EXPERIENCE OF TRANSITION
IN COMMUNITY MENTAL HEALTH CARE

(Or 'Lambeth... and Goodbye to all that')

I'm in limbo, waiting to start my new post. Two days before Christmas 1996. Lambeth Social Services is behind me. Three and a half years working there, a public service slowly being strangled of resources, in recession. Lambeth had been one of the last old-style, radical, Labour-controlled boroughs in the country, had got themselves into all sorts of debt through trying to pretend unfair government spending ceilings and financial penalties for overshooting them did not exist and through general bad management. Had also got themselves into debt because of central Government cutbacks as a backdrop to their 'high-spending' local policies. Thatcher's governments in the '80's and subsequent Conservative administrations in the '90's tried and succeeded to a large extent in getting the ideology of the day changed, so that high-spending necessarily equated to bad, in relation to public finance. Even when you had a situation like in Lambeth where the population of the borough constitute one of the most impoverished in Europe - and just about the worst in the UK on a trusted scale of social deprivation (Jarman, 1983).

Those staff left at the Mental Health Day Centres which were closed over the last twelve months, or are now being closed, like those who had always worked there, comprised various sorts. There were the waifs and strays (professionally speaking) who would not be able to get a job elsewhere, through incompetence, lack of training, unacceptable sickness record or some other such reason. Then there were those suffering particularly acute forms of the personality disorder suffered by many in this field, that stuckness which compels one to want to work with mental illness in others and see oneself as mentally healthy, in the face of any manner of evidence to the contrary. And there were those who wanted to see some quality work and a hard series of closures through to the chaotic and unsatisfactory end, because they felt so strongly for the job they had been doing at the Centres that were being closed.

We have had to preside over the dislocation of psychiatric patients from a particular type of non-institutional community resource where the council had encouraged them to make a home for themselves for almost two decades. Health-centred, person-validating, social systems-oriented, empowering mental health care. Which we would always contrast with the various forms of treatment for mental illness on offer through statutary provision within the NHS. Dislocated, these 500 clients were being, from a relatively healthy form of institution that provided some structure to their lives - Monday, Wednesday, Thursday and Friday drop-in's at Lambeth's three Mental Health Day Centres, all of which offered a slightly different menu, style of service, range of activity, theoretical approach and atmosphere. One Centre, Riggindale, concentrated on activities as much as therapeutic work within a myriad of small groups held in an old house in Steatham. I managed this Centre earlier this year for six months, during the period when its activities were being curtailed and as it was strangled of staffing resources. One Centre, Effra, was well-placed to specialise in services addressing both mental health needs generally and, in particular, the disadvantage experienced by the black community and by women around Brixton. They also ran a large cafe. All from a large ex-1970's industrial therapy unit. This was the third of the three Centres where I worked, just for the past three months since Riggindale closed and while the council have been making up their mind which direction to take. It has been chaos there, what with all the three client groups, and the remainder of all three staff groups trying to revamp the service and make it work (or sabotaging it from doing so) amidst a climate of impending doom, mutual blame and recrimination, competition for space, ill-will and madness, including at least two majorly disruptive psychiatric breakdowns (one a genuine crisis and the other feigned). And although it sounds like a cliché, yes, that was just in the staff group. Arguably, the clients handled it considerably better.

At the first of the three Centres where I worked, and the main one, Cowley House, the central thrust, up until its closure at the beginning of this year, had been large group facilitation and provision of a therapeutic milieu, in a homely building in Kennington, with crisis intervention available for clients during periods of mental breakdown, even if the client was experiencing psychotic phenomena. This crisis intervention was conducted, as was the other, preventative work undertaken at the Centre, through drop-in's and sessional therapeutic work, as well as through outreach support and practical help for people in their homes. We did some quality welfare work, getting people benefits and housing repairs with which they needed help. We would rely on the relationships within the group, client-client as well as client-staff relationships, to generate healing. It was a cohesive large group. Such relationships would also provide a safety net for the use of an innovative form of family therapy, employed to good effect even with people in psychotic states (Davidson, 1997).

Ours was a group of clients who mostly didn't like hospitals. Generally we managed to keep them out. They liked, instead, our attempts to empower them to believe in their own strengths, our attempts to understand and validate their experience, our attempts to work with them analytically - but with a light touch (Phillips, 1995) - and as a large group.

