Mental Illness: the Zombiest of all zombie categories.
Except for all the others, eh?
There are a great many of them, and they do seem to be multiplying, but is there a zombie category [aside from politics, I guess] that is more zombie than our construct of mental illness? Rampant, rampaging brain-eating hoardes of brain-eating, flesh-creeping rapacious non-thinking, non-feeling zombies gobbling-up all human life before it, imposing dead ideas, imposing disproven hypotheses and faketruths, the great mono-myth zombification as primary understanding of human difficulty and yet, whenever and wherever it does so, proves mostly to be about as useful as a chocolate teapot in a heatwave?
Ok, what’s zombie category?
I give you Ulrich Beck who coined the term…
Welcome to Zombie land, folks.
- Are you ready?
- Zombie Nursing
- Zombie Psychiatry
- Zombie Institutions of Learning
- Zombie Skule for Professionals
Paper from Australia on how the institution of Mental Health Nursing has become Zombie Category.
Tara Brabazon Professor of Cultural Studies / Dean of Graduate Research, Flinders University, Office of Graduate Research, Australia
Rise of the zombie institution, the failure of mental health nursing leadership, and mental health nursing as a zombie category.
In this paper, we propose that mental health nursing has become a zombie category, at least in the Australian context. Mental health nursing is a concept that has lost any real explanatory or conceptual power, yet nevertheless persists in public discourse and the collective imagination. In recent decades, powerful forces have contributed to the zombification of the mental health nursing workforce and the academy. An increase in medical hegemony, the ascendancy of allied health in mental health service provision, the need for uncritical and servile workers, protocol-driven work practices, and a failure of leadership to mobilize any substantial resistance to these trends have enabled the infection to spread. The recognition of zombification, active resistance against the forces that conspire to cause it, and the cultivation of genuine conscientious critical thought and debate offer the only hope of survival of mental health nursing as a thriving specialty.
The term ‘zombie’ refers to the idea of the ‘living dead’. Zombies, according to Luckhurst (2015, p. 1), are ‘speechless, gormless, without memory of prior life or attachments, sinking into an indifferent mass and growing exponentially’. In recent years the zombie concept has shuffled from the B-grade movie screen into the realms of serious academic consideration and sociological critique of public institutions (Ryan 2012; Whelan et al. 2013). Ulrich Beck (Beck & Beck-Gersheim 2002) coined the term ‘zombie categories’ to describe concepts that have lost conceptual and explanatory power in the modern globalized world (e.g. class and neighbourhood), but nevertheless persist (stalk the living), despite being dead ideas from another epoch.
This paper begs the reader to consider whether mental health nursing itself has become, or at least is well on the road to becoming, a zombie category. It will be argued that institutions (universities and also healthcare organizations) have directly contributed to the zombification of the mental health nursing workforce.
That is not to say that there are exceptional individuals (academics and clinicians) who embody the self-reflexivity, consciousness, morality, and freedom of will and action, which is the antithesis of the zombie type.
However, as in all classical sociology or consideration of complex social processes, the occasional exception does not disprove the rule (Edles & Appelrouth 2015).
This paper also focusses on the Australian context (which might be illustrative of others), because in one sense the specialty of mental health nursing is actually dead:
(i) university-based, comprehensive nursing preregistration programmes were phased in during the 1980s, replacing specialist preregistration courses (Happell & Gaskin 2013);
(ii) mental health as a specialist field of nursing was removed with the establishment of the National Registration and Accreditation Scheme in 2010;
(iii) Mental health has consistently been the least p opular practice
setting for comprehensive graduates (Happell & Gaskin 2013; Stevens et al. 2013);
(iv) A voluntary credentialing scheme through the Australian College of Mental
Health Nursing has failed to deliver significant opportunities to practice outside of the scope of practice of
non-credentialed nurses or be recognized as enabling them to undertake ‘focussed psychological strategies’ (Lakeman et al. 2014); and
(v) Australian is held up as a cautionary example for other nations considering embracing generic mental health pathways (Hemingway et al. 2016). Australian academics have assiduously chronicled the demise of mental health nursing through large numbers of peer-reviewed publications (e.g. Happell & McAllister 2014; Happell et al. 2014; Henderson & Martyr 2013), with little impact on public policy or tangible improvements in the preparation of nurses to work in mental health practice settings or their desire to do so.
