The Tidal Model
The Tidal Model represents a significant alternative to mainstream mental health theories,
emphasising how those suffering from mental health problems can benefit from taking a
more active role in their own treatment.
Based on extensive research, The Tidal Model charts the development of this
approach, outlining the theoretical basis of the model to illustrate the benefits of a holistic
model of care, which promotes self-management and recovery. Clinical examples are
employed to show how, by exploring rather than ignoring a client’s narrative,
practitioners can encourage the individual’s greater involvement in the decisions
affecting their assessment and treatment. The appendices guide the reader in developing
their own assessment and care plans.
The Tidal Model’s comprehensive coverage of the theory and practice of this model
will be of great use to a range of mental health professionals and those in training in the
fields of mental health nursing, social work, psychotherapy, clinical psychology and
occupational therapy.
Phil Barker is a psychotherapist in private practice and also Visiting Professor at
Trinity College, Dublin. He was the UK’s first Professor of Psychiatric Nursing at the
University of Newcastle (1993–2002).
Poppy Buchanan-Barker is a therapist and counsellor and was a social worker for
over 25 years. Presently she is Director of Clan Unity, an independent mental health
recovery consultancy in Scotland.

The Tidal Model
A guide for mental health professionals
Phil Barker and Poppy Buchanan-Barker

HOVE AND NEW YORK
First published 2005 by Brunner-Routledge 27 Church Road, Hove, East Sussex BN3 2FA
Simultaneously published in the USA and Canada by Brunner-Routledge 270 Madison Avenue,
New York, NY 10016

List of figures

ix The poetics of experience

xi Values

xii Foreword

xiv
SALLY CLAY AND IRENE WHITEHILL

Preface

The Self Domain: The need for emotional security

50
7

The assessment of suicide risk

59
8

Bridging: Engaging with the Self in crisis

72
9

The World Domain: Planning holistic care

88
10

The Others Domain: An anchor in the social world

105
11

The lantern on the stern: Individual Care

116
12



Appendix 1: The Holistic Assessment

218 Appendix 2: Rating scale

224 Notes

225 References

233 Index

242
Figures

4.1 Traditional hospital-community relations 40
4.2 Whole system model of integrated care 41
4.3 The Tidal Model care continuum 42
4.4

In a lifeboat;
I didn’t see it go,
Only felt the anchor rise,
The sails unfurl
And catch the wind.
Afloat
On the current of torn,
Unruly tides.
I didn’t wave goodbye
Or watch the boat escape
I was further the other way,
Complacent
That good health was locked into my shape,
Without replacement.
I know something
Had left me stranded
In the dark without a light
But then it was too late.
I faltered in my abandoned ark,
In search of fuel,
Hoping I could illuminate
The gasping lamps.
In time
I’ve made them both
A signal
That good health can now return.
© Deborah Carrick 2001
1
Values
Twentieth-century values

d
i
d
n’
t

spea
k
up

Because we thought that we weren’t dissidents.
Next they came for the asylum seekers
But we didn’t speak up—
Because we thought that we would never be asylum seekers.
Then they came for the mentally ill
And there was no one left to speak for anyone.
Poppy Buchanan-Barker and Phil Barker, 2003
Foreword
A view from the UK
In February 2004 I reached my half century. The celebrations lasted all month. One of
my friends took me to see the film Chicago. This reminded me of 1981 when my partner
took me to see the stage version of Chicago at a theatre in London’s West End. I had
been getting stressed out writing up my doctoral thesis and he decided that I needed a
night out. That night I experienced my first hypomanic episode during which I went
missing for two days. I went to the vicarage of my local church and told the vicar that I
was the Virgin Mary. He dismissed me as either being drunk or mad.
I was hospitalised for three months during which time no one explained the
‘symptoms’ I was experiencing or the medication I was receiving. Most importantly, my
identification with the Virgin Mary was confined to my notes and never mentioned again.
The conversations I had with nurses were very mechanistic, motivated by their desire to

