In their new personal viewpoint article published in The Lancet Psychiatry, David Veale and colleagues call for the prioritization of the emotional safety of patients in inpatient psychiatric institutions.
The authors draw upon their own lived experiences working as mental health professionals and, in the case of one co-author, being an inpatient, to argue that psychiatric facilities’ focus on the short-term physical safety of patients may inadvertently jeopardize patients’ sense of emotional safety and contribute to increased distress and feelings of hopelessness.
Veale and his co-authors explain that within UK healthcare settings, “safety” is broadly defined as doing no harm to patients while they are receiving care. However, they expand this definition of safety to include the absence of physical threat or bodily injury and the presence of positive supports that promote emotional and social safety. Emotional safety includes feeling safe with what is going on in one’s own mind. Social safety includes one’s perception of their context as warm and empathic.
Compared to forms of physical healthcare, psychiatric care may be more prone to making patients feel unsafe, given its reliance on coercive interventions and valuing short-term physical safety and risk management over long-term emotional well-being. The authors lay out this prioritization and the potential harms it can cause to patients:
“Our experience in psychiatric services in the UK is that being safe is often interpreted as ‘Are you able to keep yourself physically safe?’ rather than ‘What can we do to help you to feel safe?’”
“True safety does not exist without emotional safety. Focusing on physical safety alone and seeking to reduce organizational risk can mean reducing emotional safety, partly because it removes patients’ own ways of dealing with intense emotions, even if those ways are not the most helpful in the long run. This focus on physical safety to the detriment of emotional safety can, therefore, paradoxically increase physical risk, feelings of being overwhelmed, aggression, states of dissociation, and a sense of hopelessness.”
Previous research has drawn upon patient perspectives to demonstrate that feeling safe in an inpatient psychiatric setting is associated with predictable and structured care, good communication with providers, and a sense of autonomy and personal responsibility among patients. Conversely, patients feeling unsafe has been linked to their lack of access to information, poor patient-provider communication, and feeling that they are not being heard or taken seriously by staff.
Research has also been conducted to understand the perspectives of psychiatric institutions regarding patient safety. One qualitative study of mental health professionals in the UK pointed to the ways in which institutional protocols contribute to staff objectification of patients as “risk objects:”
“This objectification stems from procedures adopted for conducting risk assessments and a focus on how to deal with a person’s potential for causing harm to themselves or others, which might reduce physical safety. The management of threats is not just of threats to the patient but also threats to the staff and the organization itself. Staff is well aware that acts of self-harm or harm to other patients, or suicide, result in serious, stressful investigations with potential suspensions.
The patient’s behavior can thus become an indirect threat to the staff themselves. Hence, some forms of physical risk prevention are partly to protect the organization and staff, particularly if they can use the adherence to protocols as a defense against criticism or charges of negligence.”
The authors point to continuous nurse monitoring of patients throughout the night as an example of a common practice within institutions that may undermine patients’ emotional safety. Not only has there been no research evidence linking this strategy to suicide prevention, but patients have also reported that monitoring makes them feel objectified and unsafe and interrupts their sleep.
The current work presents a case study of a woman (“Louise”) to illustrate how hospital risk management protocols center patients’ physical safety and institutional, legal protection and, in doing so, undermine patients’ emotional safety and exacerbate distress.
Louise was hospitalized for treatment for complex PTSD following a sexual assault. Before entering the hospital, Louise had used physical exercise (running) to cope with panic-attack symptoms but was not allowed to do so while hospitalized because the possibility of her running away was deemed too risky. Instead, Louise was allowed to construct a small teepee filled with cushions and comforting objects in her room in the psychiatric ward. However, while under continuous monitoring, Louise was not allowed to go inside the teepee because she would be out of view of staff; furthermore, she was ultimately required to remove the teepee as it was deemed a fire hazard.
Louise’s requests for an emotional support hamster and a punching bag in her room as alternatives to self-harm were also denied despite existing research that points to the mental health benefits of companion animals and physical activity to promote a sense of control and reduce flashback symptoms for individuals with PTSD. Moreover, if Louise self-harms, she is taken to a “safe room” with no access to fresh air, privacy, or any objects that help her feel safe and calm.
Authors argue that the most effective way to “manage risk” within inpatient settings is to help patients feel emotionally safe. Using the case of Louise, the authors highlight how institutions are biased against centering emotional safety:
“When institutions are fearful of external persecution and prosecution, it is not surprising that they become self-protective, but doing so can undermine patients’ clinical needs and therapeutic engagement. Concerns for emotional safety become secondary to the reputation of the organization and its professionals. Safety is then defined from an organizational and professional perspective, not from a patient’s perspective.”
“Our observations are that the design of psychiatric inpatient environments should draw on a much richer, deeper understanding of the psychology of safety and safeness. In each of the examples described, Louise is acting with courage to deal with difficult emotions. She is actively seeking ways to stimulate her own soothing system by creating suitable conditions and stimuli, but she is met with a poor understanding of her needs. This lack of understanding, together with the institution’s attempts to keep itself invulnerable to criticism, disempowers her.”
The authors argue that regulations and policies must shift to require institutions to maintain patients’ emotional safety as well as their physical safety. As one strategy for doing so, authors advocate for mental healthcare providers to engage in “positive risk-taking” during clinical decision-making:
“Positive risk-taking is accepting that a risk of danger exists and, rather than seeking to prevent the risk-as-possibility by coercion and control, seeking to collaborate with a patient in minimizing the harm.”
The authors point to alternative treatment protocols currently being tested in inpatient psychiatric settings -such as the Safewards model and the Open Dialogue approach- that show preliminary promise in promoting emotional safety and enhancing social connectedness amongst patients and staff.
The current viewpoint concludes with a call for new conditions within inpatient psychiatric settings. Authors re-imagine a model of psychiatric care in which staff and patients can empathically and collaboratively weigh the risks and benefits of patients’ personal needs and requests and make shared decisions regarding treatment plans.
Recommendations from the current work align with calls for the prioritization of patient-centered outcomes within inpatient psychiatric facilities. Fundamentally, systemic change is needed at the institutional and policy levels for patients to have the autonomy to articulate what “safe” psychiatric care looks like to them and for mental health professionals to respond flexibly and creatively to promote that safety within inpatient settings.
Veale, D., Robins, E., Thomson, A. B., & Gilbert, P. (2022). No safety without emotional safety. The Lancet Psychiatry. (Link)