Coercive Measures in Psychiatry Can Hardly Be Justified in Principle Any Longer—Ethico‐Legal Requirements Versus Empirical Research Data and Conceptual Issues
Does Psychiatry Have a Valid Disease Model? The identification of a ‘true mental disorder’ implies a valid disease and diagnostic model. However, there are currently a large number of models to explain mental health problems, some of which are fundamentally contradictory (Richter and Dixon ). According to recent psychiatric taxonomic research and basic neuroscientific research, the validity of the DSM and ICD classification systems used today is highly doubtful (Lilienfeld and Treadway ). One of the problems is the differentiation of various disorders from one another (Kotov et al. ). Current taxonomic approaches such as the ‘Research Domain Criteria’ (RDoC) (Cuthbert ), the ‘Hierarchical Taxonomy of Psychopathology’ (HiTOP) (Kotov et al. ) or the ‘General Psychopathology (p‐factor)’ approach (Caspi et al. ) have been developed against the backdrop of empirical research in the neurosciences, which found that the research results were incompatible with the conventional DSM and ICD classification systems. A further problem, which is even more fundamental and significant for the topic discussed here, is the difficulty of distinguishing disordered from non‐disordered mental states. This distinction has already been regarded historically in the research literature (Kendler, Muñoz, and Murphy ) and also currently predominantly as arbitrary (Eaton et al. ). Human psychological characteristics are almost invariably dimensional or continuous in nature (Conway and Krueger ). The attempt to differentiate these dimensions into sick/healthy or normal/abnormal is, according to the relevant research, ‘… an entirely fictional and baseless notion’ (Lahey , S. 3). This means that no medical‐biological criteria are apparently used to draw the line between ill and non‐ill, but rather, according to Steven Hyman, the former director of the US National Institutes of Mental Health, a social decision is made (Hyman ). Summarising the above research findings, a valid disease model of psychiatry that distinguishes between mentally ill and mentally healthy on the basis of medical criteria cannot be assumed. There is therefore no objectifiable medical‐psychiatric determination of a mental disorder as a prerequisite for coercive measures within the healthcare system; at least not beyond changeable and controversial social values. Similar methodological problems also exist with regard to the determination of mental capacity. This is also a dimensional construct that is also influenced by temporal and sociocultural factors. As with the determination of an ‘illness’, there are no ‘hard’ cut‐offs; instead, decisions are made that are co‐determined by social assumptions and attitudes. In clinical practice, the attribution of capacity and incapacity is a ‘normative judgement’ (Trachsel, Hermann, and Biller‐Andorno , S. 224); see also Banner ( ). 

Are Psychiatric Therapies Effective? From an ethical perspective, the aim of measures taken against a person's will is to improve the health of the person concerned. This requires effective therapeutic interventions. Medical coercion may only be used if the measure can achieve an improvement in health. However, according to a recent umbrella review, pharmacological and psychotherapeutic interventions in psychiatry are generally not even moderately effective (Leichsenring et al. ). The effect sizes found in this umbrella review are 0.36 for pharmacotherapy and 0.34 for psychotherapy. According to the convention used by the Cochrane Collaboration, moderate effectiveness can be assumed from an effect size of 0.5 and strong effectiveness from 0.8 (Zeng et al. ). It should also be noted that the participants included in these studies were volunteers. People who are treated against their will can be expected to have lower therapeutic motivation and lower expectations on the impact of the treatment (Meynen and Swaab ), which usually impacts negatively on effectiveness. In addition, psychiatric interventions have been shown to have only a weak effect on suicidality, a key indication of coercive measures. According to a meta‐analysis, psychiatric therapies have only a very weak effect on suicidal thoughts, suicide attempts and deaths by suicide (Fox et al. ). In summary, this means that the criterion of the effectiveness of a therapy accompanying the coercive measure is not met for most of the people affected by coercion. 

Are Coercive Measures Used as a Last Resort and as the Least Restrictive Measure Possible? The use of coercion as a last resort presupposes that a psychiatric care system has been established in advance that effectively seeks to prevent admissions to inpatient treatment. These are, for example, crisis resolution teams or home treatment services, which should be available nationwide to prevent people with mental health problems from involuntary hospitalisation. According to a review, however, these services have so far only been fully implemented in England (not in the rest of the United Kingdom) and Norway (Lloyd‐Evans et al. ). In other countries, outpatient treatment programmes are only sporadically available prior to inpatient admission. This applies, for example, to inpatient‐equivalent treatment in Germany (Nikolaidis et al. ) or home treatment approaches in Switzerland (Stulz et al. ) which, despite positive study results, are not yet available across the board. In addition, many other crisis management options have not been exhausted. These include non‐medical crisis houses or peer‐run respites (Spiro and Swarbrick ). A widespread restriction in the treatment of people with mental illness is the closed ward door. However, minimising restrictions requires that measures are implemented to keep restrictions as low as possible. One of these measures is the open ward door. There is empirical evidence that closed doors do not contribute significantly to the prevention of absconding and suicide attempts (Huber et al. ). In a recent Norwegian non‐inferiority study, open doors proved to be non‐inferior to closed ward doors in all respects (Indregard et al. ). However, many professionals in psychiatric care are very reluctant to open ward doors (Kalagi et al. ) and the opening of wards where people have to stay against their will is not widespread. In summary, this means that coercion is predominantly not used as a last resort and as the least possible restriction. 

