great debate, The

Mental Health Nursing,  Jul 2006  by Ramsay, Mike

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There has been a well-publicised divergence of opinion surrounding evidence, clinical approach and research emphasis, within psychiatric and mental health nursing (PMHN) for some time. Debate has raged across the pages of professional journals and appears to have served not only to illuminate the divergent topics and views but also to confuse the reader. What is the PMHN in practice to make of all this? Which perspective should we apply to patient care in light of such polarised views? What should PMHN students be taught, relative to this debate? This paper explains and explores this issue, allowing the challenges for practice and learning to emerge for discussion.

The 'Great Debate'

This debate has roots dating back, essentially, to the early/mid 1990s. The debate may mirror earlier opinions expressed in psychiatry dating back to the 1960's that considered the difference between traditional medical/disease approaches and a more social interactionist view.

The American context has been chronicled well by Grob (1991) who describes the polarised positions of two distinct groups of psychiatrists in the 1960s. Grob (1991) identifies the schism, which appeared between the psychoanalytic and psychodynamic school of psychiatry and the traditionalists who followed the medical model. These respective camps have been described as 'neo-Laingians' and 'psycho-chemists' (Hamilton 2001, p24). Grob's position, however, is more explicitly reflected in the assertion regarding the academic and clinical polarity of these two camps (Hamilton 2001).

In the emergence of a 'great debate' among PMHNs, in the United Kingdom - and other westernised societies - two main protagonists have taken centre stage, abetted by other authors, who generally support their viewpoints. These individuals are Professors Gournay and Barker. Gournay espouses evidence-based empiricism, multi-professionalism and biomedical approaches. Barker celebrates individualised, personcentred care models; valuing the unique human contribution of the PMHN. These standpoints, generally, represent the two sides of Grob's chronicle, thereby providing a sense of the historical rhetoric underpinning this newer nursing debate.

The debate can be seen as hegemonic in nature, with one side apparently claiming dominance over the other (Grob 1991, Grob 1998, Repper 2000). Challenges to this hegemony come from various authors as they declare the inability of either side to fully justify their stance as the providers of the sole, definitive worldview (Grob 1998, Repper 2000, Hamilton 2001). The attendant intellectual tennis persists with a recent a exchange on the pages of one journal being particularly noteworthy (Buchanan-Barker & Barker 2005, McKenzie 2005).

This theme is further extended by the thought that such polarised debate means disagreement, rather than commonalities, are explored (Repper 2000). The schismatic nature of the debate is at odds with the realities of practice of PMHNs, Hamilton (2001) argues. Whilst evidently not written for the purposes of contributing to this debate, one can also see the value of embracing both viewpoints from Altschul (1997) who describes the areas that PMHNs should be conversant in. These range from the biomedical prerequisites of the medical model, to the value of interaction and learning from one's patient (Altschul 1997). Altschul's view cuts across the debate as it draws on important aspects of either side and attempts to reconcile the two viewpoints. Altschul's latter point about learning from the patient is reflected in the Tidal Model's fourth commitment, which beseeches the nurse to adopt the role of apprentice - and to learn from the one in distress (Barker & Buchanan-Barker 2004).

If polarity, as a feature of the debate, is its weakness then it can be highlighted broadly summarising the main threads to each of the main players' arguments. The Gournay approach concentrates heavily on explanations and interventions derived from quantitative and trial-based research, often biomedical, and would appear to be the view that is in the ascendancy, given the drive towards evidencebased practice in modern nursing care. Gournay concentrates upon severe and enduring mental illness (Gournay & Brooking 1994) especially psychosis. Criticism of this is approach is that it can be seen as being an expert-led and disease-based approach, potentially disempowering those suffering from such problems. Such reductionist thought relegates therapeutic approaches to diagnosis, treatment and cure, however, mental health care has never proved to be this simplistic.

Barker's views about human relationships, recovery and user involvement are rooted in the traditional interpersonal theories and thinking of writers such as Peplau and Altschul and do not emerge from the randomised controlled trials so favoured by those who accept the biomedical approach. Barker's Tidal Model is a synthesis of these authors' thinking, focus groups with users and Barker's own earlier work. Whilst this may not meet the top end of the evidence hierarchy that opponents may seek, it certainly has the capacity to move open-minded PMHNs to re-evaluate their practice. Barker describes the Tidal Model as 'catholic' in nature, suggesting applicability across a wide range of psychiatric care groups (Barker 2001, p234). There is increasing evidence of applicability across such care groups (Tidal Model website 2006). The model may be described as providing nursing with a valid route towards practice-based evidence, the antithesis of the more publicised movement prevalent in modern nursing (Barker & Buchanan-Barker 2004). It is such an observation that demonstrates the essence of the polarity this debate has created.