Autoethnography and mental health nursing

British Journal of Mental Health NursingVol. 11, No. 4 Autoethnography and Mental Health Nursing SupplementFree AccessAutoethnography and mental health nursingJerome Carson, Barrie Green, Kevin Gournay, Alec Grant, Andrew Voyce, Kevin Gournay, Jerome Carson, Chris Portues, Dean Whybrow, Graham Holman, Gerwyn Jones, Barrie Green, Jan Macfarlane, Jerome CarsonJerome CarsonCorrespondence to: Jerome Carson; E-mail Address: [email protected]University of BoltonSearch for more papers by this author, Barrie GreenRetired, HullSearch for more papers by this author, Kevin GournayInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonSearch for more papers by this author, Alec GrantUniversity of BoltonSearch for more papers by this author, Andrew VoyceUniversity of SussexSearch for more papers by this author, Kevin GournayInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonSearch for more papers by this author, Jerome CarsonUniversity of BoltonSearch for more papers by this author, Chris PortuesRetired. Current vaccinator, Royal Devon and Exeter HospitalSearch for more papers by this author, Dean WhybrowCardiff UniversitySearch for more papers by this author, Graham HolmanUniversity of Waikato, New ZealandSearch for more papers by this author, Gerwyn JonesCardiff UniversitySearch for more papers by this author, Barrie GreenRetired, HullSearch for more papers by this author, Jan MacfarlaneUniversity of BoltonSearch for more papers by this author, Jerome CarsonUniversity of BoltonSearch for more papers by this authorJerome Carson; Barrie Green; Kevin Gournay; Alec Grant; Andrew Voyce; Kevin Gournay; Jerome Carson; Chris Portues; Dean Whybrow; Graham Holman; Gerwyn Jones; Barrie Green; Jan Macfarlane; Jerome CarsonPublished Online:30 Nov 2022https://doi.org/10.12968/bjmh.2022.0035AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail Autoethnography and mental health nursingThis supplement for the British Journal of Mental Health Nursing has been commissioned in an attempt to explore and capture the experience of nursing staff and patients who have lived and worked in the field of mental disorder through the approach of autoethnography.Autoethnography is a means of capturing the lived experience of people in a way that allows the human interaction with a situation or sequence of events to be explored, shared and evaluated by a first party in an objective manner. It is a qualitative research methodology that has gained wider acceptance within the research literature in recent years. It has two distinct types: analytic autoethnography, which focuses on developing theoretical explanations of social phenomena, and evocative autoethnography, which focuses on narrative presentations that explore conversations and evoke emotional responses.Autoethnography has been used increasingly in the field of vocational, psychological and social science research. It is not random reminiscence, but an evidence-based approach, where the fist party, the practitioner-researcher, immerses themselves into the reflective process of an autobiographical account of theory and practice (McIlveen, 2008). It has been effectively used as a means of reflecting on practice in a range of social sciences (Voyce and Carson, 2020), and also as a means of identifying the meaning and significance of retrospective personal analysis (Bochner, 2012).Despite its humanistic and qualitative approach, the use of this method within nursing in particular has only emerged in the last 20 years, being described as a way of capturing unique insights into the impact of this profession (Peterson, 2015). There are an increasing number of first-hand, reflective accounts being published.In this supplement, Alec Grant describes that the use of this approach is a powerful way of engaging with the narrative as an evocative account of mental health nurses, other professionals and patients. He vividly describes the complexities of the role, while advocating for autoethnography as the most effective research tool to use in this arena. Alec is probably the leading British authority in this field.Many of the contributors to this supplement have experienced the life of the large Victorian asylums. They are some of the last to work or live in these hospitals. Soon there will be nobody left and such lived experience and memories will be gone. Two of the articles capture life in these hospitals. Andrew Voyce, Kevin Gournay and Jerome Carson provide a fascinating parallel description of the paradox of being in the same hospital at the same time, from both a staff and from a patient perspective. A different, but no less powerful perspective, is contained in Chris Portues' account. He approaches this by comparing the lives of the hospital staff and of the patients by describing the simple act of bathing. Both stories are profound. The opportunity for a new generation of such nurses to experience this will