Adult Psychopathology, Second Edition: A Social Work Perspective

A TRANSDISCIPLINARY VIEW OF MENTAL DISORDER

D. W. Millard

What sort of phenomenon is mental disorder? Although most people who are in contact with mental disorder may not often ask this question consciously, their every action implies that they have in mind some kind of answer to it. The nurse feeding a patient in a depressive stupor is saying that mental disorder is something to do with problems of self care; the physician prescribing an antidepressant is saying that it is something to do with biological mechanisms; the social worker’s contribution is saying it is something to do with a mismatch between psychosocial resources and needs. The patients’ and their carers’ behavior is also implying an answer to the same question.

This chapter attempts to build a bridge between concepts and practice. Multidisciplinary teamwork is of course commonplace in contemporary mental health practice. While it would be too extreme to claim an exact parallel between the varying ideas concerning mental disorder held by the different professions in the clinical team and the precise contribution each member might bring, there is perhaps a fairly close relationship between the two. Thus, we shall attempt to identify certain essential components in these concepts and to consider what may fairly be called a transdisciplinary view of mental disorder within the team approach to practice in this field.

SETTING SOME LIMITS

Mental disorder is not free of cultural relativities; how it appears is influenced by the viewpoint one takes. This chapter takes first a pluralist view, then a professional view, and lastly a British view.

A Pluralist View

The term pluralist view indicates that we shall take seriously a number of different standpoints, both philosophically and professionally. The basic assumption is that we cannot speak of mental disorder without having in mind some concept of mental order (or orderliness). Thus, the question, What kind of phenomenon is mental disorder? is part of what we wish to say about human nature in general. Mental disorder is not outside the common stock of accounts of general human experience and behavior.

Modern philosophers are interested in examining the ways in which people sometimes describe things by reference to various possible worlds. Perhaps the simplest of these is a model of two worlds: a physical world of matter and energy in which occurrences have extension in space and time, and a symbolic world. The characteristic of the first world is that events within it (like gravity) occur independently of human volition; we may certainly choose how to describe them but they occur whether or not anyone notices or labels them. The symbolic world is the world of ideas or information dependent, ultimately, on the human mind and on human volition. In sociology, the study of the first is often associated with positivist and the second with hermeneutic approaches (Giddens, 1976). The relationship between the two worlds comes to a crux in that most persistent philosophical dilemma—the mind/body problem.

Both worlds are, of course, inescapably real; and each includes the capability of influencing the other; the relationship between them is one of interaction. We are here asserting an essential place for both physical (chiefly, but not exclusively, brain) events and psychological events in the characterization of mental disorder—and our introductory question must be understood in this sense. Both the phenomena and also the determinants of mental disorder exist within these two worlds.

There are aspects of every mental disorder that belong to the physical world; after all, we know of no examples of mental events, including mental disorders, which are not related in some way to the existence of one or more particular human bodies which exist in space and time. It is the anatomical or biochemical abnormalities that chiefly account for such facts as the fairly consistent prevalence rates found in cross-cultural studies of schizophrenia, and modern psychiatric research is heavily involved in neurophysiology. But equally there are no mental disorders of which certain aspects do not belong to the second, or symbolic world; these aspects are there because of choices of the human mind—not necessarily the choices of the individual sufferer, or of those in his own family or other social group, but freely choosing human minds nevertheless.

In a different sense, pluralism involves attending seriously to the contributions of a variety of different approaches. This method is not new: for example, M. Siegler and M. Osmond, a sociologist and a psychiatrist, described in 1974 eight models of madness (medical, moral, chronic impairment, psychoanalytic, social, psychedelic, conspiratorial, and family interaction); for each, they include a range of definitions of mental disorder, statements about causes and effects, and prescriptions for the professional behavior of the caregivers and of the rights and duties of all involved. But while Siegler and Osmund conclude that the medical model is superior, we shall argue here for team practice and for a transdisciplinary view of mental disorder.

In modern practice, the transdisiplinary view seems to have developed through a number of phases. Starting from a largely unchallenged medical hegemony, the first phase was perhaps one of a rather overdone blunderbuss attack. The second has been a much more reasoned phase, which, drawing on a developed sociology of work and the professions and a sophisticated study of social policy, leads to a detailed conceptual analysis of teamwork. And the most recent phase—which, indeed, we are only just entering—is that of the empirical study of such matters as the effectiveness of members of different professional groups in the accomplishment of defined clinical tasks, and of the distribution of power and responsibility among various roles within the caregiving team.

A Professional View

We shall deal in this chapter only with what we may describe as the established professions.

The range of those who have some claim to offer a contribution to the conceptual task of characterizing mental disorder is very wide. There are, of course, the obvious health services professionals—physicians, especially psychiatrists; nurses; social workers; psychologists, especially clinical psychologists; psychotherapists and behavior therapists; the clergy; physiotherapists; and occupational therapists. Persons ordinarily included when describing psychiatric hospital settings would, in Britain, increasingly also be found in the wider community: speech therapists and remedial teachers contribute in child psychiatric settings; within special schooling for children with a variety of mental and physical handicaps specialist teachers and residential social workers find their place; the police and lawyers have their own roles; the staff and the members of a very wide range of voluntary associations and societies make a substantial contribution to mental health care; a vast network of informal caregivers, and—undoubtedly the largest group of caregivers to the mentally disordered—their relatives.

Among this extensive array, whose views count? This question becomes very pointed as soon as a further matter is raised: Where are the mentally disordered? A recent overview by Goldberg and Huxley (1980) produces some instructive figures. These authors summarize from a number of investigations in the United States and in Britain the one-year prevalence rates (the number of people who suffer from a disorder during a calendar year on at least one occasion) per 1,000 population at risk. Taking five levels of analysis, they suggest that the rate of morbidity from psychological disorder in random community samples is about 250 per 1,000 at risk per year; about 230 will present themselves to a primary medical care facility (in Britain, a general practitioner) of whom 140 will be recognized by the primary care physician as having conspicuous psychiatric morbidity. Of these, about 17 will be referred to a specialist psychiatric service and will therefore come to the notice of a psychiatrist, whereas only 6 of the original 1,000 at risk per year will be admitted to psychiatric inpatient care.

