JOURNAL ISSUE 15
From institutional logic to common knowledge: Power, action and reflexion
Faculty for Social Work
Social Care Home Hrastovec
University of Ljubljana
Community mental health is not a single unitary system or discipline; it is an interdisciplinary scientific and professional arena, a field. Instead of the triangle of the hospital, doctor and patient, it introduces a community as an adverbialiser of a collective subject based on the equality of partnership. It delineates the texture of the interdisciplinarity that goes beyond the classic scientific structure preferring the objective to object, predicate to subject. It is emancipatory in its goals and changing the role of the user, services, the value of diversity and aims at creative outcomes of stress and crisis. It is determined by diversity, connected, but consistent fragmentation, movement, critical approach and practical utopia. It is governed by the principles of pragmatics, contextuality, reflexivity and shift of power - therefore creating the everyday life as a starting point, criteria and goal of knowing and acting, simultaneously adhering to rules of situational relevance and creating the ordinary of the uncommon. By contextualisation and grounding in the experience it shifts the perspective and the power to the user, changing the method and the role of the professional into advocate, broker, innovator, but also witness and housewife. The knowing is based on dialog and experiment, critical evaluation, description and deconstruction including the actors, most importantly users, as agents of knowing.
Keywords: deinstitutionalisation, community mental health, contextual knowledge, power of users,
This paper is intended to serve as an introduction to the course of Deinstitutionalisation and Social Work. As an introduction it addresses the very basic questions of epistemological nature and is intended to discuss the very principles of the move from institution to community. The main contention of the paper is that the transformation of institutions and services also transforms the knowledge and basic assumptions of a professional practice. However, the contrary is true that for this kind of a massive move the different epistemology is needed, establishing a different point of view, a different gaze, different criteria of relevance and intervention.
It is certainly a vast area to cover in a paper. Therefore, the nature of my discussion is quite epigrammatic, expressed in a series of propositions, principles and theses. These are sometimes standing alone without much argumentation. They are meant for provoking a discussion or reflection on what the field of community health has evolved into. It very much reflects the points of departure, the basic propositions that spawn the action. In fact, this paper is based on my notes for past lectures, when we began the process in Slovenia. As such it is my aim to revisit the principles and refresh them as well as refresh our discussions with what we started with. The move from institutions was, at the start, often termed as utopian, but it is becoming a reality. However, the reality is not always what we have dreamt for. Nevertheless, my position is that we should not be content with a post-modern, realistic stance and the compromises made on the journey.
- Objectives not Objects
Not so long ago the image of mental health consisted of the grim imagery of mental hospitals (lunatic asylums), psychiatrists and their patients, sometimes not in the hospital but on their couches. Talking about mental health was as related to abnormal, pathological, and psychiatric diagnoses and classifications. These usually evoked fear, anxiety, awe, but also revolt against the repression, restraint and cruelty of electroshock, along with mystical expectations, curiosity and desire to deliver from the internal conflicts, to deliver happiness. It was a distant and secluded, but compact, world of its own, a monolithic and monothematic universe of concepts and organisation of mental distress. Our conceptualisation of mental health was determined by the classic triangle of – hospital space, a doctor and a patient (the illness).
Figure 1: Classic triangle of mental health
In the last decades, since the sixties in the West and the late eighties in East, such a monolithic approach to mental health has dissipated and dispersed. Besides the basic triangle, many other actors, activities, organisations, ideas and approaches have appeared. The development in the community was manifold: from grassroots, mutual-help groups to professional interventions at home; from enabling people to survive crises outside the hospital to group homes for people who used to live in institutions; from encouraging relatives and neighbours to live with the crazy to changing whole systems so that they not involve restraint and isolating people. Mental health increasingly became a public issue; growing awareness about the rights of people with mental distress and movement for changes in mental health have appeared. Many community services were introduced; among these are programs to provide employment, cultural and leisure activities, individualised approaches to care planning and provision, recovery and advocacy.
A completely new field, often called community mental health, emerged as an interdisciplinary field after psychiatry ceased to be the sole provider of mental health services. It is an arena where different actors meet on equal terms, service users often playing a prominent part. Development of the field was diffuse, not only spatially, but also in terms of diverse approaches, actors, processes and methods, as well as ideas and understandings. There is no longer a dominant profession, as there was in the classical psychiatry. Not only is there no longer a single agent of treatment, but the subject and the object of action – the patient and his disease – are no longer single and solid. The object has become stratified and polisignificant. Besides the individual distress, the objects of action in community mental health have also become its circumstances and contingencies, the time and space that generate it. The object of action is now also the solidarity of the people involved, the changes in the services, public opinion, stereotypes, education of relatives, providing work and employment, protecting rights, etc. In fact, there is no special object of community mental health; instead we talk about the objectives or goals.
Community mental health, in contrast to psychiatry, never had the ambition of becoming a single discipline. The main stake for the actors in community mental health is not to understand and explain the reality in order to control it, but to invent new, more efficient ways of improving it. It is more a technology than a science, more knowing how to act than explanation of the causes. While putting emphasis on interdisciplinarity, the actors of community mental health tend to borrow and take over elements of the different disciplines that are situationally appropriate and can yield the perceived goals.
The goals themselves are the joining element of this heterogeneous field. All the numerous and diverse activities of community mental health have a strong emancipatory note, either in terms of the emancipation of people in mental distress or of the phenomenon itself. Singular goals and objectives are numerous and diverse: protection of users’ rights; maintaining and enhancing social security, such as attaining benefits, suitable housing and providing work and employment; preventing crises and enabling recovery in the least restrictive environments; preventing stigmatisation, dissolving stereotypes and the role of the mental patient; supporting people to undo the harm and hardship after a breakdown or a hospitalisation; supporting the people who have been institutionalised for years to live as full fledged citizens, developing equal and partner relationships between the users and workers in the field; taking users seriously so they can influence and control the kind of services they get; changing the imagery of the mental distress and madness in people’s minds; preventing exclusion and isolation; redefining weaknesses into virtues, and so on.
