Care of Society, Not by Society
Care of Society, Not by Society:
Replacing Patient-Centred Nursing with Society-Centred Nursing in Mental Health Care Settings
Patient-centred nursing care is problematic in mental health settings because it may lead to inward looking therapeutic activity, sick role development and inertia. Interventions may over-emphasise psychiatric and psychological issues at the expense of serious re-socialisation programmes, and an imbalance of service user rights and service user responsibilities may effectively disable the practitioner. For these reasons, rehabilitation often fails service users, leaving them in bed blocked and ‘warehoused’ situations.
Society-centred care moves the focus from individual problem solving to the demands of social life as a whole, using the institutions of society as the basic building blocks of therapy. A grounded understanding of society is seen as essential before service users can be expected to enter a full social life, and emphasis is given to the basic knowledge, skills and attitudes which are needed for successful reintegration. As society functions on a reciprocal basis, it is considered crucially important that an awareness of individual rights is balanced with a sense of social responsibility, or the rehabilitation process will fail. Society-centred care is a ‘top-down’ approach, which begins with the needs and rewards of society, and enables individuals to reach them.
Although the central principles of mental health community care in the U.K. include reintegration and normalisation (Department of Health 1989, 1998), there is considerable doubt whether service users always benefit from this approach (Glenister and Hopton 1995, Hadley and Clough 1997). A variety of explanations have been offered for the failures of community care, including the assertion that individualized and normalising care approaches are implicitly culture biased, alienating some service users (Narayanasamy 2002). These views suggest that alternative cultural settings should be available for service users who have little commitment to the values and priorities of conventional capitalist society, but they do not explain why service users who appear committed to mainstream society and conventional rehabilitation, are still failing within it. Accordingly, this discussion focuses on those service users who share the values and beliefs of mainstream society, but fall short of meaningful reintegration, involvement and inclusion.
It provisionally commends two clear principles:
society should be restored to the centre of mental health rehabilitation therapy
society itself needs care
The Problems of Patient-Centred Rehabilitation Approaches in Mental Health Settings.
‘Patient-centred’ approaches can fail certain groups of service users in mental health rehabilitation settings because they can lead to inward looking therapies which have often residually confirmed the individual’s sense of ‘clinical difference’ from members of regular society. Therapies focused on the individual may breed under-confidence, sick role self imagery and insularity, because the person in therapy is bound to be discriminated from others during the ‘individualising’ process. In short, the patient-centred process may become preoccupied with individual problem-solving, rather than constructive social activity, and the day to day ethos of individualized mental health care may degenerate into specialist and rarefied clinical practices, dislocated from regular ‘outside’ society (e.g. multidisciplinary meetings, Care Programme Approach meetings, key worker discussions, ward rounds)
Because the individualist nursing approach overlaps with the powerful individualist medical model (Robinson 1991) and individualist psychotherapies, mental health rehabilitation may simply drift into top-heavy psychiatric and behavioural approaches which leave serious re-socialisation interventions until ‘later’. As re-socialisation interventions are often conducted by so