Abstract
While effective patient-provider relationships can provide vast practical benefits to health outcomes in patients, the fragile therapeutic alliance existing between mental health practitioners and patients has been made ever-contentious due to a lengthy history of neglect, abuse, stigmatization, and misunderstanding. In turn, psychiatric and psychological institutions such as behavioral health centers struggle to address not only increasing rates of mental illness and suicide, but also the emotional labor exhaustion and social taint experienced by their employees. In turn, this piece explores the dialectic tensions between mental health providers and patients through considerations of the ever-present materiality of mental illness stigma, psychiatric “dirty work,” and social taint as they occur in total mental health institutions and conceptualizes the lived experience of mental health practitioners and patients through the establishment of a phenomenological imperative in mental health discourse.
TopIntroduction
The door once open, I offered no further resistance. First, I was knocked down. Then for several minutes I was kicked about the room--struck, kneed and choked . . . My shins, elbows, and back were cut by his heavy shoes . . . As it was, I was severely cut and bruised. When my strength was nearly gone, I feigned unconsciousness. This ruse alone saved me from further punishment, for usually a premeditated assault is not ended until the patient is mute and helpless. When they had accomplished their purpose, they left me huddled in a corner to wear out the night as best I might--to live or die for all they cared. Strange as it may seem, I slept well” (Beers, 1981, p. 52).
According to Street and colleagues (2009), meaningful patient-provider relationships can create pathways to positive health outcomes through increased access to care, greater patient knowledge, shared understanding, high-quality medical decisions, enhanced therapeutic alliance, and perhaps most importantly, patient agency and empowerment. Unfortunately, however, Clifford Beers’ account of being assaulted while wearing a straitjacket by his psychiatrist and attendants is only one of many examples of how an institutionalized history of violence, abuse, neglect, misunderstanding, and stigmatization have muddied the mental health patient-provider relationship. Despite the numerous advances in both public policy and psychiatric practices that have occurred since Beers published his autobiography, A Mind that Found Itself, in 1908, from the deinstitutionalization of the American asylum system to the banning of the use of iron chains in mental health facilities, this relationship remains contentious, ever-complicated by the stigma that construes both the mentally ill and mental health practitioners as dangerous, unstable, and untrustworthy (Ebsworth & Foster, 2015).
Addressing this fragile relationship is a matter of life and death; while standard Cognitive Behavioral Therapy (CBT) has been shown to improve mental health outcomes across a wide range of mental illnesses (Erlangsen et al., 2014), only 9.5% of the US adult population engaged in psychotherapeutic treatment in 2019 (CDC, 2020). In turn, untreated mental illnesses significantly increase the risk for suicide and self-harm behaviors, with 90% of individuals who killed themselves having a diagnosable mental illness at the time of their deaths (AFSP, 2021) and only 46% of these individuals having actually received a diagnosis (NAMI, 2021). Due to the public’s stigmatized view of and lack of engagement with preventative mental health services, behavioral health centers have become the last line of defense in providing crisis intervention services, utilizing a combination of voluntary and involuntary inpatient and outpatient services to rehabilitate patients with severe mental illness, substance abuse disorders, and self-harm ideation or attempts (N-MHSS, 2018). Therefore, behavioral health experts, including psychiatrists – psychologists, psychiatric nurses, and substance abuse experts – provide critical and often life-saving services for many underserved and disadvantaged communities; yet despite such advocacy and service, no one demographic holds a more stigmatized view of mentally ill people than these mental health providers (Huggett et al., 2017; Knaak et al., 2017; Wong et al., 2015). Current scholarship suggests that this practitioner-based stigma could be a major contributor to the 70% of mentally ill individuals who do not seek treatment from healthcare staff (Henderson et al., 2013; Karp, 2020).
Key Terms in this Chapter
Health-Seeking Behaviors: Those actions (or inactions) that individuals undertake when they believe they are experiencing a health problem for the purpose of finding an appropriate healthcare solution.
Stigma Transfer: Stigma that is derived from an affiliation with an identity group or organization that experiences stigma itself.
Behavioral Health: Considerations of the means by which mental processes impact everyday life in the form of action and behavior.
Critical Narrative Analysis: A critical means of analysis that affords scholars the opportunity to utilize phenomenological principles to consider the relative efficacy of mental health discourse.
Asylum: An institution that cared for mentally ill individuals, the majority of which would close following the passage of the Community Mental Health Act in 1963.
“Total Institution”: As coined by Erving Goffman, organizations that dominate all aspects of everyday life through regimentation that blurred, if not completely erased, the distinction between private and public interactions.
Institutionalization: The process by which mentally ill individuals are subjected and admitted to mental health treatment centers.
Patient-Provider Communication: The communicative processes that occur between healthcare providers and their patients.