CCHR demands that governments commit to WHO’s “zero coercion” policy in mental health, and put an end to forced institutionalization and treatments.

By CCHR International
Mental Health Industry Watchdog
September 18, 2023
Updated 9 October 2023

On October 9, 2023, the World Health Organization (WHO) and the United Nations Office of the High Commissioner for Human Rights (OHCHR) issued their guidance on Mental Health, Human Rights, and Legislation, with recommendations to eliminate coercive mental health practices.[1] CCHR applauds the guideline, which its European office contributed to and CCHR Int attended its Zoom launch. Many of the proposed reforms need urgent implementation worldwide, especially in the U.S. where patients are forced to undergo electroshock and take psychotropic drugs and are detained in behavioral and psychiatric facilities where poor conditions endanger their lives. The guideline calls on governments to “commit by law to a ‘zero coercion’ policy.” (Page 67 of Guidelines)

CCHR research estimates that globally, every 30 seconds someone is involuntarily committed to a psychiatric hospital. In the U.S., according to David Cohen, a professor of social welfare at the Luskin School in California, involuntary psychiatric detentions outpaced population growth by a rate of 3 to 1 on average in recent years.[2] A study published in The American Journal of Psychiatry citing figures from 2014 suggests that involuntary hospitalizations account for 54% of admissions to psychiatric inpatient settings.[3] CCHR says it is important to note that once committed, an individual can be forced to undergo damaging treatment, without recourse.

In June 2022, WHO and OHCHR issued the groundbreaking draft guidance to protect the human rights of people in the mental health system and issued the final guideline in October 2023. It is aimed as a resource for governments considering legislative measures to support the transformation of mental health systems to align with international human rights law.[4] CCHR’s European office submitted input to the guidelines, as recognized by WHO.[5]

“Coercion remains a core component of existing mental health laws across jurisdictions and is a major concern,” the guidance report says. “Such practices may include involuntary hospitalization, involuntary medication, involuntary electroconvulsive therapy (ECT), seclusion, and physical, chemical and mechanical restraint.”[6] Further, “Coercion can inflict severe pain and suffering on a person with long-lasting physical and mental health consequences, which can impede recovery and lead to substantial trauma and even death.” Such “practices in mental health care violate the right to be protected from torture or cruel, inhumane and degrading treatment, which is a non-derogable [cannot be infringed upon] right.”[7]

Jan Eastgate, president of CCHR International, says the guideline is one of the strongest documents ever to condemn what WHO calls “the pernicious effects of institutionalization, the over-emphasis on biomedical approaches and treatment options, and the use of involuntary psychiatric interventions.”

In the U.S., 76.9 million Americans take psychiatric drugs.[8] The report highlights how this biomedical model “works to the detriment of other holistic and person-centred and rights-based approaches and strategies.’”[9]

In another 2021 guideline, WHO quoted former National Institute for Mental Health director, Thomas Insel, admitting that despite $20 billion being spent on mental health research, including biomedical, it hadn’t “moved the needle in reducing suicide, reducing hospitalizations” or “improving recovery.”[10] “A damning admission of failure,” Eastgate says, “that stems from the unscientific basis of psychiatric diagnoses and unworkable biomedical treatments in a system fraught with abuse passed off as ‘mental health care.’”

The guideline condemns common coercive practices such as “forced medication, seclusion and restraints.” Restraint deaths in the U.S. have been headline news for years, especially following the death of Cornelious Frederick, a 16-year-old African-American boy on May 1, 2020. He was brutally restrained in the now-closed Lakeside Academy, a behavioral facility in Michigan because he had thrown a sandwich on the floor. A coroner ruled the death a homicide.[11] The shocking death of a 7-year-old foster care child, Ja’Ceon Terry after he was restrained at Brooklawn psychiatric residential center in Louisville, Kentucky on July 17, 2022, exemplified patient abuse. The medical examiner also ruled his death a homicide.[12] 

The guideline recommends: “A person must not administer to or perform on another person any of the following—(a) deep sleep therapy; b) insulin coma therapy; (c) psychosurgery; and (d) any other operation or treatment proscribed by regulations.”[13] CCHR in Australia had lethal deep sleep therapy—often a combination of coma-producing psychotropic drugs and electroshock—banned with criminal penalties if administered, but it is not yet globally prohibited.

