The word ‘critical’
Over the next few months, we aim to publish regular blog posts from a wide range of contributors, with the hope of generating discussion and becoming clearer about what might be meant by critical mental health nursing. There are going to be a lot of different views represented. It is therefore probably helpful to say right from the start that ‘being critical’ is perhaps best thought of as more of process, a commitment to questions. It is a decision to prefer dialogue than to settle for a monologue. It follows that if every contribution agreed with the last, and if every reader liked everything written, then this could not really be said to be a critical network. Dissent is most definitely allowed.
We thought long and hard about the word critical. A bit negative, some said. In Transactional Analysis there are two types of parent: critical and nurturing. Wouldn’t we rather ‘nurture’ better nursing into existence, rather than pick holes in what we have? Well, maybe we would. We had some great conversations at the Durham conference, lots of enthusiasm and lots of positive ideas, and agreement too. However, a few people gave us the feedback that they came into nursing to be caring and don’t want to feel ‘got at’. We feel this feedback is very welcome, and expresses a legitimate fear. It is bad enough trying to persuade our managers (or, indeed, the newspapers) that not everything that happens is someone’s fault, without turning on each other! However, whatever the intentions of individual nurses, there exist many reasons to be critical. We are not proud of everything that happens under the name of mental health nursing, and there may be a need to explore those difficult issues head on, to hear from those who feel that being a nurse, and being nursed, has not been what it should have been. If we choose only to ‘focus on positive change’ we may be sweeping those experiences under the carpet. Those experiences and the confusing moments where concepts collide can teach us a lot, difficult though it may be. And nursing itself is only part of our focus: we want to consider the expectations placed on nurses in a critical way, too. Those who are attracted to this network because of their critical thoughts about psychiatry may find like-minded people here. But we are not the Critical Psychiatry Network – that already exists.
Ultimately, we hope that we will find that the word critical is not about being negative. It is about being careful. And nursing is the caring profession, is it not? The stakes are high, the issues are not just complex but they are in many ways the most complex issues humans have. How to live well? Who or what is to blame when things go wrong? What does it mean to act in the best interests of someone else? Is distress a matter of science or a matter of morality?
This network is not primarily about making people feel uncomfortable, but about bringing people who already feel that way together to find the conversations and support they need.
Please feel free to respond to this. Send an email to the network via this website. You might want to write a response for publication here, too. We don’t really see ourselves as experts (although it would be strange if we set this network up and felt we had nothing to offer) – but more like a group of nurses trying to facilitate conversations, so your thoughts are not extra, but central.
It is hard to write an overview. Much easier to get stuck into the detail. Details have the appearance of having less to do with opinion. I’m going to be brave and try to start with one kind of overview. This post is a little longer than many will be. However, we hope that it will be a conversation starter, and we look forward to receiving your views.
Critical is political
What is the difference between ‘good mental health nursing’ and ‘critical mental health nursing’?
Good practice means many things. For example, nurses may want to ensure that they are following a path that has been researched, carefully considered and evidenced. We hope that following our code of conduct will lead to good practice. It seems we mostly say that good care is somehow ‘person-centred’ – a phrase heard many times at the conference in Durham. Critical practice, however, might ask other questions. How did this kind of evidence become privileged? Whom does it suit? What does it reveal and what does it conceal? What assumptions does it rest upon about distress, society, bodies, measurement, nature, values, responsibility? Critical implies a quest for broader perspective, ‘what is really going on here?’. It is not inconceivable that critical practice might even wish to ask such questions of our code of conduct. If that is the case, it is probably unhelpful to say that good practice simply is critical, or vice versa. Lots of things can be ‘good’, but they may not be compatible. Can we ever really know this bigger picture? Is it the kind of thing for which there is a ‘fact of the matter’? This is why being critical may be a commitment to a process rather than a destination.
There is a growing ‘critical psychology’. This week they are running an ‘anti-austerity’ campaign and have written a letter with many signatures to the Guardian. Linking mental health problems with economic and social policy, they are expressing outrage that people are being scapegoated as the cause of society’s problems when they might be better thought of as the victims. Critical psychologists often go by the term ‘community psychologists’ because they want to refuse the idea that distress can be simply located within individuals. Their champion is arguably the late David Smail, and nurses may find a lot to agree with in his writing, especially nurses who have reservations about the rise of psychology and its claims. Community Psychologists are evoking all kinds of philosophical questions about mind and body, facts and values, personal identity, questioning notions of autonomy, of agency and of economic policy. When people fall off the bottom of the ladder is there something about the people who fall or is it something about the the ladder? Ought it to be a ‘ladder’ at all? Our work in mental health raises these questions, regardless of how aware we are of them.