There are three broad categories of those who might decide whether or not a particular state of affairs should count as a case of mental disorder: the patients, their relatives, or the observing and caregiving professionals. Moreover, there may be a considerable disagreement in specific cases between these judgments: the patient’s Am I going mad? the close relative’s Surely this is madness? and the psychiatric Is this person diagnosably sick? frequently yield very different answers.

The point here plainly has to do with the identity of the classes of individuals listed above, and their role in the social situations represented by the five levels of analysis in Goldberg and Huxley’s 1980 study. It is appropriate to recognize that, in limiting ourselves to a professional viewpoint, alternatives with powerful claims to be heard are being set to one side.

Nevertheless, we shall consider only the concepts of mental disorder embedded in the identity of some of the professionals involved. Occupational or professional identity is of course a matter of the range of expertise deployed by members of each profession and, therefore, of the form and content of each worker’s education and training. But it is also connected with such matters as the relative status and power of different professional groups and the varied forms of professional organization with which they work. It is not intended to imply an exclusive ownership of a particular view, but it is the case that the training and practice of physicians will be linked with a predominantly medical view, that of social workers a view which more strongly emphasizes social interaction, that of nurses or psychologists or of occupation or industrial therapists, or of ministers and clergymen, other views, and so forth.

Yet, despite the fact that psychiatrists and other psychiatric hospital-based personnel come regularly into contact with only a limited and unbalanced sample of those identified in the community as mentally disordered, in practice it is the medical viewpoint—or what people take to be the established medical viewpoint—against which all others are set to be considered. Whatever reservations may be advanced, it is in relation to the physician—the psychiatrist—that the viewpoints, powers, roles, and statuses of patients, their relatives, volunteers, and other professionals are currently debated.

The present writer would not wish to join in the wholesale condemnation that has sometimes arisen from radical commentators of the psychiatrists’ attitudes towards the management of mental disorder: they have frequently been very much more insightful and sensitive than they have been given credit for. But we are constrained by history to start our analysis from this point, and we shall in fact confine ourselves to views which may broadly be associated with the identities of physicians, nurses, social workers, clinical psychologists, and the clergy.

A British View

Finally, the author’s professional experience has been almost wholly within the United Kingdom, and this chapter is therefore written within the context of British experience. This is not too dissimilar from that throughout Western society; but no claims are made for the application of what follows in the culture of the developing countries.

We now proceed by taking individually the five professions mentioned above, and to consider aspects of mental disorder that are loosely linked with the professional identity of these key members of the multidisciplinary team.

BIOLOGICAL MEDIATION: THE PSYCHIATRIST’S VIEWPOINT

We ask first how it has come about that the medical view of mental disorder commands today the central position it clearly holds. Historically, the earliest recognition is of the social aspects of the individual’s disorder. For example, in fourteenth-century Britain the Statute of Prerogatives of Edward II made the distinction between the born fool (fatuus naturalis) and the person of unsound mind who might have lucid intervals (non compos mentis). This enactment: related to property: in the case of the mentally ill person its control reverted to the Crown during the period of his lunacy, and in the mentally handicapped it reverted permanently except for an obligation to provide for his person and estate.

During the following centuries, where any interest in mental disorder existed the focus continued to be upon its social consequences—vagrancy, pauperism, and sometimes crime; and also on such interpretations of individual behavior as could be assimilated to notions of witchcraft or demonic possession (K. Jones, 1972). The impetus for any change in the unhappy situation of such people came from social reformers, public-spirited persons who were no doubt influenced by growing national affluence and the general spread of enlightened ideas in the seventeenth and eighteenth centuries. There was growing concern about the plight of a poorly understood group, disadvantaged to the point of helplessness, residing in the lunatic hospitals and madhouses, in prisons and workhouses, and in attics and closets in private residences. Writing of this movement in the eighteenth century, K. Jones (1972) notes:

[But] William Tuke had proved at The Retreat* that lunatics could respond to kindness and trust, and Godfrey Higgins defied an Archbishop of York in making the story public. In London, a group of members of parliament investigated Bethlem, the oldest lunatic hospital in England, and others forced their way into the filth and the squalor of the private madhouses. In Gloucester, Sir David Onesiphorous Paul set in train a series of events which led to the passing of the County Asylums Act of 1808, and the first local authority institutions designed for criminal and pauper lunatics.

Medical practitioners played only a peripheral part in these developments; the early asylums usually had a layman as Master, and relations between such a person and the visiting apothecary or physician varied but were often very strained. Jones notes that it was essentially not until the middle of the nineteenth century that there appeared a new spirit of humanity and treatment, a rising class of competent asylum doctors and the beginnings of training for nurses (K. Jones, 1972).

The development of a psychiatric view of mental disorder is closely interwoven with developments occurring, also in the nineteenth century, in general medicine’s concepts of disease. At least from the time of Hippocrates, there had been available the notion of a combination of signs and symptoms occurring together so frequently and characteristically as to constitute a recognizable clinical picture. He distinguished as three separate entities the patient, the environment, and the disease. By the seventeenth century an English physician, Thomas Sydenham, had suggested that these disorders might be classified with the same exactness as we see it done by botanic writers in their treatises on plants and he too thought of such disorders as having a kind of autonomous existence with natural histories of their own—invading the body from without.

The fundamental change—indeed it constitutes little short of a revolution—was the introduction of the cellular theory of disease by the German pathologist Rudolf Virchow (1821-1902). This relocated the source of disease within the tissues of the body; instead of the concept of disease as extraneous pathology attacking normal life from outside, there grew the concept of pathological life itself (Clare, 1976).

By the nineteenth century there were several humane and enlightened medical men working in the mental health field: Dr. John Connolly, for instance, went as Superintendent to Hanwell Asylum in West London in 1839 and there introduced the moral treatment of the insane. But it is in the thought of a layman, the great Victorian philanthropist Lord Ashley, later the seventeenth Earl of Shaftesbury, that the two streams of social reform and medical development begin to be brought together. As a Commissioner in Lunacy writing in his annual report for 1844 (in which further revision of the existing legislation concerning the mentally ill was advocated) he first used:

an analogy which, though common today, must have been novel to his readers. He enquired of them what would be the reaction of the general public if patients suffering from acute physical ailments, such as inflammation of the lungs, were commonly sent to work-houses, and allowed to remain there until the disease was incurable before being sent to hospital; and stressed that the insane person was a sick person urgently in need of specialised treatment….

