Tackling the erosion of compassion in acute mental health services

Abstract

Elisa Liberati and colleagues argue that understanding the systemic and institutional forces behind lack of compassion in mental health services is key to solutions to this problem

A series of undercover investigations in 2022 exposed instances of serious abuse in UK mental health facilities. Service users were observed being verbally humiliated, subjected to unnecessary seclusion and excessive restraint, and dragged down corridors by members of staff.¹ Although extreme, these incidents reflect a broader pattern of failures in compassion in acute mental health services across the UK. Even before the extra pressures of the covid-19 pandemic, a 2018 ombudsman report, based on more than 200 sources, identified persistent shortcomings in the ability of mental health services to treat service users with kindness, dignity, and respect.² Prominent service user organisations have highlighted low levels of compassion,^{3 4 5} and similar issues have been identified by mental health staff, academics, and the psychiatric survivor movement.^{6 7 8}

Compassion is a complex concept spanning several areas of thought, such as psychology, philosophy, and Buddhist practice. British clinical psychologist and the founder of compassion focused therapy, Paul Gilbert, describes it as “a basic kindness, with a deep awareness of the suffering of oneself and of other living things, coupled with a wish and effort to relieve it.”⁹ Compassion is an essential component of resilient health systems and high quality care,¹⁰ and is a precondition for positive therapeutic relationships^{9 11}; some evidence suggests it is associated with better outcomes.^{12 13} In mental healthcare, this association is likely to be amplified: for people in extreme distress, human connection and meaningful relationships are key components of recovery.^{4 14 15}

Hanna Pickard, a philosopher and therapist based in the United States, notes that compassion requires one to consider why service users behave in a particular way, given their life experiences.¹¹ For instance, rejecting or non-trusting behaviour may be the result of trauma, abuse, neglect, and social stressors, which are often racially and socioeconomically patterned.¹¹ The ability to contextualise another person’s distress is central to compassion.⁹

Developing such a compassionate stance requires time, capacity for reflection, and an environment that values emotional as much as physical safety.^{8 11 16} But these preconditions for compassion are becoming harder to achieve in mental healthcare in many countries,^{17 18 19} particularly in inpatient services. Although failures to act with compassion happen at the interpersonal level, systemic and structural factors are eroding the capacity of mental health staff to provide compassionate care. We examine these pressures and propose ways to counter them.

Working conditions in mental healthcare

Rising demand, resource shortages, and weak organisational support are causing burnout and disillusionment among mental health staff, compromising their ability to act compassionately. Staffing levels in the UK National Health System (NHS) are insufficient,^{20 21} with declines in numbers of essential staff groups since 2009—a problem that has been exacerbated by sickness and covid related self-isolation. At the same time, demand for services is increasing.²¹ According to the Care Quality Commission, “workforce and staffing shortages remain the greatest challenge for the [mental health] sector,” with staff saying that they have insufficient time to develop relationships with patients.²⁰ Bed shortages are also severe, which means not only that patients in crisis may be left vulnerable, but that thresholds for admission to hospital have increased, so that patients who are admitted are often acutely unwell.²²

Pressured and under-resourced environments contribute to staff burnout.²⁰ In the 2021 NHS staff survey, 44% of mental health nurses and 50% of clinical psychologists reported feeling emotionally exhausted always or often,²³ which is in line with the prevalence across mental health staff across the world.²⁴ These problems are especially acute in inpatient settings, where staff are often exposed to intense negative emotions^{17 18} and may experience vicarious trauma.²⁵

Insufficient organisational support can further contribute to staff exhaustion, particularly for support staff, such as healthcare assistants, who spend the most time in direct contact with distressed patients but receive the least training and supervision.^{26 27} Training for healthcare assistants does not cover how to de-escalate conflicts and how severe mental health difficulties may manifest themselves,²⁸ both of which are vital to foster compassionate responses. Support staff also experience more abuse, poorer working conditions, and fewer opportunities for progression than other staff.²⁷

These poor working conditions and the resulting burnout are associated with more negative feelings about service users and poorer quality of care.²⁹ When burnt out staff become psychologically distanced from their work and service users, neglectful workplace cultures can arise.³⁰

Mental healthcare policies and priorities

Trends in mental healthcare policies and priorities—namely an increased focus on the biogenetic causes of mental illness³¹ and a growing tendency to practise with an eye on prioritisation and legal consequences^{14 32}—also make it harder to cultivate compassion.

