Experiences of Black Adults Evaluated in a Locked Psychiatric Emergency Unit: A Qualitative Study
Abstract
Objective:
Evidence shows that Black individuals have higher rates of coercive emergency psychiatric interventions than other racialized groups, yet no studies have elevated the voices of Black patients undergoing emergency psychiatric evaluation. This qualitative study sought to explore the experiences of Black individuals who had been evaluated in a locked psychiatric emergency unit (PEU).
Methods:
Electronic health records were used to identify and recruit adult patients (ages ≥18 years) who self-identified as Black and who had undergone evaluation in a locked PEU at a large academic medical center. In total, 11 semistructured, one-on-one interviews were conducted by telephone, exploring experiences during psychiatric evaluation. Transcripts were analyzed with thematic analysis.
Results:
Participants shared experiences of criminalization, stigma, and vulnerability before and during their evaluation. Although participants described insight into their desire and need for treatment and identified helpful aspects of the care they received, they noted a mismatch between their expectations of treatment and the treatment received.
Conclusions:
This study reveals six major patient-identified themes that supplement a growing body of quantitative evidence demonstrating that racialized minority groups endure disproportionate rates of coercive interventions during emergency psychiatric evaluation. Interdisciplinary systemic changes are urgently needed to address structural barriers to equitable psychiatric care.
HIGHLIGHTS
•
This study used qualitative interviews to explore the experiences of Black individuals evaluated in a locked psychiatric emergency unit (PEU).
•
Patients reported experiencing criminalization, vulnerability, and stigma during evaluation and commonly noted a mismatch between expectations of treatment and receipt of care.
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Despite identifying problematic aspects of mental health treatment in a locked PEU, patients also identified several positive experiences during their treatment and retained insight into their desire and need for health care.
People with mental illness comprise a growing proportion of individuals receiving emergency department (ED) care in the United States (1). Between 2007 and 2014, about 8.4 million of 100.9 million ED visits were related to mental illness or substance use (2), and an increasing number of evaluations are involuntary (3). Black people with mental illness are made vulnerable by systemic racism in the form of reduced access to adequate outpatient mental health services (4, 5) and remain overrepresented in acute care settings (6), where they are more likely than other racialized groups to undergo coercive or restrictive interventions (7–10).
Much of the growing evidence on systemic racism—encapsulating structural and individualized aspects of racism (11)—in ED treatment of Black people with mental illness relies on quantitative analyses (7–10), which are unable to capture nuances of human experiences (12). Given that emergency psychiatric evaluation may include transport by law enforcement, underinsurance, and involuntary commitment, hospital systems may either not collect or not consider seriously the feedback from patients receiving emergency psychiatric care. Qualitative methodology has been underused in psychiatric research, even though rigorous qualitative analyses represent the core of psychiatric practice (13).
Previous qualitative studies have explored predominantly White patients’ experiences of physical restraint in emergency settings, highlighting dehumanization and mistreatment and loss of freedom, self-determination, and overall sense of well-being as themes (14). In studies in inpatient settings involving seclusion and predominantly White patients, participants report feelings of being punished and provoked by staff (15). A recent mixed-methods study including focus groups and interviews with Black patients identified interconnected systems of oppression, double discrimination as a result of Blackness and mental illness, racial microaggressions, and mistrust of medical institutions as reasons for unmet needs in mental health care among Black participants (16). Data centering the experience of Black adults in emergency psychiatric settings are limited.
We have previously reported on inequities in the use of restraints with Black patients evaluated by an emergency psychiatry consultation service (9). To better elucidate processes that contribute to racially inequitable interventions, we sought to understand the lived experiences of Black individuals treated in restrictive and potentially coercive treatment settings. We therefore undertook a follow-up qualitative study to explore the experiences of Black adults evaluated in a locked psychiatric emergency unit (PEU) in a large academic medical center.
