Power and discipline in psychiatry's knowledge base
A study of older and more recent textbooks shows that the understanding of psychiatric nursing has radically changed over the years. The change in psychiatry's knowledge base has also had a direct impact on the professional identity of the nurse.
Sygeplejersken 1999 nr. 39, s. 29-38
Niels Buus, sygeplejerske, stud.cur.
This article examines the knowledge base of psychiatric nursing as described in the psychiatric textbooks. The analysis exemplifies changes in these textbooks through a presentation of four books: two older books from 1954 and 1957, and two more recent ones from 1994 and 1995. These textbooks provide the basis for a discourse analysis of the continuities and discontinuities in the knowledge base of psychiatric nursing over the years. The results of the analysis are put into perspective using elements of Michel Foucault's social philosophy.
The analysis rests on the assumption that language and practice are interwoven, that the way practice is referred to says something about practice as well as the way practice is understood at the point of articulation.
The analysis concludes that the understanding of care and the role of the psychiatric nurse has changed dramatically over the years. A dynamic understanding of the relationship between the nurse and the patient did not exist during the 1950s. Dynamics and an understanding of the patient and the nurse as being people first arose during the 1970s. In contrast, structure and observation are unchanged and considered equally beneficial in all the textbooks, albeit they are expressed in different ways.
Consequently, weaknesses are discovered in the view of care and psychiatric nursing as timeless constants. Foucault's understanding of power proves to be problematic, on the grounds that knowledge is inextricably bound to power. All knowledge becomes problematic when it is systematized and realized in a community setting.
It is often implied in the media that psychiatric care and treatment, especially the use of coercion, is a more traumatic experience for the mentally-ill person than the mental suffering itself. On the surface, such an assertion would seem paradoxical. However, in an attempt to explore the root of this issue, this article presents an historical analysis of the methods applied in psychiatric nursing as described in the psychiatric textbooks. Actions, methods and their clinical justification all exert a powerful influence on the patients and their experience of interaction with nurses in conventional psychiatry.
The textbooks form part of nursing's body of knowledge, its knowledge base. It is from this base that nurses find reasons to justify their professional actions. This implies that the knowledge base also possesses an ethical dimension, because it plays a role in determining how the nurse cares for and treats patients in reality. According to the Danish research nurse, Merry Scheel, the knowledge base therefore exerts an influence on the self-knowledge of the nurse (1:11-2).
The knowledge base, of which the textbooks constitute only a part, therefore plays a fundamental role in both the nursing profession and the professional identity of the nurses, and thus it would seem natural to examine this knowledge base more closely. The psychiatric textbooks represent part of the nurse's textual knowledge base, and the analysis subsequently reveals nothing about how nursing is carried out in practice nor the extent of the individual nurse's knowledge of the field. Furthermore, the textbooks constitute a relatively small proportion of all the literature written on psychiatric nursing. A more comprehensive description of the psychiatric nurse's textual knowledge base would therefore need to include studies from other books in the field, professional journals, newspaper articles, patient complaint cases, as well as minutes of meetings held not only within the trade union but also between the trade union, the state, and the relevant county and borough councils, etc. The textbooks therefore offer only a relatively minor and limited description of the knowledge base of psychiatric nursing.
This article examines some of the descriptions and proposals for psychiatric care outlined in the textbooks as well as its clinical justification, based on which an attempt is made to hypothesize on the potential changes and implications of such care for clinical practice in psychiatric nursing. In addition,
the article attempts to examine the potential link between the knowledge base and the self-knowledge of the psychiatric nurse.
In order to examine how the content of the textbooks has changed over the years, each of the Danish textbooks on psychiatric nursing (2-18) has been studied following the same procedure. In this respect, this article has not analyzed textbooks that focus on care providers, social and health care assistants, nor has it taken into consideration medical psychiatric books where nursing plays an extremely minor role. The research data collected has been very extensive, and consequently, only a small proportion is presented in this article. Summaries of the two 'older' textbooks in psychiatric nursing from 1954 (2) and 1957 (3) have been compared with summaries of the 'new' textbooks from 1994 (16) and 1995 (18). The books are representative of the period when they were published and taken together illustrate changing tendencies in the content of the psychiatric textbooks over the years.
In addition, this article attempts to clarify when these changes occurred through reference to all the research data, of which only a portion is recorded in the summaries.
The books analyzed were selected in order to cover the greatest time-span between the books, in the belief that this would clearly highlight any small differences and changes in the knowledge base. The two books from the 1950s were the first to be published on psychiatric nursing. The two more recent books are the only ones published during the 1990s that deal with the majority of areas covered by the field of psychiatric nursing.
The analysis of each textbook has been structured around five fundamental questions, which constitute the main focus of the study. (1) Is there an explicit or implicit description of a core of psychiatric nursing? (2) What justification is given for the care? (3) Which methods are proposed? (4) What is the goal of the care? (5) Which personal qualities are considered desirable in a nurse?
