Fear, Neglect, Coercion, and Dehumanization: Is Inpatient Psychiatric Trauma Contributing to a Public Health Crisis?

Abstract

Inpatient psychiatric hospitalization is often negatively experienced, with previous studies indicating a high frequency of traumatic occurrences. This study aimed to expand upon such research, by obtaining service user perspectives on how inpatient psychiatric hospitalization may constitute an experience of trauma. Relevant posts and comments on the Reddit community r/PsychWardChronicles were collected that described potentially traumatic experiences associated with hospitalization. Reflexive thematic analysis of the data led to the development of 3 themes: neglect and abuse, coercion and obedience, as well as dehumanization and fear. Overall, hospitalization was found to induce significant fear, which eventually acted as a deterrent to seeking future mental healthcare services. Many traumatic occurrences were found to arise from care providers’ behaviors. As hospitalization was experienced to be harmful, many patients reported complying in the hopes of being discharged. Increased fear and traumatic stress due to inpatient stays coupled with the subsequent avoidance of mental health services may contribute to a significant public health problem as many previous patients may then avoid needed mental health support.

Introduction

Inpatient psychiatric hospitalization is a common practice when individuals face severe mental health crises. Unfortunately, epidemiological research has demonstrated that following hospitalization, individuals are far more likely to face adverse outcomes such as suicide and self-harm (1,2). Although many experience therapeutic benefits from psychiatric hospitalizations, a sizable number of patients do not find their stay beneficial (3). Possibly, such poor outcomes are not only due to ineffective interventions, but also a large frequency of traumatic experiences.

Considerable research describes potentially traumatic experiences associated with inpatient hospitalization. Although strict practices and policies are associated with efforts to maintain safety, they may have the opposite effect. It has been highlighted that the seemingly favorable upholding of safety-based practices in psychiatric hospitals is rooted in fear and stigmatization, ultimately perpetuating the idea that patients are dangerous and unstable (4). Consequently, rather than therapeutically focusing on patients’ needs and desires, nurses are then found to be more interested in the strict application of rules and regulations (5). While nurses may be expected to facilitate therapeutic relationships that may aid in treatment, patients have communicated that therapeutic relationships were generally found with other patients rather than nurses (6).

The aforementioned risk-management culture has also been negatively experienced by many patients. As patients are limited to being dangerous, unstable, and mentally ill, their perspectives have been disregarded, leading many to describe their inpatient experience as dehumanizing and humiliating (7). Oftentimes, rather than being listened to and understood, patients report the trauma of restraining practices that staff members initiate to control and manage their decidedly problematic symptoms and self-expressions (8,9). When interventions occur based on inaccurate perceptions of dangerousness, patients may not only lack support, but also endure significant trauma and humiliation.

Although such research is significantly underrepresented, one noteworthy study found that during psychiatric hospitalization 31% of patients experienced physical assault, 8% experienced sexual assault, and the majority reported witnessing traumatic events (10). Another study found that the vast majority of patients were victimized during their psychiatric stay (11). Concerningly, most patients do not share traumatic experiences with staff, possibly suggesting that patients do not trust their care providers (12). These harms are further amplified by the secluded and lonely nature of inpatient hospitalization (13).

The use of coercive practices, particularly in inpatient environments where many are held on an involuntary basis, is also a source of concern due to the potential for long-standing trauma. One Nordic study found that during inpatient psychiatric stays, 49% of patients experienced coercion in Norway, and an astounding 100% of patients in Iceland reported the same trend (14). The lack of individual freedom in care decisions, coercive use of restraints, and subsequent feelings of powerlessness, sadness, anger, and fear clearly indicate the traumatic potential of inpatient psychiatric hospitalization (15). Although hospitalization is implemented for therapeutic purposes, the high occurrence of traumatic events and neglect of patients’ values through coercive practices may aid in explaining poor outcomes.

While therapeutic benefits do occur, the consequences of failing to address associated aversive phenomena may represent a significant public health problem. Such trauma may increase levels of distress in already vulnerable populations while provoking the avoidance of services intended to support suffering individuals (16). Should psychiatric hospitalizations induce systemic harm through traumatic occurrences and insufficient support, public mental health outcomes will likely deteriorate. In light of this, this study aimed to further understand experiences of inpatient psychiatric trauma using an anonymous platform to obtain forthright data.

