Two weeks ago I was in Quebec City for the annual conference of the Canadian Association for Health Humanities (CAHH) – “Creating Space” – this was the 13th conference. It was fully (well, ~90%) in-person after a hybrid return in Calgary in 2022 and it was buzzing! There were people from health professions, humanities disciplines – artists, academics, students, and practitioners. The 60 or so presentations came in various forms – traditional presentations with question and answer, workshops, and performances. It was exciting to spend two days with like-minded people and with such a profusion of different ways of envisaging and producing meeting points between health and humanities.
Amongst sessions I attended:
bringing humanities into teaching professional identity to medical students, including visits to museums, and discussions of the history of psychiatry that included service users
a professor of literature in a US liberal arts college who asked her students how they thought about their bodies and was brought up short by one response, “a body that competes” – which led to an exploration of how college athletics, driven by financial incentives, had fostered an inflexible culture of individual performance that became almost cult-like in its grip on students’ lives
a musical performance of song, where the songwriter, a medical student, invited interpretive discussion then talked about her own creative decisions behind the songs
a program to support patient storytellers in shaping and telling their stories, where presenters included a woman who talked about being with her husband as he lived with terminal cancer
a performance of a recent – COVID-time – adaptation of Camus’ The Plague put on by medical students, followed by a discussion of what affected them as they rehearsed and performed
the opening plenary session by Lisa Boivin, who is a Dene artist and bioethicist who has just completed a PhD at the University of Toronto. She talked about the institutional resistances to working with visual media and storytelling as her PhD dissertation, with a lot of humour, and beautiful examples of her work combining traditional animal lore with collage, symbols of modern medicine, and even high fashion.
Just as powerful were the conversations at every turn about common points of interest. I talked with a social worker who said that she noticed in her discipline a similar phenomenon to nursing, that humanities are present but fragmented, without a common language to show their presence. With a palliative care nurse, I discussed Buddhism, mindfulness, and interconnection and how the Mahayana “two truths” tradition acknowledges the sharp corners of everyday life that mean we go on practicing. I met a UK surgeon who runs an international program teaching values based medicine, and we found common ground in the significance of dialogue and listening, from my side using hermeneutic research. Aside from that, we also worked out we had trained in our respective professions at St. Mary’s Hospital in London at the same time and had worked on the same surgical unit as junior doctor and newly qualified RN.
I realized properly for the first time why it is called “Creating Space” – a recurrent theme, across many different points of approach, was the scarcity and importance of making space to listen and be heard in healthcare, for patients and providers. Arts and humanities can create a host of different ways of stepping back, pausing to listen, looking in, reaching out, touching, witnessing, playing, that make us more aware of where we are, what is happening around us, to us, inside us, and giving us new ways to move. If you have not already been there, and if you have, look out for Creating Space 14 in 2024 – – location TBD!
“Nothing was delivered And I tell this truth to you Not out of spite or anger But simply because it’s true” Bob Dylan
When I was a student nurse at St. Mary’s School of Nursing in Paddington, London in the mid-1980s, my female colleagues wore a traditional uniform. It was a blue and white dress, over which they wore a starched white apron and starched white collar. The aprons and collars came from a hospital laundry. They wore a white cap which also came from the laundry, though each student had to put a thread through the material at the back to pull it into shape before wearing it. My uniform was a knee length white coat with short sleeves. It had epaulettes that displayed my status, one blue stripe for a first-year student, then two and three stripes as I moved through the program. I wore a pale blue shirt and dark blue tie under the white coat and grey trousers.
Both uniforms showed tradition, but not the same one. The women’s uniform unmistakably was in a continuous line back to the Victorian origins of modern nursing, the skirt length being the most obvious concession to modernity. Mine, however, did not suggest such a distant past, but did have a military inflection in the epaulettes denoting rank, and a formality of collar and tie. Short sleeves were a practical feature for giving bed baths and cleaning bedpans, and meant male nursing students would not be mistaken for doctors.