It also acknowledges what U.S. psychiatrists refuse to admit—that ECT causes brain damage. The report is insistent that “ECT is not recommended for children, and hence this should be prohibited through legislation.”[14] Yet in the U.S., children ages 5 or younger have been subjected to ECT, as CCHR documented.

In August 2022, in commemoration of the WHO draft guidelines of 2021, CCHR posted a “MEMORANDUM: The Need for Human Rights in Mental Health Laws to End Coercive Psychiatric Practices & Abuse” on its website.[15] A resolution accompanying it, which readers can sign and forward to their legislative representative demanding reforms, points to a 2022 Harvard Law School Project on Disability in the U.S. report that reinforced what WHO says: “Institutional mental health settings, such as state-run psychiatric hospitals, routinely employ coercive forms of ‘treatment’ that are intolerable in other settings.”[16]

The U.S. has ratified the UN Convention against Torture (CAT), adopting it in domestic law, but has failed to protect Americans from torture in psychiatric-behavioral facilities. The UN Special Rapporteur against Torture stated: “It is essential that an absolute ban on all coercive and non-consensual measures, including restraint and solitary confinement of people with psychological or intellectual disabilities, should apply in all places of deprivation of liberty, including in psychiatric and social care institutions.”[17]

The guidelines also call on governments to ensure patients have the right to “refuse or choose an alternative medical treatment,” and to legally bind hospitals, psychiatrists, and doctors to abide by patients, “advance planning options,” also called Advanced Directives or Living Wills, to prevent forced unwanted treatment. CCHR has “Psychiatric Living Will” available on its website. 

CCHR praised the report’s call for accountability because without it, “human rights lack enforcement and are rendered meaningless.” CCHR has long demanded criminal culpability and the guideline notes: “When a law is transgressed, legislation should provide for effective civil, administrative or criminal sanctions and reparations.”

Eastgate adds: “The need for such guidelines is a damning indictment of the psychiatric system’s failure to protect patients’ human rights and the need for its recommendations to be enacted and enforced.”

New Guidelines Create Human Rights

The following summarizes some of the key points in the draft guideline:

Ending and Prohibiting Coercive Practices

• “Coercion is harmful in terms of both physical and mental health…. When violence, coercion and abuses occur in mental health services, not only does the service fail to help people but they compound the original difficulties by retraumatizing people using the service.” (Page 55 of Guidelines)

• The Convention on the Rights of Persons with Disabilities (CRPD), which fundamentally challenges long-standing practices in mental health systems, prohibits coercive practices. It demands a transformation in the way mental health services are provided so that all persons can exercise their right to provide free and informed consent to accept or reject treatment in mental health systems. “Denial of legal capacity, coercive practices and institutionalization must end and be replaced by community-based services and supports that enable the full exercise of human rights.” (Introduction of Guidelines)

• “There is limited evidence to support the success of coercion to reduce the risk of self-harm, facilitate access to treatment, or protect the public. Predicting self-harm or risk of harming others before the fact, apart from being ethically questionable, is extremely difficult…there is little evidence that risk assessment tools and coercive mental health treatment prevent suicide.” (Page 15)

• “To ensure a complete paradigm shift away from coercion in mental health care, legislation can prohibit all involuntary measures and mandate that all services, outpatient or inpatient, implement non-coercive responses.” (Page 66)

• “There is evidence that legislative changes can help prevent involuntary commitment and direct it towards abolition. For example, in Mexico, the General Health Law, as amended in 2022, establishes that all mental health treatment and hospitalization must be carried out on a voluntary basis; seclusion, restraints or any practices that constitute cruel, inhuman or degrading treatment are prohibited.” (Page 66) “This means that involuntary hospitalization and treatment are no longer permitted in Mexico.” (Page 67)

