Towards Collaboration: Raymond’s Story
Gayle Stockell and Marilyn O’Neill
The conversations we had with Raymond in 1990, had a profound effect on our work practices as mental health workers in a psychiatric rehabilitation center.
Raymond had been attending a discussion group* for several weeks. He had been a quiet participant but had indicated to us that he was appreciating his involvement in the group. Toward the end of a series of meetings the subject of psychiatric diagnosis and the effects on people’s experiences of life was raised. Raymond told us his story.
As a musician and high school teacher, Raymond had led a full life. He was admired for his talent with the trumpet. He was in his late thirties when his life took a change. He told us he had given much thought on how to best describe the change. He said an event that occurred when he was a student might serve to convey the change.
Raymond recalled being an art student in an art class. The art teacher had held up to the class a canvas that was white with a solitary black dot in the Centre. She asked the students to comment on what they saw. All the students said they saw a black dot. The teacher had responded by saying “but what about the rest of the canvas!”
Raymond told us that for him being diagnosed as a schizophrenic was like being seen as the black dot. He said that people had treated him as though he was the black dot and he felt as though he had become it.
This story served to have us question the psychiatric discourse of which we were part. We reflected on theories about mental illness and the ways in which those theories might be influencing our ways of interacting with people. We had been working toward taking a more collaborative approach in our work, and exploring the Narrative therapy ideas of Michael White and David Epston.. We decided to investigate and explore with other mental health workers, the history of psychiatry; its theories and the implications of these theories on our practices.
This is what emerged.
At the beginning of the 20th century, the biological account and the neurological explanations of mental illness had a great impact on the ways in which people with mental illness were viewed and treated. Throughout much of the century, these reductionist views have continued to provide the basis from which practitioners and scientists have explored such disorders as schizophrenia.
The development of potent anti psychotic drugs in the last forty years has had a considerable impact on the directions that the management of people with mental illness has taken. The researching and manufacturing of medications has been further encouraged by the need for effective symptom reducing drugs which allow people to make the move from hospital care to the community.
‘Talking’ therapy as a model of treatment has had a mixed history. Proponents of the psychoanalytic school of thought have been doubtful about the efficacy of analytic therapy for people experiencing psychosis. Some claim that such interventions may have harmful effects.
The behavioral approach has been applied in hospital care programs and used as a tool for assisting families in the care of a family member who has a mental illness. The theories about the impact that families and the wider social context has on the development and course of mental illness came into popularity in the 1950’s and the 1960’s. Family therapists and some psychiatrists became interested in exploring and taking into account the interactional processes that were occurring and were contributing to psychotic disorders. Therapies that focussed on correcting dysfunctional relationships and creating stress free milieus were developed from a psycho-educational perspective.
Mental Health Workers’ Stories
From having reviewed the history and development of some of the ideas contributing to the psychiatric discourse, we then asked the mental health workers to consider the following questions:
- What hopes and expectations did you have when you became a mental health worker?
- Which theoretical perspective informed your model of practice? What assumptions does that model make about you as a mental health worker and in what way does this model define your role as a mental health worker?
- What assumptions does that model make about clients/patients?
- How does this model define clients?
In answering the first question, many people identified personal beliefs that influenced their work. They recalled the ideals they had had when starting their careers as mental health workers. These ideals incorporated the notion of justice, and empowerment for those disabled by illness or circumstances. Many spoke about the desire to do something worthwhile and satisfying. However, many spoke of disappointments as their hopes and expectations were not realized and often got lost.
They stated that the medical model was usually the established framework from which they had to work. This model had placed certain expectations on their work practices in psychiatry. One of these expectations was that they had to be the enforcer of medication regimes that placed them in an unfavorable relationship with clients. They also spoke of the push to be on the look for symptoms and this tended to become the most significant feature of their work.
The psycho-educational and behavioral models of practice were also cited as being commonly employed within the medical model framework. The aim of these models was to provide a structure in which assessment; categorization and treatment were the principle features. These models were designed to obtain measurable results in order to provide a source of scientific data.
