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Of 'Aw ?0 l iTCAl U AND > % vV.' LEAVING THE HOSPITAL BEHIND? AN ANTHROPOLOGICAL STUDY OF GROUP HOMES IN TWO LONDON BOROUGHS CHRISTINE A. PEERING P h D LONDON SCHOOL OF ECONOMICS AND POLITICAL SCIENCE UMI Number: U041097 All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion. Disscrrlation Publishing UMI U041097 Published by ProQuest LLC 2014. Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code. ProQuest LLC 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 .'.V i. '"7..r^s£S,-T F 6667 \ j , :':. ri / v'. ' .r; yy. M J i • %:.' y k 1*-.S Ù:^À ^ , ' ;j ‘- ...> .y.'-i V j i •■ ACKNOWLEDGEMENTS Many people have helped me in the research and preparation of this thesis. My two supervisors, Dr Shulamit Ramon and Dr Peter Loizos have given me invaluable support, guidance and encouragement through all stages of the work. I would also like to thank my fellow students at L. S. E. in the anthropology and social policy departments, for our regular exchange of information and ideas. This co-operative work has been very helpful to me. I should also thank Dylan Tomlinson, from the TAPS team, with whom I was able to compare information on different aspects of the hospital closure policy. This research could not have been done without the co-operation of the voluntary organisation which has worked so hard to contribute to the new services. Their openness and helpfulness in giving me access to their work is a reflection on their commitment to the principles of care in the community. Many other workers, both in the hospital and in community based services gave me their views. I would like to thank them all, and particularly the eight workers who undertook long interviews. I would like to thank the residential staff in particular, who welcomed my presence and shared their thoughts with me. Most especially I am indebted to the residents of the three group home projects, who not only shared their thoughts, but a great deal of their personal time and space with me, and always did their best to make me feel welcome. Much of the work, over the last few years, has been theirs. Lastly, but no less, I wish to thank my family, who have put up with my work and helped me a great deal - especially mum, for all her help, Giles for his patience and for reading all my work, and Ros and Paddy for being lovely kids. ABSTRACT The thesis examines the Impact of leaving a psychiatric hospital, which Is due to close, on a group of long-stay patients. Using anthropological method, the study provides a small scale. In-depth analysis of the transition processes Involved. It alms to examine the differing perceptions produced from different positions within an institutional setting, focusing particularly on the residents' perspective, and to compare the experience of transition from the clients' viewpoints with the carers' knowledge and assumptions. The first two chapters outline the context of the study, the historical and sociological background to community care policy and the methodological and theoretical approaches taken. Chapter three uses a 'life history' approach, which recounts the experiences of the residents of a particular group home project. These accounts are compared qualitatively with the official summaries of their case histories, suggesting that rehabilitation requires a different method of understanding the patients experiences, abilities, problems and needs. Chapters four and five outline the processes of selection and preparation for leaving the hospital. The experience of leaving hospital Is analysed as a 'life crisis' and the professional handling of the move Is examined. In chapters six and seven, group home life is described in detail and compared to hospital life, bringing out key features of the environment, routines, and interactions within the home and beyond it. I focus on several areas of change and continuity in the lifestyles of the residents, their use of time and their relations to staff and others. The final section explores the conceptual models of the group home, as an aspect of community care philosophy. I focus particularly on the 'family model' of care, its bases and its implications for the quality of life of the residents, in terms of rehabilitation, social integration and the personal and social identities of the residents. TABLE OF CONTENTS CHAPTER 1. THE AIMS, METHODS AND CONCEPTUAL BASES OF THE STUDY 7 The aims and context of the study; 7 The study method; 9 The Impact of doing research; 12 Anthropological perspectives in the study; 16 Versions of reality: links between method and theory in social research; 22 Power and knowledge; 27 The concept of 'community care'; 37 The relevance