When the Tidal Model is in use, each service user undergoes an assessment with a
specifically trained mental health nurse. This is carried out in such a way that service
users feel comfortable about expressing their views. All experiences are accepted as
‘true’ and not dismissed as ‘hallucinations’ (for example) and added to the notes without
discussion. The mental health nurse discusses with the service user what the person feels
may have caused their admission and what they feel they need to do to address these
problems. Every service user receives a copy of their assessment, which is recorded in
their own words.
This process helps to build up trust between the service user and the mental health
nurse. They form a partnership whereby the nurse supports the service user through the
recovery process. The emphasis is on ‘caring with’ rather than ‘caring for’. The attitudes,
beliefs and expressed needs of the service user are accepted at each stage of the recovery
process. The user knows that the advice of the nurse may not necessarily be accepted.
This partnership works to identify what needs to be done to promote recovery, thereby
easing service users back into their home lives more effectively. There is a right time for
everything and the service user must be allowed to dictate the pace of their own recovery.
Above all the mental health nurse is always the bearer of hope and belief in recovery, no
matter what particular path they have had to follow. In that sense, the Tidal Model is truly
‘groundbreaking’.
Dr Irene Whitehill
Northumberland, England
A view from the USA
My first experience with mental illness was a breakneck journey that led me into
dimensions I had never known before, and a consciousness that would alter my life
forever. It was a spiritual experience that was colourful and scary, and it landed me in the
mental hospital.
Yet when I tried to talk about this with the psychiatrist at the hospital, he was not in
the least bit interested. This was my first experience with the medical model. I realised
that my doctor was convinced that whatever I had felt was meaningless and irrelevant,
and that my recovery depended not on understanding what I had experienced but rather

Sally Clay
Florida, USA
Preface
At any given moment, life is completely senseless. But
viewed over a period, it seems to reveal itself as an
organism existing in time, having a purpose, trending in a
certain direction.
(Aldous Huxley)
Any book is like a reflection of its authors in a stream. It captures something of the story
of who they are, but distorts the image at the same time. Such is the nature of water—
such is the nature of reflection. We hope that the reader will find something of us here
that is recognisable, in a human sense. There is much of us in the Tidal Model. However,
expressing that, as with anything else, is often difficult. Words are great tools, but as we
marvel at their beauty, we may fear what we might actually do with them.
This is a storybook. It is a story of the development of Tidal Model and a tale of the
importance of story in mental health care, if not also in all our lives. For the main part, it
is a simple story; but we hope that does not mean that the complexities and subtleties of
the life story are overlooked. Life is simple—we are born, we live and then we die. The
story of that simple progression can be made to appear complex, full of dark,
impenetrable secrets and mysteries. But the same events can reveal wonders, joy, wisdom
and amazement. It all depends on the storyteller—and the listener.
Our story of the Tidal Model mirrors closely our own development as professionals in
the field that we would choose to call ‘human services’. The Tidal Model probably says
more about our interest in people and their problems of living, than it does about patients,
clients, users, or consumers. Some of the people we have worked with over the years
have become our friends. In every case, they were our teachers. Also, they were people
whom we have grown to respect, if only from afar. Indeed, it was our privilege to work
with such people, many of whom stretched us in challenging ways. Others shaped us into
more effective versions of our original selves. Few of them could be called anything
other than ‘interesting’. We hope that we seemed half as interesting to them.

