Institutional Betrayal in Inpatient Psychiatry: Effects on Trust and Engagement With Care

Patients’ experiences of inpatient psychiatry have received limited empirical scrutiny. The authors examined patients’ likelihood of experiencing institutional betrayal (harmful actions or inactions toward patients) at facilities with for-profit, nonprofit, or government ownership; patient-level characteristics associated with experiencing institutional betrayal; associations between betrayal and patients’ trust in mental health providers; and associations between betrayal and patients’ willingness to engage in care postdischarge.

Former psychiatric inpatients (N=814 adults) responded to an online survey. Data were collected on patients’ demographic characteristics; experiences of institutional betrayal; and the impact of psychiatric hospitalization on patients’ trust in providers, willingness to engage in care, and attendance at 30-day follow-up visits. Participants’ responses were linked to secondary data on facility ownership type.

Experiencing institutional betrayal was associated with less trust in mental health providers (25-percentage-point increase in reporting less trust, 95% CI=17–32), reduced willingness (by 45 percentage points, 95% CI=39–52) voluntarily undergo hospitalization, reduced willingness (by 30 percentage points, 95% CI=23–37) to report distressing thoughts to mental health providers, and lower probability of reporting attendance at a 30-day follow-up visit (11-percentage-point decrease, 95% CI=5–18). Participants treated at a for-profit facility were significantly more likely (by 14 percentage points) to report experiencing institutional betrayal than were those treated at a nonprofit facility (p=0.01).

Institutional betrayal is one mechanism through which inpatient psychiatric facilities may cause iatrogenic harm, and the potential for betrayal was larger at for-profit facilities. Further research is needed to identify the determinants of institutional betrayal and strategies to support improvement in care quality.