This post is a version of a talk I gave to a class of practising mental health and addictions nurses. I wanted to tie together some high-level ideas that affect how we think about mental health and mental health nursing practice.
For that audience, I did not explicitly frame it as working with humanities, but it shows how we need humanities to think through what nurses do: it is there in the philosophical background to how we conceptualize (and organize hospitals etc) mind and body; it is there in the conclusion – locating mental health nursing squarely as relationships between people that happen in historical and cultural contexts – and by context, I do not mean a neutral, nice-to-know background but something that actively appears in, and shapes what passes between people.
Start with Descartes
“I have on the one hand a clear and distinct idea of myself insofar as I am a thinking, non-extended thing and, on the other hand, I have a distinct idea of the body insofar as it is merely an extended, non-thinking thing, it is certain that I am really distinct from my body and that I can exist without it.”
René Descartes, Meditations, 6th meditation, (Trans. Clarke, p. 62)
When I worked as a nurse on the psychiatric liaison team at the large Foothills Hospital in Calgary, it brought home to me how “mental” health is separated off from bodily concerns as I walked the corridors in response to consultations from medical and surgical units about suspected “psych” problems. A fair proportion of our assessments led to diagnosis of “adjustment disorder.” Put somebody in an unfamiliar environment when they are sick, make them dependent on other people, interrupt their sleep, give them mediocre food, cut them off from familiar routines and relationships, and mysteriously, they can start to feel depressed.
If we can blame Descartes for the mind-body split that is perpetuated in healthcare, we also have to think about how modern neurocentric thinking repeats and changes the picture. Separation is shifted to brain and mind, where the poor body is mostly still relegated to Descartes’ “extended thing,” the brain has special status as the centre of human life, and it is the turn of the mind to be relegated to mere brain-output. Hence the “brain-in-a-vat” hypothesis, beloved of some philosophers (and some cartoonists) where all that is essential about a person – what makes you uniquely “you” – is held in the circuits of the brain. If the brain can be kept alive in a vat, it can subsequently be downloaded (this relies heavily on computer metaphors…) into some new host (this bit is still to be worked out) where “you” will be reconstituted because, as I have heard it said by clinicians who should know better, “you are your brain.”
For $55 USD you can book yourself a place in a deep freeze in Scottsdale Arizona (good weather and airport access according to the website*) to have your brain cryogenically stored after death, ready to be uploaded into a new vehicle of some kind in the future – on the assumption that your brain contains “you.” (If you are not so sure about the neo-Cartesian, brain-in-a-vat model, you can opt for the pricier whole-body version).
*Alcor Life Extension: https://www.alcor.org/about/
Embodied Cognition
The computer metaphor of the brain where a central processing unit receives data, processes it using software programs designed for specific tasks, then sends out signals informing the body what to do is fundamentally wrong. It makes no sense that a metaphor based on a piece of human created technology should tell us how we function as evolved organic creatures. The counter view of embodied cognition is that cognition is a complex, dynamic process that involves the whole body. Of course, the brain is an essential part of the process, but so are our senses, our capacity for movement, for sense of ourselves in space, the potentialities and limits of our physical selves and so on. This way of thinking extends out into the environment, in the ways our responses to objects in the environment play a role in cognition and of course in our intersubjective responses, how our awareness and sense of other people and ourselves in relation to other people is an intrinsic part of cognition.
This way of thinking makes much more sense to me, if only for the obvious reason that in any encounter with a patient or client as an addictions and mental health nurse, you will never deal directly with their brain, nor they with your brain. Ironically, this organ that some people equate with our very self, is invisible to us and we are unaware of its actual physical presence. We relate, of course, through dynamic, complex interactions that rely on language (when we say mood or thought content, we rely almost entirely on words), facial expressions, bodily movements, patterns of behaviour over time, and then physical environments, socio-cultural environments (eg I am the nurse, with all that entails, and this other person is the patient), both implicit and reported – again through language. Embodied cognition gives us a way of understanding at a basic level what is going on in nurse-patient interactions.
