Troubling Mental Health Nurse Education

Alec Grant, PhD
30
154

Mental health nurse education in not sufficiently critical of institutional psychiatric practice. Its formal curricula in universities are often undermined by the informal curricula of practice environments. As an institution, mental health nursing pays insufficient attention to both these issues because it is an arguably un-reflexive and rule-following discipline.

I’ve been teaching mental health nurses in England for two decades. Over the years I’ve developed several inter-connected gripes about mental health nurse education and, by extension, mental health nursing more generally. I know that nurses are chronically complicit with scientifically compromised and morally dubious institutional psychiatric practices. It seems to me that undergraduate nurse teaching in the UK frequently supports this state of affairs in the form of delivering safe and bland, policy-endorsed curricula, and doing so in an uncritical way. In my view, both these things happen because, at a broad institutional level, mental health nursing is fundamentally a rule-following, insufficiently reflexive discipline.

As lead author, I recently co-wrote against the corporate construction of madness in a paper published in the international journal, Nurse Education Today (read it here). I stated the obvious in this article: that the biomedical paradigm in mental health is implicated in the corporate construction of psychosis with the pharmaceutical industry; that there are major conceptual and empirical problems with this construction; that the currently emerging and increasingly robust psychosocial paradigm changes the meaning of psychosis within non-medicalised approaches to recovery; that such changed meanings are fundamental to providing alternative values and evidence-based alternative interventions that take account of individual and community meaning contexts; finally, that all of this places a demand on mental health nurse education internationally to take a moral lead in revising its curricular and pedagogical practices.

I don’t think that anything I wrote in this paper is too controversial anymore. It’s simply a fact that the biomedical model and diagnostic ways of understanding something traditionally called ‘mental illness’ is unsupportable. The idea of gathering a large number of extremely distressed people together at once, in physical environments called ‘acute wards’, to be ‘treated’ by mental health workers has never had good press in the UK. For me, these spaces simply create possibilities for already damaged bodies to perpetuate unkindness on other bodies.

And yet I often feel totally at odds with many of my mental health nurse teacher colleagues locally and in different parts of the UK and beyond – the ones who don’t seem too concerned over the need to challenge the authority of such fundamental institutional assumptions and practices. In delivering curricula that has the seal of approval from the UK Nursing and Midwifery Council, they teach the ‘medical model’ as a legitimate way of understanding human misery, rather than as it should be taught in my view – as interesting social history. Such teachers often seem insufficiently aware of the demedicalization movement or the rationale for its existence. On reading my paper, one recently expressed surprise about the corporate role of global pharmaceutics in shaping the meaning and the vocabulary of ‘mental health’ problems. When he said ‘I have no idea that this happened’, I did a kind of double take: At first I was stuck for words. Then I remembered that I never stop being surprised about the fact that many of my colleagues are often surprised about this.

Some who read my paper responded rather defensively: ‘We do teach this stuff; it’s just that students don’t hear it!” Others protested that because they’ve been out of practice for so long, they have no alternative but to teach on the basis of established models for understanding mental health difficulties, and are not experientially qualified to speak from critical standpoint positions. Others still defended the medical model, probably positioning me as a troublesome character with a large axe to grind. Some were equivocal, saying ‘well the evidence is conflicting, so we don’t know who to believe.’ And some said nothing at all.

Meanwhile, on the wards, mental health nurse students are often exposed to an alternative curricula. On reading my work, a colleague from another English university told me of the double bind he found himself in as a mental health nurse teacher. This was that teaching the biomedical model from a critical social history perspective would not fit with the realities of nursing practice. He said that students often told him that qualified mental health nurse mentors in their practice areas insisted that the important knowledge, the knowledge that they needed, was that which best fitted practice circumstances. This colleague said that as a teacher he and his colleagues necessarily occupied a “rather unsatisfactory middle-ground, where we tacitly condone the biomedical model to some extent by realising that students find themselves working in clinical areas where it’s required.”

