The Virtue of Caring With: Exploring the necessary conditions for healing in mental health nursing.
ãPhil Barker 2002
One might hope that mental health care would involve a questioning approach to what constitutes mental health care, and to what extent health care actually exists within, if not beyond, the complex facades of our mental illness-focused systems. Increasingly, I have come to doubt that any such ethos holds much ground in the turf wars over ‘knowledge’ and ‘evidence’ in health care. Those who try to beg difficult questions, especially within nursing, risk being dismissed (at best) as agitators or (at worst) as being past their sell-by dates (Gournay, 2000). The contemporary notion of ‘science’, increasingly touted as the Royal Road to Mental Health, may have originated in the armchair reflections of Enlightenment philosophers, but philosophical reflection has become, almost, a red card offence in the halls of psychiatric academe. Almost since its inception, psychiatry has been a divided realm; split between those who seek to explain ‘mentally aberrant’ phenomena, by reference to some putative ‘underlying, physical cause, and those who appear to be in search of understanding of the many ‘different ways of being human’, that disturb society, or the person, or both. If a blunt distinction between the two camps is necessary, the former are represented by a medical (or medicalised) practice, which locates itself, firmly - if not always appropriately - within the realm of science. The latter is a ragbag non-medical grouping, more concerned with addressing the immediate needs of dispossessed and disadvantaged people, than with winning Nobel prizes. Clarke (2001) saw this distinction personified in the classic confrontation between the assertively biological approach that begat ECT and psychosurgery, and the libertarian approaches that spawned therapeutic communities, if not the whole ‘anti-psychiatry’ movement. The former was enacted best, in his view, by William Sargant (1967), who saw himself as ‘a physician in the practice of psychological medicine’. The latter was best illustrated by the hero with feet of clay - R.D. Laing (1960)- who postulated the possibilities of a ‘philosophical psychiatry’, in which the madman might be co-opted as brother-philosopher (Burston, 2000).
The hard work of recovery
At the beginning of the 21st Century, curiosity about what it means to be human is waning, at least within psychiatry, which began with the vain ambition of curing all the ills afflicting the human soul. If humans ever reflected, in any great number on the nature and meaning of their own existence, this has largely been replaced by a glut of ‘personal growth’ publications that direct people towards the altar of human development. Invariably, this is a euphemism for capitalistic iconography. In Brandon’s (2000) view, this was an exercise in self-diminishment. Jerome Frank saw the folly of this, arguably, more clearly than most:
"ironically, mental health education, which aims to teach people how to cope more effectively with life, has instead increased the demand for psychotherapeutic help. By calling attention to symptoms they might otherwise ignore and by labelling those symptoms as signs of neurosis, mental health education can create unwarranted anxieties, leading those to seek psychotherapy who do not need it. The demand for psychotherapy keeps pace with the supply, and at times one has the uneasy feeling that the supply may be creating the demand. (Frank, cited in Dineen, 1996).
This view makes a lot of sense to me, a ‘baby-boomer’ from working-class stock. In Scotland we used to say, ‘the working class man doesn’t suffer from stress. He has to get up for work in the morning". Certainly that was true of my father, and in an egalitarian sense, of my mother, who rose before him, to pave the way for his 5 am start. Brandon, who emerged from a similar background, noted wryly that today people are rapidly becoming like characters in a Woody Allen film, living ‘intentionally’ and, in trying:
"to increase our options and estimate every conceivable consequence, fun and spontaneity are reserved for the annual fortnight holiday in Benidorm, Ibiza or river rafting along the Amazon (Brandon, 2000: 3)
This culture shift (Toffler,1970) has rippled out to the shores of mental health where:
‘Consumers demand services that are easier to access. Everything from education upwards and downwards must be glycerined. (But) As Kenyon (1997) wrote: "The fact is that Brahms needs effort, not just on the part of the performer but from then listener. And we underestimate that at our peril. The big classical works – not just the huge symphonies of Bruckner and Mahler and the operas of Wagner, but also Handel operas, Bach cantatas – make demands on the listener just as do a great book or a great picture". (Brandon, 2000: p57)
It seems axiomatic to suggest that recovery in mental health, or the engagement process that might be part of its genesis, must be hard work. I have met few, if any, ‘survivors’ who said that they had no difficulty in buying their ticket to ‘recovery-land’ or that they dithered idly over which of the many therapeutic options might be easiest for them. Yet, the ravenous, I-want-it-yesterday, attitude, which is part of the fallout from the follies of the Me-generation, looks set to consume the narrative about recovery, and human possibility, in the way that only the best (or worst) consumerist models can. Already we have imported the American obsession with litigation, not just to recover appropriate compensation for malpractice but to use as another way to vent our anger at the vagaries of fate. I cannot prove it, but the evidence of the need to embrace the pain and suffering of madness, as part of the recovery process, rather than to rail against it, litters my everyday experience. Recovery involves a strenuous journey, taken over very rocky ground. The engagement process, that seeks to aid and abet recovery, is an equally daunting task, that can take the helper close to the edge of their own core humanity, and can – on occasions – tip them over, into the abyss of their own human incompetence.
