While officials responsible for psychiatry across Europe must decide whether to support the draft Additional Protocol to the Oviedo Convention, a legal text that regulate the use of involuntary interventions in psychiatry, psychiatrists discussed the problems of involuntary measures and coercion in psychiatry. It is a dilemma and potentially harmful not only to those subjected to it, but also to psychiatry.
Psychiatry’s leadership has chosen rights
The World Psychiatric Association (WPA) represents 147 psychiatric societies in 123 countries and more than 250,000 psychiatrists. Its position is unambiguous: it “recommends implementing the provisions of the UN Convention on the Rights of Persons with Disabilities (CRPD) by adopting a rights-based approach across its range of activities.” That formulation comes from Helen Herrman, Silvia Galderisi, John Allan and Maria Rodrigues, a former WPA president, a former president of the European Psychiatric Association, and members of the WPA’s ethics committee and task force on alternatives to coercion.
The WPA’s 2020 Position Statement and Call to Action, adopted by its General Assembly, notes widespread agreement among psychiatrists, other practitioners and people with lived experience that coercive practices are over-used.
It is candid that whether coercion can ever be justified remains “highly debated” in the profession. The World Congress of Psychiatry that was held in Stockholm showed that debate in the open, but the direction of travel was clear.
A presidential panel on coercion
On 24 September a Presidential Panel brought together psychiatrists from the UK, Germany, the Netherlands, Chile, Senegal and Poland. Its chair, Professor Meryam Schouler-Ocak of Charité Berlin, who also chairs the ethics committee of the European Psychiatric Association, opened with a sober assessment:
“Coercion in psychiatry, including, of course, involuntary admission, compulsory treatment, seclusion and restraint, remains one of the most complex ethical, legal, illegal and human rights challenges in mental health care. Today, there are no reliable data on coercion worldwide. Data vary between countries, and there is no reliable index on coercion worldwide.”
The panel set out to identify “practical strategies for preventing and reducing coercion while maintaining safe and high-quality psychiatric care.” Co-chair Professor Jerzy Samochowiec of Szczecin, Poland framed the answer: “the future of psychiatry lies not in eliminating responsibility, but in replacing unnecessary coercion with partnership, recovery-oriented care, and respect for human dignity.” He added that “evidence shows that coercion can be reduced without compromising safety. And the key is communication, staff training, and continuity of care.”
He described three levels of action: at the macro level, community psychiatry and continuous monitoring; at the meso level, shared decision-making, partnership with patients and trauma-informed care; at the micro level, early de-escalation and permanent staff communication training.
Dr René Keet, a Dutch psychiatrist, was most direct on evidence: “What I think we do need is what I call a rights-based, evidence-informed psychiatry.” Challenged from the floor by a colleague who argued that early compulsory medication improves outcomes, he replied that “there is only one study done on that topic and it showed no advantages of using coercion.” Using coercion is thus “an ethical choice,” not one “based on the proven effectiveness,” he clarified. He recommended moral case deliberation, because coercion is always a dilemma, used only “when there is no good outcome”: one must “choose between two bad situations.”
Keet is no absolutist; he still uses coercion in situations of great danger. His account of its damage is therefore telling: “One of the big problems with people with severe mental illness is what we call the motivation paradox. The higher the needs of care, the lesser the tendency to look for care.” Coercion, he said, “is not the only explanation for that, but it’s a very important part of the explanation.” Studies show that a number of patients later say the intervention was good, “but still half of them will never think it was a good experience.” This lead them to not seek psychiatric services in the future.
Safeguards are not enough: the German lesson
Germany, a leading supporter of the proposed Additional Protocol to the Oviedo convention, deserves particular attention. Professor Schouler-Ocak explained that involuntary treatment runs along two pathways in Germany: federal guardianship law, requiring court approval, and the mental health acts of the 16 states, which differ from one another and cover mainly acute situations. Advance directives are binding but cannot prevent placement or mechanical restraint. A pilot study from the Germany Psychiatric Society (DGPPN) found coercive measures in 8 per cent of cases, with the Penal Code’s “justifiable necessity” provision cited particularly often as legal basis, outside both statutory pathways.
The legal text is only part of the story. A 2019 comparative study in The Lancet Psychiatry (Sheridan Rains and colleagues), covering 22 countries, found involuntary admission rates from 282 per 100,000 inhabitants in Austria to 14.5 in Italy, and no relationship between those rates and the characteristics of national legal frameworks. A European Times review of 14 countries found rising trends in ten, with Austria, Germany and Switzerland showing the highest levels among countries with records. Germany lacks a consistent national statistical series, so whether safeguards work is hard to assess; Switzerland, with detailed civil-code provisions, saw its standardised rate rise by roughly 31 per cent between 2018 and 2024.
What governs coercion is how law is applied and the quality of the services behind it. More regulation offers no guarantee of lower rates.
What works, and what families say
While involuntary measures remain authorised by law, safeguards and good-practice models should be promoted. Professor Schouler-Ocak presented the Weddinger Modell from Charité Berlin: ward structures reorganised for transparency, participation, trialogue and multi-professional work. Evaluation showed that coercive measures fell, and that less mechanical restraint did not bring more forced medication or higher doses. The WPA panel also pointed to Safewards, Open Door policies and WHO QualityRights.
Family and service user organisations are among the sharpest critics of the status quo. Keet relayed their position, drawn from groups such as EUFAMI and GAMIAN: coercion signals “systemic failure”, the absence of adequate non-coercive alternatives. Families, he said, often feel left behind and want to collaborate, not merely to be “involved”. EUFAMI’s call for action demands “a fundamental shift”: “coercion must be recognized as a treatment failure.”
The legal point under international human rights law
The UN Committee on the Rights of Persons with Disabilities reads the CRPD as incompatible with involuntary measures in mental health care. In its view, detention or treatment without free and informed consent on the basis of disability violates equal recognition before the law (Article 12), liberty (Article 14), freedom from torture and ill-treatment (Article 15) and integrity of the person (Article 17). “Last resort” is no exception: the Committee calls for ending coercion, not regulating it.
The draft Additional Protocol to the Council of Europe’s Oviedo Convention moves the other way. It defines the conditions of legality, necessity and proportionality under which involuntary measures may continue. That is why it has met opposition from disability organisations, human rights bodies and the UN.
It is often assumed that psychiatrists stand on the opposite side of this divide. The World Congress of Psychiatry in Stockholm suggested otherwise.
What this means for the Additional Protocol
Three conclusions follow for those deciding.
First, the data from the World Congress of Psychiatry undermines the claim that the profession needs coercive powers codified in a European treaty. Its leaders endorse the CRPD and a rights-based approach. The congress discussion indicate coercion as a dilemma and a treatment failure to be reduced, and concede that no evidence shows it works better.
Second, safeguards alone do not reduce coercion. Countries with elaborate legislation show high and often rising rates. An instrument that merely regulates coercion risks legitimising current practice and conflicts directly with the UN CRPD Committee’s position.
Third, the realistic aim is to phase out involuntary measures. The World Congress panel pointed to: invest in community services, assertive outreach and crisis plans; in training, peer workers and family collaboration; in moral case deliberation; and in transparent, comparable data.
If a European instrument is to exist, it should be judged by whether it accelerates that transition rather than entrenching what must be left behind.
In Stockholm, psychiatry was not asking to be left alone with its coercive powers. It was asking for the resources and the legal courage to need them less.
