The Use of Coercive Measures in Forensic Psychiatric Care Legal, Ethical and Practical Challenges Birgit Völlm Norbert Nedopil Editors 123 The Use of Coercive Measures in Forensic Psychiatric Care ThiSisaFMBlankPage € Birgit Vollm (cid:129) Norbert Nedopil Editors The Use of Coercive Measures in Forensic Psychiatric Care Legal, Ethical and Practical Challenges Editors BirgitV€ollm NorbertNedopil UniversityofNottingham DepartmentofForensicPsychiatry Nottingham PsychiatricHospitaloftheUniversity UnitedKingdom ofMu¨nchen Mu¨nchen Germany ISBN978-3-319-26746-3 ISBN978-3-319-26748-7 (eBook) DOI10.1007/978-3-319-26748-7 LibraryofCongressControlNumber:2016934313 #SpringerInternationalPublishingSwitzerland2016 Thisworkissubjecttocopyright.AllrightsarereservedbythePublisher,whetherthewholeorpartof the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilarmethodologynowknownorhereafterdeveloped. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publicationdoesnotimply,evenintheabsenceofaspecificstatement,thatsuchnamesareexempt fromtherelevantprotectivelawsandregulationsandthereforefreeforgeneraluse. Thepublisher,theauthorsandtheeditorsaresafetoassumethattheadviceandinformationinthis book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained hereinorforanyerrorsoromissionsthatmayhavebeenmade. Printedonacid-freepaper ThisSpringerimprintispublishedbySpringerNature TheregisteredcompanyisSpringerInternationalPublishingAGSwitzerland Contents 1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 BirgitV€ollmandNorbertNedopil PartI TheContext 2 InternationalHumanRightsandInstitutionalForensicPsychiatry: TheCoreIssues. . .. . . . . .. . . . . .. . . . . .. . . . . .. . . . . .. . . . . .. 9 MichaelL.Perlin 3 LegalAspectsoftheUseofCoerciveMeasuresinPsychiatry. . . . . 31 Hans-J€orgAlbrecht 4 SociologicalPerspectivesofCoercioninPsychiatry. . . . . . . . . . . . 49 HughMiddleton 5 WiseRestraints:EthicalIssuesintheCoercionofForensic Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 GwenAdsheadandTheresaDavies 6 AnInternationalPerspectiveontheUseofCoerciveMeasures. . . 87 TilmanSteinert PartII CoercioninDifferentSettings 7 CoerciveMeasuresinGeneralAdultandCommunitySettings. . . 103 PeterCurtis,BradleyHillier,RachelSouster,andFaisilSethi 8 SpecialConsiderationsinForensicPsychiatry. . . . . . . . . . . . . . . . 135 NorbertNedopil 9 TheUsesofCoerciveMeasuresinForensicPsychiatry:ALiterature Review. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 AdaHui,HughMiddleton,andBirgitV€ollm 10 CoercioninForensicHealthcare:ANorthAmerican Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 185 JohannBrinkandIlvyGoossens v vi Contents 11 TheUseofCoercioninPrisonSettings. . . . . . . . . . . . . . . . . . . . . . 209 Vicenc¸ Tort-Herrando,EllenB.M.L.VanLier, Aitor-EnekoOlive-Albitzur,HansP.A.J.Hulsbos, andAlvaroMuro-Alvarez PartIII TheExperienceofCoercion 12 StaffAttitudesTowardsSeclusionandRestraintinForensic Settings. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231 TeroLaiho,AnjaHottinen,NinaLindberg,andEilaSailas 13 MentalHealthWorkers’ExperiencesofUsingCoerciveMeasures: “Youcan’ttellpeoplewhodon’tunderstand”. . . . . . . . . . . . . . . . 241 AdaHui 14 PatientExperienceofCoerciveMeasures. . . . . . . . . . . . . . . . . . . . 255 Pa¨iviSoininen,RaijaKontio,GrigoriJoffe,andHannaPutkonen 15 ServiceUser:CoercionConcern. . . . . . . . . . . . . . . . . . . . . . . . . . . 271 PeterAndrewStaves PartIV PracticalChallenges 16 BestPracticesforReducingtheUseofCoerciveMeasures. . . . . . . 285 JacquelineEwington 17 MechanicalRestraint:Legal,EthicalandClinicalIssues. . . . . . . . 