Earn
4.8 Contact
Hours
T
he Tidal Model (Barker, 2002;
Barker & Buchanan-Barker,
2005) is focused on the concept
of mental health recovery (Brookes,
2005). Practice-based projects have
been established in Australia, Canada,
England, Ireland, Japan, New Zealand,
Scotland, and Wales, ranging across
the hospital-community continuum—
from outpatient addiction services,
through acute and forensic units, to
the care of older adults with demen-
tia (Buchanan-Barker, 2004). These
projects emphasize the need for prag-
matic approaches to helping people
address their problems of human living
(Vaughn, Webster, Orahood, & Young,
1995), especially through the develop-
ment of collaborative relationships be-
tween nurses and clients.
To date, four major studies have ex-
plored the value of implementing the
Tidal Model within the discrete set-
tings of acute care (Gordon, Morton,
& Brooks, 2005; Lafferty & Davidson,
2006; Stevenson, Barker, & Fletcher,
2002) and forensic care (Cook, Phil-
lips, & Sadler, 2005). While acknowl-
edging the difficulties in demonstrat-
ing empirical proof of the relationship
between the Tidal Model and the var-
ious outcomes (Gordon et al., 2005),
these studies clearly demonstrated
gains in nursing morale and client
satisfaction, with manifest reductions
in clients’ self-harm behavior, suicide
attempts, absconding, and aggression
toward staff or other clients. Cook et
al.’s (2005) in-depth phenomenologi-
cal study sought a “reflective descrip-
tion of the nursing care experience”
(p. 538) of the Tidal Model from both
staff and client perspectives. They
noted that:
As an explicitly values-based mod-
el, it is plausible that the adoption
of the Tidal Model has caused wider
changes to the forensic unit’s unique
culture and values. The positive find-
ings of this study may therefore be de-
29
 pendent on a shift in the milieu
of the unit. (Cook et al., 2005,
p. 539)
The Tidal Model developed
from research focused on iden-
tifying what individuals and
families valued in nursing and
what nurses did (in practical
terms) that appeared to make
a positive difference (Barker,
Jackson, & Stevenson, 1999).
Consequently, the Tidal Model
originally reaffirmed the value
of the traditional commit-
ment to compassionate care
(Buchanan-Barker & Barker,
2004).
During the past 4 years, howev-
er, we have worked with colleagues
from more than 100 projects
worldwide to clarify the inherent
values of the Tidal Model. We
framed these as the moral, ethical,
and philosophical commitments
health care practitioners make
in an effort to reshape their prac-
tice (Barker & Buchanan-Barker,
2005). As Cook et al. (2005)
noted, when health care practi-
tioners commit themselves to the
adoption of a new orientation to
care and caring, the effects extend
far beyond the personal domain,
affecting both the team culture
and the social milieu of practice.
In this sense, the expressed values
of the Tidal Model have implica-
tions not only for those who re-
ceive nursing care, but also for the
health care practitioners involved
in the care delivery.
30
The Ten Commitments
Philosophically, the Tidal
Model asks specific questions
about people with mental health
problems who are seeking recov-
ery or are on the road to recov-
ery: What does it mean to be a
person? What is the nature of a
person’s experience of the prob-
lems of human living? Of course,
the fundamental question re-
mains: What is recovery? The
answers to any or all of these
questions should, at least in
principle, influence the practice
of mental health care (Brookes,
2005).
Building on our original as-
sumptions that mental health
recovery is both desirable and
possible, we developed a set of
related values, which we named
the “Ten Commitments.” Al-
though no biblical allusion was
intended, we recognized that
in making such commitments,
health care practitioners more
enacted human faith than dem-
onstrated scientific fact. How-
ever, the Ten Commitments do
make observations about hu-
man behavior, which have been
confirmed within the practice
of our many nursing colleagues
worldwide. In that sense, the
Ten Commitments represent
hypothetical truths related to
the human condition, which are
open to confirmation or refuta-
tion. However, the original em-
phasis of the Tidal Model was to
address how nurses, and others,
thought and felt about compas-
sionate caring. Consequently,
we emphasized the world of be-
liefs, rather than any notion of
empirical reality. We assumed
that the meaning of compas-
sionate caring was inextricably
tied to the values expressed by
the caregiver, and the values at-
tached to caring by the client.
The concept of recovery has
many dictionary definitions,
ranging from “economic ascen-
dancy following a decline in
fortune” to “the return of envi-
ronmental conditions to their
original state.” This focus on
language, especially metaphor,
is central to the Tidal Model.
Language is not simply a me-
dium for communication, but
the expression of an experien-
tial truth. Most definitions of
recovery define a process: some-
thing that is going on, however
abstract or ill defined. The Tid-
al Model practitioner’s aim is
to better understand, relate to,
and connect with what is going
on within the experience of the
client. The critical Tidal Model
assumption is that change is in-
evitable, although often largely
invisible. In believing that
change is ongoing, health care
practitioners seek a way to con-
nect with clients and their ex-
periences through language and
metaphor, and to clarify the
form that change is taking and
how the nurse can help the cli-
ent direct (metaphorically) this
change in a personally mean-
ingful way.
