Conference Agenda

Many service users experience coercion over the course of their involvement with mental healthcare services. This encompasses both formal coercion, e.g. in form of involuntary commitment, seclusion, restraint, or involuntary treatment, as well as informal coercion. The latter phenomenon is also discussed as psychological pressure and describes the use of various communicative strategies to direct service users’ decision-making regarding recommended treatment. Despite its practical relevance, research on psychological pressure is still scarce.

This symposium aims to show how qualitative research can contribute to a better understanding of psychological pressure within mental healthcare. It underlines the ways in which qualitative research can provide insights that quantitative research cannot supply and shows their importance for both conceptual analysis and clinical practice. Yet, qualitative research is also accompanied by unique methodological and ethical challenges. The symposium will, therefore, also elaborate on how these challenges may be carefully navigated to ensure good scientific practice.

Psychological pressure refers to communicative strategies used by professionals and informal caregivers to influence the decision-making of service users and improve their adherence to recommended treatment or social rules. Although psychological pressure is commonly used in mental healthcare services, there is a lack of conceptual understanding of the phenomenon. A first, mainly theoretical, conceptual analysis distinguishes between persuasion, interpersonal leverage, inducements and threats. Aiming to develop a conceptual model of psychological pressure based on the perspectives of service users, 14 semi-structured interviews with mental healthcare service users were conducted and analyzed using grounded theory methodology.

The analysis indicates that psychological pressure is exerted not only by mental health professionals but also by relatives and friends; and that the extent to which service users perceive communication as involving psychological pressure depends strongly on contextual factors. Relevant contextual factors were the way of communicating, the quality of the personal relationship, the institutional setting, the material surroundings and the level of convergence between the parties’ understanding of mental disorder. The results of the study highlight the importance of staff communication training and organizational changes for reducing the use of psychological pressure in mental healthcare services.

It has been shown that psychological pressure on/to people with mental illness is not only exerted by mental healthcare professionals but also by relatives and friends. Relatives of people with mental illness provide a substantial amount of informal care for their relatives with mental illness. Yet, their perspective is rarely included in research and little is known about how they exert psychological pressure and how it occurs. To fill this gap, we conducted semi-structured interviews with 11 relatives of mental healthcare service users which we analyzed according to grounded theory methodology.

Our findings show that psychological pressure is commonly used by relatives. Moreover, our analysis underlines that relatives’ use of psychological pressure must be seen in a broader context, a context in which relatives are subjected to many pressures themselves. These include, for example, their own consternation, feeling responsible for their relative with mental illness, and being dependent on professional help. Relatives describe having to navigate between service users and the mental healthcare system and to bring the two together. One way of doing so is by exerting psychological pressure which is oftentimes experienced as morally distressing and frustrating.

The process of obtaining ethical approval for a study by a research ethics committee before the start of the study has been described as “procedural ethics” and the identification and handling of ethically sensitive moments by researchers during the research process as “ethics in practice.” While some authors dispute and other authors defend the use of ethics review of qualitative health research, there is general agreement that ethics in practice is of particular importance. This presentation aims to show how procedural ethics and ethics in practice can fruitfully complement each other. It illustrates research ethics in practice by reflecting on how we identified and addressed ethical and methodological issues that arose while designing and conducting an interview study with mental health service users and relatives. We describe the challenges we faced and the solutions we found in relation to the potential vulnerability of research participants, the voluntariness of consent, the protection of privacy and internal confidentiality, and the choice of the interview setting.