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Guest editorial

2001; Wiley; Volume: 8; Issue: 5 Linguagem: Inglês

10.1046/j.1351-0126.2001.00439.x

1365-2850

Colin Holmes,

Mental Health and Psychiatry

For some years now, from my perspective, psychiatric nursing has been experiencing an identity crisis. The reasons are not difficult to pin down: changes in the organization and administration of services, changes in the nature of the clinical problems being encountered, increased accountability in the face of ambiguous social attitudes and expectations; the list goes on. Here, I will briefly discuss two of the most significant factors: biomedicalization and changes to the professional education. The discussion focuses on Australia because that is where I work, and readers may find it interesting to bring it to bear upon the situation in their own country. Firstly, then, there has been a massive resurgence in the power of the biomedical establishment, kick-started by the antipsychiatry of the 1970’s, and fuelled by much-fêted new drug options, the emergence of more refined genetic and neurophysiological research sponsored by powerful biomedical multinationals and, not least, political pressures upon psychiatrists to align themselves more closely with physical medicine. For Australians, the biomedicalization of mental health problematizes the role of nurses in several important respects. To begin with, it is at odds with the psychosocial and behavioural approaches that dominated training and role definition throughout the 1970’s and 80’s, the period during which the majority of the present Australian psychiatric nursing workforce was trained. Whereas that training made social interaction and therapeutic uses of the self central to their role, many of these nurses now see their role in terms of managing medication, maintaining patients’ safety, and marshalling the services provided by other disciplines. A steady stream of reports and service evaluations in a number of countries indicate that attempts to retain an interpersonal therapeutic focus in the face of biomedical hegemony are also undermined by staff shortages, lack of staff support strategies, inadequate resources and poor facilities. Under the influence of biomedicalization and the return of psychiatry to the medical mainstream, nurses and other mental health professionals find themselves not only uncertain about their roles but also about how to talk and think about knowledge and practice. If there is no more to psychiatry than the physical, what are they to make of the word ‘mental’ in the politically correct terminology of ‘mental health’? Although there have been spirited calls for psychiatric nurses to clarify these issues in order to help re-frame their professional roles and objectives (e.g. Dawson 1997), it is obviously not possible to resolve long-standing philosophical conundrums like the mind–body problem, and all that can be hoped for is an operational understanding of such terms for professional purposes. This has not yet happened and, in the context of biological psychiatry, the word ‘mental’ increasingly appears to be an embarrassing archaism. If the ‘mental’ element is problematic, might not clinicians simply refer to the ‘psychological’? This appears attractive, but for many commentators, especially psychologists themselves, the traditional psychological language, words such as ‘motive’, ‘feelings’, ‘happiness’, and so on – that some have called ‘P words’– are part of an obsolete lexicon, the language and concepts of a ‘folk psychology’ that has outlived its usefulness. As a result, it is becoming difficult to determine in what sense the word ‘psychological’ has credible interpersonal or experiential referents, and this reinforces its strategic function as a disciplinary/occupational boundary marker. Not only is the language of the past being rejected, however, so too are the practices, styles of work, and values. This is problematic because these have played a fundamental role in the personal and professional lives of nurses, and even though they recognize that these systems and ideas were failing, they seem to me to have done what they could to make them work and are correct in attributing much of the failure to forces – economic and political – which are outside their control. Whilst acknowledging the need for constant development, many nurses lament the loss of the positive aspects of the system they once knew, especially when they see what has been put in its place. Let me give an example of what I have in mind here: about 3 years ago, I visited a psychiatric ward in a large general hospital in Western Sydney. Unlike most psychiatric hospitals, it was a modern building, but the psychiatric ward was a cramped conventional general ward, on an upper storey, and the patients were effectively cut off from the outside world. All the symbols of serious illness were evident, including flowers and ‘get well’ cards on bedsides; some of the patients were in dressing gowns and pyjamas, and nurses stood around in starched white uniforms, garlanded by stethoscopes and carrying clipboards. I had not seen a sight like that in over 25 years of working in psychiatry. Anyone whose professional origins lay in the psychosocial ideology of the 1970’s and 80’s would have been hugely