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| The Philosophical Basis of Effective Care and Treatment in Psychiatry |
Paper presented to the Conference, ”Kvalitet, effekt og produktivitet – hvordan kombinere?” - Psykiatriens ĺrlige lederkonferanse, Stavanger, Norway, 3rd April 2003
Introduction
It
is a privilege to be invited to address this conference. As a youth I
was enthralled by the story of Thor Heyerdahl’s adventures and later
learned much from reading Ibsen and Humsun and studying the paintings
of Munch. It is indeed an honour now to visit the land, which fostered
these great men, who made such a remarkable contribution to
understanding between peoples and also understanding of the human
psyche.
My
wife and I live on the east coast of Scotland in a small village where
the Norwegian Air Force was based during World War II. At our small
harbour stand two laburnum trees, erected in 1944 alongside a plaque,
which commemorates the alliance between our two countries. This
old alliance makes my visit here today doubly meaningful and
significant, since collaboration, co-operation and comradeship will be
central to the thesis of my paper.
Care And Treatment
The
philosophical basis of effective psychiatric care and treatment is a
vast subject, especially within the context of the many influences of
age, sex, social and cultural factors on the problems of human living,
which we call mental illness or psychiatric disorder. Given the theme
of this conference I have chosen to focus on issues concerning
personhood and implications for the development of personally
appropriate, or person-centred, care and treatment. I hope to
illustrate my philosophical position by reference to my work with the
Tidal Model of mental health recovery.
People
with so-called mental illness or psychiatric disorder are commonly
assumed to be in need of ‘care and treatment’. However, if there exists
general agreement as to the meaning of ‘treatment’, the exact meaning
of the term ‘care’ remains unclear. Traditionally, nursing has been
associated with care, but psychiatric nurses have made only limited
attempts to define or explicate the concept of caring (Barker, 1989;
2000a) often choosing instead to follow the fashions of the day,
whether this be applying the various technologies of psychiatric
medicine or psychology, or – as Clarke has noted – simply ‘policing the
mad’ (Clarke, 1999).
British
and North American nurses have been the most prominent voices of the
emerging discipline of psychiatric nursing. In the USA, in the 1960s,
the humanistic focus of psychiatric nursing (Travelbee, 1969), heralded
the emergence of the therapeutic alliance, consumer/user-collaboration
and the principle of empowerment, all of which have now become part of
the contemporary psychiatric language. Arguably, these all had their
origins, at least within nursing, in Peplau’s (1952) interpersonal
relations theory. However, in recent years this humanistic emphasis has
been overshadowed by the focus on professional-ism, which threatens to
remould nursing further in the image of medicine, largely to satisfy
the demands of economic rationalism required by the healthcare
‘business’. In the USA, and more recently in the UK, this takes the
form of nurses acquiring specific ‘skills’: for example in the use of
cognitive-behavioural methods, to foster compliance with medication
(Kemp et al, 1997) and more generally compliance with the goals of
psychiatric treatment or the ‘care programme’. Despite the emphasis
given to the emerging rhetoric of partnerships and collaboration, in
practice much mental health care still stands in the shadow of
psychiatric medicine.
Power, Disempowerment and Empowerment
For
at least a century psychiatry has promoted the idea that various
psychological, social and emotional problems of living are a function
of some underlying (but as yet unidentified) biological pathology. This
provided a rationale for a huge range of psychiatric treatments - from
insulin coma, through electro-convulsive therapy (sic) to neuroleptic
medication. Forty years ago Thomas Szasz
began his radical critique of what he saw as the medicalisation of
‘problems of living’(Szasz, 1961). Although medicine has strenuously
resisted such criticisms, by re-framing the various mental ‘illnesses’
as forms of ‘mental disorder’ the American Psychiatric Association
appears to have accepted that the search for a wholly biological,
causal explanation for all forms of mental illness may be impossible.
History may suggest that this represents a subtle, but significant,
capitulation to Szasz’s critique.
Szasz’s
emphasis of the metaphorical status of mental illness is, however, only
one dimension of the movement, loosely called ‘critical psychiatry’,
which challenges mainstream psychiatric thinking on a range of gender,
race, culture and scientific issues, all with implications for the
practice of mental health care (Newnes et al, 1999).