So it’s not at all surprising that when I teach mental health nursing students in their final year, in the last module they have to take in order to qualify, they are both fully fluent and monolingual in the language of psychiatrospeak. When I ask them to describe the people they work with and their relationships with them, they mostly do so in predictably reductionist ways, which in my view violate relational and narrative courtesies. They describe these people almost exclusively in terms of DSM categories, within which their identities are totally collapsed and the broader contexts of their lives absent and not regarded relevant. So, the ‘schizophrenic’ is often given an overlay of hopelessness (‘chronic, burnt out schizophrenic’), and social judgement (‘manipulative, inappropriate, chronic, burnt out schizophrenic’). When I feed this back to many of my fellow teachers, they frequently displace blame: ‘Not our fault! This is the way that they are taught to conceptualise mental health service users by the folks in practice!’

This response has more than a grain of truth in it of course, but this does not leave my colleagues blame-free. I believe that this issue reflects a wider international problem at the institutional level of mental health nursing as a discipline, in terms of ingrained attitudes and un-reflexive rule following.  The contents pages of issues of the Journal of Psychiatric and Mental Health Nursing in recent years reveal the entrenched positions. Most of the articles that appear in this research and practice development journal are replete with medical model assumptions and a diagnostic basis for describing and conceptualising mental health service users. After a 16 year association with this journal, as article contributor, peer reviewer and longstanding member of the editorial board, I recently ended my relationship with it. I let the editor know that this was because of what I experienced first hand as an unwillingness on the part of the editorial board and peer reviewers to publish experimental, progressive and critical methodological papers. In writing against the mainstream and promoting emancipatory mental health nursing research and practice advancement, these papers challenged established editorial attitudes by rejecting orthodox biomedical assumptions, conceptual language and ‘safe’ mainstream methodological approaches.

With regard to my second point, the philosopher Hannah Arendt  asserted in her writing that uncritical rule following leaves the people involved, by default, as complicit perpetrators. Her  ‘banality of evil’ argument is that otherwise ordinary people engage in acts that later attract retrospective social and cultural condemnation. This does not imply an intrinsically wicked character on the part of these people. However, often in the wake of scandals perpetrated in the name of mental health care, whether major, large scale exposes or more minor and banal, but no less insidious, forms of day-to-day routinised abuses, nurses and other commentators are quick to  defensively invoke the ‘few bad apples’ argument. This seems to me to signal a kind of ‘othering’; a form of verbal NIMBYism where rogue individuals or practice locations are implicitly storied as ‘not like us’, not representative of the general mass of ethically attuned, caring mental health nurses. Arendt suggested that the opposite is more likely to be the case: that participation in such events is a constant possibility for everyone.

She argued that this is because of a tendency for ‘thoughtlessness’ to become institutionalized on a large scale. In her terms, thoughtlessness is a kind of routinized inability to think that serves the interests of instrumental rationality. Instrumental rationality is characterised by unquestioning adherence to cultural rules and expectations to achieve maximal organisational efficiency in relation to cultural goals. Neoliberal instrumental rationality has become increasingly prevalent in UK mental health education, research and practice in recent years, informing and shaping the activities and professional identities of contemporary nurses and other disciplines. In this context, I believe, that UK mental health nurse education and practice continues to tacitly endorse the biomedical model and its reductionist and morally reprehensible ways of relating to, and representing, users of mental health services. Sadly, I see no reason to believe that this state of affairs will change dramatically in my lifetime.

 

Support MIA

MIA relies on the support of its readers to exist. Please consider a donation to help us provide news, essays, podcasts and continuing education courses that explore alternatives to the current paradigm of psychiatric care. Your tax-deductible donation will help build a community devoted to creating such change.

$
Select Payment Method
Personal Info

Credit Card Info
This is a secure SSL encrypted payment.

Billing Details

Donation Total: $20

30 COMMENTS

  1. Thanks for trying to help change things, Alec, and I do agree, “uncritical rule following leaves the people involved, by default, as complicit perpetrators.” Sorry you feel so frustrated by the lack of progress, since of course, humanity does need to progress past these appalling neo-Naziesque days of unregulated, scientifically invalid, bio-psychiatric control, at least if the majority are to survive.

