The Interactive World of Severe Mental Illness

Case Studies of the U.S. Mental Health System

Diana J. Semmelhack, Larry Ende, Arthur Freeman, Clive Hazell, Colleen L. Barron, Garry L. Treft

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317802846
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

In our society, medication is often seen as the treatment for severe mental illness, with psychotherapy a secondary treatment. However, quality social interaction may be as important for the recovery of those with severe mental illness as are treatments. This volume makes this point while describing the emotionally moving lives of eight individuals with severe mental illness as they exist in the U.S. mental health system. Offering social and psychological insight into their experiences, these stories demonstrate how patients can create meaningful lives in the face of great difficulties.

Based on in-depth interviews with clients with severe mental illness, this volume explores which structures of interaction encourage growth for people with severe mental illness, and which trigger psychological damage. It considers the clients' relationships with friends, family, peers, spouses, lovers, co-workers, mental health professionals, institutions, the community, and the society as a whole. It focuses specifically on how structures of social interaction can promote or harm psychological growth, and how interaction dynamics affect the psychological well-being of individuals with severe mental illness.

1
Institutional Interaction Structures

In writing the first three chapters of this book, we reflected on the available literature on our topic—the social interaction structures that promote or hinder growth for psychiatric clients. (See the introduction of this volume for a definition of interaction structures/dynamics.) These reflections took into account an analysis of the structures of interaction in the eight case studies presented in chapters 4 through 11. (See chapter 13 for a list of major structures described in the case studies.)

Our examination of the available literature and our analysis of the case studies informed each other. Integrating these two sources of information, we formulated common interaction structures that affect the psychological well-being of clients diagnosed with severe mental illness.

We consider the structure of social interactions in three major areas: clients’ families, their friendships, and the institutions they belong to. This first chapter focuses on institutions. We consider mainly the types of institutions most relevant to the case studies: long-term care centers and state hospitals.

Institutional Interaction Structures That Tend to Damage Clients

Institutional interaction structures are particularly important to focus on in that each individual described in the case studies resides in a locked institutional setting. This section describes interaction structures that tend to impede growth for those with psychiatric issues. The locked nature of most long-term care centers and hospitals intensifies the importance of staff interactions with clients. On a locked unit there is no escape from the staff members who manage the care (including medical and mental health workers). Therefore, the quality of the matrix of interactions within the environment, if primarily growth-impeding, could contribute to the psychopathology.

Creating a Culture of Obedience

Institutions for people diagnosed with severe mental illness often exert on residents a great pressure for obedience and at times can be coercive (Miller, 2003; Szasz, 2002). A culture of obedience can undermine clients’ ability to grow psychologically. The inherent potential for the misuse of power by human beings (when put in authority positions over others) is best evidenced in the Stanford Prison Experiment (Zimbardo, 1971). We are not, however, opposing a hierarchical model of mental health treatment. Depending on the given staff, clients, and circumstances, a relatively hierarchical model may or may not be most effective. We aim here to explore a relatively non-hierarchical framework which operates in a nonjudgmental manner.

D. Martin (1955) captures a sense of the role of obedience in mental health facilities in a moving quotation. He cites a passage about the shock many European psychiatrists felt when they looked at their mental institutions from the perspective of reconstruction and renewal present after World War II:

… the patient has ceased to rebel against, or to question the fitness of his position in a mental hospital; he has made a more or less total surrender to the institution’s life … He is co-operative. Here ‘co-operative’ usually implies that the patient does as he is told with a minimum of questioning or opposition… . [The] patient, resigned and co-operative … too passive to present any problem of management, has in the process of necessity lost much of his individuality and initiative (pp. 1188–1190).

Wing and Brown (1970) in a prominent critique showed how mental institutions actually produced what were mistakenly thought to be negative symptoms of schizophrenia. While obedience and passivity in these institutions were considered to be symptoms of schizophrenia, these writers demonstrated that these characteristics of residents in reality were related to the phenomenon of “institutionalization,” a gradual acquiescence to a state of life that precludes participation in the community outside the hospital (Wing & Brown, 1970).

The first institutional structure we consider is aptly titled “Creating a Culture of Obedience.” A culture of obedience may cultivate an unquestioned compliance with an institution’s rules. Some rules are explicit and others are implicit. The structure for creating a culture of obedience, for both residents and staff, has two major components, which are unconsciously integrated: 1) the use of reward and punishment to support adherence to the institution’s explicit and implicit rules; and 2) an implicit cultural value system that encourages compliance with these rules.

Institutions use reward and punishment to encourage resident obedience. In addition to instituting rules for the facility as a whole, the staff designs plans that function as rules for individual clients. When a client enters the system, a psychological expert examines and diagnoses the individual. Staff develops a treatment plan for the client. This plan provides a basis for the application of reward and punishment. Diagnostic formulations and treatment plans, as official documents, carry a lot of weight. They not only have a clinical function, but also play a role in maintaining client obedience.