• “More recently, the UN Special Rapporteur stressed that purportedly ‘benevolent’ purposes, such as ‘medical necessity,’ ‘re-education,’ …do not vindicate coercive or discriminatory practices and may amount to torture. There is an immediate international obligation to end these practices.” (Page 15)

• “Legislation on mental health must therefore take a new direction away from the narrow traditional ‘biomedical paradigm’ that has contributed to coercive and confined environments in mental health services.” (Page xvii)

• “The use of any coercive measure in all mental health services is prohibited, including medical and non-medical interventions without informed consent, the use of isolation rooms and chemical and mechanical restraints, and restrictions to free movement within health services…. Shackling, chaining, seclusion, restraints, and any other form of violence, and abuse against a person with mental health conditions and psychosocial disability in the community are prohibited.” (Page 73)

• In requiring deinstitutionalization, wording for laws is recommended to state: “The creation of any form of institution is prohibited; this includes new asylums, psychiatric hospitals, neuropsychiatric hospitals…and public or private social care institutions.” (Page 94)

• “Widespread human rights violations and harm caused by mental health systems, and enabled by mental health laws, has led to a legacy of trauma that impacts many individuals and communities, and spans generations. Indeed, the structural violence and harm exercised through and facilitated by mental health laws are, in themselves, forms of historical trauma.” (Page 14)

Rights Extend to Community “Treatment”

• “In many countries, community treatment orders have been introduced as a way to reduce the need for hospitalization. Community treatment orders are legal orders made by courts which mandate service users to continue outpatient mental health medication and treatment. However, overwhelming evidence indicates that community treatment orders do not work; there is no evidence of decrease in hospitalization nor benefits for persons using mental health services.” (Emphasis added) (Page 67)

• “Coercion within the community, including shackling, should be banned by law…. In Indonesia, Law No. 18 of 2014 on Mental Health considers shackling as a criminal offence.” (Page 72)

Informed Consent & Advanced Directives

• “Coercive practices violate a person’s right to liberty and security, which is a fundamental human right. They also contradict the right to free and informed consent and, more generally, the right to health.” (Page 15)

• “All persons should be able to exercise their right to give free and informed consent to accept or reject treatment in mental health systems. Denial of legal capacity, coercive practices and institutionalization must end.” (Page 4)

• “The right to free and informed consent is a fundamental element of the right to health. It encompasses the right to consent to, refuse or choose an alternative medical treatment.” [Emphasis added] “…no mental health treatment shall be given without the free and informed consent.” (Page 55)

• “Although several countries have tightened their criteria to authorize involuntary commitment, rates have not declined; rather they are increasing, even within well-resourced mental health care systems. In a study conducted between 2008 and 2017, it was found that 11 of 18 countries reporting data experienced an increase in involuntary hospitalization rates of up to 8.45%.” (Pages 13-14)

• “Law can prohibit substitute decision-making in the provision of mental health care and support. This includes repealing the provisions that allow guardians and family members to make decisions for people receiving mental health care or support, as well as eliminating all instances in which the law allows the treating doctor to decide for the person in their “best interests”. The law can also expressly prohibit health professionals from making decisions without the person’s informed consent (see section 2.3.4) and facilitate access to supported decision-making.” (Page 48)

• “All mental health interventions and services shall be provided on the basis of persons’ free and informed consent. In no situation shall mental health internment, hospitalization or treatment be carried out against the will of the person.” (Page 68)

• “Free and informed consent is required before any mental health intervention or treatment. Free and informed consent cannot be replaced by a third party.” (Page 56)

• “Countries can adopt a higher standard for the informed consent to psychotropic drugs given their intrusive nature and potential risks of harm in the short and long term.” (Page 57)

• Legislation should adopt advance directives. “Advance plans are sometimes referred to as ‘advance directives’ or ‘living wills,’” which “allows individuals to express their will and preferences prior to when they are needed….” (Pages 49 and 60)

