The psychosocial reality of community care
Angela Foster and Vega Zagier Roberts
Introduction
Is the community simply the location for a form of care or can it be an effective container of mental disturbance? In other words, can a community offer something that is caring—in a therapeutic sense—to those who live there?
Communities were not consulted about whether or not they wanted community care and there is no shortage of evidence to suggest that many communities are worried by the idea that others identified as being deviant or mentally ill should live in their midst. Residents will argue that their particular location is not suitable and—far from thinking in terms of offering care in the form of containment—will be openly hostile, wishing to ensure that the proposed new residents are kept out of the local community. A national survey found that
‘Over two thirds of all respondents (65% of Local Mind Associations, all three voluntary organisations, 8 out of 9 (NHS) trusts, 6 out of seven housing associations) had encountered opposition to mental health facilities in the past five years’ (Repper et al, 1997:4). More often than not, what we see in such situations is evidence of communities whose members feel disturbed at the prospect of having mentally ill neighbours—that is, community members who are disturbed by their own fantasies of what this will be like—rather than by an experience of the reality. It is, of course, a minority of mentally ill people who are a cause of disturbance in their local communities.
This chapter brings together different pieces of work that examine the processes that occur between people who live and work within defined geographical boundaries, that is, within particular communities. It is in three sections: the first examines the dynamics of NIMBY (not in my backyard) and the nature of communities; the second examines the issue of homelessness, paying particular attention to mental illness and homelessness and to the complicated psychodynamics that operate between the homeless and the housed;
and the third identifies and analyses two different responses to the agitation of local residents who became concerned about the number of hostels opening up in their area.
These three sections do not fit comfortably together, particularly the section on homelessness. They contain material that we thought important to include in this book, but which remained ‘homeless’ for a considerable time. It seemed to exist as bits and pieces that should have a place but that were difficult to accommodate in that there was no obvious place where they belonged. It is as if this chapter has come to represent a kind of ‘reception centre’ for these unintegrated bits, and is in itself an attempt to examine the difficulties of assimilation and integration that communities experience.
The main theoretical underpinning of this chapter is Bion’s concept of containment—that is, that thoughts need a container in the form of a mind. He describes a model in which the container and the contained are in a dynamic relationship. The container can squeeze everything out of the contained; or the
“pressure” may be exerted by the contained so that the container disintegrates’
(Bion, 1970:107; see also the Introduction to this book, pages 3–4). In the framework of this chapter, the community (including the houses and the minds within it) is the container, and mental disturbance is the contained. In focusing on the nature of the dynamic relationship between these two, we examine the ways in which communities squeeze out disturbance and the ways in which disturbance damages communities.
NIMBY and community
The NHS and Community Care Act of 1990 was produced, not in a society that was proud to accept and show compassion towards its weaker members, but in a society where the prime minister (Margaret Thatcher) claimed that there was no such thing as society; a society in which the Welfare State was under attack.
Individualism was taking precedence over communalism, and local communities had largely ceased to provide care for their members. Bulmer(1987)writes:
Community care policy is in a shambles in part because ‘community’ has become a vacuous term, meaning all things to all people. It is very difficult to give the term consistent and useful meaning, yet it goes on being used because of its powerful and evocative reference.
(Bulmer, 1987: 214) He makes this statement after having detailed the changes that have taken place in society affecting the nature of local communities: in particular, that it is now only the socially disadvantaged who are dependent upon local contacts for care and support, while all others, with cars, telephones and so on, make use of family and friends who are widely dispersed. Such is the nature of the communities in which the long-term mentally ill are housed.
In addition, people who suffer from mental illness often choose to restrict their involvement with others. Anyone who has been institutionalized, whether
26 ANGELA FOSTER AND VEGA ZAGIER ROBERTS
remaining seriously ill or not, is likely to be lacking in the social skills and self- confidence that are needed for the difficult task of establishing oneself in a new area.
As Tudor (1996) points out, the United Kingdom has a policy of dehospitalization without a policy of de-institutionalization; that is, we set about re-housing the inmates of the old institutions without taking the more radical step of adequately preparing either the inmates or the communities for this move.
The policy of community care, of placing people in the community and not always their own—without de-institutionalisation, without addressing notions of ‘madness’, ‘mental illness’, or mental health let alone the financial, political and organisational issues which need to be addressed, may in itself be considered madness.
(Tudor, 1996: 101–2) As members of local communities—with all their insularity, their prejudices and their fears—react to the arrival of mentally ill people (who come with odd behaviour of their own), it is not difficult to see how some discharged patients come to experience life in the community—especially in the inner cities—as a sadistic attack, a form of torture filled with extreme loneliness and persecution.
Given all these factors, it is hardly surprising that attempts to integrate people with enduring mental illness in local communities often fail.
