Nursing Textbooks Treat Medicalization of Mental Health as Objective Fact

Nursing textbooks fail to present the contested nature of mental health issues, reinforcing medicalization as scientific fact.

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A new study published in Issues of Mental Health Nursing finds that influential psychiatric nursing textbooks frame mental health nursing as a purely biomedical practice, failing to convey the significant debates in the field over psychological and social factors.

The study used Critical Discourse Analysis (CDA), a method used to analyze how language is used in texts to deploy and reinforce power relations and legitimacy, to demonstrate how these texts legitimate psychiatric discourse.

Through presenting the subjectivity of mental health professionals as objective scientific facts, conveying urgency and necessity for psychiatric intervention, and fusing with other scientific and medical disciplines to lend credibility to psychiatry, such discourse can lead to taking this medicalization of professional judgment for granted and devaluing the subjectivity of patients being assessed.

Mental health discourse has been the site of a lively and contentious transdisciplinary debate, particularly concerning its conceptualization as a concept and subsequent understandings of lived experience in the context of mental health and illness,” the study authors, led by Simon Adam at York University, write.
“Correspondingly, this article examines the current state of mental health discourse in nursing education by focusing on the undergraduate pedagogy of the mental health nursing assessment in Canada.”

By focusing on nursing education, the researchers attempted to understand how much mental health nursing incorporates biomedical and other perspectives into its curriculum. To do so, they examined undergraduate nursing texts, which are central to building up nurses’ professional knowledge. The researchers believed it to be an essential strategy to interrogate, critique, and intervene in nursing practice.

To get a comprehensive view of mental health discourse in nursing education, the researchers examined the language used in three primary texts (chapter on assessment, nursing professional standards, undergraduate nursing competencies), interviewed seven students and eight instructors in a local nursing program, and wrote field notes from 9 hours of class observations.

This discourse analysis focused on the content, style (vocabulary and grammar), and composition of language use. They also aimed to analyze the language used in nursing practice by describing how discourses are used and combined with different genres (pharmacology, medicine, law) to influence psychiatric discourse and their social consequences, as well as resistance to some of these dominant discourses and considering alternative discursive hybrids.

Through this “micro-linguistic interrogation,” the researchers found evidence of the main assessment chapter of the textbook reinforced by the other texts that incorporate and legitimize psychiatric discourse in nursing education. Through this text on mental status exams, student nurses were introduced to mental illness as a medical (material) phenomenon studied through clinical and medical assessment tools.

By contrasting subjective information, knowledge rooted in personal experience and opinion, with objective information, knowledge obtained from neutral observation, the authors note how the text defines collecting subjective data for assessment in a way that might lead to the transformation of professional subjectivity into objective medical fact. They write:

“The foundational–and most influential–text defines subjective data as information gathered from the ‘health history through questions (examiner asks) and explanation (rationale).’ We find this definition rather broad and indiscriminate, potentially permitting perspectives other than that of the patient to enter into the subjective category, including those which may be contradictory to or in direct opposition to the lived experience of the person being assessed.”

Interviews with instructors acknowledge subjective factors in teaching nursing assessment well, along with the differences in patients’ assessments due to nurses’ clinical subjectivities that contradict its claim as an objective, scientific practice. The authors posit that the interpretation of the assessing nurse is based on their values and determines whether a patient’s features of appearance or behavior are appropriate, odd, or some other judgment possibly indicating mental illness. However, this interpretive element is not acknowledged in the textbook and positions the mental health nurse’s clinical judgment as coming from scientific expertise beyond questioning.

They describe a process assumed to have significant reliability across nurse assessors where the nurse’s professional interpretation takes these reports of “subjective” data along with their own observations to compare against a set of pathological categories (e.g., the DSM) to formulate diagnoses that lead to interventions. Through clinical exercises in the text, the authors demonstrate an example of how subjective data considered in assessment can altogether omit the patient’s lived experience by relying more on the reports of others (e.g., family members) who deem the patient’s behavior as socially inappropriate.

“The mental health assessment, reinforced by other texts, is for the most part linguistically designed to give matter-of-fact orders by way of imperative statements, deployed as orders, not dissimilar to what is traditionally known as doctor’s orders,” the authors write.Designed remarkably similar to an instruction manual, the mental health assessment is made to be the ‘how-to’ for the investigation and diagnosis of mental illness. Imperative statements present an authoritative, monologic account for what constitutes mental health and mental illness, and what to do about the latter.”

Findings from the analysis show how the text is constructed to convey a strong sense of certainty regarding the psychiatric basis of mental illness (avoiding discussion of social determinants) that has major public health consequences and requires urgent intervention. Thus, nursing students are assumed to take a passive role in learning, where they act as “empty shells” into which knowledge is “deposited.”

