The Tidal Model – Humility in mental health care.
Phil Barker 2000
Mental health nursing in
the UK has had a poor relationship with nursing
models. The merit of the medical model, although,
frequently contested, still governs much nursing
practice. Increasingly, nurses turn to social or
psychological models – in the form of Psychosocial
Interventions (PSI) or cognitive behaviour therapy –
to find guidance for their practice. As Michael
(1994) has pointed out, the only way many nurses can
find confidence in their own practice has been to
model themselves on another discipline.
The Tidal Model
(Barker, 2000) is a radically new approach to the
practice of mental health nursing based on a series
of research studies conducted over the past five
years, which sought to define how nurses might help
empower users and their families, and to clarify
what kind of ‘care’ people need from nurses(
Barker et al, 1999). The Tidal Model is
presently being established as the basis of nursing
practice, across the whole adult mental health
programme in Newcastle, and is being introduced into
selected clinical and teaching setting in Australia
and New Zealand, Finland, Scotland, Ireland and
Wales.
Although the Tidal Model
complements the care offered by other health and
social care disciplines, it recognises that
‘quality’ nursing care is focused on a special kind
of relationship with users and their families. The
person’s needs change from day to day and problems
are not fixed things. Life flows through people and
the problems of living they experience are equally
fluid and changeable. Effective care needs to be
based on a realisation of the changing nature of
people and their life circumstances.
The Tidal Model
emphasises the unpredictability of human experience
through the core metaphor of water.
Life is a
journey taken on an ocean of experience. All
human development – including the experience
of health and illness – involves discoveries
made on that journey across the ocean of
experience. At critical points in the
journey people may experience storms or
piracy. The ship may begin to take in water
and the person may face the prospect of
drowning or shipwreck. The person may need
to be guided to a safe haven, to undertake
repairs, or to recover from the trauma. Once
the ship is made intact or the person has
regained their sea legs, the journey may
begin again, as the person sets again their
course on the ocean of experience.
This metaphor illustrates
many of the elements of the psychiatric crisis and
the necessary responses to this human predicament.
‘Storms at sea’ is a metaphor for problems of
living; ‘piracy’ evokes the experience of rape or
the ‘robbery of the self’ that severe distress can
produce. Many users describe the overwhelming nature
of their experience of distress as akin to
‘drowning’ and this often ends in a metaphorical
‘shipwreck’ on the shores of the acute psychiatric
unit. A proper ‘psychiatric rescue’ should be akin
to ‘lifesaving’ and should lead the person to a
genuine ‘safe haven’ where the necessary human
repair work can take place.
The Tidal Model
makes few assumptions about the proper course of a
person’s life, preferring instead to focus on the
kind of support that people might need to rescue
them from crisis, and help them to chart again the
course of their own lives. Genuine psychiatric
care should be focused on appropriate forms of
‘emotional rescue’ and mental health care
should be focused on the kind of human development
that will enable the person to ‘put to sea’ again.
In this sense the Tidal Model is committed to
helping people to recover their lives, taking up the
journey of a lifetime that has been disrupted by the
experience of trauma or breakdown.
The Tidal Model
involves three distinct, but related, dimensions of
caring:
In the world
dimension, the nurse focuses on the person’s need to
be understood. This includes a need to have the
personal experience of distress, illness or trauma,
validated by others. A radically different form of
nursing assessment – the Holistic Nursing
Assessment - has been developed which documents
what is significant and meaningful to the person
now, at this point in their life journey. This
assessment, which charts the person’s journey to the
‘here and now’, identifies what needs to happen
next, to help them, and is written in the person’s
own words. This enabled autobiography is one attempt
to reduce the disempowerment experienced in the
teeth of the psychiatric storm.
In the self-dimension
the nurse focuses on the person’s need for emotional
and physical security. The nurse helps the person to
develop his or her own Security Plan, which
also is written in the person’s own voice. This part
of the care plan identifies the kind of support the
person needs to feel secure enough to tackle the
problems of living that have been identified in the
world dimension.
In the others
dimension the care plan considers the kind of
support that might be provided by other disciplines
or agencies, in order to resolve immediate problems
or lead an ordinary life. These inputs might range
from the provision of medical support, through to
support from friends or family, financial advice,
housing, education, leisure or other aspects of
community integration.
The various Tidal Model
assessments are focused on identifying what
needs to be done, in the short and longer term, to
meet the person’s human needs. These goals are not
merely focused on resolving problems of living, in a
psychiatric sense, but also try to consider how the
person’s mental health might be promoted through an
acknowledgement of existing personal strengths,
spiritual meanings and adaptability to social
circumstances.
The Tidal Model
assumes that nurses should only do what is
absolutely necessary to meet the person’s needs.
This emphasis on ‘doing what needs to be
done’ might help avoid fostering dependence or
otherwise institutionalising people. Although the
Tidal Model is informed by research, as well as
interpersonal relations theory, the care programme
is written in the ordinary language of the
individual user. There has been an unfortunate
trend, in recent years, to try to ‘teach’ people
about the experience of mental distress. This is
best illustrated by the development of
‘psychoeducation’ or ‘compliance-therapy’
approaches, which encourage the user or family to
assume a position of ‘ignorance’. In reality,
professionals are the ones who are ignorant of the
experience of mental distress. All professionals
need to develop some humility and acknowledge that
they need to learn from the people in their care.
Users – and in some cases – their families, help
professionals define what ‘needs to be done’ to help
address the problems of living associated with
mental distress
The Tidal Model care
involves a balance between individual interventions
– where the person is helped to address and resolve
individual needs, wants or wishes, within a
one-to-one relationship; and groupwork, where issues
common to others are addressed through the medium of
group processes. The Tidal Model recommends
three forms of group work:
The Recovery Group
focuses on helping to boost the self-esteem of
participants, acknowledging the values and
attributes that even severely distressed people can
bring to the life of others;
The Solutions Group
recognises that if people have an opportunity to
explore, creatively, with others their present
difficulties, they may construct their own
solutions;
The Information Group
recognises that people with mental health
problems need to be informed about many aspects of
their world of experience that, often, is kept
secret from them. This information may range from
details of medication, access to benefits, legal
issues, or advice about educational or other
community opportunities.
Although the Tidal Model
is based on research, and develops some of the
theory of interpersonal relations, it is not a
protocol driven approach. Instead, the various
‘frameworks’ within the model, merely offers nurses
guidance as to how they might structure their
efforts to empower people and to focus on what
people really need. Consequently, we expect
that the model will change dramatically as it is
applied in practice. The world is changing fast, and
all models of psychiatric and mental health care
need to acknowledge the flowing nature of our
personal and social world.
Many contemporary models of
mental health care are based on an outmoded
scientific paradigm, which assumes that people – and
their problems - are somehow ‘fixed’. Many of the
popular theories of psychiatric intervention are
based on outmoded, paternalistic ideas of ‘how
people should live’. The Tidal Model
tries to adopt a more realistic, and humble,
approach in assuming that the answers to the
question of what kind of care do people need, can be
provided by the people themselves.
References
Barker P(2000) The Tidal
Model: Theory and Practice University of
Newcastle.
Barker P, Jackson S and
Stevenson C (1999) The need for psychiatric nursing:
Towards a multidimensional theory of nursing.
Nursing Inquiry 6, 104-12
Michael S (1994) Invisible
skills. J Psychiatric and Mental Health Nursing 1
(1) 56-7
