System Entrapment: Dehumanization While Help-Seeking for Suicidality in Women Who Have Experienced Intimate Partner Violence

Grounded Theory

GT involves the study of human behavior (Morse, 2001) with the intent of understanding a social or psycho-social problem (Glaser & Strauss, 1967). Theory is generated through a constant comparative research method where data collection and analysis occur simultaneously (Glaser & Strauss, 1967). Data are initially coded line-by-line (Glaser, 1978) followed by theoretical coding that is used to establish relational statements, raising the analysis beyond description to a theoretical level (Strauss & Corbin, 1998). Theoretical sampling is used to collect further data from the participants or the literature in order to test the sensitivity of emerging hypotheses (Ford-Gilboe, Wuest, & Merritt-Gray, 2005; Wuest, 2000). Following the Glaserian style of GT, the analysis involves the identification of substantive theory that exists within and emerges directly from the data without forcing concepts or ideas onto the development of relationships (Stern, 1994). The final theory is written using memos that are created throughout the entire research process in keeping track of how the concepts and relationships fit together (Wuest, Ford-Gilboe, Merritt-Gray, & Berman, 2003).

Photovoice

PV is a visual research approach that uses participant-generated photography to describe the needs, strengths, and concerns of a community (C. Wang & Burris, 1994), stimulating change through critical reflection and empowerment (C. C. Wang & Redwood-Jones, 2001). PV involves an acknowledgment of the participants’ voice as an indicator of reality (C. C. Wang & Redwood-Jones, 2001) and is based on the person’s everyday experiences (Hergenrather, Rhodes, Cowan, Bardhoshi, & Pula, 2009). After participants generate their images that represent their experiences, they share their personal perspective of their photos and expand on the meaning of these images through a critical reflection among the other members of the PV group (Wang & Burris, 1997), enriching the study with added context (C. C. Wang & Redwood-Jones, 2001). The next step is to codify the data that arise out of the group dialogue by identifying “issues, themes, or theories” (C. Wang & Burris, 1997, p. 381).

Integrating Methods

I integrated the qualitative methods by including the PV data in the GT analysis of the interviews, that is, I analyzed transcripts of the PV meetings and the individual interviews using the constant comparative method. The integration did not compromise the integrity of either research approach; the integral aspect of GT (to create theory by raising the data to a higher level of abstraction), and the integral aspect of PV (critical reflection of self-generated photos), were maintained. Incorporating PV into the research approach strengthened the study, as photos provide a unique perspective of everyday reality that only a visual image can reveal (Harrison, 2002). Images reflecting women’s abuse experiences deepened the understanding of how violence influenced help-seeking for suicidality.

Ethics

This study adhered to the Tri-Council Policy Statement on Ethical Conduct for Research Involving Humans (TCPS-2; Canadian Institutes of Health Research [CIHR] 2014), meeting approval of the University of New Brunswick Research Ethics Board (file #2013-071) and the Horizon Health Network Research Ethics Board (file # 2013-1900). Informed and written consent for the interviews and a separate written consent for the PV meetings were obtained. Women were given a modest cash gift for their participation in the interviews and a basic inexpensive digital camera for their participation in the PV portion of the study.

Considering women’s experiences having been abused, I gave full attention to helping them feel safe participating in this study. Women had left their abusive partner at least 1 year before entering the study, most of them having left at least 5 years prior. They identified a comfortable meeting place, gave me a safe phone number to reach them, and identified personal or professional supports that helped them to manage stress. I offered the women a list of resources in case of an emergency or for further support. Following a discussion about risks related to being identified in their photos, the women consented to having their photos published in research journals. Finally, I provided women with emotional support and acknowledged them as contributors of an important body of knowledge on women’s health. All women reported that they did not feel their participation in the study increased their risk for harm and reported that the experience was rewarding.

