Institutional Forces Eroding Compassion in Mental Health Services

Increasing funding and organizational support while fostering reflexivity and de-emphasizing biomedical models can improve compassion in mental healthcare.

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A new article published in BMJ argues that to bring compassion to acute mental healthcare, practitioners and academics in the psy-disciplines must first acknowledge and understand the systematic and institutional forces that lead to a lack of compassion.

The study comes in the wake of a series of undercover investigations in 2022, exposing severe instances of abuse in UK mental health facilities. Staff were observed subjecting patients to humiliation, unnecessary seclusion, excessive restraint, and other forms of abuse. These incidents reveal a broader pattern of compassion failures in acute mental health services; a concern also raised in a 2018 ombudsman report and by numerous mental health organizations.

Compassion, described by British clinical psychologist Paul Gilbert as “a basic kindness, with a deep awareness of the suffering of oneself and other living things, coupled with a wish and effort to relieve it,” is fundamental to mental health care. Some evidence suggests that compassionate care can significantly improve patient outcomes, making its absence even more concerning.

The authors contend that while failings of compassion occur at the interpersonal level, many systematic issues lead to these failings. They write:

“Failings of compassion occur at the interpersonal level, but they are underpinned by high-level, systemic, and institutional forces. Disillusionment, burnout, moral injury, and a risk-centric culture can compromise the compassion of mental healthcare staff. Power differences between service users and staff in inpatient settings can give rise to institutional oppression. Compassion requires a reflexive ethos, an environment that prioritizes therapeutic relationships, and challenging of policies and cultures that normalize oppression.”

The research team comprised Elisa Liberati, a researcher associate at The Healthcare Improvement Studies (THIS) Institute, University of Cambridge; Natalie Richards, a research assistant at the same Institute; Sahanika Ratnayake, an independent researcher; John Gibson, a senior service user researcher at McPin Foundation, London; and Graham Martin, the director of research at THIS Institute.

Young doctor woman wearing medical coat and stethoscope over blue background with red hearts smelling something stinky and disgusting, intolerable smell, holding breath with fingers on noseThe current work aimed to examine the systematic and structural issues that impede mental health staff from providing compassionate care to service users. The authors accomplish this by exploring working conditions in mental healthcare, policies and priorities that make compassionate care challenging, and institutional oppression.

First, the authors point to poor working conditions for mental healthcare professionals, especially support staff. The UK’s National Health System (NHS) has seen declining numbers of essential staff since 2009. This staffing shortage was made worse by the COVID-19 pandemic. As a result, staff have reported not having adequate time to develop relationships with service users.

The staffing shortage and increased demand for mental health services have resulted in fewer beds being available in NHS inpatient facilities. This means some people are left without mental healthcare while the service users who are admitted are likely to be experiencing severe symptoms. The training for support staff (those that spend the most time with service users) does not include how severe mental health issues may present or de-escalation techniques. This results in understaffed, poorly trained support workers caring for the most acute patients.

According to the authors, support staff experience more abuse than other mental health professionals, poorer working conditions, and fewer advancement opportunities. The burnout associated with these working conditions leads to negative feelings towards service users. As staff becomes psychologically distanced from service users, the quality of care declines.

Second, the authors examine mental healthcare policies and priorities. The focus on biomedical explanations for mental illness tends to increase stigma. Framing mental health difficulties as a “brain disorder” distances service users from the “healthy” population as physiologically different and possibly dangerous. This emphasis on biomedical approaches in mental health also tends to overshadow well-established social factors of mental illness. When biomedical explanations are championed at the expense of social ones, the importance of the therapeutic relationship (which is essential for fostering compassion) is undermined.

Legal considerations and a focus on meeting specific targets can also detract from compassion in mental healthcare. Assessments designed to determine the risk of service users harming themselves and others are often conducted to avoid legal ramifications rather than start meaningful conversations. As a result, mental healthcare staff often experience moral injury, a “perceived violation of one’s professional integrity and concurrent feeling of being constrained from taking the ethically appropriate action.” According to the authors, this can lead staff towards emotional neutrality and undermine compassionate care.