Some theorists of embodied cognition draw heavily on the tradition of phenomenology, especially through Maurice Merleau-Ponty’s (1945/2012) focus on embodied experience. Phenomenology starts from the idea that human experience, as we all know it unavoidably, from the inside out, is important and worth taking seriously. Merleau-Ponty analysed perception as an embodied process, where we make sense of our world through our embodied presence in the world – not in the recesses of minds – or brains – that are merely carried about in extended bodies.
More recent work in embodied cognition has taken up a heuristic of “4Es” to explain the various interrelated ways in which we make sense of the world as embodied beings who are enmeshed in our environments and relationships (Newen et al., 2018). According to the 4Es model, cognition is:
Embodied – cognitions is “distributed” through body (eg. A nurse on an acute unit notices a patient pacing restlessly, they might read this as a cue to find out more what the person is thinking/feeling)
Extended – cognition “offloaded” on to aspects of environment (eg signs on the unit, computers for recording notes, storing clinical information, tracking medications)
Embedded – interactions with environment, physical and social (eg nursing on an acute unit, desk, locked door, professional/legal institutional expectations of nursing role, assumptions about diagnosis, how we read external signs of behaviours in relation to what we know about individual patients, diagnoses, drug side effects etc)
Enactive – cognition is linked to action, constant response and readjustment to environmental stimuli (eg. gamut of possible responses to restless patient, from staying put to engaging in conversation to redirecting to room to going outside etc etc)
Others have wanted to add other Es, including emotional, enculturated, or ecological – that is the drawback with coming up with a list. The addition I find the most useful for nursing is emotional, or dropping the E, affective. Antonio Damasio (2012), a neuroscientist, has argued that emotion is completely involved in cognition through what directs our attention and motivation towards what matters to us.
Mental Health Nursing
Cultures used to explain what we now think of as mental disorders in terms of spirit possession or a curse from God. For some communities, religious accounts still hold sway. In the early modern period, there was a lot of interest in melancholia as a common state that some thought came exclusively from the brain, while others saw it as an affliction of the whole person (Scull, 2015, p. 91). From around the 18th century institutionalization developed as a way of managing the mentally ill, rather than caring for them in families. Within that movement there were competing motivations, pure confinement and restriction, and so-called “moral cures” that took a more humane approach to human suffering.
By the late nineteenth century, with the rapid development of modern medicine, psychiatry emerged as a medical specialty. There were different currents in psychiatry, from seeking neurological solutions to mental problems, to emphasizing the categorization of mental disorders, and then the Freudian psychoanalytic tradition of the talking cure. Freud’s therapeutic approach was based on the assumption that mental and emotional problems in people’s lives were the result of disturbances in the hidden structures of the unconscious mind. Even if the idea of structures in the unconscious has faded outside of psychoanalytic circles, the idea of the “talking cure” has persisted: that there are therapeutic effects from talking through problems and difficulties with someone else who pays attention, does not judge, and can offer suggestions about different ways of looking at oneself, one’s thoughts, and one’s ways of relating.
Then there was behaviourism, focusing on outward behaviours in reaction against delving into the buried recesses of the mind. It too has an enduring influence, not least in Marsha Linehan’s Dialectical Behaviour Therapy (Linehan, 2020).
Other approaches persist, but all receded into the background for mainstream psychiatry once more effective pharmacological treatments for severe mental illness, notably schizophrenia, came on the market in the 1950s and then SSRIs for depression and anxiety in the 1980s.
Mental health nursing, which like nursing in general has been shaped by developments in medicine, shows traces of all of these traditions. While I was trained in an overtly psychodynamic environment of a therapeutic community in the UK, and I value very highly the therapeutic relationship, talking, aspect of mental health nursing – when I think back to working on acute care units, I can also see aspects of the asylum orderly, behaviourism, and of course the pharmacological. Our practices are often shaped by background beliefs or traditions that may never actually be stated, but are built into physical environments, policies, routines, languages, and practices. Where we work can be more or less closely aligned with what we consciously choose to believe about how we think we should work, and usually there will be a shifting mix of practices according to emergent situations, who you are working with on any given day, and even how you feel on a given day.
