[Content Warning: Discussion of harm and abuse in mental health services]
Voice any kind of pain, upset, criticism, or account of a negative experience with an NHS mental health professional, and I guarantee no matter where you are, someone will burst through the nearest door, window, or manhole to inform you that "nobody comes to work to harm people". I’ve never been given an explanation of what this actually means, but having heard and read this phrase so many times, what I have inferred from context is that "nobody comes to work to harm people" means if someone has been harmed by the words, actions, or inactions of an NHS mental health professional, this was definitely not intentional on the part of the professional, and due to this lack of intent, the harm was actually not harmful, and, as such, the person explaining how they have been harmed is being unfair, and should stop talking.
It is one of my least favourite phrases, not only because of how it shuts down the person recounting harmful experiences, but also because it doesn't really mean anything. It never seems to get broken down any further, rather it just sits in the space which should have been available for people to voice their grievances, and takes up all the oxygen, silencing any further discussion. So, I thought I would write this blog post to try and take it apart, consider what it means, why it may be said, and how it can feel to hear it.
1. Literal Interpretation
Being autistic, the first thing I go to when trying to understand words is the literal interpretation. The phrase "nobody comes to work to harm people" (in its many different forms) is unambiguous, leaving little room for a literal misunderstanding – it asserts that nobody, not one single person, comes to their job as a healthcare professional with the intent to harm people. While I am yet to see any statistics, I’m sure most people would agree it is unlikely that the majority of healthcare professionals go to work each day with the intention of harming the people they are paid and trained to care for. This does not mean, however, that nobody has this intent. Healthcare professionals are people. They can be mean, abusive, unpleasant, discriminatory, prejudiced, and commit crimes just as other people do. Predatory people often position themselves in jobs and areas of society which make it easier for them to prey upon vulnerable people. Mental health patients are some of the most vulnerable people in society. We are commonly dismissed as fantasists, dangerous, malicious, litigious, and delusional, making it easy to have complaints and concerns ignored. We may have conditions or be receiving some form of treatment which interferes with our memory, perception, and decisional capacity, making us vulnerable to manipulation and abuse. Under services we are trapped in unequal power dynamics, leaving us vulnerable to coercion. We can be detained and treated against our will, which can lead to situations where we are physically restrained or held in seclusion. We, as the mental health patient, do not lack power, social status, and control in some incidental random manner. Rather, through our experiences and in being assigned the label of “mad”, our power, social status and control are taken from us, and much of it is assumed by the mental health professional; a person who can now decide who we are, what we want, what our goals are, what is best for us, whether we are lying, whether our wants, needs, and hopes are legitimate, what aspects of ourselves are broken, and how best to fix these broken parts. The professional is trusted above us to describe and understand our lives and thoughts and pain, and that trust from colleagues and society drowns out our voices. In some ways, we cease to fully exist. It is not at all far-fetched to think that this dynamic would entice predators, abusers, and people seeking power, nor that after experience of working in this environment, some people wouldn’t take advantage of it, or begin to allow it to change them and their values.
If the phrase is considered in its literal sense, it is both untrue, and also entirely dismisses the historical and ongoing harm experienced by mental health patients at the hands of some mental health clinicians. Reams of evidence exists which proves some mental health professionals have and do come to work with the very real intention to cause harm, including neglect; mistreatment; sexual, emotional, physical and financial abuse; and even murder and manslaughter [1-9]. The suggestion that no healthcare workers have ever deliberately hurt or abused any of their patients is quite simply a fantasy. A total denial of reality which the people stating it will absolutely be aware of.. And yet it still rolls out every time a person complains or a new scandal arises.
Where absolute proof exists of the harm, such as the recent footage released by Panorama of abuses in the Edenfield Centre, it is still used, but this time it comes along with a secondary excuse - if someone has deliberately caused harm, they are not a real healthcare professional. "A mental health nurse assaulted their patient? They have no right to call themselves a nurse. That's not the behaviour of a nurse.." As if negative or harmful actions are so at odds with the medical profession, those who do harm are stripped of their qualifications and titles, becoming imposters within the ranks.. The implication being they have been pretending to be healthcare professionals all along. This leads us to consider the next interpretation, the underlying belief that healthcare workers are inherently good people.
