Behind the glass: invisible mechanisms of stigma in psychiatric institutions
- Aringas Vagonis
- May 28
- 5 min read
Updated: May 29
Stigma in psychiatric settings stems from more than just individual prejudice; it is actively maintained through institutional, linguistic, and emotional defence mechanisms. The glass-enclosed nursing station serves as the most visible symbol of these boundaries. Behind it, documentation rituals, professional language, and diagnostic categories act as institutional defences. While they help clinical staff survive the heavy emotional labour, they simultaneously create the distance from which stigma is born.
The Iron Gates
I remember the day I first drove to the psychiatric hospital for a job interview. I stopped in front of the massive iron gates separating the territory of the Psychiatric Department of Klaipėda Republican Hospital from the city street. My eyes instinctively searched for a building with regular doors; it hadn't even crossed my mind that these gates were the main entrance. As it turned out, they were unlocked.
At first glance, these gates seem like an ordinary architectural structure, merely marking the boundaries of the facility. In reality, they are a physical inheritance from an era—particularly the years of Soviet institutionalisation—when the main goal of psychiatry was to "protect" society from people with mental illness simply by isolating them. Although today these gates serve a standard territorial function, their image continues to trigger an emotional memory of exclusion. In the public perception, they act as a symbol of protection, indirectly warning that in this space, one must "be careful". I myself recall that strange feeling upon entering the territory—realizing there was actually nothing to be careful of.
In 2001, sociologists Bruce Link and Jo Phelan argued that power is a fundamental component of stigma, without which it could not exist at all. It was only when I began delving into the literature on this topic that it became clear: physical barriers maintain a much deeper divide between "us" and "them".
Power and illusory safety
In our inpatient wards, the glass-enclosed nursing station is still most often justified as a pragmatic solution to ensure staff safety, but the available research does not support this assumption. For example, research by Southard (2012) reveals that aggression levels do not rise when protective barriers are removed; on the contrary, the emotional climate improves, and the need for physical restraints decreases.
Even more significant changes are documented in the work of Ulrich and colleagues (2018). They found that redesigning ward architecture according to stress-reducing principles—including the implementation of open nursing stations—yielded substantial clinical improvements: the total number of cases requiring physical restraints decreased by 50%, and the need for coercive interventions also decreased. These figures testify that safety is created not through isolation, but through an environment that lowers overall emotional tension.
Nevertheless, as Shattell (2015) notes, for the staff, removing the glass is primarily associated with the loss of an isolated, "safe" territory. I must admit: I experience this exact anxiety, followed by relief, every time I step into the safe space of the nursing station in the acute admissions ward. It is simply calmer there. Without second thought, it feels like it couldn't be any other way.
What does the glass really protect us from?
Working with people experiencing severe mental illness poses significant challenges for both the individual practitioner and the entire team. In psychiatric settings, staff are constantly confronted with intense, primitive, and often difficult emotions. Due to blurred boundaries—dictated by the nature of mental health conditions—and primitive defence mechanisms such as splitting, projective identification, or psychotic functioning, the patient's distress inevitably affects those around them, impacting both other patients and the staff. This constant encounter with patient suffering in an unpredictable environment generates an enormous psychological burden.
To avoid burning out, staff must find ways to bear this load, or, in other words, to provide psychological containment (W. R. Bion). As Isabel Menzies Lyth observed in her 1960 analysis of nursing systems, institutions create systems of social defence. The clinical focus on administrative tasks, medication rounds, and endless documentation acts as a protective mechanism, allowing staff to psychologically detach from direct, anxiety-provoking contact. The glass-enclosed nursing station complements these rituals very literally by providing a tangible physical space for this detachment.
Maintaining the therapeutic alliance directly depends on objective team resources and the intensity of patients' suffering and symptoms. When the burden exceeds manageable limits, an unconscious pull to restrict contact emerges—what W. R. Bion (1959) calls an attack on linking. The glass and bureaucracy become the tools of this mutual process, enabling both staff and patients to retreat from emotional connection, thereby defending their own psychological stability.
Diagnosis and helplessness
While accurate diagnosis is an essential part of the medical process, reducing a patient's experience to a "case" or a "diagnosis" cements what Erving Goffman (1963) described as a spoiled identity. This becomes yet another form of social defence: by eliminating the human subject, the tension of emotional connection is eliminated as well. But what protects the staff teaches the patient something else.
Patients sense this quickly. Seeing the staff hiding behind the glass or constantly "busy," they find themselves in a situation that Patrick Corrigan (2009) frames through the lens of helplessness: "Why try?" Paradoxically, the treatment environment becomes a space that reinforces learned helplessness. Patients later carry this internalized model into their personal lives, outpatient clinics, and psychotherapy sessions, where it is frequently and rather simplistically labelled as a "lack of motivation".
Language and diagnosis as a barrier of exclusion
Social defence is not limited to physical barriers or bureaucratic rituals; the detachment inevitably bleeds into our professional thinking and everyday language. At this level—sometimes openly, but mostly quite unconsciously—the patient's capacity to know and testify about their own condition is questioned.
Philosopher Miranda Fricker (2007) defines this phenomenon as epistemic injustice. In clinical practice, this manifests when a patient's complaint about medication side effects or even somatic pain is first filtered through the prism of their psychiatric diagnosis—treated as "part of a delusion," "somatization," or "poor insight".
Usually, this is not conscious. However, if such an attitude takes root in a team or a specific ward, structural supervision, team reflection, and sometimes changes in team culture become necessary. Without these structural interventions, cultural change remains impossible, and the discrediting of the patient's knowledge becomes a destructive form of stigma that undermines the therapeutic alliance.
Seeing the invisible
It would be too simplistic to claim that psychiatric institutions directly stigmatize patients. According to Bruce Link and Jo Phelan (2001), we can only use the term stigma when five components occur together: labeling differences, stereotyping, separation, status loss (discrimination), and the power that enables it all.
The examples discussed in this essay illustrate how these components manifest in practice. Although they do not necessarily operate simultaneously in clinical reality, it is exactly this totality of isolated details that eventually forms a stigmatizing environment—one that actively repels and demotivates patients, hindering their recovery.
In my view, reducing stigma in psychiatry begins with the ability to recognize these subtle mechanisms rooted in the everyday, and the courage to constantly reflect on how our own professional defences—built to protect us from anxiety—become a barrier to those who need connection the most. In practice, this is a difficult and uncomfortable process. Yet, as a colleague aptly observed: if we do nothing, the probability of change is zero; if we begin to act, it at least becomes possible. □
