Troubling Mental Health Nurse Education

Mental health nurse education is not sufficiently critical of institutional psychiatric practice. Its formal curricula in universities are often undermined by the informal curricula of practice environments. As an institution, mental health nursing pays insufficient attention to both these issues because it is an arguably un-reflexive and rule-following discipline.

I’ve been teaching mental health nurses in England for two decades. Over the years I’ve developed several inter-connected gripes about mental health nurse education and, by extension, mental health nursing more generally. I know that nurses are chronically complicit with scientifically compromised and morally dubious institutional psychiatric practices. It seems to me that undergraduate nurse teaching in the UK frequently supports this state of affairs in the form of delivering safe and bland, policy-endorsed curricula, and doing so in an uncritical way. In my view, both these things happen because, at a broad institutional level, mental health nursing is fundamentally a rule-following, insufficiently reflexive discipline.

As lead author, I recently co-wrote against the corporate construction of madness in a paper published in the international journal, Nurse Education Today (read it here). I stated the obvious in this article: that the biomedical paradigm in mental health is implicated in the corporate construction of psychosis with the pharmaceutical industry; that there are major conceptual and empirical problems with this construction; that the currently emerging and increasingly robust psychosocial paradigm changes the meaning of psychosis within non-medicalised approaches to recovery; that such changed meanings are fundamental to providing alternative values and evidence-based alternative interventions that take account of individual and community meaning contexts; finally, that all of this places a demand on mental health nurse education internationally to take a moral lead in revising its curricular and pedagogical practices.

I don’t think that anything I wrote in this paper is too controversial anymore. It’s simply a fact that the biomedical model and diagnostic ways of understanding something traditionally called ‘mental illness’ is unsupportable. The idea of gathering a large number of extremely distressed people together at once, in physical environments called ‘acute wards’, to be ‘treated’ by mental health workers has never had good press in the UK. For me, these spaces simply create possibilities for already damaged bodies to perpetuate unkindness on other bodies.

And yet I often feel totally at odds with many of my mental health nurse teacher colleagues locally and in different parts of the UK and beyond – the ones who don’t seem too concerned over the need to challenge the authority of such fundamental institutional assumptions and practices. In delivering curricula that has the seal of approval from the UK Nursing and Midwifery Council, they teach the ‘medical model’ as a legitimate way of understanding human misery, rather than as it should be taught in my view – as interesting social history. Such teachers often seem insufficiently aware of the demedicalization movement or the rationale for its existence. On reading my paper, one recently expressed surprise about the corporate role of global pharmaceutics in shaping the meaning and the vocabulary of ‘mental health’ problems. When he said ‘I have no idea that this happened’, I did a kind of double take: At first I was stuck for words. Then I remembered that I never stop being surprised about the fact that many of my colleagues are often surprised about this.

Some who read my paper responded rather defensively: ‘We do teach this stuff; it’s just that students don’t hear it!” Others protested that because they’ve been out of practice for so long, they have no alternative but to teach on the basis of established models for understanding mental health difficulties, and are not experientially qualified to speak from critical standpoint positions. Others still defended the medical model, probably positioning me as a troublesome character with a large axe to grind. Some were equivocal, saying ‘well the evidence is conflicting, so we don’t know who to believe.’ And some said nothing at all.

Meanwhile, on the wards, mental health nurse students are often exposed to an alternative curricula. On reading my work, a colleague from another English university told me of the double bind he found himself in as a mental health nurse teacher. This was that teaching the biomedical model from a critical social history perspective would not fit with the realities of nursing practice. He said that students often told him that qualified mental health nurse mentors in their practice areas insisted that the important knowledge, the knowledge that they needed, was that which best fitted practice circumstances. This colleague said that as a teacher he and his colleagues necessarily occupied a “rather unsatisfactory middle-ground, where we tacitly condone the biomedical model to some extent by realising that students find themselves working in clinical areas where it’s required.”

So it’s not at all surprising that when I teach mental health nursing students in their final year, in the last module they have to take in order to qualify, they are both fully fluent and monolingual in the language of psychiatrospeak. When I ask them to describe the people they work with and their relationships with them, they mostly do so in predictably reductionist ways, which in my view violate relational and narrative courtesies. They describe these people almost exclusively in terms of DSM categories, within which their identities are totally collapsed and the broader contexts of their lives absent and not regarded relevant. So, the ‘schizophrenic’ is often given an overlay of hopelessness (‘chronic, burnt out schizophrenic’), and social judgement (‘manipulative, inappropriate, chronic, burnt out schizophrenic’). When I feed this back to many of my fellow teachers, they frequently displace blame: ‘Not our fault! This is the way that they are taught to conceptualise mental health service users by the folks in practice!’

This response has more than a grain of truth in it of course, but this does not leave my colleagues blame-free. I believe that this issue reflects a wider international problem at the institutional level of mental health nursing as a discipline, in terms of ingrained attitudes and un-reflexive rule following.  The contents pages of issues of the Journal of Psychiatric and Mental Health Nursing in recent years reveal the entrenched positions. Most of the articles that appear in this research and practice development journal are replete with medical model assumptions and a diagnostic basis for describing and conceptualising mental health service users. After a 16 year association with this journal, as article contributor, peer reviewer and longstanding member of the editorial board, I recently ended my relationship with it. I let the editor know that this was because of what I experienced first hand as an unwillingness on the part of the editorial board and peer reviewers to publish experimental, progressive and critical methodological papers. In writing against the mainstream and promoting emancipatory mental health nursing research and practice advancement, these papers challenged established editorial attitudes by rejecting orthodox biomedical assumptions, conceptual language and ‘safe’ mainstream methodological approaches.

With regard to my second point, the philosopher Hannah Arendt  asserted in her writing that uncritical rule following leaves the people involved, by default, as complicit perpetrators. Her  ‘banality of evil’ argument is that otherwise ordinary people engage in acts that later attract retrospective social and cultural condemnation. This does not imply an intrinsically wicked character on the part of these people. However, often in the wake of scandals perpetrated in the name of mental health care, whether major, large scale exposes or more minor and banal, but no less insidious, forms of day-to-day routinised abuses, nurses and other commentators are quick to  defensively invoke the ‘few bad apples’ argument. This seems to me to signal a kind of ‘othering’; a form of verbal NIMBYism where rogue individuals or practice locations are implicitly storied as ‘not like us’, not representative of the general mass of ethically attuned, caring mental health nurses. Arendt suggested that the opposite is more likely to be the case: that participation in such events is a constant possibility for everyone.

She argued that this is because of a tendency for ‘thoughtlessness’ to become institutionalized on a large scale. In her terms, thoughtlessness is a kind of routinized inability to think that serves the interests of instrumental rationality. Instrumental rationality is characterised by unquestioning adherence to cultural rules and expectations to achieve maximal organisational efficiency in relation to cultural goals. Neoliberal instrumental rationality has become increasingly prevalent in UK mental health education, research and practice in recent years, informing and shaping the activities and professional identities of contemporary nurses and other disciplines. In this context, I believe, that UK mental health nurse education and practice continues to tacitly endorse the biomedical model and its reductionist and morally reprehensible ways of relating to, and representing, users of mental health services. Sadly, I see no reason to believe that this state of affairs will change dramatically in my lifetime.

Article first published on Mad in America, February 23, 2016