Methods
Study Design
In this qualitative study, 11 semistructured, one-on-one telephone interviews were conducted with English-speaking, self-identified Black adults who had recently been evaluated in a locked PEU at a large academic medical center; applied thematic analysis was used to identify themes. The study protocol was reviewed and approved by the Duke University Health Institutional Review Board (Pro00108772). Study procedures were described in detail to all participants, and informed consent was obtained verbally from all participants before data collection. In reporting the results of the analysis, we followed the Consolidated Criteria for Reporting Qualitative Research guidelines for qualitative research (S1 in the online supplement to this article) (17).
Participants and Setting
Potentially eligible individuals (235 self-identified Black adults ages ≥18 years) who were evaluated in the eight-bed locked PEU in the ED of a 957-bed academic medical center between January and April 2021 were identified through a search of electronic health records (EHRs). The ED was located in Durham, North Carolina, a county of 326,000 people (54.5% White, 35.9% Black, 1.0% American Indian or Alaska Native, 5.6% Asian, 0.1% Native Hawaiian or Pacific Islander, and 13.8% Hispanic, with some individuals reporting more than one racialized or ethnic identity [18]), in a hospital in which the annual patient volume is 80,000, and the annual number of patients evaluated in the locked PEU is approximately 800–900. Individuals were ineligible if they exhibited evidence of ongoing psychiatric instability that interfered with their ability to provide consent or complete an interview.
After considering the importance of voluntary participation, we decided not to approach individuals onsite during treatment in the PEU. Weighing feasibility, accuracy, and availability of telephone data against costs of travel and risk of exposure during the COVID-19 pandemic, we felt that telephone contact was least likely to be harmful and more likely to be accessible than videoconferencing. Using a telephone number available in the EHR, a research staff member (C.L.), a medical student with experience in clinical research recruitment, called 235 potentially eligible participants from November 2021 until April 2022. In 170 cases, telephone numbers were inaccurate or disconnected, or there was no answer or option to leave a voice mail. During screening, the 65 potential participants reached by telephone were asked whether they had been recently treated in the locked PEU and whether they self-identified as Black. Individuals meeting these criteria were offered information about study procedures and asked to participate in the study. Eleven participants provided voluntary informed consent and were compensated for their time with $20 gift cards at study completion.
Data Collection
The semistructured interview guide was developed by an interdisciplinary research team of physicians (a psychiatrist, a combined internal medicine–psychiatry physician, a senior psychiatric resident, and internal medicine–psychiatric residents), qualitative researchers, a medical student, and a local community development practitioner, who together represented individuals from Black, Indigenous, and People of Color (BIPOC) and non-BIPOC backgrounds. The interview guide was informed by a review of the literature on patient experiences in restrictive settings (15, 19–22) and included open-ended questions with follow-up probes to assess patient experiences during transport to, evaluation in, and discharge from the locked PEU (S2 available in the online supplement ).
All interviews were conducted via telephone from a private location by a senior psychiatric resident (L.-A.D.) with qualitative research experience. Interviews were conducted in English and lasted between 23 and 63 minutes (mean=41 minutes), and reflective interview techniques were used to come to a mutual understanding of participants’ narratives. Interviews were recorded by using an encrypted audio device, professionally transcribed, read for accuracy (C.M.S.), deidentified, and analyzed with NVivo, version 12, a qualitative data analysis software package. Discussions to brainstorm and explore emerging themes were undertaken with the interviewer (L.-A.D.) and another member of the research team (C.M.S.). Basic demographic information was collected during interviews and through extraction from the EHR.
Qualitative Analysis
Thematic analysis was applied to elevate the voices of those with lived experience (23). Two members of the research team (C.M.S. and J.P.G.) listened to recordings, reviewed transcripts, and wrote concise memos summarizing emerging content across domains of inquiry. An initial codebook was developed on the basis of deductive and inductive themes and included representative quotes (24). The entire research team reviewed the summaries to develop a consensus on inductive thematic codes emerging from the data, which were then used to adapt the codebook. To avoid missing emergent themes, a third team member (C.L.) independently reviewed transcripts and developed a separate codebook, which was used to further adapt the codebook. Two team members (C.L. and J.P.G.) met to reach consensus on coding definitions and procedures before independently double-coding 20% of transcripts by using NVivo. All transcripts were recoded by a single physician-researcher (J.P.G.) after intercoder reliability was attained (agreement of 87.5%, κ=0.8). Data were analyzed from April through June 2022. Descriptive statistics were analyzed in Microsoft Excel, version 16.62.
