Consumers living with psychosis: Perspectives on sexuality.

Mental health clinicians work within a recovery framework that is rights based and emphasizes positive and respectful approaches to working with mental health consumers. Mental health nurses' practice is also predicated on holism and inclusiveness, yet consumers' sexuality is sometimes neglected and rights in this area overlooked. Also overlooked is sexuality as an area for investigation, particularly from a consumer perspective, even though it constitutes part of consumers' broader remit of sexual health. This paper reports findings from a case study where consumers were asked about their ability to negotiate and sustain sexual expression while residing in a long-stay mental health rehabilitation facility. There were three main findings. First, the physical space of the facility, inclusive of consumers' bedrooms, was policed by mental health clinicians with ongoing intrusions into consumers' privacy, which inhibited their sexual expression. The creation of barriers to sexual expression is counter to polices that promote recovery. Second, consumers reported significant medication-related weight gain which negatively affected their self-image and sexual sense of self. Third, the consumers spoke about their sexuality in ordinary, everyday language devoid of any hallmark of psychosis. This highlights the importance of relating to consumers about their sexuality and sexual needs from a humane rather than technical framework. Further, it foregrounds the relational aspect of the mental health nurses' role rather than the technical aspect. Yet sexuality is a topic that is often neglected, indicating that an upskilling of the mental health nursing workforce is required, to strengthen communication and relationship skills.

Madness, sex, and risk: A poststructural analysis.

The body of the one deemed mad often remains a sexual body with sexual needs. Mental health services respond to these demands of the body in various ways, including constructing rules around physical movement. In this context, we were interested in how mental health clinicians problematized the sexual needs and practices of residents of a long-stay mental health rehabilitation facility and how solutions were constructed in relation to the residents' sexual desires. This paper reports findings from mental health clinicians, as part of a case study where we addressed this question. Mental health clinicians responded to residents' sexuality from a discourse of risk. The notion of the engagement with each resident as a sexual subject was subordinated to the paternalistic notion of protecting the patient from risk. The resident became an object to be monitored and protected rather than a subject with sexual desire and agency. This paternalism also showed itself in relation to a 'no-sex on-site' rule that allowed for a shift of risk from the organization to the resident. Residents, rather than having a relatively safe place to have sexual relations, were required to find a place elsewhere, potentially unsafe, outside the facility.

The governance of sexuality in a Recovery-oriented mental health service: Psychosis, consumers and clinical approaches.

WHAT IS KNOWN ON THE SUBJECT: The intersection of sexuality and psychosis has a long history, yet research in this area has been minimal over the past few decades. Mental health clinicians practice from within the confines of a mental health system that is founded on a conflict between containment and care and that positions the consumer as an object of care. At the same time, mental health services often have a Recovery approach to care. This presents a difficulty and tension in mental health clinical work because the Recovery approach is opposed to positioning the consumer as an object. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE: The findings suggest that sexuality and sexual needs are common to both clinicians and consumers, and via identification, make the two groups more similar than different. Sexuality can problematize and so open up questions about the objectification of consumers. Consideration of consumers' sexuality and sexual needs can therefore work as a resistance to the dominant mental health approach and, in doing so, produce a more Recovery-oriented approach to treatment in terms of how the consumer is positioned. Other aspects of living that escape capture by the diagnostic system may also operate as organizing factors for a more subject-to-subject approach to treatment. THE IMPLICATIONS FOR PRACTICE: Focusing on sexuality and other aspects of living that escape capture by the diagnostic system can bring into question the way consumers are objectified by the psychiatric model of care. Abstract Introduction The Recovery approach introduced a radical shift in the positioning of consumers as subjects rather than objects of mental health treatment. While this approach has been internationally adopted, the practice of Recovery has been under-researched and a knowledge gap exists regarding the intersection of sexuality and psychosis. Aim The study aim was to investigate how sexuality was governed in a long-stay mental health rehabilitation facility that was Recovery-oriented. Method A case study methodology with a conceptual framework using Foucault's work on disciplinary power was used. Results The findings illustrated how mental health clinicians were caught between two main and incompatible models of care: a psychiatric one and a Recovery one. Discussion While the policy framework authorized a Recovery approach, clinicians practised surveillance, hierarchical observation and normalization, which are tenants of a psychiatric model of care. However, the study found that sexuality was an area that opened questions about the psychiatric model for clinicians. Consideration of consumers' sexual needs allowed the clinicians to think of consumers more as subjects like themselves than as objects to be treated. Implications for practice Consideration of consumers' sexuality opens up possibilities for questioning the objectification of the consumer via the psychiatric model.

Anxiety and surplus in nursing practice: lessons from Lacan and Bataille.

It is well established, following Menzies' work, that nursing practice produces considerable anxiety. Like Menzies, we bring a psychoanalytic perspective to a theorization of anxiety in nursing and do so in order to consider nursing practice in the light of psychoanalytic theory, although from a Lacanian perspective. We also draw on Bataille's notion of 'surplus'. These concepts provide the theoretical framework for a study investigating how some clinical nurses are able to remain in clinical practice rather than leave the profession or seek work at a distance from the bedside. We conducted focus groups and present here an analysis of two fragments of nurses' speech. We found the nurses responded from one of two positions. In the first position, the nurses focus on doctors, complain about the surplus afforded them, and call for it to be eliminated. In this way, the nursing group is similar to other groups, considered by Bataille, who also attempt to get rid of a surplus. However, in the second position, the nurses stay with the surplus, tolerating it as they nurse the patient. This latter position is one where the nurse practises with a focus on the patient rather than being distracted by their dispute over the doctor's privilege. The importance of this paper is in its illustration of two distinct positions from which the nurse can practise: one that is not optimal because the nurse is distracted and the other that is more focused on practice, and thus the nurse is in a position to provide the best care possible to patients.