This example suggests that a key difference between good mental health nursing and critical mental health nursing may that being critical is likely to be concerned with power. Who is in power, how did they get there, what suits them and how have their knowledges become privileged? In what ways are their ideas impacting on people’s emotions and experiences and might they be implicated in shaping health, illness and treatments in certain ways? How are such things shaping what gets called ‘nursing’? Nurses weald power but they are also on the receiving end of it.
A political map of distress
Where is distress located? I think this is a key question to begin critical mental health nursing. We could draw a map: start with a horizontal line on a piece of paper. On the left hand side we have ‘sub-personal’ locations for distress – it is genes, brains, chemistry, neural pathways, hormones. A little to the right we have ‘personal’ locations – it’s how I think, patterns from childhood, my education or ‘resilience’, my coping skills, my self-esteem. Then, moving a little more to the right, just over half way along the line, there are ‘systemic’ locations – it’s my social network, my relationships, my lack of resources of one kind or another, families. On the extreme right we have all the ‘isms’ – my distress is caused by oppression, racism, sexism, stigmatisation and discrimination, debt, capitalism and neoliberalism – a sort of ‘super-systemic’ location for distress. We can sketch onto the map the professions which have found their niches within each location, and maybe there are gaps, too. Notice that current mainstream psychology is just next door to psychiatry on this map, implying that there may be more similarities between psychiatry and psychology than at first meets the eye. Where you locate distress, there you conjure solutions.
If you sit on the left (which, curiously, seems to fit best with what is described as politically right wing) then everyone to your right looks increasingly unscientific, opinionated, liberal hand-wringers or moralisers. For you, nursing aims to meet the needs of service-users with a combination of medical or psycho-educational treatments, helping people to take responsibility for their actions, make progress a personal achievement, to accept their illness but maximise their potential, to be resilient, self-reliant. If you are working from the ‘sub-personal’ zone you may feel that none of this is about anything so nebulous as ‘distress in society’ or a political map of anything; it is about people being ill or people not being ill. When confronted with correlations between, say, housing density and psychosis, you may conclude that, tragically, mental illness can effect all parts of a person’s life, including employability, and, after all, benefits can’t provide people with the most expensive houses. So, ill people often are financially disadvantaged, adding to their difficulties.
If you sit on the right (politically left wing), then everyone to your left is increasingly de-politicising and individualising distress in order to control society, maintain existing power structures and let abusers and society off the hook: peace without justice! For you, the nursing role involves advocacy and is frequently concerned with equality, and instead of self-reliance you may see fulfilment as the goal. As you move further towards to ‘super-systemic’ zone, it is likely that if you do consider illness/wellness a valid distinction at all, it is only a really a mark of the severe consequences of oppression and inequality for the production of distress. When confronted with the same example about housing density, you may feel that people experience distress (and are labeled/problematised) because they are poor – the opposite of the above view. Just as in politics generally, one person’s common sense is another’s heresy. One further correlation to left and right wing politics can be seen at both extremes: the agency of the individual is increasingly lost amongst forces outside of his/her control.
Is there anywhere on this map which is politically neutral? Does this really mean that trying to help someone in distress is some kind of political act? What does the map contribute to questions of agency and responsibility? What actions do different locations enable or make less possible? What does the map tell us about ‘recovery’? Do you think of your own distress in one part, but the distress of others in another? What does ‘person-centred’ mean on this map? Is it right to make the left side (sub-personal/personal) our focus because at least it seems like the kind of things we can do something about, where progress is more easily measured? Are there patterns of movement on this map through history? Might your general position on this map reflect your personal experiences of power? Does this map shed any light on the phrase ‘mental health’? Does this map tell us anything about systems of measurement and evidence? What kinds of evidence are evoked by people in the different positions and can they be compared? Where is the money on this map? Does this map tell us anything about the word ‘professional’? Is there a place on this map which is distinctively nursing? Should there be? Are mental health nurses more politically right wing, or left, in your experience? If I try to move a person along the line, what happens? Is violence involved?
This post is by Jonathan Gadsby (mental health nurse). Please see older posts for more details about the Critical Mental Health Nurses Network and how to be part of it.