Nancy Brookes
The tidal model of mental health recovery
“Mental illnesses or psychiatric disorders are ‘problems of human living’ people find it difficult to live with themselves or to live with others in the social world. A simple idea that becomes complicated when we try to engage with it. Nurses try to help people address these problems of living, in an effort to live through them. Another simple idea, that becomes complicated at the level of practice. All is paradox”
(Personal communication, February 23, 2008).
Phil Barker
Background and credentials of the theorist
Phil Barker was born in Scotland by the sea, and thus began the influence of and interest in water, the ultimate metaphor of life (Barker, 1996a). He credits his father and grandfather with “the warmth of nurture and the discipline of boundaries,” who helped him appreciate that “life was an answer waiting for the right question,” and he, like them, became a philosopher (Barker, 1999b, p. xii). Life in this context contributed to his enduring curiosity and interest in the philosophy of the everyday, which resonate throughout the Tidal Model.
Barker trained as a painter and sculptor in the mid-1960s, and he won the prestigious Pernod Award for Young Painters in 1974. By this time, he had already become a psychiatric nurse. He continues to paint word pictures in metaphor. Barker credits art school with introducing him to “learning from Reality,” the reality of experience, which became the focus of his philosophical inquiries. His fascination with Eastern philosophies, which began at art school, flows through the Tidal Model with echoes of chaos, uncertainty, change, and the Chinese idea of crisis as opportunity. This early involvement in the arts also helps to explain Barker’s view of nursing as “the craft of caring” (Barker, 2000c, 2000e; Barker & Whitehill, 1997).
Following art school, Barker worked as a commercial artist and mural painter, supplementing his income with laboring work on the railroads and in factories. After a gap of more than 30 years, Barker returned to painting in 2006 and has become a successful, award-wining artist (see: www.mcloughlinart.com).
Barker’s “ocean of experience” surged in a new direction in 1970, when he took a position as an “attendant at the local asylum.” His fascination with the human dimension, the lived experience, and the stories of people challenged by mental distress prompted him to relocate his interest in the arts and humanities to nursing.
Barker’s early progress through nursing, although unusual, was typical of the times and the context. Soon after qualifying in 1974, Barker began to study and practice various psychotherapies such as cognitive behavioral therapy, and family and group therapy. His doctoral research, begun in 1980, featured cognitive behavioral work with a group of women living with depression (Barker, 1987). However, around this time, Barker became uncomfortable with the application of therapies to people experiencing problems in living, and the “uncertainty principle” resurfaced for him. His curiosity about life and persons provoked questions about the resilience and integrity of the people with whom he was working. Instead of “caring for” or “treating,” them, he was learning what it meant to experience distress from the people themselves. He wondered what recovery meant to people. Questions re-emerged around the following:
During his tenure as Professor of Psychiatric Nursing Practice at the University of Newcastle begun in 1993, these questions framed his research agenda and culminated in the development of the Tidal Model.
As the UK’s first Professor of Psychiatric Nursing Practice, Barker broke the conventional “academic” mold by maintaining his involvement in practice. This involvement led directly to the development of the Tidal Model. Throughout his nursing career, Barker has wondered about the proper focus of psychiatric nursing and the role of care, compassion, understanding, and courage in helping people who are experiencing extreme distress, loss of self, or spiritual crisis (Barker, 1999b). The Tidal Model was developed within this context and history. The “story knowledge” base lies at the heart of the Tidal Model. (Barker dislikes the use of the term narrative, which he prefers to call story). Barker has published in the area of psychiatric and mental health nursing since 1978. A prolific writer, he has published 19 books, over 50 book chapters, and more than 150 academic papers. He was Assistant Editor for the Journal of Psychiatric and Mental Health Nursing for a decade. Barker became a Fellow of the Royal College of Nursing (UK) in 1995, only the fourth psychiatric nurse to be so honored. He received the Red Gate Award for Distinguished Professors at the University of Tokyo in 2000. In 2001, he received an Honorary Doctorate from Oxford Brookes University in England, and a room was named in his honor at the Health Care Studies Faculty at Homerton College in Cambridge. Barker has held visiting professorships at international universities in Australia (Sydney), Europe (Barcelona), and Japan (Tokyo). From 2002 to 2007, he was Visiting Professor at Trinity College in Dublin. In 2006, he received the inaugural “Lifetime Achievement Award” from Blackwell journals, publishers of the Journal of Psychiatric and Mental Health Nursing. In 2008, he shared with his wife Poppy Buchanan-Barker the Thomas Szasz Award for Contributions to Civil Liberties at New York University.
