Managing Mental Health in the Community

Chaos and Containment

Angela Foster, Dr Vega Zagier Roberts, Vega Zagier Roberts, Angela Foster, Dr Vega Zagier Roberts, Vega Zagier Roberts

• Publisher: Routledge
• Year: 2003
• Topic: Psychology
• eBook ISBN:
  9781134704309
• Subtopic: History & Theory in Psychology
• Index: Psychology

Managing Mental Health in the Community is a guide to best practice in the management of community care for people with mental health problems.
A major theme is how to balance the 'triangle of care' that represents the needs and concerns of the user, carer (professional or family) and community. Rather than focusing on the mechanics of the task, this book aims to encourage reflective practice amongst staff, managers and policy-makers.
The experienced practitioners who contribute not only challenge some of the assumptions prevalent in the field, but also present some tried and tested interventions used to enable users, staff and managers to function more effectively in community settings.
They consider:
* how community care has developed
* the fundamental concepts of community care
* how management is affected by practice
* how care systems are designed.
Managing Mental Health in the Community should be essential reading for Mental Health Practitioners, Managers, Social Workers, Policy-Makers, Organizational Consultants and all those professionals who are committed to improving the quality of mental health services provided in the community.

Part I

The Move into the Community

This part examines issues ranging from the political to the personal related to policies of community care.

1

Creatures of Each Other:

Some Historical Considerations of Responsibility and Care, and Some Present Undercurrents

R.D. Hinshelwood

In 1960, the then Minister of Health, Enoch Powell, declared that all large mental hospitals would close within ten years—by 1970.¹ In the event, this proved grossly over-optimistic, and the target has taken much longer to achieve.²

The optimism came from three sources. First was the belief that significant cost saving would come from dismantling the large institutions, many of which were sitting on prime real estate. The second factor was the development of the psychiatric ‘wonder’ drugs during the 1950s. They gave rise to a soaring hope that mental illness could now be curable like any other medical condition. Third, at that time there had been a long-standing revulsion at the conditions in the large mental hospitals—over-crowding, depersonalization and neglect. A ‘dose’ of incarceration was, until the 1940s, more or less the only treatment for mental illness (Scull, 1977). Following the Second World War, new ideas came from social science and from psychotherapy.³ These questioned the usefulness of large institutions and pointed at their pathogenic properties (Main, 1946; Jones, 1952).

Added to this, in the 1950s there was the new self-confident NHS which believed itself the best in the world. That sudden optimism for care of the mentally ill in their families and communities has survived until very recently. Now, it is realized that things can go seriously wrong. Doubts and uncertainties about providing care in the community have risen sharply, as has the rhetoric demanding its improvement and success.

We have now reached little short of a crisis in British psychiatry. Increasing political commitment to community care has thrown increasing blame on the professionals for not providing it better (Eastman, 1997). Cost savings have begun to appear illusory even to politicians. The psychiatric services have been starved of the resources for ‘retooling’. Better quality services might simply mean more financial resources, an argument familiar to politicians. It is partly true—but only in part. It is an argument—even an exhortation—that can conceal other problems and potentialities in community care.

There are three further areas of specific neglect. First, there is the lack of specific training for community care. There are many courses but they tend to be skills based, and in the mould of traditional medical and nursing practices. I shall argue that a different dimension—one of relationship—is essential.

Second, staff working in the community need very different specific support, one that blends professional with personal. Not only have longstanding patients in large numbers been set free to be cared for in hostels, community centres and day care and often to roam the streets, but institutionally trained staff, too, have been pushed out of the traditional tightly knit, or even rigid, teams in the old hospital wards. They are required to roam the streets too in search of their liberated patients. Too often both patients and staff become lost. Staff now have to confront seriously disturbed clients—and also their anxious, often pathogenic, families on the doorsteps in the alien environment of a domiciliary visit or the hostile neighbourhood. Staff are no longer on their home territory. They lack the immediate colleagueship of the old mental hospital teams, the regular procedures and comfort of their hallowed traditions. Very special forms of training and support are required for the lone worker in these anxietyprovoking encounters.

More often than not, the pain of the new role has been overlooked. The response to ordinary human experience has been rapidly professionalized (Craib, 1994). Something like a human needs industry has inserted itself in the place of ordinary human relationships. In the ‘old days’, when community care was only a gleam in the eye, it was hoped that mentally ill people could be inserted back into networks of ordinary (or genuine) human relationships which constitute the community. Instead, without training in the latter, ex-patients are inserted back into a network of professional care with, moreover, a highly anxious network of professionals.

This leads into the third area of neglect from which community care has suffered. No attention was paid to what exactly went wrong with the large mental institutions that created the revulsion. We need urgently to consider the shortcomings of the large mental hospital—not just turn our backs in revulsion. If ultimately they failed their inmates, they did so for a reason. We have the opportunity, if we want, to learn from those failings when designing and running new agencies, services and institutions in the community. But we must also keep in mind that the specific pressures of treating very disturbed people will be the same now as before. We might then be better prepared when similar pernicious effects creep into our new community care organizations.

