Abstract: Care through Coercion?: Reframing the Ethics Debate on Involuntary Mental Health Services (Society for Social Work and Research 27th Annual Conference - Social Work Science and Complex Problems: Battling Inequities + Building Solutions)

All in-person and virtual presentations are in Mountain Standard Time Zone (MST).

SSWR 2023 Poster Gallery: as a registered in-person and virtual attendee, you have access to the virtual Poster Gallery which includes only the posters that elected to present virtually. The rest of the posters are presented in-person in the Poster/Exhibit Hall located in Phoenix A/B, 3rd floor. The access to the Poster Gallery will be available via the virtual conference platform the week of January 9. You will receive an email with instructions how to access the virtual conference platform.

Care through Coercion?: Reframing the Ethics Debate on Involuntary Mental Health Services

Sunday, January 15, 2023
Paradise Valley, 2nd Level (Sheraton Phoenix Downtown)
* noted as presenting author
Ryan Dougherty, PhD, Fellow of Clinical Ethics, Weill Cornell Medicine, New York, NY
Background and Purpose

Contemporary mental health policy attempts to balance public interests of treating serious mental illness with the personal rights of individuals. To do so, services rely on dangerousness and grave disability criteria and, in recent decades, have expanded community-based involuntary treatment programs. However, drawing from sociological and ethical theories, critics argue that coercive programs produce psychological harm and are designed to produce behavioral conformity, often at the benefit of market economies. While a rich debate exists in the literature and public sphere on involuntary programs, little ethnographic work has been conducted that directly confronts how coercion operates in real-time, including how coercion is understood, morally rationalized, and experienced by frontline providers and their clients. Understanding the rationales for coercive practices in involuntary mental health services may help us illuminate the broader sociological discourses that motivate its use.


The primary author conducted a multi-year and interdisciplinary team-based ethnography of involuntary outpatient services (OPC) in a diverse metropolitan county. Data collection included direct participant-observations of treatment sessions and semi-structured interviews of clients, treatment providers, administrative staff, and client family members related to compliance to psychiatric treatment. Ethnographic notes and semi-structured interviews were iteratively analyzed to guide data collection until thematic saturation was reached on themes related to patient preferences, autonomy, and coercion.


Involuntary services were sought by family members and providers due to their fears of an individual’s hyper-vulnerability to victimization, homelessness, and policing in their communities. Specifically, these referral sources described how previous services were unable to address their concerns and hoped that involuntary services would increase treatment compliance, deliver on basic resources, and protect clients from harm. Providers relied on coercive methods (i.e., use of threats) to gain compliance often as a last resort and, instead, used lesser forms of persuasion first (e.g., incentives) in hopes to cultivate patient-driven compliance. Regardless of the technique used, many clients felt involuntary programs undermined their autonomy, resulting in fractured relationships between them, providers, and family members. Issues of compliance were particularly focused on medications, which some clients preferred to decline due to their various adverse effects.

Conclusions and Implications

These results require social work to reflect critically on how its frontline practices may further alienate vulnerable individuals away from supportive services. Further, these results reframe coercion as not an instrument of state oppression, but rather emergent from a broader political landscape of social precarity and violence. Specifically, the emergence of involuntary services was justified to fill the gaps of a disjointed, and increasingly defunded, social welfare system that leaves individuals labeled with serious mental illness structurally vulnerable. Involuntary interventions identify these structural problems within individual actors, placing enormous burdens on clients, their providers, and communities to gain compliance in ways that create moral distress and burnout. Thus, re-envisioning a more ethical mental health system without a reliance on coercion will require acknowledging the relationship between frontline social work practice and the relationship of mental health to broader social welfare, criminal justice, and health policy.