CREDENTIALS OF 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, p. 239). He credits his father and grandfather with “the warmth of nurture and the discipline of boundaries,” who helped him to 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 also contributed to his enduring curiosity and the philosophy of the everyday, which resonate throughout the Tidal Model.

Barker trained as a painter and sculptor in the mid-1960s, and won the prestigious Pernod Award for Young Painters in 1974, by which 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. His “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 transfer 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. Nursing per se was temporarily submerged when he began to study and practice various psychotherapies such as cognitive behavioural therapy and family and group therapy. Barker’s doctoral research 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 people with whom he was working and their resilience and integrity. He was learning from them what it meant to experience distress, and he wondered what recovery meant to people? Questions re-emerged around:

During his tenure as Professor of Psychiatric Nursing Practice at the University of Newcastle, 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 continued to maintain a practice and develop 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 experiencing extreme distress or loss of self, or in spiritual crisis (Barker, 1999b). The Tidal Model was developed within this context and history. The narrative knowledge base for the Tidal Model, although particular, is not exclusive and it leaves room both for development and for other viewpoints.

Barker has published in the area of psychiatric and mental health nursing since 1978. A prolific writer, he has written 14 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 was made 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, Cambridge. He has held visiting professorships at several international universities, for example, Australia (Sydney), European (Barcelona), and Japan (Tokyo). He was visiting professor at Trinity College Dublin from 2002 to 2007. In 2006, he received the inaugural “Lifetime Achievement Award” from Blackwell journals, publishers of the Journal of Psychiatric and Mental Health Nursing.

Barker has travelled widely with his wife and professional partner Poppy Buchanan-Barker, in response to interest in the recovery paradigm underlying the Tidal Model, conducting workshops and seminars in Australia, Canada, New Zealand, Japan, Finland, Denmark, Turkey, Germany, and Ireland as well as the United Kingdom. A popular commentator on the human condition, he brings to radio, television, and the popular press his passion for and curiosity about the recovery process and personhood.

Currently, Barker is an Honorary Professor at the University of Dundee, Scotland, where he maintains a private psychotherapy practice. He and his wife have developed the recovery paradigm at Clan Unity, an 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 re-conceptualization of mental health problems and needs as unequivocally human, rather than psychological, social, or physical (Barker, 2002b, p. 233). 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 seeking to resolve problems and promote mental health through narrative approaches (Stevenson, Barker & Fletcher, 2002, p. 272).

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 specific worldview. It helps the nurse begin to understand what mental health might mean for the particular person in care, and how that person might be helped to begin the complex voyage of recovery.

The Tidal Model is not prescriptive, rather, a set of principles—the Ten Commitments—serve as the metaphorical compass for the practitioner (Buchanan-Barker & Barker, 2006, 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 mould 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 work 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, Jackson, & Stevenson, 1999a; Barker & Buchanan-Barker, 2004b). Barker enlisted the support of Dr. Whitehill and other “user/consumer consultants,” to evaluate how “user friendly” were the original processes of the Tidal Model. The involvement of “user/consumer consultants” is seen in several ongoing projects, and presents a distinctive feature of continued development of the Tidal Model.

Barker’s longstanding 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 has now redefined the specific interpersonal process as “bridging.” This term 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 can also 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 that “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 with another. Barker first discussed this idea with his mentor, Hilde Peplau, in 1994, who agreed by saying “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 that 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.” Three main theoretical frameworks underpin the Tidal Model:

The pragmatic emphasis on strength-based, solution-focused approaches acknowledges the important influence of Steve de Shazer and solutionfocused therapy.

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 non-repeating 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 can create later unpredictable changes. This hopeful message 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 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, non-linear 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 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 of the 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 an emphasis on the narrative 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, p. 8). Eight respectful, empowering interactions also 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, narrative, strength-based, and solution-seeking approaches, and is systemic. The solution-focus, a model of questions, provides specific direction for nurses. In the Holistic Assessment, nurses explore the person’s present “problems” or “needs,” the scale of these problems/needs, what is currently part of 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 healthcare team (Barker, 2000e; Stevenson, Jackson, & Barker, 2003). The 10 Commitments (Box 32-1) also support this perspective and direction. This is a significant re-framing of the view of the person-in-care and the proper focus of nursing.

USE OF EMPIRICAL EVIDENCE

Barker’s longstanding 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 meta-theory, that could be further explored through empirical inquiry (Barker, Reynolds, & Stevenson, 1997, p. 663). Over five years, from 1995, the Newcastle and North Tyneside research team developed an understanding of what people experiencing problems in living might need from nurses. They began to use their emergent findings in 1997 as the basis for the 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 in schizophrenia developed from Alanen’s studies. One understanding that underpins Alanen’s work and flows through the Tidal Model is that people and their families need to think of psychiatric 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 provide an 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 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. The relationships are fluid, requiring nurses to “toggle” or switch back and forth from highly professional to distinctly ordinary presentations of self, and relationships differ depending upon the 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 et al., 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. It 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). It developed Peplau’s assumptions about the importance of specific interpersonal transactions, and provided guidance and strategies for nurses within collaborative nurse-person relationships. Strategies include:

MAJOR ASSUMPTIONS

Nurses are involved in the process of working with people, their environments, their health status and their need for nursing (Barker, 1996a, p. 242). The Tidal Model rests on the assumptions that:

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 raw material for solutions (Barker & Buchanan-Barker, 2004a).

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

Nursing is continuously changing, internally and in relation to other professions, in response to changing needs and changing social structures. The nature of Barker’s relationship with users of services confirms his appreciation of nursing as a social, rather than professional, construct. “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 being 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 tried to extend Peplau’s original definition, by defining the purpose of nursing as trephotaxis—from the Greek, meaning “the provision of the necessary conditions for the promotion of growth and development” (Barker, 1989). More recently, he has distinguished psychiatric nursing from 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, in press).

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-nursing and a person-who-has-met-that-need” (Barker, 1996a, p. 241; Barker et al., 1995, p. 389). These responses are the phenomenological focus of nursing (Barker et al., 1995, p. 394; Peplau, 1987). This focus is 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 suggests 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).

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