Regional Community Care. II
- Author:
RATCLIFFE, M.A., M.B., D.P.M., D.C.H., and E. Y. JONES (Psychiatric Social Worker)
(concluded)
The Role of the Psychiatrist
Something of what has been said of the social worker applies also to the psychiatrist, but he has, in addition, a special and more actively therapeutic role, in the after-care team. He must be in a position to carry on, and reinforce, the therapeutic aspects of the case worker’s relationship with the patient and relatives and to prepare them either for further actual treatment or for the more detailed aspects of their readjustment. It is his responsibility to assess, and advise, on special treatment problems and to arrange for the further treatment of the patients who require it. He must discuss and supervise at all stages the handling technique of the case worker and carry the responsibility for difficult social and disposal decisions that are sometimes required. His technical knowledge is necessary in the difficult problems of job and training assessment, and he, too, must have good liaison with the Ministry of Labour. Professionally, he should act also as the link with the general practitioner, the Ministry of Pensions medical staff and other psychiatrists who will be handling the patient. He must be prepared equally to assist actively and therapeutically in the patient’s domestic environment. Here his special status gives him a therapeutic ” authority ” relationship which is lacking in the case worker/patient relationship, but which is the essential successor to that relationship. In addition to these more or less therapeutic roles, the psychiatrist has a general advisory and educational function in the team. It is his task to interpret to the case workers the technical psychological implications and limitations of the patient’s condition, personality and environment, as well as any purely medical or surgical aspects which may arise. He must co-operate with the senior psychiatric social worker in the training of younger and relatively inexperienced case workers, and be prepared to discuss and advise on the general problems of their work.
Liaison with other Bodies
It will be clear from what has already been said that the after-care team must have good and personal liaison, not only with the existing psychiatric treatment services, but with the Ministry of Pensions, the Ministry of Labour and all those social service organizations in the locality which play a part in community care or social welfare. Contacts are very necessary, too, with the individual patient’s doctor and sometimes with his employer, his social club, or some government department which can help him in his trade. Invariably these contacts are better made personally by a member of the team, rather than by letter or telephone. It is surprising how often the man who appears so unhelpful in his letters turns out to be most co-operative when met face to face, or when a full personal discussion has enabled him for the first time to see the whole picture.
Perhaps the most interesting aspect of this liaison with other organizations was its development. Whilst, in many cases, the after-care team began as suppliants requesting help, very often a reciprocal liaison and relationship was quickly built up. Thus organizations from which we had asked for help in the individual case were often the very bodies which referred other cases to After-Care for its special help. Towards the end of the period under review, an increasing number of the new referrals were reaching the after-care team from the Ministry of Labour, the British Red Cross Society, the local Social Services Committees and other similar bodies. Such a two-way relationship was of immense value both to the after-care team and to its patients.
The most important single organization with which good liaison was necessary was the Disablement and Rehabilitation Section of the Ministry of Labour, and this, too, offers a good example of the mutual two-way relationship described. The Disablement Resettlement Officers were at first approached for help in the employment problems of individual patients referred to them by the team, but so good did the liaison become that an increasingly large number of men, who were an employment problem to the D.R.O.s themselves, were referred to the after-care team for their technical advice and help. In addition, both the consulting psychiatrist and the psychiatric social worker were asked by the regional office of the Ministry of Labour to give a series of lectures at the regularly held training courses for D.R.O.s. A number of such lectures on the psychiatric and allied aspects of employment problems and rehabilitation were given during 1948. As a result, both the D.R.O.s and the after-care team gained an increased insight into each other’s work, with its limitations and possibilities, and an increased ability to help each other over individual cases. Liaison with the existing psychiatric clinic services presented its own difficulties. The wide distribution of these clinics, and their organization under so many different local authorities, prevented the close individual contact with all psychiatrists which would have been ideal. But the general relationship with the clinic psychiatrists remained good, and they were at all times prepared to extend special help and facilities for treatment. As with many private medical practitioners, the same two-way relationship of referring difficulties between the after-care team and the clinic psychiatrist took place in some instances. One difficulty, however, which did arise was that, once a patient had been referred to and taken under the treatment care of a clinic, it was sometimes difficult to obtain adequate information about the further clinical progress of the patient. This must be attributed in the main to the overworked condition of most of the clinics and their natural orientation vis-a-vis the patient’s own general practitioner.
Selection of Suitable Cases for After-Care In assessing the value of our after-care methods, we have been struck by the absence of generally accepted criteria as to what makes a case specially suitable for after-care. We did not always feel that cases had been ideally selected by the Service hospitals, whilst other patients who reached the organization later from other sources could, with benefit, have been referred in the first place. After-care was, of course, voluntary on the part of the patients, and all did not accept it after being selected for it. In formulating our own criteria we would emphasize the distinction between cases needing after-care, and those likely specially to benefit from it.
