tangled ruptures: discursive changes in danish psychiatric nursing 1965–75

© 2001 Blackwell Science Ltd

Nursing Inquiry

2001;

8

(4): 246–253

F e a t u r e

Blackwell Science Ltd

Tangled ruptures: discursive changes in Danish psychiatric nursing 1965–75

Niels Buus

Centre for Innovation in Nurse Training, County of Aarhus

Accepted for publication 6 September 2001

BUUS N.

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Tangled ruptures: discursive changes in Danish psychiatric nursing 1965–75

Psychiatric nursing and psychiatric nurses have been referred to in various ways over the course of history. These articulationsreflect and constitute the ways in which nursing is comprehended during specific periods. A rupture in these descriptions andconceptions of Danish psychiatric nursing over the period 1965–75 is identified using a discourse analytical framework,inspired primarily by Foucault. This rupture influenced all aspects of psychiatric nursing: the perception of the psychiatricpatient, the expertise and knowledge of the nurse and the care given by the nurse. The study raises questions about the culturaland social changes that occurred prior to the discursive rupture.

Key words:

discourse analysis, Foucault, nursing history, psychiatric nursing.

There are virtually no historical accounts of the everydaywork of psychiatric nurses in Denmark or the rest ofScandinavia. Accounts of different regimes of treatments, ofthe mentally ill and of other types of nurses appear to haveovershadowed this history. This article presents an analysis ofthe discourse on Danish psychiatric nurses between 1965and 1975. The aim is not to contribute directly to historicaldescriptions of psychiatric nurses’ everyday life and practice,but to examine the differential articulations of their work,so as to specify the context within which their work is com-prehended

—

in other words, to outline the set of ideas thathas formed the nurses’ understanding of their work andthemselves: how has the work of the Danish psychiatricnurses been conceptualised and understood through history?And how does that background influence the present?

HISTORY, DISCONTINUITY AND DISCOURSE: THE INFLUENCE OF FOUCAULT

The French philosopher Michel Foucault presents a frame-work for a radical constructionistic discourse analysis, whichcan be used to examine the historical differences in the

organisation of scientific knowledge. Foucault, though, hasnever described a systematic discourse analysis, merely a setof tentative suggestions, which he does not always observe inhis own analysis. Consequently, one must fill in the methodo-logical gaps when trying to follow his directions.

Foucault’s concept of discontinuity is central to under-standing his philosophical position and his concept of his-tory; it is presented here in both a meta-theoretical and amethodological sense. At a meta-theoretical level, Foucaultstresses the need to replace continuities and continuity-making entities with discontinuity (Foucault 1984). Unitiesand identity, as well as the founding subject and continuoushistory, are regarded as part of the same system of thought(Foucault 1997, 12). Any form of unity should be dissolvedin its own history, so that it appears dispersed, discontinuousand heterogeneous. This theoretical position challenges theview of the history of psychiatric nursing as a continuousdevelopment from ‘dark ages’ to the science of the presentday. Instead, one searches for the old and alien, but coherent,discourses on psychiatric nursing and the discursive trans-formations throughout history. Results should point towardthe limits and contingency of the present-day understandings.

At a methodological level, discontinuity is used to describea central part of the practice of the historian. Discontinuityappears through the historian’s perspective on history: thechoice of a suitable level of analysis, an object of analysis, a

Correspondence: Niels Buus, M.P. Bruunsgade 49, 3, 8000 Aarhus C, Denmark. E-mail: <[email protected]>

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Changes in Danish psychiatric nursing

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corpus of texts and a periodisation. Discontinuity is thereforethe deliberate product of the historian’s methodologicaldecisions: through the construction of a specific perspective,history is arranged and becomes accessible to the historian.Discontinuity determines what the analysis is sensitive to inthe material. Constructing a rupture is a way of breakingwith one’s own discourse, creating a distance to it, and thevalidity of the analysis must be evaluated according to thisrupture (Foucault 1998). A Foucauldian research strategycan involve the search for different kinds of discursive trans-formations, e.g. discontinuities inside discourses, betweendiscourses, between discursive practice and other social prac-tices (Foucault 1991), rarefactions of discourses (Foucault1981) or the interrelated processes between discourse,rationality and power mechanisms (Foucault 1990). Theshared outset for these strategies is a description of dis-courses, and the strategy used here involves a comparison ofthe discourse on the work of the psychiatric nurse at differentmoments in time, i.e. intradiscursive changes. The descriptionof these changes is followed by a discussion of the externalconditions of possibility behind these changes.