Changes in the knowledge base of psychiatric nursing are identified and analyzed in relation to the thinking of the French historian of ideas and philosopher, Michel Foucault. Foucault was chosen as a theoretical framework on the grounds that his social criticism focuses on the reconstruction of the relationship between knowledge and power, as well on how the dyad creates truths and identity.
The psychiatric textbooks
The first book on psychiatric nursing appeared in 1954: 'Psykiatrisk sygepleje: En vejledning for sygeplejersker' (Psychiatric Nursing. A handbook for nurses), and was written by Dr Arild Faurbye1. As doctors' ''assistants,'' the work of the psychiatric nurse ''involves nursing the patient's physical state, observing his mental state and affecting the patient through psychotherapy'' (ibid. 13). The book contains a detailed description of common physical disorders found at a mental hospital and instructions for how nurses should treat them. Observation is fundamental and the nurse is required to act as the doctor's 'eyes and ears' during his absence. Observation must not be total and intrusive: observation is embarrassing and should therefore be carried out discreetly. The psychotherapeutic effect on patients is achieved by establishing a regular daily routine, which over a period of time shapes lasting healthy habits.
The nurse must supervise the patient the whole time, although ''each hour should be planned'' (ibid. 102). The ward must therefore be organized so that patients have the opportunity to take part in the daily tasks together with the nurses. The ward must operate according to a set of rules, to be enforced with supple discipline (ibid 55). As a rule, patients must have ample opportunity to keep themselves occupied. This kind of environment helps the nurse to create a therapeutic framework for the patients. With regard to personal qualities, the nurse must possess an ''in-built sense of tact and intuition'' (ibid. 169), and also be aware of her own weaknesses. Using a gentle and friendly yet firm manner, the nurse should attempt to win the patient's confidence and trust (ibid 178). Theoretical knowledge about psychiatric care and treatment can help guide the actions of the nurse as she gathers experience.
The first edition of 'Psykiatri. Lærebog for sygeplejeelever' (Psychiatry. A handbook for student nurses) was published in 1957 (3). The book is divided into three parts: the first part deals with psychiatry and was written by A. Faurbye; the second part focuses on psychiatric nursing and was written by head nurse Ingrid Nielsen and the third part concentrates on child psychiatry and was written by senior medical house officer J. Egsgaard. The book contains no real definition of psychiatric nursing, but care is characterized as consisting of three basic elements: a broad version of psychotherapy, discreet and close observation of patients, and the creation of a healthy hospital environment that resembles normal daily life as far as possible.
The reasoning given to justify the care rests on the assumption that all experiences affect the mind, and that everything in the surroundings that affects the mind in a positive way can be referred to and used as psychotherapy. Observation is seen as a ''highly important task'' of the nurse, and the daily observations, the smallest details must be relayed to the doctor, whose job it is to diagnose and prescribe treatment (ibid. 64-66).
The observations must be carried out discreetly,
preferably as the daily tasks are performed, so that the patient does not feel he is being observed. Likewise, the nurse must attempt to contribute to the process of building up a detailed description of the patient's medical history. More specific forms of psychiatric care include activity treatment, behavioural therapy (hygiene) and movement therapy. The purpose of the treatment and care is to enable the patient to live as normal a life as possible. The personal qualities of the nurse must include a ''distinct friendliness and an unwavering patience'' (ibid. 72).
The section on child psychiatry differs from the other two sections of the book by virtue of its description of the mother-child relationship and the mother's care for the child. In addition, this section is the only place prior to 1974 that describes a contact relationship between the admitted child and the nurse.
'Psykiatrisk sygepleje. Lærebog for sygeplejestuderende' (Psychiatric Nursing. A handbook for student nurses) (16) was published in 1994 and written by nurses Winnie Falk and Dorthe Svarre.
The book ''quotes'' Jan K. Hummelvoll's definition of psychiatric nursing:
''Psychiatric nursing is a planned, caregiving psychotherapeutic activity. Its aim is to strengthen the patient's ability for self-care and thereby solve or minimize the patient's health problem. Through co-operation and mutual commitment, one should attempt to help the patient to self-esteem and to find his own durable values in life. When the patient is unable to express his own needs and desires, the nurse should act both as a caregiver as well as the patient's advocate. Beyond the individual level, the nurse also shares responsibility for enabling the individual to have a satisfying social community. On the social level, the nurse has a moral obligation to draw attention to conditions that cause health problems.'' (ibid: 20)2
In its description of the basis for nursing, this book clearly asserts that ''no certain knowledge'' exists in the field of psychiatry, and that treatment and care are interrelated (ibid. 18,35). No specific reference is made to ethics, because no differentiation is made between ethics and nursing in general. The care is justified on the grounds that the threatened ego must be reconstructed. The book argues that ''the mental sufferes hungerfor contact as much as they fearcontact. Yet it is understanding and contact which he needs.'' (ibid. 122) ''The ego-strengthening contact consists of a balancing act between interpreting and understanding the patient's experiences and behaviour on the one hand, whilst imposing limits on him on the other.'' (ibid. 50) The environmental therapy's framework and rules must offer security. Contact with the patients occurs on four different levels simultaneously, which means that the nurse must be able to understand what is happening: (1) in the patient; (2) in herself; (3) between her and the patient; and (4) between the patient and his surroundings. Observations are an integral part of the care. The goal of nursing is to create a changing environment for the patient in order to help him act and behave as ordinary as possible. This goal can be achieved through understanding the patient's interaction with his surroundings. In addition, the nurse should attempt to reconstruct and bring to the surface hidden emotions and feelings in the patient, for example, by using drawings to reveal the subconscious and the secret. The nurse's qualities should include knowledge about diagnosis groups, patience, a therapeutic attitude, and an ability to use herself as a person.
