Wednesday, February 19, 2020

Comments by Ywaves

Showing 5 of 5 comments.

  • 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.

  • Good idea to draw together ideas for improving/ re-vision nurse education – I think the Critical Mental Health Nurses Network (CMHNN) had some ideas about doing that too. Lecturers sharing experiences of how to do things better at the same time and jumping or getting around the various obstacles Alec names in his original post – what are the barriers to educating nurses differently and how do we get around them? I’m only a visiting lecturer, only talking to students once or twice a year, but I’d still be interested in taking part in such a conversation myself.

  • Sometimes you’ve got to keep your old banger of a car going and squeeze it through it’s MOT so so it looks good but so that it scrapes by until you can replace it! (I know this from my own car-owning experience…) I hate initiatives that make trusts ‘look good’ from the outside, like mental health wards designed by up and coming architects, which gloss over the rot in the core of them. But I suppose we are talking about improving life for the people being ‘treated’ in the system as it is, now, today, at the same time as envisioning different and better futures. Mental health nursing education, at least for now, needs to address both..

    I wholeheartedly agree and hope that the nurses we are educating today will one day create and be able to work in the contexts you describe. Nurse education can be a place to sow the seeds of these kinds of ideas, and my hope is that the growing discontent with working in the existing system will be what feeds and waters those seeds to grow into the will to make changes. Certainly letting student nurses know these alternative approaches have existed and do exist across history and the across the globe is a vital part of the work of nurse education as I perceive it – I tell these kinds of stories (Soteria, Open Dialogue, the Hearing Voices Network etc) to students because it allows them to move mentally from “there must be a better way” to “oh, there is, or there could be, and how can I be part of making that happen locally where I live and work?”

    So the stories are important, and the thinking is important (realising, I am thinking in a medical way without knowing it, realising the contradictions between that and the personalised recovery approach I claim to be working in, and understanding the need for psychosocial approaches and frameworks that are in line with whatever is most respectful to the person I am working with), but I think most important is the doing, the “nursing” or “being with” or whatever it is student nurses do.. Experiential learning.. With spaces to reflect on what actually feels good, which attitudes and behaviours and ways of understanding mental and emotional distress feel to be actually in line with all those values (care, compassion, personal choice, autonomy, authentic relationship etc) and which do not. Spaces to be honest about how shitty it feels to be part of a system of professionals that is harming the people they’re contracted to support, to feel bad about your part in, to grieve the loss of self-image as “the helper” who can “fix” and come to the inevitable humbling conclusion that all you can really do is walk alongside someone. And, critically, spaces in which to be angry and outraged about what is happening in our mental health system and society in general, to understand why it happens and to begin to re-invest that energy into creating real alternatives. Student nurses need to be able to survive those horrendous environments in order to last long enough in the profession to be part of influencing or creating anything different.

    Personally I did not survive – I trained and then left immediately, the clash with my values was too intense. There was not enough of an overt sense of solidarity or mutual support from other nurses and professionals wanting to work differently. The expectation was that I would either tow the line or leave. There must be a way of surviving in the system “as is”, to have the opportunities to be in contact with the people who you to be working with, and earn a living, and grow your interpersonal skills, at the same time as being part of creating something entirely different and better? I think nurse education must be a preparation for those environments in a way that is starkly realistic (you are now entering a shameful, abusive, deluded system, you will become an agent of that system, you’ll hurt people in the course of doing your job, so be conscious about that, don’t duck away from responsibility for those actions, understand why it happens, feel the pain of it and talk openly about it) at the same time as being hopeful (and there are many ways you can change the experience of the person in front of you, one interaction at a time, through the perspectives and the actions you take, whilst at the same time envisioning, collaboratively with those needing the support and their families, better structures in which that support could be created).

