Forced Isolation as a Form of Abuse

The American Hospital Association (AHA) this past year has launched a campaign against violence in our communities and our hospitals. The AHA has stated that physical violence is a public health threat and is costly to our nation's health systems and communities. In fact, in a report commissioned from Milliman for AHA, it was noted that $279.5 million a year is spent on public violence prevention and preparedness programs and $852.2 million a year is spent following the public violence incident, i.e., reacting to public violence. The report primarily focuses on "physical force to cause injury or bodily harm." The report, however, does not focus on additional types of non-physical violence that can also lead to injury, bodily harm, decreased health status, decreased life expectancy, increased utilization and increased costs. One type of non-physical violence that can lead to injury, bodily harm, decreased health status, decreased life expectancy, increased utilization and increased costs is forced isolation.

When people think of forced isolation, they think of the news stories where a disabled elder was locked in their home and not given food or their care was neglected. They think of the child who was locked in the basement or the closet and denied baths and food and drink. However, there is another form of forced isolation that is not so noticeable or so obvious. That form of isolation is psychological or part of a long-term bullying or abuse issue.

It is no secret that isolation is the tool of the bully and the abuser. Isolation provides the bully and the abuser free reign to not only control the victim, but it also provides the bully and the abuser to control the perceptions of the victim by outsiders. For example, a husband tells a wife that he wants her to stay home and care for the children all day. He and the children are the only ones she sees or talks to all day every day. She has a car, but the husband does not give her the funds to fix the car when it is need of repair and/or tells her repeatedly that the car cannot make it past the local grocery store. 

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Isolation doesn't only happen in the home with husbands and wives or elders in the community or even with children, it also happens at work. Imagine a coworker whose primary role is to sit at their desk and analyze data or review financial reports or even to identify pathogens. The individual may have his/her own office space and spends many hours a day alone completing his/her work. However, there are a few times during the day when this individual needs to be out of the office to collect reports, attend meetings, or to even go to lunch. Now, consider a manager or director who gets angry when the employee is not in his/her office. The manager may chastise the employee for not being in his/her office when he wanted to discuss something. Each time the employee leaves the office, the manager goes into a tirade yelling at the employee asking why he/she isn't getting his/her work done, why is he/she walking around talking to people. In order to ensure the employee reduces his/her interactions with others, the manager puts more and more work on the employee thereby limiting his/her interaction with others further.

Other forms of psychological isolation may not be so apparent.  At times, healthcare workers are so concerned with what is happening with their patients, they fail to see what is happening with their coworkers they interact with daily. Imagine now the nurse who comes to work every day. She seems like a nice person, but she rarely talks to anyone at work. When other employees ask her to join them for a drink, she politely declines and says she can't go. She always seems to be so busy with her son and her family that she rarely has time for friends at work. The other coworkers become "offended" and rarely talk to her at work and ostracize and isolate her. Eventually, the nurse leaves the organization because she has no connections, or friends, at work. One day, the nurse turns in her notice, while her manager is shocked and has no idea why the nurse quit. On her exit interview, the nurse states she felt ostracized and isolated by her coworkers and her managers.

Recent studies and research have shown that isolation does limit social interactions and thereby decreases mental stimulation. An individual, although physically in public, may be isolated and lonely, even though he/she goes to work every day. This not only occurs in the elderly, but in people of all ages. Isolation and loneliness cause a decrease in cognition. Interacting with others, bouncing ideas off of them, learning from them, and many other methods, increases cognition or mental functioning. That is, human interaction stimulates the brain.

The same studies have also demonstrated that isolation and loneliness (which is a direct result of isolation), impacts health and could be a public health threat. An isolated individual may not have access to health services when they are needed, and the person may not receive care until he/she has an acute illness.  This may be the result of abuse or an inability to tell others about health conditions. Social interaction may lead someone to recommend visiting a healthcare provider or a hospital. Without this interaction, an isolated or lonely person may not visit the provider thinking it is nothing serious, or maybe that no one cares. Caring for emergent, acute illnesses thereby increases healthcare costs.

Finally, a study published in Perspectives of Psychological Science indicated that loneliness and social isolation may be risk factors for decreased life expectancy. The study found that loneliness alone resulted in a 26% increase in mortality. Mortality is the likelihood that someone is expected to experience death. The patient's age did not matter. Thus, loneliness and social isolation result in the highest cost of all, cost of life years lost.

In order to truly address violence and the effects of violence on healthcare systems, healthcare professionals must look at the whole scope of the problem. The problem is indeed a large, cumbersome, mountain to pass over. However, by only looking at the part of the mountain that is visible, providers are not seeing all of the other challenges and pitfalls that may also arise.

Sources
American Hospital Association. Advocacy Issues. Hospitals Against Violence. Combating Violence in Our Communities and Our Hospitals. Found online at: http://www.aha.org/advocacy-issues/violence/index.shtml
M. Stempniak. AHA Report: Violence Cost U.S. Hospitals $2.7 Billion Last Year. Hospitals & Health Networks. Found online at: http://www.hhnmag.com/articles/8502-aha-report-violence-costs-us-hospitals?utm_source=newsletter&utm_medium=email&utm_content=08022017-at-memnonfed&utm_campaign=aha-today
J. Van Den Bos, N. Creten, S. Davenport, M. Roberts. Milliman Research Report. Cost of Community Violence to American Hospitals. Report for the American Hospital Association. Found online at: http://www.aha.org/content/17/community-violence-report.pdf
M. Canete-Liguel, M. Gil-Lacruz. Psychosocial Variables Associated with Verbal Abuse as a Form of Intimate Partner Violence Against Women in a Spanish Sample. Journal of Aggression, Maltreatment & Trauma.
Y. Yon, A.V. Wister, B. Mitchell, G. Gutman. A National Comparison of Spousal Abuse in Mid- and Old Age. Journal of Elder Abuse and Neglect. Vol. 26 Iss. 1,2014.
J.G. Alspach. Loneliness and Social Isolation: Long Overdue for Surveillance. Crit Care Nurse. Vol. 33, 2013. Found online at: http://ccn.aacnjournals.org/content/33/6/8.full.pdf
J. Holt-Lunstadt, T.B. Smith, M. Baker, T. Harris, D. Stephenson. Loneliness and Social Isolation as Risk Factors for Mortality. Perspectives on Psychological Science. Vol. 10 Iss. 2, 2015