Is community care a success?
R.D. Hinshelwood
Abstract: Psychiatry in the 20th Century moved from institutional care to care in the community. The hope was to abolish the deleterious effects of inpatient, hospital care, by ab0lishing hospitals. In this paper, I argue that there are hidden unconscious dynamics within psychiatric services themselves wherever the care is practised. So, institutionalisation still occurs in community care, and needs to be understood.
Keywords: Stress, defences, institutionalisation, meaninglessness, job satisfaction
In Britain community care started in a small way after WW2, with experiments by dedicated and charismatic psychiatrists. However, from the late 1950s, the introduction of new psychiatric drugs, meant that even uncharismatic psychiatrists could begin to let their patients out of the wards. The Mental Health Act in 1957, in Britain, allowed patients to be admitted voluntarily to hospital for treatment, and not just for incarceration. The idea of treating the mentally ill became more hopeful and more frequent. And the movement of psychiatric care to general hospitals in the community was a logical step. As a result, the closure of the old-fashioned large mental hospitals began to be planned in order to save money. By 1980, care in the community had become an important focus for the future of psychiatric services.
By the 1990s, however, serious concerns about the effectiveness of community care developed. Books questioning if community care was ‘illusion or reality’ (Leff 1997), or ‘chaos or containment’ (Foster and Roberts 1998) began to appear. A somewhat similar course of events has occurred in the US and in Europe, though with different timescales.
Benefits of Community Care: It is important to maintain a balanced view of community care, the success and the difficulties. The benefits of community care are in fact considerable. They arise from two important factors. First the patient is less likely to lose the necessary connections and bonding with his community, neighbours and family. Secondly, he is free of the disabling effects of the large mental institution – i.e. institutionalisation.
There is an assumption that if someone who is mentally ill can live in a normal setting, they are likely to be influenced to behave more normally. In fact labelling theory, would go so far as to say: if a person is dealt with like a normal member of the community he will lose the distinctive features that have led him to be labelled as mentally ill.
In addition, there is supposed to be a financial saving in people living independently, and outside of expensive institutions. That idea is this: if patients are more capable of self-help and self-care, then they will not need expensive helpers and carers.
Problems of community care
One of the problems of severe mental illness is that patients have often forfeited connections with their community, neighbours and even family by their deviant behaviour. Families are often loathe to accept the ill members back from hospital, in whatever condition. Labelling theory is over-optimistic in that patients have in fact behaved in a sufficiently deviant way to be distinctive enough for exclusion and confinement in the mental hospital. Therefore they became distinctively deviant within the community from which they came, and may become just as deviant when returned.
Thus patients in the community often have no connections apart from the professional carers who visit them. Indeed severely mentally ill patients are often just those people who are very relieved to be without connections. They have often giving up real connections in favour of living in a world largely of fantasy. They make, as it were, a bargain with the psychiatric institution; they put up with the bleak life there in exchange for being left alone to inhabit the world of their phantasies, delusions and hallucinations (Bott 1976). Once installed within the institution on a long term basis patients do not usually want to give it up. It is the paternalistic wishes of the professional staff who decide if and when care in the community is the best option. Community care is not the illusion the patient normally chooses – it is that of the staff.
Patients come then to be called institutionalised when they retreat into their own worlds in an institution, and become passively co-operative in order to be left alone. This process was always assumed to be a bad effect of institutions, and Goffman (1961) amongst many others, have found similar processes in other large institutions, those not concerned with psychiatry. Yet it does seem to be a particularly pernicious process in those institutions for the mentally ill. As a result it is not surprising that something like institutionalisation is particularly infectious in psychiatry.
Moreover, institutionalisation has now been found in community care agencies,
we are used to thinking of [institutionalisation] as a process that takes place within institutions but [it] can also occur within the community if the mentally ill and their carers are isolated” (Foster 1998, p. 68).
This impression is supported by figures,
It is possible for patients to be living in the community but not to be socially integrated with ordinary people… To see whether this was the case , we defined a category of social contact, termed an acquaintance, who was involved in neither providing nor receiving psychiatric care. We found that there was an increase in the proportion of patients who knew at least one acquaintance, from 19 per cent in the hospital to 29 percent in the community… It was reassuring to find that some patients had made social contact with ordinary members of the public, but they still represent only a small minority of those discharged (Leff 1997, p. 81).
There is a degree of de-institutionalisation in community care, but it is a very small effect, and the large majority, well-over two-thirds – remain socially isolated and in effect institutionalised, now within community care itself.
The hope-for financial savings to be made by closing the large institutions did not occur – because good community care turned out to be as expensive, or more expensive than institutional care.
So, community care is not a great success story, though it has some promise, if its performance could be improved.
The question therefore is how can it be improved?
