Marc Roberts

Purpose: The purpose of this paper is to examine two competing pharmacological models that have been used to understand how psychiatric drugs work: the disease-centred model and the drug-centred model. In addition, it explores the implications of these two models for mental health service users and the degree to which they are meaningfully involved in decisions about the use of psychiatric drugs. Design/methodology/approach: The approach is a conceptual review and critical comparison of two pharmacological models used to understand the mode of action of psychiatric drugs. On the basis of this analysis, the paper also provides a critical examination, supported by the available literature, of the implications of these two models for service user involvement in mental health care. Findings: The disease-centred model is associated with a tendency to view the use of psychiatric drugs as a technical matter that is to be determined by mental health professionals. In contrast, the drug-centred model emphasises the centrality of the individual experience of taking a psychiatric drug and implies a more equitable relationship between practitioners and mental health service users. Originality/value: Although infrequently articulated, assumptions about how psychiatric drugs work have important consequences for service user involvement in mental health care. Critical consideration of these assumptions is an important aspect of seeking to maximise service user involvement in decisions about the use of psychiatric drugs as a response to their experience of mental distress.

In order to be able to provide informed, effective and responsive mental health care and to do so in an evidence-based, collaborative and recovery-focused way with those who use mental health services, there is a recognition of the need for mental health professionals to possess sophisticated critical thinking capabilities. This article will therefore propose that such capabilities can be productively situated within the context of the work of the French philosopher Michel Foucault, one of the most challenging, innovative and influential thinkers of the 20th century. However, rather than focusing exclusively upon the content of Foucault's work, it will be suggested that it is possible to discern a general methodological approach across that work, a methodological approach that he refers to as “the history of the present.” In doing so, Foucault's history of the present can be understood as a productive, albeit provisional, framework in which to orientate the purpose and process of critical thinking for mental health professionals by emphasizing the need to both historicize and politicize the theoretical perspectives and therapeutic practices that characterize contemporary mental health care.

The occurrence of poor patient care is emerging as one of the most significant, challenging, and critical issues confronting contemporary nursing and those responsible for the provision of health care more generally. Indeed, as a consequence of the increased recognition of the manner in which nurses can be implicated in the occurrence of poor patient care, there has been sustained critical debate that seeks to understand how such healthcare failings can occur and, in particular, why nurses seemingly fail to intervene, raise concerns, and effectively respond to prevent the occurrence and continuation of such poor patient care. In seeking to contribute to this critical discussion, and in contrast to those “situational explanations” that maintain that the failure to raise concerns is a consequence of the contextual factors and challenging conditions to which nurses can be subject in the clinical setting, this paper will provide a resolutely philosophical analysis of that failure. In particular, it will draw upon the work of Jean-Paul Sartre—the French philosopher generally regarded as one of the most influential thinkers of the twentieth century—in order to propose that his work can be productively recontextualized to provide a detailed, challenging, and provocative critical analysis of the occurrence and continuation of poor patient care and the role of individual nurse practitioners in such healthcare failings.

The occurrence of poor patient care is emerging as one of the most significant and critical international issues confronting contemporary nursing. Indeed, while it is important to recognise that there are many examples of high quality care being provided by nurses in a multiplicity of healthcare settings, instances of poor patient care have been reported across Europe, South Africa, the United States, Australia, New Zealand, Canada and Japan (Levinson and Shojania, 2011; Aiken et al., 2012; Francis 2013; Reader and Gillespie, 2013). As a consequence, there has been sustained critical discussion that seeks to understand why nurses seemingly fail to intervene, raise concerns and effectively respond to prevent the occurrence and continuation of such poor patient care (see, e.g. Paley, 2013, 2014; Darbyshire, 2014; Roberts & Ion, 2014a, 2014b, 2015; Rolfe & Gardner, 2014a, 2014b; Scott, 2014; Timmins & de Vries, 2014, 2015; Stenhouse et al., 2016). A dominant suggestion has been that this failure can be understood as a consequence of the variety of challenging contextual or situational conditions to which nurses can be subject in the clinical setting such as high workloads, inadequate staffing levels and time pressures. In contrast to such situational explanations, however, this paper will employ the work of Jean-Paul Sartre, the twentieth century French philosopher, to consider the manner in which self-deception – and that specific form of self-deception that Sartre refers to as ‘bad faith’ – can be understood as being implicated in the failure of nurses to raise concerns about, and effectively respond to prevent, poor patient care.