In

The archaeology of knowledge

, Foucault describes threeoverlapping meanings of the concept of discourse (Foucault1997): as the general domain of statements, i.e. as language;as an individualisable group of statements, a family of state-ments

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a discursive formation; as the regulated practice thataccounts for the statements that are dispersed through a dis-cursive formation. Discourse constitutes the surroundingbackground for the statement. A statement is defined as afunction that creates a link to other statements in differentdiscursive structures and fills them with concrete content(Foucault 1997). The statement articulates the contents ofphenomena: objects, enunciative positions and concepts.These discursive elements are created by the statement,which can be recognised through this function (Foucault1997). One must identify statements and analyse theirinterrelations with other statements in order to describe adiscourse and the discursive regularities (objects, enunciativepositions and concepts) that account for the coherence ofthe discourse.

METHOD

A preliminary study indicated that a large intradiscursiverupture occurred in the articulations of the psychiatric nursebetween 1965 and 1975 (Buus 1999), and part of my thesis wasdedicated to identifying and discussing this rupture.

With reference to Foucault’s concept of discontinuity,three methodological steps were taken. First, the

object

ofanalysis was specified as ‘the work of the psychiatric nurse’.

This object is designed and regarded as ‘empty’ as possible,as an object filled with present-day meanings would distortthe analysis so that one sees only what is expected or alreadyknown. The definition of the object led to a search in thecorpus of texts for any description of a nurse at work.Second, the

period of analysis

was specified as the periodbetween 1965 and 1975. The period needs to be long enoughto get a clear description of the discursive continuities, butstill short enough not to cover too many discontinuities.Third, the

corpus of texts

was specified as all the Danish text-books on psychiatric nursing and all the material regardingpsychiatry, mental health and psychiatric nursing in theDanish Nurses Association’s journal

Tidsskrift for Sygeple-jersker

, published 1965–75. Ideally, all texts regarding thework of Danish psychiatric nurses should be included inorder to get the best coverage of the intertextual relationsbetween the statements. In practice, one must begin withtexts that will probably be central to the discourse. The corpusof texts was restricted to these texts, as the pilot-study hadshown that these types of texts were useful, and because thematerial was already extensive. The disadvantage of thisrestriction was an inability to follow intertextual leads totexts outside the corpus.

In the period 1965–75, two textbooks were published.In 1965, the fourth edition of Arild Faurbye’s MD

PsykiatriskSygepleje

was published (Faurbye 1965), followed by the fifthand sixth editions in 1969 (Faurbye 1969) and 1973 (Faurbye1973), respectively. Consultant Josef Welner is the main authorof

Psykiatri. Lærebog for Sygeplejeelever

, published by the DanishNurses Association. The second edition was published in1968, with nursing instructor Birgit Hansen as the authorof the section on nursing (Welner 1972). In 1974 the thirdedition was published (Welner 1974), with administrativedepartmental sister Sonia R. Skrumsager as the author of thesection on general psychiatric nursing. Articles in the jour-nal include political articles, a few clinical articles and manyarticles in the debate on antipsychiatry, which flared uparound 1970. The authors are mainly nurses, but doctorsand the staff journalists also have articles.

