Naomi Landau and Michael Wallbank
Introduction
In this chapter we reflect, from our perspectives as a senior social worker/care manager and community psychiatric nurse respectively in a multidisciplinary community mental health team, on our work with those who have both acute and continuing care needs. We give an account of a clients’ evening psychotherapy group which we co-conduct, as illustration.
We welcome current moves to target vulnerable people and ensure that they receive coordinated quality care. Care management and the Care Programme Approach (CPA) offer opportunities, especially on the macro level, for organizations to purchase services in response to identified needs. The attempt to develop a system of care based on need rather than on resources available is an admirable one, if one that remains difficult to convert into reality.
At the same time, we acknowledge that in any system of care there are dangers which can undermine the very objectives that they seek to achieve. In this chapter, we identify some of these. We suggest that working practices easily become defensive measures for psychiatric services, reinforcing fragmentation rather than helping clients to make the necessary connections, both internally and with their outside world.
We argue for the importance of retaining a therapeutic (‘provider’) role with clients. Recent writings on risk management emphasize the importance of the relationship between worker and client (Crichton, 1995). Therapeutic involvement is essential to engage disturbed and chaotic clients in the process of assessment at all. The danger with splitting commissioning and provision for such a fragmented client group (people with severe and enduring mental illnesses, targeted by statutory services) is that it can lead to reinforcing the internal fragmentation of the client group. Engagement with one worker proves difficult enough for most clients, let alone with a barrage of workers from different agencies. It is impossible to implement or review a care plan without an involved, trusting relationship with the client.
A second important split occurs when we identify a high priority group of clients to meet the criteria designed by the local authority for care management/
CPA (DoH, 1990a), and for the Supervision Register (DoH, 1994). Everyone is aware of much-publicized failures of the system to meet the needs of some vulnerable and difficult people. Increasingly, only people who suffer from the most serious of psychiatric symptoms have access to resources. In terms of group treatment and support, this means that they have access only to each other. This reinforces the generally perceived split between those who are ‘mental’ and the rest of the community.
This splitting off impinges dramatically on the very clients identified as most vulnerable. Where they link into group support and group treatment, they will have less opportunity to have contact with less disabled clients. Workers who traditionally used a range of resources and therapeutic skills are less likely to have access, for example, to training in psychotherapeutic responses to the needs of their more disabled and difficult clients, as these skills are seen now as relevant only to the less disturbed. A significant number of staff with therapeutic knowledge and experience are being moved into the role purely of providing
‘packages’ of care. Some workers, who trained, after all, as providers of a range of therapeutic interventions, move away from the statutory sector into other agencies where they can use them, but with a less exclusively vulnerable and difficult client group.
We argue, and do so through the example of the psychotherapy group, that our job is not to separate off but to integrate. Psychiatric services and interventions should be developed with this in mind. Otherwise, in the move away from an asylum-based system towards a community-based one, we create structures that bring about yet again a divide between people with mental illness and the wider community. We use the psychotherapy group as one example of a service that was offered as part of a package available to clients, and of how a group can be an agent for integration and connection, rather than fragmentation, when it becomes a place where clients with different needs and abilities engage with each other, and where the assessor (care manager) is actively involved in ongoing provision (treatment).
What do we mean by community, care and quality?
The thrust of this chapter is to expand on terms like ‘community’, ‘care’ and
‘quality’. These are terms to which we all attach some meaning, with little awareness as to whether this meaning is shared. We can become glib in our use of them as a way of avoiding the enormous difficulties for our clients, and also for us, in making the terms a reality.
Community
Recent UK legislation—the NHS and Community Care Act (DoH, 1990b) and accompanying Department of Health circulars—provides a legislative framework for the move in psychiatry towards mentally ill people receiving their care in the
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community. Inherent in this move is the assumption that there is such an entity as community. It is not one readily available, however, for our clients to use. In a very real sense, there is no such thing as community for most of them. It needs to be created both internally and in the outside world. Most are out of contact with themselves and others, and through mental illness they become marginalized and increasingly isolated. Hospitals provided an institutional community identified with a building. Without such a container, the notion of community becomes much more tricky.
Care
This is not something that clients can easily receive. Very often, those with mental disorders and illnesses have had very poor experiences of care, and their internal worlds are littered with attacking and rejecting objects as a result of their early experiences of inadequate care. Clients can feel neglected and workers can feel anything but caring: rather, they can feel hateful and attacking in return. The policy of care at arm’s length—care management—can serve as a defence, to increase the emotional distance between client and worker. We would argue that quality care for what is a very fragmented and out-of-touch group of people can be provided by professionals only if they have a thorough understanding of the processes of mental illness, and bring a reflective and planned approach to the work.
