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Anglo-American nursing theory, individualism and mental health care: a social conflict perspective
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International Journal of Nursing Studies 41 (2004) 21–28
Anglo-American nursing theory, individualism and mental health care: a social conflict perspective Kevin Leighton* Tees and North East Yorkshire N.H.S. Trust, UK Received 11 October 2002; received in revised form 6 February 2003; accepted 6 May 2003
Abstract This paper uses social conflict theory to reconsider the relationship of American nursing theory and individualised mental health care in the UK. It is argued that nursing theory has developed within a context of ‘American dream’ individualism, and that this ideology may be problematic for some UK mental health nurses and service users whose values and beliefs are those of different socio-political traditions. The paper explores the historical background of Anglo-American nursing theory, and then uses conflict theory to generate challenging propositions about the culture bias and political instrumentality of individualised care in mental health settings. In so doing, it critiques the ‘scientific’ and ‘liberal’ preconceptions of individualised care which have dominated mental health care policy for over a decade. r 2003 Elsevier Ltd. All rights reserved.
And Department of Health (1995):
1. Introduction: individualism and community mental health care Individualised mental health care uses a multidisciplinary assessment, planning, treatment and evaluation process to focus on the individual’s particular problems and potentials (Marks-Moran, 1992). It is applied to the whole person, rather than isolated behaviours, symptoms, or diagnostic labels, and it is distinct from institutional regime care, the personal values of the carer, or professional assumptions (Richman and Barry, 1985). It is a keystone of mental health care in the UK, as the following excerpts of official policy documents illustrate. Department of Health (1994): The hallmark of a quality service is that it is responsive to peoples’ individual needs y As approaches to care become increasingly centred on the individual, the mental health nurses contributionywill be critical to successy The Primacy of the Individual y Nursing responses and interventions should be founded upon a sound understanding of the individuals in their care (pp. (i)-18). *Corresponding author. 1 Bielby Close, Newby Farm Road, Scarborough, N. Yorkshire. YO12 6UU, UK.
Psychiatric nurses work with individuals suffering from varying degrees of mental illnessy.They have a wide variety of roles, but the main focus of their work is to assess a specific individual’s needs and recommend the appropriate treatment, therapy or care package. (p.11). Surprisingly, although individualised care is central to UK mental health policy it has rarely been targeted within the sweeping critiques of nursing theory and mental health policy which have emerged in recent years (McKenna, 1997; Hadley, and Clough, 1997). It is however the objective of this paper to examine the historical development of individualised mental health care, using a sociological perspective which casts considerable doubt on the background and efficacy of this pre-eminent care approach. Social conflict theory is chosen because it is primarily concerned with the critical study of dominant ideologies and social structures, and has the capacity to generate challenging propositions about the political nature of ‘official’ mental health care approaches. It therefore provides a socio-political analysis which could make a useful contribution to the explanation of nursing theory and community mental health care problems (Robinson, 1991; Perry, 1991).
0020-7489/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2003.05.001
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On this basis, the paper explores the socio-historical development of individualised mental health care, looking at professional ideologies, the social context of American nursing theory and the exportation of American nursing theory to the United Kingdom. This historical account is then re-framed within social conflict theory to generate a number of propositions about the political implications of individualist ideology, and the powerful biases that individualist ideology has imparted to mental health care policy.
2. Professional ideologies and individualised care One source of individualised care principles in mental health policy is the traditional pre-eminence of psychiatric diagnosis and treatment in mental health care. Science and technology, specialist skills, elite qualifications, legal powers (e.g. under the Mental Health Act, 1983), and a certain professional mystique afforded by complex medical concepts, obscure language and ‘magical’ forms of treatment such as drug therapy, have together allowed the medical profession to establish a leading role in the care and management of mental health service users (Perry, 1991). The medical approach has also tended to reinforce images and preconceptions of individual pathology as a main cause of mental disorder; such as congenital weakness, bio-chemical dysfunction, disease, organic degeneration and innate personality type problems, while social dimensions of explanation and ‘treatment’ have been comparatively marginalised. Ham (1992) has said: y.it is the individualistic, functional fitness, curative approach which is the most influential. This approach has been characterised as the medical model of health y justifying the pre-eminent position of the medical profession in health matters y (p. 225). Clinical psychologists and psychotherapists have similarly supported the individualist concept of care in mental health settings, with theories and models of childhood trauma, low IQ, poor child rearing practices, maladaptive ‘ego defences’ and cognitive distortion, while even family therapists and psychiatric social workers have largely disconnected their work from any social structural analysis which could offer more fundamental explanations of stress, alienation, anger and psychosis (Tudor, 1997). As somatic, Rogerian, psychodynamic, behavioural, cognitive and family systems therapy have all appeared largely individualist or asocial in principle, this may be one important reason why mental health nursing has remained curiously dovetailed with the individual functional fitness model.
3. Nursing theory and individualised care Many of the paradigms of nursing theory were developed in the United States between 1950 and 1975 (e.g. Peplau, 1952; Weidenbach, 1964; Orlando, 1972), including the evolution of Individualised Patient Care (IPC) principles. Taking their lead from contemporary social interactionists and psychotherapists such as Rogers (1961) and Becker (1963) a number of theorists proposed concepts, ideas and methods which collectively predicated IPC—the self-actualising nature of human action, the role of nurse as enabler, the holistic assessment of individual problems and potentials and the analytical nursing process (Choi, 1989). It is this American work which has heavily influenced mental health nursing in the UK, including the adoption of individualised care policy (Barker, 1994; McKenna, 1997), and it is accordingly of some interest to investigate the social context and origins of these theories which now predicate the individualist ethic in UK mental health nursing. 3.1. Multicultural society The United States has long been considered a cosmopolitan society which can trace its modern multicultural identity to the massive influx of immigrants received during the 18th and 19th centuries (Bromhead, 1988). Most of these immigrant groups were searching for greater political freedom or increased economic opportunity; an historical quest which was eventually imbedded in US culture as the ‘American Dream’ of individual aspiration and equality of opportunity (Smith, 1989). No wonder perhaps, that many American nursing theorists went on to assume individualism as a fundamental premise of their work, based as it was on the day-to-day norms of their society. 3.2. Affluent society The United States enjoyed an economic ‘boom’ in the years which followed the Second World War, as renewed domestic and foreign demand met massive production power recently freed from the war effort (Smith, 1989). This prosperity, which continued into the 1960s, enabled many US citizens to attain something of the American Dream, as material acquisition, business opportunities, career development and status achievement all combined to reinforce the ideology of individual effort in a rewarding society. On this background, a reinforcement of individualism in nursing theory may have occurred at just the time theorists were seeking to establish the basic concepts and propositions of their work. Griffith-Kenny (1986) has pointed out:
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In the 1960’s, as the scientific approach to nursing evolved, nurses began to question the purpose of nursing and the value of the traditional, intuitive nature of nursing practice. Nurses discussed and wrote about their philosophical bases for practice, and gradually arrived at a consensus that the common elements include the nature of nursing (actions), the individual recipient of care (client), society and environment, and healthy. (p. 5).
3.3. Conservative consensus Although American culture is in many ways disparate, with a federal government, multicultural population, wide-ranging territories and diverse geographical division of labour, it is underpinned by a conservative consensus which stresses certain shared and abiding values; including the rule of law and the rights of the individual under that law. This political consensus has also found its way into the assumptions of US nursing theory, where concrete references to alternative social systems or personal ideologies are comparatively hard to find. Griffith-Kenny (1986) has defined this point of view: Society is composed of individuals, groups, families and communities with common goals and values. Society encompasses the sociocultural, economic, political, and environmental forces and changes during reciprocal interactions and relationships. (p. 10). The assertion of conservative consensus values in the United States reflects the intolerance of American culture for radically alternative ideologies such as ‘extreme’ liberalism or traditional socialism. Indeed, socialism has appeared to be almost entirely antipathetic to American culture, even during periods of dissension; a phenomenon which can perhaps be traced to the original motivations of many early settlers, who were often leaving behind totalitarian, inflexible or ruinous societies where politicians were frequently reviled (Bromhead, 1988). Because, therefore, most US nursing theorists have assumed a social consensus about the merits of individualist ideology in their society, they have not acknowledged the possibility of fundamental conflict between holders of disparate ideologies, and they have failed to incorporate this concept within their overall nursing paradigm. This has diminished the concept of social action to American Dream ‘self-actualisation’, and has largely prevented US theorists, policy makers and practitioners exploring a wider range of lifestyle alternatives within mental health therapy (e.g. communal and pastoral ways of life).
