This week, Mad in America examines three articles around the use of coercion in psychiatry. The first argues that justifications for the use of coercive practices in psychiatry overlook long-term harms. The second finds that the challenging physical environment in inpatient psychiatric wards is a main driver of the use of coercive practices. The third reports that psychiatric staff that experience violence and use coercion against patients themselves are more likely to have a favorable view of these practices, while more years of work experience is linked to more critical views of coercion in psychiatry.
Psychiatric Coercion Reduces Patients to a Risk that Must be Managed, Causing Long-Term Trauma
A new article published in PLOS Mental Health examines the harm of psychiatric detention. This essay, authored by Sandra Ferreira from Aves Mental Health (formerly the Global Mental Health Peer Network), argues that justifications for coercion in psychiatry overlook the significant long-term consequences of these practices. The author calls for a reorientation of mental health services towards serving the best interest of patients and service users rather than allowing institutional logic to continue harming people.
In the article, Ferreira, herself a survivor of psychiatric detention and restraint, writes that she hopes to use her postgraduate degree and professional credibility to speak from a place of lived experience without the fear of retaliation or dismissal faced by others in her position.
Psychiatric coercion typically occurs during an extremely vulnerable moment for the patient, exacerbating an already lopsided power dynamic. Concepts such as “lack of insight,” “impaired capacity,” and “non-compliance” are used to strip autonomy and credibility from the patient, with any resistance framed as further proof of “mental illness.” Ferreira argues that this process prioritizes institutional intent and reduces patients to a risk that must be managed while ignoring the significant, lasting trauma caused to the individual.
Patients’ experiences and testimonies critical of forced psychiatric “care” are systematically dismissed by professionals. The combination of epistemic injustice and psychiatric treatment based on coercion and force rather than empathy results in long-lasting feelings of powerlessness, loss of agency, and fear while severely damaging the patients’ trust in the medical system.
The author makes five recommendations for moving towards a rights-based system of mental healthcare. (1) Advanced directives for mental healthcare made before a crisis occurs should be legalized and honored. (2) Mental healthcare should be decentralized away from hospitals towards peer-led and culturally responsive community environments. (3) Clinical decisions should be guided by international frameworks such as the UN Convention on the Rights of Persons with Disabilities rather than abstract concepts such as “impaired capacity” and “non-compliance.” (4) Clinicians should critically reflect on their own language, biases, and risk-focused thinking. (5) Lived experience should be recognized as core scientific data.
New Study Highlights Ward Environment as Primary Driver of Psychiatric Coercion
A new study published in the International Journal of Mental Health Nursing explores the driving factors of coercive practices within inpatient psychiatric settings. Patient “responses to challenging physical and external stimuli” was the main driver of coercive practices. This study, led by Esario IV Daguman from Southern Cross University in Australia, also identified self-harm and patient aggression targeted towards nursing staff as key drivers of the use of coercive practices.
The goal of this study was to look beyond individual-level patient risk factors to map functional, contextual, and interventional factors linked to the use of coercive practices in inpatient psychiatric units. This study was part of a larger project around coercive practices within multiple psychiatric institutions in Australia.
The authors used data from three acute adult inpatient mental health units in New South Wales, Australia. They examined 2,955 de-escalation events captured in nursing logs and administrative records and analyzed them in terms of coercive outcomes including seclusion, physical restraint, forced administration of psychotropic drugs, physical injuries, and emergency security activation. They then used machine learning to build a predictive model of when coercion was most likely.
The top functional driver, the underlying reason for a patient engaging in a behavior that was escalated towards coercive practices, was the challenging physical environment of the ward. This included factors such as high levels of noise, overcrowding, bright lighting, and lack of privacy. The top contextual factors, the actual behaviors that led to coercive practices being used against patients, were aggression towards nursing staff and self-harm. In plain language, the most common reason for staff using coercive practices against a patient was that patient showing aggression towards nursing staff as a reaction to an overwhelming environment.
The authors note that their focus on underlying functional drivers is unique in research around coercion in psychiatry. Where past research mostly looked at static factors such as diagnosis or age, this research looked at the precipitating factors that most commonly lead to coercion. This frames problematic behaviors, such as aggression towards nurses, as an attempt to communicate an unmet need.
Nurses using de-escalation techniques was also linked to the use of coercive practices. However, the authors note that this link is likely not causal. De-escalation techniques are most frequently used in already tense situations before formal coercion is used.
