Phil Barker 2000

Mental health nursing in the UK has had a poor relationship with nursing models. The merit of the medical model, although, frequently contested, still governs much nursing practice. Increasingly, nurses turn to social or psychological models – in the form of Psychosocial Interventions (PSI) or cognitive behaviour therapy – to find guidance for their practice. As Michael (1994) has pointed out, the only way many nurses can find confidence in their own practice has been to model themselves on another discipline.

The Tidal Model (Barker, 2000) is a radically new approach to the practice of mental health nursing based on a series of research studies conducted over the past five years, which sought to define how nurses might help empower users and their families, and to clarify what kind of ‘care’ people need from nurses( Barker et al, 1999). The Tidal Model is presently being established as the basis of nursing practice, across the whole adult mental health programme in Newcastle, and is being introduced into selected clinical and teaching setting in Australia and New Zealand, Finland, Scotland, Ireland and Wales.

Although the Tidal Model complements the care offered by other health and social care disciplines, it recognises that ‘quality’ nursing care is focused on a special kind of relationship with users and their families. The person’s needs change from day to day and problems are not fixed things. Life flows through people and the problems of living they experience are equally fluid and changeable. Effective care needs to be based on a realisation of the changing nature of people and their life circumstances.

The Tidal Model emphasises the unpredictability of human experience through the core metaphor of water.

Life is a journey taken on an ocean of experience. All human development – including the experience of health and illness – involves discoveries made on that journey across the ocean of experience. At critical points in the journey people may experience storms or piracy. The ship may begin to take in water and the person may face the prospect of drowning or shipwreck. The person may need to be guided to a safe haven, to undertake repairs, or to recover from the trauma. Once the ship is made intact or the person has regained their sea legs, the journey may begin again, as the person sets again their course on the ocean of experience.

This metaphor illustrates many of the elements of the psychiatric crisis and the necessary responses to this human predicament. ‘Storms at sea’ is a metaphor for problems of living; ‘piracy’ evokes the experience of rape or the ‘robbery of the self’ that severe distress can produce. Many users describe the overwhelming nature of their experience of distress as akin to ‘drowning’ and this often ends in a metaphorical ‘shipwreck’ on the shores of the acute psychiatric unit. A proper ‘psychiatric rescue’ should be akin to ‘lifesaving’ and should lead the person to a genuine ‘safe haven’ where the necessary human repair work can take place.

The Tidal Model makes few assumptions about the proper course of a person’s life, preferring instead to focus on the kind of support that people might need to rescue them from crisis, and help them to chart again the course of their own lives. Genuine psychiatric care should be focused on appropriate forms of ‘emotional rescue’ and mental health care should be focused on the kind of human development that will enable the person to ‘put to sea’ again. In this sense the Tidal Model is committed to helping people to recover their lives, taking up the journey of a lifetime that has been disrupted by the experience of trauma or breakdown.

The Tidal Model involves three distinct, but related, dimensions of caring:

In the world dimension, the nurse focuses on the person’s need to be understood. This includes a need to have the personal experience of distress, illness or trauma, validated by others. A radically different form of nursing assessment – the Holistic Nursing Assessment - has been developed which documents what is significant and meaningful to the person now, at this point in their life journey. This assessment, which charts the person’s journey to the ‘here and now’, identifies what needs to happen next, to help them, and is written in the person’s own words. This enabled autobiography is one attempt to reduce the disempowerment experienced in the teeth of the psychiatric storm.

In the self-dimension the nurse focuses on the person’s need for emotional and physical security. The nurse helps the person to develop his or her own Security Plan, which also is written in the person’s own voice. This part of the care plan identifies the kind of support the person needs to feel secure enough to tackle the problems of living that have been identified in the world dimension.

In the others dimension the care plan considers the kind of support that might be provided by other disciplines or agencies, in order to resolve immediate problems or lead an ordinary life. These inputs might range from the provision of medical support, through to support from friends or family, financial advice, housing, education, leisure or other aspects of community integration.

The various Tidal Model assessments are focused on identifying what needs to be done, in the short and longer term, to meet the person’s human needs. These goals are not merely focused on resolving problems of living, in a psychiatric sense, but also try to consider how the person’s mental health might be promoted through an acknowledgement of existing personal strengths, spiritual meanings and adaptability to social circumstances.

The Tidal Model assumes that nurses should only do what is absolutely necessary to meet the person’s needs. This emphasis on ‘doing what needs to be done’ might help avoid fostering dependence or otherwise institutionalising people. Although the Tidal Model is informed by research, as well as interpersonal relations theory, the care programme is written in the ordinary language of the individual user. There has been an unfortunate trend, in recent years, to try to ‘teach’ people about the experience of mental distress. This is best illustrated by the development of ‘psychoeducation’ or ‘compliance-therapy’ approaches, which encourage the user or family to assume a position of ‘ignorance’. In reality, professionals are the ones who are ignorant of the experience of mental distress. All professionals need to develop some humility and acknowledge that they need to learn from the people in their care. Users – and in some cases – their families, help professionals define what ‘needs to be done’ to help address the problems of living associated with mental distress

The Tidal Model care involves a balance between individual interventions – where the person is helped to address and resolve individual needs, wants or wishes, within a one-to-one relationship; and groupwork, where issues common to others are addressed through the medium of group processes. The Tidal Model recommends three forms of group work:

The Recovery Group focuses on helping to boost the self-esteem of participants, acknowledging the values and attributes that even severely distressed people can bring to the life of others;

The Solutions Group recognises that if people have an opportunity to explore, creatively, with others their present difficulties, they may construct their own solutions;

The Information Group recognises that people with mental health problems need to be informed about many aspects of their world of experience that, often, is kept secret from them. This information may range from details of medication, access to benefits, legal issues, or advice about educational or other community opportunities.

Although the Tidal Model is based on research, and develops some of the theory of interpersonal relations, it is not a protocol driven approach. Instead, the various ‘frameworks’ within the model, merely offers nurses guidance as to how they might structure their efforts to empower people and to focus on what people really need. Consequently, we expect that the model will change dramatically as it is applied in practice. The world is changing fast, and all models of psychiatric and mental health care need to acknowledge the flowing nature of our personal and social world.

Many contemporary models of mental health care are based on an outmoded scientific paradigm, which assumes that people – and their problems - are somehow ‘fixed’. Many of the popular theories of psychiatric intervention are based on outmoded, paternalistic ideas of ‘how people should live’. The Tidal Model tries to adopt a more realistic, and humble, approach in assuming that the answers to the question of what kind of care do people need, can be provided by the people themselves.

References

Barker P(2000) The Tidal Model: Theory and Practice University of Newcastle.

Barker P, Jackson S and Stevenson C (1999) The need for psychiatric nursing: Towards a multidimensional theory of nursing. Nursing Inquiry 6, 104-12

Michael S (1994) Invisible skills. J Psychiatric and Mental Health Nursing 1 (1) 56-7

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