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The Internet and the Large Group A
submission toward a post-qualifying MSc award
at the Institute of Group Analysis,
and Birkbeck College, University of London,
subsequently published in the
journal Group Analysis, December 1998 Abstract Although
communication via the Internet attracts suspicion, it is more similar to other
communication media than different. The practical workings and the experience
of membership of an Internet forum are described both through some general samples
of discourse and through a case study relating to a thread of discourse in which
the author was centrally involved. The shared features of this forum and other
groups are sketched, drawing on the case study discourse and drawing parallels
between the role and function of group analyst and that of group moderator. Other
features of the forum which demonstrate some of the large group phenomena described
in Kreeger's seminal text are also explored, challenging Foulkes' notion that
'it is ... doubtful whether ... ideal [large group] conditions are realisable'. Communication
and its Media It is inhuman, some argue, how increasingly
we communicate with each other in this medium. The enhanced communication allegedly
afforded by the Internet is a sham. Behind all these people in supposed communities
in cyberspace are lonesome individuals lacking access to relationships with real
people in physical proximity. Their resort in these circumstances
and their recompense for this state of affairs is the thrill and enchantment of
extended periods before a computer screen, lost in addiction to hi-tech wizardry.
These sad souls rely on electronically created fantasy worlds to feel they inhabit
somewhere and to experience connectedness. They do so because of deficiencies
in their social world and in their psychology. Such cyberspace
fantasy worlds, though, may be no different to the realms we inhabit, in relation
to each other, most of the time, even when in physical contact. We are
all of us experts, and, possibly, have been since our earliest infancy, at manouevring
interpersonal and intrapsychic boundaries. I experience my split-off aspects and
denied feelings, my yearned-for lost loves and the persecutory figures I am running
from or fighting with, as in you. In the same way, you manipulate your outlook
so that bits of your psyche are experienced by you as in me; or as in someone
else; or as in a number of different people within a group. My experience of you
may, thus, be no more than an experience of whoever I want you to be, and vice
versa - a fantasy. These cinematic projections from our psychic worlds, which
we both focus onto and also somehow put into each other, con-fusing (literally)
our experiences, are ubiquitous. The analytic community believe increasingly that
our collusion in this subliminal interweaving and redistribution of our shared
experience is also the cement that binds us as couples, families and groups -
our relationships may even be 'better' as a result of such processes. The understanding
of such concepts as projection, transference, introjection,
counter-transference and projective identification (broadly
as described above) has widened to both normalise and value what were previously
seen solely as psycho-pathological mechanisms (Roitman, 1989). In these circumstances,
one has to review what it might mean for relationships to be fantastical or real,
abnormal or healthy, whatever their medium. The Internet
is, moreover, not such a radical departure from something much more familiar.
The telephone requires a good deal of imaginative input to create an experience
for ourselves as of really 'being with' the person on the other end of the line.
We mostly take such communication for granted nowadays, while people who avoid
the telephone are seen as eccentric or disturbed, even attracting an 'anxiety
disorder' diagnosis. Rather than listen to the message in their experience (Smail,
1984), we assume, if they can not bear such ordinary trappings of modern life,
that they are 'mentally ill', the communication medium itself being seen as natural. Neither
is such controversy new, according to McLuhan's (19??) account of events surrounding
the launch of the printing press. The written word, as a popular medium, is relatively
recent and not without its peculiarities and hazards. What experiences will I
create in you the reader, as you become absorbed in this piece? Shall I get your
back up, or seduce you into agreement? Do I want you to respond by liking me?
Do I want to rattle your cage or incite you to revolution? Who do I imagine you
to be? And what fantasy of me have you already begun to adopt? And, to
return to the opening argument above, have we not something better to do than
communicate this way? Might it not be healthier for me to close my word processor,
switch off my computer, leave my desk and get a life? With
typically poignant images, Smail suggests sinister aspects of yet another medum
of communication we take for granted: 'Television
is a much more powerful form of ensuring uniformity of belief than was the Inquisition.