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4. Science and American nursing theory It has been argued that US and UK nursing theory adopted a generally scientific methodology as its ‘role model’ because this provided a means to academic respectability at a time when nurses were attempting to establish their own approach and subject matter, independent of their historical reliance on the medical model (Tolley, 1995). In rejecting more radical philosophical frameworks for nursing policy and practice, however, seminal nursing theorists may have only succeeded in echoing the medical model at a different level of analysis. By adopting the ‘individual functional fitness’ aspect of the medical model (Ham, 1992) nursing theorists have tended to focus on a very limited range of clinical concepts such as the immediate problems and personal backgrounds of service users, and the interventions which may be necessary to help restore their optimal states of health. This has been really no more than a sophistication of the functional fitness perspective, which has broadened the biological concerns of the medical model to issues of patient ‘adaption’ strengths (Roy, 1970), ‘self-care deficits’ (Orem, 1983), or ‘selfimprovement’ of one form or another (Neuman, 1982). Although, therefore, these theorists have talked about ‘society’ and the ‘environment’, there has been very little meaningful attention given to issues of social inequality, stress, alienation, conflicting ideologies and ways of life, and the critical issue of social control. Instead, theorists have generally assumed a social consensus (Barker and Ritter, 1995) and have failed to discuss how social forces define and dictate the conditions under which individual ‘adaption’, ‘independence’ and ‘self-improvement’ may take place, and what these terms ultimately mean. Is adaptation, for example, an acceptance of the current social system, a winning hand within it, or a role in its historical change? Is independence a goal of self-reliance imposed by government policy, an elite decision-making position in the social hierarchy, or a freedom to choose unorthodox ways of life? These questions have needed to be addressed by nursing theorists, but unfortunately US theory has been too restricted by assumptions of social ‘consensus’ and American Dream individualism to show the necessary flexibility and radicalism.
5. American sociology and nursing theory Although natural science methodology (i.e. positivism) has underpinned the structural development of US nursing theory, and this has been reflected in the weight of physical and psychological premises within the main body of theory (Perry, 1991), sociological concepts have not been entirely excluded from the process. The problem, however, has been that these concepts have been inspired by sociological theory which has itself
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cultivated notions of consensus and individualism. Functionalism which dominated US sociology in the 1950s and early 1960s generated propositions about the reciprocal nature of social institutions which plainly represented the basic consensus ideology of those times, but which left little or no room in its theoretical framework for concepts of fundamental social conflict and alternative ideology. Social unrest was instead conceived as the maladjustment of an essentially sound and evolving system, or as a psycho-social inability of some individuals to join the functional process effectively (i.e. Merton’s (1968) ‘anomie’ theory). This analysis has tended to confirm therefore conceptions of both social consensus and individual pathology; diverting theoretical attention towards poor socialisation, ineffective coping strategies and various other individual ‘inadequacies’ and deviancies. It was a theoretical development which could only have further supported the consensus and individual fulfillment principles of US nursing theory. Through the 1960s and 1970s interactionist sociology successfully critiqued the functionalist view of social reality, establishing the idea that social meanings (i.e. values, beliefs, attitudes, thought and actions) were sometimes in opposition to one another, and that ‘consensus’ was often an oppression of minorities by the ‘signifying’ value system of the state. Interest, however, tended to focus on the interactions between ‘labelled’ minority group members (e.g. psychiatric patients) and members of State agencies (e.g. psychiatrists), rather than the wider structural concerns of ideological conflict and power negotiation at senior levels of administration and legislation (Tittle, 1975). Eventually, most interactionist work in the 1970s concentrated on the distortion of ‘reasonable’ legislation by State bureaucracies, so that interactionism within nursing theory (e.g. Reihl, 1974) has tended to take the familiar form of exploring individual variations from the social norm (how an individual’s self-perception or understanding of a nursing situation is obstructing therapeutic progress), rather than a more radical perspective of the whole system surrounding health and mental health policy (how the therapy itself may be power based or culture biased, suppressing the service user’s social needs). This once again reinforced the conservative consensus of ‘American Dream’ individualism within the paradigms of US nursing theory, and opportunities to explore radical alternatives were lost.
6. The exportation of US nursing theory to the UK As McKenna (1997) has noted, the UK nursing establishment was heavily influenced by US nursing theory in the period 1975–85. This may have occurred largely because of an underlying socio-cultural affinity
between the UK and US including a common language, shared social institutions (e.g. democratic government), the inter-related capitalist economic system and important bonds of history. A strong mutual fascination between the two cultures has existed for centuries, and there has of course been a regular cross-fertilisation of academic ideas, theories and philosophies (e.g. the growth of Anglo-American Behaviourist Psychology, and developments in Information Technology). It is not surprising therefore that UK nurses looking for an academic framework to strengthen their claims for professional autonomy should choose to take their lead from US nursing theorists; particularly as American theory was well established and appeared advanced. One serious mistake may have been made, however, during the large scale exportation of US nursing theory to the UK. Whereas American culture was typified by a conservative-liberal dynamic in socio-political life (Smith 1989), UK culture has been characterised by a relationship of conservative and socialist ideas. Relevantly, Marwicke (1991) has said: y.in all kinds of ways Britain (in 1945) was and remained a deeply conservative nation; but, with the working class voting in a more unified way than ever before, and with one third of the entire middleclass going to Labour, that party gained 47.8 per cent of the vote, y. the mainstream of the Conservative Party came to feel that it had to accommodate to the changes which took place under Labour. (p. 15). and (by 1990): In many of their basic beliefs—in the welfare state, in community services, etc.—the British remained remarkably unchanged for all the impact of Thatcherism (p. 144). On this basis, US nursing theory was always likely to be threatened by the values, beliefs and attitudes of the host UK culture; particularly as these are represented by nurses and service users in a mental health situation. Whereas individualism is undeniably an integral part of US culture, and therefore the nursing theory principles which have been derived from that culture, it is decidedly less dominant in the fabric of UK culture, having to take its place alongside other important traditions and ideologies; including the collective and co-operative tenets of socialism and ‘one nation’ conservatism. The demise of extreme individualism under Margaret Thatcher has perhaps illustrated the point that these views and attitudes do not sit as comfortably in the UK as across the Atlantic. Marwicke (1991) has stated: The bitterness and division within British society in the eighties was most characteristically expressed in horrific new levels of urban riotingy Society had
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been more unified under policies which deliberately sought to avoid unemployment and to sustain social benefits, policies which recognised the place of trade unions in society, and policies which upheld tolerance and civilised behaviour as important values. (pp. 137–139). On this basis, some criticism of US nursing theory in the UK context has already been placed on record. Kershaw (1992) has noted that clinicians have sensed a ‘foreign’ background, terminology and concepts in nursing theory which has disenchanted them, while McKenna (1997) has also queried the ‘transferable’ value of US theory: ynursing theories from the US have their roots in a different culture, a different health care structure and a different nurse education scheme. (p. 106).