It will have been a complete dislocation of staff as well as clients. The staff are going to find themselves being dislocated onto the dole, when the forthcoming round of redundancies and re-recruitment to regraded posts takes place. Or they will be dislocated back into other work situations, as, for example, in my case, into nursing. Or, if any of those not already in management remain, they will be jolted into offering a quite different model of care in a service with a different ethos, which will in any event be a mere staging post towards next year's council cuts, at which point some new unitary body to dispense mental health care may have been brought into being (combining the staffing and other resources of both the National Health Service and local government Social Service departments). Community psychiatric nurses (CPN's) will have placed themselves perfectly to take the strain in fulfilling the functions of such a new statutary body. Lambeth's Social Services department will meanwhile withdraw from the field completely, except for provision of Approved Social Workers (ASW's), on hand 24 hours per day to undertake their statutary role in re-assessing people whom psychiatrists have deemed in need of compulsory detention under the Mental Health Act. And even that service can be 'outsourced' to private social work agencies, when the council has to make more of those decisions which councillors always get up at meetings and speak of being so heavy-hearted about.

Richard Appleton (Rappleton@aol.com) complained recently (Fri, 25 Oct 1996 17:43:45) on Len Bower's psychiatric?nursing discussion forum on the Internet (psychiatric?nursing@mailbase.ac.uk) regarding the interprofessional politics operating within the implementation of this new system called the Care Programme Approach (CPA). CPA was the initiative of the current government in the wake of the so-called Christopher Clunis report (Ritchie, 1994), which said that Community Care, in the years following the programme of asylum closures, was not working. There had to be better coordination of care between different services, all aimed at ensuring that the most seriously mentally ill were targetted for a service and that no one fell 'through the net' who was either particularly vulnerable or a danger to themselves or others. CPA organises care around a register of those entitled, by virtue of the seriousness of their condition, to receive a service. CPA also decrees that someone (the keyworker) should take responsibility for coordinating this care, and for ensuring that roles are identified and plans as to what each carer will do are written, implemented and evaluated by those responsible. (Subject: Re: Care Programme Approach and Supervised Discharge):

'About CPA (care programme approach) and how to work it. In my Trust fearsome debates took place in the early days, mostly about how the consultant shouldn't be a keyworker and take on the coordination and administrative tasks associated with [the] CPA keyworker [role]. After some months of this I realised he was right, consultants aren't capable. Generally they are so medically orientated you have to ask the question, can they reasonably do the job? Relieving the consultant of the prospect of this onerous task cleared the air and made way for some better placed energies.

'...As you might imagine this has presented an increase in the time I as a CPN spend in coordinating case reviews that occur yearly. The other thing that has happened is that I have become a more treasured commodity and the consultant has changed tack, willingly taking on the keyworker role now for the less involved cases.

'I wonder if you are blessed too with psychologists and OT's that put themselves outside [the role of] CPA keyworker. Personally I'm not bothered. Come the unitary mental health authority, possession I'm sure will be 9/10ths of the law, so that stuffs social workers as well.'

So for the moment the service is trying to adapt, pretending that it will still be around to participate in this new style of community work, Day Centre staff adopting keyworker status within the Care Programme Approach, work which CPN's will, in all probability, inherit in the end over the coming few years. The new Social Service mental health teams moving in to join in with this 'case management' style work are taking up the building space the drop-in used to run from. Staff of the only Centre remaining of the original three, reorganised as a team within this case management service, are having to work in spirit alongside hospital and community NHS staff, to provide a seamless service, jointly commissioned by the Social Service department of the council and two Community NHS Trusts, strictly targetted through eligibility criteria at those people who have been diagnosed by psychiatrists as having a serious and enduring mental illness. No longer will they be offering open-access to anyone self-identifying as in need of mental health care.

Generally speaking, it is the neurobiological psychiatrists who are the ones the state imbues with the power to decide what ís a serious mental illness, guardians of this strict new eligibility criteria at the portals of the service. They are the types of psychiatrist who like to focus on psychotic disorders, conditions where flimsy evidence exists for an organic - that is, a physical, rather than a psychological - cause to the 'illness'. Which furthers the interests of the pharmaceutical industry, who are able to sell their chemical products to NHS Trusts that accept such psychiatrists' view of what has gone wrong and what can help it. It does not further the health care needs of those who suffer from mental illness which is not so categorised, nor does it serve the interests of people who seek to understand and remedy the political, economic, social, interpersonal and intrapsychic roots of their ills. As Phil Barker writes (From: "Phil Barker" <P.J.Barker@newcastle.ac.uk>; To: psychiatric-nursing@mailbase.ac.uk; Date: Mon, 9 Dec 1996 12:48:54; Subject: Re: Ethical issues for mental health nurses dealing with service prioritisation):

'...there are just a few other groups of people who might be defined as 'in' serious health difficulties:e.g. people in ?

