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
Great article, Thanks for writing it.
I especially liked:
“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.”
I’ve seen this “thoughtlessness” a lot, outside of psychiatric nursing. It seems to be a really good survival mechanism. I’ve heard a lot about the neoliberal pressures keeping the idea of “mental illness” in place but this thoughtlessness seems to hit the nail more on the head. Especially since nurses don’t really benefit from neoliberalism. It does sometimes feel like the easiest way to change people’s thinking is to have the new information transmitted by a person the group sees as an authority.
If a patient/survivour says it they’re mad, if a colleague says it they’re a troublemaker, if a trusted authority says it -it’s a fact. Do you think it’s just common for humans to be obedient and adapt to what the rest of the group is doing? Or something special in our social history?
Thanks bloboff. Yes, I think it is common for humans to be obedient to group norms. Social Identity Theory (Henri Tajfel) and Self-Categorization Theory (Brian Turner) helps us understanstand that people find it easier to locate themselves as compliant members of a group in opposition to others in the vicinity (sometimes called ‘outgroup bias’). So it’s not surprising that, despite the humanistic ideoligical rhetoric to the contrary, service users are othered, as are nurses and others who call this process out. As you say, this happens in all parts of society. The trick is to live, work and stand against it – which doesn’t lend itself to social popularity. Which is why whistleblower have such a hard time.
Thank you for this – its incredible that more and more critical voices aren’t being heard – surely millions of workers everywhere have questions about their practice about what is taught and how this impacts on suffering people just like us?
This uncritical approach is seen clearly in talking therapies too – most therapists at least in the ubiquitous short term offerings within the likes of IAPT are rushing to service their next target and have barely enough time to simply reflect and plan adequately for the next distressed person they see never mind question the entire enterprise.
Self interest and the cult of me is everywhere – ‘just got to get on with it’ is the common refrain then add in debt, wants transformed to needs, group think, bias, blind spots and wilful ignorance and we have huge systems that are likely doing more harm than good for all concerned.
If/when I suffer next in life the very last place i’d wish to end up is in any mental health services – sad but true
Thanks MrMr. Agree with all that you say. IAPT captures the nastiness of the neoloberal enterprise: get people back into the markets as quickly as possible; work to targets; strip people of contexts; employ surfacy, algorithmic, technical-rational approaches. This reflects aspects of current mental health work more generally. Like yourself, I try to keep a safe distance from institutional ‘mental health’ these days.
The link in paragraph 3 is behind a subscription wall. Would there any other access available at all. Good article, thank you. Being surprised at their surprise is so common in this field, ignorance of this sort requires determined incuriousness, surely.
Hi R S W thank you for your comment, we are just looking into the link to see if there is an alternative.
hopefully this link will work for you and we have also updated the link in the blog itself:
Thank you RSW. Sorry about link but pleased that MITUK admin have now sorted this out!
Yes. Determined incuriousness, or wilful ignorance, seems to characterise institutional and professional mental health nursing. To me this indicates an absence of disciplinary reflexivity, despite all the rhetoric to the contrary. Sad state of affairs!
A truly refreshing & brave article. Having been reading much on these subjects in the last 30 years, this is a most welcome read. Hopefully things will change, but I agree it’ll take some time, and a lot of changed mindsets. I think we have become slaves to authority in many ways. Unthinking, unfeeling, carrying on the processes to which we’ve become accustomed & which our colleagues agree on – and generally living miserable lives.
Thank you, Dr Facto. Quite so.