The Danish version of Jan K. Hummelvoll's book, 'Helt ikke stykkevis og delt' (Whole not in pieces or fragmented) (18), was published in 1995. Hummelvoll is a psychiatric nurse as well as Doctor of Public Health, and an ''holistic-existential'' thinking lies behind the views presented in this book (ibid. 11). Nursing is regarded as a cultural phenomemon with care as a central feature. Hummelvoll applies his own definition2. The patient is affected through spiritual means, incorporating experiential as opposed to subconscious material. The book is divided into chapters according to central problem areas as opposed to diagnoses. Health is defined as being whole, while mental suffering is defined in terms of a person who has lost contact with himself. ''Nursing ethics emphasize the necessity of showing respect for the patient's rights and distinct character.'' The patient must be met with ''attention, challenge and care'' (ibid. 64). Attitudes and actions in the care seek to target the patient's immediate problems and involve entering into healing relations with the patient, structuring the surroundings, educating the patient, etc.
The environmental work can be behavioural or insight-orientated. The goal of the care is to explore the patient's thoughts, emotions and behaviour patterns, as well as to help the patient understand his own situation. The nurse must act as a role model, be open and friendly as well as show a strong sense of compassion.
Continuities and discontinuities in the knowledge base
The following section incorporates a general analysis and identification of the most apparent continuities and discontinuities in the textbooks in response to the analysis' questions outlined in the introduction. Table 1 illustrates selected continuities and discontinuities between the old and new books, and which are outlined in more detail in the section below.
Hummelvoll writes that care is a central feature of nursing. The term care appears in each of the textbooks, although its meaning changes. The new books consider care as a professional and relational
concept, where care is carried out in the relationship between the patient and the nurse. Apart from the aforementioned atypical section about child psychiatry (3), this meaning of the word does not appear in either of the older books. Instead the older books refer to care in terms of the relationship between mother and child, between the patient and a pet (5:64) or in terms of maintaining one's own or another's hygiene (2:49 and 3:115).
Table 1. Outline of selected continuities and discontinuities in the knowledge base
The 'old' books
The 'new' books
1. Core of nursing Changes in the form of the textbooks
Nursing the physical state, etc. Technical and practical recommendations for action
Relational care, etc. Descriptions of attitudes
2. Justification for the care
All positive effects can be called 'psychotherapy'
Psychotherapy and care are healing relations
3. Methods in the care
Observation Supple discipline
Observation Environmental therapy and limit setting
4. Goal of the care
The patient must lead a normal life
The patient must experience a satisfying sense of community
5. Qualities of the nurse
In-built tact Knowledge
Personal contact with the patient Knowledge
The more recent interpretation of care as a relational concept first appeared systematically after 1974 (10:pp111), when head nurse Sonja R. Skrumsager, inspired by the American nursing theorist, Joyce Travelbee, introduced the concept of the ''nurse-patient relationship.''
Published in 1974, Skrumsager's book was also the first of a new kind of textbook in psychiatric nursing. In contrast to the repetitiveness of previous textbooks in prescribing techno-practical nursing methods that promoted the concepts of calm, cleanliness and regularity, the new books contained descriptions of attitudes, which were to be applied in clinical practice.
In the older textbooks, the care is justified in purely professional terms, where it is argued that it is vital to affect the patient through psychotherapy in order to compensate for his inability to have contact with the world around. The more recent books, on the other hand, claim that caring relationships and understanding can benefit the patient starved of contact. Unfortunately, the research data available is too thin to confirm or reject the hypothesis that the therapeutic relationship is modelled on the family's mother-child relationship, for example, in the way described in the section on child psychiatry (3). However, the hypothesis is an interesting one to consider.
The more recent books supplement their reasoning with ethical considerations. In this respect, it was noted that reference to psychology, and especially philosophy, occurs more frequently in these later books.
The following points can be made with regard to the psychiatric nursing methods described in the textbooks. Observation is treated no differently. No change is seen regarding structure, which is deemed to have had an equally beneficial effect on the patient's behaviour and psyche. The concept of understanding, which includes the study of thoughts and emotions, is not highlighted in the older books. The more recent books, however, are extremely keen to promote understanding of all relations with the patient.
