The Tidal Model

A Guide for Mental Health Professionals

Prof Philip J Barker, Poppy Buchanan-Barker

• Publisher: Routledge
• Year: 2004
• eBook ISBN: 9781135448011
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

The Tidal Model represents a significant alternative to mainstream mental health theories, emphasising how those suffering from mental health problems can benefit from taking a more active role in their own treatment.

Based on extensive research, The Tidal Model charts the development of this approach, outlining the theoretical basis of the model to illustrate the benefits of a holistic model of care which promotes self-management and recovery. Clinical examples are also employed to show how, by exploring rather than ignoring a client's narrative, practitioners can encourage the individual's greater involvement in the decisions affecting their assessment and treatment. The appendices guide the reader in developing their own assessment and care plans.

The Tidal Model's comprehensive coverage of the theory and practice of this model will be of great use to a range of mental health professionals and those in training in the fields of mental health nursing, social work, psychotherapy, clinical psychology and occupational therapy.

Chapter 1
Tales of shipwrecks and castaways

The problem of being human

Reflecting on the self

Although people have changed greatly down the ages of recorded history, much of our twenty-first-century thinking, at least in the western world, is still dominated by the philosophical assumptions of the Ancient Greeks. Yet, if we could be transported back to the slopes of Mount Olympus, we would soon find out how much people have changed in the past two and a half thousand years. We no longer think like the Ancient Greeks and probably do not even feel as they did. When Socrates said that the unexamined life was not worth living, he could hardly have imagined how far the notion of ‘self-examination’ might be taken. Indeed, the changes that occurred during the twentieth century were phenomenal and the pace of change appears to be quickening.

In our lifetime the psychobabble of West Coast USA has become commonplace. Our parents appeared to live what the Greeks might have called ‘good lives’ without ever reflecting on their ‘self-esteem’, ‘self-image’ or ‘self-concept’. Their consciousness was not so much simpler as different. The stories of their lives were written in a different language and spoken with a different voice than might be the case today.

The gift of consciousness allows people to ‘reflect’ on their experience of self. Today, we have a host of linguistic tools, mechanisms and devices that are meant to make this self-examination easier or more productive. At the heart of this process of examination lies—at least in the developed western world—the mercurial notion of the Self.¹ However, for most people, who and what they are remains something of a mystery. Yet despite this they know that they exist and they know what this is like, even when they find it difficult to express the experience of self.

What does seem clear is that when people experience difficulties in their relationship with the core Self—or in the human relations with others—they are likely to be described as having ‘mental health problems’. Traditionally, they would be described as being ‘mad’.²

The paintings of Hieronymus Bosch, the fourteenth-century Flemish artist, have often been assumed to depict the experience of waking nightmares, such as might be experienced by someone in the most extreme form of madness. His Garden of Earthly Delights has often been interpreted as a vivid illustration of psychosis, or by the Freudians as a catalogue of wish fulfilment or sexual anxiety. Paradoxically, there is another way of viewing Bosch, which may be simpler yet more complex. Bosch’s work reflected the world view of the Middle Ages (Bosing 2001). The Garden of Earthly Delights can be interpreted as a complex warning to all who might stray from the Christian path, framed as a visual catalogue of aversion. Were we able to step into a time machine and to visit Bosch in his studio, we would likely discover that if we pointed to the sexual imagery in his work he would have no idea what we were talking about. Unlike us, Bosch never had a chance to read Freud. Although a highly intelligent man within his own society, Bosch’s notions of what it meant to be human, to be a person, were very different from what we understand today. Bosch’s story was framed by the context of his age. Today, the context has changed dramatically but the same simple truth remains: who we are is largely a function of the age in which we live. Our individual stories are framed by our reading of the world within which those stories develop. In the western world, which has become so concerned with abstract notions of the Self, it is hardly surprising that so many people frame their human difficulties as self-related problems. Were we to transport ourselves to Malaysia, or to join a so-called ‘primitive’ people, we would likely find a very different construction of ‘selfhood’ and human distress.³

Indeed, were Sigmund Freud to turn up at our door today, even he might struggle to grasp the complexity of what humans had become in the 60 years since his death. The human meanings that Freud conjured with derived from his study of ancient literature, anthropology and various cross-cultural sources, including his interpretation of Bosch’s paintings. However, the technological revolution of the latter half of the twentieth century ushered in a whole new catalogue of human being. Not only can we enjoy live dialogue with people on the other side of the globe, but also the stories that we share through our telephones and PCs are no longer framed only by our direct everyday experience, but are highlighted, touched and sometimes tainted by fragments of stories from the lives of other people. The story of our own lives and what it means to be ‘ourselves’ grows increasingly complex.

