Clinical Relevance of Informal Coercion in Psychiatric Treatment—A Systematic Review

Abstract

IntroductionAlthough informal coercion is frequently applied in psychiatry, its use is discussed controversially. This systematic review aimed to summarize literature on attitudes toward informal coercion, its prevalence, and clinical effects.MethodsA systematic search of PubMed, Embase, PsycINF, and Google Scholar was conducted. Publications were included if they reported original data describing patients’ and clinicians’ attitudes toward and prevalence rates or clinical effects of informal coercion.ResultsTwenty-one publications out of a total of 162 articles met the inclusion criteria. Most publications focused on leverage and inducements rather than persuasion and threat. Prevalence rates of informal coercion were 29–59%, comparable on different study sites and in different settings. The majority of mental health professionals as well as one-third to two-third of the psychiatric patients had positive attitudes, even if there was personal experience of informal coercion. We found no study evaluating the clinical effect of informal coercion in an experimental study design.DiscussionCultural and ethical aspects are associated with the attitudes and prevalence rates. The clinical effect of informal coercion remains unclear and further studies are needed to evaluate these interventions and the effect on therapeutic relationship and clinical outcome. It can be hypothesized that informal coercion may lead to better adherence and clinical outcome but also to strains in the therapeutic relationship. It is recommendable to establish structured education about informal coercion and sensitize mental health professionals for its potential for adverse effects in clinical routine practice.

A qualitative study of forensic patients' perceptions of quasi‐coercive offers of biological treatment

“…They suggest that informal coercion might improve treatment adherence but might also strain the therapeutic relationship, and conclude that patients and physicians tend to be positive about informal coercion as long as transparency, patient dignity, and procedural fairness are respected. They argue that there is a need for “[a] more prominent place for the issue of informal coercion and the therapeutic relationship in educative curricula of mental health professionals as well as more in‐depth qualitative and quantitative research on informal coercion” (Hotzy & Jaeger, , p. 11).…”

Mental health patients’ experiences of softer coercion and its effects on their interactions with practitioners: A qualitative evidence synthesis

“…Practitioners (termed here as including mental health nurses and other clinicians in the mental health field) and patients report contrasting perspectives regarding coercion (Hem, Gjerberg, Husum, & Pedersen, ; Hotzy & Jaeger, ; Molodynski, Rugkåsa, & Burns, ; Olofsson & Norberg, ). Some practitioners believe that coercion can help patients avoid further deterioration and involuntary treatment (Hotzy & Jaeger, ) but can also feel pressured into coercively activating patients towards discharge (Femdal & Knutsen, ). However, whilst it is important for practitioners to feel able to justify their coercion (Vuckovich & Artinian, ), they can underestimate how coercive they can become (Hotzy & Jaeger, ).…”

“…Some practitioners believe that coercion can help patients avoid further deterioration and involuntary treatment (Hotzy & Jaeger, ) but can also feel pressured into coercively activating patients towards discharge (Femdal & Knutsen, ). However, whilst it is important for practitioners to feel able to justify their coercion (Vuckovich & Artinian, ), they can underestimate how coercive they can become (Hotzy & Jaeger, ).…”

“…Although patients report mixed experiences of coercion, these are often negative (Care Quality Commission, ; The Commission on Acute Adult Psychiatric Care, ) and disproportionally affect larger numbers of people from Black and Minority Ethnic (BME) groups (Bhui et al, ; Care Quality Commission, ). Some patients perceive coercion as being detrimental to their mental health and subsequently disengage or become increasingly non‐compliant with treatment (Hotzy & Jaeger, ; Jaeger et al, ; Swartz, Swanson, & Hannon, ). Patients can also perceive coercion as being traumatic (Paksarian et al, ) or as a form of punishment or to make things easier for staff (Olofsson & Norberg, ).…”

“…Practitioners influence the experience of being coerced. For example, positive perceptions of coercion are associated with patients believing practitioners act in good faith, are beneficent, open, and honest (Bennett et al, ) when coercion is administered transparently and fairly (Hotzy & Jaeger, ), in their best interests (Lorem, Frafjord, Steffensen, & Wang, ) and through collaborative and trusting relationships with practitioners (Thogersen et al, ).…”