    And I do hope you keep fighting because, as one who had a spiritual query, misdiagnosed as a “mental illness.” I do have concern for the souls of those unrepentant “complicit perpetrators.” I see the “central bankers and corporations that will grow up around them,” that Thomas Jefferson forewarned the Americans regarding, as having most of the Western world, at this point, in essentially the same quagmire that they put Germany in, pre-WWII.

    • What has happened is that none of the parties realize there are three medical models: clinical, science, and public health. The so-called medical model that most of the MIA contributors gripe is a muddled combination of science and clinical medical models with the scientism overriding clinical sense. It isn’t necessary to use drugs at all to have a clinical medical practice, or if the practitioner does use drugs, to maintain patients in the Twilight Zone for the rest of their lives.

  2. Alec,

    I enjoyed this articulate and humane article.

    British nurses should be alarmed because they are lagging behind American mental health workers in terms of the degree of medical model distortion that informs their “treatment”. In the USA, that fabled land where 4% of the world’s population consumes over 50% of the world’s psychiatric drugs (see Grace Jackson), where drug companies advertise directly to consumers and doctors, medicalization has reached a new zenith (or rather Dark Age) where life problems are almost always conceptualized as “disorders”, with no understanding of the subjective experience of the “patient.”

    I imagine that most nurses simply lack sufficient training and understanding to truly “get” a relational, social/psychological focused approach to human suffering. The institutions that train them have sold their souls to the corporations which push the Defect (medical) model and insist on drugging, and thus the young nurses are indoctrinated into the disease model. As the Jesuits said, “Give me the child for seven years and I will give you the man.”

    Or perhaps it should be, “Give me the fledgling mental health workers for 4-6 years, and I will give you an unimaginative, ignorant, dehumanizing, pill-pushing, unmotivated, empty shell of a human helper.”

    That might be a little bit harsh 🙂 I know many mental health workers try to do their best with what little psychosocial training they have. But things could be so much better if resources were not so heavily misallocated in the direction of the fraudulent biological model.

    • A great article that encapsulates the problem with mental health nursing in the UK and around the world. As a UK-trained RMN and subsequently worked in Australia and currently New Zealand, the theory-practice gap is growing wider. In Australia and New Zealand, nursing students tend to receive approximately 4-6 weeks of mental health theory (mostly biomedical model) and 4 weeks of clinical practice, for the whole of their 3 years of nursing study. Unfortunately, this is reflected in their clinical practice once registered, and the poor public have to be on the receiving end of clinicians with varying degrees of incompetence.

      I also supervise student nurses in clinical practice in New Zealand and endeavor to encourage them to think a little more critically about this field of nursing. Some do and many don’t, as they see completing the clinical placement as a means to an end, without seeing the bigger picture.

      BPDTransformation, Yes, they may attempt to do their best, but you wouldn’t visit a dentist for a tooth extraction who has never extracted teeth, would you? Yes, they may do their best with the training that they have had, but sometimes that isn’t good enough! Until there is a fundamental shift away from the biomedical model of mental health in nursing education around the world, unfortunately not a lot will change. Some clinicians give a crap, but many don’t and there isn’t a stampede to get into the profession. That is concerning especially when other clinical groups, such as occupational therapists and social workers (who have even less mental health training) are slowly becoming dominant within the field.

      I hope that outcomes will get better for those on the receiving end of care, however I suspect it will not!!

    • You’d better look for those biological practitioners who use biological models that aren’t fraudulent and therefore don’t have any more respect for the DSM’s than I do. I don’t want to go on Voyages in Cnsciousness; having a routine life undisturbed by dysperceptions is good enough for me (though I’d definitely like to find someone willing to use niacin for benzo withdrawal and would be willing to help them- sorry, I don’t take benzos myself or I’d have already tried- because I have pertinent literature you may not have).

