Paternalism or partnership?

EDITOR - The editorial Paternalism or partnership? (BMJ 1999; 319:
719-20) is to be welcomed, as is the core suggestion that there be an
equal partnership between professionals and patients about health and
illness. As is common nowadays, there is however an implied criticism of
the "wickedness" of the ways of doctors and nurses who fall into states of
mind of being patronising to their patients. While undoubtedly unhelpful
as an attitude, it needs to be understood that it often takes two to have
a patronising/being patronised state of mind.

Patients who are in the grip of anxiety about their condition resort to
the well known mechanism of idealisation of their carers - after all, the
more omnipotent their carers the better the chance of personal survival.
This idealisation leads to the accretion of omnipotence in the staff, with
a resulting patronising attitude. Instead of being blamed for wickedness,
the staff should instead be seen as victims of these psychological
workplace dangers, and training and staff support should be geared to
helping them recognise and deal with these matters. Only then will a true
partnership be possible.

Anton Obholzer

Consultant Psychiatrist and Chief Executive

Tavistock & Portman NHS Trust

It is sad to see so much reference to user-empowerment and anti-
paternalism (1) without acknowledgement that the passion behind
therapeutic communities, social psychiatry and antipsychiatry has had the
same humanitarian and compassionate aim for the last fifty years. Thus the
idea is not new, although the mode of its expression may be.

Thereapeutic communities emerged after Maxwell Jones demonstrated, in
the wartime Mill Hill experiment, that battle-shocked soldiers soon became
more effective agents at helping each other overcome their neuroses than
the doctors and nurses were. David Clarke, at Fulbourne in Cambridge, was
one of the first to challenge the idea that doctors had every right to
lock up patients for their own convenience, in the movement that became
social psychiatry. Ronnie Laing, by detailed descriptions which put the
experience of the patient centre-stage, inspired a generation to believe
that there was a different way of conducting ourselves with patients. But
where is the vision and inspiration from these movements now?

Therapeutic communities are enjoying a resurgence of interest as one
of the few methods of treating personality disorder with good evidence to
back it (2). Indeed people with "personality disorder" (all of us, to a
greater or lesser degree, I would argue) often find it difficult to trust
people. Some are thus very sensitive to imbalances of power in
professional relationships, and often strongly react against any degree of
paternalism. The relationships they demand of professionals are honest,
open and with very clear boundaries.

Anti-psychiatry survives in a multitude of fragmentary single-issue
user groups and a few surviving or pioneering voluntary sector projects.
The former includes "Hearing Voices Network" (Manchester), "The Self Harm
Network" (London), ECT Anonymous/Shock, the UKAN (United Kingdom Advocacy
Network - Sheffield), Survivors Speak Out (London) DATA (Distress
Awareness Training Agency - Greater Manchester), and MadPride
(London). Surviving projects from the days of Laing include the Arbours
and Philadelphia Associations (both in London). Projects such as
"Community Housing and Therapy" (London) and "Threshold" (Belfast) are
trying to define new ways of delivering meaningful care in the community
that is not paternalistic (3).

Social psychiatry has not survived, and the overwhelming predominance
of psychopharmacological paradigms of mental illness leaves our statutory
services much the poorer. Although arguably fewer patients are now locked
up, many procedures and treatments - including hospitalisation - are done
for the benefit of staff without good evidence that they help patients.
For psychiatry to come in line with Angela Coulter's "currents in society"
a major change in the attitudes of the psychiatric establishment is
needed. It must incorporate a more pluralistic view of human development,
and give up the idea that "doctor knows best" about (or that any
professional "has the answer" to) human suffering, destructive
relationships and psychological symptoms. We need to learn a deeper
respect for patients than diagnosis and care programming allows (4).

The modern anti-paternalism described in the BMJ seems like a
resergence rather lacking in libido - rendered joyless and sterile by over
-management, defensive practice and political correctness. Only with some
of the fervour and inspiration from those earlier days, for bringing
humanity into our practice, will it come to life and not be an unwelcome
imposition, a managerial device, or a facet of consumerism.

Rex Haigh

(1) Coulter A (1999) Paternalism or Partnership BMJ, 319, 719-720

(2) Manning N, Lees J, Rawlings B (1999) A systematic international review
of therapeutic community treatment for people with personality disorders
and mentally disordered offenders. London: High Security Psychiatric
Services Commissioning Board. Briefing Paper available on
www.pettarchiv.org.uk/atc-briefingpaper.htm

(3) Tucker S (ed)(in press) Dialogue and Dwelling: A Therapeutic
Community Approach to Care in the Community. London: Jessica Kingsley
Publishers.

(4) Campling P and Haigh R (eds) (1999) Therapeutic Communities, Past
Present and Future. London: Jessica Kingsley Publishers. See introduction,
pp 11-16