Updated review of experiences of compulsory treatment builds the case for legal reform to be grounded in lived experiences

Following large scale reviews, new legislation for England and Wales will be debated soon in Westminster, while the Scottish Government is yet to commit to a timetable for legal reform. Mental health legislation is complex and contentious so it’s vital that the rare opportunities to review and update law are informed by best available evidence.

Whilst the law authorising non-consensual psychiatric interventions often requires clinical and risk assessments, other factors may have influence. These include the nature of mental health legislation itself, availability of hospital and community-based services, public perceptions of mental illness, diagnosis, age, gender, race and ethnicity, and contact with the criminal justice system (Aluh et al, 2023; Nathan et al, 2021; Walker et al, 2019; Barnett et al, 2019). Other demographic, economic, social and clinical risk factors have been highlighted on the Mental Elf in the past, but the pathways and mechanisms by which some factors increase involuntary hospitalisation is not always clear.

Research tells us that there are considerable variations in rates of psychiatric compulsion between countries although the causes are unclear (Sheridan Rains et al, 2019). We also know that in many countries the use of compulsion has risen in recent years (Mental Welfare Commission for Scotland, 2024; Sheridan Rains et al, 2020; Sheridan Rains et al, 2019), even though research indicates that it is not necessarily effective in terms of patient outcomes (Newton Howes, 2010; Department of Health and Social Care, 2018; Scottish Mental Health Law Review, 2022). Concurrently, some countries are beginning to reduce or even eliminate, psychiatric compulsion, in line with the UN Convention on the Rights of People with Disabilities (UNCRPD: United Nations, 2017; Committee on the Rights of Persons with Disabilities, 2014a, 2014b).

Any attempts to improve mental health legislation and to align it with such ethical and human rights requirements must actively take account of recent experiences of people with direct lived experience of being subject to compulsion and their family carers. Building on previous reviews of service user and carer experiences of compulsory measures, which have been blogged about here, Bartl and colleagues meta-synthesis of recent qualitative evidence of service users’ and carers’ experiences of assessment and detention under mental health legislation is timely and important.

Mental health legislation is complex and contentious so it’s vital that the rare opportunities to review and update law are informed by best available evidence.

Methods

By way of an update of their previous published studies up to 2018, Bartl et al searched five bibliographic databases and manually screened for published studies reporting qualitative investigations of service users’ or carers’ experiences of assessment or detention under mental health legislation between 1st January 2018 and 1st March 2023. Twenty four studies were identified, 16 relating to service users, 3 to carers and 5 to both. The project team, which included researchers with relevant personal experience, then analysed and synthesised data using a thematic synthesis approach.

Results

Studies of service users’ experiences

Most published studies involving service user experiences took place across Europe although three were conducted in the US and one each in Australia, Nigeria and South Korea. The sample sizes varied from 7 to 54 participants, with 13 of the studies involving 20 or fewer participants. Most reported age, gender and diagnosis, but few reported ethnicity. Participants had a range of mental health diagnoses.

The papers focused on various aspects of the involuntary assessment and treatment processes. For example, assessment and referral experiences, admission under mental health legislation involving the police, general acute psychiatric hospital or forensic settings detention, experiences of coercion, discharge or the experiences of black ethnic service users in the UK. Themes that were identified were emotional impact; impact on self-worth; information and involvement in care; quality of relationships; quality of the environment; discrimination (including racial); inequality of access; pathway to admission.

Studies of carers’ experiences

Eight of the identified papers included carers’ experiences, with participant numbers ranging from 3 to 21, although Bartl’s results were largely derived from six of the studies. The studies were conducted in Australia (Brisbane), England, Germany, Norway, the Republic of Ireland, South Korea, and the USA (Connecticut), and all involved someone caring for a family member.
Themes that were identified included: emotional impact (negative emotions, relief, adverse effect on carer well-being); availability of support for carers (carers’ own health, lack of information, too much responsibility); carer involvement in decision making and care (recognising carer expertise, maintaining dialogue, sharing information, confidentiality, power dynamics); carer relationships (relationships with health professionals, mediation, family relationships); quality of care (leading up to admission, detention process, care in hospital, discharge process, impact of coercion, certainty of evidence).

Findings

The updated sample of studies suggested that service user and carer experiences of compulsory admission processes were varied but predominantly negative. This negativity related to the use of coercive measures (similar to pre-2018 studies), but now also concerned racial discrimination, inequality of access and insufficient quality of community-based care as an alternative to compulsory hospital care.

