Forcibly restraining or secluding someone who is experiencing a mental health crisis can lead to severe physical injury and even death. People who have experienced these coercive measures say that they are traumatic, detrimental to recovery and engender mistrust in mental health services. They are systemic failures of care, and health-care staff may feel that using them violates their own values and morals.
It has long been WHO’s position that these interventions – in addition to not being therapeutic – are violations of human rights under all international instruments, including the United Nations Convention on the Rights of Persons with Disabilities.
So why do they continue to be used?
For those working to end seclusion and restraint through the WHO QualityRights initiative, it often comes down to a fundamental breakdown in communication between users and staff, exacerbated by systemic challenges.
“It seems like sometimes there is only a partial acceptance of human rights in mental health care,” says Roger Banks, a psychiatrist from the United Kingdom and a WHO QualityRights trainer. “People will say, well, human rights are okay until it comes to this particular issue of seclusion and restraint, but then we have to make other decisions to mitigate risk and ensure safety, to protect other people.”
Thankfully, governments and mental health institutions across the WHO European Region are increasingly working to promote alternatives to these coercive measures and change service culture for the better.
A long and winding road
There are many forms of seclusion and restraint, and they are often used together. Mechanical restraint includes using belts, straps or ropes to restrict a person’s ability to move, while chemical restraint refers to using sedatives or another medication against a person’s will. Seclusion means restricting a person’s ability to leave a room or area.
All are considered harmful, but they remain legal in most countries in the Region – to a point. Laws may restrict the amount of time a person can be secluded or restrained and permit coercive interventions in situations that pose an immediate danger to the service user or others.
Many institutions use these measures excessively. In 2018 WHO/Europe published the results of an assessment of long-term mental health-care institutions in 24 countries, focusing on the extent to which care in these institutions aligned with international human rights instruments.
Distressingly, most of the 98 institutions fell well short of standards. The report cites “egregious” examples of rights violations, including unwarranted use of coercive interventions.
Following the report, WHO started to work with national governments to improve standards of care. Croatia, Czechia, Latvia and Serbia organized trainings in WHO QualityRights to begin changing institutional culture and practices. However, this work stalled during the COVID-19 pandemic.
In 2024 things began to move again. WHO/Europe, under its European Union (EU)-funded project “Addressing mental health challenges in the EU, Iceland and Norway”, began to conduct policy dialogues with the 29 countries participating in the project. Improving the quality of mental health services through WHO QualityRights was at the top of the list for many of the countries.
WHO/Europe then brought on Roger Banks and 2 other trainers – Danny Angus and Jennifer Kilcoyne – to hold trainings in 4 countries: Bulgaria, Lithuania, Slovakia and Slovenia. The focus of these initial trainings was on promoting alternatives to coercive practices like seclusion and restraint.
“Everybody agrees about protecting human rights, but in practice, as professionals working in hospitals, we have this sense that we cannot do our work without physical restraint,” says Vesna Švab, a psychiatrist and professor at the University of Ljubljana, who participated in the training in Slovenia.
“It was the first time in my life that I really recognized that people in the room agreed with me that change has to be made. It was a fantastic feeling,” she continued.
“Chronic lack of communication” and systemic challenges
Coercive measures are often the result of improperly managed communication between users and staff. This is why much of the focus of QualityRights is on improving communication and increasing staff’s skills in de-escalating tense situations.
“I would say that coercive measures reflect a helplessness of the entire system, including staff, to understand somebody in crisis,” says peer worker Marina Vidović from Croatia, in a recent video published by the Feniks Split Association, a nongovernmental organization that supports people living with mental health conditions.
Marina goes on in the video to call coercive measures a “chronic lack of communication”. Breakdowns in communication occur for many reasons. Staff may interpret frustration or stress in users as challenging or aggressive, often due to stigma. They may not know what a person needs when anxious or stressed, or feel unable to grant a person’s requests because of safety reasons.
However, staff’s lack of skills is rarely the only reason that coercive measures end up being used.
“Many of the organizations that we’ve supported share the same systemic challenges, including a lack of staff, poor environments, and difficulties in managing risk and safety while upholding people’s human rights and delivering person-centred care,” says Danny Angus, a mental health nurse at Mersey Care National Health Service (NHS) Foundation Trust in England.
“Despite these challenges, we have proven through a national culture change programme in England, HOPE(S), that we can reduce coercive measures and improve the experience of the people we serve and support their recovery,” Danny adds.
Many countries in the Region are short of staff, although the gap is difficult to estimate. In a 2023 survey of mental health systems capacities in the EU, Iceland and Norway, over half (16 of the 29 countries) reported needing support in mental health workforce planning and capacity-building. They also cited a lack of workforce as a major barrier to mental health policy implementation.
When a busy ward does not have enough staff, seclusion and restraint may be seen as the only options to ensure everyone’s safety in a crisis. This can even be true when staff know that coercive measures are harmful – they may feel unable to act otherwise. This adds moral injury and disillusionment among staff to the list of negative impacts of coercive practices.
“We must remember the person in crisis – who is in pain, who came for help, and who must not be punished because of a lack of staff,” says Marina.
Changing minds and cultures
Promoting coercion-free care means changing staff’s daily practices and perspectives as much as institutional policy. For example, nurses, psychiatrists and ward assistants can be taught how to de-escalate tense situations, actively taking the time to listen to users’ needs and work with them to reduce stress. This can be helped along with individualized plans, which staff and users create together to help staff know what to do (and what not to do) when users are distressed.
“Seeing the person, not the diagnoses, and working side by side with the people we serve increases compassion, tolerance and understanding. These core principles create safer environments for people using and delivering services,” says Danny.
Such individual approaches are essential but not enough. Without changing the service culture and increasing resources, putting the burden of change on individual workers can lead to compassion fatigue and a return to coercive measures.
“We often see that there's a group of people who want to improve things, but they don't feel supported to work in a different way. So, what happens is you get these pockets of good practice that never really spread across the wider organization or health-care system,” says Jennifer Kilcoyne, Clinical Director at Mersey Care NHS Foundation Trust, and another QualityRights trainer.
This is why it is essential to involve leaders, from hospital managers all the way up to health ministers.
Ending seclusion and restraint
WHO’s position is that countries must set ending all use of coercive measures as the goal, rather than just seeking alternatives. Coercive measures should not even be considered a last resort, as doing so may engender the very culture that WHO QualityRights is designed to change, where coercive measures are the norm.
Jennifer says that the pockets of good practice are a good starting point. A small but motivated team of staff who champion good practices and collect data on the impact of their practices can be a strong foundation for changing workplace cultures.
Culture change is slow, but there is reason to hope. In Slovenia, new guidelines for staff on seclusion and restraint are being drafted. Lithuania has begun enforcing new regulations on the staff-to-bed ratio and ensuring availability of comfort rooms. The Safewards model is being promoted in Slovakia. Further QualityRights trainings were being organized under the “Addressing mental health challenges” project, including in Croatia in March 2025.
Most importantly, participants of the recent training are noticing a growing interest among policy-makers and leadership to promote coercion-free care. This interest was not present 8 years ago, when WHO/Europe was conducting its assessments.
Such interest suggests a burgeoning collective will to change, which is the only way to ensure that those changes stick, says Jennifer. She cites a well known proverb: “If you want to go quickly, go alone. If you want to go far, go together.”