    I do know some nurses who go to work every day, who work in ways that are as in line with psychosocial approaches as they can possibly manage, who challenge those who medicalise distress to be less unthinking and to wake up, and who invest a lot of time and energy in finding out about alternative paradigms and spreading the learnings and visions of those. At one Soteria in the pub event recently, among other speakers, I was presenting the work of our local hearing voices group – seven of our second year student nurses were in the audience! Isabel Clarke spoke about the spiritual crisis network at another Soteria in the pub event recently and there were staff from our local psychiatric hospital there. These ideas resonate with what makes intuitive sense to many staff working in mental health and to our student nurses too. They need to learn to think critically, yes, but more to the point I think they need to be supported to trust their own feelings and to stand up for what feels right against the torrents of medicalising nonsense when they are at work.

    Creating alternative places for those student nurses to one day work in a more helpful way (e.g. as part of an open dialogue team or in a Soteria house) would be wonderful, but lecturers in universities teaching students are not going to magically conjure up such places for work and healing (if you do, please can I have a job there?) The students we have now need support to be the ones to rise to positions of influence within existing hierarchies where they can influence policy and be part of creating alternatives (and become instrumental in flattening those hierarchies!). Nurse education needs to hold a vision where the nurse you are expected to become is one who is actively challenging the status quo and working in collaboration with other stakeholders to support the creation of new, different, better places and networks in which healing can happen. AND they need to know they can survive in their jobs, unsatisfactory as they are, with their values and integrity intact until such a time when they have some power to exert to make these changes happen.

    A group of our third year student nurses who formed a society to support one another to remain well in their work, through studying alternatives, reflecting on their placements and living the values they feel are the most important, have also forged strong links with our local hearing voices group. They’ve attended events together, are keen to be there as back-up if the group facilitators can’t do a week, and the two groups (the voice hearers and the students nurses) have even discussed going camping together in the summer! These student nurses give me hope – they’re clear-seeing, not caught up in the confusion and the lie of the medicalisation of distress, but they’re also resilient enough to ‘play the game’ where they need to, to get through their training and get into work, and they’ve got each other and their links with critical and alternative mental health worlds to draw strength, survival tips and inspiration from. They’ll be up for it when opportunities arise to work in more meaningful ways, and I’ve no doubt that in time they will take their place in making alternative visions become realities too.

  • 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.

  • I was in a meeting recently where a psychiatrist was talking to the family of a man who she was planning to treat with ECT. They were scared and quite confused, and they had a lot of questions about it. The psychiatrist answered their questions in absolute and definitive terms that made it sound like all their fears were either unfounded or less important than the dire ‘need’ to treat him right away. She sighed at one point in her explanations and said, “there’s a lot of stigma against ECT, which is a shame, because we know it is an extremely effective treatment”. It was maddening to watch, because the family were silenced in their questioning of her view by that statement – they did not want to appear ‘unenlightened’ by displaying ‘prejudice’ against this treatment. But the truth was, they weren’t prejudiced, they were afraid – and with good reason. After the meeting, the man’s son told me he’d known someone who’d had ECT, who had lost a lot of memories and never regained them, and who was never the same person afterwards. The family were confused, as I was, as to why it was so urgent that their father had emergency ECT, when he was beginning to show improvement and had started to eat and drink again, according to the same psychiatrist’s report? I believe that the ‘stigma’ comment made by the doctor only furthered the feeling the family had that they couldn’t question her authority. Already at the top of the hierarchy of power in this situation, the ‘stigma’ comment also appeared to raise her morally and ethically above anyone questioning her methods. It is just plain crazy to say there’s ‘stigma’ against receiving ECT against your will under an emergency section of the Mental Health Act whilst detained in hospital. People aren’t prejudiced against psychiatry’s methods, they are frightened and wary of them, and very rightly so. This ‘psychiatric prejudice’ idea is not just silencing critical thinking about psychiatry in the media; on the micro-level, it also is pushing the dynamics of Doctor-patient/carer interactions in the direction of “Doctor knows best – and if you think differently then you’re both irrationally wrong and morally wrong”. Patients/ carers don’t only have to fear looking stupid if they question the psychiatrist’s judgements, now they can add fearing looking prejudiced as well – how ironic, when the person actually demonstrating the greatest prejudice is sitting in front of them telling them their dad’s about to be given ECT.