Workers found that these approaches had them taking a controlling and powerful position. They became observers and were expected to measure people not only in terms of symptoms, but also to be watching out for behavioral and personality anomalies. The focus of their therapeutic relationship was in dealing with deficits. They said that this problem-focussed approach had them losing sight of other aspects of people, blocking the wider view of people and their context. It is also invited workers to be the judges of what was deemed ‘normal’. They said that having to determine what was a ‘truth’ or ‘reality’ put them in a powerful position. This position troubled workers because they questioned their ability to know what constitutes another person’s reality.
Some saw their roles as being the carer, nurturer of people and on occasions, being called upon to take on a parental role. People believed that these carer roles had them taking the responsibility for the directions and outcomes of the clients’ lives. They also talked about feeling disempowered when positive outcomes or ‘cures’ did not come. These responsibilities were frequently experienced as burdensome and leading to ‘burnout’.
Another assumption of the medical/scientific model was that mental health workers have to take on the position of being the objective ‘knower’ in relation to their clients. This knowledge separated them from clients, restricted them from hearing about people’s own accounts of their lives and how they understood these accounts. In their position of the ‘knower’, mental health workers became the experts on the clients and on their lives.
Part of the process of establishing and maintaining the expert status was being able to classify people using diagnostic categories. Mental health workers said that they recognized the ways in which classifying might assist them in maintaining a structure and order, but they also recognized some adverse effects for them as workers. They talked about the way in which classifications can lead them to thinking of the client only in terms of the classification or as labeled and how their view of clients and their interaction with them becomes limited.
Mental health workers talked about their role within a medical model based psychiatric system. They said that there is a tendency toward a structured hierarchy, the different professions are placed and defined within this structure. They spoke of the limitations this structure placed on them in their interactions with clients and of the struggles that can occur between the professions.
In speaking further about the limitations in their interactions with clients Workers were also able to reveal what they termed “those behind closed doors interactions” they had with people. These interactions occurred away from ‘the professional gaze’ and reflected more accurately workers’ hopes and wishes for a therapeutic relationship. However, concern was expressed that these interactions might be viewed by other workers as transgressing the so-called ‘professional boundaries’. *
In reflecting on the possible effects of the scientific/medical model on clients, many mental health workers believed that clients often found themselves in disempowered positions. They said that clients could sometimes be seen as passive recipients of treatments, dependent upon mental health workers to lead them through their illness and their lives. They become confused and disappointed when treatment programmes were experienced as unsuccessful. They may blame the psychiatric system or attribute the failure to themselves. They were seen as taking on the roles that the classification had placed upon them. The classification along with the symptoms became their focus, they lost sight of the other ways of seeing and knowing themselves. Mental health workers spoke about their concerns for the self-fulfilling prophecies occurring when clients were given a diagnosis that predicts chronicity and deterioration.
A number of clients, on the other hand, were seen to be fighting against the requirements of the system, not accepting the classifications of their illness and refusing prescribed treatments. These clients were often described in pejorative ways. Descriptions such as ‘non compliant’ were often applied.
Hopes For Story Changes
In reflecting on these stories from mental health workers, we were reminded of the ideas of Michael White. He wrote (1992) “that stories are shaping of life, and that they are real, not imagined effects- these stories provide the structure of life” (p213). We were hearing about how stories evolved as people continued to re-interpret them, as they attempted to make sense and alter their understanding. Interactions with others became highly significant in the defining of themselves.
Stories people developed about themselves when they become involved in psychiatry were being shaped by the dominant story of psychiatry. The ways in which mental illness were viewed shaped the ways in which people, those with the direct experience of mental illness and also mental health workers, viewed themselves.
