Society Needs Care Too - The Academic Background to 'Windows of Madness'

Society Needs Care Too

Replacing Patient-Centred Nursing with Society-Centred Nursing in Mental Health Care Settings

Leo Vine-Knight

Overview

Patient-centred nursing care is problematic in mental health settings because it may lead to inward looking therapeutic activity, sick role development and inertia. Interventions may over-emphasise psychiatric and psychological issues at the expense of serious re-socialisation programmes, and an imbalance of service user rights and service user responsibilities may effectively disable the practitioner. For these reasons, rehabilitation often fails service users, leaving them in bed blocked and ‘warehoused’ situations.

Society-centred care moves the focus from individual problem solving to the demands of social life as a whole, using the institutions of society as the basic building blocks of therapy. A grounded understanding of society is seen as essential before service users can be expected to enter a full social life, and emphasis is given to the basic knowledge, skills and attitudes which are needed for successful reintegration. As society functions on a reciprocal basis, it is considered crucially important that an awareness of individual rights is balanced with a sense of social responsibility, or the rehabilitation process will fail. Society-centred care is a ‘top-down’ approach, which begins with the needs and rewards of society, and enables individuals to reach them.

Introduction

Although the central principles of mental health community care in the U.K. include reintegration and normalisation (Department of Health 1989, 1998), there is considerable doubt whether service users always benefit from this approach (Glenister and Hopton 1995, Hadley and Clough 1997). A variety of explanations have been offered for the failures of community care, including the assertion that individualized and normalising care approaches are implicitly culture biased, alienating some service users (Narayanasamy 2002). These views suggest that alternative cultural settings should be available for service users who have little commitment to the values and priorities of conventional capitalist society, but they do not explain why service users who appear committed to mainstream society and conventional rehabilitation, are still failing within it. Accordingly, this discussion focuses on those service users who share the values and beliefs of mainstream society, but fall short of meaningful reintegration, involvement and inclusion.

It provisionally commends two clear principles:

 society should be restored to the centre of mental health rehabilitation therapy
 society itself needs care

The Problems of Patient-Centred Rehabilitation Approaches in Mental Health Settings.

It may be argued that ‘patient-centred’ approaches can fail certain groups of service users in mental health rehabilitation settings because they can lead to inward looking therapies which have often residually confirmed the individual’s sense of ‘clinical difference’ from members of regular society. Therapies focused on the individual may breed under-confidence, sick role self imagery and insularity, because the person in therapy is bound to be discriminated from others during the ‘individualising’ process. In short, the patient-centred process may become preoccupied with individual problem-solving, rather than constructive social activity, and the day to day ethos of individualized mental health care may degenerate into specialist and rarefied clinical practices, dislocated from regular ‘outside’ society (e.g. multidisciplinary meetings, Care Programme Approach meetings, key worker discussions, ward rounds)

Because the individualist nursing approach overlaps with the powerful individualist medical model (Robinson 1991) and individualist psychotherapies, mental health rehabilitation may simply drift into top-heavy psychiatric and behavioural approaches which leave serious re-socialisation interventions until ‘later’. As re-socialisation interventions are often conducted by social service agencies (in day centre, outreach, or hostel settings), and these are usually only reached through care manager or financial arrangements, service users may spend long periods in health care settings waiting for their social care referrals to be processed. This is the critical point where service users may lose momentum, and begin to see the clinic as ‘home’.

The problems of over-dependency, sick role development and insularity, are likely to be much worse where service users are exposed to lengthy in patient admissions, and where they are surrounded by individuals with similarly intractable difficulties. In these cases, the insularity of individualized therapies may be compounded by a suffocating culture of asocial and anti-social clinical behaviours within the immediate environment.

It may be further contended that an imbalance of service user rights and service user responsibilities in rehabilitation settings has often crippled the reintegration process. Clinicians and managers have become extremely vulnerable to criticism from users, advocates, user groups and relatives in situations where they insist on capable but reluctant service users taking more responsibility for themselves and others. In most orthodox rehabilitation settings, there is very little that can be done if a service user simply refuses to contribute, even though there may be no clinical reason why the user remains disinclined. In these situations, users may demonstrate sophisticated skills and significant motivation in the domain of leisure, but very little interest and activity in the domain of work, leaving rehabilitation practitioners both powerless and frustrated (Leighton 2002).

Most disturbingly, some service users have an almost encyclopaedic knowledge of their own rights if pressed by staff, yet remain almost insensible of their basic human responsibilities in society. They can exhibit the profoundest innocence of such things as the work ethic, taxation as the source of state benefits, and the reciprocal organisation of society. There is often no serious expectation that service users in this situation will ever use the skills they possess, and rehabilitation becomes a euphemism for continuing care, ‘warehousing’ and bed blocking. Service users are then likely to remain alienated from society, displacing their frustrations into a variety of institutional coping strategies (Leighton 2002), while practitioners ‘go through the motions’ with political correctness and the red tape of defensive documentation. Paradoxically, service users often become isolated and dissipated by their own ‘rights’, inheriting the cruelty of policy makers’ kindness.