...it is still quite an eerie experience to walk round any residential suburb
after dark and to note the extent to which people are imbibing exactly the same
impressions and information from glowing screens.' (1987
p.87) Our relationships (via both television and newspapers)
with 'media personalities' and other celebrities are seen as 'normal', despite
evident links between our idealised view of their lives and the poverty of our
self-esteem (Smail, 1984). Where we place such people in our fantasies, and where
they place us must be cause for reflection, especially in the light of recent
events surrounding the death of Diana, Princess of Wales, and the way in which
many of us responded as though we knew her personally. It seemed easy to forget
that the various views we have of her as a person, and our sentiments toward such
images, were a co-creation of our own fantasies and of media portrayals (manipulated,
in turn, both by editors and by Diana herself). The truth
probably is that our experience of the world and other people in it generally
involves greater or lesser degrees of fantasy; requires selective inattention
to the way things really are; and often belies gross denial of what stares us
in the face. None of which usually gets in our way. After all, we are tenacious
with our views and ways of constructing them - what else can we really call our
own? Who would have dared to suggest, in early September 1997, that the mass,
worldwide experience and expression of grief had as much to do with group processes
like those at the Nuremburg rallies earlier this century, as they had to do with
knowledge of a real princess? And again, in any case, although our fantasy may
be yours and mine alone, still it may not necessarily be any the less valid. In
an edition of the BBC's Newsnight transmitted soon after Princess Diana's death,
a psychologist suggested that the public display of emotion regarding this loss
was not dissimilar to the once sneered-at self-flagellation of Mullah's in Iran
following the death of Ayatolla Khomeini. The interviewer publically censured
and humiliated him. But this was surely misguided. Although the fantastical nature
of our experience may be justified by our individual and collective histories,
and although we may need to believe in our constructions, it must ultimately be
right to investigate the fantasies we inhabit. We forget that though our views
may be shared by many people (consensual reality), they are still only ever, even
at best, a version of the way things are. To climb, in
these circumstances, in our imagination, inside a computer realm, is no more mad
than imagining the presence of someone through reconstructed electronic signals
down a telephone line or from a television aerial, no more unreal than communication
via the written word between an imagined readership and a fantasised author. In
fact that is what, both on the Internet, on the phone, through written wordcraft,
via television, and through physical proximity, we do all the time -
imagine the person or people we are communicating with, as they imagine us. Peculiar
to the 'net are, simply, impressive technical possibilities for directing the
interaction, also a freedom of expression, to an extent apparently unsullied by
the interests of 'media tycoons'. All of which, if you
are still with me, may lead you, the reader to expect more of an article on the
Internet and the Large Group than is on offer. The psychiatric nursing Internet
forum this article will discuss is just really a sort of discussion group by e-mail.
...Or is it? An Internet Forum: experiences of membership I
joined the 'forum' three years back, fantasising the sort of open-air citizens'
discourse that took place in Athens around 400BC, large groups of people gathering
to play an active part in the business of the city state (polos). Members generally
refer to it, though, as 'the list', apropos the list of names and e-mail (electronic
mail) addresses of members and their computers, to each of which any messages
posted to 'the list' are redistributed. The list is essentially a computerised
forwarding service. It redistributes the messages it receives around the globe
almost instantaneously, via the 'worldwide web' of computers, linked via dedicated
telephone lines. The computer which initially receives your message, prior to
redirecting it to the computer which operates 'the list', is probably based locally
in a town. The cost is therefore that of a local call, lasting a few seconds to
make the connection, send the message, collect others and sign off. I 'post' mine
from my computer at home, plugged into an extension of the ordinary telephone
line in my house. Such are some of the technicalities of how it is done. A fuller
sketch can be found in Bowers' (1997a) paper concerning the development by psychiatric
nurses of an international professional identity via the forum. What can
be done, though, (in addition to the creation of such an identity) using
this communication web. Recently, someone I knew independently
of list membership noted how I had been flirting with Mary in the USA again that
week. Had I? I am inspired by her accounts of how she listens to her patients'
stories, certainly, moved by the poetry of her writing and impressed by how she
can walk into violent situations and have people become peaceful again. And I
recently grieved with her on the second anniversary of her father's death, sharing
with her my own experiences of loss this last year. But flirting...?! Oh well,
c'est la vie! And then there are the Canadian contingent.
I shared a more political solidarity with them at the time of Lambeth Social Services'
demise in late 1995. They responded in kind to my late night missives on return
from local council meetings where elected representatives decided to cut millions
of pounds from the community care budget, forcing the open-access Mental Health
Day Centre where I worked to close. This and the Canadian experience, public service
strikes in Ontario, struck chords. Around the world nurses asked how my service's
users were agitating and asked how the protests on the other side of the Atlantic
were going. And, again, there is the repartee from Richard
and Brenda in 'clean, green New Zealand' and Tom in Australia:
>>(1)Internet Addiction Disorder ... can't [those] with
IAD join an on-line self help group? >I thought we did. May
we presume then that we have unwittingly cured those recently 'unsubscribed' [list-]members
of the above disorder? Should we write a paper about our success? (Curzon,
1997) As another Australian said, 'This
list has 'colour, 'texture' but most of all warmth. After a cold night or day
on the trenches I look forward to catching up. As a past drug and alcohol worker
I was wondering if I was becoming addicted, but not being really comfortable with
the concept I decided that I just like it and don't need it!' (Johnson,
1997) And from Kansas, U.S.A. 'Why
would we be here if not to attest to the great strength of the human spirit, and
the longing for connectedness. ...I'm hooked,' (Thomas,
1997) While cohesiveness is, for Yalom (1985), the 'sine
qua non' therapeutic factor in groups, Foulkes (1964) suspects that cohesiveness
can be a defensive outcome, belying repressed conflict. I remarked at the time
of a conflict that had raged for some weeks this Spring, how this group has a
good core of cohesiveness, but not too much - conflicts are able to emerge. Bowers
added: 'The more time goes by on this list,
the more it seems to develop just as a group would. 'For
example, although I've never met ... regular contributors over the years, I'm
beginning to feel that really I know them quite well. Hence we can engage in good
natured (and sometimes lighthearted) discussions about all sorts of things, even
including the "Melbourne Cup" (whatever that is), and the stout and bravehearted
way in which the UK cricket team faces a long and (almost) uninterupted run of
defeats. Just as we would if we actually met regularly - some of our conversation
would be serious, and some not so serious. 'New members
joining the list might not always appreciate the relationships and dynamics that
already exist within the group/list. May I recommend patience to them. For example,
Mary's recent postings should be understood as picking up a thread of conversation
[re: pissing on each others' bonfires - envy, or on the carpet - self-destructiveness]
that actually started (I think) some months ago. 'The downside
of life on the internet is that some people seem to enjoy picking fights with
and upsetting others in ways which they would not have the courage to do on a
face to face basis. This practice is very common on some lists and newsgroups.
