You couldn’t say: It’s not my fault. You couldn’t say: It’s not my responsibility. You could say: I will deal with this. You didn’t have to want to. But you had to do it.
A Hat Full of Sky by Terry Pratchett
I take part in conversations about mental health because of my experiences as a child when one of my parents became unwell. At the time I commented a lot on parallels between totalitarian regimes, human rights abuses and mental health services. I am still thinking about these everyday ways of enabling and allowing abusive behaviour. I just want to own that perspective and its limits. An Enormity of Unbelief is the post where I think a bit about that event. I blog to make sense of my feelings and thoughts from that time. This means that I am informed and interested but much less well-informed or interesting than the many people who blog who are using the system currently, either as people who experience distress/ altered states, professionals or both. On a lighter note I am also exploring the idea that anything I want to talk about can be summarised in a Terry Pratchett quote.
Twitter is an interesting place. Partly because people talk about things that they might not talk about face-to-face. I do get quite upset when talking about mental health as so many people seem to have had so many bad experiences. I’ve started to get my head around the reasons why the things I hear upset me for instance in Why I don’t like easy stories… , Small, sad stories (1) and Small, sad stories (2). One of the reasons these experiences do not seem to get resolved is that the people who are reporting feeling harmed by interactions with professionals are not believed and are not respected. This seems to me to be a subtle form of violence; precisely because people are in pain and struggling, their reports of feeling harmed are undermined. In general, officials seem to react to feedback and complaints by attacking the validity and meaningfulness of the client/patients as a knower of their own experience. In my view this is professional abuse. It is also a lost opportunity for professional to learn how to be with and alongside people in extreme states and to develop better understanding.
These discussions seem to me to be highlighting a concept which is notable by its absence in discussions between professionals or in general conversation about care, whether in the domain of physical or mental health. The absence of professional abuse as a concept that is actively named and confidently discussed, in contexts where one person is extremely vulnerable and the other has relative power, seems strange to me. My take on it is that it makes no sense for this to be a concept that isn’t acknowledged when the explicit aim of the professional is to promote the best interests of a vulnerable person. If we do not and cannot talk about how and when this goes wrong, we are making an environment where it is more likely that the harm will happen. It seems to me being able to talk about it would help the relationship or support safer and feel safe. Like many things in mental health I think the absence of the concept itself and also the absence of upfront conversations about the concept tells us something very eloquently. Silence speaks. As people and as a society we need to start to hear silence, as around any form of abuse there is avoidance and denial. These are active, but not necessarily conscious, processes which lead to silencing. Around any form of abuse there are collective distortions in the sense-making of those involved in the situation. These distortions can be very subtle but the underlying message is often similar. People involved professional abuse are likely, in some way, to put up a shield. The shield looks like this:
- Act as though it didn’t happen or you don’t care
- Say that the client/ patient is lying (even when there is a lot of evidence for their point of view)
- Blame the victim (‘It was the client/patient’s fault’, ‘They made me do it.’ ‘They may not like it, but it is in their best interest.’)
- Minimise the harm their actions had (‘It wasn’t that bad.’, ‘It’s over now.’, ‘Why are you making so much fuss?’)
- Become angry (‘You are always blaming people.’, ‘You aren’t being fair.’ etc.)
Interestingly, these tactics fit pretty exactly with how people react when they are denying feeling a core sense of shame. They are the same behaviours for those who harm across different types of abuse in different contexts too. I will have to think a bit more about how shame and the ability to hurt others might link together specifically for professionals who harm. This is because I had always thought that professions who act in harmful ways do it because it satisfies some need in them, but now I am considering what else might be going on. This is a website link which goes into more detail about shame. http://oohctoolbox.org.au/trauma-and-shame
Professional Abuse is about harming someone in ways that are only abusive because the person doing the harm is a professional in a professional relationship with the person they are harming. A consensual sexual relationship between two adults is OK, unless it is between two people who have a professional relationship, for instance. It is also a type of harm that can only happen because one person is offering professional skills to help another person. For instance, only a doctor or nurse could sew up a serious cut. This becomes professional abuse when the same standards of care and support are not offered because the healthcare provider is providing this service to someone who has self-harmed, for instance.*
Professional Abuse can be more subtle and hard to spot when it is about interpersonal boundary violations. Some people have blogged about the persistent derailment that people who have been in contact with services get when they raise concerns. This blog is very useful http://sectioneduk.wordpress.com/2013/08/16/00but-were-not-all-like-that/ **. I am also starting to comment on specific forms of this phenomenon, for example in the post It’s not why we trained. These derailments are also professional boundary violations, when they happen in the context of a professional relationship. In my view, when these derailments happen on Twitter or general conversation, they just indicate an acceptance of bad practice. Depending on exactly how the derailment happens, they also add to the dynamic of collective silencing of professional abuse. I increasingly take the view that because ethical values and principles underpin professional practice, derailment by professionals is also an issue of professional abuse. However, boundary violations in a professional relationship can be more subtle than these derailments and include behaviours such as excessive personal disclosures by the professional, role reversals in therapy, the therapist/ provider failing to take a report of an adverse experience by a client to supervision, breaches of confidentiality and treating people without respect. Boundary violations in and of themselves are always a betrayal of trust in a professional relationship.
