We hope that when someone is struggling with their mental health, they’re able to access help that is supportive, compassionate, and empowering. But what if they instead feel pressured or manipulated by the professionals meant to help them? This influence is called informal coercion – a common, yet often overlooked, part of psychiatric care.
Informal coercion happens when professionals use tactics like persuasion, threats, withholding information, or making access to services conditional on certain behaviours, to influence patients’ decisions – for example, to encourage them to accept or stick with treatment. Unlike formal coercion, which involves more obvious restrictions such as physical restraint or treatment without consent (for example, compulsory detention in hospital under the Mental Health Act), informal coercion is often more subtle and harder to recognise.
Research shows that coercion in inpatient mental health care can be harmful, with many patients describing a loss of control, freedom, power, and choice during their stay (Hallett et al., 2025). However, most studies have focused on formal coercion, as it is easier to measure, leaving informal coercion less well understood.
A recent scoping review by Beeri and colleagues (2025) set out to fill this gap, exploring how informal coercion is defined and conceptualised in inpatient psychiatry. This blog outlines what they did, what they found, and why it matters for patients, families, and the professionals who support them.
Informal coercion is when staff pressure, influence, or manipulate patients’ decisions without using formal legal powers.
Methods
Beeri and colleagues conducted a scoping review to map existing research on informal coercion in adult inpatient mental health settings. They searched multiple academic databases for peer-reviewed studies (quantitative, qualitative, theoretical, opinion, and reviews), excluding grey literature (i.e. non-peer reviewed literature). Over 4,000 papers were double screened by the researchers, with 29 meeting the review’s eligibility criteria.
Data from each included study were extracted and thematically analysed (meaning the researchers looked for recurring themes across the papers) to explore how informal coercion was defined, how and when it occurred, and how it was described by patients and staff. These findings were then used to develop a definition and conceptual model of informal coercion in inpatient mental health settings. No formal quality assessment of the included studies was undertaken.
Results
Across the 29 studies (most from Europe), the researchers found that informal coercion in inpatient mental health care is complex, multifaceted, and often hidden. Staff often described it as a “necessary evil” or a “softer” alternative to formal coercion, while others called it a “grey zone” – operating without clear legal rules or ethical guidance.
Informal coercion can range from negotiation or persuasion through to threats, manipulation, or overt use of force. It happens in everyday interactions and is influenced by factors at three levels.
Micro (individual) level informal coercion
- Direct interactions between staff and patients, aiming to influence patients’ decisions or behaviour.
- This could involve expressing concern, emphasising treatment benefits, or more covert tactics like withholding information or making threats.
Meso (organisational) level informal coercion
- Hospital rules and routines that apply to all patients, voluntary or not.
- These regulate behaviour, maintain order, and enforce compliance.
Macro (systemic) level informal coercion
- Wider professional attitudes, policies, and laws that shape how staff view and treat patients, including stigma or rigid adherence to certain models of mental illness or distress (e.g. the biomedical model).
A working definition
Drawing on the included studies, Beeri and colleagues developed the following definition of informal coercion:
Informal coercion is part of a continuum that moves between subtle interpersonal interactions, active patient involvement in treatment decisions through negotiation, and authoritarian and physical measures, overt use of force and coercive treatments. This includes the practice of professionals wanting what is best for the patient and acting in the patient’s best interest as patient protection to increase treatment adherence and reduce harmful behaviours, and as self-protection to meet the professional demands of everyday work. Informal coercion includes the use of verbal, non-verbal or overt communication patterns, ‘legal’ coercion, deception and manipulation and abuse of power, as well as the enforcement of cultural adaptation and rule conformity, and professional attitudes and skills.
A conceptual model
The authors developed the following conceptual model of informal coercion (figure 1). In their model, informal coercion exists on a continuum – from gentle persuasion and negotiation at one end to authoritarian decisions, physical measures, and overt use of force at the other.
Figure 1: Beeri et al.’s (2025) conceptual framework of informal coercion. [View full-size]
The model also identified other key features of informal coercion, categorised into three different themes: 1) the professionals’ intention; 2) the way of informal coercion; and 3) the context of informal coercion. These are described in the table below.
Table 1: Features of informal coercion [View full-size]
Conclusions
This scoping review found that informal coercion is a widespread and complex issue in inpatient mental health care. Drawing on existing literature, the authors propose a definition of informal coercion and describe it as a “continuous, contextual concept” that can cause harm, even when well-intentioned.
They argue that greater attention to informal coercion is needed in research, practice, and training, and hope that their findings will:
help lay the groundwork for developing ethical guidelines and professional standards to protect patients’ autonomy, dignity and rights.