The sequence of the analysis was first, to identify everystatement containing the object of analysis, i.e. to find state-ments regarding the nurse at work. Then a short question-naire was used to examine how these objects were related toother objects by the statement. Second, the statements wereexamined by means of a questionnaire to determine theenunciative positions, i.e. to find out from what subject-positions it was possible to make statements on the psychiatricnurse and psychiatric nursing. The third step was to identifythe concepts used in the statements. A questionnaire wasused to examine how the concepts related to each other.

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The results created a three-layer mosaic of statementsembedded in discourse, which contained various regularities.The placement of the statement within the discursive struc-tures determines whether it repeats already existing regular-ities

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and the articulation of statements will often fall likepearls on a thread in accordance with continuous discursivepractice. Intra-discursive changes can be identified in therelations between discursive elements or as the introduc-tion of new elements without altering the general charac-teristics of the formation; as ruptures, which in time willaffect the non-discursive material (Foucault 1997). However,defining an analytical threshold of discursive changes remainsproblematic, and relies on the researcher. The descriptionof the statements’ position within the discursive structuresand the description of the discursive regularities also dependon the researcher’s acquaintance with the material and hisor her scientific and creative abilities, as regularity is notinherent in the statement. Following Peirce, I suggest abduc-tion (or hypothesis) to describe the mode of reasoning fromthe historical appearance of the statement to the hypotheticalregularities of a discursive formation (Peirce 1972, 173–4).Abductive conclusions are not infallible, and must always beverified deductively and inductively, i.e. experimentally(Peirce 1994, 178). This means that the construction of dis-cursive regularities of the identified statements can never betruly complete.

RESULTS

The results presented here describe the discursive regularitiesand the tangled ruptures of the period 1965–75. The resultsare not a complete description of the discourse of psychiatricnursing 1965–75, but rather yield a description at a certainlevel of analysis which is limited by the relationships betweenthe type of therapeutic work done by the nurse, the discur-sive resources used in analysing treatment, and the patients’problems.

The personality and work of the nurse

The character and personality of the psychiatric nurse aretwo of the most important factors that affect and influencethe psychiatric patient psychotherapeutically (Faurbye 1965,52; 1969; Hansen 1972, 48; Skrumsager 1974, 126). At thebeginning of the period, Faurbye utilises the conception ofpsychotherapy broadly: anything that affects the patientfavourably. Faurbye (1965, 1969) minutely describes thepsychiatric nurse as an upholder of morality and culture.

The long detailed descriptions of the nurse’s characterand personality used at the beginning of the period are

replaced toward the end by shorter and more general con-siderations of the importance of good contact with the patient.This break with the manner of articulating the nurse is mostobvious in Faurbye’s books. In the fourth and fifth editions,the nurse is described at length and in detail (Faurbye 1965,52–9), whereas her attitude to the patient is only brieflydescribed in the sixth edition (Faurbye 1973, 63).

The conditions of daily life in the hospital are expressedin terms of ‘a real and cosy home’ as their ideal. Keys, securitysystems, uniforms and video cameras represent functionsthat spoil the image of the ward as a home, and are thereforekept hidden as far as possible:

The wards for people with lengthy illnesses in our hospitalsfor the mentally ill function as the patients’ homes andthese in particular should be as civilian-like and homely aspossible. This includes a pleasant choice of colour (and notthe dirty yellow hospital colour), plants, pretty curtains,books, pictures and good furniture in the living rooms(Hansen 1972, 149).

Treatment is the basis of the organisation of the dailywork at the hospital. The nurse has a special position in thetreatment, as she is the person with most contact with thepatient (Faurbye 1965, 66; Olsen 1972, 9; Skrumsager 1974,111). At the beginning of the period, nursing, includingperforming domestic duties together with the patient, isacknowledged as a highly qualified job (Deneke 1967, 252):‘Dusting, caring for plants, polishing taps, washing floors,making beds and assisting in the kitchen is first rate workfor people with chronic psychoses’ (Faurbye 1965, 67). Thepatients must be kept up to scratch, so they do not dwell ontheir sick thoughts and ideas (Faurbye 1965, 68; Deneke1968, 345). There must be flexible discipline and a rule ofdomesticity in the ward.

