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In August 2019, a manuscript was published in this journal that aimed at imagining a mental health care system that renounces the judicial control to better focus on the will and preferences of those who require support. Alternative scenarios for dealing with risk, inpatient care, and police custody were presented that elicited strong and emotionally laden reactions. This article adds further reflections to this debate, aiming at contributing explanations for this unsettlement. A productive notion of criticism is discussed, and ways to achieve change toward a more human rights-oriented psychiatric practice are outlined.

Based on the UN Convention on the Rights of Persons with Disabilities (CRPD), several UN bodies, among them the High Commissioner for Human Rights, have argued for a complete ban of all coercive interventions in mental health care. The authors conceptualize a system for mental health care based on support only. Psychiatry loses its function as an agent of social control and follows the will and preferences of those who require support. The authors draw up scenarios for dealing with risk, inpatient care, police custody, and mental illness in prison. With such a shift, mental health services could earn the trust of service users and thereby improve treatment outcomes.

Coercive treatment with antipsychotic drugs was commonly used in German psychiatric institutions until it became a topic of substantial medical, legal and ethical controversy. In 2011 and 2012, several landmark decisions by Germany’s Constitutional Court and Federal Supreme Court challenged this practice in all but life-threatening emergencies. In March 2013, the new legal provisions governing coercive treatment took effect allowing coercive medication under stricter criteria. While mainstream psychiatry in Germany resumed the use of coercive medication, although less frequently than before 2012, there are examples where clinicians put an even greater emphasis on consensual treatment and did not return to coercive treatment. Data from a case study in a local mental health service suggest that the use of coercive medication could be made obsolete.