Rethinking Coercion in Psychiatry – A Pragmatic Path to Attainable Solutions

The societal trust in psychiatry has historically been precarious, shaped by the stigmatization of mental illness, fears surrounding psychiatric treatments, and ethical controversies. Coercive interventions, such as involuntary treatment, forced hospitalization, chemical or mechanical restraint, and seclusion, are seen as modern remnants of this troubled past. Even when used appropriately, these measures evoke images of abuse and neglect in asylums, reinforcing the belief that psychiatry prioritizes control over compassion. These perceptions are amplified by sensationalized media portrayals of psychiatric care, which often emphasize its most extreme aspects, deepening public fears and mistrust.[1] While modern healthcare has increasingly embraced patient-centered values of autonomy, dignity, and informed consent; restraint and seclusion, run counter to these ideals, making psychiatry seem like an outlier within medicine. Modern psychiatry, like medicine, is fundamentally evidence-based and does not promote coercion as any therapeutic strategy. No mental health professional advocates for or endorses coercion as a therapeutic approach in the treatment of any psychiatric disorder. Even at the dawn of modern psychiatry, Philippe Pinel (1745–1826), was famously responsible for the unshackling of the mentally ill at the Bicêtre Hospital, France.[2] His principles of “moral therapy” influenced countless subsequent thinkers, from Abraham Maslow to Norman Sartorius, all of whom emphasized autonomy, dignity, and human rights approach in mental healthcare. Yet, psychiatry is demonized for its use of coercion and institutionalization. While early proponents of the antipsychiatry movement like Thomas Szasz viewed mental illness as a “myth” constructed to justify forced interventions; present day activists critique overdiagnosis, pharmaceutical profiteering, and coercive practices of contemporary psychiatry.[3] Despite two centuries of concerted effort by mental health advocates and organizations worldwide, distrust in psychiatry persists, with coercion being the focus of most debates.[4] The United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) in 2006 marked a significant turning point, reframing autonomy, community inclusion, and coercion-free health services as universal rights. While countries attempt realignment of policies with these ideals, the “Geneva impasse” – a debate over whether coercion should be entirely prohibited or allowed as a last resort under strict safeguards – remains unresolved for psychiatry.[5] The World Health Organization’s QualityRights initiative and the World Psychiatric Association’s Position Statement on Alternatives to Coercion echo this global call for reform, advocating rights-based, noncoercive mental healthcare while acknowledging the challenges of full implementation.[6] Psychiatry thus finds itself trapped in a strange paradox of double speak and cognitive dissonance. By advocating for the abolition of coercion while routinely practicing it as a “necessary evil,” psychiatry actively contributes to public mistrust and undermines its own scientific credibility. In reality, medical coercion does not occur in isolation. Rather, it is a compromise “non-therapeutic” solution, implemented to protect individuals with mental health concerns from more egregious societal human rights violations, such as homelessness, destitution, chaining, physical abuse, and even sexual exploitation.[7] Coercion involves a dynamic interplay of power, influence, and control. The coerced party, often vulnerable due to dependency, marginalization, or systemic inequalities, faces negative consequences for noncompliance, leaving little room for voluntary decision-making. This imbalance of power, and lack of accountability, forms the central dynamics of all coercive events.[8] Norman Sartorius, in his book chapter “political abuse of psychiatry” critically examined the misuse of psychiatric practices for political repression, notably in the former Soviet Union.[9] He highlighted how involuntary hospitalization and forced medication were employed to suppress dissent, labeling political opponents as mentally ill to justify their detention. Voren, similarly, described the use of the diagnosis of “sluggish schizophrenia,” by the Moscow School of Psychiatry.[10] Individuals with “sluggish schizophrenia” functioned almost normally in society, but harbored symptoms of “reform delusions,” “struggle for truth,” and “perseverance,” often characterized by grandiose ideas of societal reform and self-importance! More than 43 articles have similarly documented the political abuse of psychiatry by various totalitarian regimes throughout history. But was psychiatry the perpetrator, a tool wielded by others, or a victim of manipulation in those circumstances? While the power imbalance between an individual and the institution is evident, the far greater power differential between the institution and the state highlights a complex dynamic in which psychiatry may have functioned both as a tool and a victim of state control. Many other institutions such as the judiciary, law enforcement agencies, and the press are equally susceptible to being exploited as tools of coercion.