International Journal of Mental Health Nursing (2009) 18, 116125

doi: 10.1111/j.1447-0349.2008.00591.x

Feature Article

Psychiatry, mental health nurses, and invisible power: Exploring a perturbed relationship within contemporary mental health care
John Cutcliffe1,2,3 and Brenda Happell4
University of Texas (Tyler), Texas, USA, 2Stenberg College International School of Nursing, Vancouver, British Columbia, Canada, 3University of Ulster, Jordanstown, UK, 4Department of Health Innovation and Institute for Health and Social Science Research, CQUniversity, Rockhampton, Queensland, Australia
1

ABSTRACT: Interpersonal relationships, although considered to be the cornerstone of therapeutic engagement, are replete with issues of power; yet, the concept of invisible power within such formal mental health care relationships is seldom explored and/or critiqued in the literature. This paper involves an examination of power in the interpersonal relationship between the mental health nurse and the consumer. Issues of power are emphasized by drawing on examples from clinical experiences, each of which is then deconstructed as an analytical means to uncover the different layers of power. This examination highlights the existence of both obscure and seldomly acknowledged invisible manifestations of power that are inherent in psychiatry and interpersonal mental health nursing. It also identies that there is an orthodoxy of formal mental health care that perhaps is best described as biopsychiatry (or traditional psychiatry). Within this are numerous serious speech acts and these provide the power for mental health practitioners to act in particular ways, to exercise control. The authors challenge this convention as the only viable discourse: a potentially viable alternative to the current of formal mental health care does exist and, most importantly, this alternative is less tied to the use of invisible power. KEY WORDS: invisible power, mental health nursing, therapeutic relationship, traditional psychiatry.

INTRODUCTION
Since Peplaus seminal 1952 work, the interpersonal relationship has often been posited as the crux of mental health (MH) nursing and its importance has been reinforced over time (Barker 1999; Dunwell & Hanson 1998; Fourie et al. 2005; Goodwin & Happell 2007; Horsfall & Stuhlmiller 2000; Jackson & Stevenson 2000; OBrien 1999; Perraud et al. 2006; Teising 2000). The state of

Correspondence: Brenda Happell, Department of Health Innovation, CQUniversity Australia, Bruce Highway, Rockhampton, 4702 QLD, Australia. Email: b.happell@cqu.edu.au John Cutcliffe, RMN, RGN, RPN, RN, BSc (Hons) NrSg, PhD. Brenda Happell, RN, RPN, BA (Hons), DipEd, BEd, MEd, PhD. Accepted October 2008.

contemporary formal MH care services in many parts of the world leads Fourie et al. to assert that MH nurses are generally the only professional group that consumers spend enough time with (particularly in inpatient units) to develop the trust and rapport necessary for therapeutic relationships. Yet, even though there is a broad consensus that interpersonal relationships remain a central aspect of MH nursing practice, such relationships are not free from problems and continue to be worthy of our attention and scrutiny. How the MH nurse and person in distress relate is dependent on many factors, one of which inexorably is power. Although for some, acknowledging power as a ubiquitous phenomenon in any or all interpersonal relationships is an uncomfortable experience, the authors

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would assert that it is only through such admittance that power issues can be considered, examined, better understood, and hopefully, dealt with successfully. Interestingly, though there is a notable absence of empirical and theoretical literature that focuses explicitly on power (and the issues of power) within nursing, it has become de riguer for MH nurses to talk about empowerment (e.g. Finfgeld 2004; Gallop 1997; Ryles 1999). This epistemological state creates a fascinating scenario, where practitioners espouse the theory and practice of empowerment while simultaneously being conceptually uncertain of the phenomenon called power. Accordingly, as a means to help rectify this situation, in this paper we examine power (and invisible power) in the interpersonal relationship between the MH nurse and the consumer. We aim to challenge any existing practice complacency about the micropolitics of the interpersonal relationship and, in so doing, advance an alternative discourse vis a vis power. We do so by rst briey reviewing the concept of power and by drawing on the limited literature that has focused on power in psychiatry and MH nursing. Second, we provide a number of examples derived from our collective experiences in MH care, each of which is then deconstructed as an analytical means to uncover the different layers of power as they are played out in our examples (see Clinton & Hazelton 2002; Walsh et al. 2008). As Walsh et al. previously pointed out, such deconstruction also creates a space and enables the authors to consider the case for alternative explanation(s) and to challenge the dominant discourse (or orthodox view) as the only viable discourse. We conclude by illustrating that a potentially viable alternative (if not alternatives) to the current dominant orthodoxy of traditional psychiatry (or biopsychiatry) of formal MH care exists and, most importantly, this alternative(s) is less tied to the use of invisible power.