Shift of the attention from the object to the objectives and goals is the basic epistemological turn that we are witnessing as we exit the closed institutional spaces. In those situations people were the objects (of the treatment) and were objectified. Emphasis on objectives and goals establishes another kind of syntax, from seemingly objective and objectifying to subjectifying, from seemingly passive and counter-productive to active and productive. To put it linguistically, the speech has transformed from an indicative, declarative to a volitive, optative modality. If, in the classical paradigm, it is the subject that determines the object and the predicate, in the new paradigm the predicate and its purpose determine the subject, which ceases to be univocal and which is pooled from a collective of diverse actors that participate in the action. What unifies the subject is their common purpose and objective.
We can merge the multitude of diverse objectives and goals in the realm of community mental health into four clusters:
- Improvement of the status of mental health services users or people experiencing mental distress.
- Changes in the mental health services to serve the needs, wants, desires and necessities of those in mental distress.
- Social revalorisation of madness, mental distress and otherness.
- Undoing and preventing those social processes that lead to destructive crises, and personal deterioration as well as enabling people to develop creative responses to life challenges and stress.
Improvement of status is needed, because historically, culturally and socially the status and role of the people labelled as mad or mentally ill is decidedly marginal and stigmatised. With such a label a person automatically looses a large portion of his civil rights, personal dignity, contractual power and credibility in everyday interaction. The actual distress also, for shorter or longer periods, impedes people from performing certain functions, roles or tasks; therefore, they need support, care and possibilities to compensate this absence.
Changes of services are needed since most of the traditional mental health services are segregative, controlling and serve mainly the needs of society in controlling the deviants, preserving public order, storing a surplus work force and resolving social problems by removing the protagonists. It is necessary to construct services that will achieve the opposite: include and integrate the people and allow and give them power to stay in the community and live with others.
Social revalorisation of madness, distress and otherness is needed since, with the rising importance of reason and the invention of psychiatry in the beginning of 19th century, the madness was outcast from social horizons and locked up in medical institutions. Rationality as an ideal of bourgeois society negatively sanctions all offences against reasonable conduct. Also, Emancipation of madness is a necessity of contemporary society for those who are not labelled, but are, on account of the disciplinary nature of the system, constrained and do not dare to think and act differently.
Undoing and preventing the social processes that lead to destructive crises and personal deterioration as well as enabling people to confront the life challenges and stress are needed since these are necessary components of everyday life. We need mechanisms, skills, even technologies that will enable us not only to survive these moments, but also to render them useful.
These four clusters are just four different aspects of emancipative process and are connected circularly. Attaining one goal enhances the possibility of attaining the other three.
Figure 2: Goals and objective of community mental health
The term community mental health is greatly defined by the adverbial relation indicating location – community. What is common to the situations of community mental health is the community principle. It means that the location, the space of the action, can take place anywhere in the community – in a flat, club, park or community hall; above all it means that people are not isolated or segregated by this action. In term of the actors, this means that in many processes there are many actors involved – users, different professionals, relatives, friends, volunteers, etc. Community as adverbialiser simultaneously implies that the actors are, in principle, in equal relationships and that they strive towards common goals with common effort. Community principle means that the communal events spanning from pair relationships to social changes, not just the individual and his disease, are the focus of the action. Even if the action is centred on an individual, he is understood to be an individual in the community. In terms of the method, the community principle means that in a given community available resources and means are used and that an event is dealt with in the context of its emergence.
Table 1: Community principle
The conclusion can be made that community mental health is an extremely diffuse and fragmented area. The reason for this is not only its interdisciplinary nature, but also the multitude of actors, approaches and ways of working. However, this multitude has a common starting point – territory that until recently was the property of psychiatry – with the ambition to transcend the institutional praxis of psychiatry. It is connected by common emancipatory goals and common community principles. A following provisional definition of community mental health can be summarised:
Community mental health is an interdisciplinary field developed on the territory of psychiatry with the purpose of pursuing emacipatory goals while observing the community principles. These goals are: improving the status of people with mental distress, improving and changing the services so they will follow the needs, desires and necessities of their users, social revalorisation of the mental distress and madness as well ad establishing social conditions that will preclude destructive outcomes and encourage creative resolution of human distress.
- Dynamic flexibility
3.1 Connected, consistent fragmentation (Rhizome)
One of the basic features of community mental health is its diffuse nature. Community mental health as a practice is dispersed through space and includes many different people, using different techniques and approaches. It cannot be defined as disciplines usually are, the object cannot be univocally determined, and it is difficult to draw the line between the different disciplines (e.g. medicine, health care, social work, law, education etc.). Looking at it, we do not face a unified theoretical body, a school of thought, or some central and fundamental concepts to which we would always return to find the explanation of the peripheral phenomena that we deal with at any given moment. It is not like a professional and scientific discipline formed as a tree of knowledge, with the roots (founders, fathers or formative problems), the trunk (basic methodological and conceptual body), the branches that would shoot out of it (subdisciplines) and the leaves (methods) depending on the centre and feeding back to it; it does not have a tree top – the professional institutions – under which the knowledge would rest. Contrarily, it consists of a multitude of diverse and heterogeneous conceptions, pieces of knowledge and skills, originating from diverse corners and edges, different disciplines, professions and sciences.
Professions and sciences cooperating in the area of community mental health are sometimes in principle contradictory. On the level of ideology they are sometimes even mutually exclusive – but in the community mental health setting they are complementary. Behaviourism and psychoanalysis, for example, have always been in their fundamental teaching considered antithetical. In community mental health, not only are they used in individual cases, but have also, each in its own way, contributed to expansion of community mental health. Psychoanalysis potently influenced the movement of therapeutic communities (Maxwell Jones, also Laing, Cooper, Mosher) and institutional analysis (Tosquelles, Oury, Guattari) that have opened the doors of many institutions and democratised relations between the different actors in the field; behaviourism through the social learning theories (e.g. Hollin & Trower, 1986) has enabled people who had been for long years living in the institutions to be seen as able to learn social skills in order to live outside.
Dealing with mental distress in the community forms a network of knowledge and principles without the centre and periphery. It is not only about the interweaving of different notions, sciences and disciplines, but also about the topics of interest. Issues which are usually peripheral in science, like housework and good manners, can often, in practice as well as in theory, become central. At the same time, the focus also goes to issues of a more global nature, like social division of labour, general dependence on professionals and the fundamentals of ”rational” social order in bourgeois society, etc. In the emerging network the discrete topics and knots are interconnected while functioning independently of one another.