  3. Hi Alec. Thanks for this piece. I often think about the effect of an unquestioningly medicalised/ uncritical education and practise on the student (and later qualified nurses) themselves. I do believe student nurses generally come into the profession from a place of genuine care for others. I think there’s a lot about nurse education that does support relational and narrative approaches, and that in theory at least nurses are trained to work ‘holistically’ and use themselves in a very human way in supporting others. And then there’s all the psychiaspeak as you say, and the origins of that, and the assumptions upon which all that nonsense is based.. it’s like an elephant in the room. The tutors may know the nature of that elephant, whilst the student nurses are often just vaguely aware of something that is at odds with what they’ve come to learn without knowing quite what it is. The lack of an explicit naming of the medical model in all it’s guises, and the lack of critique of it in nurse education leads to an insidious form of cognitive dissonance, eroding those fundamental core values that I believe make ‘real’ nurses. Students (and qualified) nurses often know ‘something’s wrong’ but are not often able to articulate what it is. In my experience they tend not to realise to what extent they are part of the problem. They don’t get the way that every time they define someone’s experience in a medical way, they are growing the power of that model and supporting it’s dominance in the field. Many students believe they are ‘using the recovery model’ now, at the same time as insisting their patients must ‘develop insight’ into their ‘illnesses’ and the need for pharmacological treatment that comes with that. Having to work within the dominant medical paradigm chips away at our nurses’ and student nurses’ capacity to develop their relational capacities with the people they are working with – you’re not really listening to someone if you’re basically symptom-spotting as they talk. It blocks spontaneity and the genuine movements of the heart that lead one person to empathise with and know how to support another, the care that brought them into the profession to begin with. With that value-core in a nurse suppressed or suffocated by demands to diagnose and treat, whilst at the same time saying to herself that she is “not using the medical model” (even though she is, unthinkingly, using medical language and thinking) and the resultant confusion of all that leads to a kind of learned helplessness and burn-out: “I know the system is broken but I have to survive somehow within it” or “I do believe in individual choice but when people are ill they don’t know they need the medication – they get well on meds, I’ve seen it on my placement, and they thank you afterwards for sectioning them” or just swinging between blaming the patients and families, blaming management, blaming the psychiatrists or blaming themselves for their job dissatisfaction as nurses.

    I love coming in to talk with student nurses and “getting them while they’re fresh”. Just naming the elephant in the room works wonders. Students start voicing things like, “Yeah I thought there was something weird about what I was seeing/ having to take part in on my placement but everyone was acting like it was really normal and so I thought it was just me.” It turns out, they’ve been made to feel naive, silly even, too sentimental, for wanting just to go for a walk with a person in distress or hold their hand and listen to their story without overlaying a diagnostic framework… perhaps they think, “when I’m a fully qualified nurse I will understand and accept the need for the “evidence based” kinds of treatments being done these ways.” Many students I speak to have been feeling deeply uncomfortable out on placement with the ways they’ve been mentored to nurse, as it’s conflicted with something deeper inside them – they’ve had to override their own instinct, intuition, inner wisdom, their humanity and, crucially, they invariably haven’t voiced that discomfort anywhere! It is often a great relief for them, firstly to find that their colleagues are just as uncomfortable/ angry/ fed up, but more importantly to see that a lecturer supports their discomfort… I’d like to nurture that discomfort, stoke it, because in the middle of it is knowing “this is not what nursing is meant to be” and there is the drive to strive to do things differently. In the dissatisfaction with the abuses and neglect inherent in the status quo is the fire needed for clear seeing, cutting through the crap, understanding that we’ve been conned and that we don’t have to buy into this lie any more. In the outrage about the con are also the seeds of revolution, of ‘recovery’ of the nursing profession.