of their experience. Roll all this together and the Tidal Model is a paper template for
engaging in value making. Does this generate mental health? We are not sure, as there
appears to be a multitude of definitions of mental health. However, we believe that value
making and the appreciation of value in our lives must be healthy activities for the whole
person. So, if that is true, then value making will foster mental health and the Tidal
Model may be described, appropriately, as an approach to mental health
recovery/discovery.
We hope that this book can be read by anyone with an interest in mental health care,
whichever discipline they belong to, or even if they have no special professional
affiliation. We hope that the book will be read by people who have a wide range of
interests in mental health care and way beyond. We hope that we shall not merely be
‘preaching to the converted’. We have tried to keep the use of professional jargon and
high-sounding philosophical and technical language to a minimum. If the reader stumbles
over any of these boulders in the text, we apologise. We shall try to be even more careful
next time.
Clinical and managerial colleagues at what was then called the Newcastle City Health
Trust in England deserve a special mention for their original invitation to frame the idea
of the Tidal Model as the basis for nursing practice in the mental health programme. If
they had not made this request in the first place, and had not helped support its launch
into the often difficult waters of ordinary NHS practice, we might not be writing this
Preface. So, we thank Tony Byrne, Steven Michael, Anne McKenzie and Robin
Farquharson, from the Mental Health Programme for their belief in the possibility of
change in mental health professional practice. We also thank Dee Aldridge, Aileen
Drummond, Elaine Fletcher, Clare Hepple, Clare Hopkins, Janice O’Hare, Val Tippens
and their many clinical colleagues for pushing the boat out into the incoming tide.
Special thanks are also due to Dr Chris Stevenson, who as an old friend and trusted
colleague made the perfect original crewmember, and helped develop the first evaluation
of the Tidal Model in practice. We also reserve a very special vote of thanks for Mike
Davison who in 1993 first inspired Phil Barker to begin to think about what an alternative
model of psychiatric and mental health nursing might look like.

might be taken. Indeed, the changes that occurred during the twentieth century were
phenomenal and the pace of change appears to be quickening.
In our lifetime the psychobabble of West Coast USA has become commonplace. Our
parents appeared to live what the Greeks might have called ‘good lives’ without ever
reflecting on their ‘self-esteem’, ‘self-image’ or ‘self-concept’. Their consciousness was
not so much simpler as different. The stories of their lives were written in a different
language and spoken with a different voice than might be the case today.
The gift of consciousness allows people to ‘reflect’ on their experience of self. Today,
we have a host of linguistic tools, mechanisms and devices that are meant to make this
self-examination easier or more productive. At the heart of this process of examination
lies—at least in the developed western world—the mercurial notion of the Self.
1

However, for most people, who and what they are remains something of a mystery. Yet
despite this they know that they exist and they know what this is like, even when they
find it difficult to express the experience of self.
What does seem clear is that when people experience difficulties in their relationship
with the core Self—or in the human relations with others—they are likely to be described
as having ‘mental health problems’. Traditionally, they would be described as being
‘mad’.
2

The paintings of Hieronymus Bosch, the fourteenth-century Flemish artist, have often
been assumed to depict the experience of waking nightmares, such as might be
experienced by someone in the most extreme form of madness. His Garden of Earthly
Delights has often been interpreted as a vivid illustration of psychosis, or by the
Freudians as a catalogue of wish fulfilment or sexual anxiety. Paradoxically, there is
another way of viewing Bosch, which may be simpler yet more complex. Bosch’s work
reflected the world view of the Middle Ages (Bosing 2001). The Garden of Earthly
Delights can be interpreted as a complex warning to all who might stray from the

years. When our ancestors began to daub dirt on the walls of the Lascaux caves, or
fashioned crude representations of themselves, or their idealised gods, from the rock, the
process of self-reflection that eventually meant so much to Socrates was first born.
Today our emphasis on ‘self-reflection’ is heavily focused on language. However, we
should not forget that much of our reflection is pre-linguistic and, especially in the
therapeutic setting, often goes beyond words. In a philosophical sense, what is called the
‘lived experience’ belongs to this pre-linguistic province: it is what we experience, as we
experience it, before we get down to—or are required to—attach words and linguistic
meanings to the ‘experience’.
Indeed, Rembrandt probably still represents the pinnacle of naive self-reflection on the
‘lived experience’. His 90 self-portraits present a fascinating visual story of the decline in
his fortunes and also the change in his view of himself. They are essays on ‘who’
Rembrandt is, without words. The art historian Manuel Gasser (1961) wrote: ‘Over the
years, Rembrandt’s self-portraits increasingly became a means for gaining self-
knowledge, and in the end took the form of an interior dialogue: a lonely old man
communicating with himself while he painted.’
The Tidal Model 2
Whenever we look in a mirror, we have a similar opportunity to reflect on the story
that life has written on our faces. Writing in our journal or sharing something of our story
with others offers a different kind of reflection on the journey we have taken, out of the
past to the here and now. The reflection is rarely clear-cut and steady, but it is always
revealing. Indeed, Rembrandt’s self-portraits provide us with a useful anchor for our own
reflections. We may not always be able to represent exactly what we see and feel, but the
story we relate is always true, at least for now. Our reflections are always just that—
reflections; a poor image of the complexity of the original. However, they are nonetheless
important for all that. They are reflections on what it means to be human.
Psychiatry and the colonisotion of the self
For over one hundred years psychiatry has developed its own story of what it means to be
human, promoting the idea that psychological, social and emotional problems are a
function of some underlying (but unidentified) biological pathology. Such theories