• some forms of depression ? some of whom kill themselves
• obsessive compulsive [and other anxiety] disorder[s]
• deliberate self harm (DSH)
• some forms of personality disorder ? some of whom damage themselves and others
• some 'neuroses' which involve great mental distress and social and interpersonal incapacitation
• surivors of sexual abuse
• substance abuse disorders ? some of whom die and many of whom damage large numbers of people around them'

People suffering in such ways comprised many of the client groups we were looking after but are now discharging. Phil continues:

'The social and economic cost to the country as a whole of these groups is enormous!!

'It never ceases to amaze me how many psychiatric nurses switch bandwagons at the drop of a hat. David Skidmore has pointed out that a generation ago huge numbers of psychiatric nurses wanted to be 'nurse behaviour therapists' specialising in doing therapy with people with a range of 'neurotic' [anxiety] disorders (including sexual dysfunction). Now nurses are clamouring to become Thorn Nurses, specialising in serving the so?called seriously mentally ill. Meanwhile the 'neurotic' people who were the focus of attention a generation back are now dismissed as the 'trivially mentally ill' [the worried well].

'[A]s a nurse, I think that it is nonsense to talk of determining any concept of severity on the basis of diagnosis alone. Severity ? of anything ? is contextual: depending on how much support ? personal/psychological/spiritual or familial/social and financial ? is available to the individual.

'I have worked closely (clinically) with people in psychosis for over 17 years. This has not prevented me from working with people with so?called simple disorders ? like relationship difficulties. I think that I have no axe to grind on this issue. I have to admit, however, to being astonished at the ease with which politicians and policy?makers have managed to encourage psych nurses to abandon any notion of "mental health for all" (by the year 2000 wasn't it?) and begin talking as if they should (ethical statement) only be working with one group of individuals. I have written elsewhere (Barker & Jackson, 1996) that we see no such focus on 'severity' in other areas of nursing. Imagine turning up at Opthamology to be told that cataracts may be limiting your sight but were not serious enough to merit treatment? Maybe the day is just around the corner when District Nursing will be abandoned and patients with varicose ulcers will pick up a DIY dressing pack at the chemists.

'Sure, there is a health care crisis and everything costs money. But surely nurses have sufficient experience of ordinary life to know that mental health is a bigger basket than that currently being defined by reactionary politicans.'

Perhaps what is even more astonishing is that social workers and other Social Service staff too are being successfully induced to 'abandon any notion of "mental health for all" ... and begin talking as if they should only be working with one group of individuals'.

Before I left, a psychiatrist harangued me for not adequately ensuring a client had sufficient community support prior to my leaving. She had taken him on at her out-patient clinic as a favour, because both I and the client sounded interesting. (He had fallen through that proverbial net over the previous three years and somehow I had ended up engaging with him.) It was only now occuring to her that he was someone who would need substantial medical input and no psychiatric team had yet been involved (she wasn't, herself, apparently, part of such a team or used to the procedure of putting someone onto the CPA register) and I was leaving - she had been relying on me to do everything through my relationship with him that otherwise such a team might do. So who, now, was going to be his case manager? What psychiatric nurse from which team was going to encourage him to attend out-patient appointments to have his medication reviewed? What medical cover was there? She did not seem to realise that this was not an individual failing in my professionalism. This was the end of non-statutary provision for social care by local government social services departments. I had never had to rely overly on community psychiatric nurses with their syringes at the ready before, because generally we kept people out of hospital even when very, very mad, without recourse to them. All of which enabled her, up until now, to avoid having to discharge her responsibility of assessing his eligibility for a service under CPA. He was clearly eligible, she just wasn't used to this role of gatekeeper at the portals of the service, and was especially thrown, as was the client, by the disappearance from the scene not only of me, but of the whole of the service I had been working for.

