The Healing Potential of Metaphor in the Narrative

© Phil Barker 2001

Traditionally, psychiatric nurses have employed different ways of approaching the person in their care. These reflected, at least in part, the individual nurse’s construction of the phenomena of mental ill health (Barker, 1999). These divergent, and at times conflicting approaches to the delivery of care, developed over the past half-century into various theories and models of nursing practice. Increasingly, nurses have acknowledged the need to focus on developing active methods of helping people participate in their own care, fostering the active collaboration of the person called patient and significant others (Peternelj-Taylor and Hartley, 1993). Indeed, Peplau’s original representation of the therapeutic potential of the nurse-patient relationship would appear now to have been supplemented by a variety of concerns for the political dynamics of the relationship itself (Barker and Stevenson, 2000).

Latvala et al (1999) described at least three distinct methods of helping, used by nurses, each of which suggests the power dynamic between nurse and patient. Catalytic methods, emphasise the use of participatory dialogue and assume that the responsible agency of the patient will permit the development of mutual collaboration. Educational methods give precedence to the nurse’s professional monologue, assuming that the patient is no more than a responsible recipient, and that the co-operative relationship will be driven, primarily, by the professionalism of the nurse. Finally, confirmatory methods begin with an assumption that mental ill-health arises from physical causes. This assumption limits the nurse-patient relationship to general discussion, within which the patient is a passive recipient of information. Any co-operation, which occurs does so within a hierarchical context.

The Tidal Model was developed in England between 1995-1998, from a series of studies, each of which explored the ‘need for psychiatric nursing’ (Barker et al, 1999) and more specifically the discrete nature of the power-relationship between nurses and their clientele (Barker et al, 2000). The model acknowledges that the phenomenon of ‘’mental illness’’ can be viewed from differing theoretical perspectives. However, the model also appreciates the value of construing mental health problems primarily as problems of living, which exist within a human system. These hypothetical problems delimit the effective functioning of the person at various levels: e.g intrapersonal, interpersonal, transpersonal, spiritual. The Tidal Model employs a pragmatic and respectful approach to the identification of such problems of living, echoing the view expressed by Alanen et al (1991) that people with serious mental health problems and their families needed to be helped to :

"conceive of the situation (e.g. admission) as a consequence of the difficulties the patients (sic) and those close to them have encountered in their lives, rather than as a mysterious illness the patient has developed as an individual"

This attitude emphasises the centrality of the lived- experience of the person and her/his significant others. In its open acknowledgement of the need for mutual understanding between nurse and patient, the Tidal Model may accommodate a variant of the ‘catalytic’ method described by Latvala et al (1999). In the United Kingdom, at least, this emphasis on mutuality differs markedly from the contemporary popularity of ‘pyschosocial’ and other cognitive-behavioural interventions (e.g Brooker and Butterworth,1994), which bridge the confirmatory and educational approaches to helping. Perhaps unwittingly, these often openly pledge support to a biomedical construction of ‘mental illness’ and the inherent ‘problems of living’.

Despite the emerging participative rhetoric, in most Western countries nursing practitioners are aware that the medical model is stronger than ever, implying that people need to be treated rather than ‘cared for’, far less ‘cared with’ (Dawson, 1997). This suggests that any new model of mental health nursing practice must emphasise not only the specific ‘need for nursing’ (Barker et al, 1999), but should also be congruent with the person’s need for medical and other therapeutic interventions.

The Tidal Model was introduced originally into acute psychiatric care settings (Barker, 1998) but has since developed the concept of a 'care continuum', with demonstration sites in hospital, community, rehabilitation and forensic settings. The model emphasises the person's need for three discrete forms of care - 'critical', 'transitional' and 'developmental – representing different, hypothetical stages of the care and treatment process. The care continuum spans the hospital-community divide emphasising that need should be the primary focus for care, rather than the setting within which care is delivered. Although the model is intended to complement the care and treatment offered by other disciplines, its primary emphasis is the exploration and development of the lived-experience of the person-in-care. Specific emphasis is given to ways of revealing and clarifying meanings and values, which the person attaches to, or associates with, problems of living. Where appropriate, this exploration extends from the intrapersonal domain, through interpersonal conceptions of Self and Other, to address what might be defined, classically, as the religious, mystical or spiritual dimensions of self-hood (Barker, 2000). In every instance, however, the constructions of the various dimensions of the person’s experience of personhood are realised through mutual discussion. The completion of each assessment and the development and modification of each care plan becomes, therefore, an act of co-creation – involving the active collaboration of the person and those involved in her or his immediate care.

