Regional Community Care1
- Author:
RATCLIFFE, M.A., M.B., D.P.M., D.C.H., and E. V. JONES (Psychiatric Social Worker)
Now that the Regional Psychiatric After-Care Service for ex-service personnel, first organized py the National Association for Mental Health m 1944, is shortly to come to an end, at least m its present form, we feel it may be of interest to detail the results and experiences of this work jn one region. This is felt more strongly, because many of the problems presented to the regional organization, as well as some of its solutions of these problems, are entirely different from those encountered in other forms of Psychiatric social work.
The service in this region was first organized from a Nottingham office in 1946, but the present survey covers the years 1947 and 1948 ?nly, since that period represents best the gradual build-up of the regional organization once the initial teething troubles had been overcome. The region itself is a large one geographically, and includes most of the economic and social community problems commonly found in England. .There are three large industrial cities, mainly prosperous, in the region, as well as a number of smaller industrial and country towns, whilst there is a large, relatively densely populated mining area in the north-west. Almost the whole of the eastern and southern part of the region is agricultural, and characterized by small, widelyscattered villages with poor intercommunications. The area includes also a small port and a number of seaside towns. As a result of this varied distribution of population, the availability of existing psychiatric services, both hospital and clinic, was patchy throughout the region. Thus, whilst the industrial areas had usually a well-organized treatment service, in many of the rural areas communication and other difficulties meant that only a very limited diagnostic clinic service was available for out-patients, and that often only at some distance.
During the two years ending December 31st, 1948, the case load in the region was as follows: Total number of cases handled 659 New cases received: (a) From Service Hospitals 149 (b) From other sources 247 396 Cases closed during the period .. 269 Types of case referred? Psychoneurosis .. .. 332 Psychosis .. .. .. 168 Psychopathic personality .. 51 Borderline M.D. .. .. 25 Organic disabilities .. .. 53 Undiagnosed .. .. 30
The After-Care Team
Although the After-Care team could be held, in its widest sense, to include all those individuals and agencies who are drawn in to help in the community care of the individual case, the essential basis of the team is the psychiatrist, psychiatric social worker and assistant social workers acting together. The individual roles of each will be considered separately, but it cannot be too much emphasized that the approach to the patient must always be by the whole team, the functions of each member complementing those of the others. In this region, the team consisted of the Consulting Psychiatrist, a senior psychiatric social worker and two or three assistant social workers. In addition the cases in one large industrial city were covered by the psychiatric social workers of the city Mental Hospital and the Local Authority. Each case worker had her own portion of the region to cover and, so far as possible, each case worker had full and continued responsibility for the patient (under the supervision of the senior P.S.W.) for the whole period of after-care. The psychiatrist and all the case workers met at weekly case conferences, whilst the psychiatrist was available at other times also for discussion of special individual problems with a case worker.
At approximately monthly intervals a larger case conference was held to which were invited psychiatrists, psychiatric social workers, and other social workers from the neighbouring Psychiatric Hospitals, Child Guidance Clinics and University. Started originally to discuss the problems of individual cases of special difficulty, these larger case conferences were becoming an interesting and valuable group situation for the discussion of general problems of community care.
