People suffering from mental illness are often looked differently and do not have equal access to all the opportunities in life. Though, patient’s family and the health care providers can play a fundamental role in the lives of these mentally ill people. Through offering a proficient care with warmth attitude they can certainly bring an optimistic change in them. But, imagine what if these caregivers are the reason of mistreatment with mental patients? This is an ethical issue which I recently came across during my clinicals and therefore decided to explore it in depth. Thus, the following paper is an attempt to analyze this issue by integrating an ethical model, highlight its significance and to discuss the causes, effects on mental health and practical strategies to overcome this immoral issue of mistreatment with mental patients.
On my clinical to psychiatric ward civil hospital I encountered a 60 years old female, married and diagnosed with obsessive-compulsive disorder (OCD). The chief complaints of patient were severe headache and aggressive behavior. Since 20 years patient had history of recurrent depressive illness characterized by weeping spells and low energy. On asking about the support system patient became gloomy and said “I am alone and nobody likes to be with me and care for me”. Further she said that due to her habit of cleaning things again and again her family becomes angry and speaks harshly to her. On spending some time with patient I came to know that how much she loved them but nobody came to meet her since she had got admitted. After taking history of patient that day I also observed that when my patient called the nurse to inquire about the medication timings, nurse replied rudely that “how many times you will ask the same thing again and again. You are mentally ill but please let us remain in good health” and then that staff nurse after making vicious gesture got out of that ward. This incident made patient further depressed. It is an issue which is ethically wrong, as caregivers who should help the patient when they are in true need are abusing them. As the professional code of ethics explains the significance of this ethical issue, which is the base of social morality that “first of all, do no harm”. It also emphasizes that the purpose of nonmaleficence includes not only definite harm but also the risk of harm (Clinical Ethics, 2004). Therefore, an ethical person must be constantly careful about the possible negative consequences of his words and actions with the mental patients. Furthermore, according to the world health organization, In Pakistan we come across upsetting stories about the mistreatment of mentally ill people due to societal hostilities daily (Gadit, 2008). Though, it is difficult to understand why such people are maltreated in Pakistan, an Islamic country where religious teachings are followed. Therefore, to discover the reasons behind this immoral deed, to identify actions to lessen this in society and also to make the caregivers inculcate this thought to support these people in their difficult times, I consider this issue as significant and therefore decided to highlight it in my paper.
As defined by SAVE project of social services that mistreatment is a breach of person’s human and civil rights causing despair. And, this violation can appear once or constantly (SAVE Project, 1995). Mistreatment of elderly person may include physical, psychological or financial exploitation and it can be intended or unintended. Intentional mistreatment involves a purposeful effort to inflict harm such as physical abuse or mauling. On the other hand, unintentional abuse takes place when an unplanned action results in damage, such as ignorance or a lack of desire of the care providers to offer proper care (Jones, Holestege, & Holstege, 1997). As verbalized by my client that at home she was beaten harshly and was always ignored by the caregivers. Moreover, nurse also verbally mistreated the patient and showed lack of desire to care. However, the empirically generated model, which is an ethical model, provided by Fulmer & Malley (1987) gives in depth details of causes and risk factors leading to mistreatment in mental patients. They divided the causal factors of mistreatment into four major categories including physical and mental impairment of the patients, increased strain on caregivers, family history of domestic violence and the societal attitudes. This model elucidates that domestic violence such as abuse and neglect are the behaviors which are learned at home and are passed from one generation to the next. Thus, elder abuse may be a continual phenomenon learned in childhood. Secondly, the stress on caregivers can also lead to mistreatment. Facing behaviors by the elderly mental persons like drug abuse, recurrent falls, incontinence or aggressive behaviors, the caregivers become exhausted and can lash out their resentment on these innocent beings. As happened with my client that due to her habit of cleaning things repeatedly, caregivers always offended and taunted her. Other external stressors such as loss of job, personal illness or low income can also place overwhelming demands on care providers which results in violent behaviors. Furthermore, this model suggests that the ill health of elderly persons in itself is a reason for abuse. Functional impairments lead to dependency on a caregiver for the activities of daily living. As these needs raises, the stress level of caregivers further increases. As faced by my patient, who was always reliant upon her family and husband for daily routine work. This created frustration for the family and at last they left her at psychiatric hospital. Lastly, there are several societal attitudes that contribute to mental person’s maltreatment. Among these attitudes, Stigma is the most common in psychiatric settings. There are many reports affirming that such patients are teased in communities by unkind names (Gadit, 2008). Moreover, according to the World Health Report (2001), stigma and prejudice are the main hindrance faced by the mentally ill today, these abstain them from seeking appropriate care (Rameela, 2004). Besides this, patients are also mistreated in the ward settings by the staffs, as occurred with my client. This is because, persons in institutional care are dependant, extremely fragile or chronically ill. In addition, problems such as low salaries, staff shortages and poor working environment increase the chances of mistreatment. (Lucas & Stevenson, 2006).
