Book review: ii Critical Mental Health Nursing: observations from the inside

Following on from Part i

In fairly recent studies at Lancaster University (2014-2016) autoethnography was notable by its presence. Given the importance of reflection in mental health theory and practice and the self-reflective approach of autoethnography and its qualitative, objective - subjective focus it is not surprising that several chapters adopt autoethnography. From Wikipedia:

Autoethnography differs from ethnography, a social research method employed by anthropologists and sociologists, in that autoethnography embraces and foregrounds the researcher's subjectivity rather than attempting to limit it, as in empirical research. While ethnography tends to be understood as a qualitative method in the social sciences that describes human social phenomena based on fieldwork, autoethnographers are themselves the primary participant/subject of the research in the process of writing personal stories and narratives. Autoethnography "as a form of ethnography," Ellis (2004) writes, is "part auto or self and part ethno or culture" (p. 31) and "something different from both of them, greater than its parts" (p. 32). In other words, as Ellingson and Ellis (2008) put it, "whether we call a work an autoethnography or an ethnography depends as much on the claims made by authors as anything else" (p. 449). https://en.wikipedia.org/wiki/Autoethnography

Gadsby's chapter 1 "Nursing violence, nursing violence" starts in this research vein. The title is quite an affront to many nurses. These two words do not mix, violence an abomination, antithetical and counter to all that 'nursing' should represent. This is in part why 'care scandals' are so shocking given the vulnerability of those affected and impacted for years to come. Gadsby points straight to the challenge:

"I do not like to say, as  some critics do, that reforms of mental health nursing is impossible; I think of good moments and good colleagues and feel it betrays them. I worry that this chapter will feel that way too." p.14.

There no better learning than when your assumptions are turned on their head; you are forced and can see for that instant the other side of the coin, even if, like an optical illusion it snaps-back. Gadsby presents three conversations. Inevitably in conversations there is the verbatim transcript (as if recorded audio-video), then there is our account of what was said and then what is recorded on paper or in the electronic record. Jonathan Gadsby points out that he was selective in his accounts and this is a prime judgement for mental health nurses. What is pertinent is looking at this from the patient's^* perspective. The complexity of his (John) mind was likely to be interpreted as illness, and this presages coercion and loss of his future.

"He took care of their (mhn's) mental state. I have come to believe that this is common; our simplistic stories leave our service users having to channel their real lives into fairly useless false binaries and sanitised, dishonest versions of their actual experiences, in order to gain or retain any power. p.15.

Rereading the section for this review on 'John' I was surprised it was so short. Reading this was like revisiting several clients of old. 'Old' bears specific mention as some of the situations used in the book, are quite dated - John refers back to 2004. The lessons and insights are still salutary. In exploring 'violence' the chapter starts by explaining debt violence. It is 'social inclusion' in practice (and an appeal to and for justice?) to see this, considering austerity and campaigns stressing the links (ties) between financial vulnerability and mental illness. On 'nursing violence', Gadsby discusses three areas: a few bad apples, 'genre violence' and the world is violent.

My ward experience as a charge nurse was brief 1982-1985, so I have been removed from the 'frontline' of mh services. Without being ageist I've been twice-removed in working with older adults. Since becoming a Community Psychiatric Nurse in 1985 if the narrative had been wholly positive: the funding, policy, education ... what would the experience for patients, staff and carers? If mhn could ask itself the miracle question of solution focussed therapy, what would our history, present, future be like?

Some of Gadsby's points are shocking and reveal the experiential fact of the few bad apples. There is an overlap here with Nikki Marfleet, a speaker at this past week's Health and Justice Summit. @TheLRH stressed the need for assuring that both good and difficult conversations with staff take place. As a student nurse and newly qualified nurse you recall wondering who you were to work with next shift: and not just management-wise. It was not necessarily the 'who' you would be working with, as the 'attitude'. This is a fact of life within many occupations, but in mental health the impact can be literally that. Nikki noted that the difficult conversations can be positive as well as challenging behaviours and attitudes as the desired team culture is built. The bottom line though on the tenor of the difficult conversation is can you, do you, really want to keep that bad apple? I have seen situations were the approach was, if continued, provocative and not deescalating. We have all met them, the individuals, who, even after giving them the benefit of doubt, you are left wondering why are you still here (and somewhere quiet you tell them).

The Recovery Star (Triangle updated) saw Gadsby as a life-coach being an early adopter. 'Recovery' features markedly in the book. The figure and description of Smith's work - 'The structural model of genre'. There are practical insights here, especially for new student nurse. As Gadsby writes of, "trying to change the system from within.", I smiled ruefully. I used to feel sympathy, oops sorry! empathy, for the patients on the Long Stay ward [37A] and others. I had a distinct sense that as a new group of students started, the patients rolled their eyes (and not in some oculargyric crisis*) but out of their patience (yes, the patient's patience) being tested to maximum. As the students set-to to change the behaviour pattern of some key individuals (were they viewed as such?). They slept late, smoked too much, might palm - pretend to swallow their medication, they spent too much time on their beds, their personal hygiene was poor. They were certainly 'key' as subjects for our student assessments; yes, me too.

In my reading, Gadsby alludes to the rationale by which people are attracted to mental health nursing (p.22). Perhaps stories have a formative role to play? [At risk of a slight digression] Recently I've been really surprised by the psychological and medical content of TV programmes I was watching from age 10-11. Star Trek's "Dagger of the Mind" for example; UFO with "Sub-Smash" and "The Man Who Came Back" and many others (in contrast to many peers at the time I only saw "One Flew Over the Cuckoo's Nest" in the 80s).

If that is (was) about 'future nurses' Gadbsby refers to Burstow's institutional ethnography, and one "notion of how psychiatry is perpetually on the cusp of a humane scientific breakthrough" (p.23) Critically, this is not Star Trek, but how Burstow explains the violence of the present in terms of time. Gadsby teaches psychiatrists too and this book has lessons for the whole 'multidisciplinary team'. He points out how models of care as we deliberate on 'caring about' versus 'caring for'.

Hodges' model is a 'health career' model, not a model of care, but it can help facilitate all forms of care.

Gadsby and other authors here identify many polarities: care and control, advocacy and correction. In the late 1970s and 1980s we were not just nurses, but 'patient advocate'. The nurse literature and rising profile of human rights called this into question. In mental health though for some formal meetings you may struggle to have an independent advocate present (is that time playing with us again - temporal violence of however many hours, days, months?).

individual

|

INTERPERSONAL : SCIENCES

humanistic ----------------------------------------------- mechanistic

SOCIOLOGY : POLITICAL

|

group

The person - individual - self
"proximal experiences"	"over the power horizon" the STATE "distal power"

Gadsby correctly anticipates that this account of experiences, thought and conclusions may be read as damning. The book as whole provokes a real double-bind. The violence is a reality (yes, look at the World, p.25) and so often violence is the news^#. So too, is the compassion to effect (constant) change; even as the medication is administered in the sacrifice zones (pp.27-28).

Gadsby writes: "We frequently work within models that fail to make sense of the connections between inner and outer experience, past, present and future..." (p.25).

Yes, don't we just (whether accidentally or not).

Difficult as this is, this text is vital reading for CMHNs, nurse students and a much wider audience.

More to follow - with possible additions^# here...

^*Seriously, I am grateful to say I have not witnessed this in my 41 year career.


Parts iii

Part iv

Bull, P., Gadsby, J., Williams, S. (Eds.) (2018) Critical Mental Health Nursing: observations from the inside, Monmouth: PCCS Books. ISBN 9781910919408