'Them And Us' In Mental Health

When I was a user of services I was often criticised by workers for having an out-of-date and undesirable ‘them and us’ view of the world of mental health. It bugged the hell out of me, because for years I had been trying to act from the opposite perspective (I still am) - but then something would happen that sent me back to thinking ‘they’ occupied some other world. In my everyday life I try to let-go of preconceptions, but then someone says or does something, which shows they still perceive, believe in, or approve of some basic divide.

Now of course, it must be to some extent what I choose to notice, and we all have a tendency to notice differences rather than similarities. However it is unfortunate that most of the time it is workers who are inclined to assert there is no more (or should not be any more) ‘them and us’. I’m also as aware as anyone that amongst workers there is a range of ‘lived experience’ - I myself, between my first and second admissions, was briefly a student mental nurse.

The answer to why a ‘them and us’ situation (and it is a social situation, not an attitude) persists, and perhaps must persist, despite the increasing dialogue between workers, users and carers is really very simple. But first, a look at the proposition:

‘As part of the human condition, we are all engaged in the same daily struggles to maintain our wellness. There are no “them” and “us” - just us. Commonality between us all is emphasised rather than differentiation. Some of us may need more robust wellness strategies than others, but the process is similar for us all. Our daily routines, our relationships and our levels of resilience become very important in maintaining our wellness.’ (Devon LIT Workforce Development Group Recovery - Concepts and application Version 2. 10.4.08)

(This is the missing item referred to in my January post - The Recovery Movement [part one] )

A few years ago I came to the conclusion that as part of my own self-management I had to treat every encounter, every relationship as personal. For the irony is, that the mental health system has traditionally been structured around providing impersonal, bureaucratic care for clients whose very problems manifest themselves in an inability to maintain intimate relationships! My only solution, to guarantee that I act for the right reasons, and feel the right emotions - is to only turn-up to do something today, because someone I care about has asked me to be there, or because I am likely to meet someone I’m attached to.

The fundamental building blocks of ‘them and us’ are the Mental Health Act and client confidentiality. By virtue of being a user it is so easy for workers to maintain the notion that you’re the one with the problem. You feel constrained in the way you are with them - I must look calm, not agitated, the things I say must sound reasonable. Because you know the person you’re talking to only has to make one phone call, express their ‘concern’, and a whole chain of events may lead to the use of the Act. It’s a sense of vulnerability that persists despite it being over five years since my last admission. I know my self-management skills are excellent, that there is no need for me to ever be an in-patient again, but nonetheless, the feeling remains that the obligation is on me to conform to their perceptions of reality. In a sense, my fear still allows ‘them’ to define what ‘appropriate’ behaviour is!

Client confidentiality is presented as protection for the client, but it’s convenient for them too. Remember, in the vast majority of encounters it is we who disclose not them, and our notes usually record what they choose to record. They decide what can be kept confidential and what they are ‘obliged’ to share with other workers and agencies. Equally, you inform them about concerns regarding yourself, and occasionally other clients, and they choose whether to act. And there need be no comeback for them. Because you are seen as the one with the problem the quality of your knowledge and judgement is rarely acknowledged, let alone acted upon.

There is however a third factor which helps to maintain them and us, it is the way that Involvement (public participation and feedback) is organised. Involvement procedures have become as bureaucratic as the rest of the mental health industry. The rules and regulations, intended to be objective, calculable and de-personalised in order to treat everyone the same, with fairness and equality, mean the individual can rapidly be lost - more remoteness is the last thing someone needs who has become ‘ill’ as a result of a lack of communication skills in interpersonal relationships!

No one service user’s view becomes any more valid than that of another on any particular issue. Although we have differing skills, this counts for nothing - we are all ‘experts by experience’. So when at a meeting each of us gets an equal opportunity to state our views and we say different things, the consensus seeking Chair (having allowed us to ‘let of steam’) need take forward to others - what? One mechanism of bureaucratic control is to be told that whatever your view is, though legitimate, is yours alone - a cause for individual complaint or change in treatment, but not a reason for workers to question their working practices.

