Critical thinking and contemporary mental health care: Michel Foucault's "history of the present".

In order to be able to provide informed, effective and responsive mental health care and to do so in an evidence-based, collaborative and recovery-focused way with those who use mental health services, there is a recognition of the need for mental health professionals to possess sophisticated critical thinking capabilities. This article will therefore propose that such capabilities can be productively situated within the context of the work of the French philosopher Michel Foucault, one of the most challenging, innovative and influential thinkers of the 20th century. However, rather than focusing exclusively upon the content of Foucault's work, it will be suggested that it is possible to discern a general methodological approach across that work, a methodological approach that he refers to as "the history of the present." In doing so, Foucault's history of the present can be understood as a productive, albeit provisional, framework in which to orientate the purpose and process of critical thinking for mental health professionals by emphasizing the need to both historicize and politicize the theoretical perspectives and therapeutic practices that characterize contemporary mental health care.

A critical analysis of the failure of nurses to raise concerns about poor patient care.

The occurrence of poor patient care is emerging as one of the most significant, challenging, and critical issues confronting contemporary nursing and those responsible for the provision of health care more generally. Indeed, as a consequence of the increased recognition of the manner in which nurses can be implicated in the occurrence of poor patient care, there has been sustained critical debate that seeks to understand how such healthcare failings can occur and, in particular, why nurses seemingly fail to intervene, raise concerns, and effectively respond to prevent the occurrence and continuation of such poor patient care. In seeking to contribute to this critical discussion, and in contrast to those "situational explanations" that maintain that the failure to raise concerns is a consequence of the contextual factors and challenging conditions to which nurses can be subject in the clinical setting, this paper will provide a resolutely philosophical analysis of that failure. In particular, it will draw upon the work of Jean-Paul Sartre-the French philosopher generally regarded as one of the most influential thinkers of the twentieth century-in order to propose that his work can be productively recontextualized to provide a detailed, challenging, and provocative critical analysis of the occurrence and continuation of poor patient care and the role of individual nurse practitioners in such healthcare failings.

Prevalence of Pompe disease in 3,076 patients with hyperCKemia and limb-girdle muscular weakness.

OBJECTIVE: We prospectively screened a large European cohort of patients presenting with hyperCKemia and/or limb-girdle muscular weakness (LGMW) for acid α-glucosidase (GAA) deficiency by dried blood spot (DBS) investigation. METHODS: DBS were collected from 3,076 consecutive adult patients from 7 German and British neuromuscular centers. All specimens were investigated for GAA deficiency by fluorometry. Samples with reduced enzyme activity were subsequently investigated for GAA gene mutations. RESULTS: Of 3,076 patients with DBS samples, 232 patients (7.6%) showed low GAA enzyme activity. Of these 232 patients, 55 (24%) presented with isolated hyperCKemia and 176 (76%) with hyperCKemia and LGMW. With both features present, 94% of the patients showed a low enzymatic activity. Mutational analysis found GAA gene mutations in 74 patients (2.4%); herein 70 patients were heterozygote for the common GAA gene splice-site mutation c.-32-13T>G. The most common clinical presentation in the confirmed Pompe cohort was a limb-girdle phenotype (85.3%) combined with ventilatory insufficiency (61%). Isolated hyperCKemia was found in 12%, while 2.7 had hyperCKemia and ventilatory insufficiency only. CONCLUSIONS: In a large cohort of unselected adult patients with hyperCKemia and/or LGMW, we found a prevalence of late-onset Pompe disease of 2.4%. Therefore, targeted screening of such a population should be encouraged in clinical practice.

How providers influence the implementation of provider-initiated HIV testing and counseling in Botswana: a qualitative study.

BACKGROUND: Understanding the motivations and perspectives of providers in following guidance and evidence-based policies can contribute to the evidence on how to better implement and deliver care, particularly in resource-constrained settings. This study explored how providers' attitudes and behaviors influenced the implementation of an intervention, provider-initiated HIV testing and counseling, in primary health care settings in Botswana. METHODS: Using a grounded-theory approach, we purposively selected and interviewed 45 providers in 15 facilities in 3 districts and inductively analyzed data for themes and patterns. RESULTS: We found that nurses across facilities and districts were largely resistant to offering and delivering provider-initiated testing and counseling for HIV (PITC) for three reasons: (1) they felt they were overworked and had no time, (2) they felt it was not their job, and (3) they were afraid to counsel patients, particularly fearing a positive HIV test. These factors were largely related to health system constraints that affected the capacity of providers to do their job. An important underlying themes emerged: nurses and lay counselors were unsatisfied with pay and career prospects, which made them unmotivated to work in general. Variations were seen by urban and rural areas: nurses in urban areas felt generally overworked and PITC was seen as contributing to the workload. While nurses in rural areas did not feel overworked, they felt that PITC was not their job and they were unmotivated because of general unhappiness with their rural posts. CONCLUSIONS: The attitudes and behaviors of providers and barriers they faced played a critical role in whether and how PITC was being implemented in Botswana. Provider factors should be considered in the improvement of existing PITC programs and design of new ones. Addressing constraints faced by providers can do more to improve supply of human resources than merely recruiting more providers.

Disaggregating the Universal Coverage Cube: Putting Equity in the Picture.

Abstract-In recent years, the World Health Organization's "Cube Diagram" has been widely used to illustrate the policy options in moving toward Universal Health Coverage. The Cube has become a globally recognized visual representation of health system reform choices, with its axes defined by: (1) the services covered by pooled funds, (2) the population covered, and (3) the proportion of costs covered. The Cube shows the difference between the current national coverage situation in a country and the policy goal of universal health coverage, identifying where major gaps exist. The essential feature of the Cube diagram is that it shows a country's coverage situation in terms of national averages. As a result, it does not present or call attention to significant disparities in coverage across population groups, which are characteristic of most low- and middle-income countries. This article recommends adding a new diagram that disaggregates the Cube. The new diagram, called the Step Pyramid, allows a policy maker to visualize specific choices in expanding the coverage status of different population groups. This new diagram can help policy makers focus explicitly on equity concerns as they set priorities in moving toward universal health coverage. The paper explains how to construct a Step Pyramid diagram, provides a hypothetical illustration, and then uses data from Mexico to create an example of a Step Pyramid diagram. The paper concludes with a discussion of the strengths, limits, and implications of both the Cube and the Step Pyramid.

Agenda Setting and Policy Adoption of India's National Health Insurance Scheme: Rashtriya Swasthya Bima Yojana.

Abstract-Rashtriya Swasthya Bima Yojana (RSBY) is India's largest health insurance scheme. Launched in 2007, it now covers over 37 million, mostly poor, families. This massive scheme represents a major departure from past approaches to government support for health care in India. In this article, we use data from key informant interviews, published and unpublished documents, and newspaper reports, applying Kingdon's framework for agenda setting and policy adoption to explain how RSBY became national policy. India's government-operated health care delivery system had consistently failed to meet its most basic objectives-especially for the poor. A variety of previous reform efforts had been unsuccessful. Then, in 2004, the result of the national election was seen by the victors as representing a mandate to address deprivation among those in India's vast unorganized sector. That election also brought to the fore a new set of policy makers who were willing to introduce subsidized health insurance that made extensive use of the private sector. Technological advancements offered the reformers both new options and new experiences on which to base their innovations. A group of policy entrepreneurs, including Congress Party leaders, technocrats, and senior government officials, collaborated with international agencies to develop the RSBY approach, place it on the agenda, and assure its adoption as national policy. This analysis explores factors that made this significant equity-oriented health reform possible in India and provides lessons for health reformers in other countries who seek to learn from India's experiences in moving toward universal health coverage. Finally, we suggest some adjustments in Kingdon's framework to help apply his ideas in different contexts.

