Beyond Clinical Dehumanisation towards the Other in Community Mental Health Care

Levinas, Wonder and Autoethnography

Catherine A. Racine

• Publisher: Routledge
• Year: 2021
• ISBN:
  9781000363432
• Edition: 1
• Topic: Philosophy
• Subtopic: Ethics & Moral Philosophy

Beyond Clinical Dehumanisation Toward the Other in Community Mental Health Care offers a rare and intimate portrayal of the moral process of a mental health clinician that interrogates the intractable problem of systemic dehumanisation in community mental health care and looks to the notion of "wonder" and the visionary relational ethics of Emmanuel Levinas for a possible cure.

An interdisciplinary study with transdisciplinary aspirations, this book contributes an original and compelling voice to the emerging therapeutic conversation attempting to re-imagine and transcend the objectifying constraints of the dominant discourse and the reductive world view that drives it. Chapters bring into dialogue the fields of community mental health care, psychology, psychology and the Other, the philosophy of wonder, Levinasian ethics, clinical ethics, the moral research of autoethnography and the medical humanities, to consider the defilement of the vulnerable help seeker, the moral injury of the clinician and look for answers beyond.

This book is an ethical primer for mental health professionals, researchers, educators, advocates and service users working to re-imagine and heal a broken system by challenging the underpinnings of entrenched dehumanisation and standing with those they "serve".

1 James' Story

When we met, James was almost 19 and profoundly suicidal.¹ He had been hospitalised when he told his father his fantasy of killing both his parents and then himself. He watched violent films, played violent video games with his friends, slept half the day and abused marijuana. Unable to concentrate or cope, he dropped out of a computer program at a local technical college and was unemployed and living at home with his father and brother. By the time our work began, he had spent 20 days in the adult psychiatric ward of a large local hospital. This is a long time for a young man to spend watching adults play out the dark consequences of the kind of future one might prefer to avoid. He had also experienced his first coercive treatment when he was sedated and placed in isolation at the beginning of his hospital stay.²

I remembered the room well from a visit to the emergency psychiatric department of the same hospital. A colleague had taken me to meet one of the referring psychiatrists as part of my orientation when I started working in community mental health. The psychiatrist had shown me the “quiet room” with a single hospital bed mattress lying forlornly on the bare floor of a small, dim, windowless room that locked. Not long after our tour began, it was apparent that the “quiet room” was now occupied by a distressed woman, and she screamed for the duration of our interview. She screamed as though she was being tortured. I startled slightly in my chair with each fresh explosion of harrowing sound that filtered through the door of the office where we sat, while the psychiatrist continued talking as though nothing was happening and my colleague suppressed a small smile. It was a whiff of bedlam I will never forget. Not infrequently, people I worked with who had spent time in that room expressed such horror at the possibility of being sent back there that they would refuse hospital assistance.³ Of course, patients didn’t always have a choice.

Clinical files were doled out at team meetings twice a week. Cases were presented by intake nurses and assigned, sometimes under duress, to clinical staff already staggering under caseloads beyond their capacity.⁴ I had established a modest reputation for taking cases no one else wanted and offered to take James’ following the long silence in the room after his file was presented. It was a difficult file, but there were reasons for my magnanimity. After several years on intake, I had finally claimed my role as a therapist and was very willing to work with the least favoured in clinical practice.⁵

My first job in this community mental health centre had been on intake. It was demanding work and essentially a triaging position that required me to separate those who qualified for service from those who didn’t. The reality was much more complicated and fraught because the primary task of intake was mainly that of gatekeeper. The intake clinician stood between those desperate souls trying to access service and the often fluid “mandates” of the various teams within the Centre that we were constantly negotiating.

Further complicating the picture was the priority given those discharged from hospital to our Centre. The demand for care far exceeded our capacity. My intake colleague and I were refusing up to seventy percent, and more, of all requests for service while attempting to support those we turned away, either by counselling them on the phone or seeing them if they showed up in person at our door. Suggestions would be given, resources and phone numbers offered and some kind of plan suggested, which was carefully documented. If the individual showed up again or deteriorated and came back through their physician’s office or the hospital, or if they complained to the manager about being refused service, there had to be a paper trail. We had to confirm that the institution and clinician were not responsible, or irresponsible, and had done what was legally defensible despite the refusal of service.