Results
Of the 65 potentially eligible individuals reached by telephone, 11 completed verbal consent and participated in one-on-one telephone interviews. The median age of these participants was 28 years (interquartile range=25–41), and most (64%) were women. All participants had a history of mental illness, 73% had a history of substance misuse or substance use disorder, and 64% had a history of housing instability or homelessness. Of 11 participants, 55% were admitted to inpatient psychiatry after evaluation. Complete participant characteristics are provided in Table 1.
| Characteristic | N | % |
|---|---|---|
| Sex | ||
| Male | 3 | 27 |
| Female | 8 | 73 |
| Gender identity | ||
| Man | 3 | 27 |
| Woman | 7 | 64 |
| Nonbinary | 1 | 9 |
| Non-Hispanic Black or African American | 11 | 100 |
| Age in years | ||
| 20–29 | 6 | 55 |
| 30–39 | 2 | 18 |
| 40–49 | 2 | 18 |
| 50–59 | 1 | 9 |
| Marital status | ||
| Single | 9 | 82 |
| Divorced | 2 | 18 |
| Highest level of education | ||
| Completed high school | 3 | 27 |
| Some college | 6 | 55 |
| Completed college | 1 | 9 |
| Advanced degree | 1 | 9 |
| History of housing instability or homelessness | 7 | 64 |
| History of psychiatric diagnosis | ||
| Any | 11 | 100 |
| Depression | 5 | 45 |
| Anxiety | 2 | 18 |
| Posttraumatic stress disorder | 4 | 36 |
| Bipolar disorder | 1 | 9 |
| Schizophrenia or schizoaffective disorder | 5 | 45 |
| History of substance misuse or substance use disorder | ||
| Any | 8 | 73 |
| Tobacco | 4 | 36 |
| Alcohol | 3 | 27 |
| Cannabis | 6 | 55 |
| Stimulant or cocaine | 1 | 9 |
| Admitted to inpatient psychiatry after evaluation | 6 | 55 |
| Psychiatric hospitalization within 12 months of evaluation | 5 | 45 |
| Medical hospitalization within 12 months of evaluation | 1 | 9 |
| Emergency department (ED) visit within 12 months of evaluation with psychiatric consultation | 6 | 55 |
| ED visit within 12 months of evaluation without psychiatric consultation | 2 | 18 |
Individual review of interview recordings and transcripts by two team members (C.M.S., J.P.G.) suggested no new themes after six interviews, and subsequent review by an additional team member (C.L.) resulted in no new themes after review of eight interviews (25). Consensus discussion among team members resulted in the identification of six major themes. Patients experienced criminalization, stigma, and vulnerability before and during their psychiatric evaluation. Although patients identified several helpful interventions during transport, evaluation, and discharge from the PEU and described insight into their desire or need for treatment, they also noted a mismatch between their expectations of treatment and the treatment they received and reported various stigmatizing experiences. The major themes, representative quotations, and participant suggestions on improving care are detailed in Table 2.
