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Uncommon Sense: The value base of the Tidal Model | ||||
| Poppy Buchanan-Barker, 2004 | |||
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It
is just over five years since the publication of the first report on
the Tidal Model (Barker 1998). Since then nurses from all four corners
of the globe have begun to express interest in this alternative model
for mental health recovery. What began as a
local attempt in Tyneside to re-focus acute mental health nursing care,
has developed into recovery paradigm for the whole mental health
continuum, proving attractive to staff in both hospital and community
settings, working with older and younger people alike (Barker, 2002).
By far the commonest comment received through the Tidal Model website
is – “this reminds me why I came into nursing in the first place”. The
Tidal Model develops Peplau’s original emphasis on the nurse-patient
relationship (Peplau, 1952) to include an appreciation of the chaotic
nature of change, which is the only true constant (Barker, 1996). The
Model emphasises ways that nurses might help people in their care
become aware of the small changes which are occurring to them, and through
them, as part of their everyday reality. Most importantly, the Model
emphasises pragmatic ways that people might learn ‘what works’ for them
and why. Such ‘personal wisdom’ represents the basis of the
person’s recovery – the knowledge they will use to navigate the
metaphorical storms of the recovery voyage. International Developments By
the beginning of 2004 almost 100 formal Tidal Model projects had been
established worldwide. Most of these projects are in England, Wales and
Scotland, but exciting developments are also happening abroad. Nurses
in the Irish Republic were the first to introduce the Model into
community care – first within a day hospital project and then in a
Primary Care setting at Tosnu – Gaelic for ‘a fresh start’ -, attached to a health centre in Cork city. In New Zealand, nurses at the Rangipapa forensic
service in Porirua have been developing their care around the Tidal
Model for almost three years and were the first forensic service in the
world to adopt the model. The Tidal Model’s emphasis on narrative has
proven particularly attractive to the indigenous Maori and Pacific
Islands people, who greatly value the power of story telling. In
Canada, nurses at the Royal Ottawa Hospital have implemented the model
across most of their services, including their substance abuse
programme – both residential and community. This represents the first
use of the model with people with drug and alcohol related problems.
The Royal Ottawa Hospital has developed a specific curriculum for
teaching the model and one of the graduate students has developed the
model for use in family work. Finally, in Australia there is
considerable interest in using the model within palliative care. The
model’s focus on the ‘here and now’ of everyday experience aims to
identify the conditions necessary for promoting what the person would
call a ‘good life’. Naturally, the same process is possible for
promoting the idea of a ‘good death’, which is the culmination of the
‘good life’. A Philosophy of Constructive LivingAlthough
the Tidal Model has led to the development and adaptation of specific
‘tools’ of assessment and care delivery, it is essentially a
philosophical approach to mental health care. The Model emphasises the
fact that the individual nurse is the key ‘tool’ that might begin to
unlock the person’s potential for recovery. The principles upon which
the Model is based, and the various principles for its practice are,
like all theories, merely ‘ideas on paper’. The Model assumes that
knowing ‘how’ to aid recovery is more important than simply knowing
‘that’ recovery is possible. Consequently, the focus is always on the
recovery attitude and the infinite range of possible practices that
might flow from such an attitude. Regrettably,
in much contemporary nursing practice the emphasis is on
‘documentation’ and other forms of paperwork, which can dominate the
nurse’s field of vision. Most of these paper templates derive from
legislation or come via some other ‘top down’ route. Not surprisingly,
the point of these paper exercises is often either lost or
unclear to the practitioner, far less the person in care. In the Tidal
Model the paperwork is seen as similar to the ship’s log: merely a
record of the journey that has been taken and the various events that
have occurred en route. The record is merely an attempt to capture some
of the attempts that have been made, to help the person begin or
undertake the voyage of recovery. The Tidal Model developed from practice research into what people needed nurses for: what do people and their families value in nurses? –what do nurses do
that appears to make a difference? (Barker et al 1999). Related
research on the dynamics of empowerment (Barker, Leamy and Stevenson,
2000) helped develop further our understanding of how the nurse and the
person (and/or family) could become a team – working together to
identify and enact the necessary steps on the road to recovery. At
its heart, the Tidal Model is an attitude to caring for people in
mental distress and their families. Without the mind set the technology
is worthless. This is clearly one of the most challenging features of
the Model, especially for the ‘novice’ practitioner. In the current ‘evidence-based’ culture of health care, there is an assumption that certain processes or procedures either work
or don’t work. This may be partly true of some medical interventions –
such as the effects of drugs or ECT, which act in a physical manner.