and scope of the study; 43 CHAPTER 2. THE GROUP HOMES IN THE HOSPITAL CLOSURE PLANS: 48 BACKGROUND AND CONTEXT The development of institutional care: two historical views; 49 Nineteenth century growth and reforms, moral management and psychiatry; 51 The movement towards community care; 53 Community care and the background to hospital closure plans; 55 The role of the voluntary sector in community mental health services; 62 The current hospital closure programme; 54 The local service plans; 65 The voluntary organisation: background and structure; 71 Group homes in the planning process; 73 CHAPTER 3. PATIENTS AS PEOPLE 78 On oral history and reminiscence; 78 Group homes residents as part of the hospital population; 79 The case history; 82 The life history 84 CHAPTER 4. LEAVING HOSPITAL: POLICY AND IDEOLOGY 115 Selection and preparation of patients to move to group homes: the formation of policy; 115 Policy and process for each project; 119 The criteria of client selection; dependency; 125 Implicit criteria of selection; 135 The relationship between selection and rehabiliation; 142 The meanings of rehabilitation; 143 Methods of rehabilitation; 147 Concluding points. 149 CHAPTER 5. LEAVING HOSPITAL: TRANSITION. 153 Leaving hospital as a rite of passage; 153 The experience of leaving hospital; 157 Implications for the transition; 163 Change and loss: the impact of leaving hospital; 164 CHAPTER 6. HOSPITAL AND HOME 177 Introduction 177 The hospital ward; 178 The group home; 185 The home environment as compared to the hospital ward; 189 The status of the hospital patient; 192 The hospital structure and staff roles; 194 The attitudes of nursing staff to the hospital and to group homes; 199 The role of medication in hospital life; 202 Day time activities in the hospital; 205 The hospital; the group home and the issue of rehabilitation; 207 CHAPTER 7. EVERYDAY LIFE IN THE GROUP HOME 211 The status of residents In the group home; 211 Relationships within the group home; 215 The residential groupworker; 219 Staff induction and training; 220 Domestic activity in the group home; 224 The role of medication in the group home; 227 The psychiatric day centre and its role in group home life; 237 Understanding group home life; staff views and residents' views; 239 Concluding points; 247 CHAPTER 8. MODELS OF GROUP HOME LIFE 251 The role of choice in group home life; 252 On independence as an ideal; 253 The notion of the group home as a substitute family; 254 The parent/child model of staff/client relations; 258 The social contacts of the residents; 262 Ideas about the nature of mental illness; 265 Kinship, adulthood and the notion of dependency; 270 Whose home is it? A case study; 275 Norms and their re-inforcement; 281 Concluding points; 283 CHAPTER 9. CONCLUSION 288 Age and transition: the sick role and the construction of time; 288 Methodological conclusions; 291 From de-hospitalisation to de-lnstitutionalisation: some policy Implications; 291 BIBLIOGRAPHY 296 CHAPTER 1 THE AIMS, METHODS AND CONCEPTUAL BASES OF THE STUDY The alms and context of the study My aim was to carry out a qualitative study of life in a group home for former long stay psychiatric hospital patients. This was linked to general policy questions about hospital closure, aiming particularly to compare life in hospital to life 'in the community' and to understand what the changes mean for those involved. More generally, the study aimed to throw light on the nature of certain social institutions, and the cultural assumptions they rest on, through looking at a period of critical change. In doing so, I wished particularly to bring forward the viewpoints of the patients who were affected by these important changes, to show what the experience was like for them. Therefore, the study explored the move out of hospital, taking in the patterns of care throughout the process, the attitudes and working practices of the different carers involved, and the impact of these patterns on the residents and staff of the projects studied. It aimed to look at staff working methods and philosophies, to compare those of hospital and community based staff, and to compare staff attitudes to the perceptions of their clients. More importantly, to examine how everyday life in the group home compares with professional ideas of what it is, or should be like. The study was carried out in North East London area, focused on the decision of the North East Thames Regional Health Authority (NETHRA), in 1983, to close two psychiatric hospitals over a time span of approximately 10 years. The philosophy behind this policy in the UK context [which will be discussed in chapter 2] is given to more than one interpretation at the general level.