With his wife and professional partner, Poppy Buchanan-Barker, Barker has conducted recovery-focused workshops and seminars in Australia, Canada, New Zealand, Japan, Finland, Denmark, Turkey, Germany, Ireland, and the United Kingdom. A popular commentator on the human condition, Barker brings to radio, television, and the popular press his passion for and curiosity about the recovery process and personhood.
Barker is currently an Honorary Professor at the University of Dundee in Scotland and a psychotherapist in private practice. He and Poppy Buchanan-Barker have further developed the recovery paradigm at Clan Unity, their international mental health recovery and reclamation consultancy in Scotland.
Theoretical sources
The Tidal Model is focused on the fundamental care processes of nursing, is universally applicable, and is a practical guide for psychiatric and mental health nursing (Barker, 2001b). The theory is radical in its reconceptualization of mental health problems as unequivocally human, rather than psychological, social, or physical (Barker, 2002b). The Tidal Model “emphasizes the central importance of developing understanding of the person’s needs through collaborative working, developing a therapeutic relationship through discrete methods of active empowerment, establishing nursing as an educative element at the heart of interdisciplinary intervention” (Barker, 2000e, p. 4) and seeks to resolve problems and promote mental health through narrative approaches (Stevenson, Barker, & Fletcher, 2002).
The Tidal Model is a philosophical approach to recovery of mental health. It is not a model of care or treatment of mental illness, although people described as mentally ill do need and receive care. The Tidal Model represents a worldview, helping the nurse begin to understand what mental health might mean for the person in care, and how that person might be helped to begin the complex voyage of recovery. Therefore, the Tidal Model is not prescriptive. Rather, a set of principles, the Ten Tidal Commitments, serve as a metaphorical compass for the practitioner (Buchanan-Barker & Barker, 2005, 2008). They guide the nurse in developing responses to meet the individual and contextual needs of the person who has become the patient. The experience of mental distress is invariably described in metaphorical terms. The Tidal Model employs the universal and culturally significant metaphors associated with the power of water and the sea, to represent the known aspects of human distress. Water is “the core metaphor for both the lived experience of the person …. and the care system that attempts to mold itself around a person’s need for nursing” (Barker, 2000e, p. 10).
Barker describes an “early interest in the human content of mental distress …. and an interest in the human (phenomenological) experience of distress,” which is viewed in contexts and wholes rather than isolated parts (Barker, 1999b, p. 13). The “whole” nature of being human is “re-presented on physical, emotional, intellectual, social and spiritual planes” (Barker, 2002b, p. 233). This phenomenological interest pervades the Tidal Model with an emphasis on the lived experience of persons, their stories (replete with metaphors), and narrative interventions. Nurses carefully and sensitively meet and interact with people in a “sacred space” (Barker, 2003a, p. 613).
A feature of Barker’s nursing practice has been his exploration of the possibilities of genuine collaborative relationships with users of mental health services. In the 1980s, he developed the concept of “caring with” people, learning that the professional-person relationship could be more “mutual” than the original nurse-patient relationship defined by Peplau (1969). Barker further developed this concept during the 1990s in a working relationship with Dr. Irene Whitehill and others who used mental health services (Barker & Whitehill, 1997). This led to the “need for nursing” and “empowerment” studies as well as a commitment to publish the stories of people’s experience of madness, and their voyage of recovery, complete with personal and spiritual meanings (Barker, Campbell and Davidson, 1999; Barker, Jackson, & Stevenson, 1999a; Barker & Buchanan-Barker, 2004b). Barker enlisted the support of Dr. Whitehill and other “user/consumer consultants,” to evaluate “user friendly” qualities of the original processes of the Tidal Model. This involvement of “user/consumer consultants” is seen in several ongoing projects and represents a distinctive feature of continued development of the Tidal Model.