    I believe nurses who can actually nurse at work are happier, weller, and less likely to burn out that nurses who are playing at being pseudo-doctors. But it’s hard to go it alone – nurses and student nurses need each other. They need to exchange not just intellectual critiques of the medical model but the raw pain, despair and outrage at finding themselves immersed in it. They need to experience and to process the necessary guilt for their part in the abuses this system propagates. And they need to exchange ideas, practical, down to earth, top tips on how to be a radical mental health nurse, how to survive and be the nurse you want to be in an environment that wants to shape you otherwise. They need networks and mentoring and support and they need each other, most of all each other, to stand up against the stream and do what feels right, reclaim their profession, challenge practise and change culture. I take my hat off to any nurse that can see clearly all that is wrong, can see what needs to be done and attempts, day by day to do things differently, that takes real courage. To sit down with a patient and write a “care plan” together in a language that is meaningful to the person rather than psychiatric language. To advocate the person’s own framework and perspective towards the rest of the treating team. To question the use of language and of treatment on an ongoing basis. To bring it back to the human level – of course he’s kicking off, he hasn’t been allowed to leave the ward in three weeks, don’t write that down as further “evidence” of his “illness” just give him leave to go to the shops, I’ll go with him… Student nurses DO need to be educated in a way that prepares them for the realities of the horrors they will face out in practise, but that doesn’t mean teaching them to pipe down and follow the status quo. It means encouraging them to question everything, to be clear and courageous enough to challenge injustice and oppression in effective ways, and to work in ways that promote a sense of meaning both for them and for the people they are serving. They need education that supports them to survive intact, fully human to the core, in the dehumanising environments they will inevitably end up working in at the same time as feeling empowered to hold and fight for a vision of something better, fairer, closer to the vision of what brought them into nursing to begin with.

  4. Thanks, Alex. I got the idea for benzo withdrawal using niacin because it’s possible to easily withdraw people from alcohol using megadose niacin, which I did twice back in my sorcerer for freaks days. With alcohol the withdrawal time is shrunk from 2 weeks to 2 days; the benzos have a withdrawal period of months, being fat soluble, leading me to suspect you’d have to continue for several months on a couple of grams of time-release B3 per day once acute withdrawal ended.
    Another curiosity about B3 is that it’s attracted to the same neural receptors as the benzos when it’s in the amide form, which is what piqued my interest in the first place.

  5. Hi Alec,

    I would be interested in getting a group of us together and have a conversation about mental health nursing education. We could do something along the lines of the CMHNN and have a website, either independent of them or ask them if we could attach ourselves to their website, or have a Facebook page or both. Please let me know what you think? Either way, I’m in! You can contact me via FB, LinkedIn or [email protected].

    Regards, Nick.

  6. Dear Alec

    I am struggling a little bit with de-coding some of what you’re referring to, and it’s frustrating because it’s hard to process or respond when I’m not sure what you mean. At the same time, this has been a really stimulating thread and I’d like to stay involved in the conversation so I am going to swallow my pride and just ask –

    I think I understand ‘hybrid’ identity if by that you mean wearing lots of different ‘hats’ as you describe – ex-patient/ survivor/ professional/ lecturer etc? But I am not sure what silo means in this context: “I think we need to get to post-silo’d identity position.” Do you mean not being pigeon-holed as a patient/ carer/ nurse/ psychiatrist/ tutor etc and all just meeting one another as equal human beings?

    Regarding the paragraph on Zimbardo etc, are you saying it’s basically hopeless/ pointless to try and prepare nurses to remain human in situations that are set up to “reverse humanity” as you put it? I feel a little bit disappointed, as if it you must think me naive to be so ‘hopeful’ in such a situation. It is not that I am blinded in any way to the horror of the situation – I have more than enough experience of our existing mental health system to collapse in despair (I have done, many times). I’ve experienced it as a patient, carer, nurse, advocate, activist and lecturer. I do not defend the hierarchies, the dehumanising, inequality, racism, sexism, homophobia, transphobia, xenophobia, classism, violence, intolerance, abuse, whitewashing, manipulating, fudging, or outright lies inherent in it. I am not even going to bother speaking about “psychiatry”, or drug companies, or capitalism, waste of breath. And yet I do remain hopeful, and not only for a utopia in which the whole system collapses and is replaced by crisis centres and recovery houses and support groups. I’m hopeful also that the people working within the current system also have the potential to become resources if they are supported to do so, if they are helped to wake up and come together and remember what they came to do.

