Difficult patients excluded from psychiatric treatment

Some patients suffering from depression receive treatment while others do not. In fact, some are even turned away. According to Assistant Professor Jeppe Oute from the Centre for Alcohol and Drug Research at Aarhus BSS, one of the reasons is that some patients are regarded as difficult and time-consuming by professionals in psychiatric sector.


“My study shows that the people who are excluded are often those who do not act in accordance with how healthcare professionals believe that a normal patient should act,” Jeppe Oute explains.

The results build on qualitative interviews conducted amongst healthcare professionals at two psychiatric hospitals and they form part of a comprehensive Danish anthropological field study. An article on the study has just been published in the journal “Nursing Inquiry”.

The results point towards several systemic and interpersonal reasons for why some people are not offered treatment.

The systemic reason
“In our healthcare system, patients are treated according to a very sharp systemic division i.e. drug and alcohol treatment in one system and psychiatric treatment in the other. However, we know that about half of the people in the psychiatric system actually have problems with both,” says Oute.

The classic issue - i.e. patients falling between two chairs - occurs when patients wish to receive treatment for their psychological problems. In the psychiatric system, patients are told that cannot receive treatment before they have dealt with their drug or alcohol abuse. Thus they are sent onward in the system only to be told by the alcohol abuse therapist that they cannot receive treatment for their alcohol abuse until they have been treated for their psychological problem.

For this reason, patients are often sent back and forth between two systems that rarely communicate.

According to the researcher, this is a problem because it is actually possible to treat patients for two issues at the same time. But why is this so rarely done? There are several explanations, but one interpersonal explanation is found in the view of human nature that is dominant e.g. in the field of psychiatry.

Asymmetrical power structure
“In the healthcare system and in the psychiatric sector, there are different cultural views on what constitutes a patient. These views are rather stable,” says Oute. 

In the psychiatric sector, patients are seen as objects of illness. Doctors, nurses and other health staff often talk about the individual patient by using phrases such as: “He is depressed” or “she is borderline”.

In this way, the patient is described as an object of illness instead of as “a person who has problems with his mood or energy levels”, which would be a more humanistic way of referring to human beings. 

“The study shows that when healthcare professionals view the patient as an object of illness, it is a way for them to legitimise that they can decide what to do with the patient, who is often regarded as an unresisting object. The power structure is asymmetrical, and thus the patient is regarded as difficult and ‘atypical’ when he or she resists,” says Oute.

The question of gender
The study is new and indicates that the exclusion of difficult patients is linked to the professional view of the relationship between good and bad patients. The latter are patients who attempt to treat their depression by consuming e.g. alcohol. This is a strategy used by both men and women, although mostly men.

“People who attempt to solve their problems in this way are called masculinised patients. They stand in contrast to patients who are compliant and respectful towards the healthcare professionals and whom you could call feminised patients. The question of gender not only deals with whether the patient is a man or a woman, but rather how doctors, nurses and other employees in the psychiatric sector categorise patients according to their own gender stereotypic interpretation of the patient’s symptoms and ways of reacting,” Oute explains and continues:

“What often happens it that treatment is only offered to feminised patients, because healthcare professionals perceive women’s conditions and ways of handling their illness as more appropriate and fitting. Thus women are prioritised over men. This partly explains why more women than men are diagnosed with depression and are offered treatment.”

Psychiatric sector under financial pressure
According to the study, the above explanations for why some patients receive treatment while others do not should be seen in relation to the fact that the psychiatric sector has undergone a reform for the past ten years. The reform demands that more patients must pass through the psychiatric system - and at a faster rate than before. In addition, there are fewer employees in the psychiatric sector. As a healthcare professional, you have to take this challenge into consideration, e.g. by prioritising the treatment of patients whom you believe will benefit from being treated.

“Ultimately, the exclusion of masculinised patients can lead to an increased risk of suicide for men suffering from depression. It might be possible to minimise the number of suicides if the healthcare system was geared towards helping patients with their psychological problems as well as their alcohol and drug abuse, and if the gender stereotypic perception of people in the psychiatric system would change and practitioners not be under financial pressure to help some patients and not others,” says Oute.

The study is based on 45 qualitative interviews. The field work was carried out at two different psychiatric hospitals. The informants consisted of 29 members of nursing staff, including psychiatric nurses. In addition, ten medical doctors and six psychologists and social workers took part in the study. A total of 37 women and eight men took part in the study and they were between 32 and 61 years of age.

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Further information

Assistant Professor Jeppe Oute
Tel. +4587165765

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