MENTAL HEALTH NURSING AS A ZOMBIE CLASS
Allusions to the death of psychiatric and mental health nursing have been frequent in recent years. Holmes (2006) argued that the process of professional extinction was already well underway, and Hurley and Ramsay (2008) have suggested that mental health nursing was sleepwalking towards oblivion (alluding to the inevitable demise of the specialty in the UK, should they adopt the Australian model). Others have pondered whether ‘mental health’ nursing is an anachronism (Cutcliffe et al. 2013) or an aspirational myth (Barker & Buchanan-Barker 2011) constructed to palliate the anxiety arising from a realistic appraisal of the practice of nurses who work predominantly with people diagnosed with mental illness. Nurses and commentators might talk about mental health nursing and emancipatory concepts, such as recovery, but what nurses actually do is often at odds with the rhetoric (Barker & Buchanan-Barker 2011).
Nurses continue to be employed by state mental health services in Australia (making up approximately 64% of the workforce), but their relative numbers are shrinking (Australian Government., 2013). The number of allied health professionals, such as psychologists, working in state-funded services increased by 120% in
the 10 years to 2011, whereas the nursing workforce contracted by 7%. In Australia in 2015 there were 84.2 nurses per 100 000 population who worked in mentalhealth, and 88 per 100 000 registered psychologists (Australian Government, 2017). This ascendancy of psychologists (particularly in primary care) and erosion
of nursing numbers has been commented on in other countries (Jong & Schout 2016).
In Australia ‘Better Access to Mental Health Care’ is the largest programme that provides subsidised access to ‘focussed psychological strategies’ provided by psychologists, occupational therapists, social workers, or general practitioners. Nurses (regardless of experience or qualifications) have been excluded from this scheme, presumably because they are deemed not to have the competence to provide such a service. The one scheme to support mental health nurses in primary care settings, ‘The Mental Health Incentive Programme’ (MHNIP) is an incentive payment paid to practices to employ nurses, and has been frozen for close to a decade (Lakeman et al. 2014). In contrast to ‘Better Access’, in which the practitioner is cast as an autonomous professional, the intent of the MHNIP is for nurses to follow a plan formulated by a medical doctor to treat and monitor people diagnosed as having a mental illness.
Nurses more than any other occupational grouphave played an instrumental role to medicine, often being required to acquiesce to a medical formulation or diagnosis and administer ‘treatments’ prescribed by medicine. The history of psychiatry is replete with failed and often brain damaging treatments (Breggin 1997), and indeed a compelling contemporary critique of psychiatry suggests that diagnostic inflation and overprescription of psychiatric drugs have led to an epidemic of iatrogenic disability (Whitaker 2010).
Throughout history, nurses have been the group that administers (sometimes forcibly) whatever somatic treatment is in vogue; from insulin coma therapy to depot neuroleptics. A workforce that thinks too much about these matters would be ineffectual. To get by, blind faith in medicine and treatments, and obedience, would be more adaptive than critical thinking or resistance (Lakeman 2013).
Historically, nursing has served to be the eyes and ears of medicine (Lakeman 2014). They could at least assess, intelligently report, and take part in a conversation around diagnosis and treatment. With the doubling of the medical workforce in Australia in the 10 years to 2015, almost all as specialists or specialists in training (Australian Institute of Health and Welfare, 2016), this need for nursing to be ancillary perceptual and sometimes analytical extensions of medicine has been diminished and devalued. Rather, the workforce requirement is more for a body of people to be the strong arm or defensive shield of medicine; containing, coercing, enforcing, and administering treatment. One potential consequence is that working as a mental health nurse (i.e. being a nurse who works in a ‘mental health settings’) is apparently the most dangerous ‘profession’ in Australia (Lakeman 2015).
It is also been noted (at least by other disciplines) that increasingly mental health care has become procedurally driven, risk averse, and concerned about rationing scarce resources (Tew 2014, p. 41). In the Australian context, mental health work is driven by computer protocols to gather data to feed activity based funding logarithms (See: Independent Health Pricing Authority, 2016). In this new world order, creative, thinking, reflexive practitioners are not required, and indeed anything that does not fit the model of care, as determined by the computer system, is not seen to exist. In this world, a compliant, docile workforce following protocols, pathways, procedures, and assiduously auditing themselves is necessary for the maintenance of what is increasingly becoming (like education) a production line process.
