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This is a group project my part of the assignment is : A model or theory that can be used to bring about the change ( Treatment of post traumatic stress disorder in Veterans ) .
How the theory influence in to this treatment ?
The word document is a draft that the group did for the 1st assignment, is for you to have and idea . The journals is for you to used in the paper , i also send the references,.
No necessary 2 full pages, 1 1/2 TOPIC . Overview of the theoretical and practical
basis of a new model of psychiatric and mental
health nursing practice.
PURPOSE . To illustrate the history of the
development of the model and some of the
processes that aim to re-empower the patient and
develop genuinely collaborative approaches to
SOURCES . Literature review, author’s research,
and related clinical experience.
CONCLUSIONS . The Tidal Model provides a
practice framework for the exploration of the
patient’s need for nursing and the provision of
individually tailored care.
Search terms: Empowerment, holism,
interdisciplinary teamwork, narrative, nursing
theories and models, psychiatric nursing
Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 7 9
Phil Barker, PhD, RN, FRCN, is Professor of Psychiatric
Nursing Practice, Department of Neuroscience and Psychia –
try, University of Newcastle, England.
Despite the popular acceptance of the hypothesized,
biological, and/or genetic basis of serious mental disorders
(such as schizophrenia), a considerable body of research
challenges these assumptions (Dawson, 1997;
Johnstone, 1999). More important, there is evidence that
viable alternatives to such biological constructions of
mental distress exist, suggesting the possibilities for
more holistic forms of psychosocial intervention (Alanen,
Lehtinen, & Aaltonen, 1991; Pylkkanen, 1997). The
Tidal Model springs from a similar set of assumptions to
those expressed in the work of Alanen et al. when they
suggested that people, their families, and those close to
them need to be helped to:
Conceive of the situation (e.g., admission) as a consequence
of the difficulties the patients and those
close to them have encountered in their lives, than
as a mysterious illness the patient has developed as
an individual. (p. 97)
Such a pragmatic and respectful approach to addressing
the lived-experience of the person and her/his significant
others is diametrically opposed to the so-called p s y –
choeducational approach, which assumes an organic basis
for schizophrenia (Brooker & Butterworth, 1994). Despite
more than 40 years of sustained criticism, the medical
model continues to dominate the interpretation of mental
health problems and intervention within mental
health services (Newnes, Holmes, & Dunn, 2000; Szasz,
Although originally associated with a particular discipline
or school of thought, the medical and, more recently,
the biopsychosocial model stimulated by Engel
(1977) and other ‘psychosocial’ models (e.g., Foa, 2000)
are all used by various disciplines in their efforts to establish
what needs to be done in the name of care and
treatment. It is not surprising that a specific model of
Phil Barker, PhD, RN, FRCN
The Tidal Model: Developing a Person-Centere d
A p p roach to Psychiatric and Mental Health Nursing
nursing for psychiatric and mental health care has failed
to emerge, at least within the United Kingdom, or that
nursing theories have been so badly received by nurses
themselves (Gournay, 1995; McKenna, 1997). Unlike
medicine and disciplines drawn from the social sciences
(e.g., clinical psychology, social work), nursing has long
been viewed as an intellectual lightweight, with limited
research and no home in either the health or social sciences
Traditionally, nurses have been cast as a supporting
act in the therapeutic drama. As Nightingale first acknowledged,
nurses are akin to foot soldiers: carrying
the generals’ plans into the battle against illness
(Nightingale, 1860/1969). Despite 200 years of effort to
establish an independent voice and a distinct understanding
of the need for nursing (Barker, Jackson, &
Stevenson, 1999), nursing still appears to be haunted by
the ghosts of the Crimea (Group & Roberts, 1974). Given
that the overall plan of mental health care continues to
involve the attribution of a medical diagnosis and the expression
of specific medical interventions, albeit through
the medium of nursing, the need for any distinct model
of nursing has been seriously challenged (Gournay,
1 9 9 5 ) .
