Ida, Psychotic Patient

[The following text is an example or "case" that can serve as a starting point for reflection and discussion. Some examples may be based on real events, while others are fictional representations.]

Ida is a young girl who has been admitted to a secluded unit in an acute psychiatric ward for the first time. She is psychotic, experiencing delusions and paranoid thoughts. In the ward, she is quiet and polite. She keeps to herself in her room and is hesitant to initiate contact, whether with fellow patients, the staff, or the researcher conducting participatory observation in the unit. Over time, however, she becomes more comfortable, spending more time in common areas and engaging with those present. With her calm and gentle friendliness, she seems to attract interest and goodwill from others.

Over the course of just over a week, she improves rapidly, and discharge is approaching. A couple of days before she is set to leave, the researcher asks if Ida would be willing to participate in an interview. Ida agrees, and they schedule a time for the following day. She says she believes she has something important to share about her experience of being psychotic and hospitalized in an acute ward for the first time. However, the next day, she seems evasive. When the researcher gently refers to their interview agreement, Ida says she thinks it would be better if the researcher asked some of the other patients instead. The researcher intuitively feels that she should keep her distance and let Ida be by herself. Shortly thereafter, Ida is discharged.

The researcher is uncertain about how to interpret what happened. She wonders whether she acted unethically by “imposing” on Ida. She had been eager to collect data from her because Ida had seemed like a reflective individual who could provide valuable information. Could it be that the researcher did not fully acknowledge that Ida had recently been psychotic? Did she overestimate Ida’s capacity? Was Ida more vulnerable than what was apparent in the everyday events on the ward?

Ida is readmitted after a couple of weeks. She appears very ill. She speaks incoherently and moves restlessly and unsteadily around the ward. She is unkempt and unable to dress or feed herself. Yet, she remembers exactly who the researcher is. In consultation with the staff, the researcher decides this time to keep her distance from Ida to avoid disturbing or frightening her. At the same time, they agree that the researcher should not leave the ward, as that could cause Ida to become unsettled, wondering what had happened and why. Ida appears scared and distressed, and the staff face a challenging task in creating a sense of safety for her.

One day, Ida approaches the researcher in the corridor and says clearly and insistently—almost shouting and pleading: “Can’t I please be left out of the research project? Please!” The nurse, who is present and witnesses the situation, tells the researcher that this shows how ill Ida is. Ida believes that the researcher is conducting “measurements”—secret monitoring and recording—and she is pleading not to be made a victim of hidden experiments.

Does participatory observation in an acute psychiatric ward impose an unacceptable additional burden on patients, perhaps particularly on psychotic individuals who are vulnerable due to their unclear grasp of reality? Or could meeting a researcher interested in their thoughts and experiences be a positive experience for patients with limited autonomy, freedom, and capacity to consent? In this case, should the researcher ascribe value to the consent initially given by the patient? Could that consent have been more informed and rational than the later refusals? Could the researcher have provided more detailed information to help orient the patient to reality, or would that have placed additional strain on and further confused her? Can potentially valuable knowledge gained from a research project justify the burden on patients, as expressed directly and indirectly in this case?

Note: This is a translation of the Norwegian original text by Johanne Svanes Oskarsen.