| Theme and definitions | Representative quotations | Participants’ suggestions for improving quality of care |
|---|---|---|
| Criminalization: feeling of confinement, restraint, and criminalization during transport, evaluation, and discharge from care in the PEU. May use words such as handcuffs, police, or security in a way that denotes restriction of personal liberty and choice. | “I was never supposed to be actually in your psychiatric ward or jail or whatever it was ’cause that’s what it felt like.” (participant A) “So, if I had known what the unit was like . . . and if I had [been] given a different perspective on what I was doing, then maybe yes, but if I had known I was going to [the hospital] to a jail cell, I would have . . . not gone.” (participant C) “I got treated just like I’m a prisoner.” (participant G) | Decrease law enforcement involvement in initial and ongoing psychiatric care; decrease use of handcuffs and ankle restraints during transport: “I think it was just the police presence that just like threw it all off. Other than that, I was fine with the staff and everything. Honestly, I don’t believe that police should play a role when it comes to mental health crises and being the first ones to be called out, because a lot of police officers are not trained well enough for that, and so I believe personally that having social workers or just a whole different unit for mental health not only calms down the [crisis] in itself, but it also makes the patient feel better.” (participant C) |
| Vulnerability: sense of powerlessness, which could be psychological or physical. Could also be a perception of threat to safety or sense of impending danger. | “Yeah, and then, check this out: in cuffs for a female that’s . . . like four seven, four eight [feet and] not even a hundred pounds. But then, I get there, three officers are there.” (participant G) “Being in the hospital in that situation was just a lot. It was just a lot for me [because] it was just bringing up a lot of the traumatic experiences that I’ve already been through. . . . Then they gave me lorazepam that literally felt like they knocked me out for, like, 2 days, . . . I don’t remember how long I was in there.” (participant A) “I was actually cold the whole time because we were only allowed . . . to have one blanket. The mattresses were really thin.” (participant C) “Sometimes you’re the only woman in the unit there, and it [does not have] a door or anything, and so it can be unsafe at times.” (participant E) | Adopt a trauma-informed approach to patient care in emergency psychiatry settings; proactively attend to patients’ physical comfort and basic human needs (shelter, clothing, nutrition, hygiene): “I don’t have any bad thoughts about anything they did except for the . . . doctors in the back; they made the decision for me to leave, and . . . if they would just maybe talk to [their] patients about it first before [they] just decide.” (participant H) “Keep their cool. Meaning staying more level headed than that. . . . Just not causing a ruckus, not getting 20 people for one person, you know, just being normal, I guess.” (participant D) |
| Positive experiences: the patient recalled specific actions on the part of personnel involved in transportation, evaluation, decision making, or discharge from the PEU. Examples include “They were nice to me” and “they tried to calm me down.” Absence of harm is not the same as helpful. | “[The emergency medical technician] . . . seemed trustworthy, and she was concerned about my health, and . . . she was really kind, too. . . . I calmed down . . . after speaking with the woman; she calmed me down.” (participant I) “[The nurses and doctors] made sure that I got the medication that I need.” (participant J) “The personnel and employees, you know, they’re not there to hurt you. They’re there to help. So, they are great.” (participant K) | Use small gestures of kindness, communicate authentically with patients in crisis, seek to understand and answer patients’ questions, and use timely prescription of necessary medications to avoid further crisis: “Just make it more personable. Each patient is their own case and should be treated as such. That’s about it.” (participant K) |
| Insight: the interviewed patient expressed insight into the presence of mental illness, including the potential benefit of seeking and obtaining care, including in the emergency department. | “I just literally felt like I was losing my mind.” (participant A) “I wasn’t on my medication, and I was drinking heavily, and so I got into . . . an argument with my dad, and so I know me and my temper, and before I did something that would land me in jail, I called the police.” (participant B) “I was really stressed out, so my eczema started to flare up, and then . . . my mental health started to decline.” (participant F) | Engage in goal setting and patient-centered interventions, gain historical context and input from patients, and provide clear guidelines and parameters for patients in emergency psychiatry settings: “If we can state a goal or something . . . just find out what’s important to the patient.” (participant I) “I guess to walk patients through what’s happening. Like, just going through and in an easy-to-understand way, bringing up information when it comes up [throughout the stay].” (participant F) |
