History of violence performed by family on people with mental illness following hospitalization

Abstract

Objective

Violence experienced by people with mental illness may result in serious psychological effect. The impact may cause relapse among them which raises the case prevalence. This study aimed to identify the description of the history of violence performed by family on people with mental illness following hospitalization.

Method

The study design was qualitative with a descriptive phenomenological approach.

Results

The result identified six themes, which included family's knowledge deficiency as the cause of violence experienced by people with mental illness, main caregiver as perpetrator of violence on people with mental illness, physical abuse as the common type of violence experienced by people with mental illness, helplessness as the impact of violence, distraction as coping mechanism, and expectation of people with mental illness to be relieved from violence.

Conclusions

The study result suggested that all psychiatric nurses provide cognitive therapy for the victim of abuse and family psycho-education therapy for the abuser to prevent the recurring of abuse on people with mental illness.

Introduction

The act of violence has seen a significant rise in number over the years; however, it is quite delicate to obtain data which addresses violence toward people with mental illness. Short et al. claimed that the absence of data was associated with their incapability to report to the authority.¹ In spite of its absence, a study by Choe, Teplin, and Abram revealed a significant correlation between the history of being a crime victim and perpetrator of violence.²

An individual suffering from mental illness who experiences physical abuse could be injured or had his body damaged or even dead, while psychological abuse would result in traumatic experience.³ The traumatic experience would turn into a stressor.⁴ The stressor prolongs the recovery of people with mental illness. It leads to an increase in their prevalence all across the globe. Therefore, proper treatment plays a pivotal role in the recovery of people with mental illness.

Management of people with mental illness following hospitalization often turns out to be ineffective. The family is among factors which contribute to such ineffectiveness. The family is not well-informed in caring for the patient at home which leads to violence performed by family member itself. The situation is considered as a stressor which may induce relapse among people with mental illness following hospitalization.

Based on statements above, a qualitative study with the phenomenological approach is appropriate to be employed to identify the history of violence which may help nurse in developing nursing care for people with mental illness post-hospitalization and family.

The novelty of the study was phenomenon of family treatment toward people with mental illness after hospitalization. Studies on the same phenomenon had been conducted, though it mostly emphasized on experiences which contributed to mental illness, such as Newman's study which described the traumatic experience as the etiology of schizophrenia.⁵ However, there had never been a study conducted to explore the history of violence which performed by family on the individual with mental illness following hospitalization.

Method

The study design was qualitative with a descriptive phenomenological approach. Participants were people with mental illness post-hospitalization who selected through purposive sampling technique with criteria of having a history of admission in psychiatric hospital, living with family, having a history of experiencing violence, proper communication, and PANSS score ≤ 60.

Total of 7 participants who lived in the working area of the health center in Bangka was involved in this study. Data collection was held from April 2nd, 2017 to May 3rd, 2017. Colaizzi approach was applied to analyze the data. This study was conducted by applying research ethics, such as autonomy, anonymity, confidentially, justice, beneficence, and non-maleficence.⁶

Results

There were 17 categories identified which concluded into 6 themes. The themes included:

• 1)

  Family's lack of knowledge as the reason of violence on people with mental illness, as expressed by the following participant:

“My brother is a fool; he couldn’t tell anyone, he is obtuse. If I ever intrude someone or start breaking glasses, he threatens to strangle and kill me. He didn’t know what to do in that situation and instead threatened to kill and strangle me”.

• 2)

  The main caregiver's perpetrator of violence on people suffering from mental illness, as reveled by the following participant:

“My brother took me to the hospital to get treatment by using BPJS insurance which he owns and yet he is the one who frequently beats me”.

• 3)

  Physical abuse as the most common type of abuse on people with mental illness, as stated by the following participant:

“Lately, I have been punched when I take a nap”.

• 4)

  Helplessness as an impact of violence, as expressed by the following participant:

“Well, I think this is how my life should be, it would be too late to fix it as long as I stay with my parents”.

