Feature

Chaos and containment in community care

Politicians and policymakers need to understand the experiences of front-line community care workers rather than constantly redesigning the system they work in, argue Angela Foster and Vega Zagier Roberts

There are many different ways to think about mental illness and its treatments. These vary from a strictly medical view that locates illness firmly within the individual and takes a functionalist approach to treatment, a moral view that sees treatment as re-training, to a socio-political view that implies a radical social approach to treatment. The history of mental illness illustrates these differing views and the different approaches to treatment and care they have given rise to.

Most people involved in caring for mentally ill people in society have some knowledge of all of these views, but professional training plays an important part in determining our opinions, values and biases. The inability of the medical profession to cure mental illness, and the closure of long-stay hospitals, means there are now even more people with differing views working in the field. While this provides a greater variety of skills and approaches, it can also lead to conflict and misunderstanding.

Some of this conflict and misunderstanding is about the nature and purpose of community care itself. Is it a way of saving money? Is it a response to the shortcomings of long-term hospital care and the effects of institutionalisation? Is it a way of providing more humane treatment? Is it a recognition that care rather than treatment is what is required? Or is it a belief that through becoming re-integrated into their communities, those who suffer from mental illness will become more integrated within themselves and so become less disturbed?

There are good arguments to be made for all of these points. But if the community’s attitude to mental illness is at best one of liberal indifference, will those who are disturbed fare any better outside the large mental hospitals than they did inside? Some people, including ex-patients of these hospitals, would argue that life in the community is worse. Perhaps the community (society) had a vested interest in ‘warehousing’ those people identified as mad, bad or useless, in order that those of us who remained could safely project all our mad, bad and useless bits onto them, disowning them in ourselves.

Chaos and confusion exist in the minds of all of us, and even more so in the minds of people who are mentally ill. A chaotic mind muddles things — thoughts, ideas, plans. In extreme cases, the individual’s sense of identity gets lost. These internal difficulties have a direct impact on our external relationships and on our lives. Misunderstandings arise, leading to feelings of anger and persecution and so to paranoia. Relationships become impoverished.

In this manner, what started as inner chaos is likely to spread, ‘contaminating’ the people and systems around us — our families and friends, and our workplaces. There are, as we know to our cost, chaos and confusion in all our families and in all the teams and organisations in which we work. If we are honest, we acknowledge that our own ‘mess’, and that of our organisations, add to the chaos and confusion in any system of care.

People engaged in caring work inevitably experience failure: there are always clients whom we cannot help enough. We may be able to retain some sense of balance between the pain of recognising our shortcomings and the hope that our efforts are nonetheless worthwhile, but if we are overwhelmed by a sense of inadequacy we may start to feel persecuted by anxiety. We may then defend ourselves by splitting off what we perceive as bad and locating it in others, through a process of projection. So health care workers may idealise themselves while blaming managers, or an agency may idealise its own work while denigrating the work of other agencies.

These processes in care systems are further complicated by the often massive projections from the client group into the staff, who may then unconsciously identify with the projections. For example, adolescents may split off and project either authoritarian or rebellious aspects of themselves; the staff of an adolescent unit may then begin either to behave like adolescents themselves or, alternatively, to become uncharacteristically harsh and punitive.

When different staff members identify with different projections it can produce serious discord within a team, who then fight out what is actually an internal conflict within each adolescent client. Similarly, staff working with people with mental illness may experience a fragmenting of their own thought processes, or an emotional ‘deadness’ similar to that of some clients.

If staff involved in caring work can ‘hear’ the unconscious communications of their clients, they are more likely to provide the containment needed. If they are filled up with their own pre-occupations and fears, or feel overwhelmed by the projections, they will not experience these as communication but rather as a psychic assault to be warded off, for example by distancing themselves emotionally, or by acting them out as described above. When systems of care provide adequate containment for staff, then they in turn can contain their clients’ anxieties and projections.

People who have the misfortune to suffer from severe and enduring mental illness are acutely aware of their chaos (inner fragmentation) and of the feelings of anxiety that accompany it. They also have great difficulty in containing (integrating) this within themselves and are therefore even more likely than other people to use unconscious processes in an attempt to rid themselves of what feels unmanageable.

Unfortunately this only increases their feelings of disturbance, as they come to feel that something important is missing inside them. They then are likely to become less, rather than more, able to manage themselves.

These are the people most likely to be provided with care plans which identify the systems that will make up their individual ‘package of care’ in the community. Our aim in creating these care systems is to provide a form of containment in which chaotic bits of an individual are first understood and then managed by workers in the system. Subsequently — if possible — they are internalised by the individual, having been transformed into something that feels understandable and manageable. If this occurs, the individual has become able to act as the container to those parts of him or herself that were previously contained by the system.

However, as systems get bigger and ever more complex, there is much more scope for increasing chaos rather than increasing containment. We can all identify times when the ‘caring’ system appears to be more disturbing and disturbed than the client; times when all the people involved seem to be acting out the disturbance rather than thinking about and understanding it.

Hence the emphasis that is placed on effective collaboration among care providers in order that the system that is created is maintained.

Effective collaboration is possible provided workers are supported in ways which enable them to reflect on their experiences, both individually and collectively. We are concerned that the current emphasis on managerialism — on ‘managing’ both workers and clients — is encroaching on carers’ space to think about the nature of the feelings their work engenders in a way that is both limiting and dangerous. The constant emphasis on organisational change, which itself puts workers under additional stress, can be viewed as a defence against the often unchanging nature of the client group.

It hardly needs to be said that mental health services and the people working in them are under ever greater stress, with less control over which clients are taken on, leading to work with more disturbed people without a commensurate increase in resources.

In theory, clients are supposed to make use of a service, internalise the gains, and move on. In reality, many are unable to do this and are therefore emotionally unable to ‘move on’.

One way of obscuring this harsh reality, at a time when resources for long-term care are scarce, is to establish a work environment in which, for a variety of reasons, there is a throughput of workers in place of the desired throughput of clients. While it may be necessary or even desirable for workers to move on more rapidly than their clients, this can often be a sign of burn-out rather than a sign of health. The degree of pain and stress many of them suffer in the process is — we believe — often greater than it needs to be.

Inevitably policy changes will continue to be made; some necessary and some unnecessary or inadvisable. Regardless of the changes, the fundamental nature of mental health work remains, as does the risk of excess pain and disturbance to those engaged in it.

We need to attend to and understand the experience of front-line workers, whose voices can so easily be muffled by the ‘noise’ of policymakers, politicians, the media, and even service users.

Angela Foster and Vega Zagier Roberts are editors of Managing mental health in the community: chaos and containment, Routledge, 1998.