Sociodemographic characteristics
We conducted 10 interviews. Participants ranged between 18 and 55 years of age. Nine participants were male, and one was female. Nine of the ten participants were unemployed and only one had attained a tertiary level of education. The median years with mental illness was eight and a median number of times that a patient had absconded was two. Five participants were single, three were separated or divorced, and two were married. The most common diagnosis among the participants was bipolar affective disorder (n = 6), while two patients were being managed for schizophrenia, and two were being managed for substance use disorders. The median number of years with mental illness was eight, and the median number of admissions was four.
Experiences influencing absconding from the psychiatry hospital
We identified different experiences that influenced patients’ engagement in absconding from the psychiatry hospital ward. Using thematic analysis, we summarized the findings into four main themes including: (1) stigma, (2) experiences with caregivers: mixed emotions, (3) poor hospital resources and services, and (4) the influence of mental illness symptoms. We describe each of these themes below.
Theme 1: Stigma
Patients did not want to be seen in a psychiatry hospital. They described hatred towards being admitted in a psychiatry ward as it reportedly made them feel inferior to others. The experience of hospitalization also led to confusion and distressing beliefs about how they developed a mental illness. One participant illustrated this feeling in the following quote:
“I feel stigmatized. I would wonder what I am doing among patients with mental illness … I am not ill, a full man like me who studied engineering and is supposed to be at [work], so from that I would look for a way out and I absconded.” (Participant 10)
The facilities were felt to be designed in a way that promoted stigma. Some participants explained the dreaded experience of being put in seclusion rooms, describing it as a horrific experience. Those who were put in seclusion lived in fear of being secluded again, influencing their thinking and feeling as though they needed to abscond from the hospital. Many patients described the experience of being in the seclusion room as a dehumanizing encounter. A patient described his fears associated with the seclusion room as follows:
“The seclusion room made me so hungry to the extent that I felt like dying … I could not hold it anymore and I had to eat a whole T-shirt, the one I was putting on. It is a terrible place, and I cannot wish any person to be isolated there. It is just a cool dark room … but the problem is that there is no food and no freedom. You cannot see or talk to any person; somehow, it makes you get scared.” (Participant 7)
Some participants compared being in the psychiatry hospital to being in prison, where their movements were restricted and they lacked the freedom to do what they wanted. This environment was described as leading to patients feeling as though they were being contained not because of their illness, but because they were a menace to the community, deserving of punishment. Thus, for some participants, absconding was a way of regaining freedom, dignity, and independence:
“We live in a situation whereby all the time you are under watch and control … you feel as if you are useless and that you cannot do anything for yourself.” (Participant 8)
Theme 2: Experiences with Caregivers: Mixed Emotions
Some patients reported that their caregivers on the psychiatry ward could, at times, treat them like infants whose everyday activities needed to be controlled. Patients noted that expectations of caregivers, which included remaining in the hospital at all times to provide for patients, was not always experienced as supportive or comforting. For example, caregivers would routinely take on tasks which included washing clothes for patients, purchasing food, getting medications, and bathing them. Tasks that patients could normally do independently, were removed from them and taken over by caregivers, which was experienced as minimizing for them and also resulted in profound boredom. This unintended infantilizing exacerbated feelings of being of no use:
“Sometime you feel you want to go to church and there is no way because people around you cannot allow you to move. In case you want to buy anything for yourself, there is no time or space for you to do so.” (Participant 8)
“Sometimes they try to stop me especially my mother… she does not want me to move around. But if I get the chance, I do the things I want like buying anything I want from the shops.” (participant 7)
“But all in all, this condition is not good…. there is nothing to do.” (Participant 5)
Other study participants were acutely aware of the burden that was associated with caregiving, leaving patients feeling guilty and burdened themselves as they watched their own caregivers become overwhelmed and distressed. Patients spoke about hearing their caregivers express their own intense emotions, resulting in an added negative experience for them that was associated with wanting to escape. Patients were aware, in particular, of the monetary costs associated with caring for them, leading to a kind of desperation for both caregiver and patient which was thought to be remedied through absconding:
