Bread and Roses: activist imaginings for the future of mental health nursing

Dear Readers,

One of our number has become a professor! We are very pleased to be able to publish Mick Mckeown‘s inaugural professorial lecture. Mick has been a great support and source of energy and inspiration to the network from soon after we formed. No critical thinker automatically loves establishment recognition, but Mick’s appointment to the position of professor is a testament to a very positive development: When someone like Mick can rise to that level it may be said that genuinely critical thinking is not the end of a career in mental health nursing! Phew!

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It’s exciting and humbling in equal measure to be in a position to give this talk. Those who have known me long enough, and there are some of you in the room, will know that I’m something of an accidental academic. There may even be some who think, professor? ‘bloody hell’ how did he manage that! I can let you know, I share some of that sentiment. I have, though, tried to take my academic career seriously and, without pretension, I don’t feel out of place and do think I have some things to say that are worth saying. Indeed, I feel so strongly about some of these points that I tend to find myself saying the same thing over and over again, perhaps in different ways. Given that I refer to a body of work, I risk a superficial journey through it, so I hope you will bear with me on that score. In this vein, I hope to populate my talk with activists’ slogans and anecdotes and refer to the odd piece of scholarly work I have myself produced. Ideally, anyone interested could go on and read further.

My lecture title of ‘bread and roses: activist imaginings for the future of mental health nursing’ reveals my interests and hints at adventures in more than one world. As a worker in the NHS, as a trade unionist, and as a teacher and researcher in the university. For me, all of these various experiences have tended to reinforce a belief in a need for progressive social change, including important changes within the mental health care field, and beliefs about the most desirable means for achieving such change. From this perspective I contend:

  • We need to focus upon the establishment of a progressive alliance between mental health service users, refusers and survivors and the staff who work in those services and their trade unions.
  • We need to be able to articulate a new politics of mental health to drive these alliances forward and formulate the most appropriate end goals to strive for
  • All of the protagonists within these struggles are best thought of as activists, including critically engaged academics.
  • Models of deliberative democracy, co-operation and relationship building can help us organise for a better future.

Nurses and other social movement actors can draw upon activism to suggest these alternative futures.  In a spirit of persuasion, provocation and poignancy we may contemplate workplace democracy, inclusive of workers and service users, as a utopian, yet realisable, means of organising health and social care services. This would better harness relational nursing skills, congruent with democratic and dialogic therapy, education and research and new left populism.

 

The prevailing neoliberal political economy is the enemy of socialised welfare services and arguably precipitates much of the mental distress that presents itself to services.

We need to start with the context. Contemporary mental health services exist in a particularly hostile operating environment. The prevailing neoliberal political economy is the enemy of socialised welfare services and arguably precipitates much of the mental distress that presents itself to services. On top of this, the coercive character of much of what passes as mental health care is itself a consequence of the enmeshment of governance and psychiatry in the service of social control and intolerance of difference. I argue that mental health nurses are susceptible to deceptive imaginings that we occupy a singularly virtuous occupational role and this can blind us to socio-political actualities.  As much as I wish to celebrate the best of mental health nurses and their practice, I concur with my old tutor Terry Adams who said on our first day of nurse training – I think to disabuse the self-righteous and self-congratulatory – some nurses may deserve to be canonised, but some need to be shot out of a canon. Notwithstanding individual virtues: inescapably, mental health nursing finds itself complicit within an alienating psy-complex of biomedicine and social control operating under an overarching neoliberal polity and risk society.

…some nurses may deserve to be canonised, but some need to be shot out of a canon.

I think theory is important, but it is not separate from action. My favoured theorists help us make sense of democratic aspirations, complement a call for a new politics of mental health, or a revisiting of some old politics, and inform organising tactics and processes. These include contributions of notable critical thinkers beloved of activists, such as Marx in the first instance: “it is not sufficient to make sense of the world, the important thing is to change it”. Those advocates of democracy associated with the Frankfurt School such as Jurgen Habermas, and their attempt to resurrect critical left thinking after the disasters of Nazism and Soviet totalitarianism.  Peter Sedgwick’s Psycho Politics, and the explicit democracy and humanism in the work of Paulo Freire. Sedgwick had the crucial insight that the activist goal of transforming society neatly encompasses the relational transformation required of psychiatry. The emergent field of mad studies promises one escape route, as do alternatives capitalising on core skills and values, or appreciation of nursing as a labour process. If we don’t think knowledge is completely indivisible from power, then at least we might agree that ignorance is disempowering. When we hear people or politicians advancing the notion that expertise or theory is a distraction (say from real-world or practice) or decrying ‘ideology’ – this is often an absurd, less than subtle, attack on ideas itself. And usually is presented in a self-illusory denial that the protagonists’ position is itself equally informed of ideas or ideology. Arguably, the politics of university tuition fees and threats to academic staff pensions are part of an attack on knowledge production itself, and the re-restriction of access to a narrow segment of society.

Mental health nurses and mental health nursing education should be much more informed by critical perspectives and be an active part of the necessary change.