The nonsense of ‘effective’ nursing
I remind myself, at least of some of the human facts, before proceeding. The pursuit of happiness and human excellence, which have become the mainstays of the humanistic, personal growth camps, have bred, albeit inadvertently, the contemporary obsession with celebrity, the beauty myth and the vicarious pleasures that are the virtual fuel of the mass media. If my parents generation spent most of their waking day engaged with the everyday business of working, laughing, weeping and loving, today people spend much of their time watching the carefully rehearsed, or disingenuously ‘candid’ lifestyles of people behind the Big Brother camera, or enacted in one soap or another. These distractions – for they take us away from our ‘lived experience’ of being here, now – gloss over the true complexity of life, as it is lived, as surely as our eyes glaze over before the one-eyed god in the corner of our living room. A true human being like Orwell would, doubtless, be distressed that not only has his National Lottery become fact, but his Big Brother has become a post-modern icon. These concerns have generalised to mental health where, as Clarke (2001) noted, nursing has become self-satisfied with its:
" pursuit of ‘professionalism’, accompanied by the easy acceptance of forensic incarceration, the happy embrace of the techniques of ‘control and restraint’, the abysmal absence of irony at the sinister language of ‘assertive outreach’. The benightedness that refuses to accept the complexities, conscious or otherwise, that lead some patients to decline treatments; the accompanying denial that civil liberties may be violated when compulsorily ‘treating’ patients, ‘in the community’ are all typical of such modern discourse"(Clarke, 2001:97)
In his essay on ‘The Nonsense of Effectiveness’, Don Bannister (1998) famously said that, were he to ask how effective a conversation was, he would need to begin by questioning the question. Given the many possible meanings of ‘effective’ it is a nonsense simply to ask it. Mental health professionals have largely ‘bought’ the nonsense of ‘effectiveness’ and abandoned the inquisitiveness that Bannister thought de rigeur. In Clarke’s view there is no greater offender than nursing, which appear most comfortable to offer grossly institutionalised responses to people in mental distress. This is not a problem, since we cannot see the people diminished by such institutionalised responses, hidden as they are, by the multiple barriers to human engagement that bolster the bureaucracy of mental health services.
What has any of this to do with mental health care and, specifically, the discipline of nursing? Given that nursing has, traditionally, been caught in the long shadow cast by psychiatric medicine, and has frequently been coloured by changing socio-political mores, it is not surprising that, today, mental health nursing (as it euphemistically describes itself) is undergoing radical changes, few of them ironically (in these self-directed times) of its own making. Here, I beg some simple questions about the basis of the discipline of nursing people in mental distress and to consider what a radical model of caring in mental health might involve.
If nursing, as a discipline, were based on the ‘reflective practitioner’ models that are in common academic currency, nurses might ask, routinely, the following question:
"Would I be happy (or content, or satisfied) to be committed for care and/or treatment within the service in which I presently am working?
Or, more importantly, nurses might reflect on the most vulnerable member of their family or social circle: someone whom they love - a parent, or a child or a friend. In reflecting on that person’s essential vulnerability, they might become aware of how they are touched, invisibly, in the way that the power of emotions touches everyone. For every patient is someone’s parent, or child, or sibling, or lover or friend.
"Would I be happy to commit this person to the care of the services of which I am a part?
Few nurses ask this question, framed as it is within this highly personal context. Moreover, when I have asked nurses to offer a heart-felt response to this question, some find the interrogation painful, others view it as a manipulative assignment. Although statistics always flatter to deceive, less than 5% of any audience has ever answered "yes". The catch – for indeed the question is manipulative - lies in the context of commitment.