    I am inspired by Joanna Macy’s ‘Work that Reconnects’, which she used to call ‘Despair and Empowerment’ work – I like the old name as it describes the essence – that through allowing for despair to be fully felt and experienced, and grieved, we are empowered to envision and create a better, kinder world. I am hopeful because I still see the goodness in those nurses, even the ones acting horribly a few years into their work. I fully agree that they could do with better environments to demonstrate that goodness in, but my point is that the majority of nurses being trained TODAY will not end up working in those environments, at least not straight away.

    What advice would you give a mental health nurse working somewhere in the system today? Other than, leave your job and invest all your time and energy into building something outside of the system, probably on a volunteer basis? I feel very much connected to the plight of those individuals and families who are attempting to get their needs met as I type this sentence, right now, in February 2016. They might not be so interested in plans to make things better some day, when their crisis is so much more immediate than that. I’m very much all for new paradigms and building alternatives outside of mainstream settings, of course I am, and if we could gather momentum and get funded and do these things quicker that would be amazing. However quickly these alternatives develop won’t be fast enough for my friends who are needing the support tonight though. So I would like the nurses who are tending to them this evening to be working in a way that is humane, human, supportive, equal, honest, respectful, compassionate, hopeful, and sustainable (not burning out and leaving two months into their relationship beginning), even within the givens, the limits, the constrictions of the system they are working within.

    What do you suggest to the nurses working or currently studying with a view to working within statutory services now? I suggest that we teach them to recognise, and to bear those cultural contradictions, and to do what they can to humanise the environments they work in anyway. And of course to subtly undermine and eventually be part of entirely overturning the existing order – Rufus May used to refer to himself as a spy-chologist and I like the idea of training spy-chiatric nurses too. I believe there are networks of them out there in the system already, and they need to find each other, because allies on the inside are what will help them make those micro-revolutions, one ward round at a time, whilst others write blogs and papers and present at conferences and try to win funding grants, slowly turning the wheel for real change on a structural/ societal level.

  7. I’ve been really enjoying this post and comments.

    Firstly, yes, I always hoped the CMHNN website would develop a set of pages for and about nurse education. I’m hoping to think some more about the Willis Shape of Caring review and how we might piggyback a lot more critical ideas into the course because of it. Certainly there is a remit there to demedicalise and deinstitutionalise nursing, and an intriguing possibility about special training for community roles – perhaps that maybe a chance to shoehorn in more ideas about what community actually is and what shapes it? But I have also been reflecting recently that demedicalising and deinstitutionalising are not as important as depathologising. As usual, it is survivor networks I have to thank for that point of view.

    In regards to this comment thread, all I can say is that I have taught critical ideas to six cohorts of mh nurses over the last three years. I have been bolted on to their course at the end for just a few hours and, although I have been very grateful for that opportunity, I think it is very unfair on the nurses that it should be so, and frustrating for me to try to ‘do’ critical mental health in about 4 hours. To me it is clear that if it is worth the attempt of getting nurses to see what the world looks like outside of their very particular and peculiar ’emplotment’, then it needs to start much much earlier. I need to do what I have been doing more slowly, more gently and right from the first year.

    It has been interesting to see how the classes have responded. I have felt torn in the very rationed time available about whether to devote time to thinking about the problems of validity of psychiatry, or instead try to take a bigger view of the range of ideas and the politics of distress in society. I have gone for the latter, because I don’t want to give the impression that the problems of psychiatry are mainly down to not quite getting the science right yet… although students are stunned when I tell them a very few things about, say, the validity of the ‘chemical imbalance’ trope. I also feel that without this broader political viewing, then there is nothing there of critical psychology, and I feel some of the most important critical thinking applies to both and is better understood that way. As a community mental health nurse I felt that psychology was the antidote to the excesses of psychiatry, and I think many nurses a drawn to that idea.