Normalisation is, for instance, one of crucial concepts in community mental health. However, it comes across in two almost contrary meanings. Foucault (1978) speaks of normalisation as a process triggered in 19th century creating norms of what is correct, average and adjusted. It was used for effective disciplining of the population by the standardisation of individuals, their classification and control. On the other hand Wolfensberger (1983) speaks of normalisation as a process taking place in the end of 20th century. Now normalisation means the right, but also the necessity, of people previously segregated in special institutions to live normal, ordinary lives, as lived by the majority; it also means the transformation of the services needed to achieve this purpose. So, we have the same word, one with a negative connotation and another with a positive one, denoting different and separate concepts, operating on two different levels: one on the deconstruction of the power, the other on the register of the positive programme of undoing the segregatory mechanisms of exclusion of the different, the deviant. However, the independent use and autonomous function do not mean that two different concepts (of normalising individuals in the first instance and normalising situations in the second), that by linguistic coincidence have the same name (homonym). The connection can be a very productive one (Flaker, 1994). Whereas Wolfensberger’s normalisation points to one of the possible ways out of disciplinary power relations, connected to the foucauldian conception of normalisation it can be understood also as practical critique of the normalisation in everyday life.
There is no hierarchy in the principles community approach. The principles that we discuss are not subordinated to one another. The principle of singularity is not superior to the principle of collectivity; the principle of being critical is not superior to that of flexibility.1 The principles and concepts discussed complement each other; moreover they construct each other. In this way they give the consistency to the whole conceptual network that makes community mental health more than just eclectic, postmodern shed.
1 The order in which they appear in this text and the clusters they are joined are arbitrary, solely a function of the text, and do not reflect the importance of one principle over the other
Unarborescent distribution of principles and concepts can be termed rhizomatic (Deleuze, Guattari, 1988, pgs 6-21):
[A] Rhizome is a subterranean stem, absolutely different from roots and radicles. Bulbs and tubers are rhizomes. Animal pack (rats) also. It shoots in all directions and at the same time connects. Rhizotmatic principles are of connecting heterogeneous sprouts and their multiplications in countless variations, creating ruptures and breaks, that are not signifying an end or a beginning, a series, linking to other growths and back to those that they have divided from, therefore changing them without signification. The genealogy of the rhizome cannot be traced, the rhizome can only mapped. In fact it is a map that modifies and corrects itself.
…Unlike trees or their roots, the rhizome connects any point to any other point, and its traits are not necessarily linked to traits of the same nature; it brings into play very different regimes of signs, and even nonsign states. The rhizome is not reducible neither to the One nor the multiple…It is composed not of units but of dimensions, or rather directions in motion. It has neither beginning nor end, but always middle (milieu)… When multiplicity of this kind changes dimension, it necessarily changes in nature as well, undergoes a metamorphosis. Unlike a structure, which is defined by a set of points and positions and by binary relations between the points and biunivocal relationships between the positions, the rhizome is made only of lines of segmentarity and stratification as its dimensions, and the line of flight or deterritorialisation as the maximum dimension after which the multiplicity undergoes metamorphosis, changes in nature… Unlike the tree, the rhizome is not the object of reproduction: neither external reproduction as image-tree nor internal reproduction as tree structure. The rhizome operates by variation, expansion conquest, caption, offshoots. Unlike the graphic arts, drawing, or photography, unlike tracings, the rhizome pertains to a map that must be produced, constructed, a map that is always detachable, connectable, reversible, modifiable, and has multiple entryways and exits and its own lines of flight… In contrast to centred (even polycentric) system with hierarchical modes of communication and preestablished paths, the rhizome is an acentred, non-hierarchical, nonsignifying system without a General and without an organising memory or central automaton, defined solely by a circulation of states. … is totally different from the arborescent relation: all manner of “becomings.”
A rhizomatic, fragmented connectivity does not apply only to the interdisciplinarity and the mesh of concepts but also to activities and actions, initiatives, actors, various arrangements, things and events that can be encountered in this area. These are also fragmented but connected. In the life world of a person, for instance, there can be connections of: self-help groups in a users’ organisation, therapeutic groups in hospitals, individual counselling in social services and work in a cooperative, but also a chat in a café, a trip with friends, family gatherings, etc. Heterogeneous activities in different institutions with different procedures mix in a variety of relationships. Alongside other everyday activities of a person they form a map that changes constantly - where rupture of an activity does not represent “getting worse" or “getting better," but transition to a different level of action, pursuing other, similar or different goals.
Relatives’ groups, that would be initially founded with a purpose of mutual support in dilemmas and distress that they experience when their relatives are in crisis, can, in moments of resentment, direct their actions into the pressure for change in treating mental distress; they can connect with the user groups or groups of professionals to enhance the rights and freedom of users. Thus, such relatives’ groups are enhancing their autonomy vis-à-vis the professionals as well as the users. This autonomy simultaneously purports cooperation – on the institutional level as well as on the level of everyday contacts of relatives, users and professionals.
Such a rhizomatic, diffuse concept of community mental health not only provides a better picture of the area but is in itself an active principle of the community approach to mental health. It is not only a way of connecting knowledge, skills and understanding, but also the actors, initiatives, practices, activities, events, things and arrangements in this area. Both are true: the community mental health principles are rhizomatic and the rhizome is a principle of such practice.
Community mental health was always, in many ways, a movement. It was established by various social movements; it is also a social move, a shift, and it is a very mobile and volatile phenomenon.
Social movements. The instigators, if not the main leaders and the motor, of community mental health were different social movements. However, unlike established and structured disciplines, community mental health has never become a speciality, a discipline of its own; it never became an institution - the strength was always derived from a movement. In the sixties these were mainly movements of professional dissent (antipsychiatry, Democratic psychiatry in Italy); in the eighties and nineties they were movements of volunteers, users and relatives.