As with the organisation of the hospital, everyday life inthe ward is conceptualised with the private home as itsmodel. The woman, the nurse, functions according to Hansenas a ‘mother figure’ (Hansen 1972, 161) for the patients,who are therapeutically affected by her housewifely qualities.The nurse is best described at the beginning of the period asa cultivated housewife, who is capable of creating and par-ticipating in cosy and homely, healthy and natural settingsfor the patients.

Reference to the nurse as housewife puts her in a particularrelationship to the patient: the nurse, through her work,aims to influence the patient to adopt good and healthy habits.The patient is cured by patient, authoritative behaviour, bythe nurse reining in deviations. The patient’s problem is pri-marily that he cannot conform to social norms, and the aim ofnursing is to produce a sociable, normal, natural and ordinaryindividual

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the nurse affects social behaviour.




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Specialised psychiatric nursing

The work of the nurse is also categorised and describedaccording to the different types of mental illness the groupsof patients suffer from. The common factor in descriptionsof patients is the way in which mental illness affects thepatient’s personality; nursing is the direct intervention tocounter the symptoms of illness.

The nursing of schizophrenic patients consists, at thebeginning of the period, of combating autism by planningthe environment to have a favourable effect, and, at the end,of offering contact (Faurbye 1965, 106; Skrumsager 1974,125–36). In the case of depression, nursing at the beginningof the period consists of surrounding the patient with acalm, friendly and understanding environment and care-fully monitoring the patient’s physical functions. At the endof the period, the nurse must establish a degree of contactthat enables the patient ‘to express his needs and feelings’(Skrumsager 1974, 128).

At the beginning of the period, Faurbye writes on thenursing of neurotics: ‘With regard to the nurse’s generalattitude it can be said that it should be equidistant frommisplaced sentiment and soul searching with the patientsand from unsympathetic coolness and criticism’ (Faurbye1965, 185). At the end of the period, Skrumsager writes: ‘Whenthe patient displays symptoms, which can, for example, beanxiety or convulsions, the nurse must demonstrate by herattitude that this does not make any impression’ (Skrumsager1974, 133). In this quotation, direct counteraction of thepatient’s condition has disappeared in favour of an indirectand psychologically motivated treatment. Taking the neuroticpatient’s appeal at face value is deemed not to be therapeutic.

Between the start of the period and its end, a changein the reasoning behind nursing takes place. Early on, thenurse as a housewife affects the patient’s psychological statedirectly, by means, for example, of hygiene, or his anxiety withcalm, and inertia with occupation. Later, care is founded inpsychological theories, which results in the transparency ofcare disappearing, since a psychological understanding of thepatient’s personality dictates a certain therapeutic behaviourtoward certain patients.

Treatment

Observations made by the nurse are of assistance to the doctorin making a diagnosis (Skrumsager 1974, 116), which greatlyinfluences the decisions made for and about the patient(Hansen 1972, 160). The nurse must be familiar with numer-ous treatment methods: psychotherapy, somatic therapy andrehabilitation. She must not take active part in all the

specialised methods of treatment. In the case of conversa-tional therapy, she participates by listening. She must notbegin a conversation in depth about the patient’s psychologicalproblems, as this requires special training in psychotherapy:‘[It] is more important to listen than to say anything yourself ’(Faurbye 1965, 56). In group treatment, she participatespassively in her role as leader of the group, ensuring onlythat a suitable subject is discussed. In the case of suggestion,her ability to provoke confidence provides the therapeuticeffect. She participates actively in work and occupational treat-ment, exercise, recreation and entertainment. During somatictreatment, the nurse must supervise.

Throughout the entire period, the nurse’s active part ofthe treatment lies mainly in influencing and affecting thepatient by inviting confidence, planning the environment ofthe ward favourably and performing tasks with the patient.The nurse is never deemed part of the hospital’s more spe-cialised methods of treatment, apart from being familiarwith these methods.