For the above reasons, this book suggests that mental health rehabilitation should pursue an assertive society-centred approach, which uses naturalistic social therapies alongside necessary clinical interventions, as soon as practically possible in the rehabilitation process. It is imperative in a situation where legal rights overwhelm legal responsibilities, that service users entering a rehabilitation setting should immediately sense the normality of social involvement, responsibility and reward, before a clinical syndrome of sick role, over-dependence and inertia can develop. In short, it is only by restoring society itself to the moral and practical centre of therapeutic activity, that the community care principle will thrive. This is a ‘top-down’ approach, which uses the basic communal principles of a democratic society as the primary source of individual rehabilitation therapy.

Society-Centred Care

Effective rehabilitation mental health services should reflect society as closely as possible in their philosophy, objectives and interventions. This will then ensure that service users receive the most appropriate overall therapy for rebuilding their lives and returning to society as contributing and rewarded members. Ideally, society itself should be the main setting for therapy, rather than the hospital or other clinical settings.

According to this perspective, physical, psychiatric and psychological cares have to be augmented with effective social interventions so that service users can increase their social involvement, social understanding, meaningful occupation, and sense of social responsibility. If comprehensive social interventions are omitted or devalued, service users may remain alienated from society, leading to inward looking activity, clinical stagnation and rehabilitation failure. In particular, an over-emphasis of physical, psychiatric and psychological concerns, at the expense of social issues, may promote over-dependence, ‘sick role’ development, and de-motivation amongst service users who then perceive the clinic as their ‘norm’, and society as remote.

Putting society back at the centre of therapy means that service users should become aware of the basic pattern of social life, including simple facts about the role of education, work, leisure, family, religion, media and culture. This should be linked to progressive ‘hands on’ experience of these institutions in natural or naturalistic settings (e.g. regular educational groups in local colleges, real work experience, current affairs discussions on the unit). Society-centred rehabilitation recognises that more people understand social life, the less they will fear it, and the more socially involved they are likely to become, so it recommends a ‘grounded’ approach, where society is entered, experienced and explained in a way central to the rehabilitation process. This is in direct contrast with rehabilitation approaches which look at individual psychiatric and psychological problems in comparative isolation, and then struggle to reconnect the person to society because of intervening sick role development.

Rehabilitation which puts society at the centre of care is in many ways a ‘functional’ approach which must involve people in constructive activity. It is essential to remind service users throughout the rehabilitation process that they have responsibilities as well as rights, and that they should contribute as well as receive. If this balance is lost, rehabilitation therapy will invariably fail, because service users will be incapable of dealing with normal reciprocal relationships in society. For that reason, work should be an implicit and ever present part of the culture of the unit. Work should not be the final goal, it should be the first and most continuous therapy (see Richmond 1999).

This again contrasts with rehabilitation approaches which see work as an ideal outcome, rather than as an essential method. Constructive activity within these systems may remain a distant prospect, because the idea of work is undermined during the early stages of therapy by service users who fear future commitments.
This philosophy of society-centred care encourages a positive environment, where goal directed constructive activity is the day-to-day norm, not the exception. It anticipates a culture of rich social activity, not medical incapacitation and institutional lethargy. It expects therapy to be partly directive, driven, and relatively short term, in a fully social context.

Society-centred rehabilitation may be mediated through a number of mental health care models, but the recovery model (Turner-Crowson and Wallcraft 2002) appears to be one of the most suitable for service users who have previously experienced severe mental health problems.

Society-Centred Interventions

Service users will develop the most appropriate skills and attitudes for returning to society, if society itself forms the basis of interventions. Interventions should reflect society as far as possible, taking their lead from the institutions which make up social life: education/training, the family, work, leisure, health, media, norms and values.

Ideally, rehabilitation work should be set within the mainstream settings of society (e.g. real workplaces, natural families), with practitioners acting as guides and models, but where service user skills and attitudes are too challenged for natural settings, there is then a role for preparatory work in specialist day centres and residential settings. On that basis, rehabilitation units should provide (a) residential therapy for service users who cannot access suitable day centres, and (b) care co-ordination for service users who require a combination of community day centre activities.

The recovery model implies that service users should receive a balanced cross-section of interventions which reflect the structure of mainstream society. Critical factors within this perspective are:

 education
 conventional norms and values
 work

Service users may require basic re-education in literacy, numeracy, geography, history/culture and science before they can be properly involved in society. Without these keystones they will not understand society, or be motivated to fully participate in it. Interventions should be a combination of simple general discussions (e.g. basics of arithmetic, locating home town on a map of the U.K., explaining how medication helps, etc.), and focused practical exercises (e.g. speaking clearly, counting change, finding places in home town using a local map and bus routes, practising self-medicating procedures). This will gradually restore a sense of grounding and belonging which many service users have lost.