never be presented again.The fascinating reflections of Dean Whybrow, Graham Holman and Gerwyn Jones provide insights into their individual journeys into the profession. Their contribution includes both the experience of dealing with the enormous impact of military service on mental health and a view that the role is fluid, reflecting the social, cultural and political situation of the times. They conclude that autoethnography is an incredibly powerful and valuable means of capturing this, and perfectly suited to the purpose. As with all the articles in this supplement, their article links theoretical and autobiographical reporting to be faithful and comprehensive accounts. They assist in addressing educative or catalytic authenticity (self-explicitation). It also enables the reader to experience a situation or circumstance to which they may never have had the opportunity to be exposed, while encouraging shared learning and understanding.To complete this supplement and to underline the value of this approach, the contribution from Barrie Green, Jan Macfarlane and Jerome Carson describes the use of autoethnography as an educational and academic tool. Adopting the methodology assisted two mental health nurses to gain PhD accreditation from their reflections of their lives as mental health nurses and academics.The decision to use an autoethnographic research method is informed by several factors, including the wealth of knowledge of the authors, the limited number of such accounts, the inherent humanity of the subject matter, and the inevitable and unstoppable impact of the lived reality of mental illness in society. There are also fewer mental health nurses who were trained in the era of the ‘asylum attendant’. The editors felt that it was important to record some of the essence of this. Hopefully, this supplement captures the richness of lived experience, the source material and evidence that was/is that of the authors' and unique to them. As a reflexive tool, autoethnography is perfectly suited to this task before such recollections are lost forever. It is hoped that these accounts might inspire other mental health nurses to adopt an autoethnographic approach.It is an honour to have such rich contributions from a range of experts in the field, the expertise being that they are ‘experts by experience’. Each account brings a different picture from a part of their lives, the autoethnographic style is merely a vehicle to present this. The editors hope that you enjoy reading these accounts.What has autoethnography got to offer mental health nursing?AbstractI will unpack the assertion that autoethnography has a lot to offer mental health nursing in this article, mostly by showing rather than telling. What follows amounts to a ‘meta-autoethnography’ (an autoethnography focusing mostly, but not exclusively, on my selected autoethnographic work). My aim is less to showcase (although this is an unavoidable effect of meta-autoethnography), more to display a selection of quoted material from this work. Hopefully this will positively contribute to my argument for autoethnography's usefulness and may encourage some readers to follow up on some of my references and embrace the approach.Introduction: my backgroundI am an ex-mental health nurse, or should I say ‘psychiatric nurse’, given my vintage? I trained in the mid-1970s and practised for 6 years post-qualifying. I then became a cognitive behavioural psychotherapist and worked for the NHS for a few years. Following that, I was course leader for the BSc in cognitive behavioural therapy, then course leader for the MSc in cognitive therapy at the University of Brighton. I then moved into narrative inquiry, specifically autoethnography. However, since the late 1990s, I have maintained my academic interests in mental health nursing. I have regularly contributed to the mental health nursing press and have taught and mentored mental health nurses at undergraduate and postgraduate levels, including qualitative research teaching and supervision. Increasingly over the years, my writing and teaching practices have been informed by my hybrid identity standpoint position: as an ‘autoethnographer-mental health academic-practitioner-user and survivor of the mental health system’. More about this later.Teaching mental health nurses was a regular event for me before retiring in 2017 from my position as Reader in Narrative Mental Health at the University of Brighton. Now, I continue to work as an independent scholar, and visiting professor at the University of Bolton, with a special interest in autoethnography, mentoring and supervising doctoral and postdoctoral students and writing either single or co-authored work (Grant, 2018a, b; Klevan et al, 2020; Grant et al, 2021; Klevan and Grant, 2022). In 2020, I was proud to receive the International Conference of Autoethnography Inaugural Lifetime Contribution Award, ‘in recognition of making a significant contribution to the development and nurturance of the field of autoethnography and those working within it’.In view of all of this, I think that I am well-placed to write an article in answer to the question: ‘What has autoethnography got to offer mental health nursing?’ My short answer is: ‘A lot!’. But first, I need to explain what it is.What is autoethnography?The first thing I should say is that autoethnography needs to be contextualised as a critical qualitive research set of practices (Grant, 2020a). The role of critical qualitative research is to scrutinise and, if appropriate, take issue with dominant cultural narratives. When they take the form of empirical research, theoretical, conceptual or policy positions, dominant narratives are of course valuable. However, they can also be harmful to the extent that they generalise, stereotype and exclude nuanced and detailed lived experience (Adams et al, 2017), often from ideological positions of power, which tend not to be made explicit. Perhaps most importantly, dominant narratives do not tell you what lived experiences and lived realities feel like or provide enough detail about the impact those experiences and realities can have on lives. In contrast, though deliberately and critically focusing on personal experiences, autoethnographers provide a valuable ‘insider’ alternative to such dominant narratives. Put more strongly, autoethnography offers researchers the opportunity to speak lived experiential truth back to power, and to claim explicit robust standpoint positions. Standpoint theory (Rolin, 2009) states that an individual's knowledge and perspectives are shaped by their social and political lived experiences within fields of power. People writing from a standpoint position should be respected as fighters for a vision based on such experiences.Moving on to its component parts, autoethnography is comprised of representation and analysis (graphy), whereby the autobiographical and personal (auto) become connected to, and often take issue with the cultural and social (ethno). The most popular mode of autoethnography is narrative or written textual work. However, there are other possible forms and modes of representation, such as autoethnographic animation. Having worked closely with her across several dimensions of her research, I have no hesitation in saying that in my opinion Susan Young is the world leader in this sub-genre, and would urge you to read her work (Grant and Young, 2021; Young, 2021; 2022a, b).The style autoethnographers usually adopt at best ‘features concrete action, emotion, embodiment, and introspection… (and) claims the conventions of literary writing’ (Grant, 2020a). In this latter respect, autoethnography fuses together the social sciences and humanities paradigms in, for example, employing creative non-fiction and poetry (Short and Grant, 2016), and novel, non-standard forms of text construction (Short et al, 2007, and excerpt from this article below).In terms of its social science underpinnings, the critical relationship between autoethnography and the sociocultural world is key to understanding the approach. Charles Wright Mills (2000) urged social researchers to nurture and develop the ‘sociological imagination’, to turn their private issues into matters of public concern. When taken seriously, this requires autoethnographers to be ‘philosophically, politically, theoretically and empirically “savvy”, about the relationship between (their) biographies and the socio-cultural historical periods in which these are situated’ (Grant, 2020a). Because much of history tends to go on behind our backs, autoethnographic inquiry calls out for such a high level of critical awareness, precisely to examine and, when necessary, contest how history is represented and reported in dominant cultural narratives.Autoethnography requires high levels of critical reflexivityIn turn, critical awareness pulls on high levels of autoethnographic researcher reflexivity (Grant, 2020b). A key question illustrating the meaning of reflexivity is, ‘how does who I am, who I have been, who I think I am, and how I feel affect my autoethnographic inquiry?’ (Grant, 2020b). This can be shortened to: ‘What do I think and feel about the way I think and feel?’ Most of the time in our everyday human lives, the way we think and feel is habitual and unscrutinised. This has to be the case, otherwise we would get nothing done. However, to paraphrase Ellis (2007), a seminal and prolific trail-blazer in the approach, critical reflexivity is inseparable from the process of producing autoethnography. For Ellis, critical reflexivity refers to ‘the constant internal struggle, or dialogue, we have with ourselves about how we represent ourselves and others in our research’.What autoethnography offers: my meta-autoethnographic profileHaving explained what autoethnography is, and the importance of the sociological imagination and reflexivity in its practice, I will now focus on the work that I have produced that speaks to mental health nursing practice and education, in the areas of breakdown and recovery and critiquing mental health nurse education. Although I have written quite a few book chapters and articles in these areas, I will limit myself to one selected text from each along with an illustrative quote. This will help you get some sense of some of the ways in which I approach my autoethnographic work.Mental health breakdown and recoveryIn 2007, along with our non-autoethnographic interlocutor Liam Clarke, Nigel Short and I wrote about our recent experiences of breakdown and recovery. We tried to do this in a way that satisfied the general tenets of qualitative research, while simultaneously troubling the sanitised, distanced approach of mainstream qualitative and quantitative methodologies. The extensive quote that follows displays aspects of the relational and organisational politics of ‘mental health care’ in stark, close-in detail, and how I experienced myself within this power matrix. Challenging dominant narratives on recovery, a strong message coming from it is that conditions conducive to recovery can be attributed to the persistence of good friends and colleagues, and quite a bit of luck.The quote also shows how the paper was constructed based on unconventional and effective forms of data, including diary entries, emails, and reflections and comments from friends, relatives and colleagues, all presented in a ‘messy text’ triple column form (Short et al, 2007).Alec (diary note)Adrian (email)Liam (commentary)I had the disappointing (rather than surprising) experience in Spring 2006 of spending three days in an NHS acute ward. I was very disturbed, distressed and frightened.Apart from the intake assessment done by a nurse, I had no conversations with any of the nursing staff. They came to my side room to check that I had not committed suicide, every half hour. Interaction consisted of a brief smile and nothing else…Although they were very busy, there were times when I saw them gathered around the nursing station at the end of the corridor, when I opened my door to occasionally peek out. A few days pass and I'm moved to a private clinic.I can remember you becoming unwell and visiting you at home while you were on sick leave. At the same time, I was also working for the Community Mental Health Team (CMHT) in your location and with the Psychiatrist who was your Responsible Medical Officer (RMO).It was noted by the team that your mental state was deteriorating due to an increased number of calls to the duty team and concern was expressed about your general well-being. It was recognised by the team and I that alcohol was a major contributing factor to your decline…… I came to work one Monday morning and was informed by a colleague that you had been admitted to the local Psychiatric Inpatient Unit. I felt shocked by this, knowing the conditions on the unit and was immediately concerned about your well-being. My first action was to phone you and ask if you were alright and if you wanted to remain there. You told me that it was terrible and asked me to help you find a better alternative.I spoke about your situation with a number of people we both know. In particular I phoned a close colleague who was a mutual friend and had also been supporting you. We spoke about your situation and what could be done to help you and both agreed that you were in the wrong place.I then decided to contact your RMO and discuss your circumstances with him. The RMO also felt that you could not be treated effectively in the inpatient unit. Not only had you taught some of the nurses working on the ward but due to your position in the University, it would be likely that you would teach them in the future.He suggested that I contact members of the Out of Area referral's funding panel and make them aware of the circumstances of your admission, along with the potential difficulties associated with your existing or potential future relationships with members of staff on the ward.Within a matter of minutes the RMO replied via email supporting my request and this was soon followed by emails asking me to contact members of the Out of Area referral's panel directly via their mobiles.The Director of Specialist services who knew both you and me personally was immediately supportive, questioning why you had been admitted to the local Unit in the first place…we agreed that The Priory would be the most appropriate placement due to the specialist Alcohol Programme that they run.Another member of the Out of Area referral's panel was less supportive, stating that there was nothing The Priory could offer that the local Unit could not do. She was argumentative with me, and I felt she was condescending about the manner in which I was approaching your potential treatment.She questioned my every decision and displayed a lack of empathy towards the circumstances