These ostentatious differentiations of rank and discipline have long since been swept away by the universal adoption of scrubs. Student nurses in Canada still sometimes have a “capping ceremony” as part of their graduation, which is a symbolic throwback in the name of tradition, not a part of everyday dress. The nurse’s cap seems to have some lingering symbolic weight. A Google search for “nurse emoji” – a quick visual check on where the culture is at – brings up a lot of images of faces with caps, or cap-suggestive patches on their heads, though also images of generic “woman health worker” – capless, but resolutely female. Scrubs on the other hand, appear to be free of tradition, they have a neutral air, entirely a matter of practicality – but they cannot be outside of history or free of symbolic valences. They speak of scientific, technical omnivorousness that merges with bureaucratic techne and presumed objectivity. They rub out distinctions between the sexes, or of rank, even in many cases of function, unless colour coded to separate surgeons from cleaners, or nurses from physiotherapists. Everyone is only too aware of the hierarchical reality of hospitals, like a medieval stacking of angelic orders, but its signalling has become a lot quieter.
“A symbol is something that facilitates recognition, and the dearth of symbol is a characteristic feature of the historical moment in which we find ourselves.” Gadamer (1987) p. 74
It is not hard to seize on tracks of tradition in relation to nursing, but it also does not take long to find different claims to nursing tradition. It is harder to settle on one uniform (pun intended) tradition. Is it centered on compassion, bedside practice, problem solving, social justice? Will it be found in some essential value or in practice, in hospitals or homes, or university departments? A cursory search for articles using nursing and tradition in their titles shows a range of usages. Some are about nursing in relation to a tradition of something else, where the something could be a cultural or religious tradition; or some element of nursing, like the tradition of community nursing. Some are personal accounts of taking part in activities like capping ceremonies that are consciously about connecting with tradition – though that only circles back to the question of what tradition?
Arendt and Gadamer, those two very different students of Heidegger’s, were both concerned with tradition in the second half of the twentieth century. Arendt, Jewish refugee from Nazi Germany, whose major work (1968) was an attempt to anatomize totalitarianism, said that tradition had been ruptured completely (1961/2006), meaning the tradition of Western political thought. She wanted to work through what happened and concluded, not least from her own experience, that totalitarianism (of fascism and communism) was such a radically new and distinct phenomenon that there was no returning to tradition as if nothing had happened. Gadamer, the German philosopher who pursued his career quietly during the Nazi era, not personally supportive of the regime, made tradition a theme of his major work Truth and Method (2004), published in 1960. He recognized the fragmentation of tradition, which was already a theme of literary and artistic modernism before the 1930s but argued that nonetheless we can only understand ourselves in the world from out of tradition. It provides the “horizon” – to use one of his favoured words – of our view of the world. Fragmentation may be a feature of tradition but it does not mean that tradition is lost as the vector of transmission of understanding from past into present. Arendt’s thought was political and outward looking while Gadamer’s was philosophical and unpolitical. Perhaps there is no need to choose between their two positions – rupture or reconciliation – because they are in effect looking at different aspects of tradition. For thinking about nursing and tradition, their ideas ready us to look for signs of rupture and fragmentation – and continuity that includes them.
Is there a tradition of nursing as such, beyond composite strands of practice or haphazard personal experiences? Florence Nightingale seems like a good bet for the founder of a tradition of modern nursing, building on, but different to previous, less systematized caring roles. According to Arendt, tradition needs a foundation point, by which later participants in the tradition continue to orient themselves and their sense of meaning and identity. Notwithstanding criticisms of Nightingale against contemporary standards, it is hard to think of any other person that could come as close as she does to representing the foundation-point of modern nursing. Tradition, however, is never the automatic transmission of an unchanging foundational moment. To believe that it can be marks out some upholders of traditions, but even the most purist is in denial of their own selectivity and distortions (think of Second Amendment absolutists in the US – they have no interest in any other amendments to the Constitution, they gloss over the awkward fact that an amendment by definition is counter-absolutism, and they ignore any changes in social context – not to mention firearms technology – since 1791). It is the belief in the foundation that grounds tradition, not unchanging facts. To that extent, if Nightingale seems like a foundational figure, then she is. But founding what?
The ground of tradition was shifting under Florence Nightingale’s bed, from where she continued to influence policy in her later years, in her own lifetime. What she had founded, what she thought she had founded, was drifting away from her vision. Bostridge (2009) in his biography discusses the push to professionalize nursing, which as we know was successful – all modern nurses partake in that tradition – against Nightingale’s objections. It diverged from her religiously-inspired sense of nursing as vocational, determined by the movement from inner self to outer world, not external regulations. Yet that too is part of nursing’s image and self-image down to the present. When Nightingale turned her attention to the health of Britain’s overseas imperial armies, and compiled cutting-edge pie charts to present epidemiological evidence, did she see herself as “nursing”? We are happy to assume so, for it gives us a foundational moment not only of bedside caring, but also statistical research, population health, and policy-making.
