The following is an interview, conducted with Mark Evans. The Network would like to thank Mark for this comprehensive and personal piece, which explains why he has chosen to leave the profession immediately after qualifying. At our recent conference, it was noted that one of the problems with teaching students a more critical outlook is that they may decide to leave (which is, of course, not a reason to avoid doing it, but certainly has important implications). It will be clear to readers that Mark’s choice is mental health nursing’s loss. However, as you will see, Mark is not someone who makes such decisions lightly.
Mark believes that the mental health system serves the elite within our society. We feel that no critique of mental health nursing could be complete if it ignored that premise. We also feel that Mark’s writing forms a first-rate explanation of what it means to say that ‘the personal is political’.
Mark’s piece is upsetting – or it should be. Please feel free to comment on it or ask questions, which Mark will read.
What led you to train to be a mental health nurse? What attracted you to the role?
When I applied to do my mental health nurse training I was already working fulltime in health care – but on a neurosurgical ward as a Health Care Assistant (HCA). I continued to do this role, part-time, throughout my training and still do it today. It is a job that I find fulfilling and enjoyable. Interestingly, in sharp contrast to that of psychiatry, the service that we provide is almost completely uncontroversial. Perhaps this is something that we will explore later on in the interview.
We can break mental health nursing down into two components: the nursing side of things and the mental health side of things. As indicated above, I do find helping people recover from ill health, or to live and die with minimal suffering, to be rewarding work. That said, if I am honest, I do think that it was the mental health side of things that really drew me to do my training. I find mental health fascinating and think that it should be understood as of central importance – much more important than say, the Gross Domestic Product (the measure for economic performance at the national level) for example. The fact that mental health remains a peripheral subject is, in my view, a reflection of the topsy-turvy world in which we live – a world system that puts profit before people.
Coming back to your question, as I was working as a HCA, to enter into the field of mental health, via nursing, just seemed like a natural progression.
When did you start to realise that you might not want to be a MH nurse? What were the key moments or realisations?
Broadly speaking, I would say that there were / are two main issues that put me off wanting to work as a mental health nurse – one specific to mental health and the other generic to nursing.
The generic reason has to do with the top-down style of management, within contemporary nursing, and its consequences. There is a mantra in modern nursing that says “if it is not written down then it did not happen”. This mentality has led to a proliferation of paperwork which basically means that nurses spend a lot more time in front of a computer and a lot less time with patients / service users. This is a very common complaint within nursing today. It always amazes me that the nurses within the team with the most experience are always furthest away from the patients / service users. It seems that the higher up the hierarchy a nurse goes the less time they spend actually nursing. Comparatively, HCA’s have very little paperwork and therefore can spend lots of quality time with patients / service users – I like that!
This shift in culture, within nursing, is all tied up with the social process of professionalisation – which is a product of the insane logic of the broader economic system which can be traced back to Thatcherism.
The more specific reasons for me not wanting to work as a mental health nurse can be broken down into the following categories: (1) hypocrisy; (2) authoritarianism; (3) deception.
One thing that became very clear to me during my first placement was the disparity between theory and practice. Mental health theory is full of language that sounds incredibly progressive. For example, people talk a lot about things like; social inclusion, working in partnership, evidence based practice and challenging inequality. There is also a lot of time spent looking into and trying to understand power dynamics. Now, to be absolutely clear, I love this stuff! The problem is, all of these great ideas pretty much go out of the window when it comes to practice. In multi-disciplinary team meetings (MDT’s) and ward rounds, for example, it is very unlikely for staff to seriously challenge what the psychiatrist says. This, I think, has to do with the institutional design of the organisations in which we work, which reflect broader society, and that systematically undermine the progressive values that underpin the theories mental health professionals consistently pay lip-service to. It seems to me that, unless we address these institutional factors, mental health theory will always be something of a cruel joke.
Another thing that struck me about the practice of mental health promotion was that I did not really feel like I was nursing. In contrast to the neurosurgical ward, where I was used to working, mental health wards felt more like prison wings – with a greater focus on security and risk than safety and care. In short, I felt more like a prison guard than a nurse. Mental health nursing is much more of an authoritarian role – which made me feel more like I was more part of the problem than the solution.
Perhaps the greatest obstacle, for me, emerged as I progressed through my training. As is the case with all nurses, part of my training included the administration of medication. However, in mental health the administration of medication is more complex and controversial for two main reasons that are in many ways intertwined.