The accounts from mental health workers and our own experiences of working within the psychiatric discourse have encouraged us further in our exploration of collaborative ways of working. We have been asking ourselves, and others, how we might be able to name those practices that are disabling and limit possibilities for favourable change. We hope to discover ways that have us becoming more connected and more able to open to seeing beyond ‘the black dot’. We thank Raymond for giving us his story and for letting us share it.
We became interested in change through our experiences of working in psychiatry. In our histories as mental health workers with a variety of work and educational experiences, we were predominantly influenced by the medical model. From 1988, we worked in a psychiatric rehabilitation Centre that applied the psycho-educational, cognitive- behavioral framework to compliment the medical model interventions used by the wider service.
The rehabilitation Centre situated in a large suburb of Sydney was known as a Living Skills Centre and was part of an integrated community mental health service. This Centre was recognized as the first of its kind and was available to be viewed by both local and international visitors. It had a culture of energy and innovativeness.
As a service, it provided a daily facility for more than one hundred people who had experienced a mental illness. Approximately forty people a day used the service. The majority of the people attending the Centre had been given the diagnosis of schizophrenia. Others had experienced what was described as manic- depression, severe depression or anxiety disorder. There were predominantly more men attending the Centre than women.
The scientific, psycho-educational paradigm was used in developing a five-day a week program of activities. The programs were designed to assist people in returning to mainstream functioning, toward what was deemed to be ‘normalization’. The programs consisted of educational group work activities, social and leisure pursuits and pre-vocational training. For some, all that the Centre offered was a safe environment.
Our work was to educate and train, to socialize and to be role models. It was understood because of psychosis, people either had lost living skills or had never had the opportunity to learn them. We provided energy and motivation to engage people in the range of activities thought to be beneficial to their rehabilitation. We were both nurturers and carers in providing a safe and accepting environment.
This model of rehabilitation was supported by empirical studies and could provide a measurable outcome-focused way of working. It offered clearly defined procedures for obtaining the outcomes. One such procedure was to assess client’s assets and deficits and from that basis establish goals and steps needed to obtain the goals.
Working in this way had raised a number of dilemmas for us. The questions we asked ourselves were about the effects that these rehabilitation procedures had on the ways in which both clients and mental health workers viewed themselves, their relationship with others and the experience of psychosis.
- What it meant to people to be viewed in terms of deficits, to be guided toward life style choices.
- How much the psycho-educational model influenced the way in which we came to understand, interpret and communicate with clients
- What was deemed normal and who were the best judges of normality?
- The position we often found ourselves in, in selecting for clients the value of one reality or truth over another. We questioned the meaning that this selection had for them.
- How much the relationship between mental health workers and people experiencing psychosis was effected by our belief in the need to care for and nurture. Did this invite dependence? Was being dependent a helpful aspect of rehabilitation?
Our dilemmas and frustrations were brought to a head by the challenging behaviours of a few young men. These men hovered around the periphery of the Centre only becoming involved in order to respond to family or case managers’ expectations. Some used the Centre as a place where they could obtain information for drug and alcohol related gatherings.
It became necessary for us to address these dilemmas to work out other ways of offering rehabilitation. We wanted to learn about the ways the men were experiencing mental illness and about their involvement with the mental health service. It occurred to us that the way to learn about what was happening for them was to ask them about their experiences and the views they had of themselves.
The young men were invited to join in a group. We wrote to them asking them to come and talk about their experiences of mental illness and their management of it. We were interested in learning about the effects that the illness and the system were having on them.
This was the beginning of a collaborative way of working. The conversations we had with these men in the group changed our views about them and our roles as mental health workers. These conversations incorporated the ideas and tools of the narrative approach developed by Michael White and David Epston (1989).
This collaborative approach offers people who experience mental illness the opportunity to understand themselves and their illness differently from the interpretation that is often imposed by the scientific models. They are invited to be the authorities on their own experiences. They are assisted in separating themselves from their problems so that they can identify the restraints that are limiting their lives and limiting the view they have of themselves. They are then able to see and talk about their lives differently. They may select preferred directions, develop self understanding and experience being in control.
