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Mental Health Nursing: When We Do Harm

What happens when empathy and collaboration get left behind?

Source: Kelly Sikkema/Unsplash
Source: Kelly Sikkema/Unsplash

Dan Warrender, lecturer in mental health nursing and Mentalization-Based therapist, on an uncomfortable relationship with the profession he loves.

One night when I was 17, I walked home and saw a girl perched on the edge of a bridge. Head down, staring into the river below, legs dropping into the dark. I stopped to speak to her. Initially she said she was fine, and just wanted to be left alone. I wasn’t happy with walking past and leaving her on the edge of a bridge, and said I didn’t mind if she didn’t want to talk to me, but I would stay with her anyway. Years have passed so exact details are hazy, but we struck up a rapport. She was a few years older than me, and had been struggling through recovery from heroin addiction. Someone had called her a “f*cking junkie,” undermining her efforts to stay clean, and her self-esteem was crushed. We spoke for an hour or so, and I had no masterplan other than hearing her story. She eventually swung her legs around onto the bridge and stood up. She thanked me for listening, kissed me on the cheek, and left. I walked home and had a warmth in my soul, thinking I’d been of value to another human being. It was this feeling and purpose which years later guided me towards a career in mental health nursing.

Fast forward 15 years or so and I’m in a woman’s doorway, trying to encourage her to come into the hospital. She’d been detained under the Mental Health Act, and I was the nurse escort assigned to bring her to the ward. With me was a nursing assistant, psychiatrist, and the woman’s family hovering uncomfortably in the background. She had a diagnosis of schizophrenia, and though I’ve little faith in psychiatric diagnostic systems anymore, it is certainly this which allowed the Mental Health Act to be used. I was uncomfortable given that I didn’t know her. I didn’t know her story or history, other than a brief description of what was currently ‘wrong.' I was going purely on the psychiatrist’s word that she was unwell and needed to be brought into hospital for treatment. I had no reason to distrust the psychiatrist who I had full respect for, but I wish I’d had the opportunity to assess her and put some time in to build a relationship. In truth, she didn’t seem ‘well’ (whatever that is according to social norms), and appeared both unkept and pressured in speech. She was angry, and though this could be pathologized as part of her ‘illness,’ it could more sensibly be viewed as a natural reaction to uninvited guests coming to her home.

I remember feeling pressure from the ward. Not unusually we were short-staffed, and colleagues were hoping I could hurry and get back as soon as possible. I longed to take my time and build a relationship, but even then, who was I kidding? At the point of approaching someone’s door with detention papers and an ambulance, it would be hard to justify that my role was ever intended to be therapeutic. Our approach, fuelled by the medical model, saw an illness to be fixed, not a person to be understood. I wonder if spending more time with her would have helped me come to terms with what I was about to do, at least happy that I had tried my best to build a relationship before resorting to violence. Yes, what you are about to read was violence.

We talked and still she did not agree that she was unwell. She refused to come with us willingly. Behind her and inside the house was a mess of furniture, clothing, and clutter. I knew what we were about to do, and we needed space for that. We grabbed her arms and pulled her outside, forcing her down onto a stretcher. She was shouting and screaming. We drew up intramuscular medication, while she pleaded “please don’t inject me with poison!” We still injected her with medication, then continuing to hold her down, wheeled her into the ambulance. I remember being glad that the house was in the middle of nowhere, so her dignity would be protected. On reflection, it was more my dignity I wanted to protect. I wouldn’t have been comfortable with my mum watching what I was doing. It was a ‘nurse escort,’ but it felt like a kidnapping. This was all legal, but it felt wrong. A valuable reminder that the law and ethics are not synonymous.

I had been on several nurse escorts before, but most often people did come ‘willingly’ and I could still convince myself that I was the good guy. There was no hiding this time. A cognitive dissonance saw war between my behaviour of using power, coercion, and restraint, against my values of empathy, compassion, and collaboration. I was now a million miles away from talking to the girl on the bridge. This was something very different, and looking back, I still wonder how I did it. I can only assume a subconscious othering of a human being. If I had empathised with her situation fully, and imagined her experience, how could I have abused her in that way? I can only assume a momentary tactical switching off of empathy, seeing her as a task to be accomplished rather than a human being with feelings. This is reminiscent of an interview with a U.S veteran who served in the Vietnam War, who said he only killed one human being, the first one. After that, all he killed were objects, referred to through racial slurs. They were not seen as human. Othering protects us from the reality of our atrocities.

