“Voluntary in quotation marks”: a conceptual model of psychological pressure in mental healthcare based on a grounded theory analysis of interviews with service users
The use of coercion in mental healthcare services is controversial and has sparked off public debates around the world and academic debates across disciplines. A common distinction in the literature is that between ‘formal’ and ‘informal’ coercion [1, 2]. Formal coercion refers to interventions carried out against the will of mental health service users, including involuntary hospital admission, involuntary treatment and coercive measures, such as seclusion, mechanical restraint and chemical restraint [3,4,5]. Informal coercion, on the other hand, refers to communicative strategies used to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. While formal coercion is legally regulated in most countries , informal coercion is typically not regulated by law [1, 2]. Moreover, while the various forms of formal coercion are defined clearly, a generally accepted definition of informal coercion is still lacking [1, 2].
Szmukler and Appelbaum  developed a first conceptual analysis of what they call “treatment pressures,” distinguishing between persuasion, interpersonal leverage, inducements and threats. Persuasion involves influencing service users’ decision-making by means of rational argumentation; interpersonal leverage involves conditional changes in emotional attitudes within interpersonal relationships; inducements involve conditional proposals to make people better off if they accept the proposal; and threats involve conditional proposals to make people worse off if they refuse the proposal.
These communicative strategies are discussed in the literature under the header “informal coercion” [1, 2]. A note on terminology is thus in order. Szmukler and Appelbaum  prefer the term “treatment pressure” over “informal coercion” for conceptual reasons. They argue convincingly that persuasion, interpersonal leverage and inducements need not involve coercion and that only pressures at the upper end of the spectrum do (see also [8, 9]). Accordingly, they propose to use the more neutral term “treatment pressures” to refer to the full spectrum. Anticipating our findings, we found that the communicative strategies outlined by Szmukler and Appelbaum are used not only to improve treatment adherence but also to improve adherence to social rules. As with treatment pressures, pressures to adhere to social norms need not involve coercion. For these reasons, we will henceforth use “psychological pressure” as an overarching concept encompassing both treatment pressure and pressure to adhere to social norms. Figure 1 depicts the conceptual relationships between psychological pressure, treatment pressure and informal coercion.
The use of psychological pressure is prima facie morally problematic because it can compromise the voluntariness of service users’ consent  or involves treating service users unfairly . Szmukler and Appelbaum  rank the various communicative strategies hierarchically based on the level of pressure involved, resulting in a spectrum that ranges from persuasion at the bottom end to threats at the top end. The authors note that the use of pressure can be either morally permissible or impermissible, depending on the level of pressure and the strength of the justification one has for exerting it: the higher the level pressure, the stronger one’s moral justification must be.
Ample empirical evidence is available on formal coercion, particularly on its prevalence [12,13,14], stakeholders’ attitudes toward it  and the methods by which it can be reduced [16,17,18]. By contrast, the scientific evidence on psychological pressure is scarce and normative guidance for professionals is mostly lacking . This is partly due to the lack of a clear definition and workable operationalization. Further exploratory and conceptual research is thus needed.
Various empirical studies have indicated that psychological pressure is common in mental healthcare services [1, 2]. Professionals in a large international focus group study identified both positive and negative effects of psychological pressure. Positive effects included enhanced treatment adherence, avoidance of decompensation and reduction of formal coercion; negative effects included an impairment of the therapeutic relationship and coercive stigma of services .
Survey and focus group studies with mental health professionals suggested that professionals often use psychological pressure unknowingly [19,20,21,22]. Moreover, the focus group study carried out by Valenti and colleagues  revealed a dissonance between professionals’ attitude and practice, with professionals disapproving of forms of psychological pressure that they continue to use in their daily routine. This points to the possibility of social-desirability bias in qualitative and survey studies on the topic with professionals. The lack of awareness and underreporting of psychological pressure in research studies at least tentatively suggests an unreflective use of psychological pressure in clinical practice.
Explorative quantitative survey studies indicated that professionals see the use of psychological pressure as a less restrictive alternative to formal coercion [20,21,22]. These studies also showed that professionals tend to underestimate the level of psychological pressure. The more that professionals approved of coercion, the more they tended to underestimate the level of pressure; and the higher the level of pressure, the higher the degree of underestimation [20,21,22]. If the burden of justification increases as one moves upwards in the hierarchy of psychological pressures, these findings tentatively suggest that professionals regularly use psychological pressures in unjustifiable ways.
Psychological pressures can be analyzed not only in terms of what is said, but also in terms of by whom, why, how, when and where things are said. The scope of Szmukler and Appelbaum’s conceptual model  is restricted to what is said by professionals to improve treatment adherence and does not consider the larger context of interaction. Sjöström’s [23, 24] notion of “coercion contexts” provides a promising theoretical framework for a more comprehensive analysis of psychological pressure. “The term context,” Sjöström notes, “serves to stress that coercion will carry different meanings for different actors in different situations” ( p41).
Several empirical studies that include service users’ perspectives indicate that the scope of analysis should be broadened to capture the full phenomenon. The inductive analysis of focus groups with mental health professionals carried out by Pelto-Piri and colleagues  suggested that the communicative strategies outlined by Szmukler and Appelbaum  should be supplemented with the strategies cheating, disciplinary style, and reference to rules and routines. Studies on perceived coercion underlined that service users’ perception of coercion depends not so much on isolated actions [26, 27] as on contextual and procedural factors, such as interpersonal relationships and procedural fairness [28,29,30,31,32,33]. Procedural fairness denotes the extent to which service users feel that they are being taken seriously and treated with respect [26, 34, 35]. In other qualitative studies on psychological pressure, service users reported pressure to adhere to recommended treatment and remain healthy from relatives and friends [25, 36], as well as from the dominant biomedical model of health and illness [23, 28, 35, 37].
The aim of our study was to develop a conceptual model of psychological pressure based on the experiences and perspectives of service users. Our research questions were as follows: (1) Which forms of psychological pressure do service users experience during inpatient stays and in their social environment? (2) How do service users evaluate these forms of psychological pressure? We expected that the analysis of the data would provide indications for potential strategies to reduce psychological pressure in mental healthcare.