An exploration of jealousy in nursing: a Kleinian analysis.

It is well established that nursing practice produces considerable anxiety, and it can also give rise to envy and jealousy. While envy in nursing was identified in the literature more than 50 years ago, there remains a paucity of articles addressing either envy or jealousy for nurses. In a recent research study on current experiences of clinical practice, we analysed a fragment of nurses' speech via Klein's theory of jealousy. The results revealed that the nurses expressed jealousy at the privilege afforded to doctors. We argue that it is important to acknowledge jealousy in nursing practice because it has the potential for 'spoiling' effective care delivery and as such, can have detrimental ramifications in the health system. Also, jealousy may keep the nurse from fully focusing on their nursing practice in that it divides the nurse's attention and so limits the nurse's treatment of the patient. Nurses' jealousy of doctors is a taboo topic in nursing, and yet it warrants serious consideration due to the potential deleterious consequences that can arise when this dynamic is present.

Discourses of anxiety and transference in nursing practice: the subject of knowledge.

The nurses' relationship to knowledge has been theorised in a variety of different ways, not the least being in relation to medical dominance. In this study, the authors report on one of the findings of a case study into nurses' anxiety informed by psychoanalytic theory. They argue that the nurse's subjection to the knowledge of the other health professional, inclusive of the doctor, can be a transference arising in the context of anxiety for the nurse. Grasped by anxiety, the nurse finds their own knowledge insufficient and in this moment can operate a transference to their non-nursing colleague, who obligingly, responds. This transference is not present in the change-of-shift handover report though, when the other's knowledge is suspect, even open to derision. Thus, this reference to the knowledge of the other is not consistently present in nursing and can be seen to be just one way that nurses organise themselves in relation to anxiety. Therefore, those wanting to break down the medical dominance of the nursing profession might consider other ways nurses might organise themselves in relation to anxiety, so that the political dominance of the other is not reinforced via transference to that other.

Occupational distress in nursing: a psychoanalytic reading of the literature.

Occupational stress in nursing has attracted considerable attention as a focus for research and as a consequence multiple objects of nurses' stress, or 'stressors', have been identified. This paper puts into question the dominant conceptual and methodological approach to occupational stress in nursing research by both foregrounding the notion of anxiety and juxtaposing it with the notion of 'stress'. It is argued that the notion of 'stress' and the domination of the questionnaire have produced a narrow reading of the topic. Some of the literature on occupational stress/anxiety in nursing is reviewed and our analysis illustrates how the identified objects of stress have a tendency to multiply contingent on the number of studies undertaken. Thus definitive objects of nurses' stress remain elusive. We argue that a return to the notion of 'anxiety' and methodological approaches other than empirical ones can bring both depth and breadth to the consideration of occupational distress in nursing. Further, we argue that the object of 'anxiety' is unconscious, thus unknown, and given this, a more informative approach is to map nurses' response to anxiety, the discursive formations arising out of anxiety, rather than attempt to define those objects of anxiety.

Discourses of anxiety in nursing practice: a psychoanalytic case study of the change-of-shift handover ritual.

This paper reports on the findings of a study that considered how anxiety might function to organise nurses' practice. With reference to psychoanalytic theory this paper analyses field notes taken during a series of nursing change-of-shift handovers. The handover practices analysed met all the criteria for a ritual, as understood in psychoanalytic theory, and functioned to alleviate anxiety in the short term while symbolically expressing a forbidden and unknown knowledge. We argue that the handover ritual contained certain prohibitions, yet allowed some expression of the prohibited knowledge in a disguised way. The prohibition concerned how the patient affected the nurse, that is, moved the nurse to love and hate the patient. We argue that this prohibition is expressed, in disguise, via the displacement of affection for the patient onto other nurses and through negative stereotyping of some patients. We also argue that these prohibitions of the handover mirror broader prohibitions within nursing, and thus the rituals of the handover become an expression of how professional prohibitions are enacted in practice. We conclude that the important implicit function of the handover ritual is to keep anxiety at bay, thereby enabling the nurse to commence practice rather than being immobilised by the effect of potentially overwhelming anxiety.

Patient or consumer? The colonization of the psychiatric clinic.

Information is given a privileged place in the psychiatric clinic, as illustrated by the prevalence and volume of data to be collected and forms to be completed by psychiatric nurses. Information though is different to knowledge. The present paper argues that information is part of a managerial discourse that implies commodification whereas knowledge is part of a clinical discourse that allows room for the suffering of the patient. Information belongs to the discourse of managerialism, one that positions the patient as customer/consumer and in doing so renders them unsuffering. The patient's suffering is silenced by their construction as a consumer. The discourse of managerialism seeks a complete data set of information. By way of contrast, another discourse, that of psychoanalysis offers the institution the idea that there are always holes, gaps, and uncertainty. The idea of uncertainty, gaps, things remaining unknown and a limit sits uncomfortably with the dominant discourse of managerialism; one that demands no limits, complete data sets, and many satisfied customers. This market model of managerialism denies the potential of the therapeutic relationship; that something curative might be produced via the transference. In addition, the managerialist discourse potentially positions the patient as both illegitimate and unsuffering.