Practical utopia. Principles of community mental health are based on a vision - collective imagery of what is to be achieved. These goals can be utopian – in the sense of wanting to achieve something that does not exist yet. Movements are founded on the hope that they could create something that will change the society that will improve the condition for users as well as workers and create more justice, a new social reality. Utopia can have a small range, it need not necessarily encompass a big issue; it can be, for instance, a self-help group in a town or a crisis centre for users, but they can also be on a bigger scale, like changes of the system, closing of hospitals, new mental health legislation etc. The characteristic of practical utopias is that they can be, in a given social and historical moment, realised.
This distinguishes the practical utopias from the false ones. The word utopia is usually used for something that is not realisable, that is not realistic enough, that lacks critical sharpness of historical and social deliberation. We can still remember, in the field of mental health the psychotherapeutic utopia, which was politically naïve. Some authors (e.g. Carl Rogers, 1980) sincerely believed that if psychotherapy were part of general culture and a big proportion of the population would undergo some treatment, we would, in few decades, live in a happy society. It may be hard to distinguish from the utopias that are just a mirage, and in effect an apology for the status quo, and the ones that present the moving force to create new possibilities. However, an attempt can be made to summarise what has made utopias in mental health productive and what could constitute a practical utopia:
- Need to have a vision, a goal, which has to be exciting enough for the members of the movement;
- Nurture critical analysis of actual social conditions, power relationships and contradictions;
- Goals of a single movement have to encompass different levels of action and creation and should not be confined and focused on just one major goal that is binding for everybody;
- At least a part of the utopia has to begin to take place, has to be tangible.
- Movement has to be capable of forming coalitions with other social forces and movements.
However, practical utopias must also:
- Remain autonomous and independent
- Avoid dependency, being just transmitters of prefabricated schema, traditions or uncritical and untested ideologies.
A characteristic of the movements is that they are usually not permanent. They have their cycles of beginning, flourishing and then they usually wither, disappear or fade out. Movements die when they reach, at least in part, their goals, when the goals cease being exciting or when they appear to be unrealisable. Movements cease being movements when they “grow up,” when they acquire certain social power that they have to maintain, then maintaining the power becomes the end in itself and the goals become just a declarative façade. The finality of the movements is a quality and also a virtue that distinguishes them from institutions, schools and sects. These function on the assumptions of eternity. Although the community mental health movements were often connected with charismatic figures (e.g. Basaglia, Jones, Laing, Cooper, etc.), until now they were lucky enough not to settle in a form of school or a sect. These charismatic figures did became icons in a way, but a good side of this is that there were no senseless discussions about what the founder really said, schisms and the legacy struggles leading to the narrow mindedness and inability to act that would be based on the pledge to one truth and one leader.
Finality and the inability of being established and instituted do not mean that the community mental health movements do not leave any traces or echoes. Most of community mental health projects have been integrated into the establishment, into the mainstream of single disciplines; either they have been colonised by existing institutions or they “grew up” (i.e. adjusted to function in an institutional environment). A great number, maybe a majority of the community mental health activities started as a movement, have reached permanence as a special formation in the voluntary, sometimes in the public, sector. It operates as a kind of semi-institutional hybrid – on one hand as an established, organised and routine activity, on the other there is still a scent of the exciting goals of the movement.
A second, maybe more important, way that movements have an impact on community mental health is that the movements also have, besides the visible and direct (Guattari – molar) effects (e.g. concrete new services, new organisation), effects that cannot be seen immediately, but come up (sometimes unexpectedly) later, somewhere completely different (molecular action). Ideas, initiatives and fantasies are spreading out in a capillary fashion through the social tissue.
Delayed translation. Bosnian psychiatrist, Ismet Ceric, as a young psychiatrist studying in the West in the sixties, encountered the ideas of Basaglia, Laing and others. When he came back he could not do else but work in the fashion of the existing system. After the war, when psychiatry was reconstructed and having the power of the leading expert, these experiences and memories inspired him to implement the community model.
Resurfacing. In Slovenia the first mental health movement appeared in 1975. In the wake of antipsychiatry a dissident psychiatrist, Ana Rojnik, formed the Association for Help in Mental Distress; professionals, students and users joined in order to establish alternative practices. This, however, was torpedoed by official psychiatry through political means. In 1988, as a part general swarming of the ideas in the changing society, the Committee for Social Protection of Madness was founded in Hrastovec; it was the largest long-stay institution in Slovenia to promote closing of the institutions, the human rights of users and the rehabilitation of the madness. In 1995, Tanja Lamovec splintered off to establish an autonomous users' organisation. The idea of users running crisis centres was short-lived and the club ceased to function before she died. In 2008 a group of users, supported by a European project, established a new organisation: Bridges – Dissatisfied Users of Psychiatric Services.
Inversion – reversion. In 1987 a youth camp was organised in Hrastovec, the largest total institution in Slovenia; it was the last stop for mental health and learning disabilities. It had tremendous internal and external effects. The staff and inmates raised hopes and saw practical possibilities of a different life or work. However, there was also a negative reaction. After two years, the camps had to be organised outside the institution, thus removing people from the facility. This led to establishing, in 1992, the first group home in Eastern Europe; it housed four inmates from Hrastovec. This was the inception of community services in Slovenia. The movement itself was, by 1995, expelled from Hrastovec and no longer allowed to return until 2001. However, Hrastovec became a symbol, an infamous total institution in Slovenia. In order to change, in 2001 a new management was installed and the protagonist of the movement re-invited. Hrastovec became a symbol of successful deinstitutionalisation.
Refrain. One should not forget that the inception of psychiatry was not marked only by closing. The early 19th century utopia was constituted on the notion of liberating the insane. Moral treatment was socially based, and Connolly in Hanwell Asylum introduced the model of No Restraint. Similarly, community mental health was spun by the Open Doors concept around World War II. These concepts were prominent in the Italian reform, which abolished the total institutions. No matter how successful the reform was, there are still closed doors and restraining measures in Italian mental health services. In 2007 at the No Restraint meeting in Merano, Lorenzo Toresini formed the club No Restraint Services and European Association Against Restraint in Mental Health.