Last, the authors explore institutional oppression in mental healthcare. Due mainly to laws that allow for involuntary admission, power imbalances are inevitable in inpatient mental health facilities. Service user wishes and preferences are often ignored in such environments. Involuntary admission and treatment in mental healthcare also reflect larger societal prejudices. In 2021, Black people in England and Wales were four times as likely as white people to be involuntarily detained due to mental health issues. Black people were also ten times more likely to be forced into community treatment.

The authors note that while many psy-professionals attempt to improve these policies, real change would require a cultural shift and a willingness to confront long-held policies that would contain those in distress rather than compassionately understand them.

The authors offer several strategies to counter the lack of compassion in mental healthcare. Greater investment in mental healthcare and primary and social care is a necessary first step. Mental healthcare professionals need improved organizational support, including training in deescalating conflict and how severe mental distress may present.

Mental health professionals should be given time to reflect on their work with service users, which can increase their ability to recognize unconscious stigmas and other unhelpful behaviors that can impede compassion. Supervision and training should emphasize approaches to mental health other than the biomedical model.

The psy-disciplines must also confront mental healthcare’s oppressive features, especially involuntary inpatient treatment. The authors conclude:

“Complex problems demand nuanced and comprehensive interventions, especially in healthcare systems recovering from the COVID-19 pandemic. But improving compassion is too important—for service users and mental health staff alike—to indulge in despair or to wait indefinitely for policy change. Intervening to change what we can, at the interpersonal, therapeutic, and organizational levels, will at least soften the worst effects of the barriers to compassion we face. And it might even form a foundation for broader change.”

One of the study’s key insights is the importance of contextualizing another person’s distress as central to compassion. Hanna Pickard, a philosopher and therapist, notes that understanding why patients act in specific ways—often due to trauma, abuse, or social stressors that are often racially and socioeconomically patterned—is vital for compassionate care.

Research has shown the difference compassion can make for people experiencing suicidal crises. Researchers have championed the advancement of compassionate care, as have family members of service users. In an interview with Mad in America, Helen Spandler emphasized the need to place compassion over theoretical allegiances in mental healthcare.

 

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Liberati, E., Richards, N., Ratnayake, S., Gibson, J., & Martin, G. (2023). Tackling the erosion of compassion in acute mental health services. BMJ. https://doi.org/10.1136/bmj-2022-073055 (Link)

10 COMMENTS

  1. I know the paper did not try to address the issue that people choose to remain working for dehumanizing institutions, when their obligation is to abstain of working in conditions that are dangerous and/or harmfull to service users.

    Is a basic general profesional responsability beyond health care. And maybe even legal as part of strict liability. It’s an important issue I think, that is being swept by blaming institutional forces, which was the point of the article. But it’s a caveat, it seems a red herring, looking for the keys where there is more light. Or less problems to publish.

    Second, funding/expense into MH uncare, probably in great part is a reflection of it’s actual perceived value to payers, funders or service users. There is also institutional capture, but that’s trying to keep the funds flowing. And that’s a problem too.

    Lack of funds is a market force that in a working market economy should and will allocate more money into something else.

    It’s a market signal that the value provided by MH uncare is not worth the money put into it…

    Granted, not only is in MH, but in other areas of health care. But that is also a reflection of not getting the money’s worth. So much so the US is among the worst countries on health indices and among the top spenders. And it is among the countries, informally, that is more skeptic of the value of modern medicine.

    And very few people actually has looked at a compilation table of the benefit/harm vs expenses of the most common medical treatments for chronic diseases. I invite anyone and everyone to look for one, or individual pieces and reach a different conclusion…

    One could try to rationalize the incongruence, the allegations, the evidence base, the denials, the drama, the polarization, etc. But at it’s most simple, to my mind, is a market force. Wisdom of the crowds. Experience and knowledge of the individual participants. And institutional capture of course.

    Hence the cohersion, customers have to be forced to be “service users”. Otherwise the MH uncare system wouldn’t get enough money even to pay the salaries… of underpayed, harmed, and overworked employees. Next step in that descending spiral is enslaving them just to keep the system going…

    The situation seen in it’s simplest form, even agnostic, is that bad…

    And this case is probably the only one where people of not white skin color are devoted more resources in health care (!?) per person/service user, I imagine. Which tells you a lot beyond economics. Is analogous to other forms of incarceration. Why?, I mean beyond the rationalizations, the reasons are THE important thing.

