Mrs. Mitchell, 75, lives alone and has mild cognitive impairment and depression. She’s stopped eating and lost five pounds over two weeks, telling you, “I feel too sad to eat.” Her medical workup hasn’t found anything wrong. Her daughter, Alice, is concerned and wants her hospitalized. You agree that inpatient treatment might help, but Mrs. Mitchell refuses. You’re left weighing whether involuntary hospitalization is clinically necessary or if there’s a way to move forward collaboratively.

In geriatric psychiatry, interventions like involuntary hospitalization, restraints, or treatment over objection are sometimes used to manage acute psychiatric crises, protect individuals from self-harm or harm to others, and ensure necessary treatment when an older adult lacks decision-making capacity. These choices can be ethically and clinically tricky, especially for family members navigating the same difficult terrain. One promising tool to reduce reliance on coercive practices is shared decision making (SDM), where clinicians incorporate patients’ and caregivers’ preferences into treatment ­planning.

What counts as coercion? 
Coercion in psychiatry can take two forms: formal and informal. It involves anything that overrides or unduly influences a patient’s ability to make their own choices. Treatment crosses into coercion when it’s imposed without the patient’s valid consent, especially if their decision making is impaired and less restrictive options are unavailable.

Formal coercion
Many of us are familiar with formal, legally sanctioned types of coercive practices, including physical interventions (eg, seclusion, restraints, forced positioning) and chemical interventions (eg, injectable sedatives, antipsychotics). These measures are typically governed by state mental health laws and require precise documentation about imminent risk to self or others. We can often, though not always, reduce formal coercion through high-quality conversation (verbal de-escalation, SDM) and continuous staff presence, especially for agitated patients with dementia or delirium.

Informal coercion
Informal coercion can be much harder to spot. This includes persuasion that crosses the line into manipulation, threats, lies, guilt-tripping, and limiting patients’ access to financial or physical resources (Billé V et al, BMJ Open 2024;14(2):e079549). For example, it would be acceptable if Alice incentivizes her mother to eat by offering a trip to her favorite restaurant, but coercive if she threatens to stop paying her mother’s mortgage for refusing treatment.

Striking a balance
The World Psychiatric Association recognizes that coercive practices compromise several human rights—including liberty, autonomy, and non-discrimination— and use should be minimized (www.tinyurl.com/46kkvwz8). Yet appropriately applied coercive practices can uphold the right to health by offering care patients might not otherwise have (www.tinyurl.com/yd2a9vaj). Understanding the types, contexts, and impacts of coercive practices and alternatives can help minimize their use (Pelto-Piri V et al, BMC Res Notes 2019;12:787).

Risk of coercion in older adults
Geriatric patients often present with varying degrees of cognitive decline, physical frailty, or care dependence. These factors can make it harder to safely honor patient choices. We may feel pressured to act quickly, especially when families are overwhelmed or when safety is in question. But we still need to take time to assess decision-making capacity and pursue the least restrictive alternatives first.

Before using psychiatric coercion, officially confirm whether your patient has capacity to consent or decline treatment (Applebaum P, N Eng J Med 2007;357:1834–1840). Should your patient lack decision-making capacity, you will need to find a surrogate decision maker (see CGPR Oct/Nov/Dec 2023).

You first assess whether Mrs. Mitchell’s cognitive impairment limits her ability to decline psychiatric hospitalization. If she retains capacity, you must respect her refusal—even if you disagree.

SDM: A practical path forward
SDM is more than just informed consent. It’s a collaborative process where you work with the patient (and often their loved ones) to explore treatment options, understand their values, and identify acceptable paths forward. In many cases, this approach can resolve tension before coercion becomes necessary (Tonelli MR and Sullivan MD, J Eval Clin Pract 2019;25(6):1057–1062). Here’s how to apply it in real life:

Assess urgency
Is there an immediate, life-threatening risk? If not, explore other options. 

In Mrs. Mitchell’s case, her weight loss is concerning, but not acutely dangerous. This gives you room to talk and plan.

Validate real-world barriers
Families may push for quick solutions due to exhaustion or fear. As clinicians, we might feel these same pressures. Coercive practices may gain appeal under strained circumstances, but we owe our patients the least-restrictive means possible. We can acknowledge these pressures as we work toward solutions.

You tell Alice, “I can only imagine how hard it is to keep track of your mother’s nutrition alone. It sounds like you’re concerned she may become sicker at home.”

Explain the risks of coercion
Whenever we choose coercive practices for our patients, we run the risk of them experiencing anxiety, social isolation, iatrogenic harm (eg, from physical or chemical restraints), depression, and trauma. Moreover, if we overuse these practices, we risk eroding trust with our patients and their families. 

You tell Alice, “I understand how worried you are about your mom’s health. She might benefit from inpatient care, but since she’s saying no, let’s focus on supporting her at home for now. Pushing too hard can make her anxious or less willing to share how she’s feeling. Our priority is hearing her concerns and working with her.”

Discuss unmet needs, past experiences
Some patients hesitate to accept treatment because of past experiences where they felt coerced or unsafe, including negative healthcare or policing interactions (Alang S et al, Health Serv Res 2021;56(6):1104–1113). We can’t give promises about what will happen on units we refer to, but we can listen, validate concerns, and explore what would help the patient feel supported. Discussing past experiences can build trust and make them more open to care.

Talking with Mrs. Mitchell, you learn about her prior experience of a voluntary hospitalization. She tells you that she hated wearing a hospital gown and staying away from home for weeks. 

Review realistic, patient-centered treatment options
After you’ve done the work to understand your patient’s needs, you will be more equipped to find a compromise together. If inpatient care isn’t ideal right now, consider other mutually agreeable treatment options.

You tell Mrs. Mitchell that she can bring her own gown or loungewear from home if she agrees to psychiatric hospitalization. You also discuss options like attending a partial hospitalization program instead. 

Leave the door open for change
New information and circumstances may prompt a shift in treatment preferences, and models of care evolve to meet people’s needs. Keep checking in with your patient’s treatment preferences and consider new models of care.

While attending the partial hospitalization program, Mrs. Mitchell meets a peer support specialist who helps her reconsider how inpatient hospitalization might benefit her mood and weight loss. Mrs. Mitchell thanks Alice and you for giving her time and space to make this decision on her own.

Carlat Verdict: Coercion in psychiatry is sometimes necessary, but always as a last resort. SDM is the goal, but in practice it’s not always achievable. Prioritize transparency, respect, and clear communication. Let patients retain as much autonomy as possible while keeping them safe and promoting recovery. With patient, honest discussion, older patients can make informed choices that support their well-being on their own terms.