The marginalized status of nursing also might explain
why so many mental health nurses have tried to validate
their therapeutic standing as nurses by training in a parallel
discipline, or field of therapy, that is more established
and possesses a higher social status (Michael,
1994). The ubiquitous concept of the nurse (psycho)therapist
implies, perhaps, that nursing per se is not, or
could never be, therapeutic (Williams, 1996). S o m e
nurses have explored the possibilities of established general
nursing theories or models for mental health nursing
practice (Flaskerud, 2000; Jones, 1996; Murphy et al.,
2000). However, despite a consistent academic critique of
the myriad assumptions of medical and biopsychosocial
model (Barker, 1997; Barker & Stevenson, 2000; Hopton,
1996), many nurses appear satisfied to settle pragmatically
for a subordinate role within a medically dominated
mental health service (Abbondanza et al., 1994;
8 0 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001
Mental health nursing has for so long accepted what
Nolan (1993) saw as a “supportive” role, that the idea of
developing a distinct theoretical formulation for practice
(or a model from which to map care) increasingly has
been described as unnecessary (Gournay, 1995). Although
reservations have been expressed about the appropriateness
of some models of nursing for mental
health nursing (Barker & Reynolds, 1994), there can be
no serious objection in principle to establishing the discipline
of psychiatric nursing on nursing theory, or to the
construction of nursing models to support the enactment
of nursing practice. Indeed, the establishment of such a
theory-based model of nursing practice could be described
as a professional obligation (Hopton, 1996).
Emphasis continues to be placed on multidisciplinary
teamwork and models such as the biopsychosocial model
(Chafetz & Ricard, 1999) that arguably might facilitate
such teamwork. Nursing practitioners are aware that the
medical model is stronger than ever in clinical psychiatry
( A n t a i- Otong, 2000; Dawson, 1997). Similarly, theorists in
the social sciences show no sign of abandoning their development
of various psychological and social models
that might further illuminate alternatives to traditional
psychiatric medical treatment (Callahan & Bauer, 1999;
Markowitz, 1999). These developments suggest that any
model of psychiatric and mental health nursing practice
must emphasize the need for nursing, and be congruent
with the responses of other disciplines to the person’s
need for medical and other therapeutic interventions.
A Research-Based Nursing Model
The Tidal Model (Barker, 1998, 2000) was developed
from the Newcastle University 5-year study of the need
for nursing (Barker, 1996; Jackson & Stevenson, 1998),
which generated a substantive theory of nursing practice
in mental health care (Barker, Jackson, & Stevenson,
1999). The need-for-nursing study sought to clarify the
discrete roles and functions of nursing within a multidisciplinary
care and treatment process.
In translating into practice the theory of the need for
nursing, the Tidal Model developed many of Peplau’s
The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health
assumptions about the importance of interpersonal
transaction and incorporated a model of the process of
empowerment (Musker & Byrne, 1997) within the nursepatient
relationship, developed within a parallel study
(Barker, Leamy, & Stevenson, 1999). The Model of Empowering
Interactions (Barker, Leamy, & Stevenson,
2000) defined seven specific interpersonal interactions
that appeared to be necessary for the person-in-care to
experience empowerment. These theory-generating
studies continued the tradition of inquiry involving the
interpersonal processes of nursing practice (Altschul,
1972; Peplau, 1952), which sought to clarify further what
nurses should do as a caring response. This interest in
the “proper focus of nursing” (Barker & Reynolds, 1994)
has become unfashionable, as emphasis has switched to
multidisciplinary teamwork. Given the key position of
nursing as the agent of most therapeutic intervention,
however, there is at least some value in clarifying the
basis from which nurses might work i n t o the multidisciplinary
The Tidal Model was introduced into acute psychiatric
care settings (Barker, 1998) but has since developed
the concept of a care continuum, which emphasizes the
person’s need for three discrete forms of care: critical,
transitional, and developmental. The concept of the care
continuum spans the hospital-community divide, emphasizing
that need should be the primary focus for care,
rather than the setting within which it is delivered
The Tidal Model is a radical, catholic model of psychiatric
nursing practice, focused on the care processes that
are fundamental (radical) to nursing practice in mental
health and possessing a universality of application
(catholic) that would render it appropriate for any care
setting and any mental health population. The model
provides an emphasis on spirituality that often has been
lacking from practice models in psychiatric nursing. The
emphasis on exploring and developing the lived experience
of the person-in-care is focused specifically on the
meanings and values the person attaches to or associates
with her or his experience. In some cases, this exploration
will extend beyond the transpersonal to address
Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 1
relationships with conceptions of self and others that
might be defined classically as religious, mystical, or
Although focused on identifying the necessary processes
of nursing care, the actual caring practices involved
are intended to be complementary to the care
and treatment offered by other disciplines. In this sense,
the model attempts to aid the development of interdisciplinary
The Tidal Metaphor
Borrowing from chaos theory (Barker, 1996), the Tidal
Model emphasizes the fluid nature of human experience,
characterized by incessant change and unpredictability.