Electroshock Causes Harm

• The report recognizes the brain-damaging effects of ECT and the “significant controversy” that surrounds its use: “In Slovenia and Luxembourg, ECT is not available; and in many countries, there has been a dramatic decline in its use. Moreover, there are calls to consider banning ECT altogether,” which CCHR insists should occur. (Page 58)

• “If permitted, ECT must only be administered with the informed consent of the person concerned. International human rights standards are very clear that ECT without consent violates the right to physical and mental integrity and may constitute torture and ill-treatment. People being offered ECT should also be made aware of all its risks and potential short- and long-term harmful effects, such as memory loss and brain damage.” (Page 58)

• “ECT is not recommended for children, and hence this should be prohibited through legislation.” (Page 58)

• “Therapies and interventions to change a person’s sexual orientation, gender identity, or gender expression are prohibited.” (Page 82)

Prohibiting Seclusion and Restraints

• “There is a growing consensus that all forms of restraint and seclusion in mental health services should be eliminated… Not only are seclusion and restraint contrary to international human rights law, their use is incompatible with a recovery approach, counters the purpose of care and can lead to physical and psychological harm, even death.” (Page 72)

• In response to concerns about restraint use leading to harm and death, legislation should “prohibit the use of seclusion and restraint in any health or social care facility.” (Page 72)

• “Coercion also takes place outside hospitals in community-based mental health services, residential facilities, family homes and the community in general. The practice of shackling persons experiencing intense distress or unusual perceptions has been documented in various countries.” (Page 72)

• “In Indonesia, Law No. 18 of 2014 on Mental Health considers shackling as a criminal offence.” (Page 72)

• “The use of any coercive measure in health services is prohibited. This includes medical and non-medical interventions without free and informed consent; the use of isolation rooms and chemical and physical restraints; and restrictions to free movement.” (Page 73)

• “Shackling, chaining, seclusion, restraints, and any other form of violence and abuse against a person with mental health conditions and psychosocial disabilities in the community are prohibited.” (Page 73)

• This is because “Seclusion or solitary confinement and the use of restraints, including chemical restraints, are frequently used as a way to enforce compliance to treatment and medication.” (Page 11)

• Because of their prohibition, all episodes of chemical and physical restraint and seclusion should be recorded and made available to the independent monitoring body.” (Page 72)

Biomedical-Drug Model Unworkable—Psychotropic Drugs

• “…human rights violations continue to exist in mental health care settings. There is an overreliance on biomedical approaches and treatment options and inpatient services….” (Page 4)

• Laws should “transition away from a narrow emphasis on biomedical approaches towards a more holistic and inclusive understanding of mental health.” (Page 4)

•  “The legitimization of civil commitment civil commitment has contributed to high rates of people being admitted to and living in institutions, condoned discrimination and human rights abuses, entrenched barriers and neglected reform….” (Page 14)

• “Medical professionals have the obligation to inform persons using mental health services of the possible risks, harms and side effects in the short, medium and long term associated with use of the proposed psychotropic drugs, and of the right to initiate a process of discontinuation and to be supported to do this safely.” (Page 58)

• Legislation should “require medical staff to inform about the right of service users to discontinue treatment and to receive support for that. Support must be provided to help people safely withdraw from drug treatment.” (Page 58)

• “The health authority shall report, on regular basis, the availability of discontinuation programs for psychotropic drugs.” (Page 58)

• “Mental health services must make provisions for an adverse drug reactions register with a clearly defined procedure for reporting, and a well-documented process for addressing adverse outcomes.” (Page 58)

Professional Responsibility and Criminal Liability

• “Accountability is an important component of the human rights framework. Without accountability, human rights lack enforcement and are rendered meaningless. Governments and other actors are accountable to rights holders, and mechanisms need to be established to define clear responsibilities, to measure and monitor progress, and to engage with rights-holders to improve policy-making.” (Page 28)