The social construction of mental illness, especially through the diagnostic process, has long been the subject of debate (e.g Conrad, 1992; Daniels, 1970; Farber, 1987). However, Kirk and Kutchins (1992; 1997) made the original observation that the repeated revisions and additions to the DSM were not initiated by working clinicians, but stemmed from the influence of the census, medical groups, the army or psychiatric researchers. In effect, the ‘good clinician’ knows that however many diagnostic categories are available, the resolution of the person’s problems (of living) must begin with seeking to understand rather than simply classify the ‘patient’.
Aside
from concerns about the reliability and validity of psychiatric
diagnosis (Kirk and Kutchins, 1992) the narrowness of the diagnostic
approach is problematic. As Laing (1967) noted: “it is an approach that
fails to view persons qua persons, and degrades them to the status of
‘objects’”. Almost forty years later, psychiatry’s failure, in general,
to try to understand people and the critical role of the creation of
meanings within the therapeutic relationship, remain enduring concerns
(Kismayer, 1994; Modrow, 1995).
Such
concerns led Grob (1983) to describe psychiatry as a political and
professional ‘movement’ - rather than a scientific enterprise concerned
with caring for people who were definably ‘ill’. Beverly Hall, the
distinguished North American nurse argued that psychiatric diagnosis,
and a narrow medical model, served only to disempower people, rather
than to help them. Their adverse effects upon nursing practice led Hall
(1996) to argue for the recognition of human values over ‘objectivity’
in mental health care. In a related vein Dumont (1984) exposed the
fallacious distinction between illness and wellness in Western thought,
suggesting the urgent need for a paradigm shift in the
conceptualisation of ‘mental illness’.
However,
psychiatry has a remarkable capacity to shrug off its many critics,
whether philosophical, scientific, social or political. Despite being
the butt of many popular jokes, at the beginning of the 21st
Century, psychiatry retains its patriarchal power (Barker and
Stevenson, 2000). This is illustrated by the number of people around
the world who continue to be hospitalised, or required to accept (often
dangerous) psychiatric treatment, (many against their will), for an
‘illness’ or ‘disorder’ for which there exists no definitive empirical
‘test’. Neither should we forget the cruel irony in the fact that:
“Psychiatrists,
of course, do ask for tests such as CT scans on their patients, but
these are to exclude the possibility of brain damage. In other words,
they are checking to see if there is a real brain problem, evidence of
illegal drug use or whatever. Once they have concluded that there is
nothing demonstrably amiss with the patient's brain or biochemistry,
they tell the person that they have a condition that results from a
biochemical problem. But they don't have a test that could prove a
so-called mental illness was actually organic in origin (Newnes, 2002)”.
The
idea of people taking (or being required to take) powerful drugs, with
multiple deleterious ‘side-effects’, for a physical condition – like
cancer or diabetes – in the absence of a diagnostic test, would be seen
as ludicrous if not morally suspect. That so many people, in most
Western cultures, readily accept this state of affairs, and that so
many nurses – traditionally defined as their carers, if not ‘advocates’
– enable this system, attests to the enduring supremacy of traditional
psychiatric treatment in contemporary mental health care.
Colonisation and Power
For over 30 years Szasz has used slavery as the choice psychiatric icon (Szasz, 2002).
“The
psychiatric profession has, of course, a huge stake, both existential
and economic, in being socially authorized to rule over mental
patients, just as the slave-owning classes did in ruling over slaves.
In contemporary psychiatry, indeed, the expert gains superiority not
only over members of a specific class of victims, but over the whole of
the population, whom he may ‘psychiatrically evaluate’.(Szasz, 1974:
135).
In
Szasz’s view, any form of involuntary hospitalisation is a ‘crime
against humanity’, and the practice of psychiatry echoes the
fundamental human rights violation perpetrated by slave-owners, who
also justified their practices as being, somehow, in the ‘best
interests’ of the childlike, primitive, or otherwise enfeebled ‘negro’. In this sense, Szasz was the first writer to explore psychiatry’s colonisation of the self.
Psychiatric
power has long been invested in the number of patients held by the
psychiatrist and - in descending order of importance - the
psychologists, nurses, support workers and various ancillary staff
responsible for ‘treating’ or ‘caring’ for the patient. With the advent
of de-institutionalisation, people who once were patients have become,
at least in principle, citizens again. However, in Szasz’s view, for
the majority, who were transferred into various forms of state-funded
support, all that was achieved was that “they are now maintained like
pets rather than being locked up in the zoo” (Szasz, 2000). Those
who once were slaves – made to work in hospital laundries, farms and
wards for their keep, and who were paraded, and made to undress
emotionally, before ogling students, to reinforce the mastery of the
doctor – have now escaped and have found their free voice in the
community. Or have they? Autonomy remains as elusive as ever.