In emphasising the fluid nature of human experience, the Tidal Model borrows from chaos theory (Barker, 1996), recognising that change, growth or development occur through small, often barely visible changes, following patterns, which are – paradoxically - consistent in their unpredictability. This provides the basis for the core metaphor – water:

Life is a journey undertaken on an ocean of experience. All human development, including the experience of illness and health, involves discoveries made on a journey across that ocean of experience.

At critical points in the life journey the person may experience storms or even piracy (crisis). At other times the ship may begin to take in water and the person may face the prospect of drowning or shipwreck (breakdown). The person may need to be guided to a safe haven to undertake repairs, or to recover from the trauma (rehabilitation). Only once the ship is made intact, or the person has regained the necessary sea-legs, can the ship set sail again, aiming to put the person back on the life course (recovery).

Unlike normative or adaptational psychiatric models, the Tidal Model holds few assumptions about the proper course of a person’s life. Instead, it focuses on the kind of support that people believe they need to live their own ‘good life’. The Tidal Model recognises that the life experiences associated with mental ill-health are invariably described in metaphorical terms (Barker, 2000). People who experience life crises are (metaphorically) in deep water and risk drowning, or feel as if they have been thrown on to the rocks. People who have experienced trauma (such as injury or abuse), or those with more enduring life problems (e.g. repeated breakdowns, hospitalisations, loss of freedom through compulsory detention), often report loss of their ‘sense of self’, akin to the trauma associated with piracy. In such instances, people need a sophisticated form of life-saving (psychiatric rescue) followed, at an appropriate interval, by the kind of developmental work necessary to engender true recovery. This may take the form of crisis intervention in community or the ‘safe haven’ of in-patient settings. Once the rescue is complete (psychiatric nursing) the emphasis switches to the kind of help needed to get the person ‘back on course’, returning to a meaningful life in the community (mental health nursing).

The model assumes that the practical focus of psychiatric and mental health nursing differs. The former requires supportive, and often dramatic, interventions, where the person is vulnerable and potentially dependent. The latter emphasises a more egalitarian relationship, within which collaborative and empowering interventions have the potential to facilitate personal growth and discovery.

The Tidal Model is predicated on the use of a range of discrete holistic (exploratory) and focused (risk) assessments, each of which generates person-centred interventions that emphasise the patient’s extant resources and capacity for personal solution-finding. The templates for assessment and intervention contained within the model act as a springboard for creative exploration of the need for nursing (Barker et al, 1999), rather than delimiting the nurse’s practice through the exercise of tight protocols. By acknowledging the need for a continuously flexible response to the person the Tidal Model also recognises the inherently chaotic nature of human behaviour, and human experience (Barker, 1996).

The Tidal Model assumes that people are their narratives (MacIntyre, 1981). The person’s sense of self, and world of experience - including experience of others - is inextricably tied to the life story and the various meanings generated within it. The Tidal Model constructs a narrative-based form of practice (Barker and Kerr, 2001). This differs markedly from some contemporary forms of evidence-based practice. The former is always about particular human instances, whereas the latter is based on the behaviour of populations, whose elements are merely assumed to be equivalent. More importantly perhaps, the narrative focus of the Tidal Model is not concerned to unravel the causative course of the person's present problems of living, but aims to use the experience of the person's journey and its associated meanings, to chart the 'next step' that needs to be taken on the person's life journey. As part of this conjoint, exploration of the person’s ‘world of experience’ the assessment record is written entirely in the person’s own voice, rather than translated into a third person account, or into professional language [See Appendix  1]. The nurse and the person in care co-create a narrative account of the person’s world of experience This includes the identification of what the person believes (s)he needs, at that moment, in terms of nursing intervention, and holds the promise if what ‘needs to happen’ to meet that need .

