In the deductive analysis we found several examples of persuasion, interpersonal leverage, inducements, and threats. This was expected since these forms of informal coercion were presented to the groups. Persuasion was described as commonly used, according to some participants in almost every consultation. Some participants did not accept that persuasion should be regarded as a form of informal coercion. They described that it sometimes could be more like a negotiation, reported by Rugkåsa et al [6] as negotiating agreements.
Many participants described how interpersonal leverage could influence the desicion-making process. Some of them said they used it almost all the time with patients with whom they had built up a confidence and an alliance, while others regarded it as wrong to use the personal relationship. Participants saw no problems in using small inducements, like an extra cigarette, coffee, or a walk, often as part of a negotiation in order to get the patient to accept medication, for instance. On the other hand, to use support or treatment as an inducement was regarded as very problematic. Some participants worried about that the use of interpersonal leverage and inducements risked to pass into blackmail in some situations.
In situations like the ones you brought up, suicide-threat situations, I think that on a number of occasions I’ve said: “I’d be really sad if you took your own life.” I’m using the therapeutic situation and there’s an element of blackmail, but there’s also an element of inducing guilt and shame. It’s not effective in the long run. I understand that. But in the short-term it can be very effective. You have to consider whether it’s OK to prevent the patient from doing this.
Participants described that when a patient after persuasion/negotiation did not accept a proposition they could immediately turn to threats of for example forced medication or involuntary admission. They discussed the intricate border between giving information and threatening the patient.
In the inductive analysis, we found three more categories of informal coercion. One was cheating the patient. Participants considered it wrong to give medicine without the patient being aware of it, but one participant reported having done that. When asked if this was acceptable, the answer was:
I want to say no, but I was the one that put the bloody tablet in the sandwich - so no. Then it’s all right then.
Strategic dishonesty and deception have been reported also in a study of psychiatrists’ experiences of consultations involving anti-psychotic medication [12], and Lidz et al. have previously identified deception as a form of coercion-related behaviour in the psychiatric admission process [13].
Another form of informal coercion found in our study was using a disciplinary style, like not saving any food if the patient was late for dinner or not allowing them to eat in the dining room when smelling bad. This form was not mainly used as a treatment pressure but rather as a pressure to adhere to societal norms and rules.
The third form was referring to rules and routines. Even voluntarily admitted patients may not be allowed to leave the ward without approval from the doctor, and the ward rules are the same for all patients.
My experience, in our department at any rate, is that there are quite a lot of things that we tell them. You can’t drink coffee whenever you want. You can’t smoke whenever you want. You can’t wear the clothes that you want to wear. This applies to voluntary and involuntary patients in our department. If anything, this is covert coercion. That those who shouldn’t even encounter coercion, do anyway to a great extent. I recognise this.
Participants also described situations of coercion from other stakeholders, namely relatives and other authorities than psychiatry. Relatives may threaten the patients to break the contact if they don’t accept the treatment offered.
The threats don’t just come from us; from the measures we use. Often they come from the patient’s nearest and dearest. “If you don’t admit yourself to hospital, if you don’t take your medication now, we’ll stop taking care of you.” Sometimes, these really are the toughest threats. They are already alone and they’re going to lose those who mean the most to them.
Regarding other authorities, participants described for instance that social services may demand that the patient undergoes a certain treatment in order to get financial support. This is in line with reports from the US and the UK of leverage from the social welfare and other systems [14, 15].