2. Othering of people who cause harm
Being employed in healthcare does not give any indication of a person’s character, morals, or ability/desire to harm others. We desperately need to move away from the black and white concept of “good people” vs “bad people”, using shallow markers such as area of employment to judge whether someone is capable of causing harm. In medical school one of my modules involved personal development. It was very interesting to have group discussions about why we had individually chosen medicine, why we wanted to be doctors, and our journeys to medical school. Mostly, people chose medicine because they liked science and wanted to pursue it within a dynamic field which involved working with people; came with social status; good job opportunities; the potential for a good salary; and boosted their egos. In one session people described the mountains of voluntary work they had done to get into medical school, and our tutor commented that it seemed like people had only done this work to make their applications more impressive. She asked us to raise our hands - who had done voluntary work before coming to med school - we all raised our hands. She asked who was still doing voluntary work, everyone but me lowered their hands. It was quite uncomfortable. Healthcare is a profession, not a religious calling for people who just desperately and selflessly wish to help others.
Within society we often reduce people who cause harm down to less than people. Think about how we consider child abusers, rapists, murderers etc. We have such a distorted view of who commits these crimes, we are frequently shocked when we discover that they look, sound, and act just like us; when we discover that they are not cartoon villains, or monstrous creatures. Monsters don’t exist – just people. When we view people in such black and white terms, good or bad, and then make the bad people non-human, we separate ourselves from the possibility that these people could exist in our individual worlds, that these people could, in fact, be us. This has the unfortunate effect of allowing good-looking, charming, and apparently respectable people to get away with committing crimes, because they do not “look the part” [10-12]. Alongside the 'monsterfication' of abusive people, society actively deifies others, such as healthcare workers, raising them up higher than regular people, making them more than human. They become Gods, saints, and angels. This only serves to widen the gulf between those who cause harm and those who work in healthcare.
A healthcare professional may deliberately harm individual patients, while also caring for other patients in a professional and compassionate manner. They may not think to themselves "I can't wait to go to work today to cause harm", but it doesn't mean their actions aren't deliberate in the moment, or even calculated over a longer period. Patients are often divided by staff into hierarchies of deservedness - those at the bottom may not even register to some professionals as people [13-16]. Certain presentations and behaviours within mental health services (such as self-harm, repeat suicide attempts, the questioning of medical authority, complaints against staff etc) are frequently met with fear, disgust, disdain, annoyance, anger, and even hatred [17-19]. Some patient groups, such as those labelled with a personality disorder diagnosis, may face these attitudes from staff even without displaying any so-called “difficult” behaviours, purely on the basis of the label [20,21]. The pre-installed stigma within certain labels apparently justifies all manner of abusive, cruel, violent, and negligent staff behaviour, which is so deeply harmful, not everyone survives it [22].
The overall intention of people coming to work in a healthcare setting may be to help people, but this doesn't mean they are not capable of deliberately inflicting harm. It also doesn’t mean that despite the purest and saintliest of intentions, if they accidentally cause harm, this harm won’t be devastating to their patient/patient’s family. This leads me to the next point - intention.
3. Intention
In the contexts I have commonly heard/read the phrase used, it appears to indicate that even without knowing the clinician or having any understanding of what happened to the patient, the person asserting "nobody comes to work to harm people" is confident that even if harm occurred, it was not intentional. It’s seemingly a mantra within all healthcare specialties.