But to say that we (I) kept clients out of hospital through the relationships we offered and facilitated sounds too self-idealising to be accurate. There is every chance that, by and large, such clients as those we kept functioning in the community even when acutely ill already had CPN's working with them, as well as other psychiatric back up. Perhaps it was all a fanciful dream that through provision of therapeutic community, mental illness was (or even could be) healed; a fanciful dream connected with a deceitful self image I hold onto of myself as a psychiatrically healthy healer of others' minds. It is like that personality disorder mentioned earler, needing to be the mental illness professional, needing others to play the patient. Which calls to mind my new job, part, as I see it, of the grand scheme of exploring the boundaries between professional and patient. What are the boundaries through crossing which a professional becomes a patient, or through crossing which a patient becomes a professional? Do such boundaries really exist? Do we not each of us fall to some extent into both camps? How permeable are such boundaries if they do exist? Can (and do) we simply move across them from time to time, moment to moment? Or is there a sense in which a patient is not allowed to be a professional and is deluded or grandiose to consider it? Is there a sense in which a professional has failed if allowed formally to become a patient? How permeable should these boundaries be? And whose interests does any of this serve? Are the beneficiaries of a rigid distinction between professional and patient those with (professional) power, alone? Or those who choose to be the patients too?

I'll be working at Springfield Hospital on the outskirts of South London, UK, one of the old Victorian asylums. Most of them are long since shut down, the patients decanted 'into the community'. At Springfield I understand there were once over two thousand beds, and now there are about 180. The hospital is now no longer part of the National Health Service (NHS), but part of a locally based organisation, 'Pathfinder Mental Health Services NHS Trust'. The hospital houses such entities as community teams and Rehabilitation & Continuing Care services, rather than beds and patients, for the most part. Rather like the Day Centre no longer hosting open-access drop-in's for clients, instead using the larger part of the building to house case management teams.

I have been working for Lambeth Council's Social Services department since I qualified as a psychiatric nurse three and a half years ago, so I am not sure exactly what being part of an NHS Trust means ? the change from the relationship of being employed by the national entity, the NHS, to being employed by a local entity, the NHS Trust, happened while I have been a psychiatric nurse working on the peripheries of psychiatric nursing services. The last time I worked for a hospital it was unambiguously part of the NHS, via a 'Regional Health Authority'. As I understand it, the status of a Trust means that the hospital is still nominally part of the NHS, but run as one of those semi?statutary government "quangos", kind of autonomous and run by a board of Trustees ? worthy local citizens (Tory goverment appointees - see Hutton, 1995), and independent managers (often from private industry rather than with health service backgrounds). And if Joe Capitalist Nurse/Psychologist comes along with a service that is well marketed, economically attractive and professionally constructed (probably in that order), the District Health Authority (one level below the Regional Health Authority) really have to buy that service rather than 'purchasing' the service currently provided by the Trust within the old hospital set?up. Its starting to happen: I have noticed on the television news that Trusts are being dismissed as providers of services, and left to fold and dispose of their assets (including property assets). I guess the proceeds of this disposal return to the public purse, after the managers and administrators have earned a bit more money out of the process. Meanwhile, the District Health Authority takes its custom elsewhere.

The patient's experience in these circumstances is powerfully illustrated in the following passage (Cameron, 1996).

'It's just stopped raining when I leave the cafe, waving goodbye to George.

'"Take care now, Mary," he tells me. "Be good, Mary."

'That's what they all tell me, to be good. And mostly, these days, I am. Mostly now I am a sweet old lady in a fur?trimmed coat, a familiar figure on this route through the northern outskirts of London. A most suitable candidate, you might say, for community care.

'That's what they call it, the hospital closing down. They come in hordes now, these new ones, shivering down the long corridor which they call an architectural marvel. They visit us in the wards, and talk of preparation and of freedom, wearing their uniforms of blue jeans and earrings, the men too. They like to tell me they understand. The painting woman wears lots of silk scarves and her blackened eyes are smug with secrets. We sit around a table with poster paint and sheets of sugar paper and she looks at my little headless figures with a grave pleasure. Fat Stella sometimes comes and paints too but she never finishes her picture once she starts crying. The painting woman seems to like this; she holds Stella's hand and tells her she's doing well. When Stella's sobs begin the painting woman looks at her with pride, like she's hit the jackpot.