Methods

Data Collection

Data was collected by reviewing all posts on the subreddit “r/PsychWardChronicles.” It is described as a platform to “share your stories/experiences from the psych ward as a patient or staff member/doctor. Or share interesting/funny stories that are topic related from others” (17). Although prior qualitative research generally involves interviews, using an online platform such as Reddit involves many unique benefits. Particularly, Reddit is a popular venue for which individuals can anonymously share their mental health-related experiences, which may ultimately lead to more honest and forthcoming answers given the stigma associated with psychological conditions (18). Data collection was completed for 1 week until August 18, 2021, which involved reviewing all comments on threads posted on r/PsychWardChronicles. All relevant posts and comments were collected (n = 262), with posts related to aversive experiences associated with inpatient psychiatric hospitalization being accepted (17).

Ethics

All posts found on Reddit are publicly available information and no direct research was conducted with any human subject, and therefore ethics approval was not necessary. Even so, to protect anonymity as much as possible, it was ensured that no identifying information is found on any selected quotation and no usernames are found in this article.

Methodology

Given the strict adherence to established policies and regulations in psychiatric practice which fail to adequately consider patients’ values and needs (5,7), this study aimed to place greater emphasis on patients’ lived experiences and subjective perspectives. Given the flexibility required to accommodate for the subjective nature of the undertaken research, reflexive thematic analysis was deemed suitable as the method does not entail strict adherence to an established set of procedures, but rather the thorough engagement of researchers in the development and execution of the research process (19). Prior to developing themes, the data was read multiple times to ensure saturation and an improved understanding of the traumatic potential of psychiatric hospitalization from the perspective of service users. Then, broad thematic clusters were developed, allowing for subjective interpretations from readers themselves. These thematic clusters were developed with the aim of answering how inpatient psychiatric hospitalization may constitute an experience of trauma.

Results

Thematic analysis led to the development of 3 broader themes including neglect and abuse, coercion and obedience, as well as dehumanization and fear. They are all discussed below.

Neglect and Abuse

A recurrent theme was either insufficient or abusive care. While several examples were mentioned, many agreed that the practices they were subjected to were potentially illegal or required significant change. One individual shared “I’m sure there's better ones out there but they really aren't great and alot of them should be legally looked into in my opinion” (17). Many examples provided valuable insight into the occurrence of this sentiment.

They sent me into the last available room, kept the lights on (and didn't let me turn them off), left my door open, and turned off the heating in my room. I sat there cold, tired, and afraid for several hours until the people from the next shift arrived… Eventually one of the other patients asked me if I forgot to bring clothes or something. Turns out, the people from the night shift were supposed to give me my clothes, but never did. (17)

Similar examples were found in others with one individual sharing that “a therapist asked me if I would have sex with him” (17). Individuals told stories of unthinkably criminal, traumatic events. For example, one individual shared “My psych nurse was scanning me with the contraband wand [you know the thing used to check sharps] and he said to me he wanted to spank my ass with it” (17). While some did harm, others seemingly neglected to do their work. One communicated “As a tech, I saw a lot of mistreatment from nurses… just lack of empathy and not wanting to deal with patients, so they’d hide” (17). Sometimes doctors were simply not present “Doctors are supposed to see you every day and often don't come for days” (17). When encountering one patient who was very scared of balloons, nurses “decided it would be funny to tie balloons to him while he was sleeping” (17). “They don't realise that it makes us more psychotic” was commented by another individual who had a frightening experience (17). One experience from a pediatric facility demonstrates how damaging abusive behaviors from staff can be.

