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The Role of the Psychiatric Nurse

by Ben Davidson B.A., R.M.N.

Abstract

• Mental illness is popularly conceived as a disorder located in the individual. This is a misconception. An alternative view is proposed, based around the writings of David Smail and referring to R. D. Laing's work and the author's professional and personal experience.

• The concepts and techniques of psychiatry and associated disciplines pathologise individuals. The theme that they therefore do more harm than good is developed.

• In place of these techniques we should implement the process of 'Taking Care' described by Smail. This process is explained as demystification and comfort, and some of its benefits and difficulties are examined in relation to clinical practice.

• Finally, the role of the psychiatric nurse in clinical work with individuals and issues of professional identity are considered. The merits of a reformulation of our role and identity in line with the preceding analysis are emphasized.

What can be the relevance of the psychiatric nurse to the life of a person who is mentally ill? To do justice to this question, it is necessary to examine what 'mental illness' is, how best to care for those 'suffering from it' and the role psychiatric nurses might usefully play in that care. My starting point is the position held by David Smail, a senior clinical psychologist and academic, and the ensuing discussion will use Smail's work as the basis for examining all of these issues.

David Smail is currently honorary special professor in clinical psychology at Nottingham University and head of clinical psychology services in Nottingham. His reputation as a clinician is widespread but his popularity is by no means universal, particularly as his work since 1973 has embodied scepticism regarding the clinical and theoretical claims of the psychology/psychiatry/psychotherapy industry (the psych industry). Although abnormal behaviour, chaotic experience and states of emotional distress are popularly conceived as disorders located in individuals, Smail rejects any attempt to pathologize people in such states and avoids using ideas from any conceptual system which does so. In this regard, such concepts as 'biochemical imbalance', 'behavioural dysfunction', 'cognitive malfunction', 'faulty learning', 'developmental arrest' and 'family dysfunction' all appear to him to pathologize individuals and thus to mislead, both in terms of theory and clinical practice.

Central to Smail's approach is the belief that we live in a 'dysfunctional' society and emotional, cognitive or behavioural disturbance 'within' an individual (or for that matter a family) is essentially a natural result of the intolerable pressures and constraints imposed by that society. These pressures and constraints increasingly impinge on individuals the lower their position within the hierarchies of wealth and power. Thus, when we observe the emotional, cognitive and behavioural 'symptoms' of the sort of individual, medical ailment that is taken to constitute 'mental illness', we are suffering from a misconception. No matter whether they are classified as neurotic or psychotic, these symptoms are, in Smail's view, more accurately and usefully to be understood as a form of communication wherein the individual is expressing and responding to the havoc wreaked by other individuals or by society at large on her or his embodied experience in the world (Smail, 1984 pp. 92-93 & chapter 5).

Any such extreme expression of intense internal frustration, anger, pain, despair, confusion, misery or fear is unfortunately, according to Smail, likely to be seen as 'illness', for 'being ill' appears to be the only metaphor (or euphemism) available to represent such states. We use similar metaphors in everyday life:

Recently, when my four year old son was crying, I tried to comfort him, but my comforting was half-hearted. My impatience and irritability undoubtedly showed through and I may well have sounded quite cross with him. He became inconsolably distressed. At the time I concluded (and I caught myself telling him) that he was merely 'tired'. This was easier than acknowledging and validating the real sense of hurt and rejection he felt in response to my behaviour.

In much the same way, according to Smail, the ordinary and inevitable misery and suffering which arise as a more or less direct result of painful and unjust forms of social organisation are represented disingenuously by society as more or less obscure processes of 'illness' (cf 'tiredness') requiring professional expertise to diagnose and treat them.

Sometimes I have found that people appear to be reasonably satisfied with this conventional description and treatment of their condition. In many cases, however, individuals seeking (or at least open to) some alternative explanation for their troubles than 'illness', and uneasy about the treatment they expect to receive, have to accept the conventional explanation and treatment anyway, together with its enforcement by assorted agencies and experts.