One way professional abuse continues is that it is not challenged by staff when it happens. The behaviour is not named for what it is and the links between specific actions, ethical principles, values and rules are not made clear. In some ways staff seem to have no official, accepted protocol or script for helping each other to maintain professional boundaries. My observation is that what seems to happen instead is that all staff join in with collective distortions in their thinking. They seem to also identify with the staff member not the client/ patient/ service user. Indeed, this happens even though in all professional settings, the professional might be in the client/ patient role at a different time. It seems that this is linked to the ‘Them’ and ‘Us’ culture which seems so strong in mental health discussions. In some ways it seems like it could be a defence against staff knowing that they could be on the receiving end of their own behaviour if they ever became vulnerable. A clear indication of this is the use of the pronoun WE in contexts where there is a disagreement or a complaint is being made. The organisation seems to act as one to protect the professionally abusive actions of staff. I was surprised during a conversation on Twitter recently when a Tweep reported* that when she was sutured after self-harming the nurse made a complaint about the doctor who did this without providing anaesthetic. I might have had serious questions about to what extent the nurse failed in her professional duty and was indeed professionally abusive in not stopping the doctor from suturing without anaesthetic at the time. Nevertheless, the behaviour is still unusual in that it happened at all. It should be celebrated and breaks down the ‘Them’ and ‘Us’ culture which seems to permeate mental health services. The nurse’s behaviour made a lot more sense to me when the Tweep made it clear later in the conversation that the nurse was an agency one – not likely to be around for long. This made me think about the bystanders professionally abusive behaviour. In most codes of ethics allowing others to continue to abuse is not allowed. It seems that staff are most likely to recognise, name and act to stop professional abuse when:
- they are not themselves reliant on the organisation e.g. for pay or promotion
- they are not themselves part of the organisation e.g. agency staff
- they are new to the organisational culture and so have not come to see the organisation in the same way as other staff
- they do not identify with the organisation
- the member of staff complained about is already isolated within the organisation
- the member of staff complained about is already being bullied within the organisation
I guess that it might not be a great idea for people who are in contact with ‘services’ to talk about professional abuse or put it on the radar for conversations, as lots of judgements which might not be helpful are likely to be made about them. If you are a service user reading this and it chimes with you, be wise, be safe, take care of yourself. However, I do think it is professionals’ job to talk about this concept and topic. I do think it is the job of bystanders to these conversations to make the radical move of naming professional abuse and linking professional behaviours to ethical values, principles and rules. Society needs to learn how to encourage everyone to query behaviour when it does not seem to reflect these core elements of human decency and morality. This is an act that has its dangers. I predict that when anyone makes the links between ethics, behaviour and professional abuse explicit, the shield will come up. That ‘shield’ is not neutral, as like any form of defense it works best if it is an attack. It is weaponised. The only way abusers can continue their behaviour is to destroy the person who is trying to stop them – destroy them as valid knowers, destroy their strength to carry on or destroy their social support. It makes sense then, doesn’t it, that the staff who act to stop professional abuse do so as whistleblowers, after it happened, when they have left the situation and not at the time. Like the nurse in the Tweeps story.
*I have asked the Tweep concerned if I can use her Twitter story and she agreed it was OK.
** I have permission from @sectioned_ to post the link to her blog here