Drawing upon recent clinical practice experiences and relevant literature, discuss the following statement: ‘The modern mental health nurse is guided in clinical practice by the concepts of recovery and service-user involvement.’
This essay seeks to explore some of the contentious, and often complex, issues associated with contemporary trends in mental health nursing, and to relate them, as far as is possible, to the author’s experiences as a student nurse in clinical practice. In particular, it addresses current (and anticipated) relationships between mental health nursing, the recovery approach and service-user involvement. To that end, as psychiatric rehabilitation begins to ‘redefine itself’ for the twenty-first century, it will be necessary to disentangle the various conceptual threads that run through the discussions surrounding the meaning and scope of ‘recovery’ for both nurses and people with mental health needs (Shepherd et al. 2008: 3).
In the first instance, as ‘a concept whose philosophical boundaries and practical implications are still contested’ the semantic, definitional problems linked to ‘recovery’ could prove vital to understanding the implications of the recovery approach for mental healthcare (Wallcraft 2005: 127). The Sainsbury Centre for Mental Health (SCMH) notes that ‘recovery’ is ‘something of a contested term’ (Shepherd et al. 2008: 1). Repper (2005), too, acknowledges that, among the principal ‘difficulties’ associated with the concept of ‘recovery’ is the fact that it ‘lends itself to so many different interpretations.’ Elsewhere, it has been suggested that ‘recovery may well be so deeply personal that it defies definition’ (Buchanan-Barker and Barker 2008: 94). Nonetheless, despites its status as an ‘elusive concept with multiple definitions’, it is important to recognise that the intangible quality attributed to ‘recovery’ has come to be seen by many of its adherents as a virtue (Higgins and McBennett 2007: 852).
According to Long (2005), the tendency towards diverse and wide-ranging interpretations of said concept only serves to ‘highlight the subjective experience of recovery [my emphasis].’ By looking more closely at this emphasis on the subjective experience of mental illness we will be able to shed some light on the goals and philosophy of the recovery approach, assess its theoretical strengths and weaknesses, and evaluate its potential as a practicable approach to mental healthcare, in terms of both service-user involvement and mental health nursing.
Despite spending a substantial amount of their training in clinical placement, where service-users are encountered on a daily basis, it is ironic, if unsurprising, that student nurses’ understanding and interpretation of ‘client-centred’ mental healthcare should be mediated, for the most part, through official sources. Recommendations and policy guidance on ‘recovery-oriented services’ are a case in point, and in discussions concerning government-sponsored proposals to implement the recovery approach the following supporting literature is frequently cited: the Department of Health’s Ten essential shared capabilities: a framework for the whole of the mental health workforce (DoH 2004); the National Institute for Mental Health in
Making recovery a reality (Shepherd et al. 2008), for instance, distinguishes ‘clinical recovery’, whereby ‘the person has been restored to previous levels of functioning, from ‘the unique journey’ of ‘social recovery’ embarked upon by someone who has invested their hopes in a recovery approach to coping with their mental illness (Shepherd et al. 2008: 2; Higgins and McBennett 2007: 852).’ Accordingly, and as is consistent with comparable appraisals, recovery is here understood, not as simply ‘recovering from illness’, but as recovering a sense of human agency from a life that has been dramatically interrupted and re-shaped my mental illness. Thereafter, Making recovery a reality sets out to expound upon the government’s strategy for ‘promoting recovery’, previously outlined in The Department of Health’s Ten essential shared capabilities (DoH 2004: 3) as follows: ‘Working in partnership to provide care and treatment that enables service users and carers to tackle mental health problems with hope and optimism and to work towards a valued lifestyle within and beyond the limits of any mental health problem.’
This incorporation, or mainstreaming, of the recovery model in the
Anthony’s interpretation of recovery reflects a wider struggle, embodied in the recovery approach as a whole, to resist the reduction of people with mental illness to their symptoms. That is to say, the recovery approach seeks to transcend the paradigm of chronicity that has long been entrenched in mental healthcare, largely as a consequence of the dominance, for the greater part of the twentieth century, of biological psychiatry. Separating out the person from his or her illness is thus a guiding principle for a recovery-oriented approach to mental health (Roberts and Wolfson 2004: 39). The relevance and the validity of establishing recovery-oriented mental health services, however, hinges, to a large extent, on the question of whether or not nurses can (or should) act as ‘advocates’ for their clients.