The goal of the care remains unchanged in all the textbooks: the patient should be able to function in a social setting. The later books supplement this goal by highlighting the importance of providing the patient with insight into his own situation.
However, a difference is noted between the textbooks regarding the personal qualities desirable in a nurse. The older books believed it necessary for the nurse to be aware of her weaknesses, a point extended in the new books to include a need for the nurse to develop self-knowledge.
Power, surveillance and discipline
The French historian of ideas and philosopher, Michel Foucault developed whilst at university an interest in a fraction within French philosophy; ''the historical epistemology'' (19). One of the issues for historical epistemologists and Foucault is to investigate the conditions for scientific knowledge, and to
determine what constitutes scientific theory. Epistemologists claim that scientific theory is a social construction of reality and that scientific concepts determine how people understand and construct reality. Foucault extends this thinking by analyzing the conditions for scientific concepts and theories. ''One cannot talk anything at any time'' (20). There are thus limitations in language for what one can say and therefore for what one can know. On the other hand one can raise questions, as Foucault does, about what prerequisites must be in place for discursive and linguistic articulation.
Foucault's thesis, Madness and Civilization, turns the accepted view of mental illness as a disease on its head. Through an historical analysis, Foucault demonstrates that the understanding of madness has changed dramatically throughout history. The modern view of madness as a mental illness is therefore a social construction that is meaningful in today's society but which cannot claim to hold the truth behind madness. Madness and Civilization examines the interplay between power and knowledge in psychiatry. Foucault specifically chose psychiatry because the psychiatrist finds himself in a dubious field that would never achieve normal scientific status in a Kuhnian sense, and because it is a field that has a political, cultural and social function. Psychiatry has contributed little to objective knowledge, yet it is a field that has been of immense social importance (21).
Through his analyses Foucault attempts to show that what in the past is incomprehensible for the present is not without its own systematic structure (22). His analyses result in a relativism that demonstrates that the present need not look as it does.
Foucault's later work was directly inspired by Nietzsche, who applied genealogy (meaning the ''study of family history'' ) as a method for history, an ''effective'' and ''real'' history that seeks no origin. Genealogy demonstrates that the historical beginning is not an inalienable identity but rather the fragmentation of other things (23:79). For Foucault, the goal of genealogy is to reconstruct the power struggle that disqualifies certain forms of knowledge and creates truths and identity. Foucault claims that the intention in this power struggle is determined by the metaphor, ''the will to knowledge.'' This reducing metaphor has no justification other than itself and refers therefore to no subject. In other words, there is ''no-one'' pulling on the strings of power.
Foucault never had any wish to develop a complete power theory, a view he emphasized by referring to his thoughts on power as a form of power ''analytics,'' designed to map out how power should be investigated. Inspired by Nietzsche, Foucault constructs a new and temporary understanding of power:
''Power is not an institution, it is not a structure, neither is it a certain strength with which certain selected individuals are endowed. It is the name given to a complex strategic situation in a particular society.'' (24:99).
Foucault questions the interpretation of a theory of power as a form of repression by a ruthless dictator (24, 25). It must be stressed that Foucault does not completely reject the repressive hypothesis, but he believes that it is not sufficient in the study of certain phenomena. Foucault therefore tailors an understanding of power to suit those areas he investigates: the history of the prison (26) and the history of sexuality (24).
The link between power and knowledge
Foucault claims that power in modern society is productive, in the sense that it produces knowledge and thereby truths.
''We should admit rather that power produces knowledge (...); that power and knowledge directly imply one another; that there is no power relation without the correlative constitution of a field of knowledge, nor any knowledge that does not presuppose and constitute at the same time power relations'' (26:27).
It is in the discourses that the link between power and knowledge is to be found. Power is activated in the following way: it is realized indirectly through the knowledge base and in the articulation of scientific practice. Consequently, the genealogical discourse analysis of, for example, nursing discourse is important, because it exposes the invalidation of certain types of knowledge in favour of ''true'' knowledge.
''Bio-power'' is linked to the state's goals regarding the population's health and well-being. From the 18th century onwards bio-power technologies have been developed and refined to normalize and regulate the population (27).
Foucault claims that ''nothing in man not even his body is sufficiently stable to serve as the basis for self-recognition or for understanding other men'' (23: 87-88). This statement incorporates the belief that every aspect of the body can be changed. We are therefore more a product of culture rather than of nature. Power shapes the body and the subject's understanding of it. Foucault is radical in his belief, claiming that the body is shaped not as a result of the human being's ability freely to produce and reproduce cultural meaning around it, but according to the configurations of bio-power.