Although intended to decrease stigma, the framing of mental distress as a disease like any other has not helped advance compassion.^{31 33} Receiving a psychiatric diagnosis is, for some, a welcome validation of their experience and an avenue for seeking care.³⁴ However, attributing mental health difficulties solely to brain disorders or genetic factors can create negative attitudes towards service users—casting them as potentially dangerous and physiologically different from the rest of the population—and hinder humane and compassionate responses.^{31 33} Biogenetic understanding of mental illness can also increase prognostic pessimism³⁴ and overshadow the social determinants of mental distress, thus de-emphasising the importance of comprehensive case formulations and therapeutic relationships, both of which are fundamental to compassion.^{31 33}

Greater focus on meeting targets and legal ramifications also hinder compassion. In a climate of chronic resource shortages, mental health staff can be prone to a production line mentality, where beds need to be “protected” from service users.^{8 14} This “us versus them” mindset is incompatible with compassion. Reducing the risk of service users harming themselves or others is vital in acute mental healthcare. But safeguarding assessments, intended to assess and mitigate for such risk, can be influenced by the need to exonerate staff from responsibility, rather than acting as a prompt for meaningful conversations about the distress of service users.^{14 16 35} An Australian survey in 2013–14 found that 72% of 164 mental health staff agreed that they often reflected on the potential medicolegal consequences for themselves with the decisions they make about an individual’s level of risk.¹⁹ Risk stratification and prioritisation also mean that service users can be rejected from services with contradictory arguments, such as being too sick or not sick enough.^{14 36}

If staff cannot provide good quality care in these circumstances, occupational moral injury may follow—that is, the “perceived violation of one’s own professional integrity and concurrent feeling of being constrained from taking the ethically appropriate action.”³⁷ As with burnout, moral injury can erode compassion. To cope with seeing individuals in deep distress denied much needed care, staff may become emotionally neutral, disconnecting from the pain experienced by service users.¹⁴

Institutional oppression

As in other high pressure, under-resourced environments, mental health staff may struggle not only to cultivate compassion but also to challenge ways of working that conflict with their values. Sometimes, they may even comply with behaviours that outsiders might see as unacceptable,^{30 38} thus furthering oppressive environments. Such “normalisation of deviance”³⁸ demands particular attention in inpatient mental health, where power imbalances are pronounced and the restriction of the rights of service users is legally permitted.

The Mental Health Act of England and Wales establishes that, under specific circumstances, people can be detained and treated without consent. It is intended to protect individuals (and those around them) at a time when they may be too distressed or confused to make informed decisions, and can be important in preserving life.³⁹ However service users’ experiences of detention are often negative. While views of the appropriateness of detention vary, fear and distress during detention are common, particularly in relation to the use of force.⁴⁰ Failure to involve service users in decisions about their own care, sometimes because staff assume that service users are incapable of understanding information, can also contribute to such distress.^{40 41}

Worryingly, patterns in detention reflect broader structural injustices. In England and Wales, in 2021, black people were more than four times as likely as white people to be detained under the Mental Health Act⁴² and 10 times more likely to be subjected to community treatment orders—compulsory treatment provided in the community.⁴² In addition, there is the potential for serious harm in detention. Between April 2021 and March 2022, 325 people died under detention or while subject to community treatment orders. Of these deaths, 66 were of an unnatural cause and 53 were confirmed suicides.⁴³

The 2021 independent inquiry into the Mental Health Act concluded that “the current legislation goes too far in removing people’s autonomy” and that sometimes people “are excluded from decisions [and] treated with neither dignity nor respect.”³⁹ Concerted efforts from service user organisations⁴⁴ and within some areas of psychiatry⁴⁵ have sought to reduce restrictive practices, such as physical restraint and seclusion, and reform of the Mental Health Act is under way.³⁹ These are positive signs, but tackling institutional oppression and promoting compassion require cultural change and effort to challenge policies and practices that frame distress as requiring containment ahead of compassionate understanding.

Opportunities to promote compassion in healthcare

Compassion is central to the provision of healthcare. It is enshrined in the NHS Constitution, where it is linked with patient safety, experience, and outcomes.¹³ Mental health staff serve people at times of basic human need, when they need compassion most. Yet, in the UK and worldwide, the preconditions for compassion have been severely eroded.

