Abstract Background Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. This phenomenon is also commonly referred to as informal coercion or treatment pressure. Empirical studies indicated that psychological pressure is common in mental healthcare services. No generally accepted definition of psychological pressure is available to date. A first conceptual analysis of psychological pressure focused on staff communication to promote treatment adherence and distinguished between persuasion, interpersonal leverage, inducements and threats. Aim The aim of this study was to develop a conceptual model of psychological pressure based on the perspectives of service users. Methods Data were collected by means of semi-structured interviews. The sample consisted of 14 mental health service users with a self-reported psychiatric diagnosis and prior experience with coercion in mental healthcare. We used theoretical sampling and contacted participants via mental healthcare services and self-help groups to ensure a variety of attitudes toward the mental healthcare system in the sample. The study was conducted in Germany from October 2019 to January 2020. Data were analyzed according to grounded theory methodology. Results The study indicated that psychological pressure is used not only to improve service users’ adherence to recommended treatment but also to improve their adherence to social rules; that it is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties’ understanding of mental disorder. Conclusions The results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services. 

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“Voluntary in quotation marks”: a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users

Objective: Paths toward referral to involuntary psychiatric admission mainly unfold in the contexts where people live their everyday lives. Modern health services are organized such that primary health care services are often those who provide long-term follow-up for people with severe mental illness and who serve as gatekeepers to involuntary admissions at the secondary care level. However, most efforts to reduce involuntary admissions have been directed toward the secondary health care level; interventions at the primary care level are sparse. To adapt effective measures for this care level, a better understanding is needed of the contextual characteristics surrounding individuals' paths ending in referrals for involuntary admission. This study aims to explore what characterizes such paths, based on the personal experiences of multiple stakeholders. Method: One hundred and three participants from five Norwegian municipalities participated in individual interviews or focus groups. They included professionals from the primary and secondary care levels and people with lived experience of severe mental illness and/or involuntary admission and carers. Data was subject to constant comparison in inductive analysis inspired by grounded theory. Results: Four main categories emerged from the analysis: deterioration and deprivation, difficult to get help, insufficient adaptation of services provided, and when things get acute. Combined, these illustrate typical characteristics of paths toward referral for involuntary psychiatric admission. Conclusion: The results demonstrate the complexity of individuals' paths toward referral to involuntary psychiatric admission and underline the importance of comprehensive and individualized approaches to reduce involuntary admissions. Furthermore, the findings indicate a gap in current practice between the policies to reduce involuntary admissions and the provision of, access to, and adaptation of less restrictive services for adults with severe mental illness at risk of involuntary admissions. To address this gap, further research is needed on effective measures and interventions at the primary care level.

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Between No Help and Coercion: Toward Referral to Involuntary Psychiatric Admission. A Qualitative Interview Study of Stakeholders' Perspectives

The rights to legal capacity, personal freedom, and safety during psychiatric hospitalizations at a general hospital.

A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective.

Elisa Liberati and colleagues argue that understanding the systemic and institutional forces behind lack of compassion in mental health services is key to solutions to this problem

Tackling the erosion of compassion in acute mental health services

Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals.

Elvira Pertega

Papers

Experiences of involuntary psychiatric admission decision-making: a systematic review and meta-synthesis of the perspectives of service users, informal carers, and professionals.

A systematic mapping review identifying key features of restraint research in inpatient pediatric psychiatry: A human rights perspective.