Recruitment and Sample

English-speaking women at least 19 years of age living in New Brunswick, Canada, who had left their abusive partner at least 6 months prior to the study and had sought help for suicidality either during or after IPV were recruited voluntarily through advertisements in physician offices and health clinics. The sample included 32 women between the ages of 19 and 68, most of whom lived in urban areas. Suicidality and IPV were self-identified and self-defined. One participant described suicide as a desire to kill herself so that she could have a “break” from life, an “answer” to her problems. Another participant explained how she felt before she overdosed on pills: “I felt frustrated. I felt sick of living. Just frustrated feeling this way every single day. I feel trapped in my own body.” Suicidal thoughts and attempts were unique for each woman with varying intensities at differing periods of time after leaving the abusive partner. Women in this study described IPV as their partner controlling their lives through verbal insults, isolation from family, physical harm or threats, nonconsensual sex, limited access to finances, children used as pawns, and/or other forms of intimidation. Among the 25 women who had children, eight no longer had custody of her children. Three women completed some high school, 20 had a high school diploma, and nine women obtained some postsecondary education. Two participants were students, 5 were employed, and 25 were unemployed at the time of the study.

Data Collection

I met with each woman once for an in-depth interview, leading with the question “How did you find help for suicidality after IPV?” or “Tell me about your help-seeking for suicidality.” After the interview, women residing in a local urban city of NB were invited to participate in a PV group to further explore help-seeking with other women who had similar experiences with IPV and suicidality. Seven women signed a PV consent form agreeing to participate in the groups, that the meetings would be audio recorded, the recordings would be transcribed, and all data would be stored in a file with a privacy-protected password. We met as a group for five 2-hour meetings. During the first meeting, the participants engaged in a brief training on the functioning of the camera and on how to capture images that represent their experiences. Women were then invited to take pictures on their own time that represented their help-seeking and returned to subsequent meetings prepared to describe the meaning of their self-selected photos with the images displayed on a screen for the rest of the group to view.

A guide used to facilitate the critical reflection of the photos was the mnemonic “SHOWeD”: What do we See here? What is really Happening? How does it relate to Our lives? Why is the situation occurring? What we can Do about it? (C. C. Wang, Morrel-Samuels, Hutchison, Bell, & Pestronk, 2004). The group’s critical reflection of the images was based on Freire’s (1970) theory for critical consciousness (Wallerstein & Bernstein, 1988), where women created new knowledge about their experiences through collective dialogue. This process compliments the philosophical perspective of the study, feminist ethical theory, a lens through which the context of women’s lives was critically examined.

Analysis

Rather than a predefined research question, a GT study begins with an area of inquiry (Glaser & Strauss, 1967) and as the data are collected concurrently with the analysis, the area of inquiry develops richness and is further defined. Line-by-line coding of initial interviews began with the descriptive concepts being locked out, feeling isolated, and getting nowhere, codes that continued to develop through a simultaneous analysis of the PV data. One woman in this study shared a photo of a girl covering her ears with her eyes closed symbolizing, “I can’t hear you! I can’t hear you!” conveying others’ rejection or refusal to listen to her experiences of suicidality. The meaning of her image was coded as being ignored, stuck in exile, and feeling minimized, codes that were compared with a grouping of other codes including hitting a brick wall, being stuck in quicksand, and getting nowhere during exerted efforts to connect with HCPs. All of these codes collapsed into the categories locked away from the world and being stuck, eventually merging with codes denoting loss of freedom into the concept System Entrapment.

The theory continued to develop through theoretical coding as I observed how conceptual indicators of a code connected to the dimensions of other codes. System Entrapment emerged as a contributor to suicidal ideation, a finding that led to more questions about the role of IPV in relation to System Entrapment because abuse had also been found to be a contributor of suicidal ideation. I tentatively hypothesized that System Entrapment and IPV were somehow connected in relation to suicidality. Theoretical sampling helped to clarify the relationships between these emerging concepts. During subsequent interviews, I asked newly sampled women more about IPV outcomes and tested these data against the data on suicidal thoughts in the context of System Entrapment. Theoretical sampling allowed me to see that IPV intensified the relationship between System Entrapment and suicidality.

Entrapment

The core property of Entrapment is dehumanization, an erosion of perceived personhood and reason for existing characterized by low self-worth, lack of belonging, and hopelessness. Entrapment is situated within a context of unequal power imbalances, coercion or low levels of autonomy, and a low sense of dignity, factors that contribute to dehumanization. Dehumanization encapsulates all aspects of women’s lives, including their thoughts, emotions, and behaviors. All forms of Entrapment contain women’s belief that they have little control over escaping dehumanization. Feeling trapped makes fully participating in life or realizing one’s personhood extremely difficult. The three forms of Entrapment overlap and influence one another (Figure 1).

