Journal of Psychiatric and Mental Health Nuning, 1996,

Clinical notice board Editor: June Andrews

From modernism to postmodernism: the implications for nurse therapist interventions In her article in the first edition of the Journal of Psychiatric and Mental Health Nursing, Hildegarde Peplau (1994) notes the increasing pressure on psy- chiatric nurses to return to a role of being responsi- ble for the care and administration of physical, physician-determined treatments. In the face of this - of which I would suggest the ‘Family Manage- ment’ approach to psychosis is a good example - she advocates that nurses take up the challenge to become predominantly change agents, developing this by observing new challenges and empirically testing new ideas and approaches. I wholeheartedly support this view and suggest the ideas offered by postmodernism, and the therapeutic approach informed by postmodern ideas - second-order therapy - as the most relevant and potentially useful challenge we face. These ideas have impor- tant implications not just for therapy, but also for the way we generally view and respond to our clients and their situations, and are therefore most deserving of Professor Peplau’s exhortation.

To illustrate: During a recent conversation a colleague said to

me: ‘David is a schizophrenic and will need medica- tion and careful looking after for a long time - that is the reality!’. He continued: ‘David also shows no insight whatsoever. I just can’t convince him that his parents going away for a weekend has made him worse’.

His comments seemed at face value to be valid, reasonable and logical, especially in the context of David’s current situation and his recent behaviour. They are also comments which, up until a while ago, I would probably not have thought twice about. However, more recently I have been much less accepting, and habitually find myself looking at and challenging such assertions, the assumptions

Scottish Board, Royal College of Nursing, 42 South Oswald Road, Edinburgh EH9 2HH. Scotland

behind them and the meanings they generate. Doing this - thinking more carefully about the lan- guage and the context, as well as the premises, ideas, and meanings behind our clinical workaday language, concepts and descriptions-is something I and many of my colleagues are increasingly doing. The impetus has been our gradual disillusionment with the traditional ways of thinking, describing and conceptualizing our clients’ conditions and sit- uations, coupled with a desire to be more perma- nently effective in helping clients, especially those described as having severe/enduring mental health problems. However, seeking pathways to different and better clinical involvement has had to involve significant changes in our own thinking, conceptu- alizing and practice.

This shift in our thinking can be thought of as part of a process - also taking place in very many other aspects of society - of moving from modernist to postmodernist thinking, and is a vital prerequi- site, I believe, to our becoming more effective Nurses.

To elaborate: The Western concept of reality is that the reality

of objects, behaviour patterns, defining frameworks and descriptions, is ‘true’, universal and immutable, and therefore there to be discovered, and ‘known’. Science is usually seen as the ultimate arbiter of what is ‘real’. This Newtonian, world view is basi- cally reductionist - reality can be reduced to con- stituent ‘truths’ or ultimates. In our own field it manifests in the shape of the postulated reality of diagnoses and syndromes. This emphasis on lineal causality and indisputable reality - rather than con- textualization, meaning and interpretation - has become known as the modernist philosophy. Since it forms the basis for the conventional ‘scientific’ view of the world, this philosophy was essential to the invention and the development of our modern, technological society. It can be said to have served us well in this respect and, in the specific medical context, in dealing with most physically originating

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illnesses. For example: viewing diphtheria as being a true, ‘real’ entity, having a discrete existence, and therefore being a reality with a main ‘cause’-a microorganism - has undoubtedly proved useful. The modernist framework is essential to the medical view of diphtheria and has enabled suffer- ers to be very successfully treated. Virtual eradica- tion has been made possible by immunization. However, this approach has not been successful in eradicating mental health problems, especially the ones we describe as ‘psychotic’, which, despite huge amounts of (almost exclusively) biological research aimed at identifying the cause, remains a largely intractable, devastating problem for so many people (Warner 1985).

Postmodernism is a very different way of viewing the world and of constructing reality, which poten- tially offers much for our approach to mental health problems. Whilst modernism holds that reality is objective, postmodernism holds that reality is subjective, not fixed, nor ‘true’ and immutable, and therefore cannot be imposed. ‘Reality’ is seen as being very much in the eye of the beholder, and as such being ‘multiversal’ (having potentially as many realities as there are people exposed to it) rather than universal. It is con- structed by meaning, social and physical context, interpretation and language. For example, a wrist- watch can have many realities: as a time-measurer; as a status symbol; as a gift; as collateral for a loan, etc., all of which realities are dependent upon the context, description and meaning for the individu- als involved. However, even its basic reality as an instrument for telling the time would not exist to someone who could not tell the time. Stierlin (1994) offers some help with this: he refers to reali- ties being in two basic states: ‘hard’ realities which are commonly agreed on, and in which state allows a useful common function (e.g. a watch, or the concept of diphtheria): and ‘soft’ realities which are more open to dispute, negotiation and change. Psychiatric diagnoses, he postulates, fall very much into the latter domain and yet are so often still seen as being in the former.