A lot can be done by improved training of health professionals. Those most experienced in psychiatry have mostly trained in hospitals and institutions, and the first generation of health professionals who practised community care, did so on the basis of intuition and enthusiasm.
In Britain there have been attempts to integrate psychiatric community services with community professionals in other branches of medicine, in order to try to inject more experience of home based and clinic based care. This has been remarkably unsuccessful in my experience since the enthusiasm for caring for grateful, physically ill patients, is markedly different, and greater, than caring for disturbed and disturbing mentally ill patients, who often lack the appreciative regard that staff need.
At this point I should like to go more deeply into one aspect of psychiatric work which is often not given much, or enough, attention. We tend to focus on patients – but stress is equally a problem for the carers. Because of a lack of attention to the carers, community care is vulnerable to the effects of this neglect.
Caring for the carers
This draws our attention to the kinds of emotional reactions that staff suffer (see Hinshelwood 2004). If close contact with psychotic patients affects families, friends and neighbours, it is likely to have a similar human impact on psychiatric staff. It will do so in a variety of ways that vary with the past histories of individual staff members. However, there are general features too, ones which come from the nature of psychotic anxiety. These are particularly connected with the way psychotic patients rid themselves of their experiences by making others feel them instead. Joe Berke commented, ‘Schizophrenia is an expertise in producing disquiet in others’ Berke 1979, p. 23). I will describe the kinds of experiences staff must manage in themselves; and later what effect this has on working together as a team or as a complex of many psychiatric services linked together.
Now, the experience of being closely in contact with severe emotional and mental disturbances is complex and distressing and can be unpacked. Many workers may not agree with me. Perhaps they are right and not affected by patients suffering in these ways; but it is equally possible they and their teams have managed the impact out of their conscious awareness at work. Here is a series of possible dimensions of the impact I have been referring to.
First, one of the important features is the sense of despair and helplessnesss. This gets through into the staff, and they feeling hopeless about helping.
Secondly this is not transmitted in words. Psychotic patients use another, non-verbal route to make that direct transmission of affect.
Thirdly, 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. We give it a meaning – that they may become violent and injure us.
Fourthly, there is another, less clear, fear. That is to do with a feeling that we will, ourselves, get madness inside us as well. We fear we will become a mind out of control too, and therefore mad.
Fifthly, there is a particular way in which we experience our patients. That is the sense of meaninglessness in the patient’s experience and anxiety. It is a feeling that we are dealing with something that is without meaning, senseless; and this, is connected to feeling overwhelmed by something out of control.
Sixthly, and finally, the meaninglessness causes another reaction. We tend to pull away from our patients. We reach 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 express their protest with a redoubled intensity of their symptoms.
These are experiences that we suffer in our work. They play on our feelings about our work. Like our patients, we have an unconscious level to our feelings.
Unconscious expectations: My experience in healthcare is that these specific kinds of anxiety occur – about the suffering, stress and madness of the patients and clients. These have a particular impact on those of us doing the work. Indeed the impact is often exacerbated by the very reasons which led us into the work in the first place. So often, we ‘chose’ a career as a carer because of some ill or unhappy person in our own families which we grew up in. The urge to put them right is often very strong, and is based on immature wishes and phantasies which we had when young.
Those phantasies in general tend to represent very unrealistic wishes, often called omnipotent, in which the expectation is to restore someone to full health and happiness. When those wishes are transferred later onto our patients there is the same unexamined expectation – omnipotently to restore people to complete health and happiness.
There are important consequences when we have omnipotent and unrealistic expectations of what we can do. The consequences are aggravated by being unconscious and at that level of mind which comes from infancy rather than from a sophisticated view of the problems to be solved. Being unconscious it is difficult for anyone to address that level of expectation.
What are those consequences? I want to concentrate on one of them in particular. When we do our job and achieve results, it is a source of satisfaction. However, like everything else in life the results are likely to be good, only to a certain degree. Nothing is ever perfect. Good-enough is what we must live with. However, those are sophisticated expectations – to do a job well enough. It is a different matter when we come to the unconscious level. There an unreality dominates, and perfection is expected and this may be especially so in high-stress work like mental health. The job must be perfectly done, and in our case the clients must be restored to perfect mental health. As a result, we probably have two separate reactions to the results of our work;
- First, a conscious appreciation, judged by the realistic circumstances – what is achievable with a specific client, and with the resources and opportunities available.
- Secondly there is an unconscious reaction demanding perfection but finding, in reality, only imperfection.
The latter will arouse a degree of feeling a failure – a lack of satisfaction in the job. In a job like mental healthcare there is inevitably a lot of feeling of failure floating around.
In my view the psychiatric services are particularly prone to being undermined by feelings of failure, for these reasons. But the point at the moment is that these feelings which spring from the unconscious level have to be dealt with – and have to be dealt with without a proper recognition of where they come from.