In the first category could be placed most of the recovered, or partially recovered, psychotics. Whilst it would be untrue to say that no recovered psychotic will really benefit by after-care, it is true that, if many post-psychotic symptoms remain, little can be done in the way of active help. Nevertheless, such cases remain in urgent need of general supervision, and advice and support to the relatives may be of very great value. They are thus, rightly, regarded as suitable for referral. This need for supervision is perhaps even greater with ex-service psychotic patients than with those from civilian hospitals. The tendency, described in very general terms, is for the Service hospital to discharge its patients, for administrative reasons, at a rather earlier stage of recovery and with less personal preparation of the relatives than do the corresponding civilian mental hospitals. Such ” nearrecovered ” psychotics are apt to produce very difficult disposal decisions for the after-care team.
The true constitutional psychopath and the grossly socially unstable individual are almost always entirely unsuitable cases for after-care, as is the very chronic hysteric with fixed inaccessible symptoms related to an insoluble environmental problem. Such patients are too apt to use, or try to use, the after-care organization as just another means of escape, and a mature relationship rarely if ever develops in this type of case.
It would, however, be far from correct to regard all cases with a long-standing neurotic background as unsuitable. The insecure, inadequate individual, who has broken down with frank symptoms under slight stress, is often one with whom a satisfactory therapeutic relationship can be built up. Such men may begin by leaning too heavily on the support of the case worker, but with good technique a remarkably satisfactory attitude towards the problems of life, with great and lasting benefit to the patient, can be built up. Where the breakdown was of an anxiety or hysterical type, and where it was reactive to some considerable personal stress, a similar mature approach to the problem may be developed. Again, the case worker will have to initiate all the early moves in solving the domestic or work problem, but she can do so in such a way that the patient feels himself realistically facing up to the very problems which caused his breakdown. It is in this type of case that the team-work of psychiatrist and case worker together is so valuable.
The borderline mental defective presents another special problem of after-care. Here again the role is a supervisory one, but if the employment problem can be satisfactorily handled, and the employer and relatives tactfully helped in methods of handling, such men can give valuable service, under guidance, to the community.
The ex-prisoner of war is another type of case where after-care is of special value. Unfortunately, many of our cases of this type reached us through other organizations a considerable time after the patient’s release from the Services, and many presented a very difficult problem. The difficulty that such men have in facing, and adjusting to, the inevitable problems of post-war life is very real and its effects are cumulative. Their very difficulty of adjustment means that they are often overwhelmed by those very social and economic difficulties which they cannot understand. Such men are in urgent need not only of active therapy but of careful guidance and help. Many have, as a result of their difficulties, serious domestic problems, and these, too, require special handling.
The solution of a domestic, work or emotional problem, though essentially a part of treatment, is often difficult for the psychotherapist working alone, and with his special relationship to the patient as an individual. Such cases are most suitable for the team approach of both psychiatrist and case worker, and they formed, for obvious reasons, a considerable proportion of the cases referred from Service hospitals. The criteria for suitability for after-care are thus rather different from those governing the selection of cases for more orthodox and direct therapy. In brief, it is our opinion that the after-care team has a very definite place in the treatment of those very cases which fail to respond quickly to more direct and individual therapy. As such, the after-care team has an important part to play in the community’s total mental health organization.
Conclusions
Although we fully realize the rather special nature of the particular after-care scheme here described, it is felt that some general conclusions are valid and applicable to the general sphere of community care. Some of these conclusions are not new, but have been proved elsewhere in the established team-technique of many child guidance clinics and some adult psychiatric clinics and hospitals. Nevertheless, we feel that they justify repetition, especially at this time when so many local authorities are assuming, for the first time, the responsibility for after-care, and when the lack of trained personnel render a considerable proportion of these authorities severely under-equipped to meet their new task.
1. After-care must represent a complete team approach by both psychiatrist and psychiatric social worker. Each has a definite individual role to play, but, in the integration of their efforts, each is augmented and complemented.
2. After-care is not merely social welfare and assistance in the ordinary meaning of the words, but is an active therapeutic process demanding special skills and techniques from its team members. The team must therefore consist of adequately trained psychiatrist and psychiatric social workers (or social workers under the supervision of P.S.W.s) each of whom is prepared to appreciate and understand the dynamic socio-psychological aspects of the clinical problem.
3. Very close personal co-operation and liaison is necessary with many bodies, both voluntary and established, whose work touches on community care or the social services. Without such liaison it will be impossible for the team to appreciate, as they always must, both the limitations and possibilities of the reality situation.
4. After-care represents an important, and numerically large, part of any scheme which is to provide for a total mental health service in a community. Apart from its function of continuing and augmenting the more orthodox forms of therapy, an after-care organization has the means of helping patients who would otherwise never reach the net of the orthodox treatment clinic. There seems here to be the justification of an after-care organization on a regional basis, closely working with the orthodox clinic but organized and administered separately from it.
The capacity to understand the individual … depends on our sensitivity, our intelligence, our experience, and our training. But not on these only. To understand we must see clearly, and we do not see clearly if we are blinded by envy, pride, personal ambition, jealousy, fear or greed. No amount of intelligence or training will make us understand if our observations are deflected by these distorting influences. Professor J. C. Spence.
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