We have to cancel psychiatric nursing and forge a new way forward

Discussion over whether the terms 'mental health nurse' and 'psychiatric nurse' are synonymous or represent divergent nursing perspectives and practices is long-standing. Forchuk (2001) suggested the 'double name' of psychiatric/mental health nursing reflected an ambivalence or duality of purpose, or both. Barker (2001) argued that psychiatric nursing is concerned with addressing the immediate distress and 'disorder' associated with a psychiatric crisis, whereas mental health nursing employs a long-term view, concentrating on assisting individuals to develop ways of living with, overcoming or otherwise recovering from mental health challenges. Cutcliffe (2008) conceptualised psychiatric-mental health nurses as consisting of two distinct groups. One as a subservient discipline, an extension of psychiatry's social control mechanisms, believing mental illnesses to have a neurobiological origin, and thereby placing the problem within the individual. This group regards mental health challenges as 'disorders' that need to be fixed, even by force. Consequently, pharmacological interventions and restrictive practices are de-rigueur for this group. The other group regard mental health challenges as everyday problems of living. A common human experience. This group believes themselves to be a therapeutic agent in supporting individuals to establish meaning and understanding of their problems and to find ways to manage or cope with their mental health challenges, not necessarily a fix or cure. Building therapeutic relationships (regardless of whatever therapeutic approach is applied) is considered critical to this group (Cutcliffe, 2008). Barker and Buchanan-Barker (2011) later questioned whether mental health nursing needs to negotiate a formal separation from the traditional psychiatric family. However, they note that this would require the provision of something distinctly different from psychiatric nursing, "something more health promoting" and therefore more liberating than traditional psychiatric nursing. Cutcliffe et al. (2013) observed that whatever title is used does not necessarily reflect the true nature of clinical practice. For example, the everyday activities of mental health nurses typically have little to do with 'mental health'. However, these authors do acknowledge the argument for mental health nursing to align with principles of mental health promotion and associated social determinants of health. Based on this discussion, 'psychiatric' and 'mental health' nursing are not synonymous or interchangeable. One is concerned with the treatment of illness and 'disorder' from a biomedical perspective, while the other with optimising health and wellbeing through a social determinants' lens. However, nursing must now confront the reality that the biomedical approach to the treatment of mental distress upheld by mainstream psychiatry has been exposed as unfounded. Despite decades of investigation, a neuro-biogenic cause for mental illness has not been explicated. It is now accepted that mental health challenges are predominantly determined by social factors and human experiences of adversity and trauma (United Nations High Commission for Human Rights, UNHCHR, 2019). This leaves the psychiatric/mental health nursing profession with a predicament that needs to be resolved, albeit one that could be emancipatory for nursing. What we know is there is no established pathophysiology, disease process or identifiable biomarkers associated with any psychiatric diagnosis. There are no blood tests or scans. There is no 'chemical imbalance' of the brain. Psychiatric diagnoses rely purely on a subjective assessment of 'symptoms' and broad diagnostic criteria. Indeed Nour et al. (2022) concluded that despite years of intense (and costly) neuroimaging research, there is still no neurobiological account for any psychiatric condition. Similarly, Torrey (2023) has surmised that not a single gene has been found that can be causally linked to 'schizophrenia' and disconcertingly the research in this field has yielded no improvements in treatments. Psychiatric diagnoses are not scientific facts. By illustration, when the DSM-5 field trials, were conducted across eleven academic psychiatric centres in Canada and the USA, the pooled degree of agreement for the diagnosis of 'major depressive disorder' and 'generalized anxiety disorder' were categorised as questionable. The diagnoses 'bipolar disorder', 'schizophrenia' and 'borderline personality disorder' were all categorised as good. Only 'PTSD' achieved a very good level of agreement (Regier et al., 2013). This was hardly a resounding endorsement of diagnostic validity, and scarcely cause for celebration (Scull, 2021). Racial, gender and socio-economic disparities are also evident in psychiatric labels. For example, in the USA, African American men are four times more likely to be given a diagnosis of 'schizophrenia' than their white male counterparts, and Latino men three times more likely (Schwartz & Blankenship, 2014). Women represent 75% of those diagnosed with 'borderline personality disorder' (Nicki, 2016). Regarding the label du jour, Attention Defecit Hyperactivity Disorder (ADHD), the youngest children in a school year, and those from disadvantaged backgrounds, are considerably more likely to be diagnosed with and/or medicated for "ADHD" than their classmates (Batstra et al., 2023). Growing doubts and concerns are now evident about the efficacy and associated iatrogenic harms of psychiatric treatments. Most notably antidepressants, which are widely prescribed internationally, have had their fundamental justification for mechanism of action 'the serotonin hypothesis for depression' debunked (Moncrieff et al., 2022). Meanwhile, there is increasing recognition of their side effect burden which include weight gain, cardiovascular problems, sexual dysfunction, protracted withdrawal and increased suicidality (Hengartner & Plöderl, 2019; Horowitz et al., 2023). It is posited that