Barker’s long-standing appreciation of Eastern philosophies pervades his work. The work of Shoma Morita is a specific example of how the philosophical assumptions of Zen Buddhism were integrated with psychotherapy (Morita, Kondo, Levine, & Morita, 1998). Morita’s dictum—”Do what needs to be done”—resonates in many of the practical activities of the Tidal Model. In contrast to the zealous “problem-solving” attitude embraced by much of Western psychiatry and psychology, Morita believed that it was futile to try to “change” oneself or one’s “problems,” which come and go like the weather. Instead, the focus should be on answering the questions:
People have the capacity to live and grow through distress, by doing what needs to be done. For people who are in acute distress, especially when they are at risk to self or others, it is vital that nurses relate directly to the person’s ongoing experience. Originally Barker called this process engagement, but he has since redefined the specific interpersonal process as bridging, a supportive human process necessary to reach out to people in distress. This emphasizes the need to build, creatively, a means of reaching the person; crossing in the process, the murky waters of mental distress (Barker & Buchanan-Barker, 2004b).
The Tidal Model may be viewed through the lens of social constructivism, recognizing that there are multiple ways of understanding the world. Meaning emerges through the complex webs of interaction, relationships, and social processes. Knowledge does not exist independently of the knower, and all knowledge is situated (Stevenson, 1996). Change is the only constant, as meaning and social realities are constantly renegotiated or constructed through language and interaction. Barker believes “all I am is story; all I can ever be is story.” As people try to explain to others “who” they are, they tell stories about themselves and their world of experience, revising, editing, and rewriting these stories through dialogue. Barker first discussed this idea with his mentor, Hilda (Hildegard) Peplau in 1994, who agreed that “people make themselves up as they talk” (Barker, 2003a; Barker & Buchanan-Barker, 2007b).
Barker credits many thinkers with influencing his work, beginning with Annie Altschul and Thomas Szasz. His view of mental health problems as problems of living popularized by Szasz (1961, 2000) and later Podvoll (1990) is a perspective he prefers to diagnostic labeling and the biomedical construction of people and illness (Barker, 2001c, p. 215). He agrees with Szasz that it is futile to try to “solve problems in living.” Life is not a problem to be solved. Life is something to be lived, as intelligently, as competently, as well as we can, day in and day out (Miller, 1983, p. 290). The challenge for nursing is to help persons live “intelligently” and “competently.”
Travelbee’s (1969) concept of the Therapeutic Use of Self flows through the Tidal Model and provides an anchor for the “proper focus of nursing.” The following three main theoretical frameworks underpin the Tidal Model:
1. Peplau’s (1952; 1969) Interpersonal Relations Theory
2. Theory of Psychiatric and Mental Health Nursing derived from the Need for Nursing studies
The pragmatic emphasis on strength-based, solution-focused approaches acknowledges the important influence of Steve de Shazer’s solution-focused therapy, although, as noted above, Barker does not believe that there can be any “solutions” for problems in living, merely pragmatic strategies for living with such problems. The influence of Denny Webster and her colleagues in Denver in the early 1990s, introducing de Shazer’s ideas into nursing practice, significantly shaped the development of the Tidal Model (Webster, Vaughn, & Martinez, 1994).The Tidal Model draws its core philosophical metaphor from chaos theory, where the unpredictable yet bounded nature of human behavior and experience can be compared to the flow and power of water (Barker, 2000b, p. 54). In constant flux, the tides ebb and flow; they exhibit nonrepeating patterns yet stay within bounded parameters (Vicenzi, 1994). Barker (2000b) acknowledges the “complexity [of] both the internal universe of human experience and the external universe, which is, paradoxically, within and beyond the individual, at one and the same time” (p. 52). Within this complex, nonlinear perspective, small changes create later unpredictable changes; a hopeful message that directs nurses and persons to identify small changes and variations. Chaos theory suggests that there are limits to what we can know, and Barker invites nurses to cease the search for certainty, embracing instead the reality of uncertainty. Know that “change is constant,” one of the Ten Tidal Commitments, identifies and celebrates change in people, circumstances, relationships, and organizations (Barker, 2003b; Buchanan-Barker & Barker, 2008). This perspective also presents challenges in trying to understand people, relationships, and situations. It directs inquiry in qualitative, nonlinear ways, such as action research, grounded theory, phenomenology, and critical theory (Barker, 1999a).