It became clear at an early stage that, if he was to participate fully in the team, the psychiatrist must have clinical access to the case material. In a widely scattered region such as this, with numerous widely separated clinics under different authorities, actual clinical contact with every patient had obvious difficulties. The problem solved itself in two ways. The Consulting Psychiatrist was also Regional Psychiatrist to the Ministry of Pensions and to the Army and R.A.F. Thus much of the clinical material passed automatically through his hands, whilst the Ministry of Pensions were at all times most co-operative in arranging for men to be called in for interviews and treatment assessment by the psychiatrist. This practice, which was in conformity with the general supervision policy of the Ministry, had the added advantage that many patients who were at first unwilling to consider treatment would readily attend at a Ministry interview and could there be persuaded by the psychiatrist to agree to clinic treatment of which they stood in need. It also laid .open to the psychiatrist, certain in-patient treatment facilities which, at least before July 5th, 1948, were difficult or impossible of access through other channels. There remained still three groups of patients for whom special and individual arrangements were made. Where specific employment recommendations were requested by the Ministry of Labour, where a patient, clearly in need of treatment, was unwilling to consider any other approach and where a “domestic situation warranted a single active therapeutic interview, the Consulting Psychiatrist arranged, within the framework of the team service, to see the patient and/or his relatives himself. In the unhurried atmosphere of an hour’s interview, it was often possible to do a great deal to resolve the specific difficulty or to prepare the way for further acceptance of treatment. Such special interviews might at first seem to cut across the functions of the orthodox psychiatric treatment services, but this was not in fact the case. Although of undoubted therapeutic value, their main function was not active therapy, but rather the orientation of the patient’s attitude towards a better rapport v/ith future psychiatric treatment. Many patients who had previously strongly resisted the treatment of which they were in need, were by this means persuaded to accept it. No attempt was made to continue treatment in further private interviews, but the patient was put in touch with the appropriate in- or out-patient treatment clinics which he now viewed in a much more realistic and satisfactory light. In all cases, with the patient’s consent, details of his past social and psychiatric history were passed to the clinic psychiatrist. It was also invariably the practice to obtain the consent and approval of the man’s own general practitioner before such a special interview was arranged. In no case was this refused, and usually the suggestion was welcomed. A copy of the psychiatrist’s report was sent in each case to the doctor so that he remained fully in the treatment picture and could be guided in his handling of the patient. The Role of the Psychiatric Social Worker The main source of patients to the organization was from the Service Hospitals, though, as will be shown later, an increasing number of cases were being referred from other sources towards the end of the period under survey. By far the greatest portion of. the patients referred were at all times personnel invalided on psychiatric grounds from the Army, Royal Navy or R.A.F. In most cases from the Service Hospitals there had been a preliminary interview at the hospital by a P.S.W., in which the general policy of after-care had been described to the patient, and his agreement obtained on postdischarge of after-care. A report from this interviewing P.S.W., and a hospital report, Were normally available to the regional organization, but usually there was no preliminary personal contact between the regional P.S.W. and the patient before his return home. This represents the first, and perhaps the most formidable, difficulty which the after-care team had to surmount, and is the largest single difference from the more common type of psychiatric social work centred on an existing clinic or hospital. In the latter type of organization the patient, and to a lesser extent his relatives and environment, are already centred to some degree on the case worker before actual after-care begins. This may be the result of an interview between worker and patient, whilst he is still in the clinic or hospital milieu, which renders comparatively easy the identification in the patient’s mind of the worker as part of the psychiatric treatment he is having. Or, at least, there remained the strong factor that contacts had already been made between the clinic and the patient, as well as with his relatives, his doctor and perhaps his employer; the case worker, as part of the clinic team, was thus already accepted by, and orientated towards, the patient’s environment and background. In the type of after-care here described the situation was very different. A contact had been made with the patient in hospital and the ground had usually been very well prepared, but the contact had not been an individual one by the case worker who was to conduct aftercare. The home background to which he was to return had seldom been prepared and, since the relatives had normally taken no part in his original referral to the Service Hospital, their attitude was not orientated to continued after-care or help. Then, too, the very fact of invaliding from the Service and the return to civilian life was a profound environmental change for the individual concerned. Not only did he have to make the difficult adjustment from hospital to home, but, at the same time, he had to accustom himself to a total change of environment, with its loss of old possibilities and difficulties, the gain of new responsibilities and opportunities and the profound emotional reaction of pleasure or guilt or both resulting from his invaliding. The psychological readjustment problems of the post-release period of the ex-service man are considerable in themselves, and they tend to conflict with, as well as augment, the difficulties of translation from hospital to home environment.