Reflected in a glass, darkly

The human project involves trying to make sense of ourselves, asking ‘Who am I?’ and ‘What on earth am I doing here?’ We have been doing this for literally thousands of years. When our ancestors began to daub dirt on the walls of the Lascaux caves, or fashioned crude representations of themselves, or their idealised gods, from the rock, the process of self-reflection that eventually meant so much to Socrates was first born.

Today our emphasis on ‘self-reflection’ is heavily focused on language. However, we should not forget that much of our reflection is pre-linguistic and, especially in the therapeutic setting, often goes beyond words. In a philosophical sense, what is called the ‘lived experience’ belongs to this pre-linguistic province: it is what we experience, as we experience it, before we get down to—or are required to—attach words and linguistic meanings to the ‘experience’.

Indeed, Rembrandt probably still represents the pinnacle of naive self-reflection on the ‘lived experience’. His 90 self-portraits present a fascinating visual story of the decline in his fortunes and also the change in his view of himself. They are essays on ‘who’ Rembrandt is, without words. The art historian Manuel Gasser (1961) wrote: ‘Over the years, Rembrandt’s self-portraits increasingly became a means for gaining self-knowledge, and in the end took the form of an interior dialogue: a lonely old man communicating with himself while he painted.’

Whenever we look in a mirror, we have a similar opportunity to reflect on the story that life has written on our faces. Writing in our journal or sharing something of our story with others offers a different kind of reflection on the journey we have taken, out of the past to the here and now. The reflection is rarely clear-cut and steady, but it is always revealing. Indeed, Rembrandt’s self-portraits provide us with a useful anchor for our own reflections. We may not always be able to represent exactly what we see and feel, but the story we relate is always true, at least for now. Our reflections are always just that— reflections; a poor image of the complexity of the original. However, they are nonetheless important for all that. They are reflections on what it means to be human.

Psychiatry and the colonisotion of the self

For over one hundred years psychiatry has developed its own story of what it means to be human, promoting the idea that psychological, social and emotional problems are a function of some underlying (but unidentified) biological pathology. Such theories provided a rationale for every kind of psychiatric treatment—from insulin coma, through electro-convulsive therapy to neuroleptic medication. However, the contemporary psychiatric story, wherein the professional professes an expert knowledge of what it means to occupy this or that mental state, still stands in Freud’s shadow.

Freud’s most ambitious and impertinent analysis was of Leonardo da Vinci (Freud 1947). Taking the fragments of biographical information available to him, Freud framed a psychoanalytic story, which his translator believed ‘fully explained Leonardo’s incomprehensible traits of character’ (Brill 1947:27). Freud himself acknowledged that what he had produced was ‘only…a psychoanalytic romance’ (Freud 1947:117). However, in addressing the possible weaknesses of his story of Leonardo’s sexuality, he was at pains to excuse psychoanalysis from any blame:

If such an undertaking, as perhaps in the case of Leonardo, does not yield definite results, then the blame for it is not to be laid to the faulty or inadequate psychoanalytic method, but to the vague and fragmentary material left by tradition about this person.

(Freud 1947:118)

Little has changed in the half-century since this curious romance was published. Our newspapers and magazines show psychiatric professionals following in Freud’s footsteps as they craft often fantastic stories about the inner workings of the minds of celebrities and other icons of the popular culture. In the clinic, psychoanalysis may be dead and buried but the legacy of Freudian interpretation still reigns. People may today be described as having ‘mental health problems’, but the professional reading of those problems has changed little since Freud’s day. Now, a range of biological, genetic, cognitive and social factors is employed to explain the story that the person brings to the psychiatric setting. Invariably, those professional readings of our human distress overpower, and ultimately submerge, the plain language account that is often spoken or written in powerful metaphorical language (Barker 2000d). The colonising effect of psychiatry, and its various theories, represents the last territorial frontier (Barker and Buchanan-Barker 2001). Some of the people with ‘mental health problems’ may now call themselves users or consumers, but many of them still refer to ‘being bipolar’ or ‘having dysfunctional beliefs’. The insinuation of ‘lunatic language’ (Buchanan-Barker and Barker 2002) into the culture reflects the continuing power of psychiatric imperialism. The mental health ‘user’ or ‘consumer’ may be freed from the old ‘patient’ label, but remains chained to the psychiatric discourse.

Neuroscientific triumphalism

In our youth the psychoanalytic culture reigned supreme and everything from sports cars to bottles of beer on a film commercial was attributed psycho-sexual significance. Over the years other psychological, biological and genetic theories have emerged, all claiming to offer the final explanation for why we do what we do and what it all means. Arguably, neuroscience has taken up Freud’s baton in attempting to explain most, if not all human behaviour. In an elegant piece of intellectual arrogance Francis Crick wrote:

You, your joys and your sorrows, your memories and your ambitions, your sense of personal identity and free will, are in fact no more than the behaviour of a vast assembly of nerve cells and their associated molecules.