    How do they respond to this repoliticisation? Mostly, they seem to find it good, but it really takes them a lot of effort to see their subject as something that has anything to do with politics. I usually shy away from saying more overt things about psychiatry’s connections with the far right, because I don’t want them to think I am some kind of dismissible extremist, and in any case, they never seem to have heard the word ‘eugenics’ before. It became apparent yesterday that the class was not really familiar with the idea of ‘left’ and ‘right’ in politics anyway. Politics is separate to nursing in their view…. so we have to cover a lot of ground. It is my aim for each class to be able to understand something of the phrase ‘the personal is political’ by the end of the time we have together – both the interpersonal and the intrapersonal.

    I find it very very irritating when students tell me that really, things have changed now, and they are more holistic, less medical. I really relate to the part of the article above in which Alec says that there is an idea that really, there is already all this critical thinking going on, and really, psychiatry is not all medical, and really, I am making a strawman out of psychiatry. If that were true, then there is simply no way – no way at all – that the students could be so astonishingly ignorant of the world outside of their ghetto. And, like Alec, I don’t think they can be blamed all that much – not yet, anyway – because they see themselves at the bottom of a big hierarchy and are just hoping to get good enough, learn the right words, to get a job, to become qualified. YWaves, I admire the time and space that you seem to have developed with students. At present I have to fly in like a kind of aerial bomber and zoom off again – the worst way of effecting real change; the killer lecture. The good news is that this is going to change for me, I am being employed by the university and I hope to be able to get into different parts of the course, actually get to know the students a bit more, etc.

    Finally, it has been interesting to me to teach similar material with student social workers, qualified psychiatrists and (soon) AMHP’s. Social workers are also nothing like as switched on politically as I would like, but they do seem to get it faster – but then they have less to lose. The medics were hard to draw into conversation, and I suppose they can’t have enjoyed my ‘portrait of a psychiatrist’ section, adapted from Bonnie Burstow, in which I suggest that psychiatrists use future evidence for current practice (among other things).

    It seems we have an awful lot to do. I look forward to continuing these conversations.

  8. Hi Alec,
    Thanks for your reply.
    The reasons I feel that demedicalising and deinstitutionalising are not as important as depathologising are something like this (although I want to think more about this).
    1. Demedicalising: Well… taking the bio out of explanations of experience has seemed like a crucial step in emancipating people as more complex, raising them as people who can make sense but also being more vulnerable to others – our multi-storied selves. I think that biomedical explanations of experience are unacceptably reductionist, and they reinforce mind-body dualism (even though weirdly they often claim otherwise), are highly politically contentious, scientifically spurious etc. So, in the main, I am absolutely for the demedicalising of distress in society. Yet two things make this a bit more nuanced for me. Firstly, within the Hearing Voices Network are a number of different ideas about where voices come from and these ideas are in some ways comparable to bio, psycho and social (not that they would be happy with those terms and I understand why). Their ‘bio’ is encapsulated in their story called ‘common human experience’ (it does not necessarily follow that it would be biological, but that is the way they use it). Yet in holding this bio view, they crucially do not pathologise. To have voices as a common human experience is to find solidarity and to be able to make demands upon the state under the guise of equality and non-discrimination. They can see voice-hearing as an ability. I think the HVM has shown me that one can have a constructive and empowering biological explanation (although neither psychiatry nor the HVM have any established grounds scientifically for that view, only that we have bodies and therefore something of our experience is bodily experience, which is weak). It is possible and helpful for some people. It is using biology as a story, ironically, which undermines it as biology, but there you go – wheels within wheels and exactly what psychiatry does anyway. The same is true of psychological and sociological arguments from the HVM. They manage both without making the voice-hearer faulty.