Whatever the clinical presentation, the Tidal Model gives precedence to the story, since this is the location for the enactment of the person’s life: it is the theatre of experience in which reflection and discussion result in a contemporaneous script editing. The caring process begins and ends here, since all people express a need to develop (create) a coherent account of what has happened, and presently is happening to them, in the light of their personal experience. This account is most meaningful when framed in the patient’s vernacular, illustrated by the metaphorical language drawn from the person’s history and socio-cultural context.

In the course of mental health care and treatment it is commonplace for nurses to note that people 'change their stories'. This is a reflection of how consideration of the past in the light of the present (which is changing) serves notice that the person is also involved in creating the future (which is imaginary). It is folly, therefore, to talk of some putative 'true story' – since this is no more than a pattern of context or agency. Instead, the nurse aims to help the person develop a story, which takes account of how the person is presently making sense of life events (including the process of care) as and when they occur( See Appendix 2).

In translating the metaphor of the script edit, into care planning language, the model proposes that each person should be assessed only once (holistically) during each period of contact with the service. This assessment leads directly to the development of the first care plan, which is reviewed and revised daily with the person (where the person is in residential care), tailoring and adapting the processes of care, to fit what might be small, but significant, changes in the person’s presentation. The ‘story’ taken at the first holistic assessment, becomes the opening chapter of the story of the current episode of care. This is written conjointly, page by page, and is closed only when the person is ready to make the transition to home, or to a new care setting.

The experience of mental ill health is inherently disempowering. Although services are often described as offering mental health interventions, invariably these focus only on limiting the personal and interpersonal damage that result from problems of living. Consequently, psychiatric care and treatment can compound the original disempowerment scenario of ill-health. The Tidal Model attempts to address directly the most common form of disempowerment - the failure to afford a proper hearing to the personal story of the experience of problems of living. Traditionally, the medical model has deflected attention away from the lived experience, translating this unique, subjective account, into the para-language of medicine. Many psychological models, or psychotherapies do likewise, reframing the lived experience as one kind of psychological schema or another. The personal account is thus reduced to the level of its apparently commonly occurring parts. This view is not a condemnation of psychiatric or psychotherapeutic diagnosis per se, but is merely an acknowledgement of the limitations of this way of re-presenting the human experience of problems of living, especially where this is afforded primacy.

The Tidal Model tries to avoid reducing the person to a 'patient phenomenon', whilst recognising the impossibility of developing anything more than a provisional account of the person's life experiences (which are in constant flux), and the person’s immediate need-for-nursing (which also is subject to change). By incorporating specific empowering interactions, drawn from empirical research (Barker et al, 2000) the Tidal Model puts the person’s experience, and unfolding life-narrative centre stage. The nurse provides the necessary support to ensure the person’s emotional and physical safety, (self domain) helps the person explore and identify what needs to change, to facilitate recovery (world domain) and explores the possible roles of professionals, family and friends, in the whole recovery process (others domain). Hopefully, the constructive, collaborative, nature of the nurse’s work in these three domains of practice, helps to ‘power up’ the person in the process.

The Tidal Model is presently the subject of a range of pilot evaluations in several countries – Japan, Australia, New Zealand, Ireland and Canada. A major multidimensional evaluation has been completed in Newcastle, England, where the model was first developed, and where several hundred nurses, across nine acute psychiatric wards, and their associated community teams, a community 24-hour nursing unit, and a forensic unit, are employing the Tidal Model as their core practice. The Newcastle ‘process’ evaluation focused on the experience of the model, from the perspective of nurses, multidisciplinary team members and users of the service (patients). Using a semi-structured interview format, professionals and patients were asked to compare and contrast their experience of this approach to care, with other models of mental health care, with which they were familiar. The interviews with patients was led by a team of specially-trained ‘user-focused monitors’, all of whom had experience of psychiatric care, as patients. (This user-focused evaluation will report in early 2002). A related outcome evaluation collected data on the possible outcome effects of the model across a range of variables: e.g. length of stay in acute units, use of medication, use of ‘containment’ procedures, such as special observation and control and restraint procedures, incidence of violence, suicide and self-harm (See Fletcher, Stevenson and Barker, 2001).