7. UK nursing theory McKenna (1997) has also stated: In the 1980’s and 1990’s some British Nurses followed their American counterparts and began to formulate theories y The stimulus for these theories may have been the perception that American theories were not suitable for practice in the UK (p. 99). Although UK theories may have emerged, in part, because of the perceived ‘unsuitability’ of US theory, this does not necessarily mean that UK theorists have now identified the specific ‘culture shock’ problems of assumed social consensus and individualism in the American work. Indeed, a review of the UK theories which emerged in the 1980s shows quite the opposite, with Minshull et al. (1986) still emphasising concepts of ‘independence’ without grounding this in broader sociological terms, and Castledine (1986) producing a similarly uncritical concept of ‘adaption’. Even in the period 1990–2002, new initiatives have continued to emphasise ‘recovery’ and ‘personal responsibility’ (Turner-Crowson and Wallcraft, 2002), without acknowledging the social context, ideological alternatives and culture bias associated with these phenomena. Indeed, McKenna (1997) has listed nineteen ‘main theories’, only two of which are British (Roper et al., 1983; Minshull et al., 1986) clearly indicating the failure of UK theory to offset US influence.
8. Social conflict theory and individualised mental health care The ‘culture shock’ between US nursing theory and UK society may be explored and elaborated using social
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conflict theory. Here capitalist-individualism is seen as the dominant UK political ideology which has ‘trickled down’ into a whole range of social institutions including mental health care (Winship, 1998). Unlike US society, however, there is also a strong socialist-collectivist tradition in this country which is not represented by official individualist mental health policy, and may lead service users and staff members to consciously or subconsciously reject official policy because they perceive it as unsuitable (Leighton, 2002). This in turn may exacerbate the ‘theory–practice divide’ in mental health nursing situations (Rolfe, 1996; Mulhall, 1997).
9. The social conflict view Social conflict theory has a number of historical roots and sociological expressions, but the perspective chosen for this paper involves a theory integration of interactionist, critical and psychodynamic concepts (Box, 1987). This approach represents all three metaconcepts of sociology (social action, social structure and psychodynamic processes), and responds to the call for more socio-political research into nursing issues (Perry, 1991). It is a perspective mainly concerned with the critique of dominant ideologies and institutions, and may be considered suitable for exploring and questioning the ideological background of individualised care in mental health. According to Box (1987), social groups are complex and interpenetrating, co-operating in some ways and conflicting in others. They may all use a variety of tactical manoeuvres to secure and improve their positions, but it is really the widespread overlap of interests between groups which establishes (or changes) State ideology. Society tends to reproduce itself on the basis of socialisation through established institutions, and those groups who do not share the overlapping interests of State ideology will be marginalised. Within this perspective, the role of the subconscious is also emphasised, as individuals may use ‘ego defence’ coping strategies to negotiate the frustrations of marginalisation and social conflict. This view of social life develops the idea of dominant State control with an ‘ebb and flow’ view of tactical alliances, subconscious adjustments and incidental changes (Box, 1987).
10. Conflict theory, individualism and individualised care Capitalist-individualism may be considered a dominant UK ideology which represents the interests of certain inter-locking social groups, and helps to maintain the State through variety of ‘acceptable’ cultural values, such as entrepreneurial initiative, economic competition and consumerism (Winship, 1998). Capitalist-individualist
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ideology is expressed and socialised through a wide variety of social institutions such as government, commerce, education and law enforcement, and in doing so it conflicts with a range of alternative ideologies and secondary traditions such as socialism. Winship (1998) has said: The modern notion of the individual has redefined who may be seen as a worthy member of society. Individualism may be characterised by the belief that one should stand independently (look after numberone) and take responsibility for yourself and your immediate family. The monetarist vision of individualism focused on putting money back into peoples’ pockets so as to give them individual choice about how to spend their money. With the philosophy of privatisation and private ownership, and the capture of large markets by businesses selling private health care, private pensions, and private insurance, the thrust towards the radical individual has resulted in the destruction of collectivism where the concept of public has been vilified and degraded. (p. 271). As part of this process, individualism has also ‘trickled down’ into the institution of health care, providing a powerful paradigm for mental health care provision in the UK. Individualist nursing theory from the United States (McKenna, 1997), government policy (e.g. Department of Health, 1995), professional policy (UKCC, 1992), and well-established medical individualism (Ham, 1992) have together provided the individualist context for modern psychiatric nursing activity, while other individualist therapies (Laungani, 1997), and a general ethos of individualist ideas (Jones, 1994), have completed the almost water tight regime of clinical directives and social assumptions around practitioners.
11. Hegemony Although the conflict perspective used by Box (1987) does not involve a ‘conspiracy’ interpretation of the State, it instead suggests that dominant ideologies and institutions will tend to emerge on the basis of overlapping interests, subconscious motivations, day-to-day socialisation, and the acceptance of incidental advantage. In this way, it may be argued that individualised mental health care emerged partly because government expenditure could be reduced by emphasising selfreliance and closing expensive Victorian hospitals (Smoyak, 1991), and partly because the government’s image could be improved by removing embarrassing ‘asylums’. More subtly, it may have been advantageous to ‘deny’ social stress and social problems by focusing effort on personal responsibility and individual pathology (Morrall, 1998), while the alternative collective
lifestyle of service users could be safely absorbed back into the individualism of greater society. The government could have assuaged liberal critics by presenting individualised mental health care as a ‘humane’, democratic solution to mental health problems, while ‘allied’ medical doctors would have been pleased to observe an individualist treatment model as part of the community care reforms. Those service users who were successful would add to the turnover of local business as new ‘consumers,’ while even those who publicly failed within the psychiatric community care system would nevertheless reinforce ‘consensus’ by demonstrating deviancy and the stigma of censure (Sumner, 1983). Winship (1998) has commented: Therapeutic individualism has ridden in tandom with the influencing political climate and can be found particularly within the last fifteen years in Britain, which has been dominated by the politics of free market individualism. Individualism has come to represent a philosophy and psychology of ‘self’ (p. 271). And Morrall (1998): ytherapy is dishonest because it accentuates individual accountability in situations where the state, or sections of society, or society as a whole, is ultimately responsible. (p. 253). Accordingly, the current domination of individualist ideology in society and the prevalence of individualised therapy in mental health care implies a degree of social conflict. This is not only because attention is diverted from the social causes of mental health problems, but also because practitioners and service users who have greater affinity with alternative ideologies such as collectivism and spiritualism will be effectively disabled by the system. In this country, communal values have a very long and deep-seated tradition, and there may yet be a time when a modern collective alternative to individualised mental health care is demanded and officially accepted. Melluish (1998) has suggested that: ythis involves challenging the individualist models of understanding so often used within mental health services, which obscure or deny the wider social context. (p. 266).
12. Summary of propositions The application of social conflict theory (Box, 1987) to individualised mental health care policy generates the following propositions. Firstly, individualised mental health care is effectively a concept, or ‘meaning’, which incorporates a range of values and beliefs about society, motivation, and the role of the nurse. These values and beliefs may take the form of underlying assumptions in
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official policy. There are many other possible care approaches (e.g. psychiatric institutional care and therapeutic communities), all of which incorporate their own values and beliefs about society, motivation and nursing activity. Individualised mental health care currently dominates mental health care policy as a ‘signifying’ meaning, while other care concepts are repressed, dormant or yet to be realised; rather than superseded in the any ‘evolutionary’ sense. Individualised care theory and policy is an expression of capitalist-individualist ideology, which has been being socialised through the institution of health care and effectively represses alternative care approaches and the values and beliefs implied by them. The State may benefit from individualised care endorsement by: (i) emphasising the cost-saving concept of self-reliance, (ii) diverting concern from the possible socio-economic causes of health and mental health problems, and (iii) providing the economy with ‘rehabilitated’ workers and consumers. Individualised care theory and policy tends to ‘objectify’ nursing practice; giving it the appearance of ‘natural’ superiority through scientific rigour, when it is actually based on partial ideology. Individualist US nursing theory and the ‘shadow’ of medical individualism have been important factors in the establishment of ‘therapeutic individualism’ in the UK, but the important collective traditions of socialism and ‘one nation’ conservatism may provide a significant underlying challenge. ‘Insiders’ such as mental health nurses and service users may hold beliefs and values which conflict with individualised care policy, leading them to ‘neutralise’ the policy in practice and to implement alternative forms of care approach (e.g. personal intuitive interventions, or collective management). This would exacerbate the ‘theory–practice’ divide in these situations (see Rolfe, 1996; Mulhall, 1997). A more ‘holistic’ mental health care service would involve the assessment and empowerment of individuals’ socio-cultural and spiritual preferences, as well as their physical, psychological and family needs. This would ensure that issues of lifestyle, socio-political attitudes, philosophical/religious outlooks, and the organisation of work, education, leisure and ‘home’ were thoroughly addressed within mental health care. It would be consciously beyond the canopy of capitalist cultural assumptions and preconceptions, and it would imply wider, pluralistic mental health care provision (see Podvoll, 1991; Camphill, 1999; Barker, 1999).