This study had two main limitations. The data was mostly recorded by nursing staff, but analyzed by the authors using machine learning. Involving frontline staff and people with lived experience of psychiatric coercion in the interpretation of the data could lead to more accurate results. This research was conducted within three mental health wards in New South Wales Australia, limiting generalizability to other populations.
Exposure to Violence and Use of Coercion Linked to Greater Acceptance of Coercive Practices
A new study published in Comprehensive Psychiatry finds that psychiatric staff were more likely to view coercive practices favorably when they had experienced more physical violence and frequently used coercive practices against patients themselves. This research,led by Klara Czernin from the Medical University of Vienna in Austria, also reports that more years of experience working in psychiatry was linked to more critical attitudes towards coercive practices.
The goal of this study was to examine how factors such as experiencing violence at work, emotional burden from verbal abuse and witnessing coercion, years of experience working in psychiatry, and feelings of insecurity at work affected staff attitudes towards the use of coercive practices in psychiatry.
The authors recruited 1,585 mental health professionals from Germany that worked in adult, child, and forensic settings. Each participant completed a self-report survey concerning their attitudes towards coercion and answered questions about how often they experienced things like violence, verbal abuse, feelings of insecurity, and witnessing coercive practices at work.
Several factors were associated with more positive attitudes towards the use of coercion in psychiatric settings. Staff that had higher rates of exposure to violence, felt unsafe, experienced emotional burden after verbal abuse, and those that frequently used coercive practices against patients had more positive views of coercive practices. Older age and working in forensic settings was also linked to more favorable views of coercion in psychiatry.
Staff that experienced emotional burden after witnessing coercive practices and those that had more years of work experience in psychiatry had more critical views of coercion. The authors note that receiving support after a violent incident at work reduced feelings of insecurity. The authors hypothesize that this could prevent violent experiences from translating into more acceptance of coercive practices.
This research had four main limitations. The study’s design means the data can only speak to associations, not causes. The self-report nature of the surveys means the data is susceptible to misremembering, differences in interpretation, and participants giving socially acceptable rather than true answers. The authors measured attitudes towards towards coercion rather than behavior. Some unmeasured factors could have influenced attitudes towards coercion, such as organizational culture, staffing levels, and patient characteristics.
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Czernin, K., Oster, A., Mahler, L., & Baumgartner, J. S. (2026). Staff attitudes towards coercion in psychiatry: The role of violence, emotional burden, and insecurity – evidence from a nationwide study using multiple regression and moderation analyses. Comprehensive Psychiatry, 148, 152711. (Link)
Daguman, E. I., Yoxall, J., Lakeman, R., & Hutchinson, M. (2026). Functional, contextual, and interventional drivers of formal coercion in acute mental health units: A feature analysis. International Journal of Mental Health Nursing, 35(1). (Link)
Ferreira, S. (2026). Held but not healed – why coercive practices undermine mental health and Wellness. PLOS Mental Health, 3(4). (Link)
“Older age and working in forensic settings was also linked to more favorable views of coercion in psychiatry.” Good idea (sarcasm) … since mass murdering the elderly is a good idea, psychiatry. I know enough to protect and educate my mother.
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Yay, that you care enough to protect, in its purest and truest sense.
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I didn’t know there was a “logic” to coercion.
It is more on the level of a compulsion, of a mental sickness itself.
In the field of crime, we do agree that force may be needed to apprehend and subdue the offender. And that incarceration may be indicated for some of them. I think it’s that point where a “psychiatric episode” briefly mimics criminal behavior that frightens people into deciding to use coercion or violence. Others in the system – themselves quite insane – target people in moments of distress as they are the easiest to harm. That sort of thing needs to be stamped out – particularly in this field.
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Maraming salamat for taking the time to write about our work, Richard. I really enjoyed reading your piece and appreciated how thoughtfully you captured what we were trying to say.
One of the things that means a lot to me is helping challenge the idea that formal coercion is simply a consequence of the actions of people receiving care. Your blog helps bring that conversation to a wider audience and highlights the broader functional, contextual, and system factors that shape these events.
Thank you again for helping share the work.
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There may always be a need to restrain folks of all ages with actual cognitive impairments, even when the (“mad” or nonsense) notions of “mental illnesses/disorders” and “personality illnesses/disorders,” like the easily probably nonsense notion of “nociceptors” have been thoroughly and universally debunked.
I may be much to blame for for fact that none of these notions has yet been, possibly because in writing to all the learned journals to which I have thus far written, I omitted to mention that if they put me on the cover I would buy at least five copies for my mother: Sorry.
“Psychiatry does not commit human rights abuse. It is a human rights abuse.”