This is how I interpret M.Ward's recent contribution (please let me know if I'm
wrong)(2). It really is best to try to ignore comments like
these - unfortunately I know how hard that can be. Having the support of other
list members can be really helpful at times like these, and I'm glad Dominique
received that support from the list.'(3) (Bowers,
1997b) I added to this that 'several
of us have forged a relationship over the last three (?) years that includes collaboration
on a ... text ... edited via e-mail without some of us ever having met each other(4).
Others of us have finally met through the collaboration, even if (Peter) they
couldn't remember much about the evening the following day. And as Mary pointed
out, when you work in an area with ... stresses and need to unwind, a list like
this can be a perfectly appropriate place, if others want to use it in the same
way.' (Davidson, 1997a) As
a specific example of how the forum may serve a range of related purposes,
a recent discourse comes to mind, involving an initiative I co-ordinate at Pathfinder
Mental Health Services NHS Trust, set up in 1995 and aiming to developing a system
of employment practices encouraging the recruitment of psychiatric service users
within the Trust. At the end of May this year, I was snowed under with preparations
for a conference to launch of Pathfinder's 'Charter for the Employment of People
with Mental Health Problems'. It was the first time I had organised such an event,
and the first time I had had to give a public speech - to 150 people, including
the media. In the midst of this, a message appeared in the forum:
'In recent weeks I have been ... trying to coax my health
professional colleagues into inviting 'service users' ... into ... service planning
... discussions. A number of themes ... have been kicked up. 'From
the professionals its been [concerns] around de-professionalising health care
and [about] the invited users, [even if they have been] carefully vetted, [using]
a service planning meeting as an extended opportunity to get therapy, [or to express]
personal recrimination for a crap job in the past. 'The
users, of whom there are few that volunteer, unless they have a proverbial axe
to grind, expect that their [individual] views about the service are going to
be influential in effecting change[. Then, later, they] complain about not being
taken seriously, tokenism, when things don't happen the way they want. 'Question
- how do other places get constructive user involvement ? 'Got
any suggestions anybody? 'Richard :)' (Appleton,
1997) I replied as follows: 'Richard, '>how
do other places get constructive user involvement ? 'Try
employing them, as well as consulting them, for a start. 'Of
course they'll be pissed off if their views are sought but not actioned. ...Service
users do not get paid for such involvement in these exercises; they have an appropriately
greater passion about the subject; and, very often, they have a far greater resonance,
I guess, with issues of not being heard, believed, taken seriously, being abused
etc. 'An obvious way of changing the situation where users'
views can be canvassed for free and then ignored, is to give such users (i) a
wage for offering their opinions and then (ii) the power to make decisions based
on them.' (Davidson, 1997b) I
then talked about the sort of accomodations we make at Pathfinder, both in the
recruitment process and beyond, in compliance with the Disability Discrimination
Act (1995), to ensure that appointments of users are a success. I emphasised that
an experience of madness had to be in addition to the other skills, experience
and knowledge necessary to do the job; I explained that, accordingly, we were
in the process of changing the person specifications for most clinical (and other)
posts in the Trust (including service management); and, finally, I outlined the
political activity that had made this possible. This exchange
prompted a fascinating discourse, involving more than 20 nurses worldwide who
contributed, and a further 330 who observed (or 'lurked', to use 'net parlance).
The discourse was remarkable for the intensity both of consensus and of contrast
which emerged(5). After the debate had been going
on for some three weeks, I asked whether anyone would be interested in seeing
a more detailed progress report of the User Employment Project I run. Several
people (from Hertfordshire and Essex, UK, and from California and Sweden) asked
for copies of the Project Report by 'snail mail', and several more (from Wales
and New Zealand) asked specifically for me to send it to the list. The list moderator
also contacted me with an urgent message asking me to ensure it was no larger
than the system could comfortably handle and to take certain precautions regarding
the spread of computer viruses. Once I reassured him on these points, he counselled
me on lobbying the body who hold the professional register for psychiatric nurses
in the UK, along with some user-employees, to discuss recent hostile pronouncements
of its staff; he suggested getting Nursing Times to make user-employment a campaign
issue; and he encouraged me to think about putting together some of the recent
discussion as an article in its own right! This thread
of discourse was one among perhaps seven others, during a three week period in
mid June. Thereafter it became interweaved with, or simply absorbed into other
discourses - such as a passionate exploration of the mission of psychiatric nursing
and a gripping display of professional territoriality surrounding an advertisement
in the professional press, inviting applicants without psychiatric nurse training
to apply for a post of Professor of Psychiatric Nursing. The thread was poignantly
counterbalanced by more practically focussed discussions, such as what assessment
tools and measures to use on acute in-patient admission and how safe is it to
let patients on a secure ward shave themselves and with what precautions do you
dispense the razors, if at all. The themes both of user consultation and user
employment will be taken up again, just as they had resurfaced this time around
from past dialogues. I mention this particular thread because I am centrally involved
in the subject and benefitted greatly from my involvement in the discourse. While
it developed, work had never been so busy, my service manager and clinical director
were away at ceremonies in Hong Kong and conferences in Canada (respectively),
and I was left handling the project alone for the first time, trying to find the
right balance between 'accomodation' and 'firm management' for a series of psychiatric
and other crises in the project team. The forum was my venue for narcissism and
arena for feedback. And, as outlined earlier, this feedback was both supportive
and challenging. The group was both cohesive and could bear conflict. I valued
belonging to the forum and used it as one might use any interpersonal network.