Mental health nursing faces a number of profound crises of legitimacy necessitating critically inspired remedies. These are highlighted in my co-authored paper ‘The future of mental health nursing: are we barking up the wrong tree?’. A crisis of legitimacy means that fundamentally there is a question of public faith in a particular group or institution. At heart, these are matters of what we see as right or wrong in society. In this sense, mental health nursing’s legitimacy crisis is intimately bound up with a larger crisis of confidence in psychiatry, particularly a narrow biological psychiatry that dominates in practice and denudes the relational potential of the nursing role. The national review of nurse education indicated another, parallel, larger existential crisis for mental health nursing, whether mental health nursing should even continue as a distinct field within nursing. Ultimately, this paper of ours goes on to pose the question – not whether we should be training mental health nurses anymore, but what are we actually teaching them, for what purpose? The conclusion, congruent with the central argument I wish to make here, is that mental health nurses and mental health nursing education should be much more informed by critical perspectives and be an active part of the necessary change.

Sedgwick and the mad studies activists call for cross-sectional alliances between activists in the mental health field. In a number of publications and activism within my own union, I have argued that workers in mental health services, through their unions, should build and strengthen alliances with radical service users and survivors. This is the quest for mutually beneficial solidarity: Unity is strength. All for one and one for all. I have explored, however, how the solidarity at stake in cross movement alliances is often imperfect, reflecting the power imbalances already evident between staff and service users in the system they work in. For example, in a fairly recent strike in mental health services in Manchester, there were substantial numbers of service users who actively supported the striking nurses. Indeed, the local press took the side of the nurses but did so by reinforcing various negative stereotypes of service users.  The union did little to challenge these, preferring the immediate benefit of media and public support, rather than being concerned about extending longer-term solidarity. In other disputes, service users have, for example, occupied day services in the interests of supporting workers, but then desired a negotiation about what actually goes on in those services. In the 1970s the emergent Mental Patients Union modelled itself on trade union archetypes, but unsuccessfully petitioned the TUC for membership. So the historical relationship between workers’ unions and organised service users is complicated and not always wholehearted in the demonstration of solidarity.

Sedgwick makes the case for situated, small scale enactments of alternatives to standard psychiatric care that can prefigure more wholescale transformations.  In doing so he was inspired by the anarchist ideas of Victor Serge, ally of the Bolsheviks. Many such alternatives have been organised and some of these have been user led. They are often typified by a commitment to democratised relationships and relational activity is prioritised as the helping force rather than medication or other physical treatments. As pointed out, for Sedgwick, these relational dimensions also hold the potential for ensuring political solidarity and action. The fact that relational processes can drive therapy and perhaps political action was reflected in our evaluation of a football and mental health project, that amongst other things bolstered mutual support and solidarity amongst peers. So much was this the case, that we were able to use the lyrics of YNWA to structure our reporting of these characteristics.

We need nurses who will stand up for themselves and others and politically inspired causes – and that such a disposition could be the basis for a new form of activist professionalism.

The famous anti-slavery slogan of Frederick Douglass: ‘power concedes nothing without demand’ has been taken up by the labour movement over the years and displayed on union banners. It was worth revisiting Douglass’s words at greater length to appreciate their implications for consciousness raising and action:

The whole history of the progress of human liberty shows that all concessions yet made to her august claims have been born of earnest struggle. The conflict has been exciting, agitating, all-absorbing, and for the time being, putting all other tumults to silence. It must do this or it does nothing. If there is no struggle there is no progress. Those who profess to favor freedom and yet deprecate agitation are people who want crops without plowing up the ground; they want rain without thunder and lightning. They want the ocean without the awful roar of its many waters. This struggle may be a moral one, or it may be a physical one, and it may be both moral and physical, but it must be a struggle. Power concedes nothing without a demand. It never did and it never will.

I have worked with these sentiments to argue that nurses ought to become more critically disposed and nurture a RECALCITRANT standpoint both to their work and wider social inequities. Recalcitrance and indignation are valued attributes of social movement activists, but these terms are often used pejoratively in professional workforce contexts. Moreover, recalcitrant patients are seen as a problem or are described as exhibiting challenging behaviour. My argument is to look for virtue in both forms of recalcitrance, we need nurses who will stand up for themselves and others and politically inspired causes – and that such a disposition could be the basis for a new form of activist professionalism. In tandem with such developments, we need to be insightful of what seemingly recalcitrant patients may be indicating to us through their actions.

When individuals reject treatments and routine practices, especially those delivered coercively or under legal compulsion, even when they do so aggressively or violently, or perhaps particularly in such circumstances – are they telling us something? Are they coherently or incoherently, intelligibly or unintelligibly, forcefully or passively, exposing the crises of legitimacy already described? I think, at least some of the time, the answer has to be, yes they are! Service users and staff are harmed, physically and emotionally, in such a system – in a vicious cycle of mutual alienation.

Mad studies and other commentators have persuasively highlighted the implicit, or even epistemic violence that is embodied in psychiatry. The very ways we have of knowing things are shot through with violence and have violent and hurtful consequences. Again, the importance of critical ideas and theory is more than an abstract consideration here – the experience of mental health care is illuminated by allowing the space for development of critical thinking. And opportunities for remedy are perhaps revealed.

