Does informal coercion impede the establishment of a therapeutic relationship? Or is persuasion or inducement one of these creative ideas to replace other de-escalation methods? The extent and the impact of applied informal coercion in therapeutic communication are often not recognized by practitioners, although they might interfere with a positive therapeutic relationship (6). Informal coercion is a frequently used form of communication to influence treatment outcomes. As a weaker form of coercion, it can be de-escalating if applied critically in a recovery-based environment. It needs to aim at reducing the use of seclusion and restraint and always requires moral justification and evaluation.

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San Francisco police have been using drones to catch car break-in suspects and investigate sideshows for months but internal emails show they knowingly broke the law by buying the crime-fighting tech.

Another concern, which Steeves didn’t address, is that evidence gathered through unauthorized technology could give defense attorneys grounds to challenge cases — including those the SFPD highlighted to justify its drone use.

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John Lindsay-Poland, a writer who advocates for demilitarizing the police through American Friends Service Committee, said SFPD appears to be the only agency in California to use drones without prior approval since AB 481 became law.

Supervisor Shamann Walton then brought up some of the same concerns as the Electronic Frontier Foundation, but struggled to get a straight answer.

“This internal email was sent during the early stages of our drone procurement process and does not represent the department’s position and did not then,” officer Robert Rueca, an SFPD spokesperson, told The Standard. “Also, that email was written without engaging with the city attorney’s office and did not reflect input from that office.”

Health professionals may respond to aggression with de-escalation techniques, but a still predominant response to aggression and especially violence in psychiatric settings is a “physical” one. We have to think about which uses of measures in which situations of everyday life are really necessary, or could be replaced by other creative ideas or practices. Within these perspectives, we focus on a nursing approach, being aware that aggressive behavior affects the whole treatment team in mental health settings.

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“If we want to stay out of the political fray and buy drones in order to use them in efficient ways that help the department,” Steeves advised, “we may want to wait until after the election to start the AB 481 approval process.”

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It is not only formal coercion but also informal coercion that is looked upon as negative and often hampers a therapeutic relationship (4, 5). Informal coercion is common but underestimated by health professionals (6). Informal coercion or treatment pressure (7) comprises subtle forms of communication mostly with the aim of preventing formal coercive measures or of improving treatment adherence (8). It can range from persuasion or inducement to more distinct forms like threats (9). Szmukler and Appelbaum (10) divided informal coercion into hierarchical degrees of persuasion, interpersonal leverage, inducement, and threats. A study from 1998 (11) also revealed the demonstration of force as a relevant form of coercion. The authors grouped the forms of coercion into nine degrees: persuasion, inducement, threats, show of force, physical force, legal force, request for a dispositional preference, giving orders, and deception (11).

When asked for comment on Steeves’ warning as well as outside criticism about the department violating state law, SFPD offered a narrow response.

The aim of mental health practice should be to develop a high and critical awareness toward the use of coercive measures including informal coercion.

“A law enforcement agency violating the law sets a bad example for the community,” Lindsay-Poland said, “and puts at legal risk the prosecutions in which drones were used.”

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SFPD leaned heavily on the city attorney’s language when it made its case for Dorsey’s proposal at the Sept. 9 Rules Committee.

Until then, according to state law, it can’t legally use drones — but SFPD apparently can’t be penalized for that either. AB 481 has no enforcement mechanism beyond admonishment from state authorities or pressure from the public.

There are several concepts that address aggression, but little is known about successful strategies to prevent and deescalate aggressive behavior (16). Gaynes et al. (16) found in their systematic review that if there is a risk of aggressive behavior, multimodal approaches like the “Six Core Strategies” have the potential to reduce the use of restraint and seclusion. The “Six Core Strategies” were developed and supported by the National Association of State Mental Health Program Directors in the USA (17) to prevent aggressive behavior. One of its pivotal strategies concerns the commitment of institutional management such as the Chief Executive Officer (CEO) or chief medical doctors/head nurses. Leadership is described as not only the commitment to a vision, an attitude, and a plan to reduce the use of seclusion and restraint, but also the involvement of management in those practices (17). The second strategy is the use of data to inform practice, which means the monitoring of units’ or shifts’ rate of seclusion and restraint and of patients’ characteristics. The third strategy focuses on development and training of the teams toward a recovery-based treatment environment. The training involves, among other things, the exploring of rules. The authors claim—as mentioned above—that closed wards often have historic rules and procedures that are no longer appropriate to state-of-the-art treatment and not in line with a recovery-oriented, least restrictive practice (17). The fourth strategy concerns the use of prevention and assessments tools, and the fifth strategy concerns the inclusion of the patients themselves in improvement strategies or facility committees. Moreover, the inclusion of family members or peers is recommended. The last strategy focuses on debriefing techniques that aim to reduce the traumatizing effects of coercive measures for both patients and staff. Detailed, recommended questions units can ask themselves, exploring potential triggers, are, for example, “was the individual worried about anything?” or “did the individual have to wait an inordinate time for something he or she wanted?” (18). Steps for debriefing and procedures are explained and templates are available.