• Access to justice for persons with mental health conditions and psychosocial disabilities has commonly been restricted, affecting their right to a fair trial and denying them the possibility to contest arbitrary detention, forced treatment and abuses in mental health services. Examples include laws that restrict a person’s right to file a complaint or stand trial; diversion from criminal, civil and administrative processes resulting in deprivation of liberty, forced treatment and institutionalization; lack of credibility; ineffective remedies; and lack of legal aid.” (Page 21)

• “Access to justice is also essential to accountability. It allows persons interacting with mental health services to challenge human rights violations and to enforce rights, including the right to an effective remedy…. Effective remedies also entail the duty to investigate and bring to justice those who are responsible, to hold them to account, combat impunity and prevent repetition of violations.” (Page 29)

• “When a law is transgressed, legislation should provide for effective civil, administrative or criminal sanctions and reparations. Such sanctions should be proportional to the gravity of the offence, the severity of the harm and the circumstances of each case. It is the responsibility of each country to determine the system… for health and non-health related offences and penalties.” (Page 105)

• “Legislation on professional liability has important implications for mental health provision. While professional liability for medical malpractice can help ensure that health providers meet an adequate standard of care and respect people’s rights, inadequate liability regulation can hamper efforts to eliminate coercive practices in mental health services.” (Page 105)

• “…the work of monitoring and accountability bodies, such as courts, national human rights institutions and monitoring bodies, with the participation of persons with lived experience, contribute to raising the visibility of human rights challenges and fostering the respect and protection of human rights.” (Page 29)

• “Data collection and public access to information are also necessary to ensure transparency and to enable monitoring by both civil society and the general public.” (Page 113)

• “Moreover, those deemed ‘unfit to stand trial,’ or of comprehending their criminal actions are usually placed in mental health facilities, without due process and under strict regimes, sometimes indefinitely.” (Page 111) “All people subject to criminal proceedings shall receive the same treatment and have the same opportunities to respond to an accusation or present a defense.” (Page 113)

Supporting Patient Complaints

• Service users should have the “right to report complaints and initiate legal proceedings concerning any aspect of mental health care.” This includes any human rights violation committed….” (Page 154)

• “Persons who use support need to be informed of their rights and the complaints mechanisms available.” (Page 52)

• “Appropriate mechanisms shall be established to receive and investigate complaints regarding the ill-treatment of a person with mental health conditions and psychosocial disabilities in the community, and to provide effective redress.” (Page 73)

• Current and former service users should have the right to issue complaints and initiate legal proceedings concerning any aspect of mental health provision, including treatment, behavior, or conduct. Effective remedies should be available to challenge any human rights violation committed in the context of such services, including deprivation of liberty, institutionalization, and other coercive practices.” (Page 103)

• “Legislation can outline the procedure for submission, investigation and resolution of complaints mechanisms. Such complaints mechanisms should be accessible, easy to use, expeditious, transparent, and effective. Information about complaints procedures should be prominently disseminated so that all persons using mental health services, their families and advocates are informed of its relevance, applicability, and how and where to lodge a complaint.” (Page 103)

• “Legislation can also ensure that complaint adjudicators, such as national human rights institutions or courts, provide remedies that are individually tailored and include redress and reparation for the harm suffered…victims and survivors should be entitled, whenever possible, to restitution, compensation, rehabilitation and guarantees of non-repetition.” (Page 103)

Monitoring Bodies Established to Prevent Abuse

Bodies need to be established to monitor abuses and violations in the mental health field, as ultimately, they can prevent these. Such bodies should:

• “Conduct regular and unannounced inspections of mental health settings or services, public and private, as deemed necessary. During such visits, they should have unrestricted access to all parts of the health service and service users’ medical records as well as the right to interview any person in the service in private.” (Page 102)

• “Provide guidance on eliminating coercion in mental health services and monitor the implementation of such guidance.” (Page 102)

• “Collect data and statistics on service provision, for example, on the duration of hospitalizations, the use of specific treatments and interventions, physical comorbidities, suicide, and natural or accidental deaths.” (Page 102)

• “Monitor the practice of major, invasive or irreversible interventions; ensure these are undertaken only with free and informed consent;  where necessary, strengthen protections.” (Page 102)