The staff, for example, psychiatrists, psychologists, nurses, social workers, and certified nursing assistants, track each client’s behavior. An environment is created wherein client behaviors are constantly monitored and evaluated by staff (Goffman, 1961a). They evaluate client behavior in regular meetings and make plans for future behavior. In between these meetings, ‘bad’ behavior is written up and punished. At other times, clients may be rewarded. What may seem to an outsider to be relatively minor rewards and punishments can become extremely significant for residents, in part due to the deprivations they endure in institutional life (Goffman, 1961a; Weinstein, 1994). Such deprivations include, but are not limited to, lack of privacy, poor quality food, and lack of opportunities for social interaction or pleasure. For example, residents may have to wait an entire day for a cup of coffee. Punishments and rewards may involve whether one receives small items purchased for clients, coffee, passes to leave the facility, privileges to smoke, or permission to go on trips in the community. Sometimes the staff makes these privileges part of behavior plans (and at times the clients have some input). At other times, the presence or absence of these privileges functions as a more general means of encouraging ‘good’ behavior. Describing the use of punishment and privileges in mental institutions, Goffman (1961a, p. 52) says, “The over-all consequence is that co-operativeness is obtained from persons who often have cause to be unco-operative.”

More implicit rewards and punishments play a decisive role in the management of resident behavior (Taylor, 1979). The institution has power over the fulfillment of the most cherished wish—the wish to be released from the facility. This is a major source of obedience. Residents often feel like inmates condemned to living out their lives under prison-like conditions. Yet, at the same time, the residents fear being expelled from the institution. If expelled, they may become homeless (Hopper, Jost, Hay, Welber, & Haugland, 1997), end up in jail (Teplin, 1984), or be placed in a much worse facility—such as a nursing home, perhaps in an unknown location where they have no relationships (Simon, Lipson, & Stone, 2011). Past experiences with being homeless, abandoned, hungry, or unsafe can make the threat of being expelled terrifying. This is especially the case since many of these clients already are vulnerable to feeling paranoid. The threat of expulsion functions as an important motivation for compliance with the explicit and implicit rules within the facility.

Additionally, events that appear to have no link with reward and punishment can be perceived as punitive by the client. Hospitalization often functions in this manner. Clients sometimes hide the expression of their intense emotions due to fear that they will be hospitalized, or placed in a locked ward. Similar threats result from the practice of using ECT, isolation, or physical restraints. The use of force, including the ability to affect whether clients remain in the facility, ultimately lies behind the less intimidating dynamics (such as reinforcement of positive behaviors) that encourage resident compliance. This is partly because the residents, to a significant extent correctly, see themselves as having few choices in the day-to-day management of their survival outside of a facility.

Another powerful implicit form of reward and punishment comes from staff attitudes toward clients. At times, the staff offers clients affection and understanding. This can have a great impact given clients’ isolation and social deprivation. In addition, clients generally want to please the staff. At other times, staff members explicitly or subtly adopt demeaning, punitive, or condescending attitudes toward residents. This is often conveyed through word choice or tone of voice. Without being aware, staff can at times be outright cruel or physically abusive, and clients may feel helpless and unable to defend themselves. The threat of being demeaned and chewed out for undesired behavior makes for a constant source of obedience. A vulnerable client’s whole day can be ruined by an abusive interaction with a staff member. One client in a nursing home, for example, became furious for more than a day over a fairly common incident:

I had a horrible flashback, and I urinated twice in my bed. I told the nurse what happened. She said I was trying to manipulate staff. I got written up for it. Why did she do that? I couldn’t help what happened to me!

However, after strongly criticizing abusive behaviors by staff, Barton (1966) says:

Before judging staff too harshly it must be remembered that mentally ill and elderly people can be maddening and exasperating and the chronic shortage of staff in most situations results in all but the most saintly employees becoming irritable and short tempered at times. (p. 14)

The self-righteous critic, Barton (1966) adds, “should work eight hours a day ‘with his hands in excreta’ for a few days before exploiting these tragic incidents with harsh criticism …” (p. 14). Barton is suggesting that one needs to look at staff’s actions from their perspective—working for a low wage, in a pressured environment with little admiration for the work that they are doing. The work of caring for institutionalized individuals could be viewed as demeaning by society as a whole. The actions of staff are part of a system that includes clients, job conditions, clients’ families, the staff members’ colleagues and superiors, and the dependence of these factors in various ways on the larger social system within which the treatment center is embedded.

Another aspect of reward and punishment involves the client’s family, friends, guardians, pastor, or other caring persons who may visit. Many residents manage to retain few links to those in the community. They depend on these visitors for a number of things, including advocacy, or having someone to get them out of the institution for a little bit of time. Since connecting with those outside the facility is so crucial for residents, and may not happen often, residents may feel obligated to maintain the expected behaviors of these visitors. The expectations of family members, of course, can have an especially powerful effect on residents’ behavior. Growth promoting expectations of family members allows the individual to feel connected to society as a whole.