Challenges. Movement always needs challenges. Ideologies are liberating only while they are in the making; they are oppressive once they are established, says Sartre (Lovell & Scheper - Hughes, 1987). When some goals are realised, some become out-of-date, become boring or not worthy of striving for, because of this there is need for new ones or to transform previous ones. There is no programme that is good for all times; there is no final solution to social contradictions. In order to remain productive there is a need to remain in the state of flux. The ideas, concepts and the actual ways of working, the practices, need to change constantly. Community mental health cannot be ordered in a stable pattern.
Shifts. Movement in community mental health is represented by different shifts. These shifts are conceptual (see figure below), but also real. There is a real shift of people who are being resettled from the institution to the community, and consequently there is also shift of work place from the institutions, surgeries, offices into real life spaces. There is also a real shift of power: from professionals to users, from psychiatrist to nurses and social workers, from the wardens to enablers.
Figure 3: Propositional shifts of community mental health
Shifts of removal, confrontation, encouragement and projects
The propositional shifts point to dialectical movement of denouncing the existing apparatuses of oppression, creating the antitheses and alternatives that lead towards new syntheses, practical and realistic utopias. If denouncing and alternatives were the main focus and the heart of the movement in the early days, now, when the deinstitutionalisation is the mainstream international policy, seeking new and astute syntheses is the main principle at work. We are not interested so much in what we want to escape from and fight against, but what are we fighting for and striving to. In spite of that, it is of utmost importance to know the former to properly do the latter, we have to reflect, look back (in anger) to see where we are coming from and what we stand against. Sometimes new staff, which have not worked and experienced the total institution, are more likely to reintroduce disciplinary attitudes based on some common sense. Trying to find new ways requires awareness, sensitivity and bringing to attention the oppressive mechanisms of the old services. The logic of oppression, discipline, closing and segregation is very resilient and continues to go on in new alternative services. Denouncing, of course, is of paramount importance, where oppressive logic still prevails. The deinstitutionalisation machine (Flaker, 1998) is polemic and at the same time programmatic.
In various ways, being critical is a constituent principle of new praxis in mental health. Firstly, community mental health directly denounces
mechanisms of oppression in the field of mental health; it has targets that the criticism is directed at. Secondly, it is about critical judgement of the processes and phenomena regarding their social, cultural, historical and contextual positioning. It is about critical consciousness, be it in theoretical production or in everyday practice.
4.1 Three targets of criticism
The first target of criticism is the total institution and the logic of closing. Criticism of its effects - institutionalisation (Barton, 1959), its fine analysis as a social entity and how it takes up identities and transforms them (Goffman, 1961), the archaeology of institutional knowledge and its becoming (Foucault, 1961/1972), production of the micro politics of power (Foucault, 1978), its social function (Castel, 1976), and its role in the politics of oppression (Basaglia, 1968) - have given the fundaments to the practice of deinstitutionalisation2. These critiques have shown that the logic of closing away people with mental distress is based solely on the social fabrication of normalcy and protection of the social norms, order and peace. For the wellbeing of the closed away ones, closing away is not only unnecessary, but destructive. Community mental health is unambiguously an anti-institutional movement that demands cessation of closing away and detention as a condition for real care and help to people in distress.
The second target is the medical model, also including other practices (in psychology, education etc.) that want to reduce human diversity to one explanatory dimension. Critique of the medical model is not directed only at harmful medical treatment (e.g. ECT, insulin, psychosurgery, neuroleptics), but also at the inappropriateness of medical terminology and generally at illness as a false metaphor. Criticism is not confined to the critique of medical imperialism (Illich, 1975). It is, moreover, the criticism of total dispositive, of the diagram of help that was taken up, developed and perfected by medicine. The target is the mechanism of condensing diverse and heterogeneous dimensions of distress into the individual body - the reduction of interpersonal, class, gender, cultural complexities to a single explanatory scheme. Another criticism is that it establishes a dominant explanation that is based on the power of the professional in a hitherto formed relationship. In doing this, community mental health is movement-contesting and opposing the incontestable professional power.
2 N.B. The fact that the first three major works by Barton, Goffman and Foucault have appeared practically at the same time (1959-1961), but in different milieu, and treating the same subject from diametrically different points of view (medical, sociological, epistemological), attests to the paradigmatic breakthrough in its own right.
The third target is the role of “mental patient.” In some way the role, label, stigma and career of “mental patient” are direct products of institutionalism, it’s the other side of the coin. Poverty, isolation, negative expectations, scapegoating, visibility, lack of encouragement and aspirations are even more important in the moment when somebody leaves the hospital and enters the domain of the post-psychiatric practice. Critical interest in the role of the mental patient appeared at the same time as the critique of the total institution (Goffman, 1961; Scheff, 1966; Szasz, 1970). Research into the fate of the mental health users outside the institution (Estroff, 1981; McCourt-Perring, 1993; Barham & Hayward, 1995; Flaker et. al., 1995; Flaker, 2007) has shown that the mental patient role is more resilient than the institutions that created it and that it also persists in the open environments of community mental health.
4.2 Historical critique
History is usually used (e.g. in the psychiatry textbooks) in an apologetic way to legitimise the present by proving that the profession is developing, is progressive, and that today’s psychiatry is more humane in comparison with the cruelty of the past. A more productive way is to use history as a mirror (Illich, 1981). There we can see the contemporanity as not taken for granted, but as something that has become and has not always been the same (e.g. there were times when the lunatic asylums did not exist; those who are now mental patients were once saints, heretics, court jesters or village fools; in the industrial society the asylums were, above all, the warehouses of the (defunct) work force). The use of history can be in deconstruction (Foucault); by looking at the past we can, as the archaeologists do, discover how the different layers, parts of the hospital, concept of illness and the role of mental patient were invented and then how the parts and the whole machine function in the present. In this way we can deconstruct the machines of mental health.
History is not only a tool of knowing, but also of acting. By getting to know and knowing the history we can create a new future, become its subjects in the Marxist sense (Freire, 1972; Fanon, 1963), realising the socio-historical relationships that we have been born into. We get to know how history influenced the way we live now and the way we want to live, thus giving us an epistemological opening to visualise how we want to change these situations.