Nursing tradition is more bound up with modernity than it sometimes seems, certainly more divided and multiple than can easily be decided. Modern nursing emerged in the wake of modern medicine, in some ways compensating for the diagnostic algorithmic mindset of scientific medicine, yet also an active participant. It shares, though differently, the same tension between aggregation and individuation as medicine. Nursing tradition is only typical of tradition in the industrial era in that it is fragmented, partial, contested.
“Nothing is better, nothing is best Take care of yourself* and get plenty of rest.” Bob Dylan
*The official Bob Dylan website gives “Take heed of this…” but he sings “Take care of yourself…” on the first of three takes on the 2014 Bootleg Series set, which is the version included on the 1975 Basement Tapes album. It seems more appropriate in this context.
References
Arendt, H. (1968). The origins of totalitarianism. Mariner. Arendt, H. (2006). Between past and future. Penguin. Bostridge, M. (2009). Florence Nightingale. Penguin. Dylan, B. (1968). Nothing was delivered. http://www.bobdylan.com/songs/nothing-was-delivered/ Gadamer, H.G. (1987). The relevance of the beautiful and other essays. Cambridge University Press. Gadamer, H.G. (2004). Truth and method. Continuum.
Simone Weil’s most famous essay is entitled “The Iliad or The Poem of Force,” written in the late 1930s and first published in December 1940 when France had been conquered by Nazi Germany. Weil admired Homer’s Iliad as “the purest and loveliest of mirrors” for its truthful depiction of “force” as a constant factor in human affairs, which she defined as “the x that turns anybody who is subjected to it into a thing”(Weil, 2005, p. 183).
Everyone, in Weil’s view, is subjected to force, even those who exert power over others since they are blind to how they are themselves altered by force and to the possibility of their own destruction. It is a very different, and darker, view of power than fashionable algorithms of victimhood and oppression that are tacitly based on an assumption that if only oppressor group A has its power taken away then victim group B will be set free. Weil was not persuaded by an easy calculus of liberation. Coming from left wing circles in the 1930s, more anarchist than Marxist-Leninist, she was already well-aware that the Russian revolution, had not set anybody free, least of all the workers. She worked in car factories in Paris for a while and found the experience dehumanizing, because of the relentless, exhausting physical demands, and for the way roles of workers, foremen, and managers locked everyone into an oppressive system. She was keenly sensitive to injustice, to the denial of human beings of opportunities to flourish to their best capacity, but did not indulge in fantasies of deliverance from suffering as such, which is bound up with natural limits to human existence.
In her analysis of the Iliad, and in the world around her in 1939-40, it was not hard to find examples of force as the violence of war and conquest. It would be a mistake, however, to lose sight of her point about the pervasive presence of force as that tendency for people to become indifferent to the suffering of others. With this in mind, she makes a point, almost in passing about the relation between force and prestige:
A moderate use of force, which alone would enable man to escape being enmeshed in its machinery, would require superhuman virtue, which is as rare as dignity in weakness. Moreover, moderation itself is not without its perils, since prestige, from which force derives at least three-quarters of its strength, rests principally upon that marvellous indifference that the strong feel towards the weak, an indifference so contagious that it infects the very people who are the objects of it. (Weil, 2005, p. 199)
She argues first that we get into trouble with force, which is inevitable, when we lose a sense of proportion. The best we could do would be to strive for a sense of balance in relations with others, yet force by its nature seeks expansion and domination. But then she adds that even given moderation, force has another trick to play through the love of prestige. Since prestige is a question of how people look in others’ eyes, she is suggesting that the appearance of strength is seductive and can entice attention away from the suffering of others even among those who themselves are subject to the strong. Donald Trump’s appeal to millions of voters in the US, the fervour of his supporters, even in the face of his demonstrable lying and attempt to overthrow an election, look like a case example of Weil’s point. There does seem to be some element of reflected prestige that people feel in their vocal support of Trump, regardless of whether his stint as president brought them any tangible benefits at all.
