1/ SYNOPSIS

Although the popular view is that care and treatment of people with mental illness rests in the hands of psychiatrists, in reality psychiatric nurses are by far the biggest group of mental health professionals; spend the most time with people experiencing mental illness; and dispense the great majority of psychiatric care and treatment. More than any other mental health professionals, psychiatric nurses have the power both to facilitate the recovery process and to compound further people's difficulties. Not infrequently, the effects of nursing intervention - especially in institutional settings - have been directly harmful.

The importance of psychiatric nursing as a power for good or ill has long been recognised. In the mid 19th Century the English alienist John Connolly (1856) admitted that:

"All [the physician's] plans, all his care, all his personal labour, must be counteracted, if he has attendants who will not observe his rules."

In Connolly's day, the assumption was that attendants - later to become nurses - existed only to do physicians' bidding. Although contemporary psychiatric services have changed greatly in the intervening years, the ethical literature in psychiatric nursing continues to suggest that nurses' core function is to support the execution of medical practice. Such literature focuses on dilemmas arising for nurses as they assist doctors in physical treatment; dispensing medications; and implementing mental health legislation. Little has been written about the ethical dilemmas involved in the nurse's role as advocate, companion, therapist or fellow pilgrim to the person in mental distress. The ethical dilemmas involved in these other roles arise from a philosophy of psychiatric care markedly different from that of traditional biomedicine and psychology. This is the philosophy of care deliniated in Barker and Davidson's text, highlighting the politics of mental illness, the social context of personhood and the spiritual dimensions of mental health.

'PSYCHIATRIC NURSING - ETHICAL STRIFE' is an international collection of reflections on such ethical issues for psychiatric nurses and for society. These reflections are drawn from the everyday world of delivering care, treatment, therapy and other forms of support, across all areas of mental health services. Consideration of more abstract philosophical issues has been kept to a minimum, in an effort to address directly the nurse's experience of ethical uncertainty, as well as the possible means of resolution. The text is designed primarily to serve as a source of stimulation for the individual reader, providing an opportunity to reflect further on the implications of ethical issues for their own practice. Given the multifarious nature of explanatory models and treatment modalities, and also the personal nature of ethical striving, the editors have discouraged any 'oracular' solutions to readers' dilemmas. Instead, the authors expect that their contribution will challenge the reader to review their existing ethical perspective, in the true spirit of education.

The authors are drawn from the United Kingdom, the USA, the Caribbean and Australasia, and are mainly psychiatric nurses whose thinking is rooted in experience of practice. Other authors represent a variety of disciplines - user-advocacy, psychiatry, social work and psychology - and all have strong connections to psychiatric nursing practice. They are all authors whose work informs the ethical debate.

Major changes are taking place in mental health service delivery and many more changes have been mooted regarding the role and preparation of psychiatric nurses. In the developing debate over the 'true needs' of people in mental distress, and the 'proper means of responding' to such needs, ethical challenges are already emerging for nursing and for society. In this climate of emerging controversy, PSYCHIATRIC NURSING - ETHICAL STRIFE is likely to become a landmark text.

The text contributes to the further development of ethical critiques from two main ideological perspectives on psychiatry which emerged in the UK and USA in the '60's. The first of these focusses on issues related to power and its abuse, as well as other economic and social factors which underpin people's alienation and distress. Abuse of power has been defined by various authorities, especially Illich and Szasz, as a characteristic feature of all medical services and one of the critical characteristics of psychiatry. The considerable potential within psychiatry for further exploitation of vulnerability and abuse of power over people is therefore given particular emphasis as an ethical concern. Both naturally occuring (ie interpersonal) power and also power which is legally constructed is highlighted.

The text's second focus is on individuals' struggle to reconstruct and make sense of their experience. The process of developing personal meaning for psychiatric disorder and the process of integrating unfamiliar experience are seen as powerful tools in facing adversity and as important aspects of individual growth. Endorsement has thus thus been given to consideration of the spiritual aspect of psychiatric experience and the pastoral component to psychiatric nursing care.

The editors have aimed to transcend the traditional polarisation of such 'political' and 'personal' perspectives. The ethical analyses offered recognise the contribution of political, economic and interpersonal issues to the construction and 'colouring' of experiences conventionally described as 'mental illness'. They also acknowledge the existence and importance of an 'inner world', accessible to introspection and representing the subjective reflection of individuals' spiritual struggles. The editors emphasise the complementary nature of such socio-political and spiritual perspectives.