disappointed to think that this is where we had travelled in the intervening quarter of a century. The effect of such an environment on the thoughts, feelings and practices of nurses is profound. As mental health problems become recognized as common to the majority of the population rather than reserved for a peculiar minority, as the links between physical and psychological states become more obvious, and as popular notions of mental disorders correspond ever more closely to those of simple physical disorders, there is developing, alongside professional ‘mainstreaming’, a cultural mainstreaming, which may ultimately succeed in reducing the stigma attached to mental health problems. On the other hand, mental illness, regardless of its aetiology, is ontologically and experientially different from kidney disease or diabetes, and the hope that mainstreaming psychiatric services would help reduce stigma, has only served to heighten the sense of difference. This is most obvious when in-patient facilities are colocated, as in the hospital ward I just described. Health departments and bureaucrats have sold mainstreaming not primarily on economic grounds, which are perhaps in truth the main motivation, but on the basis that they would enable psychiatric services to piggyback on the professional and ideological prestige of general medical services, and thereby obtain vicarious respectability for mental disorders. There is no evidence that this has happened. In fact, recent reports confirm that mental illness is still highly stigmatized, and that mentally ill people are still systematically discriminated against and seen as easy targets for exploitation, mugging, assault and general terrorization when identifiable in the community. Furthermore, mainstreaming has robbed psychiatric services of their autonomy, allowed them to be exploited because of the grossly unequal power balance in relation to general medical services, and forced them to adopt policies and practices that are inappropriate to the special needs of their clients. Most importantly, however, mainstreaming has alienated people with mental illness from their own subjectivity by insisting, against their own experience, that they are ill in the same sense that a person with kidney disease is ill. In view of all these effects, the confusion among mental health professionals as to their roles is hardly surprising. The sense of professional identity and the operational autonomy that went with being separate from mainstream medical services, the tranquil surroundings and comprehensive on-site mental health services that characterized stand-alone facilities, and the provision of services to people who had a mental health problem but who were not psychotic or at obvious risk of harming themselves or others, have been lost. What such a system provided was actually more akin to a true ‘mental health’ service than the risk-based psychiatry forced upon us today by the need to restrict potentially infinite demands on an under-resourced system, despite the politically correct terminology which requires us to be called ‘mental health nurses’ instead of ‘psychiatric nurses’. Many of the people who found refuge in, and treatment from, the psychiatric facilities of the past would today not be considered sufficiently ill to gain access to professional services and, if we were to be accurate, many of us have become ‘mental illness nurses’. Not that there are no genuine ‘mental health nurses’: precious resources are indeed spent on preventive strategies and mental health promotion but, whilst this is going on, many seriously mentally ill people are left to sleep in shop doorways and roam the streets in rags, or to sit alone in dingy rooms of boarding houses speaking to nobody from one month to the next. Nurses know that the provision of services for people with mental illness must move forward. They know the clock can not and should not be turned back, but they wish that this was not at the expense of aspects of care they believe are crucial. For my own part, this includes the notion of ‘asylum’, not as a dilapidated Gothic warehouse, but as a place of comfort and refuge, a retreat from the pain and confusions of everyday life ‘in the community’, and where professional help is readily available. I wish we had retained and developed a service with a genuine mental health orientation rather than moving to one rationed on the basis of risk assessment, where people are turned away unless they are a direct threat to themselves or others; I wish we had the resources to provide a comprehensive service. But mostly I wish we had staff in sufficient numbers, with appropriate skills and were able to retain them for the long-term benefit of the service and its users. This brings me to the second factor contributing to the identity crisis, and this concerns the education of nurses for work with people who have a mental disorder. In Australia, there have been very significant and, I would argue, poorly thought out changes to the ways in which psychiatric nurses are recruited and trained. The trajectory of these changes was sealed over 20 years ago, when professional nursing organizations expressed support for changing to ‘comprehensive’ courses located in the tertiary education sector. This included support from the only