The veracity of the claim that mental health nurses are guided by the concepts of recovery and service-user involvement depends upon the extent to which the philosophy of advocacy is, or can be, translated into practice as a person-centred process of enablement and social inclusion. The conceptualisation of the mental health nurse as paternalistic and custodial, and concerned with little more than symptom management, has given way to a vision of the nurse as a partner in their patients’ strengths-based recovery and empowerment, and a coach in their resistance to learned helplessness (Roberts and Wolfson 2004: 40; Barker and Buchanan-Barker 2005; DoH 2007; Buchanan-Barker and Barker 2008: 95; Shepherd et al. 2008: 3). By investigating the basis upon which the parameters of advocacy have been determined, the author’s own recent experiences can be evaluated against the criteria for combining advocacy and the recovery approach that have come to exert a decisive influence on current thinking in mental health practice.
According to Gadow (1983: 45), advocacy demands ‘that individuals be assisted by nursing to authentically exercise their freedom of self-determination.’ Kohnke (1982: 2) argues: ‘The role of the advocate is to inform the client and then to support him in whatever decision he makes’. Though a little more circumspect, Shepherd et al. (2008: 3-4) have reiterated these positions more recently, suggesting that professional advocates exist ‘to provide [the client] with the resources – information, skills, networks and support – to manage their own condition as far as is possible’. They also add that ‘there is an intrinsic value in supporting people in trying to achieve the goals they set for themselves, even if [their advocates] think these goals are not ‘realistic’.’ Early criticism of this perspective suggested that it was rare for either party in the nurse-patient relationship to conceive of their roles in terms of ‘advocacy’ or ‘recovery’ (Melia 1987; Fowler 1989). My research and observations in practice confirm, not only that this is still the case, but also that attempting to elide the distinction between nursing and advocacy could have unforeseen, and potentially negative, consequences for the therapeutic relationship between nurses and their clients.
One might argue that my recent clinical placement with EMI (Elderly Mentally Ill) CPNs (Community Psychiatric Nurses) must necessarily have restricted my insights into the recovery approach, the average age of the client base seemingly situating this area of mental healthcare outside of the, purportedly, more fully implemented project of recovery-oriented practice in adult services. Yet, such an assumption would suggest both a patronising view of the elderly and a misleading view of elderly mental healthcare. It is true that many older mental health service-users retain traditional views about doctor-patient and nurse-patient relationships, which tend to reflect the kind of deference towards the medical profession that was established in the middle of the last century (Fitzpatrick 2001). Yet, by the same token, just as received wisdom tells us that the recovery approach ‘can be applied to anyone who experiences a significant mental health problem at any age’, I would stress that the values and expertise of modern mental health nursing (much of which, though not immediately distinguishable as the ‘recovery approach’, would satisfy champions of the latter) are, arguably, having as positive an effect in this field as they are in any other (Shepherd et al. 2008: 20).
Depression is the most common mental health problem for older people. Furthermore, together with psychotic disorders, organic mental illness is exacting a heavy burden on an ageing population (Beirne 2000; Chew-Graham et al. 2007: 364; McCabe 2008). With this in mind, one would expect the paucity of research into how to develop the recovery approach for the benefit of older people with mental illness to be a cause of alarm to those for whom the transformation of mental health services along client-centred lines is imperative. For instance, a study conducted into the characteristics of ‘psychosocial transition’ in the event of a stroke (a major predictor of organic mental illness), expressed concerns about ‘the need to review the meaning and experience of the term “adjustment to stroke” and the everyday terms “recover” and “recovery”’ (Dowswell et al. 2000: 513). The recovery model has been linked to various projects involving older patients with dementia (Buchanan-Barker 2008: 94). However, despite ‘the growth of a strong and effective user and carer movement for dementia’ it has been argued that ‘additional evidence is required to explore, test and evaluate’ claims for ‘the applicability of the recovery approach to dementia care nursing’ (Banerjee and Chan 2008: 52; Keady 2008: 72).