THE CONCEPT OF POWER: AN OVERVIEW

Even a cursory search of the dictionary denitions of power will illustrate that the term has many meanings and applications across a wide range of contexts, circumstances, and disciplines. In its simplest form, power is dened as: the ability to do or act; the capability of doing or accomplishing something; a great or marked ability to do or act; strength; might; and force (Allen 2006). Other denitions include: power as the possession of control or command over others; authority; and ascendancy (e.g. power over peoples minds). The denitions also refer to political power, whether located in (and enacted by) an individual, group, organization, or a state (e.g. political

or national strength, such as the balance of power in Europe). Additional denitions refer to the power conferred upon or delegated to people that attain certain positions (e.g. legal ability, capacity, or authority: the power of attorney or as authority granted to a person or persons in a particular ofce or capacity, such as the powers of the Prime Minister or President). Perhaps, as an extension of political power, power also is to be found to refer to military strength or might. Power is a concept that transcends common secular contexts and has particular meaning within the physical sciences, most especially physics (e.g. where it is dened as the amount of work done or energy transferred per unit of time and the time rate of doing work, and/or a particular form of mechanical or physical energy, force, or momentum) and mathematics (e.g. where it represents the product obtained by multiplying a quantity by itself one or more times). Importantly, it is found also within social and health sciences (e.g. the proposition of King (1981) that power is inherent within social systems) and, although of a noted vintage, the psychological notion that power is inherent in the nature of people and played out in power over another (Adler 1966; Berle 1969; Rosinski 1965). Power also has a theological application and denition, where it refers to a deity or divinity (e.g. the heavenly powers). Robust linkages between traditional psychiatry and coercion/power are increasingly documented in more recent literature (e.g. Bracken & Thomas 2001; Hannigan & Cutcliffe 2002; Heffern & Austin 1999; Rogers & Pilgrim 2001; Szasz 1994; 1997; Walsh et al. 2008). An examination and critique of historical and sociopolitical literature pertaining to MH and psychiatry show very clear links with social exclusion and control, and incarceration (be it in madhouses, workhouses, asylums, prisons, and more recently, general hospitals). Indeed, Szasz (1997) offers a persuasive and compelling argument that the focus of psychiatrys mental illness originates from a legal (or quasilegal) rather than a medical context; for Szasz then, one cannot think or talk about psychiatry without simultaneously thinking or talking about power and control. For Bracken and Thomas (2001), these links were forged during the Enlightenment era. Szasz (1994) offers similar remarks. Subsequent to these origins, Bracken and Thomas (2001; p. 726) state that:
Substantial power was invested in the profession through mental health legislation that granted psychiatrists the right and responsibility to detain patients and to force them to take powerful drugs or undergo electroconvulsive therapy.

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Ironically, the substantial power that traditional psychiatry and with that, the agents and associates of traditional psychiatry, wield has not been the focus of too much debate, though there is evidence of an emerging body of work in this area. As the authors pointed out in the Introduction, the publications that emanate from within MH nursing that focus on the (ab)use of power are few in number; whats more, they are vastly outnumbered by the papers that focus, uncritically, on further applications of this power. For example, even the most cursory of reviews of the contemporary literature that focuses on so-called nurse prescribing in MH care shows that the majority of papers published adopt an uncritical stance. They do not even consider or debate whether or not this is an activity in which MH nurses should be engaged. They say little or nothing about the huge shift in power that comes with prescriptive authority or, indeed, about how this is a de facto extension of psychiatrys power. Instead, what such literature focuses on is more effective ways to enhance compliance or adherence, managing the role conict between psychiatrists and MH nurse prescribers, training and competency issues in being a nurse prescriber, and correctly identifying and managing side-effects (e.g. Jones 2008; Jones & Jones 2008). Nevertheless, for some, the relationship between traditional psychiatry (or biopsychiatry) and power/ control is not only difcult to refute or deny, but the increase in public awareness and various service user groups has reached the point that more open and honest dialogue is now not only essential but inevitable. As Bracken and Thomas (2001; p. 726) purport that:
Ignoring the fact that psychiatry has a particular coercive dimension will not help the credibility of the discipline or ease the stigma of mental illness. Patients and the public know that a diagnosis of diabetes, unlike one of schizophrenia, cannot result in their being forcibly admitted to hospital.

generalization. Each of the examples in this paper is based on real clinical practice, which have been drawn from several cases from various international settings (rather than restrict our examples to one site or country; thus, arguably reecting the ubiquitous nature of power in MH-related relationships). As this paper focuses on the identication of previously hidden or invisible power in interpersonal relationships in a MH services context and in order to maintain the condentiality of all the people involved, all names and identifying features have been altered.

