SIMON GELSTHORPE
Clinical Psychologist, Bradford Community Health NHS Trust

If you are reading this piece then I assume that you, like me, are keen to see the current system of mental health services alter in some way.

You will already be aware that there is precious little in the literature about this to help guide us However, I would recommend you seek out and read Philip Barker and Ben Davidson’s (1998) book Psychiatric Nursing – Ethical Strife and the recent article by Green and Bloch (2001).

In my idealistic fashion I believe that it is more likely to change, if within it there are more people who want it to be different.

I also know that the way the system currently treats people is so disturbing for some staff that they leave and go to work elsewhere. This may well be the right personal choice for them but I would prefer to have as many people in the system who want it to change. Hence my quest – to find out from those people who have stayed, their "top tips" (their strategies, techniques) for staying and still coping, even though they regard the system as fundamentally flawed.

My way of getting these top tips was twofold. Using the internet I sent out a request to several email lists asking, "How do you manage to carry on working in a mental health system that you fundamentally disagree with? What do you do? What do you think to yourself?" Secondly, I targeted a few individuals who I knew might have helpful things to offer. My thanks to those who have joined in.

As a consequence I have spoken to or corresponded with a couple of dozen people from an assortment of professional backgrounds and a variety of countries. Their replies have been very varied but what follows is my analysis of the themes that run through their advice. These are ways of dealing with the situation that people have genuinely found useful and helpful and which therefore, I feel, have some true validity. My hope is that in sharing these with you they prove useful to you as well.

Broadly speaking, people’s responses seem to fall within two main categories – those techniques and practices which people use to protect themselves (which I have labeled Keeping Ourselves Okay, KOO) and those which people use to try to change the nature of mental health services (Change Services, CS). All respondents seem to use a mix of both types of strategy. Naturally, techniques that change services have the extra benefit of keeping us feeling okay since we see the improvement to services as improving the lot of service recipients. However the reverse is not always true, some techniques for keeping ourselves okay do not impact directly to change services – they serve to enable us to continue working in services and keep a state of relative health.

I have further categorised these two types of technique by attempting to locate the level or sphere of influence using a three way split of self, local and national. (A model I have used before in Gelsthorpe, 1999). This is summarised in the table .

What follows are fuller explanations of people's responses, which are briefly presented in the table. In each case I offer an explanation for their categorisation. They are presented in the order of frequency with the most frequent presented first.

The most frequently reported strategy was mustering support. This was mentioned in a variety of different ways and hence can be located in several of the table’s cells. Being around like-minded people who share our values and ideals is clearly beneficial to our wellbeing and can be done through very personal local contact but also extends to organisations which have wider catchment areas, for example regional or national groups. However we feel that these sources of support can also effect change to services. Grouping with others locally may enable the setting up of services or new guidelines to improve services as well as helping us feel better. On a wider scale, membership of campaign groups nationally may bring about change to policy, governmental advice and therefore services.

This was expressed by people in different ways and includes the sense that even if it is only a small part of the wider service, our own little bit of work does make a difference, however slight. It seems to be about recognising that however small it is, each of us has a personal sphere of influence in a service that we can affect. Where we are on the management ladder may alter how wide our personal sphere of influence is, but we all impact on services by being part of them. It also seems important to remind ourselves that this is the case. Hence it appears in both the "Keeping ourselves okay" field and also the "Change services" field.

Conversely (and only protective) was the idea that we may not have the sphere of influence to prevent bad practices in the wider service, effectively saying to ourselves "I know I would not want to treat people in that way, but I can not do anything about it happening elsewhere at the moment since it’s outside my control".

Several people mentioned that moving and changing jobs had been really helpful. Rather than defeatism it is seen as a way of keeping fresh and committed and preventing despondency and burn-out. Just as reminding ourselves that we have our own sphere of influence is important, it appears that just the thought that we can move and get a different job is helpful in keeping ourselves okay. We may not actually move, but reminding ourselves of the option can work too. It is also seen as a way of spreading good practice, which could also impact on our own practice (KOO/self, CS/Self). Another facet of this is moving to work in a service where our ideas are more welcome, or at least, less troublesome.

