Coercion and power in psychiatry: A qualitative study with ex-patients [2019]

• Qualitative study on relational aspects of coercion in psychiatry with ex-patients.

• Coercion was described as a process of de-subjectivation of patients and staff.

• It felt as if power resides within the interactions of patients and staff.

• Encounters described as non-coercive were marked by more individuation.

• We need to tackle the underlying power dynamic to reduce coercion in psychiatry.

Coercion is a controversial issue in mental health care. Recent research highlights that coercion is a relational phenomenon, although, it remains unclear how this intersubjective context should be understood. The aim of this study is to propose an interactional model of the relational aspects of coercion that enhances theoretical understanding, based on the assumptions of patients.

The research question was studied by means of interpretative phenomenological analysis. Twelve people who had psychiatric hospitalisations were interviewed in-depth, using broad open questions relating to the experience of coercion and power in psychiatry. Data were collected in 2016 and 2017 in Belgium.

Across participants’ accounts we observed a specific structure. The relational quality of coercion seemed to be embedded within a process where individuals were one-sidedly approached as a ‘sick patient’, which led to profound segregation between staff and patients. This segregation caused a form of de-subjectivation: participants felt that important aspects of their subjectivity were neglected and they experienced professionals as de-subjectivated. They felt as if power resides within the (non-) interactions between patients and mental health workers. De-subjectivation arose and was enlarged within relations by broken contact, by silence in coercive acts, and by the necessity of patients to conform to the professionals’ treatment regime. Helpful encounters that were not deemed coercive were those where patients and staff were individuated, which altered their relation.

To understand the relational quality of coercion, interventions like seclusion and house rules should also be understood within this structure of de-subjectivation. We need to tackle this dynamic if we want to reduce coercion in psychiatric care.

Evi Verbeke, Stijn Vanheule, Joachim Cauwe, Femke Truijens, Brenda Froyen
Social Science & Medicine, Volume 223, February 2019