Foucault
(1980) argued that all healthcare workers – whether involved in direct
care and treatment or in research – contribute to, and are part of, the
dominant discourse, which privileges some experiences, and labels,
dismisses, and marginalizes others. Indeed,
the emphasis of the dominant discourse of psychiatry on interpreting,
labelling, and ultimately silencing, the voices of many of the people
in our ‘care’, is the stock in trade of our practice.
The Potential of Post-psychiatry
Some
psychiatrists, like Bracken and Thomas in England, suggest that we are
moving to a ‘post-psychiatry’ position, which acknowledges the
relativism inherent in all social constructs – like illness and
wellness. However, before we can talk seriously about ‘postpsychiatry’
(Bracken and Thomas, 2001) we need to give up the use of the empty, but
damaging, nosology of the DSM and ICD; we need to stop administering
psychoactive medications against a person’s expressed wishes; and we
need to eschew the use of the detention powers inherent in our Mental
Health legislation.
Around
the world, most psychiatric nurses now call themselves, mental health
nurses. It is axiomatic that if psychiatric nursing wished to enact
genuine mental health nursing it would need to begin to dismantle its
involvement in detaining, containing and otherwise controlling people
in mental distress, and begin to construct a more formal discipline
focused on nurturing mental health. Clearly, making an actual, as
opposed to cosmetic, change to the practice of psychiatric nursing will
be difficult. Indeed, under some social and political restraints, the
development of genuine mental health nursing may prove impossible.
Nurses may be obliged to be ‘keepers’ of the mentally ill, as they have
been for generations.
These coercive dimensions of contemporary psychiatric practice are linked to the colonising power of 19th
Century psychiatry, as Szasz – and historians like Scull – have
suggested (Scull, 1979), which generated a more subtle, but no less
powerful paradigm of social control(Leifer, 1990; Robitscher, 1980;
Schrag, 1978). The
colonisation literature in psychiatry remains limited, focusing mainly
on the after-effects of colonisation – as a socio-cultural phenomenon –
especially featuring the ‘mental health’ of indigenous peoples, like
the Australian Aborigine, the Maori or the Native Americans (Deiter and
Otway, 2001; Samuels, 2000). However, the concept of the ‘colonisation
of the self’ also finds an echo in the literature on oppression
(Bulham, 1985) or the more specifically in feminism (Hawthorne and
Klein, 1999). Szasz challenged psychiatry to confront its failure to
address the persecution and exploitation, inherent in its supposedly
humanitarian ‘care and treatment’ programmes (Szasz, 1994). In that
sense, he re-located the ‘mentally ill’ alongside other ‘dispossessed’
persons, whose core identity had been demeaned or misappropriated:
notably women and all non-white/ non-Christian peoples. For all such
peoples, self-determination lies at the core of their struggle to
recover their full human status (Alves and Cleveland, 1999).
Recovery – the Conspiracy of Hope
This
prompts us to ask - how do people, who have been diminished by the
disabling experience of mental ill-health, stigma, and often
inappropriate care and treatment, begin to recover their full human
status. This question should be the paramount consideration for any
mental health professional who aims to develop a quality service.
Moreover, without such a focus, any emphasis on productivity and
efficiency would surely be worthless.
Dr
Patricia Deegan emerged from the experience of seven years of
hospitalisation and treatment for schizophrenia, to become a
psychologist and, arguably, the leading voice in the recovery movement.
She wrote:
“The
goal of the recovery process is not to become normal. The goal is to
embrace our human vocation of becoming more deeply, more fully human.
The goal is not normalization. The goal is to become the unique,
awesome, never to be repeated human being that we are called to be. The
philosopher Martin Heidegger said that to be human means to be a
question in search of an answer. Those of us who have been labeled with
mental illness are not de facto excused from this most fundamental task
of becoming human. In fact, because many of us have experienced our
lives and dreams shattering in the wake of mental illness, one of the
most essential challenges that faces us is to ask, who can I become and
why should I say yes to life? (Deegan, 1996a)”
The end of the 20th
Century witnessed a rebirth of anxiety over the moral and ethical basis
of psychiatry, if not also its scientific validity (Bracken and Thomas,
2001). Some psychiatrists began to acknowledge openly the inherent
‘ideology’ of psychiatric medicine. Schaeff (1992), an American
psychiatrist, described how her training instilled assumptions about
‘treatment’, which required patients to adjust themselves to fit ‘into
an addictive, sexist, racist, self-destructing society’. In the UK
Double (2002) acknowledged that biomedicine directs psychiatrists away
from understanding the patient as a person, reducing her/him ‘to a
brain that needs its biology cured’. Although George Engels’ (1977)
original biopsychosocial model has at last found its way into the
parlance of contemporary psychiatry, often this is used merely to oil
the wheels of the traditional psychiatric process. However, the various
critiques of psychiatric treatment and its fundamental theoretical and
philosophical base have stimulated, if only indirectly, the emergence
of the recovery movement, which has even begun to influence government
health departments like that of England and Wales (e.g. Department of
Health, 2001). However, the concept of recovery begs the fundamental
question: “what is psychiatry actually needed for?”