In the community care service it was therefore necessary for the case worker to build up her contact with patient, relatives, doctor and employer on foundations which she had to lay herself, and to overcome in the process a good deal of preliminary suspicion or even antagonism. But, if this was the difficulty, it represented also the need for such a type of contact, whilst the strength and value of it, once well established, was very great. Very frequently patients were referred who were hostile to even the suggestion of doctors, clinics or hospitals, but who were equally clearly in urgent need of further psychiatric treatment. Whether the motivation is the often unrecognized identification of future treatment facilities with the authoritarian Service atmosphere from which he has just escaped or whether it is that he is ” referred ” rather than attending of his own choice, it is certainly the experience of one of us (T.A.R.) with similar ex-service cases seen elsewhere that the ex-service man is, in general, much less willing to accept treatment offers than his wholly civilian counterpart. In such cases the Psychiatric Social Worker can often, even at her first interview with a recalcitrant patient, achieve the sort of personal relationship which the patient has never before experienced.
Because of this relationship, the patient can often be persuaded to accept treatment, or at least take the next step towards it, even though he may rationalize his acceptance of it by the thought that he is doing it solely to please the person with whom he has developed this new and satisfying relationship. Similarly, once this relationship is established, the worker will be in a position to make suggestions on the handling of the environmental, personal or work problems without the patient’s feeling that he is accepting an authoritarian order or being given ” charitable ” or ” good ” advice. This technically acquired ability to build up a mature relationship in which the worker can both ” give ” and ” not give ” as the total situation demands, isthe essential criterion of psychiatric social work, as a part of complete mental health service to the community, and distinguishes it from most other forms of social work.
If the first duty of the case worker is to establish this contact and relationship with the patient himself, her second and equally important task is with the patient’s immediate environment.
It is equally important to the patient to help in the adjustment of the home environment as it is to help in his own adjustment. Indeed, in some cases the case worker/relatives’ relationship assumes greater importance than that with the patient, and the worker finds herself more and more directing her after-care technique towards the relatives in close contact with the patient. In almost all cases, however, the relatives will require help and the opportunity of discussing their worries, anxieties and difficulties about the patient. Here, too, the role of the case worker is an important one. Even if the patient is already receiving treatment, the need will still remain for an unhurried, free discussion of these problems. The relief to the relatives, and the benefit to the patient, of this type of discussion, is very great. It is perhaps unfortunate that so many clinics, and even psychiatric clinics, fail to realize the importance of this aspect of their work, a failure which in part must be attributed to their present overworked state. Many of these ex-service men have* emotional readjustment difficulties, marital or interpersonal, quite apart from their psychiatric disabilities, and the relationship built up by the case worker with both patient and relatives gives her a powerful therapeutic weapon in handling such problems.
The ex-service man, especially if he has had long service, is often greatly out of touch with the changing employment and social milieu in which he finds himself, a lack of touch which the Service authorities have often done too little to reduce before his invaliding. Often he is not anxious or able to explore the possibilities and responsibilities of these new situations for himself. The admirable opportunities offered by the Disablement and Rehabilitation Services of the Ministry of Labour, for example, are often little understood by the patient, and consequently neglected by him. The value of the case worker’s negotiating the first interview with the D.R.O. and giving both him and the patient the benefit of her knowledge and experience of any special employment problems involved is one of the largest single benefits of the after-care service.
The active therapeutic role of the case worker is more difficult to define or delimit. Technically the relationship which she builds up with the patient is similar to that which appears between psychiatrist and patient during the more superficial and ” active” forms of psychotherapy, but her relationship remains more on patient’s ” own level a fact which limits her active therapeutic role, but aids her ” counsellor ” role greatly.
{To be concluded) Psychiatry has been referred to as the Cinderella of medicine but I question sometimes whether that branch of psychiatry which deals with the more privileged in intelligence?with intensive psychotherapy and careful training of personnel?isn’t the Cinderella of the last page of the story where dreams come true, while the psychiatry concerned with mental deficiency is the earlier Cinderella still sitting by the fire in scientific tatters. George S. Stevenson J
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