People with mental health diagnoses are often the victims of violence and abuse, both within and beyond mental healthcare systems. Media reports of sexual abuse, violence, neglect, and human rights violations within psychiatric facilities are common. Service users have also reported abuse during outpatient treatment. A new study examines abuse of service users in mental healthcare settings by healthcare workers.

This research, published in BMJ Open, finds that reporting and documentation of abuse in psychiatric settings is inconsistent and prevalence rates vary widely. While some studies report no abuse, others have found that nearly 80% of services users experienced abuse at the hands of mental health workers. The current work, led by Kei Matoba from the Kansai Medical University in Japan, also finds that service users with a history of physical or sexual abuse were more likely to be victimized by healthcare workers in mental health settings. The authors write:

“We found that abuse was reported in multiple forms—physical, psychological, sexual and economic abuse, neglect and human rights violations—with highly variable prevalence. We also identified several factors associated with abuse, including past experiences of abuse and gender-specific patterns, and information about the psychological impact on victims … We found that patients’ experiences of abuse were not limited to the distress caused by coercive treatment and also included clearly abusive behaviours that went beyond therapeutic intent. These experiences often stemmed from the attitudes and actions of healthcare professionals during the administration of treatment, rather than the treatment itself. ”

It is important to note that the prevalence rates reported in this study describe the percentage of participants that reported abuse, and not the percentage of healthcare workers that perpetrate it. It is possible that the abuse documented in this study is perpetrated by a small minority of healthcare professionals.

Background

Both research literature and service users with lived experience of inpatient treatment have reported abuse in psychiatric hospitals. Media reports have also documented a lack of consequences for the institutions where these abuses occur, as well as insufficient and difficult reporting procedures. This means abuse in inpatient psychiatric settings is rarely documented and likely under-reported.

Service users have also reported abuse during outpatient treatment. Media coverage of sexual abuse by therapists shows how predatory providers can exploit their positions of power to rape and sexually assault vulnerable clients. Experts have noted that some therapists dismiss service user complaints about violations of therapeutic boundaries as a symptom of mental “illness.” These kinds of violations may precede rape and sexual abuse. This dismissive attitude serves both to blame service users for the professional failures of their therapists, and to shield predators that use psychotherapy as a pretense for their crimes.

There are also media reports of billing fraud, a kind of financial abuse that describes when a provider charges insurance for services that were never rendered. This can result in claim denials, insurance investigations, lawsuits, and disrupted care for the victims.

Study Details

The goal of the current research was to examine the nature and scope of literature on abuse in mental healthcare systems, the types of abuse that occur, the prevalence, and factors that may make abuse more likely. The authors searched academic literature databases for studies related to service user abuse by healthcare workers in psychiatric settings. They divided abuse into six categories: neglect, human rights violations, physical abuse, psychological abuse, economic abuse, and sexual abuse. In total, the researchers investigated 61 studies in the current review.

The included studies were conducted in 17 different countries, with most coming from Japan (16), the US (16), and the UK (11). Other countries represented in the current work include: Germany, Nigeria, France, Portugal, Kenya, Italy, South Africa, Australia, Switzerland, Lesotho, Sweden, Finland, Hong Kong, and Indonesia. The majority of studies (47) examined abuse in inpatient psychiatric settings. Thirteen studies investigated abuse in mixed settings, and one in a community setting.

Twenty seven included articles had no participants, with reports of abuse pulled exclusively from documents, 23 had only service user participants, 7 had only healthcare staff as participants, and 4 had service user, carer, and healthcare staff participants. Most of the included studies did not explicitly define abuse. The studies that did define abuse most often used the World Health Organization’s definition of sexual violence and the Psychiatric Experiences Questionnaire definition of abuse.

Twelve of the included studies reported on abuse prevalence, with four of those using the same dataset. This means eight datasets on abuse prevalence were included in the current work. All eight studies reported prevalence rates for physical and psychological abuse, as well as human rights violations. Prevalence rates ranged between 5% to 65% for physical abuse, 0% to 79% for psychological abuse, and 9% to 61% for human rights violations. Six studies reported prevalence rates for neglect, ranging between 0% to 79%. Five studies reported on sexual abuse, ranging between 0% to 21%. Just two studies reported prevalence rates for economic abuse, ranging between 15% to 36%.

Ten studies examined the associations between abuse and other factors. Experiencing child abuse, prior sexual abuse, and prior physical abuse was linked to higher rates of abuse at the hands of healthcare professionals in mental healthcare settings. For men, a history of sexual and physical abuse in childhood or adulthood was associated with additional abuse by healthcare staff. For women, a history of adult sexual abuse was linked to additional abuse by staff in mental healthcare settings. Service users reported symptoms of PTSD, psychological distress, and avoidance of psychiatric facilities as consequences of abuse by staff in mental healthcare settings.

Twenty-nine studies discussed ways to prevent abuse by healthcare staff in psychiatric settings. At the level of care delivery, these studies recommend cultivating respect and trust for service users, using trauma-informed approaches to care, and promoting ethics and a culture of learning. At the organizational level, research recommends establishing guidelines and systems of accountability, increased training and support for staff, and listening and responding to external viewpoints. At the societal level, this research advocates for addressing historical abuses, evidence based systemic reforms, and embracing human rights-based systems of care.

The authors conclude:

“Our findings suggest that preventing abuse in psychiatric settings requires both attention to individual attitudes and behaviours, and structural and cultural changes within healthcare institutions. A trauma-informed, ethically grounded approach to care, supported by institutional mechanisms and policy-level reforms, is likely to be essential to foster safer and more respectful mental health services. ”

Limitations

The authors acknowledge several limitations to the current work. The literature search was carried out using both Japanese and English language databases, but the authors were more proficient in Japanese. This means the literature search for Japanese language literature was likely more comprehensive. Neither service users with a history of abuse in mental healthcare settings nor healthcare workers were consulted during the development of this research. Including service user perspectives in particular could have broadened the definition of harm and resulted in more robust data. There is no generally recognized way to identify abuse in psychiatric settings. This means prevalence rates will vary widely depending on the methods used to measure abuse. The authors did not seek out studies that examined stigma, harm, or boundary violation, so some forms of abuse were likely missed.

Additionally, while studies from across the globe were included in the current research, the majority came from Japan, the US, and the UK, limiting generalizability to other populations.

An Environment of Abuse

While it may be tempting to blame individual healthcare workers for the mistreatment service users suffer in their care, both research and healthcare worker experiences place much of the responsibility for these abuses on systemic issues and institutional failures. One study found that the power imbalance between mental healthcare staff and service users paired with the vulnerability of people seeking or forced into psychiatric services sets up the conditions for abuse. This same research revealed that psychiatric nurses have pointed to the refusal of institutions to self-correct, administration ignoring staff concerns, emotional stress and burnout, frequent exposure to service user violence, and limited staff training and support as leading to abuse in mental healthcare settings.

Research has found that staff shortages are common in psychiatric settings, often leading to a reliance on coercive measures rather than rights-based approaches. Experts have also pointed to a lack of oversight that allows harmful practices to go unchallenged as contributing to abuse by mental healthcare staff. The tendency of people to disbelieve psychiatric service users, toxic culture among staff, and a narrow focus on diagnosis and symptom reduction all likely foster the abuse suffered by service users in psychiatric settings.

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Matob K, Teshima T, Yayama S, et al. Abuse of people with mental illnesses perpetrated by healthcare professionals: a scoping review. BMJ Open 16 (1). (Link)