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Addressing the erosion of compassion in acute mental health services: analysis

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Liberati E, Richards N, Ratnayake S, Gibson J, Martin G. Tackling the erosion of compassion in acute mental health services. BMJ 2023; 382 :e073055 doi:10.1136/bmj-2022-073055


Acute mental health services in the UK have been criticised for a lack of compassion. In late 2022, a series of undercover investigations into inpatient mental health facilities exposed repeated instances of verbal humiliation, unnecessary seclusion, and excessive restraint of service users. Although extreme, these incidents are part of a wider pattern. Shortcomings in services’ ability to treat service users with kindness, dignity, and respect, have been consistently highlighted by regulators, service user organisations, academics, and staff themselves.

Mental health staff, particularly in acute care, help people at times of basic human need, when they need compassion most. Compassion, sometimes described as “a basic kindness, with a deep awareness of the suffering of oneself and of other living things, coupled with a wish and effort to relieve it” (Gilbert, 2009), is central to healthcare provision, and there’s even evidence to suggest that it’s associated with better outcomes.

Yet, there are systemic barriers to compassion in mental healthcare, particularly in inpatient settings. This article examines these barriers, focusing on working conditions, mental healthcare policies and priorities, and institutional oppression, and looks at what can be done to counter them.

We explain how rising demand and resource shortages along with a lack of organisational support, are leading to burnout and disillusionment among staff, making it more difficult to respond compassionately to service users. For some staff, feeling burned out can lead to an increase in negative feelings, psychologically distancing staff from their work and from service users at times when they need compassion and empathy the most.

Some trends in mental healthcare may also make it harder to cultivate compassion. A focus on meeting targets and protecting organisations from legal disputes can affect the ways staff interact with service users. For example, when staff need to assess patients’ risks of suicide or self-harm, these conversations can become focused on exonerating staff from responsibility than on having meaningful discussions about mental distress that might help to prevent harm.

The article also discusses how power imbalances in inpatient settings may sometimes give raise to patterns of oppression, resulting in service users being excluded from decisions, disempowered, and sometimes deprived of their legal rights, in ways that sadly mirror broader social injustices.

Although these are complex problems, requiring interventions at multiple levels, evidence from organisational learning and healthcare improvement can offer starting points to counter the erosion of compassion in mental health settings.

In England and Wales, a reform of the Mental Health Act is underway, but cultural change is required to reframe mental distress as needing contextualisation and compassionate understanding, not just containment. Supporting reflexive practices (revisiting an experience to develop new understanding, so as to inform the response to similar situations in the future) may help develop understanding, skills, and compassion. It is especially important for staff working with people with severe mental illnesses, who are often subject to stigma, to reflect on instances where restrictive practices have been used and think about alternatives.

It’s also important to improve the environments of care. Problems caused by staff exhaustion and disillusionment must be taken seriously, with training, supervision, and organisational support available for those in caring roles. Moving away from a culture that focuses on legal risk and target-meeting is also important to promote safe and appropriate care for service users and families, and for staff’s own wellbeing at work.

There’s a need for long-term solutions that mental healthcare professionals can’t achieve on their own, including better resourcing. The way forward will involve improved training and organisational support, along with reflexive practices, recentring the therapeutic alliance, and the development of evidence for collaborative therapeutic approaches. Compassion breeds compassion: it must be role modelled through kind and intelligent leadership and placed at the heart of supervision, training, and professional development.

The paper sets out the challenges and ways forward.

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