The Function of the
Ten Commitments
Given its origins in clinical
practice, it was assumed that the
development of the Tidal Model
would be shaped by health care
practitioners, who in turn would
be influenced by the Tidal Mod-
el’s philosophical assumptions
September 2006
and values. The Ten Commit-
ments were first defined in an
attempt to clarify the value base
of the Tidal Model (Buchanan-
Barker, 2004). Since then, the
Ten Commitments have also
served as the basis for the de-
velopment of audit and research
criteria, evaluating the extent to
which health care practitioners
enact the Tidal Model values,
and the extent to which clients
are aware of and appreciate these
values.
The client’s story is the be-
ginning and endpoint of the
helping encounter. The story
embraces not only the account
of the client’s distress, but also
the hope for resolution. This is
the voice of experience.
In traditional practice, the
client’s story is usually trans-
lated into a third-person, pro-
fessional account. Thus, the
client’s story (my story) be-
comes the professional’s view
of that story (history). In the
Tidal Model, every effort is
made to retain the client’s
unique narrative account. In
practical terms, this involves
writing all assessment and care
plan records in the client’s own
voice and, whenever possible,
in the client’s own handwrit-
ing (Barker & Buchanan-Bark-
er, 2005).
The client has developed a
unique way of expressing his
or her life story, representing
to others that which the client
alone can know. The language
of the story, complete with its
natural grammar and personal
Journal of Psychosocial Nursing, Vol. 44, No. 9
metaphors, is the medium for
expressing the abstract experi-
ence of the client and repre-
sents the key tool for framing
the emerging story of the cli-
ent’s recovery (McLeod, 1997).
By contrast, professional stories
written about clients are, tradi-
tionally, framed by the arcane,
technical language of psychi-
atric medicine or psychology
(Kutchins & Kirk, 1997). By
valuing the client’s natural
language, the Tidal Model
conveys simple, yet powerful,
respect for the client.
The client is writing a life
story, but is hardly an open
book. Health care profession-
als need to develop ways of
expressing genuine interest
in the story so they can bet-
ter understand the storyteller.
Often, professionals are inter-
ested only in what is “wrong”
with the client or in pursuing
particular lines of professional
inquiry (e.g., seeking signs and
symptoms). Genuine curiosity
reflects an interest in the cli-
ent and his or her unique ex-
perience, as opposed to merely
classifying and categorizing the
features, which may be com-
mon to other clients.
The client is the expert on
his or her life story. We can be-
gin to learn something of the
power of that story, but only if
we apply ourselves diligently
and respectfully to the task by
becoming the apprentice.
It is a philosophical tru-
ism that no one can ever truly
know another person’s experi-
ence. However, health care
professionals often talk as if
they know their clients better
than the clients know them-
selves. No matter how much
time we spend with clients,
our knowledge about them will
never equal their knowledge
about themselves. The client
remains entirely in charge at
all times; this is a fundamental
premise.
The client has developed a
powerful storehouse of wisdom
through the enactment of his or
her life story. In mental health,
that story is often framed by
powerful metaphors, which at-
tempt to convey something of
the magnitude of the client’s
distress (Barker, 2002). A key
task for the professional ap-
prentice is to assist in revealing
that wisdom, which will help
sustain the client and guide
the voyage of recovery.
The client and the profes-
sional apprentice become a
team. If this relationship is to
prosper, each must be willing
to confide in the other. The
professional apprentice is in a
privileged position and should
model this confidence-building
by being transparent at all
times and helping the client
understand exactly what is be-
ing done and why. By retain-
ing the use of the client’s own
language and by completing all
assessments and care plan re-
cords together, the collabora-
tive nature of the professional-
client relationship becomes
even more transparent.
31

The client’s story contains
many examples of what has
worked for him or her in the
past or beliefs about what may
work for him or her in the fu-
ture. These represent the primary
tools that need to be used to
unlock or build the story of re-
covery. The professional toolkit,
commonly expressed through
ideas such as evidence-based
practice, describes what appears
to have worked for other clients.
Although potentially useful, this
should be used only if the client’s
available toolkit is lacking.
The professional apprentice
and client work together to con-
struct an appreciation of what
needs to be done. The first step
is the crucial one, revealing the
power of change and pointing to-
ward the ultimate goal of recov-
ery. The client repeatedly takes
that crucial step, moment by
moment, which could ultimately
lead to the destination called “re-
covery.” This focus on change,
moment by moment, reminds
us of the importance of working
with the client in the “me now”
stage, addressing what needs to
32
be done to help advance the cli-
ent to the next step.
There is nothing more valu-
able than the time the appren-
tice and client spend together.
Time is the midwife of change.
Often, health care professionals
complain about lack of time to
work constructively with clients.
However, through creative at-
tention to their work, they are
often able to make time to do
what needs to be done (Lafferty
& Davidson, 2006).