Example 1: Removal of personal freedom

Anna is a 23 year old woman who has an extensive history of contact with MH services, most often as a result of her thoughts about harming herself. During her most recent admission to an acute psychiatry unit, which was precipitated once again because she was experiencing intrusive and pervasive thoughts about taking her own life, Anna was placed on close observations. During the second day after her admission, Anna was still having some thoughts about harming herself and met with one of the MH nurses on the unit. When the nurse asked how Anna was feeling, she replied, Well, Im still having some suicidal thoughts. The nurses response was to take Annas vital signs and then leave. Anna did not think much of the interaction as she had offered an honest report of how she was feeling and so she went back to reading her book. A few minutes later, the psychiatrist assigned to Anna appeared and asked her, Well, I hear youre feeling suicidal? On hearing Annas positive response, he asked her, Do you want me to put you in restraints? Anna was shocked by the question and just did not know what to say to the psychiatrist, who repeated, What do you want me to do? Then, the psychiatrist said, Well, Im going to put you in restraints and Anna was placed in physical restraints for 24 h. During this time, the three others who shared her room looked at her and asked, What did you do? Anna later reported to her MH nurse that she felt very uncomfortable with what was happening, that she feels that she was being stereotyped. She also reported feeling ashamed and disgraced. Anna made a plan that, when she was next asked by the psychiatrist how she was feeling, she would not/could not tell him the truth and that, when asked if she was still suicidal, she would lie. Two hours after this next exchange occurred, where Anna did deliberately mislead her psychiatrist, she was discharged. The enactment of power by the professionals in Annas story will be seen by some as unsophisticated and obvious (i.e. the removal of her personal freedom) but, in other

ILLUSTRATING THE USE OF POWER

This section presents a number of examples to illustrate health professionals use of power over consumers. Numerous authors have declared the epistemological utility of examining real cases (e.g. Stake 1994; Yin 1989). Indeed, Stake (1994; p. 240) purports that:
Naturalistic, ethnographic case materials, to some extent, parallel actual experiences, feeding into the most fundamental processes of awareness and understanding.

Such increased awareness and understanding, in turn, enable naturalistic generalizations or idiographic

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ways, the enactment of power is less obvious. In this example, biopsychiatry might be thought in terms of Foucaults (1984; 2002) ideas of government, as a form of activity that aims to shape, guide, or affect the conduct of some person or persons (see also Gordon 1991). Despite the notion that MH services exist to help consumers with their MH issues, Anna struggled to have her fears and concerns heard. The micropolitics of power/ resistance produced not only the action of the removal of her personal freedom and increased professional surveillance but also communicated a message of what would be allowed to be discussed and what would not be allowed. It is these implicit expressions of power that are less obvious and arguably less visible (to some) and, yet, the authors would argue, should be of major concern to MH nurses. Rather than engage with Anna and help her deal with her suicidal thoughts, the professionals default to the (ab)use of power. These unsophisticated and crude expressions of power were met, ironically, with an inversely sophisticated resistance as Anna knew which answers she needed to provide (whether or not these were true or accurate was moot) in order to enact her resistance. Interestingly, the argument can be made that when resisting moral/resocializing treatment, it makes sense to resist with immoral (e.g. deliberate and purposeful deceit) behaviour. Alternative approaches to the use of power could have included the MH nurses attempting to help with her suicidal thoughts/feelings by attempting to engage Anna (Cutcliffe & Barker 2002). The MH nurses could have asked her: Where does it hurt?; What might I offer you in terms of help?; and How might we work through this together?