From our experience, the effect on workers of focusing exclusively on people with severe and enduring mental illness is ultimately detrimental to clients. Many of those targeted as being high priority are not willing participants in care (a consideration often overlooked in ideas of a client-led package of care). A large minority enter the care system via compulsory admission and have gross problems in engaging, often attacking that socalled care and the care managers, rejecting contact and intimacy. When these are the only people targeted, the effect can be numbing for workers creating a ‘caring’ group that is numb, rather than alive and sensitive to the issues and demands that this work requires. It can produce a defensiveness that leads to poor practice and care. The danger of current trends is that skilled workers with expertise in many fields leave the public sector, leaving behind a demoralized and defensive service (see Chapter 1).
Quality
There is a widespread desire among politicians and managers (and indeed clinicians) to find ways of setting standards, of measuring the value or effectiveness of care. However, the danger is that, in attempting to define concrete measures of quality, we lose the very quality we seek to ensure. The system that attempts to measure quality is defensive and ends up emphasizing quantity. The legislation is born out of a very real anxiety about caring for large
numbers of psychiatric patients in the community, following drastic reduction in the number of beds available to mental health teams. It is an awesome task.
Attempts to package care and to quantify interventions are a way of coping with the anxiety generated. The systems developed so far can mask the very complex issues involved. Foster (1993; see also Chapter 5) talks of how the system itself becomes psychotic—taking flight into unreality as a dysfunctional way of coping with the anxiety aroused. Attempts are made to deal with anxiety by prescribing numerical measures, e.g. response time to referrers, numbers of face-to-face contacts with clients, rapidity of response, etc. Our experience as workers is that staff time and preoccupations become focused on producing these statistics.
Driven by the new anxiety of meeting statistical targets, workers lose the capacity to reflect together on effective ways of responding to the real needs and confusion of the clients. In the current debate, quality—as opposed to quantifiable measures—gets squeezed out.
Nonetheless, it is important to have a concept of quality, and to attempt to measure the value of interventions. We believe that this can be done in a meaningful way by attempting to examine outcome measures. This is what we have attempted in evaluating our group (see pages 172–3).
The history of the group
Foulkes (1990) wrote: The community is represented in the group.’ We are working with clients whose disturbances are, at root, problems in communication, in connection and in belonging. We work in a team which aims to provide clients with a sense of community. We do this through the use of a local community centre—running mainly activity-based groups there—and through our networking and the commissioning of care. We would argue that the team also does this in all aspects of its therapeutic interventions, not least through the psychotherapy group.
The group is a slow, open one: that is, new members are able to join the group over the course of its lifetime—and some members leave—but the group is given time to prepare for these changes, and due consideration is given by the group coordinators as to when the group is ready for them.
Work for us began with joining a weekly supervision group at the Institute of Group Analysis (IGA). That work was crucial to the subsequent life of the group, helping us to plan and reflect on the continuing process. We agreed to meet with potential members three times before they joined the group, to assess and to prepare them for the group. We put advertisements and notices for the group in places that our clients frequent, such as drop-in centres and GP surgeries. We assessed a total of seventeen people with a broad range of need, from those requiring care management (diagnosed as suffering from severe and/
or enduring metal illness) to others with less severe problems. Of these seventeen, nine were not allocated places, either by their own choice, or because we felt the group did not meet their needs, or because the needs of the group as a
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whole contra-indicated their joining. Of the original eight people who joined, three dropped out earlier than we recommended: we knew there was a risk of people leaving in flight, thereby repeating established patterns in their lives.
However, most group members, including those who left, have seen marked changes in their functioning. At the time of writing, the membership includes clients who have recurrent and long-standing mental illnesses and qualify for care management under our local authority’s eligibility criteria; others with severe and long-standing personality problems (borderline/psychotic, or antisocial personality disorder with depressive symptoms); and one with some personality problems who suffers from crippling anxiety.
The life of the group: the group process
The group members
Members bring into the group current difficulties in their work, accommodation, intimate relationships and families. They bring a history of such difficulties from the past, and an account of their first significant relationships with their families of origin or substitute families. They bring their experiences of not coping and of illness. Neglect and abuse feature prominently in their histories, as does a pattern of repetition in their relationships.
Within the group they encounter feelings in relation to the group as a whole, to individual group members or to the conductors, which are often familiar feelings for them. They use a variety of mechanisms—denial, projection, displacement—
to keep these feelings at bay. They nonetheless communicate these feelings in very powerful ways. For instance, one member has been consistently muddled about the timing of breaks—missing sessions immediately before and after, and attending the centre during the break while denying having any difficulty with separation.