As the fundamental duty of all care providers is to perform efforts to improve the quality of life of patients. However, if these caregivers would show such an abusive behavior to the mental patients this will affect their psychological as well as physiological health. As shown in my client who along with psychological symptoms also suffered from insomnia and decreased appetite due to worries of being alone. Besides, as mentioned in literature that, negative behaviors and biases towards those having mental illness is the greatest hurdle to recovery (Chambers et al., 2010). Like, it was observed in my patient who lost all the hopes of being in normal condition as before. This was shown in her verbal comments that “everyone thinks that I am mad and therefore behaves with me in harsh manner and I am sure I will never be fine again”. This shows that how important role the caregivers and their attitude play in the development of mental patients. As very rightly said that “Support has been known to help influence and motivate a behavior change in a positive way” (Clark et al., 2005, p.20). Thus, if there would be lack of support system for these people it would lower their self esteem, intrinsic motivation and leads to decrease self concept (Lowder, 2007). If these mentally un well people are discriminated, this would hinder their ability to assimilate into society and this can lead to social isolation. Also, according to labeling theory, that once public label these people as mentally ill, their presence becomes undesirable in community hence leading them to social seclusion (Lowder, 2007). As happened with my client that when she asked her husband once to meet their relatives, he had beaten her scarcely with wooden stick just because he felt ashamed to take her in family gatherings. This affected her personality immensely and from that onwards she herself remained lonely and isolated. By reflecting upon this we can imagine that how a single dishonest action or altitude of caregivers can massively effect patient’s life. In addition, the interpersonal model of violence in mental health by Chappell and De Martino (2003) also agrees to the point that if patient’s needs and wishes are blocked till great extent, it would intensely affect patient’s mental health hence leading to disturbing effects such as ineffective adherence to treatment schedule and destruction of self (See appendices). Like, my patient tried several times to commit suicide in order to decrease her loneliness and suppress her aggression towards others. This show that it is very significant for caregivers to strengthen the mental health of these people rather than making them more vulnerable to harmful health consequences as conferred above.
After thorough literature search I found out some practical interventions to promote the ways of reducing mistreatment with mental patients. It would be on individual, family, community and government level. At individual level, patients should be granted liberty to take decisions regarding their life and should not be tortured or harmed. This is supported by Human Rights Act (1998) that states “no one shall be subjected to torture or to inhuman or degrading treatment or punishment” (Clinical ethics, 2004, p.24). In addition, the stair case model illuminates intervention strategies concerning abuse prevention in 3 steps which are reluctance, recognition and rebuilding. This includes interventions such as breaking through denial, decreasing social loneliness, sorrow and self blame, providing teaching and advocacy (Loughlin & Duggan, 1998). Health care professionals can integrate these interventions in their care framework. I also attempted to apply this model in my patient’s care. I tried to make my client verbalize her feelings by providing her concrete objects like blank paper and colors. This helped her in verbalizing her internal feelings which were not shared with others since long time. Moreover, throughout my clinical weeks I remained engaged in care through non judgmental speech and body language. As supported by literature that your speech and nature should convey respect and a non-judgmental attitude (Loughlin & Duggan,1998). To lessen social isolation, I involved my client in group occupational therapy and also focused on her hobbies that were, drawing and coloring the religious names. In this way I was able to socialize her to some extent. As supported by literature that, Support groups provide a channel for people with OCD to get emotional support while learning how to manage their condition. Also, this helps victims to lessen the barriers that the memories of abuse place in the way of normal life (Davis, 2008; Child abuse, CPS facts). In addition, abuse creates sense of hopelessness and low self esteem in patients as discussed earlier therefore caregivers should be taught to encourage and praise clients on their little efforts to boost their self concept.
On family level, a good communication and involvement in patient care can be a best defense against mistreatment. Moreover, providing psycho education can also enable family members to remain involved in the care. As, the stress level of caregivers can also be reduced by providing tips of care giving to them and involving in family therapy (Davis, 2008). At community level, social and health workers including community leaders should have responsibility for identifying cases of mistreatment and then organizing interventions to lessen the risk of any future abuse (Loughlin & Duggan, 1998). Moreover, I recommend that the psychological counseling services as well as social gathering area for mental patients should be established in the community, where these people can socialize themselves. On government level, various laws and punishments for the abusers and extensive awareness campaigns on care and destigmatization of mental illness should be arranged (Raj, 2009). Besides, government should also set up monitoring system to ensure that human rights are being followed in all psychiatric facilities (Gadit, 2008). Lastly, I recommend that with the help of mass media cases of abuse with mental patients should be reported so that the strategies should be planned on local and national level to minimize the risk of any future abuse.
It was a good learning experience for me to write a scholarly paper. I have learnt the importance of promoting mental health without abusive and negative attitude. Moreover, faculty facilitation and literature review helped me to learn and integrate all concepts related to the issue which will help me in my future clinical settings.
In conclusion, the above provided evidences are overwhelming that the mistreatment with mental patients is the disobedience of human rights as strongly proved by human rights declaration that “All human beings are born free and equal in dignity and rights.” (UDHR, 2006, p.2). In addition, the paper also discussed the causes and consequences of this immoral issue of mistreatment with mental patients. Now, it’s the duty of caregivers to adhere to the strategies provided above, in order to offer a competent care with encouraging attitude and bring a positive change in the lives of these people.