The implications of this approach for mental health interventions has been taken up and devel- oped over the last 30-odd years by Bateson (1972), Maturana et al. (1987) Von Foerster (1981), and others. They argue that diagnoses, syndromes and therapist-imposed realities and solutions often impede and may even prevent clients from achiev- ing healthy outcomes from therapy. My colleague’s

labelling of David as ‘schizophrenic’ could be seen as a good example of an imposed reality. David may be displaying a fairly predictable pattern of symptoms, but in the postmodern framework the term schizophrenia is seen only as a more or less useful way of conceptualizing and describing this situation, and not a reality per se.

White & Epston (1990), and Hoffman (1985, 1990) have been leading exponents of postmodern- based therapy, which has become termed ‘second- order’ therapy. ‘First-order’ therapy is seen as being informed by modernist principles which emphasize the primacy of ‘discovering’ or imposing realities in terms of diagnosedsyndromes. Further emphasis is made upon trying to discover and be able to ‘know’ the problem and its causes and thence supply a scientific label. Prescriptive, therapist-determined interventions and outcomes tend to follow, which often necessitate therapists engaging in trying to convince clients of their own views and to instruct them accordingly.

Second-order therapy, by contrast, is concerned with producing healthy shifts in underlying belief and understanding and holds that in these situa- tions there is no universal reality to ‘know’ or be discovered. Emphasis is put upon the client’s story, upon their lived-experience and upon language and descriptions that fit with their understanding of their situation. Time spent by therapists determin- ing a diagnostic or syndrome label is thus largely wasted, as is time and effort spent instructing clients in desired behaviour and convincing them of the therapists view of the reality of their situation. Better outcomes (Retzer & Simon 2991) are possi- ble when focusing on the exploration of explana- tions, descriptions, meanings and underlying pre- mises in a collaborative, non-judgemental way with the client - and family where possible - in a dis- course that seeks to explore clients’ dilemmas and concerns and give logic to their situation, behaviour and distress.

My colleague’s description of David as ‘schizo- phrenic’ carried with it a premise and expectations of chronicity and disablement and the implicit assumption that psychotherapy would not be useful. Further, schizophrenia being seen as the reality carried the meaning that David’s disagreeing with the therapist’s view could be seen as ‘lack of insight’, and his view of reality potentially false. A further therapist-imposed reality was that of his parent’s absence causing his relapse - perhaps valid as an opinion and an idea for discussion and exam-

0 1996 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 3,269-271

Clinical n

ination, but plainly very questionable as an indis- putable reality per se - especially when viewed in a postmodern framework.

I and some of my colleagues are currently engaged in developing and evaluating a programme of second-order therapy to clients with severe mental health problems, mainly enduring. All carry the label ‘psychotic’. The therapy we offer is based on the second-order principles discussed above. What emerges, following successful engagement, is often striking. Client behaviour which at first seemed illogical and bizarre often begins to makes more sense when set in the context of the story they tell about what has happened to them or of the situ- ation they are in. Symptoms often then can be seen as having a kind of logic, for example: as a useful way of coping; as a way of enlisting help; or as a way of communicating by indirect metaphor.

Our results have yet to be fully collated, but cer- tainly a large proportion of clients eventually tell a story of being victims of serious abuse, or of being stuck with intractable emotional dilemmas which in themselves preclude open discussion. Provisional results are encouraging and seem to concur with Stierlin’s (1994) and others’ findings that real improvements take place when there is a change

on the part of client and/or family away from a belief or premise in the client’s condition as being ‘illness’.

References Peplau H. (1994) Journal of Psychiatric and Mental

Health Nwsing, 1,3-7. Warner R. (1985) Recovery fiom Schizophrenia: Psychiatry

and Political Economy. Routledge, London. Stierlin H. (1994) Ambivalence and Conflict Management

with Psychotic Patients. Lecture at Liverpool University, 1 September 1994.

Bateson G. (1972) Steps to an Ecology of Mind. Ballantine, New York.

Maturana H. et al. (1987) The Tree of Knowledge. New Science Library, Boston & London.

Von Foerster H. (1981) Observing Systems. Seaside Ca. Intersystems.

White M. & Epston D. (1990) Narrative Means to Therapeutic Ends. Norton, London.

Hoffman L. (1985) Beyond power and control: towards a ‘second-order’ family systems therapy. Family Systems Medicine, 3 , 381-396.

Hoffman L. (1990) Constructing Realities: an art of lenses. Family Process, 29, 1-12.

Retzer A., Simon F. (1991) A Followup Study of Manic Depressive and Schizoaffective Psychoses after Systemic Family Therapy. Family Process, 30, June 1991,139-156.

RICHARD WILLIAMS Haven House

Hessel East Yorkshire

UK

Q 1996 Blackwell Science Ltd, journal of Psychiatric and Mental Health Nursing 3,269-271