Annie Altschul, the Grande Dame of British psychiatric nursing (Barker, 2003a, p. 12), along with Hilda (Hildegard) Peplau, was one of Barker’s mentors. Altschul’s influence, especially her early appreciation of system theory, is evident in the Tidal Model, as is her interest in understanding rather than explaining mental distress and her belief that people need more straightforward help than many psychiatric theories suggest.
Barker credits Peplau, the mother of psychiatric nursing, with his becoming “an advocate for nursing as a therapeutic activity in its own right” (Barker, 2000a, p. 617). Peplau introduced her interpersonal paradigm for the study and practice of nursing in the early 1950s and defined nursing as “a significant, therapeutic, interpersonal process” (Peplau, 1952, p. 16). A defining characteristic of the Tidal Model is emphasis on story in the person’s own voice.
The empirically derived empowering interactions framework suggests that improvement in the person’s situation and lifestyle is possible, building on strengths is better than focusing on problems, collaboration is key, participation is the way, and self-determination is the ultimate goal (Barker & Buchanan-Barker, 2004a; Barker, Stevenson & Leamy, 2000). Eight respectful, empowering interactions bring generally invisible nursing interactions into the practice arena (Michael, 1994). De Shazer’s (1994) influence is evident as he asserts that change and intervention “boils down to stories about the telling of stories, the shaping and reshaping of stories so that troubled people change their story” (p. xvii).
The strength base of the Tidal Model emphasizes searching for and revealing solutions, and identifying resources. The theory integrates the need for nursing studies, collaboration, empowerment, interpersonal relationships, story, strengths-base, and solution-seeking approaches, and is systemic. In the holistic assessment, nurses explore the person’s present ‘problems’ or ‘needs’, the scale of these problems/needs, what is currently in a person’s life that might help to resolve problems or meet needs, and what needs to happen to bring about change (Barker, 2000e; Barker & Buchanan-Barker, 2007a). Nurses help identify and mobilize persons’ strengths and resources, and the person’s goals direct the work of the health care team (Barker, 2000e; Stevenson, Jackson, & Barker, 2003). The Ten Tidal Commitments support this perspective and direction (Box 32–1).
This is a significant reframing of the view of the person-in-care and the proper focus of nursing.
MAJOR CONCEPTS & DEFINITIONS
The theoretical basis of the tidal model*
The Tidal Model begins from four simple, yet important starting points:
The three domains: A model of the person*
In the Tidal Model, the person is represented by three personal domains: Self, World, and Others. A domain is a sphere of control or influence, a place where the person experiences or acts out aspects of private or public life. Simply, a domain is a place where one lives.
The domains are like the person’s home address. Their house or flat has several rooms, but the person is not found in each of these rooms all the time; rather the person is sometimes in one room, and sometimes in another. The personal domains are similar. Sometimes the person is mainly in the Self Domain, and at other times the person is mainly in the World or Others Domain.
The Self Domain is the private place where the person experiences thoughts, feelings, beliefs, values, and ideas that are known only to the person. In this private world, the distress called “mental illness” is first experienced. All people keep much of their private world secret, only revealing to others what they wish them to know. This is why people are often such a “mystery” to us, even when they are close friends or relatives.
In the Tidal Model, the Self Domain becomes the focus of our attempts to help the person feel “safe” and “secure,” where we try to help the person address and begin to deal with the private fears, anxieties, and other threats to emotional stability related to specific problems of living. The main focus is to develop a “bridging” relationship and to help the person develop a meaningful Personal Security Plan. This work is the basis for development of the person’s “self-help” program, which will sustain the person on return to everyday life. The World Domainis the place where the person shares some of the experiences from the Self Domain, with other people, in the person’s social world. When people talk to others about their private thoughts, feelings, beliefs, or other experiences known only to them, they go to the World Domain.