On their own, actions that function as punishments and rewards might not have a strongly coercive effect on the residents, or residents might rebel. The more or less acknowledged practice of reward and punishment, however, is integrated into an implicit cultural value system. This system creates a culture in the facility that encourages residents to take for granted the institution’s chosen practices. Behaviors are (mostly unconsciously) divided into ‘good’ and ‘bad.’ These categories are implicitly defined by the institution. The word ‘good’ implicitly associates compliant behavior with desirable qualities, making the behavior seem to be naturally and unquestioningly desirable. Other words do a similar job, including ‘appropriate’ versus ‘inappropriate’ and ‘healthy’ versus ‘unhealthy.’ Connotations of goodness or badness can also work in the same manner, as when a staff member says that a client ‘needs to’ take a shower—implying that taking a shower at that time is ‘good’—or when a client is described as being ‘late,’ which is ‘bad.’ ‘Good’ and ‘bad’ and related words can obscure the basis for the judgments they convey. They leave the impression that this judgment is obvious and agreed upon. The words can seem to suggest generally accepted social meanings and norms.

In reality, however, the basis for the judgments underlying the use of the words ‘good’ and ‘bad’ is quite complex. The institution’s policymakers establish the rules behind many of these judgments. Many factors, however, play a role in determining the behaviors that come to be thought of as ‘good’ or ‘bad,’ including the funding available for carrying out practices; state policies; mental health theories, opinions, and practices; socially dominant community attitudes toward mental illness; client needs; the threat of lawsuits; social norms; the wishes of the client’s relatives; and the attitudes of the institution’s personnel, especially those directly responding to the client behavior (who are most often low-level employees with high-stress jobs, low pay, and little or no training in the field). For the most part, the clients themselves are not involved in determining which of their behaviors are considered ‘good’ or ‘bad,’ although in some cases clients can give some input into their treatment plans. Most of the factors listed above, moreover, include various parties whose opinions conflict with each other, sometimes at a fundamental level.

The apparent simplicity and general agreement about values suggested by the use of the word ‘good’ is, therefore, an illusion. The word can take everything for granted. ‘Good’ and ‘bad’ tends to obscure exactly who determines that a behavior is good or bad, or how this determination is made. In a bureaucracy, it often occurs that no one is responsible for the institution’s rules. They just seem to somehow exist. One is left with the feeling that there is no need to reflect on what lies behind the judgments being made, or to consider the question of the client’s own judgment of his behavior.

When one does reflect on the underlying value system of institutions for those diagnosed with severe mental illness, one might find that what is valued most is efficiency (especially as financially defined), the reproduction of the institution itself, the meeting of various regulations imposed on the institution from outside, compliance in taking medication, orderliness, obedience, punctuality, cleanliness, and politeness (Gammonley, Zhang, & Paek, 2010). Significantly less valued is the experience and the emotional lives of the residents, their standard of living, a systemic view of their behavior (rather than one that focuses only on individuals’ behavior), initiative, responsibility for one’s own treatment and way of living, privacy, the physical beauty of the environment, connection with the community, stimulation, meaningful and purposeful work and other activities, autonomy, community, relationships, social interaction, collective responsibility, therapy, self-actualization, empathy, caring and compassion, and respect for the dignity of the residents (Kayser-Jones, 1990).

If staff and clients regularly reflected on the meaning of behaviors rather than blindly accepting them as ‘good’ or ‘bad,’ they might consider the experiences and motivations behind their behaviors, the systemic causes and consequences of their behaviors, and how the clients and staff might want to change these things. Staff and clients might cultivate ideas about what they would consider most valuable in an institution and what to do about it.

Later in this chapter we will consider the dynamics of ‘therapeutic communities.’ In these therapeutic community settings, staff and clients reflect on the meaning of behavior rather than simply identifying behaviors as good or bad. Staff and clients think about the results of their institution being the way it is and how they might go about changing it (Main, 1977). The implicit value system is turned into an explicit one (Pestalozzi, Hinshelwood, & Houzel, 1998). Together with clients, staff may engage in a non-judgmental unpacking of meaning that would be impossible in a judgmental atmosphere. An environment in which such things take place encourages critical thinking rather than obedience. Such an environment might in part be characterized by Rogers’s necessary and sufficient conditions for therapeutic change, including empathy, unconditional positive regard, and congruence.

The cultivation of obedience discourages agency and initiative (Milgram, 1963, 1974). It contributes to resident apathy and lethargy. In facilitating compliance, the in...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Introduction
• 1 Institutional Interaction Structures
• 2 Social Interactions With Families
• 3 Social Interactions With Friends
• Introduction to the Cases
• Epilogue
• Index