[11] However, while significant “systems of checks and balances” exists to ensure the autonomy of these institutes, psychiatry – and medicine in general – rarely enjoys similar protections. For instance, in current day United States, the Protect Reporters from Exploitative State Spying Act and the First Amendment safeguard press independence, but reproductive healthcare providers face state regulations on abortion without comparable protections,[12] leaving them far more exposed to external control. Coercive influences exist on a continuum in society and manifests in various forms, permeating daily life.[13] In workplaces, employees face threats to job security or performance evaluations to enforce compliance. Financial coercion includes aggressive debt collection, monopolistic practices, or high-pressure sales tactics. Social coercion arises through peer pressure, family expectations, or restrictive societal norms that limit personal freedom. Technological coercion, such as algorithmic nudging, privacy trade-offs, dark patterns, subscription auto-renewals, and greenwashing, underscores its growing prevalence. Even in healthcare, patients may feel pressured into procedures, influenced by advertisements, or compelled to make unwanted decisions in emergencies. Women may experience coercion in cesarean sections or sterilizations, cancer patients may be pressured into clinical trials without full information, and elderly individuals may be prematurely institutionalized. Differentiating coercion from the related concepts of persuasion, manipulation, and influence, therefore requires a close examination of the autonomy retained by the individual. Coercion involves force, threats, or pressure to compel action, significantly undermining autonomy. Manipulation exploits vulnerabilities through deception, similarly, eroding agency. In contrast, persuasion employs reasoning or emotional appeals to foster agreement, while suggestions respect the individual’s freedom by providing recommendations without pressure.[8] When discussions on coercion expand into debates about the ethics of persuading mentally vulnerable individuals, opinions often become too varied and subjective to allow for consensus or actionable solutions. Similarly, societal coercion of the mentally ill is a complex issue requiring multisectoral and multidisciplinary collaboration to develop effective interventions.[14] While these are critical human rights concerns warranting attention, they do not directly contribute to the current crisis of trust in psychiatry. In fact, psychiatry occasionally enjoys moments of public recognition, akin to Pinel’s legacy, as a savior of the oppressed when individuals confined and chained (at home, or in places of faith) are “rescued” and brought to hospitals for care.[15-17] By contrast, focusing the debate on issues of “clinical coercion,” enables targeted implementation of effective interventions aimed at reducing and ultimately eliminating such practices. All clinical coercive practices, such as compulsory treatment (including long-acting injections), involuntary admissions, in-patient restraint and seclusion, to procedures such as electroconvulsive therapy, sterilization, and lobectomy are uniformly opposed, though these practices differ significantly in the degree to which they infringe upon patient autonomy.[18] “Zero coercion” policies often result in a reductionist view about these complex issues, where all advises appear coercive to patients and where clinicians resort to defensive medicine, adhering to policy rules, but drifting away from the Hippocratic principles. Coerced outpatient treatment, often referred to as assisted outpatient treatment (AOT),[19] or mandated community treatment, involves requiring individuals with severe mental illness to adhere to treatment plans while living in the community. These mandates often include medication adherence, regular therapy sessions, and other mental health services, enforced through court orders or similar mechanisms. Proponents argue that AOT improves outcomes by reducing hospitalizations, ensuring medication adherence, and protecting public safety. Critics, however, highlight the importance of voluntary, patient-centered care. Globally, countries such as the U.S., the U.K., Canada, and Australia implement AOT to address non-compliance and prevent crises, while nations such as Germany, Italy, and Norway prioritize voluntary care and human rights.