Intake was traditionally a nursing stronghold that had been challenged by a maverick manager at our Centre who believed a change of the old guard was needed. He had hired me as clinical counsellor along with a social worker to take over the two intake positions shortly before his retirement. The backlash was brutal, and the rift between nursing staff and other clinical professionals became ever more acrimonious. My intake colleague and I were scapegoated for being in positions we—apparently—had no right to hold.⁶

Three months later, the day my probation period was over, I wanted to bring a cake to work to celebrate with my new colleagues but thankfully never did. That was the day I read with incredulity an email the nurses had circulated to every staff member concerning a meeting to discuss their collective outrage about the recent intake hires—my social worker colleague and myself—to which they had invited the head of their nursing union. We didn’t go, why would we? The whole staff jammed into the meeting room that afternoon behind closed doors, and with the halls empty and silent, the two-woman intake team got on with their job. Later we learned that the cries of incompetence about the non-nursing intake team had failed to move the manager and he’d dug in his heels. Some nurses suggested he was so out of touch he was likely dementing. Dementing? What were they saying about me? I knew what some of them were saying about the patients I presented at intake meetings, and not only the nurses, other clinical staff as well.

Coming into a government-paid job from the non-profit sector had almost doubled my salary overnight, but the price was steep. I ruefully remembered my joy a few weeks in when I approached the manager to express my pleasure with the work and the fascinating challenges it provided. His measured smile and quizzical response, “Wait a while”, proved all too prophetic. Several years later, I was finally given a counselling job on the ASTAT team, and two nurses were moved back into their “rightful” positions on intake.⁷ My social worker colleague had long since moved on to safer pastures in another team within our Centre. It was an immense relief for me and a reclamation victory for the nurses. Even the messiest cases failed to daunt me after that, and I may well have aligned myself with the most unwanted, having made it through the fire of my professional ostracisation. James himself was nothing if not an outsider.

During his hospitalisation, James had been assessed by a psychiatrist, tested by a psychologist and been later referred to the outpatient Early Psychosis Intervention (EPI) program, for yet another psychiatric assessment with a specialist in psychotic illness. James met the mandate for the program, having never been prescribed antipsychotic medication, and was sent for follow-up with the EPI social worker who worked on our team. The hospital workup he had received was intensive and extensive but ultimately vague. The sheer volume of documentation filled with conflicting assessments and narratives speculating about an 18-year-old young man with no previous history of mental illness was bewildering. This psychiatric hash would follow him the rest of his life and be damning should he ever need to defend himself legally or find himself dealing with any number of situations requiring evidence of his mental health history. Beyond that, what would it do to his sense of self?⁸

When James was discharged from hospital, he was advised to go home and monitor himself for signs of psychosis, which is remarkable advice for a labile 18-year-old who was using recreational drugs and suicidal. How could he adequately determine such symptoms, let alone respond to them responsibly? When we met, James still had no idea what he should be looking for, and I saw the shadow of fear on his face when he asked me to tell him. I outlined my understanding of psychosis, especially its connection to marijuana abuse in youth.⁹

The combined diagnoses from the three respected specialists who had assessed him were all but meaningless. They ranged widely from major depression and anxiety to prodromal or early psychosis through to borderline or possibly antisocial personality disorder or features, complicated by marijuana abuse. His interest in speaking about philosophical matters had also been duly noted, and patronised as intellectual posturing. Following his hospital stay, James never did follow up with the EPI clinician on our team. Instead, he stopped his medications and dropped out of a system too overwhelmed to notice or care, only to re-emerge three months later when he became suicidal once again. James returned to the hospital, was sent back to our mental health centre once again and assigned to me. By then he had also started to use LSD regularly with his girlfriend, a fact he willingly shared to my enormous chagrin, which added more risk to this already suicidal youth and his predisposition to psychosis.

James intimidated me from our first handshake. He was tall, rawboned, ashen, unkempt. He was aloof, emotionally flat and answered questions in monosyllables with a fixed gaze and glacial disdain. James had felt neither understood nor valued from his first encounter with the mental health system. Our initial meeting was another opportunity for him to confirm what he already knew about a chaotic and ineffective service. He’d been asked the same questions too often by too many people and invaded, observed, assessed, judged, labelled and incarcerated with too few results. He scoffed at questions about how homicidal he might be and denied a history of self-harm but admitted spending time as a boy tearing the wings off bees to watch their behaviour. He blandly claimed his suicidality was insignificant, which alarmed me given the deadly statistics.¹⁰ I hoped he was bluffing.