professional organization specifically for psychiatric nurses, the Australian Congress of Mental Health Nurses, which endorsed in 1977 ‘the principle of basic comprehensive training’ (Creighton & Lopez 1982, p.107). In New South Wales, this principle was discussed again early in 1979 by the Minister for Education and the Nurse Education Board, and a committee was established to examine and report on the implications of introducing comprehensive training. In its report, colloquially known as the ‘Pink Report’ because of the colour of its cover, the Committee was ‘unanimous in its support for the introduction of comprehensive courses as the usual way of preparing nurses for registration to function in the health care facilities of New South Wales’ (Grimshaw 1980, p.57). The most telling comment in the Pink Report, however, concerns the rationale for this position, namely that ‘it is the lack of skills in these areas on the part of many nurses on the general register that is behind the push for a more comprehensive preparation’ (p.30). In other words, comprehensive courses were needed not in order to benefit psychiatric care, but in order to address inadequate psychological skills in general nursing, and it was this that was driving the agenda for the reform of psychiatric nurse education. Despite strongly expressed and well-founded objections, especially from many psychiatric nurses, comprehensive tertiary education became the holy grail for nurse education in New South Wales, and eventually other States. Significantly, the Committee suggested that two thirds of the role of psychiatric nurses was ‘psychosocial’ and did not believe that competencies in this area required placement in a psychiatric hospital. This profoundly demeaning attitude toward psychiatric nursing, reflected in the view of some Australian university staff, that it requires no special expertise to teach psychiatric nursing skills, and that it is perfectly acceptable for them to be taught by nurse academics without psychiatric qualifications or experience; ‘it’s just common sense’ was the response when I challenged this practice in one major Australian university nursing school. As the Pink Report made clear, it was ‘one of the aims of comprehensive preparation to blur the differences between the psychiatric and general registers, particularly in the domain of psycho-social supportive skills’ (p.16). It was argued by opponents of the changes, back in the 1980’s, that psychosocial elements in comprehensive nurse education ‘replace or dilute the psychiatric nursing components’ and would have serious implications for the future quality of care given to the mentally ill (p.47). Today we are reaping the rewards of that blurring of roles in the form of an identity crisis and a complete inability to move forward on the issues of recruitment, education and role definition. These then, biomedicalization and professional changes, are just two of the factors contributing to the sense of crisis in psychiatric/mental health nursing in Australia. What do we need to do? Nobody has a magic bullet that will cure the ills of the psychiatric system in Australia, or anywhere else. What we do know is that, today, the notion of ‘a life in nursing’ is outdated, and young people want qualifications that are ‘portable’, enabling them to switch the focus of their career in tandem with changing needs, inclinations and job opportunities. Many young people who would like to work with people who have a mental disorder do not want to be generic nurses, and do not want to be specialists like clinical psychologists or psychiatrists. We need a radically new approach to developing a workforce for the years ahead, and a 3 year university training dedicated specifically to mental health and mental disorder but separated from the disciplinary identities that have riven the mental health services in the past would seem the logical choice. In other words, a new cadre of mental health worker, with a new qualification and new role that is ‘postdisciplinary’, based around issues and problems and the skills to deal with them rather than around the restrictive practices of disciplinary protectionism. This would more accurately reflect current trends in research practice, and scholarly notions as to the nature of knowledge and the artificiality of professional boundaries, and would do more justice to the reality of complex, unbounded, dynamic events in the material and subjective worlds of those whom the service should serve. In reality, I do not believe this is likely to happen, mostly because of the fear of the new among my colleagues and the determination on the part of government not to provide anything but the bare minimum in relation to what are still the ‘Cinderella services’. I fear that, just like the asylums themselves, psychiatric services in Australia will suffer ‘demolition by neglect’, with the burden of caregiving shifting to the family, and facilities staffed by a transient, largely untrained workforce. This would be a sad reflection on a nation that boasts the good life and is wont to take the high moral ground in its relations with its neighbours, but its most significant impact would be on the lives of people with serious and enduring mental disorder, compounding our continuing neglect of their needs and rights.