    Finally, I doubt education will do the trick of improving MH uncare. I have personal experience of physicians in training and “teachers” knowing, as in answering exams correctly, some even writing them!, but in practice doing that which is contraindicated or harmfull to the patient. Simple as that, one with over 10yrs experience in the “job”, as a posgraduate especialist.

    I am not talking of moral issues, I am talking of academic ones. The moral issues were in the majority of those cases glaringly negative. The rest, yeah, institutional forces: do what I do wrong not what I say right. That’s not lack of compassion that’s impunity.

    To me, it was not lack of training, but moral failings that can’t, IMO, be addressed by education. It already failed: at least because said education did not provide the benefit of coming out with a moral, decent, law abiding person. For all those years of training. And 10yrs experience in the job prescribing exams to new trainees.As bad as that…

    But it fits into the let us try again mentality… we know better now… we can still learn and change!. We LEARNED so much…

    I am not saying anyone should stop or can’t learn, just some things can’t be taught academically, and to try it, you have to remove impunity at least.

    And take into account the market has spoken even screamed: We want to put our money into something else. Hence I guess the paper, like in I can give you a discount on moral injury to “service users” if you give mo’money to adress the workers issues FIRST.

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  2. I so much appreciate your emphasis on compassion and the link to the Helen Spandler interview where she contrasts the use of “compassion” with the current day term “empathy”. They are not the same, as she points out.

    “It’s not that there is either compassion in the individual or compassion in society — you can’t have one without the other. The problem with our current society is there’s all this talk about self-care and empathy. Still, it often boils down to buying more stuff for yourself — “Oh, you deserve it, you’re worth it!” rather than a deeper sense of compassion which is about connecting with our own suffering and the suffering of others.”

    Thanks for the article and your perspective.

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  3. I’ve had many interactions with people who work in the system where their attitude is, “I will neither feel nor demonstrate any compassion to this patient/client/service user/beggar.”. There is a belief shared by many working in the system that if they feel even the slightest compassion, it’s evidence that they are being manipulated, conned, or distracted from their mission (which is to lay down the law and demonstrate the consequences of “non compliance with treatment”). I don’t know how much worse my experience was because I had a borderline label than it would have been otherwise.

    Many people working in the system see patients and service users as morally deficient. They have many code words to express these thoughts in our medical records. We are somehow so mentally ill that we’re clueless as to how mentally ill we are, while also being malingerers who are perfectly capable but enjoy gaming the system. If we stay in treatment, it reflects badly on us. If we drop out of treatment, it reflects badly on us. Practically anything we do just proves that they were right about us.

    Sometimes we don’t have to do anything. Two psych nurses arguing with each other on the ward? Obvious who the culprit is: the borderline patient. She’s “splitting” (wow, to have so much power! I wish.)

    I could go on, but anyone who’s been harmed by this system knows what I’m referring to.

    They have moral injury now? Maybe so, but I’d rather have moral injury than the constellation of injuries I received as a patient in the mental health system, from psych drugs, ECT, TMS, dozens of psych ward experiences and the ongoing trauma of being othered by society.

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    • Morally injured or not, they keep working in those “institutions”. I could compare it to a “bad relationship”/codependency, that kind of another baseless construct but in this particular case with common sense observations to back it up. Similar to “narcicistic abuse” or mobbing. Victims not always leave.

      The problem to my mind is that morally injured individuals in positions of authority who have shown callous behaviours towards persons imputed disability are gonna lash against recurrent victims, not against their victimizers. They are gonna identify with victimizers instead with the victims, to my mind in most cases. I’ve seen it, physicians in training identify with physicians with “psyhcopatic” behaviours instead of colleague trainees victimized or worse, patients. Some behave duplicitously.

      Why they keep working there when their skills are SO valuable in other markets? Because they obtain a benefit that some other job would not provide. Simple market dynamics that deals in human suffering. They do have choices, they are not in the military. And after leaving they rarely tell the truth about what they did.

      Some might try to explain silence after leaving as part of moral injury, but to my mind the thing is it’s just a continuation of irresponsibility and lack of sincere guilt and shame of what they actually did.