And…
“All psychiatry is coercive, actually or potentially — because once a person walks into a psychiatrist’s office, under certain conditions, that psychiatrist has the legal right and the legal duty to commit that person. The psychiatrist has the duty to prevent suicide and murder. The priest hearing confession has no such duty. The lawyer and the judge have no such duties. No other person in society has the kind of power the psychiatrist has. And that is the power of which psychiatrists must be deprived, just as white men had to be deprived of the power to enslave black men.”
– Thomas Szasz.
From “Dr Thomas Szasz Quotes on Psychiatry as a Human Rights Abuse | CCHR Australia”
https://share.google/2UqGeWqpkoAfxwsvM
“As we grow older and realize more clearly the limitations of human happiness, we come to see that the only real and abiding pleasure in life is to give pleasure to other people.”
P.G. Wodehouse, “Something Fresh” (“Blandings Castle, #1”).
Quotes by P.G. Wodehouse (Author of My Man Jeeves) https://share.google/zd1YJjhmiUCEopQFa
If we are all equal, and each unique, then which of us is not?
If we are all “neurodiverse,” then which of us is not?
If we are all “sinners,” then which of us is not?
If we all have minds and (sub-) personalities which are ill, which of us does not?
Personally, I believe I am seriously cognitively impaired long before I have lost the last of my sense of humor, though, of course, I don’t see it that way at the time…
Wishing you mirth, love and laughter, and with thanks for a REALLY great article,
Tom.
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I can recognize American psychiatric facilities in these studies from my own personal experiences. There’s also a recognition that many different kinds of people inhabit that workspace, and may have had personal violence enacted upon them in the past from their own families. We have a long way to go in advancing better care for patients who are mentally unwell. Thank goodness for more modern thinking about the entire field.
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Australia
Discrete CCTV with audio (full privacy protections) are the only current way to observe real life real time realities. These frames should be used for learning, teaching, and ongoing supports as needed.
Staff – their presence, their absence, their approach (hostile energy can be felt) provoke incidents that often lead to aggressive and or violent reactions. Patients per se, know who is safe, who can be trusted. Staff, like all humans, have patterns of thinking, and patterns of behaviours – Situations, contexts, and people would be cues.
Research on staff presumptions, assumptions, judgements, projections, thinking, thought processes, attitudes, beliefs, and default behaviours is missing. Only CCTV with audio can give such information.
Staff, staffing standards, should also be upgraded to ensure line of sight and hearing with another qualified staff member.
Sadly, staff are prone to making up events to fit their documentation, which is a legal process.
Self reports are known to be of little accurate value.
Cognitive dissonance does not bother staff in situations where there are no higher authority figures directly present and or there are no other qualified witnesses – for example other staff, visitors, office admin., visiting medicos, … .
Based on direct experiences, direct observations – visual and auditory.
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More generally, those doing the coercing often regard themselves as protectors, reformers, or heroes acting in service of truth, morality, science, or God.
Because they experience themselves as virtuous, they commonly enough fail to recognize the coercive nature of their actions. The same can be usually be said of their attempts at manipulation.
Although some circumstances warrant coercion, in ordinary relationships between autonomous adults, coercion often amounts to imposing one’s worldview, or demanding conformity to it, rather than respecting the other’s right to live according to their own worldview and conscience.
Notice our laws, “economic necessity,” and religious doctrine provide fine foundations for life-governing systems of coercion—externally imposed carrots and sticks compelling conformity to imposed systemic dysfunction.
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You should familiarize yourself with the psychopathic personality, which describes a being willing to severely coerce others with no sense of empathy of guilt.
It is not productive to offload all the responsibility for these behaviors on “systems of coercion.” Though these may exist, the source of them and most insane coercion is the psychopath. We can learn to detect such people and move them off those positions.
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Not likely.
Psychopath is not a legally acknowledged nor binding word.
Hiring, HR, hire psychopaths for the qualities that they believe will enhance their business, institution, et cetera, because a psychopath will do whatever it takes to enhance (power, status, looks, design, charm, influence, money, money, …, ) themselves. And in that order, supposedly the business, institution will also be uplifted to thrive.
Larry, you must know something in advance, that to date no other person yet knows. Maybe a book is in the making.?
Babiak, Hare, Simon, and many others note how successful psychopaths are.
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They also know how dangerous psychopaths are!
And so did Lobaczewski, who wrote Political Ponerology many years ago, and offered suggestions for getting psychopaths out of positions of power, at least in government. There is a substack about his work by the same name.