Medical observation: objectivity and theory

Observation of the patients is basic in nursing. As has alreadybeen said, the nurse deals with the patient all day, whichoffers her the possibility both of having close contact withthe patient and of observing the patient. Knowledge of psy-chiatric symptoms and the progress of illnesses is a necessityfor the nurse, who is in a position to observe where and whenthe doctor cannot. Observation of symptoms covers: intel-ligence, perception and attention, state of consciousness,personality, memory, orientation, way of thinking, feelingsand also will, action and movement (Welner 1972, 15–31).

The nurse’s observation of the patient is directed at amedically construed symptomatology. Hansen states plainlythat: ‘One is interested in all the qualities described in thechapter on the study of psychiatric symptom’ (Hansen 1972,156). The nurse therefore functions as the doctor’s ‘eyes andears in the ward’ (Faurbye 1965, 14), and changes in the focusof her attention are dictated by a medical discursive practice,which is centred on the specific deviance in the patient.

Observations are nearly all centred on qualities in thepatient that cannot be directly observed, and that render theobservations uncertain. Hansen would like thorough andobjective observation and reporting of the patient’s behavi-our. To ensure objectivity, the nurse must not let herself beinfluenced by her sympathies or antipathies to the patient(Hansen 1972, 155–6). Faurbye recognises this problem,too, and is of the opinion that the doctor must know thenurse so well that he takes the nurse’s personality intoaccount when hearing her report (Faurbye 1965, 91). In this


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way, Faurbye overrules the nurse’s assessments by an inter-pretation of the assessments in her report.

For both Faurbye and Skrumsager it is important to keepthe objective observations of the patient and the interpreta-tion of the observations well apart, as pure observation ismore valuable than the nurse’s interpretation of it (Faurbye1965, 92; Skrumsager 1974, 117). At the end of the period,Skrumsager suggests improving the interpretations, both bymaintaining the division between the directly observableand the interpretation, and by requiring a presentation of thetheoretical background for the interpretation (Skrumsager1974, 118–19).

The requirement to make known the theoretical back-ground of an assessment has led to a number of observationsbeing rejected: observations appearing only as the nurse’sfeelings, not as assessments; and observations made bynurses who do not master theoretical explanation, and there-fore cannot present a theoretical background for theirobservations, are disregarded.

Throughout the entire period, the medical discoursedictates the nurse’s observing gaze by setting up the symptoma-tology and the normal against the abnormal. Her gaze isdirected by a medical discursive formation, but the discursiveresources drawn on to interpret the observations are based,at the end of the period, on theoretical structures ratherthan on common understanding.

To affect and to be in contact with

Two different strategies exist in the articulation of ‘thatwhich is therapeutic’ in the nurse’s work with the patients.At the beginning of the period, therapeutics are connectedto a superficially indifferent, authoritative and determinednurse, who acts practically and listens rather than talks,favourably

affecting

the patient’s behaviour. Faurbye comparesthe psychiatric patient with children and animals:

Those, who come from the countryside know, that horsescan immediately feel on the reins when they get a newdriver, even though they might not have seen him. Anynervousness or lack of confidence is immediately trans-ferred to the horses (Faurbye 1965, 78).

His point is that the lack of experience in the inexperiencedand uncertain nurse can be felt by the patient and can leadto unrest and maybe physical violence. Therapeutics areconnected to a good hand on the reins and act to counter thepatient’s symptoms, which are lethargy and inactivity morethan a lack of emotional contact.

The other, and later, articulation is related to the notionof

contact

with the patient. Here, the patient’s symptom isprimarily understood as a lack of emotional contact to his

surroundings, rather than as lethargy. Like Faurbye, Skrum-sager asserts that anxiety can be transferred from person toperson and lead to assault. The difference is that Faurbye isable to identify the source of the anxiety, whereas Skrum-sager must analyse all the factors that can affect the ‘viciouscircle’ in the anxious contact between the nurse and thepatient (Skrumsager 1974, 127). Implicit in the contact istherefore a circular relationship between the nurse and thepatient. This circular movement makes it impossible to finda single causal factor, since additional factors can always befound. The nurse, too, is a contributing factor. The patient’sconduct in the ward cannot be understood without takinginto consideration the circular contact with the nurse andthe surrounding environment.

