Informal coercion towards discharge: The entanglement of formal and informal coercion in social resource introduction

BACKGROUND: Coercion is a central issue in psychiatric practice, and understanding its nature is essential for developing effective coercion reduction strategies. However, the epidemiology and impact of informal coercion during a single hospitalization, as well as its relationship with formal coercion, remain unclear. This study aimed to estimate the prevalence and characteristics of informal coercion during a single hospitalization; to assess whether informal coercion was associated with the intended effect of introducing social resources; and to identify risk factors associated with its use, particularly formal coercion. METHOD: This retrospective cohort study was conducted at an urban psychiatric emergency hospital. A total of 659 individuals with acute schizophrenia were examined for experiences of informal coercion in the context of social resource introduction. A quasi-experimental design using inverse probability of treatment weighting and modified Poisson regression was employed. RESULTS: Approximately 22 % of participants experienced informal coercion. Specifically, 9.1 % were subjected to threats, 4.7 % to inducements, and 11 % to persuasion. Threats and inducements increased the likelihood of social resource introduction but were also associated with limitations of the participants' choices regarding discharge and post-discharge life decisions. Involuntary admission was the strongest predictor of informal coercion, and condition for discharge is the most prevalent gain implied in threats. CONCLUSION: Informal coercion towards discharge was a structurally embedded practice linked to formal coercion. Two forms of informal coercion were identified: extra-legally constructed medical authority and informal legal transplantation. Reducing informal coercion requires limiting formal coercion, clarifying discharge criteria in law, and expanding non-coercive social resources.