This was another popular way of coping. The gist is to ensure that we have a balanced existence with a real life outside work. The lesson seems to be to ensure that we have enough personal investment outside work to offer a sense of perspective and keep us well, and to keep sight of this. Some people mentioned acknowledging to ourselves the notion that work is still only 40 hours per week. Families and cricket were particularly highlighted as useful ways of realizing that work and mental health services are not everything. Since this does not impact on services it falls into the Keeping ourselves okay/self category.

As frequent as real life was having a personal philosophy. This is fairly hard to define but includes the notions of being true to ourselves, having values and sticking to them (jokingly cited by one as stubbornness), and keeping to our principles. Using these as our guidelines is obviously helpful and was also expressed as "knowing what I am for rather than what I am against". In terms of the framework it is located firmly in the Keeping oneself okay/self domain but clearly guides our practice in our services.

Several of us mentioned supervision and explained that it has many different outcomes. Certainly it was mentioned as a way of keeping ourselves okay both on a personal level and also on a wider local level through other people. Similarly people reported that we seek supervision to help keep up the standard of our own clinical practice (CS/Self) while giving supervision may also help to maintain or promote good practice in others (CS/local).

Research was another popular response. In these times of evidence-based practice, we recognize that research evidence is a powerful tool in shaping services. People’s replies included a sense that by doing research (either locally or wider) we are helping to move on service change by adding to the evidence base and hence I have filed it under Change services. This has the benefit of keeping us feeling okay while also (possibly) supporting service change on a local and national level. People liked the idea of writing and publication. Spreading the word is a definite positive way of keeping feeling okay as well as trying to impact on services and hence it appears also in KOO.

It may be splitting hairs to separate audit from research but this is a pre-existing distinction in people’s minds. Several British respondents mentioned the growth in Audit and Clinical Governance as positive opportunities to influence services. Since both are concerned with setting standards and the quality of care, people mentioned them as institutionalised change processes. Several people said they are involved locally in what appear to be bureaucratic exercises to bring about change. (CS/local)

This may sound mercenary but several of us reported that we manage to carry on by reminding ourselves that we get paid for doing so. Although it does not necessarily result in feeling okay it was an important aspect of helping us carry on staying in the mental health care system. (KOO?)

Another theme was the conflict with other staff that can arise for people who express any dissent or dissatisfaction with the services we offer in the mental health system. A defence for this was the suggestion that it is important for us to be knowledgeable and informed about the aspects we want to criticise and the alternatives we might want to suggest or offer. We feel that it helps equip us for the debates and arguments often raised as likely consequences of dissent, so we can enter these more confidently and armed with the facts.

Some people mentioned using literature both as information, escape and inspiration. Certainly it fitted into the KOO/Self category but perhaps also overlaps with some aspects of the personal philosophy (see above) in the way that we may draw guidance and strength from fictional work.

This refers to our capacity to look at ourselves and notice if we are being corrupted. Again it is very much a strategy to keep ourselves feeling okay while at the same time monitoring the standard of our own practice (KOO/Self and also CS/Self). Conversely it is important to look out for and make a mental note of any positive changes to the service to keep ourselves okay – not just to focus on the negative aspects of the service.

Although we have already mentioned the notion of our personal sphere of influence, there was a related aspect of perhaps being able to prevent excessive damage to service users by highlighting practices and calling them into question.

Perhaps surprisingly very few people mentioned having a sense of humour as a way of coping – perhaps it goes without saying. Or perhaps some things are not appropriate to joke about. This however is more about a way of looking at the world which enables us to "see the funny side" of mental health services (not the funny side of people’s real difficulties) and perhaps the absurdities of some mental health practices. Presumably some adventurous comics may try to use humour to change the perception of mental health services, but here it is much more a way of keeping ourselves okay.