The first reason has to do with the fact that service users are often being “treated” whilst under a section. The second reason has to do with the fact that the prescribed medication is intended to treat an underlying pathology that has never been identified. So, mental health nurses can often find themselves in a situation where they are forcing people to take medication for an illness that may not exist. Furthermore, it should be understood that we are talking about medication that often has serious, sometimes lethal, side-effects.
Coming from a background in adult nursing, this all seemed quite strange and somewhat disturbing to me. In neurosurgery, for example, treatment is always informed by the identification of an underlying pathology – brain tumor or intracranial bleed, for example. Even where patients lack capacity to make informed decisions, I never felt or feel any of the concerns that I experienced in mental health with regards to being part of a team who are delivering that treatment.
Furthermore, as far as I am aware, if we do not know what is wrong with a patient we will acknowledge that and continue to explore for underlying causes of the problem. In psychiatry it is almost the opposite. Everybody acts as if an underlying pathology has been identified and is well understood and that a treatment with a good evidence base is available. This, it seems to me, is pure deception. If psychiatrists understand mental health problems anywhere near as well as they pretend then the contrast between psychiatry and neurology, that I am highlighting here, along with the controversies, would be nowhere near as evident.
The problem is that if mental health professionals were honest about what we actually know about mental health then they would lose most of their credentials – so in the end this also ties in with the issue of professionalisation. Also, an honest discussion about mental health would almost definitely have a negative impact of the profit levels within the psychopharmaceutical industry – again, something that ties in with the insane logic of the current economic system.
Readers will be concerned to hear that you think that mental health nursing could be an unethical choice of career! Can you say more about that?
Anyone who has studied mental health will know that it is, and always has been, a controversial field with a long and rich history of dissent. As far as I can see, there are two main reasons for this controversy.
The first simply has to do with how little is actually known about mental health. This means that we can have competing explanatory models informing treatment – models that often contradict each other. So we all know that there are biological models, psychological models and social models. The direction of causality for each of these models, however, is different. There have been attempts at formulating “biopsychosocial” models – but, as far as I can see, these have not successfully addressed the underlying tensions between the various competing models or resulted in a better understanding of mental health promotion.
So, the controversy is real. However, controversy, by itself, does not equate with immorality. I have already indicated, above, why I think current mental health promotion is ethically questionable. To illustrate this point further I would highlight the relationship between the dominant model for mental health promotion – namely, biopsychiatry – and the dominant ideology within society – namely, neoliberalism.
Whilst we do need to be careful when making such connections there does seem to me to be a valid argument to be made here. We might start by asking: What is the evidence base for the dominance of biopsychiatry within the field of mental health promotion? I think that anyone who takes an honest look at this question would have to conclude that it is poor. This, then, prompts another follow-up question: In whose interests does the continued dominance of biopsychiatry serve? As already indicated, possible answers to this question include (1) those with a vested interest in maintaining the credentials of the profession – most notably psychiatrists, and (2) the pharmaceutical corporations.
In addition to these more obvious connections, however, I would like to add that my feeling is that the continued dominance of biopsychiatry serves elite interests more generally. To appreciate this point we need to consider mental health promotion from a very different perspective. Social models typically understand mental health problems as being caused by social factors such as conflict / war, poverty / inequality and abuse / neglect.
Understanding mental health promotion from a social perspective impacts negatively on elite interests in a number of ways. Generally speaking, however, it would mean the introduction of progressive social reforms so that the political and economic systems function in the interests of the general public. Such a position is contrary to the values that underpin neoliberal ideology. It is for this reason – which, incidentally, has nothing to do with evidence based practice – that I think social approaches to mental health promotion have been systematically marginalised.
Hopefully, from the above, you can see why I think that working within mainstream mental health services could be considered unethical.
There may be many readers who share your concerns about the dominance of biomedical models, but they may feel that they are able to help to redress the balance in some way. Did you see any practice which you felt achieved this? What made you feel that it would not be an option for you?
There is no doubt in my mind that mental health professionals can do many things that minimise the damage done by biopsychiatry. I did actually consider entering the field with such an approach in mind.
However, what put me off, in the end, was the feeling that I would not make much of a difference. Damage limitation is not the same as remedy and I was only really interested in putting things right. This conclusion, I should add, was mostly the product of feeling isolated and powerless. If I felt that there were more people around with similar interests and intentions then I may well have decided differently.