This provides the basis of the core metaphor of the Tidal
M o d e l – – w a t e r :
Life is a journey undertaken on an ocean of experience.
All human development, including the experience
of illness and health, involves discoveries made
on the journey across that ocean of experience.
At critical points in the life journey the person
experiences storms or even piracy (crisis). At other
times the ship of life may begin to take in water
and the person may face the prospect of drowning
or shipwreck (breakdown). The person may need
to be guided to a safe haven to undertake repairs,
or to recover from the trauma (rehabilitation). Once
the ship is made intact or the person has regained
the necessary sea-legs the ship may set sail again,
aiming to put the person back on the life course
Unlike many normative psychiatric models, the Tidal
Model holds few assumptions about the proper course
of a person’s life, preferring instead to focus on the kind
of support people might need to rescue them from crisis,
or to help put them back on the life course (development).
The Tidal Model recognizes that the life experiences
associated with mental ill health are invariably described
in metaphorical terms. People who experience
8 2 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001
life crises are (metaphorically) in deep water and risk
drowning, or they feel as if they have been thrown onto
the rocks. People who have experienced trauma (such as
injury or abuse), or those with more enduring life problems
often report loss of their “sense of self,” akin to the
trauma associated with piracy. In all these instances,
people need a sophisticated form of lifesaving (psychiatric
rescue), followed at an appropriate interval by the
kind of development work necessary to facilitate true recovery.
This may take the form of crisis intervention in
the community or the “safe haven” of inpatient settings.
Once the rescue is complete (psychiatric nursing), the
emphasis switches to the kind of help needed to get the
By acknowledging the need for a
continuously flexible response to the
person, the Tidal Model also recognizes the
chaotic nature of human behavior, and
especially of human experience.
person “back on course,” returning to a meaningful life
in the community (mental health nursing). The model
assumes that the practical focus of psychiatric and of
mental health nursing differ: the former requiring more
direct interventions, involving a highly vulnerable and
potentially dependent person; the latter emphasizing a
more egalitarian relationship, which involves an even
more collaborative approach to education, personal
growth and discovery.
The Tidal Model recognizes that people’s need for
nursing cannot lie in some either/or world of community
or hospital, general or specialist service, acute or
continuing care, but rather flows across these artificial
boundaries, as the nature of the person’s needs shift,
often imperceptibly. This focus on the care continuum
aims to promote the kind of seamless care that risks becoming
mere rhetoric. The caring response, expressed by
nursing, needs to flow with the person, adapting itself to
the person’s changing needs. Regrettably, the worlds of
community and residential care have suffered from artificial
distinctions. If we maintain a focus on the needs of
the person—for critical, transitional, or developmental
care—the interdependence of different services, to meet
different needs, becomes apparent.
The Tidal Model is represented by a range of holistic
(exploratory) and focused (risk) assessments, which generate
person-centered interventions that emphasize the
person’s extant resources and capacity for solution finding.
These various assessment and intervention processes
are intended to support rather than restrict practice.