antipsychotic drugs do hold short-term benefits, however, there is mounting evidence of poorer outcomes for people exposed to antipsychotics long-term such as obesity, diabetes, cardiovascular disease, lipid abnormalities, arrythmias, myocarditis, changes in brain structure and function, and elevated mortality rates (Bergström & Gauffin, 2023; Pillinger et al., 2020; Voineskos et al., 2020; Whitaker, 2020). Another mainstay of psychiatric treatment internationally has also seemingly failed the effectiveness test. Read et al. (2019) concluded that "there is no rigorous evidence whatsoever" that Electroconvulsive therapy (ECT) has any benefit for the three conditions for which it is primarily recommended, while the US Food and Drug Administration (United States Food and Drug Administration, 2020) has warned that the long-term safety and effectiveness of ECT has not been demonstrated. A recent randomised, double-blind, sham-controlled trial to evaluate the efficacy of ECT in people with so-called "clozapine-resistant schizophrenia" found no evidence that ECT is better than sham-ECT for this patient group (Melzer-Ribeiro et al., 2023). Restrictive and coercive practices remain commonplace in mental health services and nurses are routinely complicit in engaging in such practices. Yet, the lowest proportions of people reporting a positive experience of mental health care are those subjected to involuntary inpatient hospital stays (Loughhead et al., 2023). There is overwhelming evidence that restrictive practices such as physical and chemical restraint and seclusion cause significant psychological distress and harm including feeling threatened, dehumanised, fearful, angry, anxious and re-traumatised (Bendall et al., 2022; Butterworth et al., 2022). This is despite the clinical effectiveness of restrictive practices in treating 'serious mental disorders' not being supported by available scientific evidence (Zaami et al., 2020). The negative effects of restrictive practices are not just confined to the hospital setting. A meta-analysis and meta-regression of community treatment order (CTO) usage conducted by Kisely et al. (2023) found there is no evidence that CTOs reduce bed-days or admissions or that they address the issue of the 'revolving door'. Moreover, the review found that people from a migrant background were 47% more likely to be subjected to CTOs. People on CTOs report feeling disempowered, stigmatised and insufficiently informed on the reasons for being placed under an order (Brophy et al., 2019). It is curious that despite the lack evidence to support psychiatry's scientific legitimacy and paternalistic practices, psychiatric discourse continues to maintain its authority and power (Crowe, 2022). The fact that a burgeoning and vocal psychiatric survivor movement exists, with claims of abuse from psychiatrists and mental health services, and that exposure to psychiatric treatments has left people harmed and traumatised (Adame et al., 2017), should prompt humbled reflection from nurses on how their 'care' and practices have contributed to this stance. It should also provoke collective motivation for change. With the recognition (even amongst many psychiatrists) that mainstream psychiatry's focus on neurobiological and genetic causes for mental illness and their associated diagnoses and treatments amounts to faith-based pseudoscience (Timimi, 2015), it is surely time to cancel 'psychiatric nursing' and unite under one professional title. It is simply untenable to justify the continued use of the term 'psychiatric nurse', proposed by Cutcliffe et al. (2013) as oxymoronic. As Barker and Buchanan-Barker (2011) suggested, mental health nursing should now establish an independent professional identity and negotiate a different relationship with mainstream psychiatry. However, this will require something much more meaningful than simply aligning under one title. There needs to be substance, conviction and purpose, and a willingness to collectively challenge the status quo. Responding to the needs of people in mental distress (rather than mechanically assessing their risks) must become the focus for mental health nursing. This will require mental health nurses to question traditional alliances and practices and be prepared to have uncomfortable interactions with colleagues. For example, Gadsby and McKeown (2021) acknowledge that enforcing pharmaceutical interventions is viewed by many recipients as a physical assault and experienced as degrading and humiliating. They discuss the rights of nurses to conscientiously object to forced pharmaceutical intervention, given questions over the effectiveness of psychotropic drugs and concerns for physical and psychological harms associated with this practice. Within the context of complex interlocking professions and systems this would entail robust discussion, a commitment to critical thinking, teamwork, nursing unity and mutual support, as the potential exists for teams or systems to vilify or sanction an objecting nurse. While these authors concede that nurses opposed to enforcing psychotropic drugs on people can simply leave acute wards or community teams and work in other roles, this removes critically engaged nurses where they might be influential, perhaps promoting human rights and more reflective practice, leaving only nurses prepared to do the 'dirty work of psychiatry' (Gadsby & McKeown, 2021). There is plenty of guidance on the way forward for mental health nursing. For some years the UNHCHR has advocated for reform of mental health care, opining that the status quo, preoccupied with biomedical interventions, including psychotropic drugs and non-consensual measures, is no longer defensible in the context of improving mental health (United Nations General Assembly, 2017). The global body has warned against unsophisticated "screen and intervene" approaches that prioritises "ineffective practices" such as involuntary hospitalisation and the excessive use of antidepressants, over practices based on contemporary public health and human