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Cited by 23Healthcare Decision-Making and RestraintsPsychotherapy Techniques and ApplicationsPsychiatric care and mental health services

Coercion and the Inpatient Treatment Alliance

Open access
Lawrence, Ryan E., Perez-Coste, Maria M., Bailey, Jennifer L., DeSilva, Ravi B., Dixon, Lisa B.·2019·Psychiatric Services
DOI 10.1176/appi.ps.201900132
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Abstract

OBJECTIVE: The importance of building a strong treatment alliance is widely accepted and uncontroversial. Quantitative research suggests that coercive experiences during psychiatric treatment negatively affect the treatment alliance, but reveals little about how this happens or how patients navigate treatment relationships while experiencing coercion during psychiatric treatment. METHODS: Fifty psychiatric inpatients were interviewed at two hospitals. Patients were asked open-ended questions about the relationship between the treatment alliance and a set of coercive treatment experiences (court-mandated treatment, involuntary hospitalization, locked facilities) and whether such hospital experiences affected the patients' plans for future adherence. Interviews were audio-recorded, transcribed, and qualitatively analyzed. RESULTS: Many participants reported events where coercion made it difficult to form a treatment alliance. An imbalance of power, lack of control, and insufficient participation in treatment planning were described as experiences that interfered with the treatment alliance. Other participants felt the treatment alliance was maintained despite coercive experiences and spoke of good communication with the psychiatrist, understanding the rationale behind interventions, and feeling the psychiatrist was trying to keep the patient's best interests in mind. CONCLUSIONS: Coercive experiences remain undesirable and are frequently detrimental to the treatment alliance. Nevertheless, patients and clinicians should continue to seek a strong treatment alliance even when treatment plans include coercive elements. Efforts to improve communication, to explain the rationale for treatment plans, and to show that clinicians are trying to act in the patient's best interests may help to preserve a therapeutic alliance.

Integrity signals

Registry

Crossref · 10.1176/appi.ps.201900132

Cites

18 of 18 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

4 of 31 cited sources checked · 2 supported · 0 flagged · accuracy not yet measured

  • Premisecitation
    § Coercion and the Inpatient Treatment Alliance

    Only one qualitative study has addressed coercion and the treatment alliance among inpatients.

    “Qualitative research is needed; however, only one such study has addressed coercion and the treatment alliance among inpatients.”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] source

      The Discussion identifies coercion as a barrier to therapeutic relationships among psychiatric inpatients, so this paper is a qualitative study addressing the stated topic. Our copy does not establish that it was the only such study. (LLM, conf=0.85)

      Experimental — accuracy not yet measured
  • Findingown data
    § Coercion and the Inpatient Treatment Alliance

    Many participants reported events where coercion made it difficult to form a treatment alliance.

    “Many participants reported events where coercion made it difficult to form a treatment alliance.”
    Quote in the paperSubstantial claim
  • Findingown data

    Six patients said the alliance was harmed by being involuntarily hospitalized.

    “Six patients said the alliance was harmed by being involuntarily hospitalized.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Among the 40 codable responses, a majority (N=27) said their inpatient experiences had no effect on their willingness to adhere to the outpatient plan.

    “Among the 40 codable responses, a majority (N=27) said their inpatient experiences had no effect on their willingness to adhere to the outpatient plan, sometimes making a sharp distinction between inpatient and outpatient experiences.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Three patients said it was difficult to engage in treatment because they did not want to be there.

    “Three patients said it was difficult to engage in treatment because they did not want to be there.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 19
  • Classified as probably not a substantial claim. 25

  • May combine two claims.

    Premisecitation
    § Coercion and the Inpatient Treatment Alliance

    That qualitative study was small (N=19) and recruited some participants by advertising in a mental health newsletter, increasing the risk of selection bias.