With that in mind, as indicated above, I think to put things right requires understanding the dominance of biopsychiatry within the broader socioeconomic context. So, it is not really just about addressing the issue of the dominance of biopsychiatry. There are also broader issues that relate to social justice that we cannot afford to ignore here.
You said that psychiatry serves the interests of the elite. That is a very striking thing to say.
The basic ideological function of mainstream psychiatry is to shift attention away from social factors that cause mental health problems and towards biological explanations.
Biopsychiatry says that mental health problems are the product of faulty genes that result in chemical imbalances in the brain that, to rectify, requires medication. Looking at mental health problems from this perspective frames the debate in such a way that makes certain discussions seemingly commonsensical and others completely off the radar.
For example, if the government were serious about the prevention of mental health problems (which they say they are) then they would be busy formulating domestic and foreign policies that minimised the risk of conflict and war. In reality, however, the government is busy doing pretty much exactly the opposite. The same is true with regards to poverty and inequality – both a product of a form of social descrimination that no one in mainstream politics or mental health ever discusses, namely classism.
The last thing that political and economic elites want is for the public to be thinking about important issues like war and classism, etc – and mental health is a constant potential point of entry for this to happen. Therefore there has to be an account of mental health problems, supported by the professionals within the field, that distract people away from these issues. That account is biopsychiatry.
Have there been any key thinkers or texts which have helped you think about this and make your decision?
I have a general distrust of intellectuals. This is because, as far as I can tell, for their own benefit, they mostly just serve power. A striking exception to this, I think, is Noam Chomsky. He is one of the few intellectuals I have come across who seems genuinely interested in truth and justice. Other examples would include Bertrand Russell and Erich Fromm – the latter of which actually worked within the field of mental health. I like Fromm’s general approach to mental health promotion – what he called “normative humanism” – which I think represents a challenge not only to mainstream psychiatry but also to much of critical psychiatry.
George Albee’s focus on the prevention of mental health problems via the promotion of social justice also appeals to me. Here is how he concluded his 1986 paper, Toward a Just Society:
Primary prevention research inevitably will make clear the relationship between social pathology and psychopathology and then will work to change social and political structures in the interest of social justice. It is as simple and as difficult as that!
Joanna Monceiff’s alternative account of psychiatric drug action – what she calls “the drug centred model” – is, I think, an important innovation. Psychologists, such as Richard Bentall and Lucy Johnstone, are doing some important work on the development of more humane ways of understanding emotional distress and psychological disturbances that could result in an alternative to the psychiatric classification systems (DSM and ICD). On that point, the Hearing Voices Network have undertaken a very good critical analysis of the latest edition of the DSM (5) that is available on their website.
I also always enjoy reading Oliver James who, in the prologue to his best seller – Affluenza – wrote:
My focus is on why we are so fucked-up, not with dangling a false promise of the possibility of happiness. In short, my new theory is that the nasty form of political economy that I call Selfish Capitalism caused an epidemic of the Affluenza Virus [a set of values which increases our vulnerability to emotional distress], accounting for much of the increase in distress since the 1970’s.
What would your hopes be for a Critical Mental Health Nurses Network?
If such a network had been up and running during the time that I did my training then things might have panned out differently for me. This is because I probably would not have felt so isolated and powerless. So, I guess, from this I would have to argue that one of the primary functions of a network for critical mental health nurses should be to help overcome that sense of institutionalised and learned helplessness. The irony here, of course, is that this learned helplessness, that results from feelings of isolation and powerlessness, is exactly what mental health professionals are supposed to address. So, the fact that mental health nurses are feeling the need to set-up their own network says a lot, it seems to me, about the current state of affairs.
In addition to that primary function I personally would like to see mental health nurses using their collective power – as the largest profession within the field – to push for more honest discussion about mental health promotion, both amongst fellow professionals and service users. This, in my opinion, would need to include frank and open discussions about the diagnostic methodology and medication marketed for mental health that are used in psychiatry on a daily basis. In addition to these more obvious points, I would also like to see a discussion about the kinds of social factors that I have tried to highlight above – namely, how things like the profit motive and other socioeconomic factors, including elite interests, generally distort mental health practice.
More specifically, I would like to see critical mental health nurses highlighting the ways in which social structures (including, and perhaps especially, their own workplaces) systematically undermine the values that everyone within mental health promotion, including the government, pay lip-service to.
In short, I would like to see this network of critical mental health nurses making an important contribution towards the development of more humane ways of promoting mental health, which – as I have tried to convey – would need to include contributing to the transition towards a sane society.