The various methods that have been defined in the
training program for the model (Barker, 2000) help the
nurse gain a better view of the person and the territory
of care. The templates for assessment and intervention
contained within the training materials act as a springboard
for creative exploration of the need for nursing,
rather than delimiting the nurse’s practice through the
exercise of a tight protocol. This principle may appear to
conflict with the overvalued emphasis on guidelines,
protocols, and carefully scripted interventions, evident in
much of the evidence-based healthcare literature—or
some psychotherapies. However, by acknowledging the
need for a continuously flexible response to the person,
the Tidal Model also recognizes the chaotic nature of
human behavior, and especially of human experience
The Dimensions of Personhood
The Tidal Model embraces a caring construct, which
frequently appears to be obscured by a myriad of therapeutic
concepts borrowed from other disciplines or fields
of human inquiry (Reynolds & Scott, 1999). Whereas
most, if not all, therapeutic constructs aim to effect some
change in the presentation of the person who is represented
as patient or client, the Tidal Model has more
The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health
modest ambitions, which may ultimately be more ambitious.
Rather than engaging with the disorder or illness,
the Tidal Model focuses on contacting the person
(Barker, 1997). The aim of this engagement is to understand
the present situation of the person, which includes
the relationship with illness and health. Although the
nurse expresses a curiosity about the person, this is in
pursuit of knowledge of what is happening within the
person’s experience of world, self, and others, and what
this might mean for the necessary care of the person.
The model employs three dimensions as a means of
representing personhood: world, self, and others.
W o r l d . In the world dimension, the focus is on the
person’s need to be understood. This includes a need to
have the personal experience of distress, illness, or trauma
validated by others. A specific assessment format (the
Holistic Nursing Assessment, Table 1) documents, in the
person’s own voice, the significant and meaningful events
occurring at this particular time, and what the person perceives
as needing to be done to respond to these events.
S e l f . In the self dimension, emphasis is given to the
person’s need for emotional and physical security. A
specific assessment format, the Security Plan (Table 2),
identifies the kind of support necessary to ensure personal
security and to offset the risk of harm to self or others
through direct action or neglect.
O t h e r s . In the others dimension, emphasis is given to
the kind of support and services the person might need
to live an ordinary life. This dimension emphasizes the
need for specific medical, psychological, or social interventions,
including other vital areas of everyday living
such as housing, finances, occupation, and leisure.
Within each of these dimensions, the nurse aims to
explore the person’s construction of experience through
narrative (Saunders, 1997), employing the concept of
the therapeutic alliance (Hummelvoll, 1996). In each dimension
of assessment and intervention, emphasis is
given to engaging the person fully in the process of determining
and, where possible, contributing to the interventions
that might meet the person’s needs. The
narrative structure of the model is developed expressly
in the care plans, where the assessment record docuPerspectives
in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 3
ments the person’s needs and problems verbatim,
rather than translating the person’s account into professional
The necessary care required by the person will invariably
involve a balance or fusion between the differing
Table 1. Overview of the Holistic Nursing Assessment
1 . Problem origins (How current problems began)
2 . Past problem function (How this affected me)
3 . Past emotional context (How I felt in the beginning)
4 . Developmental history (How things have changed over
t i m e )
5 . Relationships (How this has affected my relationships)
6 . Current emotional context (How I feel now)
7 . Holistic content (What do I think all of this means?)
8 . Holistic context (What does all of this say about me as a
p e r s o n ? )
9 . Needs, wants, and wishes (What needs to happen now)
1 0 . Expectations (What do I hope that the nursing team will
do for me?)
Table 2. Overview of Format Used to Develop the
1 . How do I feel today?
2 . How safe do I feel right now?
3 . What would help me feel safer?
4 . What are the chances that I will harm myself?
5 . To what extent do I think the nursing team can help me?
6 . What exactly could the nursing team do to help me?
7 . Who else could help me feel safer?
8 . How, exactly, could they be of help to me?
9 . How confident am I that I can keep myself safe until I
meet with my primary nurse again?
1 0 . (If the person is at risk of self-harm) What have I done, or
what have others done, in the past that helped me feel
1 1 . What can I do now to make myself feel more secure?
1 2 . How can the nursing team help me feel more secure?
constructions of the person and her/his significant others.
The empowerment, narrative basis of the Tidal
Model, acknowledges that what needs to be done will be
determined largely by the person’s personal science ( M ahoney,
1974). The model draws heavily on systemic and
solution-oriented approaches (Webster, Vaughn, Webb,
& Playter, 1995), which emphasize personal problem
solving, and reveal and employ personal resources.