At age 4, Craig was sometimes abandoned for days at a time and left to look after two younger sisters. Other times he looked on while his single mother engaged in prostitution in their single room. At age 5 he was taken into care. Despite these and other experiences of severe emotional and physical deprivation, perhaps precisely because these painful experiences were so hard to accept, he retained a desperate optimism and buoyancy through his childhood and adolescence. This optimism was encouraged at the childrens' home where he lived. It was also in conformity with the overwhelming social pressure to accept one's lot and be happy. It did not begin to fade until his 20's. Since the recent death of his mother he has only managed to cling onto some final shreds of this optimism by adopting a set of beliefs which include a view of himself as a Hindu demi-god with superhuman powers to set the world aright and control heaven and earth by magic. When unable finally to maintain these beliefs he sinks alone into the compounded misery and turmoil of 28 emotionally gruelling years.

Although he desperately wants to understand his experience, his involvement with traditional psychiatric services over two years has not helped. Despite two hospital admissions and intense contact with many psychiatrists and nurses, this contact has served to force him into a reluctant acceptance that his troubles are a biochemical matter (bi-polar affective disorder - manic-depression); that is, they represent something wrong with him. He is struggling to free himself from this view with very little support and meanwhile is being treated with psychotropic medication which makes it something of an effort for him even to think.

It is demoralising and uncomfortable and taxing to acknowledge and validate the real hurt Craig and countless other clients have suffered. Furthermore, given the ascendancy of a scientific, empirical view of reality wherein subjective experience is generally either devalued or invalidated completely, both clients and those treating them find it hard not to succumb to pressures to accept the conventional wisdom. In these circumstances, it is much easier to call experiential suffering and its results 'illness' and treat them as such.

Smail's ideas, as well as borrowing from some analytic theory, are very much reminiscent of Laing's middle period of work (Laing, 1967) where he reframed psychotic experience and symptom as a form of communication, a pilgrimage and a struggle for freedom and meaning.

Smail's work also parallels Laing's in his skepticism regarding the right of society to proclaim itself 'sane'. He calls into question many of the cultural beliefs and values we hold most dear, including the pursuit and idolization of happiness, the faith we place in science and experts for our salvation and our compulsive view of the self as an object (Smail, 1984, 1988). Laing too contextualized and reframed our conventional ideas regarding 'sanity. For example, he drew attention to,

'the condition of alienation, of being asleep, of being unconscious, of being out of one's mind, ... of ... normal men [who] have killed perhaps 100,000,000 of their fellow men in the last fifty years.'

(Laing, 1967 pp. 25-30)

Although one may be inclined to insist that someone whose experience is psychotic appears in some significant way to be 'ill', while the rest of us are not, the most this can really mean is that they are statistically abnormal, for example like a plane no longer flying in formation with the rest of a squadron of planes. Laing urged us not to make the mistake of assuming that society (the rest of the planes still flying 'in formation') is 'on course' and therefore in any particularly superior position (Laing, 1967 pp.25-30 and pp. 55-76). The holocaust, the Vietnam war, the prevalence of childhood sexual abuse, Western support for Pol Pot's regime in Cambodia and financing of the death squads in Central America, together with countless other examples, show that present day society as a whole seems also pretty much off course.

As Laing made emphatically clear in his work, however, this is not to say 'that the person who is "out of formation" is more "on course" than the formation.' (Laing, 1967 p.119) - although, of course, she or he might be! Likewise, Smail does not believe that a person labelled as 'mentally ill' is, by virtue of her or his sensitivity to the pressures and constraints that society or life imposes, necessarily more 'sane' than the rest. Neither does he believe that her or his suffering should be somehow idealised. He simply insists that it is a mistake to see the locus of the problem as within that individual.

Smail argues, furthermore, that, by virtue of the assumptions built into them which pathologise individuals, the various concepts and techniques of 'the psych industry' probably make it more rather than less hard for clients correctly to assess their situation and act accordingly, however innocently these concepts and techniques are used.