In the Tidal Model, the World Domain is the focus of our efforts to understand the person and the person’s problems of living. This is done through the use of the Holistic Assessment. At the World Domain, we try to help the person begin to identify and address specific problems of living on an everyday basis through use of dedicated One-to-One Sessions.
The Others Domain is where the person acts out everyday life with other people, such as family, friends, neighbors, work colleagues, and professionals. The person engages in different interpersonal and social encounters that may be influenced by others, and may—in turn—influence others. The organization and delivery of professional care and other forms of support is in the Others Domain. However, the key focus of the Tidal Model is dedicated forms of group work—Discovery, Information-Sharing, and Solution-Finding.
By participating in these groups, the person develops awareness of the value of social support, which can be received from and given to others. This becomes the basis of the person’s appreciation of the value of mutual support, which can be accessed in everyday life.
Water—a metaphor†
The Tidal Model emphasizes 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 intact or the person has regained his or her sea legs, the journey can begin again as the person sets his or her course on the ocean of experience.
This metaphor illustrates many of the elements of a 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 a “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 an acute psychiatric unit. A proper “psychiatric rescue” should be akin to “lifesaving” and should lead the person to a genuine “safe haven,” where necessary human repair work can take place.
Guiding principles‡
Getting in the swim—engagement beliefs§
When people are in serious distress, they often feel as if they are drowning. In such circumstances, they need a “lifesaver.” Of course, lifesavers need to engage with the person—they need to get close—to begin the rescue process. To get in the swim and to begin the engagement process, we need to believe the following:
■ That change is inevitable—nothing lasts
■ That ultimately, people know what is best for them
■ That people possess all the resources they need to begin the recovery journey
■ That the person is the teacher, and we, the helpers, are the pupils
■ That we need to be creatively curious to learn what needs to be done to help the person now!
Therapeutic philosophy
Continuum of care¶
As needs flow with the person across artificial boundaries, care is seamless with the intention of the person returning his or her “ocean of experience” within his or her own community. Across the care continuum, people may need critical or immediate, transitional or developmental care. Practical immediate care addresses searching for solutions to the person’s problems, generally in the short term, and focuses upon “what needs to be done, now.” People enter the care continuum for immediate care when experiencing an initial mental health crisis, possibly entering the mental health system for the first time or with people familiar with the system when a crisis occurs. Transitional care addresses the smooth passage from one setting to another, when the person is moving from one form of care to another. Here, nursing responsibilities include liaising with colleagues and ensuring the person’s participation in the transfer of care. The other end of the continuum is developmental care, where the focus is on more intensive and longer-term support or therapeutic intervention (See Figure 32–4).
*Barker, P. J., & Buchanan-Barker, P. (2007a). The Tidal Model: Mental health recovery and reclamation. Newport-on-Tay, Scotland: Clan Unity International.
†From Barker, P. J. (2000d). The Tidal Model—Humility in mental health care. Retrieved from http://www.tidal-model.com/Humility%20in%20mental%20health%20care.htm
‡Retrieved from www.tidal-model.com/Clarifying%20the%20value%20base%20of%20the%20Tidal%29Model.htm
§Barker, P. J. & Buchanan-Barker, P. (2004). Beyond empowerment: Revering the storyteller. . Mental Health Practice, 7(5), 18–20.
||From Barker, P. J., & Buchanan-Barker, P. (2007a). The Tidal Model: Mental health recovery and reclamation. (pp. 30–31). Newport-on-Tay, Scotland: Clan Unity International.
¶From Barker, P. J. (2000e). The Tidal Model Theory and practice. (pp. 22–24). Newcastle, UK: University of Newcastle.
Use of empirical evidence
Barker’s long-standing curiosity about the nature and focus of psychiatric nursing and the stories of persons-in-care led to the development of a theoretical construction of psychiatric nursing, or a metatheory, that could be further explored through empirical inquiry (Barker, Reynolds, & Stevenson, 1997, p. 663). Over 5 years, from 1995, the Newcastle and North Tyneside research team developed an understanding of what people experiencing problems in living might need from nurses and began using their emergent findings in 1997 as the basis for development of the Tidal Model.