But what is the difference between a deliberate and an accidental harm to the person harmed? If a person dies due to clinical negligence, does it make them less dead if the negligence was unintentional on the part of the staff member? What about when staff feel their very deliberate actions are justified and ultimately for the best, such as "tough love" or the use of harmful clinical policies such as TEWV’s BPD+ protocol [23] - does this make the harm less harmful? Why is staff intention brought up every time people discuss harm from services? The implication is that it isn’t as bad. There is little to no consideration of the actual harm caused, nor how an unintended harm could be potentially more upsetting to the person harmed, who may feel that their safety or welfare wasn't important enough to even be considered by the professional.
Interestingly, research finds that if someone is shown an example of a harm which occurred intentionally and one which occurred unintentionally, even if the harms are absolutely identical, they are more likely to view the unintentional harm as less harmful in comparison to the intentional harm [24]. Far more so than unintentional harms, intentional harms elicit the desire to blame, condemn and punish [25-27]. Accordingly, staff may downplay, dismiss, or reconceptualise harm to patients due to an immediate defensive reaction potentially based on one or more of the following:
Avoidance and fear of disciplinary procedures. There is reportedly a “toxic fear” of disciplinary action within medical professions [28,29]. The disciplinary, investigatory, and fitness to practise procedures have been noted to elicit strong negative reactions in healthcare professionals, including anger, fear, anxiety, depression, and even suicidal ideation [30]. A report into GMC investigations between 2005-2013 found that 28 doctors ended their lives while undergoing fitness to practise procedures [31]. Research finds that fear of complaints and potential investigation leads to high levels of avoidant and defensive practice [32]. Looking at it from this perspective, it makes sense that healthcare professionals would decree that all harms are unintentional, nobody wants to be the “guilty” party, facing blame, punishment, and stressful disciplinary or investigative procedures. Complaints procedures, however, support learning and safety in services. While they may be stressful for individual staff, these processes are ultimately supposed to improve patient care, and make the clinical environment safer for everyone. Where professionals have harmed someone, it is only right that they take responsibility for this, and at the very least, work to improve their practice.
Inability to sit with feelings of privilege and shame. It can be hard to accept that you hold power or privilege – particularly when you don’t feel powerful or privileged. Refusal to acknowledge your own potential to harm can lead to ultra-defensiveness, dismissal of complaints, ignoring things that are obviously wrong, placing blame for failures on patients, automatically believing colleagues over patients etc. It's so much easier to say to yourself that the patient is an arsehole and deliberately being “challenging” or making “malicious” complaints than it is to recognise yours or your colleague’s immense power in the patient-clinician interaction, and how your/their actions could have caused harm. Repeating a mantra which theoretically reduces the severity of the harm based on the intent of the staff member minimises shame and guilt. To me, what they are really saying is "I do not go to work intending to harm people, which means if I have harmed someone, it's not as bad, because it was an accident, and I'm a good person".
Staff tribalism. Siege mentality is absolutely rife within healthcare [33]. Healthcare professionals commonly exhibit an “us v them” attitude, where staff permanently feel under attack from patients, families, the media, and society. The belief that we are all out to get them can lead to strong reactions to perceived criticism, as staff pull together to protect their own. “Nobody comes to work to harm people” is an entirely uncritical and reactionary defence of people considered to be in one’s own camp.
Staff identity. Allegations of harm can challenge healthcare professionals strongly held identities as "healers" and "helpers". For many people, their work in healthcare is their identity. They are a doctor, or a nurse, or a psychologist. That role and title don't get left behind at the end of the day when they go home. The suggestion that they could be responsible for harm - something which goes entirely against the very purpose of their role - can lead people to question their entire identity or feel their work is being devalued. This provides strong motivation to react defensively, or ignore and avoid the possibility that they, or others with the same identity, have caused harm.
Belief that patients are lying. This is probably the most important factor to consider when discussing medical professionals dismissing patient complaints - the widespread and strongly held belief that patients are always lying. This comes in several shades, everything from asserting that patients are innocently mistaken or confused, to describing patient complaints as deliberately malicious. Given the everyday dismissal of patients' self-described physical and psychological issues by healthcare professionals, it could be that the culture of disbelieving everything a patient reports in clinical practice also rolls over into complaints against staff. With a combination of all the factors listed above, this would make sense, as an inherent lack of patient credibility combined with professional defensiveness would create a strong barrier between staff and the ability to hear patient complaints. The unquestioned acceptance that patients are not telling the truth, whether or not it is even believed, allows staff to utilise their position of professional and societal power to silence and discredit patients for their own benefit.