13. Conclusion By applying social conflict theory to the history, theory and policy of individualised mental health care, this paper has highlighted a significant culture bias within one of the main mental health care concepts used
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in the UK. It has attempted to detail the development of individualist bias, to lay bare its nature, and to present some of its implications. It has suggested, in particular, that the wholesale importation of individualist US nursing theory may have conflicted with the legitimate beliefs and values of some UK practitioners and service users.
References Barker, P.J., 1994. A partnership for change. Nursing Times 90 (20), 44–47. Barker, P.J., 1999. Philosophy and practice of psychiatric nursing. Churchill Livingstone, Edinburgh. Barker, P.J., Ritter, S., 1995. What to do with nursing models. Journal of Psychiatric and Mental Health Nursing 2, 325–327. Becker, H.S., 1963. Becoming a marijuana user. In: Becker, H.S (Ed.), Outsiders: Studies in the Sociology of Deviance. Free Press of Glencoe, New York. Box, S., 1987. Recession, crime and punishment. MacMillan, Basingstoke. Bromhead, P., 1988. Life in Modern America. Longman, New York. Camphill Trust, 1999. Botton Village Life. Association of Camphill Communities. Camphill Press, Danby, North Yorkshire. Castledine.G., 1986. A stress adaption model. In: Kershaw, B., Salvage, J. (Eds), Models for Nursing. Wiley, London. Choi, E.C., 1989. Evolution of nursing theory development. In: Mariner-Tomey, A. (Ed.), Nursing Theorists and their Work. C.V. Mosby, St. Louis. Department of Health, 1983. The Mental Health Act. HMSO, London. Department of Health, 1994. Working in Partnership— A Collaborative Approach to Care. HMSO, London. Department of Health, 1995. Building Bridges: A Guide to Interagency Working For the Care and Protection of Severely Mentally III People. HMSO, London. Griffith-Kenney, J.W., 1986. Relevance of theoretical approaches in nursing practice. In: Griffith-Kenney, J.W., Christiansen, P.J. (Eds.), Nursing Process—Application of Theories, Frameworks and Models. Mosby, St. Louis. Hadley, R., Clough, R., 1997. Care in Chaos: Frustration and Challenge in Community Care. Cassell, London. Ham, C., 1992. Health Policy in Britain—The Politics and Organisation of the N.H.S. MacMillan, Basingstoke. Jones, B., 1994. Politics U.K. Harvester Wheatsheaf, Brighton. Kershaw, B. 1992. Nursing models. In: Jolley, M., and Brykczynska, G. (Eds.), Nursing Care—A Challenge to Change. Edward Arnold, London. Laungani, .P., 1997. Replacing client-centred counselling with culture-centred counselling. Counselling Psychology Quarterley 10 (4), 343–351. Leighton, K., 2002. A Sociological Study of Bed Blocking in Psychiatric Rehabilitation Units. Journal of Psychiatric and Mental Health Nursing 9 (4), 447–457. McKenna, H., 1997. Nursing Theories and Models. Routledge, London.
ARTICLE IN PRESS 28
K. Leighton / International Journal of Nursing Studies 41 (2004) 21–28
Marks-Moran, D., 1992. Rethinking the nursing process. In: Jolley, M., Brykczynska, G. (Eds.), Nursing Care— The Challenge to Change. Edward Arnold, London. Marwicke, A., 1991. Culture in Britain Since 1945. Blackwell, Oxford. Melluish, S., 1998. Community Psychology: A Social Action Approach to Psychological Distress. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing—Ethical Strife. Arnold, London. Merton, R.K., 1968. Social Theory and Social Structure. The Free Press, New York. Minshull, J., Ross, K., Turner, J., 1986. The human needs model of nursing. Journal of Advanced Nursing 11, 643–649. Morrall, P., 1998. Clinical Sociology and Empowerment. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing— Ethical Strife. Arnold, London. Mulhall, A., 1997. Nursing research: our world, not theirs? Journal of Advanced Nursing 25, 969–976. Neuman, B., 1982. The Neuman Systems Model: application to nursing education and practice. Appleton-Century-Crofts, Norwalk, CT. Orem, D.E., 1983. Nursing: concepts of practice. McGraw-Hill, New York. Orlando, I., 1972. The Discipline and Teaching of the Nursing Process. Putnams, New York. Peplau, H.E., 1952. Interpersonal Relations in Nursing. G.P. Putnam and Sons, New York. Perry, A., 1991. Sociology—Its Contributions and Critiques. In: Perry, A., Jolley, M., (Eds.). Nursing—A Knowledge Base for Practice. Edward Arnold, London. Podvoll, E.M., 1991. The Seduction of Madness: a compassionate approach to recovery at home. Century, London. Reihl, J.P., 1974. Application of interaction theory. In: Reihl, J.P., Roy, C. (Eds.), Conceptual Models for Nursing Practice. Appleton-Century.Crofts, New York. Richman, A., Barry, A., 1985. More and more is less and less: the myth of psychiatric need. British Journal of Psychiatry 146, 164–168.
Robinson, J., 1991. Power, Politics and Policy Analysis in Nursing. In: Perry, A., Jolley, M. (Eds.), Nursing— A Knowledge Base for Practice. Edward Arnold, London. Rogers, C., 1961. On Becoming a Person. Houghton Mifflin, Boston, MA. Rolfe, G., 1996. Going to extremes: action research, grounded practice and the theory–practice gap in nursing. Journal of Advanced Nursing 24, 1315–1320. Roper, N., Logan, N., Tierney, A., 1983. Using a Model for Nursing. Churchill Livingstone, Edinburgh. Roy, C., 1970. Adaption—a conceptual framework for nursing. Nursing Outlook 18 (3), 42–45. Smith, N., 1989. The U.S.A. Since 1945. Wayland, Hove, Sussex. Smoyak, A.S., 1991. Psychosocial nursing in public versus private sectors. Journal of Psychosocial Nursing 29, 6–12. Sumner, C.S., 1983. Rethinking deviance: toward a sociology of censures. In: Spitzer, S. (Ed.), Research in Law, Deviance and Social Control, Vol. 5. JAI Press, Greenwich, CT, pp. 187–204. Tittle, C.R., 1975. Labelling and Crime. In: Gove, W.R. (Ed.), The Labelling of Deviance. Wiley, New York. Tolley, K.A., 1995. Theory from practice for practice: is there a reality? Journal of Advance Nursing 21, 184–190. Tudor, K., 1997. Being at Dis-ease with Ourselves: alienation and psychotherapy. Wiley, London. Turner-Crowson, J., Wallcraft, J., 2002. The recovery vision for mental health services and research: a british perspective. Psychiatric rehabilitation Journal 25 (3), 245–254. United Kingdom Central Council, 1992. Code of Professional Conduct. UKCC, London. Weidenbach, E., 1964. Clinical Nursing, A Helping Art. Springer, New York. Winship, G., 1998. Democracy in psychiatric settings: collectivism v. individualism. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing—Ethical Strife. Arnold, London.
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Anglo-American nursing theory, individualism and mental health care: a social conflict perspective Kevin Leighton* Tees and North East Yorkshire N.H.S. Trust, UK Received 11 October 2002; received in revised form 6 February 2003; accepted 6 May 2003
Abstract This paper uses social conflict theory to reconsider the relationship of American nursing theory and individualised mental health care in the UK. It is argued that nursing theory has developed within a context of ‘American dream’ individualism, and that this ideology may be problematic for some UK mental health nurses and service users whose values and beliefs are those of different socio-political traditions. The paper explores the historical background of Anglo-American nursing theory, and then uses conflict theory to generate challenging propositions about the culture bias and political instrumentality of individualised care in mental health settings. In so doing, it critiques the ‘scientific’ and ‘liberal’ preconceptions of individualised care which have dominated mental health care policy for over a decade. r 2003 Elsevier Ltd. All rights reserved.
And Department of Health (1995):
1. Introduction: individualism and community mental health care Individualised mental health care uses a multidisciplinary assessment, planning, treatment and evaluation process to focus on the individual’s particular problems and potentials (Marks-Moran, 1992). It is applied to the whole person, rather than isolated behaviours, symptoms, or diagnostic labels, and it is distinct from institutional regime care, the personal values of the carer, or professional assumptions (Richman and Barry, 1985). It is a keystone of mental health care in the UK, as the following excerpts of official policy documents illustrate. Department of Health (1994): The hallmark of a quality service is that it is responsive to peoples’ individual needs y As approaches to care become increasingly centred on the individual, the mental health nurses contributionywill be critical to successy The Primacy of the Individual y Nursing responses and interventions should be founded upon a sound understanding of the individuals in their care (pp. (i)-18). *Corresponding author. 1 Bielby Close, Newby Farm Road, Scarborough, N. Yorkshire. YO12 6UU, UK.
Psychiatric nurses work with individuals suffering from varying degrees of mental illnessy.They have a wide variety of roles, but the main focus of their work is to assess a specific individual’s needs and recommend the appropriate treatment, therapy or care package. (p.11). Surprisingly, although individualised care is central to UK mental health policy it has rarely been targeted within the sweeping critiques of nursing theory and mental health policy which have emerged in recent years (McKenna, 1997; Hadley, and Clough, 1997). It is however the objective of this paper to examine the historical development of individualised mental health care, using a sociological perspective which casts considerable doubt on the background and efficacy of this pre-eminent care approach. Social conflict theory is chosen because it is primarily concerned with the critical study of dominant ideologies and social structures, and has the capacity to generate challenging propositions about the political nature of ‘official’ mental health care approaches. It therefore provides a socio-political analysis which could make a useful contribution to the explanation of nursing theory and community mental health care problems (Robinson, 1991; Perry, 1991).
0020-7489/$ - see front matter r 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2003.05.001
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On this basis, the paper explores the socio-historical development of individualised mental health care, looking at professional ideologies, the social context of American nursing theory and the exportation of American nursing theory to the United Kingdom. This historical account is then re-framed within social conflict theory to generate a number of propositions about the political implications of individualist ideology, and the powerful biases that individualist ideology has imparted to mental health care policy.
2. Professional ideologies and individualised care One source of individualised care principles in mental health policy is the traditional pre-eminence of psychiatric diagnosis and treatment in mental health care. Science and technology, specialist skills, elite qualifications, legal powers (e.g. under the Mental Health Act, 1983), and a certain professional mystique afforded by complex medical concepts, obscure language and ‘magical’ forms of treatment such as drug therapy, have together allowed the medical profession to establish a leading role in the care and management of mental health service users (Perry, 1991). The medical approach has also tended to reinforce images and preconceptions of individual pathology as a main cause of mental disorder; such as congenital weakness, bio-chemical dysfunction, disease, organic degeneration and innate personality type problems, while social dimensions of explanation and ‘treatment’ have been comparatively marginalised. Ham (1992) has said: y.it is the individualistic, functional fitness, curative approach which is the most influential. This approach has been characterised as the medical model of health y justifying the pre-eminent position of the medical profession in health matters y (p. 225). Clinical psychologists and psychotherapists have similarly supported the individualist concept of care in mental health settings, with theories and models of childhood trauma, low IQ, poor child rearing practices, maladaptive ‘ego defences’ and cognitive distortion, while even family therapists and psychiatric social workers have largely disconnected their work from any social structural analysis which could offer more fundamental explanations of stress, alienation, anger and psychosis (Tudor, 1997). As somatic, Rogerian, psychodynamic, behavioural, cognitive and family systems therapy have all appeared largely individualist or asocial in principle, this may be one important reason why mental health nursing has remained curiously dovetailed with the individual functional fitness model.
3. Nursing theory and individualised care Many of the paradigms of nursing theory were developed in the United States between 1950 and 1975 (e.g. Peplau, 1952; Weidenbach, 1964; Orlando, 1972), including the evolution of Individualised Patient Care (IPC) principles. Taking their lead from contemporary social interactionists and psychotherapists such as Rogers (1961) and Becker (1963) a number of theorists proposed concepts, ideas and methods which collectively predicated IPC—the self-actualising nature of human action, the role of nurse as enabler, the holistic assessment of individual problems and potentials and the analytical nursing process (Choi, 1989). It is this American work which has heavily influenced mental health nursing in the UK, including the adoption of individualised care policy (Barker, 1994; McKenna, 1997), and it is accordingly of some interest to investigate the social context and origins of these theories which now predicate the individualist ethic in UK mental health nursing. 3.1. Multicultural society The United States has long been considered a cosmopolitan society which can trace its modern multicultural identity to the massive influx of immigrants received during the 18th and 19th centuries (Bromhead, 1988). Most of these immigrant groups were searching for greater political freedom or increased economic opportunity; an historical quest which was eventually imbedded in US culture as the ‘American Dream’ of individual aspiration and equality of opportunity (Smith, 1989). No wonder perhaps, that many American nursing theorists went on to assume individualism as a fundamental premise of their work, based as it was on the day-to-day norms of their society. 3.2. Affluent society The United States enjoyed an economic ‘boom’ in the years which followed the Second World War, as renewed domestic and foreign demand met massive production power recently freed from the war effort (Smith, 1989). This prosperity, which continued into the 1960s, enabled many US citizens to attain something of the American Dream, as material acquisition, business opportunities, career development and status achievement all combined to reinforce the ideology of individual effort in a rewarding society. On this background, a reinforcement of individualism in nursing theory may have occurred at just the time theorists were seeking to establish the basic concepts and propositions of their work. Griffith-Kenny (1986) has pointed out:
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In the 1960’s, as the scientific approach to nursing evolved, nurses began to question the purpose of nursing and the value of the traditional, intuitive nature of nursing practice. Nurses discussed and wrote about their philosophical bases for practice, and gradually arrived at a consensus that the common elements include the nature of nursing (actions), the individual recipient of care (client), society and environment, and healthy. (p. 5).
3.3. Conservative consensus Although American culture is in many ways disparate, with a federal government, multicultural population, wide-ranging territories and diverse geographical division of labour, it is underpinned by a conservative consensus which stresses certain shared and abiding values; including the rule of law and the rights of the individual under that law. This political consensus has also found its way into the assumptions of US nursing theory, where concrete references to alternative social systems or personal ideologies are comparatively hard to find. Griffith-Kenny (1986) has defined this point of view: Society is composed of individuals, groups, families and communities with common goals and values. Society encompasses the sociocultural, economic, political, and environmental forces and changes during reciprocal interactions and relationships. (p. 10). The assertion of conservative consensus values in the United States reflects the intolerance of American culture for radically alternative ideologies such as ‘extreme’ liberalism or traditional socialism. Indeed, socialism has appeared to be almost entirely antipathetic to American culture, even during periods of dissension; a phenomenon which can perhaps be traced to the original motivations of many early settlers, who were often leaving behind totalitarian, inflexible or ruinous societies where politicians were frequently reviled (Bromhead, 1988). Because, therefore, most US nursing theorists have assumed a social consensus about the merits of individualist ideology in their society, they have not acknowledged the possibility of fundamental conflict between holders of disparate ideologies, and they have failed to incorporate this concept within their overall nursing paradigm. This has diminished the concept of social action to American Dream ‘self-actualisation’, and has largely prevented US theorists, policy makers and practitioners exploring a wider range of lifestyle alternatives within mental health therapy (e.g. communal and pastoral ways of life).