4.3 Social critique
It is important, even necessary, to look at institutions, models and roles from the point of view of the society. One reason is that the domain of mental health has been dominated by the explanation and treatments based on biological and psychological perspectives. This not only individualises social phenomena and makes them into psychological problems, but also establishes a scientific paradigm that codes concepts of individual and psyche as scientific tools. Putting the emphasis on the social dimensions and aspects of mental health phenomena is not only an antidote to pervasive individualisms, biologisms and psychologisms, but is also a critical stronghold for developing and evaluating the thought. It is the tool of the criticism, but also the goal of action (social change, innovation). But, it is not an epistemological, gnoseological goal in itself. Sociologism is a reductive practice too, and in society is a paramount and covering term.
In community mental health we are interested in the social construction of phenomena at hand (especially institutions, models and roles), in social power and oppression and in changes in the social and power relations in mental health, as well as the possibilities that community mental health can provide changes in general. Special attention is given to the relationships of domination and oppression. We are interested in class oppression and the condition of the lower strata and working class in mental distress treatment, but also how mental health services are functioning as a special apparatus of class domination. Similarly, attention is directed at gender dominance, special gender positions in receiving services and the role of women in providing mental health care. We also need to consider the supremacy of western, white culture in defining mental health and care as well as racial and ethnic discrimination in mental health provisions.
Besides these classical social issues there are two major questions that are prominent in community mental health. One is the question of social change, transformation and transition. The issues are not only transformation of the welfare system and social solidarity, and transformation of society as a whole, but also of transformation of single services, conversion of institutions into networks, of processes of involving users and creating democratic organisations. The other question is the question of madness and reason in our society. Parallel with the rise of the psychiatric institution, reason prevailed as the unchallenged principle of social organisation. Post-psychiatric practices, by having returned madness back into the community, in their own way pose the question of reason.
Contextuality is the main positive stake of the new mental health practices. To act in the context is the main realm of post-institutional practice.
Abstraction and extraction from the ordinary context are the basic institutional operations. By doing this, by ignoring the context, the knowledge of the person’s distress is limited; it makes the possibilities of knowing how it emerged scarce. At the same time, we bind the criteria of our professional action to the situation where it takes place, namely, to the logic and rules of the (total) institution itself.
Coming into the community makes the ordinary lives of people important. Firstly, we know and understand the person’s distress or crisis better; secondly, we form more adequate responses. Professional problems become ordinary; the arguments and legitimising of the solutions, deeds and instruments need to derive from the very same everyday circuit. Professional interventions become ordinary, everyday manoeuvres (Flaker, 1994).
5.2 Ground level
Concepts and conceptual frameworks of community work evolve from everyday events. Concepts used must derive from the situations and situational analysis. Theories become grounded and street level (Glaser & Strauss, 1967; Lipsky, 1980). Ground level means the connection to everyday events, use of everyday language that is easily understood and dealing with the banal; it has little or no universalistic aspirations, uses material at hand and the contents of the context. The main criterion is being pragmatic – i.e. as long as it works.
The essential differences between community mental health and the sciences are that it is exquisitely borrowing from the latter the conceptual apparatus of talking about everyday life – sociology, anthropology and social history3 of everyday life – and is oriented toward action. If the goal and task of the previously-mentioned disciplines are to understand and explain everyday life, the task of community mental health would be to act - to be active in that life. The scientific goal is an informed action: not explaining, but changing the reality. Pragmatics can thus be understood not as testing the theoretical concepts in everyday life but their creation. The questions that mental health workers ask are not “Why and how this happened?” but “What and how is it to be done?” We are not interested in structure, psychopathology nor grammatics, but in pragmatics of everyday life.
3 The exception is, of course, social work and other sciences of action. The epistemologies are very similar, but with different histories (cf. Flaker, 2006). There are of course pedagogy, medicine and nursing, which are sciences that are about what is to be done. However, these tend to be interested more in grammatical rules of action, with definite institutional framework that makes the grammatical approach not only possible but necessary since they are about how to conform people to the institutional rules. In this way these disciplines produce esoteric epistemology, valid in the institution and determined by it, negating the value of everyday life outside the institution. However, this is also their epistemological deficit.
A singular person or phenomenon is no longer a representative of their class, but is of interest in their own right. Their universal value is but indexical, pointing to the type of situation and clusters of issues that we have to deal with. The foreground is inhabited by idiosyncrasies and singularities. These are the objectives of understanding and the starting point of action. We are interested in biographies of singular people (Urek, 2006) and, even more so, anecdotes and single situations.
The objects of the work in the community are no longer individuals, their correction and exclusion, but situations. The logic of this turn is rather simple. If the previous paradigm was about adapting individual people to the situation, in most cases by his or her exclusion, the vocation of the new paradigm is in changing situations to accommodate the phenomena that previously could not be contained in everyday life.
In this case the definition of the term situation is considerably broader in comparison with the usual ineractionist definition in sociology. It is not only about the immediate social and material milieu in which participants are situated, not only the place and space, but also contingencies coming from relations, expectations, roles, etc.
The important concept is the situation definition – how the situation is being defined for the participants and how they define it, what roles they are playing, what in a situation is relevant (and what is not), how participants are understanding the happenings and what they expect and do (Goffman, 1956, 1963), how the experience is organised and what happens, what the frames that organise the experience are, the events and eventualities (Goffman, 1974), how our experience is framed and what the rims are.
Frames and the events in them can be understood only within the very same situation or the frame that constitutes it. There is no experience, deed or event in everyday life that is independent of its context of appearance. If we use another frame to understand an event, we have changed its happening (Garfinkel, 1967). This is why we have to go back and investigate the context of distress, event and frame and organisation of the experience.
5.7 Ordinary of the uncommon
While emphasising the ordinary, in the context of mental health we also witness the extraordinary, exceptional events and experiences. These are events where ordinary frames fail, heterogeneous frames mix and frames appear fabricated and false. It is about situations: when things happen and these unusual events cannot be explained within ordinary frames (e.g. “supernatural” events); when somebody within an existing frame uses another, inappropriate frame; or when somebody uses a frame that is unacceptable to others who happen to be present. It is about mistakes, misunderstandings, comedies of mistaken identities, etc.