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Figure 1.

The core property of Abuser, Trauma, and System Entrapment is dehumanization.

Abuser and Trauma Entrapment

Abuser Entrapment represents feeling hopeless about escaping IPV. Abuse in the form of physical, emotional, sexual, financial, and isolation from loved ones entails a sense of being controlled. Conceptualizing IPV as feeling trapped is not new; however, Abuser Entrapment illustrates a novel concept of dehumanization in relation to being abused leading to a loss of meaning in life and a disconnection from living. One woman described Abuser Entrapment in her photo of a knife, the weapon her abuser used to control her (Figure 2), “That was the same knife that my ex-husband had and threw it at me the last day that I was at our house. I just have a feeling of wind right beside my head. He could have killed me.”

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Figure 2.

The knife that an abuser threw at a participant.

While this participant’s life was in danger by being physically controlled, emotional abuse eroded her sense of self. Name-calling, isolation from loved ones, and other coercive tactics and emotional abuse are the most attributable to dehumanization.

Feeling hopelessness that Abuser Entrapment will never end contributes to Trauma Entrapment or the context for suicidality that coexists with depression, anxiety, or PTSD, leading to dehumanization. Trauma Entrapment is a state of mind characterized by personal devaluation and the urgent need to take control of or escape unbearable psychological pain through suicide. The term Trauma is an acknowledgment of the impact that IPV and other violent trauma have on suicidality, an important addition to the literature because the role of IPV in suicide assessment and intervention is absent. A woman in this study explained her need to escape the pain of being abused through suicide: “I just dropped to the ground in the snow. Like it was just, I asked God to come and get me because I couldn’t take it no more so I went downstairs and went and got my husband’s gun.” The pain of being in an abusive relationship characterized by isolation and disconnection from others lead to a desire to escape this unbearable existence by ending her life.

Trauma Entrapment represents the despair and hopelessness of suicidality, leaving little energy to escape from psychological pain. A participant described being stuck with suicidal thoughts: “It is hard to change your thoughts . . . When you’re suicidal it just stays there with you. It is always in the back your mind. You don’t get rid of it.” Suicidality impeded her ability to control her thoughts, contributing to a feeling of being trapped within her own mind. This experience of Trauma Entrapment required her to seek others’ help since she was not able to end suicidality on her own. Seeking help begins when women feel they cannot manage the suicidality any longer, a process that leads to additional dehumanization upon approaching HCPs. Reminiscent of Abuser and Trauma Entrapment, dehumanization continues within the health care system.

System Entrapment

System Entrapment is a perception of dehumanization through the invalidation of women’s suicidality and trauma within the health care system, eroding their sense of security and fuelling the desire to end life. Invalidation from HCPs’ judgmental attitudes, disregard of women’s trauma experiences, and minimization of suicidality were the most dehumanizing aspects of System Entrapment, leading to alienation and feelings of abandonment. The System refers to acute care services designed to help people with urgent health problems, such as, psychiatric units, EDs, or crisis hotlines, and nonacute services designed for people with less urgent problems, such as, counseling centers and family physician offices. One woman experienced System Entrapment when a crisis line worker did not take her suicidality seriously, leaving her feeling abandoned and stuck with managing her pain alone.

I called and the girl was like, "Yeah . . . yeah . . . Okay." . . . another time she didn’t even say anything. She offered no help, no support, no words, nothing. I hung up. I had called all of the crisis lines. That’s all there is.

Even slight intonations of the crisis line worker’s voice conveyed invalidation, immediately creating feelings of dehumanization. System Entrapment occurs at any time, during all levels of urgency from contemplating help before reaching out, to requesting help for depression, to seeking help after a suicide attempt. System Entrapment is a unique addition to the literature, as it offers a theoretical representation of diverse help-seeking experiences. System Entrapment adds a deeper and contextual understanding of suicidality through rich descriptions of women’s need for help, treatment barriers, and their response to these barriers.

Interactions with HCPs

System Entrapment occurs most frequently during interactions with HCPs. The feeling of being invalidated occurred by being over-powered or controlled, not being taken seriously, and being judged. One woman’s photo of having her picture taken from high above illustrated a sense of powerlessness and low self-concept in relation to the HCPs while she sought help: “When you reach out and you say I’m suicidal. I have anxiety, I have whatever, people look down on you and you don’t want [that]!” (Figure 3).