We arrived back at the ward and she slept the rest of the day. Seeing signs on the wall stating ‘zero tolerance’ for violence directed at nursing staff stung of hypocrisy. Perhaps we should be leading by example? The next day was more comfortable for me, as I was doing the part of the job I loved, the talking, the being with, the empathy and understanding. I’m not sure if I expected any different, but she was hostile towards me. She clearly didn’t trust me, still didn’t agree with her detention, and didn’t want to talk about her mental state with me. I apologised, and I genuinely meant it, but it was too little. Indeed, how could I build trust and relate to her, when the first thing I needed to do was empathise with her experience of being restrained and forced into hospital? I was the perpetrator! Empathising with her meant acknowledging the damage I had done, and seeing that my actual self and ideal self were out of sync. It was here I was faced with the reality of having such a dual role, carrying the contradictions stemming from historical roles of pastoral care and agent of the state. I wanted to build a relationship with her and understand her experience, but in the way was the trauma I had inflicted upon her. The primary ethical obligation is non-maleficence, that first we do no harm. Though here, the first thing we did was harm, then tried to build from there. The foundation of a therapeutic relationship was sabotaged, giving it no chance. She gave me no time, and she was absolutely right to do so. I understood. One part of my role stood in the way of the other.

Sometimes, the ethical merit of an action can be found through its consequences, with bad things justified if they have good outcomes. Sadly, in this case, there were no such good outcomes. There were no thanks for ‘saving her from herself,’ or whatever other justification we had given ourselves. She refused to engage with us and spent all her time in bed. She was eventually discharged, on a low dose of a medication, which she had less than convincingly agreed to take once at home. I was glad to see her leave given she didn’t want to be in hospital, but I had to ask myself, ‘What was the point?’ Why put us both through that? Why did she have to experience that trauma? Why did I have to go against my values? Where were these glorious consequences that outweighed my horrible actions? There were none. The questions followed. Is it better sometimes than to do nothing? If to help we must harm, do we not make our jobs all the more difficult? What happens when our version of ‘safety’ isn’t safe for the person we are supposedly trying to protect? We need to consider what we can do instead, as surely, surely there must be a better way? That question is for every mental health nurse, and should guide the future of the profession.

I worry in writing this, that my fellow mental health nurses take issue with my words. I have many treasured colleagues still working in the front lines of the profession, and I don’t doubt for a minute their intentions. My intentions were pure, but what I did was horrible. At times the consequences may rightly be viewed as positive, though I still think we overlook the damage we can do. I don’t believe any mental health nurses are ‘bad’, at worst they are just not given the space to think critically or debrief appropriately, in a system that often frames other human beings as tasks. Working on a ward, I never once heard the words ‘ethics’ or ‘human rights’ in conversations with colleagues. That is what is most worrying. The use of such power should never become routine, but it has. When things become routine they become ritual, and we can forget what they really mean for people. If we want to know what they mean, we take a step into another persons’ mind and take their perspective. Imagine it was you.

Mental health nurses still do a whole lot of good, and I don’t want to overlook that. I write this to encourage people to think and to have conversations, not to slam the entire profession. I have been pleased to see openness about our role in contributing to people's distress rather than alleviating it, not because I am proud of it, but because being honest may be the first step to a better way. The power threat meaning framework, framed as an alternative to psychiatric diagnosis, highlights the power which professionals have over people as potentially contributing to their mental distress. Meanwhile, a book on critical mental health nursing begins with an apology to recipients of mental health care, “for the many historical and present ways in which mental health nurses have contributed to your distress and disempowerment.” Trauma-informed care principles also emphasise the role services can have in inadvertently retraumatising people, though I would argue that this may not always be retraumatising, but can be us traumatising through our actions in of themselves. Furthermore and most relevant to this situation, the critical mental health nursing network held an important online debate on mental health nurses conscientiously objecting from enforcing treatment. I would have embraced this option if I could have. Whilst this debate raised many more questions than answers, at the very least as a profession we are talking about it.

I can’t imagine what that woman thinks of me now. I hope she has forgotten, for her sake and mine, but I doubt it. Most of my life I’ve held the belief that I am fundamentally a good person, yet my actions in instances such as this, of which there were more than one, do not fit with that self-ideology. It may be that as human beings, we are fundamentally good. However, once we step into the mental health nursing role, inside the system as it currently operates, we are very much in a grey area, somewhere in between good and evil.

This piece was also posted on Dan Warrender’s personal blog. It was kindly reposted here with his permission. You can follow Dan on Twitter @dan_warrender.

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