However, even here the ‘placebo’ can account for at least some of the
change effected (Evans, 2003). It is important to emphasise that the
Tidal Model per se does not work. The practitioner is the
instrument or medium of change. If the practitioner does not have the
capacity to use the Model appropriately and creatively, then the practitioner will likely generate disappointing results. . However,
this is true of all ‘therapies’ and approaches involving interpersonal
interaction (Hubble et al, 1999). For many nurses, the opportunity to
exercise their creativity whilst honing their existing interpersonal
skills is one of the attractions of the Model. The
Model embraces very specific assumptions about people, their experience
of problems of living and their capacity for change. These values –
which I called the Ten Commitments – probably represent the key
attraction for nurses who are more interested in helping people make
their own changes, rather than trying to manage or control patient
symptoms (Barker and Buchanan-Barker, 2004).
In
keeping with these values, the Tidal Model avoids cumbersome jargon,
cherishing ordinary language, especially the person’s natural voice.
The Model is focused on what needs to happen for people to feel that
they are moving forward in their lives. This emphasis on ‘constructive
living’ embraces the belief that we all are in a constant process of
change, albeit one involving often highly subtle changes. What we need
to do is to navigate the process of change – steering ourselves, and
the ship of our lives, through our ‘sea of troubles’ in a constructive
direction. Reclamation: In Our Own VoiceTraditional
psychiatric care often diminishes the person’s voice, especially by
over reliance on diagnostic jargon (Kirk and Kutchins, 1997).
Regrettably, many people have come to talk about themselves using the
technical terminology of psychiatry and psychiatry, as if their own
story – spoken in the vernacular – was not good enough (Buchanan-Barker
and Barker, 2002; Furedi, 2003). This suggests how the narrative of all
our lives has been colonised by psychobabble (Barker, 2003). The Tidal
Model recognises that people’s ‘lived experience’ is understood best in
their natural language – using the metaphors and grammar that fits most
easily with the way they naturally talk about such experiences.
Consequently, the Tidal Model focuses on helping people reclaim the story of their distress and, ultimately, that of their whole lives. Increasingly, we have called this approach recovery and reclamation.
In much the same way that land that was once submerged by the sea, is
reclaimed for use as part of the mainland, so that part of the person’s
life, which was submerged – and invalidated – by the effects of mental
distress, may be reclaimed to become part of the whole person. The
first practical step in aiding this process of reclamation, is to write
all the main assessment ‘stories’ and care plan action, in the person’s
own voice; instead of translating the story into the third person of
professional note-taking. This emphasis on ‘my story’ – as opposed to a
professional interpretation – is probably the aspect of the Model that
most appeals to service users and may well be the most unique feature
of the Model. Certainly it is the most dramatic illustration of the
nurse’s desire to work actively with the person, in co-creating
the story of the need for care. As the American mental health advocate,
and psychiatric survivor, Sally Clay has said: “The
Tidal Model makes authentic communication and the telling of our
stories the whole focus of therapy. Thus the treatment of mental
illness becomes a personal and human endeavour, in contrast to the
impersonality and objectivity of treatment within the conventional
mental health system. One feels that one is working with friends and
colleagues rather than some kind of “higher-up” providers. One becomes
connected with oneself and others rather than isolated in a
dysfunctional world of one’s own” (Clay, 2004). The Evidence of Human CaringThe
person’s story contains not only the details of circumstances, which
led to the need for help in the first place, but also holds the promise
of what needs to be done, to address the ‘need for nursing’. By
beginning to talk about what is ‘wrong’ and what might be done to
‘right’ it, the person begins to give birth to what needs to happen
next. If this is not an actual solution, it will at least represent a
constructive step in the direction of finding a solution, or beginning
to live with these problems of living. For this reason, talking,
conversation and discussion are the key ‘tools’ of the Tidal Model. Although
influenced by different schools of psychotherapy the Tidal Model is not
a form of psychotherapy or counselling. As a therapist and counsellor
myself, I believe that it is more important than that! It involves live
conversation – the natural process through which, as Sally noted, people discover more of themselves through discourse with others. A
common story told by people on the receiving end of the Model is that
“it doesn’t feel as if I am being treated; it just feels as if someone
is listening to me”. Perhaps because nurses
are often viewed as very different from therapists, they have an
opportunity to establish different working relationships with the
people in their care. The Model emphasises ‘ordinary’ conversation as
the medium for identifying where the person is ‘at’ and what needs to
be done to move forward. Most nurses – and the various ‘assistants’,
‘aides’ and others who support them – do not have formal
psychotherapeutic training. However, my experience is that this does
not prevent nurses from being able to transform the ‘ordinary’ into an
‘extraordinary’ and powerful form of helping. In
their role as ‘patients’ people possess the deepest and most extensive
knowledge of what it is like to be in need of nursing care. The primary
task facing nurses – and other members of the helping team – is to
learn from the person what needs to be done, to address or meet
their need. The Model has borrowed the use of this term – ‘doing what
needs to be done’ – from the work of the Japanese psychiatrist, Shoma
Morita, who over 80 years ago began to develop a form of ‘constructive
living’ therapy, influenced by Zen Buddhism and the principle of
acceptance of change (Morita et al, 1998). The conjoint work of the
nurse and the person in care is to negotiate what really needs to be
done now, to address or respond to the person’s current problems of
human living. Within such collaboration nurses may set the stage for
the drama of care, and act as sophisticated ‘stage hands’. However,
ultimately the person is the key actor and scriptwriter – the star of
the whole show. Believing in NursingResearch
over the past decade provides evidence that service users and their
families’ value nursing and nurses (Barker et al, 1999; Rogers, Pilgrim
and Lacey, 1993). However, as a discipline
nursing still appears to struggle to assert its professional identity.