• “Maintain registers of mental health settings accredited for outpatient and inpatient treatment, and outline and enforce quality and human rights standards for such accreditation.” (Page 102)

• “Propose administrative and financial penalties for breach of legislative provisions, including the withdrawal of accreditation and closure.” (Page 102)

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[1] World Health Organization, OHCHR, “Guidance on Mental Health, Human Rights and Legislation,” 9 Oct. 2023

[2] “Study finds involuntary psychiatric detentions on the rise,” UCLA Newsroom, 3 Nov. 2020, https://newsroom.ucla.edu/releases/involuntary-psychiatric-detentions-on-the-rise

[3] https://www.cchrint.org/2022/07/11/end-coercive-psychiatric-practices-against-african-americans/; “Involuntary Commitments: Billing Patients for Forced Psychiatric Care,” The American Journ. of Psychiatry, 1 Dec. 2020, https://ajp.psychiatryonline.org/doi/10.1176/appi.ajp.2020.20030319

[4] https://www.ohchr.org/en/calls-for-input/calls-input/draft-guidance-mental-health-human-rights-legislation-who-ohchr

[5] https://www.ohchr.org/en/calls-for-input/calls-input/draft-guidance-mental-health-human-rights-legislation-who-ohchr

[6] World Health Organization, OHCHR, “Guidance on Mental Health, Human Rights and Legislation,” 9 Oct. 2023, p. 13

[7] Ibid., p. 15

[8] https://www.cchrint.org/psychiatric-drugs/people-taking-psychiatric-drugs/

[9] Op. cit., World Health Organization, OHCHR, “Guidance on Mental Health, Human Rights and Legislation,” p. 13

[10] https://www.cchrint.org/2021/06/11/world-health-organization-new-guidelines-are-vital-to-end-coercive-psychiatric-practices-abuse/; “Guidance on Community Mental Health Services: Promoting Person-Centered and Rights-Based Approaches,” World Health Organization, 10 June 2021, p. 215, https://www.who.int/publications/i/item/9789240025707

[11] https://www.cchrint.org/2020/09/09/task-force-against-racism-and-modern-day-eugenics-launches-vital-website/; Tyler Kingkade,” Video shows fatal restraint of Cornelius Frederick, 16, in Michigan foster facility,” NBC News, 22 July 2020, https://www.nbcnews.com/news/us-news/video-shows-fatal-restraint-cornelius-fredericks-16-michigan-foster-facility-n1233122;  https://www.cchrint.org/2020/06/23/task-force-launched-to-combat-institutional-racism-in-psychiatric-industry/

[12] https://www.cchrint.org/2022/09/30/mental-illness-awareness-week-another-restraint-another-death/, Deborah Yetter, “7-year-old died at Kentucky youth treatment center due to suffocation, autopsy finds; 2 workers fired,” Louisville Courier Journal, 19 Sept. 2022, https://www.usatoday.com/story/news/nation/2022/09/19/death-child-jaceon-terry-brooklawn-kentucky-youth-center/10428004002/

[13] Op. cit., World Health Organization, OHCHR, “Guidance on Mental Health, Human Rights and Legislation,” p. 59

[14] Ibid., p. 58

[15] https://www.cchrint.org/memorandum-need-for-human-rights-in-mental-health-laws/

[16] Matthew S. Smith & Michael Ashley Stein, “When Does Mental Health Coercion Constitute Torture?: Implications of Unpublished U.S. Immigration Judge Decisions Denying Non-Refoulement Protection,” Fordham International Law Journal, Vol 45:5, 2022, https://ir.lawnet.fordham.edu/ilj/vol45/iss5/2/, p. 785

[17] A/HRC/22/53, “Report of the Special Rapporteur on torture and other cruel, inhuman or degrading treatment or punishment, Juan E. Méndez,” United Nations, General Assembly, Human Rights Council, Twenty-second Session, Agenda Item 3, 1 Feb. 2013, p. 15, http://www.ohchr.org/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf