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My family have used mental health services for three generations. I experienced my first hypo-manic episode in 1981 when I was writing up my doctoral thesis. During the past twenty-four years I have had sixteen episodes that have led to hospitalisation.
I first met Professor Phil Barker in 1983 when he had just taken up the Chair of Psychiatric Nursing Practice at Newcastle University and I had just launched myself as a User Consultant under the name of Section 36. During his ten years in Newcastle we worked on several projects and spent many hours sharing our views on user empowerment, self-management and recovery. I felt privileged when he asked me to comment on the Tidal Model in its early stages. I feel equally privileged and delighted to speak about the Model today.
Phil and Poppy Buchanan-Barker co-wrote this Guide on the Tidal Model for Mental Health Professionals. They have asked me to consider whether or not the Tidal Model helps service users on their recovery journey. I will do this largely by reading quotations taken directly from the book. Before we can do this I feel it necessary to look at the meanings of recovery.
Elements of Recovery
The Chambers 20th Century Dictionary definition of ‘recover’ is ‘to cure’. In the context of mental health ‘recovery’ is generally not accepted as being synonymous with ‘cure’. From her work with service users Repper observed that:
‘Recovery does not mean that all suffering has disappeared, or that all symptoms have been removed, or that functioning has been restored.’
Pat Deegan, a clinical psychologist with a late childhood-diagnosis of schizophrenia recognized ‘recovery’ is not a ‘cure’ but sees no reason for despair.
‘ Being in ‘recovery’ means I know I have certain limitations and things I can’t do. But rather than letting these limitations be an occasion for despair and giving up, I have learned that in knowing what I can’t do, I also open up all the possibilities of all I can do’.
Acceptance is a key factor in the recovery process. Again, Pat Deegan notes:
… an ever-deepening acceptance of our limitations. But now, rather than being an occasion for despair, we find our personal limitations are the ground from which spring our own unique possibilities. This is the paradox of recovery…that in accepting what we cannot do or be we discover what we can be and what we can do … recovery is a process. It is a way of life. It is an attitude and a way of approaching the day’s challenges’.
Simon Champ, a prominent Australian mental health activist, also views recovery as a lifelong process which requires important changes in ‘self’ :
I have come to see that you do not simply patch up the self you were before developing schizophrenia, but that you have to actually recreate a concept of who you are that integrates the experience of schizophrenia. Real recovery is far from a simple matter of accepting diagnosis and learning facts about the illness and medication. Instead, it is a deep searching and questioning. A journey through unfamiliar feelings, to embrace new concepts and a wider view of self. It is not an event but a process. For many, I believe it is a lifelong journey’.
Despite painful times Anthony believes that we should always be hopeful as the recovery period brings with it periods of personal growth.
‘ Recovery is described as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and/or roles. It is
a way of living a satisfying, hopeful and contributing life, even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.’
The Tidal Model
In my view, hospitalisation is a form of ‘containment’ rather than a ‘therapeutic process’. Service users are expected to ‘entertain’ themselves by talking amongst themselves, watching television, sitting in the smoking room, playing pool or attending occupational therapy. Mental health nurses need to break out of the mechanistic routine, which restricts their dialogue with service users.
When the Tidal Model is in use, each service user undergoes a holistic assessment with a specially trained mental health nurse. All experiences are accepted as ‘true’ and not dismissed as ‘hallucinations’ (for example). The mental health nurse discusses with the service user what the person feels may have caused their admission and what they feel they need to do to address these problems. Every service user receives a copy of their assessment, which is recorded in their own words.
This process helps to build up trust between the service user and the mental health nurse. They form a partnership whereby the nurse supports the service user through the recovery process. The emphasis is on ‘caring with’ rather than ‘caring for’. The attitudes, beliefs and expressed needs of the service user are accepted at each stage of the recovery process. The user knows that the advice of the nurse may not necessarily be accepted.
‘The person’s story lies at the heart of the Tidal Model…..The Tidal Model is a philosophical approach to the recovery or discovery of mental health. It is not a ‘treatment’ model, which implies that something needs to be done to change the person. Instead the Tidal Model assumes that the person is already changing, albeit in small and subtle ways….In the Tidal Model ‘water’ is used as the core metaphor.
Following the Holistic Assessment the service user enters into a period of ‘Individual Care’ and ‘Group Care’. One to one Individual Care sessions are arranged on a daily basis.
