This week, Mad in America examines three studies around coercion in psychiatric treatment. The first study finds that involuntarily treated patients are commonly given antipsychotics doses in excess of daily recommended thresholds. The second finds that coercion, humiliation, and fear are linked to lower perceived quality of care in acute mental health units. The third reports that psychiatric detention fell in neighborhoods that sent mental health co-responders with police officers on emergency mental health calls.
Antipsychotic Doses Commonly Exceed Recommended Threshold During Psychiatric Detention
A new Latvian study presented at the European College of Neuropsychopharmacology Congress finds that the daily antipsychotic dose exceeded the British National Formulary recommended threshold for a majority of patients held in involuntary psychiatric detention. This research, led by Jevgenija Ivanova from the University of Latvia, also finds that treatment with multiple psychotropic drugs is common during involuntary psychiatric detention.
The goal of this research was to examine the prescription of psychiatric drugs for patients held against their will at the National Center of Mental Health in Riga, Latvia. The authors used data from the hospital’s electronic medical records to investigate prescription patterns for involuntary patients. In total, the authors used data from 88 patients.
Eighty-one percent of included patients had a diagnosis of schizophrenia and all patients included in the current work were prescribed at least one antipsychotic. Sixty-six percent of patients received an antipsychotic dose that exceeded the British National Formulary recommended daily dose threshold. Just 10% of participants were prescribed a single antipsychotic drug, 30% were prescribed two, 34% were prescribed three, and 26% were prescribed four or more during their detention. The most common combinations of multiple classes of drugs were antipsychotics and mood stabilizers (44% of patients), and antipsychotics, mood stabilizers, and benzodiazapines (8%).
This research had several notable limitations. The retrospective design means the authors only had access to data that was documented by clinicians. The 88 patient sample size was quite small, which limits genralizability. This research also took place within one psychiatric institution in Latvia, further limiting generalizability both within Latvia and to other populations.
Experienced Coercion Linked to Lower Perceived Quality of Care in Acute Mental Health Units
A new Spanish study published in the Journal of Clinical Nursing finds patients that experience higher levels of coercion and humiliation in acute mental health units report lower perceived quality of care. This research, led by Khadija El-Abidi from the University of Barcelona, also found a similar but weaker relationship between higher levels of experienced fear and lower quality of care scores.
The goal of this study was to investigate how the experience of coercion, humiliation, and fear affected perceived quality of care in acute mental health units in Spain. The authors collected data from 255 participants that were institutionalized in 12 acute mental health units across Spain. Participants rated their experienced levels of coercion, humiliation, fear, and perceived quality of care upon discharge. The quality of care rating involved six dimensions:
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Secluded – privacy, respect, and protection in situations of vulnerability
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Encounter – quality of the relationship with staff
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Participation – involvement with decision making
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Support – support received during hospitalization
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Secure – sense of physical safety
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Discharge – clarity and involvement in discharge planning
Higher levels of coercion, humiliation, and fear were linked to lower quality of care scores in all six dimensions. Coercion and humiliation were more strongly linked to lower quality of care scores than fear in all six dimensions. The secluded dimension of quality of care showed the strongest link to patient experiences of coercion and humiliation, with each one unit increase in the measure of coercion and humiliation associated with a 2.25 unit decrease in the secluded quality of care dimension. The secure quality of care dimension had the strongest association with patient experiences of fear, with each one unit increase in the fear measurement linked to a 0.34 decrease in the secure quality of care score.
This study had three main limitations. The design means this data cannot speak to causation. While the study found a link between coercion, humiliation, and fear to lower quality of care scores, it cannot definitively say that these experiences caused lower perceived quality of care. The measures of coercion, humiliation, and fear were self reported, meaning the data could be biased by misremembering and participants reporting what they thought the researchers wanted to hear rather than what they actually experienced. This study was conducted entirely within Spain, limiting generalizability to other populations.