These concerns aside, in so far as I would defend a recovery approach, and identify it as a guiding principle for mental health nurses, it is because intrinsically patient-centred therapeutic interventions and principles are practised by mental health nurses irrespective of the Department of Health’s ambitions to effect a radical transformation of mental healthcare. It is striking, for example, that the much-trumpeted ‘Tidal Model’ of recovery, which is often held up as something approaching a qualitative shift in nursing philosophy, fails to distinguish itself, not only from the recovery approach per se, but from the axiomatic principles of therapeutic optimism that have long applied to mental health nursing (Roberts and Wolfson 2004: 39; Berger 2006; Buchanan-Barker and Barker 2005, 2008).
For instance, there is an emphasis in the literature on the need for mental health professionals to: ‘recognize the humanity of the people they work with’; ‘value their versions of events’; ‘appreciate the devastating impact of mental health problems’; and ‘believe that everyone can grow within and beyond the limits of their problems’ (Higgins and McBennett 2007: 854-845). Buchanan-Barker and Barker (2008: 93, 98), accepting that the prevailing view among mental health nurses is that ‘people should participate in, if not actually lead, their own recovery’, concede that, in as much as the Tidal Model of recovery has been endorsed it amounts to nurses ‘reclaiming their original caring vocation.’
None of this is meant to suggest that the recovery approach has not influenced or guided the principles of modern mental health nursing practice. Rather it is meant to suggest that it has not replaced them. That is to say, the ‘compassionate caring and genuine ‘nursing’’ that Buchanan-Barker and Barker (2008: 95) insist the recovery approach (‘Tidal’ or otherwise) requires of contemporary mental healthcare is readily evident in the everyday practice of mental health nurses. Such everyday practice, however, also highlights the problematic nature of ‘advocacy’ – not least because it is assumed to be co-extensive with ‘recovery’.
During my recent clinical placement, the one agent of ‘recovery’ notable by his/her absence from Community Care Assessments was the nominated patient advocate. In keeping with a recovery approach the role of religious, cultural and personal fulfilment are highlighted in the relevant documents produced for the purposes of specialist contributions to the assessment. Yet it is recognised that, just as assessing the care needs of clients should remain the preserve of social and healthcare professionals, the role of the advocate is to uphold the best interests of the client, regardless of whether those (ideally) self-determined interests coincide or conflict with the therapeutic relationship between nurses and clients or, crucially, a nurse’s specific responsibilities under the Mental Health Act (Clark and Bowers 2000; Edwards et al. 2000; Marriott et al. 2001; Hurley and Linsley 2006). This reveals the tension between nursing and advocacy, on the one hand, and recovery and service-user involvement on the other.
Because of the person-centred nature of their profession, modern mental health nurses are, by nature perhaps, advocates for – and partners in the recovery of – their clients. Nonetheless, adopting advocacy in the fullest sense entails recognising it as an essentially ‘socio-political activity’ (Mitty 1988). In that sense, for nurses to act as advocates beyond the duty of care demanded of them they must act independently of a profession that has been further compromised by the compulsion to extend its role in implementing new and draconian amendments to mental health legislation. Indeed resisting the trend to push mental health professionals into a more authoritarian role may be the prerequisite for the principles of recovery and service-user involvement to be given greater scope for development.
To conclude, I would argue that there is much evidence to support the claim that contemporary mental health nursing is guided by both the recovery approach and service-user involvement, but that attempts by the Department of Health and others to exploit or usurp the momentum underpinning these trends represents an unwarranted intrusion into mental healthcare that may well neutralise or weaken its more dynamic, independent initiatives. As it stands, official interpretations of a recovery-oriented approach to mental healthcare are, at best, innocuous and philosophically immature, and, at worst, disingenuous – even to the point of disguising an authoritarian agenda.
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