Loss of Control and the Chronic Mentally Ill in a Rural Day-Treatment Center

PROBLEM. What do chronically mentally ill clients consider to be the core variable in maintaining health, and how do they go about doing this? METHODS. A grounded theory design with analysis of interviews of seven chronically mentally ill clients in a rural day-treatment center. FINDINGS. The core variable in maintaining health according to chronic mentally ill clients is preventing loss of control. A process was discovered that clients used to do this. CONCLUSIONS. Chronic mentally ill clients prevent loss of control by using informal relationships to adapt behaviors, attitudes, and feelings within a supportive environment. If this fails, they turn to formal sources of control such as therapists, case workers, or other mental health providers. Key words: Chronic mentally ill, loss of control, qualitative research The deinstitutionalization of chronically mentally ill people has placed a fragile population in communities expected to provide mental health services to them. Clients seek out these services when they perceive a need for them. This grounded theory study concerned these health-seeking behaviors. Caplan (1995) reminds us that the "process of defining normality has always involved far more `art' (politics, values, social mores) than science" (p. 38). Corin (1994), in her work on the social and cultural matrix of health and disease, suggests that "different forms of stress are powerfully shaped by the social and cultural milieu in which individuals are embedded" (p. 93). Mechanic (1994) writes that medical problems "occur in a social context complicated by issues of class, race, gender, work, family, and community ties" (p. 102). Chronic mental illness is even more affected by these variables because of the stigma society associates with it (Goffman, 1961). Society, through its norms and value systems, communicates standards and expectations of behavior that include role behavior. Manneheim (1957) proposes that "social control is the sum of those methods by which a society as a group of people tries to influence human behavior to maintain a given order" (p. 29). Inherent in these methods is the setting of covert and overt boundaries on behavior. Social control is implied through such phrases as "appropriate," "acceptable" behaviors, and statuses. Corin views the control structures in society as not only having the function of maintaining order but also providing a mechanism for the implementation of new coping strategies. All social institutions, regardless of their other functions, contribute to maintaining social control. A major process for maintaining social control is the socialization of new members into social groups and institutions. Although societies have specialized agencies responsible for externally maintaining control--for example, police and the mental health establishment--it is the internal or self-control achieved through successful socialization that makes human society possible. Mechanic (1994) writes that it is now "commonplace that health is shaped by the material and environmental conditions of life and by the sociocultural structures that people create as much as by their genes and individual health behavior" (p. 105). Socialization requires role-taking, which George Herbert Mead describes as an interactive process (Briggs, 1988; Wilson, 1982). Part of this process is role negotiation with others and the environment. Therefore, socialization has an emergent and situationally controlled character or nature. The factors affecting role negotiation and the taking on of role-prescriptive behaviors are: the distribution of power, maintenance of individual identities, internalization of values, and standards of conduct (Hurley-Wilson, 1988). In highly structured settings, participants have little opportunity for role negotiation because the rights and duties of roles are specified in advance. In a less structured setting, there is a greater amount of role negotiation in which participants must establish and maintain situational identities and recognize the identities of others (Goffman, 1961; Goslin, 1969). …