    “That study was small (N=19) and recruited some participants by advertising in a mental health newsletter, increasing the risk of selection bias (9).”
    Quote in the paperSubstantial claim1 of 1 sources checked
    • cites [9] source

      The Method > Participants section reports 19 participants recruited by volunteer sampling, including two through an advert in a local mental health charity newsletter. The paper does not explicitly assess whether that recruitment increased selection-bias risk; that is the citing authors’ inference. (LLM, conf=0.83)

      Experimental — accuracy not yet measured

  • May combine two claims.

    Study design and conductcitation

    The current sample is larger than other qualitative studies on this topic among inpatients (N=19) and outpatients (N=6-15).

    “The current sample is larger than other qualitative studies on this topic among inpatients (N=19) (9), and outpatients (N=6-15) (11,12).”
    Quote in the paperNot a substantial claim2 of 3 sources checked
    • cites [9] source
    • cites [11] source
    • cites [12] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    All patients were interviewed on locked inpatient units.

    “All patients were interviewed on locked inpatient units.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Two patients did not think the sign-out letter had changed the treatment relationship, because the psychiatrist already knew the patient wanted to leave.

    “Two patients did not think the sign-out letter had changed the treatment relationship, because the psychiatrist already knew the patient wanted to leave.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    One patient explained that the alliance was unaffected because the emergency room doctor who hospitalized him against his will was different from the inpatient psychiatrist who treated him.

    “One patient explained that this was because the emergency room doctor who hospitalized him against his will was different from the inpatient psychiatrist who treated him.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    For some (N=3), the sign-out letter was purely motivated by a desire to leave the hospital, and the inpatient treatment alliance played no role in the decision.

    “For some (N=3), the sign-out letter was purely motivated by a desire to leave the hospital, and the inpatient treatment alliance played no role in the decision.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    One patient said the court experience had no impact on the treatment alliance because the psychiatrist and patient already knew what the other wanted.

    “One patient said the experience had no impact on the treatment alliance because the psychiatrist and patient already knew what the other wanted.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most participants reported a strong treatment alliance; however, a wide range of experiences was represented.

    “Most of the participants reported a strong treatment alliance; however, a wide range of experiences was represented (Table 2).”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Nineteen patients reported having been involuntarily hospitalized at some point in their lives, and one additional patient had been involuntarily held in a psychiatric emergency room.

    “Nineteen patients reported having been involuntarily hospitalized at some point in their lives, and one additional patient had been involuntarily held in a psychiatric emergency room.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § Coercion and the Inpatient Treatment Alliance

    Other participants felt the treatment alliance was maintained despite coercive experiences and spoke of good communication with the psychiatrist, understanding the rationale behind interventions, and feeling the psychiatrist was trying to keep the patient's best interests in mind.

    “Other participants felt the treatment alliance was maintained despite coercive experiences and spoke of good communication with the psychiatrist, understanding the rationale behind interventions, and feeling the psychiatrist was trying to keep the patient's best interests in mind.”
    • Also stated in: § DISCUSSION · plain
      “Other participants, who felt the treatment alliance was maintained despite coercive experiences, spoke of good communication with the doctor, understanding the rationale behind various interventions, and feeling the doctor was trying to keep the patients' best interests in mind.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Many patients said the inpatient treatment alliance was unaffected (N=7) or remained strong (N=6) despite the involuntary status.

    “Many said the inpatient treatment alliance was unaffected (N=7) or remained strong (N=6) despite the involuntary status.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Patients said the involuntary experiences were difficult because they felt as though they had no control over decisions, they did not feel like full participants in treatment planning, and they were not able to manage their lives outside the hospital.

    “Patients said the involuntary experiences were difficult because they felt as though they had no control over decisions, they did not feel like full participants in treatment planning, and they were not able to manage their lives outside the hospital (e.g., not able to make money).”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Another participant said she knew she needed the hospitalization.

    “Another participant said she knew she needed the hospitalization.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Five patients had ever been to court for treatment-related reasons.

    “Five patients had ever been to court for treatment-related reasons.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    One participant suggested that the overall treatment experience was more important than voluntary or involuntary status.

    “One suggested that the overall treatment experience was more important than voluntary or involuntary status.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Most (N=37) said the locked doors had no effect on the treatment alliance, often because it was what they expected.