One contributor expressed a way in which my involvement was, in turn, useful to
the forum, 'I'd simply like to congratulate
you on your project - it is a spellbinding read, I found myself uplifted by its
values, and posting examples of good practice to the list for wider dissemination
and comment is just one of the most important ways in which the list demonstrates
its worth. Thanks.' (Wolsey,
1997) Dynamic Administration The
process of managing the forum has been described by the list's owner (Bowers,
1997a). He refers to the list as an open group without a moderator. It would be
more accurate, I believe, to characterise it as a 'moderated, open' group, Bower's
style of moderation the same as those group conductors who tend to be less obtrusive
in their analytic work. The process of moderation, in these circumstances, parallels
what are the two main functions of the conductor in group-analytic therapy. Managing
the boundaries of the forum, the interface between the group and the outside world,
so as to facilitate an experience of safety and protection (Foulkes, 1975a ch.6),
is crucial to the survival of a group as a discrete entity. Ensuring the culture
is conducive to safe, open and challenging discourse, is similarly crucial. Perhaps
the defining feature of group-analytic practice is this Janusian perspective -
looking two ways at once. Group analysis studies its object (the group) by looking
simultaneously within and without. The analysis of the group's constituent parts
and their inter-relations goes hand in hand with a synthesis of the group (and
its parts), along with other such entities, into the context within which they
all co-exist. Context, political, economic and cultural, is as critical in fully
appreciating the individual and his intimate relations as the dyads and other
relationships, now internalised as intrapsychic phenomena, that have formed him.
As Foulkes writes: 'Human beings always live
in groups. Groups in turn cannot be understood except in their relation to other
groups and in the context of the conditions in which they exist. We cannot isolate
biological, social, cultural and economic factors ... mental life is the expression
of all these forces...' (Foulkes,
1975b p.37) The analyst (or Internet group moderator) has
two practical tasks in this respect - to enhance the flow of communication within
the group boundaries (by, among other means, facilitating a balance between cohesion
and challenge), and to attend to events beyond those boundaries, both by taking
charge of the administration of the group's setting and by translating 'external
material' brought within these boundaries, where appropriate, as matter pertaining
to the dynamic flow of communication 'here and now'. This latter task, attending
to events at and beyond the boundaries of the group, ever in the service of the
group's better understanding of its experience, Foulkes (1975a ch.6) calls 'dynamic
administration'. Bowers often validates, also translates list members' fury at
others' misuse of the list by explaining the significance of events at the boundaries;
he has also recently appreciated list members' welcome of new members 'in his
absence'. The list itself, like any other healthy group, will take on some of
this role in time. As I complete this paper, a potential conflagration is averted
by group members' ability to respond to challenges that certain material is not
relevant. A lengthy and full discourse about Diana's death is justified, at least
twenty members have argued (in response to another dozen who are wearying of the
subject and call angrily upon members to remember our proper focus and organise
the forum better), insofar as we all resonate with certain aspects of her story
and might learn through exploring such issues how better to respond to our patients.
Bowers has also recently expressed gentle skepticism at the degree of consensus
from list members' 'down under' in relation to the view of psychiatric nursing
presented by a list member on his six week lecture tour of the Antipodes. 'Wasn't
there even a bit of conflict, or disagreement' he asks effectively. The
large group and the list The communication processes
within the forum can, however, also be likened to what Kreeger (1994) has elaborated
as the dynamics of the large group, a developing interface between intrapsychic,
interpersonal, political, professional, cultural and societal reflective exploration. It
is possible, in the small group, to combine individual psycho-dynamic therapy
and social awareness. One may change one's form of psychic experience, all the
while taking into account the other seven or so people at large in the group and
one's relation to them, and to it. The well-constituted group represents, in microcosm,
with its eight divers members, society-at-large. In the large group the possibilities
are similar and yet different. The group is, much more, society at large.
It is possible, but harder (at least, initially) in a large group to experience
psychic vulnerability, and to tolerate exploration of intrapsychic (or, indeed,
interpersonal) material (although evidently it occurs, as will be noted by anyone
looking through the archives of the discussion at the Internet site mentioned
above). Meanwhile, though, one may begin to identify with different small groups,
all the while taking into account other groupings in the emerging multi-layered
culture and one's relation to them, and to it. For example, in the user-employment
discourse mentioned above a clear split emerged between those who were professionally
and personally skeptical about the idea, and those who enthusiastically embraced
it. One saw how members of each group gradually learnt to experience identification
also with the other. Another split was between groupings whose views were steeped
in personal experience and passion, and those whose views were primarily intellectual.