315 SusanElcockandJessicaLewis 1 Introduction € Birgit Vollm and Norbert Nedopil Thisbookisdedicatedtotheuseofcoercivemeasuresinoneareaofpsychiatry— forensic psychiatry. Forensic psychiatry is a subspecialty of clinical psychiatry which operates at the interface between law and psychiatry. It is concerned with patientswhohavecommittedan,oftenserious,offenceandarefrequentlydetained insecureandmostlyhighlyrestrictivesettings.Thepurposeofthisdetentionisseen astwofold:careandtreatmentforthepatient(fortheirownsakeaswellasinorder toreducefuturerisk)andprotectionofthepublicfromharmfromtheoffender.This dualrolecancausedilemmasforthepractitionerwhohasconflictingobligationsto thecommunity,thirdparties,otherhealthcareprofessionalsaswellasthepatient. Due to the nature of forensic psychiatry, both in terms of its clientele and the settings it operates in, the use of coercion seems to be therefore—rightly or wrongly—an integral part of its practice. It is thus surprising that—despite the plethora of academic writing about coercion in psychiatry in general—very little literatureexistsfocusingspecificallyonforensicpsychiatry—maybeareflectionof what Perlin (in the first chapter of this book) refers to as ‘an extra level of socialisolation’ofthis‘mosthidden’patientgroup. Whatiscoercion?AccordingtotheOxfordDictionaryofEnglish,itisan‘action or practice of persuading someone to do something by using force or threats’. Coercion usually occurs when one party has power over the other and does not necessarilyhavetoinvolveobviousthreatsoruseofforcebutcanpurelyconsistof B.V€ollm(*) DivisionofPsychiatryandAppliedPsychology,SchoolofMedicine,Universityof Nottingham,Nottingham,UK NottinghamHealthcareNHSFoundationTrust,Nottingham,UK e-mail:[email protected] N.Nedopil DepartmentofForensicPsychiatry,PsychiatricHospitaloftheUniversityofMu¨nchen, Mu¨nchen,Germany e-mail:[email protected] #SpringerInternationalPublishingSwitzerland2016 1 B.Vo¨llm,N.Nedopil(eds.),TheUseofCoerciveMeasuresinForensic PsychiatricCare,DOI10.1007/978-3-319-26748-7_1 2 B.Vo€llmandN.Nedopil animplicationthatsuchforcecouldbeused.Itisthereforeimportanttodistinguish betweenobjectiveandsubjectivecoercion,objectivecoercionbeingtheactualuse of coercive actions while subjective coercion describes the perception that such measuresmaybeused. Objective and subjective coercion do not correlate well—some people may perceive actions which are not objectively coercive or intended to be coercive neverthelessasthreatsorcompulsionwhileothersmayperceiveobjectivelycoer- civemeasuresinfactashelpfulratherthancoercive,makingthedelineationofthe subjectareaevenmorechallenging. In psychiatric settings, coercive measures may be used in three principle situations,thoughinpracticetheymaynotbeclearlydistinguished:(1)Torestrict apatient’sfreedomsonamediumtolongertermbasistopreventharmtowardsself or others (e.g. offending), (2) to force a patient, who may or may not lack competencytoaccepttreatmentheorsherefusesand(3)intheshort-termmanage- ment of a situation where there is a high likelihood of aggression or violence perpetratedbythepatient. Thoughthisbookisprimarilyconcernedwiththiskindofcoercion,theconcept of a ‘sliding scale’ of pressure to accept treatment, introduced by Szmukler and Appelbaum (2008), is a useful starting point in describing the various forms coercionmaytakein(forensic)psychiatricsettings.Theslidingscaleincludes: (cid:129) Persuasion—theappealtoreasonand/oremotionstoacceptthesuggestedcourse ofaction (cid:129) Interpersonal leverage—where the patient–clinician relationship is used to put pressure on the patient, e.g. by pointing out the disappointment caused by the patient to his or her mental health worker if refusing the suggested course of action (cid:129) Inducement—the use of positive rewards if the action suggested by the mentalhealthprofessionalisaccepted (cid:129) Threats—e.g. the threat to lose particular benefits such as the therapeutic rela- tionship itself or threats to use more aversive measures such as detention or physicalforce (cid:129) Compulsory treatment finally is the situation where all choice is taken away fromthepatientandthetreatmentisdeliveredagainsthisorherwishes