Magical thinking and moral injury: exclusion culture in psychiatry

Abstract

Summary This is an article about exclusion. We might not like to admit it – even fail to realise it – but National Health Service (NHS) mental health service structures have become increasingly focused on how to deny people care instead of help them to access it. Clinicians learn the art of self-delusion, convincing ourselves we are not letting patients down but, instead, doing the clinically appropriate thing. Well-meant initiatives become misappropriated to justify neglect. Are we trying to protect ourselves against the knowledge that we're failing our patients, or is collusion simply the easiest option? Problematic language endemic in psychiatry reveals a deeper issue: a culture of fear and falsehood, leading to iatrogenic harm. An excessively risk-averse and under-resourced system may drain its clinicians of compassion, losing sight of the human being behind each ‘protected’ bed and rejected referral.

Liaison psychiatry practitioners’ views on accessing aftercare and psychological therapies for patients who present to hospital following self-harm: multi-site interview study

“…11 Liaison psychiatry, owing to its placement in acute hospitals and role in the provision of psychosocial assessments for patients who have self-harmed, provides an important pathway to aftercare. 6,12,13 Although significant service issues for patients seeking help for selfharm are indicated, [14][15][16][17][18] no studies have investigated barriers and facilitators to accessing aftercare from the perspective of staff referring on to services. Working closely with staff and patients to understand the service context may provide opportunities to improve patient safety and access to aftercare.…”

Psychiatrists’ Experience of a Peer Support Group for Reflecting on Patient Suicide and Homicide: A Qualitative Study

“…Our study gives warning that that distilling the complexity of suicide risk in this way can reinforce false notions about the ability of clinicians to be able to control and prevent such incidents. It also risks shutting down genuine communication between mental health professionals and the patient [ 35 ].…”

Effecting change and improving practice in a regional Emergency Department: A Mental Health Nurse Practitioner's perspective

“…2020, pg.1)’, is important, so is ED's role in raising concerns and advocating for better service access, other than waiting in a busy ED (Allison et al . 2019; Beale, 2022; Van Der Linden et al . 2019; White & Brooker 2020).…”

“…Overall, endeavours to advocate for better access to care for those experiencing mental health issues, often influenced by drug and social factors (Yap et al 2020), remain a key focus for the local ED. Whilst ownership, in accepting and providing mental health care within this acute setting when there is 'nowhere else to go (Duggan et al 2020, pg.1)', is important, so is ED's role in raising concerns and advocating for better service access, other than waiting in a busy ED (Allison et al 2019;Beale, 2022;Van Der Linden et al 2019;White & Brooker 2020).…”

“…Internationally, a recent publication identified that the United Kingdom's (UK) National Health Service (NHS) highlighted concerns around a lack of accessibility and availability of mental health services (Beale, 2022). Positive findings reported from the RPAH project, in particular the MHLN (NP) role, found improved patient experiences and outcomes, increased ED staff confidence, and reduced workload activity on overstretched mental health services (Wand et al 2021a;White & Brooker 2020).…”