Coercion in Psychiatry: A qualitative study of socialization, normativity and relationships in the psychiatric institution

The dissertation “Coercion in Psychiatry - A qualitative study of socialization, normativity and relationships in the psychiatric institution” takes up the discussion about coercion in psychiatry from a socialization theoretical study of the institutionalized normative reasonings for coercion between patients and professionals in psychiatric practice. More specifically, the dissertation explores how both formal coercive measures and subtle processes of coercion are constituted institutionally through interactions between patients and professionals, through the organization of the psychiatric practice, as well as through ideas about mental illness, rationality and dangerousness. In this way, the overall aim is to gain insights into the normative dynamics connected to coercion, but not to judge coercive practices despite their ethical implications.

The dissertation is based on an ethnographic study of four closed inpatient wards and one psychiatric emergency room in Region Zeeland in Denmark in 2020 and 2021. The study lasted four months and involved participant observation and interviews. The dissertation explores how patients and professionals are confronted with normative practices, and it discusses the societal embeddedness of these arrangements and implications for the subjects. More specifically, and drawing on the works of Norbert Elias and Jürgen Habermas, the dissertation explores how patients and professionals are confronted with civilizing ambitions and institutionalized rationales in situations of formal coercive measures and subtle processes of coercion.

The dissertation suggests that the institutional setup and normative background of the psychiatric institution and practice distort possibilities for the patient-professional relationship to be characterized by a democratic and humanistic intersubjectivity. The dissertation argues that coercion is more than the concrete and immediate situations with formal coercion; coercion is also present, when it is absent though the potential risk of coercion and through the collectively shared previous experiences with and knowledge about coercion. It is suggested to understand coercion beyond its immediacy, as a dynamic phenomenon, which guides and informs experiences and justifications, and becomes an essential part of the now. Further, it is argued how coercion also exist as processes of subtle coercion which are constituted in the communicative interactions between patients and professionals. Finally, the dissertation suggests that subtle coercion can be constituted in the patient-professional relationship as succeeding or replacing efforts which ‘successfully’ revoke a formal coercive measure.

It is discussed how formal coercive measures have been installed politically as well as in research as something ultimately wrong, which should be reduced or, at best abolished. A contribution of this dissertation is an argument of how these efforts have ‘black boxed’ the concept of coercion and in this endeavor, the nuances of what the phenomenon of coercion is in practice, how it works and functions between people in the everyday life, are disregarded. An implication is that only formal coercive measures are conceptualized as something to be reduced. Coercion is an extremely paradoxical phenomenon, in that efforts to reduce coercion produce coercion. This paradox prompts a revisiting of coercion on a conceptual level in research and practice.