Psychiatric coercion and violence: ethical, legal and preventive aspects

Coerción psiquiátrica y violencia: aspectos éticos, legales y preventivos

Natalia K. Rzhevskaya

Belgorod State University, Medical Institute, 301015, 85 Pobedy St., Belgorod, Russia, Rusia

Viktor A. Ruzhenkov

Belgorod State University, Medical Institute, 301015, 85 Pobedy St., Belgorod, Russia, Rusia

Victoria V. Ruzhenkova ruzhenkova@bsu.edu.ru

Belgorod State University, Medical Institute, 301015, 85 Pobedy St., Belgorod, Russia, Rusia

Inna S. Khamskaya

Belgorod State University, Medical Institute, 301015, 85 Pobedy St., Belgorod, Russia, Rusia

Uliana S Moskvitina

1Belgorod State University, Medical Institute, 301015, 85 Pobedy St., Belgorod, Russia, Rusia

This work is licensed under Creative Commons Attribution-NoDerivs 4.0 International.

According to the WHO¹, violence is «the use of physical force or power, threatened or actual, against oneself, another person, or against a group or community that either result in or has a high likelihood of resulting in injury, death, psychological harm, maldevelopment or deprivation». Makushkin et al.² define violence as any type of behavior that is intended to cause harm to physical health, psychiatric health, well-being, insult, and humiliation. Cruel treatment and violence include physical and psychological cruelty, sexual abuse, isolation, various types of exploitation, disparagement, restriction of legal rights and freedoms, psychopharmacotherapy with inadequate doses of drugs. Coercion is an act of an external mental, physical, material, or organizational impact on a person’s consciousness, will, and behavior³.

The basis of the biopsychosocial model of psychiatric care includes preserving the patient’s personality and his socio-environmental adaptation, improving the quality of life, and respecting his rights and freedoms⁴. At the same time, the stay of people with mental disorders in a psychiatric hospital is fraught with various restrictions, coercion, and violence⁵. Due to several reasons, the rights of patients with mental disorders in many cases are violated in the social and domestic sphere, in the educational and working process during medical care is provided⁶, including psychiatric care⁷.

For the above-mentioned reasons, we were prompted to analyze the ethical, legal, and preventive aspects of coercion and violence measures applied in a psychiatric hospital based on literature data.

We performed a literature review over the last five years in the databases, including PubMed, Medical-Science, Elibrary, Web of Science, Scopus., focusing on the problem of application of various forms of coercion and violence against mental health patients by medical staff in psychiatric hospitals in different countries. Mentioning the concept of "violence against the mental health patients" in keywords was the criterion for selecting articles. A total of 832 articles were found, categorized by country, and their data extracted.

Persons with mental disorders are often dangerous for themselves and the others, at which point the measures of physical restraint and other forms of restricting their rights are applied during psychiatric care is provided. Involuntary admission to a psychiatric hospital in a total number of hospitalizations is up to 8.6%⁸, while the proportion of people who undergo coercive treatment in a psychiatric hospital is 27.6%⁹. The evidence indicates that the prevalence of involuntary admissions in different countries is determined by the legal characteristics and specifics of the ethical aspects of the psychiatric care in each state and makes up 3-38%¹⁰. According to the data of Makushkina¹¹, the rate of involuntary admissions to psychiatric hospitals in Russia is about 44.4 per 100 thousand people; the prevalence of involuntary admissions in Western Europe is from 17 to 46.8 per 100 thousand people in the population¹².

Among the patient population who were hospitalized involuntarily, men predominate at the age of around 43 years (63.5-67.2%), single status (61.9-80.5%), and unemployed (69.5%)¹³. Patients with schizophrenia is up to 40.6-60.9%, with mood disorders -32-34.8%, with organic mental disorders - about 19%^14,45. In addition, the psychomotor agitation is up to 2.6 - 52% of cases among medical emergencies in a psychiatric hospital¹⁵. Among risk factors for the development of psychomotor agitation with destructive behavior are male sex, young age, schizophrenia-related disorders, and systematic intake of psychoactive drugs, involuntary admissions, rehospitalizations, and episodes of aggressive behavior in past medical history¹⁶. The measures of physical restraint are applied to such kinds of patients in 10-30% of cases during the emergency medical treatment is provided¹⁷.

A disregard of the legitimate interests and patients’ rights and their social ills is widespread among medical staff of the psychiatric service¹⁸. Also, the vague legal and clinical fundamentals of using measures for restricting the rights of persons with mental disabilities lead to many violations and abuses in this sphere¹⁹. Persons with mental disorders are forced to execute a consent to voluntary psychiatric hospitalization and medical intervention and are refused a request to review their medical records; they are also under 24/7 observation and they take medicine and receive treatment procedures under the close control²⁰. In the psychiatric unit patients deal with the impossibility of free movement and intimacy, they are denied to discontinue medical treatment at any stage or because of an immediate release. Many patients note the impossibility of obtaining any information about the received medical treatment and the refusal of an attending physician to discuss the tactics of the therapy measures²¹.

Involuntary admission to a psychiatric hospital has many areas of concern, which are related to its ethical, legal, clinical, and social aspects²². The balance of timeliness of medical care, the safety of the others, and the respect for the patient’s rights is a problem in performing an involuntary admission, regardless of the socio-political establishment and the level of state economic development²³.

