This article discusses initiatives aimed at preventing and reducing ‘coercive practices’ in mental health and community settings worldwide, including in hospitals in high‐income countries, and in family homes and rural communities in low‐ and middle‐income countries. The article provides a scoping review of the current state of English‐language empirical research. It identifies several promising opportunities for improving responses that promote support based on individuals’ rights, will and preferences. It also points out several gaps in research and practice (including, importantly, a gap in reviews of non‐English‐language studies). Overall, many studies suggest that efforts to prevent and reduce coercion appear to be effective. However, no jurisdiction appears to have combined the full suite of laws, policies and practices which are available, and which taken together might further the goal of eliminating coercion.

Aims.: There are growing calls to reduce, and where possible eliminate, the use of seclusion and restraint in mental health settings, but the attitudes and beliefs of consumers, carers and mental health professionals towards these practices are not well understood. The aim of this study was to compare the attitudes of mental health service consumers, carers and mental health professionals towards seclusion and restraint in mental health settings. In particular, it aimed to explore beliefs regarding whether elimination of seclusion and restraint was desirable and possible.Methods.: In 2014, an online survey was developed and widely advertised in Australia via the National Mental Health Commission and through mental health networks. The survey adopted a mixed-methods design, including both quantitative and qualitative questions concerning participants’ demographic details, the use of seclusion and restraint in practice and their views on strategies for reducing and eliminating these practices.Results.: In total 1150 survey responses were analysed. A large majority of participants believed that seclusion and restraint practices were likely to cause harm, breach human rights, compromise trust and potentially cause or trigger past trauma. Consumers were more likely than professionals to view these practices as harmful. The vast majority of participants believed that it was both desirable and feasible to eliminate mechanical restraint. Many participants, particularly professionals, believed that seclusion and some forms of restraint were likely to produce some benefits, including increasing consumer safety, increasing the safety of staff and others and setting behavioural boundaries.Conclusions.: There was strong agreement across participant groups that the use of seclusion and restraint is harmful, breaches human rights and compromises the therapeutic relationship and trust between mental health service providers and those who experience these restrictive practices. However, some benefits were also identified, particularly by professionals. Participants had mixed views regarding the feasibility and desirability of eliminating these practices.

Seclusion and restraint are interventions currently permitted for use in mental health services to control or manage a person’s behaviour. In Australia, serious concerns about the use of such seclusion and restraint have been raised at least since 1993. Consumers and their supporters have also expressed strong views about the harm of these practices. This paper presents the results of ten focus group discussions with people with lived experience of mental health issues and also carers, family members and support persons in relation to the use of seclusion and restraint. The 30 consumers and 36 supporters participating in the focus groups convened in four Australian cities and one regional centre discussed their understandings of the use of seclusion and restraint and its impact on the people involved. Participants also presented their observations about poor practice and what contributes to it as well as providing ideas and recommendations regarding strategies to reduce or eliminate seclusion and restraint. Focus group discussions were recorded and transcribed, then analysed using the NVivo 10 qualitative data analysis software with a general inductive approach used to analyse data. This analysis enabled consideration of the responses to key questions in the focus groups as well as the identification of emerging themes. Six themes emerged from the analysis, these being: human rights, trauma, control, isolation, dehumanisation and ‘othering’, and anti-recovery. Examples of poor practice identified by focus groups included the use of excessive force, lack of empathy/paternalistic attitudes, lack of communication and interaction and a lack of alternative strategies to the use of seclusion and restraint. There was a confluence of factors identified by participants as contributing to poor practice, with the main factors being organisational culture, the physical environment, under-resourced mental health services and fear and stigma. Focus group participants in the main viewed seclusion and restraint practices in mental health settings as unnecessarily overused, exacerbating problems for individuals, carers, staff and the broader system of care. This study highlights that lived experience of both consumers and their supporters can make an important contribution to mental health services and its ongoing reform.