| Mismatch between expected and actual care received: the account provided by the patient depicts a mismatch between what they had perceived would be therapeutic and what transpired during transportation, evaluation, or discharge from the PEU. | “I’ve felt like it was a complete blatant disregard for the simple fact that I literally told everybody I am tired. I’m exhausted. I just need a moment, and I don’t feel like anyone cared.” (participant A) “I feel like I would have calmed down a lot earlier in my whole crisis if my experience in the psychiatric unit wasn’t like it was, because I think I cried for 32 hours straight.” (participant C) “I feel that it was worse, like, the way that they ran it made me worse.” (participant D) “Well, the beds are uncomfortable, of course, it’s a flat bed, it’s a mattress. I mean, there is nothing there keeping me from falling out [of] the bed or getting out [of] the bed, or they’re just uncomfortable in general.” (participant K) | Strive for individualized care that accounts for patient-level differences in illness, severity, and circumstances; maintain facilities with hospital-grade cleanliness; facilitate patient dignity in activities of daily living such as bathing, grooming, and eating; and provide access to programming (groups, activities) or, if not feasible in the environment, provide alternative forms of entertainment: “Have a heart. Feel something. If you cannot feel you should not be working in that field.” (participant A) |
| Stigma: patient reports experiencing, perceiving, or witnessing (derogatory) treatment based on any or all of the following: presence of mental disorder, racialized identity, ethnic identity, or cultural background or beliefs. | “I just felt like they were down on me more than they saw the value in me. They don’t communicate as much to Black people like they do [to] White people. Instead of talking to a Black person, they’ll just give you an injection to make you sluggish.” (participant D) “I have been in the hospital a time before or two, and they automatically assumed that I was having an episode and took me in. For some reason they look down on people with mental health issues, and really, we all have mental health issues depending on the circumstance and just going on in your life at the time.” (participant E) “Because of all the stuff, you look around at the other patients, they don’t treat them like they treat the Blacks and other minorities.” (participant G) | Ensure all staff receive appropriate training in cultural sensitivity, trauma-informed care and programs that support real-time intervention (e.g., upstander training): “To be treated fairly. Everybody’s to be treated on one accord, fairly.” (participant J) “Not be judgmental. I wasn’t treated unfairly, but there [were] some people in there who were being mistreated.” (participant B) “Well, stuff was going on since this Black History Month. Look at all this stuff that we had to go through, and we still [are] going through it, and I’m tired of [being oppressed]. [Staff] can act like they got compassion, like [they’re] human.” (participant G) |
Criminalization
Most participants (N=9, 82%) experienced aspects of transport, evaluation, and treatment that were perceived as criminalizing their mental health condition. One participant noted,
I had four police officers against me. I was talking, I was fine, I’m not a criminal, I’ve never been a criminal and so, honestly, personally, for me, that just made it worse. Being handcuffed as well, I was just acting like why am I being cuffed like a criminal? (participant A)
Another participant reported, “[The police] were like we can’t take you to the jail if you don’t have a reason to go to jail, and I was like okay, so, when I got to the hospital it was kind of like you all took me to jail anyway” (participant C). Participants also reflected that the nature of the locked PEU or interventions they underwent made them feel like an animal or something other than human. For example, one participant reported, “They give you that medicine to calm you down, but when they give you that medicine, you [are] stuck in a room for 2 or 3 days, and I feel like that’s not right. You [are] just treating us like animals” (participant J).
Vulnerability
All of the participants reflected on their limited agency, sense of vulnerability, or both during the psychiatric evaluation, ranging from how they were transported to the ED to the interventions they underwent while there. “[The intake nurse] looked mad, and I was just like, lady . . . the way you look, I don’t think this is going to work. I’m scared, and then . . . she left me in there. She got upset, like, I was just like . . . can you calm me down, ’cause I’m really scared?” (participant A). Another participant reported, “I felt like the whole hospital was against me; when they took me [from the PEU to a psychiatric hospital], I felt relieved. . . . I didn’t trust the medicine that they were giving me, and I didn’t trust anything that they were giving me” (participant D). In some cases, vulnerability included a lack of agency regarding the next steps in care: “They just told me they found me a bed, and I left; . . . that part was kind of frustrating ’cause I didn’t want to go that far, and I also didn’t really want to go to a, like, inpatient facility” (participant H). Some participants described vulnerable experiences as traumatic: “It literally, it just gave me another . . . it was traumatic for me. It felt traumatic after that—that’s what I felt like” (participant A). Another participant simply reported, “I felt violated” (participant G).