Institutions and Institutionalization: Containing Madness

Too often we are driven by simplistic views about those large institutions, which then drive us forward blindly. For instance, it is sometimes implied that if large psychiatric hospitals have failed, then the answer would be to create small ones, or to be non-psychiatric (avoid labelling, etc.), or to have non-hospital-like treatment centres, and so on. Such simplistic reversals do not address many other important factors detrimental to our work. Important (and interesting) underlying factors need to be taken into account. We do know something about them. We now need to explore those factors that distort our institutions (whether a hospital or community care). And I shall attend to the roots in our relationships to the work and our patients/clients—rather than to the professionalized practice of our skills.

The patient arrives in the service, but more than this, his or her disturbance too enters the organization (Spillius, 1976,1990; Conran, 1985). A psychiatric service exists to take disturbed people away from the community that can no longer cope with the degree of madness. This is no mean task. All mental health workers are immediately aware of its magnitude as soon as they go into the work. It is not surprising that something odd, and woeful, happened in those old psychiatric hospitals—institutionalization (Martin, 1955; Barton, 1959; Goffman, 1961). Though often in a campaigning style, these early writings indicate a quite sophisticated view:

[T]he patient has ceased to rebel against, or to question the fitness of his position in a mental hospital; he has made a more or less total surrender to the institution’s life… he is co-operative. Here ‘co-operative’ usually implies that the patient does as he is told with a minimum of questioning or opposition. This response on the part of the patient is very different from that true co-operation essential to the success of any treatment, in which the patient strives to understand, and work with, the doctor in his efforts to cure… [the] patient, resigned and cooperative… too passive to present any problem of management, has in the process of necessity lost much of his individuality and initiative.

(Martin, 1955:1188–90)

In this description, the distortion to the personalities of vulnerable people results from processes inherent in the institution itself. The power relations are clear, but the patients have lost much more than just power. They have lost significant aspects of themselves—individuality, initiative, enquiry and self-determination. They have lost their active selves. Not only their mental disorder, but now the institution takes a hand in them ‘losing their minds’. A rather similar description was given by Main, in reviewing his experience which started in Northfield Hospital in the Second World War:

[O]nly roles of health or illness are on offer; staff to be only healthy, knowledgeable, kind, powerful and active, and patients to be only ill, suffering, ignorant, passive, obedient and grateful. In most hospitals staff are there because they seek to care for others less able than themselves, while the patients hope to find others more able than themselves. The helpful and the helpless meet and put pressures on each other to act not only in realistic, but also fantastic collusion… [The] helpful will unconsciously require others to be helpless while the helpless will require others to be helpful. Staff and patients are thus inevitably to some extent creatures of each other.

(Main, 1975:61)

Both staff and patients are implicated in a collusion, an inter-group exchange of personality characteristics: what patients lose of their healthy side accumulates in the staff; and what the staff get rid of in terms of their more negative attributes resurfaces within the patients. Personality characteristics are redistributed in the social field—and between two groups: the group of patients vulnerable to losing their personalities, and the group of staff who want to build themselves up in successful medical and curative careers. Care is, certainly, benignly intended but it can swerve off into malignant effects. These ‘unintended’ intentions are unconscious aspects of the people in the institution (or, loosely, the ‘unconscious’ of the institution). Therefore to understand these institutions, and their capacity to be malign and therefore perhaps their potential to be curative—we need to direct our attention to these powerful, strange and unconscious relations between patients and their carers.

Because of their unconscious quality, these effects cannot be simply eradicated. We need to study these human processes and grasp that whatever goes wrong in psychiatric institutions involves the transfer of aspects of personality from one group into another, and vice versa. The work I have quoted targets in on the characteristic of helpfulness, and its matching partner, helplessness. These polarize between the groups.

Loosely, the distortion of attitudes, and ultimately of work practices, that comes from personal needs of the workers is called a ‘social defence system’ (Menzies, 1959; Miller and Gwynne, 1972). The perception of a helpful/helpless dimension and divide is part of a cultural set of attitudes that is sought, for defensive reasons, by all the members of the institution: for the staff in terms of their careers, and their sense of confidence in being care workers; for patients, the opportunity to regress in order to combat the frustration and conflicts of the real world. These are deep meanings transacted, usually unconsciously, between the two groups.

The Psychotic Experience

I claim therefore an important connection: the awful task of containing the intolerable psychotic experience directly influences the organization and enhances the problems of psychiatric institutions. Shared distress in the work arises from the nature of psychosis itself—or, perhaps we should say, from the nature of psychotic personalities themselves. Typically that distress is not formed or articulated in words; meaning itself gives way to an experience of meaninglessness. And this is contagious. It has a direct effect on others and, in fact, percolates through the whole system.⁴ Psychotic patients are very effective at this non-verbal impact. Being a communication of meaninglessness, its communicative function is lost. It becomes merely an emotional impact, an unidentifiable experience. That impact is very unpleasant and by its nature very hard for staff to talk about in words.

