Given my background you might expect me to argue that senior, qualified professionals are the most important members of any multi disciplinary team. But you’d be wrong.

It’s true that I’d really like to be able to say that. After all – we all like to feel important, don’t we? But the truth is that such people are relatively low on the list of priorities and that’s how it should be.

To understand what I mean we’ll need to review a little of the research that has been developed over the last fifty years or so.

We’ll begin with High Expressed Emotion. This is a concept that has fallen out of fashion in recent years – not because it’s not accurate but because it’s not sufficiently trendy. This is a great shame because when care workers understand the concept of Expressed Emotion their clients are likely to fare far better than when they don’t. We’ll cover High Expressed Emotion in much more detail in later instalments but for now a basic overview is enough.

The idea was first introduced by George Brown in the late 1950s and onwards (Brown G. et al 1958) and then later refined (Brown & Rutter 1966) to mean three distinct types of behaviour:

Criticism

Hostility

Over-emotional involvement

The basic idea is that for people to avoid relapse – and in modern terms to recover from disorders such as schizophrenia it is important that expressed emotion is managed. At first this is managed by the care workers but over time the individual is helped to develop the skills they need to manage the amount of expressed emotion they are exposed to for themselves and also to deal constructively with it when it does occur. In short they develop the sorts of skills and environmental management techniques that most people use without thinking about it.

Brown’s original work was interested in the roles of families but the principles apply equally to any social group including care settings.

In many ways the idea of High Expressed Emotion is simply a way of restating the much older beliefs of William Tuke, an 18th century quaker who developed ‘Moral Treatment’, a method of working with the ‘insane’ that involved respect, value and meaningful contribution. Somewhat radically it also involved reasonable food and clean accommodation. Tuke founded the York Retreat in the 1790s with apparently remarkable success using little more than respect for the individual, good basic low tech care and an ethos of involvement and appreciation.

So we begin to see that the importance of good quality social interaction and supportive environments is not to be underestimated. Clearly the person best placed to influence the environment of the individual is the person who is there most of the time. That is not the therapist or the psychiatrist – nor is it likely to be the community psychiatric nurse or social worker. The person who has most influence over an individual’s social environment is the unqualified and often unsung support worker or care assistant. Their work, and their attitude to that work is one of the most crucial elements of the care process. Without them all the therapy in the world will fail because the service-user will be too distracted dealing with their real world difficulties to think about the sometimes difficult issues raised in therapy sessions.

One way that I explain this to unqualified workers in training sessions is this:

“Your stuff works without me. My stuff can never work without you. Now then – who do you think is most important?”

More recent research was conducted by the World Health Organisation in two consecutive studies over a period totalling 25 years. Collectively the studies are known as ISOS or ‘The International Study of Schizophrenia’. This study produced some remarkable results. In short it demonstrates that places where there is good social support, involvement and respect – where the individual is valued tend to have much higher recovery rates than the developed world where there is access to high-tech medications and talking therapies but a stigmatising culture. Once again – the emphasis is upon social situations rather than treatment. (Harrison G. et al 2001).

Similair findings are reported by the British Psychological Association in the ‘Recent Advances’ document from 2002. This describes a number of psychosocial approaches to psychotic and other mental disorders.

Key to the findings of the BPA is the concept of the self-fulfilling prophecy. This is the ‘give a dog a bad name…’ principle that seems to be mirrored throughout human existence. As a general rule people live up or down to the expectations others place upon them. If then, support workers do not expect their service-users to recover there seems little likelihood that they will.

This phenomenon was best identified some 40 years ago in the famous ‘Pygmalion in the classroom’ experiment at ‘Oak School’ by Jacobson & Rosenthal. Fortunately their original work has been reprinted and is available again. It is well worth a look (Rosenthal R. & Jacobson L. 2003).

When we bring all this information together it is obvious that the most important part of any multi-disciplinary team working with mentally disordered people is not one of the professionally qualified, highly skilled and lettered clinicians who sees the service-user rarely and briefly. The most important work is done by the unqualified support workers and care assistants who work day in, day out to develop good quality relationships with individuals, not patients and who have the power in many cases to influence the environment in which those people spend their time.

To ignore the value such care workers bring to the team is to miss the point entirely. We professionals are far less significant than we might think. A healthy acknowledgement of that simple truth may be a very good and appropriately humbling place to begin.