'And then George comes to teach me how to cook. George, with his ponytail and his girl's voice who is young enough to be my grandson, comes to teach me how to live outside, in the pristine flats which they tell us will be our new homes. I like going to the supermarket. George lets me choose our lunch, and he enjoys explaining to me the value of the coins and notes. The ladies on the till call me 'love' and 'dear' and they nod and smile at George, telling him what a marvellous job he's doing. Usually I compliment George on the way back to the hospital, knowing that a bit of flattery will mean that he lets me sit with a cup of tea while he makes the lunch. It was George who took me to see the little box where they think I will live. I told him straight away that I would not go, that the hospital had suited me well enough for seventy years, but George patted my hand and told me that even the most wonderful opportunities took some getting used to. He told me I would do well on the outside, that my community orientation was already perfect and my social skills almost impeccable. He said they would all be proud of me.'

Of course, as I mentioned, Springfield Hospital is long since shot of most of its long-stay patients. They were shunted out to the community some time ago, and the resources consumed by the so-called worried-well (like the Day Centre where I have most recently worked) have been re-allocated to them. The ousted, 'worried well' clients are being shunted into places offered by voluntary groups, often work-oriented programmes to get them back into 'normal' occupational patterns and structures for the way they spend their time.

Which is interesting in relation to this new post of mine. The post is 'Project Coordinator' for a small User Employment Project. The project has been going a year and has just attracted considerable funding so it can develop - mine is a newly created post and one of my first tasks will be to recruit the next few members of the team. The project has also won the backing of the executive board of Pathfinder Mental Health Services NHS Trust for its goals - in the form of a committment to work towards a target quota of 10% of the workforce of Pathfinder Mental Health Services NHS Trust being current or ex-users of psychiatric services.

So far, the patients who have been employed by the Trust as a result of the endeavours of the project have all ended up working in care assistant type posts in rehabilitation hostels and other such settings within Rehabilitation and Continuing Care Services, the division of the Trust out of which the project is run. My brief is to spread outwards - persuade ward managers and CPN teams within the Acute Services, for example, that they too can only benefit from the particular expertise that experience of mental breakdown confers on a candidate for a clinical post, if that candidate is suitable in all other ways too. Administrative and anciliary posts throughout the hospital will be next. And after Springfield hospital, other areas of the Trust, such as St. George's hospital, which has many non-psychiatric areas, will be my target. I have to work with the Personnel Department to revise Person Specifications for posts, so that, for example, being trained as a Registered Mental Nurse (RMN) might remain an essential qualification, but personal experience of a serious mental health problem would be a preferred qualification. This was the way the ideal person for my post was specified.

Its ironic. One of the most vociferous and politically aware clients at the Day Centre was absolutely petrified of being made to go back to work. He was depressed, drank heavily and had a fairly serious personality disorder of the kind which made many people feel dismissive and sadistic towards him. He would harangue you in a uniquely one-way form of communication. 'Don't you all understand,' he shouted at me for three and a half years.

'I can't work in this state. The new Incapacity Benefit is only payable if a doctor finds me incapable of working. Don't you understand, I can't be expected work in this state. I'm very, very scared about it. Very very worried indeed, I can tell you. What I want to know is will I get the proper backing when I have to see the doctor. They're up to the 'D's' now. It'll only be a matter of time before they get to my surname. Ohhhhh yes. Then the shit will hit the fan.'

For years I have told him he will get all the backing he needs. Someone will be there. I'll be there. Now, three years on, with the DSS reaching the surnames beginning with 'L' and his case about to be reviewed, I am leaving and the service is shutting down. He was almost jubilant when I told him I was going.

'What did I tell you? I need support and when I need it most there's no one there to give it.'

I had finally become bored a few months ago of validating his anxieties, so I tried irony on him.
'Oh well, if it all goes wrong and you want to come over to Springfield, I'll see if I can help you find some sort of work in the hospital.'

It was sadistic, without a doubt, as were a number of other sarcastic comments I have made to him over the past couple of months about his repetitiveness. Particularly in view of the fact that his family have for decades taken the attitude that he is workshy and should simply pull himself together. The father, an ex-army major, talks to the family, in front of my client, when someone who is criminally insane achieves notoriety on the television, of how these people should be put down, particularly if they are black.

Dennis: 'But don't you understand, I am very very ill. Mentally ill. I can't work in this state. You should take my feelings seriously.'