themselves users or consumers, but many of them still refer to ‘being bipolar’ or ‘having
dysfunctional beliefs’. The insinuation of ‘lunatic language’ (Buchanan-Barker and
Barker 2002) into the culture reflects the continuing power of psychiatric imperialism.
The mental health ‘user’ or ‘consumer’ may be freed from the old ‘patient’ label, but
remains chained to the psychiatric discourse.
Neuroscientific triumphalism
In our youth the psychoanalytic culture reigned supreme and everything from sports cars
to bottles of beer on a film commercial was attributed psycho-sexual significance. Over
the years other psychological, biological and genetic theories have emerged, all claiming
to offer the final explanation for why we do what we do and what it all means. Arguably,
neuroscience has taken up Freud’s baton in attempting to explain most, if not all human
behaviour. In an elegant piece of intellectual arrogance Francis Crick wrote:
You, your joys and your sorrows, your memories and your ambitions,
your sense of personal identity and free will, are in fact no more than the
behaviour of a vast assembly of nerve cells and their associated
molecules.
(Crick 1994:3)
As Szasz pointed out, this was hardly a new idea. As early as 1819, Sir William
Lawrence, President of the Royal College of Surgeons, had declared: ‘The mind, the
grand prerogative of man, is merely an expression of the function of the brain’ (Szasz
1996:84). Increasingly, people attribute their various problems of living to a specific
biochemical imbalance, or to their brain chemistry in general. If the neuroscientific
juggernaut continues to colonise our culture, it is only a matter of time before brain
chemistry will explain every slip of the tongue, as psychoanalysis did last century.
Mental illness as metaphor
Cultural antecedents
The past twenty years have witnessed a dramatic change in the status of psychiatric
patients, many of whom are no longer content with the passive role assigned to them by
psychiatric medicine, but who wish to play a more active part in the care and treatment of
their problems (Read and Reynolds 1996). Indeed, the challenges posed by groups in the

didn’t quite mean and guilts I didn’t quite understand. Because of them, I
had forced my poor wife, who was far too young to know what was
happening, into a spoiling, destructive role she never sought. We had
spent five years thrashing around in confusion, as drowning men pull each
other under.
(Alvarez 1970:279)
Much later, Alvarez found himself moving, imperceptibly, into a more optimistic, less
vulnerable frame of mind and, like so many other ‘failed suicides’, he began to reflect on
the meaning of his suicide attempt:
Months later I began to understand that I had had my answer, after all.
The despair that had led me to try to kill myself had been pure and
unadulterated, like the final, unanswerable despair a child feels, with no
before and after. And childishly, I had expected death not merely to end it
but also to explain it. Then when death let me down, I gradually saw that I
had been using the wrong language; I had translated the thing into
Americanese. Too many movies, too many novels, too many trips to the
States had switched my understanding into a hopeful, alien tongue. I no
longer thought of myself as unhappy; instead I had ‘problems’. Which is
an optimistic way of putting it, since problems imply solutions, whereas
Tales of shipwrecks and castaways 5