Emergency Mental Health Co-responders Reduce Involuntary Psychiatric Detentions in the US
A new study published in Nature Human Behavior finds that sending an expert mental health co-responder with police officers to emergency calls involving mental health significantly reduces involuntary psychiatric detentions. This research, led by Thomas Dee from Stanford University, also reports that co-responders were linked to an overall drop in emergency calls where mental health was the primary factor.
The goal of this study was to examine co-responders impact on the prevalence of psychiatric detention, mental health emergency calls, arrests, and criminal offenses. The authors present data from two quasi-experimental examinations of co-responders effects on mental health emergency calls in San Mateo County, CA. The first compared outcomes of mental health emergency calls in neighborhoods that implemented a co-responder program to those that did not. The second looked at outcomes of calls that received a co-responder versus those that did not within neighborhoods that had implemented this program.
The first quasi-experiment reports that having a co-responder present with police officers in calls involving mental health emergencies was linked to a 16.5% decrease in psychiatric detentions. This translates to 370 less detentions over the two years of the pilot program. The authors estimate that this saved these communities somewhere between $300,000 to $800,000 per year in psychiatric detention costs. There was also a statistically significant reduction of emergency calls where a mental health issue was the primary concern. The second quasi-experiment found that psychiatric detention was reduced by 11.5%, translating to 174 less detentions over two years. While arrests and criminal offenses were lower when co-responders were present, these decreases were not statistically significant.
There were three main limitations with the current work. While the study design included quasi-experimental data, these were not true experiments. This means the data cannot conclusively say that co-responders caused the observed reduction in psychiatric detention. Due to a lack of data, the authors were not able to evaluate some relevant outcomes, such as the long-term effects of the co-responder program for subjects, outpatient therapy participation, and government/non-profit resource program participation. As this research was done using data from a single county in California, generalizability to the rest of the US and larger populations is limited.
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Dee, T. S., & Pyne, J. (2025). Emergency mental health co-responders reduce involuntary psychiatric detentions in the USA. Nature Human Behaviour, 10(1), 148–155. (Link)
El‐Abidi, K., Sanchez‐Balcells, S., Roldán‐Merino, J. F., Ruiz, A. V., Cañabate‐Ros, M., Garcia‐Sanchez, J. A., Muñoz‐Rouco, E., Pérez‐Moreno, J. J., Pita‐De‐La‐Vega, J., Rubia‐Ruiz, G., Santos‐Pariente, C., López, A. M., Golmar, L. J., López, C. E., Perez, J. G., Pastor‐Bernabeu, M. V., Coelho, J., Misouridou, E., Lluch‐Canut, M. T., Moreno‐Poyato, A. R. (2025). Examining the association between perceived quality of care and experienced coercion among patients in acute mental health units in Spain: A National Cross‐Sectional Study. Journal of Clinical Nursing, 35(2), 766–774. (Link)
Ivanova, J., Cernika, K., & Vrublevska, J. (2026). Pharmacological treatment among involuntary psychiatric patients: Real-world patterns of polypharmacy. Neuroscience Applied, 5, 106801. (Link)
What stood out to me here is that coercion doesn’t begin inside psychiatric settings—it often starts much earlier, within a person’s immediate social environment.
By the time someone reaches the psychiatric system, they’re already responding to something: accumulated stress, relational breakdown, instability, or forms of exclusion that may not be visible to others.
What this article highlights—overmedication and lower perceived quality of care—seem to be “downstream” effects of the lived experience context being diluted or eliminated from view. Once separated from its causes, distress is now behavior to be managed.
Psychiatry doesn’t introduce coercion so much as formalize and intensify patterns already present. Our systems of governance themselves are systems of coercion.
Coercion often exists first in relationships (pressure, misunderstanding, exclusion). Through “discussion” (group think/gossip), a social consensus arises (labeling, humiliation, reputational framing). Then, after the cumulative effect drives a breakdown or behavior issues, it becomes institutional (diagnosis, medication, confinement).
At each stage, the original causes of distress become less visible, while the individual becomes more defined by their response. People want a diagnosis so they know what’s wrong.
If we take seriously the idea that people always respond to something—even when we don’t fully understand what that is—then instead of asking, “How do we control this behavior?” we would ask, “What conditions produced responses of distress, and why are those conditions being overlooked?”