Hubbard called them Suppressive Persons and had his own suggestions about how to keep them under control. His work dates from the 1960s.
So there is nothing “new” about these ideas; they have simply gone unnoticed or ignored for all this time.
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Finding it called “coercion in psychiatry”, rather than, trauma and drug based conditioning for human, drug, and arms trafficking, akin to mk ultra, with only 7 comments in the thread is as good as it has gotten in over a decade.
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Sad, isn’t it.
Appeasing behaviours chosen out of necessity to limit the harm that is going to be inflicted. “Take the pill, or I’ll shove it down your throat” said the petite nurse, as she stood demurely, while blocking the bathroom doorway. She achieved her own adrenaline rush followed by a dopamine reward rush.
It is unlikely that any notes and or logs, capture the whole reality of any given event. Add to that, that it is the nurse who calls the doctor, intern, resident, registrar, and relays their narrative to this middle person, who then relays their interpretation of the nurse’s narrative to the qualified doctor, psychiatrist on duty via direct personal communication, or via phone call.
What could possibly get lost in translation?!
“de-escalation events captured in nursing logs and administrative records”
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Mark, please forgive my confusion: It is genuine – and, along with stupefaction, obliviousness and denial, one of my more helpful superpowers – and I don’t understand from the above whether you consider pharmacracy, – or that fhat form of government at the people, from the people, against the people, as practiced by those states which sanction and mandate coercive psycho pharmacology on their citizens, together with the abolition/outlawing of
“sin”/”sinfulness,” ( for which, thank Heaven!)
free will,
the subconscious mind,
the psyche,
the soul,
eccentricity,
Idiosyncracy,
temperament,
personae/subpersonalities and such practices as “laboring under a peculiarity of temperament” while
institutionalizing humorlessness and hypocrisy to the nth degree to be
(a) a jolly good thing, all round,
(b) a hideously ghastly and egregious thing,
or, more likely, I suspect
(c) another thing, completely, and it probably not a nasty branch of (hyperreligious) Judaeo-Sauline, Aristotelian, materialist, so-called science or scientism, please?
VERY best wishes!
Tom.
“A man’s subconscious self is not the ideal companion. It lurks for the greater part of his life in some dark den of its own, hidden away, and emerges only to taunt and deride and increase the misery of a miserable hour.”
– P.G. Wodehouse, “The Adventures of Sally.”
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It’s hard to follow what all you speak of, people often having different meanings to words they use (even in the same language), but thanks for sharing. My comment is a little confusing, isn’t it? I’m shattered inside, they have my inner child (split personalities) literally cracking a smile on my face when bad things happen to us (is that some sort of Munchausen by proxy?), apparently, part of an mkultra program, or something, they created, then set off over 10 years ago, making me remember the abuse in rituals (creating the CPTSD, which they misdiagnosed as schizophrenia, thinking that I was lying about not hearing voices) to then “justify” having me repeatedly locked up for more violent and chemical reconditioning (repeated wellness checks, over a decade now, again and again and again and again and again and again), in fact (locked up 9 months one time, mind you, I haven’t even done anything to actually hurt anyone, other than their feelings), forcing me off the cannabis, so that, the main personality (the sober one) could be brought forth for further conditioning (left spitting and pissing blood after being deprived the right to urinate or defecate, literally, physiologically, never mind that they were picking me up and body slamming me to kick me in the head just cause i wanted to complain about being hit by the food cart), the one other ape victim (aped by a cop, of course), fought back and found herself with a skull busted open by the cop’s daughter working the crisis center, the cops bringing their guns to remind me I have no rights and that it could even be a “felony” (they like to make up words to “justify” the continuation of the trafficking) for ape victims to write down and express how they might feel (part of the mk ultra program to further condition us). So being locked up in such an environment really, only served to recompound the traumas (like creating sex kittens), leaving me screaming even more and more and more. I guess I am having a “bad reaction” to the “medical care” most everyone seems to submit to and find “helpful”. The more I talk to such people (the majority of people), the more i realize that they’re all just simply groomed for the continuation of the abuse (would do the same horrible things, heck, stick me in the right place, and I’ll do it too). As for your concerns or perspective to it being tied to religious matters, yes, of course, this little devil on my left shoulder and the angel on the right are clearly just authorities using the esoteric sciences, “playing” (as if this is a game) the bad cop, good cop, routine, but we all know that they’re all bad, cause they are the kinds of people that want to make a living from violently and chemically forcing their ways upon everyone, cause it’s the “law’ and their “job” (more words they like to make up for the continuation of abuse). One cop even said “I wouldn’t do this if it were up to me”, while grabbing me to be locked up. The doctor decided not to abuse me that day either. That was an interesting