The answer to these questions says something about our attitude to commitment, in its dual senses, since it means both to pledge oneself – involving the act of charitable giving - but also means (or used to mean) the act of consigning someone to the care of another. Today, the destination to which society consigns people in mental distress is more likely to be characterised by little more than confinement. Indeed the commitment embraced by many care agencies today is framed in the manner of Pilate, who through his literal act of washing his hands of Jesus, provided us with the apt metaphor for consigning (or committing) people to the hands of others. Although it may be unfashionable, there may be a virtue in recalling what words, at least, used to mean. Commitment reminds us that we have the power to pledge ourselves and, at the same time, the power to abdicate - leaving people and their problems to be addressed by others or, as can be the case, leaving people to be exposed to the vagaries of fortune. Commitment might, therefore, mean opting in but it can also mean opting out. For a discipline that emerged from a one-thousand-year old vocational history (Barker, 1999b; Clarke, 2002) nursing in the 21st century might care to ask itself, to what extent it is still involved in providing the conditions under which the person might be healed, by Nature or by God. Or, in its pursuit of institutionalised power (Barker 2000) has it surrendered its lofty if diffuse ideals in favour of a more pragmatic social-policing role (Morall, 1998)?
Power comes in a variety of forms and few of these are not disguises. The everyday business of engaging with others involves a careful balancing act – ensuring that we display just enough vulnerability to complement the power of the other, whilst at the same time hoping that they will reciprocate in much the same way. Such engagement is always risky since, by exposing our vulnerability, however fleetingly, we risk losing the chance to influence the proceedings. We risk losing the advantage, which often we feign not to possess. At times, the boundaries of our selves can become blurred within such exchanges as we dance a verbal tango, weaving our words – and the selves for which they advocate – seamlessly, yet provocatively, with the words of the other. Many now argued that the interpersonal paradigm, framed famously by Hildegard Peplau, is outmoded, in this era of ‘case management’ and ‘brief intervention’ (Gournay, 2000) However, when invited to explore the possible basis of their unique role, most nurses quickly identify the abstract, but all too real, interpersonal exchange – whether verbal or non-verbal – that takes place when nurse meets patient. The comparison of a conversation with a dance may be apposite, since – at least from the observer’s standpoint - it is not entirely clear who is leading, and who is following. In functional terms, we could say that all true human relationships involve a temporary sacrifice of the self. As Yeats wisely remarked, "how can we know the dancer from the dance?" This begs the question, of course: "how true are our therapeutic relations?" Are we pledging ourselves as helping (i.e. potentially helpful) agents, or are our relations with people in care no more than political in character, paying only lip service to the notion of engagement?
The Metaphor of Madness
We began this century with lofty ideals about furthering the medical notion of finding various cures for mental illness. Increasingly, however, we have come to doubt the validity of that core construct. Despite the fashionable assumption, predicated on a largely North American infatuation with genetics and biomedicine, that the riddle of madness will, ultimately, be found in the gene pool, or in the size of one’s ventricles, madness, in its various guises, is enjoying a renaissance. Perhaps we only have more ways of classifying and categorising it, but the mad world recognised by Laing in the mid 1960s, where one in four would be manifestly distressed, if not disabled, by some form of madness, has come to pass. Indeed, his figures seem a little conservative, for such a supposedly radical voice. To some extent the contemporary classification of any or all human foibles as one form of mental disorder or dysfunction or another provides an echo of Freud’s once provocative thesis concerning the predatory way that our deepest pathology insinuates its way into our everyday lives.
History may well conclude that Szasz’s (1961) assertion that mental illness is a myth was finally found to be right, although many would say, for all the wrong reasons. The human phenomenon called ‘mental illness’ or ‘mental disorder’ has many correlates – biological, chemical, psychological and social. However, as Szasz has recently noted, in physics, we use the same laws to explain why planes fly, and why they crash. However, psychiatry uses one set of laws to explain so-called sane behaviour, attributable to choices (reason) and another set to explain insane behaviour, attributed to causes (disease). For Szasz (2001), this is akin to the theory of phologiston, once presumed to be a part of the nature of combustion. What is actually going on within and around people when they are described as in states of ‘mental illness’ is, to say the least, highly complex, but is predicated on the same laws of choosing and reasoning as other aspects of the person’s life. These ways of being human (Jenner et al, 1993) involve a different set of behaviours, but stem from the same root of reason and choice. A frivolous, but meaningful example might be the all too common experience of encountering someone, described as in a ‘florid psychosis’ (and, by implication, completely out of touch with reality) who manages to suspend the psychotic state long enough to beg, light and subsequently smoke a cigarette. Coleman (2000) offered similar examples, from his own experience, of how the apparently irrational behaviour of the person in psychosis, is a mask for the highly-intentional choices of the person.