Mind/Body
None of the historical approaches to mental health nursing does a particularly good job of tackling the forced separation of mind and body in our thinking. The emphasis on taking people out of society and shutting them away in the asylum movement treated the body as something to be controlled, a kind of reckless puppet controlled by an out-of-control mind. Freud created an inner psychic world – we are subject to inexplicable moods, bad memories we can’t shake off, habits we know are not good but seem to come from a source outside of our conscious control – even though the detailed model is unprovable. All the variations that have followed contain an important truth about a need for communication and contact with others, and the lingering influence of our experiences, but inner worlds knowable only by saying what is on your mind still has a sense of Descartes’ thinking as the bottom line of human life. Behaviourism acknowledges significance in what our bodies are doing but does not satisfactorily connect that to the world of experience in which each person lives. In psychiatry, there was almost a sigh of relief with the turn to neurology and biochemistry, that psychiatrists at last could be real doctors treating real diseases in the brain with real chemicals. But for the reasons already discussed, the brain is not all there is to it (not to mention the very imperfect state of knowledge of brain functioning and effects of the wonder-drugs, which stubbornly only seem to work well for about a third of patients, and that is leaving side-effects out of account).
Now there is a combination of developments in mental health (and addictions) that are beginning to put together aspects of human life and human problems of living (as Phil Barker [2005], the creator of the Tidal Model calls them) in realistic and helpful ways. That does not mean to say that perfect solutions or treatments are suddenly going to appear, but that for nurses it does suggest ways of practicing that are not necessarily new, but can be put on a firmer foundation and given more purposeful application.
Out of the Vat, Into the World
Mostly in addictions research, an emphasis on epigenetics – the combination of genetic disposition with environmental influences – attachment theory, and understanding of neural pathways of reward and sense-of-security have laid the foundation for a historical and contextual way of looking at individuals’ “problems of living.” Problems come from somewhere – or a variety of somewhere – in time and place, and in relationships with others. It is a way of seeing compatible with 4Es theory, understanding how people develop patterns of response and coping.
Trauma informed care draws on these emergent ways of thinking – it comes at the old Freudian insight that past life events matter for present problems of living, but instead of making it about symbolic structures in the recesses of the unconscious, it is about actual events in people’s lives.
We need to pay more attention to integrative ways of healing, which includes what we call treatments and nursing care. Bessel van der Kolk’s (2014) book about trauma, The Body Keeps the Score has a lot about this – his subtitle is Brain, Mind, and Body in the Healing of Trauma.
Nursing as a profession is well placed to take a leading role in the future of mental health care. We are used to dealing with people in all kinds of environments (not in the controlled space of an office), dealing with them over time, being alongside them for the ordinary nitty gritty problems, not just what health professionals define as the Problem, we are flexible and eclectic in our approaches – perhaps even more so than we realize. What we have not been particularly good at in the past is connecting all these things and pointing out to ourselves and to others how this flexibility and eclecticism is not a weakness, it is a strength. It enables us to work with patients and clients more fully, more flexibly, and where they are starting from in their own lives. Not least, nursing knowledge inflected with awareness trained in the humanities can foster sensitivity to how histories and cultures shapes people’s experiences and the meanings they make for themselves.
References
Barker, P.; Buchanan-Barker P. (2005). The Tidal Model: A Guide for Mental Health Professionals. Brunner-Routledge.
Damasio, A. (2012) Self comes to mind: Constructing the conscious brain. Vintage.
Descartes, R. (2003). Meditations and other metaphysical writings (Trans. D.M. Clarke). Penguin
Linehan, M. (2020). Building a life worth living: A memoir. Random House.
Merleau-Ponty, M. (2012). Phenomenology of perception (Trans. D.A. Landes). Routledge.
Newen, A., de Bruin, L., & Gallagher, S. (2018). The Oxford handbook of 4E cognition. Oxford.
Scull, A. (2015). Madness in civilization. Princeton.
Van der Kolk, B. (2014). The body keeps the score: Brain, mind, and body in the healing of trauma. Penguin.
Nursing and Humanities 