Yet the department is still seeking retroactive approval, which must pass through the Rules Committee in a continued discussion Monday before going to the full board for a vote.

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Prop. E passed, drones were bought, and the SFPD began openly touting its new gadgets. In a press conference last month, Mayor London Breed and SFPD Chief Bill Scott cited the arrests of suspected car burglars as proof that voters were right to give police more leeway.

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“Prop. E does not supersede state law,” Steeves wrote in a Feb. 28 email to department leaders obtained by the Electronic Frontier Foundation and shared with The Standard.

Now the San Francisco Police Department is asking city leaders to approve the drones after it ignored warnings from within its ranks that it should have held off. Newly unearthed SFPD emails show the first call for caution came months ago from one of its own policy experts.

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Health professionals like nurses respond to aggression and violence with de-escalation techniques, and still often with coercive measures. Such measures applied by institutions are often rooted in historically grown traditions rather than evidence, reflection, or formation. In this article, we present de-escalation strategies integrating a high and critical awareness toward traditions and the practice of formal and informal coercion.

Steeves also told her colleagues that rushing to buy drones could put the SFPD in the middle of a political controversy.

“This email from Feb. 28 is kind of a smoking gun,” he said, referring to Steeves’ warning. “Their own policy person told them ahead of time to pump the brakes on the drones because they’d need prior approval, yet they immediately started buying these drones despite that warning. Everything they did afterwards was in violation of state law.”

In constitutional countries, mentally ill people are the only human beings who can be detained without being accused of an offense. Compulsory measures are often based on aggressive behavior aiming to calm down a situation and the involved persons (1). Its use, though based on judicial and ethical principles or guidelines (see, for example, DGPPN 2018), negatively impacts attitude toward treatment and is always perceived as negative by patients (2). Patients reject compulsory measures more distinctly than health professionals and even more clearly if they have already experienced those measures and if they were admitted involuntarily (3). The most strongly rejected form of coercive measures for patients, relatives, and health professionals are net beds (which are not used any more in Switzerland), fixations, and seclusion (3). The use of either fixation or seclusion or both in psychiatric institutions is often determined by regional history and traditions of institutions and management and is currently being questioned in many European countries. Empirical evidence or definable indicators of the benefit or harm of applying coercive measures are rare. Psychiatric institutions with a psychiatric care contract are very often trapped between help and violence, the expectations of authorities and the public, as well as the expectations of the patients and their families or relatives.

Nursing practice is often characterized by relatively close physical contact for extended time periods, sometimes lasting over hours. Also, due to this, nurses in the psychiatric setting may be familiar with aggression toward them (20). It is known that targeted aggressive behavior can lead to anger, and (unreflected) anger can lead to reactions, which are disciplinary or even coercive (21). A strategy of de-escalation with commonly shared procedures, as the two models described before, can support balanced alternative reactions of nurses and other health professionals in a treatment team. That is why we recommend multimodal de-escalation strategies encompassing several different approaches.

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The perception of coercion has been shown to never be neutral, but either positive or negative (22). Coercion can only be regarded as necessary when it immediately ensures integrity, autonomy, and safety of patients and staff. However, informal coercion can be seen as coercive in the sense that it still restricts patients’ voluntary and autonomous decisions. If the patient has a positive therapeutic relationship to the professional performing the coercion, he more readily perceives the coercion itself as morally right and accepts more pressure than if a stranger performed it (22). It is easier to “take advice” from someone you trust.

Asja Steeves, SFPD policy division manager, said that even if voters passed the law, it doesn’t excuse the department from abiding by Assembly Bill 481. Authored by then-Assemblyman David Chiu, the 2021 law requires police to get the blessing from city electeds before using new surveillance tools.

