Informal Coercion Linked to Reduced Autonomy

Research shows that coercion in psychiatry is common, with some experts calling it a near universal standard practice. Both academic literature and the lived experience of patients report harm stemming from coercive psychiatric practices such as retraumatization, increased psychiatric symptoms, impaired social functioning, and dehumanization. One expert has argued that, despite widespread use, coercing people into treatment is both ethically and scientifically suspect.

A new study examines informal coercion in one Tokyo hospital during psychiatric hospitalization, finding reduced autonomy for hospitalized patients related to discharge. This reduced autonomy was also present after discharge in the form of restricting where patients could live.

Where formal coercion most typically takes the form of psychiatric detention and forced treatment, informal coercion is less obvious, often involving persuading, threatening, inducing, and manipulating patients into accepting treatment. It can be so subtle, and is such a common feature of psychiatric treatment, that mental health and social services staff are sometimes unaware that they are using it or simply do not consider it coercive.

The current work, published in the International Journal of Law and Psychiatry, finds that involuntarily detained patients were more likely to experience informal coercion compared to service users that were admitted voluntarily. This research, led by Hiroyasu Ino from the University of Tokyo, additionally finds that more than one in five people experienced informal coercion meant to force them into using social services during a single psychiatric hospitalization. The authors write:

“Necessary Evil” or Unnecessary Harm

Patients have reported negative experiences of informal coercion, including an erosion of self-image and loss of dignity. Patients have also described informal coercion as “emotional blackmail” and a “cruel trade” in which they are asked to comply with treatment in order to retain privileges such as seeing their family.

Research has found that experiencing informal coercion can erode the therapeutic relationship, create distrust of mental health services, lead to avoidance of care in the future, and create insecurity when support, such as housing, is contingent on agreeing to specific treatment. Experts have also questioned how some psychiatric treatment can be voluntary, calling the implicit threat of compulsion a “coercive shadow.”

Some clinicians have expressed concerns about the use of informal coercion due to a lack of legislation, clinical guidelines, and documentation around these practices. One study found that while some mental health staff disapprove of informal coercion in theory, they still use it in practice. Other experts have framed informal coercion as a “necessary evil” meant to increase treatment adherence and avoid harsher coercive practices. For example, the current work reported that informal coercion was linked to increased social service utilization as a positive outcome. While social services can involve employment assistance, housing assistance, and access to other important resources, some service users have reported negative experiences. Research shows that informal coercion is also used to pressure people into potentially harmful treatments, such as using antipsychotics.

Study Details

The goal of the current work was to estimate the prevalence of informal coercion meant to increase social service utilization during a single hospitalization, determine whether informal coercion increased the likelihood of social service utilization, and examine factors that may be associated with informal coercion.

The authors recruited participants from the Tokyo Metropolitan Matsuzawa Hospital in Japan. To be included in the study, participants had to have a diagnosis of schizophrenia, schizotypal disorder, or schizoaffective disorder. Patients were excluded from the study if their diagnosis had changed within two years after discharge, their diagnosis was unconfirmed or misclassified, their hospitalization lasted less than three days, they were transferred from another hospital, or they were admitted for a physical illness, electroconvulsive therapy, or a clinical trial.

The researchers extracted data from patients’ electronic health records. Based on previous research and discussions with a psychiatrist and neuroethicist, informal coercion was defined as threats, inducements, persuasion, and interpersonal leverage. A statement that non-compliance with an intervention would result in some loss was considered a threat. Inducements were defined as staff offering some gain contingent on participating in an intervention. Staff changing their attitude towards a patient that refused an intervention was considered interpersonal leverage. The authors defined persuasion as recommending an intervention based on a realistic accounting of its benefits and risks.

As the authors regarded threats and inducements as the most coercive forms of informal coercion, they divided participants into three groups: those that were threatened and/or induced, those that were persuaded, and those that did not experience informal coercion related to social service utilization. The current study found no instances of interpersonal coercion.

Social services were defined as official, medical, or disability welfare, and housing or economic support for people with a mental health diagnosis. The authors defined social service introduction as cases in which patients were not using a service before admission, and began to use the service after discharge. In total, the authors examined data from 659 participants with the majority (78%) admitted involuntarily.

Twenty-two percent of participants (145) were exposed to informal coercion in an effort to introduce social services. Seventeen of these participants experienced multiple forms of informal coercion. Eleven percent were persuaded, 9.1% were threatened with losses if they refused social services, and 4.7% were induced with gains if they used social services. Threats most often revolved around delayed discharge. Inducements were most often related to permission to work and choose one’s own place of residence. The authors note that mental healthcare staff and clinicians have no authority in the Japanese context to deny employment or housing. This means these inducements were dishonestly framed and likely constitute extra-legally constructed medical authority. This means informal coercion can start in the hospital and follow patients into the community, even in the absence of legal authority.

Persuasion did not increase social service utilization upon discharge. Threats and inducements were linked to a 68% increase of social service utilization. Staff were more likely to threaten and induce patients that were unmarried (2.06 times as likely), had additional psychiatric diagnoses (2.10), and those not using a long acting injectable antipsychotic (2.47). Patients that had been involuntarily detained were three times more likely to be threatened or induced towards social service utilization compared to voluntary patients.

The authors note that using coercion to introduce social services does not guarantee they will be utilized properly or have the intended effect. Due to coercion having long-term negative effects, the authors argue that non-coercive and supportive measures should be taken first.

As delayed discharge was the most common threat used against patients, informal and formal coercion were deeply intertwined. In other words, without the presence of formal coercion, there would be little to no basis for threats. In the current work, these threats most often depended on ambiguous discharge conditions, which the researchers argue should be clarified. The authors conclude:

Limitations

The authors acknowledge several limitations to this research. They only examined informal coercion related to social service utilization inside a hospital setting. Including informal coercion related to drugs and behaviors, as well as that occurring outside hospital settings, would likely significantly increase the overall prevalence. There was a higher percentage of involuntarily admitted participants compared to national averages in the current work. The use of informal coercion was extracted from medical summaries. This means informal coercion that was not documented or occurred outside staff observation would have been missed. Given that experts have raised concerns about the lack of documentation of informal coercion, this is a significant limitation. Additionally, this research was conducted at a single Tokyo hospital, significantly limiting generalizability to other populations.

The “Coercive Shadow” of Psychiatry

Due to the ever-present threat of psychiatric detention and forced treatment, teasing apart formal and informal coercion in psychiatry may not be possible. As in the current work, some informal coercion is only possible due to the implied threat of instituting or extending formal coercion. Several experts have pointed to this “coercive shadow” of psychiatry, an often unstated threat felt by patients when pressured to comply with treatment. Research has found that this can result in patients “voluntarily” agreeing to unwanted interventions to avoid the humiliation and stigma of psychiatric detention. Research has also found that past experiences of coercion can play a role in informal coercive measures in psychiatric settings, altering how patients experience and adhere to “voluntary” treatment.

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Ino, H., Akabayashi, A., Takimoto, Y., & Nakazawa, E. (2026). Informal coercion towards discharge: The entanglement of formal and informal coercion in Social Resource Introduction. International Journal of Law and Psychiatry, 105, 102183. (Link)