Similar convergence occured here. And again, a typical group process (scapegoating)
was seen to occur during a humorous caricaturing of one list member by two others
as a drunkard, serving to deflect onto him their (and, indeed, perhaps, the group's)
anxiety immediately after an eruption of fury between two other members of the
list. The interpersonal matrix of experience, communication, cohesion, conflict
and change is, however, in the large goup, ever wider. There is an emergent corrolary
with our relation, as a whole culture in that group, to realms of humankind's
experience yet beyond. The archetypal perspective, the world of myth, is ever
closer. In relation again to the user-employment discourse mentioned above, the
myth of the wounded healer (the user-employee) emerges. In a parallel discourse
on the technical skills of the behaviourally trained psychiatric nurse, the myth
of the alchemist-magician, extracting what is sullied from lead and turning it
into gold, is also around. The myth of the shaman, the conduit between heaven
and earth (mental breakdown as spiritual breakthrough), also that of the 'wounded
healer', appear frequently, while in the 'psychiatric nursing mission' thread,
mentioned above, the myth of the hermaphrodite, the joining of the masculine and
feminine, appears as two distinct styles of nursing - psychiatric nursing and
mental health nursing. Three powerful myths, pervading so much discourse. A fitting
preoccupation for what I believe might represent a re-emergence of the sort of
prototypical forum described in Hellenic times above. Conclusion My
opening metaphor for 'the list' was as a citizen's forum in ancient Greece. The
metaphor is apt. Not only may we discourse within safe boundaries on the Internet,
as we did in the forum, but just as in Hellenic times democracy was compromised
by the inferior position of slaves and women, both excluded from participation,
so on the Internet the commnunity is incomplete, insofar as 90% of the world's
population is denied access to even the telephone, let alone the personal computer.
Moreover, freedom of expression can never be guaranteed, as Socrates discovered
to his cost. Nevertheless, if 'the problem for the members
of the small group is how to feel spontaeneously, [and] for the large group it
is primarily how to think ... its mindlessness' (De Mare, 1975 pp.152-3), we might
agree at least that the Internet forum described above succeeds in facilitating
communication where expression both of feeling and thought, where both intrapsychic,
interpersonal and societal exploration, is possible. Considering the possibility
of a healthy, functioning large group, with 'free and frank', intense and authentic
communication, receptive to the influence of reality and able to 'from time to
time look back on its moves', Foulkes (1975b p.44) wrote: '[no]thing
like the ideal ... (namely that, say, 80-100 people should meet daily for a period
of about two years) has as yet been realised. It is, indeed, doubtful whether
such conditions are realisable.' (p.45) Evidently,
with some 450 members across five continents meeting at all times throughout the
day and night in 'cyberspace' and discoursing at the rate of around 30 pieces
of dialogue per day (average over 12 months), while the forum described is not
exactly what Foulkes had in mind, his doubts may arguably have been proved unfounded. Appendix
- condensed version of the forum debate on user employment For
more of a flavour of the discourse, a transcript can be found with all the other
archived discourse from the forum, at "http://www.mailbase.ac.uk/lists/psychiatric-nursing/archive.html",
in this case within the archive for June 1997. In the following content analysis,
the discourse and the relationships between participants is inevitably drained
of its 'colour' by rendering the language in which messages are expressed down
to less than about 25 per cent of their original content. The following, however,
is aimed at demonstrating more the flow and pace, and ultimately the integrity
of the discourse - the way in which the forum operates, as Bowers stated, just
as any healthy group might be expected to. In the following
mapping of contributions, I have counted Appleton (who opens the discourse with
his request for advice) as contributor A and his first message 'message 1' (ie
A1), and myself as contributor B, with my first message 'message 1' too (ie B1). A1 I
have been trying to coax my health professional colleagues into inviting 'service
users' into service planning discussions. Professionals express concerns around
de-professionalising health care and about users, even if they have been carefully
vetted, using a service planning meeting as an extended opportunity to get therapy,
or to express personal recrimination for a crap job in the past. The few users
who volunteer expect that their individual views about the service are going to
be influential in effecting change. Then, later, they complain about not being
taken seriously, tokenism, when things don't happen the way they want. How do
other places get constructive user involvement? B1,
responding to A1 Try employing them,
as well as consulting them, for a start. Of course they'll be pissed off if their
views are sought but not actioned. Service users do not get paid for such involvement
in these exercises; they have an appropriately greater passion about the subject;
and, very often, they have a far greater resonance with issues of not being heard,
believed, taken seriously, being abused etc. An obvious
way of changing the situation where users' views can be canvassed for free and
then ignored, is to give such users (i) a wage for offering their opinions and
then (ii) the power to make decisions based on them. These are the sort of accomodations
we make at Pathfinder, both in the recruitment process and beyond, to ensure that
appointments of users are a success, and to comply with the Disability Discrimination
Act (1995). An experience of madness has to be in addition to the other
skills, experience and knowledge necessary to do the job. We are in the process
of changing the person specifications accordingly, for most clinical (and other)
posts in the Trust (not just service managers'). This is the political activity
that has enabled it all to happen. C1, responding
to A1: Where I work in the USA, a group rather
than individual approach is advantageous, for the following reasons. A2,
responding to B1: User employment doesn't happen
where I work, but does at a place I visited in Canada, as follows. It excited
me. Here is a taste of how it is a battle, particularly with psychologists, to
make any such thing work here in the UK. D1: We
involve service users as follows in New Zealand. It needs certain conditions,
as follows, to make it work. A3, responding to D1: Please
give me more specific information about how you involve users. B2,
responding to A2: I have the same battle with
psychologists and psychotherapists particularly; it surprises me, maybe I'm naive.