Strengths and limitations
This review is the first to map how informal coercion is defined and understood in inpatient mental health care – addressing an important research gap. By including a wide range of study types – from empirical research to theoretical and opinion pieces – it captured diverse perspectives from both patients and professionals. The thematic synthesis provided a structured way to identify recurring patterns, and the development of a conceptual model offers a foundation for future research, practice and policy.
However, there were also some limitations. Studies not published in English or German, and those on certain populations (e.g., people with neurodegenerative conditions, cognitive impairments, addictions, eating disorders), were excluded. While these decisions helped keep the scope manageable, they may limit the generalisability of the findings.
More detail on how the conceptual model was developed – including its iterative refinement with input from nurse scientists – would have improved transparency and made it easier for others to build on their work. While the authors did acknowledge that their own beliefs and assumptions may have influenced the findings, more explicitly sharing some of these reflections would have helped readers interpret the results in context.
Perhaps the most notable limitation is the absence of involvement of people with lived experience of inpatient mental health services in the design, conduct, or write-up of the review. Their perspectives could have challenged academic and professional assumptions, drawn attention to overlooked forms of informal coercion, and helped ensure the conceptual model reflected the realities of those most affected. The authors’ decision to exclude grey literature to “maintain a professional level of discourse” may have similarly sidelined lived experience perspectives.
The first study to systematically map how informal coercion is defined and understood could have been strengthened with more lived experience involvement.
Implications for practice
This review highlights just how complex and layered the concept of informal coercion is. Even when someone feels like they’re making their own decisions, those choices may be subtly shaped by professional influence, systemic pressures, or cultural expectations. This raises a difficult question: where is the line between guiding someone and pressuring them?
Some tactics, like deception or manipulation, are widely viewed as unacceptable because they negatively impact patients’ autonomy and dignity, erode trust, and damage professional integrity. Others, such as persuasion or shared decision-making, are generally seen as more ethical. But there is a wide grey zone, and there is a degree of subjectivity – the same action may feel supportive to one person but coercive to another, depending on the intent and context. Views on where to draw the line between “legitimate influence and illegitimate pressure” therefore vary.
We need more research to better understand how patients, families/carers, and staff view and experience informal coercion, what factors they think contribute to it, and how they think it could be addressed in inpatient psychiatric settings. This should explore similarities and differences across different countries, types of inpatient settings, professional roles, and among people with different intersecting identities (age, gender, ethnicity, social class, disability, or neurodivergence).
Beeri and colleagues call for more ethical and legal guidance on informal coercion, along with formal training for professionals, to promote care that respects patients’ dignity, autonomy, and rights. But many questions remain: should guidance be universal or tailored to specific settings or situations? How can it stay up to date as clinical practice evolves? How can organisations be held accountable to adhere to it? How far can informal coercion be reduced in environments with such entrenched power imbalances between patients and staff? Individual reflection alone isn’t enough – it is clear that lasting change will require broader system-level changes.
Whatever the approach, future research, ethical and legal guidance should be co-produced with people who have lived experience of inpatient psychiatric care, their families/carers, and a diverse range of staff. It will be especially important to involve marginalised groups, such as black patients and migrant groups, who we already know are disproportionately subjected to formal coercion in inpatient psychiatric care (Barnett et al., 2019). Doing so will help to ensure that future research, guidance, and policy on informal coercion reflects their experiences and needs, promoting care that is more fair, respectful, and empowering for all.
There are many shades of grey when it comes to determining what informal coercion means.
Links
Primary paper
Beeri, S., Baumberger, E., Zwakhalen, S., & Hahn, S. (2025). Conceptualisation of Informal Coercion in Inpatient Psychiatry: A Scoping Review. International Journal of Mental Health Nursing, 34(3), e70076.
Other references
Barnett, P., Mackay, E., Matthews, H., Gate, R., Greenwood, H., Ariyo, K., Bhui, K., Halvorsrud, K., Pilling, S., & Smith, S. (2019). Ethnic variations in compulsory detention under the Mental Health Act: a systematic review and meta-analysis of international data. The Lancet. Psychiatry, 6(4), 305–317. https://doi.org/10.1016/S2215-0366(19)30027-6
Hallett, N., Dickinson, R., Eneje, E., & Dickens, G. L. (2025). Adverse mental health inpatient experiences: Qualitative systematic review of international literature. International Journal of Nursing Studies, 161, 104923. https://doi.org/10.1016/j.ijnurstu.2024.104923