The following section describes three of the disciplinary technologies of bio-power that shape docile bodies: observation, normalization and examination. (1) Observation plays an important role for control over the inmates. The term ''inmates'' covers a wide range of social groups, including factory workers, prisoners, patients, the mentally-ill, soldiers and pupils. Although bio-power technologies are developed in society's institutions, they are prevalent
throughout all areas of society. Observation leaves nothing outside the visual scope, and various architectural finesses can facilitate full visibility over the institution from a single position. (2) Normalization is linked to the constant comparison of the inmates, where anything deviating from the norm is punished, and anything within the norm is rewarded. Normalization therefore creates a homogeneity amongst the inmates by objectifying and individualizing the inmate. (3) Examination:
'' The success of disciplinary power derives no doubt from the use of simple instruments; hierarchical observation, normalizing judgement and their combination in a procedure that is specific to it, the examination.'' (26:170).
Examination creates individuals through comparison and documentation, where observation is transformed into a tool for power, and where those examined are transformed into objects for scientific evaluation.
Subjectification and confessional technology
The influence of bio-power does not limit itself to objectifying techniques. Foucault claims that confession is a cultural, western phenomenon that arose in the church's sacrament of penance. Confession can be found everywhere in modern society and the hermeneutical interpretation is an integral part of the human sciences. The application of hermeneutical interpretations according to the rules of scientific discourse leads to the emergence of ''confessional technology.'' The key to understanding this technology lies in the belief that experts can help the human being tell the truth about himself. Confessional investigation is not judgemental, as in the examination stage, but analytical. ''The confession of truth is engraved in the heart of the individualizing procedures of power (24:66).'' Expert interpretation is necessary, and the subject must acknowledge the interpretation. Foucault plays on both meanings of the word ''subject'' : firstly, in terms of being subjugated to or dependent on others, for example, as an object for science, and secondly, in terms of being a self-conscious individual (28).
Together, examination and confessional technology imply that the human being is an object as well as a subject in both senses of the word. One of Foucault's examples concerns an insane man who believed himself to be Ludwig XVI (29). Treatment consists of ''reflecting'' the mad man in his own madness so that he recognizes himself to be insane. In this way, the mad man becomes objectively insane in himself and ends up an observer of his insanity. The circle is complete: insanity becomes objective and the insane man is subjugated to his role as an insane person. The physical chains are replaced by psychological ones: his self-knowledge of the insanity. Disciplinary technology therefore not only has an effect on docile bodies but also creates and affects the mind.
Foucault claims that power and knowledge are closely linked to each other as well as productive. Consequently, power is inaccessible and Foucault's own studies are part of the production of knowledge and power. The French sociologist, Jean Baudrillard, has criticized Foucault for this in his book, Forget Foucault (30). Foucault never claimed that he could detach himself from power and would therefore in principle agree with Baudrillard. However, Baudrillard asserts that Foucault's writings reflect power in such a way that they do not permit objective scrutiny and criticism. Baudrillard poses the question: what exists before something can be articulated? Braudillard believes that the ''the will to knowledge'' as an overall guiding principle is too simplistic and problematic.
Baudrillard levels some valid and sharp criticisms at Foucault, although his own attempt to dig beneath Foucault's writings ends in a somewhat unsatisfactory and flawed argument that the secret of power is that power does not exist but is dead.
Foucault did not outline the possibilities that exist for resisting power in any explicit manner. Power is an omnipresent condition, and resistance therefore exists as an inherent part of this relationship. Foucault's attention towards power's crafty manipulation of certain aspects of community life, simultaneously with the lack of instructions for dealing with resistance, indicates a certain helplessness. Foucault claims, however, that his position should not lead to resignation but rather to ''hyper- and pessimistic activism'' (31:231-2).
This brief outline of certain aspects of Foucault's sharp indictment of society and its institutions serves as the basis for the discussion below on developing a perspective of the psychiatric nurse's knowledge base as described in the textbooks.
The knowledge base in relation to Foucault
The basis for discussion is primarily situated in the field of tension between the conclusions reached concerning continuities and discontinuities in the knowledge base and Foucault's thinking. In addition, certain statements in the textbooks will be examined closely in order to give the discussion an added dynamism.
Foucault claims that the human sciences, by and large, appear disciplinary in nature and that psychiatry itself is a ''dubious'' field. Is this thesis supported by the textbooks? The textbooks describe the structure's beneficial effect. There is undeniably a change in the wording that is employed in the description of the structuring: for example, ''environmental therapy'' is used instead of ''supple discipline.'' There is, however, no major change in the assessment of the structure's beneficial effect, which
indicates a linguistic alteration rather than a change in method. The structure's effect falls close to Foucault's assumption that every aspect of the body can be shaped; in this case, by bodily discipline. The necessity for close observation, which Foucault attaches to examination, is likewise assigned equal importance in the textbooks. The major difference in the nursing methods regarding content can be found in the goal of the more recent books that the patient must develop through an understanding of his own situation. Foucault argues that discipline shapes individuals by creating an objective knowledge about the inmates; in this case, the patients. This objective knowledge must be acknowledged by the patient in order to gain insight about himself. According to Foucault, the patient's understanding of his situation is related to a scientific discourse that subjectifies the patient. The patient learns to interpret his own ''symptoms'' in a scientific discourse. The patient is subjectified in two senses of the word: subjected to a scientific discourse and as a self-conscious individual. Consequently, one is forced to recognize that disciplining has played and still plays a role in the methods employed in psychiatric nursing.