The similarity between mental and physical illness was repeatedly stressed by reference to patients, hospitals, and nurses, avoiding the derogatory and emotionally coloured terms then still in common use. (K. Jones, 1972, pp. 143-144)

The medicalization of care for the mentally disordered—and, with it, a medicalized view of the nature of mental disorder—developed over the next century or so from the sowing of that seed.

The determinative power of the analogy between physical disease and mental disorder can scarcely be overstressed. It inspired the great observers of psychopathology—Freud and his followers, Karl Jaspers and others—to more and more detailed descriptions of mental phenomena in parallel with the work of histopathologists, bacteriologists, and the like. It inspired the work of the great classifiers from Emile Kraepelin and Eugene Bleuler down to the devisers of the World Health Organization’s International Classification of Mental and Behavioural Disorders (ICD, 1993) or the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM IV, 1994). It inspired research into the causes and mechanisms of mental disorder in such areas as focal infection, degeneration, or genetics and the details of subtle but disruptive biochemical changes. It inspired the search for better treatment than the old practices of physical restraint and unpleasant experiences like the cold shower and the rotatory swing, along lines such as the removal of septic foci and malarial or insulin treatment down to the prescription of effective drugs, convulsive therapy, and the like. And it seems certainly to have brought to psychiatrists an aura of authority that they derived, at least in part, by association with the more obvious successes of their surgical and general medical colleagues.

The establishment of the preeminence of a medical view of the nature of mental disorder, symbolized by the adoption of the phrase mental illness, thus seems to have resulted from the combination of political pressures that it should so be seen, the corresponding willingness of psychiatrists to accept and use the power and prestige thus ascribed to them, and developments in the natural sciences, which fed the growing clinical and technological expertise of medicine at large. The familiar medical model (though in fact, there exist several medical models, e.g., Clare [1976], Siegler & Osmond [1974] acquired and retains its pre-dominance.

We must, however, note several refinements. First, psychiatric disorder does not reside entirely within the individual but exists also in terms of that person’s relationships with his immediate social environment. Nevertheless, the manifestations within the individual are sufficiently distinct to be classified in a system (see MD-10, DSM-IV) about which, especially if standardized interviewing techniques and relatively precise definitions of the technical terms are used, respectably high degrees of agreement between practitioners can be obtained. In modern psychiatry both research and practice rest upon this foundation.

Second, the cause of any mental disorder is always multiple. Three broad classes of causal factor are involved. Two are

genetic: fixed at the moment of conception, and establishing a program whose working out involves biological mechanisms and adequate environmental conditions; and

factors acquired as a consequence of subsequent life experience from conception onwards and somehow stored up; (Psychodynamic, behavioral, cognitive and other learning or socialization theories exist to explain how such storing-up occurs, and how past events are influential in contemporary life. Biological mechanisms are also involved, and the massive research enterprise into brain function, using techniques such as brain scanning and Magnetic Resonance Imaging [MRI] is rapidly expanding our knowledge of these matters).

Factors drawn from these two classes are held to interact with one another to produce an individual with certain personal characteristics (premorbid personality factors) which themselves interact in turn with influences drawn from:

the current situation—(the sense organs and central nervous system being, of course, a unique apparatus for converting environmental events into internal events).

This complex sequence of interactions manifests itself in the subjective experience and overt behavior of the person concerned.

Third, management, like causation, is almost always multidimensional. It frequently calls on some combination of social and environmental adjustment, psychodynamic or behavioral, individual or group, methods of psychological management, and physical treatments. The relationships existing between causes, the phenomena of disorder, and management plans are more influenced by the individual characteristics of a particular case than by the class characteristics of the diagnostic category to which any particular individual belongs.

Finally, the prediction of the course and outcome of mental disorders is less certain than that of physical disease because such disorders are not abnormalities of a mechanistic system; indeed there may be absolute limits which may occur as a matter of principle to the predictability of human behavior, whether in health or in disorder.

It is clearly because of the importance of biological mechanisms in mediating the interaction between genetic, earlier life experiences and the current situation in producing mental disorder that the claim of the psychiatrist to a place in the transdisciplinary team is so strong. And this fact colors his attitudes and that of others towards him. All concerned have a tendency to ascribe to biological mediation a kind of primacy over the social or psychological dimensions of mental disorder (about which the expertise of the psychiatrist is shared with other members of the team)—doubtless a part of the Western culture’s tendency to ascribe a primacy to the physical world over the symbolic world. So the practice of the team sometimes implies an assault on the authority of the psychiatrist.

PERSONAL COMPETENCE: THE NURSES’ AND PSYCHOLOGISTS’ VIEWPOINTS

From the time of Hippocrates, the literature has made clear that never in practice has the physician unaided been responsible for the care of the sick. In this section we consider the views of mental disorder contributed by two professions, nursing and clinical psychology, which emphasize deficiencies in personal competence—albeit of rather different kinds.

Nursing

It is said that a Madame Le Gros attempted in 1645 to provide special training for those looking after the mentally ill in the Petites Maisons in France, and some legal recognition for such training was obtained in that country in 1801. Once the tradition that the mentally disordered were cared for adequately in the various Religious Houses had faded, the history of the development of nursing from its origins in low-status domestic service calling for little or no education or occupational organization is closely related, so far as mental disorder is concerned, to the development of the institutionalized care of the insane outlined in the previous section. In the nineteenth century the attendants, both male and female, working in mental institutions were seldom sufficient in numbers; nor in general were they the right kind of people for that type of work. As in the case of psychiatry, so with psychiatric nursing—the parallels with general medical developments are important.