There are two main ways in which these unconscious undermining feelings can be dealt with. One has unconscious harmful consequences; and one with more beneficial effects.
- First, most commonly, feelings are moved around the interpersonal network, leading to unconscious institutional dynamics which interfere with the work. This first method gives rise to various interpersonal phenomena, including problems with the task. I shall describe this further in a moment.
- The second method, is a supervisory one. The problem of failure most often arises when the unconscious expectations do not match the conscious ones, when the unconscious expectations are for an unrealistic perfection, and the conscious ones are more to do with a sophisticated appreciation of what can really be done. Therefore that problem can be helped by strengthening the appreciation of what is realistic. In my view the most useful thing in supervision or consultancy is to help the workers to recognise what expectations are realistic, and to help them to recognise how much they want other results, unrealistic results. In this way the unconscious level of experience is acknowledged and worked with, by comparing those perfectionist feelings with the conscious appreciation of reality.
Social dynamics of the institution
Now, the institutional pathology.
There are processes, at the level of the institution itself, for making life tolerable in the presence of psychosis. These organisational processes, institutionalisation, are driven by the ways we, as individuals, cope with the unpleasant impact of our work. Let me mention just a few of these that derive from the painful situation for staff.
Demoralisation: If many staff are subject to feeling a failure, then the first danger to the team is that the team itself will become demoralised. People cannot give each other the support, encouragement and praise which is needed, when they themselves feel they are not doing a good job, or not getting the suppor5ive appreciation they need. Some simple organisational indices of demoralisation are: high rates of sick-leave, absenteeism and turnover of persons in the team. When such things happen, the team feels unstable, and unsupportive and the morale tends to get worse. A disastrous spiral, or vicious circle, takes place.
Stereotyped patients: However, there are ways in which the team members can collectively help themselves. One is to deny the feelings of helplessness and despair. In this sense the collective attitudes support the individual psychological defences. The experience is repudiated. Then, it is very common for the staff to agree that those feelings are located in their patients – only. A rigid perception of themselves and their patients grows up, as Main described, patients are stereotyped as ‘only ill, suffering, ignorant, passive, obedient and grateful (Main 1975, p. **).
Scapegoating: This process leads to a different outcome when one particular patient is elected into a position to carry all the hopelessness. He is the ‘scapegoat’. And he usually gets worse clinically – thus confirming the way the staff have decided to see him. Often he is then sent off to some other part of the service – the locked ward, the refractory behaviours unit, or wherever. Then, the team find another suitable patient to be elected to the role. And that sequence may go through a number of cycles.
Routinisation: The meaninglessness of the patient’s experiences and anxiety is very corrosive of the staff’s ability to continue with empathy and understanding. The distance to which the staff retreat can then be institutionalised by a systematic process of turning the work into a set of routines – one could say mindless routines.
Blame: Alternatively the staff team can collectively change their direction of interest. Instead of feeling hopeless about their patients, a new attitude grows up. This is a view that the patients could be helped but there are not enough resources in the team. The problem is believed to be the managers who keep them so short of staff, of training, of money and so on. There may be some truth in the shortage of resources but staff feel and behave as if they were under siege against their employers who don’t understand them, or who are stupid, or who may be deliberately hostile. The team can feel happy together, and maybe even happy with their patients, so long as they have an external enemy they can fight.
Schisms in the service: Alternatively, the team may become divided within itself. If each person has the feeling, absorbed from the patients, of being hopeless, then they can export that feeling by electing others in the team as the hopeless ones. This can lead to a lot of mutual denigration of each other, often not expressed. In this case nobody can really get a proper picture of who is doing good work and who is not. Realistic perceptions of each other and mutual support are both lost. One characteristic feature of schism in our service is where psychiatrists begin to promote physical treatments based on biological aetiologies, and psychotherapists and psychologists emphasise in contrast the human and relational aspects of their patients’ distress. The two ideas and segments of staff can get into mutual opposition sometimes becoming implicitly denigrating of each other – and sometimes even explicitly
Fragmented agencies: The last phenomenon is a similar process, one to which community care agencies are specifically prone. One agency can project the despair and hopelessness into another team within the community services. Different teams then get into the same mutual denigration of each other – the domiciliary team, the day hospital, the in-patient ward, etc. Then the service itself becomes fragmented.
With these various processes, occurring at the level of the organisation, the quality of the service must get worse. Changing staff, high levels of absence and temporary staff, scapegoating of patients or colleagues, and splits within and between teams must all have a very negative effect on the work done. In turn this will affect people’s morale as they realise that they do not give the best chances to their patients. Once again this plays on the crucial gap between the high hopes that staff have of themselves, and their apparently ‘low’ expectations. The lack of job satisfaction enhances all the doubts the staff have about themselves, about each other, and about their employers. Paranoid attitudes become entrenched, and self-fulfilling.