Christine was forced to have sexual intercourse with her father from the age of four, and subsequently with a group of his paedophile friends. In adolescence her account of her past and her expression of distress were time and again disbelieved by every figure of authority from her mother to doctors and police. Her resulting sense of unreality and dissociation were seen out of context and taken, together with other unextraordinary phenomena, to be 'symptoms' of 'mental illness' (schizophrenia), to be treated chemically. Her belief that she had been sexually abused was taken, subsequently, to be a delusion. And making such claims and expressing distress as she did, was thereafter seen as no more than melodrama and 'attention seeking behaviour', to be discouraged by ignoring or disattending to it, or by sedating her.

Smail suggests that concepts and techniques of behaviour modification, cognitive restructuring, psychoanalysis and chemical control shift both responsibility and blame for their distress onto individuals, worsening their problems by overlaying their misery and suffering with mystification and guilt, as was evidently the case with Christine (and also Craig) above. No doubt the reader can supply countless further examples from clinical experience.

The remainder of this article will summarize what Smail thinks society's response ought to be, and will outline my own view of how psychiatric nurses could participate in this response.

The process of 'taking care'

In place of the techniques of 'the psych industry', Smail suggests the process of 'taking care'. Although he does not himself make the case, I suggest that the psychiatric nurse is particularly well-placed to undertake this activity, and that to the extent that any psychiatric nurse does 'take care', she or he becomes relevant in a beneficial way to a person who is 'mentally ill'.

Despite his skepticism about 'the psych industry', Smail states: 'There will no doubt always be a place for therapy' (Smail, 1988 p.142). For Smail, the aims of therapy are demystification and comfort. He defines demystification:

'as establishing what is the case ... the examination and clearing of the confusions which surround the person's deceived or self-deceiving view of what lies behind [her or his] "symptoms" [through a process of] negotiat[ing] a view of what the patient's predicament is about which both the patient and therapist can agree.'

(Smail, 1984 p.4)

He goes on to explain,

'It seems to me essential for people to enter into, to have the full opportunity to alter and argue with the processes whereby someone else arrives at a formulation of "the problem".

(op. cit.)

Demystification

The process of demystification is a complex one requiring enormous skill and understanding. It is easy to underplay the difficulties faced in keeping one's own prejudices and idiosyncratic views out of this negotiation (Smail, 1978). It is easy also to underestimate the effect on this negotiation of one's being in a position of power over a client. At the risk of oversimplification, however, the spirit of this process may be represented as follows:

When we uncover a complete picture of your life history we will realise that it is natural for you to be feeling/thinking/behaving/relating this way. These patterns and states of mind are more than likely 'the reasonable upshot of [your] life history' (Smail, 1984 pp.12-13) which we can, if you like, explore together.

There is a certain humility in adopting and conveying this attitude that, like oneself, the client has a completely acceptable uniqueness. Such humility, it seems to me, is essential and all too rare. But perhaps that is understandable. The adoption of this demystifying and normalizing attitude often requires a great deal of effort, strength and faith, as significant parts of clients' life histories often appear impenetrably obscure, to them no less than to anyone else. A reductionist view is frequently simpler. Moreover, as already suggested, it is no easy feat to acknowledge and validate the experience of someone who has suffered in a way we prefer not to recognise, particularly if they can hardly bring themselves to acknowledge it. A medical view, say, is frequently less demoralising.

The greater simplicity and reassurance within a reductionist view are extremely powerful motivating factors. Often I meet clients who experience quite unusual and apparently bizarre phenomena, such as walls screaming at them, voices instructing them to cut themselves to get rid of the bad blood, their spines crumbling and time bombs primed to go off inside them. Others seems to have been left feeling so precarious and under such threat that they choose not to step outside their homes, sometimes hardly even to move or speak.

Vernon rarely ventures outside the bedroom of his first floor council flat. He is a handsome man in his early thirties, but he is tortured by an excruciating and overwhelming shyness. Virtually his only human contact is with a community psychiatric nurse who visits him once every week. Vernon insists sometimes that these visits are designed to humiliate him as his key worker is so much more confident and better looking than he is. At such times Vernon asks his visitor to leave so that he can 'get on with his own life'. Other times he welcomes this contact and talks a little, for example about his hopes of finding a girlfriend. This seems to represent some progress from the situation three years ago when Vernon had no real human contact and was twice arrested and once severely beaten after exposing his erect penis to female neighbours in the street or on their doorsteps.