Developments in general nursing originated in the Crimean War (1854). There were no army nurses; most of the orderlies were feeble old pensioners, many of whom were unfit even to carry a stretcher. Thus Florence Nightingale introduced women nurses into the hospital at Scutari and, in response, public funds were raised to endow the first British School for Nursing at St Thomas’s Hospital, London; it opened in 1860.

The Earl of Shaftesbury’s reference to psychiatric hospital nurses has already been noted; training and an examination for them in Britain was begun by the Royal Medico-Psychological Association (the predecessor of the Royal College of Psychiatrists) in 1891, but is now superseded. The General Nursing Council in Britain, established in 1919, instituted its mental nursing certificate two years later, so that by the early 1920s there were two separate forms of qualification for mental nurses, but many people employed in this role had … neither the will nor the ability to take either (K. Jones, 1972).

In the early stages of its development, nursing training was very dependent on medical doctors—who therefore taught nurses a simplified version of what they themselves knew, i.e., basic anatomy, physiology, an elementary account of pathology and treatment of disease, and so forth—material which was only of partial relevance to the essential nature of the nursing task. This emphasis tended to identify both general and psychiatric nurses with the doctor’s interest in biological mediation and to impel them into the role of simply carrying out doctor’s orders in their management of the mentally disordered.

But the developed concept of the professional role of the nurse has as its central purpose to carry out aspects of self care which the patient, temporarily through illness or permanently through disability, is incapable of carrying out for himself. Although this is a matter related to medical treatment it is, in fact, a response to the patient’s illness (and, indeed, its treatment) different from the physician’s response. The emphasis here is on a greater independence of nursing from medicine, seen not only in the care of the individual but also of his personal and material environment—so that the management of a ward regime and working with relatives becomes part of the job.

This rise in the status, educational expectations, and achievement of nurses, and in their power and responsibility has implications for psychiatric nursing both in hospital and in the wider community. The end point of this development is the identification of a nursing view of mental disorder significant enough to modify the psychiatric viewpoint.

A theologian, David Jenkins, has offered a distinction between:

… interdisciplinary co-operation (where everyone contributes his or her bit of a clearly defined sort from a clearly defined discipline) and transdisciplinary work where everyone finds his or her bits (and therefore his or her discipline) changed by the effects of the common work in hand. (Jenkins, 1960)

This distinction is reflected in the title of the present chapter.

In considering the persuasiveness of the nurses’ contribution to the transdisciplinary view of mental disorder, three areas are important: the nurse in relation to the hospital; the nurse in relation to the patient; and the nurse in relation to the community.

The participation of nurses in the evolution of hospital style residential care from its poor-law precursors was for both good and ill; they were part of the shift from the perception of the mentally disordered as people who created uncomfortable problems for society to their perception as individuals with certain kinds of personal incompetence, or need, or, indeed, illness. And such a shift was, in its time, a necessary and humane development. But they were also part of the social mechanisms which produced the pathologies we now call institutionalization, familiar from the technical contributions of Barton (1959) and Goffman (1961) and cruelly portrayed in novel and film, as in One Flew Over the Cuckoo’s Nest). On the other hand, their influence in maintaining high morale and open institutions (Revans, 1976) is paramount, as is their role in such specialized regimes as the therapeutic community (M. Jones, 1952).

Secondly, at the individual level nurses, being in contact with the mentally disordered day and night, saw mental disorder in a rather different light, and exerted powerful influences in understanding it that differed from those of the physicians. Their view was of mental disorder as a much more detailed matter—as a range of interferences with the competence of the individual to manage his or her own life. At its most fundamental, the problems of such patients might include eating or drinking enough to sustain life, attending to bowel and bladder function or to the details of personal hygiene, and so forth. At a higher level, they might include matters to do with table manners, dressing, and generally presenting oneself in a socially acceptable fashion; at a higher level still, they would include problems of occupying one’s time in a way both satisfying to the self and contributing something to the common good. Plainly such problems include questions of relationship, not only between patient and staff but between members of the patient community and between individuals and their families, employers, and society at large.

The contribution of nursing to the multidisciplinary team derives from this analysis. It ranges from very fundamental physical caregiving (e.g., for the profoundly mentally handicapped, psychotic patients in grossly autistic phases, the brain damaged, or older persons with advanced degrees of dementia) through therapeutic activities such as detailed planning of the hospital patient’s day (both in its group aspects and for individuals) to highly specific interventions in which the psychiatric nurse is the key worker in behavioral therapy, counseling, family therapy and the like.

The third factor is that, as part of the growing emphasis on community care and (in Britain) a relative failure on the part of the personal social services to take over adequately from National Health Services, psychiatric nurses have increasingly followed their patients out into the community or gone out to meet them there. The range of functions is similar to that noted above: aspects of physical care, the supervision of medical treatment such as long-term maintenance drug regimens, coping with psychiatric emergencies, the observation and reporting back of the patient’s clinical condition, the management of interpersonal and family relationships, and so forth.

In the context of the comprehensive service, it is likely that a generic role will be assigned to the nurse, and that she will acquire legitimate therapeutic and preventative function in dealing with the relationship problems and social difficulties of the patients …. Nurses should profit from the experience of other related disciplines (especially health visiting and social work) in the development of interactional skills; and, until a frame of reference specific to psychiatric nursing is developed, they must draw relevant concepts from related fields. (Sladden, 1979)

We see here, then, progress towards the full development of the psychiatric nurse in his or her therapeutic role in the multidisciplinary team, both in the institution and in the community—where, as Goldberg and Huxley (1980) have made clear, most of the patients are. However, the starting point is not the biological mediating mechanisms central to the physician’s expertise, but rather strengths and weaknesses of personal performance that are not relevantly categorized by the medical systems of classification.

Clinical Psychology

Clinical psychology is a younger, numerically smaller profession whose influence is founded more on an independent knowledge base than on its members’ availability to undertake a central role in the team. As an experimental discipline, psychology began with the establishment by Wilhelm Wundt of the first laboratory in Leipzig in 1879.