Working the wider political field is crucial, which we are doing as follows. I'm
finding some of this difficult, please help. D1,
responding to B1: Hello, I'm new. I am impressed
with your user-employment policy. We don't collaborate that well where I work
in the USA, despite legislation. I am also impressed also with the way you employ
service users. I am sad we haven't shifted polarised and false attitudes to the
mentally ill here. We can all be encouraged by what you do and I encourage you
to continue. B3, responding to D1: Careful
not to idealise our institution or the UK. We are probably not so different from
your organisation. Here are some examples of poor attitudes. And I am not immune
to them myself. I have to remind myself why they're wrong, like this. But yes,
what we are doing is successful. Thanks for your encouragement.Welcome. E1: I
support the motivation in A1 to involve service-users in planning. In New Zealand
we consult with groups [cf C1], successfully and enthusiastically. Some technical
problems occur, eg around confidentiality and boundaries of roles. Here are other
considerations as to how such policies can work, in relation to service ethos
and institutional dynamics. I am not sure about user-employment [B1], you don't
need to have experienced mental illness to be able to empathise with others who
do. E2: Here is
an example of a disaster which makes me worry about employing service users [B1].
How can these concerns be addressed? F1: I
have worked with many nurses who are psychiatrically ill, many physically so.
Here are examples. I share both the philosophy of user-employment[B1] and the
concerns [E2] about employing service users. In my own work, such concerns are
manifest in the following scenario where I overidentify with patients. PS Here
is a caricature of what I am experiencing in work and life right now, which has
some bearing on the discussion. Can the structure of work make you ill? G1,
responding to B3: In my experience it is true
[B3] that nurses who have experienced illness are more compassionate. There are
still the issues of working with countertransference [cf F1] and managing relapses.
I also have experience of this not being worked with at all well, as follows. B4
responding to F1: I agree with F1 [& G1].
We should be developing the supervisory structures to help avoid such overidentification/countertransference.
And as in E1/E2, empathy can thus only be enhanced for all nurses. I had to dismiss
someone today who appeared to me unable to do voluntary work because of these
issues. But the question is always there, were those his issues or mine ... yes
supervision is essential to untangle such confusions. But for most of the people
I work with, their experience of 'illness' makes them better nurses. I feel for
you with your work/domestic problems, F. H1: Its
obvious that most of us have experience of mental health problems and it helps
our work. Other sub-disciplines of nursing recognise this,as we should do. Here
is some of my late father's wisdom on the subject, which it is good to share with
you I1 responding to H1: Here
is some similar wisdom, Shakespeare's. I have learned recently that there is a
legal obligation regarding employment and disability. I agree somewhat with the
ideas in H1, all our work benefits from personal experience, but I believe there
should be a boundary reflecting popular sentiment regarding mental health and
illness, ability/inability to do a job, as I anticipate disasters, such as in
G1 [and E2]. Such boundaries - past hospitalisation eg - would protect such employees
and their colleagues from disasters. Further accomodations should also be made
to ensure such appointments are a success. H2 responding
to I1 I agree with you, I. Our employment practice
should treat people properly if they are unwell, but let's not underestimate ability
to cope, or overestimate the degree of current illness. That would be discriminatory
and wrong, while we are too lenient on others who have no diagnosis but who are
incapable. Let's make sure the place we put this boundary is fair. This is where
in the world I am and what the climate is like. J1
responding to I1: I1 is bigoted and makes me,
as a person who has reached psychosis, very angry. Here is some of my story. With
the ethos of services and the attitudes of staff like I, the outcome would have
been disastrous for me if I had been formally diagnosed. And if I had been hospitalised
I would not be able to work now as a senior nurse, according to I's view. The
boundary he proposes is mistaken, for a number of obvious reasons, as follows.
Some diagnosed people I would trust with my life, other non-diagnosed ones I wouldn't
trust to nurse the cat. Please let us look at people on their individual merits
and not allow our views to be biased by psychiatric diagnosis K1
responding to H1: Garbled message, prefaced by
concerns that the views expressed might result in scapegoating, and finally offering
a framework for managing service-user appointments. I2
responding to J1: I am sorry you consider me 'bigoted'.