It seems that some of us, like Vernon, are so overwhelmed by feelings of fear and threat that the ensuing shyness is completely debilitating. In others, this sense of threat manifests in fearful hallucinations or delusions and in particular phobias and obsessions. Some people have such fear of making any move at all they are catatonic. It is difficult to discern where such fear and sense of threat come from, whether from frightening contact with others close to us, through terrifying experience of society and its enforced norms of thought, experience and behaviour, whether from life itself, or, again, as a result of the treatment received within the psychiatric system. But in any event, the experience and subjective world of clients in such states seem to have been so devastated that I often find it too awful and dismaying to want to explore it. The 'act of faith' I mentioned above seems at such times to be more a plunge into the abyss. And yet I am sure I am not alone in discovering that in response to such an 'act of faith' clients begin to accept their experience so that even the most traumatized begin to unfold as people. This is, of course, not necessarily to cure the individual's 'symptoms'. But it may,

'bring them face to face with circumstances in their lives which are distressing, and which they can only ignore at the cost of "neurotic" [or psychotic] suffering. Often, admittedly, this is to replace one kind of suffering with another, and whether or not this seems a good idea depends on one's values. To me, it seems more constructive, and essentially more hopeful, to recognise that real difficulties, real evils and real pain arise in the world around us through our conduct towards one another than it is to resort, albeit unawares, to self-deceiving strategies which, for example, allow 'illness' to provide the explanation, and indeed the form, of our misery.'

(Smail, 1984 pp. 2-3)

Comfort

Smail's emphasis on comfort as the other main function of therapy makes it clear that a realistic appraisal of clients' predicaments should be followed by empowering and encouraging them 'to do what [they] can to confront those elements of the predicament which admit of some possibility of alteration.' (Smail, 1988 p.4). It is an appalling indictment of our society that such basic 'kindness, encouragement and comfort' (Smail, 1988 p.142) are in such short supply (and commercial interests are so powerful) that they need to be commodified and sold in the market-place by professional 'experts' in the field, or doled out begrudgingly by an overburdened NHS. In ideal circumstances such support and love might be expected and supplied freely and naturally by family and friends for whom we are, surely, but poor substitutes. Nevertheless,

'For many people psychotherapy provides the only source of comfort they are likely to find in what has been, for them at least, a predominantly cruel world.

(Smail, 1988 p.4)

It does appear possible to offer clients something through a relationship with them which serves as comfort and nurturance. In an interview recorded shortly before his death Laing referred to this something as 'co-presence'. He defined this as,

' ... a sort of harmless, inviting presence that doesn't offer threat, isn't felt as threatening, isn't felt as pulling in, isn't felt as doing anything, as just being - but alive, vibrant, actively being.'

(Tougas et al, 1989)

The provision of this sort of comfort is not a product of professional training and is not measurable in terms of some objective criteria of expertise. Neither is it reducible to blind optimism or cheerfulness. Laing defines co-presence further as 'a field effect taking place prior to and behind any words spoken'.

It is more a mark of one's humanity to be able to just be with someone, no matter what state they are in, without needing to act on them in some way, without attempting to change them to suit one's own book, so to speak, and yet still vibrantly alive to their humanity. But if the distressed and desperate states which are conventionally known as 'mental illness' arise out of our conduct towards one another, then their resolution too must issue from this interface between people, out of a healing common ground that can be established through a therapeutic relationship.

In the context of such a therapeutic relationship, that is one characterised by this absence of threat, by co-presence and by encouragement and comfort, it seems to me (so far) that clients do eventually feel sufficiently safe and courageous to tackle aspects of their experience and life which are amenable to development. Moreover, they often do so without the need for any specialist techniques or esoteric knowledge. What seems often to count for more is the quality of the physical environment (Stokeld, 1990) and the constancy of the nursing care (Strang, 1982). Although there is often little that can be changed and it is frustrating for both the client and oneself to acknowledge that there is neither any way of undoing past experience, nor any cure for the suffering it has brought, one can at least, in such a nurturing, unthreatening physical and psychological environment, work towards a position where the client is seeing things as they really are and accepting her or his own experience and potential.