In a remarkable body-swerve, some sections of the contemporary mental health community have abandoned the debate about the phlogiston status of mental illness, in favour of talking about ‘mental health problems’. Ironically, they are echoing Szasz’s original advocacy of Harry Stack Sullivan’s use of the term ‘problems of living, which he coined to describe the ways of being human shown by people in psychotic states (Evans, 1996). ‘Problems’ connote the kind of things that disturb people in the social world, rather than in the abstract world occupied by concepts such as health and illness. However, this also implies that such problems will be amenable to solutions. Alvarez (1971), writing of his own suicide attempt, observed how, initially, as in a dream, he believed that his death would solve the problem of his life.
"I thought death would belike that: a synoptic vision of life, crisis by crisis, all suddenly explained, justified, redeemed, a Last Judgement in the coils and circuits of the brain. Instead, all I got was a hole in the head, a round zero, nothing. I’d been swindled (p. 282)."
With remarkable foresight, Alvarez anticipated the emergence of the ‘problem-solving’ ethos that underpins many of today’s services.
"The despair that had led me to try to kill myself had been pure and unadulterated, like the final, unanswerable depair a child feels, with no before or after. And childishly, I had expected death not merely to end it but also to explain it. Then, when death let me down, I gradually saw that I had been using the wrong language: I had translated the thing into Americanese. Too many movies, too many novels, too many trips to the States had switched my understanding into a hopeful, alien tongue. I no longer thought of myself as unhappy; instead I had ‘problems’. Which is an optimistic way of putting it, since problems imply solutions, whereas unhappiness is merely a condition of life which you must live with, like the weather. Once I had accepted that there weren’t ever going to be any answers, even in death, I found to my surprise that I didn’t much care whether I was happy or unhappy: ‘problems’ and ‘the problem of problems’, no longer existed. And that in itself is already the beginning of happiness"(p. 282)
In some respects, Alvarez still is avant garde. Today, even the mental health user/consumer movement has embraced the notion of ‘problems’ without appreciating how they have surrendered to the American obsession with solving, aggressively, every difficulty that life throws up. Alvarez ‘s gentle alternative is more provocative and draws from an Oriental tradition concerning acceptance, which is only slowly gaining ground in the West. In re-defining as problems, the wildest vagaries of heart and mind, we suggest that all such disruptions are amenable to solutions. Of course, in so doing we aid and abet, perhaps unwittingly, the generation of more and more ‘prescribed solutions’ for our various human ills. If Jenner et al (1993) are right, and ‘serious’ forms of madness, like schizophrenia, are more a ‘way of being human’ than an ‘illness’ or ‘disorder’, then the challenge is to work out how to live with, accept or make human sense of such experiences, rather than to ‘fix’ them.
The Metaphor of Nursing
While political correctness clearly has changed the surface texture of madness, the phenomena that our linguistic contortions signify remain much the same. Some mental health ‘problems’ are malign forces, disabling and ultimately destroying personhood, if we fail to address them. Others are little more than signs that we are alive and smarting from the teachings of the resident philosopher within us all, called experience. However, in both cases, we need to consider how we respond to such human distress – whether it is called a serious mental illness, or some presumably trivial form of human upset (Barker et al, 1998). These are not lofty philosophical issues. This is the very stuff of everyday life. What, exactly, are we dealing with when we talk about nursing people with mental health problems? Nurses, perhaps more than any other discipline, appear content to talk about applying mental health nursing to various forms of mental illness, when clearly health and illness lie at opposite ends of some hypothetical spectrum (Barker et al, 1998). Sadly, this is all too typical of the monocular vision bred of political correctness. More important, stands the question -how do we go about dealing with such phenomena?