By combining psychiatric discourse with other discourses (e.g., public health, safety, surveillance) and drawing upon the authority of local and national institutions (e.g., the Mental Health Commission of Canada), such texts lead to a sense of medical legitimacy for psychiatry. The authors found the language of the mental health nurse to be primarily composed of hybrids of converging discourses. From their field notes, the authors commented that

“Students become trained in speaking in this hybrid way, in this case, with the goal of invoking a sense of urgency and alarm around mental illness. By way of drawing on language of safety and surveillance, the idea of urgency is invoked and articulated to the need for quick and necessary intervention. This strategy generates importance and, by association, lends legitimacy to psychiatric discourse and, subsequently, a psychiatric response to mental health conditions.”

From this Critical Discourse Analysis, the authors discuss some of the implications on nursing education and nursing knowledge. By demonstrating that the ideological strategy for psychiatry’s discursive legitimation has a taken-for-granted objective “scientific” discourse, this finding is troubling when considering the problem of professional judgment and, at times, the patient’s subjectivity being deemed as irrelevant in assessment.

As the authors point out, to avoid entrenchment in potentially marginalizing biomedical discourses, mental health nursing should diversify its language beyond psychiatric discourse to aim for epistemological justice by drawing on other critical genres and lived experience narratives.

Psychologists in the UK have analyzed the use of psychiatric discourse by UK legislators to construct mental health professionals as “experts” that treat mentally ill “patients” in need of intervention for public safety without reference to the latter’s lived experience.

Previous research has examined how different discourses, including religious, medical, and legal, have constructed drug use, with the disease model of addiction allowing for the psychiatrizing of the drug user that distances the provider from the patient’s subjectivity. The discourse of recovery that valorizes personal responsibility and abstinence has also been experienced as oppressive to people with substance use issues who face stigma when unable to meet such neoliberal standards.

While work continues to grow on critically analyzing mental health discourse, this study marks the first foray into understanding how mental health nursing texts use discourse to socialize student nurses into their professional roles in assessing and treating mental illness.

 

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Adam, S., Gold, E., & Burstow, B. (2022). From subjective opinion to medical fact: A critical discourse analysis of mental health nursing education. Issues in Mental Health Nursing, 1–9. https://doi.org/10.1080/01612840.2022.2113940

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Javier Rizo
Javier Rizo is a graduate student-trainee in the Clinical Psychology PhD program at UMass Boston. His current area of research is qualitative psychotherapy research, with a primary interest in promoting human rights-based framework in psychiatry through the education and training of mental health clinicians and researchers. Javier is committed to building a social justice psychiatry, working to incorporate humanistic, interdisciplinary and critical perspectives on mental health, with particular interest in the role of healers and common factors models of psychotherapy.

6 COMMENTS

  1. I have zero doubt, “how much mental health nursing incorporates biomedical and other perspectives into its curriculum.” I have a nurse friend whose never heard of the DSM, nor heard about the fact that the antidepressants and ADHD drugs could create the “bipolar” symptoms.

    https://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing-ebook/dp/B0036S4EGE

    Nor had she any knowledge about the facts that the antipsychotics can create both the positive and negative symptoms of ‘schizophrenia,’ via anticholinergic toxidrome, and neuroleptic induced deficit syndrome.

    https://en.wikipedia.org/wiki/Toxidrome
    https://en.wikipedia.org/wiki/Neuroleptic-induced_deficit_syndrome

    So I have zero doubt that the medical and psychiatric communities, collectively, have been outright lying to the nursing community … and the world … for decades.

    Let’s hope my “one in a million” medical researcher findings – according to the head of family medicine, at one of the most well respected American hospitals – will help bring back some semblance of sanity, and some actual truth telling, to America’s nurses, and the public, perpetrated against too many of us, by the too greedy American medical industry.

    I hope the mainstream medicals doctors, who want to cover up their and their “partners” malpractice, will some day grow up, and realize there is a God, and you’re not in charge. The doctors are NOT in charge, but those who were keeping track of the monetary systems may be. But that’s NOT the globalist banksters, whose globalist banker system the doctors’ worship.

  2. Just a couple of quotes that I found depictive:

    “Through presenting the subjectivity of mental health professionals as objective scientific facts, conveying urgency and necessity for psychiatric intervention, and fusing with other scientific and medical disciplines to lend credibility to psychiatry, such discourse can lead to taking this medicalization of professional judgment for granted and devaluing the subjectivity of patients being assessed.”

    and

    “However, this interpretive element is not acknowledged in the textbook and positions the mental health nurse’s clinical judgment as coming from scientific expertise beyond questioning.They describe a process assumed to have significant reliability across nurse assessors where the nurse’s professional interpretation takes these reports of “subjective” data along with their own observations to compare against a set of pathological categories (e.g., the DSM) to formulate diagnoses that lead to interventions.”

    What’s the difference between this and schoolyard bullying? He’s weird, there’s something wrong with him, becomes the impetus to take action. In both cases it’s making people think they are doing something that needs to be done to keep society healthy. Both cases are based on social norms as well. And both cases statistically lead to a more dysfunctional society.