Example 2: Forced administration of medications

Brian is a 35 year old man who has had several admissions to the MH service. He was diagnosed with schizophrenia and comorbid substance abuse. The MH staff considered Brians prognosis to be poor and he was generally described by using terms like uncompliant, treatmentresistant, and uncooperative. Jenny is a 25 year old woman who was admitted for the rst time with a diagnosis of bipolar affective disorder. Her mood was elevated and she was dressed in what might be termed a sexually provocative manner. Brian was noticed to be spending a lot of time with Anna, offering to show her around the unit and help her settle in. Brians primary nurse took him aside and warned him not to try anything funny with her. After several warnings to leave Jenny alone, Brian began to protest loudly that he is being treated unfairly and

stated that he and Jenny have a special bond. As he became louder, the nurses became more insistent. A nurse brought an as required (PRN) dose of medication. Brian insisted that he does not need any medication and that he is only being friendly to a fellow patient and he should not be forced to take medication. After further negotiations, an intramuscular injection was prepared and administered to Brian by force, against his will. As a result of his marginal behaviour, the MH nurses viewed Brian as having little life potential. For many people with so-called severe and enduring mental illness, the best that such individuals as Brian can hope for is to be well maintained though medication. Such cruel compassion, as Szasz (1994) terms it, is used purportedly to prevent relapse. Relapse in the current mental illness orthodoxy is a serious speech act in that it produces actions, such as persuading, threatening, restraining, and controlling (Holmes et al. 2004; Weitz 2004). The statements regulated by this orthodoxy are well rehearsed; for example, the relationship between medication and relapse. As Walsh et al. (2008) purport, speech acts are taken for granted and they might not necessarily be accurate or based on a solid, robust empirical underpinning, but they are seen by some MH practitioners (and society) as legitimate knowledge. In the biopsychiatry alternative discourses about the efcacy of medical interventions (Breggin 1997; 2003; Geddes et al. 2000; Kirsch & Sapirstein 1998; Leucht et al. 2003), side-effects including the exacerbation of abnormal mental and behavioural conditions, discrepancies within pharmaceutical research (BBC 2008; Cohen 2002; Healy 2005; Moncrieff & Double 2003), and ethical concerns about the marketing power of pharmaceutical companies (BBC 2008; Montcrieff et al. 2005; Thomas et al. 2005) are marginalized as efciently and effectively as Brians understanding of his experience. However, Brian is struggling to have some normal life experiences, including an intimate relationship. Indeed, Brians irtatious behavior with Jenny could be construed as further evidence of his attempts to experience a normal life and, yet, this was a life that staff attempted to control. Even if Brian was acting in a proigate manner, alternatives concerned with helping Brian explore less dissolute and less challenging ways of interacting with the opposite gender were not considered. Instead, Brians attempts are seen as something that needs controlling (not modifying), as something that the MH staff members need to exert power and control over. However, it has been argued that to control someones intentions of intimacy can be interpreted as denying the individual the right to love and feel loved.

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Example 3: Deciding what will and what will not be discussed

Jarrod is a 19 year old man who experienced his rst psychotic episode after a big week of smoking marijuana and drinking alcohol. He was admitted briey to the inpatient unit and stabilized on psychotropic medication. Jarrod attended his rst appointment with the psychiatrist in the community clinic. He was very anxious about what happened to him and had a number of questions for the psychiatrist that included: How does the medication work?; Does it have any side-effects?; How long will I have to take it for?; Can I stop before I go overseas in 2 months?; Am I mad?; and Will this happen to me again? The psychiatrist replied, Let me ask the questions, young man and continued with the psychiatric interview despite Jarrods obvious distress. The nurse present nodded in apparent agreement with the psychiatrist and did not speak on behalf of Jarrod. In ignoring Jarrods questions, his psychiatrist and MH nurse invalidated and marginalized him. This simple act of government, in a Foucauldian sense, shapes conformity, both in thought and in the role assigned to Jarrod by his diagnosis (and most likely, the prognosis assigned to this case). Jarrod appears to experience some benets from his current medication and treatment at this time in his life. Medication and treatment appear to enable him to achieve a certain social functionality and free him from the overarching possibility of connement. Yet, accepting medication and treatment also limits his opportunity to embrace aspects of a fuller life. His learning and interpretations of his experience are disregarded. Throughout this scenario, there is little or no place for Jarrods questions, little or no curiosity by the medical or nursing staff regarding what motivates Jarrod to ask about medication, little or no attempt to explore what he has learned about medication, and little or no response that might establish a foundation for change. Furthermore, there was no opportunity provided to explore the nature of Jarrods concerns or to seek to understand the nature of the help that Jarrod felt he wanted. The psychiatrist exercises power, moving the conversation back to the mundane, asking about Jarrods daily activities, and dismissing him within a few minutes. Jarrods questions could be interpreted as a sign that he is contemplating change. According to Prochaska (1999), change begins with a period of contemplation and self-education. Yet, in this scenario, Jarrods conduct is shaped not through asking and receiving responses to his own questions but through a lack of response. Questions and comments are validated through the response of the receiver (Gergen 2007).