I am trying to take an unprejudiced and balanced view - [this is carefully elaborated,
repeated and defended. I restates his position, softening it to some extent but
obviously taking exception to J1 and subtly putting J in his place, gently but
with a sarcastic edge: 'I think you will find...', 'those who have ... mental
illness ... should [be] protected from bigoted people like me...' and finally
with a thinly veiled challenge as to the severity of the illness J claimed to
have had. I asks:] 'what of people who are treated by depot injection, ie with
serious, ongoing illness, in employment?' E3 responding
to J1: I sympathise with your anger J. I work
with students every day with SMI, generally excellent nurses as a result, having
wrestled with their demons and won. I have also been involved with students and
staff who have no insight into the degree to which their behaviour is impaired
and adversely effects others. One should act, but how? I don't think I was being
as bigoted as you thought. E-mail is an ambiguous medium. I agree with J1 about
hospitalisation being the wrong criteria to draw a boundary - and any line drawn
in the sand is arbitrary - but I do believe we all have a responsibility to protect
patients and each other. Psychiatric diagnoses too are a very poor means of drawing
that line. I too am angry at the ethos of services and the attitudes of staff. E4
responding to K1: Either you are irredemably lost
in management-speak, K, or the brew must be good down in the cold south of NZ
tonight. L1: In
my experience as an administrator, whether the individual can do the job is the
only important consideration. Here is an example of a nurse with bi-polar illness
where the appointment is a great success, and another with a similar emotional
problem where we couldn't continue to employ her. We should make the same "reasonable
accomodation" we would make for other disabilities, as long as the staff member
can do a complex job requiring interpersonal skills. B5
responding to E4: Here is a translation of what
E was saying, which I think is an outstanding idea that we already practice. B6
responding to L1: I completely agree with L -
whether the individual can do the job is the only important consideration - and
I use these ideas as my guiding principle when it comes to the practicalities
of running the User Employment Project. The position is ethically sound, politically
astute and a great practical success. K2 responding
to E4 and B5: Restatement of L1, this time without
the apparent 'benefit' of any brew - whether the individual can do the job is
the only important consideration. Caution aired regarding problems with user-employees'
sick-leave. M1 responding to L1: Regarding
L1, I have experience of an individual with SMI with whom I work doing a number
of difficult jobs very well, as follows. I agree that whether the individual can
do the job is the only important consideration. N1
responding to J1: Right on J! Give 'em hell. Not
everyone who has been hospitalized or suffered an acute episode is non-functional,
stupid, or unable to control themselves. For supposedly intelligent, well educated
people, you psychiatric nurses are awefully closed minded. B7
responding to K2: I agree, as before K. The sickness
record of user-employees though is far superior to Trust staff as a whole, for
which various reasons, as follow, spring to mind. Are not sickness records like
these impressive? G2 responding to H1: While
empathy is important [H1], it's not all that makes up a good psychiatric nurse.
Empathy through experience (and one can be empathetic without the experience)
is of little value if the person can't perform the role. If the person can, then
no problem [ie restatement and endorsement of L1]. O1: Recall
the stereotypes mentioned in C1 - tokenism, isolation. This discussion has been
about employing individual service users, and the problems of individual nurses
with, presumably, mild mental health problems. Of course this is important, but
we should focus more on what users want from nurses and demand from the service
- is there anything we are blatantly missing out? Is it right for mental health
provision to be imposed from the supposed well onto the supposed sick.? J2
responding to O1: Jim Read, a Mental Health Consultant
and Survivor of The Mental Health System, spoke recently about how he asks people
'if they had a crisis where they felt overwhelmed by bad feelings or they had
lost their ability to function in the world, what they would want?' The answers
tend to be similar no matter who he is asking - quiet, comfort, nice surroundings,
proximity to family and friends, clear information, someone they can trust, somewhere
where it is OK to scream, practical help, and sometimes medication if necessary.
Nobody has ever said that they would like an acute admission ward in a psychiatric
unit. It is indeed time we took our customers seriously. P1
responding to J2: Thanks J. I direct an international
project exploring exactly this issue - findings generally supporting Jim Read's
view. At a conference this week, one of the Sainsbury's 'Pulling Together' research
team discussed what was 'special' to psychiatric nursing - Psychiatric nurses
included only tasks such as giving medication, doing observations, giving injections
and assessing risk. It may only be a matter of time before our clientele 'get
us' under the trades description act. I hope nurses wont be seduced by the evidence-based
claptrap and the urging to drop everything they have ever done (well) in favour
of learning new therapies. People don't want therapy (at least not in the first
instance) they want validation, support and someone to be a kind of fellow-pilgrim.
