Newsportal - Ruhr-Universität Bochum
“If you take your pills, you can have a packet of cigarettes on top of that.” A sentence like this is often heard in psychiatric care. But at which point does it become coercive?
For answering this question, Dr. Matthé Scholten and Christin Hempeler, together with colleagues, have received an award.© RUB, Kramer
Award winners from Bochum: Christin Hempeler, Dr. Mirjam Faissner and Dr. Esther Braun (from left)
Psychiatric Staff Often Unintentionally Exert Coercion
Some coercive measures such as involuntary medication or compulsory medication are regulated by law in psychiatric institutions. In day-to-day care, however, pressure is often exerted on patients through verbal communication to bring them to undergo treatment or take medication – for example, when a psychiatrist threatens a patient that their family won’t be allowed to visit them if they don’t take their medication. A team around Christin Hempeler from Ruhr University Bochum, Germany, investigated at which point such forms of communication cross the line into informal coercion. The researchers received an award from the German Association for Psychiatry and Psychotherapy, Psychosomatics and Neurology (DGPPN) for their analysis.
The research was carried out as part of the “SALUS” research group led by Dr. Jakov Gather. The DGPPN Prize for Philosophy and Ethics in Psychiatry and Psychotherapy was awarded on December 1, 2023. This year, the prize money of 6,000 euros was split. Both award-winning projects are based at Ruhr University Bochum.
Christin Hempeler, Dr. Esther Braun, Dr. Sarah Potthoff, Dr. Jakov Gather and Dr. Matthé Scholten from the Institute of Medical Ethics and History of Medicine and the LWL Clinic for Psychiatry, Psychotherapy and Preventive Medicine at Ruhr University Bochum published the award-winning paper on informal coercion in the American Journal of Bioethics in July 2023. The other half of the prize was awarded to Dr. Mirjam Faissner and Dr. Esther Braun for a paper published in the Journal of Medical Ethics in October 2023. This paper had also resulted from a collaboration between the LWL Clinic for Psychiatry, Psychotherapy and Preventive Medicine and the Bochum Institute for Medical Ethics and History of Medicine. The head of the institute, Professor Jochen Vollmann, has introduced ethics in psychiatry as a priority area.
Interviews with patients and a novel concept
While a great deal of research has already been conducted into legally regulated, formal coercion in psychiatric care, research into informal coercion is comparatively scarce. The Bochum-based team tackled this issue because it plays a major role in clinical practice. Even if mental health professionals wish to act in the supposed interests of patients, they may intentionally or unintentionally create pressure in their verbal communication that is tantamount to coercion.
For a study published in BMC Psychiatry, the research team interviewed 14 patients with mental illness to find out how they experience verbal pressure. In the present project, which has received the DGPPN award and was published in “The American Journal of Bioethics”, the team developed a philosophical concept based on empirical findings that can be used to describe informal coercion. Both their own and other empirical studies have shown that the context of communicative interactions determines whether coercion takes place. This was not reflected in the previous concept of informal coercion. So far, only threats have been considered coercive, but not other forms of treatment pressures.
Context is key
“If I tell a patient that they can’t see their family if they don’t take their medication, that’s a threat,” says Christin Hempeler from the Institute of Medical Ethics and History of Medicine. Her assessment is based on the fact that refusing to take the medication puts the patient in a worse position than they are entitled to – they do, after all, have a right to see their relatives.
The situation becomes rather more complicated if there’s an apparent offer: For example, if the healthcare specialist offers the patient a packet of cigarettes in exchange for taking their medication. “A proposal is considered an offer if, upon refusal, all that happens is the patient not receiving a possible bonus. But to assess whether an interaction constitutes coercion, it’s not enough to merely look at what is being said,” explains Christin Hempeler. “You also have to consider what the patients believe will happen to them if they refuse the offer and the context in which the interaction takes place.” For example, the environment plays a role: If there’s a restraint bed in the room, the patient could justifiably assume that they will be restrained and forcibly medicated if they refuse the medication in the context of such an offer, especially if they’ve previously observed this procedure with other patients. Under certain circumstances, offers can also have a coercive effect.
“We’re aware that there’s a fine line in deciding whether a patient could legitimately believe that they could face negative consequences if they reject treatment,” says Christin Hempeler. “We don’t want our work to be interpreted as a blanket accusation against mental health professionals. Our aim is to point out the potential for improvement and raise awareness of the issue.”
Recommendation for action
According to the researchers, a possible solution would be to emphasize during the consultation that there won’t be any negative consequences if a patient refuses a treatment proposal. “For example, you can offer a reward for taking medication and, at the same time, make it perfectly clear that there won’t be any repercussions if the offer is not accepted,” says Hempeler.
The work was embedded in the “SALUS” research project, which is funded by the Federal Ministry of Education and Research. It examines the conflicting priorities between patient autonomy, well-being and personal safety that often exists in psychiatric care. In a next step, the team plans to draw up recommendations for action for mental health professionals to reduce informal coercion.
The DGPPN Prize was awarded for the following study:
Christin Hempeler, Esther Braun, Sarah Potthoff, Jakov Gather, Matthé Scholten: When Treatment Pressures Become Coercive: A Context-Sensitive Model of Informal Coercion in Mental Healthcare, in: The American Journal of Bioethics, 2023, DOI: 10.1080/15265161.2023.2232754
Prior to that, an empirical study on this subject had been published:
Sarah Potthoff, Jakov Gather, Christin Hempeler, Astrid Gieselmann, Matthé Scholten: “Voluntary in Quotation Marks”: A Conceptual Model of Psychological Pressure in Mental Healthcare Based on a Grounded Theory Analysis of Interviews With Service Users, in: BMC Psychiatry, 2022, DOI: 10.1186/s12888-022-03810-9
The other half of the DGPPN prize was awarded for the following study:
Mirjam Faissner, Esther Braun: The Ethics of Coercion in Mental Healthcare: The Role of Structural Racism, in: Journal of Medical Ethics, 2023, DOI: 10.1136/jme-2023-108984
18 December 2023