Positive Experiences
Despite describing several traumatic experiences and vulnerability, all participants reflected on positive experiences with individual staff or care team members. One participant noted positive interactions with the treatment team:
That was a really nice experience because I had come in on my birthday, and . . . [the nurse] was just like, well, “Happy birthday, I’m going to try to do the best I can for you.” And she actually went and got me a little ice cream cup. The doctor that I had at the time was also really nice. She answered every question I had. (participant C)
Another participant reported, “I feel like everything is set up to best help people the way they need help” (participant H). Another respondent identified several helpful interventions:
They made sure that I had medications for going through withdrawal, so I wouldn’t be in there shaking. They made sure I had my regular medicine. The nurses came and checked on me. Doctors came and talked to me and gave me the resources . . . that I could use for when I got out. (participant B)
Insight
Nearly all (N=10, 91%) participants recognized the need for psychiatric evaluation or treatment. In describing this self-awareness, one participant noted, “A lot of stuff that I deal with as far as like mental health or . . . my anxiety and depression. . . . Most people in my family just [said], like, ‘You just want attention,’ and I was, like, ‘No, I need to go talk to somebody before I lose my mind’” (participant B). Another participant noted, “Well, I needed [the evaluation] because I was in psychosis, you know, I was having delusions” (participant I). Another participant stated, “I called the emergency department because I felt, like, that I needed some help” (participant J).
Mismatch Between Expected and Actual Care Received
Despite identifying a need for help, all participants noted a mismatch between what they had anticipated as being therapeutic and the means by which they underwent evaluation. One participant noted,
I felt like I needed help and care, but what I was given was [not] help and care. . . . So, basically, I needed more of a stable environment, and once, as soon as I got into the hospital, . . . it was the complete opposite of what I thought. I needed something more peaceful. I needed more communication, and I just wasn’t getting that there as a patient. . . . I felt I was in more of a crisis there than I actually was before I got there. (participant C)
In a statement reflecting themes of criminalization and stigma as well as the mismatch between expected care and care received, another participant reported, “I know [the police’s] role at the time was probably safety and concern, but that’s just not what police, the energy police officers give me now” (participant A). Another participant expressed a sense of mismatch or injustice by relaying, “It’s not fair that I’m still stuck in the hospital when I didn’t do anything to be in here” (participant E). Answering “no” to a question about whether anything was helpful, one participant explained that the experience felt harmful: “I feel like I would have calmed down a lot earlier in my whole crisis if my experience in the psychiatric unit wasn’t like it was” (participant C). Describing how individualized and patient-centered care would have been more therapeutic, one participant differentiated between what they had perceived as helpful staff in the setting of unhelpful policies: “The personnel and employees you know, they’re not there to hurt you. They’re there to help. So, they are great. It’s just the procedures . . . need to be, like, kind of looked at, that’s it” (participant K).
Stigma
All participants reported feeling as though their transport, emergency care, or discharge was detrimentally affected by their mental illness, racialized or ethnic identity, cultural practices, or financial status. One respondent noted, “I kept hearing voices. I felt like I was held hostage, and then I felt like I was being neglected a little bit” (participant D). One participant noted that “I just feel like if I was another race, they wouldn’t have thrown me in the back of a police car with handcuffs on just to take me to the emergency room” (participant B). Wondering aloud about reasons for negative aspects of their experience, one participant said, “I don’t know if that was because I was in the psychiatric unit, and, you know, they don’t really listen to you when you’re in crisis or [if] that was just my whole experience in general” (participant C). Another concluded, “I get Medicaid, so my Medicaid pays for that; so I guess that’s the true reason why minorities get treated differently” (participant D).
Discussion
To the best of our knowledge, this study is the first qualitative assessment of treatment experiences of Black adults in a restrictive emergency psychiatric setting. The participants reported experiencing vulnerability, criminalization, and stigma during the psychiatric evaluation. The participants described insight into their desire and need for treatment and noted a mismatch between their expectations of treatment and the treatment they received.