Were we to treat a psychotic patient by psychoanalysis, we would be interested in these ‘impacts’ upon the psychoanalyst in the sessions. But when we deal with psychotic patients we are not working in this way. We do not specifically examine our feelings so closely. Nevertheless, all mental health workers psychiatrists, nurses, psychologists and so on—do suffer from the strong emotional impact from their patients, and respond emotionally Very often we simply react to our feelings by trying to stop them. I will describe what I mean.

A young woman came to my out-patient clinic when I was a young psychiatrist. She had previously been in hospital for a number of months and, typically, she had little affect or initiative. Each time I saw her I found myself trying to instil some hope and enthusiasm into her to think of a job, to make friends, to attend a psychiatric club. Each time she agreed with me. And I felt better. And each time she came back to the next appointment she had done nothing; I would feel despondent and set about renewing my efforts to enthuse her.

That describes a repeated pattern with this patient. She made me feel despondent or despairing; and subsequently I managed to talk to the patient so that I could give back hope to myself. My efforts were useless in putting hope into her, but I was effective in removing the unpleasant despair in myself. At that time, in the early 1970s, we were familiar with the ironic instruction: you should give patients drugs if it makes you feel better. So the climate of opinion at the time helped me, with patients like the one just mentioned, to realize that I was operating as much for my benefit as for the patient’s.

We must accept certain things about working with psychotic people: that they do affect their helpers; that the effects are unpleasant; and that our work may in turn be strongly affected by our internal state and our need to make it easier for ourselves, for example by giving drugs, or keeping an emotional distance (see Chapter 13). There are several general features to this impact and our anxious response to the way that psychotic patients rid themselves of the experience by making the staff feel it instead.

1. With my schizophrenic patient, one of the important features was the sense of despair and helplessness. She got through to me a feeling of being hopeless about helping her.
2. This was not transmitted to me in words. A direct transmission of affect occurs by some other, non-verbal route.
3. There is often a connected feeling of fear. It is the fear of something going quickly out of control. This may be experienced as either madness or violence, a mind going out of control. This is frightening to us as mental health workers. It makes us afraid of our patients and we give it a meaning—that they may become violent and injure us.
4. There is another, less clear, fear. That is to do with a feeling that we will get madness inside us as well. We fear that we will become a mind out of control, and therefore mad.
5. There is a particular way in which we experience our patients. It is the sense of meaninglessness in the patient’s experience and anxiety. It is connected to feeling overwhelmed by something out of control. It is a feeling that we are dealing with something that is without meaning, senseless.
6. And finally, the meaninglessness causes another reaction. We tend to pull away from our patients. We reach for a kind of emotional distance from them, as if they are not properly human; or not properly alive. And, sadly, patients very frequently become aware of such pulling away – and may, in the form of redoubled symptoms, express their concerns or protests about the staff’s retreat from them.

Our work creates particular stresses and workers can often suffer burnout. We feel that our personal resources are finished and we cannot go on. The implication is that a special attention needs to be given to the mental health staff, and to their specific need for support, since, in an important sense, the staff’s experiences are a cri de coeur on the part of their patient.

Expectations and Realities

In considering the ‘mental health’ of workers, the crucial factor of what makes people elect to go into the caring professions is important. Invariably we have high hopes of restoring people from dreadful states back into whole and happy persons. This task may have only limited chances of success, and perhaps this is especially so in working with psychotic people. Very small changes for staff may be a great achievement for a patient. But such small gains may seem insignificant to a member of staff seeking to create a completely healthy, new personality in the patient. Thus a major and painful gap opens between the achievement that members of staff demand of themselves and one that is realistically achievable. It leads to acute personal difficulties which often go quite unrecognized, and create an acutely lonely staff member in danger of burnout, as the person strives for greater and greater evidence of success, against the realistic possibilities, and out of touch with their colleagues. It can equally be a burden for patients subjected to the insistence of a member of staff to ‘change’ or ‘get better’ for the sake of that staff member.

How do these phenomena, which make for stressed staff, affect the service itself?

Effects on the Service

What has emerged in providing community care is that the distortions found in the old large institutions recur within the organizations of agencies in the community. Very little is specific to the large institutions. Some of these processes include the following:

• Demoralization: If many staff are subject to feeling despair, then the first danger to the team is that it will become collectively demoralized. People cannot give each other the support, encouragement and praise that is needed when they themselves feel that they are not doing a good job. Some simple indices of demoralization include: high rates of sick leave, absenteeism and tur...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• Contents
• List of illustrations
• Notes on contributors
• Preface
• Acknowledgements
• List of abbreviations
• Introduction to the theoretical basis of this book
• Part I: The move into the community
• Part II: Managing anxiety in the system
• Part III: Learning from the experience of face-to-face work
• Part IV: Initiatives for empowerment
• Index