The contact-relationship between the nurse and thepatient denotes the communication between them. Thenurse wishes to speak

with

the patient, rather than just offerfriendly sympathy (Olsen 1971, 79). In order to speak withthe patient and create free communication, the distancebetween the staff and the patient must be reduced by dis-solving the hierarchical roles that have traditionally existedbetween them (Skrumsager 1972, 8). Descriptions of thecontact relationship and the significance of the communica-tion are articulations of the relationship as very personal andclose.

There is no doubt that nurses and patients have alwaysbeen in close contact with each other. Patients and nursesspend their everyday life together. Throughout the period,the intimacy changes into a close contact relationship, thatis to say, that the being together on a practical level isreplaced by a psychological and verbal intimacy; a move-ment from a bodily intimacy toward an intimacy thatinvolves and penetrates the patient’s person and mind toa far greater degree.

Technical concepts and explanations

Fastidious personal hygiene and dressing reflect back onthe mind (Faurbye 1965, 72). This conclusion, drawn at thebeginning of the period, is based on daily experience anddoes not refer to theoretical models.

The patient’s personality is described and understoodin terms of psychological models and terms (for example,Faurbye 1965, 218–20; Welner 1972, 21–3). In particular,the terms ‘ego’, ‘super-ego’ and ‘id’ (or libido). The weakpersonality is thus a person with a weak ‘I’, where the psycho-logical defence mechanisms function on a primitive level,so that primitive, childish and chaotic feelings dominate(Welner 1972, 22). These psychological models are used toexplain the nurse’s work:




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The environment and rhythm of the day are two decisivefactors in the treatment. As was evident in the medical section,the psychotic, schizophrenic patient has defence mecha-nisms that are inadequate in varying degrees. For this reason,one attempts to give the patient support both by means ofcontact and by structuring everyday life and its many smallfunctions in such a way as to meet the patient’s needs. In asense,

one replaces the weak ego and over-ego

with a certain firm,external framework

(Skrumsager 1974, 127, italics added).

Skrumsager’s objective is to be able to describe, usingpsychodynamic terminology, how environment and dailyrhythm can have a therapeutic effect on a patient. It is interest-ing that the borrowed psychological terms describe nursingas it already existed. The concepts do not evolve in nursing.They had not originally been construed to explain theexternal structure’s positive qualities for weak personalities,but Skrumsager makes this theoretical connection. Theconnection is plain and can explain the nurse’s work to agreat degree. A direct conclusion is drawn between a theoreticalpsychological discursive formation and an everyday discur-sive formation based on experience. A theoretically baseddiscursive practice is thus constituted and layered on top ofthe ‘original’ discursive practice based on general humanand daily experience.

The use of technical/theoretical terms creates an articu-lation of the nurse without stressing the work as connectedexplicitly to gender. It occurs mainly through the specialisationof the terms that describe nursing and the nurse: ‘motherfigure’ is described as ‘the object of identification’ or ‘a contactperson’ (‘sol’ 1967, 129; Skrumsager 1974, 114). The rupturemeans that it is difficult to follow the gendered aspects of thework, as daily life does not show up clearly when describedby ‘the new experts’. The arrival of a new discursive, theoreticallayering does not of course exclude the possibility of thepractical and highly gendered practice continuing regardless.

SUMMING UP A TANGLED RUPTURE 1965–75

Throughout the period, the patient’s deviations are expressedfrom the point of view of a humanistic medical discursiveformation that puts the focus of attention on the patient’sabnormal mental condition, on observation and on thetreatment of the condition

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for the good of the patient. Adiagnosis is made based on background observation of thepatient, his medical history, information about his childhoodand mental trauma. Thus, the doctor holds the dominantenunciative position, from which the important can be dis-tinguished from the unimportant in the treatment. Thenurse is reduced to taking care of the patient’s everydayproblems. Treatment is planned based on diagnosis.