Not only does the practitioner not need to think, but the reduction of mental health care into a set of tasks, procedures, and processes cannot only deaden initiative, but also contribute to the zombification of the workforce. It has long been recognized that those who are unable to exercise initiative in their work or find some kind of creative outlet risk losing these capacities.
Adam Smith (1827, p. 327), who was the principal author of the modern stratification of labour, suggested that people working in the lowest in the lower tiers of creative endeavour observed:
The man whose whole life is spent in performing a few simple operations, of which the effects are perhaps always the same, or very nearly the same, has no occasion to exert his understanding or to exercise his invention in finding out expedients for removing difficulties which never occur. He naturally loses, therefore, the habit of such exertion, and generally becomes as stupid and ignorant as it is possible for a human creature to become.
Like zombies, the idea of mental health nursing will not die. Despite comprehensive nursing being the basic nursing qualification, and the registered ‘mental health’ or psychiatric nurse being an historical artefact, the Australian Mental Health Commission (2015) review of mental health programmes recommended that 1000 ‘registered general nurses’ be immediately retrained as ‘mental health nurses’ (which they suggest could be done in 1 year) to address a projective workforce shortfall in 2016. The government did not take up this recommendation, and there was no published commentary on it at all. The notion of the ‘mental health nurse’
continues to be invoked and applied to people who can make no reasonable claim to the title, and in keeping with notions of the zombie category, it is employed as if it were a living, clearly-defined category of nursing (when it is clearly not).
Nurses, including those who are identified as mental health nurses, are in a large part a product of their education. While some academics in Australia might claim the mantle of mental health nurse (or might even be credentialed), by and large full-time academics in Australia are conspicuous by their lack of recent, meaningful experience in the craft they are supposed to teach. Indeed, such real world experience might be considered an obstacle to obtaining ‘tenure’ in the modern age. Tenure arose as a protection from being sacked for exercising the duty to tell the truth, regardless of how unpalatable that might be to others, including one’s bosses (Fuchs 1963). The pathway to tenure and secure employment has little to do with demonstrating skill in one’s craft. Tenured members of the academy often hold themselves up as leaders and invoke leadership as the means to promote and enhance the occupation of mental health nursing.
However, leadership to date has failed to enhance, promote, extend, or expand mental health nursing because of the zombification of the academy, leadership, and mental health-care institutions.
The concept of the ‘zombie bank’ is an archetypal zombie institution, which was popularized in the recent global financial crisis as a representation of contemporary capitalism in crisis (Nelms 2012): Undercapitalized, if not entirely bankrupt, with little hope of recovery, but kept alive by vast injections of capital from governments and sucking the life out of the economy through voracious consumption of tax money, capital, and labour. There is an increasing recognition that other zombie institutions might be in our midst. Arguably, universities, mental health services, professional guilds, hospitals, and programmes have many features of zombie institutions. As Whitaker (2010) notes, the vast investment in mental health drugs and the expanding mental health industry has not demonstrably improved the mental health of nations (quite the opposite), and with an absence of any self-consciousness, lobbyists point out that globally mental health is in fact deteriorating rapidly and they demand more resources (Prince et al. 2007).
The university ought to be the institution that the public can look to, to point out these paradoxes. However, far from living up to the ideals of the university as conscience of society (Brubacher 1982), or at least offer a critical commentary, the university itself has become mortally infected with production line processing of students, and nonsensical targets around research and ‘academic’ outputs (Whelan et al. 2013).
The zombification of the neoliberal university (Whelan et al. 2013) and the Australian academy in
particular (Ryan 2012) has been given recent attention.
The following description, while sounding nonsensical to outsiders, will have immediate resonance for any academic in Australia:
Universities are increasingly populated by the undead: a listless population of academics, managers, administrators and students, all shuffling to the beat of the corporatist drum…the source of the zombie contagion lurks in the form of dead hand, mechanical speech.
Academic zombie speech is peppered with affectless references to DEST points, citation indices, ERA rankings, ARC applications, esteem factors, FoR codes, AUQA reviews and the like. Aca-zombies participate in numerous Rber-zombified, government-sponsored quality assurance exercises, presided over by powerful external assessors. (Whelan & Gora 2010).