Especially when many of those conditions have already been identified by public and global health research as significant drivers of mental distress.
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When I went through a breakdown / awakening process in 1998, I came to use the phrase, “Forget the hokey-pokey. Abuse, manipulation, domination, and control — that’s what it’s all about.” And I have long said that if I could add in “coercion” to that phrase, I would do so.
That phrase isn’t just about the mental health system. That came from truly assessing how overly manipulated we all are by the common systems around us. That was truly an “awakening” with regard to understanding how all of that affected me. In addition to the two questions you ask toward the end, there is also the question of “How do we help someone through what they are experiencing (a byproduct and result of the conditions involved) to something that works better for them?”
I see the question: “What conditions produced responses of distress, and why are those conditions being overlooked?” as being extremely important to the overall system, especially the last part of that. And that is where the system has been lacking in general for decades. When I think of the data that hasn’t even been collected related to that question, it is mind-boggling, and irresponsible, to not capture it.
From your first sentence, I thought of the conditioning involved with all the pharmaceutical marketing — which isn’t allowed in most other Western countries — and how that impacts our social environment. And so many are led to believe that is based on actual science (as opposed to hijacked “science.”)
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On the general toxicity of giving more than the daily recommended thresholds of antipsychotics, this concerns me as they are able to inflict significant heart damage and I notice sales of portable home ecg machines must be doing well from the items out of stock. This is relevant for antipsychotic-induced prolonged qt interval, which requires, potassium AND magnesium electrolytes (not just potassium) as well as regular ecg . It is all thrown out for convenience or lack of time, communication. I find the best way to sort it is to look after myself, I stop feeling re-traumatised and trapped. Ideally a person to person chat to request these would happen but after several mentions to nurse, doctor, and not much progress it’s back to me. This makes sense to me only in terms of the “excessive neutral grounds ” I must constantly cultivate to remain out of the mental health unit. So my quasi qualified talk ends. I’m for reduced coercion humiliation and trauma. I need that oxygen pumping to my head. OK sometimes I need help to get through to healthy. I am anticipating the ODESSI trial recommendations due out from UK later this year will be a good lot of printed “vitamins” It’s a medical shame that side effects aren’t.
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Why would anyone with a brain in their head think “coercion, humiliation, [and] fear,” would result in a good “perceived quality of care upon discharge?” I’m quite certain, no coercion, no humiliation, and no fear would result in much better “perceived quality of care upon discharge.”
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No kidding. That’s what’s problematic with coercion in general—it may produce compliance, but it undermines trust, understanding, and long-term stability. What’s the goal here, anyway—assuring conformity to a sick society, or understanding one’s responses to conditions and events that are common in a sick society?
Focusing on the latter might prove more useful.
Though coercively forcing behavior can create conformity and control, it comes at the cost of relationship and meaning and understanding.
It’s like older dog training methods that relied on force—harsh punishment might produce obedience, but it doesn’t build trust or understanding. Books like Gun Dog (Wolters) recommended harsh physical punishment to enforce compliance. In some cases, similar ideas have even shaped how people think about raising children—prioritizing obedience and societal conformity over understanding and belonging.
While that might produce results in the moment, it comes at the expense of learning and the relationship itself. Most trainers have since moved toward positive reinforcement.
The same tension seems present here: control, obedience, and compliance are prioritized over welfare, learning, and trust—treating behavior as something to be coerced rather than something to be understood. Actually understanding could really help.
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It’s actually a type of oppression – or at least leads to it — due to the power imbalance. When fear is involved, that doesn’t generally lead to health with respect to relationships and human functioning.
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It must be an integrated part of the way the healing system works, whether it be body, heart or mind, that there is an expectation of recovery, and so hope. Rather than going on in this fashion, from coercion and humiliation, to settle into survival with diminish(ing) quality of life, that becomes a steeper gradient with the obscurity of what it is supposed to achieve. Natural quiet fosters growth while fear of speaking the truth is altogether a wrong kind of silence.
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