In
Deegan’s view recovery does “not refer to an end product or result” or
that “one is ‘cured’ (or even) that one is simply stabilised or
maintained in the community” (Deegan, 1996b). Rather,
“recovery often involves a transformation of the self wherein one both
accepts one’s limitations and discovers a new world of possibility
(Deegan, 1996b)” In that sense people do not ‘get rehabilitated’, since
this implies that they are passive objects being manipulated – or at
least shaped – by the forces of the rehabilitation programme. This is
one particular connotation of the word rehabilitation that Deegan finds
“oppressive”.
Deegan
rejects the view that there can be such a thing as a “hopeless case”,
acknowledging that ‘giving up’ is often a way of surviving in
environments that are oppressive and which fail to nurture and support
the person. When Marie Balter was asked: “Do you think that everybody
can get better?” she replied
“It’s
not up to us to decide if they can or can’t. Just give everybody the
chance to get better and let them go at their own pace. And we have to
be positive – supporting their desire to live better and not always
insisting on their productivity as a measure of their success”. (Balter
and Katz, 1987: 153)
In
Deegan’s view Balter was acknowledging the need for a conspiracy of
hope - developing the concept of developing ‘power with’ or ‘creating
power together’, eschewing the traditional power we exercise over
people (Miller, 1976). The English word conspiracy derives
from the Latin conspirare, meaning to ‘breathe the spirit together’.
This suggests one arm of the philosophical attitude necessary for
enabling the development of the recovery ethos.
The Tidal Model: An alternative paradigm for ‘caring with’.
The Tidal Modelâ (Barker,
2002) is a model of mental health recovery, which I developed between
1995-1998, drawing from a series of my research studies, which had
focused, initially, on the ‘need for psychiatric nursing’ (Barker et
al, 1999) and the discrete nature of the power-relationship between
nurses and the people in their care (Barker et al, 2000). The Tidal
Model acknowledges that the various phenomena, which we call ‘’mental
illness,’’ can be viewed through different theoretical lenses. However
the model asserts the virtue of viewing such phenomena, primarily, as
problems of living that can delimit the effective functioning of the
person on various intrapersonal, interpersonal, transpersonal levels.
The Tidal Model employs a pragmatic and respectful approach to the
person recognising, as Alanen and his colleagues in Finland (1991) did
in the 1990s, that it is important to help people and their families
conceive of their situation “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( Alanen et al,1991)”. By emphasising the centrality of the
lived-experience, of the person and her/his significant others, the
Tidal Model emphasises the need for mutual understanding between the
nurse and the person in care. As a result, the possibilities for a
personally-appropriate, contextually-bound form of care, are
established.
Originally
introduced in to acute care settings (Barker, 1998), the Tidal Model
has since developed the concept of a 'care continuum', with 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. These represent
different, hypothetical stages of the care 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 may 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. Like Deegan, I believe it
is essential to begin by trying to find out who is the person who has
become the patient, and who might this person become, given the right
kind of care and support.
The
Tidal Model gives specific emphasis to ways of revealing and clarifying
meanings and values, which the person attaches to, or associates with,
her or his 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 each instance, however, the constructions
of the person’s experience of personhood are realised through mutual
discussion, and all assessments and care plans are acts of co-creation,
between the person in care and those supporting her/him. My colleague,
Irene Whitehill and I originally called this the process of ‘caring
with’ (Barker and Whitehill ,1997).