Contemporary mental health care is a complex, challenging and contested field of professional practice. The authority of mental health professionals and the legitimacy of their interventions are subject to ongoing critical examination, and those who use mental health services are increasingly calling for greater involvement in how their experiences are understood and addressed (Beresford, 2010; Rapley et al., 2011; Campbell, 2013; Cromby et al., 2013). In order to be able to provide informed, effective and responsive mental health care in this challenging and changing context – and to work in an evidence-based, collaborative and recovery-focused way with mental health service users in particular – there is a recognition of the need for practitioners to possess sophisticated critical thinking and reflective capabilities (McKie & Naysmith, 2014; Roberts, 2015). While acknowledging that many practitioners already possess such critical capabilities – and also recognising the variety of means by which they can be acquired (Brookfield, 2001) – this paper will situate the facilitation and further development of those capabilities in the context of the work of the twentieth century French philosopher Michel Foucault. However, rather than focusing exclusively upon the content of his work, the facilitation of the critical capacities of mental health practitioners will be situated in the context of the general methodological approach that can be discerned across Foucault’s works – and his historical studies in particular – a methodological approach that he refers to as the ‘history of the present’ (Foucault, 1991, p. 31).

Aim
A discussion of how Arendt's work can be productively re-contextualized to provide a critical analysis of the occurrence of widespread participation in poor nursing care and what the implications of this are for the providers of nursing education.

Background
While the recent participation of nurses in healthcare failings, such as that detailed in the Francis report, has been universally condemned, there has been an absence of critical analyses in the literature that attempt to understand the occurrence of such widespread participation in poor nursing care. This is a significant omission in so far as such analyses will form an integral part of the strategy to limit the occurrence of such widespread participation of nurses in future healthcare failings.

Design
Discussion paper.

Data sources
Arendt's Eichmann in Jerusalem: A Report on the Banality of Evil and Thinking and Moral Considerations: A Lecture. In addition, a literature search was conducted and articles published in English relating to the terms care, compassion, ethics, judgement and thinking between 2004–2014 were included.

Implications for nursing
It is anticipated that this discussion will stimulate further critical debate about the role of Arendt's work for an understanding of the occurrence of poor nursing care, and encouraging additional detailed analyses of the widespread participation of nurses in healthcare failings more generally.

Conclusion
This article provides a challenging analysis of the widespread participation of nurses in poor care and discusses the opportunities confronting the providers of nursing education in limiting future healthcare failings.

In a recent paper the authors proposed that the work of Hannah Arendt could be employed to provide a productive understanding of how it is that systemic ‘moral catastrophes’ can occur in modern health care systems (Roberts and Ion, 2014). From an Arendtian perspective the widespread participation of practitioners in those catastrophes – such as that typified by the events at Mid Staffordshire NHS Trust (see, e.g. Francis, 2013) – cannot coherently be understood by invoking notions of ‘inherent evil’ or ‘wickedness’ but should rather be understood as a consequence of an ‘authentic inability to think’ or ‘thoughtlessness’ (Arendt, 1992; p. 288)

The phenomenon of suicide is one of the primary concerns for mental health professions. The health-care literature is dominated by discussions that focus variously on local and national suicide prevention policies, on the assessment of those individuals judged to be at risk of committing suicide as well as the appropriateness and efficacy of interventions for those who express suicidal ideation and display suicidal behaviours. What appear less frequently in the literature, however, are critical analyses of the concept of suicide and, in particular, critical reflections on the manner in which the concept of suicide has been, and continues to be, understood or ‘framed’. In an attempt to respond to this apparent omission, this paper will suggest that the work of Albert Camus, and his philosophical work The Myth of Sisyphus in particular, can be understood as providing a significant reconceptualization and reframing of suicide. In doing so, it will be suggested that Camus's work not only challenges how the concept of suicide has traditionally been situated within the context of mental illness, but can also be understood as challenging the efficacy of the interventions that have been associated with an understanding of suicide within that context.