For the purposes of this chapter, the emphasis is upon the contribution of scientific psychology to defining with some accuracy the aspects of behavior that represent defects in personal competence. Following the contributions of people like Alfred Binet, who was chiefly interested in education and who is remembered for his work on intelligence in school children and in establishing the techniques of psychometrics, psychologists in clinical posts with the mentally disordered made increasing use of psychological tests in the characterization of a wide range of the abilities of mentally disordered individuals. Throughout the first half (broadly speaking) of the twentieth century the contribution of psychologists on the side of therapy was largely confined to the work of those who became psychoanalysts or who drew on dynamic theory as psychotherapists.

Both contributions were particularly notable within child psychiatry. But in recent decades psychologists have increasingly abandoned formal psychometric testing for much more detailed behavioral analyses of patients’ problems, and with this has come greater involvement in the planning and management of programs of behavioral therapy. Patients with certain forms of mental disorder have benefited particularly. It is not too much to say that this contribution has, in Britain, revolutionized the prospects for the mentally handicapped. And the other notable area of application of these principles is in the field of the neuroses, particularly in phobic anxiety and obsessional states.

The result of these changes has been to promote clinical psychology to a much more prominent place in the clinical team—and the associated viewpoint to greater influence on the transdisciplinary view of mental disorder. Of course, the psychiatrists had always contemplated psychological symptoms in their descriptions of mental disorder. But their main interest has been in looking behind these phenomena, as their medical and surgical colleagues looked behind the patients’ symptoms and signs, to understand a more fundamental reality—the disease lying beyond them.

A classical protagonist of the view that the behavior disorder ought not to be the province of the psychiatrist was Hans Eysenck, who wrote (1975, p. 5) that

[T]he behavioural part of psychiatry deals with disorders of behaviour acquired in large part through the ordinary processes of learning, unlearning, or failure to learn. Neurotic disorders, personality disorders, and many types of criminal conduct probably come under this heading; these are not to be constructed as disease in the usual medical sense of the word, and their treatment is subject to many ethical and social considerations which would be largely irrelevant to the medical disorder discussed above …. And let us note that the subject which is fundamental to an understanding and the treatment of behavioural disorders is psychology, not medicine.

Eysenck proceeded to propose a divorce in which the organically based part of psychiatry is left in the hands of conventionally trained psychiatrists (assisted where necessary by clinical psychologists operating, for example, token economy regimens to counteract the effects of institutionalization) but the behavioral-psychiatry side would be taken over either by behaviorally trained psychiatrists—whom he envisages as omitting much of the general medical content in their current training—or by psychologists.

This development has not occurred in practice, but its underlying significance is that the mental disorder is to be viewed as a problem in personal competence—the individual case to be investigated and treated in terms of its own characteristics (rather than as a member of a diagnostic class in the medical system)—and that the relationships between one aspect of the characteristics of the case and others are sufficiently described in purely psychological terms. Thus the links between previous experience and the behavior and experience that currently constitute the mental disorder are psychological; the biological apparatus can be assumed to be invariant in this relationship, and so ignored. The major theoretical systems of psychology—Freudian, Kleinian, those derived from learning or socialization theory and so forth—are alternative accounts relating past to present. Similarly, the links between the current behavior and experience and the treatment process and outcome are conceived in psychological terms—in the construction of counseling or behavioral modification programs, their implementation, evaluation, and the like. Although the methods of psychologists approximate as closely as possible to positivism, these phenomena belong to our second, symbolic, world.

SOCIAL SIGNIFICANCE—THE VIEWPOINT OF SOCIAL WORKERS AND THE CLERGY

Most multidisciplinary teams working in the field of mental disorder in Britain today would include a social worker as a member, often in a fairly prominent role. It would be rather less common to find a clergyman in this situation. But every hospital will have a chaplaincy service, and in some the chaplain may be the key worker for the individual client or family—a reflection of the part now played by instruction about the behavioral sciences in general, and mental disorder in particular, in the training of many ordinands. There is some justification for discussing social workers and clergy together—the similarities are such that it is not surprising that the social worker is often popularly thought of as the twentieth-century successor to the priest. In fact, this popular notion is highly misleading; nevertheless, it is characteristic of both these professions to understand and to account for the phenomena of mental disorder by reference to the wider context in which it is placed.

Social Work

We shall consider both the general development of social work and its application in the field of mental disorder. Social work in Britain emerged in the nineteenth century from the application of the provisions of the Poor Laws. It attempted to make distinctions between individual cases—at least in terms of the two famous classes, the deserving poor and the undeserving poor—and it set itself to alleviate the position of some in the former. The account of these earliest beginnings in Woodruffe’s From Charity to Social Work (1968) makes it clear that, although the focus of work was the individual case, the conceptual framework for understanding and responding to the client’s predicament was entirely one of socioeconomic forces. It was not until social work had spread from Britain to North America in the closing decades of the nineteenth and the early years of the twentieth centuries, and American social work had become influenced—indeed, swamped—by what Woodruffe calls the psychiatric deluge that the profession started to develop a vocabulary and a system of ideas that enabled it to consider social work problems on the basis of personal psychopathology. Early in the century this personal emphasis was not particularly Freudian but it rapidly became so; the espousal by social work of psychoanalytic theory dates from this time. This tendency was never as wholehearted in Britain as in America, and in recent decades the pendulum has returned to a more central position. Thus, it is perhaps fair to characterize social work today as being concerned with problems of psychosocial adjustment—problems that are located neither exclusively within the individual nor within the environment, but precisely in the interaction between the two.

The involvement of social work in the mental health field began in America during the phase of the psychiatric deluge in the setting of the law courts and in child guidance. Recrossing the Atlantic in the 1920s, practice in this area understandably emphasized psychology and individualism. But the growing professional education of social workers (in such institutes as the London School of Economics, and later in many other centers) held the balance for successive generations of practitioners between the psychological and the sociological, the individual and the environmental aspects of mental health problems both in childhood and adulthood.

This balance is manifest in the social work contribution to a transdisciplinary view of mental disorder. At the macrosociological level it stresses that a person’s disorder cannot be wholly accounted for without considering such matters as that person’s place in a class structure or ethnic group or that person’s occupational, economic, or housing status; moreover, at a microsociological level, family interaction, peer group, or school influences are regularly found to be significant. Both predisposing and precipitating factors (life events) are relevant—e.g., Brown and Harris’s work on The Social Origins of Depression (1978). Yet not every person exposed to such influences in fact develops mental disorder, so individual and psychological components also play their part in accounting for the particular case.

