Award for scientific research 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.

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.

Christin Hempeler from the Institute for Medical Ethics and History of Medicine © RUB, Kramer

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.