Here, Jarrod learns that that it is unacceptable to speak to power. The possibility that Jarrod might participate in learning about his condition and making decisions about his needs and potential treatment alternatives was not explored or even considered.

Example 4: Deciding what will be and what will not be addressed

Donni is a 57 year old man with a past history of major depression and suicidal ideation. Donni rst attempted suicide at the age of 17 years following the deaths of his mother and his best friend within a 2 month period. Over the following 12 years, he attempted suicide on a number of occasions, generally precipitated by relationship breakups, job losses, or extended periods of unemployment. At the age of 31 years, Donni met his long-term partner, Susan. Although they both wanted children, Susan did not conceive and they decided to let nature take its course rather than trying to force the issue. Donni and his wife lived quietly and uneventfully despite neighbours describing them as a bit odd. Donni continued to take antidepressant medication prescribed by his general practitioner. Six months ago, Donnis wife died after being diagnosed with pancreatic cancer. Donnis neighbours described his behaviour since then as crazy. His appearance was very dishevelled and he was frequently observed to be shouting obscenities loudly although no one was in sight. Donnis only companion is a golden retriever that his wife gave him as a 50th birthday present. Donni was admitted to the MH unit after the police attended a scene where Donni threatened to blow himself up because he no longer deserves to live. On admission, Donni was preoccupied with the safety and welfare of his dog, who he stated has not been fed or walked for 2 days. He continually expressed concern that there is no one to look after the dog and, if the dog dies, life will have even less purpose. The psychiatrist was clearly impatient with Donni, reminding him that he is very busy and needs to nish the assessment. The psychiatrist continued to ask questions about his medication history, whether he is hearing voices, and if he knows the day/date/time. The psychiatrist did not acknowledge the importance of the dog in Donnis life in continually diverting the conversation from this topic. A further, though perhaps less visible expression of power, is that of deciding what will (and will not) be addressed. In the biopsychiatry discourse, the issue of exploring how Donni came to be crazy and suicidal requires no discussion. Furthermore, Donnis concern about his dog was not considered to be a valid focus, indeed he was viewed as wasting the psychiatrists valu-

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able time. The matter that Donni felt was important to his psychological well-being, his relationship with his dog, is marginalized. Donnis story illustrates the strategy of omission. For the psychiatrist, the most important issues are his illness history, the medication he is taking, and whether or not he has taken it as prescribed. The omission might have been well intended but it retains the clinicians power to shape Donnis behaviour, to decide what should be important to him, and to maintain the denition of his experience within the parameters of the accepted discourse: within the biopsychiatry discourse. Donni is not behaving appropriately, in that he (as a recipient) is implicitly challenging the roles of the service-providers. The challenge is met by a return to conversation about daily activities, which serves to communicate a clear message of exactly who will be deciding what is going to be addressed in these encounters.

about her future goals and, although Sandra made some attempt to vocalize what she felt was in her best interests, it was not discussed with her and was quickly dismissed. Listening to Sandra might be seen to negate the importance of a biological perspective (and its associated interventions) and the view that health professional knows best but, as Bracken and Thomas (2001) point out, it does refuse to privilege such explanatory frameworks at the expense of other (consumer-held) alternative views.