II.
There are some who are in darkness And the others are in light And you see the ones in brightness Those in darkness drop from sight. (Brecht, 1931)
When I re-read Weil’s essay recently, her comment about prestige struck me in a new way. I thought about how prestige operates in health care professions and how it can cover up degrees of indifference towards the weak, in Weil’s phrase, or in more contemporary terms, towards patients, those in need of help, and the marginalized. And how layered, enfolded depths of shadows thrown by the light of prestige exist too between and within health professions.
Modern medicine as a global entity carries a lot of prestige. It is not hard to see why. The childhood mortality rate has plummeted over the past 150 years, notwithstanding inequalities that still exist (see a chart that shows just how dramatic the drop has been here: https://ourworldindata.org/child-mortality-in-the-past). The benefits of modern medicine are so great they are hard to keep in sight. Even people who are critical of “biomedicine,” when it comes down to it are often more concerned about problems of distribution and access than the entity itself. Nursing is carried along in its wake, catching some rays of reflected glory. In the world of healthcare, nurses have less prestige than doctors, but within nursing, more technology-rich, higher acuity specialties like ICU or emergency nursing have higher prestige than those like mental health or geriatric nursing, that are mostly unwired and slower paced with less obviously lifesaving outcomes. Registered Nurses have more prestige than Licensed Practical Nurses, who have more prestige than nursing aides. Unmistakeably, as one moves up the steps of that pyramid, there is less contact with bodies and body fluids, and more contact with technology.
ICU nursing is highly complex, working with patients with the most extreme conditions still compatible with being alive. Of course. But Weil’s point was not that prestige cannot be associated with people using their strengths to beneficial ends in an instrumental sense. We all want the best biomedicine can provide when we need it.
Her point about prestige, however, does reveal something about how we chronically run into communication problems in healthcare. Talk to anyone who has had a lot of interactions with healthcare professionals, and they will invariably be able to give you vividly different accounts of what it feels like to be heard and cared for or treated indifferently (even when “the treatment worked,” and they are profoundly grateful for it). Most of the time, communication problems result in nothing more than unneeded frustration or anxiety, and sometimes, errors of losing sight of people in the shadows of prestige have disastrous consequences.
And as Weil noticed, those basking in prestige use it without even noticing they are doing so. It feels natural. Definitions of “prestige” in contemporary usage have in the Shorter Oxford Dictionary: “respect, reputation, or influence derived from achievements, power, wealth, etc.” and in Merriam-Webster: “1. standing or estimation in the eyes of people: weight or credit in general opinion. 2: commanding position in people’s minds.” These attributes may come about from individual achievement, or at least a powerfully projected self-belief, or they may be prestige by association with a group or, let’s say, a profession. Too often, we make assumptions about what patients need or want or ought to want without taking the time to ask them. We rely on the prestige of a title and location to set the standards for communication and unwritten rules that patients are expected to follow – and for the most part, they quickly pick them up and follow them.
III.
Prestige is about seeing and being seen. It is not entirely in the eye of beholder, but neither is it entirely under the control of the person with the prestige. It arises in chiasms of appearances and perceptions, projections and interpretations. Etymologies bring out the importance of prestige as a way of seeing and being seen. There is an association with magic and illusion, from the French, “prestige (16c.) “deceit, imposture, illusion” (in Modern French, “illusion, magic, glamour”), from Latin praestigium “delusion, illusion.” Related is “prestidigitator,” a nimble-fingered magician or juggler, related to the Italian “presto” meaning “quick.” One thinks of the dexterity of the surgeon and at the same time of fluttering thumbs shoring up self-projections on social media.
IV.
Those are a few thoughts sparked by Simone Weil’s comment about prestige in relation to healthcare. Her comment about the relationship of prestige to force does have application to how we look at layers of difference in healthcare and more importantly at the communicative space between professionals and patients. Her view that the Iliad is a mirror is important. She is saying it can show us things about ourselves that are there, whatever we might think. That is different from naming a problem to be fixed or from claiming to have special insight into both problem and solution, which leads to moral arrogance. I have no suggestions except to try to notice when and how prestige shows up, like magic! We are all on the hook of force and of prestige. We can try to catch it in our environments (not hard to find in academia) and most of all in ourselves. That is Weil’s point. It is not a bad attitude that we need to eliminate, but an aspect of force that is always there in human affairs. To live with it as well as we can seems like a modest aim, but it is a lifelong practice.