Thinking critically about the occurrence of widespread participation in poor nursing care.

AIM: A discussion of how Arendt's work can be productively re-contextualized to provide a critical analysis of the occurrence of widespread participation in poor nursing care and what the implications of this are for the providers of nursing education. BACKGROUND: While the recent participation of nurses in healthcare failings, such as that detailed in the Francis report, has been universally condemned, there has been an absence of critical analyses in the literature that attempt to understand the occurrence of such widespread participation in poor nursing care. This is a significant omission in so far as such analyses will form an integral part of the strategy to limit the occurrence of such widespread participation of nurses in future healthcare failings. DESIGN: Discussion paper. DATA SOURCES: Arendt's 'Eichmann in Jerusalem: A Report on the Banality of Evil' and 'Thinking and Moral Considerations: A Lecture'. In addition, a literature search was conducted and articles published in English relating to the terms care, compassion, ethics, judgement and thinking between 2004-2014 were included. IMPLICATIONS FOR NURSING: It is anticipated that this discussion will stimulate further critical debate about the role of Arendt's work for an understanding of the occurrence of poor nursing care, and encouraging additional detailed analyses of the widespread participation of nurses in healthcare failings more generally. CONCLUSION: This article provides a challenging analysis of the widespread participation of nurses in poor care and discusses the opportunities confronting the providers of nursing education in limiting future healthcare failings.

Capitalism, psychiatry, and schizophrenia: a critical introduction to Deleuze and Guattari's Anti-Oedipus.

Published in 1972, Anti-Oedipus was the first of a number of collaborative works between the French philosopher, Gilles Deleuze, and the French psychoanalyst and political activist, Felix Guattari. As the first of a two-volume body of work that bears the subtitle, Capitalism and Schizophrenia, Anti-Oedipus is, to say the least, an unconventional work that should be understood, in part, as a product of its time--created as it was among the political and revolutionary fervour engendered by the events of 'May 1968'. However, this paper will suggest that Anti-Oedipus--as a critique of psychoanalysis and the Oedipus complex, as well as being a study of the relationship between capitalism and schizophrenia--should also be understood in a less 'time-bound' fashion. In particular, the paper will examine Deleuze and Guattari's formulation of a concept of 'desire' and its employment in relation to subjectivity, time, capitalism, representation, and the radical 'therapeutic' practice that they refer to as 'schizoanalysis'. Moreover, nearly 40 years after the events of May 1968 and against possible doubts concerning the contemporary relevance of psychoanalysis, it will be suggested that psychoanalysis and the Oedipus complex are to be understood as symptomatic of a wider 'malaise' that can be discerned within psychiatry, psychotherapy, and contemporary capitalist society itself, and that it is this that forms the broader target of the book's critique. Accordingly, by providing an accessible and critical introduction to Anti-Oedipus, the paper also hopes to stimulate further discussion and research regarding both the critique and the contribution that the work can make to contemporary psychiatry, psychotherapy, and mental health nursing generally.

Gilles Deleuze: psychiatry, subjectivity, and the passive synthesis of time.

Abstract Although 'modern' mental health care comprises a variety of theoretical approaches and practices, the supposed identification of 'mental illness' can be understood as being made on the basis of a specific conception of subjectivity that is characteristic of 'modernity'. This is to say that any perceived 'deviation' from this characteristically 'modern self' is seen as a possible 'sign' of 'mental illness', given a 'negative determination', and conceptualized in terms of a 'deficiency' or a 'lack'; accordingly, the 'ideal''therapeutic' aim of 'modern' mental health care can be understood as the 'rectification' of that 'deficiency' through a 're-instatement' of the 'modern self'. Although contemporary mental health care is increasingly becoming influenced by the so-called 'death' of the 'modern self', this paper will suggest that it is the work of the 20th century French philosopher, Gilles Deleuze, that is able to provide mental health care with a coherent determination of a 'post-modern self'. However, a Deleuzian account of subjectivity stands in stark contrast to 'modernity's' conception of subjectivity and, as such, this paper will attempt to show how this 'post-modern' subjectivity challenges many of the assumptions of 'modern' mental health care. Moreover, acknowledging the complexity and the perceived difficulty of Deleuze's work, this paper will provide an account of subjectivity that can be understood as 'Deleuzian' in its orientation, rather than 'Deleuze's theory of subjectivity', and therefore, this paper also seeks to stimulate further research and discussion of Deleuze's work on subjectivity, and how that work may be able to inform, and possibly even reform, the theoretical foundations and associated diagnostic and therapeutic practices of psychiatry, psychotherapy, and mental health nursing.