Barker supports learning from, using, and integrating extant theory and research, as well as the experience of reality—”evidence from the most ‘real’ of real worlds” (Barker & Jackson, 1997). An example is the “need adapted” approach to caring with people living with schizophrenia developed from Alanen’s studies in Finland. One understanding that underpins Alanen’s work and flows through the Tidal Model is that people and their families need to think of admission to a psychiatric facility as a result of problems of living they have encountered and not as a mysterious illness that is within the patient (Alanen, Lehtinen, & Aaltonen, 1997).
The power of the nurse-patient relationship demonstrated through Altschul’s pioneering research in the early 1960s and Peplau’s paradigm of interpersonal relationships contribute to the empirical base of the Tidal Model. Altschul’s study of nurse-patient interaction in the 1960s provides empirical support for the complex, yet paradoxically “ordinary” nature of the relationship (Barker, 2002a). Altschul’s study of community teams in the 1980s raised questions about the “proper focus of nursing” and the “need for nursing,” and both Altschul and Peplau provided evidence related to interprofessional teamwork.
Two of Barker’s theory-generating studies provided the empirical base for the Tidal Model. The “need for nursing” studies (Barker, Jackson, & Stevenson, 1999a, 1999b) examined the perceptions of service users, significant others, members of multidisciplinary teams, and nurses, and it sought to clarify discrete roles and functions of nursing within a multidisciplinary care and treatment process and to learn what people value in nurses (Barker, 2001c, p. 215). They demonstrated that professionals and persons-in-care wanted nurses to relate to people in ordinary, everyday ways. There was universal acceptance of special interpersonal relationships between nurses and persons, echoing Peplau’s (1952) work. “Knowing you, knowing me” emerged as the core concept in these studies. The nurse is expected to know what the person wants even if it is not verbalized or is not clear, and needs are constantly changing (Jackson & Stevenson, 2004, p. 35). Professional nursing performance is described in three roles identified as (1) ordinary-me, (2) pseudo-ordinary/engineered-me, and (3) professional-me. Relationships are fluid, requiring nurses to “toggle” or switch back and forth from highly professional to distinctly ordinary presentations of self, and all relationships differ depending upon the required role (Jackson & Stevenson, 1998, 2000). The “pseudo-ordinary or engineered-me is likened to a see-saw” (Jackson & Stevenson, 2004, p. 41). Sometimes people need someone to take care of them, other times someone to take care with them (Barker, Jackson, & Stevenson, 1999a; 1999b). The studies suggested that nurses respond sensitively to persons’ and their families’ rapidly fluctuating human needs. They need to “tune in to what needs to be done now,” to meet the person’s needs (Barker, 2000e). Nurses are translators for the person to the treatment team and the “glue” that holds the system together (Stevenson & Fletcher, 2002, p. 30).
The second study focused on the nature of empowerment and how this is enacted in relationship between nurses and persons-in-care and resulted in the Empowering Interactions Model (Barker, Stevenson, & Leamy, 2000). This was developed with Flanagan’s Critical Incident Technique (Flannagan, 1954) within a cooperative inquiry method (Heron, 1996), using a modified grounded theory approach (Glaser & Strauss, 1967). The study developed Peplau’s assumptions about the importance of specific interpersonal transactions, and it provided guidance and strategies for nurses within collaborative nurse-person relationships. Strategies included the following:
• Being respectful of people’s knowledge and expertise about their own health and illness
• Putting the person in the driver’s seat in relation to the interaction
• Seeking permission to explore the person’s experience
• Valuing the person’s contribution
• Being curious as a way of validating the person’s experience
• Finding a common language to describe the situation
• Reviewing collaboratively, and inspiring hope through designing a realistic future together
Major assumptions
Two basic assumptions underpin the Tidal Model. First, “change is the only constant.” Nothing lasts. All human experience involves flux, and people are constantly changing. This suggests the value of helping people become more aware of how change is happening within and around them in the “now” (Barker & Buchanan-Barker, 2004a). Second, people are their stories. They are no more and no less than the complex story of their lived experience. The person’s story is framed in the first person, and the story of how they came to be here experiencing this ‘problem of living’ contains the raw material for solutions (Barker & Buchanan-Barker, 2004a).