“The only challenge is that the caregivers are really bothered a lot: looking for food to feed their patients outside the facility, they also actually do not have enough money with them. This reason makes caregivers request for an early discharge or abscond with their patients, even when the patient is not yet cured properly.” (participant 4)
Another patient described the loneliness that was associated with having caregivers around but not being attended to by them, thereby worsening their experience:
“The reason why patients with mental illness abscond is because caregivers do not take care of them. If their caregivers are always by their side, then they wouldn’t think of absconding. But when they are alone, they get the idea of absconding.” (participant 2)
Other study participants talked about noticing how caregivers managed the stress of dealing with sick patients through physical violence and abuse. This kind of treatment directed at patients was noted and experienced as highly distressing, as well as being associated with a kind of helplessness. These feelings of distress often culminated in a double need to escape, which included escape from hospital as well as escape from abusive caregivers:
“Caregivers are different. There are caregivers who, when their patients annoy them, they react by hitting them, but they do it with good intentions to scare you from doing wrong things. (Participant 5)
“In most cases, what is so challenging and annoying, is when you are in such a condition (having mental illness) and you find that people (caregivers) are just abusing you … you also feel uncomfortable being around such people because, at the end of the day, we do not ask to be in such a situation.” (Participant 8)
Theme 3: Poor Hospital Services
Poor hospital facilities also appeared to be associated with absconding. The living conditions were described as poor with overcrowding, poor staffing, limited to no security, as well as lacking in basic services such as places for cooking and engaging in self-care.
Unpleasant living conditions in the psychiatry hospital
Some participants mentioned that the living conditions at the hospital were unpleasant. Substandard levels of cleanliness across all living spaces, the use of seclusion rooms, the absence of methods like games or sports to engage patients, a lack of basic services such as providing food, and overcrowding were all factors that were associated with absconding. This is illustrated by the following quotes:
“The toilets at this hospital are always dirty so we find it hard to use them” (Participant 2)
“… you feel uncomfortable with the smell of the medicines that are all over the hospital all the time. It is disgusting.” (Participant 1)
Porous facilities
Participants mentioned that the psychiatry hospital was not well secured, as identified by an open gate and complacent or absent security personnel. In addition, patients found it hard to differentiate between other patients and their caregivers since they did not have identification cards or uniforms. This made it easy for patients to leave the hospital with no one suspecting:
“I did not use any trick to abscond. I just passed through the gate and no one stopped [me] because I had no luggage. I passed by the gate like I was just going outside but I never came back.” (Participant 2)
In addition, participants mentioned that the psychiatry hospital lacked basic security measures of maintaining patients within its boundaries, as illustrated by this participant:
“Since this psychiatric hospital has no security lights and is not fenced with electric wires, you can easily jump over the fence and escape. And there is no security at the gate so it would be easy to just pass and abscond.” (participant 3)
Lack of basic services
A lack of basic services provided to patients by the hospital, most notably food, was another reason given for absconding. Participants noted that their caregivers could not always afford to buy food for them, leading patients to spend days without consuming anything but their medications. One participant described how a lack of food forced him to abscond from the hospital:
“I was left here at the hospital alone, so I became lonely. It is always better for patients with mental illness to stay with their caregivers [because] they need food to be available, but I had none of that. It was 4:00pm and I hadn’t eaten anything, so I escaped and decided to go home so that I could maybe get [something] to eat.” (Participant 2)
“The issue of feeding remains a challenge … In most cases, we do not feed very well, not like we feed when we are at home and, in addition to that, we cannot have access to freedom as human beings just like when we are out there with friends and family.” (participant 5)
Overcrowding in the psychiatry hospitals was another reason for absconding raised by participants. This phenomenon also affected caregivers such that absconding was a preferable solution to the conditions that needed to be endured at the hospital.
