Blogging on Good Therapy

A GoodTherapy.org Featured Column written by Greg Madison, Ph.D.

Click here to contact Greg and/or see his GoodTherapy.org Profile.

What kind of response does ‘the community’ offer to its members who are experiencing distress? Increasingly since the 1950s, many British and North American mental health services have been devolved to the community level. This de-institutionalization is promoted as an indication that we live in progressive and caring societies. The ‘community care movement’ is based upon the idea that institutions segregate people from the rest of society and that this is unacceptable. But I wonder if the development of community care policy really is an expression of these laudable intentions. As I will suggest later, the tragic shooting deaths in Dunblane Scotland in 1996 offer a bleak backdrop for confronting the lack of care in our communities and our attitudes towards our fellow citizens who are psychologically distressed.

Community care services are supposed to offer an enlightened and benevolent alternative to incarceration. New psychoactive drugs enabled psychiatrists to control behavioral symptoms so that patients could leave hospital sooner or be treated entirely as out-patients, allowing more flexible and socially-minded intervention. Of course this view equates mental distress with a medical model of ‘illness’. Provision is primarily drug-centered rather than caring in a broader sense.

The “propaganda” surrounding the change in mental health provision assumes a cohesive community that actually wants to support the mentally distressed. A more cynical perspective might be that psychiatry’s role is to manage distress cost-effectively in order to maintain current social roles. For example, it is cheaper to provide medical treatment to a distressed (unpaid) housewife, and maintain her at home and in that role, than to let her “break down” and have to provide expensive hospital accommodation and family support. Community intervention gives the appearance of a humane society caring for distressed citizens. This appearance of care bolsters the legitimacy of the state while simultaneously masking the possibility that individual misery is really a product of social relations. It protects society from a radical overhaul.

A community can potentially facilitate the re-socialization of an ex-psychiatric patient, and this can be associated with a decrease in symptoms. However, the ability of the community to fulfill this role is questionable not only because of its attitude to the ex-patient but also because of the increased atomization of society as it adapts to 21st century capitalism. Psychiatry can label and prescribe, but it cannot create the sense of community, and the interpersonal ties, which are necessary for integration. The result of maintaining the mentally distressed in a setting where they cannot be received is that they are kept on the fringe, where they are subject to control rather than care. And as acceptance can facilitate recovery, so can rejection aggravate the already difficult position of the individual, adding greatly, perhaps unbearably, to their distress.

The Dunblane Tragedy

In the small village of Dunblane, Scotland, on the morning of March 13, 1996, Thomas Hamilton, aged 43, shot dead 16 young children and their schoolteacher before turning a gun on himself. In order to try to get a sense of this man and the community in which he lived, I reviewed the newspaper articles for the week immediately following the tragedy (all the quotes below are from these articles). My main intention is to inquire about the community attitude towards Hamilton and the impact this may have had upon his life.

Thomas Hamilton was raised to think that his grandparents were his mother and father and that his real mother was his sister. His natural father had left when Hamilton was eighteen months old. He only discovered the truth at the age of thirty-eight. According to neighbors at the time, the grandmother tried to convince people that Hamilton was her son by inventing stories of the pregnancy and labor. Meanwhile the real mother was shut away. In primary school, Hamilton was described as a loner, ‘… who didn’t play with other children…. In secondary school he was still considered an ‘outsider whom no one liked’. In his early twenties, Hamilton became active as a volunteer with the Scouts, until in 1974 he was expelled due to ‘irresponsibility’. As an adult Hamilton operated his own DIY shop and was viewed by local shopkeepers as ‘ambitious’. His business collapsed in the early 1980s due to rumors that he abused boys. None of these rumors were ever substantiated. He never worked again.

Dunblane is a comfortable prosperous place and is one of the communities in which Hamilton operated boy’s clubs after his expulsion from The Scouts. It has a population of 8000 and very little unemployment. It is made up of mostly ‘conventional’ two-parent families who own their own homes. There are remarkably few single parents. A quiet, traditional way of life was enjoyed by young parents and retired couples; A Gothic cathedral towers over the tiny high street where shops have been in the same families for generations. Butchers, bakers, and florists still close for an old-fashioned half-day on Wednesdays … There is no McDonalds or multi-plex cinema … Many families have settled in Dunblane because it is considered a safe and clean place to bring up youngsters …

It is described as an idyllic community for the prosperous young families who live there. For someone in mental distress however, it could have been a very different place. Research studies suggest that a homogeneous tight-knit community of single-family dwellings can be a most alienating and rejecting environment for anyone who is ‘marginal’.

The attitude toward Hamilton is obvious from a comment made by a neighbor who moved to the area four years ago; ‘The first thing you heard from people here was that the guy was weird’, ‘ He made your flesh crawl, he was rubbing his hands and walking with a stoop’. He was described as ‘creepy’, ’smarmy’, ‘He looked like something from outer space. I called him Spock because he was like an alien’. There are many references to his appearance, and his gait; ‘ He just seemed to walk at the one pace, he sort of crept along by the side of the hedge’. We get the impression of an extremely isolated man who was perceived as ‘weird’, ‘devious’, ’sick and perverted’.

Hamilton lived in a world of rumors and these rumors about Hamilton seemed to start partly because of his unusual demeanor. Police and education authorities investigated him but nothing could be proved, meanwhile boys stopped coming to his clubs and his business failed. Hamilton wrote to council authorities, the Scouts, his MP, and in desperation even to the Queen herself. A city councillor recounts meeting him in the street; As usual he brought up the subject and again said that he was being harassed by inference and innuendo. He said people still seemed to suspect him of this conduct but how grateful he was that nobody had been able to get any proof because there wasn’t any. I was really listening to a man who had this burden and was trying to unload it a bit.