    “Most (N=37) said the locked doors had no effect on the treatment alliance, often because it was what they expected.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Eight participants reported positive experiences that increased their willingness to be adherent, including working together with the psychiatrist to create the outpatient plan and having helpful therapeutic experiences that provided a model for what aftercare could be like.

    “Eight participants reported positive experiences that increased their willingness to be adherent, including working together with the psychiatrist to create the outpatient plan and having helpful therapeutic experiences that provided a model for what aftercare could be like.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    While some participants felt that coercive experiences made it difficult or impossible to work with the inpatient psychiatrist, others experienced the inpatient psychiatrist as well intentioned, even when coercive measures had been used.

    “While some participants felt that coercive experiences made it difficult or impossible to work with the inpatient psychiatrist, others experienced the inpatient psychiatrist as well intentioned, even when coercive measures had been used.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S4 (based).

    Premisenone given
    § Coercion and the Inpatient Treatment Alliance

    Quantitative methods that reduce complex experiences to statistical associations reveal little about how coercive experiences affect the treatment alliance.

    “Additionally, quantitative methods that reduce complex experiences to statistical associations reveal little about how coercive experiences affect the treatment alliance.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation
    § Coercion and the Inpatient Treatment Alliance

    Only a few studies exist on coercion and treatment alliance among inpatients; their sample sizes are small for quantitative analyses (N=79-164) and they are spread across just a few countries (Australia, Ireland, England, and Switzerland).

    “Only a few studies exist, their sample sizes are small for quantitative analyses (N=79-164), and they are thinly spread across just a few countries (Australia, Ireland, England, and Switzerland) (5)(6)(7)(8).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [5] source
    • cites [6] source
    • cites [7] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Recruitment was only in one city and within one hospital system.

    “Limitations of the study included recruitment only in one city and within one hospital system.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    The goal was to include the perspectives of all psychiatric inpatients, so inclusion criteria were broad and exclusion criteria were minimal.

    “The goal was to include the perspectives of all psychiatric inpatients, so inclusion criteria were broad and exclusion criteria were minimal.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    A checklist of the consolidated criteria for reporting qualitative studies with comments is included in the online supplement.

    “A checklist of the consolidated criteria for reporting qualitative studies with comments is included in the online supplement (10).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [10] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The interview questions tended to stratify treatment relationships into two categories (good alliance or difficult relationship).

    “The interview questions tended to stratify treatment relationships into two categories (good alliance or difficult relationship), and future studies could take a more nuanced approach by exploring varieties of treatment relationships.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductown data

    After 50 interviews, there were no new ideas or concepts emerging, suggesting that theme saturation had been achieved.

    “After 50 interviews, there were no new ideas or concepts emerging, suggesting that theme saturation had been achieved.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    The questionnaire remained consistent throughout all interviews to facilitate comparisons of participants' responses.

    “The questionnaire remained consistent throughout all interviews to facilitate comparisons of participants' responses.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Not all participants had experienced all the forms of coercion assessed in the interview.

    “Not all participants had experienced all the forms of coercion assessed in the interview.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductcitation

    Use of the Inpatient Treatment Alliance Scale is a methodological strength of the study design.

    “Use of the Inpatient Treatment Alliance Scale is a methodological strength of the study design (13).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [13] source

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    In a large qualitative study, outpatients described choice and autonomy as central to recovery and coercion as a major hindrance.

    “In a large qualitative study, outpatients described choice and autonomy as central to recovery and coercion as a major hindrance (16).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [16]

      Couldn’t be matched to a paper in Crossref, so it can’t be checked.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A quantitative study among outpatients reported that higher treatment satisfaction was associated with a better working alliance and less perceived coercion.

    “Similarly, a quantitative study among outpatients reported that higher treatment satisfaction was associated with a better working alliance and less perceived coercion (17).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [17] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Outpatient studies have consistently found that fear of coercion is an obstacle to seeking psychiatric care.

