Power Imbalances in Mental Health Care

 
In the attempt to make psychiatry a legitimate medical specialty diagnostic criteria were developed. In Canada, psychiatrists use DSM-5 diagnoses not just to organize, but also to justify treatment. In an era where we know about the importance of patients being active partners in their care, we must seek the input of our patients on their agreement or disagreement with diagnostic criteria. In practice, especially in the inpatient system where most people who are admitted are involuntary patients, the healthcare system maintains a culture of clinicians having power over patients. The imbalance of power sustains a system where clinicians, most prominently psychiatrists, are the ultimate decision-maker and nurses become stuck in a murky place of advocating for patients, exercising their own autonomy of holistic and person-centered care, while also acting on psychiatrists orders. The process continues to be a top-down approach despite attempts to embrace and implement collaborative care directed by the goals and needs identified by the patient.  

In the Canadian mental health system, clinicians may even come to see it as their right to enforce or force mental health patients to do what the treatment team, non-inclusive of the patient, decides. The uncomfortable occurrences continue of clinicians patronizing and minimizing patients’ situations, sometimes including misunderstanding and even ignoring their traumas in a way that makes those who want to uphold principles of recovery, patient-centered, and trauma-informed care feel not only uncomfortable but exhausted by the lack of empathy and compassion guiding clinical practice. It is emotionally draining to hear co-workers make critical judgments that belittle patients for making autonomous decisions, for example, “how often do they do what we say?” or “how often do they follow through?” In some clinical settings, for various reasons including stressors like lack of education, training, staffing, and well-matched guiding models to direct care, the default of clinicians can be to assume a position of distrust, and enact care using an underlying sense of paternalism. Where are the checks and balances to ensure that we check ourselves and ask questions about if we are being patient-centered and relational? 

In education sessions, on policies, on health organization posters buzz words abound like “destigmatize”, and “trauma-informed practice” while simultaneously reinforcing stigmatization, rejecting those seeking help because of moral judgments about circumstances like substance use, poverty, engagement in sex work, etc. When do we turn the mirror on ourselves to recognize the harms that we cause by not accepting people as they are and where they are at, deserving of care regardless of life circumstances? 

Strong arguments have been made by mental health clinicians, including nurses, that the Diagnostic and Statistic Manual, the psychiatrists guide mental health patient care and the systems clinical guide, is harmful. Nurses have begun publicly questioning the value of the diagnostic and statistical manual. We must question how diagnoses are used in practice, and their value in guiding not only clinical decision-making but how we understand the patient as a whole person. When nurses use statements like, “we honour and capture the patient voice”, the evidence must support if this is, in fact, what we do. 

There are ways that nurses can lead the way in determining how and if we include the patient voice in their care. For example, do we let patients co-create their healthcare record? Do patients have the opportunity to add information to their charts? In a day and age where electronic systems are a reality, where documentation can be co-created, we still maintain barriers. Or, does practice continue to be led by the overarching belief that the truth will be too much for the fragile Patient?

While the mental institution system within which psychiatric care was born once included nurses as the handmaiden of the psychiatrist, this is not their role today. Programs are now called centres for Mental Health. Does this mean a shift in the power of the hierarchy of psychiatry? Do these shifts indicate new opportunities for mental health nurses to take a lead role in mental health care in collaboration with patients and families? Does this mean that there is understanding and recognition that mental health and mental illness are concepts that encompass more than a disease model of mental illness? At the center of re-branding and re-structuring of mental health care, deliberate consideration must be made about where mental health nurses fit. 

“At the core, we are all the same…there is no US and THEM (MHCC, 2009).”

Love,

Michelle D.