The workforce however is divided into professions with what are thought to be unique sets of knowledge and skills (the specialised division of labour) which they must maintain, or lose their value in the job market. There are good reasons therefore for them not to work collaboratively, and management may also concur, not wanting their workforce to identify a collective interest with each other. The Involvement worker stands between client and service provider or commissioner, describing themselves as facilitators or trainers (training staff how to Involve, and clients how to become involved) but may in reality act as ‘gatekeepers’. They will encourage the client to see beyond their own problems and learn the manners of consultation and compromise. But often what occurs is a process of incorporation, whereby the powerful group facing opposition seeks to incorporate the members of opposing groups into their own organisation as a way of nullifying that opposition. Such individuals often rapidly take on the values of the group to which they were formally opposed, and indeed can then be used as a channel for ‘selling’ the dominant group’s set of values back to opposition groups as a whole. As Involvement develops, as users and carers sit on various NHS committees, it is unclear whether they sit there in their own right or as in some sense ‘representatives’ of their own groups or networks. A few years ago my local mental health trust formalised its payment policy for Involvement. (Workers are always keen that the ‘contribution’ of clients and carers be recognised; in their turn some will refuse to attend unless they are paid). The Trust recognised three levels of payment, each with its own mini ‘job description’ on the expectations and obligations of the role, from simply turning-up, to doing work for and being responsible to a particular committee whilst at the same time being a ‘representative’ of, and feeding back to, any user or carer group the individual might belong to!

Involvement activity also has something of the character of ‘consumer rights’ or political ‘special interest’ groups. In a them and us situation you are not only the victim of the powerful in terms of rights and resources, you also allow them to define the terms of the debate and the ‘world view’ you have of yourself. For example, complaining that the experts aren’t expert, but instead of taking back power, simply demanding better experts! And in forming networks and lobby groups there is also the danger that ‘complaining and campaigning’ becomes an end in itself - a different kind of dependency where you remain tied to those who seem to oppress you rather than seeking a genuine alternative. Worse still, in trying to be an effective opposition, the way your own group is organised may come to look much like those you seek to challenge. There is the phrase ‘grievance gravy train’ (first used in New Zealand) to describe the activities of individuals and special interest groups who used employment, welfare and equal rights legislation; not just for the resolution of individual disputes, but for the building of careers, organisations and political influence for their own sake. (New Zealand also provided the term ‘Pro-sumer’ - meaning a professional consumer of health and social welfare services).

The reason such processes as bureaucratic control, incorporation and special interests occur and serve to further underpin ‘them and us’ is that health authorities are not actually prepared to negotiate with those they seek to help. Nowhere in law is anything conceded apart from the right to be consulted. Through Involvement activities you can turn yourself into a professional patient, rewarded for conforming (accepting training in how to ‘present’ your experiences, or how to become a quasi worker by formalising peer support!) At worst Involvement becomes an add-on to traditional practice, a way of making work and expanding influence. Alas during my four years involved in Involvement I cannot think of a single issue raised by users or carers in a forum which then led to a change in the way workers practiced during their day-to-day encounters with clients. But then groups being what they are, once you express such pessimism it rapidly comes to be seen as disloyalty!

Those who pursue a Recovery approach sometimes claim to have gone beyond the need for formalised Involvement because relationships are negotiated at every level between client and worker in an open and transparent way. But it remains the case with Recovery, as with any other client-centred approach, that the worker will always claim your views are valid, but only to you. They will never accept that your views could be representative. They will waste thousands of pounds on surveys designed by themselves in order to gather opinion, little realising that a few hours spent reading user’s blogs will furnish the entire range of opinion from across the globe. Equally, they will never concede that you could have superior knowledge on the causes and best treatment of mental distress - by definition the mental patient cannot have a greater insight than them, despite the common mantra that you ‘know yourself best’.

Despite all the above the relationship between user and professional may become very close. Often the same workers who have tried to support you over many years are those with whom you end-up trying to negotiate. You like and are attached to them, but they do not reciprocate the hard work you have put into trying to affect real reform. You listen to a hypocritical remark, or occasionally a blatant untruth which they have convinced themselves must be the case, and you know for certain sure, that now ‘it’s not me, it’s the others’ and that it is time to leave.