Today, more than at any time in psychiatric history, we have become obsessed with certain kinds of evidence, and questions about the efficacy and efficiency of interventions. An all too common question, increasingly asked by nurses, keen not to be viewed as passé, is – does this or that intervention ‘work’? An intriguing if naïve question, since everything ‘works’ in some way, even when it seems to be doing nothing – which is an outcome in itself. Alvarez’s ‘solution’ worked, although he did nothing, other than to accept his state of mind. Perhaps the question we need to be asking is:
When people called nurses are involved in a process that they, or others, call engagement we need to ask: ‘what (exactly) is going on?’ Rather than focus blindly on what might happen, as a (presumed) consequence of this process, we might try to understand the shifting patterns that characterise the quality of this engagement.
Of course, all of this is metaphorical. Things don’t work in the way people work. We simply can’t find any other way to describe such happenings, without comparing it to something else. Metaphor is vital to the world of mental illness since, as Tom Szasz (1987) has repeatedly pointed out, whatever it is that we are dealing with – and he was in no doubt that people were in distress – such distress was not an illness, as such (Barker, 2000). Today we talk about buildings being sick and the economy being sick, reminding us, perhaps, that the sickness that overtakes these inanimate things might be close to the sickness of the soul or the spirit that we call mental illness (Cooper, 1986). Given the context of nursing, where many of the functions involved in caring, involve the manipulation (metaphorically) of abstract elements – support, platonic love, respect, dignity, power – it is important that nursing, as a discipline, recognises that its vocation belongs to a quite different territory of evidence: the world of experience.
The Tidal Model (www.tidal-model.co.uk) is predicated on the assumption that human experience is fluid. Experience ebbs and flows, like the tides of our seas and river estuaries. The Tidal Model also acknowledges that the life force – or prajna as it is called in the East – flows in and out of us, with each inhalation and exhalation. As we breathe in and out, we balance – literally – on the cusp of life and death (Barker, 2000a;2000b;2001a). The power of water is not something that can be controlled, but through acknowledging how it works, it may be understood. Such understanding can illuminate us. We know that we can drown in a few inches of water, but the same amount of water can cleanse our system. It is a strange force that can kill or cure. The Tidal Model, which began as a professional nursing model of care (Barker, 1998), has been extended to embrace the nursing relationship that might be engaged in by any helping agent (Barker, 2001b). Wilkin (2002) wisely noted that in all human relationships, there is no exact science to help us to navigate our relations with others, far less ourselves. Coleridge (1831) declared:
"the light which experience gives is a lantern on the stern, which shines only on the waves behind us!"
Wilkins added, "in the absence of any absolute truths, it makes good sense to extract the oils from our nursing experiences to fuel the lamps that light up our future practice."(Wilkins, 2002). This aptly illustrates how one person’s experience (the nurse) of another (the patient) flows in and through the other, in a constantly changing narrative (Barker, 1996). If one accepts this view then assumptions about doing things which ‘work on’ another, become nonsense.
The power of water, as it is used within the Tidal Model, is a metaphor for the killing or curing of the spirit that we used to call madness. That at least a few people have described the process of emergence from the madness in positive terms, illustrates the spiritual nature of the experience itself (Clay, 1999; Deegan, 1993) Although it is hardly popular, I no longer apologise for talking about psychiatric care in spiritual terms, for madness does appear to be the place that the spirit of women and men risks extinction (Clay, 1999). When we stop to consider the importance of even the simplest of interactions with this valuable, vulnerable person who – temporarily – is the patient, we realise that this is a sacred space, and we need to tread carefully and sensitively, and to consider to what extent we might have the wisdom, rather than the technical know-how, to help facilitate this process of recovery or re-emergence.
What are we talking about when nurses talk of engaging people in mental distress? We engage with nothing more than their stories - the representations of themselves and their experiences, which have come to represent their understanding of who they are what they mean as persons. It seems axiomatic that people can – at one moment – appear to be in great distress, and – at another moment – can appear quite different. Nurses working within the assumptions of the Tidal Model are interested to know how such change occurs. In particular, they are interested to know what part the person played in this change. The Model assumes that nurses learn from people about the nature of their distress, here and now and, in so doing, learn what, if anything, might ‘need to be done’ to help alleviate it.
However we should urge caution against rushing in to alleviate distress, or at least we should avoid forcing the re-shaping of the narrative that is a person’s life. Too many of our contemporary models emphasise what Szasz (1994) has called a ‘cruel compassion’. Psychoeducation may be one example. In their Cochrane Centre review, Pekkala and Merinder (2002) note that :
"schizophrenia can be a severe and chronic illness characterised by lack of insight and poor compliance with treatment. Psychoeducational approaches have been developed to increase patients' awareness of their illness and its treatment".