Whenever there is a legitimacy crisis, a social movement that addresses the felt democratic deficit will spontaneously emerge

Together with Helen Spandler, and survivor activists like Jan Wallcraft, who has a long history of working with public sector unions, we have promoted the idea of a grassroots truth and reconciliation process for addressing the hurts and harms caused by psychiatry. We also hope that such a process could form a prefigurative model for building the foundations for the sort movement alliances we also seek. We believe that such endeavours could feed into and out of the wave of union renewal and organising programmes currently underway in the public sector, with my own union, unison, in the vanguard. Indeed, we have taken these ideas into the union’s democratic forums, notably at last year’s health conference, and received a positive response.

So, arguably we need recalcitrants and mavericks – people who will challenge the status quo and stimulate a deeper political dialogue. We also need that commitment to careful democracy, and need to be able to navigate the potential tensions between the two.

Habermas has given us an idealised form of deliberative democracy that can be seen to inform the horizontal structures and interactions of new social movements and the better forms of labour movement democracy. Indeed, Habermas’s big idea is that it is communication – communicative action – that drives all social change. He also noted that whenever there is a legitimacy crisis, a social movement that addresses the felt democratic deficit will spontaneously emerge to ensure that ill-served voices are potentially heard. Research of ours, focused on processes of service user involvement, chimed in with Habermasian ideas, with one participant remarking “it’s the talk” when trying to explain the most valuable aspect of the process. Other commentators have extended the value and practice of deliberative democracy by questioning Habermas’s privileging of rationality and bringing in respect for the legitimacy of strong emotions. Gardiner talks of ‘wild publics and grotesque symposiums’, and acts of protest can be conceived of as part of deliberation. Marian Barnes speaks of care-full deliberation, deliberations full of care – taking care of the talk, but also caring for each other in the process.

So, arguably we need recalcitrants and mavericks – people who will challenge the status quo and stimulate a deeper political dialogue. We also need that commitment to careful democracy, and need to be able to navigate the potential tensions between the two. It is worth remembering that Sedgwick was a persuader; within the IS, a movement riven with splits, he seldom fell out with those he argued with.

The democratic potential represented within public services is completely wrecked on the rocks of hierarchical management and epistemic contradictions.

So where does all this take us? Ultimately, I feel, a strong conceptual case can be made for workplace democracy within mental health services. That is, the very organisation of day to day care practices are shaped by bringing together the empowered voice of employees and service users. Similarly, the strategic development of services can be organised this way. There is ample policy rhetoric in favour of service user voice and involvement, and even the Francis report pointed out a need to strengthen employee voice in the NHS. Yet, the democratic potential represented within public services is completely wrecked on the rocks of hierarchical management and epistemic contradictions. New left populism and developments such as the Preston Model at least raise the possibility of alternative, cooperative democratic forms – and perhaps some of these can be in the health and social care sector.

If mental health nurses and others are to be ready for new democracies and new systems of care, they arguably need to be better equipped with recalcitrant, provocative, critical knowledge and be able to practise critical thinking, for themselves and collectively, becoming critical persuaders of colleagues and power-brokers. We hope that the book covers all of what a good mental health nurse needs to operate practically, to survive and practise in mental health services as they are presently constituted.

But we hope that they will also be in a position to be agents of change, activists, able to envisage and work for a better and more fulfilling future for all. This is a challenging proposition, and demands no small amount of courage and commitment (and maybe some chocolate along the way). Every maverick will face resistance and sometimes, as Jonathan swift realised may be opposed by a veritable ‘confederacy of dunces’. But no-one should be alone, we have the potential power of our collective organisations to harness and draw upon.

In taking on this challenge, I hope they (you) will have high aspirations, and may be moved to action by the words of that beautiful union song, Bread and Roses:

Hearts starve as well as bodies, give us bread, but give us roses.

Yes, it is bread we fight for, but we fight for roses, too.

Postscript

On coercion and critical responses, I just want to say something about some of my old mates. First, Tommy Chamberlain, who was one of the cleverest people I have known, who had a brilliant music collection, impressive quad music system, whose mum always made you chips, and who sadly took his own life. And I know we can’t speak for Tommy, but I think part of his story is a telling indictment of public attitudes and mental health services, then and now. I think Tommy was as fearful of being admitted to services as he was fearful of losing his mind, and this for me meant he didn’t get all the help he could have had. That said, the help on offer isn’t always what people want or need ….

Second, my old and current colleagues who work and have worked within mental health services, these folks include people who have spent whole careers in mental health practice. They demonstrate in their work the sort of nurse you would want by your side should you ever succumb to serious mental distress. Someone who knows the value of nursing and despairs at the cuts and reorganisations but continues to offer really effective, supportive and therapeutic input despite the state of the NHS rather than because of it.

For me, however, Tommy’s story behoves us to contemplate the limits of coercion, rather than a complete retreat from all instances of coercion, even if a range of softer care alternatives are available to us. These are incredibly difficult moral issues, and I certainly don’t have easy answers. I do know, that in the moment when it mattered I wish somebody had been in a position to stop my friend from doing what he did.

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