Example 6: Use of language and terminology

Jarrod (described in case study 3) met with his primary nurse, Teresa. He asked her a number of questions about his diagnosis, treatment, and prospects for the future. Teresa told him that he has a drug-induced or, possibly, a schizophreniform psychosis and will require neuroleptic medication for the rest of his life. When Jarrod asked her, what those big words mean, she repeated them rather than explained them and told Jarrod that he doesnt need to know the science, he just needs to take his medication and focus on getting well. Jarrod attempted to steer the conversation towards his interest in alternative methods for explaining and treating his so-called mental illness. Teresa laughed and replied, Dont waste your time Jarrod, theres no evidence that stuff works, the sooner you take your medication as prescribed, the sooner you can get on with your life. A subtle and, yet, ubiquitous manifestation of power is in the very words and language used. The use of language is a strategic act that often preserves relational asymmetry. Gergen (2007) suggests that power is an artifact of language. Through language, a professional can construct a context in which the consumer must guess at what is communicated. Most speech includes a command and a report function (Watzlawick et al. 1967). The report is spoken while the commands are embedded within the tone, inection, words omitted, facial expression, and posture. Perhaps, a more subtle aspect of command is the maintenance of differential understanding. Differential understanding is preserved in the use of professional jargon when speaking to or about the consumer. There is an unspoken message indicating, Everybody understands this talk; therefore, you must understand, or be decient. As a result, the consumer is disempowered. As a strategic act, language also denes consumer health. If a consumer is to become better, in the biopsychiatry discourse, better is dened as a reduction in symptoms and an increase in compliance in terms of response, behaviour, and medication. Jarrod offers some alternative knowledge and explanations for his experience. He has explored alternative possibilities for

Example 5: Making decisions about consumers best interests

Sandra is a 35 year old woman who is currently on a community treatment order (CTO). The conditions of the CTO include that she live with her elder sister and attend the local MH service on a weekly basis for ongoing treatment. Today, when Sandra met with her case manager (Lindy, a MH nurse), she made two requests. First, that she is given permission to move in with her new boyfriend and, second, that her medication dosage be reduced to minimize the distressing side-effects. Lindy quickly said no to both requests. She told Sandra that moving in with her boyfriend would be a big mistake, that just like last time, Sandra would stop taking medication and it would only be a matter of time before she was in (the MH unit) again. She suggested that this might be a goal that Sandra can work towards by complying with treatment and sorting out her MH issues. To the medication request, Lindy stated that, Its up to the doctor to reduce your medication; until then, keep taking it and youll be ne. No further discussion of either point was encouraged. Given what occurred in this example, it is perhaps worthy of note that, in a study that explored the meaning of patient dissatisfaction with the National Health Service in the UK, Coyle (1999) concluded that complaints were related to the concept of personal identity threat. The patients interviewed during this study reported feeling disempowered, devalued, dehumanized, and objectied during their care, components of which included the sense of a lack of consultation and a lack of input to care decisions, both of which are evident in Sandras encounter. There was no discussion about what Sandra wanted and how her needs could be met. Sandra was not asked

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medication and treatment. Yet, in the biopsychiatry system in which he is involved, Jarrod cannot participate as an informant. The use of empowering discourse as an alternative invites Jarrod into dialogue, provides clarication, and encourages active participation (Virtanen et al. 2007; see also the Hearing Voices Network in Romme & Escher 1994). Jarrod is considered to be an expert on his needs, responses, and desires. There is a attening of the hierarchy between the clinician and the patient; the process of treatment and change are cocreated outcomes of their combined expertise.

DISCUSSION
The examples in this paper and the limited deconstruction that we have subjected them to enables the authors to argue that there is evidence of a dominant discourse (or orthodoxy) of formal MH care that perhaps is best described as biopsychiatry or, to borrow the parlance of Bracken and Thomas (2001), traditional psychiatry. Attached to, or more accurately, within this are numerous rules that provide the power for MH practitioners to act in particular ways, to exercise control. The case examples and their analyses serve as a form of an alternative discourse and help challenge the dominant discourse and its associated rules as the only viable discourse. By exploring the contemporary limits of the necessary, as Foucault (1979; 2002) would say, one can construct a cogent argument that potentially viable alternatives to the current dominant discourse of formal MH care do exist and, most importantly, these alternatives are less tied to the use of invisible power. For example, the discourse of recovery may provide one such viable alternative and there is increasing evidence that recovery is being seen as pivotal to 21st century formal MH care (see the review of MH nursing by the Scottish Executive (2006) and by the UKs Chief Nursing Ofcer (Department of Health 2006)). Recovery is an alternative that brings with it a greater sense of hope, self-determination, dignity, and ultimately, ownership of experiences. It is self-deterministic in that it promotes individual journeys of discovery, coping with, living with, and/or eventually being void of symptoms. It is selfdened and so dees the traditional descriptions in which mental illnesses have been framed. This shift in discourse towards recovery incorporates a shift in how power is enacted. The recovery paradigm opens up space for service users to articulate their experiences of living with mental ill health on their own terms. No longer do they have to be subservient to a biomedical (or biopsychiatry) discourse. Nor do they have to be

