When I started my clinical training, following a particularly egalitarian preclinical course, I was struck by the rigid hierarchy that pervaded the wards. Surgeons were the most hierarchical, followed by physicians, with psychiatrists trailing a way behind, but not entirely free from the prevailing attitudes. As a medical student I was near the bottom of the power pyramid, but above the junior nurses and the patients, who occupied the lowest stratum. As Jim Birley pointed out in a paper in the BMJ, the staff members who shared the lower depths with the patients were the ward cleaners. As a result they communicated much more with the patients than did any other staff, and knew their personal stories, their fears and hopes. However, the nature of the hierarchy was such that orders flowed downwards while information flowed in the opposite direction, but did not include the emotionally valuable material patients shared with the cleaners.
Juliet Foster is a social psychologist who has conducted qualitative research on the views of clients (her term) attending two day centres and a group admitted to an acute ward. She was interested in their understanding of their own illnesses, how this differed from the formulations made by the psychiatric staff, the effect of becoming a service user on their self-image, and the process by which they came to terms with the changes in their lives. She supplemented this ethnographic material with an analysis of texts from four newsletters produced by mental health organisations for a readership of users and carers. Her aim was to give a voice to the users of our services whose views are often unsought or disregarded. She writes that:
‘In the realm of academia, the voices of those who have been diagnosed with and considered to have mental health problems have been conspicuously absent’.
She interviewed over eighty service users, but the recorded quotes and reported comments do not reflect the richness and diversity I expected from a sample of this size. After an introductory chapter setting out her aims, she presents an extensive review of the literature on the attitude to people with mental illness of the public, professionals and the users themselves, the latter being scanty and justifying her research. All the usual suspects have been rounded up, and readers familiar with this field could skip this section. The next few chapters on sociological constructs and the author's method failed to grip my interest, and I was relieved when I finally arrived at the meat of the book, where the voices of users speak out. The users' recourse to humour in their characterisation of the professionals involved in their care is both surprising and amusing. The structure of the ward round or user review allows no opportunity to demonstrate their fund of irony and satire, and few professionals become aware of this counterculture. One user on the admission ward referred to a psychiatric nurse as Nurse Ratched (from One Flew Over the Cuckoo's Nest). When Foster asked him which nurse he was referring to, he replied that it could have been any of the three on duty.
Foster's thesis, which the book title reflects, is that:
‘Clients use their own experience to describe, define and make sense of mental health problems in general, and that their definitions also change and develop as the client's experience changes and develops, and as they interact with other individuals’.
Hence her metaphor of a journey. Her conclusion is that:
‘suffering from a psychosis does not negate that client's beliefs about his or her own mental health and treatment’.
I endorse this statement emphatically and urge you to read this book if you doubt it. The structure of the book is much more that of a research dissertation than a narrative, and I would have welcomed a much greater proportion spent on users' own words and reflections. However, Foster does us a service by flattening the professional hierarchy and allowing us the always enlightening, and sometimes chastening, experience of hearing what our clients think of us and our treatments.
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