      They feel bad about what they’ve been exposed and done to them, not about what they did to someone else. That’s a common confusion IMO when dealing with moral injury cases.

      It’s sort of the Raskolnikovian anguish, the fear of prison or condemnation, not sincere guilt, but might look like it.

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  4. How are these people suddenly so sensitive? They’re wounded, they’re burned out, they have moral injury. Just accept it, mental health system and the people who uphold it: You failed. Unless it was your plan all along to harm vulnerable people.

    They were never shy about telling me about all of my deficiencies and that I was personality disordered and I had poor judgement and everyone hated me because I was “inappropriately angry” and “need to use your GIVE skills more!” and that I would wind up completely alone (yes, one DBT therapist actually said that to me. It wasn’t anywhere close to the cruelest thing a treatment provider said to me.). If you can dish it out, you better be able to take it.

    Either they meant to do harm, or they tried to help and they failed miserably. Either way I don’t see how giving them even more money would fix anything. The war on mental illness is like the war on drugs: Either a colossal failure, or a means to achieve goals that were not the goals that were advertised.

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  5. Ugh

    I don’t see compassion becoming a key skill for so called professionals in the USA anytime soon. Maybe in the uk they’ll get training, maybe a little fake it till you make it kind of thing? Probably better than nothing.

    Part of the cruelty is socioeconomic. In private facilities it isn’t until one hits the upper middle class that one even deserves their expertise. And the flip side of that is a person with a “good enough “ background or family behind them having too much power. As for the poor and working class… it appears to be a “let them eat Haldol “ situation.

    Some of it is the social Darwinism that is more prevalent and extreme in neoliberal countries which probably explains the dire situation in the USA. Segments of the uk seem to have repudiated the Thatcher agenda, which might explain why so much interesting research is coming out of the uk.

    Turning to Szasz, I think one sees how cruelty and abuse are inescapable as long as the mental health industry exists. Slavery demands various forms of punishment and control of the enslaved after all. If Ativan group therapy and occasional activities doesn’t do the trick, then there’s always shock operations involuntary confinement guardianships and a punitive use of chemical restraints.

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    • The caveat of being “affluent” is that there are narratives of persons incarcerated in the mental health exploitation system until the money runs out. To my mind, not necesarily better.

      There are narratives of persons that just shut their health insurance to obtain some sort of freedom.

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  6. I had only two experiences in my many decades of life with psychiatry/psychiatrists. The two experiences with psychiatry were both very terrible experiences. At both points in time, as fate would have it, all of a sudden in my life a large volume of very bad experiences happened and some even traumatic, and practically all at once, one after the other, with no adequate time between each bad experience in the large volumes for healing. I ended up in hospitals.

    During hospital stays during both times, I was so harmed and at times literally abused. Not all staff were bad, some quite good, but too large a percentage were bad, and given the fact that the bad was unacceptably bad, even to the point of abuse, that cannot be described as “healthcare”. It is the opposite. Some of it should be chargeable offences. That isn’t exactly what a person in severe emotional distress should be put through.

    In the first instance, the hospital stay pushed me to suicide attempt. I did not enter suicidal, but what I went through at their hands created that.

    One experience was two decades ago, however the other was only approximately a year ago. This recent time had nothing to do with staff shortage in the hospitals. What I witnessed was plenty of staff. So I have to conclude that “staff shortage” is being overused as an excuse (Canada).

    So there you go… nothing has gotten better, if anything much worse. There is not only too many psychiatrists and staff without compassion, but many are quite dangerously abusive and cruel. THIS IS DEFINITELY a very serious and more than just concerning problem. It should be considered a crises.

    My last experience was so bad that I will never ever again go into a hospital, for any reason, no matter what, if it has something to do with me as the patient. I would only go now as a visitor and/or in support for someone that needed me. Is this how “healthcare” is supposed to make us feel?

    Another very serious issue is notes and records by doctors and staff. The corruption there. Serious further harm can come from that.

    The degree of misdiagnosis, incompetence, negligence, biases, recklessness, egos, abuse of power, dishonesty, spitefulness, and even deliberate falsifying in records by too many mental health “healthcare providers” is unacceptable.

    And is there any accountability? which will aid in bringing healthcare to a reasonable point?

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