Psychiatrists, psychologists and other therapists often only have
fleeting or highly selective contact with service users – engaging in a
form of psychiatric ‘hit and run’. Yet these are the disciplines, which
dominate the public story of mental health care. Maybe the public have
come to believe in the importance of these disciplines, because they
believe so strongly in themselves. Despite their strength in numbers –
accounting for at least 60 per cent of the mental health workforce, and
often more than 90 per cent of professional contact time – especially
in residential care – nurses remain marginal figures in the politics of
mental health. However, within the Tidal Model nurses are the ‘ordinary
seamen’ on the good ship Recovery – the key crewmembers who will help
the person in care navigate towards the possibility-land of recovery.
On such a metaphorical ship the Captain is not the psychiatrist, or psychologist, locality manager or social worker, but is the person in care. In this highly scientific and technological age it is almost taboo to talk of belief far less faith. Faith can move
mountains, and represents a critical factor in recovery. People need to
believe that recovery is possible. Similarly, professionals need to
believe in the person’s capacity for recovery if this is to happen.
However, nurses need to believe in themselves as vital crewmembers on
the person’s voyage of recovery, if their value is to be fully
realised. Sadly, many nurses appear dispirited and struggle to express
their belief in their therapeutic potential. However, people like Sally
Clay who have made the recovery journey, are in no doubt as to the
value of the ‘extraordinary ordinariness’ of genuine nursing. If a
revolution in mental health care is taking place within the Tidal
Model, this involves nurses re-discovering the value of nursing as a
therapeutic practice in its own right. Interdisciplinary
teamwork is important, but ultimately will prove ineffective if nurses
– the core members of any team – do not believe in themselves, and
their capacity to enable the process of recovery. This talk of faith
clashes somewhat with the rhetoric of evidence-based practice, with its
assumption that there might be one method, which might be the ‘best’
way to work with all, or at least most people. The wisdom of common
sense tells us that people vary greatly. What ‘works’ for one person
will not work for another. Often what ‘works’ for one person, at one
moment, will not ‘work’ for them even a short time later. Effective
caring is about being sensitive to such subtle changes; building these
tidal rhythms into the flexible care the person needs. Good nursing
draws from a well of common sense that taps into the evidence of what
takes place between the nurse and the person in care. Often, this is so
rare, that it really should be called ‘uncommon sense’. This uncommon
sense is, at least, as powerful as the evidence of what ‘works’ for
people in general. The Virtues of NursingThe
Tidal Model is probably the first recovery approach, which grew
directly out of nursing research and was developed in practice by
practising nurses. We live in an era when nurses are being repeatedly
asked to convert to ‘multidisciplinary models’, to become this or that
kind of ‘therapist’, and even to consider the possibility that mental
health nursing might not survive, at least not as a discrete
professional discipline. These various threats to the nursing identity
are clearly part of the attraction of the Tidal Model, which reminds
nurses of their core value and offers a medium for developing and
extending the practice of a ‘genuine nursing of the mind’ (Podvoll,
1991). Most nurses’ experience of theoretical frameworks involve models
of nursing that were developed in university departments, far from the
‘care face’ of actual practice. That the Tidal Model was developed from practice-based research into psychiatric nursing, and is being developed in practice by practising nurses, seems to validate the discipline. As noted earlier, for many nurses nursing is not about
curing people or even fixing them. Politicians and tabloid editors may
want nurses to become gaolers, turn keys or community police. However,
many nurses want to return to the essence of nursing as a caring
discipline. Nursing involves – as Nightingale said - putting the person
in the right conditions to be healed by Nature or by God. The Tidal
Model accepts this as the essential heart of human caring: what do we
need to do to help put the person in the right conditions so that (s)he
might begin and continue the voyage of recovery? , It is heartening
that so many nurses are attracted to returning to the roots of their
vocation, re-engaging with the whole story of human distress and
recovery. The metaphor of the voyage of discovery of mental health, reminds us of the need to be pragmatic in planning care. It also reminds us of the healing potential of metaphor itself. When
we talk of ‘mental’ distress, words often fail us and so we resort to
metaphor. It is ‘as if’ we are drowning; it is ‘as if’ we have been
boarded by pirates. The voyage of care is also very much a metaphor. When
people are shipwrecked by the experience of mental breakdown, they need
a safe haven where they can rest before beginning the necessary repair
work, which will make them sea-worthy again. We all may have a general