One of the tactics we use when encountering unusual events is to use rules of relevance. This means that an unusual event might not be relevant for the action at hand (within the situation) – and we just leave it aside (ignore it, forget about it, take no notice) and proceed with the relevant. E.g. if somebody in a given moment feels persecuted, it might not be important who is persecuting him and why; what can be more relevant for the situation at hand might be whether the person in question is experiencing or causing any harm. Sometimes it is necessary to put the issues of content and reality into brackets and to deal with the material effects and what is practically important. We might never know the causes, but we will definitely experience the effects. After all, the shop attendant does not care if the buyer is delusional or not, what is relevant is if the buyer has the money and if the shopkeeper has the merchandise.
Insisting on the rules of relevance might, however, tempt us to introduce the concept of paramount reality. This schutzian concept is a social fact only as a normative one, and being such it has to be taken critically. Goffman (1974) shows that realities consist of a multitude of diverse frames that change form situation to situation, from moment to moment.
Tactics that can be used resist the dominance of the ordinary, everyday-life reality are of accepting and validating minor realities. These tactics are, in a way, opposite to the previously mentioned tactics of applying the rules of relevance. In accepting a story, vision, construct, statement, outburst etc., we switch from the rule of practical relevance to the criteria of aesthetic and ethic value of immanent relevance. In other words, if we hear something weird from somebody, we may not judge that on the grounds of how relevant it is to our (common) action, but sit back and listen, enjoying the difference, the story. After all, when an artist presents a picture we do not protest that it is not real (even realistic pictures of fruits can not be eaten), but put it in a frame and hang it on the wall (if we put it in the loft it is not because it is not relevant, but because it is not aesthetic).
Ethical relevance derives from the right to be different or, less euphemistically, the right to madness. This right can be the guidance not only in accepting minor realities, but also in acknowledging the rules of practical, everyday-life relevance. When we avoid unusual phenomena on the account of their irrelevance, we do not need to negate their initristic value, at least for the person experiencing it; we do not need to take away their existence, just their relevance in the actual frame. Work in mental health is the art of coexistence of diverse realities. The stake is that the existence of minor realities also changes the major ones.
Mixing frames, comedy of mistaken identities and mistakes are funny parts of our lives. Turns of the frames, their inversions, make us laugh. When Buster Keaton falls down the staircase, his stone-like, unchanged face points to the inconsequentiality of what could be a tragedy - this makes us laugh. There are numerous events like that in the field of mental health. However, the irony and black humour that were synonymous with madness in the epoch prior to the Enlightenment (court jesters have disappeared in the Age of Reason; Lever, 1983) are swept under the carpet very much in traditional services – to be practiced only privately among the staff or users. Laughter and humour are basic tools to the juggler of the frames of existence.
5.9 Ordinary actors
Community mental health, by diffusing action and spreading in the field, has involved many new actors, many of them not by speciality but by being close and active in a person’s life world. It has already been noted that staff of low standing in institutional settings, like cleaners, maintenance workers or orderlies, may have a greater impact on an inmate’s well-being than the highly professional staff. The doctor was the peak of the pyramid: the top of the signifying processes in the place, the most important other and the maker of decisions. Some users report, though, that it was the ordinary, brief and accidental encounters (e.g. in passing in the yard) with the doctors that made more difference than long hours of consultations.
In the diffuse camp of community care, the ordinary people play an even greater role. These might be the people who are involved in the life of the users, the family, friends, neighbours, co-workers and even accidental bystanders. They can either play the role of adversaries, exerting pressure and contributing to the distress, or they may be helpers, allies, secondments and witnesses who support and acknowledge people in distress. It has been shown that given the right support, these people can become crucial in a person’s recovery and well-being (e.g. Leff & Vaughn, 1985); special circles of friends can be made (e.g. Perske, 1988) to support a person in crisis or on a long-term basis; networks can be woven to provided extra support when needed and when natural networks hardly exist. Special attention, training and support can be given to people in the community who are at points of busy traffic and who are natural listeners and confidants, such as bartenders, hairdressers, shop attendants, policemen, firemen, teachers, etc.
Shift of power
6.1 Self-help – for whom?
Illich’s critique of growing professional power, especially medical, is but one of many. It has shown that profession and professionalism acquire, in modern society, a similar function as the clergy did in the past. The result is that increasing professional power disables people to help themselves, in their own right, with the resources available. “You must see the doctor” is the most frequent answer to any problem or distress. Professional power is destructive to the power of the people – individuals, groups and communities - to take care of themselves (Illich, 1978, 1981).
On the other hand, self-help has become one of the magic words and a rising movement on the scene of health and other services. It is seen as a criticism of bureaucratic, multinational giants of power, iatrocracy and welfarism. On the other hand, Illich et al (1977) are analysing how the self-help rhetoric often cover the imperialism and colonialism of the professionalism that uses self-help not only as a way of cutting costs, but also as a way of entering the most intimate and remote areas of human reality. The medical model of self-help is to teach the users to do to themselves the things that would otherwise be done by professionals. Therefore, it is of the utmost importance to ask the question “do we have the power to help ourselves by using our own power?”
6.2 User perspective
The essential turn the power shift presents is in seeing situations from the perspective of the users and not the other way round - i.e. from the perspective of the professionals or the public. Practically, this means that the user’s word is to be believed at face value and is decisive, that it is necessary to enter into the shoes of the user, to look with his eyes and try it on our own skin. It does not mean just changing the view-point, but actually getting users involved in planning, organising and delivering mental health services to him- or herself personally or to other users. Moreover, it involves enabling the users to lead the services.
6.3 Partisanship - advocacy
We are leaving positions where make-believing neutral intervention into reality was a synonym of professionalism and its prerogative. Being unbiased and objective is not only an ideological fiction of the rationalist professionalism that always proves to be impossible, but also its antithesis of being biased and partisan is a pragmatic postulate. It is simply impossible to do something with somebody for his of her sake if we do not establish a common value base that will institute a mutual pact, because doing something together for his or her own good is defined by the person themselves (Brandon, 1991).