• 5)

  Distraction as a coping mechanism, as revealed by the following participant:

“Using a headset (to listen to music) like this before sleeping at night keeps my fear of being beaten and sadness away”.

• 6)

  The expectation of people with mental illness to be relieved from abuse, as stated by the following participant:

“I want to move away, build my own home, and live independently”.

Discussion

Family's lack of knowledge as the reason of violence on people with mental illness

The family who cares for a patient with mental illness after the discharge from the hospital should possess adequate knowledge of caregiving for such patient. It is because 88% of relapses were affected by the family's knowledge deficiency.⁷ Knowledge about caregiving for people with mental illness may affect the family's behavior or attitude toward them.⁸ The family should demonstrate a positive attitude when the patient exhibits both positive and negative symptoms of psychosis.⁹ The family who can identify clinical manifestations of psychosis would respond faster in determining the best possible measure for the patient. Wuryaningsih, Hamid, and Daulima described that family was required to know the history of abuse experienced by people with mental illness.¹⁰ Family with proper knowledge would never commit violence on them.

Participants of this study experienced different treatment. They stated that their family had no idea what to do when psychotic symptoms were manifested. Instead, the family committed physical and verbal abuse on them. They experienced psychological abuse in the form of harsh words and high intonation. The statement indicated that family possessed a poor level of knowledge in communicating with the patient. Khoirunnisa, Hamid, and Daulima revealed that there was an alteration in the family's emotional response toward the patient with mental illness following hospitalization.¹¹ Stigma is a factor that may aggravate social interaction. Therefore, it is necessary for the family to possess adequate communication skill.

The treatment of people with mental illness usually takes a long time. Typical and atypical antipsychotics could be administered for such patients.⁹ Psychotropic drugs have both positive and adverse effects. The adverse effect causes them to refuse to take the prescribed medication. Two participants of this study were affected by the adverse effects of antipsychotic drugs. Body stiffness and sleepiness were among those effects. Family's knowledge deficiency on medication, especially its adverse effect, caused the family to force them to take medication without any regard for their condition that had been affected by the drug.

Main caregiver as the perpetrator of violence on people with mental illness

People with mental illness usually live with their family member who takes the role as caregiver to provide care and support for them.¹² Caregivers of participants in this study were all from nuclear family, including parent and sibling. Caregiver plays a crucial role in the recovery of people with mental illness.

The caregiver role comprises a great burden. The burden increases when the patient is suffering from schizophrenia. A study by Koujalgi and Patil revealed that caregivers of schizophrenic patient perceived a greater burden than caregivers of a patient with depression.¹³ The burden affects caregiver's attitude in providing care for the patient at home.

Caregivers should be able to provide comfort and safety for a person with mental illness, yet in often they become the abusers themselves. In this study, the abusers were their main caregivers including father, mother, and sibling. It indicated that the family was not regarded as a safe and comfortable environment for them. This coincided with Oram, Trevillion, Feder, and Howard's study which claimed that people with mental illness had a higher risk of experiencing abuse within the family than any other populations.¹⁴ Hence, main caregivers should be provided with health services from professionals, and health insurance should be provided for people with mental illness to lower the burden perceived by family in caring for the patient.¹⁵

Physical abuse as the most common type of abuse on people with mental illness

Majority of participants of this study experienced physical abuse committed by family. The physical abuse involved torture and shackle (pasung/pemasungqn). The abuse resulted from the family's lack of knowledge on caregiving for people with mental illness, both in methods or treatment.

Apart from torture, applying shackles/pasung is another type of abuse committed by family on people with mental illness. Pasung was performed by locking and restraining the patient. The family applied Pasung due to patient's behavioral aberration and stigma.¹⁶

Tantrum was also a reason for a family in performing pasung. Mariyati, Hamid, and Daulima also described the tantrum as the reason for restraining.¹⁷ Nonetheless, pemasungan could not be justified. Restraining and pemasungan is a violation of human rights which had been addressed in laws. Therefor, family's knowledge about the laws is critical so pemasungan could be mitigated.