The reemphasis on the social aspects of mental disorder might seem in the psychiatrists’ historical perspective to be a turning back of the clock toward an early nineteenth century understanding from which medicalization rescued the sufferers; it might seem as if a century of progress were being thrown away. But this is clearly not so; an emphasis on social causation does not involve judgments of social culpability.

Some of the factors that are represented particularly clearly by the social worker’s membership of the transdisciplinary team belong to the world of physical reality, others to the symbolic world. Thus their contribution in practice will include both the provision of material resources: money, places of residence or day care, and so forth, and also efforts through counseling or psychotherapy to modify how the mentally disordered person and relevant others construe or symbolize and their relationships. The emphasis, ultimately, is upon the individual’s place in society—objectively or subjectively conceived. And the large involvement of social workers in many centers, not only in the conjoint assessment of patients but in treatment independently or as cotherapist, exemplifies the fruitfulness of the social approach.

The Clergy

It is largely a reflection of the limitations of the author that this section is written from the Christian perspective. In general, the political and cultural assumptions of Western societies were Christian in origin. But beginning somewhat before the first edition of this book and, I judge, accelerating markedly since, such societies have been increasingly making space for non-Christian religions old and new. This multifaith emphasis is reflected in the literature—see, for example, Psychiatry and Religion: Context, Consensus and Controversies edited by Dinesh Bhrugha (1996)—but it has become exceedingly difficult for any individual to represent the whole breadth of these considerations. In any case, it remains true that in the English-speaking world the best explored interface between mental health and religion is that involving Christianity.

We should not fall into the trap of equating the view of the Church with that of the clergy—still less with that of any individual clergyman or minister. But just as we have attached a particular viewpoint concerning mental disorder to other members of the clinical team, so it will be convenient to regard the clergy as embodying a religious view. Like social workers, their concern is with the individual’s place in a larger context: in this case, a cosmic context. Going back in history no further than the Renaissance, two points of impact of the Church on the mentally disordered may be noted: the Church as the only effective form of public care, often through the monastic hospices, for this as for other needy groups; and the Church as the source of theories of mental disorder. The modern successors of both are relevant to our theme.

Although the Church’s role in providing institutional care for the mentally disordered has been taken over in Western societies by the secular authorities, certain influences remain. Some of these are vestigial: hospital organization still has overtones of obedience, disciplines like plain food and early rising, and nurses’ salary scales which hint that work satisfaction might offset a vow of poverty; but others are not. For instance, in Britain, the National Health Service made from the outset formal provision for hospital chaplaincy services, and the significance of the chaplain as personifying the churches’ presence in the institution is clear.

The chaplain’s presence symbolizes, first, the importance of the individual patient or staff member: insofar as persons are thought of as the objects of Divine regard, there is no source more absolute of the value systems that surround them. Of course, proponents of atheistic philosophies would reject the fundamental assumption, but where it is granted the ultimate significance of the individual is further affirmed. The premise of a personal God further asserts that the significance of humankind is diminished unless due care is taken of each individual as a biological and psychological being having status in a social and historical—and in some sense, an ultimate—context. In addition, while it is not possible to read off from this point any particular ethical decision concerning a particular patient, the general necessity to take seriously questions of values and ethics is established by it.

It may be objected that formal chaplaincy arrangements are not made in the same way in the community at large where, as shown by Goldberg and Huxley (1980), the overwhelming majority of mentally disordered actually are found. But the hospital is not only a place of care and treatment, it is also for staff and patients alike a source of ideology (Wilson, 1971). Experience in a hospital tends to establish norms in the minds both of patients and their relatives—and, even more powerfully, of students in the various caregiving professions who are trained there—concerning life and death, health and disease, technology, human relationships and so on. And such norms pervade the wider society and there influence the attitudes and behavior of us all. The hospital is A Place of Truth (Wilson, 1971) and the chaplain will expect to contribute as teacher and learner to the development of this understanding.

Some clergy will interpret their duty of pastoral care towards individuals to explicitly include working as a psychotherapist; others will maintain a greater degree of separation between psychological and spiritual forms of care. Some will take it as a duty to involve themselves in the management of the health-delivery organization; others will confine their institutional activities to the conduct of public worship. Many will take the view that the distance between religion and mental health provision has become too wide in Western societies.

It is perhaps worth rehearsing the basis for this view. The following is a condensed quotation from Fulford (1966) that refers to empirical research bearing on this theme:

It is said that religions attract the mentally unstable—but the mental health of the followers even of new religious sects is if anything above rather than below average …. It is said that religions may have their origins in madness … but madness can also be a source of creativity in art and science …. It is said that religious experience is phenomenologically similar to psychopathology (visions are like hallucinations, for example)—but this is to confuse form and content: normal and pathological varieties of religious experience stand to be differentiated by essentially the same criteria as normal and pathological varieties of non-religious experience …. It is said that paranormal experiences are a product of definable patterns of brain functioning—but … paranormal experiences are no less invalidated by their grounding in physiology than are normal experiences. It is said that religions are harmful, that they induce guilt, for example … but religion, no more than psychiatry is not harmful as such. It is also said, conversely, that religious belief is ineffective—but there is empirical evidence that it is not, improved coping for instance being correlated with religious faith in a variety of adverse situations …. (Fulford, 1966, pp. 5-6)

Thus, the interpretation of healing both as the gift of God and as part of the mission of the Church does not make it in some way special or even opposed to secular clinical social work, but rather leaves it consistent with that endeavor.

THE MULTIDISCIPLINARY TEAM AND THE TRANSDISCIPLINARY VIEW

We have assembled a collection of stereotypes of mental disorder that have developed within five professional groups commonly represented in multidisciplinary clinical teams working with adults. By the sixteenth century, the Old English word team (originally, a group of animals harnessed together to draw an agricultural implement) was being applied to a number of persons jointly involved in a common action (as in tug-of-war) and, later, to examples (such as a football or cricket team) where there is considerable differentiation of function. The principles from these two sporting illustrations also exist in the organization of any caregiving team; once role definition is achieved with respect to each member it is possible to emphasize role blurring or role differentiation.