The Process of Change
Unlike normative or adaptational psychiatric models, the Tidal Model holds no assumptions about the proper
course of a person’s life. Instead, it focuses on the kind of support
that people believe they need now, to take the next step on their
recovery journey. The metaphorical language of recovery and journey is
emphasised since, as Deegan (1996a) and others (Barker et al, 1999)
have illustrated, the process of entering, surviving and recovering
from seriously disabling life crises, is invariably expressed in
metaphorical terms. This is the language of everyday reality. This is
how most people talk of their private experiences – whether of wellness
or illness, happiness or sorrow, achievement or loss. This emphasis on
the rich metaphors that people use to describe such experiences differs
markedly from the often vacuous jargon of psychiatric medicine or
nursing diagnosis (Barker, 2000).
The Metaphor of Madness
People
experiencing 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), 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 (or psychiatric rescue)
followed, at an appropriate interval, by the kind of developmental work
necessary to engender true recovery. Such ‘rescue’ may take the form of
crisis intervention in community or the ‘safe haven’ of a crisis house.
In nursing terms, 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).
Currently,
there exists a vogue for protocols and standardised care packages,
which are administered to groups of patients with common diagnoses. By
contrast, the templates for assessment and intervention contained
within the Tidal Model serve only as a springboard for the creative,
conjoint exploration of the person’s need for nursing. It
is assumed that, although people may share similar needs, a genuinely
person-centred approach must begin with the assumption that the
person’s needs are unique and, as such, require a uniquely focused care
plan.
The
model also recognises that – like the tides – the person’s needs are
constantly flowing and changing. Consequently, any care plan needs to
be provisional and inherently flexible, in recognition of the
inherently chaotic nature of human behaviour, and human experience
(Barker, 1996); something that is bounded but infinitely changeable.
Nothing but Stories
Traditional
psychiatric practice – whether in medicine or nursing – is
characterised by what Buber (1958) called the I-it relationship. The
person who becomes the patient is cast as the ‘other’ and the person
who is the professional invariably adopts a powerful position over the
‘other’. Oliver Sacks articulated clearly the importance of moving away
from such an “I-it” when he wrote:
“To
restore the human subject at the center – the suffering, afflicted,
fighting, human subject – we must deepen a case history to a narrative
or tale; only then do we have a ‘who’ as well as a ‘what’, a real
person, a patient, in relation to a disease – in relation to the
physical…the study of disease and identity cannot be
disjoined…(stories) bring us to the very intersection of mechanism and
life, to the relation of physiological processes to biography (Sack,
1970, p.viii).
The Tidal Model assumes that people are
their narratives (MacIntyre, 1981). All that we have to work with is
the ongoing story of the person’s life – a story which unfolds, and to
which we gradually gain access, as the person acts as the biographer of
her or his own life experience. 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 (Casey
and Long, 2002). The Tidal Model seeks to construct a narrative-based form of practice (Barker and Kerr, 2001), which differs markedly from most contemporary forms of evidence-based practice.
The narrative approach accepts that the person’s experience is singular
and unique, whereas the evidence-based approach emphasises abstractions
from the behaviour of large numbers of anonymous people, within
research populations, whose features are merely assumed to be
equivalent.
The
narrative focus of the Tidal Model is not concerned to unravel the
causative course of the person's current problems of living, but rather
aims to use the experience of the person's journey and its associated
meanings, to chart the 'next step' - what needs to be done to help the
person make progress on the life journey.
In my own voice
As
part of this conjoint exploration of the person’s lived 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. The nurse and the person in care co-create a narrative
account of the person’s immediate world of experience This includes the
identification of what the person believes (s)he needs, at that moment, in terms of nursing intervention, and what ‘needs to happen’ to meet that need (Barker, 2002).
In
the course of mental health care and treatment it is commonplace for
nurses to note that people 'change their stories'. Within the
philosophy of the model, 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). Cixious (1993) noted:
“I’ll tell you frankly, that I haven’t the faintest idea who I am, but at least I know I don’t know (p51).
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.
Extending
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
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 or context. The story recorded at the first holistic
assessment, becomes the opening page of this particular chapter of the
life 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 Conspiracy of the Hopeline
The experience of mental ill health is inherently disempowering. Although often described as offering mental health care,
psychiatric services often focus only on limiting the personal and
interpersonal damage resulting from problems of living. In so doing,
they often compound the original disempowerment scenario. 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 person’s story is plundered to provide the necessary
materials for the psychiatric formulation, and the consequent
‘intervention’. Frequently this begins with the requirement that the
person abandon his or her own story of human distress, in favour of the
professional perspective – especially that framed by diagnosis. Contemporary
practices like psychoeducation are examples of how professionals
require the person not only to abandon their own story, but to convert
(like a religious recruit) to the psychiatric story, complete with its
principles, assumptions and language. The parallels with colonisation
are apparent.
