This is the introduction to 'The Convention on the Rights of Persons with Disability: Next Generation Thinking', a special edition of the Human Rights Law Review. It is now almost twenty years since the CRPD was passed by the UN General Assembly, and a great deal of interpretive work has occurred since that time. Initial euphoria has given way to the hard intellectual graft of trying to interpret the Convention in a way that ensures the ongoing agency and autonomy of people with disabilities, while developing practical solutions and directions that will make real differences in the lives those people. The special edition is a contribution to those broader discussions, and this introduction gives a flavour of the papers in the collection.

A great deal of scholarship has explored how human rights, through the Convention on the Rights of Persons with Disabilities (CRPD), should affect disability policy and practice. This paper asks the reverse question: how does the framing of rights in the CRPD affect how we need to think about human rights? The CRPD's two main human rights shifts are a strongly indivisible reading of human rights, where civil/political rights are inseparable from economic and social rights, and a much stronger realization that human rights are not just the role of governments of States Parties, but civil society more broadly. The paper explores the resulting challenges to human rights law, including ambiguities surrounding immediate and progressive realization of rights, difficulties in identifying violations of rights and determination of how enforcement is to happen, tensions in the role of the state, and the problem of getting civil society on board for human rights promotion and change.

It is now more than a quarter of a century since the Law Commission completed its ground-breaking report on mental capacity, a report that became the Mental Capacity Act 2005. Since that time, there have been fundamental changes in the legal, social, and academic understanding of people with mental disabilities, and the pragmatics of legislative implementation have exposed difficulties that the Law Commission did not foresee. This paper considers key elements of the Act in light of those changed expectations and the experience of implementation

In the last decade, questions have been raised in the United Kingdom about the overuse of psychotropic medication in the elderly and among people with learning disabilities. This chapter considers the policies on rapid tranquilisation of 120 NHS Trusts in England from the perspective of law and human rights. While law is routinely considered as a framework for the policies, it is rare that the policies provide much by way of helpful commentary on what the law actually states or permits. The chapter also identifies problematic aspects of many of the policies from a human rights perspective. With few exceptions, the stated justifications for intervention are based on risk and dangerousness. The policies rarely take express account of the emotional or psychological impact of rapid tranquilisation. While some policies provide what appears to be a standard statement that the Trust respects human rights and equality, the failure to provide robust processes of engagement with the patient raise doubts as to how that representation is carried into practice.

Forensic care settings are often isolated spaces with high levels of security. Where these settings are overly restrictive, this can affect recovery, autonomy and the therapeutic milieu. It is not clear what phenomena patients themselves identify as restrictive and how, subjectively, they experience these. Semi-structured interviews were conducted with 18 patients in secure hospitals in England. Respondents included male and female patients with mental illness or personality disorders on both civil and criminal detentions. The results suggest a model of restrictiveness consisting of five themes: (1) the antecedent conditions to restrictive phenomena; (2) restrictive phenomena themselves; (3) how these are enacted, (4) how these phenomena were subjectively experienced by patients; and (5) the consequences of these phenomena as expressed by patients. Restrictiveness understood in this way is broader than "least restrictive practices" typically understood as restraint, seclusion and forced medication. Respondents' comments encourage us to rethink the unintended effects of placing individuals within secure hospitals.

Where safe, forensic mental health systems should provide care in the least restrictive environment possible. Doing so can maximize patient autonomy and empowerment while minimizing unnecessary social disconnection and stigmatization. This study investigated whether patients’ perceptions of restrictiveness were associated with demographic, clinical, and legal characteristics. The Forensic Restrictiveness Questionnaire (FRQ) was used to measure perceptions of restrictiveness in 235 patients in low-, medium-, and high-secure settings in England. The results showed that restrictiveness scores were significantly higher for patients who experienced an adverse event in the past week or were diagnosed with a personality disorder compared to those with a mental illness. A regression analysis suggested that only diagnosis was predictive of FRQ scores when controlling for perceptions of ward atmosphere and quality of life. Age, length of stay, ethnicity, level of security, legal section, and offence type were not associated with FRQ scores. Future research should investigate the roles that individual symptoms, insight into illness, mood, personality, and expectations of care have in influencing perceptions of restrictiveness.