The role of the stafflgroup conductors
Our role as conductors has been to transform these unconscious primary processes into conscious experiences and feelings. In the above example, the group member is, in fact, repeating an experience of gross neglect. He was abandoned by his natural mother at birth and experienced abuse in a variety of institutions. In letting the group down so consistently, he is attempting to displace these powerful but most uncomfortable feelings onto the group as a whole. In turn, the group denies experiencing being rejected or let down by him, as they too share unacknowledged experiences of rejection and neglect. In the group we have looked at how this client’s feelings about breaks are being expressed in this acting out, which reflects recurring patterns in his experience of work and in his relationships which are often very damaging to him. He
anticipates loss, rejection and abuse by initiating separation himself, and in turn provokes the hostility of the group through his actions.
There is resistance to our attempts to interpret the content of the group. Such denial is understandable; these are very isolated people for whom connection is terrifying because of their history of being repeatedly let down. However, as group members continue to bring material that confirms these patterns, so their resistance lessens and they begin to own and recognize in themselves and in each other these previously unknowable feelings.
It is the role of the conductors to nurture this sense of connection, and of meaning to be found in relationships within the group—i.e. to create a sense of community. The group is reluctant to examine the meaning of absences because the sense of the absence of good primary objects is so painfully present in their lives. By paying attention to the minutiae of the comings and goings of this
‘community’, we attempt to create their own internal ‘packages of care’.
The role of supervision
We derived important insights from the fact that supervision itself took place in a group, with issues for us as co-conductors often mirrored within supervision. We were able to explore our own counter-transferences in the group itself, within the safety of supervision. For instance, during the assessment process, we disagreed over the suitability of one applicant, and were able to look in supervision at how this disagreement reflected the client’s own ambivalence about joining the group and wanting to change; a conflict that culminated in his not returning for his final assessment appointment.
Another time, we brought our extreme anxiety about one group member who expressed self-destructive and suicidal ideas. This was a client with a long history of breakdown previously framed solely in terms of a psychiatric diagnosis of manic depression with a consequent need for hospitalization. In the group, she began to explore alternative ways of understanding her experience, most notably the way that she might be using her role as patient to avoid looking at painful, angry feelings. The work brought her enormous rage to the surface, which was expressed both towards the group and then turned inward against herself. In supervision we found ourselves at times reproaching each other, albeit subtly, about our own interventions, and considering additional psychiatric assessment. We came to recognize that, although we had to take her suicidal thoughts seriously and liaise with her GP and psychiatrist (something that we always discussed with prospective members of the group, and within the group itself), our counter-transference feelings could also be understood as our colluding with her powerful need to see herself and the group as requiring protection from her destructive feelings. It was vital that we and the group contained her—tolerated, understood and helped her to think about these feelings
—rather than merely getting rid of them and, most dangerously, getting rid of her from the group.
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The value of working as a group
Working with such high-risk clients, who project destructive fantasies onto the group and onto the conductors, demands an ability to provide containment while our own counter-transferences are so hard to bear. Their impulses are to reject and spew out rather than stay with and reflect. We, as conductors, were often identified initially as the only people in the group capable of containing such feelings so as to be able to reflect on them. Our task has been to trust the group to do that work, to allow the group members to model for each other ways of providing such a thinking capacity.
We have made the point that people in the group come with different histories and differing experiences of psychiatric services: some with a long history of major mental illness; others experiencing recent crises, driving them to begin confronting vulnerable aspects of themselves. In addition, some are apparently enthusiastic to work, and grasp at the process eagerly, while others show their ambivalence more clearly. Most are defended and confused. By trusting the group to do the work, we as conductors allow connections to be made within the group at the individual members’ own pace.
For some of the group members, one of the most difficult things to face has been that problems that have been previously always framed in terms of illness can be understood in other ways; ways that do not deny the reality of illness, but nonetheless give them more control—in itself a frightening prospect. They do this by making connections with other members of the group. Some of those other members share similar problems in relationships and in taking control of their lives, yet do not have the same illness model on which to fall back, and, what is more, insist on ‘normalizing’ many of the experiences of their ‘ill’ co- members. One result can be that group members who previously explained all their difficulties in terms of mental illnesses are forced to look again at how they view themselves.
If the group were composed wholly of those meeting care management criteria, it would function (if at all) in a very different way—the learning and modelling would fall far more onto the conductors rather than on the group as a whole. The main, or only, reflective role would be ours, and this would work against the group learning process. It would not provide the same opportunity to the more damaged members of understanding and recovering through the insights of others less ill and less prone to psychosis. It would be more difficult to move to a position where health would be seen as located not just in the conductors but in the group as a whole.
What must be apparent to the group members is our own trust and confidence in each other as co-conductors, developed through the supervision that we receive. Good coupling, bad coupling and failure to couple at all have been issues for all group members. One member joined us when she was suffering from crippling panic attacks and delusions about her body. She attributed her current problems to a history of unsatisfactory, casual sexual relationships,