More positive accounts referred to collaborative and kind approaches by professionals, as well as offering choices (including community options where possible) and keeping the person informed at all stages of admission, which were appreciated, even where the situation was urgent and serious.

One person seemingly comforting another by holding their hand

While most experiences of mental health compulsory admission processes were negative. Positive experiences related to collaboration, choice and being kept informed.

Conclusions

Unsurprisingly, Bartl concluded that improving experiences of non-consensual interventions may be achieved through increasing service user and carer involvement in treatment decisions, providing information in good time and at key stages of the admission process, the training of key professionals, addressing discrimination, and investing in community alternatives to inpatient care.

Strengths and limitations

The robustness of Bartl’s review is evidenced by its search methodologies that followed established guidelines accompanied by the diverse skillset of the project team. In particular, including researchers with lived experience in the project team was said to provide depth to the analysis, interpretation, and writing of the resultant paper. However, the authors concede that lived experience involvement could have been improved by involvement earlier on in the project, including drafting the review protocol. Moreover, most effectively involving lived experience as research participants continues to be an evolving process. The authors acknowledged that the studies considered in this and in the pre-2018 reviews tended to focus on data collected from interviews and/or focus groups, which may not be the most effective or appropriate means for achieving accurate data.

The experience of, and impact upon, marginalised ethnic groups and upon carers was reinforced in this review. However, given there were only a few post 2018 studies that related to these groups, further research is clearly required here. Additionally, as the review focused on compulsory admission, the authors acknowledged that comparisons of experiences of involuntary treatment by persons who were previously voluntary patients could not be made.

The main strength of the review, however, lies in its highlighting again that mental health compulsion is something that is primarily and intimately experienced by service users and carers, and the importance of this. All in, this latest review corroborates, refines and to some extent furthers what we already know, or have suspected, about experiences of mental health compulsion from those subject to it.

A particular strengths of this review was the varied skill sets and experience of the research team, including lived experience representation.

Implications for practice

The findings and conclusions of the Bartl review reinforce the often traumatic and negative specific experiences of both service users and carers associated with psychiatric assessment and admission and related coercive practices, building on previous reviews (Akther et al, 2019; Hemmington, 2019; Stuart et al, 2020; Onwumere, 2020). Moreover, it reminds us that the adverse experiences of mental health coercion can be exacerbated by factors such as racial discrimination and inequalities in accessing appropriate support.

This body of research provides an important evidence base for mental health law and policy reform, such as that currently taking place with the English and Welsh Mental Health Bill 2024, and the Scottish Government’s programme of reform of mental health and capacity law. As stated at the outset, lived experience informed law, policy and practice are ethical and human rights imperatives, as is the need to reduce, even eliminate, non-consensual psychiatric interventions and to develop alternatives (United Nations, 2017; Committee on the Rights of Persons with Disabilities, 2014a, 2014b). Achieving this would be enhanced by ensuring non-discrimination and the economic, social and cultural rights that underpin the availability of, and access to, such alternatives.

Law provides a framework and impetus to improve the rights and experiences of service users and carers. It can help drive reductions in psychiatric compulsion by requiring timely and appropriate alternatives and much greater respect for the service users’ will and preferences. This must be accompanied by a system of accountability and monitoring to ensure equality and non-discrimination in access to such support and services, and greater creativity in service delivery (Scottish Mental Health Law Review, 2022), even in times of constrained resources.

If there is a genuine commitment to improving experiences of service users and carers, then these reformed processes and outcomes must be informed by evidence from lived experience throughout. However, as Machin, Nyikavaranda and Jeynes rightly point out in their lived experience commentary on the Bartl review, the pace at which essential knowledge revealed by research is practically acted on is glacial.

We cannot continue to wait. Urgent action is needed to enhance the experience of detention and, or even, dare we say it, earlier supportive interventions.

While legislative reform can be frustratingly slow as is currently being experienced in both England and Wales, and Scotland. However, in the meantime, there is much that can be done through policy and practice, and related culture, underpinned by funded research, to considerably improve the experiences of service users and carers. Mental health legislation may authorise non-consensual interventions, but this does not mean their use is essential or the only option.

While the pace of legal reform may be slow, there is much that can be done to improve practices and culture outside the law.

Statement of interests

Jill Stavert is Professor of Mental Health and Capacity Law at Edinburgh Napier University and lead of its Centre for Mental Health Practice Policy and Law Research. She was a member of the Scottish Mental Health Law Review (2019-2022) executive team and an expert adviser to the Independent Review of Learning Disability and Autism in the Mental Health Act (2018-2019).

Links

Primary paper

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

Other references

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.