, The process of Individual Care involves developing a collaborative relationship within which the person can begin to develop awareness of the resources that (s)he currently possesses, which might be used to address the problem of living; what additional resources (support) might be needed; and what needs to happen next, to begin to move off on the recovery journey.
Three forms of group work provide a supportive social structure for the Individual Care:
The Discovery Group
The Information Group
The Solutions Group
The Discovery Group brings together service users to discuss a set of pre-prepared questions that aim to generate simple reflection and light-hearted as well as meaningful conversation. Two members of the professional team normally lead the Discovery Group, but over time group participants may take turns in leading the session.
‘The Discovery Group therefore aims to provide a setting within which people might experience a boost to their self-esteem, reclaiming in the process some of the personhood that has been lost, either as a function of the experience of mental ill-health, or of the experience of psychiatric care and treatment, or both. The Discovery Group provides an opportunity within which members may reclaim and develop further their ability to share with others, on a simple yet mutually rewarding basis, through simple question and answer sessions’.
‘The Information Group aims to provide ‘practical’ advice to people about services they are presently using, or services that they might consider using. This advice is delivered in ‘plain’ language, preferably in an entertaining, interesting or otherwise accessible way’.
‘Francis Bacon’s dictum that ‘knowledge itself is power’ is the primary motivation behind the Information Group. Without knowledge we are not only ignorant, but also powerless.’
‘The people who lead the Information Group should have in-depth knowledge of specific topic areas who can comfortably answer intelligent and searching questions from people in care and perhaps also staff members.’
‘There are an infinite number of possible topics for the Information Group, but experience of the Tidal Model projects around the world suggests that the following are most popular:
Current care and treatment
Psychotherapy and counselling
Nutrition and well-being
Social security benefits
Specialist mutual support groups
Housing and supported accommodation.’
‘The potential contribution to Information Groups that might be made by user/consumer-advocates, psychiatric survivors, or others who have navigated the recovery journey, is inestimable. Apart from special knowledge of the recovery journey, such people come carrying a huge beacon of hope. Their very presence signals the ‘possibility’ of recovery, but also frames this within a realistic storyline.’
‘The Tidal Model emphasises the necessary search for solutions. Given that the problems of living which people experience determines the need for help, both lay and professional, it follows that we should be focused on solutions to these problems.
However, unlike some other therapy models or treatment systems, we do not believe that the professionals have the answers to the person’s problems……the Tidal Model needs to be tailored to suit every person in the programme. Everyone needs a theory of their own to explain how they got there, and how they might move off again, back onto the ocean of experience. So the pragmatic focus on finding solutions is carried over into the work of the Solutions Group.
The Solutions Group is part of the ‘heavy work’ of care-helping people to learn more about themselves and their problems and instilling hope in the recovery process.
The Solutions Group is highly practical and focuses on conversations about change that is already taking place within individual members. What subtle examples of change is the person already becoming aware of? Alternatively the group will focus on conversations about what change might be like; how participants will know change when they encounter it.’
The Tidal Model focuses upon the unison between the service user and the professional helper. However
‘…..the Tidal Model is an anti-professional approach to mental health care . It does not believe that there is special knowledge concerning mental health, known only to the professional, that can bring about the resolution of serious problems of human living, or speed the person’s recovery. The Tidal Model proposes that only the person can ever own such knowledge……..However, the person needs the sophisticated support to plan and execute the process of recovery.
Finally the book offers us ‘Ten Commitments’ which distil the essence of the practice of the Tidal Model.
‘Value the voice: the person’s ‘story’ is the beginning and endpoint of the whole helping encounter. The person’s story embraces not only the account of the person’s distress, but also the hope for its resolution. This is the voice of experience. We need to guard it well, as the voice begins to help the person to make her or himself anew’.
There is no doubt in my mind that the Tidal Model promotes the process of recovery. The key features that set it aside from other models are:
It is based on the personal stories of service users.
It is based on ‘caring with’ rather than ‘caring for’.
It is a holistic model of care.
It recognises that knowledge is ‘power’.
It focuses upon solutions rather than problems.
It promotes self-management and empowerment.
It promotes the concept of ‘therapeutic experience’ rather than containment.
In this sense, the Tidal Model is truly groundbreaking.
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