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Figure 3.

The participant felt that HCPs looked down on her while seeking help.

This image conveys disempowerment while seeking help. Being gatekeepers of treatment, controlling how the services are run, and enforcing the rules that women were obligated to follow automatically places HCPs in a position of authority, leaving women feeling less powerful.

System Entrapment can be concrete and overt when HCPs use physical restraint, making power imbalances more obvious. Involuntary treatment through mental health laws awards great power to HCPs, as women were locked within an institution for a specified period of time. In addition, physical restraint within psychiatric units consisted of being locked in a seclusion room, secured to a bed with straps, and sedated with psychotropic medication, contributing to isolation and loss of dignity. One participant described a sense of being over-powered with her photo of handcuffs, a representation that “reach[ing] out . . . equals having a loss of freedom.” (Figure 4).

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Figure 4.

Handcuffs represented being shackled to a system that has control over women.

Physical restraint is not only dehumanizing due to overt control over the body but also feeling betrayed and alienated by the HCP. A woman in the study described locked seclusion and the influence of the HCPs actions on her suicidality: “[They] put you in [seclusion] and you feel like you are in a cage and there are two nurses that sit behind glass and watch you steady. It was very scary. That doesn’t help me. It makes me worse.” Being observed behind an enclosure amplified her alienation and sense of dehumanization. The invalidation of being placed in a locked room intensified with the knowledge that the HCP assigned to observe the person in seclusion literally holds the keys to freedom. While some aspects of HCPs’ position are helpful, such as the authority to administer emergency medication in a crisis, infringement on women’s freedom by telling them what to do and how to feel is an ethical violation within the context of a hierarchical dynamic.

Perceived judgment

Perceived judgment is a major source of System Entrapment during interactions with HCPs through HCPs’ lack of empathy and shamming of women’s humanity, leading to the most intense feelings of being controlled and dehumanized. Women believed HCPs judged them for having problems that were beyond their control and labeled them as “crazy” due to having been categorized with a psychiatric diagnosis. Judgmental attitudes were seen by the women as being influenced by the stigma of having been in an abusive relationship and wanting to kill themselves as illustrated in one participant’s photo of a gavel (Figure 5).

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Figure 5.

The photo of a gavel represented being judged.

This participant also described being judged with a metaphor of a magnifying glass: “I felt like [the HCPs] are going to look at me through a magnifying glass which would just make me look more broken and they find my faults and I couldn’t face that.” This metaphor symbolized fear of being shamed or dehumanized by being analyzed and criticized while seeking help. Being judged is a well-established aspect of suicide stigma; however, this study adds to this knowledge an understanding of how perceiving judgment deflates the self-concept and distorts meaning in life.

Perceiving judgment is particularly intense within EDs, the entry point for treatment of most acute mental health crises. The functioning of the ED involves system processes and policies that are designed to treat physical ailments while invalidating the mental health needs of someone who is feeling suicidal. Women in this study were not taken seriously if their health problem was not manifested as a physical aliment. One woman explained: “I come in [to the ED] looking half decent and I am told, ‘Why are you coming here? You look fine!’ They do not take into consideration the symptoms or what I’m going through.” HCPs did not believe that she needed help because she did not look sick. Attention to emotional distress, disturbing thoughts, and other psychological health consequences of trauma are regarded as unimportant, contributing to System Entrapment.

Women experienced stigma and feared judgment before actually reaching out for help. Emotional problems are considered within society to be private matters that ought to be managed without professional help; therefore, women spent a lot of time gathering courage and contemplating whether they should approach the system. A woman in this study believed that mental health stigma hindered her knowledge of how to reach out: “I was like what do you do? Who do you see? It is just hard. Again, it’s the stigma. It’s not knowing how to access mental health. Like who do I call?” Perceived judgment also contributed to women’s basic human needs being overlooked. Help for everyday problems, including transportation to therapy appointments and money to feed their children, were difficult to access. Women were treated for their crisis symptoms only, dismissing more important concerns. One woman explained:

I have had psychiatrists and psychologists and medical doctors and friends and nurses say to me, “Are you sure you aren’t bipolar?” And I say, “No, it’s not bipolar. It’s fucking . . . it’s my life! My life is really hard! . . . I need help with the practicalities. I have no support network.” . . . My urgent matters were practical, getting a lawyer, getting [my abuser] out of the house, getting us separated.