Time, human being and mental health care: an introduction to Gilles Deleuze.

The French philosopher, Gilles Deleuze, is emerging as one of the most important and influential philosophers of the 20th century, having published widely on philosophy, literature, language, psychoanalysis, art, politics, and cinema. However, because of the 'experimental' nature of certain works, combined with the manner in which he draws upon a variety of sources from various disciplines, his work can seem difficult, obscure, and even 'willfully obstructive'. In an attempt to resist such impressions, this paper will seek to provide an accessible introduction to Deleuze's work, and to begin to discuss how it can be employed to provide a significant critique and reconceptualization of the theoretical foundations and therapeutic practices of psychiatry, psychotherapy, and mental health nursing. In order to do this, the paper will focus upon Deleuze's masterwork, and the cornerstone to his philosophy as a whole, Difference and Repetition; in particular, it will discuss how his innovative and challenging account of time can be employed to provide a conception of human life as a 'continuity', rather than as a series of distinct 'moments' or 'events'. As well as discussing the manner in which his work can provide us with an understanding of how life is different and significant for each human being, this paper will also highlight the potential importance of Deleuze's work for logotherapy, for the recent 'turn' to 'narrative' as a psychotherapeutic approach and for contemporary mental health care's growing interest in 'social constructionism'. As such, this paper also seeks to stimulate further discussion and research into the importance and the relevance of Deleuze's work for the theory and practice of psychiatry, psychotherapy, and mental health nursing.

The production of the psychiatric subject: power, knowledge and Michel Foucault.

The issue of power has become increasingly important within psychiatry, psychotherapy and mental health nursing generally. This paper will suggest that the work of Michel Foucault, the French philosopher and historian, has much to contribute to the discussion about the nature, existence and exercise of power within contemporary mental health care. As well as examining his original and challenging account of power, Foucault's emphasis on the intimate relationship between power and knowledge will be explored within the context of psychiatry and mental health nursing. This is to say that the paper will investigate Foucault's account of how power and knowledge are central to the process by which human beings are 'made subjects' and therefore how 'psychiatric identities' are produced. In doing so, it will be suggested that Foucault's work can not only make a valuable contribution to contemporary discussions about power and knowledge, but can also provide a significant critique and reconceptualization of the theoretical foundations and associated diagnostic and therapeutic practices of psychiatry and mental health nursing.

Ethical analysis in public health.

Public-health regularly encounters serious ethical dilemmas, such as rationing scarce resources, influencing individuals to change their behaviour, and limiting freedom to diminish disease transmission. Yet unlike medical ethics, there is no agreed-upon framework for analysing these difficulties. We offer such a framework. It distinguishes three philosophical views, often invoked in public-health discourse: positions based on outcomes (utilitarianism), positions focused on rights and opportunities (liberalism), and views that emphasise character and virtue (communitarianism). We explore critical variations within each approach, and identify practical problems that arise in addressing the ethical dimensions of health policy. We conclude by examining challenges posed by the feminist argument of ethics-of-care and by postmodern views about the nature of ethics. Health professionals need enhanced skills in applied philosophy to improve the coherence, transparency, and quality of public deliberations over ethical issues inherent in health policy.