The nurse's role?

As nurses, we occupy neither a defined theoretical position with regard to 'mental illness' nor a particularly prestigious or valued position within the hierarchy of 'the psych industry'. This seems to me to lead to nurses experiencing a sense of disempowerment, out of which we often rely on a medical framework both for understanding and treating clients, and for our professional and clinical sense of identity. Paradoxically, however, this lowly position and lack of definition in our theoretical approach leaves us in a situation where we can more easily accept the adjustment to our thinking and practice that acceptance of Smail's view requires.

Many of the tools for this adjustment are already at hand. For example Egan's (1990) counselling model which nurses sometimes use encapsulates the range of skills involved in helping someone tell and understand their story. With further training in demystification and empowerment, perhaps with regular involvement in patients' care of groups like Mind and Survivors Speak Out, psychiatric nurses could become adept, or more adept, in this work. If we do choose to move from the medical view we so often fall back on, there is certainly no reason why we should be any less proficient in the dispensation of comfort and in the supply of this unthreatening co-presence than those who have had the good fortune to train as doctors, psychotherapists or other more highly valued professionals. And as 24-hour carers adopting the role both of therapist and friend (Strang, 1982) it may even be that we are more effective. Furthermore, I believe that the adoption of a defined theoretical position and a model of clinical practice as outlined above would probably enhance not only the efficacy of our work, but also our social position by establishing a clear professional role and identity distinct from psychiatry and well beyond the role of hand-servants to the medical profession.

Skills and training for demystification and comfort

In order to implement care comprising these elements of demystification and comfort, the skills needed are, of course, considerable. But it is not inconceivable that resources, currently allocated to training nurses somewhat randomly in a hotchpotch of different therapies and a diffusion of antagonistic systems of thought, might be reallocated to training nurses sequentially in:

• awareness of and sensitivity to socio-economic power and interpersonal power issues as they contribute to mental suffering, distress and anxiety, together with the appropriate skills in demystifying, empowering and facilitating clients in telling their story;

• damage limitation in interaction with clients to prevent the abuses of trust and power Masson (1988) describes and any other harm;

• working with people who are severely disturbed (psychotic) without reliance on medication or other forms of restraint or damaging placebos - for example employing concepts and skills as used in Kingsley Hall by Laing, Berke et al. in their work with Mary Barnes (Berke and Barnes, 19714) and as still used at The Arbours Crisis Centre* and elsewhere in analytic work with people who are psychotic (Segal, 1964);

• comfort, nurturance, encouragement and co-presence, in the context of which, finally, supplementary techniques in dynamic, behavioural or cognitive change may be fully explained and then offered to clients for them to use if they wish.

If this is done and our identity and role become defined accordingly, I believe that the care we implement will be more effective. But whether or not these changes occur in our profession as a whole, I believe that to the extent that we serve individually to demystify, comfort and empower a person who is 'mentally ill' in the way suggested above, we are both relevant to their life, and also exercise a benign influence on it. Equally, to the extent that our involvement in the life of this person serves to mystify and discomfort them further, we are relevant and, like so many others, do damage. It is imperative that this relevance and benign influence are enhanced.

Conclusion

In 'The Politics of Experience' Laing wrote as follows:

'A revolution is currently going on in relation to sanity and madness both inside and outside psychiatry. The clinical view is giving way before a point of view that is both existential and social.

(Laing, 1967 p.110)

Personally, I have not seen much of it.

In my experience, the general consensus amongst psychiatrists and nurses appears to be that Laing (where anything is known of him at all, that is) was an interesting and extremely idiosyncratic product of the 60's psychedelic culture, but best consigned to history and, of course, quite mad. Unfortunately, neither Laing's, nor Smail's, nor anyone else's social and existential perspectives have taken over from the medical model of madness within psychiatry, nor really even seriously challenged it**. Neither does there seem to be much evidence that psychiatric nursing is moving towards an approach resembling the one outlined above, and any attempt to do so would seem to be undermined by our acceptance of the medical model and willingness to encourage the use of medication.