The Tidal Model rests on the following assumptions:
• There are such “things” as psychiatric needs.
• Nursing might in some way meet those needs (Barker & Whitehill, 1997, p. 15).
• Persons and those around them already possess the solutions to their life problems.
• Nursing is about drawing out these solutions (Barker, 1995, p. 12).
The Tidal Model assumes that when people are caught in the psychic storm of “madness,” it is “as if” they risk drowning in their distress or foundering on the rocks; it is “as if” they have been boarded by pirates and have been robbed of some of their human identity; it is “as if” they have been washed ashore on some remote beach, far from home and alienated from all that they know and understand.
Nursing
“Nurses are involved in the process of working with people, their environments, their health status and their need for nursing” (Barker, 1996a, p. 242). Nursing is continuously changing, internally and in relation to other professions, in response to changing needs and changing social structures. “If any one thing defines nursing, globally, it is the social construction of the nurse’s role” (Barker, Reynolds, & Ward, 1995, p. 390). Nursing as nurturing exists only when the conditions necessary for the promotion of growth or development are put in place (Buchanan-Barker & Barker, 2008). Nursing is “an enduring human interpersonal activity and involves a focus on the promotion of growth and development” (Barker & Whitehill, 1997, p. 17) and present and future direction (Barker & Buchanan-Barker, 2007a). Barker extended Peplau’s original definition, clarifying the purpose of nursing as trephotaxis from the Greek: “the provision of the necessary conditions for the promotion of growth and development” (Barker, 1989, 2009). He emphasizes the distinction between “psychiatric” and “mental health” nursing. When nurses help people explore their distress, in an attempt to discover ways of remedying or ameliorating it, they are practicing psychiatric nursing. When nurses help the same people explore ways of growing and developing, as persons, exploring how they presently live with and might move beyond their problems of living, they are practicing mental health nursing. (Barker, 2003a; 2009).
Nursing is a human service offered by one group of human beings to another. There is a power dynamic in the “craft of caring,” one person has a duty to care for another (Barker, 1996b, p. 4). Nursing is a practical endeavor focused on identifying what people need now; collaboratively exploring ways of meeting those needs; and developing appropriate systems of human care (Barker, 1995, 2003a). The proper focus of nursing is the “need” expressed by the person-in-care, which “can only be defined as a function of the relationship between a person-with-a-need-for-nursingand a person-who-has-met-that-need”. (Barker, 1996a, p. 241; Barker, Reynolds, & Ward, 1995, p. 389). These responses are the phenomenological focus of nursing (Barker, Reynolds, & Ward, 1995, p. 394; Peplau, 1987); a focus on human responses to actual or potential health problems (American Nurses Association, 1980). These may range across behavior, emotions, beliefs, identity, capability, spirituality, and the person’s relationship with the environment (Barker, 1998a).
Nursing’s exploration of the human context of being and caring supports nursing as a form of human inquiry. Being with and caring with people is the process that underpins all psychiatric and mental health nursing, and this process distinguishes nurses from all other health and social care disciplines (Barker, 1997). “Nursing complements other services and is congruent with the roles and functions of other disciplines in relation to the person’s needs” (Barker, 2001c, p. 216).
Person
Within the Tidal Model, interest is directed toward a phenomenological view of the person’s lived experience, and his or her story. “Persons are natural philosophers and meaning makers devoting much of their lives to establishing the meaning and value of their experience and to constructing explanatory models of the world and their place in it” (Barker, 1996b, p. 4). Nurses are able to see and appreciate the world from the person’s perspective and share this with the person. People are their stories. “The person’s sense of self and the world of experience, including the experience of others is inextricably tied to their life stories and the various meanings they have generated” (Barker, 2001c, p. 219). People are in a constant state of flux, with great capacity for change (Buchanan-Barker & Barker, 2008) and engaged in the process of becoming (Barker, 2000c). They live within their world of experience represented in three dimensions: (1) world, (2) self, and (3) others.