Considerations about what it might mean to think, and about what inherited presuppositions determine what thinking is thought to consist of, are not readily reflected upon in the mental health care literature. However, this paper will propose that such considerations are of relevance to, and possess important implications for, the mental health professions, and it will do so within the context of the work of the 20th century philosopher Gilles Deleuze. In particular, the paper will provide an accessible exposition of what Deleuze refers to as the ‘dogmatic image of thought’, along with an examination of his suggestion that this traditional image, and its associated presuppositions, not only determine what is considered to be the ostensible ‘nature’ of thought, but also delineate what the activity of thinking ought to be concerned with. Moreover, it will be argued that Deleuze's exposition and critique of the image of thought can be understood as seeking to sensitize mental health professionals to the dangers of unreflectively perpetuating a restrictive notion of what it means to think, as well as being an exhortation to develop critical, creative thinking in the mental health professions that moves beyond the bounds of that traditional, dogmatic image of thought.

Over recent years a series of reports (Health Service Ombudsman, 2011; Patient's Association, 2011; Francis, 2013) have dented the reputation of the British health care system, and of nursing in particular. Specifically, they have questioned the traditional view of the nurse as a compassionate and caring professional. Taken together these present an image of a profession that may have lost its way and is failing in its primary aim of alleviating suffering. Few would argue that the most significant event to date was the recent failure of the Mid Staffordshire NHS Foundation Trust.

The manner in which the arts can enhance the practical, therapeutic concerns of mental health professionals is becoming well established in the health care literature. What gets discussed less frequently, however, are those aesthetic frameworks that propose to give an account of the possible ‘meaning’ and ‘purpose’ of art. In response, this paper will elucidate the aesthetic theory of the Hungarian philosopher Georg Lukács and will suggest that his concept of specific particularity enables an understanding of how art, and literature, poetry and drama in particular, can be employed as an educational resource that can contribute to the development of the ‘emotional capabilities’ of practitioners. However, insofar as Lukács' works are philosophically complex and challenging, his concept of specific particularity will be discussed within the context of Samuel Beckett's dramatic work Ohio Impromptu. In doing so, it will be suggested that Ohio Impromptu is not only productive for the elucidation of Lukács' aesthetics, but also illustrates how the arts provides practitioners with a valuable educative opportunity to engage with, and critically reflect upon, a multiplicity of affective dimensions, thereby enhancing the practitioner's ability to move towards achieving an empathic understanding of, and ‘emotional resonance’ with, those receiving mental health care.

The active involvement of those people who have at one time used, or who continue to use, mental health services has come to be seen as a central feature of both the policy and the practice of modern mental health care. However, while those people who use mental health services may face a variety of obstacles to active participation in their care and in the provision of mental health services more generally, this paper will draw on the work of Gilles Deleuze, arguably one of the most important philosophers of the late 20th century, to suggest that the language of psychiatry – and, in particular, the attendant valuations or ‘sense’ of psychiatry's diagnostic categories – serve to restrict the participation of people in their individual care and in the provision of mental health services. Accordingly, it will be suggested that the challenge, as well as the opportunity, that confronts mental health nurses is to facilitate greater, more active user participation by practising in a manner that elicits the resources, capabilities and potential that service users possess, thereby challenging the prevailing and restrictive sense of the diagnostic categories by which people are identified, and by which they come to identify themselves.

The concept of emotional intelligence is gaining increasing precedence in the nursing literature, with particular emphasis placed upon its importance for various aspects of the nursing profession and the demand for greater attention to be given to its development in the education of nurses. Accordingly, this paper will seek to contribute to this emerging body of research by proposing that the employment of poetry in the education of mental health nurses provides a valuable opportunity for the development of emotional intelligence and, in particular, the development of one of the central characteristics of emotional intelligence; namely, empathy. Moreover, while the nature of the relationship between nursing and the arts is gaining increasing attention, this paper will focus upon the account of art given by Gilles Deleuze – one of the most important philosophers of the 20th century – and his long-time collaborator Felix Guattari. In particular, in order to develop a Deleuzo-Guattarian account of the educative power of poetry, and the manner in which it provides a valuable opportunity for the development of emotional intelligence, and of empathy in particular, this paper will employ their account of the ‘percept’ and the ‘affect’, introduced in their final collaborative work What is Philosophy?