Forensic psychiatric care settings are intended to be more therapeutic than penal settings. More homely, recovery-oriented, person-centered, and less overtly punitive. However, forensic inpatient hospitals are highly secure, risk averse, and can diminish patient autonomy. A body of research is investigating how patients experience care and how these experiences are associated with treatment outcomes. The self-report FORENSIC RESTRICTIVENESS QUESTIONNAIRE (FRQ) is a 15-item measure of patients' perceptions of the restrictions upon their autonomy. There has been interest in validating the FRQ in several countries. Despite preliminary empirical support for the FRQ, its psychometric properties are not well understood. In this paper we draw on Item-Response Theory (IRT) to investigate the properties of individual FRQ items to identify candidate items for alteration, removal or retention to assist researchers validating the FRQ in new contexts. Results suggest the FRQ is more sensitive to measuring the perceptions of patients that have above average amounts of perceived restrictiveness. Measurement error rises sharply for the approximately 5% highest scoring respondents but is low for the majority of individuals. Users are likely to respond in a dichotomised manner and not use the 'Not Sure' option. The response category 'Not Applicable' should be removed from a revised FRQ.

The United Nations Convention on the Rights of Persons with Disabilities (CRPD) is rightly seen as a break from the past in mental capacity law. At the same time, implementation will occur in the specific existing legal and administrative contexts of each State. This article uses English mental capacity law to explore these issues. The English Mental Capacity Act 2005 (MCA) can be considered the best of the “old” paradigm. The article argues that there are continuities between it and a CRPD-compliant approach. These continuities should be built upon. Further, the implementation of the MCA is still in recent memory. The lessons of that implementation will have considerable application to moves toward CRPD compliance. CRPD compliance is not just about specialist stator guardianship régimes. It is also about a myriad of law, currently capacity based, located in specific legal areas such as contract, wills and succession, and criminal law. Reform in these areas will involve not just disability law, but successful integration into those other legal areas, a matter requiring the involvement of those knowledgeable in those other areas. Since change in these areas will involve the removal of disability as a gateway criterion, they will affect the public as a whole, and the thus, determination of the degree and sort of intervention that the broader public will consider appropriate.

[This corrects the article DOI: 10.3389/fpsyt.2019.00805.].

G. Szmukler's paper1 needs to be understood in the context of the Convention on the Rights of Persons with Disabilities (CRPD) as a whole, and what the CRPD endeavors to achieve. The motivation for the CRPD was an acknowledgement that existing legal and policy approaches, both at the international and the national levels, were not delivering human rights for people with disabilities2. As that relates to people with mental disabilities, that is unlikely to be contested by the readers of this journal. We are all aware of institutional systems in which people with mental disabilities may spend most of their lives in conditions that are frankly deplorable. Countries of the global North sometimes portray themselves as somehow above this, but a perusal of the reports of the European Committee for the Prevention of Torture suggests that none of us has much to crow about3. Life in the community is often not much better. Poverty is endemic, no doubt in part reflecting the risible employment rates of people with mental disabilities. Community housing is often substandard. There is little evidence of meaningful social integration, but certainly evidence of being the victims of violence, exploitation and abuse4. These problems are international: we all have to own them as they relate to our own countries, wherever we are. In that sense, the CRPD is an attempt to hit the reset button. It tries to create a fresh start in international human rights law, envisaging a world where people with disabilities do get to enjoy the rights and the meaningful lives that the rest of us take for granted2. When commentators speak of the CRPD introducing a “new paradigm” , that is what is meant: it is an acknowledgement that the way we have approached human rights of people with disabilities since the Second World War (and perhaps for centuries before) needs a fundamental rethink. Fundamental to that is a challenge to rethink the role of the state, and its relationship to people with disabilities. Traditionally, the role of the state has been one of control. Mental disabilities provide a particularly clear example of this: we have locked up people with mental disabilities because of perceived dangerousness, or “for their own good” , or to remove them from the public gaze, or to allow their family carers to work. When we have established community programmes for them, social workers and similar professionals have been expected to keep a close eye on their lives. Usually this has been done with good intentions; but it has created a second class citizenship, where rights are contingent in a way not experienced by the rest of society. The CRPD is not anti-state or libertarian. Instead, it re-casts the state, not as a manager of people with disabilities, but in a support role. If people with disabilities are to enjoy the meaningful lives the rest of us expect, supports have to be put in place to bring this about, and that requires either service provision by states, or services provided under state regulation. The services do need to be what people with disabilities want, however: these people should not be required as a matter of state policy to take what is on offer, any more than any other citizen should. The CRPD envisages a world where people with disabilities get to make the same choices as the rest of us. Szmukler is correct that a number of international human rights bodies have been slow to pick this up, but that is appropriately a criticism of those bodies. It is difficult to see how the existing human rights systems that those bodies perpetuate can provide the legal, cultural, policy and ideological shifts that are required to make human rights real for people with disabilities. The failure of these existing systems for people with disabilities was, after all, the reason why the CRPD was perceived as needed, and the international human rights bodies noted by Szmukler need to own that truth. That is not necessarily to say that the position of the CRPD Committee is to be taken uncritically or as unassailable. It is to say that the problems the CRPD is intended to address are real, and critics of the CRPD position should be challenged to provide positive alternatives, rather than to trot out the approaches of the past that have proven insufficient. What does all this mean for Szmukler's analysis? Three points are of particular relevance. The first is that in Szmukler's analysis, as elsewhere in the literature, the debates about capacity, supported vs. best interests decision-making, and the CRPD Committee's General Comment No. 15 take place in isolation from the bigger pictures of what needs to change for people with disabilities. Unsurprisingly, physicians view these issues through the lens of medicine and the effects on their practice. Almost certainly, this will only be a small piece of what is required. Further, decision-making is only relevant if there are options to choose between. The changes needed to realize the CRPD ambition will no doubt include provision of the best available standards of health, but provisions for example concerning the structures of social care and benefits, housing, and community integration will also be pivotal. We should all be working with people with disabilities to articulate those broader changes in ways relevant to our own countries. The discussion of how decisions should be taken in “hard cases” needs to occur in that broader set of contexts, not just within clinical treatment. The second issue is how far Szmukler's analysis actually diverges from the CRPD Committee's approach in General Comment No. 1. He does seem to suggest that the influence of the will and preferences of a person with disability in determining a decision should be directly proportional to the clarity and reliability of those will and preferences. That already seems to be moving a considerable distance from the hard capacity/incapacity divide of current law. Szmukler might well be agreeable to proper support being offered to the person with disability in reaching and articulating views. While he does not use the phrase, his view would appear to be that, in hard cases, decisions should be taken based on the “best approximation” of the person's will and preferences – the CRPD Committee's approach. There is admittedly some divergence on what constitute hard cases, but the similarity of Szmukler's position to that of the Committee is notable. Certainly, versions of Szmukler's approach could mean a considerable move from the managerial ethos of the current system – and that is very much consistent with the CRPD. Finally, there is the question of who should support the person with disability in articulating his/her will and preferences, and deciding what weight should be given to divergent views expressed by the person. Psychiatrists, like many other care professionals, have for generations been at the centre of the culture that people with disabilities are to be managed by the state – the old paradigm. If a will and preferences approach is to be provided by psychiatrists in a non-managerial way, and if psychiatrists are to have the trust of people with disabilities in providing the support in articulating will and preferences, psychiatry will have to break from the old, controlling paradigm. It is not clear whether psychiatry as a profession is ready to make that break.