6.4 Analysis of power and empowerment
A power shift is important for both the professional protagonists and the users. How to acquire the power is the crucial issue for the users, as they are defined by the lack of it. Continuous analysis of power, cartography of power sources and making alliances that will enhance control over life contingencies is vital from the user’s point of view. From the point of view of the service providers (regardless of whether they are users or professionals) an analogous process is equally important; the difference is in the position or standing. The user’s position is defined by the lack of power while the position of the provider is defined precisely by the power that he or she was given by the power centres to carry out the services. The provider’s analysis of power and the programme of empowerment thus derive from the delegated power and necessity to delegate it down the power scale (Basaglia, 1987).
This kind of analysis is a filigrane work (knitting or lacing). At the same time it might be finding and building the momentum for larger scale and more long-standing changes.
The shift of power is a conflictual business. It is true, at least to some degree, that the destructive force of conflict can be overcome by negotiation or mediation and the result is not necessarily zero sum - gaining power is not necessarily at the expense of the other and the participants in the conflict can all gain something - but it is still about struggle and fighting. Thus, the dialogue is not only a tool, but also a weapon. Dialogue does not mean only a conversation of two or more actors, but words that cross or even pierce through (prefix dia- through, not di- two) or transverse the matter. In Freire’s (1972) sense of the word, it is about people that oppression deprived of the words to reacquire or repossess themselves. Words that are practically meaningless (professionals sometimes term users talk as glossolalia) transcend to words that are in action, are productive, and that can change reality.
The power is never individual, it is always combined. The issue of empowerment has been profaned in the last decades, attributing the power mainly to personal assertiveness - feeling strong and powerful. But to do something, in a social sense, to actually change something, even if it is the quality of one’s life, we need to combine forces. The individual is by definition lost, alone and isolated - hence, powerless. Union of people is mighty. To link, to persuade, to align and ally, to provoke and combine yields the change - a product that is working. Individualisation of people, separating them from their peers, dividing enables the rule and the crowd is unruly.
Power derives from partnership, user collectives, users and providers collectives.
The role of the professional, as community mental health is shaping it, is profoundly changing. The questions of power, more so of imebededness in the context, point to the fact that the most qualified mental health professional is the user him- or herself. The discussion above can be summarised into the figure of a new professional who needs not be paid and academically trained. We do not refer only to paid and academically trained professionals, but also to those who dedicate an important part of life to the issue – users and their loved ones included.
Firstly, we have seen there is the need of a “go-between,” of a broker and mediator. People who experience mental health distress, whether it is a crisis or long-term difficulties, need other people who can do things when they cannot or that can help with issues that need special skills or knowledge. They need the power that is being taken away or that they cannot realise or implement. Somebody is needed to link them to resources that they may need or might be loosing. If discrepancies in frames and confusion of identities take place, a confidant and translator or interpreter might be needed. If there is conflict, a mediator is needed that will establish a minimal common ground between the people involved (even if it is a battleground). This may be a person who has access to power; who may not be powerful him- or herself, but who has the knowledge of how power works; and who is able to connect, but also give up his own power and/or use the power invested in him and delegate it to the user.
Secondly, there is a need for things to happen. The new professional figure has to enable processes to happen - they must be a facilitator; they must pick up the processes where they stopped and create where they lack. Also, they must prevent destructive processes from taking place, but not at the expense of not taking risks. An innovator is needed to construct new responses, multiple meanings and clues, new and critical awareness and to raise consciousness, but also to rearrange things materially and organisationally: an organiser (manager) but also a housewife (organising la ménage). The skills and knowledge are needed to sense the needs, desires and necessities of the people, but also to transform this knowledge into action, material arrangements and organisational forms in the seamless way, like housewife does, inconspicuously, with silent leadership that acknowledges everybody and bases the activity and action on the relational logic of being together.
On one hand such a person might be considered a superman (or rather a superwoman), a many faceted multi-component genius. As such, she clearly does not exist. On the other hand, it is an ideal that may apply to anybody; there is nothing special that requires this figure to be a specialist, having a particular discipline and profession. What makes the work described in the community mental health context different from the generic work of living together and institutes it as a profession? The obvious answer is, of course, that the person is put into the position of performing this work, that special power is invested in him or her, both officially and unofficially. When it is officially, the person becomes a functionary of mental health; he does not even need to pretend to know anything or be able to do things - he just has to follow instructions. If the person is to be chosen from the people to perform the role, he needs to show the knowledge and skill to be chosen, but also to get the trust of the people by discipline.
There are positive and productive features of classic professional discipline, like punctuality, respect, accessibility, reliability, confidentiality and responsibility. From a professional we can expect that he or she will be there at a certain time and a certain manner and that he will be acting in our interest. However, the new professionalism also enables professionals to be more human: to feel, laugh, joke and swear, to be able to make mistakes and express themselves freely. The new discipline is also about being honest and sincere about our own investments in the situation. Discipline is also about the continuous and tedious reflective analysis of the power relationship we act in; it is also about being disciplined in avoiding the pitfalls of professionalism (professional mystification, jargon, stigmatisation of the users, coalitions with other professionals, Pygmalion complex, craving to help, etc.; cf Flaker, 2003). We need not be only reflective about it, but also efflective, sharing this discipline with users and doing something about it.
There are two types of knowledge a new professional of mental health needs – the knowledge he or she needs to acquire (study) and the knowledge he or she needs to produce (research). We have discussed the first type quite extensively and come to the conclusion that there is no body of knowledge but a network, a rhizome. However, there is consistency in the critique; so, community mental health professionals should know how to hit the targets when they see them, they should also know about living everyday life (Goffman and Foucault are the main authors to study - maybe Deleuze and Guattari also). They should also know how to analyse power (my favourites are Gramsci and Basaglia). On the plane of producing knowledge, the main tools that should be used and developed are methods of critical appraisal and action research. Knowledge production should be experimental - only through action, trying and practicing can we develop skills and innovations. This should be done in a participatory manner involving and including diverse actors – especially users - thus creating, using and developing local knowledge (Illich, 1981; Grebenc, 2006; Ramon, 2003). To avoid colonialisation, this has to be done in dialogue. Reflection and efflection should not only construct pieces of knowledge and reality, but also deconstruct it.
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