Failure of integration, resulting in increased physical and emotional isolation from one’s community, means that some people become more disturbed, resulting in frequent hospital admissions. Others largely disappear from view and remain isolated in their own homes, surrounded by four walls, watching ‘life’
through a television set. An extreme example of this was brought to a discussion group by a care worker. She described a woman who needed more help than the worker could provide because of her incontinence. However, in the course of discussion a fuller picture of this client’s situation emerged. The client had vitrually no contact with the outside world; she did not see anyone else, nor did she wish to; she had no television and bought no newspapers. Her home was extremely sparse and she appeared to have no life in her. In fact she seemed to have given up any attempt to control her life or her body.
Here we have a sense of a container with nothing inside—not contained.
The homeless and the housed
The homeless present a different picture, one that we (the housed) see. We are forced to see the homeless as we go about our lives, and when we trip over them
—if not literally, then metaphorically—homelessness has an impact on us. We feel disturbed by their plight, especially if they approach us wanting something from us. This impact is even stronger if the people we see in this state are
mentally ill. They may communicate their disturbance to us by behaving oddly, talking incoherently or shouting aggressively as we pass in the street. Much as we might like to ignore them—and more often than not we pretend that we have not seen them—we are affected by them. They stir up our fear and anxiety.
Homelessness is a political issue, a social issue and—in terms of the dynamics between the homeless and the housed—a psychological issue. Very often these aspects of homelessness are divided or split between the players on the scene.
The homeless client often takes on the role of wanting (or not wanting) concrete practical help. Workers often respond to this request at face value by providing practical help and accommodation or, when resources are not available, by taking on a political role, becoming indignant on the client’s behalf about what should be available but is not.
Clearly the provision of adequate housing is important in any civilized society. Leff (1997) cites research indicating that there has been no rise in the proportion of mentally ill people among the homeless population, but rather
the increased presence of the mentally ill on the streets must be a direct consequence of the increased number of homeless people. The mentally ill have few financial resources and so suffer the fate of others at the lowest socio-economic levels when low-rent accommodation becomes scarce.
(Leff, 1997: 170–1) He suggests that the mentally ill who are most likely to end up homeless are not those who have been carefully (and with extra financial resources) resettled in the community from the long-stay mental hospitals, but rather those who are discharged from admission wards in local hospitals without adequate after-care provision or, in the case of the young mentally ill, those running away from or thrown out of their family homes.
However, merely providing housing is not enough. All too often, homeless mentally ill people who are housed soon become homeless again. While it is important that we address the issue of resources, unless we are able to encompass the psychological element and to think symbolically about the meaning of the transactions that take place between the homeless and the housed, we are in danger of failing to achieve any common understanding and therefore failing to bring about any change even when resources are available.
Research indicates that a high proportion of homeless people have histories of institutional care as a result of parental neglect or abuse, and concludes that These findings suggest that disruption of parent-child relationships has the long- lasting effect in some individuals of attenuating the formation of bonds and facilitating the drift into vagrancy’ (Leff, 1997:172). For people with such histories, vagrancy may feel like a safer, better alternative to the homes that failed them. Such early experience also leads to a state of mind in which
28 ANGELA FOSTER AND VEGA ZAGIER ROBERTS
emotional containment in the form of relationships, and physical containment in the form of a home, are avoided.
A young homeless man responded well to the care that was offered to him on the streets so that workers were happy to be involved with him and keen to see him progress to a stage where he could move into his own flat which they helped him to furnish. But a few weeks later the flat was destroyed by its occupant, who then left it to return to the streets.
We can conceptualize this as the acting out of a mental state so destructive that it smashes everything inside the mind (the contained) and also smashes the mind (the container): a mental state that appears to be uncontainable. It is likely that what had made the move into a flat possible for this client was the relationships that he gradually built up with workers. Once he was housed, these were less available. The four walls of his flat could not replace the container that these relationships had provided, nor could his mind. Smashing the flat can be understood as an attack on the self—a self experienced as full of persecuted and persecuting ‘bizarre objects’ (Bion, 1956). We suggest that for these people, homelessness may be not only a physical reality but also a state of mind.
It is hard to conceptualize homelessness as a state of mind, yet we encounter examples of it when we feel disturbed or threatened by mad behaviour in public places. Whether or not we understand the content of what is being said to us, we feel that it is not directed at us personally. We just happen to be in what feels like the wrong place at the wrong time. Most of us, as we move around our local communities, carry with us a ‘community in our minds’ consisting of those from whom we get and to whom we give care and support. Our community is housed in our minds along with our sense of identity. Those for whom homelessness is a state of mind have none of these advantages. Sometimes our ‘housed minds’ are disturbed by what is inside us; if our ability to contain the disturbance is depleted, for example by stress, then we may ‘act it out’. Sometimes our minds are disturbed by what is outside and we will manage to contain this or not again depending on how adequate our mental container is at that time. Both these situations stir up our anxiety and we therefore react strongly to being confronted by others who clearly are failing to contain their own disturbance. These unfortunate individuals are then easily targeted as receptacles for mad, unwanted and feared aspects of ourselves which we wish to disown and locate in others.
Having made use of others in this way, we then want to keep as far away from them as possible.