This article explores and outlines four possible pathways for law reform in the area of compulsory mental health admission and treatment in Hong Kong: the (i) abolition, (ii) risk of harm, (iii) mental capacity and (iv) consensus pathways. The discussion of each pathway takes into account local challenges in implementation, as well as Hong Kong's international commitments for the protection of rights. In outlining these pathways for reform, the authors intend to also provide a blueprint for regulatory change in other jurisdictions that are in the process of reforming their mental health laws.

Summary Many psychiatrists in the UK may be surprised to find that the Government ratified a convention ten years ago that suggests compulsory mental health treatment be prohibited. The Convention on the Rights of Persons with Disabilities is arguably the most important legal instrument that no one in psychiatry ever discusses, but if moved from ratification to enforcement it would have enormous effect on day-to-day practice. Here, Dr Paul Gosney argues that the convention if enforced would be damaging for the people it aims to protect, whereas Professor Peter Bartlett defends it as a necessary challenge to the inequalities in our current system.

Mentally disordered offenders may be sent to secure psychiatric hospitals. These settings can resemble carceral spaces, employing high levels of security restricting resident autonomy, expression and social interaction. However, research exploring the restrictiveness of forensic settings is sparse. A systematic review was therefore undertaken to conceptualize this restrictiveness. Eight databases were searched for papers that address restrictive elements of secure forensic care in a non-cursory way. Fifty sources (empirical articles and policy documents) were included and subject to thematic analysis to identify 1) antecedent conditions to, 2) characteristic attributes, 3) consequences and 4) 'deviant' cases of the developing concept. The restrictiveness of forensic care was experienced across three levels: individual, institutional and systemic. Restrictiveness was subjective and included such disparate elements as limited leave and grounds access, ownership of personal belongings and staff attitudes. The manner and extent to which these are experienced as restrictive was influenced by two antecedent conditions; whether the purpose of forensic care was to be more caring or custodial and the extent to which residents were perceived to be risky. We argue that there must be a reflexivity from stakeholders between the level of restrictiveness needed to safely provide care in a therapeutic milieu and enable the maximum amount of resident autonomy.