In addition, the differences in the formulations found in the textbooks indicate that the bodily disciplining described in the old textbooks with what are now considered politically incorrect terms have been supplemented with a psychological dimension using confessional technology. Power technologies undergo change while structure and understanding remain basically two sides of the same coin: disciplining of the patient.
The necessity for the nurse to have self-knowledge
Foucault claims that power and knowledge are inextricably bound to each other. A field of knowledge is always accompanied by power relations. This field of knowledge produces objects for knowledge, as described in the previous section.
As mentioned earlier, confession plays a role in creating the patient's self, his mind. Power subsequently produces those realities that are treated in psychiatric nursing discourse. Nursing's desire for understanding and the development of a scientific discourse that can explain and describe relational factors results in relations between the patient and their surroundings becoming realities over time. This might explain the absence of any reference to relations in earlier textbooks, because this concept was not articulated at that time. Relations were not ''objective'' at the time the earlier books were written, and therefore it was not possible to transform them into objects for knowledge.
The nurse's use of herself as a person and the demand for her to have self-knowledge are concepts which only appear in the new books. The nurse's professional ''self'' is perhaps also a reality, emerging in the wake of power's production of knowledge. She is therefore subject to individualizing technology in the same way as the patient, and must be self-aware from a scientific discourse in order to be able to use herself ''as a person.''
Altogether, it would appear that relations with the patient, the patient's self and the nurse's self may have first become realities after the adoption of the confession's individualizing technology in psychiatric nursing. In this way, power and knowledge form a double-edged sword that individualizes, objectifies and subjectifies both the patient and the therapist. It becomes clear here that subjectifying the patient involves a personal awareness of one's own ''objective'' pathologies. The nurse's analytical and professional self is not one attached to an ''objective'' pathology to the same extent. Although power and knowledge affect both parties, this ''objective'' insanity is supremely difficult to capture: objectively insane and subject in both senses of the word.
Change in the character of the textbooks
The above provisional conclusions can perhaps throw light on the differing characters of the textbooks. The older books do not acknowledge the patient and the nurse as people. This means that the relationship between the nurse and the patient is described only in terms of a static relationship between things or objects. Nursing actions are subsequently nothing more than practical techniques. This view is superseded in the more recent books by descriptions of dynamic relations between self-aware people/subjects, in line with the above description of the creation of subjects through individualizing power-knowledge. ''Healing relations'' have not been objects for knowledge in the earlier books and therefore appear as a new method in the later books. Perhaps the development of a dynamic relationship between the nurse and the patient has helped encourage the textbooks to move away from descriptions of technique in favour of descriptions of attitude, which to a degree implies taking a personal standpoint. In view of Foucault's thesis that ''one cannot talk about anything at any time,'' it would seem likely that nothing but procedural textbooks could have been written until there was a recognition of the patient and the nurse as people/subjects: subjects in relation to the articulation of a powerful scientific discourse about psychiatric nursing.
Care in psychiatric nursing
Foucault has not carried out any explicit analysis of psychiatric nursing. The above shows, however, that his thinking on objectifying and subjectifying the patient must have a certain relevance for the nurse. If
one accepts Foucault's views, then many aspects of care are undermined, because one is forced to ask whether disciplining is acceptable. It becomes clear why Foucault regards psychiatry as a dubious field, because of its social importance today and in the past. Foucault's descriptions of the development of the normalizing society run parallel to the development of a disciplining psychiatric nursing. This is a difficult problem because psychiatric nursing is historically linked to the normalizing society. Can one imagine a method of nursing which is not founded in society's demands for normalization? Foucault's thinking suggests that nothing is natural or everlasting. Consequently, we have major opportunities to change our practice, although we must still bear in mind the Foucaultian point that one cannot solve all problems once and for all: change results simply in the appearance of power in a new guise.
The concept of relational care is unique to the later books. Does this mean, as in the case of the dynamic patient-nurse relationship, that care is a more recent discovery? Is it the power-knowledge relationship that has enabled psychiatric nurses to articulate care?
Hummelvoll defines psychiatric nursing as a ''psychotherapeutic and caregiving activity.'' The definition allows for a change in the actual implementation, that is, in the methods, without changing the underlying psychotherapeutic or caregiving basis. It is explicitly stated that psychiatric nursing is part of the normalizing society, which begs the question of whether this also applies to care. Using Hummelvoll's definition, it is possible to interpret care as the desire to persuade the other to conform to the norms of society. For this reason, disciplining is accepted as a part of the care for the patient. This interpretation of care as strategic implies a kinship with bio-power. It is difficult to offer plausible interpretations of the ''caregiving activity'' without any link to power, because the systematic use of care produces knowledge and ''truths'' about care. This results in the previously mentioned consequences for those who are given care, and one therefore returns to the original interpretation of care as disciplinary in nature. If one sees care as a resistance phenomenon, the phenomenon cannot be used systematically, because the systematics push it towards the opposite extreme, namely power.