Supervision
For a long-time it has been recognised that workers in social and mental health work suffer burn-out. We can put up with the stress to a certain limit, but it uses up something in us and, in the end, our resources are finished and we cannot go on. The implication is that we must pay special attention to mental health staff. Staff support is all important.. There are several reasons we should act, not least because staff will leave or fall ill due to burnt-out without support. Also it is simply inhumane to do nothing, when we know that staff are suffering – even at n unconscious level. Furthermore, it is only with adequate support that staff can continue to attend at all to the experiences that the patients – and they themselves – are going through. The direct impact of severely disturbed patients is to create, actually in those around them, the experience of despair. It is the worker’s own good intentions towards patients that make them most vulnerable to these kinds of non-verbal communications. It is important that the experiences of the staff team are recognised as a cri de coeur on the part of the patients.
It might not be going too far to claim that attending to the mental health of the workers is as important as attending to the mental health of the patients. Supervision must therefore be sensitive first of all to the staff’s ‘countertransference’ feelings
The implications for supervision are great. The supervisor needs to be aware of a number of things:
- He must be aware of the fragility of the professional confidence of psychiatric workers, and how easily this can descend into despair and demoralisation;
- He needs to lay some emphasis in his supervision on the unconscious omnipotent ambitions of the staff which lead so easily to feelings of failure;
- He needs then to be aware of the organisational phenomena;
- He needs to know that the strain of the work is not contained within the presentation of the work, and will seep into comments, and grumbles about the organisation etc.;
- He needs to be aware of the way that the task and role of the supervision itself, might be affected by the group dynamics of the organisation; and this means to try to conduct an internal supervision with himself; and
- Thus he needs to be an internal supervisor, and to teach this idea to his supervisees, so that they may begin to grasp how they are carried away by the dramatisations within the organisation; especially the drama of omnipotent staff completely curing the worst partients.
When working in an institution it is important to bear these sorts of distorted perceptions in mind, if possible. My view is that the distortions of task and role are the easiest to observe. Clearly we might call for someone who stands in a more objective position. Someone from outside. However it is not impossible for someone, buried inside the organisational dynamics to become aware of what he is involved in. It is not an impossible requirement. It is a requirement to straddle two psychological positions (a) to have a subjective experience, and (b) then to think about it as if it were an objective way to assess another sensitive human being. We are of course familiar with this position straddling subjective and objective functions. Because that is exactly what a psychoanalyst does. He engages with his patient as another person, and thus exists in a subjective empathy – but then he thinks carefully about what that relationship between them is, what is happening between the two of them in a more objective way. It is a half-in/half-out quality; and is called a reflective practice.
Supervision takes place at the level of the individual, group or institutional dynamics. It is not easy to disentangle one from another, and one has to bear in mind a flexible movement from one to the other in one’s thoughts as a supervisor. The individual dynamics contribute to the group, and vice versa, and the inter-group dynamics to the organisational. A supervisor has to work as always to bring new light on the situation the supervise brings to him. But in addition he must endeavour to understand the role that he, his supervisees, and his supervision group, play for the organisation.
Conclusions
I have described a division of the roads. We can continue as we did in the old days in the large mental institution, with stabilised unconscious dynamics obstructing the work of staff and patients; or, we can institute, in our new community care agencies, a different approach which tries to look at the processes that in the old days caused these problems, and we can learn from them. My message is we need to learn about the pain and suffering of our staff first, before we can help our patients. The skill of psychiatrists is to be able to support nurses in their work, and to do it in an appropriate way. We need to be aware of the frustration of only moderate success. Part of the skill of the nurse is to make use of that support and to discuss our patients in a realistic way, acknowledging our emotional wishes, and frustrations. We need to be always alert to the fact that moderate success is still success.
References
Berke, Joseph (1979) I haven’t had to go mad here. London: Penguin.
Bott (Spillius), Elizabeth (1976) Hospital and society. British Journal of Medical Psychology 49: 97-140.
Foster, Angela (1998) Psychotic processes and community care: the difficulty in finding the third position. In Angela Foster and Vega Roberts (eds.) Managing Mental Health in the Community: Chaos and Containment in Community Care. London: Routledge.
Foster, Angela and Roberts, Vega (eds.) (1998) Managing Mental Health in the Community: Chaos and Containment in Community Care. London: Routledge.
Goffman, I, (1961) Asylums: The Social Situation of Mental Patients and other Inmates. London: Penguin.
Hinshelwood, R,D. (2004) Suffering Insanity. London: Routledge.
Leff, Julian (1997) (ed.) Care in the Community: Illusion or Reality. Chichester: Wiley.
Main, T. (1975) Some psychodynamics of large groups. In Kreeger, L. (ed) The Large Group: 57-86. London: Constable. Republished (1989) Main, T.F. The Ailment and Other Essays. London: Free Association Books.