content with the paternalistic way in which MH services are delivered. The prescriptive manner in which mental distress has been/is managed is no longer acceptable to a growing number of service users. This shift has major implications for the MH nurseconsumer relationship: MH nurses will be less likely to be asked to take on the role of empowerer (whatever this term might mean) and will be increasingly expected to take on the role of facilitator (of individual journeys of recovery). Our analysis also has highlighted that exercising power over consumers occurs in a variety of ways, some subtle, some less so. There is also evidence that exercising such power appears to be bound up with the very nature of the dominant discourse and its associated rules. That, as key authors such as Szasz (1961; 1994; 1997; 2007) and Bracken and Thomas (2001) point out, current MH care has become coupled with coercion and control; of greater concern, is the compelling evidence that some recent MH care policy has become more coercive and power-laden (Hannigan & Cutcliffe 2002). The rules within the dominant discourse themselves in many interpersonal encounters often become expressions or uses of power. But, the use of power, as our examples demonstrate, is played out in more subtle ways than what is said. In keeping with postmodernist thinking, the words that are missing (from the interaction between consumers and psychiatrists and/or MH nurses) are just as important as those that are there (Cheek 2000). The words that are not used (e.g. non-answers to certain questions) also can be an expression or use of power. What becomes clear from the analysis of these examples and the consumers stories is that such encounters or, more accurately, a series of encounters, are replete with the expression and (ab)uses of power. The authors would argue that it requires acutely selfaware practitioners to be mindful of, and thus shy away from, the use of such invisible power. This is especially required because there is, as has been noted by Moreell (2007), something insidious and seductive about the nature of power. Although MH nurses might set out with the best intentions and highest motives, eventually the use of power will become an end in and of itself; the power will corrupt the person who wields it (see Actons axiom or Moreell (2007)). Furthermore, there are important questions that hitherto have gone unanswered concerning the question: Can MH nurses operate in a way that is genuinely focused on power-sharing in a system or governmentality that is built on propagating this power? With the shift to community care, the issue of acknowledging and addressing visible and invisible power is reiterated and underscored. Care in the community

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brings with it a different set of challenges for MH nursing. A growing number of people diagnosed with what is now termed severe and enduring mental illness are spending an increasing amount of time in the community away from the gaze of the mental institution. This could be one reason why the traditional psychiatry perspective of MH has maintained its inuence throughout the past few decades. Biopsychiatry knowledge, as a serious speech act, can be used as a means to govern and control and is, therefore, justied as an intervention for those potentially at risk to themselves or others; in this case, people with so-called severe mental illness. As a consequence, care in the community has quickly become treatmentorientated (Warner et al. 1997), the consequence of which is the neglect of the social and spiritual needs of the service user, coupled with a corresponding tightening-up of custodial or policing compliance within associated community care MH policy, that is, CTOs (Hannigan & Cutcliffe 2002). If MH nurses remain acquiescent to the current govermentality and its associated speech acts and uses of power, they will continue to deny the human stories of tragedy and misfortune that are associated with so many people in mental crisis. It is these stories, these phenomenological narratives, that help to connect one human to another. Failing to acknowledge them further denies the right to express the need to nd acceptance and to be understood and to receive expressions of love, compassion, and understanding (which are all axiomatic elements of Peplaus (1988) theory of MH nursing) and, thus, in many cases exacerbates the persons mental distress.

conicting knowledge available to service users as to the causes and interpretations of MH problems.

REFERENCES
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CONCLUSIONS
The use of power (and, to a lesser extent, the associated resistance/power/resistance cycle) that has been described in this paper is likely to continue if MH nurses allow the power of biomedical (biopsychiatry) discourse to go unchallenged. Maybe, all the more so because the (ab)uses of power can be unobtrusive or even invisible. It is perhaps time for MH nurses to rediscover Peplaus (1988) seminal work and review how it might be possible for the consumers narrative (including the context in which personal crisis occurs) to be facilitated by a human process of meaningful engagement. This might only happen in a context that allows alternative views, most especially the consumers own explanations and views, to be explored as a way to nding meaning and subsequent solutions for someone who is experiencing a MH crisis. Furthermore, it would appear that some MH professionals have yet to come to terms with the alternative and

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