rights principles (United Nations High Commission for Human Rights, 2019). A recent report co-published by the World Health Organisation and the UNHCHR titled 'Mental health, human rights and legislation' (World Health Organization and the United Nations, 2023) advocates for a seismic shift in in mental health care. This necessitates a transition away from a narrow emphasis on biomedical approaches towards a more holistic and inclusive understanding of mental health. Mental health and well-being are strongly associated with social, economic, and physical environments, as well as poverty, violence, and discrimination. However, most mental health systems focus on diagnosis, drugs, and symptom reduction, neglecting the social determinants that affect people's mental health. The report reminds us there are diverse ways of being, thinking, sensing, expressing, and making sense of the world. There is no "normal" or "right" way to be and therefore people should be able to exercise their right to give free and informed consent to accept or reject treatment in mental health systems. Legislation should also require health professionals to inform people about their right to discontinue treatment and to receive support in this. Support should be provided to help people safely withdraw from treatment with drugs (World Health Organization and the United Nations, 2023). A starting point for refashioning mental health nursing is to focus on what people want from mental health nurses. Greater involvement in decisions about their care and the critical importance of the therapeutic relationship and human connection have been repeatedly highlighted (Horgan et al., 2021; Lakeman et al., 2023; Newman et al., 2015; Wand et al., 2022) along with attention to an individual's unique needs, preferences, circumstances and goals, recognising the importance of self-determination, empowerment, and cultural values (Loughhead et al., 2023). With patient-centered care the cornerstone of contemporary healthcare, it makes no sense for 'treatment' or 'management' plans, and clinical practice guidelines to be based on whatever unscientific label has been attributed to an individual. There is no homogeneity in psychiatric labels. People are not their diagnosis. The educational preparation of mental health nurses will need to change. Mental health conditions have historically been portrayed as problems residing in the individual. The aim being to "cure" or "fix" the person so that they could become "normal", rather than promoting social change, diversity and inclusion (World Health Organization and the United Nations, 2023). The United Nations High Commission for Human Rights (2019) contend that mental health education has over-relied on the biomedical model to explain mental distress and to prioritise pharmacological interventions. The education of the mental health workforce should be adapted to emphasise the social and underlying determinants of health and equip health-care workers with the attitudes, knowledge and skills necessary to build relationships and avoid the inherent paternalism of the mental health system (United Nations High Commission for Human Rights, 2019). Mental health nursing could take inspiration from Lifestyle Medicine training which is based on three core principles; an understanding of the socioeconomic determinants of health, an emphasis on behaviour change skills and support for the six pillars of Lifestyle Medicine. These six pillars are; mental well-being, healthy relationships, healthy eating, restful sleep, physical activity and avoidance of harmful substances and behaviours. Key approaches in Lifestyle Medicine include person-centered care, health coaching, social prescribing, and the use of group consultations (Fallows et al., 2023). Instead of staffing clozapine and depot clinics, mental health nurses could establish deprescribing services and programs aimed at informing and supporting people to safely and carefully reduce and potentially completely cease their psychotropic drugs. This could be undertaken in collaboration with people from a lived experience and diverse consumer and survivor backgrounds and colleagues from medicine, nutrition and dietetics, exercise science and pharmacology. A collaborative approach is essential to create a mental health system that respects human rights, prioritises care and support over control, and supports individuals in achieving their full potential (World Health Organization and the United Nations, 2023). There is also a need for mental health nurses to be actively engaged at the community and population health level addressing social determinants, treatment choice, and support for living a contributing life (Daya et al., 2020). The task ahead and the transformation required is not for the faint-hearted. Although maintaining the status quo poses ethical challenges for mental health nursing. Doing and saying nothing is not an option, and the International Council of Nurses (2021) code of ethics upholds the right to conscientiously object to participating in a particular procedure. There is clearly a case for broadening the right to conscientious objection to a range of psychiatric treatments and paternalistic interventions in support of evidence-based practice. Once 'psychiatric nurse' goes in the bin we can commence the process of adding true meaning and purpose to the title and the work of mental health nurses. Although mainstream psychiatry continues to enjoy considerable political influence and public trust, the sheer weight of evidence disproving its foundations, leaves it on shaky ground. As Timimi (2020 p. 300) stated, whether it takes 5 or 50 years, 'the medical model in mental health is an unsustainable busted flush'. Mental health nursing would be wise to distance themselves from mainstream psychiatry now, before this reckoning arrives. Timothy Wand is an Editorial Board Member of the IJMHN. He reports no other competing interests. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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