Despite having psychological difficulties, identifying a label for her mental health problems was not her priority but rather she needed “practical” help for her family.

System Entrapment is sometimes difficult to recognize. Nonetheless, subtle forms of invalidation can be highly dehumanizing. Women felt judged by being treated like an illness instead of a person. HCPs focused on symptoms while avoiding getting to know the women and lacked empathy toward the reasons behind their suicidality. One woman recounted that some HCPs would medicate her anxiety symptoms instead of talking to her about the problems contributing to her anxiety:

[HCPs] need to check in. They need to see what’s going on. We all fit this nice little box. I have depression so check, check, check . . . Calm me down! Don’t just [say] ‘Here’s an Ativan.’ [Do] something!”

This participant emphasized the need to be seen, taken seriously, and understood. Women also felt judged as being dramatic and weak when they expressed despair, anger, and other intense emotions. Perceived judgment occurred during intake assessments, crisis interventions, therapy sessions, casual conversations, and quick exchanges of information, leaving women feeling dehumanized in a variety of ways by different HCPs.

Fearing judgment may prevent women from seeking help. A participant described feeling like a burden when contemplating asking the nurses for help when they were talking in the nursing station, “They just wouldn’t bother with me. And some nurses made you feel like you were bothering [them] . . . This didn’t help my depression because you feel like you have nobody to go to.” Interactions with HCPs mirrored women’s worth. If women felt that they were not accepted, they believed that they were unacceptable; when felt that they were not taken seriously, they believed that they were not worth being taken seriously. The feeling of being trapped is solidified by the cyclical nature of invalidation. Not being taken seriously increases psychological pain, which then may increase expressions of this pain toward the HCPs, who in turn become defensive and continue to invalidate. The vicious cycle creates a feeling of being at the mercy of the system.

Perceived judgment is also manifested as expectation to change or to deal with problems independently. Women felt threatened by HCPs’ assumption that they needed to learn new skills or to cope more effectively because this suggested to women that they were not good enough as they were. Due to the loss of control while suicidal, women interpreted HCPs efforts to end their suicidality as coercive. When one woman in the study presented to the ED or called the crisis line, she perceived that the HCPs either did not believe her suicidality or they blamed her for being in crisis. She perceived that the HCPs judged her as exaggerating her psychological needs and pressured her to manage on her own using coping skills:

[HCPs] really want to get rid of you if you have called more than once . . . So if you are in a crisis you don’t want to hear "Use your skills" . . . It is like, hello? I am calling you . . . like I am calling you for help! I am calling you to talk with.

This participant believed that the HCPs had unrealistic expectations. Her photo of a rock (Figure 6) explains how she felt pressured to cope on her own: “[This picture represents] people telling me I had to be strong, solid like a rock, to be able to stand by myself.”

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Figure 6.

The rock represented pressure to be strong.

The pressure to be completely independent was overwhelming. Although women intended on making changes through their help-seeking, HCPs’ expectations about ending suicidality by insinuating that women ought to fix their problems resulted in dehumanization.

In summary, System Entrapment is a sense of dehumanization as a result of being invalidated by perceiving judgment, not being taken seriously, and feeling pressured to manage one’s problems independently while seeking help for suicidality after IPV. Abuser Entrapment contributes to Trauma Entrapment and both contribute to System Entrapment. System Entrapment also deepens Trauma Entrapment. The irony that seeking help for suicidality intensified suicidality has critical practice and policy implications.

Awareness of Power Imbalances

Creating awareness throughout the health care system of how power imbalances influence System Entrapment will help challenge dominant assumptions about women’s suicidality. Awareness of the following overlapping contexts help identify ways to decrease power imbalances and dehumanization: (a) trauma and violence, (b) gender stereotypes, and (c) coercive treatment. Preventing retraumatization in women who have experienced violent trauma is enabled through trauma and violence informed care (TVIC). Challenging oppressive gender stereotypes helps to ease pressures and judgments placed on women who are suicidal. Finally, recognizing overt and subtle forms of coercion in the treatment of suicidality is urgently needed to decrease System Entrapment. All three contexts contribute to women feeling weak, blamed, and dehumanized, experiences that are addressed within TVIC.