Mental health nurse education supports institutional psychiatric practice in an insufficiently questioning way. 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.
It’s been five months since my last blog post. Since then, I’ve made the decision to retire as a mental health academic. I will do so on my 65th birthday, in May next year. Knowing I’m in my last few months of full-time employment has been liberating, so I’ve recently been posting more on social media on the basis of my accumulated knowledge and writing, and this has extended into my email correspondence. All of this has been great as it forces me to write in different and often very concise ways.
I’ve often wondered what a realistic information sheet for service users entering UK acute mental health wards might look like. So a few weeks back I posted the following on Facebook for my friends, some of whom are survivors and some mental health nurses:
“Dear service user,
You are about to stay in an environment where, as has been repeatedly documented in recent decades, you have a one in three chance of being physically, emotionally or sexually abused.
You will receive a diagnosis that has no scientific credibility and is made on the basis of social rather than biomedical judgements, although the people making the diagnosis and those who support them pretend it is the latter.
If your stay is prolonged, your diagnosis will change repeatedly, corresponding to changes in your psychiatrist. This will also happen if, after your discharge, you re-locate and are subsequently treated in a different part of the country. This may well confuse and/or annoy you or both
During your stay with us, you will be bored a lot of the time, or anxious, or both. The chances are that the only ‘therapy’ you can realistically expect to receive will be drug therapy. You probably won’t have the negative short and long term effects of these drugs explained to you, and what should be their judicious use over a short period probably won’t happen to you. You are likely to be in drug therapy for a long time.
If you don’t like all of this and try leaving, we may well legally detain you.”
This provoked a supportive and warm reaction among my Facebook friends, some of whom played around with the information sheet, extending it, as follows:
“And you will be expected to eat, shit and watch tv, just like the rest of the population of consumer/non-citizens” …
“And be grateful for this”…
“And be ever so ‘humble’”
Soon after, in response to a newspaper article written by a mental health nurse who likened acute ward nursing to being a soldier in a war zone, I joined a twitter dialogue which had just called for more Government resources for UK mental health. I sent out this tweet:
From abuse and human rights perspectives are we all ethically compromised in placing ‘pts’ and ‘nurses’ in acutewrds https://t.co/sD0HqoBvl1
— Dr Alec Grant (@DrAlecGrant) July 17, 2016
one critical clinical psychologist twitter friend responded with:
@DrAlecGrant @markacradcliffe Good points. But currently there are almost no alternatives — Lucy Johnstone (@ClinpsychLucy) July 17, 2016
To which I replied:
That’s right, but the default posiion is dreadful, and (Mark) more resources might result in more of the same. https://t.co/SBOspnbbYP
— Dr Alec Grant (@DrAlecGrant) July 17, 2016
My twitter colleague agreed, and my parting shot was:
@ClinpsychLucy @markacradcliffe Sad state of affairs. And lack of criticality among consumer uncitizens – and that includes MH workers.
— Dr Alec Grant (@DrAlecGrant) July 17, 2016
Within the last couple of weeks, following another twitter conversation, I responded to a request from an Antipodean professor of mental health nursing to send her my most recently published papers. These were about empathy building and the reduction of ‘othering’ practices through nurses writing and practicing on the basis of hybridity (as both mental health nurses and user-survivor). Anticipating that our exchange probably wouldn’t result in a sustained academic dialogue, I said to her at the end of my email:
“Any feedback/reaction from you would be great! In my final year before retirement, I’ve more or less given up on the idea of robust debate and critical exchange in mental health nursing (which I’ve also more or less given up on). Sad neoliberal, technical-rationalist times we live in. All the best, and thank you very much for your interest in my work.”
“Dear Alec, thanks for your papers. They look fascinating. Please don’t despair of mental health nursing! There are pockets of excellence in many places but neoliberalism does have great power. However the Recovery movement means that consumers /service users can take matters into their own hands more and more. (This indicates that) things will have to change for the better at some stage…”
Although the likelihood is that she didn’t intend this, I felt that my message was trivialised and that her words were patronising and invalidated my position. So I tried to respond reasonably, but firmly:
Dear XXXXX, Thank you. I know there are pockets of excellence, and I am part of the recovery-survivor movements as part of my (multiple) stakeholder profile. That said, after 42 years in mental health, in plural roles, I am firmly of the view that mental health nursing in general – at practice and education levels – lacks sufficient levels of criticality, imagination, and professional and disciplinary reflexivity. Disappointing, but not really surprising. And, like our rail system in the UK, things are always on the point of getting better. Nurses and nurse educators collude with oppressive practices in mental health, at all levels. I despair for good reason.