Taylor (1994) described how the dynamic processes involved in nurses’ use of narrative, in exploring the patient’s experience of illness, could ultimately be construed as engendering healing. In a related vein the Tidal Model assumes that nurses need to get close to the people in their care, so that they might explore (together) the experience of health and illness. This might have healing effects for nurse as well as patient

Health care has, however, become increasingly technical and emotionally distant (e.g. through the use of computers), and bureaucratic (through the influence of protocols). As a result, many people with mental health problems, as well as some professionals, have called for a re-emphasis on the importance of the human relationship between ‘patient’ and ‘carer’ (Newnes et al, 1999). Despite major developments occurring in health, the practice of psychiatric and mental health nursing appears still to be predicated on a kind of confession (of trauma and physical and emotional vulnerability) within an intimate conversation (the assessment/therapeutic dialogue). However, post-modern, secular, society increasingly appears reluctant to acknowledge the potential for anything more than a materialistic construction of mental health problems. The exploration of the meanings which people attribute to the experiences in their lives is one definition of ‘spirituality’ (Barker, 2000). As such, it is possible that, for some patients, the process of working with the narrative of their problems of living might, ultimately, be construed as a form of spiritual inquiry.

Despite the continued popularity of nursing as a ‘human’ intervention in various surveys of psychiatric staff (e.g. Rogers et al, 1993) it remains unclear, what exactly is the functional relationship between the nurse’s ministrations, and any benefit perceived by the patient. The Tidal Model may represent another conceptual framework through which nurses might explore, Nightingale’s proposition that their primary role is not to cure or heal directly but rather, is, to organise the conditions under which the patient might be healed by Nature or by God.

References

Alanen Y, Lehtinen K and Aaltonen J (1991) Need-adapted treatment of new schizophrenic patients: experience and results of the Turku project. Acta Psychiatrica Scandanavica 83, 363-372.

Barker PJ. (1996) Chaos and the way of Zen: psychiatric nursing and the 'uncertainty principle'J Psychiatr Ment Health Nurs. 3(4):235-43.

Barker P.(1998) It's time to turn the tide. Nurs Times. 94(46):70-2.

Barker P (1999) The Philosophy and Practice of Psychiatric Nursing. Edinburgh: Churchill Livingstone

Barker P (2000) Working with the metaphor of life and death. J Med Ethics: Medical Humanities 26, 97-102.

Barker P and Kerr B (2001) The Process of Psychotherapy: A journey of discovery Oxford: Butterworth-Heinemann

Barker P , Leamy M and Stevenson C (2000) The philosophy of empowerment Mental Health Nursing 20 (9) 8-12.

Barker P and Stevenson C (2000) The Construction of Power and Authority in Psychiatry Oxford: Butterworth Heinemann

Barker P, Jackson S, Stevenson C. (1999) What are psychiatric nurses needed for? Developing a theory of essential nursing practice.J Psychiatr Ment Health Nurs. 6(4):273-82.

Brooker C and Butterworth T (1994) Training in psychosocial intervention: the impact on the role of community psychiatric nursing. J Adv Nurs 18(4) 583-90

Dawson PJ. (1997) A reply to Kevin Gournay's 'Schizophrenia: a review of the contemporary literature and implications for mental health nursing theory, practice and education'.J Psychiatr Ment Health Nurs. 4(1):1-7.

