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The first rule of medicine seems a simple one: “Primum non nocere”, or “Above all, do no harm”. Students, physicians, and educators alike believe and uphold this unspoken law to preserve the integrity of medical and nursing practice. This fundamental axiom seems to appear around every corner: it is engraved on plaques, transcribed on certifications, and carved into doorframes. The words reverberate down the halls of our hospitals, clinics, and courtrooms, as if the walls themselves speak them in whispers. First, do no harm. It seems straightforward enough, does it not? After all, what doctor, technician, or nurse would intentionally inflict damage on a patient? The very soul of healthcare seeks to cure the sick, diagnose the ill, and medicate the ailing. However, I present to you an ugly truth: we can only treat what we can fully comprehend. Unconscious ignorance and pre-formed judgments have the potential to be far more dangerous than an errant needle puncture or pharmacological mismanagement. One of the most misunderstood issues facing the medical community today is that of mental illness, and the connotations are far reaching. Over the years, great strides have been made to eliminate the stigma associated with such afflictions. However, mental disorders largely remain a shadow-filled alley that no one wants to venture down. It is only by illuminating the darkest corners of the human psyche that we can begin to combat the shame and fear that reside there.
Historically, treatment of the mentally ill has left much to be desired. Patients were institutionalized and classified as lunatics. Many were chained to the floor, and allegations of abuse and neglect ran rampant. Complete isolation and rest therapy were common ways of handling these individuals. While we now know empirically that placing patients in circumstances of congregate stress can exacerbate their illnesses and retard effective treatment (Freckelton, 2011), society had no explanation for certain behaviors. Loved ones were sent away to insane asylums, mainly because that was easier than having to explain erratic behavior to friends and family. As the number of these asylums increased, and mental illness became more prevalent, science began to look for further explanation and treatment for these conditions. Sadly, inhumane and deadly remedies began to become commonplace (Chung, 2010). Patients were submerged in ice baths until they lost consciousness. Early forms of electroshock therapy began to emerge. Probably the most frightening of all these barbaric treatments involved a form of partial exsanguination. The belief was that if all the bad blood were drained from an individual, they would be able to return to a state of mental health. Instead, this practice killed a horrifying amount of people. Even this could not compare to the rise of the trans-orbital lobotomy in the mid-1900’s. Despite the advances made in medication management – Thorazine made its debut around the same time (Carpenter & Davis, 2012) – the complications and deaths associated with these radical procedures are unarguably deplorable. Eventually the medical community realized that treatment practices were undermining the very science of psychiatry; a paradigm shift was underway (Horwitz & Grob, 2011).
While we have come a long way from the therapeutic nihilism that has dominated psychiatry in previous generations (Patterson, 2012), mental illness remains one of the most stigmatized health conditions (Verhaeghe & Bracke, 2012). This stigma is present not only in generalized society, but also in healthcare professionals. Far too often patients in the throes of a manic or psychotic episode receive nothing but irritation from the hospital staff delegated to their care. Nursing staff members argue amongst themselves on who is going to receive the problem patient. On understaffed and busy medical/surgical units, it is all too easy to reject a sense of empathy in the name of efficiency. The implications of this are numerous and far reaching. It is an understood fact of neuropsychology that the behavior of an individual is not completely a conscious cognitive function. (Bargh & Morsella, 2008). Instead, our minds resemble icebergs, with only a small portion of our neural processes occurring in a place where we can thoughtfully acknowledge them. Holding onto preconceived notions or biases affects the way that we view and treat others, even if we are not completely aware of it. This is causing a decrease in the quality of care patients with comorbid psychiatric conditions receive. It has been established that patients with comorbid psychiatric diagnoses undergoing treatment for acute myocardial infarction are statistically more likely to be sent to lower quality facilities (Cai & Yi, 2013). Patients suffering from a severe mental illness are less likely to engage in preventative and annual health care (Lord, Malone, & Mitchell, 2010). The amount of time that nurses spend in the room of a mentally ill client is notably less than the time spent in the room of a client without a psychiatric disorder. Even social workers, while they tend to exhibit more permissiveness and self-reporting empathetic behaviors, are not immune to cognitive bias (Richmond & Foster, 2008).