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4. Science and American nursing theory It has been argued that US and UK nursing theory adopted a generally scientific methodology as its ‘role model’ because this provided a means to academic respectability at a time when nurses were attempting to establish their own approach and subject matter, independent of their historical reliance on the medical model (Tolley, 1995). In rejecting more radical philosophical frameworks for nursing policy and practice, however, seminal nursing theorists may have only succeeded in echoing the medical model at a different level of analysis. By adopting the ‘individual functional fitness’ aspect of the medical model (Ham, 1992) nursing theorists have tended to focus on a very limited range of clinical concepts such as the immediate problems and personal backgrounds of service users, and the interventions which may be necessary to help restore their optimal states of health. This has been really no more than a sophistication of the functional fitness perspective, which has broadened the biological concerns of the medical model to issues of patient ‘adaption’ strengths (Roy, 1970), ‘self-care deficits’ (Orem, 1983), or ‘selfimprovement’ of one form or another (Neuman, 1982). Although, therefore, these theorists have talked about ‘society’ and the ‘environment’, there has been very little meaningful attention given to issues of social inequality, stress, alienation, conflicting ideologies and ways of life, and the critical issue of social control. Instead, theorists have generally assumed a social consensus (Barker and Ritter, 1995) and have failed to discuss how social forces define and dictate the conditions under which individual ‘adaption’, ‘independence’ and ‘self-improvement’ may take place, and what these terms ultimately mean. Is adaptation, for example, an acceptance of the current social system, a winning hand within it, or a role in its historical change? Is independence a goal of self-reliance imposed by government policy, an elite decision-making position in the social hierarchy, or a freedom to choose unorthodox ways of life? These questions have needed to be addressed by nursing theorists, but unfortunately US theory has been too restricted by assumptions of social ‘consensus’ and American Dream individualism to show the necessary flexibility and radicalism.
5. American sociology and nursing theory Although natural science methodology (i.e. positivism) has underpinned the structural development of US nursing theory, and this has been reflected in the weight of physical and psychological premises within the main body of theory (Perry, 1991), sociological concepts have not been entirely excluded from the process. The problem, however, has been that these concepts have been inspired by sociological theory which has itself
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cultivated notions of consensus and individualism. Functionalism which dominated US sociology in the 1950s and early 1960s generated propositions about the reciprocal nature of social institutions which plainly represented the basic consensus ideology of those times, but which left little or no room in its theoretical framework for concepts of fundamental social conflict and alternative ideology. Social unrest was instead conceived as the maladjustment of an essentially sound and evolving system, or as a psycho-social inability of some individuals to join the functional process effectively (i.e. Merton’s (1968) ‘anomie’ theory). This analysis has tended to confirm therefore conceptions of both social consensus and individual pathology; diverting theoretical attention towards poor socialisation, ineffective coping strategies and various other individual ‘inadequacies’ and deviancies. It was a theoretical development which could only have further supported the consensus and individual fulfillment principles of US nursing theory. Through the 1960s and 1970s interactionist sociology successfully critiqued the functionalist view of social reality, establishing the idea that social meanings (i.e. values, beliefs, attitudes, thought and actions) were sometimes in opposition to one another, and that ‘consensus’ was often an oppression of minorities by the ‘signifying’ value system of the state. Interest, however, tended to focus on the interactions between ‘labelled’ minority group members (e.g. psychiatric patients) and members of State agencies (e.g. psychiatrists), rather than the wider structural concerns of ideological conflict and power negotiation at senior levels of administration and legislation (Tittle, 1975). Eventually, most interactionist work in the 1970s concentrated on the distortion of ‘reasonable’ legislation by State bureaucracies, so that interactionism within nursing theory (e.g. Reihl, 1974) has tended to take the familiar form of exploring individual variations from the social norm (how an individual’s self-perception or understanding of a nursing situation is obstructing therapeutic progress), rather than a more radical perspective of the whole system surrounding health and mental health policy (how the therapy itself may be power based or culture biased, suppressing the service user’s social needs). This once again reinforced the conservative consensus of ‘American Dream’ individualism within the paradigms of US nursing theory, and opportunities to explore radical alternatives were lost.
6. The exportation of US nursing theory to the UK As McKenna (1997) has noted, the UK nursing establishment was heavily influenced by US nursing theory in the period 1975–85. This may have occurred largely because of an underlying socio-cultural affinity
between the UK and US including a common language, shared social institutions (e.g. democratic government), the inter-related capitalist economic system and important bonds of history. A strong mutual fascination between the two cultures has existed for centuries, and there has of course been a regular cross-fertilisation of academic ideas, theories and philosophies (e.g. the growth of Anglo-American Behaviourist Psychology, and developments in Information Technology). It is not surprising therefore that UK nurses looking for an academic framework to strengthen their claims for professional autonomy should choose to take their lead from US nursing theorists; particularly as American theory was well established and appeared advanced. One serious mistake may have been made, however, during the large scale exportation of US nursing theory to the UK. Whereas American culture was typified by a conservative-liberal dynamic in socio-political life (Smith 1989), UK culture has been characterised by a relationship of conservative and socialist ideas. Relevantly, Marwicke (1991) has said: y.in all kinds of ways Britain (in 1945) was and remained a deeply conservative nation; but, with the working class voting in a more unified way than ever before, and with one third of the entire middleclass going to Labour, that party gained 47.8 per cent of the vote, y. the mainstream of the Conservative Party came to feel that it had to accommodate to the changes which took place under Labour. (p. 15). and (by 1990): In many of their basic beliefs—in the welfare state, in community services, etc.—the British remained remarkably unchanged for all the impact of Thatcherism (p. 144). On this basis, US nursing theory was always likely to be threatened by the values, beliefs and attitudes of the host UK culture; particularly as these are represented by nurses and service users in a mental health situation. Whereas individualism is undeniably an integral part of US culture, and therefore the nursing theory principles which have been derived from that culture, it is decidedly less dominant in the fabric of UK culture, having to take its place alongside other important traditions and ideologies; including the collective and co-operative tenets of socialism and ‘one nation’ conservatism. The demise of extreme individualism under Margaret Thatcher has perhaps illustrated the point that these views and attitudes do not sit as comfortably in the UK as across the Atlantic. Marwicke (1991) has stated: The bitterness and division within British society in the eighties was most characteristically expressed in horrific new levels of urban riotingy Society had
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been more unified under policies which deliberately sought to avoid unemployment and to sustain social benefits, policies which recognised the place of trade unions in society, and policies which upheld tolerance and civilised behaviour as important values. (pp. 137–139). On this basis, some criticism of US nursing theory in the UK context has already been placed on record. Kershaw (1992) has noted that clinicians have sensed a ‘foreign’ background, terminology and concepts in nursing theory which has disenchanted them, while McKenna (1997) has also queried the ‘transferable’ value of US theory: ynursing theories from the US have their roots in a different culture, a different health care structure and a different nurse education scheme. (p. 106).