Inforensicpsychiatry,coercionismostlythoughtofintheshort-termmanage- mentofaggressionorviolence(seefurtherbelow).Thereare,however,alsolong- termcoercivemeasuresapplied,e.g.forcingthepatienttoacceptdepotmedication in order to be transferred to a lower level of security or to be released into community treatment. Generally, accepted definitions of coercion hardly exist. Whilewewouldhavepreferredallauthorsusingthesamedefinitionsforcoercive methodswithintheirchapters,ithassoonbecomeapparentthatthisaspirationwas not achievable. This is an authors’ practice in different countries using different definitions and they write from their own experience within their countries. We have therefore decided to not edit out the overlap between chapters to allow the reader to appreciate the particular author’s viewpoint and definitions used within 1 Introduction 3 theirchapters.Thishastheadditionaladvantagethatallchaptersareself-contained, facilitating the selective reading of chapters of particular relevance to individual readers. There are four main methods of coercion in the short-term management of patients [descriptions mainly according to Department of Health (2008) and NationalInstituteofClinicalExcellence(2015)]: 1. Physicalrestraint:Thepatientismanuallyheldbyatleastonememberofstaffto restrictmovement.Thisisoftenthefirststeptootherinterventions(2–4below) butmayoccasionallyalsobeusedasthesolemethodofintervention. 2. Mechanical restraint: A device, such as a belt, is attached to a patient with the aim of restricting patient movement. Equipment used in this way should be approvedforsuchuseandstafftrainedinitsapplication. 3. Seclusion: The placement of a patient alone in a (largely) bare room, usually lockedorotherwisepreventingfreeexit,thateitherhasorhasnotbeenassigned forthispurpose.Theroomprovidesalow-stimulation,safeenvironmentforan acutelypsychiatricallydisturbedpatient. 4. Involuntary medication (also termed ‘chemical restraint’ or ‘pharmacological restraint’or‘rapidtranquillisation’):Theadministrationofmedication,typically via intramuscular injection, against the patient’s will with the aim to lightly (butnotheavily)sedate,therebyallowingimprovedcommunication. Thisvolumeconsistsoffourparts.PartIaddressessomeofthecontextinwhich coercioninforensicpsychiatryhappens—legal,sociologicalandethical.Itcovers legalaspectsofcoercionbydescribingsomeofthekeylegalframeworksconcerned with the protection of human rights of those institutionalised in (forensic) psy- chiatric institutions, emphasising the importance of scrutinising the conditions of confinement and ensuring procedures are in place to challenge any violations of human rights. Part I also includes a sociological viewpoint challenging us to embrace a wider perspective of psychiatry than a biological one, recognising the contributionsocialsciencesmakestounderstandingthecomplexinterplaybetween societies,organisationsandindividuals.Inthecontextofcoercion,thismeansthat psychiatrymustreflectontheroleassignedtoitinthecontrolofsociallyundesir- ablebehaviour.AdsheadandDavies,intheirchapteronethicalissues,againinvite us to take a broader view when they argue that care and coercion in forensic psychiatry are linked and that patients are constrained by their life stories in many ways, even without overt coercion by healthcare professionals. Steinert finallyremindsusthat,whilepsychiatricpracticeinallcountriesreliesontheuse of coercion, there is wide variation in which methods are seen as acceptable in different countries, indicating that policies and practice are shaped more strongly by values and attitudes of the general public as well as professionals than by the applicationofscientificevidence. PartIIofthisvolumeisdedicatedtotheuseofcoercivemeasuresinparticular settings.Curtisetal.giveanoverviewoftheuseofsuchmethodsingeneraladult settings.Theirchapteralsogivesagoodoutlineofthevariousmeansofcoercion,