Obviously, this presents a serious concern. As aspiring nurses, we are currently studying—and should be bound by—the same ethical standards of those that are in practice. If it is the aim of nursing to treat patients in a holistic and all-encompassing manner (Portillo & Cowley, 2011), where does healthcare worker bias fit in? What can we do to change the way that we think, and in turn, the way that we behave? Our role is supposed to be that of a patient advocate: we assess, diagnose, and intervene on behalf of those we serve. It is impossible to completely fulfill this role if we allow ourselves to be carried away by subconscious fear of what we do not completely understand. While this tendency is innate to human nature and not unique to nurses, we are on the front lines of patient care and must hold ourselves to a higher standard for the sake of those we have promised to attend to. Stigma hurts; it is our obligation as aspiring medical professionals and members of society to ease this pain. We must stand together, rise up against preconceived notions, and shout from the mountaintops that it is ok to seek help. We must eviscerate the body of societal stigma, the inner darkness of our own minds, and honestly confront our own fears. More than one paradigm shift has already occurred in the mental health sphere; it is more than time to catalyze another. No more shall patients fail to seek treatment due to fear of judgment. No more shall our opinions of someone be shaped by a diagnosis. It is time for mental illness to leave the roll belts and back rooms and step out into the sunlight. We have come a long way both as a medical community and a society, and the time has come to keep moving forward. Together, we can make a difference: one day, one interaction, and one patient at a time.
Bargh, J., & Morsella, E. (2008). The Unconscious Mind. Perspectives on Psychological Science, Vol. 3, No. 1, From Philosophical Thinking to Psychological Empiricism, Part I (Jan., 2008), pp. 73-79
Cai, X., & Li, Y. (2013). Are AMI Patients with Comorbid Mental Illness More Likely to be Admitted to Hospitals with Lower Quality of AMI Care?. Plos ONE, 8(4), 1-7. doi:10.1371/journal.pone.0060258
Carpenter, W., & Davis, J. (2012). Another view of the history of antipsychotic drug discovery and development. Molecular Psychiatry, 17(12), 1168-1173. doi:10.1038/mp.2012.121
Chung, D. S. (2010, March). Biomedical Approach is Not Good Enough for Treating Severe Mental Illness. East Asian Archives of Psychiatry. pp. 4-5.
Freckelton, I. (2011). The Architecture of Madness: Insane Asylums in the United States, by Carla Yanni. Psychiatry, Psychology & Law, 18(1), 160-162. doi:10.1080/13218719.2010.521484
Horwitz, A., & Grob, G. (2011). The Checkered History of American Psychiatric Epidemiology. The Milbank Quarterly , Vol. 89, No. 4 (December 2011) , pp. 628-65
Lord, O., Malone, D., & Mitchell, A. J. (2010). Receipt of preventive medical care and medical screening for patients with mental illness: a comparative analysis. General Hospital Psychiatry, 32(5), 519-543. doi:10.1016/j.genhosppsych.2010.04.004
Patterson, P. (2012). What Insane Asylums Taught Us. USA Today Magazine, 141(2806), 62-64.
Portillo, M., & Cowley, S. (2011). Working the way up in neurological rehabilitation: the holistic approach of nursing care. Journal Of Clinical Nursing, 20(11/12), 1731-1743. doi:10.1111/j.1365-2702.2010.03379.x
Richmond, I. C., & Foster, J. H. (2008). Negative attitudes towards people with co-morbid mental health and substance misuse problems: An investigation of mental health professionals. Journal Of Mental Health, 12(4), 393.
Verhaeghe, M., & Bracke, P. (2012). Associative Stigma among Mental Health Professionals: Implications for Professional and Service User Well-Being. Journal Of Health and Social Behavior, 53(1), 17-32.