Father: 'Bugger the feelings, shoot the bastards.'

Nevertheless, his lobbying activity, along with that of a few other well-organised clients, persuaded the council to delay the closure of the Day Centre for yet another two months, pending further reports from the service manager as to the adequacy of provision for the clients like him who will have to be discharged. Which leaves me feeling curiously hostile. Let him have to get a job; he can bloody well be capable and organised enough when it comes to political lobbying. Why should he get away with being well when he feels like it, and a patient when he can't be arsed? I am not alone in feeling this way about him. He has earned a reputation, along with a number of his peers, as one of these professional patient-activists in the disability rights/psychiatric service user movement.

Which prompts the question why, in this era of 'patient-empowerment', is the patient who politicises their role viewed even by professionals like me with such suspicion and contempt?

They are regarded with suspicion partly because, I believe, their existence is a threat. It is a threat, firstly, in political terms: The professional's status is threatened by service users who not only have strong views of what they want from us, but who also have power to influence policy makers' decisions. Maybe they will decide they no longer need psychiatric nurses. Or social workers. That our professional qualifications are worth doodly-squat. We are threatened, secondly, interpersonally: The professional's work routine and workload is threatened, our jobs are made more difficult when users have the confidence to insist to us that we take their preferences seriously, rather than just deliver the type of service we want to, in whatever way we see fit. And, thirdly, we experience a great deal of threat intra-psychically: Well-organised 'professional service users' highlight the fact that a psychiatric patient and a professional can be one and the same person - which, looked at the other way around, draws our attention uncomfortably towards the fact that we mental health professionals, like many other people, act like patients, even if we are not so diagnosed, much of the time. The main difference being that we have, so far, been lucky enough to avoid undergoing the social ritual of diagnosis by a psychiatrist.

Well, some of us have. I was intuitively fearful of contact, and managed to avoid any with a doctor or psychiatrist when I had a mild psychotic episode, lasting some three months when I was sixteen, occasioned by adolescent crisis and distressing family dynamics, as well as a surfeit of hallucinogenic chemicals. I guess this was a major factor in my lifelong interest in political/interpersonal dynamics, psychiatric 'breakdown' and spiritual 'breakthrough'. The first origins of this interest, though, probably go back further still, to a close sibling's 'disappearance' from my family for a period of compulsory psychiatric admission when she was aged eighteen and I was a young child (Davies, 1997). I learned from her in my adolescence, at the time of my own difficulties, what fate befell one at the hands of the psychiatric system, and was very glad to have support and guidance from her which enabled me to cope through that period without recourse to professional treatment. When I went into psychotherapy aged 29, in emotional crisis and seeking to understand the origins, as well, hopefully, as a way out of the difficulties I was experiencing in relationships, I finally underwent an assessment by a psychiatrist. I was filled with fear of finally being found out. It felt similar to the way always, as an adolescent, I regarded (and avoided) contact with the police. This was also the commencement of my career as a mental health professional, as I was in the process of applying for admission onto a course to train as a psychiatric nurse, which was in turn a way of gaining the clinical psychiatric experience I needed in order to get a place on a psychotherapy training. So my entry into the mental health sphere represented, from the outset, an uncommitted position as to whether I was patient or professional. I have maintained this position ever since, flirting with both roles. And now I have a job celebrating it.

Which is rare. And, to an extent, uncomfortable. And, possibly, the uniqueness of such a role is also connected with the reason why patients who politicise their role are sometimes viewed, even by professionals like me, not only with suspicion because they are a threat, as above, but also with contempt. Contempt, along with triumph and other such states, is a facet of Klein's representation of envy (Mitchell, 1986). Envy is where someone else has something we want, and as a result we consign the thing to damnation, curse it, try to convince ourselves it is bad and we wouldn't want it under any circumstances anyway. We try to destroy the goodness in the thing. We nurture contempt for it. But honestly, wouldn't you just love to be able to give some paid professional all the shit clients give us, no holds barred, no hesitation or guilt? Wouldn't do any good, of course, but just for a day? I believe the contempt we experience for 'professional service users' is not unconnected with our need to act every bit as uncontainedly as they often do, but our sense that in our role we just can't. So, damnit, why should they be allowed to sneak into our roles? Of course, as professionals, our need to act crazy is subsumed into the patient (partly as a result of that same compulsion which induces us to work in this field in the first place) and we experience the release of discharging feelings through such 'shitty' conduct only vicariously. But hell, that's a terrible way to carry on, isn't it - discharging feelings, giving everyone around you shit like that? Don't expect to be treated with respect as a professional if you can not conduct yourself as a civilised person the rest of the time. Contempt. Envy.