Australian higher education has undergone rapid waves of change, described by Ryan (2012) as massification, marketization, corporatization, and managerialism. The later phases have permeated other branches of the public sector, such as health-care provision, culminating in current preoccupations with auditing, efficiencies, compliance, quality, and measurement. True
to nursing’s humble and servile beginnings and traditional deference to authority, nursing has been conspicuously quiet with respect to any of these changes.
Arguably, it has demonstrated little resistance, and appears on the face of it to be mostly acquiescent, and conformist in satisfying the demands of the organization.
That the demise of mental health nursing is profligately documented in Australia is in part because the metrics of publishing and research outputs are what the aforementioned assessors are concerned about.
Every conversation is a potential research project and a peer-reviewed paper. Rarely is there any serious critique of the status quo from academic quarters (genuine critical thought is not valued or rewarded).
Recommendations for improvement are usually couched as exhortations for more or better leadership, or statements about mental health nurses or academics being ‘well placed’ to act. Even where a serious critique of the restructuring of a national mental health service at the expense of some of the most needy (e.g. Jong & Schout 2016), the critique is published to a
nursing audience, rather than to those who might have the political power or interest to intervene. Zombies do not engage in protest, and are rather ineffective lobbyists.
SURVIVING A ZOMBIE HOLOCAUST
If zombie films teach us anything (and let’s imagine they do), it’s that zombie pandemics result in the ruinous collapse of society. Only a handful of people survive, and these small bands of refugees find themselves living an existence that is characterized by running and stockading, until they are ultimately overrun. They endure ongoing attacks by the undead and the threat of their own zombification.
A key figure in the zombie movie genre, writer/ director George Romero, observed that his movies are ‘stories about how people respond or fail to respond to
(change)’ (McConnell 2009). Over the course of the 20th century, mental health nursing in Australia has endured changes to factors that were integral to its professional identity (Molloy et al. 2016). The wind down of the standalone psychiatric hospital system, adjustments to its educational preparation, and the loss of the nursing profession’s recognition of its difference
through specialist registration have all contributed to an increasingly ambiguous role for mental health nursing in the changed world of 21st century mental health care (Hercelinskyj et al. 2014).
Faced with progressive zombification of the specialty, the remaining mental health nurses can hide in the hope that they can sustain the onslaught and somehow continue on into the uncertain future. Or they can fight back. As Munz et al. (2009, p. 146) surmise, ‘it is imperative that zombies are dealt with quickly, or else we are all in a great deal of trouble’. The resistance,
which has already taken place, has not have appeared to have slowed the contagion. As noted earlier, the assault has most recently been focussed on the use of scholarly literature without any obvious impact. Position statements and policies, be they from The Council of Deans of Nursing and Midwifery (Australia and New Zealand) (2015), the Australian Nursing and Midwifery Federation (2015), or the Australian College of Mental Health Nursing (2015), have done little to
arrest the plague.
If mental health nursing has become a zombie category, resistance must involve the collective voice of the living and be targeted to ensure maximum effect (Ryan
2012). Looking at the contemporary milieu of mental health nursing in Australia, the challenge for the speciality is where this collective voice can be gathered. Existing within separate rigid and bureaucratic systems, the synergy that might exist between mental health nurses within practice and education settings is at best constrained.
Within the education and health systems themselves, we see further fragmentation into separate, often competing, institutions and services. The relationships between different areas is more often characterized by rivalry than camaraderie, as neoliberal governance nurtures competition rather than cooperation. Both the Australian College of Mental Health Nursing and the Australian Nurses and Midwifery Federation who would seem natural vehicles for dissent, both advocate for conditions that, if realized, could strengthen mental health nursing in its fight against zombification. However, these organizations, being themselves conservative to the point of obsequiousness, have failed to stir significant action from those who might have power to effectively intervene. One thing that seems guaranteed in many zombie movies is government inaction right up until the point that it is too late to contain an outbreak (Zealand 2011).
To successfully avoid a zombie doomsday requires a quick and aggressive response from the living and healthy (Munz et al. 2009). For mental health nursing in Australia, the response to the creeping erosion of the profession has been neither. The results to date would
seem to indicate that mental health nursing is losing the war. This would appear to be in keeping with another quintessential zombie movie theme; that everything turns out badly for everyone in the end (Evans 2009).
On a more optimistic note, recognition and resistance might offer some hope, and the Australian experience might provide salutary lessons for the survival of mental health nursing in other parts of the world.