The Art of Doing Minimal Harm to Mental Health

In recent years there has been an expansion of knowledge and practice of quaternary prevention, mainly through Primary Care (1,2). This is a demanding clinical activity, which requires exhaustive knowledge of the potential damage that can be inflicted on patients, recognize them in our own practice and then put into play, alternatives that eliminate them or, at least, reduce them.

Mental health is a particularly diverse field of care, poorly delimited, complex in its conceptualization, heterogeneous in its practices and with effects that are difficult to measure. Subjectivity impregnates, enriching and complicating this discipline and also contributes to hide the damages it can produce. All of this highlights the need to clarify and account for iatrogeny and its conditioning factors in the practice of mental health, the starting point for developing a clinic based on the art of doing the minimum damage.

Sociocultural and ethical determinants of iatrogeny

Current psychiatry and psychology have reached an unprecedented expansion in recent decades: mental health services have grown ostensibly, psychopharmacological and psychotherapeutic treatments have become popular, both psychiatry and psychology have a relevant presence in legal, employment, academic, social … and through the media their professionals successfully promote the importance of these disciplines.

This social success is accompanied by an expropriation of the mental health of citizens who feel that they can no longer face many of the daily life events without consulting a professional. Dependence on and reliance on “psi” technology has reached extraordinary levels because its positive effects have been exaggerated and the harm it does has been neglected.

Counseling, cognitive-behavioral, psychoanalytic and all kinds of therapies appear as almost magical remedies that can eliminate the discomfort of the subject produced by the conscious confrontation with life. Similarly, psychopharmaceuticals have become the only response to many of the ordinary conflicts, which has favored their sales have skyrocketed. In these days, our conception of a full life is a life without suffering, not a life in which we are able to handle it.

This dependence on mental health professionals also occurs in a society devoted to individualism, where everyone is responsible for their success or failure and social conflicts become personal matters. At the same time, in the subject itself there has been a transformation of his ethical dilemmas and the frustration of his professional, family or personal desires into mental problems.

Everything is referred to mental health, which has become a consumer good sold by the pharmaceutical or psychotherapeutic industry (5). In this way, psychiatry and psychology have expanded their field of action in an almost unlimited way, so their potential capacity to harm people is extraordinary, as we shall see.

Curiously, the rise and expansion of these disciplines occurs even when there is no definitive conceptualization of mental illnesses, there persists a lack of knowledge of their causes, generation and development and theories that try to account for it are diverse and with approaches and treatment proposals that are sometimes antagonistic.

In the case of psychiatry, the current hegemonic model is the biomedical one, centered on symptoms and the individual, which relegates context, sociocultural factors, history, etc. to a second level. This model is highly influenced by the commercial and financial interests of the pharmaceutical industry mainly and is protected by a pseudoscientific authoritarianism whose neurochemical basis is not proven.

This way of understanding mental problems that the human (culture, values, meanings…) cannot apprehend with its positivist tools, favours excesses and prejudices in the practice of mental health.

All these conditioning factors favour interventionism and that this is also carried out from a vertical, paternalistic dynamic, in which the patient is placed in the hands of an “expert” professional who names what the patient has and decides what treatment he or she should receive.

On many occasions, it would seem that the professional possesses not only the scientific-technical knowledge, but also the moral judgment to decide wisely what is best for the benefit of the patient without having to count on his opinion.

The patient is often relegated to obey and trust blindly in the professional who acts guided by the principle of beneficence to the detriment of the principle of autonomy. However, the principle of non-maleficence (primum non nocere) is the first and most fundamental principle of the health professional, without disregarding the others.

The Hippocratic principle primum non nocere has traditionally been understood in this way: act in the best interests of your patient or act in such a way that the harm caused by treatment does not exceed its benefits. The problem is that, from this perspective of benefiting the patient, along with an exaggerated optimism of treatments, many episodes of atrocious interventions have been written into the history of medicine and psychiatry from its beginnings to the present day.

The trepanations, the moral treatment, the insulin coma, the malariotherapy, the lobotomy… all were carried out to benefit the patient. Primum non nocere expresses two parts: a mandate to help and a mandate not to harm. The permissive interpretation of this principle gives priority to the first over the second and has justified these atrocities (8).

But there is another interpretation more in line with the doctrine of informed consent and shared decisions. It is the preclusive interpretation of the primum non nocere, in which priority is given to the mandate not to harm over that of helping the patient.

Doing no harm does not mean “not intending to harm” nor does it mean “hoping not to harm”. Thus, implicitly, there is also a mandate to be as aware as possible of the potential harm that may result from the intervention. In the case of coercive interventions, the obligation not to harm increases in importance with respect to consensual treatments where the patient voluntarily assumes the risks.

This interpretation allows that, even if the interventions exceed the benefits of the harm, they can be annulled in the case of consensual treatment by the will of the patient and, in the case of non-consensual treatments, by a court or by a prior directive of the patient when he was competent, through a power of attorney or a declaration of advance directives.

Moreover, it is this preclusive interpretation that is most in line with current best medical practice, which necessarily requires adherence to the doctrine of informed consent. The permissive interpretation, on the other hand, reflects a medical paternalism.

All these social, cultural, economic and ethical conditions favour an excessive, biased clinical practice, centred on “illness” and on the professional, who has extraordinary power. However, the iatrogeny derived from the practice of mental health can be reduced by a professional who is aware of the harm it can cause, of his intellectual and personal conflicts, and who is capable of building horizontal therapeutic relationships as far as possible.