[20] When mandated by a court or state, AOT inevitably involves some loss of autonomy and agency for the individual. However, its primary motive is often benevolence – securing the well-being of the person and ensuring public safety. Crucially, the loss of autonomy in AOT is generally confined to treatment decisions, with individuals retaining their broader social rights. On the spectrum of coercion, AOT arguably represents one of the least intrusive approaches. Yet, implementing AOT remains a challenge, due to mistrust often rooted in historical injustices. Mistrust in Psychiatry also stems from the perceived questionable credibility of psychiatric diagnoses and treatments, a perception often reinforced by media stereotypes. In medicine, decisions often rely on an etiological framework supported by objective, irrefutable evidence, facilitating collaborative care and shared decision-making. Psychiatry, however, lacks such clear-cut evidence for many conditions, making diagnosis and treatment highly subjective. This creates a significant challenge for collaborative care in psychiatry, as shared decision-making relies on a foundational truth – the diagnosis – which in psychiatry is not a fact, but is a “consensus expert opinion.” When supported by clear evidence and an unambiguous course of action, mandatory treatment is often viewed as just and non-coercive. For instance, mandatory quarantine at ports of entry, testing for HIV and infectious diseases, and isolation for multidrug-resistant tuberculosis rarely provoke opposition. However, in the absence of robust evidence, medical decisions can become contentious, leading to conflict and litigation. The COVID-19 pandemic highlighted this dynamic distrust, with widespread protests against mandatory isolation, vaccination, and social distancing.[21] These strategies, though informed by decades of clinical experience, were perceived by the public as subjective opinions of a powerful few, lacking irrefutable evidence and therefore falling short of objective truth. The presence of alternative approaches proposed by equally authoritative figures further undermined their legitimacy, making such coercion feel unjust and oppressive.[22] Psychiatric diagnoses and treatments face similar challenges. The field is marked by diverse and often conflicting opinions on “valid” diagnoses and the “correct” approach to management, each advocated with equal intensity. This lack of consensus can make psychiatric decisions appear arbitrary and reliant on the clinician’s discretion. For patients, such variability can feel unjust, making psychiatry a particularly bitter pill to swallow. Alternatives to coerced treatment, such as collaborative decision-making, open dialogue approaches, crisis intervention teams, and peer support programs, have shown demonstrable effectiveness and have been successfully implemented in some developed nations. However, these approaches require substantial political commitment and significant investment in community and support infrastructure, making them challenging to adopt in many low- and middle-income countries (LMICs).[23] For most LMICs, advanced directives (where patient pre-consents to a particular treatment for episodes) and nominated representatives (where patient hands over treatment decisions to trusted others) remain the most cost-effective alternatives to forced treatment, and therefore should be aggressively implemented. The other highly debated issue in psychiatric coercion is the role of inpatient restraint in management of psychiatric disorders. Universally depicted as a severe infringement of individual basic right, restraint can be traumatizing, dehumanizing, and often counterproductive, exacerbating mistrust and worsening mental health outcomes. Restraint can also lead to re-traumatization, particularly for patients with histories of trauma, such as abuse, neglect, or violence, as it often mirrors their past experiences of powerlessness and harm. The act of being physically or mechanically restrained, or even chemically sedated against one’s will, can evoke feelings of fear, helplessness, and violation, reinforcing psychological distress rather than alleviating it.[24] Despite these concerns, restraint orders continue to be widely implemented across countries and institutions, shaped by cultural norms, legal frameworks, and the availability of resources.[25] To understand the complexities of inpatient restraint, parallels need to be drawn with law enforcement, the other societal institution granted the authority to use restraint to maintain order and prevent harm. Globally, police officers are trained in restraint techniques designed to subdue violent individuals while avoiding lethal force. They are legally empowered to infringe upon the rights of a few to protect the rights and safety of the majority. While most restraint events by law enforcement are considered lawful, ethical, and necessary, any misuse – whether based on religion, race, caste, or personal vendetta – tarnishes the authority of the institution, sparks public outrage, and erodes trust between the police and the community. Interestingly, societal demands have consistently focused on accountability, transparency, training and for banning specific techniques such as chokeholds and carotid restraints. However, there has never been a serious call for the complete abolition of restraint in law enforcement, recognizing its necessity in maintaining safety under certain circumstances.