Little research exists on how to improve compassion in mental healthcare—a gap that needs addressing. Evidence from organisational learning and healthcare improvement offers starting points in countering the decline in compassion and fostering resilience in individuals and systems.

A necessary first step is material improvement of the environments of care. Under-resourced environments that breed burnout and moral injury are not conducive to compassion. Despite recent investments, UK mental healthcare services are not meeting required standards of quality, especially compared with physical healthcare.⁴⁶ It is a familiar refrain, but greater investment in mental healthcare, in partnership with the voluntary sector and primary and social care, is vital.

High levels of exhaustion, low morale, and disillusionment among staff must be taken seriously and tackled through improved organisational support. Assistant staff, who spend the most time with service users, need training in how to de-escalate conflict and how severe mental health difficulties may manifest themselves. This will help to contextualise behaviours, which is crucial for compassionate responses.

Fostering reflexivity among mental health staff more broadly is important for enhancing compassion and countering disillusionment and burnout. Reflexive practice involves revisiting an experience to develop new understanding, with a view to informing the response to similar situations in the future.⁴⁷ When meaningfully done, reflexive practice can expand staff’s capacity to recognise unconscious stigma and behaviours that are contradictory to compassion. A reflexive ethos can be nurtured both through informal mentoring and peer support and more formal spaces, such as Schwartz rounds—where staff come together to reflect on the emotionally demanding aspects of their work. Evaluations of Schwartz rounds in UK healthcare organisations, including mental health services, suggest they are effective in reducing psychological distress⁴⁸ and may foster compassion.⁴⁹ This kind of space may be particularly useful for understanding the roots of negative incidents in inpatient settings and for exploring alternative approaches, particularly where detention is concerned.

Conceptualisations of mental distress focused narrowly on biological functioning have proved unhelpful in fostering compassion towards service users. At the level of clinical teams, these conceptions can be countered through supervision and training that emphasise alternative thinking—including through case studies presented by service users and their families. These interventions can also shed light on the dangers of risk centric practices, namely narrow approaches to risk assessment focused on the legal ramifications of incidents.

Promoting therapeutic approaches that empower service users, focus on collaborative therapeutic relationships, and encourage attention to the social determinants of distress may help mitigate the erosion of compassion caused by reductionist and risk centric approaches. Trauma informed,⁵⁰ recovery based,⁵¹ peer led,⁵³ and compassion focused⁵² therapeutic approaches all constitute attempts to embed compassion firmly in clinical interactions. Although more evidence for some of these approaches is needed, some service users and healthcare staff endorse their benefits.⁵⁰ A good example is Open Dialogue, a model of care provision that ensures the consistent inclusion of the families of service users and wider social networks in the treatment, with a view to exploring the meanings behind mental health symptoms. This approach originated in Lapland, Finland, and is now being piloted in other countries,⁵⁴ including in a controlled trial in England.⁵⁵

Finally, more must be done to tackle institutionally oppressive aspects of the mental healthcare system. Despite global calls for an approach to mental healthcare grounded in human rights,⁵⁶ much of the campaigning in these areas has been spearheaded by service user groups. Initiatives such as the World Health Organization’s QualityRights, which supports countries to improve the quality of mental health services and promote human rights within them,^{46 57} are important to ensuring that the principles of human rights are applied in daily practice. Such initiatives are the work of many hands, and mental health staff and leaders have a vital responsibility to ensure that efforts of this kind have positive outcomes.

Breaking down the barriers

The barriers to compassion in mental healthcare, particularly in inpatient settings, are wide ranging. Policy and legal impediments to compassion require long term solutions that go beyond what mental healthcare professionals can do on their own. Yet (to paraphrase Margaret Mead), social change often starts with small groups of thoughtful, committed citizens: healthcare leaders, frontline staff, researchers, and educators have pivotal roles to play.

Improved training and organisational support, reflexive practices, recentring of the therapeutic relationship, and endorsement of collaborative therapeutic approaches are all important to empower service users and foster the resilience staff need to practise compassion in difficult working conditions. Importantly, compassion breeds compassion: it must be modelled through kind and intelligent leadership and placed at the heart of supervision, training, and professional development.

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 organisational 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.

Key messages.

• 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 prioritises therapeutic relationships, and challenging of policies and cultures that normalise oppression