by Rolf Sundet
Rolf is Specialist in clinical psychology and Professor Emeritus, University of South-Eastern Norway, Faculty of Health and Social Sciences, Department of Health, Social and Welfare Studies, Centre for Mental Health and Substance Abuse.
In June 1972 I got off the bus outside the village of Lier, Norway, slowly walking towards the regional mental hospital. I was 18 years old with both anxiety and tense expectation about this new experience; working as a nursing assistant in a mental hospital. I was received by the nursing principal who informed me that I was to work on Ward 23. I was sent on a round to get my nursing assistant uniform, keys and a place to stay. My living quarters was in a house named the House of Brothers.
I was first given my uniform, a set of grey trousers with a blue line on each leg which reminded me of the trousers the local brass band, and a short white jacket which reminded me of a jacket of a waiter. I looked like what might be called a “brass-band waiter”, whatever that might be, and I felt pretty uncomfortable in this outfit, belonging to the “jeans-and-T-shirt”- generation. The set of keys was heavy with many keys and with one that did not look as a key at all. It was flat, round with two small knobs on one side. I was informed that this was named the “belt-key”. With a very serious mind the woman who gave me the keys said that this key was a very important key and no patient must be given access to it.
Walking around the hospital I noticed the distinct layout. Six huge buildings contained the wards, three for women and three for men, and in addition there was a building for administrative staff and one with different workshops. All this was at the bottom of a hill with a couple of the wards a bit up in the right side of the hill. On the left side of the hill all the living quarters of the different staff were laid out. At the top there were villas where the doctors lived, just above a set of buildings for the senior nursing officers. At the foot of the hill was a set of apartment buildings where the other nursing staff lived, and lastly some smaller buildings for nursing assistants. The anomaly here was the House of Brothers which was placed on the side, but on a level between the doctors and the senior nursing officers and I learned that no power hierarchy is completely perfect.
When I started to work on the afternoon shift, I discovered what the strange “belt-key” was all about. Every night the 16 patients on the ward were strapped down in their beds and the key was used to lock the belt so that it could not be opened by the patient. I never got a clear answer why we did this, except for some vague statement about prior violence, long ago. Somehow this act of strapping down people was also referred to as “caring”.
Another practice was that every Tuesday all patients were given an enema, and again it was difficult to get an explanation for why this was done. An older nursing assistant who had worked there for years just stated that this had been going on since the patients arrived at the ward and now their bowl movements where ruined so they had gotten “addicted” to the enema. The closest I got to an official explanation was that this was part of the “caring” procedures of the ward.
Why am I writing this? What do these personal memories have to do with my paper – “A just assemblage in mental health services – the necessity of and possibilities for service diversity”?
For me it was the beginning of a journey that still goes on—to get to know and get an understanding of mental health work, psychologically oriented practices and psychiatry. What is this, and what are the challenges and problems I have experienced in this journey?
The then geographically stated hierarchy is no longer geographical, but still retained as a mental and organisational hierarchy with distinct power relations. Further, that the definition of both “caring” and the knowledge that this “caring” builds on, was and is in the hands of basically two professions: the psychiatrists and, my profession, the psychologists. Today these are seen as “specialists” whose job it is to monitor the practice of other staff and see to that it follows accepted guidelines of practice. The other professions and the “unskilled labour” are still, now as then, basically seen as “helpers” for these professions, although words like collaboration, coordination and equality can be heard in the corridors of power. Today these words are also used to describe the relationship between staff and patients, but what is a good outcome, or “caring”, is basically decided by the staff, although the message is that the patient should be heard.
To be heard is not necessarily the same as being taken seriously, believed and being responded to in accordance with one’s preferences and perspectives. This is still only in the beginning and perhaps no more advanced today than when a patient at Ward 23 one day objected to the belt, and was told that this is what is “good for you”. Today we might have more sophisticated language, but power issues are still blurred and not necessarily attended to by words such as “efficacy”, “best practice”, or “therapy that works”. In the end it is the central professions of psychologist and psychiatrist who have the last words on what is best for the patient in front of them.
Like in the beginning of the 1970s, it is the knowledge situation, combined with the ideas of government and organisational governing of practice that is decisive. Today this is manifested in an entanglement of three different parts of health care and treatment. First the medical model which decides both who should be in charge (psychologists and psychiatrists), the sequence of necessary actions such as assessment, making a diagnosis and then treatment. What assessments and treatments should be used is decided by research that values and gives precedence to the Randomized Control Design, with the ideological supposition that what works for the many, works for the one. And lastly, that this sequence of actions and their possible results are brought under control of a special managerial ideology and organisational practice; New Public Management with standardization and documentation as the main control tools. Clinical autonomy is to be restricted and there is an increasing demand to follow the rules, principles and the practice that are brought forth through RCT-based knowledge.
Now, as in 1972, all this is subsumed under the idea that just treatment is that everybody gets the same treatment, that is; we do the same thing to everybody. Symbolically “belt” and “enema” for all are still the law of the land.
What the journey has taught me is that the group-based knowledge of an RCT is at best a starting point. It points to areas of causation and not to specific causes for the single patient. People are different in a fundamental sense which makes each of us unique. This uniqueness includes that there might be people who are best cared for by being strapped down or given an enema and if so, one must show how it can help the person in front of us, always being aware of the possibility that this “caring” is actually a violation of the other.
The real presence of diversity, difference, and uniqueness is therefore what this journey has taught me. What we need is a science for the individual and individuality, not only as a field of generalised knowledge, but the development of knowledge that is specific for this person. This means that the de-contextualization and de-subjectification that RCTs bring forth must be stopped as the main source that governs our practice. This again means that we need a concept of causation that allows for singularity, uniqueness and specific knowledge of the person in front of us.
The paper is an attempt to think about how diversity and difference could be a better path to create a just and helpful mental health practice for all. One must keep in mind that generated practices are always in danger of ending up “strapping” the other down, or inflicting an enema that over time ruins not only bowel movements but all the life movements of the person. The aim must be to create a mental health service that can respond to the individuality, difference and uniqueness of each person we meet. From my journey this means to allow for a way to understand how and why we become the person we are connected to how causality operates and what it is: a causality that makes it possible to understand an individual both as they are and what they might become and not as an expression of a group identity and generalisation. Further, we become who and what we become, always within a context of living and in relationships with both animate and non-animate entities, and where collaboration and the safeguarding of difference are central to our life.
My suggestion is that these extended and entangled relationships might profit from the perspectives of an assemblage, not only as a tool for bringing about a just mental health service, but perhaps also in strengthening hope of a more viable life than our ecological and climate crisis points to. The simple fact is that when you destroy an environment and the living context of persons, you destroy those persons. Person and context, persons and their relations, are therefore sacred.
Causality, Complexity and Evidence in Health Sciences 