Research, coercion, and the accountability dance

There’s something innately uncomfortable about reading research that tries to discover what you did to cause your own, needless, suffering. This is the world of mental healthcare; it’s a world that fixes blame onto its own participants, a world that strives to find fault in the individual, rather than unpicking or unpacking systematic inequalities, injustices and disadvantages. If you are someone who has used mental health services, and you are exploring the research that dictates the treatment you receive, you will inevitably discover that you are considered to be – in at least some form – the architect of your own destruction.

In my experience writing a blog for The Mental Elf, a website that provides free and accessible insights into modern, evidence-based mental health research, I felt immediately aware of the disparity between my own “ground level” experiences at the receiving end of mental ill-health treatment, and the understanding of mental health practice informed by the authors of the paper I reviewed, Predicting coercion during the course of psychiatric hospitalizations.

The study, which was published in 2023 and had been previously undertaken at a large adult psychiatric hospital in Switzerland over three years, intended to examine the relationship between patients’ clinical and sociodemographic circumstances and any consequential coercive measures used in their treatment, with the aim of identifying ‘“risk factors” that corresponded with increased coercion in care. One key finding of Müller et al.’s research became apparent by the end of the paper; in the case of the patients admitted to the psychiatric hospital where the study took place, most patients who were subjected to coercive treatment received these measures during the first week of their admission. Other findings suggest that patients with psychotic or manic episodes were more likely to be exposed to coercive measures, as well as those who had a history of previous hospital admissions.

Practically, as a previous patient of psychiatric hospitals, it’s difficult to imagine the implications of these findings at the ground level of mental healthcare. Firstly, the author’s categorisation of ‘coercion’ was extremely narrow, consisting of only three types of coercive measures; seclusion, forced medication and mechanical restraint. Other types of restraint and coercion such as those listed on the Restraint Reduction Network website – like physical, chemical, psychological, cultural and environmental restraint, as well as blanket rules and surveillance – were not identified or referenced by the authors of the paper.

It’s not only incredibly disappointing that all other types of coercion beyond those that are professionally “obvious” were overlooked, particularly when the recency of the study is considered, but also harmful to those receiving mental healthcare. During my own hospital admissions, it was the more “subtle” types of coercion that had the most potent and lasting effect on the way I viewed myself and my external world; when research neglects to acknowledge the vast scale, breadth and intrinsic nature of coercion in psychiatry (in all its forms), then the results of studies like these are essentially inadmissible in day-to-day practice.

Little reference is made to external factors – that is, factors other than the patient themselves – which could impact the use of coercive measures, and where reference is made the authors link these factors back to a “problem” with the patient. For instance, Müller et al. (2023) suggest that ‘waiting times on the ward, not being allowed to leave and rigid ward rules can [lead to aggression]’, in turn leading to the use of coercion. Simultaneously, however, the authors suggest that it is a patient’s lack of ‘capacity to adapt’ and limited ‘adjustment skills’ that lead to this so-called ‘aggression’, rather than the constricted and confined nature of hospitals. Thus, the authors imply that any resulting coercion is the fault of the patient for “not coping”, rather than the fault of the institution for not providing a safe, responsive and therapeutic environment.

The paper is scattered with inconsistencies that seem to point the finger of blame towards the patient without basis. On the one hand, the researchers identify IA (involuntary admission, or being sectioned) as a risk factor for increased coercion, yet, as the authors themselves acknowledge, ‘IA in itself is of [a] coercive nature’. If IA is, in itself, a form of coercion – as the authors (accurately, in my opinion) suggest – then it can’t also be a risk factor for coercion. Despite this, the authors go on to explain that a patient being involuntarily admitted may ‘aggravate destructive behaviour’ (2023), resulting in coercion. Again, the patient is viewed as responsible for, and an active participant in, their own coercion.

‘Aggression’, ‘aggressive behaviour’ and ‘aggressive persons’ (Müller et al., 2023) are frequently identified throughout this paper as precursors to the use of coercive measures, and the authors appear to imply that coercive practice is a normal or necessary response to ‘aggressive behaviour’, but ‘aggression’ isn’t one of the clinical “risk factors” this study measured or intended to measure and the researchers don’t provide a definition of their interpretation of what is considered aggressive. This persistent reference to ‘aggression’ as an antecedent to coercion is yet another thorn in the flesh for patients who are subjected to coercive measures; ‘aggressive behaviour’ has negative connotations, implies a sense of threat, and depicts a situation where the use of force is necessary.  I’m reminded of incidents from my own time in psychiatric hospitals, watching children shout or cry and, in response, being pinned down by adult men – members of hospital staff – sometimes for hours at a time. Aged 16, I was once physically lifted off the floor by two male members of staff, each restraining one of my arms, because I threw a cup on the ground in a moment of powerless, voiceless distress. Would the authors of this study consider this action ‘aggressive’? Would it be necessary, in their perspective, for me to have been publicly assaulted, humiliated and degraded, like I was?

The reality of this research is that it refuses to hold psychiatric institutions and their governing organisations to account for coercive practice. By asking what it is a patient has done to cause coercion, the true causes of coercion are overlooked: a lack of specialist, well-trained staff; inappropriate ward environments; institutional malpractice; diagnoses that seek to blame individuals for their distress; and, most importantly, coercive measures being fundamental to current mental health treatment. Coercion and mental healthcare are so intrinsically interlinked that, at present, it is difficult to see a way forward without a paradigm shift in the way we understand, approach and manage mental ill health and distress.

Nima Cas Hunt (she/her) is a writer and co-founder of non-profit group First Do No Harm. She is committed to ensuring the voices of those with lived-experience of mental ill health and distress are actively involved in the design of mental healthcare, and a firm believer in the power of services that move away from the pathologising of distress. Her Twitter/X is @nimacashunt.