Letter to the Editor_843 1..2

Causes of mental distress do matter

I would like to comment on some assertions about thenature of nursing made in the recent Editorial by Happell(2012), entitled: ‘Treat the brain; communicate withthe mind’. Happell commends readers to read Sandy Jeff ’sbiography. Sandy, we are told, suggests that ‘mental illnessdoes exist and has a biological cause’ (p. 95), and Happellgoes on to suggest that despite dissenting and conflictedvoices about the nature of mental illness, it is ‘The impactof mental illness or mental distress, rather than the causes’that ought to be the primary focus of nursing (p. 95).

Happell does acknowledge that notions of causeare influential in how services are structured, but Ibelieve this downplays the importance of presumptions ofcausation in the relationship between nurses and serviceusers, generally. The notion of causation is importantand central to the nurse–person relationship for severalreasons. First, nurses in many settings undertake instru-mental roles, or administer treatments prescribed byothers, sometimes with coercion and force. Invariably,they administer drugs with potentially serious adverseimpacts on people’s health and well-being, based onspeculations about biological causes of illness. Wherepeople are forced to take a drug against their will, andthey report the effects as unpleasant, noxious, or disabling(which people often do), then speculations about whatmight be causing these problems (the drugs or someunderlying disease process) are exceptionally important tothe person’s well-being.

Second, many people engage with psychiatric serviceswhen they are in crisis, and understanding what is goingon or getting to the root cause of problems, be theyinterpersonal, an issue of coping, support, or perception,is at the heart of effective helping in crisis (Aguilera 1990).Often people do seek help with difficult problems, andsometimes problems are simply best solved. Third, theway people view problems and the best way they are to beaddressed is a key component of the therapeutic alliance(Dryden 2009). If there is great dissonance betweenthe way helpers and service users see problems, theyare less likely to develop a helpful working relationship.Thus, being open-minded about perceived causes ofproblems, and finding a way of framing problems andsolutions that makes sense to all parties, will definewhether the relationship is useful or not.

Lastly, prematurely assuming causation of problemscan foreclose on opportunities to explore and make senseof what is going on. Jureidini (2012) suggests that psychi-atric diagnoses have become ‘unexplanations’. They mightaccurately describe a phenomenon, but they often get inthe way of understanding an individual. The assumptionof a biological cause for all manner of problems preventsexploration and remediation of actual causes, and thedevelopment of formulations that capture the richnessand complexity of a person’s experience.

Happell also raises the issue of discrimination andstigma, which are experienced by people both within andoutside the health-care system, and suggests that this mustbe addressed. The reasons why people are perceived tohave problems have a great influence on stigmatizing atti-tudes and discriminatory behaviour. In relation to peoplewith schizophrenias, those who perceive the problem to becaused by biological factors have been found to perceivepeople with schizophrenia as unpredictable and out of con-trol (Thornicroft 2006). Thus, causal theories are very in-fluential in understanding and addressing discrimination.

A wide reading of biographies written by former serviceusers, survivors, and those diagnosed with mental illnesshumbles health professionals who hold simplistic generali-zations about the nature of mental illness, or who under-estimate the capacity of people to endure adversity, extractmeaning from experience, or heal and recover. Finding thebest way to understand a problem is critical to effectivehelping. Health professionals, including nurses, must dealwith their sense of uncertainty and resist prematurelyimposing theories of cause and effect in the interest ofdeveloping a shared understanding. Causes are centrallyimportant to most nursing relationships, as they are topeople who seek to recover from mental health and socialdifficulties.

Richard LakemanSchool of Health and Human Science, Southern Cross

University, Lismore, New South Wales, Australia

REFERENCESAguilera, D. (1990). Crisis Intervention: Theory and Methodol-

ogy, 6th edn. St Louis: C.V. Mosby Co.

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International Journal of Mental Health Nursing (2012) ••, ••–•• doi: 10.1111/j.1447-0349.2012.00843.x

© 2012 The AuthorInternational Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.

Dryden, W. (2009). The therapeutic alliance as an integratingframework. In: W. Dryden & A. Reeves (Eds). Key Issues forCounselling in Action. (pp. 1–17). London: Sage Publications.

Happell, B. (2012). Treat the brain; communicate with themind. International Journal of Mental Health Nursing, 21(2), 95–95.

Jureidini, J. (2012). Explanations and unexplanations: Restoringmeaning to psychiatry. Australian & New Zealand Journal ofPsychiatry, 46 (3), 188–191.

Thornicroft, G. (2006). Shunned: Discrimination againstPeople with Mental Illness. New York: Oxford UniversityPress.

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© 2012 The AuthorInternational Journal of Mental Health Nursing © 2012 Australian College of Mental Health Nurses Inc.