Belief that medicine is inherently good. As previously mentioned, there’s a persistent belief within many areas of medicine and healthcare, particularly mental health services, that therapeutic interventions cannot be harmful, and that when carried out by someone who has good intentions, the person cannot do harm. This is completely false and can cause professionals to discount or dismiss information which does not align with their existing beliefs. Last year I wrote about some of my experiences with psychological formulation, and how I had found it harmful. I received a number of responses from professionals informing me that formulation is not harmful if done properly. They refused to accept that a competent, well-meaning, and professional intervention could have caused harm, it must have been done wrong. I wrote this blog in response. Iatrogenic harm is well recognised within most areas of medicine. While mental health services are yet to catch up with their recognition and understanding of iatrogenic harm, patients and survivors provide endless accounts of experiences of harm through academic research, books, news articles, campaigns, social media, zines, blogs, and artwork. If you haven’t heard us, you haven’t been listening. Try reading some articles from the following organisations: Recovery in the Bin, Asylum Magazine, National Service User Network, and Mad Covid.
Personally, I believe that if a professional can’t recognise, acknowledge, and sit with the understanding that harm occurs within mental health services, they shouldn’t be working in mental health services. Denial of harm only increases its potency and contributes to a stagnant culture in which people and practices refuse to change for the better. Harm happens; we gain nothing by pretending it doesn't, or minimising the responsibility of professionals. If you are a healthcare professional reading this, it is likely that you have already harmed someone, and/or will go on to cause harm in the future. This is not an invitation to be complacent or resign yourself to the idea that harm is inevitable (and therefore you needn’t bother trying to guard against it), it is the opposite. Being aware that your words, actions, and inactions hold the very real potential to negatively impact, hurt, traumatise, frighten, and harm your patients is vital to ensuring continual reflection and growth.
As a person who has experienced immense harm at the hands of mental health professionals - both as a patient and a carer - and who copes with this harm by openly discussing it online, receiving a response which includes any variation of “nobody comes to work to harm people” is deeply hurtful. It not only entirely dismisses abuse by health professionals on a wider scale, but attempts to guilt and gaslight the person sharing their experience into silence, through the categorical statement that not only did the person who harmed them not mean to, but absolutely no healthcare professional means to cause harm, ever. If, as a healthcare professional, you are listening to someone talk about harm they have experienced from healthcare services, before jumping in with #NotAllStaff or #NobodyComesToWorkToHarm, please stop and realise that the conversation is not about you, it is not about your emotions, it does not need to massage your ego or ensure everyone knows that you are a Good Person™. Your feelings are not important in this conversation. What is important is that you listen and learn from that person’s experience without reacting defensively.
Iatrogenic harm is very real, very common, and can destroy lives. It is vital this reality is accepted. How can people heal within a system which refuses to acknowledge the harm it continues to cause? How can staff expect services to grow and improve if they refuse to acknowledge the areas which require change? How can patients ever trust that services will learn from mistakes, and actually keep us safe, if they won’t admit those mistakes in the first place?
When thinking about mental health staff refusing to hear about harm, I often return to the words of the Kerr/Haslam public inquiry, which concluded that these two psychiatrists were able to sexually abuse countless vulnerable mental health patients over a 40 year period, simply because they worked within a staff culture in which patients were “routinely disbelieved” and thought to have “invented or exaggerated their concerns or complaints”.
Don’t be those staff.
Don’t continue to perpetuate that culture.
Recognise your power and privilege, and start listening.
And to anyone who has experienced harm from mental health services, I believe you and I stand with you.
Love and rage,
Wren
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