Meanwhile, outside 'the psyche industry', despite attempts to market a rose tinted version of 'Care in the Community', it is clear from the most cursory examination that neither the political establishment nor society generally have not taken up the 1960s call to love and live in harmony with their fellow citizens, especially if they are mad. The clinical view seems altogether more safe and less personally burdensome.

It is clear, therefore, that Laing's optimism regarding this so-called revolution in psychiatry was ill-founded, and we may mourn and despair that in these dark ages such a beacon of insight and humanity as Laing has left the world. It is heartening to discover in these circumstances that Smail keeps the lamp burning. It would be even more heartening to discover that there are psychiatric nurses trying to develop this kind of work and interested in forming a professional association based around the ideas above.

Footnotes

* The Arbours Association is a registered charity, set up in 1973 by Morton Schatzman and Joseph Berke, both colleagues of R.D. Laing, three years after the famous Kingsley Hall experiment had finished. The Arbours advertises itself as an organisation founded 'in order to assist people in emotional distress and offer alternatives to traditional mental hospital treatment'. They currently run a Crisis Centre, three long-term residential communities, a consultation service and a psychotherapy training programme. Further information from: The Arbours, 41 Weston Park, London N8 9SY; Telephone 0181 340 8125; see also Berke's accounts of his work (Berke, 1974, 1981).

** Ironically, at the same time as Laing's views appear to be more or less universally discarded within psychiatry (if they were ever given credence) many psychiatrists do what they can to covertly to hijack and sanitise Laing's social and existential insights in a way that makes them almost support a reductionist view, as for example, with recent work on High Expressed Emotion in the families of schizophrenics, in which nurses and other practitioners now undertake specialist training. This work seems to me to issue directly from Laing's and Esterson's insights, e.g. 'Sanity, Madness and the Family' (Laing and Esterson, 1964).

Acknowledgement

I should like to acknowledge the generous advice and help given to me by Ms Sue Ritter, lecturer in Nursing Studies at the Institute of Psychiatry, Denmark Hill, London SE5 8AF, UK.

REFERENCES

Barnes, M. & Berke, J. (1971) Mary Barnes: Two Accounts of a Journey Through Madness, Free Association Books, London.Berke, J. (1981) I Haven't Had to go Mad in Here: The Psychotic's Journey from Dependence to Autonomy, Penguin, Harmondsworth.

Egan, G. (1990) The Skilled Helper - A Systematic Approach to Effective Helping, 4th edition, Brooks Cole Publishing, California.

Laing, R.D. & Esterson, A. (1964) Sanity, Madness and the Family, Penguin, Harmondsworth.

Laing, R.D. (1967) The Politics of Experience, Ballantine.

Masson, J. (1988) Against Therapy: Emotional Tyranny and the Myth of Psychological Healing, Fontana/Collins, London.

Segal, H. (1957) An introduction to the work of Melanie Klein, Heinemann, London.

Smail, D. (1973) Medicine and mental illness, Dent, London.

Smail, D. (1978) Psychotherapy: a Personal Approach, Dent, London.

Smail, D. (1984) Illusion and Reality: the Meaning of Anxiety, Dent, London.

Smail, D. (1988) Taking Care: an Alternative to Therapy, Dent, London.

Stokeld, A. (1990) Building on Metaphors. International Journal of Therapeutic Communities (Berke J., ed.), Vol; II, No. 4

Strang, J. (1982) Psychotherapy by Nurses - some special characteristics Journal of Advanced Nursing.

Tougas, K., Shandel, T. & Feldmar, A. (1989) Did You Used to be R. D. Laing? Channel Four, London & Third Mind Productions Inc., Vancouver. (TV documentary transcript.)

Originally published as 'What can be the relevance of the psychiatric nurse to the life of a person who is mentally ill?' in Journal of Clinical Nursing (1992), Vol 1 No. 4 pp.199-205.

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