The recruitment processes of the Trust will have to be reviewed, that's for sure, especially the Occupational Health procedures. I have always in the past hidden my psychiatric career (and usually also my experience as a patient in psychotherapy), wisely I believe. After all, as MIND recently publicised (on the day I heard I had got this job, as a matter of fact), one faces more employment discrimination because of a psychiatric history than if one has a criminal record. I had to see a doctor for a follow-up appointment after I had seen the Occupational Health nurse for an initial screening. The screening process had filtered me out as a result of my disclosure of unspecified past mental health problems. The doctor was undoubtedly aware of this employment discrimination statistic, understood also no doubt that the whole point of the project I was being recruited to was to address and remedy such inequality. Nevertheless, a psychiatric history is something, well, qualitively different, isn't it, from a history of gastric problems or back-ache? She was clearly troubled by my story. 'But you just said you didn't go into psychotherapy because you had been psychotic, that this 'being psychotic' was all a long time in the past. Now you are saying it was connected. Which is it?' Even as a professional, with ample skills at thinking, writing and talking about mental health and illness, I felt very much wrong-footed and on the defensive in this interaction. I was aware I had only a little time to put on the right show to convince her I was safe. I did a reasonable job, waffling about taking an ecological, holistic approach to mental health, that a psychosis at sixteen could not be dissociated from general life problems and difficulties in relationships. I refrained from self-diagnosis as suffering from a personality disorder at this point - that would have been pushing it. Perhaps I should have gone for broke there though:

'I have a personality disorder and am proud at least to be able to be honest and self-aware enough to acknowledge that. It was because of it that earlier this year my fiancee had an abortion she always swore she could never go through with, and then left me. It was down to my fear of intimacy, and my never being able to stop being in love with someone else who I'd fallen for fifteen years ago and who was always totally unavailable anyway (probably, she and my therapist argued, the main reason I loved her). But then she (the old flame) died of a heart attack. And shortly afterwards my fiancee had an accident and has ended up severely brain-damaged. And I am seeing, through the manic, sexually-obsessed and drug-dependent way I am coping with all of this, how terrified of aloneness, grief and despair, how disordered I am. My psychosis at sixteen was occaisioned by a similar pattern of coping with loss and depression. And I am in therapy as a patient because I need to be, using it more than I have ever managed to before.'

On reflection, I am glad I screamed none of this at the doctor. Boundaries. She didn't need to know, I didn't need to reveal myself. All must remain contained, hidden (!) and ordered. In any event, some, including my best friend would say all these relationship difficulties are merely because I have not found the right person yet, and I am mad to be diagnosing myself this way. Or to put it another way, as I do when feeling more positive - a short-lived, adolescent, drug-induced psychosis within a High Expressed Emotion family, a few reactive depressions, a series of failed, co-dependent relationships, substance dependency and a mild personality disorder - what's so abnormal about that? The Occupational Health rigmarole was very trying, though, and I was left with grave concerns about the difficulties likely to be experienced by the formally diagnosed, real McCoy, psychiatric patients I am supposed to be ensuring the Trust recruits. All of these feelings of both fear and compulsion regarding exposure, and the helplessness, vulnerability and anger I experienced, I see as part of the social dynamics of the situation, the cultural and ideological forces 'in the ether' influencing the two of us in that situation, as much as any particular lack of understanding on the doctor's part or any particular paranoia or craziness on mine.

If my brief is to work towards this target of a 10% quota of the workforce being either current or past users of psychiatric services, I think that I have to facilitate a process whereby the Trust as a whole can look at the political, interpersonal and intrapsychic dynamics of the boundaries between professional and patient. I am excited about the idea of aiming to initiate a large group forum, catering for a regular attendance of 20 - 75 people connected with the Trust, to explore such issues. All successful recruitees of the project might be expected to attend, together with prospective recruitees and other patients and sympathetic staff within the Trust. Later, possibly, staff representatives from every team, every ward might be expected, might even want to attend. The group could appoint or elect a sub-committee to organise a yearly conference and quarterly workshops, both run jointly by professionals and users. Someone would have to head that project, possibly me. Then again, Dennis from the Day Centre might be good at that, part time, depending on the outcome of his work-related medical examination to establish eligibility for Incapacity Benefit. Get a job, Dennis.