Similarly ‘compliance therapy’ (sic) may also be a cruel euphemism for obliging people to see the world from our perspective and ours alone (Perkins and Repper, 1999). Given the contemporary ambition of nursing to ‘empower’ itself, it is unsurprising that many nurses are keen to adopt such approaches. Sadly, the fact that they can only gain such power, at the expense of the person in their care, escapes most nurses. Having cast ourselves in the role of psychiatric experts, it is rarely easy to acknowledge that really we know nothing of any consequence about the experience of mental distress. Humility and professionalism live at opposite ends of the psychiatric street.
We need to remember that the current page of the storybook of a person’s life - how anyone is here and now – is only the latest entry in a story that has a meaningful beginning. For many people, their understanding of where they are, now, and what they need to do, now, to move forward, lies in an appreciation of where they first began to experience their distress.
For Pat Deegan, (Barker,1999a) the first real signs of that distress originate in what she has called the desolation of winter - the season of anguish. For anguish involves living in terrible pain, which seems endless and futile, and leads to nothing more than more pain. When people begin to take a stand against that anguish they transform it into suffering. In Pat Deegan’s own experience of madness, this stand was redemptive. Ron Coleman (2000) took a stand against his own anguish, as well as against the psychiatric system that heaped grief on top of anguish. Ron learned how to suffer for others as well as himself. Therein lay the seeds of his recovery. Suffering breaks the cycle of anguish when pain becomes something that will never be forgotten, but can be used to help people to move forward.
How do nurses help people transform their anguish into suffering? How do they help them to use their spiritual pain to step from the darkness of alienation into the light? There are no easy answers to these questions. What seems clear is that much of what passes as standard ‘mental health nursing’ practice is far removed from such facilitation. Many people who have been forcibly drugged, injected, restrained, placed under ‘observation’, or otherwise ‘treated’, describe such experiences as rape. A loaded word if ever there was one, but the cowering Self, who has witnessed the savage power of madness might be forgiven for expecting mental health nurses to represent psychiatric rescue, rather than what someone in one of my studies called ‘adding insult to injury’. How can we assure the people committed to our care that they will not be subjected to the rape of the Self?
The enigma of empowerment
Addressing disempowerment is rarely easy, especially in traditional custodial institutions – and I use the term advisedly – like acute psychiatric wards and more secure settings. We talk about participating and collaborating with people in our care. But how do we do this? Cahill (1998) identified five attributes, which were necessary for participation to occur.
In essence, the nurse needs to ‘do’ something ‘with’ the person, which might be construed as empowering. This kind of relatedness is what Irene Whitehill – the user-advocate – and I have called ‘caring with’ the person (Barker and Whitehill, 1998). We need to care about the person – which is the basis of our compassion. Sometimes we show that by caring for the person, when they are vulnerable. But the empowering basis of participatory care involves caring with. If we do this, at the very least, we avoid contributing further to their disempowerment.
When the spirit of the person begins to break the loss of hope and ultimately the will to live isn’t far behind. The loss of hope inspires the need to develop what I have called ‘hopelines’. The instillation of hope, even if only the hope for a peaceful death, lies at the heart of care. We cannot afford to ignore the power of hopelessness and its partner helplessness. Some of the finest accounts of how people submit to hopelessness and how they also kept the flame of the spirit alive, are to be found in the accounts of Holocaust survivors. Viktor Frankl touched his own spirit when he experienced torture and medical experimentation at the hands of Nazi doctors. Frankl experienced his epiphany when one day he realised that no matter what they did to him, they could never touch his human essence. In that moment he made contact with the invisible spirit within him and he grasped his own power and holding on to it he knew that he could never be defeated. Killed perhaps, in body, but never destroyed in spirit.
It was perhaps no accident that Frankl went on to establish a psychotherapy that helped develop a focus on the spirit. Logotherapy (Frankl, 1964) focused on helping people to find the personal meaning of their distress and from this meaning to build hope for change and the future.
Only a few of us have had the kind of human schooling, that sensitised Frankl to ‘what needs to be done’ to help people in distress. However, we all have the same potential to care with people, to empower them. However, we must take some risks with our own self-hood to make such an engagement.