understanding of what a ‘safe haven’ would be like, but genuine
person-centred care requires us to explore the specifics of what this
might be, for this person, at this point in her or his life. Once
people begin to find their ‘sea legs’ again, they will be ready to set
sail again on their ‘ocean of experience’. However, only the person can
tell us when they are ready’. Only the person knows where they were
headed when the disaster of the shipwreck struck. The experience of
psychic shipwreck often leads to a review of the person’s life, and a
serious change of plans for the next stage in the life voyage. Only the
person can approve these plans. The person was, is and will always
remain the Captain of the ship. This metaphor teaches us the most
important skill of all - professional humility. Pro-person not Anti-PsychiatryThe
Tidal Model makes a special point of avoiding the use of jargon and
especially endorsing the use of psychiatric and psychological
constructs of ‘mental illness’, preferring instead to talk of mental
distress or ‘problems of living’. This has led many people to ask if
the Model is ‘anti-psychiatry’. The
philosophy underpinning the Model finds little value in being ‘anti’
anything, except perhaps obviously objectionable things like abuse,
indignity, the infringement of human rights and other, more subtle
forms of disempowerment. Instead, it is ‘pro-person’. It
is interesting that many psychiatrists and psychotherapists find an
echo of their own caring disposition in the Tidal Model, and recognise
that the tide is turning in favour of the ‘pro-person’ approach. Dr
Tsuyoshi Akiyama came to the UK to study nurses practising the Model in
England and, on his return to Japan, translated all the available
training materials into Japanese, so that he could teach both his
psychiatrist and nursing colleagues in Tokyo. Dr Akiyama noted that: The
Tidal Model helps the patients to be aware of and accept themselves as
they are and it helps them to aim at changing at the same time. This is an interesting therapeutic contradiction. This
therapeutic contradiction coincides with much Chinese and Japanese
philosophy. The patriarchal model is fading away in Japanese mental
health care. Now it is legally required to
respect the patient’s right and to provide appropriate explanation to
obtain consent. Many Japanese psychiatrists are still not fully aware
of this change. They do not understand the
necessity and the value of healthy assertion, and do not appreciate
what the nurses can contribute in this task (Barker and Buchanan-Barker, 2004). Rather
than seeing this as a challenge, psychiatrists like Dr Akiyama view
this as complementary to their own work. Dr Jean-Claude Bisserbe is
Professor of Psychiatry at the University of Ottawa. Commenting on his
nursing colleagues’ adoption of the Tidal Model he said recently: “The
Tidal Model is an excellent approach. It parallels and enriches
physicians' clinical approaches with its assessment of the patient's
personal clinical picture. In our setting, it supports the move to a
research-based program. Nurses have a closeness in their
relationships with patients, and their involvement needs a framework
with goals and boundaries as offered by the Model. The Tidal
Model promotes nurses' self-confidence, fosters interaction, and
increases inter-disciplinary teamwork. The Personal Security
Assessment and Plan, especially for suicide is excellent, tactful, and
thorough. Nurses who practice within the Tidal Model don't need
anything more, it is enough”. (Barker and Buchanan-Barker, 2004). The
move towards the development of genuinely empowering and person-centred
forms of mental health care has begun, but there remains much to be
done to make this a reality for everyone in mental health care. As part
of its own contribution to the recovery paradigm, the Tidal Model has
covered a considerable amount of water in a very short space of time.
In the process, has seen the need to make several adaptations to its
working practices and to clarify further its philosophical focus. This
reminds us that the voyage of recovery is something that both
professionals and the people in care need to undertake. It reminds us
too that the voyage – not the destination – should be our primary
focus, if we are to stay on course. For
some professionals, the pragmatic humanism of the Tidal Model may prove
to be challenging. However, just as a lifesaver cannot execute a rescue
without getting wet, so the mental health professional must,
metaphorically, ‘get into the water’ with the person in distress, to be
of genuine assistance. For some professionals, the task of negotiating
the ‘psychiatric rescue’ and supporting the ‘necessary emotional
repairs’ needed before recommencing the voyage may prove too difficult.
Genuine psychiatric rescue and genuine mental health
discovery are not for the foolhardy, and certainly not for the faint
hearted. We all need to ask ourselves, what kind of a person, showing
what kind of commitment, would we want to be ‘there’ for us, were the
ship of our lives to founder on the rocks? The answer might tell us
much about the kind of mental health professional we need to become
ourselves, and need to facilitate in our students and colleagues. References
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