Comments by Alec Grant, PhD

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  • Hi Mardy9,

    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.


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  • Hi Stephen,
    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’.

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  • 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.

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  • Dear all,
    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!

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  • 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)

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  • Hi Becky,

    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.

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    Thank you for your posting. Good to hear from you in this conversation. I think you’ve got to one of the core ethical dilemmas for MH nurse educators, internationally: the social psychology of knowledge and practice transfer. Progressive, critical higher education curricula are always likely to be undermined by regressive, service unit curricula. It takes a brave and resilient student/nurse (and educator!) to stand up for the former, and the social psychology of group compliance tells us LOUDLY that such people are likely to have a hard time, despite policy rhetoric on whilstleblowing. In my local experience, nurse educators often get around these contradictions by saying something like “what happens to students after they leave the classroom/get into practice is not my responsibility”. I think that critical mental health nurse educators should focus more on the ethics of knowledge and practice transfer.

    Thank you for clarifying the demedicalisation … not as important as de-institutionalisation… issue. This makes a lot of sense. Hearing voices as a biological essential without pathologising this makes sense in anthropological terms, in terms of the ‘self’ as a social, storied self, and in poststructural terms of people being constituted within, and constituting, discourses or master (stories) narratives. And, of course, we know that a big percentage of the population admit to hearing voices but don’t see this as a problem.

    And what you say about the possibility of someone regarding themselves as ‘mentally ill’ without pathologising themselves is interesting too.

    I’m mindful, as you say, that you are at the beginning of the publishing game, and I’m an old lag in this regard. So I’ll give you, and other reads, my own personal take: For the last few years I’ve kept up a sustained critique on mental health journal editorial and peer review, and orthodox research practices. I’ve already sent you my papers that speak to this and would be happy to send them to anyone else, if they email me directly ([email protected]). In 2011, on invitation from the then editor, I wrote a paper critiquing the absence of performance and experimental qualitative research articles in the Journal of Psychiatric and Mental Health Nursing. I saw this as a privileging of safe, postpositivist methodologically-informed papers, whether qualitative or quantitative, in keeping with a dominant normative representational agenda. This resulted in a rebuttal which denied all my points, from an invited regular contributor to the journal. I then wrote a counter-rebuttal. Essentially, I sustained my original argument, and broadened it out from a social/human science perspective: I saw excellent examples of progressive qualitative research in social science journals, including my own work, that in my opinion put the safe and anachronistic editorial and representational practices, and out-of-date peer reviewers, of the JP&MHN to shame. In 2014, I critiqued the conventional qualitative research in the journal from a poststructural perspective, in a paper titled Troubling ‘lived experience’: a post-structural critique of mental health nursing qualitative research assumptions. In 2015, I formally divorced myself from the journal, as peer reviewer, article contributor and late, longstanding member of the editorial board because of what I saw as increasing levels of technical rational conservatism in editorial and peer review practices following changes in the editorial board and the arrival of a new editor. I have recently revisited my critique in an in-press paper for the journal, Nursing Philosophy, called Living my narrative: Storying dishonesty and deception in mental health nursing. Finally, I have a paper in review in the same journal which argues that ‘ researchers in mental health nurse qualitative inquiry, who display a phenomenological-humanist bent…, continually endorse the validity of institutional psychiatric assumptions, practices and ways of representing human psychological distress.’

    In summary, I feel that the mainstream journals remain out of step with progressive social and human science representational practices, at editorial and peer-review levels. The article construction guidelines in the main journals constrain, discipline and undermine creative ways of writing up qualitative research (difficult for ‘messy text’ and postructural autoethnography, eg) .This results in a constant reification of the orthodox – at representational, ontological, epistemological and paradigm levels. Papers in the main are written in linear, neorealist ways; describing coherent subjects; using traditional ways of knowing (the big 3: trad Phenomenology, ethnography and grounded theory); proceeding from postpositivist, liberal-humanist, or illness paradigm assumptions.

    Not really surprising, but, personally, very disappointing.

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  • Thank you for your comment Jonathan. I think you’re correct in saying that we need to re-imagine ‘community’ and the place and nature of community work within this. I’d also be interested in hearing more from you about ‘demedicalising and deinstitutionalising a(being) not as important as depathologising.’

    I also agree that the critical dimension to MHN education should be given far greater credence, and it’s interesting and telling that NMC policy and the Willis review don’t seem to support this (although I’ve yet to read the latter thoroughly). Like you experience, critical psychosocial input is bolt on at the University of Brighton.