Drawing on personal experience, Deegan (1996b) described the colonising psychiatric influence at work when:
“Professionals said we were making progress because we learned to equate our very selves with our illness. They said it was progress because we learned to say “I am a schizophrenic”…and each time we repeated this dehumanising litany our sense of being a person was diminished as ‘the disease’ loomed as an all powerful ‘it’, a wholly Other entity, an ‘it-itself’ that we were taught we were powerless over.”
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 a person’s life experiences
(which is in constant flux), and the immediate need-for-nursing (which
also is subject to change). By incorporating understandings of 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. Using another metaphor, the person is ‘in
the driving seat’. 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). These suggest the presence of a ‘hopeline’ that might
link the person, metaphorically, to the supportive environment where
(s)he might begin to feel secure enough to begin the recovery process.
Research and Development
The Tidal Model is presently the subject of a range of evaluations in several countries – Japan, New Zealand, Ireland and Canada as well as the UK. Two extensive evaluations of the implementation of the model, across an Adult Mental health programme in Newcastle, England, have been reported (Fletcher and Stevenson, 2001; Stevenson, Barker and Fletcher, 2002) and a user-focused evaluation of the direct experiences of care by service users, also has been completed (Stevenson, Barker and Fletcher, 2002). Given the pragmatic, collaborative nature of the model, it lends itself best to process evaluation. However, preliminary evaluation has also suggested some of 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. There are also indications that by emphasising the need to develop care ‘in vivo’ with the patient, the nurse saves time, which would normally have been spent in the office, writing up a report on the interaction. In this sense, the emphasis on collaboration has generated some productivity gains for the nursing team.
Conclusion
My
friend, Simon Champ, an Australian artist with over 20 years experience
of treatment for schizophrenia (2002) described the frustrations felt
by consumers of mental health services, at their lack of involvement in
research:
“The
colonisation of consumer experience begins with the problem of research
agendas that, for the most part, are not determined by the consumers
themselves. An example that illustrates this is in the area of recovery
from schizophrenia. When consumers are asked what aids recovery, high
on their list is ‘the need for hope’. This clearly is seen as a key to
recovery by consumers but rarely rates in research agendas (p24)”.
Arguably,
the exclusion of consumers from decision-making within research teams
is the least of their problems. Despite the burgeoning rhetoric of
social inclusion and partnerships (Meagher, 2002) many users/consumers
still are maintained in a dependent position by the psychiatric system
(and its social services allies). Indeed, one of the clearest examples
of the success of the colonising influence of psychiatry and psychology
is the way that people often narrate their difficulties as
psychological problems, rather than simply as aspects of their lives.
In Rogers’ (1995) view psychology and psychiatric medicine continue to
represent domineering systems for encoding and treating human beings.
Despite
the evidence of independent research, which suggests that
users/consumers value nurses more highly than any other mental health
discipline (Rogers et al, 1993), nurses appear to have difficulty in
accepting such approving statements concerning the value of care. At
the same time the recovery literature embraces powerfully the concept
of care and the human values associated with human caring, seeing these
as essential environmental prerequisites for the commencement of the
recovery journey.
Jean Vanier (1988) talked of the value of “accompaniment” – walking, metaphorically, with people as they make the painful journey necessary to reclaim their lives and, arguably, their human selves. Contemporary psychiatry may be working hard to reform itself but the shadow of psychiatric colonisation still hangs over us all. To foster genuine alliances with people who have been doubly disempowered – by their distress and the psychiatric process – we need to demonstrate our willingness to walk with them, to value and respect their narrative and to learn from them what might need to be done to help further their recovery.
In
conclusion, we might remind ourselves of the importance personal
experience, for developing our understanding of our selves, and
communicating this to others. Ibsen wisely wrote:
"...
And what does it mean, then to be a poet? It was a long time before I
realized that to be a poet means essentially to see, but mark well, to
see in such a way that whatever is seen is perceived by the audience
just as the poet saw it. But only what has been lived through can be
seen in that way and accepted in that way. And the secret of modern
literature lies precisely in this matter of experiences that are lived
through. All that I have written these last ten years, I have lived
through spiritually
This
captures the spiritual essence of the narrative. If we can develop ways
of helping people to relate the story of their mental distress, they
may not only help us to see more clearly that which they have lived
through, spiritually, but this story may also provide them with the
beginnings of an attempt to understand their predicament. It may also
help them begin to come to terms with, or overcome, the human problems
that have blighted their lives.
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