We might begin by considering the possibility that some of the ‘problems’ that our clientele show, might be examples of them taking a stand against the rape of the Self, I mentioned earlier. We talk glibly about people being non-compliant, treatment resistive, lacking insight or passive-aggressive. These are not simply highly judgemental terms, for which we need to find a politically correct euphemism. These are simply the wrong way to ‘read’ people, at least if we care to understand them. These kinds of active resistance can be life enhancing. These may be signs of the person’s strength and refusal to succumb to hopelessness. This ‘resistance’ is something we need to build on, through mutual understanding, not crush through further manipulation.
I am aware that such a view will not satisfy our political masters, at least some of whom see some mentally ill people as a nuisance. Why can’t people just fit in? Why can’t they just take their medication? Why can’t they just do, exactly, as the Care Programme Approach says they should? Why can’t they just accept the tough hand that life has dealt them? Working with people in great mental distress brings us into close contact with our own vulnerabilities of not also our own spiritual wounds. The theologian Martin Buber (1970) provided us with an elegant means of appreciating the cycle of dehumanisation in care when he distinguished the I-Thou and the I-It relationships. The I-Thou relationship is marked by compassion, love and recognition of the sanctity of life. When we are sufficiently open to encounter the ‘thou’, we embrace, revere and honour the sanctity of the person’s humanity. We encounter the ‘Thou’ every time you see a reflection of your own most valued - most vulnerable - family member or friend, in the eyes of your patient or client. For many of us such true compassion is difficult and, instead, we settle for I-It relationships, where we objectify the person. Of course, when we treat others as objects – requiring ‘observation’, for example, rather than for human engagement – we strip ourselves of our own humanity, as well. When we enter into the compassionate caring of the I-Thou relationship, we deepen our own humanity. Compassion care requires as, literally, to suffer with someone.
Within the Tidal Model I have talked about the need to get into the water with people – a lifesaver cannot rescue without getting wet – we cannot do the necessary business of compassionate caring, without encountering at least something of what it is like to be in at the deep end. Frieda Fromm Reichman (), who developed a psychoanalytic framework for working with people in psychosis, famously sat on the floor with a man who was playing with his own shit and began to handle it herself. The bravery of such an encounter – which illustrated the starting point for a true engagement with the person in the sacred space of his distress – is largely denied us now. Most of us cannot even contemplate the possibilities of such a close encounter. Instead we try to develop ways of manipulating people from a distance: hence the re-emergence of the panopticon of observation. Few would stand, idly by, watching someone in great physical distress, but this is often what passes for ‘care’ in acute psychiatric settings. Increasingly, all our efforts at psychiatric rescue are like deep-sea fishing from the relative comfort of the shore.
When I entered the psychiatric field Neil Armstrong had just taken his famous one small step for man on the moon that was heralded as a huge leap for humankind. Thirty years later the ambitions of the psychiatric system – at least at the political level – is to ensure that our services are ‘safe, secure and supportive’(Department of Health, 1999). Strategy is important but is worthless, if we do not have the level of commitment and capacity at the care face to ensure that people in deep human, if not spiritual crisis, are engaged in a manner that is fitting to the nature of their plight.
A sports team can have the best coach, equipped with the best strategy that can be mustered. However, if the team does not possess the highest level of fitness, supporting the highest level of commitment to winning, then they are beaten before the game starts. Sport provides a crude, but useful analogy for what is expected of people who are asked to nurse people in great mental distress. In the USA some hospitals hire university students to take over the menial task of observing suicidal patients, asserting that such surveillance is not appropriate for professional nurses. In the UK some Trusts have even employed security firms to do a similar surveillance work on acute wards. These post-psychiatric developments are either a clarion call to re-engage with caring for people in great distress, or a signal that nursing, and those who manage them, have abandoned care in favour of containment. Arguably, anyone with even a modicum of medical preparation could monitor and advise the psychiatric team of the ‘presentation’ of the patient – which is often all some psychiatrists ask for in a ‘good nurse’. However, the only people who can provide the necessary conditions for the promotion of human growth and development - acknowledging the root definition of nursing – to nourish – will be those with a heart big enough for the task.