Service users should be constantly exposed to mainstream norms and values through outside social activities, one to one reminders, and group work. These norms and values should include self-respect, respect for others, rights and responsibilities in society, and the need to compromise and reciprocate. Interventions should include coaching in basic manners and social skills (e.g. please and thank you habits, turn-taking in conversation, shopping routines), role play on how to compromise and co-operate in social situations (e.g. making decisions, sorting out disputes, dividing work fairly), practising how to budget with money, and broader discussions on the reciprocal nature of society (e.g. why people work – to provide food, shelter, clothes etc.; why we should help – because we receive from others, because it gives a feeling of worth, and so on).

Service users should take personal responsibility for their rooms and appearance, and they could be involved with the day-to-day upkeep of the unit, using a domestic job roster agreed at community meetings. One to one therapy should develop individual constructive interests (e.g. cooking, gardening), and regular groups should be used to discuss basic work processes in society (e.g. food production, manufacturing, building, office work) with associated visits to increase understanding.

Day centre referrals should be included for low level training and re-socialisation activities, and mainstream further education centres should be used for more specific and progressive courses. Community based work experience should be accessed through local Health Trust and Social Service initiatives, the Learning Skills Council, and other similar organisations.

Interventions based on education, norms and values, and work would be essential for a realistic rehabilitation service, because without them service users would remain over-dependent and alienated. However, the family, media, and leisure institutions of society would also provide important opportunities for re-socialisation (e.g. improving family dynamics, discussing current affairs, visiting working museums etc.), while psychological, psychiatric and physical issues would remain significant, but not overpowering, factors.

Summary and Conclusion

This discussion has focused on the potential problems of orthodox patient-centred rehabilitation approaches in mental health settings in the U.K., proposing an alternative society-centred perspective.

It may be argued that the pendulum of individualized care and patient rights in mental health has now swung too far, and that it is in danger of leaving behind the communal principles of society at large, and the important rights of other groups - health care users elsewhere in the N.H.S. who are receiving under-financed care, rehabilitation practitioners who can make no headway with users who have simply ‘opted out’, and tax payers who blindly fund the often ineffective health care system (Halle and Day 2001). This reflects a much bigger problem in the U.K., where individualism has slowly eroded many of the communal principles on which a fair and democratic society should be based (Winship 1998).

It may now be time to revisit the ethics of a collective conscience, and to put increasing clinical emphasis on opting in, rather than out.

Society needs care too.

References

Department of Health, (1989). Caring for People – Community Care in the Next Decade and Beyond. London: H.M.S.O.

Department of Health. (1998). Our Healthier Nation: Modern, Dependable. London: H.M.S.O.

Glenister, D. and Hopton, J. (1995). The Illusion of Progress. Nursing Times. August 2nd.Vol.91.No.31.

Hadley, R. and Clough, R. (1997). Care in Chaos: Frustration and Challenge in Community Care. London: Cassell.

Halle, M. and Day, M. (2001). £10 Billion, That’s How Much N.H.S. Wastes of Your Money Every Year. The Daily Express. London: Express Newspapers.

Leighton, K. (2002). A Sociological Study of Bed Blocking in Psychiatric Rehabilitation Units. Journal of Psychiatric and Mental Health Nursing. Vol.9. No.4. August. pp. 447-457.

Leighton, K. (2003). A Social Conflict Analysis of Collective Mental Health Care: Past, Present and Future. Journal of Mental Health. Vol.12. No.5.Oct. pp.474-489.

Leighton. K. (2004). Anglo-American nursing theory, individualism and mental health care: a social conflict perspective. International Journal of Nursing Studies. Vol.41. January. pp.21-28.

Narayanasamy. A. (2002). The Access Model: A Transcultural Nursing Practice Framework. British Journal of Nursing. May 9-22. 11(9). pp.643-650.

Richmond, L. (1999). Work as a Spiritual Practice. London: Piatikus.

Robinson, J. (1991). Power, Politics and Policy Analysis in Nursing. In Perry A. and Jolley M. (Eds.) Nursing - A Knowledge Base for Practice. London: Edward Arnold.

Turner-Crowson, J. and Wallcraft, J. (2002). The Recovery Vision for Mental Health Services and Research: A British Perspective. Psychiatric Rehabilitation Journal. Winter. Vol.25.no.3. pp.245-254,

Webb C. (1991). Action Research. In Cormack D.F.S. (Ed.). The Research Process in Nursing. Oxford: Blackwell.

Winship, G. (1998). Democracy in Psychiatric Settings: Collectivism v. Individualism. In Barker P. and Davidson B. (Eds.). Psychiatric Nursing - Ethical Strife. London: Arnold.