“…the living conditions of the caregivers is also not good. Sometimes the patients together with the caregivers are so many, that the space provided is so limited for both, this may prompt the caregivers also to assist the patients in escaping from the facility because of the poor conditions.” (Participant 8)
Loneliness and seclusion
The intolerable environment of the psychiatry hospital was perceived to be worsened by the severely damaged social connectedness that was a result of the hospital experience. Many patients were seeking social engagement and relationships but were often unable to find this. This was clearly illustrated in the following memo describing the patient experience:
"This patient is describing the loneliness of being on a journey of recovery. They are not at their worst, but also not at their best. They are invisible to others; they can escape without being seen or heard. They want to wear a uniform—something that makes them identifiable and distinguishable from others. Like food, social connection is a basic need. The attempt to escape loneliness is futile, as it is always there. Even when the patient is at home, they say they are waiting for something.
Moreover, according to some participants, being in the hospital was extremely boring due to the lack of engagement in meaningful activities. Thus, patients getting tired of their daily could also motivate their desire to abscond:
“I was exhausted from the hospital because all I would do is sleep all day and swallow medicine. I knew that if I went to the village, I would at least go to the pitch and watch a football match.” (Participant 4)
Financial challenges
Participants noted that most patients with mental illness are not employed and face financial challenges such that they depend on their caregivers to purchase the items that are required for basic existence in the hospital. This could become costly for caregivers, who had to ensure that patients got three meals a day; yet, the majority of caregivers were not financially stable themselves, leading patients to go without their basic needs being met. A participant illustrated how financial challenges forced them to abscond from the hospital:
“Most patients abscond due to lack of financial support. … I was given money just in case I wanted to buy a Rolex [snack], but just because I wanted us to save money and economize, I would tell them, ‘Let's go home.’ But there are patients that do not have money to afford buying food all the time, so this causes them to escape.” (participant 4)
Theme 4: The Influence of Mental Illness Symptoms
Participants reported that symptoms of mental illness were, in part responsible for patients absconding from the hospital. For example, the presence of psychotic symptoms during admission, particularly commanding auditory hallucinations, instructed patients to leave the hospital. Many felt compelled to obey these voices. Others mentioned that persecutory delusions made them scared of everyone around them, leading them to feel unsafe in the hospital. Hence, they absconded to find safety away from the hospital. Participants’ experiences are described below.
“When you are escaping it’s because you become scared that people around you are going to kill you, so you have that sense of fear, your minds tells you, ‘Why don’t you get out of this place because these people will kill you,’ so you get motivated and do whatever you can to escape.” (participant 3)
“Once, I escaped because I heard a voice from God telling me to leave the hospital and go to church. The message was so strong that I had to do everything possible to be in church, so I absconded. When I reached church, the messages stopped.” (participant 8)
Other symptoms associated with some types of mental illness were reported to be responsible for patients’ absconding behavior. For example, some patients had a high libido and described this as being one of the reasons why they absconded from the hospital. The need for sex motivated them to leave the hospital at any cost, as illustrated by the following quote:
“By the way, when I get attacked [by mental illness], I always have a mindset of knowing where my home is, so I think about going back home and I think about having sexual relations with my wife, so I feel like I am missing out in the process of delaying here while receiving treatment, so this motivates me to abscond…” (participant 3)
Other participants reported that during admissions, they were occupied with thoughts of leaving the hospital and described a kind of desperation, admitting to a willingness to do anything to make sure they could remove themselves from the restraints of the hospital setting. In the following quote, a participant illustrated how patients could become deceitful in order to abscond and stop these thoughts:
“First, I would develop thoughts of absconding and going back home … so, I would simply lie to my mother or any other person taking care of me that I am going out to use the toilets and I just disappear from there … and go home.” (participant 3)