    I think that, in the main, mental health nursing, and mental health nurse eduction is de-politicised, and no surprises there given our times. I think that this reflects (hats off to Chomsky) the wider state of apathy and lack of citizenship in the general public these days: people as neolib consumers, with student nurses as consumers of knowledge in our neolib universities. I too experience entire cohorts of young people who don’t know what ‘left and right wing’ mean.

    I’m also not sure that bolt-on psychosocial education will have any lasting effect in this context, and might gradually be excised from nurses as a function of their socialisation to institutional psychiatry.

    I stopped being a member of MHNAUK (Mental Health Nurse Academics UK) because of this very thing: my perception of a lack of criticality in their organisational rationale and meeting agendas. I saw rule-following tendencies played out in this group, in terms of taking the lead from policy and taking issue with it only to the extent that it threatened the integrity of MHN as a profession.

    So, yes, we need ‘the CMHNN website (to) develop a set of pages for and about nurse education.’

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  • Yes Ywaves, I do mean that I think we have to move beyond narrow professional self serving and assumptions, binaried (well-sick) ways of looking at the world, and recognize our common humanity. And not just that, we also have to change our conceptual and classification systems and thus our vocabularies.

    I don’t think you are naive at all – I didn’t mean to imply what you’re inferring. I think we have no other choice right now but to try to effect change from within, and make existing services better, recognizing their systemic, multi-level contradictions. The pull of normativity is a strong one though, and felt ‘goodness’ can be socialized out of young students/nurses who start with the best of intentions – something (naive) humanism fails to sufficiently acknowledge. And sometimes recovery initiatives that exceed the biomedical and the institutional psychiatric are pulled back into line, colonized. This happens all over the place too – my Mad Studies friends in Toronto recently wrote about the ways that service user lived experience narratives are given an institutional psychiatric spin in the service of window dressing of service delivery out there

    I see the normative pull happening a lot – no surprises – and have written about it over the years in my autoethnographic work with Nigel Short, including in the book I led a few years back, Our Encounters with Madness, I hear it happening around the world, most recently from my Norwegian colleague, Trude Goril Klevan.

    But I think also we should have our eyes to the future.

    I tell students all of this, but they often don’t have the years, experience or nous to hear. I agree with your comments that nurses need to face up to and bear these cultural contradictions. Spy- chiatrics a neat metaphor!

    So I’m with you.

    I’ve since spoken with Jonathan Gadsby of CMHNN and we’re meeting up when he comes down my way in May. He seem supportive of a crit. MHN educator arm. Steve Williams is keen to join forces too. All good!

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  • I’ll be speaking to Jonathan Gadsby/CMHNN later today, and meeting with Jonathon soon, about the idea of a Critical Mental Health Nurse Educator’s arm to CMHNN. Great idea, Nick (speaks to YWaves points too). Will keep you (ALL) posted on this blog. Thanks also bcharris for your positing.

    A question I have frequently asked my friend Phil Barker, with regard to his Tidal Model, is how is it possible to empower people in environments that are not really about empowerment.Teaching people to be humane in fundamentally non-humane environments that are informed by a mixture of social control and a narrow ineffective view of human distress as ‘mental illness’,, where most of them are likely to be socialised out of their humanity by the alternative curricula of institutional psychiatric business as usual to varying degrees, speaks to the triumph of hope over experience in my opinion.

    And this needs to be looked at in a wider cultural context. You don’t have to be a Zimbardo to see a connection between the reverse humanity effect that takes places in institutional psychiatry, where psychiatric (as opposed to mental health – to use Phil Barker’s distinction) nurses are complicit, and the Magdalene Laundries. The outside world/ environment is never neitral. It wasn’t bad nuns in neutral Magdalene Laundries. It’s never bad nurses in neutral psychiatric facilities

    I write, speak and teach from an explicitly hybrid subjectivity position (
    ). I think we need to get to post-silo’d identity position. So, I’m also with Anne Cooke (BPS) and Ron Coleman (Mad Economy) here about the need for Crisis Centres and Recovery Houses in the medium to long-term, while leaning more towards Coleman’s view that these need to be independent of statutory services, because of the cultural contradictions I speak of above.