Since I was in the pediatric psych ward, there were many little kids. The nurses were so mean to them. They yelled at them whenever they didn't listen to them, locked them in their room and I would hear them crying all night. One night, I knocked on the nurses's office and asked to make a call. They would not let me, and they looked at me like I was crazy. They slammed the door in my face saying I wasn't allowed to. The nurses and doctors were extremely condescending and racist to me and my parents. During consults, they “sympathized” by saying they “understand” my cultures because they know that “Asians” can be strict. What the hell? I had no idea where that came from. Never in any of my consults I said anything about my family being strict. (17)

Coercion and Obedience

While neglect and abuse from any health care professional is highly troubling, it must be considered that patients are particularly vulnerable given the use of involuntary hospitalizations and other coercive practices. Thematic analysis pointed to several examples where coercive practices may be potentially traumatic.

So once I’m supposed to be on my last day and my psychiatrist walks me to her office and sits me down and she's like “You won't be going home today. We decided to hold you for another month or two.”

b i t c h w h a t ?

So they waited for the day I got my hopes up to tell me I can't go home for MONTHS?! (17)

The use of such coercive practices can be highly traumatic, causing feelings of hopelessness and powerlessness. Psychiatrists already have the power to hold patients against their will, leaving the potential for significant harm and ultimately highlighting the need for clear and honest communication in care (20). Not only did patients not know when staff members were being dishonest, but they also feared that staff members would lie at their expense. One individual wrote “I kept begging to see the doctor and the nurse said ‘if you continue to push to see the doctor, you might be forced to stay longer’” (17). One individual talked about how “not getting food if I didn't act right was definitely hard” (17). After recognizing that their needs would not be met following an experience that caused post-traumatic stress disorder (PTSD), they decided to demonstrate obedience by lying in the hopes they would be discharged as demonstrated by one individual sharing “everyone is so condescending. I lied my ass off and got out within three days” (17).

Dehumanization and Fear

The multitude of co-occurring aversive phenomena during inpatient stays led many to report feeling dehumanized. For instance, as one individual realized their condition was particularly severe, they did not feel treated like others.

I was one of the “bad” patients that they expected would never recover from their mental illness, or to be stuck in the realm of psychosis for a long while but luckily something snapped in me. None of the staff ever took me serious/ kept a good eye on the patients. (17)

While shared experiences point to questionable practices at inpatient psychiatric hospitals, high levels of traumatic pasts must be considered when realizing the damage that can be done.

This made me so ashamed of my body and humiliated, as a rape survivor this was horrifying to me. They watched me as I got undressed and watched me as I dressed in these awful scrubs… I was never left alone and I felt humiliated. I had no sense of privacy at all, I wanted to see the doctor and get out that night. (17)

One hospital worker, with years of experience, also recognized how inpatient psychiatric hospitalization can be an invalidating and traumatic experience.

You will be asked a ton of repetetive questions and will more than likely feel like you aren't being listened to. I cannot even count the number of times I’ve heard a hospital social worker, nurse, or doctor accuse someone of malingering or outright deny that someone is telling the truth about what they’re feeling. For many (I would honestly argue most) people, the experience of going to the hospital and being treated this way is invalidating and traumatic in itself, often becoming a deterrent to seeking actual mental health treatment later on. (17)

Indeed, many did report that inpatient hospitalization was highly traumatic ultimately causing immense fear that inhibited them from further accessing support. Individuals shared that they “only went once, traumatic enough that I get panic attacks in hospitals” (17). Another disclosure provided a clear example of how inpatient hospitalization led to a diagnosis of PTSD as they stated, “I’ve been admitted to three hospitals and the last hospital gave me a chronic nightmare syndrome when I was 15 and I still suffer from it at 19, I’ve been diagnosed with PTSD since my last visit” (17). Looking back on past hospitalizations, another individual shared “Glad the safest ill ever be is with myself. Fuck those workers and nurses. Im disgusted” (17). Overall, while previous themes discussed aversive phenomena during inpatient stays, several disclosures demonstrate how these experiences cause fear well into the future potentially leading to diagnoses like PTSD and the avoidance of needed support.

Discussion

This study provides valuable insight using an anonymous platform likely entailing more honest and transparent disclosures. The many identified traumatic occurrences help explain why the experience of psychiatric hospitalization may play a causal role in some eventual suicides (21). Although the presence of PTSD in inpatient settings has received considerable research (22), there is little literature on inpatient psychiatric hospitalization as a cause for diagnoses of PTSD, among other distressing responses to adversity. Nevertheless, given the apparent traumatic potential of hospitalization, and the association between PTSD and post-discharge suicides (23), more research must consider the potentially longstanding harms of psychiatric hospitalization.