Are Psychiatric Coercive Measures Taken for the Benefit of the Persons Affected? Beneficence and non‐maleficence are core arguments for justifying medical measures against a person's will. The defence against danger alone, in particular the danger to other persons, could also be achieved by non‐medical coercion. The police and judiciary should be able to do this. It has already been stated above that psychiatric therapies are not really effective from the perspective of professional expertise. There is also evidence on the consequences of coercive measures from a psychiatric perspective, for example, a non‐negligible risk of physical harm and death (Kersting, Hirsch, and Steinert ). A comparative observational study recently also found that isolation measures have negative consequences for the mental health of those affected (Baggio, Kaiser, and Wullschleger ). Another perspective—and one that is even more relevant to the issue at hand—is that of the persons affected by coercion. According to ethical guidelines such as those of the German Ethics Council, the persons concerned would have to subsequently consent to the measure. The subjective assessment by the persons concerned after a coercive measure has been carried out would generally have to be positive in order to determine their mental health and legitimise the measure. However, several systematic reviews come to the consistent conclusion that the vast majority of people who have experienced psychiatric coercion do not see it this way (Aguilera‐Serrano et al. ; Akther et al. ; Chieze et al. ). Instead of the positive effect, the people affected tend to experience punishment, powerlessness and humiliation. In summary, this means that psychiatric coercion is at best experienced by a minority as a measure to promote mental health, but for the most part does not lead to the well‐being of the people affected. 

Can the Autonomy of the People Concerned Be Restored at all Through Coercion? Restoring the autonomy of the person concerned is another justification for the use of coercion. Autonomy and a person's free will are related concepts that are also discussed in the context of neuroscience (Müller and Walter ). Personal autonomy (Buss and Westlund ) and in particular free will (O'Connor and Franklin ) are among the most controversial concepts in philosophy and there are profound scientific reasons that make free will appear to be an illusion (Sapolsky ). In view of the conceptual ambiguities, it is completely unclear whether personal autonomy as such can be affected by mental disorders. Moreover, autonomy is always a question of perspective. People who have to undergo psychiatric treatment against their will often experience a loss of autonomy rather than a regaining of autonomy as a result of involuntary admission (van den Hooff and Goossensen ). This means that it is at least unclear whether autonomy is affected by a mental illness and whether it can be restored through a coercive psychiatric measure. 

Conclusions The above analysis suggests the following findings: (1) psychiatry does not have a valid disease model that can clearly distinguish between disorder and non‐disorder; (2) psychiatric therapies are not even moderately effective; (3) coercive measures are predominantly not used as a last resort and as the least possible restriction; (4) psychiatric coercion is predominantly not used for the benefit of the persons concerned; and (5) it is unclear at a conceptual level whether people's autonomy can be reduced by a mental illness and whether it can be restored by a coercive measure. In summary, this means that none of the five central ethical and legal criteria for the use of coercion in psychiatry are clearly and unambiguously fulfilled according to the current state of research. There is insufficient evidence for the effectiveness of coercive measures in psychiatric care (see recently Hofstad et al. ). Psychiatric coercion can therefore hardly be justified any longer from an ethical and empirical perspective. The above analysis therefore comes to the same conclusion as the human rights argumentation of Zinkler and von Peter ( ): psychiatric treatment should in principle only be voluntary. However, it goes without saying that an immediate abolition of psychiatric coercion would result in considerable problems and dilemmas (Richter ). At present, prisons and other institutions in the legal system are not appropriate places to provide psychosocial support for people in crisis. Furthermore, it is not to be expected that coercion in psychiatric care will be viewed negatively in politics and the legal system any time soon. This has two consequences for psychiatry in general and for nursing and psychiatric care in particular. Firstly, efforts must be made—together with those affected and other professions in psychiatric care—to ensure that coercion in psychiatry is abolished in the medium to long term. In this context, some authors may even see the need for active resistance or conscientious objection (Gadsby and McKeown ; Sidley ). While only a minority of experts are of the opinion that the abolition of coercion is possible (Birkeland et al. ), experts with lived experience put forward many arguments in favour of abolition (Suslovic ). Secondly, however, it is still necessary to work towards reducing coercion on every ward and in every community service. For example, there is increasing evidence of racial and ethnic disparities in coercive measures in inpatient care, which cannot be tolerated in principle (Singal et al. ). It is imperative that nurses and other mental health professionals examine in each individual case whether alternatives to measures against the person's will are also available in the current care system. 

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The author declares no conflicts of interest. 