Life is a developmental voyage, and people travel across their “ocean of experience.” This voyage of discovery and exploration can be risky, and people have both a fundamental need for security and a capacity to adapt to changing circumstances. The “journey across our ocean of experience depends on our physical body on which we roll out the story of our lives” (Barker & Buchanan-Barker, 2007a, p. 21). The Tidal Model “holds few assumptions about the proper course of a person’s life” (Barker, 2001a, p. 235). Persons are defined in relations, for example, as someone’s mother, father, daughter, son, sister, brother, friend and also in relation with nurses.
Health
Barker provides the provocative definition of health put forth by Illich (1976) as “the result of an autonomous yet culturally shaped reaction to socially-created reality. It designates the ability to adapt to changing environments, to growing up …. to healing when damaged, to suffering and to the peaceful expectation of death. Health embraces the future …. includes the inner resources to live with it (p. 273). Health is a personal task where success is “in large part the result of self-awareness, self-discipline, and inner resources by which each person regulates his/her own daily rhythms and actions, his/her diet, and his/her sexuality” (Illich, 1976, p. 274). Our personhood, connections, and fragility “make the experience of pain, of sickness, and of death an integral part of life” (Illich, 1976, p. 274). Illich’s (1976) description illustrates both the chaotic and Zen sense of “reality.” “Health is not ‘out-there,’ it is not something to be pursued, gained or delivered (health-care). It is a part of the whole task of being and living” (Barker, 1999b, p. 240).
“Health means whole …. and is likely linked to the way we live our lives, in the broadest sense. This ‘living’ includes the social, economic, cultural and spiritual context of our lives” (Barker, 1999b, p. 48). The experience of health and illness is fluid. Within a holistic view, people have their own individual meanings of health and illness that we value and accept. Nurses engage with people to learn their stories and their understanding of their current situation, including relationships with health and illness within their worldview (Barker, 2001c). Ill health or illness almost always involves a spiritual crisis or a loss of self (Barker, 1996a). A state of disease is a human problem with social, psychological, and medical relations, a whole life crisis. Nursing with the Tidal Model is pragmatic and focused upon persons’ strengths, resources, and possibilities, maintaining a health orientation; the Tidal Model is a healthy theory.
Environment
The environment is largely social in nature, the context in which persons travel within their ocean of experience, and nurses create “space” for growth and development. “Therapeutic relationships are used in ways that enhance persons’ relationships with their environment” (Montgomery & Webster, 1993, p. 7). Human problems may derive from complex person-environment interactions in the chaos of the everyday world (Barker, 1998b). “Persons live in a social and material world where their interaction with the environment includes other people, groups, and organizations” (Barker, 2003a, p. 67). Family, culture, and relationships are integral to this environment. Vital areas of everyday living, including housing, financing, occupation, leisure, and a sense of place and belonging are areas of environment (Barker, 2001c).
The divide between community and institution is artificial and rejected as needs flow with the person across these boundaries. Much psychiatric and mental health nursing takes place in the most mundane of settings, from day rooms of hospital wards to the living room or kitchen of the person’s own home (Barker, 1996b). With critical interventions, nurses make the person and the environment safe and secure. Engagement is critical, and the social environment is critical for engagement. When people are deemed to be at risk, they need to be detained in a safe and supportive environment, a safe harbor until they return to their ocean of experience in the community (Barker, 2003a). “Nurses organize the kind of conditions that help to alleviate distress and begin the longer term process of recuperation, resolution or learning. They help persons to feel the ‘whole’ of their experience ….. and engender the potential for healing” (Barker, 2003a, p. 9).
Theoretical assertions
The Tidal Model is based upon four premises concerning practice, which Barker developed in the mid-1990s with the “expert nurse” focus group (Barker, 1997). These premises were validated by a group of former psychiatric patients led by Barker’s colleague of many years, the mental health service user and activist, Dr. Irene Whitehill.
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