The Tidal Model gives precedence to the
story told by the person, since this is the
location for the person’s enactment of life.
The Tidal Model assumes that people a r e their narratives
(McIntyre, 1981). People’s sense of self and world of
experience, including experience of others, is inextricably
tied to their life stories and the various meanings they
have generated. The Tidal Model generates a narrativebased
form of practice that differs markedly from the
concept of evidence-based practice, which holds sway at
present. The former is always about particular human
instances, whereas the latter is based on the behavior of
populations whose elements are merely assumed to be
equivalent. More important, perhaps, the narrative focus
of the Tidal Model is not concerned with unraveling the
causative course of the person’s present problems of living,
but aims to use the experience of the person’s journey
and its associated meanings to chart the next step
that needs to be taken on the person’s life path. As part
of this conjoint exploration of the person’s world of experience,
the assessment record is written in the person’s
own voice, rather than translated into third person or
professional language. Emphasis is given to the livedexperience
of distress, by using a first-person narrative:
e.g., “ This all began for m e . . . when I started to . . . and
then I began to . . . and this made m e feel . . . so I b e l i e v e d
8 4 Perspectives in Psychiatric Care Vol. 37, No. 3, July-September, 2001
that . . .” Research suggests that this simple strategy may
empower the person (Barker et al., 2000). The nurse and
the person in care cocreate the narrative of the world of
experience, which includes an identification of what the
person believes she/he needs in the form of nursing.
The Tidal Model gives precedence to the story told by
the person, since this is the location for the person’s enactment
of life. The caring process begins and ends here
since people invariably need to develop (create) a coherent
account of what has happened and is happening to
them in light of their personal experience. In the course
of mental health care and treatment, it is commonplace
for nurses to note that people change their stories. This is
a reflection of considering the past in light of the present
(which is changing) and serves notice that people are involved
in creating their future. It is folly, therefore, to
talk of some putative “true” story: This is no more than a
pattern of context or agency. Instead, the nurse aims to
help the person develop a story, which takes account of
how she/he is making sense of life events (including the
process of care) as they occur.
Moving From Disempowering to Empowerment
The experience of mental ill health is disempowering,
limiting the person’s ability to function in everyday life.
When mental health problems endure or recur frequently,
the family or community often view the person as disabled.
Although the person is offered a mental h e a l t h s e rvice,
this invariably is focused only on limiting the personal
and interpersonal damage that can be caused by
living with mental illness. The processes of psychiatric
care and treatment often add to the disempowerment of
the person. This ranges from the manifest restrictions imposed
by confinement under the law to the subtler limitations
enacted by being placed under observation in the
hospital or deemed noncompliant by an assertive outreach
team. The model attempts to address directly the
most common form of disempowerment, which involves
the failure to afford a proper hearing to the person’s story
of the experience of problems of living. Traditionally, the
medical model has served as a means of deflecting attenThe
Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health
tion from the lived experience of the person, translating
this unique, subjective account into the paralanguage of
medicine, where the person’s account is reduced to the
level of its apparently commonly occurring parts. This is
not a condemnation of psychiatric diagnosis per se, but is
merely an acknowledgment of the limitations of this way
of representing the human experience of problems of living,
especially where this is afforded primacy.
The three dimensions of the Tidal Model aim to avoid reducing
the person to a “patient phenomenon,” while recognizing
the impossibility of developing anything more than a
provisional account of the person’s life experiences and the
person’s immediate need for nursing. By embracing the
principles of empowering interactions drawn from empirical
research (Barker, 2000), the Tidal Model puts the person’s
experience and unfolding life narrative center stage, and, in
so doing, powers up the person in the process (Parse, 1981).
Research and Development
The Tidal Model was introduced in two pilot sites in
acute psychiatric admission wards in Newcastle, England,
in 1997. Over a period of 30 months, the original
model was revised and adapted, and the present model
was introduced in May 2000 across the whole adult
mental health program, comprising eight admission
wards and their associated community support teams.