7. UK nursing theory McKenna (1997) has also stated: In the 1980’s and 1990’s some British Nurses followed their American counterparts and began to formulate theories y The stimulus for these theories may have been the perception that American theories were not suitable for practice in the UK (p. 99). Although UK theories may have emerged, in part, because of the perceived ‘unsuitability’ of US theory, this does not necessarily mean that UK theorists have now identified the specific ‘culture shock’ problems of assumed social consensus and individualism in the American work. Indeed, a review of the UK theories which emerged in the 1980s shows quite the opposite, with Minshull et al. (1986) still emphasising concepts of ‘independence’ without grounding this in broader sociological terms, and Castledine (1986) producing a similarly uncritical concept of ‘adaption’. Even in the period 1990–2002, new initiatives have continued to emphasise ‘recovery’ and ‘personal responsibility’ (Turner-Crowson and Wallcraft, 2002), without acknowledging the social context, ideological alternatives and culture bias associated with these phenomena. Indeed, McKenna (1997) has listed nineteen ‘main theories’, only two of which are British (Roper et al., 1983; Minshull et al., 1986) clearly indicating the failure of UK theory to offset US influence.
8. Social conflict theory and individualised mental health care The ‘culture shock’ between US nursing theory and UK society may be explored and elaborated using social
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conflict theory. Here capitalist-individualism is seen as the dominant UK political ideology which has ‘trickled down’ into a whole range of social institutions including mental health care (Winship, 1998). Unlike US society, however, there is also a strong socialist-collectivist tradition in this country which is not represented by official individualist mental health policy, and may lead service users and staff members to consciously or subconsciously reject official policy because they perceive it as unsuitable (Leighton, 2002). This in turn may exacerbate the ‘theory–practice divide’ in mental health nursing situations (Rolfe, 1996; Mulhall, 1997).
9. The social conflict view Social conflict theory has a number of historical roots and sociological expressions, but the perspective chosen for this paper involves a theory integration of interactionist, critical and psychodynamic concepts (Box, 1987). This approach represents all three metaconcepts of sociology (social action, social structure and psychodynamic processes), and responds to the call for more socio-political research into nursing issues (Perry, 1991). It is a perspective mainly concerned with the critique of dominant ideologies and institutions, and may be considered suitable for exploring and questioning the ideological background of individualised care in mental health. According to Box (1987), social groups are complex and interpenetrating, co-operating in some ways and conflicting in others. They may all use a variety of tactical manoeuvres to secure and improve their positions, but it is really the widespread overlap of interests between groups which establishes (or changes) State ideology. Society tends to reproduce itself on the basis of socialisation through established institutions, and those groups who do not share the overlapping interests of State ideology will be marginalised. Within this perspective, the role of the subconscious is also emphasised, as individuals may use ‘ego defence’ coping strategies to negotiate the frustrations of marginalisation and social conflict. This view of social life develops the idea of dominant State control with an ‘ebb and flow’ view of tactical alliances, subconscious adjustments and incidental changes (Box, 1987).
10. Conflict theory, individualism and individualised care Capitalist-individualism may be considered a dominant UK ideology which represents the interests of certain inter-locking social groups, and helps to maintain the State through variety of ‘acceptable’ cultural values, such as entrepreneurial initiative, economic competition and consumerism (Winship, 1998). Capitalist-individualist
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ideology is expressed and socialised through a wide variety of social institutions such as government, commerce, education and law enforcement, and in doing so it conflicts with a range of alternative ideologies and secondary traditions such as socialism. Winship (1998) has said: The modern notion of the individual has redefined who may be seen as a worthy member of society. Individualism may be characterised by the belief that one should stand independently (look after numberone) and take responsibility for yourself and your immediate family. The monetarist vision of individualism focused on putting money back into peoples’ pockets so as to give them individual choice about how to spend their money. With the philosophy of privatisation and private ownership, and the capture of large markets by businesses selling private health care, private pensions, and private insurance, the thrust towards the radical individual has resulted in the destruction of collectivism where the concept of public has been vilified and degraded. (p. 271). As part of this process, individualism has also ‘trickled down’ into the institution of health care, providing a powerful paradigm for mental health care provision in the UK. Individualist nursing theory from the United States (McKenna, 1997), government policy (e.g. Department of Health, 1995), professional policy (UKCC, 1992), and well-established medical individualism (Ham, 1992) have together provided the individualist context for modern psychiatric nursing activity, while other individualist therapies (Laungani, 1997), and a general ethos of individualist ideas (Jones, 1994), have completed the almost water tight regime of clinical directives and social assumptions around practitioners.
11. Hegemony Although the conflict perspective used by Box (1987) does not involve a ‘conspiracy’ interpretation of the State, it instead suggests that dominant ideologies and institutions will tend to emerge on the basis of overlapping interests, subconscious motivations, day-to-day socialisation, and the acceptance of incidental advantage. In this way, it may be argued that individualised mental health care emerged partly because government expenditure could be reduced by emphasising selfreliance and closing expensive Victorian hospitals (Smoyak, 1991), and partly because the government’s image could be improved by removing embarrassing ‘asylums’. More subtly, it may have been advantageous to ‘deny’ social stress and social problems by focusing effort on personal responsibility and individual pathology (Morrall, 1998), while the alternative collective
lifestyle of service users could be safely absorbed back into the individualism of greater society. The government could have assuaged liberal critics by presenting individualised mental health care as a ‘humane’, democratic solution to mental health problems, while ‘allied’ medical doctors would have been pleased to observe an individualist treatment model as part of the community care reforms. Those service users who were successful would add to the turnover of local business as new ‘consumers,’ while even those who publicly failed within the psychiatric community care system would nevertheless reinforce ‘consensus’ by demonstrating deviancy and the stigma of censure (Sumner, 1983). Winship (1998) has commented: Therapeutic individualism has ridden in tandom with the influencing political climate and can be found particularly within the last fifteen years in Britain, which has been dominated by the politics of free market individualism. Individualism has come to represent a philosophy and psychology of ‘self’ (p. 271). And Morrall (1998): ytherapy is dishonest because it accentuates individual accountability in situations where the state, or sections of society, or society as a whole, is ultimately responsible. (p. 253). Accordingly, the current domination of individualist ideology in society and the prevalence of individualised therapy in mental health care implies a degree of social conflict. This is not only because attention is diverted from the social causes of mental health problems, but also because practitioners and service users who have greater affinity with alternative ideologies such as collectivism and spiritualism will be effectively disabled by the system. In this country, communal values have a very long and deep-seated tradition, and there may yet be a time when a modern collective alternative to individualised mental health care is demanded and officially accepted. Melluish (1998) has suggested that: ythis involves challenging the individualist models of understanding so often used within mental health services, which obscure or deny the wider social context. (p. 266).
12. Summary of propositions The application of social conflict theory (Box, 1987) to individualised mental health care policy generates the following propositions. Firstly, individualised mental health care is effectively a concept, or ‘meaning’, which incorporates a range of values and beliefs about society, motivation, and the role of the nurse. These values and beliefs may take the form of underlying assumptions in
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official policy. There are many other possible care approaches (e.g. psychiatric institutional care and therapeutic communities), all of which incorporate their own values and beliefs about society, motivation and nursing activity. Individualised mental health care currently dominates mental health care policy as a ‘signifying’ meaning, while other care concepts are repressed, dormant or yet to be realised; rather than superseded in the any ‘evolutionary’ sense. Individualised care theory and policy is an expression of capitalist-individualist ideology, which has been being socialised through the institution of health care and effectively represses alternative care approaches and the values and beliefs implied by them. The State may benefit from individualised care endorsement by: (i) emphasising the cost-saving concept of self-reliance, (ii) diverting concern from the possible socio-economic causes of health and mental health problems, and (iii) providing the economy with ‘rehabilitated’ workers and consumers. Individualised care theory and policy tends to ‘objectify’ nursing practice; giving it the appearance of ‘natural’ superiority through scientific rigour, when it is actually based on partial ideology. Individualist US nursing theory and the ‘shadow’ of medical individualism have been important factors in the establishment of ‘therapeutic individualism’ in the UK, but the important collective traditions of socialism and ‘one nation’ conservatism may provide a significant underlying challenge. ‘Insiders’ such as mental health nurses and service users may hold beliefs and values which conflict with individualised care policy, leading them to ‘neutralise’ the policy in practice and to implement alternative forms of care approach (e.g. personal intuitive interventions, or collective management). This would exacerbate the ‘theory–practice’ divide in these situations (see Rolfe, 1996; Mulhall, 1997). A more ‘holistic’ mental health care service would involve the assessment and empowerment of individuals’ socio-cultural and spiritual preferences, as well as their physical, psychological and family needs. This would ensure that issues of lifestyle, socio-political attitudes, philosophical/religious outlooks, and the organisation of work, education, leisure and ‘home’ were thoroughly addressed within mental health care. It would be consciously beyond the canopy of capitalist cultural assumptions and preconceptions, and it would imply wider, pluralistic mental health care provision (see Podvoll, 1991; Camphill, 1999; Barker, 1999).