For some, the goal of changing services is to be achieved on a national level (CS/national) by piggybacking on the power and authority of professional organisations. Often consulted by the government on issues of policy or service development, our professional bodies are seen by some as a way of "getting the message across" to the people who count – namely ministers and civil servants. Ironically, for some the exact reverse is true, since some of us see our professional organisations and their conservatism as part of the system’s problem.

I think this is a technique for depersonalising conflict in the workplace when debate about services can get heated. It runs along the lines of "I am putting forward a point of view, if it is criticised by others they are criticising the view rather than me (even if it does not feel like that). Similarly if I am criticising a practice or view I am not criticising the person holding it. It seems that this is a way of making arguing and debating more comfortable for us (KOO).

Admittedly this piece of work has an explicit focus on staff and professionals and deliberately so. However, this reply (I feel) brings us back to earth and grounds us in the reality of mental health work. However unhappy we professionals feel about our system, we can be sure that it is much worse for those people who are receiving it rather than just working in it. Yet it is those very people for whose benefit we continue to work. Although I have included this in KOO/Self it seems to be used as a spur to carry on, a powerful motivator rather than explicitly keeping ourselves okay.

Not often used as a reply in the research but this based on the principle that if society as a whole wanted the mental health system to change, then it probably would. Creating public demand for services to change needs a way of communicating with the public and the media are one way of reaching them – hence this falls into the change services/local or national sphere.

Let me add now that although this study is based on the principle that it is better if more people can stay working in the system I do not want to criticise people who do not stay. I believe it is quite okay not to stay in the system. Indeed, in the KOO/self category there is "take a break". Some respondents said that they had taken breaks of one form or another to "recharge" their batteries or to get a different perspective. However for some people it is almost impossible (for financial or personal reasons) to leave the system or change jobs and for them I hope that some of the above are helpful.

One of the recurrent aspects of replies is our use of "war/battle" terminology. People mention "sticking my head over the parapet", being "armed with information" and of being "personally attacked" when daring to offer criticism. It obviously feels that to express dissent is to enter into a war. Hardly surprising then that it is so difficult and that we feel the need for some form of protective armour. Indeed I guess that defending ourselves psychologically is the thrust of the KOO strategies. Psychodynamically oriented theorists may call them "defence mechanisms" and cognitive theorists refer to them as "coping strategies" but we clearly feel that their defensive (from expected attack) and protective functions are essential to being able to carry on.

KOO strategies may not change services and are therefore open to the criticism that they merely support the status quo by enabling people to put up with a bad system. However most people reported a mixture of techniques – some protective and some to change services. In this respect it seems to me that keeping ourselves okay (KOO) is not a way of putting up with a failing system but a way of enabling us to carry on pressing for change, for which we use other (CS) ways. As such it seems important to have a personal balance of strategies including both KOO and CS methods. Equally people’s use of strategies may well vary over time – more KOO at difficult times, more CS when the opportunity arises for change.

In my article from 1999 I explored some of the uncomfortable emotional responses to working in psychiatry that we can expect. Although many of the KOO strategies may be ways of coping with these uncomfortable emotions, I am not suggesting that we should try to get rid of these feelings since those uncomfortable emotions can be important drivers to motivate us to push for progress in mental health services. For example there can be a real positive advantage to feeling extremely angry about coercive practices and wanting to see them replaced by collaboration.

Lastly I do not see this as a finished piece of work. I will be pleased to hear further suggestions and thoughts on "sticking around in a crappy system" (as one person put it). My email address is HermanEwtix@hotmail.com.

Barker, P.J. & Davidson, B.,1998, (eds) Psychiatric Nursing – Ethical Strife. Arnold. London.

Gelsthorpe, S.D.,1999, Psychiatry: We are all paid to disagree. Using the bad feelings positively. Clin Psych Forum 127:16-19.

Green, S.A. & Bloch, S. (2001) Working in a Flawed Mental Health Care System: An Ethical Challenge. Am J Psychiat, 158:1378-1383.