Halfway through our first session, I knew beyond all doubt that I did not want to work with James. He scared me half to death but finding someone else to work with him would be tricky. He was a hot potato given the lack of follow-up he’d received that had enabled him to slip away only to be brought back through our doors via the hospital for a second time, and now he was high profile. Not just because he was at such high risk, but because our Centre had failed to keep tabs on him and there was no more margin for error—we would be liable if anything happened to this kid.

A community mental health centre is comparable to a MASH unit, with limited resources and staffing and incoming wounded attended by whoever can handle the next casualty.¹¹ If a help seeker didn’t like the clinician assigned to her case, she would likely be pathologised, viewed as demanding or shown the door but never offered the luxury of another choice. Nor could a clinician easily pass on a file. It just wasn’t done, and I had never attempted to negotiate such a manoeuvre, but this was different. Being afraid of a patient would be a frank admission of professional inadequacy, although the “danger card” could be played, but not easily in this case as James had not done anything, yet.

There was little love lost between the line manager and a great many of us who reported to her. She was in over her head and not suited to her job in this pressure cooker, and she managed her anxiety by micromanaging the rest of us. I approached her and casually explained my wish to transfer the file. Without missing a beat, she looked up coolly from her desk and told me I was welcome to trade the file with whoever on the team might be willing to pick it up. Checkmate. I tried half-heartedly to talk to a couple of colleagues about a trade but knew it wouldn’t fly. Everyone was maxed out and nobody was going to pick up a file like this. I talked to two trusted colleagues about the matter and decided to try again. There remained one faint hope.

Typically, psychiatric nurses were assigned people with a history of schizophrenia or bipolar disorder with mania—those who were or had been floridly psychotic. Such patients were higher up the ladder of pathological legitimacy as opposed to those dealing with “acute situational stressors” who were generally seen by the counsellors.¹² I pressed my advantage and informed my line manager that James’ case was not a good fit because it meant “working outside of my scope of practice”. This doublespeak was to remind her of those professional limitations of the institutional hierarchy from which she benefitted more as “medical” staff than I did, and that was to my ethical credit to respect. To disregard them placed her in an ethically compromising bind.

I stood in my line manager’s office, looking over her shoulder while she flipped through James’ file. “It’s a dog’s breakfast”, she said, and grudgingly agreed to pass the file on to a nurse who unexpectedly left the following week for another position. The file bounced back to me; there was nothing to be done, but psychosis was the least of my worries. Here was an unknown teenager with no previous psychiatric history and an inconclusive diagnosis following a lengthy stay in hospital. Against his will, James had been certified and hospitalised for expressing an interest in killing his family and himself and, according to one assessment, might have an “antisocial or borderline personality disorder”.¹³

James was now using LSD in addition to having a long-standing marijuana habit and could deadpan a seasoned professional for an hour with spine-tingling effect. He knew exactly how to express in few words a brooding ambivalence towards a system of care that, far from helping, had wasted his time and diminished him as a human being. He was a loose cannon I had done everything possible to avoid for fear that he might be a danger to me, find out where I lived, come to my home or kill himself on my watch.¹⁴ There was no choice but to confront this spooky kid who was young enough to be my grandson.

James had no good reason to like me, given my failed attempt to have his file transferred. I soft-pedalled my embarrassment the day I invited him into my office for our second meeting to explain that the nurse who was to have taken over his case had left our Centre. James eyed me levelly, silently. He had been passed around from one professional to another since his first contact with the system. Everyone had listened, for there is nothing quite like a homicidal and suicidal youth to capture professional attention, but no one had heard him. He stonewalled for the first several sessions and resisted my every attempt to leverage a connection. It was a standoff, and the tension was palpable.

T...

Table of contents

• Cover
• Half Title
• Series Page
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgements
• Introduction
• 1 James’ Story
• 2 Three opponents of wonder
• 3 From behind the mask: Writing autoethnography
• 4 Wonder: A turn towards the divine
• 5 Levinas and the wholly/holy other
• 6 Clinical application and beyond: The function of the holy
• 7 The politics of need and desire
• Index