I don’t expect her to get back to me with a response to my papers; I’m not even sure that she’ll read any of them. I’ll be pleasantly surprised if I’m proved wrong.
The idea that things are not what they are promoted as in “mental health care”, and indeed may be the opposite of this, has an Orwellian ring to it. Nurse academics write about the need to make acute wards more caring and empathic. This is a bit like painting a car that has no engine and is forever going nowhere. To extend this metaphor, nurses write about choice in our neoliberal times, while the average mental health service user’s choice about the help they receive is akin to Henry Ford’s 1920s customers having any colour of automobile they wanted. Providing it was black.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
The situation is just as bad in the United States.
It sounds like you should hire a military plane and drop leaflets with your “Abandon All Hope Ye Who Enter Here” warning about the abysmal state of psychiatric treatment, across the grounds of your biggest mental hospitals. That would be a public service!
Thanks BPDTransformation. I know things are just as bad across the pond, yes. A leaflet airdrop is a great idea!
Great post! Please provide the article or reference for the 1 in 3 chance of being abused. It’s a good argument against being sent to a psych ward. And sent to partial hospitalization day treatment instead if the doctors and family insist on conventional treatment. Too bad ppl don’t know about the recovery approach.
I’ve summarised the evidence to back up the data on acute ward abuse in:
-Freedom and consent. In: Barker P. (ed). 2003. Psychiatric and Mental Health Nursing: The craft of Care. London: Arnold (pp 522-531 of 639 pages).
-Grant A. The problems of freedom and consent: Combating denial in mental health nursing. In:Barker P. (ed). 2009. Psychiatric and Mental Health Nursing: The craft of Care. 2nd edn. London: Hodder Arnold (pp 626-634 of 757 pages).
This will be updated in:
Leigh-Phippard H, Grant A. Freedom and consent. In press for: Chambers M. (ed). In press. Psychiatric and Mental Health Nursing: The craft of Care. 3rd edn. London: Arnold. (This book is due out at the end of this year).
People don’t know about the non-institutional psychiatric recovery approach, and there’s the constant problem of institutional psychiatry culturally appropriating and colonising ‘recovery’, so that it becomes another form of oppression.
Sorry Becky, refs in my reply should read:
Grant A. Freedom and consent. In: Barker P. (ed). 2003. Psychiatric and Mental Health Nursing: The craft of Care. London: Arnold (pp 522-531 of 639 pages).
Grant A. The problems of freedom and consent: Combating denial in mental health nursing. In:Barker P. (ed). 2009. Psychiatric and Mental Health Nursing: The craft of Care. 2nd edn. London: Hodder Arnold (pp 626-634 of 757 pages).
Leigh-Phippard H, Grant A. Freedom and consent. In press for: Chambers M. (ed). In press. Psychiatric and Mental Health Nursing: The craft of Care. 3rd edn. London: Arnold. (due out end 2016)
There was some interesting debate in the parliaments of Victoria and Western Australia about a survey which claimed to show that 45% of women who had been admitted to psych wards in the previous year reported being sexually assaulted Alec. I can dig out the reference in the Hansards if you wish.
I really like your letter to prospective clients lol. But didn’t anyone ever tell you that talking egalitarianism in a caste system amounts to heresy? And you will become an ‘untouchable’ before lunch time?
Good luck and please keep speaking truth to power.
Thanks boans. I think I’ve been an untouchable for a long time now! That ref would be great if you can access it for me. Shocking stat, isn’t it!
Good on you – there seems to be more and more people speaking out, but resistance to change in the psychiatric world is remarkable. Our charity group in Australia of parents of mentally ill took matters into our own hands by finding a USA scientist who was having good results using vitamins and minerals and brought him out to Australia and now have 200 doctors trained , including some psychiatrists . His book Nutrient Power is now translated into 6 languages – our aim is to have it taught in medical schools, but pigs might fly at this stage. He is now training in USA , and we have had a London doc come out to do the training in Australia. Our website is http://www.biobalance.org.au and his is http://www.walshinstitute.org. The ironic thing is, none of our own children are on the protocol, in my case a doctor ( Pyschiatric) told him only quacks prescribe vitamins so he refuses to go on it.