of your admission and the potential impact this had on the ward staff.Despite her obvious objections, the support of the Director of Specialist Services and your RMO appeared to show more favour and within a few hours I was informed that your transfer to The Priory would happen later that day.When I visited you at the local inpatient unit I was met by members of staff that I knew and had also taught in the past. They were all intimidated by your presence and unsure how to approach your case. I consulted your notes and found a basic care plan that did not even identify alcohol as being a contributing factor to your admission. There was no treatment contract present and no recorded breathalyser results. The only notes recorded mentioned that you had ‘settled in well to the ward and were socialising with other patients’ and that you had ‘slept well’. I became aware later that you were in fact drunk when you were admitted and I was surprised that the admitting staff had not addressed this issue.…The environment was cold and sparse and there appeared to be no therapeutic interaction with staff, bar the distribution of medication and checks every so often to see if you were actively suicidal.…The transfer to The Priory took place the next day and when I visited you a week later and saw the therapeutic programme you were engaged in, I knew that my persistence and consultations towards transferring your care had been worthwhile.I am curiously struck about the degree to which both Alec and Nigel's commentaries touch on the behaviours of others and even, on occasions, the supposed thinking of others. I imagine this reflects the balance between the self as an expression of culture, as well as the ethnographic desire to frame experience within the ambit of others within the story.The poet Patrick Kavanagh (1904–1967) likened the self to ‘an illustration’ a belief hardly in keeping with the fashions of his later years or now. Indeed, the ‘auto’ in ethnography surely takes the terrain of qualitative research to its furthest edge both in form and content.Yet, it is the second commentator (to my left) who, although ostensibly well, comes across as more personally revealing (at this stage), more declarative of the emotional effects of psychiatric hospitalisation.In psychiatry, there exists a conservation history of containing professionals when they become mentally unwell.At all costs, find a more exclusive ‘attic’ in which to shore up the secrecy of their distress: hide from the world's gaze the astonishing idea that being mad is not ‘other’ but ‘we’…View as image HTML Critiquing mental health nurse educationIn a shift of focus from my experience of breakdown and recovery to the politics of nurse education, I presented and analytically discussed events from various times in my nurse education career in a critical meta-autoethnographic performance chapter (Grant, 2018). My explicit aim was to ‘uncover the contradictions between the rhetoric and the reality of mental health nursing education and practice’. The quoted material that follows (Grant, 2018) recounts an uncomfortable conversation between myself and my critical covert voice (in italics), and a Deputy Head of School:‘The Debating Society An office in a university School of Nursing and Midwifery. A Deputy Head of School in charge of the nursing curricula across all branches. And Dr Grant.Deputy Head:You have an idea, Alec?Alec:ebating societies.Deputy Head:Where?Alec:Here.Deputy Head:Why?Oh God…Alec:Nurses don't do formal debate, irrespective of what branch they're in. Nurses can't debate. Nor can they critique. They think critique and debate amount to being nasty. They confuse debate and critique, in person or in writing, with ad hominem attack.Deputy Head:They're encouraged to debate in teaching sessions and critique in their essays.I hate nursing and nurse educators.Alec:You think so?Deputy Head:You clearly don't. So how do you propose we move forward?Alec:Debating societies.Deputy Head:How would they change things?Alec:Have you by any chance seen the 2007 Denzel Washington film, The Great Debaters?Deputy Head:Yes. How's that relevant?Alec:Emancipation of an historically under-valued cultural group? Academic confidence building through preparing to defend your ground and principles in formal debate, in front of an audience? Couple of wee things, maybe? And it would help reduce the contradictions between what we practice and preach.Deputy Head:What contradictions?Alec:The ones that are always apparent.Deputy Head:(…)Alec:(…)But not to you.Deputy Head:I suppose I can put a call out in the next school magazine to see if there are any students who are interested in forming one.Big of you.Alec:Right. A couple of points. There needs to be more than one group to have a debating society.Deputy Head:I know that. I'm well aware of that.Alec:And we need to role model it.Deputy Head:We?Alec:Us. Academics. This being a university and