The metaphor, ''the will to knowledge'' categorizes events so far in terms of good and bad. Is there an analogous metaphor, for example, ''the will to care,'' where the intentional force is good? No, because the metaphors are not comparable and because the concept of ''good'' and ''bad'' presupposes judgement of an implicated subject. Consequently, the care metaphor is not without an outer reference point. A difference can therefore be made between ''knowledge of care'' and ''practical application of care,'' where the former up until now can be separated into good and bad, and the latter open to judgement. This facilitates the existence of the paradox outlined in the introduction concerning the use of coercion in psychiatric nursing, where knowledge of care forces the nurse to act in such a way which the patient does not see as caring.
Falk and Svarre claim that ''no certain knowledge'' exists in psychiatry. Such a self-referential and paradoxical statement can be difficult to accept because one cannot simply rule out the possibility of certain knowledge in psychiatry. This does not prevent Falk and Svarre from providing hard facts, for example, about the patient's hungerfor contact! However, in the light of the above considerations, it makes no sense for Falk and Svarre to categorically reject the existence of compelling truths, because power is forever bound to the creation of knowledge. Their own authorship is in itself a consolidation of a powerful discourse about the psychiatric patient, regardless of how much they emphasize the reverse.
This last criticism can also be levelled at Foucault and his philosophy, and is indeed done so by Baudrillard. For even though Foucault writes contextually-dependent analyses, he is at the same time a knowledge-creator with a link to power. As described earlier, resistance cannot be systematized.
The goal of the care
If one accepts the claim that psychiatric nursing, to a greater or lesser extent, is built around disciplinary technologies, one must raise the question of what is meant by freedom. Can one talk about freedom within the bounds of the normalizing society? As long as the goal of the care is for the patient to function in social settings, this is undoubtedly achieved for some patients at the expense of their sense of freedom. Is it more important to function in society than to have control over one's own life? Hummelvoll's definition contains expressions such as ''durable values in life'' and ''life in a satisfying social community'': Such expressions leave the reader confused, as it is not clear which yardstick is used to determine what is meant by values or satisfying. It is natural to interpret the yardstick as society's normalization procedure, which supports the previous thesis that psychiatric nursing is primarily disciplinary in nature. Hummelvoll's definition goes on to describe that the nurse must draw attention to conditions that cause health problems. What if nursing itself is part of the problem? Is it possible to change a field of human science, in this respect, psychiatric nursing, which, according to Foucault, has developed alongside disciplinary technologies, and which clearly has a social function? Change would seem to be impossible, partly because of the field's historical appearance and function, and partly because resistance in a Foucaultian sense cannot be systematized through the existing system. Finally, it should be noted that Foucault's thinking itself creates the ever-present
problem of choosing between several dangers, where one must endeavour to select the least bad.
The above discussion deals with the knowledge base of psychiatric nursing as reflected in the textbooks in the period from 1954 until today. The analysis of the changes in the textbooks applies aspects of Foucault's authorship in order to provide a perspective.
This Foucaultian perspective concludes that psychiatric nursing is basically rooted in disciplinary technologies. In addition, it is suggested that the development of psychologically disciplinary technologies has played a role in the construction of the patient's self, the nurse's professional self and the relation between them both. Furthermore, the changes in the character of the textbooks can be explained in terms of the articulation of the nurse as a person. It can be concluded that the change in the knowledge base directly influences the nurse's professional identity.
It is clear that Foucault demands that society's development should constantly be met with reservation and scepticism, because power is such a fundamental condition and so fleeting that it continuously changes character. Foucault can be criticized for developing a form of power analytics that makes it possible to find power everywhere, and which subsequently implies that much of knowledge in principle is repressive and problematic. In the discussion, it is suggested that care and treatment in psychiatric nursing are linked to a strategy, a bio-power, where the goal is to help the patient conform to the norms of society.
The discussion concludes that clear changes have taken place in the way psychiatric nursing is articulated. The question now raised is why it is so important and meaningful to emphasize relations and care in psychiatric nursing. One provoking explanation is offered by the anthropologist, Anne Knudsen, who, in her small debatebook, Her går det godt send flere penge (All is well send more money) writes:
''Many current activities of women employed in the public sector today are modelled on tasks that families generally used to be able to cope with effectively.'' (33:56)
Knudsen's argument can be interpreted that women articulate family values in the professional nursing discourse that in a way legitimizes public care relations.
Keywords: Discipline, Foucault, knowledge, knowledge base, power, psychiatric nursing, textbooks.
- Faurbye introduces her book by emphasizing the need for a special training programme in psychiatric nursing. Such a programme has taken a long time to establish, evidenced by the fact that the graduation of the first batch of specially trained psychiatric nurses did not occur until summer 1998.