But civil liberties advocates say the SFPD is proving Steeves right, too, by now scrambling to get into compliance with state law through a proposal from Supervisor Matt Dorsey, a former police communications boss, that would retroactively legalize the department’s drones.

In Germany and Switzerland, one concept is the ProDeMa® that provides a practical guideline for healthcare professionals to deal with aggression (19). The guideline aims to convey de-escalation interventions and to develop a professional approach. As in the “Six Core Strategies,” there are different steps of de-escalation. The first step, the prevention of aggression, involves getting in contact with or gaining the attention of a certain person. ProDeMa® emphasizes that without contact, de-escalation may not occur. Getting in contact is linked to asking about the wishes and needs of the person. The second stage intends to change one’s own perspectives of aggressive behavior before reacting, while during the third phase, an understanding of the causes is developed. The art is not to ask “why” but, for example, “what would help.” The next two steps deal with verbal and nonverbal de-escalation techniques to calm down a person and to master a difficult situation. Nonverbal de-escalation, for example, comprises the protection of the own person. The last stage describes least restrictive and patient-friendly holding techniques, immobilization, or, in some hospitals, fixation.

About a week before the March 5 election, the SFPD was planning what drones to buy if voters expanded police powers by passing Proposition E. But a department analyst noted that Prop. E alone did not give police authority to unilaterally add drones to its arsenal.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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Matt Guariglia, a policy analyst with the Electronic Frontier Foundation, said the department is trying to quietly correct a mistake it knew full well it was making.

The important fact is the underestimation in particular of stronger forms of informal coercion and formal coercion (6, 7). Yet, health professionals with a positive attitude toward weaker forms of informal coercion, like persuasion or leverage, tend to underestimate its occurrence more than health professionals who disapprove its use. Correspondingly, inpatients perceive the attitudes of professionals and their interaction as the most important factors concerning coercive measures (12). In order to avoid coercive measures through de-escalation strategies, health professionals need to have specialized training and be aware not only of the use of informal coercion but also of the importance of a respectful and empathetic attitude and ward climate, a positive admission process, as well as debriefing strategies after coercive measures (12).

The meeting kicked off last week with Acting Lt. Eric Batchelder rattling off the ways a drone’s-eye-view has helped police. He said the department has six drones that were used in 65 missions — 18 of which led to arrests.

In comparison to other wards, the risk for aggressive behavior is increased in mental health units (13). In mental health departments, conflicts can arise as a result of interpersonal interactions between staff and patients and also between patients. De-escalation has been defined as the use of techniques including verbal and nonverbal communication skills aimed at defusing anger and stopping aggression (14). It is an approach for managing aggressive and violent behavior in a more humane manner and is arguably more dignified and less coercive than physical interventions. In addition, this guideline (14) highlights how medication can be used as a part of de-escalation strategies, but medication does not stand for de-escalation on its own. De-escalation also involves the use of verbal and physical expressions of empathy, creating therapeutic alliance, and nonconfrontational limit setting that is based on respect. The pivotal strategies focusing on de-escalation are communication, approach, de‐escalator qualities, assessment and risk, getting help, and containment measures. Different types of aggression are met with different interventions (15).

Deputy City Attorney Bradley Russi affirmed that state law requires city supervisors to sign off on drone use, but argued that when voters passed Prop. E “they stood in the shoes of the board for approval — at least for the first year.”

Common to all theories of de-escalation is the prevention of aggression by intervening before it occurs and by calming the patient. The dominant controlling attitude to calming the patient in traditional understanding should be transformed into a collaborative endeavor, where individuals are encouraged to help themselves calm down by applying their own abilities and power (23). This requires a culture of empowerment of individuals. Such a culture should also involve the critical reflection of historically evolved rules, such as groups, which are not allowed to leave, or visiting hours, which could be individually arranged. In this context, practicing de-escalation for calming the psychiatric patient may also serve as an experimental learning opportunity for patient and staff. We propose a structured and commonly shared approach encompassing critical evaluations of historic courses of action, reflections, and discussions on personal experiences and attitude, and the use of informal coercion in order to facilitate the prevention and management of aggression and violence.

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

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The spontaneous response to an aggressive behavior depends on how it was perceived, experienced, and interpreted, and depends on the attitudes and values of the perceiving person itself.