One of the most challenging figures in the history of ideas, the 19th century German philosopher Friedrich Nietzsche, exerts a powerful and enduring influence over modern thought. Indeed, while those working in the healthcare professions may have traditionally found Nietzsche's work largely inaccessible, there is now an emerging body of healthcare research that seeks to elucidate and explore the relevance of his ideas for the healthcare professions generally, and for the theory and practice of nursing in particular. Accordingly, this paper will seek to contribute to this emerging body of research by suggesting that Nietzsche's work can be employed to provide a productive understanding of how recovery from mental illness can be facilitated, and it will attempt to do this by focusing on what is arguably Nietzsche's most seemingly obscure notion, namely, the ‘eternal return’. In particular, by drawing upon contemporary research into the concept and experience of recovery, the paper will suggest that the discovery of new meaning is central to that process and that, this being so, Nietzsche's notion of the eternal return can provide a productive theoretical framework that can be employed by mental health professionals to orientate and guide therapeutic interventions towards that end.

Western civilization has, over its relatively recent past, undergone dramatic, unparalleled changes. The historical period in which these changes have occurred is commonly referred to as ‘modernity’, and although modernity has had profound repercussions on all aspects of people's lives, what has received less attention in the nursing literature is how modernity has influenced, and continues to influence, the mental health of modern men and women. In an attempt to address this, the following paper, drawing on the work of Szasz, Nietzsche and Frankl, seeks to present an accessible introduction to one of the most salient features of modernity; namely, the erosion of those traditions that gave life a meaning or a purpose, and that provided people with ready answers to the problem of how they ought to live. The paper will then introduce some of the possible consequences of this on the mental health of modern men and women, as well as providing preliminary suggestions as to how mental health nursing might respond. In doing so, the paper also seeks to stimulate further discussion and research into how modernity has influenced, and continues to influence, the mental health of modern men and women, and how psychiatric and mental health nursing might respond.

Published in 1972, Anti-Oedipus was the first of a number of collaborative works between the French philosopher, Gilles Deleuze, and the French psychoanalyst and political activist, Felix Guattari. As the first of a two-volume body of work that bears the subtitle, Capitalism and Schizophrenia, Anti-Oedipus is, to say the least, an unconventional work that should be understood, in part, as a product of its time – created as it was among the political and revolutionary fervour engendered by the events of ‘May 1968’. However, this paper will suggest that Anti-Oedipus – as a critique of psychoanalysis and the Oedipus complex, as well as being a study of the relationship between capitalism and schizophrenia – should also be understood in a less ‘time-bound’ fashion. In particular, the paper will examine Deleuze and Guattari’s formulation of a concept of ‘desire’ and its employment in relation to subjectivity, time, capitalism, representation, and the radical ‘therapeutic’ practice that they refer to as ‘schizoanalysis’. Moreover, nearly 40 years after the events of May 1968 and against possible doubts concerning the contemporary relevance of psychoanalysis, it will be suggested that psychoanalysis and the Oedipus complex are to be understood as symptomatic of a wider ‘malaise’ that can be discerned within psychiatry, psychotherapy, and contemporary capitalist society itself, and that it is this that forms the broader target of the book’s critique. Accordingly, by providing an accessible and critical introduction to Anti-Oedipus, the paper also hopes to stimulate further discussion and research regarding both the critique and the contribution that the work can make to contemporary psychiatry, psychotherapy, and mental health nursing generally.

Although ‘modern’ mental health care comprises a variety of theoretical approaches and practices, the supposed identification of ‘mental illness’ can be understood as being made on the basis of a specific conception of subjectivity that is characteristic of ‘modernity’. This is to say that any perceived ‘deviation’ from this characteristically ‘modern self’ is seen as a possible ‘sign’ of ‘mental illness’, given a ‘negative determination’, and conceptualized in terms of a ‘deficiency’ or a ‘lack’; accordingly, the ‘ideal’‘therapeutic’ aim of ‘modern’ mental health care can be understood as the ‘rectification’ of that ‘deficiency’ through a ‘re-instatement’ of the ‘modern self’. Although contemporary mental health care is increasingly becoming influenced by the so-called ‘death’ of the ‘modern self’, this paper will suggest that it is the work of the 20th century French philosopher, Gilles Deleuze, that is able to provide mental health care with a coherent determination of a ‘post-modern self’. However, a Deleuzian account of subjectivity stands in stark contrast to ‘modernity’s’ conception of subjectivity and, as such, this paper will attempt to show how this ‘post-modern’ subjectivity challenges many of the assumptions of ‘modern’ mental health care. Moreover, acknowledging the complexity and the perceived difficulty of Deleuze’s work, this paper will provide an account of subjectivity that can be understood as ‘Deleuzian’ in its orientation, rather than ‘Deleuze’s theory of subjectivity’, and therefore, this paper also seeks to stimulate further research and discussion of Deleuze’s work on subjectivity, and how that work may be able to inform, and possibly even reform, the theoretical foundations and associated diagnostic and therapeutic practices of psychiatry, psychotherapy, and mental health nursing.