NIMBY might then be thought of as the community saying there is ‘no room at the inn’. But in other ways, as illustrated above, the homeless might be saying that ‘the inn, any inn, is unthinkable’, that it is better to be out on the streets than enclosed somewhere with one’s own bizarre mental contents. In addition, the homeless person who refuses to be housed, or to be housed in anything but the worst accommodation, might be saying that the inn is unsuitable, too ‘posh’ or too intrusive or too demanding. It is difficult enough to be confined with one’s own madness, but many people fear that they will also become the receptacle of
other people’s madness. ‘Care’ in such circumstances is experienced as the intrusion of other people’s bits, whether they are meant to be helpful—in the form of practical or emotional aid—or whether they are actually other people’s projections (for example, when the client is expected to be pathetic, helpless and grateful when in fact he or she feels enraged).
Homeless people feel anxious that others will be intrusive with their curiosity, their looks, their questions and their knowledge. One homeless person, when asked why he and others were so reluctant to use the medical help on offer, said
‘because we’re afraid of what you might find’ (E1-Kabir and Ramsden, 1993:
163). As El-Kabir and Ramsden suggest, this fear is both concrete, for example fear of what physical illness might be found on examination, and psychological in terms of what might be ‘seen’ and ‘interfered with’ mentally. To overcome such resistence in clients requires patient and sensitive intervention by workers.
In an unpublished paper on work with young homeless people, Martin Roberts (1996) writes: ‘I gradually worked with Mark to a point whereby I felt he was able to hear and understand that he was maybe in need of a supportive mental health project.’ Roberts had been available to Mark over a number of years during which Mark would come and go, sometimes disappearing for long periods. During this time Roberts had been thinking and learning about how he and his project might provide the sort of containment that people like Mark could use. Roberts’ struggle to find a way of holding Mark in mind, and Mark’s recognition that in Roberts he had found someone prepared to engage in this struggle (rather than someone who sought a quick solution), meant that Mark was eventually able to consider the possibility of holding himself and his needs in his own mind.
To hold in mind that which the client finds impossible to hold in mind is no easy task. Roberts recognizes this and, in relation to another client, writes:
‘Could I take the risk of caring for him?’ When we seek quick solutions, we are avoiding taking this risk by organizing and controlling rather than connecting. We are afraid to connect: afraid that our minds will not be able to take the strain—not least because connection requires us to be in touch with our own homeless bits, those parts of our own minds that we do not wish to house. We are afraid that if we try to house them, our own mental homes/containers will collapse under the strain, leaving us too in a homeless state of mind. But this is the struggle in which we have to engage if clients with homeless minds are to find their own mental and physical accommodation. As Roberts realized, Mark needed the sort of accommodation that could hold him.
In a therapeutic community for ex-drug addicts, on good days the residents would play a song that went like this: ‘Our house is a very, very, very fine house with two cats in the yard. Life used to be so hard. Now everything is eeasy ‘cos of you.’ The house was indeed ‘nice’—luxury accommodation in comparison to what most residents and staff were used to. But the main point to this story is that it was a managed house and a communal house. Its disturbed and destructive residents were not left to their own devices, nor were the projections that flew
30 ANGELA FOSTER AND VEGA ZAGIER ROBERTS
around left unchecked. Chaotic clients need this, and if they are dealing with more than one agency, they also need these to be part of a well-integrated system of care that can hold rather than split further their fragmented bits. Thus, Roberts writes:
[B]oth voluntary and statutory agencies…are now linking together and integrating their work in order to provide strong enough and flexible enough care that is able to withstand and work with the unbearable feelings and the desperate situation that the young person is struggling to manage and is presenting the agencies with.
Is it conceivable that communities too might find ways of doing this?
Case studies
The two case studies below describe two different approaches to establishing mental health care agencies in ordinary neighbourhoods, and two different responses to the agitation of local residents. Both took place in similar places:
prosperous enclaves in an inner-city area where property was already being used for mental health services, causing considerable alarm and opposition among local residents.
Scott’s Green was an attractive triangle of enclosed garden surrounded by large Georgian houses. One side of the green belonged to the health authority, and houses previously used as nurses’ residences were being turned, one by one, into mental health care agencies. On the second side of the triangle were elegant and expensive private properties, while the third side was a dual carriageway through-road. On one corner was a three-storey house which the local NHS Trust proposed now to convert into a twelve-bed residential unit for patients leaving long-stay hospital. They applied for planning permission, and in response to local protest they invited representatives from the local residents’ association to a public meeting to discuss their concerns. Few turned up to this meeting, and those who did were so vehement in their objections that little dialogue was possible.
At this point, the Trust joined the Scott’s Green Residents’ Association as a local business, and two members of the Trust board began attending the association’s regular meetings. Many of the residents who attended the meetings supported local provision of community care in principle, but were concerned about drugs, alcohol and violence on the streets, as well as about the number of mental health agencies that had recently opened around the Green, and about the implications of the arrival of twelve more acutely disturbed people into their neighbourhood. As the local residents became better acquainted with the Trust board representatives, they began to shift from global objections (fantasies) to voicing specific concerns (realities), for example that rubbish would accumulate, that their doorsteps would be fouled, that every time smoke alarms went off the