The nurse’s work is defined and enacted within thisgreater strategy. However, a rupture, which has consequencesfor the way the nurse’s work is defined and described, occursin the perception of the mentally ill. At the beginning of theperiod, the patient is considered lethargic. The aim of treat-ment is therefore to activate him and to counter the lethargydirectly. The nurse structures the patient’s social behaviourby structuring and organising his everyday life, and practisinggood conduct together with him. Models and descriptionsof the nurse’s work are based on the housewife, who influ-ences the patient and gives him good habits. The basis forthe nurse’s work is to be found in everyday life in a good andhealthy home.

At the end of the period, the patient is viewed as a personin poor emotional contact with his or her surroundings. Theaim of treatment therefore becomes to improve this contact.Communication and the nurse’s relationship with thepatient improve contact. The nurse’s contact and the environ-mental structures strengthen the patient’s weak personality.The nurse’s work is articulated from the point of view of aneutral, genderless therapist role that finds theoretical reasons

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discursive resources

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for the work in psychodynamics.The practical and gendered functions lose priority in thediscourse, whilst the theoretically correct attitude toward thepatient wins more and more favour.

The practical, everyday discursive practice of the psychiatricnurse is overshadowed by a new discursive practice, in whichtheoretical reasoning, and especially psychological theory,are used to understand and explain practice. The demandfor theoretical bases for observations functions as a way ofregulating access to the discourse. Whilst nurses earliercould articulate and present their ideas of the good andnormal home in the wards, difficult and foreign sets of ideasrupture these constructs during this period, and emerge asnew frames of understanding. This rupture creates newexperts among the nurses. The expert is no longer the prac-tically competent ‘housewife’ nurse with energy and breadthof outlook, writing admonitory reports about the practice,but nurses with theoretically pondered expertise. Access tospeaking from the enunciative position of the nurse hasbeen changed.

DISCUSSION

The discourse analysis in this article is not an ‘objective’description of history ‘as it was’, but a construction createdfrom a construed perspective. As a researcher, I have tried tobreak with my own discourse point by point by choosing ahistorical angle. An evaluation of the analysis must be madein relation to the validity of the construed perspective. Are


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there sufficient arguments for choosing precisely this objectand this corpus of texts? Further, one must judge validity inrelation to the method used within the constructed perspec-tive for the analysis. Is there sufficient argumentation in rela-tion to the interpretation of the influence of each statementin the discourse? In order to meet these requirements forvalidity, an analysis must include a precise description of themethod used as well as quotations, careful paraphrases andtranslations (with careful choice of words in keeping withthe period of time in question), and exact references ofsource. This affords others the possibility of going to thesame sources, checking the analysis and judging whether theconstruction of statements and discursive formations is validwithin the construed perspective.

To what degree do discursive changes constitute socialand cultural changes, compared to merely reflecting them?(inspired by Fairclough 1992, 55). The tangled rupture canbe used to consider the question in regard to the analysishere. For one thing, there is a rupture in the conception ofthe patient. Having been regarded as lethargic, he is laterregarded as being in poor emotional contact with hissurroundings. Additionally, there is a rupture in the mannerof articulation of the nurse’s work, from a strategy based oneveryday experience to one based on theory: a rupturebetween descriptions of a housewife of a very gendered natureand the descriptions of an apparently genderless contact-person. The importance of qualifications in the daily prac-tical work with the patients disappears. This wide conceptionof knowledge is replaced by a narrow conception of know-ledge as specialised and theoretically grounded.

