Nuts Running the Nuthouse
This week I'm turning behavioral pathology back on those of us who work in mental health. I basically specialize in unpopular and uncomfortable topics, so it's a natural fit!
I recently finished the excellent We've Been Too Patient: Voices From Radical Mental Health. It's a collection of essays, mostly by people with lived experience, challenging the biomedical model of mental health and dominant approaches in treatment. One point that was raised in multiple pieces was about mental health impairment among providers and other staff. One professional spoke to the stigma he has seen, toward himself and colleagues, from disclosing or showing their own struggles: "looks like a case of the nuts running the nuthouse." One survivor of involuntary hospitalization wrote bluntly that the staff "were more fucked-up than we were."
I rarely hear these issues discussed in professional circles; we don't want to stigmatize ourselves or each other. But my personal thought has always been: of course! Who do you think is drawn to this field? People with totally uncomplicated inner lives? Would anyone be interested enough in psychological suffering to dedicate their career to it– with a severe pay penalty– lacking any first-hand experience? And hasn't madness always brought us the most important critiques of what is or is not considered "normal" anyway? Today I'm a self-employed therapist, but in another era I easily could have been institutionalized (or hanged for witchcraft). Regarding substance use specifically, "addicts running addiction treatment" is the explicit model in many facilities, with only people in recovery eligible for hire.
But ex-patient and survivor accounts point to harm caused by staff impairment, and that needs to be taken seriously. Staff in mental health facilities, particularly in locked and institutional settings, have a tremendous amount of power over patients. They may engage in forced drugging, physical restraint, isolation, or forced surgeries--and these are among their sanctioned practices at work, aside from any extra abuse or harassment they inflict of their own accord. Outpatient staff have different functions but still a great level of power, as in withholding medications, reporting patients to authorities, or triggering legal consequences for patients in mandated treatment.
This is the less sympathetic side of moral injury in our work. (Here's an earlier post on the topic:)
Rosalie Genova
VA psychiatrist Jonathan Shay first identified moral injury as a clinical issue. He saw it as an "undoing of character" among his patients, combat veterans of the Vietnam war. Some people certainly enter the military with violent fantasies of terror, suffering, and death. But Shay theorized that others became this barbarous type where before they were not. They had changed, from the outside in, through following immoral orders and participating in senseless violence that disregarded victims' humanity as well as soldiers' own.
I suspect all of this applies to coercive health and social service work as well. Some people come for the license to degrade and abuse, and many others are "undone" morally and ethically by the job. Even if we continue to engage with patients respectfully, we still compromise our mental health when we work in a system that exploits both our patients and ourselves. Here are some specific exacerbating factors I have witnessed:
- Self-disclosed mental health challenges being weaponized. Several colleagues have told me they confided in supervisors about personal mental health difficulties, then saw that information weaponized to discredit concerns they raised about the environment or workload.
- A hierarchical chain of abuse (or, to keep the military theme, "shit rolls downhill.") Management of mental health facilities mock and mistreat front-line employees. Staff have no standing to defend themselves, and may displace their resulting bitterness and anger onto patients.
- Patients as imperfect victims. Patient complaints of abuse and harassment may be disregarded because by definition, the complainants all have "behavioral health" labels. Especially if they don't want to be in treatment, patients can be presumed making things up in hopes of getting out. When one of my patients reported sexual abuse by a physician, my supervisor said "these people will say anything." Management never considered that the reported conduct might actually have happened.
At the close of We've Been Too Patient, madness is framed as the ability to imagine a different reality. It often comes with suffering in the current one, and strong feelings about what needs to change– all of which is threatening to structures of authority. In this spirit, I hope we will all embrace our madness, or strive to go mad, and embarrass these sick systems.
Next week: Why credentialing will never fix poor quality treatment.