Role blurring is held to be valuable in, for example, therapeutic community ideology, which stresses the importance of the common therapeutic potential of all staff and, indeed, also of the patients. In mental health practice more generally, however, most members of each profession would probably claim that their expertise extends significantly into adjacent fields.

Role differentiation—having defined what each person must do, then let each stick to his or her own task—is frequently advocated in the interests of efficiency. In the management of that complex system comprising the individual suffering from mental disorder together with his or her relevant personal and social environment a better quality of care is achieved; care offered by an individual being seen as in some way inferior, harmful, or actually impossible. A second argument concerns cost-effectiveness: a less expensive but equally adequate service may be offered by one team member rather than another. However, in practice, both some degree of differentiation and also some degree of overlap of function are likely to be usual, and the discrete stereotypes we have described appear to be influential.

In this final section, we consider team relationships in the light of our analysis of the transdisciplinary view of mental disorder through the phases outlined earlier: the attack on medical hegemony, the phase of conceptual analysis, and the empirical study of teamwork in various settings.

Regarding medical hegemony, there exists a large literature reporting investigations of the mutual perceptions of members of different occupational groups. In an early example, Miles (1977) studied in three British psychiatric hospitals the roles of psychiatrists (n = 6), nurses (n = 16), social workers (n = 17), and occupational therapists (n = 12). All respondents ranked the psychiatrist highest in order of importance, but there were disagreements concerning other groups, physicians and nurses ranking second in importance only the nurses, and members of the other groups ranking themselves equally as second. None of the psychiatrists were willing to concede to any other specialty a so-called area of exclusive competence, while senior practitioners in the other disciplines working in the same hospital wards did claim areas of such competence.

Too much weight must not be placed upon a single small study, but the conflicting attitudes revealed here probably remain very widespread. They represent an implicit claim on the part of the other professionals that the nature of mental disorder is such that the viewpoint of the psychiatrists, derived from their medical background, is only partial.

The phase of conceptual analysis applied to such matters may be represented by the work of the Health Service Organisation Research Unit of Brunel University (Brunel Institute, 1976). As a profession develops an increasing specific body of knowledge and practice that nonmembers can recognize, several things follow. First, members will tend to form a variety of professional associations; second, they will begin to take an interest in training and setting qualifications for practice and influencing conditions of employment for members, and, third, they develop:

… certain very specific standards and norms of behaviour. Certain things are invariably (and therefore properly) done this way; other things should be avoided. Of particular interest from the organisational point of view are any standards which are regarded as absolute and binding …. (Brunel Institute, 1976)

Standards, as represented, for example, by a voluntary code of conduct or by the authority of a statutory registering body may require an accountability to professional norms which overrides any accountability to colleagues within the team. But it is the duty toward other team members that more directly concerns our theme.

The Brunel workers’ terminology will help us here. Thinking chiefly of the issue of the physicians versus the rest, they define four models of relationship: managerial, prescribing, monitoring and coordinative. The first and last need not concern us here. In a managerial relationship, the manager has responsibility for the direct and constant appraisal of the subordinate’s performance: even if practicable, such a relationship could not have an ethically defensible place in the life of a multidisciplinary team. At the other end of the spectrum is a coordinative relationship, in which someone is

expected to take the lead in suggesting specific action or programmes and in reviewing progress, but does not have managerial rights and cannot issue binding rulings or instructions in situations of sustained disagreement …. (Brunel, 1976)

This seems only common sense if teamwork is, in fact, to work at all. A physician might sometimes take this role but clearly need not do so. There is an obvious professional duty upon members to be coordinated, and a right to expect that the team relationships will be limited in this way.

The real debate has surrounded the extent to which physicians may have prescribing or monitoring relationships in respect of other team members. Of monitoring which, the Brunel terminology suggests, is a relationship

… in which the monitor is expected to keep himself aware of certain specifically defined areas or aspects of activity, to discuss deviation from acceptable standards in these areas and to report serious or continual deviation to higher authority …. (Brunel, 1976)

Some would be doubtful although others might accept this. A structure of rights and duties would follow fairly obviously from this kind of arrangement if it was in force.

The chief discussion surrounds the question of whether the physician has, or should have, prescribing authority in relation to other team members. A prescribing relationship, according to the Brunel workers:

… arises where a member of the occupational group has by virtue of his membership of that group the right to determine the objectives to be pursued and the contexts to be observed in specific cases by members of certain other occupational groups whose knowledge base is encompassed by that of his own [italics added]. (Brunel, 1976)

It is that matter of the encompassing profession that is at the heart of the problem.

The analysis offered in this chapter suggests both why it is that psychiatrists should claim the role of an encompassing profession and also why the nature of mental disorder is such as to make such a claim inappropriate.

This view is beginning to percolate through the empirical literature. Two examples must suffice. First, in relation to the assessment and management of patients with acute self-poisoning, studies in London (Newson-Smith & Hirsh, 1979) have compared the effectiveness of psychiatrists and social workers and in Oxford (Catalan, Marsack, Hawton, Whitwell, Fagg, & Bancroft, 1980) psychiatrists and nurses had found the nonmedical professionals to be equally effective. And, second, in relation to the rehabilitation of long-stay psychiatric patients, a study from a British mental hospital of a quite successful program (Barker, Woods, & Anderson, 1977) notes without differentiation that the primary therapists were nurses, social workers or chaplains. In practice, this kind of approach has become increasingly widely accepted in the mental health field.

The Transdisciplinary Team

How, then, may role differentiation and role blurring be reconciled? We may think of this in terms of the image of a cartwheel. Each spoke represents one of the contributing professions, and the patient is at the hub. At the rim, each profession is at its furthest from its neighbors; this represents the extreme of professional identity and specialization. Individual practitioners may be thought of as moving in and out along their own spoke. As the spokes converge on the hub of a wheel, the closer team members get to being able to undertake one another’s tasks, the closer are they likely to be to territory which is also shared with the patient—who is, of course, less preoccupied with the technicalities of the pathology but more concerned with his or her suffering and its alleviation. Conversely, the further they are from one another, the further each is from the patient and the more they are in their separate worlds of high specialization in traditions, institutions, training, and the like.