    “Outpatient studies have consistently found that fear of coercion is an obstacle to seeking psychiatric care (14,15).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [14] source
    • cites [15] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Many coercive experiences were not specifically assessed in this study, including forced medication, seclusion, and restraint.

    “Many coercive experiences were not specifically assessed in this study, including forced medication, seclusion, and restraint, which are important categories of experiences that can affect the treatment alliance.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim. May combine two claims.

    Study design and conductnone given

    Two of us coded the interviews independently and discussed discrepancies until consensus was reached.

    “Two of us (R.E.L. and M.P.-C.) coded the interviews independently and discussed discrepancies until consensus was reached.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductcitation

    Participants completed the Inpatient Treatment Alliance Scale, a 10-item self-report instrument designed for use on inpatient units.

    “Participants then completed the Inpatient Treatment Alliance Scale, a 10-item self-report instrument designed for use on inpatient units.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [13] source

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The interviewer was not a member of the patient's treatment team.

    “The interviewer was not a member of the patient's treatment team.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    We used a grounded theory approach to analyze the data, which allowed themes to emerge from the interviews.

    “We used a grounded theory approach to analyze the data, which allowed themes to emerge from the interviews.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    Data were not available on study nonparticipants, so it is not known whether their experiences differed from study participants.

    “Data were not available on study nonparticipants, so it is not known whether their experiences differed from study participants.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    The study did not assess length of time since illness onset.

    “The study did not assess length of time since illness onset.”
    Quote in the paperNot a substantial claim
38 of 38

  • The paper relies on this without support.

    The full range of coercive psychiatric treatment practices is broad and includes interactions with staff, imbalances of power, seclusion and restraint, forced medication, and lack of patient involvement in treatment planning.

    “The full range of coercive psychiatric treatment practices is broad and may include interactions with staff, imbalances of power, seclusion and restraint, forced medication, and lack of patient involvement in treatment planning.”

  • The paper relies on this without support.

    Coercive experiences are undesirable in clinical settings.

    “Coercive experiences remain undesirable and are frequently detrimental to the treatment alliance.”
    “While coercion is never desirable in clinical settings, patients, clinicians, and policy makers should consider that, for some patients, positive treatment experiences and a good treatment alliance remain possible even when coercive measures have been used.”
2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Clarkin JF, 1987, Hosp Community Psychiatry, 38, 871

Cited by

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Related

Authors
Lawrence, R. E., Perez-Coste, M. M., Bailey, J. L., DeSilva, R. B., & Dixon, L. B.
Affiliations
NewYork–Presbyterian Hospital (US)
ORCID
Venue
Psychiatric Services
Publisher
American Psychiatric Association Publishing
Published
2019-12-01
Volume
70
Issue
12
Pages
1110-1115
ISSN
  • 0022-1597 (ISSN-L)
  • 1075-2730
  • 1557-9700
DOI
10.1176/appi.ps.201900132
OpenAlex
W2971603291
Cited by
23
References
17
Citations by year
2026: 3 · 2025: 2 · 2024: 7 · 2023: 1 · 2022: 2 · 2021: 6 · 2020: 2
FWCI
2.92
Type
journal article
Language
en
Open access
Locations
  • Psychiatric Services (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • Department of Psychiatry, Columbia University
  • National Institute of Mental Health (R25MH086466)
Topics
  • Social Sciences › Psychology › Clinical Psychology › Healthcare Decision-Making and Restraints
  • Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
  • Social Sciences › Psychology › Clinical Psychology › Psychiatric care and mental health services
Keywords
treatment alliance, psychiatric inpatients, involuntary admission, court-ordered treatment, power imbalance, medication adherence, patient-clinician communication, patient participation in treatment planning, patient experience
MeSH terms
Adult, Aged, Aged, 80 and over, Mental Disorders, Coercion, Commitment of Persons with Psychiatric Disorders, Communication, Female, Hospitals, Psychiatric, Humans, Inpatients, Interviews as Topic, Male, Middle Aged, New York City, Physician-Patient Relations, Qualitative Research, Young Adult

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