With only 31% of Black Americans with mental illness receiving the care they need compared with 50% of White Americans, approaches that are intentionally socially conscious and trauma informed are needed to reduce barriers to care, especially for minoritized populations (26). Evidence shows that mental illness among Black people goes untreated—not as a result of a lack of help seeking or insight on the part of Black patients but because of structural factors such as intergenerational poverty, decreased access to health care, and, as illuminated in this study, traumatic experiences in health care settings and society at large (16, 27–30).
We conducted this study to elevate the voices of patients whose feedback may go unheeded in society and health care. Consistent with common perceptions and existing data from predominantly White individuals restrained in the general ED and secluded in inpatient psychiatric settings, most of our participants reported experiencing physical or emotional vulnerability during the process of evaluation (31). Promoting recovery and wellness requires attention to the physical environment and psychological safety (31). Participants in our study, as in others, reported needing and appreciating regular and clear communication, interpersonal connection, and individualized care (32).
In addition to challenges reaching potential participants by telephone, only about one in six individuals reached during the recruitment stage consented to participate in the study. Black individuals receiving police-involved emergency psychiatric care may have been less likely to participate in the study because of concerns over traumatic reexperiencing. Challenges involved in recruiting participants may also indicate that patients are skeptical that systems will change. The themes identified herein may therefore underestimate the distressing nature of the experience.
Although this study was not designed to compare Black and non-Black experiences, some of the participants’ narratives highlight how intersectional vulnerability and stigma may contribute to traumatic experiences in emergency psychiatry. Themes of stigma related to race and ethnicity were common, as were themes of feeling stigmatized by virtue of having inadequate health insurance or mental illness. Many participants described feeling criminalized or as though the treatment environment had many features in common with jail. For some, the involvement of law enforcement raised concerns for their physical safety. These findings are consistent with the growing recognition that both Blackness and mental illness are criminalized (33–35). Of note, some participants reported that they did not think that race affected their experience and highlighted isolated positive experiences with their care team that communicated a sense of shared humanity.
Several participants noted that they were less involved in decision making than they desired. Indeed, previous interventions to increase shared decision making among patients with mental illness have led to increased perception of better care quality among minoritized patients (36).
We asked each participant to suggest one thing that could have improved their experience of emergency psychiatric evaluation. Participants’ pragmatic suggestions included improving the physical environment of care to include basic cleanliness of the PEU as well as access to personal hygiene products and opportunities to use them in a dignified way. Participants also emphasized the importance of communication for goal setting and orientation to the environment, access to communication with family and friends outside of the ED, and clearer expectations regarding the next steps in treatment. Even considering that law enforcement involvement may have been the safest or most practical method of access to care, participants also suggested a more individualized approach to decision making regarding transport via law enforcement and the use of restraints such as handcuffs or shackles.
Patient-level feedback from those receiving inpatient or urgent psychiatric care is infrequently operationalized or included in health care agency quality assessments (31, 32). One ostensible reason for omitting feedback from psychiatric patients is incomplete development of quality metrics; however, we speculate that stigma or bias against individuals with mental illness contributes to delays in identifying and measuring meaningful quality metrics and in incorporating patient-level feedback.
Sharing feedback from our study participants with leadership has resulted in concrete plans for improvement in our institution’s emergency psychiatry services. Clinical leaders are currently developing an orientation guide to the emergency psychiatry service, implementing reminders to care providers that patients benefit from regular updates and input into their ongoing treatment planning, and are renewing attention to the physical environment. On a systems level, in response to statutory changes in 2020, institutional leaders have been working to identify practical ways to safely and securely transport patients having a psychiatric emergency that will not necessarily involve law enforcement or restraint.
Themes of stigma and lack of agency are not unique to Black patients, but in considering barriers to psychiatric care in the context of structural racism and long-standing inequities, clinicians must recognize that these scenarios are traumatic and promote care avoidance. Our findings highlight areas in need of focus to improve equity of emergency psychiatry care. Although it may take time for meaningful transformative community-involved interventions to decrease stigma, criminalization, and vulnerability and to achieve equitable access to effective mental health care, interim strategies—such as those suggested by patients—may improve patients’ experiences.