V.
Imagine a corporate institution, let’s say a university, deciding that prestige was a questionable thing, and then appointing a Director of Humility to organize humility workshops for all. Given the premise, what a prestigious post that would be!
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).
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.
Simone Weil (1909-1943) was a powerful thinker of the 20th Century, who declared that philosophy, “(including problems of cognition[1], etc) is exclusively an affair of action and practice” (Weil, 2015, p. 362). She is often described as a mystic, which is at least partly true, as long as one remembers that mysticism can have a phenomenological intensity of attention to the vibrant actuality of the here-and-now. (See for example Meister Eckhart’s interpretation of Mary and Martha meeting Jesus, which he turns upside down, making the practical Martha the true hearer. See also the Zen tradition, starting with Dogen’s Instructions to the Cook).
Philosophy-as-action is one reason why Weil ought to be of great interest to nurses, though she is barely mentioned in the nursing philosophical literature. Another reason is that one of the themes in her thinking as “affliction” which is close to suffering, in its usual senses, but for her meant degradation of human dignity to the point of “total humiliation” (Weil, 2005, pp. 90-91).
She usually associates affliction with outside forces, whether of nature, as in a life-altering disease, or harsh working conditions, or political oppression, though it also depends on a person’s response to external force. “The degree and type of suffering which constitutes affliction in the strict sense of the word varies greatly with different people. It depends chiefly upon the amount of vitality they start with and upon their attitude towards suffering” (Weil, 2005, p. 90). Affliction is connected with compassion by way of recognition that the potential for affliction is always present, since we are subject to external forces and ultimately to the force of nature in the form of death. Hence, “Compassion is the recognition of one’s own misery in another,” (Weil, 2015, p. 209) yet “In order to feel compassion for someone in affliction, the soul has to be divided in two. One part absolutely removed from all contamination and all danger of contamination. The other part contaminated to the point of identification” (Weil, 2015, p. 97).
Her way of talking about affliction and compassion in these quotations begins to give a flavour of her writing. She is challenging in the demands she makes on the reader – misery and contamination are not words one expects to find in contemporary sanitized accounts of a human phenomenon like compassion, which Weil sees as a vexed, conflicted thing for the very reason it is human phenomenon.
That is one of the reasons I suspect Weil does not feature in nursing literature. As sympathetic readers from T.S. Eliot to Robert Zaretsky (2021) have pointed out, you have to be prepared to think against her as much as with her. T.S. Eliot wrote, “I cannot conceive of anybody’s agreeing with all of her views, or of not disagreeing violently with some of them” (Eliot, 2002, p. viii). There is no such thing as a Weilian, like a Marxist or a Foucauldian, and she would have abhorred the very thought of such a being. This inbuilt resistance to conformism grants her thinking an incommensurability that is frustrating and moving at the same time.
Another reason she has not been more discussed is that her work was almost entirely published posthumously and her ideas are scattered across articles, essays, notebooks, and letters. It makes it difficult at times to grasp even her most important concepts as she says different things about them in different moments and contexts. She moved from an idiosyncratic near-anarchist position in the 1930s to a profound religious belief in the last years of her life. Either or both of those are enough to deter many readers. And yet, like many others, I find a compelling quality to her work that is utterly defiant of the orthodoxies of her own lifetime and of the present moment.
This is a somewhat scattershot introduction to Simone Weil’s thinking – I had started out intending to discuss one of her observations about force and prestige, which I have not even mentioned yet. I wanted to give a semblance of an introduction with some suggestion of why I am writing about her on this site, about Nursing and Humanities. I will come back to the prestige thing!
References
Eliot, T.S. (2002). Preface. In S.Weil, The Need for Roots. Routledge.
Weil, S. (2005). An Anthology (S. Miles, Ed.). Penguin.
Weil, S. (2015). First and Last Notebooks: Supernatural Knowledge. Wipf & Stock.
Zaretsky, R. (2021). The Subversive Simone Weil: A Life in Five Ideas. The University of Chicago Press.
[1] An intriguing aside – was Weil an enactivist avant la lettre?
Nursing and Humanities 