Someone once described the power, influence, dominance, hegemony – call it what you like – as ‘sticky’. This nails the problem for me. It’s such an enduring worldview, nomatter how much it is critiqued, which resists – as you have described – alternatives. There’s no other option but to keep battling on, so good luck to you and your colleagues in what you’re all trying to achieve.
I’ve linked that report in my comment below
link to the report mentioned in parliamentary Hansards here
What I found interesting was the debate which followed the tabling of this report and, rightly so, the methodology was questioned. I am sure I will come across that debate which is well worth a read.
I wrote much the same on the internet 3 or 4 years ago. It’s okay. I have always been ahead of the curve, so to speak.
It costs nothing to be kind, they once said. It’s gradually dawning on people the true cost of our new ways of living and relating. Kindness is now something which is being commodotised. Many people are nervous about what it means, and nervous about what might happen if they attempt it.
There is a lot of money to be made running workshops reminding people what kindness is, and challenging them to risk it.
I think if people are going to be paid to be kind, they should earn their money. And they should be seen to be consistent. And if they are not consistent, they should be accountable.
One problem with kindness is that humans often rationalise their cruelty as a specific version of kindness. The “cruel to be kind” conceit.
What I say to those merchants of abuse in the name of kindness is: whatever happened to being kind to be kind?
One of the things for which I am most grateful to my psychiatrist is his keeping me out of the hospital system, particularly as it has become clearer to me that my problem is not “depression” but complex trauma (including but not limited to sexual assault by a psychiatric nurse).
The risks for women in a psychiatric inpatient setting in the state in Australia where I live are considerably worse than 1 in 3. A 2013 report (linked below) on sexual victimisation alone showed that the rates of sexual harassment were around 67%, and sexual assault around 45%. I am not sure how much the situation has improved since then, but anyone who has been following the news in the last few years cannot help but be be aware that Australia has (or should have) an appalling reputation with regard to its treatment of detainees of all sorts – in prisons, immigration detention and as involuntary psychiatric patients.
You are best kept out of hospital. Ultimately, mad people are best not being hospitalised at all. We need new models of care and rehabilitations. Hospitals tend to infantilise and people often unwittingly regress into child-like behavior. The nurses and doctors become mommy and daddy in a very dysfunctional family dynamic.
Mommy and daddy have their favourite patient/siblings. Mommy and daddy conspire to utterly destroy some of their childrem to teach them important life lessons about behaviour, and adherence to rules, and knowing when and when not to speak to power.
Mental health hospitals are sadomasochistic dungeons and perhaps to survive this many of the vitims that pass through delude themselves into thinking something kind and medical is actually happening.
The kind of people that are attracted to these settings are — whether they know it or not — the kind of people that get off on the abuse of power.
Of course, in an actual consenting S&M setting, there are safe-words agreed upon when the pain is too much. In this way the consenting adults can indicate that the S&M has reached its limits.
In hospital settings there are no safe-words. Please stop this now, you are hurting me too much, will often be ignored. Instead, the torture goes on until the tortured person is expresses gratitude and thanks.
I’m glad to see some treatment of the nursing factor in psychiatric care. Nurses’ discretion with PRNs appears to have the power to neutralize doctors’ reassurances not to over-medicate patients. Do nurses find themselves in double -binds as to whether to contact attending physicians? How do nurses triage the patients on the nights that are described as “war zones”? Whose best interests are served in over-crowded and under-staffed wards? Which types of patients are subjected to the worst forms of chemical battery and what factors contribute to that? What are psychiatric nurses doing to expose human rights abuses and neglect of medical investigation in psychiatric wards?
As a former patient in the state hospital where I now work, I would have to state that many of the nurses there are not the cream of the crop. There are some really good ones who totally care about the “patients” but for the most part they are like rejects that can’t find jobs in real hospitals. I worked around and with nurses for over fifteen years and the ones in the state hospital were the worst overall. Of course, one of the problems is that salaries for people who work there are not the greatest so I guess you get what you pay for. I don’t think anyone would ever blow the whistle on unethical practices.