This councillor, as well as a council ombudsman and some parents, felt Hamilton was being treated unjustly. Meanwhile, daily life was becoming increasingly alienating, as Hamilton wrote in a letter to the Queen; ‘I cannot even walk the streets for fear of embarrassing ridicule’. Since childhood Hamilton was isolated. It seems that being an isolated person became the community’s excuse to isolate him even further, until he found himself unemployed and humiliated as he walked the streets of his own neighborhood.

After the murders, articles appeared from so-called experts, forensic psychiatrists mostly, who offered different opinions as to the source of Hamilton’s problems and whether he was ‘ill’. Questions of whether Hamilton was ‘mad’, ‘evil’, or both serve to highlight our current confusion and inadequate understanding of so-called mental illness. The newspapers all focused on Hamilton as an individual, not upon the community in which he lived. There were even letters to the editor which suggested that Hamilton should not have been in the community at all. These letters focused on the inadequacies of community care and called for the power to force treatment on individuals because ‘treatment does work’.

There were a couple of articles that did draw a link between Hamilton and the community; ‘strong community ties can have only increased the pressure on loners like Hamilton, when despite the bonding of most of the population, they found themselves excluded. A successful community is one which is able to reach out to everyone living in it, no matter how unattractive they may be’. Another of the few more enlightened columnists wrote; ‘there is something up with our way of life, and no amount of repression will quite rub it away … Dunblane has something behind it … Something crazy, of course, but something real’. To make even a little sense of what happened in Dunblane, and to understand it as a general warning, we need to acknowledge and understand the role of the community. In other words we need to look at how ‘… the two worlds met, close-knit community and unraveling mind’.

Community care is about ‘community’

There is a dangerous contradiction between care in the community and the medical model that currently underlies it. Current policy relies upon maintaining the mentally distressed in community settings where they are viewed as ’sick’, different in kind from their neighbors. This thinking relieves both the state and community members from facing the anxiety of identifying with the mentally distressed or questioning the social causes of their condition. It encouraged the community to view Thomas Hamilton as different from them, eliciting scorn rather than empathy. There is no lessening of the tragedy which Hamilton caused, but there is a warning of the situation which may arise when individual distress and community rejection collide. We need to develop models of community care which are willing to address the dehumanizing aspects of contemporary communities.

The unconventional Irish psychiatrist Ivor Browne says we need to make ‘Being’ a priority and ‘Doing’ a by-product of our societies; ‘ To be is the primary task of a human being, any doing or function which deprives him of his consciousness as a Being is destroying him as surely as slow starvation’ (Browne, 1972,p.1). Too often we find ourselves working in servitude to the structures we initially designed to work for us. Our communities have increasingly sold their souls to the markets. Our ruthless and competitive communities are often so “sick” that as independent individuals we need to create a barrier against them. The more we have to create a barrier the more difficult it is to develop intimate and loving relationships and the more impossible it is for us to experience ‘care’. We need a humane model of community which emphasizes our shared experiences and values of independence within interdependence.

Removing symptoms alone (the medical model) does not result in a ‘normal’ person. A person implies a caring community, one that does not simply individualize distress or label it as individual illness. If we insist that distressed members of our communities are different from us, we impair our capacity to empathize and our potential to understand ourselves. We must realize that there is a social meaning to distress, a meaning that we can understand because we are subject to the same forces. When the community cannot recognize itself in the face of the mentally distressed, that is of grave concern; … the “return to the community” of mental health patients is a return in an alienated form: the community receives back a part of itself in a form not recognizable as having belonged, or as still belonging, to that community.

Concluding Summary

We cannot continue to use the medical model to maintain the distinction between distressed individual and host community without impairing the therapeutic potential of community care. A model of mental distress that acknowledges social and economic factors is necessary in order to alter the meaning of ‘care’ from custodial care and drug treatment to care as empathy for the welfare of another person as a whole human being. This is described by Heidegger as caring for other dasiens, constituting beings, and he terms it ’solicitude’.

Perhaps it is obvious that the community health care system cannot be separated from the overall social system. One cannot escape the thought that as the mentally distressed are maintained in an unprepared, unwilling, and under-serviced community, there will be a corresponding hardening of community attitudes towards them. There will be no welcome for a stranger who we do not recognize as ‘one of us’. Community attitudes to the mentally distressed expose the crucial need for a radical attitude to mental health; the necessity to accept as political and social what has been hidden as personal, silent pain.

What are the ramifications of this for us as psychotherapists? How will this be presented to us in our consulting rooms, and what will be our response? Can we continue to see our work as isolated from and unrelated to the work needed in our communities as a whole? To have ‘care in the community’, it seems that we need to develop a community that incorporates a willingness to reach out to the “otherness” in others, without the motive of control and without the certainty of complete understanding. As therapists I think the time has come for us to grapple with the economic, political and social context of the lives of our clients and ourselves. Otherwise we risk becoming complicit with forms of life that engender distress to the point of becoming increasingly unlivable. Surely the many tragedies since Dunblane, where rejected person has taken vengeance upon their rejecting community, shows that we live in a time when a psychotherapist must also be a communal therapist, using what we have learned about human psychology to comment upon and critique the prevailing forces that are mutilating our contemporary communities.

©Copyright 2008 Greg Madison, Ph.D. All Rights Reserved. Permission to publish granted to GoodTherapy.org. The following article was solely written and edited by the author named above. The views and opinions expressed are not necessarily shared by GoodTherapy.org. Questions or concerns about the following article can be directed to the author or posted as a comment to this blog entry. Click here to contact Greg and/or see his GoodTherapy.org Profile.

This entry was posted on Monday, February 4th, 2008 at 7:46 pm and is filed under Cultural & Social Issues, The Human Being of Therapy. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.