Inequitable treatment for Black individuals in emergency psychiatry settings and in civil commitment (9, 37) may not be primarily a problem of interpersonal racism. We recommend bolstering outpatient resources for patients who are under- or uninsured, collaborating with the local criminal legal system to ensure a therapeutic and collaborative response to patients experiencing mental health crises, and providing appropriate staffing for outpatient and emergency psychiatry services. Because some patients will require inpatient care and prolonged time in ED psychiatry settings can be traumatic, we also recommend working to eliminate barriers to timely inpatient care, which can include proxies for insurance status and may disproportionately disadvantage Black patients (Smith et al. [2021]; unpublished data).
Our study had limitations, including a single geographic location, relatively brief interviews, and a potential power differential between interviewer and interviewees. With its small sample size, this study was not intended to reflect the experience of all psychiatric patients or all Black patients but is offered in hopes of prompting institutional reflection and reconsideration of modifiable aspects of systems of care. Data generated from this analysis did not include the views of patients who declined to participate or could not be reached by telephone. Individuals we were unable to reach may not have had access to a telephone, a proxy for social vulnerability (38). Also, although the themes were identified by both men and women in our study, men were underrepresented in the analysis. In addition, although race was self-identified in this study, we understand that race is a social construct and that the heterogeneity of individual experiences cannot be captured in a single qualitative study. Our analysis also encompassed a relatively small sample size. However, a systematic review found that thematic saturation is often reached at a sample size of nine to 17 (39), and our analysis reached thematic saturation of themes by the eighth interview. Finally, although our study focused on Black participants, all psychiatric patients are vulnerable and likely share similar experiences of care regardless of race or ethnicity. Whether or not Black patients experience different care in emergency psychiatric settings, structural circumstances in society—and the experiences reported by our participants—suggest ways to mitigate trauma and improve Black patients’ experience of care. Further research is therefore welcome and necessary.
These limitations notwithstanding, this study helps to fill the gap in knowledge of the experiences of Black individuals evaluated in a locked PEU. Elevating the voices and experiences of minoritized patients has the potential to improve care for all. We recommend a focused and intentional approach to identify and remediate interpersonal racism and systematically eradicate vestiges of structural racism in the environment of care.
Conclusions
A growing body of evidence demonstrates racial inequities in the treatment of patients receiving emergency psychiatric care. Elevating the voices of Black adults evaluated and treated in a locked PEU revealed that even in situations in which patients recognize the need for help, they are at increased risk for various intersecting adverse experiences, such as criminalization, vulnerability, stigma, and unhelpful care. Our findings underscore the need for interdisciplinary systemic changes to decriminalize and destigmatize the delivery of emergency psychiatric care with the overarching goal of achieving health equity.
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Information & Authors
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Published In
History
Received: 15 October 2022
Revision received: 21 January 2023
Accepted: 15 February 2023
Published online: 12 April 2023
Published in print: October 01, 2023
Keywords
Authors
Author Contributions
Drs. Smith and Daley contributed equally to this work.
Competing Interests
Dr. Tweedy reports receiving royalty payments and speaking engagement compensation from Macmillan and Macmillan Speaker’s Bureau. Dr. Gagliardi reports receiving compensation for her role as associate director of the Train New Trainers Primary Care Psychiatry program. The other authors report no financial relationships with commercial interests.
Funding Information
This study was supported by the Duke Center for Research to Advance Healthcare Equity (REACH Equity), supported by the National Institute on Minority Health and Health Disparities (award U54 MD-012530); Hubert-Yeargan Center for Global Health; and Duke University School of Medicine, Department of Medicine. The sponsors had no role in the study.The content is solely the responsibility of the authors and does not necessarily represent the official views of Duke University, the Indian Health Service, the U.S. government, or any of its agencies.
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