I think the institutional psychiatric system allows for the employment of a kind of random mix of caring and non-caring people. Among the latter group, as you say are the flotsam and jetsam of society. Once employed in the UK mental health system, it’s very difficult to get rid of people unless they do something very serious that would bring the org into critical public scrutiny. It’s often the case that some of the worst people have the greatest power, irrespective of formal rank in the org. And whistle blowers are punished by challenging the power status quo. This would be denied of course by orgs who strive to maintain a public veneer of professionalism and ‘care’.
Thank you all for joining this blog disussion. Everyone who’s posted over the last three days has said important and interesting things. I want to join the conversation with a considered response to all of this as soon as I can. I’m on holiday right now and as soon as I can over the next few days, U’ll do this. In the meantime, keep the comments coming!
Thanks for the update Mr Alec Grant
I hope you continue contributing your voice beyond retirement.
Thank you to all who’ve joined the conversation since the 29th of July (and I can absolutely assure you that my voice will continue post-retirement!).
The accuracy of the 1 in 3 stat clearly varies from country to country, and as a function of what constitutes abuse and how it is measured. What is constant though is that the potential for abuse in all of its forms, for those admitted to acute wards. It seems to me that this needs to be understood in the context of nurses and other MH workers, already damaged, inflicting further damage on those fulfilling the patient role. The former group will be re-damaged by these actions and so the process roles out and never stops.
Reactions to abuse stats and stories are telling. I’ve yet to read the Australian report and will do when I get back from holiday. I know though that they evoke polarised, binary oppostional readings. People read (often defensively) from the cultural positions they’ve been socialised into.
The twitter reactions to this kblog, even from people who sign up to and write from a crit MH position
are interesting> My blogpost has been described as “gloomy” abd “pessimistic” by some. Like all of us, mental health workers are blinded by their own perspectives – in their case usually humanistic – in a kind of triumph of constantly unfulfilled hope over experience and the blindingly obvious.
People inevitably speak and behave from their inscription in cross-cutting paradigms. The dominant biomed paradigm, shaped by and in institutional psychiatry, tends towards the production of binaried subject positions. So, patients are always, inevitably, located differently from mental health workers. This gives rise to forms of benevolent paternalism, and what I and others have described as “empathic violence”, in the teaching and writing of the latter group.
This stuck state of affairs is reflected in attempts to reduce “othering” practices. These are always doomed to fail since they proceed from the very paradigm conditions producing othering. Anothering related phenomenon is the emergence of “celebrity survivors”. who are lauded and feted by “progressive”, but unreflexive mental health academic and service staff, who image that they are role-modelling kindness.
Kindness is an interesting issue. Clearly people can “care” in technical-rational ways without being kind. Unreflexive kindness amounts to pseudo-kindness. The pedagogy and praxis of kindness requires the critically reflexive sensibilities that Paulo Friere, Charles Wright Mills and others, myself included, have written about: acute and other mental health nurses and workers need to know how their work functions in wider systems od power and oppression.
A normative curricula (academic and service) prepares nurses to further perpetuate oppression in the ultimate service of increasing the profits and biomedicalisation of human misery by BigPharma, and social control. For things to change, we need a critical pedagogy that facilitates the development of critical consciousness and praxis (theoretically-informed action).
In relation to these changes we need completely new forms of service that square with the emerging psychosocial paradigm. We need crisis houses, recovery (in the non-institutional psychiatric sense of the term) provision and related community provision, including Open Dialogue, HVM, and survivor-professional partnerships based on formulation rather than diagnosis. All of this re-positioned in social- rather than health-care, as Kinderman and others argue.
So tweaking a fundamentally damaged system, the ideological, political, economic and corporate-influenced infrastructure of whichnever changes, is naïve and ultimately doomed to failure. This is why no amount of tidal-modelling and user-involvement will work in the face and existence of such infrastructural dominance. Cultuyral appropriation and colonisation are the order of the day in such circumstances. ‘Recovery’, recovery colleges, lived-experience initiatives, etc. wll continue to be shaped in accord with colonising master principles _ mutated to a level that poses minimal threat to institutional psychiatric business as usual.