My manager at the Day Centre gave me a bollocking a few days before I left, about how badly I had handled my leaving. I hadn't taken responsibility for properly handing over my responsibilities or talking through with clients and staff the impact of my departure from the service. My view was that I was dragging myself in to work to complete the tasks and interactions I hadn't been able to from my sickbed over the previous ten days, where I had been coughing myself half to death with this virus that has been making the rounds, at the same time as re-experiencing all the devastating losses I have gone through this year. Leaving Lambeth after such a period of intense engagement with the place seems to have thrown me into an experience of all my other partings, as if I've just woken up to what I have had to leave behind this year, for the first time. But essentially, all the handovers and goodbyes that I needed to do at work, I had done. And all this 'talking through' stuff was pretty rich, coming from someone who had just decided to dispense with the fortnightly staff dynamics/support meeting, as there were more pressing needs and not enough money in his budget to pay for the group psychotherapist who came to facilitate the group.

The locum deputy manager felt sure this was all just my manager's way of being pissed off I'm going, as he has such a lot of respect for me and he's been relying on me to support him in holding things together across the two remaining Centres to a large extent this year while he was acting up into the role of Resource Manager. He'll miss me. I'll miss him too. Loads. He has been my mentor for the last three and a half years. I guess it says a lot about the dynamics of the place that this was how he expressed it.

I came back for my last few days to an atmosphere of complete depression and failure in communication amongst staff. A deputy manager who had been off on sick leave for six months had just returned, and in the few days I was still there finally agreed that he was really still not up to being back at work, and may never be. Another deputy manager, recruited to the post I had been acting up into earlier in the year, started work and immediately lost any good will that might have been extended his way, by making a series of the most outlandishly sexist remarks to women in the staff team - get this: You remind me of my wife, who is short like you; we have a problem when we dance but not when we make love'. One other staff member had been told that with all the clients' complaints and the disciplinary she was facing, it really was better if she just left, while a good reference was still on offer.

My therapist told me not to do my usual grandiose stuff and take responsibility for it all - I was leaving and it really wasn't my problem. It was just Lambeth's chaos.

Good advice.

I did some more goodbyes, and said a few I'd already done again, and managed to elicit some communication and fun with those of the team who bothered to stick with it. Nothing more heroic than that though.

It is Boxing Day now, four days since I started writing this and another twelve days before I start at Springfield. Its been a shit year. But I am ending it with a sense of achievement at completing the first term of my psychotherapy training, a sense of achievement at having the manuscript for my first book (Barker & Davidson, 1997) accepted by the publisher so it can finally go into production, and a sense of achievement at getting this exciting job. Also, of course, I am ending the year in grief and despair at losing the two people in my life I was closest to. Probably why I've been a hermit the last few days, reflecting and writing, rather than celebrating Christmas.

Well, I figure something transcending both achievement and loss has been born here in fairly inauspicious circumstances.

And yet, at the same time, the really heroic task is yet to come.

Here's to periods of transition. Happy New Year.

References

Barker, P. & Davidson, B. [eds.] (1997, in print) PSYCHIATRIC NURSING: Ethical Strife Arnold, London.

Barker, P. & Jackson, S. (1996) Seriously Misguided Nursing Times 92 (34) pp 5?8.

Cameron, S. (1996) Walking in Melingardo, S. [ed] Short Circuits Virago, London.

Davidson, B. (1997) The Paradox of Psychiatric Nursing: Making a difference by attempting to change nothing Nursing Times.

Davies, E. (1997, in print) Avalon in Barker, P. et al [eds.] From the Ashes of Experience Whurr, London.

Hutton, W. (1995) The State We Are In

Jarman, B. (1983) Identification of Underprivileged Areas British Medical Journal Vol 286 pp. 1705?1709.

Mitchell, J. [ed.] (1986) The Selected Melanie Klein Penguin, Harmondsworth.

Phillips, A. (1995) On Flirtation Faber and Faber, London.

Ritchie, J.& Lingham, R. (1994) The Report of the Inquiry into the Care and Treatment of Christopher Clunis HMSO

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