(Crick 1994:3)

As Szasz pointed out, this was hardly a new idea. As early as 1819, Sir William Lawrence, President of the Royal College of Surgeons, had declared: ‘The mind, the grand prerogative of man, is merely an expression of the function of the brain’ (Szasz 1996:84). Increasingly, people attribute their various problems of living to a specific biochemical imbalance, or to their brain chemistry in general. If the neuroscientific juggernaut continues to colonise our culture, it is only a matter of time before brain chemistry will explain every slip of the tongue, as psychoanalysis did last century.

Mental illness as metaphor

Cultural antecedents

The past twenty years have witnessed a dramatic change in the status of psychiatric patients, many of whom are no longer content with the passive role assigned to them by psychiatric medicine, but who wish to play a more active part in the care and treatment of their problems (Read and Reynolds 1996). Indeed, the challenges posed by groups in the UK such as Survivors Speak Out and, more recently, The Hearing Voices Network have shown how many formerly passive patients reclaimed their distress and applied their own labels within a philosophical framework that is personally and culturally meaningful. They have joined ranks with North American psychiatric survivor radicals, Crazy Folks, and their European political partners the Irren Offensive. All such groups aim to reclaim to story of the experience of madness and to challenge the territorialisation and colonisation of madness by the psychiatric establishment. This has led indirectly to the de-emphasis on mental ‘illness’ and the insinuation of the notion of ‘mental health problems’ into the popular culture.

However, as with much of the western culture, the idea that we might have ‘mental health problems’ has North American origins. In his seminal treatise on suicide, the poet and critic Al Alvarez reflected on his own attempts to kill himself, while a visiting scholar at a New England university:

A week later I returned to the States to finish the term. While I was packing I found, in the ticket pocket of my favourite jacket, a large, bright-yellow, torpedo-shaped pill. I stared at the thing, turning it over and over on my palm, wondering how I’d missed it on the night. It looked lethal. I had survived forty-five pills. Would forty-six have done it? I flushed the thing down the lavatory.

(Alvarez 1970:279)

Alvarez’s suicide attempt had not been the singular actions of a man alone. On reflection, he became all too aware that his story of despair did not stand alone. Indeed, nothing stood apart from the life he shared with others:

The truth is, in some way I had died. The overintensity, the tiresome excess of sensitivity and self-consciousness, of arrogance and idealism, which came in adolescence and stayed on and beyond their due time, like some visiting bore, had not survived the coma. It was as though I had finally, and sadly late in the day, lost my innocence. Like all young people, I had been high-minded and apologetic, full of enthusiasms I didn’t quite mean and guilts I didn’t quite understand. Because of them, I had forced my poor wife, who was far too young to know what was happening, into a spoiling, destructive role she never sought. We had spent five years thrashing around in confusion, as drowning men pull each other under.

(Alvarez 1970:279)

Much later, Alvarez found himself moving, imperceptibly, into a more optimistic, less vulnerable frame of mind and, like so many other ‘failed suicides’, he began to reflect on the meaning of his suicide attempt:

Months later I began to understand that I had had my answer, after all. The despair that had led me to try to kill myself had been pure and unadulterated, like the final, unanswerable despair a child feels, with no before and after. And childishly, I had expected death not merely to end it but also to explain it. Then when death let me down, I gradually saw that I had been using the wrong language; I had translated the thing into Americanese. Too many movies, too many novels, too many trips to the States had switched my understanding into a hopeful, alien tongue. I no longer thought of myself as unhappy; instead I had ‘problems’. Which is an optimistic way of putting it, since problems imply solutions, whereas unh...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Figures
• The Poetics of Experience
• Values
• Foreword
• Preface
• Chapter 1: Tales of Shipwrecks and Castaways
• Chapter 2: Philosophical Assumptions: A Credo
• Chapter 3: Throwing Out the Lifelines: The Meaning of Caring
• Chapter 4: Manning the Lifeboats: The Tidal Model In Practice
• Chapter 5: A Map of the Territory
• Chapter 6: The Self Domain: The Need for Emotional Security
• Chapter 7: The Assessment of Suicide Risk
• Chapter 8: Bridging: Engaging With the Self In Crisis
• Chapter 9: The World Domain: Planning Holistic Care
• Chapter 10: The Others Domain: An Anchor In the Social World
• Chapter 11: The Lantern On the Stern: Individual Care
• Chapter 12: All Hands to the Pumps: Group Care
• Chapter 13: Making Waves: Theoretical and Philosophical Undercurrents
• Chapter 14: Origins and Developments: In the Shallows and In the Deep
• Chapter 15: The Voyage from Recovery to Reclamation
• Chapter 16: The Compass: The Ten Commitments
• Epilogue
• Appendix 1: The Holistic Assessment
• Appendix 2: Rating Scale
• Notes
• References