The first rupture changes the psychiatric nurse’s workwith the patient. The principles of care are described differ-ently in one stroke of a pen, and they change in the courseof the next few years. After the rupture, the nurse has a rad-ically different picture of the patient and his problems and,as a result, expressions of her view of nursing differ greatly.The problem is that this changed verbalisation of the patientand his problems involves the other ruptures, which changesthe way in which the patient is articulated, at the same time.The three ruptures are therefore interwoven.

The question now is: what were the conditions of pos-sibility prior to the ruptures that occurred over the period1965–75? In psychiatry, the theory of contact-disturbanceshad been known long before this period, without makingany impact on the discourse of and about nurses, or on theirtheories. Why was this conception of the patient so delayed?Do the concepts of the patient change because he behavesdifferently after the invention of new medical and physicalmethods of treatment from the beginning of the 1950s?Does a real relaxation between the groups of staff in the

hospital hierarchy take place? Why do the explicit verbalisa-tions of the nurse as a public housewife disappear?

Ruptures in the articulation of social phenomena haveconsequences for how we understand and act in daily life,but these ruptures are made possible only by social andcultural change. Changes in linguistic and practical actionsare therefore of a piece. Language is a constitution of reality,but conditions for changes in language exist not only in dis-cursive dynamics, but also in the conditions of possibilitymade by social and cultural change.

There are thus many indications that the way in whichnurses think and feel both about and in their practice haschanged greatly between the start and the end of the period,for the very reason that significant notions concerningnurses’ work have undergone great changes. The develop-ment of the notion of interpersonal relations at the end ofthe period means that, in order to talk to the patient andevaluate his self-consciousness and mental condition, thenurse must develop a ‘professional’ self-consciousness. Thepoint is that the nurse’s professional and psychological selfonly comes into being when the patient is perceived to be aperson with a self. This is a radicalisation of Armstrong’s thesisthat the patient’s subjectivity is created through his relation-ship with the nurse. Armstrong is apparently unable to seethe relationship’s influence on the nurse’s subjectivity, herself (Armstrong 1983, 458–9). The introduction of the rela-tionship paves the way for a new psychological understand-ing, which aims to describe the patient

as well as

the nurse.Psychological knowledge is more than empty, linguistic

forms. It shapes reality, that which is possible to think, andcreates a certain intervention with things (cf. Rose 1996, 41–66): the modern nurse’s conception of her practice is tightlybound to the development of knowledge of the patient, aknowledge that indirectly has profound influence on thenurse’s conception of herself. In other words, the power ofthe discourse, functioning so that more and more personaldetails about the patient become important to science, isalso a power technology that includes the nurse.

Discourse analysis is unable to account for the fact thatnurses do not necessarily work in accordance with experts’ideas about their work. There can also be a discrepancybetween what nurses say they do and what they actually do.There may be cases where the nurse has never worked inaccordance with the ideas of the experts. There may also bea time lag before the verbalisation of the expert’s ideas of thework becomes a part of the nurse’s everyday work.

Discourse analysis therefore needs to be supplementedwith more detailed historical descriptions. This can be donepartly by expanding the text corpus of the discourse analysisand partly by comparing ideas in the various periods with




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historical and statistical material. Having such material wouldallow for a more precise analysis of changes in the field ofpsychiatry and the wider social changes. It would thenbecome possible to examine the interplay between discur-sive and practical practice in the constitution of social reality.

CONCLUSION

‘The historian is insensitive to the most disgusting things; or,rather, he especially enjoys those things that are most repug-nant to him’ (Foucault 1984, 91). At times, it is repugnant toshake the generally accepted and apparently natural ideasabout the work of the psychiatric nurse. I have tamperedwith the foundations on which I, too, build my professionalidentity

—

and at times, it has not been possible to shore upthis crumbling foundation, when the analysis indicatescoincidence and incoherence. The analysis shows that it hasbeen possible to think about and articulate psychiatric nurs-ing without terms like ‘relation’ and ‘ego’. This insight aloneindicates that psychiatric nursing can be thought about andunderstood very differently, and that the aura of self-evidencein the theoretical framework of psychiatric nursing is a resultof historical contingency.

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