day. It was my first meeting with the social worker after being let out of the state hospital, my family falsely accused me of wanting to hang myself with my physical therapy rope (how dare I want such a thing?), setting off the program to make me shout APE over and over again, so yeah, they called the cops on me that day, again, they keep coming every now and then to keep the abuse going because my inner child wont shut up and stop sending out emails to anyone and everyone. You speak of a man’s subconscious self not being the ideal companion, yeah, that’s where voices ended up being wired to, I had freaked out and basically threatened to ill everyone on the planet if they ucked with my ears, so that wire got left hanging in my subconscious. For much of my life, it was simply just a bunch of racing thoughts I could barely make out, or simply ignored. I can sense the chakras (or whatever it is) pulsating when they probe me telepathically (like the evil eye watching, making a movie out of my life). My “transmitter” is apparently broken to always be on, while my “receiver” leaves me with racing thoughts I can’t make out. They like to use people speaking as such as “justification” for force more drugs. I can’t believe how many drugs they want me on. Yes, authorities, and those functioning for them, seem to be completely conditioned and groomed for it, even bred for it. I can’t help but see it as such, used to be able to try to find good in people, but it’s just not really happening anymore, and it’s not so much that things have change, but instead, that they changed my perspective in trying to turn me into what I hated (which they did get pretty far with)
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You don’t want to be forced to take drugs that are not of your choosing, but you are willing to take drugs of your choosing, even though both versions cause detrimental effects. How do you see any difference to outcomes for yourself and the possible impacts on others?
As for families – some members are quite sinister, with hidden motives, agendas, intentions, while presenting a different face to most of those they meet and interact with. Their narratives and stories are purposefully created to be believed. Their dark side is well hidden, not under proper moral, ethical, management.
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Possibly:
We all have within ourselves positives and negatives. If either is acknowledged alone, we are not whole and authentic.
If the negatives are acknowledged As Well, such parts can be integrated and treated with insights and care, to enable better and wiser choices and decisions and paths.
Basically, if our not so pleasant parts are ignored, they can pop up as ugly and mean, seemingly uncharacteristic.
Not sure how that all sits within the models and frameworks of psychiatry, psychiatric mindsets and the insistance on pushing psychiatric drugs and treatments that are known to change how the foundational brain functions, regardless of well learnt social norms, civilities, and understandings of respect and dignity.
Why some people lose it and others don’t.
Why some change from passive to aggressive.
Why, why, why.
Maybe psyche responses are all about truly trustworthy and genuinely supportive care for the person (any age, any demographic) experiencing an acute crisis, emotional distress.
It is doubtful that a psychiatrist, and or psychiatric staff in any setting will offer anything more than drugs, possibly accompanied by further restraints of some sort.
An industrial that runs on evading liabilities and maximising power. Is this not coercive control?
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A lot of us are here because it is obvious to us that Psychiatry (and most of Psychology) doesn’t know what it’s doing.
I come from the angle of studying Hubbard’s work.
He recommended a new mode of therapy back around 1950 and was thoroughly rejected by all the professional groups and many individual psychiatrists. Even after working with a few psychiatrists who tried to learn his methods, he concluded that psychiatry – as a group and as individuals – didn’t know what it was doing and didn’t really care.
And since I have yet to find a psychiatrist (have found a few psychologists) who have studied Hubbard, I have come to a similar conclusion. Hubbard has come the closest to explaining why. Yet no one who is “serious” has studied his work, so this remains a big “mystery.”
It’s time to move on to theories and techniques that are more workable. Damn Psychiatry.
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Mentionioned – power and manipulation and coercive control.
There are, given the circumstances disproportionate power imbalances.
It is time to research the mental machinations of staff who for unknown to the general public reasons choose to be reactive. The same behaviours enacted in a home would likely be criminalised and charged by police and a justice officer.
Since fear is a common denominator for both staff and clients, patients, maybe more needs to be discovered about its core causes and presentations.
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Has anyone read the mentioned article?
Has anyone looked at the aves website?
The PLOS article is advocating for academics with lived experiences to be placed in better and higher positions of authority and influence, and to be taken seriously, when it comes to politics, policies, research; and to be paid properly for their efforts.
“A new article published in PLOS Mental Health examines the harm of psychiatric detention. This essay, authored by Sandra Ferreira from Aves Mental Health (formerly the Global Mental Health Peer Network)”
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I haven’t. Tell me why I should.
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