I only hope that there are enough nurses around to grasp the nettle of this challenge
and to provide the kind of quality care whch people with mental health problems
need. I3 responding to P1: Greetings
P. Hopefully new government policy may help establish greater intakes of such
nurses. B8: It sounds
as though mine is the only NHS Trust with a particular policy regarding the employment
of service users. Addressing O1's concerns about tokenism and genuine involvement
is certainly a part, but only a part of its remit. Here it is.. Q1: I
endorse what Pathfinder is doing as follows, but wonder what support is on offer
for people already working for Trusts who have mental health problems B9
responding to Q1: Q, thanks for your response
and support. I am trying to address the 'us and them' culture of the Trust, as
I do presentations with staff teams. I also want to set up a large group forum
to explore boundaries between the identities of professionals and patients, and
how and when they are crossed. This, together with other monitoring issues, is
one of my three targets for the next year. The other two were (i) publicity and
(ii) recruitment to supported posts. Once we have a clearer picture of the level
of mental health problems amongst staff already in post within the Trust as a
whole, perhaps we can start to address the concerns you raise, with the support
of those in positions of power who need hard evidence before they'll practice
even picking their nose. R1 responding to B8 and
the mailed report: I'd simply like to congratulate
you on your project - it is a spellbinding read, I found myself uplifted by its
values, and posting examples of good practice to the list for wider dissemination
and comment is just one of the most important ways in which the list demonstrates
its worth. Thanks. Q2 responding to B8 and the mailed
report: B, thanks for the mailed report. It is
good that the project works at breaking the them and us myth and deconstructing
the taboo around mental health workers having mental health problems [B9], good
also that there is sympathy for such mental health workers, which has not always
been my experience. I will certainly continue to follow the project with interest.' J3
responding to B8 and the mailed report: B, thanks
for the mailed report. Its very impressive and pleasing to see that some people
have gone so far along the road of reducing discrimination against those labelled
with mental health problems. We have some user involvement in the planning of
our nurse training curricula and in the delivering of lectures where I work. At
our last validation meeting with the E.N.B. user representatives on the planning
group actively participated. Doing more seems to be a slow process. Sadly some
of the slowness is in convincing our colleagues of the value, never mind the essentialness,
of user involvement. References Appleton,
R. (1997a) Subject: users of the service; Date: Thu, 12 Jun 1997 19:16:16 -0400
(EDT); From: Rappleton@aol.com; Sender: psychiatric-nursing-request@mailbase.ac.uk Bowers,
L. (1997a) Constructing international professional identitity: what psychiatric
nurses talk about on the internet. International Journal of Nursing Studies 34(3)208-212 Bowers,
L. (1997b) Subject: Re: Sociology; Date: Tue, 11 Mar 1997 19:39:20 +0000; From:
Len@lenbow.demon.co.uk; Sender: psychiatric-nursing-request@mailbase.ac.uk Curzon,
B. (1997) Subject: Re: Internet Addiction Disorder; Date: Thu, 20 Mar 1997 15:01:22
+1300; From: ajmac@iconz.co.nz (Brenda & Tony MacCulloch); Sender: psychiatric-nursing-request@mailbase.ac.uk Davidson,
B. (1997a) Subject: Inappropriate use of the list; Date: Wed, 12 Mar 1997 14:47:26
-0500; From: Ben_Davidson@compuserve.com; Sender: psychiatric-nursing-request@mailbase.ac.uk Davidson,
B. (1997b) Subject: users of the service; Date: Fri, 13 Jun 1997 19:58:00 -0400;
From: Ben Davidson@compuserve.com; Sender: psychiatric-nursing-request@mailbase.ac.uk De
Mare, P. (1975) The politics of large groups in Kreeger, L. The Large Group: Dynamics
and Therapy, Karnac, London Foulkes, S.H. (1964) Therapeutic
Group Analysis, Maresfield, London Foulkes, S.H. (1975a)
Group-Analytic Psychotherapy: Method and Principles, Maresfield, London Foulkes,
S.H. (1975b) Problems of the large group from a group-analytic point of view in
Kreeger, L. The Large Group: Dynamics and Therapy, Karnac, London Johnson,
M. (1997) Subject: Re: Inappropriate use of the Mail list; Date: Thu, 13 Mar 1997
19:14:56 +1000; From: m.johnson@cqu.edu.au (Matthew Johnson); Sender: psychiatric-nursing-request@mailbase.ac.uk Kreeger,
L. (Ed.) (1994) The Large Group: Dynamics and Therapy. Karnac, London Roitman,
M. (1989) The Concept of Projective Identification: Its Use in Understanding Interpersonal
and Group Processes Group Analysis (Sage, London) Vol 22 pp.235-248 Smail,
D. (1984) Illusion and Reality: the meaning of Anxiety. Dent, London Smail,
D. (1987) Taking Care - An alternative to Therapy. Dent, London. Thomas,
C. (1997) Subject: Re: Love you; Date: Thu, 13 Mar 1997 20:50:34 -0500; From:
carol s thomas <csthom@one.net>; Sender: psychiatric-nursing-request@mailbase.ac.uk Wolsey,
P. (1997) Subject: Re: Part 2 - User Employment Project Report; Date: Wed, 25
Jun 1997 12:07:19 +0100; From: Philip Wolsey <opdc@opdc.co.uk>; Sender:
psychiatric-nursing-request@mailbase.ac.uk Yalom (1985)
The theory and Practice of Group Psychotherapy, 3rd edition. Basic Books, New
York Footnotes 1.
Chevrons denote that the text following is quoted from an earlier message
in the thread, double chevrons that the quotation is earlier still, and so on.
2. Bowers asked later that 'M.Ward ...
not ... be confused with Martin Ward of Oxford, UK' 3.
Dominique had asked for some ideas to help with a course assignment and had
been 'flamed' by a 'lurker' who no one seemed to know, and who then left the forum.
4. 'PSYCHIATRIC
NURSING: Ethical Strife' edited by Phil Barker and Ben Davidson published
by Edward Arnold
5. A condensed
version of the discourse is appended below; for more of a flavour of the discourse,
a transcript can be found, together with all the other archived discourse from
the forum since 1995, at "http://www.mailbase.ac.uk/lists/psychiatric-nursing/archive.html".
©
The Author
Please
let me know what you think.
Also, any enquiries concerning reproduction should
be sent either in writing to the following address,
or by E-mail by clicking
on my name: Ben
Davidson, 8 Elsie Road, London SE22 8DX., England. |