    So, my hybrid (hyphenated, provisional, dialogical) subjectivity position as Alec Grant is: ex-psychiatric nurse-CBT practitioner-academic-writer-survivor of the UK institutional psychiatric system-sometimes teacher of under-and postgrad. Mental health nurse-narrative scholar. In terms of hybrid identity and autoethnographic narrative inquiry, it was a great pleasure to recently foreword Steve Williams excellent book, Recovering from Psychosis (
    ). I think hybrid voice undermines inevitable mental health professional silo positioning.

    I was recently also asked to do a foreword for Corrie et al. 2016. Assessment and Case Formulation in Cognitive Behavioural Psychotherapy. 2nd edn. SAGE. Having been the lead editor on the first (2008). I did it from my vantage point of narrative scholar-ex CBT figure. The irony of my foreword being explicitly critical of monological methodologies and therapeutic approaches in a book that, despite being helpful, is all about those (more so than the first edn) didn’t escape me, and I hope sent a friendly signal to its readers.

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  • Hi Nick,

    I recognize your concerns about the CMHT model and have first hand experience of the problems you describe. However, I’m thinking of social care relocation of services much more in line with the outline framework proposed by Peter Kinderman in his recent book, A Prescription for Psychiatry, where the hierarchies are flattened. I’m not thinking in terms of a vocabulary that includes phrases and words such as ‘delivering care’ or having ‘leaders’ in this – quite the opposite: co-participation with people in mutual relationships to help them with their problems in living (to borrow a phrase from Tom Szasz and Phil Barker), that would use different professional knowledges as a resource. I wouldn’t want to see one oppressive hieararchy giving way to another in the name of emancipation.

    So, in the kind of community model I would like to see, their would be professional folks from a range of disciplines, with different skills, intra-acting in a helpful, facilitative way, rather than interacting in a jarring way on the basis of implicit beliefs about the primacy of their profession or right to ‘lead’.
    I think your idea about ‘develop (ing) a group of like-minded individuals such as the posters on this site, who are mental health nurse educators to develop solutions to some of the issues that have been raised.’ is a great one! I’d be up for that!

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  • Thank you Ywaves.
    I’m with you on most of what you say. However, I think we need to work hard as educators to encourage our students to be acting to create new environments – in line with the psychosocial vision expressed by many in critical mental health, towards community-based initiatives, where nurses work alongside those in recovery (expressed in person by person, existential rather than institutional psychiatric, terms), as co-workers/facilitators. So nurses need to learn about community co-facilitation of voice hearing networks, open dialogue and the kinds of deeply contextual community recovery approaches advocated by my esteemed Norwegian colleagues, Trude Goril Klevan and Bengt Karlsson. This would dis-embed ‘mental health’ from traditional healthcare contexts and relocate them in social care. I think the idea of trying to instill virtue ethics in people to help them survive dehumanising environments to which they will be socialised is contradictory. Better to work at revisioning the environments. It’s foolish to paint a car to make it look pristine when it keeps failing its MOT (UK regular maintenance check)!

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  • Thank you bcharris. Years ago, with extreme psychological distress interrupting my life, I spent weeks in a detox and rehab clinic. Withdrawing from benzos was horrible. I was on them in combo with antipsychotics. I know what it’s like – at least for me. In line with Kinderman’s argument in A Prescription for Psychiatry, we need medical doctors in ‘mental health’. But, to paraphrase him, drawing on an analogy, women in labour are helped by physicians, but this doesn’t make pregnancy a disease.

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  • (Sorry, my first response was to BPDTransformation… Now replying to nickfitz/both of you – forgive, new to blogging as a blog poster)

    What you both say is worrying, but not surprising. I’m pleased that you’ve further filled me in on some of the details of MH Nursing in the USA and NZ. I think that the UK is going down the NZ route in regard to minimalist and generic training (as opposed to critical education). I wish that UK nurse educationalists gave more of a crap, to use your phrase nickfitz.

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  • Re clinical psychology: ‘…how hard it works to make sure everything stays the same whilst at the same time presenting itself to the world as the progressive and liberal minded’. I think you could just as easily be talking about mental health nursing here Mark. And don’t forget that it’s the Division of Clinical Psychology of the British Psychological Society that have formally stood out against the medicalization of human misery in the last 2 or 3 years, in the form of ‘Understanding Psychosis and Schizophrenia’ and ‘Time for a Paradigm Shift…’ Mental Health Nurse Academics UK seems one of the most conservative, normative policy-following collectives I’ve come across. This is matched by editorial policy in the Journal of Psychiatric and Mental Health Nursing. Really glad that I’m not part of either any more!

    That said, Stranger than Kindness is a great novel!

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