It is over one hundred years since Freud founded psychoanalysis, which, at least for a time, promised to solve the riddle of madness. When someone asked him why did he always sat behind the patient during the analysis, Freud answered honestly that he wasn’t the kind of person who could sit looking people full in the face for 8 hours a day. What Freud needed and what his clientele needed were, clearly, two quite different things. Things haven’t changed much. Today, we still find it difficult to confront madness. For many professionals, and many patients and their family and friends, gain reassurance if not succour, from the idea that some abstract ‘other’ is responsible (at least temporarily) for directing the human tragedy of their lives. That out ‘scientific’ conceptualisations of schizophrenia, bipolar disorder or borderline personality, differ little – at least in their function – from the abstract, highly malicious demons, which once were thought to have taken charge of our psyches, seems to escape us. We still find it difficult to look at people simply, yet profoundly, as people at the centre of a metaphorical maelstrom, which threatens to engulf, and ultimately, drown them. We find it hard to face the kid who had dreams of being an astronaut or maybe just a father or lover, but who ended up as just another user with a ‘serious and enduring mental illness’. We find it hard to face the dreamer who won’t take his medication, won’t fit in to this grossly misshapen society, and who has ended up as either a nuisance to his family or to the politicians who, ultimately direct the mental health care traffic.
The base language of caring
I can understand why nurses might find it difficult to engage patients as people. We haven’t spend all this time trying to figure out what to call our the people in our care, patients, our clients, our users, our consumers – when the simple fact that we could just call them people was staring us in the face. Maybe – like Freud – all this language is a clever way of avoiding eye contact. Certainly, it reflects the political nature of our relations with those whom we are charged to care for. By redefining their basic humanity as some other – most often now I the language of capitalist consumerism – we avoid confronting the fact that, their pain is as much ours, as it is theirs.
These language games remind us how far we have travelled away from the root language of Greek, where the notion of pity for others reflected a common understanding that the ‘other’ was in a very real sense part of us, by dint of its otherness. The Greeks had no need for self-pity, for it was understood that others would fulfil this function on behalf of the pitiable person. In another, and more specific sense, the emotion of pity could not be self-administered since, one could no more feel pity for oneself than one could envy oneself: all such emotions served social functions.
Pity may no longer be part of the therapeutic canon, but this might simply illustrate how far we have descended, rather than progressed, since Hellenic times. William Blake’s famous image of Pity illustrates Macbeth’s soliloquy on the contemplation of Duncan’s murder. Blake unites Shakespeare's two images of pity--the babe ‘striding the blast’ and heaven's cherubim on horseback. His image shows an angel, flying across the night sky, on a brilliant white charger, dropping the tiny, naked child into the sleeping figure of the mother below.
And pity, like a naked new-born babe
Striding the blast, or heaven's cherubin horsed
Upon the sightless couriers of the air,
Shall blow the horrid deed in every eye
That tears shall drown the wind.
Blake clearly draws a connection between the sacred, which is weighed out carefully, and the profane, characterised perhaps by everything that is terrestrially bound
In most mental health services – hospital or community – nurses greatly outnumber other disciplines. Nurses may have little overt power but, as Stein long ago acknowledged, they have great covert power, which they can – and often do – use to influence the care (and indeed treatment) that people in distress receive. The general public may believe that the psychiatrists is the all-knowing, psychiatric professional but, in many settings, psychiatrists are rendered impotent by the subtle machinations of nurses’ underground power base. Whoever replaces nurses as the ‘foot soldiers’ of mental health care, will likely possess the same power’ albeit with the same perceived lack of authority (Barker and Stevenson, 2000).
The real challenge to developing a genuinely ‘engaging’ relationship with people in mental distress, involves not so much the putative ‘illness’ from which they ‘suffer’, but the person on whose shoulders we erect these absurd concepts. The next person to whom we pay a ‘domiciliary visit’, or whom we interview in a ‘consulting room’, or whom we wrestle to the floor, in a ‘de-escalation manoeuvre’, is someone’s mother, or someone’s son. This is a person who may well have once dreamed of being somebody, rather than just another mental health statistic. When she or he welcomes us in, or bars the door – literally or metaphorically – we shall begin to know what the politics of engagement is really all about.
This is the challenge that faces all those who would use the everyday discourse of human contact and conversation as the primary medium for the delivery of ‘help’. For the present, such people are called nurses but, in the post-psychiatric future all manner of professionals, para-professionals or genuine amateurs, might replace them. Whatever the name or the distinguishing features of the agent, the challenge will likely be the same: to establish how to use ordinary human-to-human interaction in an extraordinary way.
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