The participation of the patient himself in the legal trial, according to the norms of international law, is mandatory. However, it is not uncommon in practice of the psychiatric hospitals that the patient is not called to a court session, and the judgment is made based on medical records, which violates the human right to protect their legitimate interests²⁴.

The patients who are hospitalized involuntarily have a very negative perception of their freedom of movement restrictions and total control, physical restraint, and a compulsory drug administration²⁵, which often turns to be the subject of violations and abuse by medical staff, including its performance without any medical prescription²⁶.

Mental disorders are often accompanied by psychomotor agitation with aggressive tendencies, which calls for application of isolation, physical restraint measures, forced drug administration, whit the consequence of abuse of patient's rights to human dignity, physical integrity, and personal freedom^27,28. In the practice of psychiatric hospitals, it is also not uncommon that psychopharmacological drugs are used in high doses as a way of punishment for patients with aggressive destructive behavior²⁹.

The application of physical restraint measures in a psychiatric hospital is regulated by article 30 of the Federal Law of the Russian Federation of July 2, 1992 No. 3185-1 “On Psychiatric Care and Guarantees of Citizens' Rights during Its Provision”, and the requirements of this statutory document are generally violated by psychiatrists administering the measures of physical restraint to the patients who were hospitalized voluntarily³⁰.

Patients deal with rough treatment, threats, and unjustified use of physical force, coercion to work in the hospital department on the part of the medical staff³¹. Many people with mental disorders also noted that they were not able to contact hospital administration with a request to report about violations of their rights, or that the answers to their complaints were rather formal³².

The patients in psychiatric hospitals experience various forms of indirect coercion by medical staff: they are involved in food delivery, loading and unloading operations and repair works, cleaning the premises of the psychiatric unit and the hospital site, monitoring and caring for other patients³³. About 80% of people with mental disorders complained of a lack of autonomy and freedom of action in the ward, they also negatively behave towards the constant control by medical staff³⁴, including during the performing of personal hygiene - 25%³⁵. Patients also complain of the impossibility of personal visits with family members and private phone calls that are carried out only in the presence of medical staff or are prohibited completely^36,46.

The main reasons that lead to the discrimination of psychiatric patients are insufficiently clear legal fundamentals for restrictions of rights and freedoms of people with mental disorders by medical staff, an extremely simplified case analysis, which require its application, low legal competence, and poor knowledge of bioethics principles among medical staff in psychiatric hospitals³⁷. Coercion in any form, which is applied in a psychiatric hospital, reduces significantly patients' compliance until they completely abandon the treatment, and also increases the frequency and severity of aggravation of psychopathological symptoms³⁸.

In the case of involuntary admission, before the trial, a person has already been in a psychiatric hospital for some time and has been deprived of freedom of movement, which is similar to imprisonment and that’s why it also requires statutory regulation³⁹. Involuntary admission to a psychiatric hospital requires of all the participants of this process to have interdisciplinary knowledge: the judiciary must have certain knowledge in the psychiatric area to analyze the medical part of the process and the psychiatrists must have legal competence to make decisions that lead to the legal consequences for their patients⁴⁰.

In providing psychiatric care patients’ rights restriction requires clear legal and clinical regulation, including the establishment of principles of legal and social protection for medical staff and patients themselves⁴¹.

The main objective of bioethics in providing psychiatric care is to develop tolerance and an open-minded attitude of psychiatrists and medical staff to people with mental disorders. On the other hand, it is necessary to limit coercive measures to the level of clinical necessity and expediency⁴².

A differentiated approach to the application of the restrictive measures and the discussion of the treatment policy with the patient, when he is offered a choice of physical restraint, the drugs’ administration or isolation in an individual ward, or 24-hour observation, gives a positive therapeutic effect, increases the level of trust to the attending physician and patient’s compliance⁴³.

At the present stage of psychiatry and society development, the main aim of the psychosocial therapy and rehabilitation should consist in the consensus achievement between the psychiatrist and the patient on the issues of treatment, compulsory use of the psychotherapeutic approach, destigmatization of not only the patient himself but also his milieu and medical staff of psychiatric service⁴⁴. As it is prescribed in Article 27 of the Federal Law of the Russian Federation of November 21, 2011, No. 323-FZ "On fundamental healthcare principles in the Russian Federation", the development of a responsible attitude of persons with mental disorders to their state of health is also within the competence of psychiatrists. It should develop policies and treatment approaches designed to respect patients' autonomy and reducing institutional coercion. Future research should focus on mental healthcare policies targeted at empowering treatment approaches, respecting the patient's autonomy, and promoting reductions of institutional coercion.

The evidence indicates that the legal framework specifying the powers of psychiatrists in the course of the restricting the rights of persons with mental disorders is not developed sufficiently at present; there are no medical criteria for the application of restrictive measures, which lead to abuse in this field. Prevention of coercion and violence in a psychiatric hospital should be based on the development of a contract (bioethical) approach to the interaction in the “patient-medical staff” system, and the development of a respectful attitude of the medical community to their patients. On the other hand, the transition from the paternalistic model, which is traditionally used in psychiatric practice, to the bioethical (contract) one will increase the level of patients' responsibility for their health, their behavior, and create a sufficient level of compliance in a friendly therapeutic environment. The psycho-educational approach, which complies with the bioethical concept of psychiatric care, also promotes positive contact with patients, increasing his interest in cooperation with psychiatrists and medication adherence.