Similar to previous research (10), this study exhibited a substantial frequency of abuse and sexual harassment. Notably, many such occurrences were perpetrated by care providers. The frequent mentioning of such misconduct suggests that this may be a systemic problem. Even so, since coercive practices often cause patients to feel devalued and powerless (24), such occurrences are perhaps more likely to go unnoticed. If mental healthcare providers can look beyond their assumptions about patients, and treat them with dignity rather than invalidation and dehumanization, traumatic occurrences can be identified and addressed which may diminish fear associated with care.

The traumatic potential of psychiatric hospitalization is also partially attributable to broader systems and policies. For instance, although European nations demonstrate a similar incidence of psychiatric distress, levels of coercion and restraint differ massively across nations, suggesting that different policies can diminish the traumatic potential of inpatient hospitalization (14,25). Furthermore, lack of funding and staffing are associated with greater use of seclusion and restraint (26). When resources are lacking, it is more feasible to restrain or disregard a distressed individual, rather than provide a humane response that addresses their unique needs and feelings. Indeed, several identified instances of neglect may have been avoided should the hospitals have been better funded and staffed.

Many actions that patients describe as humiliating and dehumanizing are described by care providers as justified and necessary. As an example, while nurses often focus on the beneficial aspects of forced medications, patients find this practice humiliating and frightening (27). Even so, patients often fear the consequences of refusing medications (28), demonstrating how the coercive nature of psychiatric hospitalization effectuates obedience at the expense of individual values. As obedience was found to emerge in response to fear associated with care, it is imperative that inpatient settings embrace patients’ values, rather than disregard their desires. Otherwise, partaking in treatment may not be experienced as beneficial, but rather as a method of survival to avoid further traumatization.

As inpatient psychiatric hospitalization was found to involve significant fear and dehumanization, leading to enduring distress and diagnoses of PTSD, it is understandable that individuals reported distrusting and avoiding mental healthcare. Trust is crucial for mental health care to be effective, and if inpatient facilities dismantle patients’ trust the effects are likely to be most devastating amongst individuals most in need of support. To rebuild trust, researchers and practitioners must improve services by engaging with service user perspectives, rather than limit patients’ feelings and beliefs to mere symptoms of mental illness as often occurs (29). In doing so, patients can play an active role in service development, allowing traumatic occurrences to be resolved and care to be more aligned with patients’ needs for support. Especially when considering the aforementioned association between psychiatric hospitalization and suicidality (1,2,21), victimization (11), and sexual assault among others (10), failing to tackle such phenomena may involve a significant public health problem as there may be increased distress unfortunately tied with a lack of needed, therapeutic support.

Limitations

Given the use of the anonymous platform Reddit, no information regarding participants is available. This presents a challenge as mental health services differ greatly across nations. While aforementioned themes were clearly apparent in the data, future research would benefit from increased demographic information in specific geographic contexts, so that more specific conclusions and implications can be derived. Nonetheless, findings from this study clearly indicate the traumatic potential of inpatient psychiatric hospitalization well beyond individual practices like restraint and involuntary admission, warranting further research into the prospect of a public health crisis. More comprehensive studies would likely derive more specific findings to inform public health research and service delivery accordingly.

Conclusion

Inpatient psychiatric hospitalization repeatedly fails to provide therapeutic benefits. Instead, individuals are confronted with highly traumatic experiences, in situations where they may already feel powerless due to the use of coercive practices. Although poor practices, negligent nursing behaviors, and overall poor efficacy of psychiatric interventions may be to blame, the multiplicity of harmful occurrences suggests that inpatient psychiatric trauma is not only a service delivery issue, but possibly contributes to a significant public health problem. Rather than solely focusing on psychiatric interpretations and nursing perspectives, there is a clear need for more qualitative and quantitative research that addresses the concerns of patients in order to facilitate therapeutic stays that help rather than harm individuals.