Background: Supporting the decision-making of mental health service users fulfils professional, ethical and moral obligations of mental health practitioners. It may also aid personal recovery. Previous research on the effectiveness of supported decision-making interventions is limited. Aims: The study aims to explore from several perspectives the barriers and facilitators to supported decision-making in an Australian context. Supported decision-making was considered in terms of interpersonal experiences and legal supported decision-making mechanisms. Methods: In all, 90 narrative interviews about experiences of supported decision-making were conducted and analysed. Participants were mental health service users who reported diagnoses of schizophrenia, psychosis, bipolar disorder and severe depression; family members supporting them and mental health practitioners, including psychiatrists. The data were analysed thematically across all participants. Results: Negative interpersonal experiences in the mental health care system undermined involvement in decision-making for people with psychiatric diagnoses and family carers. Mental health practitioners noted their own disempowerment in service systems as barriers to good supported decision-making practices. All groups noted the influence of prevailing attitudes towards mental health service users and the associated stigma and discrimination that exist in services and the broader community. They believed that legal supported decision-making mechanisms facilitate the participation of mental health service user and their family supporters in supported decision-making. Conclusions: Enabling supported decision-making in clinical practice and policy can be facilitated by (1) support for good communication skills and related attitudes and practices among mental health practitioners and removing barriers to their good practice in health and social services and (2) introducing legal supported decision-making mechanisms.

Objective: The main objective of this paper is to compare the mental health Acts of the eight Australian jurisdictions and the 13 Canadian jurisdictions on three major issues: involuntary admission criteria, treatment authorization/consent and compulsory treatment in the community, in the light of international trends towards patients’ rights. Method: The legislation was examined against the background of rights instruments such as the Canadian Charter of Rights and Freedoms and the United Nations Convention on the Rights of Persons with Disabilities. Results: It was found that some Canadian involuntary admission criteria require the likelihood of bodily harm whereas all Australian Acts have broad harm and deterioration criteria. Unlike all Australian jurisdictions, some Canadian jurisdictions allow for the refusal of treatment that may be required for discharge. In addition, Canadian community treatment orders are much more restrictive than in Australia because they require a person to have considerable previous hospitalization despite meeting the committal criteria. Australian jurisdictions can use community treatment orders as a least restrictive alternative to inpatient status without prior hospitalization. Conclusions: The paper concludes that there are significant philosophical differences regarding the purpose of involuntary admission between Australian and some Canadian jurisdictions where treatment refusal is possible. Australian mental health Acts have a relatively stronger ‘treatment’ focus than some Canadian Acts. The apparently stronger ‘rights’ focus of some Canadian laws (such as the permission of treatment refusal) can paradoxically result in a denial of liberty rights. The way in which the relevant legislation is shaped in both countries will increasingly be affected by international trends towards the rights of individuals with disabilities.

Objective: This paper examines the perspectives of consumers and their supporters regarding the use of seclusion and restraint in mental health settings. Methods: Five focus groups for consumers and five focus groups for supporters were conducted in four Australian cities and in one rural location. The 66 participants were asked about strategies to reduce or eliminate the use of seclusion and restraint in mental health settings. Results: All participants supported the reduction of the use of seclusion and restraint. Barriers to reducing these practices related to the environment, the effects of drug and alcohol issues, lack of a human rights focus and poor recognition of trauma, stigma and discrimination. Strategies for reducing or eliminating seclusion and restraint included workforce development, environmental and cultural changes. Conclusions: Participants clearly identified that the status quo needs to change and conveyed urgency for action. Participants suggested that the involvement of supporters and a range of consumer roles are integral to reducing the use of seclusion and restraint. The findings support the current policy emphasis of working towards the elimination of these practices. What is known about the topic?: Mental health policies across many jurisdictions support the reduction and elimination of restraint and seclusion. Evidence suggests those subjected to restraint and seclusion largely experience a range of harmful consequences. No studies focus on the views of supporters of consumers regarding the reduction and elimination of seclusion and restraint, whereas the views of consumers appear in a minority of international studies. What does this paper add?: The research enabled an opportunity to hear from people who have been personally affected by and/or have lived experience of these coercive practices. Participants identified local reforms that can uphold the human rights of consumers. They suggested practices to increase accountability, peer support and family involvement, areas that have not been analysed in depth in any of the seclusion and restraint literature. What are the implications for practitioners?: This paper will give healthcare services a deeper insight into how to reduce or eliminate restraint or seclusion from the perspective of those with lived experience.