For mental health workers a collaborative approach offers the opportunity to deal with overwhelming problems. It allows mental health workers to develop alternative ways of viewing and conversing with people. This frees them to re-evaluate issues of responsibility and control in the therapeutic relationship and to move toward hopeful practices.
2000 ON – A CURRENT PERSPECTIVE
A few years down the track it is possible to add some reflections on ‘the profound effects’ of Raymond’s story. Raymond donated his story to others believing it to be useful. Some years after he shared this unique description of his experience of mental illness he told us that the telling of it had been significant for his life. The black dot (illness) experience had required isolation of Raymond and had him loose touch with ways that he had previously had of knowing himself, his world and others. He told us how developing his own wisdom had become possible in the rehabilitation centre groups and how the process of those groups had allowed him to reclaim ability for conversation.
Naming the black dot, and the questions asked in an attempt to appreciate the richness of this metaphor, had made visible knowledge of many things in Raymond’s experience of life. He was able to appreciate the societal and cultural beliefs that had supported the dominance of the black dot experience. Then he was free to explore questions asked of the validity and usefulness of these ideas for his life. This done, he had set about recovering other knowledges that had formerly contributed to the rich canvas of his life and to reinstate those preferred by him.
It is intriguing now to think about the practices that assisted Raymond to reclaim and to reconstruct an enabling story for his life, a story, which provided an alternative to the “black dot” story of marginalisation and isolation. Those practices represented then and might continue to represent and an alternative story for psychiatry. They shift us from the practices required of, and described by worker as, disabling of themselves and the people who consult with them. An alternative story that might allow room for more hope for psychiatry’s work.
The introduction of a Narrative perspective pre empted and informed the groups in which Raymond started to reclaim his canvas. Some participant’s had previously named the groups, as “Worthy of Discussion”. The facilitators of the group had in collaboration with previous participants the researched the processes of Narrative conversation and explored the re storying accounts of the groups. This can be read about in O’Neill, M. & Stockell, G. (1991) Worthy of Discussion: a collaborative group therapy. In ANZ Journal of Family Therapy. The use of narrative practices as the scaffold of conversations has encouraged the recovery of useful alternative stories by many participants. This has had a flow on effect to the practices of the workers in the mental health service. This shift gradually evolved into a change in perspective on rehabilitation after a mental illness experience.
Those understandings that had developed out of the dominant societal and professional discourses about psychiatric care and intervention came under continual questioning. Asking, as a matter of course, about their history, effect and purpose, revealed unhelpful aspects of practices and of the culture of mental health service provision. Alongside these revelations were the discoveries of the unique and helpful knowledges that people who consulted these services were often unable to access when they were redefined by the dominant discourses that psychiatry and our culture supported about chronicity and deterioration. The workers who explored alternative ways found they were free to move themselves away from the position of experts on the lives of others and free to expand their interest beyond that which a focus on symptematolgy required of them. It became more likely that their practice would represent ways of entering into the realm of tentative exploration of local knowledge and the wisdoms of lived experience. These approaches enabled them to participate with others in the constructions of a preferred way of knowing themselves and of being in their lives. These were knowledges that were based on what was known to be useful rather than on knowledges of deficit, illness or inadequacy.
So the conversations that we had with Raymond in 1990 and again in 1995 have provided a rich metaphor through which to try to appreciate more vividly the experience of those who encounter mental illness and develop a relationship with mental health services. It has encouraged many workers to keep on asking questions of the dominant professional discourses. It has invited workers to continue to explore and evolve practices that fit with a narrative perspective and that respect idea of how peoples stories might evolve through their interaction with others. This has engendered a much greater mindfulness of asking question of the taken for granted aspects of work practices, a continual collaborative inquiry to establish what is helpful or unhelpful about what we might think say or do and the evolution of more enabling conversations as therapy.
O’Neill, M. & Stockell, G. (1991) Worthy of Discussion: a collaborative group therapy. In ANZ Journal of Family Therapy.