    One further aspect to that is a person I met recently who went on the most extraordinary voyage of personal discovery upon accepting that his voices were ‘medical illness’. He reasoned it this way: If his voices were ‘real’ then he had to follow them (and he quickly got into all kinds of difficult territory with telepathy and self-identity and other things). However, if they were ‘medical’, then they came from him, and if they came from him then their content came from him. If their content came from him this was a key to his self (he called it his ‘sub-conscious’ and his memories) that few people had. Although it was confusing, eventually he was beginning to understand his emotions in a whole new way by thinking about what these voices were trying to tell him and why. He did this without knowing anything about the HVM. For me, this very clever and articulate person challenged the thought that I had that the story ‘medical’ was always necessarily wrong – for him it wad been a great source of liberation (shame about the sedating crap the nurses kept doping him up with and the fact that he had to learn not to tell them about his fascinating thoughts because they just interpreted it as more illness and got the dose increased). So, I concluded that what made him different to so many people who accept their experiences as medical is that he managed to not pathologise his thoughts and voices in the process. He was allowed to think (I mean he gave himself permission) whatever he liked and learn by it. So, although that is the first story I have come across quite like that myself, and I would have to admit that his interpretation of ‘medical’ is rare, I did think it said something interesting to me about pathologisation being key.

    Now that I have written the above I have changed my mind a bit though! It is those points about biology and ‘medical’ being stories which are important. If I am happy with them only as certain kinds of stories rather than as other kinds of stories, then I still want to explode their myths as apparently unstoried natural science, don’t I?! Hmmm. So I still want to de-medicalise.

    2. De-institutionalisation: This one is much simpler. I think if we don’t de-pathologise then we don’t de-intitutionalise. We might close a lot of beds, we might set up community teams etc etc, but if they are still pathologising then the institution of psychiatry is alive and well. I think the NHS has more or less failed to de-intitutionalise (even though that is unfair to some small pockets and some individuals), and I used to be a great believer in my role as a CPN in AO and EI. When I first started in EI in 2008 the buzz words were ‘diagnostic uncertainty’. Now it is ‘earlier and better diagnosis’. Not much to celebrate there. So, once again, the institution of psychiatry (along with much of psychology) is there is maintain the integrity of the story of distress-as-pathology, and we can do that in any location, it seems.

    As for the NMC: I am not an expert about the NMC in general, but in setting up the Critical Mental Health Nurses Network I felt the NMC code of conduct was an ally. There are loads of statements there about our responsibility to evidence, our responsibility to raise concerns, to make our service-users informed and empowered, to escalate concerns about safety etc. I interpret all of that as supportive of the aims of the critical mental health nurse.

    Finally, I am really interested in your thoughts about peer-reviewed journals and academic orthodoxy etc. I want to open conversations about the undemocratic nature of journals (it’s scandalous) and I wonder what may be said about that. I am at the beginning of that game and I don’t know if I want to play, basically. I’ve just done a PhD which would have been quite impossible without some extremely creative re-interpretation of copy-right law, shall we say, and, well, theft. Couldn’t have done it otherwise and I know I am far from the only one. Now I am stepping over into a paid researcher role, I would rather be honest about the broken and corrupt system than pretend it gives me what I need. And, as you imply, I have doubts about how much I can respect the peer process anyway.

    Cheers, Jonathan

  9. Alex

    As a peer worker in a “state hospital” here in the United States who has the responsibility of educating new staff hired into said “hospital” about trauma informed care, I can relate to much of what you’re writing about here. One of the problems I see is that it doesn’t do a whole lot of good for me to educate new people coming into our culture here when we throw them to the wolves by placing them out on the units among the “old” staff who’ve been here for years and who are determined to do things the way that they’ve always done them.

    There are no real attempts in my “hospital” to develop any kind of continuing education for nurses and all staff so that we can reinforce in people what we first told them about in orientation. You have to keep giving people “boosters” along the way for things to take.

    Nurses where I work are the most problematical as far as departments go because they insist on looking at the so-called “patients” as “other” and as less than they are. They dismiss everything that “patients” on the units tell them and attribute everything to their “illness”. They do not see the fact that all the people on the units have strengths and talents that can be used in walking with people towards healing and well-being.

    We are also a teaching “hospital’ and so nursing students go through here in droves. Many of the students still retain an appreciation for their own humanity and the humanity of others. They do good work with the “patients” assigned to them. But I fear that this is stamped out of them as time goes on and the system has its way with them. The few nurses in my “hospital” who admit to their own “woundedness” and who are willing to work as true healers out of that woundedness are ostracized by the rest of the nurses.