The cost of coercion

I’m currently a part-time member of the NSW Mental Health Review Tribunal in New South Wales, and after 45 years working in mental health, I’m approaching retirement.

I began my career in the days when community mental health crisis teams genuinely operated as community services. 

• We worked on a 24-hour basis
• We responded to people where they were
• We went out into the community in the middle of the night if someone needed support.

Later, I moved into education, managing training for health staff in the prison system and then working more broadly in mental health education with the NSW Institute of Psychiatry. I’ve also spent the last 21 years working part time on the Mental Health Review Tribunal.

Front row seat

That work has given me a front row seat to the way our system has evolved. Through the Institute I delivered education programmes in all states in Australia, and this experience has left me increasingly concerned that we are developing a coercive mental health system.

The machinery of coercion

The Tribunal exists under the Mental Health Act. It is designed as a safeguard.

When someone is involuntarily detained in hospital, they appear before tribunal members who determine whether that detention remains the least restrictive option consistent with safe and effective care.

A typical panel includes a lawyer, a psychiatrist, and another suitably qualified person. In my case, that comes from decades working in mental health and education.

We also authorise community treatment orders, electroconvulsive therapy, and decisions relating to forensic mental health patients.

The intention is oversight and fairness.

That realisation sharpened for me when I completed an International Diploma in Mental Health Law and Human Rights through the World Health Organisation. At first, sitting in rooms with psychiatrists and lawyers from around the world, I thought Australia was doing reasonably well. But the more I understood both the United Nations guidelines and our own legislation, the clearer it became that we still have significant room for improvement.

It is my opinion that we can rely too heavily on coercive orders to deliver treatment.

Orders, compliance, and control

Community treatment orders were introduced in New South Wales in 1990.In practical terms, these orders require people to comply with treatment conditions. Usually that means medication. It can also mean attending appointments, seeing case managers, completing urine drug screens, or undertaking blood tests. These are not suggestions. They are mandatory.

First responders, not best responders

If a person does not comply, and services believe there is risk involved, police can ultimately be used to return them to hospital for assessment. That is one of the clearest examples of coercion in the system. We now use police far too often because we no longer have the community-based responses we once had.

Years ago, if somebody was struggling, we went to them. We did not automatically bring them back into institutional settings. We did not assume the only answer was police intervention or hospital admission. Now, particularly after hours, police often become the first responders.

Assumptions not always on target

At the same time, we operate within a framework that frequently assumes people lack capacity simply because they are involuntary patients.

That assumption matters.

• It means substitute decision making becomes the norm.
• Doctors are given broad authority to make decisions on behalf of people they may barely know.

Rediscovering community

One of the most hopeful moments I’ve had in recent years came while attending a conference focused on alternatives to acute mental health care. I’ll admit I began the conference somewhat cynical. I found myself thinking that many of the ideas being discussed were things we had already been doing decades ago. But when peer-led crisis services and peer hubs began to be discussed, I became genuinely excited.

The crisis team I worked on many years ago operated a respite centre where people could stay instead of going to hospital. It was a community response built around support rather than control. Somewhere along the way, many of those models disappeared. Hearing about the return of peer-led spaces, crisis centres, and community hubs felt important because they offer a fundamentally different entry point into mental health care.

Heartened by the return of Peer

The idea of a peer hub operating openly in a shopping centre particularly resonated with me. A place sitting alongside banks, supermarkets, and retail stores sends a powerful message that mental health belongs in ordinary community life, not hidden away behind institutional walls. That is the direction we should be moving toward.

Risk and retreat

I understand why services have become more cautious. The world has changed since the 1980s. Methamphetamine has changed the landscape significantly. Violence and risk are real issues for staff working in the community.

I am not arguing that we return blindly to the old days of lone workers knocking on unfamiliar doors at three o’clock in the morning with nothing but a torch. That would be foolish.

But I do believe we have retreated too far from community-based engagement because we have become excessively risk averse.I believe in short-term risk for long-term gain. That means calculated risk. Managed risk. Intelligent risk.

Meet on their turf

It means being prepared to meet people on their own turf rather than constantly insisting they come to us. Too often our systems are designed around organisational convenience instead of human need.

I have seen community treatment orders requiring people to attend appointments with doctors they have to pay for themselves, and then pay for the medication we are legally compelling them to take. That reveals how coercive the system can become.

Training the workforce we need

One of the biggest problems we face is workforce capability. The mental health component of nursing education is deeply inadequate. We need to make mental health work more attractive, and then we need to train people properly for community-based practice. We need clinicians who are capable of working with people where they are, not simply expecting people to bend around service requirements.

But peer workers alone cannot solve the problem. We need a broader return to genuine community mental health care. That means going to where people actually are.

I volunteer with an organisation called Orange Sky, which provides laundry services for people experiencing homelessness. Working alongside those services, I regularly see community models that make far more sense than highly institutional approaches. People can access doctors, Centrelink, dentists, and support services all in one community setting. That is the kind of thinking we need more of.

Maintaining Hope

After decades in mental health, it is easy to become cynical. There are days on the tribunal where I feel as though all I am doing is repeatedly authorising community treatment orders for people caught in the same cycle over and over again. Sometimes it can feel hopeless. But I am constantly reminded, particularly by colleagues and people working directly alongside consumers and peer workers, that hope matters.

You have to maintain hope. Without it, systems become mechanical. Care becomes procedural. People become problems to manage instead of human beings to support.

For me, that is the central challenge facing mental health care.

We need to move away from systems built primarily around coercion and control and back toward systems built around engagement, trust, dignity, and community.