Impact of Psychiatric Hospitalization on Trust, Disclosure and Working Alliance with the Outpatient Psychiatric Provider: A Pilot Survey Study

Abstract

Introduction The relationship between inpatient psychiatric experience and subsequent outpatient psychiatric care remains highly understudied. We conducted a voluntary, anonymous, self-report, pilot survey study to explore the impact of current or recent psychiatric hospitalization on patients’ ability to trust their outpatient psychiatric providers, particularly with respect to the disclosure of symptoms such as suicidal thoughts. Methods A survey was conducted in a psychiatry practice-based research network (PBRN) of six outpatient community psychiatry clinic sites within four regional agencies and at an adult inpatient psychiatry unit of a tertiary-care academic hospital in the Cleveland area. We asked patients to record characteristics of their hospitalization, perceived changes in attitudes, and complete a working alliance inventory. Sixty-two surveys were collected. Results Most respondents had high working alliance scores with their outpatient providers and a low prevalence of coercive experiences during hospitalization. A minority (15%) experienced a reduction in trust with their outpatient provider. Nonetheless, a substantial percentage of respondents expressed a lower likelihood of disclosing various concerning psychiatric symptoms and behaviors to their outpatient provider. Thirty-six percent reported they are less likely to disclose thoughts of harming self. Percentages for subjects reporting a reduced likelihood of disclosing thoughts of harming others, hearing voices, not taking medications as prescribed, and substance use ranged from 21-29%. At the same time, there were also trust-enhancing effects: a substantial number of patients reported an increase in their ability to trust psychiatric providers and an increase in the likelihood of disclosure of psychiatric symptoms. Exploratory analyses revealed significant associations of gender, race, outpatient provider involvement in hospitalization, and involvement of police during admission with trust, disclosure, and working alliance. Conclusion Even with a high therapeutic alliance and low perceived coercion during inpatient psychiatric hospitalization, the experience can lead to a disruption of trust and transparency with the outpatient psychiatrist in a considerable proportion of patients.

A qualitative meta-synthesis of service users’ and carers’ experiences of assessment and involuntary hospital admissions under mental health legislations: a five-year update

“…Some studies reported on people’s experiences of positively changing perceptions of mental ill-health but this tended to be single respondents rather than the majority view (35, 41). Social proximity of others, and recovery-based and meaningful activities whilst on the ward were reported (32, 33, 34, 37, 39, 49, 50, 54, 55) as having potentially positive impacts on self-esteem and independence.…”

“…Family and friends were described as a source of emotional support and advocacy at times, although service user accounts of tension, distrust and being misinterpreted during and after admission were also often reported (33, 34, 35, 39, 42, 43, 45, 47, 48, 49, 50). Similarly, other service users could be a source of peer-support and positive social interaction, although there were also reports of potential conflict and violent confrontations, a source of fear (33, 34, 36, 40, 47, 49, 50, 52, 55). Some of the papers in this review (33, 39, 47, 48, 50, 52, 55) also described how coping with various aspects of involuntary treatment often led to people ‘Playing ball ’, a concept initially described in one of the studies (48) and included as a new sub-theme.…”

“…Similarly, other service users could be a source of peer-support and positive social interaction, although there were also reports of potential conflict and violent confrontations, a source of fear (33, 34, 36, 40, 47, 49, 50, 52, 55). Some of the papers in this review (33, 39, 47, 48, 50, 52, 55) also described how coping with various aspects of involuntary treatment often led to people ‘Playing ball ’, a concept initially described in one of the studies (48) and included as a new sub-theme. This covers instances of people adapting their communication towards staff and others, e.g.…”

“…Dump you in the room to be stared at like some sort of strange animal.' (51) The detention process was seen (32,33,34,35,39,40,41,42,44,45,47,48,51,53,55) as contributing to stigma, for example through being perceived less credible or as dangerous by others (e.g. in daily life, or staff on the ward) due to having a mental health condition, or being seen to be taken and/or handcuffed by police.…”

Early trajectory of clinical global impression as a transdiagnostic predictor of psychiatric hospitalisation: a retrospective cohort study

“…It can sometimes have negative medical consequences by disrupting trust and transparency in the doctor–patient relationship. 2 It can also have negative social consequences by interrupting career progression and limiting career prospects due to stigmatisation. 3 Children and adolescents admitted to psychiatric hospitals might miss out on educational opportunities, which could contribute to social exclusion.…”