- The attentive reader will wonder what is meant by the expression, ''enabling the individual to have a satisfying social community.'' The explanation for this is that Hummelvoll has been misquoted. Below is Hummelvoll's own definition (18:35):''Psychiatric nursing is a planned, caregiving and psychotherapeutic activity. Its aim is to strengthen the patient's ability for self-care and thereby solve or minimize the patient's health problems. Through mutual co-operation and commitment, one should try to help the patient regain his self-esteem and to find his own durable values in life. When the patient is unable to express his own needs and desires, the nurse acts both as caregiver as well as the patient's advocate. Beyond the individual level, the nurse also shares responsibility for enabling the patient to live his life in a satisfying social community. On the social level, the nurse has a moral obligation to draw attention to and influence conditions that can cause health problems.''
- Scheel M. Vidensgrundlag etik og sygepleje. København: Munksgaard; 1991.
- Fauerbye A. Psykiatrisk sygepleje. En vejledning for sygeplejersker. 1. udg. København: Dansk videnskabs forlag; 1954.
- Faurbye A, Nielsen I, Egsgaard J. Psykiatri. Lærebog for sygeplejeelever. 1. udg. København: Nyt Nordisk Forlag Arnold Busk; 1957.
- Faurbye A. Psykiatrisk sygepleje. 2. udg. Dansk Videnskabs Forlag; 1957.
- Faurbye A. Psykiatrisk sygepleje. 3. udg. Dansk Videnskabs Forlag; 1962.
- Faurbye A. Psykiatrisk sygepleje. 4. udg. Dansk Videnskabs Forlag; 1966.
- Welner J, Hansen B. Psykiatri. Lærebog for sygeplejeelever. 2. udg. København: Nyt Nordisk Forlag Arnold Busk; 1968.
- Faurbye A. Psykiatrisk sygepleje. 5. udg. Dansk Videnskabs Forlag; 1969.
- Faurbye A. Psykiatrisk sygepleje. 6. udg. Dansk Videnskabs Forlag; 1973.
- Welner J, Skrumsager SR. Psykiatri. Lærebog for sygeplejeelever. 3. udg. København: Nyt Nordisk Forlag Arnold Busk; 1974.
- Welner J, Skrumsager SR. Psykiatri. Lærebog for sygeplejeelever. 4. udg. København: Nyt Nordisk Forlag Arnold Busk; 1977.
- Welner J, Skrumsager SR. Psykiatri. Lærebog for sygeplejeelever. 5. udg. København: Nyt Nordisk Forlag Arnold Busk; 1982.
- Welner J, Skrumsager SR, Thorsen H. Psykiatri. Lærebog for sygeplejeelever. 6. udg. København: Nyt Nordisk Forlag Arnold Busk; 1987.
- Antonsen J, Bjerre T, Just E. Psykiatrisk sygepleje. Grundbog. København: Munksgaard; 1989.
- Bonde M, Johanson M. At arbejde med psykisk lidende mennesker en indføring. København: Gyldendal; 1990.
- Falk W, Svarre D. Psykiatrisk sygepleje. København: Nyt Nordisk Forlag Arnold Busk; 1994.
- Strand L. Fra kaos mod samling, mestring og helhed. Psykiatrisk sygepleje til psykotiske patienter. København: Gyldendal, Norsk Forlag; 1994.
- Hummelvoll J.K. Helt ikke stykkevis og delt. Psykiatrisk sygepleje. København: Hans Reitzels forlag; 1995.
- Broady D. Sociologi og Epistemologi. Stockholm: HLS Förlag; 1991.
- Foucault M. The archaeology of knowledge. London: Routledge; 1997.
- Foucault M. Truth and Power. In: Gordon Editor. Power/Knowledge. New York: Pantheon Books; 1980.
- Foucault M. The birth of the clinic. An archaeology og medical perception. London: Routledge; 1997.
- Foucault M. Nietzsche, Genealogy, History. In: Rabinow P.The Foucault Reader. New York: Pantheon Books; 1984.
- Foucault M. Viljen til viden. Seksualitetens historie 1. Frederiksberg: Det lille forlag; 1994.
- Foucault M. Two Lectures. In: Gordon C. Editor. Power/Knowledge. New York: Pantheon Books; 1980.
- Foucault M. Discipline and punish. The birth of the prison. Penguin Books; 1991.
- Foucault M. The Politics of Health in the Eighteenth Century. In: Gordon C. Editor. Power/Knowledge. New York: Pantheon Books; 1980.
- Foucault M. The subject and power. In: Dreyfus H, Rabinow P, Foucault M. Beyond Structuralism and Hermeneutics 2. ed. The University of Chicago Press; 1983.
- Foucault M. Madness and civilization. A History of Insanity in the Age of Reason. London: Routledge; 1997.
- Baudrillard J. At glemme Foucault. København: Rhodos; 1982.
- Foucault M. On the Genealogy of Ethics. In: Dreyfus H, Rabinow P, Foucault M. Beyond Structuralism and Hermeneutics 2. ed. The University of Chicago Press; 1983.
- Knudsen A. Her går det godt send flere penge. København: Gyldendal; 1996.