[26] Psychiatric wards function as microcosms of the society. Like any social system, they are governed by rules, norms, and hierarchies that aim to maintain order while addressing individual needs. Restraint, in this context, often serves as a last-resort mechanism to restore equilibrium when the system is threatened by acute disturbances. Herbert Simon, (a Turing prize and Nobel economics prize recipient) in his sociological concept of “bounded rationality,” highlighted how decision-making in real world remains constrained by time, information, and resources. Simon proposed that individuals and systems aim for “satisficing” – decisions that are good enough given the circumstances – rather than striving for perfection. In psychiatry, these constraints are amplified by the high-stakes nature of the work.[27] Decisions about restraint in emergency situations must often be made rapidly, based on incomplete information, and in resource-limited settings. Zero-coercion policies frequently assume optimal conditions: adequate time for de-escalation, complete access to patient information, and sufficient resources for alternative interventions. These conditions are rarely available in practice and expecting a clinician in an overburdened emergency ward to resolve a violent incident without coercion disregards the practical limitations of their decision-making environment.[28] Forcing clinicians to adopt a zero-restraint policy in psychiatric care or other medical context could have complex and unintended consequences. The absence of restraint would likely increase the risk of harm to patients, staff, and caregivers, as crises could escalate during periods of agitation if alternative strategies fail to act swiftly. Clinicians would face ethical dilemmas, torn between adhering to the policy and their obligation to protect individuals from immediate harm. In cases where harm does occur, institutions and clinicians might face legal repercussions, especially if it is argued that restraint could have prevented the incident. A zero-restraint policy could also lead to an over-reliance on sedative medications or antipsychotics, raising concerns about overmedication and its ethical implications. Furthermore, institutions may respond by denying admission to high-risk acute cases, managing them under medical emergencies, or transferring them out to other centers. Zero-coercion policies, much like utopian visions of or to the risk a paradox where the absence of control in rather than A more approach might be to restraint through evidence-based strategies that respect autonomy. In the short measures such as transparency, accountability, and – similar to those in – a with In of family a role in psychiatric decision-making, coercive measures to protect in where family presence in the ward is family occasionally restraint when other experience of the necessity of restraint, in shared decision-making, which rather than erodes clinical For patients the presence of a family while under restraint is and the of the In where family may not be available to patient during similar to police or providing access to patient could trust and transparency, ensuring that decisions are both and Psychiatric institutions must also of restraint through must and mechanisms. and can ensure and promote ethical patients and their in the of restraint policies can and foster a of shared implementing patient with external and coercion experience at the time of could human rights that might by that universal training of all in restraint should be In the absence of such decisions restraint should be to are with the to such and restraint by ward and security should be to coercion are and but substantial investment in infrastructure, and political making them a for most For one of the most effective to coercion is to prevent psychiatric crises from to the where coercion intervention programs, mental health services, and can and address issues they out of control. inpatient treatment, and peer support can effective alternatives to restraint and also requires addressing the broader social of mental homelessness, and lack of access to and healthcare contribute to treatment and of mental By these systemic issues, society can an where individuals the of psychiatric reducing the need for coercive interventions. In the absence of such system the of all coercion can be but not To – can do but coercion in psychiatry demands a practical to and safety while striving systemic that prioritize autonomy and By recognizing the of psychiatric care and a patient-centered psychiatry can that are both ethical and

Récupéré en direct depuis OpenAlex et désinversé. Les résumés ne sont pas conservés dans cette base de données : les index inversés représentent 8,6 Go des 9,3 Go de texte de la base, et le serveur dispose de 13 Go libres.