Latvala E, Janhonen S and Wahlberg, KE (1999) Patient initiatives during the assessment and planning of psychiatric nursing in a hospital environment. J Advanced Nursing 21(1) 64-71

MacIntyre A (1981) After Virtue Notre Dame, USA: Notre Dame University Press

Newnes C, Holmes G and Dunn C (1999) This is madness: A critical look at psychiatry and the future of mental health services. Ross-on-Wye: PCCS Books

Peternelj-Taylor CA and Hartley VL(1993) Living with mental illness: Professional/family collaboration. Journal of Psychosocial Nursing and Mental Health Services. 31, 23-28

Rogers A, Pilgrim D and Lacey B (1993) Experiencing psychiatry London: MIND/Macmillan

Taylor B J (1994) Being Human: Ordinariness in Nursing Melbourne: Churchill Livingstone

Appendix 1: Overview of The Holistic Nursing Assessment

The Holistic Nursing Assessment is a six-page document. A copy of the blank format is given to the patient/client, who is invited to choose who should write the responses – him/herself or the interviewing nurse. The assessment covers 15 discrete areas. (On completion, the nurse makes a copy of the original record (which is lodged in the patient’s care plan) and a copy is provided for the patient’s reference).

Details of time, date and place of the assessment, and who is involved.

General overview of current problem(s)

Problem origins (how this began)

Past problem function (how this affected me)

Past emotions (How I felt in the beginning)

Developmental history (How things have changed for me over time)

Relationships history (How this has affected my relationships)

Current emotional state (How I feel now)

Holistic content (What I think this means)

Holistic context (What this says about me as a person)

Needs wants and wishes (What needs to happen now, or what I want or wish would happen)

Expectations (What I expect the clinical team to do for me)

Evaluation of the problem (rating the emotional distress, degree of disruption to life activity and degree of control over the problem)

Personal resources

Resolution of the problem (how will I know when things are different - what needs to change to allow this to happen?)

Appendix 2: Archie’s Story

Archie was a 20-year old, described as having a paranoid psychosis, who had tried to set fire to himself, (allegedly) in response to his 'voices'. Considered to be a ‘high risk, Archie was transferred to a secure unit, where the admitting nurse helped him explore the wider context of his current problems, beginning with the circumstances of his transfer:

Nurse: So, Archie, what’s brought you here?

Archie: (very agitated) " They told me to do it. They did, they said it was the only way…I got a sign, lots of signs, in the stars..like black everywhere…the only way, I mean they did. They said ‘it’s the only way’

N: Uh huh, they did. Can you tell me who they are, Archie?

A: I dunno. I mean I dunno who they are. But they told me.

N: I see. And when did you first become aware of them …?

A: They’re like voices…I keep hearing them, talking ..lots of talking shit. Burn, burn, boy, burn! I, oh, I don’t remember when they first came…long time ago. Been a long time.

The nurse invited Archie to talk more about the ‘voices’ and asked Archie to "help me understand what’s happening". She also invited him to stop and rest at points, and to decide what bits of the story he wanted written down, to help the team understand better what was happening with him.

As the nurse listened carefully, using his language, pacing herself to Archie’s rhythm, Archie gradually became calmer and more coherent. The nurse then paraphrased Archie’s story, so far.

N: So, let me see if I have understood what you have been saying Archie. Just stop me if I have misunderstood you. You came here….(paraphrased story).

Then the nurse invited Archie to "tell me what you think all of this means?" Almost without hesitation Archie replied:

A: It means I have a chance to be reborn.

N: Reborn? Can you tell me a bit more about that?

A: Yeh, like, make a fresh start, y’know, begin again. Have a clean sheet, a fresh start, a blank page.

N: This is important, yeh?

A: I guess. I guess I f***** up, big time. That’s what they kept telling me. I guess they knew. They weren’t talking shit.

N: So, what do you think that says about you as a person?

A: Well…maybe….I’m not so bad after all. I mean, like, getting a second chance and all that. Maybe. Just maybe.

In a more traditional interview, as soon as Archie begun talking about the ‘voices’, given his history, the nurse might have moved (precipitately) towards identifying ‘risk management’ strategies, like medication and ‘special observations’. Archie was clearly a high risk of harm to self and others. However, by exploring - rather than closing down -the narrative, the nurse began to involve Archie in ‘what needed to be done’ to help him.