medication properly and in detail with doctors:

When I felt like they believed in me, I could start to believe in myself again. While, when I just had to fall in line and it was just a matter of following rules, I felt like an object. I didn’t feel like a human being anymore. People who treated me humanely were the ones who helped me the most. (Participant 8)

Discussion

The authors acknowledge the limitations of this study. It is a small-scale study so one has to be wary of generalisation from it. The backgrounds and experiences of the participants in mental health services is also somewhat unusual.  However, this does not mean that there are not potentially important messages for all those involved in mental health services in this study.

I would suggest that the most important of these is the need to focus on relational approaches. This would require that services and mental health professionals reject the bureaucratic managerialism that focuses on risk assessment and risk management. It would also require a more open and honest discussion about the uses and abuses of mental health legislation.

Conflict of interest

I have worked as an approved social worker so have carried out assessments under the MHA and detained people against their will.

Mental Health Question Time #MHQT

Follow #MHQT from 6pm tonight for a public discussion on what can be done to reduce detentions and use of the Mental Health Act. Our expert panel features George Szmukler, Steve Gilbert, Bryn Lloyd-Evans, Lade Smith, Mark Trewin, Rai Waddingham, Alex Ruck-Keene and Claire Henderson.

Links

Primary paper

Verbeke E, Vanheule S, Cauwe J, Truijens F, Froyen B. (2019) Coercion and power in psychiatry: A qualitative study with ex-patients. Soc Sci Med. 2019 Feb;223:89-96. doi: 10.1016/j.socscimed.2019.01.031. Epub 2019 Jan 22. https://doi.org/10.1016/j.socscimed.2019.01.031

Other references

Keown, P., Murphy, H., McKenna, D. and McKinnon, I., 2018. Changes in the use of the Mental Health Act 1983 in England 1984/85 to 2015/16. The British Journal of Psychiatry, 213(4), pp.595-599. https://doi.org/10.1192/bjp.2018.123

Smith, J.A., 2011. Evaluating the contribution of interpretative phenomenological analysis. Health Psychol. Rev. 5 (1), 9–27. https://doi.org/10.1080/17437199.2010.510659

Photo credits

• Photo by Rostyslav Savchyn on Unsplash
• ermadz x CC BY 2.0
• Photo by Bernard Hermant on Unsplash