The French philosopher, Gilles Deleuze, is emerging as one of the most important and influential philosophers of the 20th century, having published widely on philosophy, literature, language, psychoanalysis, art, politics, and cinema. However, because of the ‘experimental’ nature of certain works, combined with the manner in which he draws upon a variety of sources from various disciplines, his work can seem difficult, obscure, and even ‘willfully obstructive’. In an attempt to resist such impressions, this paper will seek to provide an accessible introduction to Deleuze's work, and to begin to discuss how it can be employed to provide a significant critique and reconceptualization of the theoretical foundations and therapeutic practices of psychiatry, psychotherapy, and mental health nursing. In order to do this, the paper will focus upon Deleuze's masterwork, and the cornerstone to his philosophy as a whole, Difference and Repetition; in particular, it will discuss how his innovative and challenging account of time can be employed to provide a conception of human life as a ‘continuity’, rather than as a series of distinct ‘moments’ or ‘events’. As well as discussing the manner in which his work can provide us with an understanding of how life is different and significant for each human being, this paper will also highlight the potential importance of Deleuze's work for logotherapy, for the recent ‘turn’ to ‘narrative’ as a psychotherapeutic approach and for contemporary mental health care's growing interest in ‘social constructionism’. As such, this paper also seeks to stimulate further discussion and research into the importance and the relevance of Deleuze's work for the theory and practice of psychiatry, psychotherapy, and mental health nursing.

The issue of power has become increasingly important within psychiatry, psychotherapy and mental health nursing generally. This paper will suggest that the work of Michel Foucault, the French philosopher and historian, has much to contribute to the discussion about the nature, existence and exercise of power within contemporary mental health care. As well as examining his original and challenging account of
power, Foucault’s emphasis on the intimate relationship between power and knowledge will be explored within the context of psychiatry and mental health nursing. This is to say that the paper will investigate Foucault’s account of how power and knowledge are central to the process by which human beings are ‘made subjects’ and therefore how ‘psychiatric identities’ are produced. In doing so, it will be suggested that Foucault’s work can not only make a valuable contribution to contemporary discussions about power and knowledge, but can also provide a significant critique and reconceptualization of the theoretical foundations and associated diagnostic and therapeutic practices of psychiatry
and mental health nursing.

Drawing upon the author’s experience as a mental health nurse lecturer, this paper suggests that many mental health nurses seem to have difficulty engaging with the ethical issues in psychiatry, and appreciating the relevance of those issues to their everyday practice. In an attempt to address this difficulty, this paper will present a framework that can serve as an accessible introduction to the ethical issues in psychiatry. Reflecting upon general, clinical examples from psychiatric practice, it will be suggested that many ethical issues in psychiatry are concerned with acts of paternalism and with the common justification for those acts. Having presented this framework, the paper will then subject it to a preliminary critique by drawing upon contemporary, critical approaches to health care ethics. It is hoped that this will serve to stimulate both a deeper appreciation of the relevance of ethics to the practice of mental health nursing and an ongoing critical consideration of the ethical issues
in psychiatry.

Contemporary mental health care is an exciting, challenging and changing field. Established practices and traditional ways of understanding mental health and distress are being challenged, both by those who work within and those who use contemporary mental health services. The authority of mental health professionals and the legitimacy of their interventions are open to question as never before, and those who use mental health services are increasingly calling for greater involvement in how their experiences are understood and addressed. In this changing and challenging environment, the roles that you will be required to perform as a qualified mental health nurse are becoming increasingly sophisticated. Not only will you be expected to identify, evaluate and apply various forms of information, research and evidence to your mental health practice, but you will be expected to work in a recovery-focused way with those who use mental health services and this will require an awareness of how your own assumptions, values and beliefs may affect your practice in both productive and non-productive ways. Contemporary mental health nursing therefore demands that you become an informed, self-aware and proactive mental health professional and central to achieving this is the ability to engage in critical thinking and critical reflection. This book will enable you to begin to develop your critical thinking and reflective capabilities for your work in both the clinical and university setting and, importantly, it will do so by situating critical thinking and reflection in the context of the debates, challenges and changes that characterise contemporary mental health care.