    The one difference may be that the behavior of people guided by mental health guidelines can be even more aggressive. The behavior isn’t just overlooked, as with schoolyard bullying, but it’s condoned, rewarded and promoted. And as far as I know schoolyard bullies don’t usually get paid for their behavior……

    How much empathy does it take for anyone to pay attention and see what the medicalized part of the mental health system really is doing to people? And how are they rewarded for ignoring it?

  3. Interesting to see the way nurses are trained. Perhaps more interesting are the first year study books for our upcoming Doctors and Psychiatrists. It seems as though the austere medical mechanical physical approach that is so effective in treating our broken limbs and our infectious diseases is extended to include our reactions to what goes on around us.

    The hurt of the mind that experiences war, bullying, personal loss, grief, rejection etc. is also fair game for pathological description. The Doctor’s training understandably involves a physical assault on the brain, whether by surgery, toxic chemicals or electric shock. An endless endeavour to find the magical gene combination responsible for the elixir of life. I wonder who will be the first to discover happiness. And who will make us all that way, irrespective of the real world in which we live, that knows of no such constant.

  4. So basically this article points out the way ‘mental health’ nurses are trained in the corrupt practice of ‘verballing’? Our police are usually sent for “Creative Writing’ courses until they get the hang of being vague and creating suspicion via the use of their ‘sworn statements’. Though I also note this article doesn’t describe the way that others then pick up on the forged documentation produced using this practice and then utter with those documents.

    “Verballing is the false attribution of a confession or admission to a suspect. On the evidence before the Royal Commission, the practice of verballing ranged in degree between the fabrication of an entire record of interview or statement, in which a full confession is made, to a subtle change of words to cast greater suspicion on a suspect. Ultimately, if the verbal were contested in court, the police officer involved might commit perjury in support of the false statement.”

    [mental health have no such need, and simply ‘kosh’ the complainant for the ‘illness’. With no avenue for complaint, and the State denying access to legal representation, the system lends itself to much worse abuses that the courts]

    “Some witnesses before the Royal Commission admitted verballing, and said that the practice was commonly used, even encouraged, within the CIB. Others denied having verballed a suspect and denied having seen it done by other officers.”

    [immunity being the key to whether officers admitted ‘verballing’ or not. Quite prepared to perjure themselves to a Commission, which proved the point made by the Commissioner regarding the concealment of the corrupt practice. Those who did were no doubt ‘flagged’ as corrupt]

    “It was explained to the Royal Commission that an officer might verbal a suspect whom he believed was guilty in order to secure a conviction and that, on other occasions, an officer might verbal a suspect in order to disguise a breach of policing procedures or a failure to take adequate notes of a conversation.”

    “The practice of verballing has some serious implications for the administration of justice. An accused may be convicted wholly or in part on the basis of fabricated evidence, bypassing the checks and balances of the law designed to ensure that each accused has a fair trial.”

    Police have a history of using the practice to subvert human rights and enable wrongful convictions. And the consequences of the use of this corrupt practice for victims of psychiatric abuse can be fatal, and have been on many occasions (“edited” for convenience after the fact, with the victims being used to justify increases in budgets for more abuses). ‘Legal representatives’ coerced to ensure they are not ‘over zealous’ when it comes to providing assistance to victims of human rights abuses, and in my instance happy to forge a letter from the Chief Psychiatrist based on the fraudulent set of documents they were provided by the State (not that anyone would dare look, and if they have their silence and ‘Judas behaviour’ speaks volumes. Such little value placed on human life by the State with those who do ‘have the stomach for it’ receiving financial and career gains. And as ‘confidential informant’ for the State you will receive protections not afforded those who you are committing offences against…… reality will be “edited” to suit the after the fact preferred truth)

    The use of the practice in mental health services in my State is rampant. Our Chief Psychiatrist even encouraging the practice, uttering with, and refusing to even examine documents known to have been forged with this method. ‘The grounds noted on the statutory declaration are considered to be reasonable grounds’. It would seem a bit silly to forge ‘evidence’ of a ‘mental illness’ using the practice and NOT meet the standard set by the law, which is then denied by the Chief Psychiatrist to ensure that he doesn’t need to look any further that the forged document? (“suspect on reasonable grounds that the person be made an involuntary patient” [with criteria set out in the law] becomes “the mental health practitioner need only ‘suspect’ on grounds they believe to be reasonable that the person requires examination by a psychiatrist”….. arbitrary detentions enabled by the person charged with the protection of the community from human rights abuses? Well done to the fascists in creating an environment where the law is totally subverted, and all they need do is fabricate ‘evidence’ and then “edit” the documents to utter with.)

    I have no doubt that the “serious implications for the administration of justice” is doubled by the ability of police to use mental health facilities as centers for excellence in torture technologies. Police referrals based on ‘verbals’ to ‘verballing’ mental health workers resulting in the questions requiring answers being extracted with the ‘chemical kosh’ and electricity, and making a mockery of human rights and legal protections for the community.

    Still, when I think about it, we are going to need the ability to abuse human rights with where the world is heading. Once the fog of war descends, the only rule is that there are no rules.

    https://www.youtube.com/watch?v=0XrYoNbO-78