Helplessness as the impact of violence

Helplessness in people with mental illness may be resulted from abuse. The helplessness may be manifested as apathy or passive attitudes such as laziness in doing activities, being quiet, or indifference. Rasmawati, Daulima, and Wardani revealed that withdrawal was the early manifestation of pemasungan.¹⁸ The withdrawal would lead to psychological exacerbation of the patient.

People with mental illness might be afraid of internal or external dangers due to a history of abuse.¹⁹ The fear was demonstrated as a sense of dread and worry which caused them to avoid a threatening situation. Avoidance is the easiest method to keep oneself away from violence.

The fear due to violence may also lead to other consequences. The fear may result in adaptation problem which becomes the early symptom of post-traumatic syndrome. Jaquier and Sullivan revealed that there was a significant correlation between fear and severity level of post-traumatic syndrome.²⁰ Thus, fear should be managed properly to prevent it from becoming a traumatic experience. Cognitive behavioral therapy was among therapies provided for people with mental illness to relieve traumatic experience.²¹ Another identified form of hopelessness was giving in to the situation. It was because the abuser was their main caregiver whom they depend their lives on. This led to a feeling of hopelessness when they were abused. Hence, their independency should be promoted.

Discharge planning is a program aimed to promote independency of people with mental illness as well family's knowledge and skill in caring for the patient. Other programs, such as rehabilitation, should also be implemented to reduce patient's dependency on other people. Rehabilitation program such as occupational therapy might promote functional independence of people with mental illness.²² Therefore, a patient who is independent in managing the activity of daily living and financial would have a lower dependency level on the family which keeps him away from abuse.

Distraction as a coping mechanism

Distraction is a diversion of attention into a more comfortable and pleasing situation. Preference of activities by people with mental illness, such as doing a hobby and praying was among the options to distract the patient from aftermath of abuse.²³ Even though the activities were simple, the distraction might offer significant merit for patient.

The patient might feel safe and relaxed in a comfortable and delightful situation.²³ Distraction could be more useful in the form of social activities. Social activities can improve a patient's quality of life, especially for a patient with negative symptoms of psychosis. Turning attention into social activities would maintain and improve patient's social skill.²⁴ Hence, distraction was an appropriate choice since it is a positive coping mechanism.

The expectation of people with mental illness to be relieved from abuse

The expectation of people with mental illness for his self is the first step to be free from abuse. They wish to live independently. The independency here implies financial independency. A patient who has his revenue may have a lower dependency level on the family. Nonetheless, health professionals need to implement preventive measures to prevent the family from committing violence on them.

The preventive measures involved providing antipsychotic drugs in a health facility and conducting health education. Health education had a significant impact on a family's anger management.²⁵ Aside from health education, nursing therapies may also be provided for the family to prevent them from committing abuse on patient.

Conclusion

Abuse on people with mental illness resulted from the family's lack of knowledge on caregiving for them. The family didn’t know about caring method and treatment of patient. Several family members were indicated as abusers, even the main caregiver who was supposed to serve as protector also committed abuse. The abuse committed by main caregivers included physical, psychological, sexual abuse, and neglect. However, physical abuse was the most common type of abuse on people with mental illness.

Among the impacts of abuse was helplessness. Patient with helplessness would exhibit apathy/passive behavior, fear, and giving in to the situation. Therefore, the patients used distraction by doing a hobby and praying as a coping mechanism to relieve psychological effects.

The abuse provoked expectation from people with mental illness to be free from it. The have expectations for themselves, such as the desire to do activities that generate money and to part ways with the abuser. For the family, patients expect family to support them in treatment and not to abuse them. For health professional, they expect a steady supply of medication in health facilities and provision of health education for the family. The study result suggested that all psychiatric nurses provide cognitive therapy for the victim of abuse and family psycho-education therapy for the abuser to prevent the recurring of abuse on people with mental illness.

Conflict of interests

The authors declare no conflict of interest.

Acknowledgements

This work is supported by Hibah PITTA 2017 funded by DPRM Universitas Indonesia No. 384/UN2.R3.1/HKP.05.00/2017.