all.Deputy Head:Don't think so.Alec:Why not?Deputy Head:Well, it's easy for you. You always teach from your published work and research.Alec:Isn't that what we're all supposed to do? Research-based pedagogy rather than knowledge always coming in from some mystical and mythical outside? Deputy Head: People are afraid of you.Alec:I'm a pussycat. What are they afraid of?Deputy Head:Your knowledge. Your confidence.Alec:Shouldn't we practise what we preach? Wouldn't doing so help in the development of knowledge, confidence and standpoint positions among our colleagues?Deputy Head:(…)Oh…bugger.Alec:Look, tell you what, I'll start the ball rolling. There are guidelines in print for setting debating societies up. It's straightforward. You and I can do the first one? It'll be fun.For me. In more ways than one.Deputy Head:Let me think about it?Months pass, and months turn into years. Every so often along the way, prior to their retirement, Alec reminds the Deputy Head of School about the idea and they, generously, never stop thinking about it. The Deputy Head of School's successors think about it a lot too, say they love the sound of it and, as of 2017, have great ideas about key people other than themselves and their academic colleagues who might be interested in getting this initiative off the ground.And in his 65th year, Alec looks forward to his impending retirement.’Dishonesty and deception in mental health nursingAs I approached retirement, I did not let up on my preoccupation with the constant gap between the nursing rhetoric and ideology voiced by mental health nurses and their educators, and how these people behaved on a mundane day-to-day level, in and out of work and classroom.In Living my narrative: storying dishonesty and deception in mental health nursing (Grant, 2016), I argued that that such dishonesty and deception are always an inevitable part of the lives of mental health nurses and their educators, myself included, and I tried to make philosophical sense of this.My discussion focused on my regular experience of finding myself constantly teaching and writing against the grain of mainstream mental health nursing curricular content and clinical practice. I saw each of these areas resting on implicit and explicit categorical distinctions between nurses and service users or patients, and a knowledge base supportive of those distinctions.The lack of fit between my evolving hybrid scholarly identity and such curricular and practice assumptions led me to develop a complex, defensive antipathy towards the institution and practice of mental health nursing. This had grown steadily year on year, and especially since my negative experiences as an inpatient. The following excerpt from Grant (2016) highlights this:‘The Dinner Party… I thus experienced the contradictions between professional and educational rhetoric and displays of disparaging and “othering” accounts of students and qualified staff about the people they purport to be in the business of caring for, as deeply offensive. They could be talking about me in my days as an acute ward patient, and some once were. However, I am by no means free of blame in this regard.At a recent social event, I spent the evening with a group of mental health nurse educators. Over dinner, we shared nostalgic stories of our times as student mental health nurses back in the 1970s and 1980s. One of my companions described the first time he met a patient after the latter's lobotomy. His graphic description of how this seemed to change the shape of the patient's head and facial features was met with guffaws by my companions. I joined in with the laughter.Later at my home, I became pre-occupied with lots of conflicting thoughts and felt a mixture of mild self-disgust and bitter irony over the fact that my collusion in storying patients in “othering” and abusive ways sat badly with my narrative ethical standpoint, and current scholarly purpose. I had also shared one or two patient anecdotes, breaking my own rules in the interests of maintaining bonhomie, and co-constructing a group identity through the use of humour.This account is illustrative of my being constantly troubled by a question that never goes away for me: Why are many mental health nurses and others working in mental health, myself included from time-to-time, complicit with such practices?'What I believe autoethnography can offer mental health nursing: my summary positionI think the implicit message in the examples I have given from my own work is that autoethnographic texts can be used as a moral conscience resource for mental health nurses and their educators. I also believe that, in the full versions of the texts that I have quoted from, my high levels of reflexively informed disclosure and critical cultural analysis display how I role model the exercise of the sociological imagination. But, of course, you must decide for yourselves about the legitimacy of my assertions.In the examples