Consider a situation where the particular task performed for and with the patient appears the same whether the worker be physician, nurse, psychiatrist, social worker, chaplain, or member of any other professional group. This may occur particularly, perhaps, in respect of psychotherapeutic or counseling tasks (but other examples exist). Borrowing a concept from Gestalt psychology, we may suggest that individual practitioners will see this work figured against the background of their own discipline. The psychiatrist engaged in psychotherapy is not prescribing a drug; the social worker is not providing a material resource; the nurse is not substituting for self care; the psychologist is not engaged in mental measurement; the clergyman is not conducting a public rite. The psychotherapeutic task may be the same; but the varied backgrounds against which this ostensibly identical task is performed are also relevant. Transmitted by all manner of nuances of attitude and language, they influence the task performance and enrich the range of possibilities available to the patient. Thus it is legitimate within a team that a particular function may be allocated more upon the basis of, say, the personal qualities of those involved than on their professional identities.

Returning to our image of the cartwheel, the rim thus represents professional separation, with its preoccupations with part-function, pathology, and, often, high technology. The hub represents the less constrained territory sufficient to enable the professionals to enter into a therapeutic alliance with the patient and collaboration with one another. It is the territory of the holistic approach, in which the transdisciplinary view of mental disorder is matched by the multidisciplinary practice of the clinical team.

REFERENCES

*A Quaker hospital for the mentally disordered, opened in York, England in 1796.

American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, fourth edition. Washington, DC: Author.

Barker, G. H. B., Woods, T. S., & Anderson J. A. (1977). Rehabilitation of the institutionalised patient. British Journal of Psychiatry, 130, 484-488.

Barton, R. (1959). Institutional neurosis. Bristol: John Wright.

Bhugra, D. (Ed.). (1996). Psychiatry and religion: Context, consensus and controversies. London and New York: Routledge and Kegan Paul.

Brown, G. W., & Harris, T. (1978). The social origins of depression. London: Tavistock Institute.

Brunel Institute of Organisation and Social Studies. (1976). Professionals in health and social service organisations: A working paper. Uxbridge, England: Author.

Catalan, P., Marsack, P., Hawton, K. E., Whitwell, D., Fagg, J., & Bancroft, J. H. J. (1980). Comparison of doctors and nurses in the assessment of deliberate self-poisoning patients. Psychological Medicine, 10, 483-492.

Clare, A. (1976). Psychiatry in dissent. London: Tavistock Institute.

Eysenck, H. J. (1975). The future of psychiatry. London: Methuen.

Fulford, K. W. M. (1966). Religion and psychiatry: Extending the limits of tolerance. In Bhugra, D., op. cit. (pp. 5-56).

Giddens, A. (1976). New rules of sociological method. London: Hutchinson.

Goffman, E. (1961). Asylums. New York: Doubleday.

Goldberg, D., & Huxley, P. (1980). Mental disorder in the community. London: Tavistock Institute.

Jenkins, D. (1960). Resources for being human. Contact, 36, 2-19.

Jones, K. (1972). A history of the mental health services. London: Routledge and Kegan Paul.

Jones, M. (1952). Social psychiatry: A study of therapeutic communities. London: Tavistock Institute.

Miles, A. (1977). Staff relations in a psychiatric hospital. Britain Journal of Psychiatry, 130, 84-88.

Newson-Smith, J. G. B., & Hirsch, S. (1979). A comparison of social workers and psychiatrists in evaluating parasuicide. British Journal of Psychiatry, 134, 335-342.

Revans, R. W. (1976). Action learning in hospitals. London: McGraw Hill.

Siegler, M., & Osmond M. (1974). Models of madness, models of medicine. New York: Macmillan.

Sladden, S. (1979). Psychiatric nursing in the community. Edinburgh, Scotland: Churchill Livingstone.

Wilson, M. (1971). The hospital—A place of truth. Birmingham, England: University of Birmingham, Institute for the Study of Worship and Religious Architecture.

World Health Organization (WHO). (1993). International Classification of Mental and Behavioural Disorders (10th Revision). London: Her Majesty’s Stationery Office.

Woodruffe, K. (1968). From charity to social work. London: Routledge and Kegan Paul.

CASE MANAGEMENT AS A STRATEGY OF SOCIAL WORK INTERVENTION WITH THE MENTALLY ILL

Irene A. Gutheil and Roslyn H. Chernesky

Case management is an approach to service delivery that works to ensure that clients with complex, multiple problems and disabilities receive all the services they need in a timely, effective, and appropriate fashion (Rubin, 1992). Its primary goal is to organize, coordinate, and sustain a network of formal and informal supports and services that individuals may require for optimal functioning and well-being (Moxley, 1989). Case management has always had a dual focus: It is both client-oriented and system-oriented. Therefore, a second goal is to redress shortcomings in service delivery in order for services to be both available and accessible to individuals who may need them. To be effective, case managers must understand individual clients, their needs and supports, as well as be knowledgeable about agencies, communities, and service delivery systems.

This chapter examines case management in mental health, reviews recent thinking about this method of practice, and considers some issues faced in implementing case management. After more than twenty years of case management programs and practice, a considerable body of knowledge has emerged that illustrates the breadth and diversity of what has become a critical intervention strategy for services to vulnerable individuals who show a high level of internal impairment, who have a low level of access to external resources, and who are faced with overwhelming Stressors (Gitterman, 1991). The chapter’s focus on the strengths model of case management reflects the increased attention to strengths in social work practice.

APPLICATION OF CASE MANAGEMENT TO MENTAL ILLNESS

Case management is especially appropriate for clients with serious and persistent mental illness (SPMI). The term SPMI includes individuals with diagnoses such as schizophrenia and major depressive disorder that reflect enduring symptoms, neurocognitive impairments, disabilities, and deficits in everyday functioning. When symptoms are controllable through a continuing course of medication, periods of remission may