13. Conclusion By applying social conflict theory to the history, theory and policy of individualised mental health care, this paper has highlighted a significant culture bias within one of the main mental health care concepts used
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in the UK. It has attempted to detail the development of individualist bias, to lay bare its nature, and to present some of its implications. It has suggested, in particular, that the wholesale importation of individualist US nursing theory may have conflicted with the legitimate beliefs and values of some UK practitioners and service users.
References Barker, P.J., 1994. A partnership for change. Nursing Times 90 (20), 44–47. Barker, P.J., 1999. Philosophy and practice of psychiatric nursing. Churchill Livingstone, Edinburgh. Barker, P.J., Ritter, S., 1995. What to do with nursing models. Journal of Psychiatric and Mental Health Nursing 2, 325–327. Becker, H.S., 1963. Becoming a marijuana user. In: Becker, H.S (Ed.), Outsiders: Studies in the Sociology of Deviance. Free Press of Glencoe, New York. Box, S., 1987. Recession, crime and punishment. MacMillan, Basingstoke. Bromhead, P., 1988. Life in Modern America. Longman, New York. Camphill Trust, 1999. Botton Village Life. Association of Camphill Communities. Camphill Press, Danby, North Yorkshire. Castledine.G., 1986. A stress adaption model. In: Kershaw, B., Salvage, J. (Eds), Models for Nursing. Wiley, London. Choi, E.C., 1989. Evolution of nursing theory development. In: Mariner-Tomey, A. (Ed.), Nursing Theorists and their Work. C.V. Mosby, St. Louis. Department of Health, 1983. The Mental Health Act. HMSO, London. Department of Health, 1994. Working in Partnership— A Collaborative Approach to Care. HMSO, London. Department of Health, 1995. Building Bridges: A Guide to Interagency Working For the Care and Protection of Severely Mentally III People. HMSO, London. Griffith-Kenney, J.W., 1986. Relevance of theoretical approaches in nursing practice. In: Griffith-Kenney, J.W., Christiansen, P.J. (Eds.), Nursing Process—Application of Theories, Frameworks and Models. Mosby, St. Louis. Hadley, R., Clough, R., 1997. Care in Chaos: Frustration and Challenge in Community Care. Cassell, London. Ham, C., 1992. Health Policy in Britain—The Politics and Organisation of the N.H.S. MacMillan, Basingstoke. Jones, B., 1994. Politics U.K. Harvester Wheatsheaf, Brighton. Kershaw, B. 1992. Nursing models. In: Jolley, M., and Brykczynska, G. (Eds.), Nursing Care—A Challenge to Change. Edward Arnold, London. Laungani, .P., 1997. Replacing client-centred counselling with culture-centred counselling. Counselling Psychology Quarterley 10 (4), 343–351. Leighton, K., 2002. A Sociological Study of Bed Blocking in Psychiatric Rehabilitation Units. Journal of Psychiatric and Mental Health Nursing 9 (4), 447–457. McKenna, H., 1997. Nursing Theories and Models. Routledge, London.
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K. Leighton / International Journal of Nursing Studies 41 (2004) 21–28
Marks-Moran, D., 1992. Rethinking the nursing process. In: Jolley, M., Brykczynska, G. (Eds.), Nursing Care— The Challenge to Change. Edward Arnold, London. Marwicke, A., 1991. Culture in Britain Since 1945. Blackwell, Oxford. Melluish, S., 1998. Community Psychology: A Social Action Approach to Psychological Distress. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing—Ethical Strife. Arnold, London. Merton, R.K., 1968. Social Theory and Social Structure. The Free Press, New York. Minshull, J., Ross, K., Turner, J., 1986. The human needs model of nursing. Journal of Advanced Nursing 11, 643–649. Morrall, P., 1998. Clinical Sociology and Empowerment. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing— Ethical Strife. Arnold, London. Mulhall, A., 1997. Nursing research: our world, not theirs? Journal of Advanced Nursing 25, 969–976. Neuman, B., 1982. The Neuman Systems Model: application to nursing education and practice. Appleton-Century-Crofts, Norwalk, CT. Orem, D.E., 1983. Nursing: concepts of practice. McGraw-Hill, New York. Orlando, I., 1972. The Discipline and Teaching of the Nursing Process. Putnams, New York. Peplau, H.E., 1952. Interpersonal Relations in Nursing. G.P. Putnam and Sons, New York. Perry, A., 1991. Sociology—Its Contributions and Critiques. In: Perry, A., Jolley, M., (Eds.). Nursing—A Knowledge Base for Practice. Edward Arnold, London. Podvoll, E.M., 1991. The Seduction of Madness: a compassionate approach to recovery at home. Century, London. Reihl, J.P., 1974. Application of interaction theory. In: Reihl, J.P., Roy, C. (Eds.), Conceptual Models for Nursing Practice. Appleton-Century.Crofts, New York. Richman, A., Barry, A., 1985. More and more is less and less: the myth of psychiatric need. British Journal of Psychiatry 146, 164–168.
Robinson, J., 1991. Power, Politics and Policy Analysis in Nursing. In: Perry, A., Jolley, M. (Eds.), Nursing— A Knowledge Base for Practice. Edward Arnold, London. Rogers, C., 1961. On Becoming a Person. Houghton Mifflin, Boston, MA. Rolfe, G., 1996. Going to extremes: action research, grounded practice and the theory–practice gap in nursing. Journal of Advanced Nursing 24, 1315–1320. Roper, N., Logan, N., Tierney, A., 1983. Using a Model for Nursing. Churchill Livingstone, Edinburgh. Roy, C., 1970. Adaption—a conceptual framework for nursing. Nursing Outlook 18 (3), 42–45. Smith, N., 1989. The U.S.A. Since 1945. Wayland, Hove, Sussex. Smoyak, A.S., 1991. Psychosocial nursing in public versus private sectors. Journal of Psychosocial Nursing 29, 6–12. Sumner, C.S., 1983. Rethinking deviance: toward a sociology of censures. In: Spitzer, S. (Ed.), Research in Law, Deviance and Social Control, Vol. 5. JAI Press, Greenwich, CT, pp. 187–204. Tittle, C.R., 1975. Labelling and Crime. In: Gove, W.R. (Ed.), The Labelling of Deviance. Wiley, New York. Tolley, K.A., 1995. Theory from practice for practice: is there a reality? Journal of Advance Nursing 21, 184–190. Tudor, K., 1997. Being at Dis-ease with Ourselves: alienation and psychotherapy. Wiley, London. Turner-Crowson, J., Wallcraft, J., 2002. The recovery vision for mental health services and research: a british perspective. Psychiatric rehabilitation Journal 25 (3), 245–254. United Kingdom Central Council, 1992. Code of Professional Conduct. UKCC, London. Weidenbach, E., 1964. Clinical Nursing, A Helping Art. Springer, New York. Winship, G., 1998. Democracy in psychiatric settings: collectivism v. individualism. In: Barker, P., Davidson, B. (Eds.), Psychiatric Nursing—Ethical Strife. Arnold, London.