An interdisciplinary evaluation of the model in practice
is being conducted, involving nursing, medicine, occupational
therapy, and patient advocates. The evaluation is
employing an action research methodology to monitor
the processes and effects of the implementation of the
model across three main domains: nurses’ perceptions of
the utility of the model in practice, patients’ perceptions
of the personal benefits of receiving care within this
model of nursing practice, and other disciplines’ perceptions
of the extent to which the model enhances interdisciplinary
A number of pilot sites have been established across
a range of clinical settings worldwide—from a rural
mental health service in Adelaide, Australia, to a
medium secure facility in Cardiff, Wales, to Japan, AusPerspectives
in Psychiatric Care Vol. 37, No. 3, July-September, 2001 8 5
tralia, New Zealand, Finland, Ireland, and Scotland.
These additional pilot sites (about 15) will allow a degree
of cross-national, as well as cross-cultural, comparison
of the model in action (Narayasamy, 1999). For example,
one of the sites in New Zealand offers a
culture-specific mental health program for the indigenous
Maori people; it largely eschews the assumptions
about illness that are characteristic of western psychiatric
C o n c l u s i o n
Although nursing has a longstanding attachment to
the concept of caring through interpersonal relationships,
increasingly this has been usurped by demands for “evidence”
of their utility within a postpositivist research
paradigm (Barker, 1999; Stevenson, 1996). As Taylor
(1994) has demonstrated, however, the dynamic processes
involved in nurses and the people in their care, encountering
and negotiating (through narrative) the experience of
illness, can ultimately engender healing, and are experienced
as such by people receiving nursing care. The Tidal
Model assumes that nurses need to get close to the people
in their care, so they may explore (together) the experience
of health and illness. Although (or perhaps because)
health care is becoming increasingly technical and emotionally
distant (e.g., through the use of computers), many
people with mental health problems are calling for care
and treatment to reemphasize the relationships between
themselves and their careers. In this context it is notable
that Harry Stack Sullivan’s biographer suggested that Sullivan’s
key contribution to psychotherapy and psychiatry
was his “ever present awareness of the need to convey respect
for the patient and to maintain the patient’s own
self-esteem” (Evans, 1996, p. 3).
In quite a different context, the Irish philosopher and
theologian John O’Donohue (1997) has argued that contemporary
. . . an excessive concentration on the notion of relationships.
It is a constant theme on TV, film and
media. Technology and media are not uniting the
The Tidal Model: Developing a Person-Centered Approach to Psychiatric and Mental Health
world. They pretend to provide a world that is i n –
t e r n e t t e d , but in reality, all they deliver is a simulated
world of shadows . . . “relationship” has become
an empty centre around which our lonely
hunger forages for warmth and belonging. (p. 39)
O’Donohue (1997) notes that in the early Celtic
church, a person who acted as a teacher, companion, and
spiritual guide was called an anam cara (a soul friend),
someone “to whom you confessed, revealing the hidden
intimacies of your life” (p. 35). It is evident that the practice
of psychiatric and mental health nursing is still predicated
on a kind of confession (of trauma and physical
and emotional vulnerability) within an intimate conversation
Only our postmodern secular society feels uncomfortable
about acknowledging (as O’Donohue does) that this
process is spiritual, since it involves, as Frankl (1964) defined
it, an exploration of the meanings that people have
attributed to the experiences in their lives.
The Tidal Model acknowledges that the life problems
that overtake and threaten to drown people described as
suffering from mental illness can be construed at a fundamental
level as spiritual crises (Morris, 1996). It also
acknowledges that the kind of care nurses need to deliver
to respond effectively to such crises may appear ordinary
(Taylor, 1994), but, given the context of care and
the often-limited resources available, can represent acts
of extraordinary courage and compassion.
The Tidal Model provides a medium through which
nurses may explore again the proposition first articulated
by Nightingale (1860/1969): that their primary role
is not to cure or heal people directly, but to organize the
conditions under which the person might be healed by
Nature or by God.
Author contact: email@example.com, with a copy to the Editor:
m a r y 7 7 @ c o n c e n t r i c . n e t
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