The Tidal Model assumes that
change is inevitable because it is
constant. The common truth is
that nothing lasts. The task of
the professional apprentice is to
help the client develop awareness
of how change is happening and
how knowledge could be used to
steer the client out of danger and
distress and back onto the course
of reclamation and recovery.
Our ongoing evaluation of
Tidal Model projects in other
countries suggests that the Ten
Commitments provides a simple
means of establishing health care
practitioners’ fidelity to the Tidal
Model’s philosophical and value
base. Each commitment has been
translated into an evaluation cri-
terion, used to analyze or appraise
written records of assessment and
care or the behavioral interactions
between nurses and clients.
Reclaiming the story
The first Tidal Model com-
mitment is to value the client’s
own voice. This is reflected in
the way health care practitioners
help clients write the various
stories of assessment and care
plan action in their own words,
using their own metaphors and
literary styles, rather than trans-
lating the story into professional
note-taking. This emphasis on
my story, as opposed to the pro-
fessional interpretation of histo-
ry, is probably the aspect of the
Tidal Model that appeals most
to clients. This focus on co-cre-
ating the story of the need for
care is a dramatic demonstration
of the health care practitioner’s
desire to work actively with the
client. As Sally Clay, the Ameri-
can mental health advocate and
psychiatric client, noted:
The Tidal Model makes au-
thentic communication and the
telling of our stories the whole
focus of therapy. Thus the treat-
ment of mental illness becomes
a personal and human endeavor,
in contrast to the impersonal-
ity and objectivity of treatment
within the conventional mental
health system. One feels that one
is working with friends and col-
leagues rather than some kind
of “higher-up” providers. One
becomes connected with oneself
and others rather than isolated
in a dysfunctional world of one’s
own. (2005, p. xv)
The client’s story contains not
only the details of the circumstanc-
es that led to the need for help in
the first place, but also holds the
promise of what needs to be done
to advance the process of recovery.
September 2006
Consequently, talking, conversing,
and discussing, whether in formal
one-to-one sessions or in a variety
of formal and informal group set-
tings, become the key tools of the
Tidal Model.
Various schools of psychother-
apy influenced the development
of the Tidal Model. However,
the Tidal Model is not a kind of
psychotherapy or counseling per
se. As psychotherapists ourselves,
we value the practice of different
kinds of counseling and psycho-
therapy. However, we recognize
that ordinary conversation has a
power often not found in the for-
mality of therapeutic discourse
(Zeldin, 2000). Such “extraor-
dinarily ordinary” discourse pro-
vides a medium for people dis-
covering more about themselves
through contact with others, as
Sally Clay noted.
A common story told by people
with direct experience with the
Tidal Model is that “rather than
coming away feeling [you are] just
another client, you feel as though
you matter” (Cook et al., 2005,
p. 538). Indeed, the kind of rela-
tionship described by Clay (2005)
involves a more egalitarian focus,
which participants in Cook et al.’s
(2005) study described as a level-
ing of the relationship between
nurse and client.
The first responsibility of any
helping team is to learn from the
client what needs to be done to
address or meet the client’s needs.
We borrowed the term “doing
what needs to be done” from the
work of the Japanese psychiatrist,
Shoma Morita, who more than
80 years ago developed a kind
of psychotherapy, influenced by
Zen Buddhism and the principle
of acceptance of change (Chen,
2005). The Tidal Model express-
es a similar appreciation of the
conjoint nature of the work of
health care professionals and cli-
ents in negotiating what needs to
be done to address or respond to
Journal of Psychosocial Nursing, Vol. 44, No. 9
K EY P OIN T S
1. The “Ten Commitments” are a set of values related to the philosophical
assumptions of the Tidal Model that mental health recovery is both desirable
and possible.
2. The Ten Commitments represent hypothetical truths related to the human
condition and are open to confirmation or refutation.
3. The Tidal Model expresses an appreciation of the conjoint nature of the work
of health care professionals and clients in negotiating what needs to be done to
address or respond to clients’ problems of human living.
Do you agree with this article? Disagree? Have a comment or questions?
Send an e-mail to Karen Stanwood, Executive Editor, at kstanwood@slackinc.com.
We're waiting to hear from you!
clients’ problems of human liv- (2005). The tidal model as experienced
by patients and nurses in a regional fo-
ing. Within such collaboration,
rensic unit. Journal of Psychiatric and
the professional is assigned as a Mental Health Nursing, 12, 536-540.
member of the crew and the cli- Gordon, W., Morton, T., & Brooks, G.
ent is recognized as the captain of (2005). Launching the tidal model:
the ship (of life). Evaluating the evidence. Journal of
Psychiatric and Mental Health Nursing,
12, 703-712.
References Kutchins, H., & Kirk, S.A. (1997). Mak-
Barker, P. (2002). The tidal model: The ing us crazy. New York: Free Press.
healing potential of metaphor within
Lafferty, S., & Davidson, R. (2006,
a patient’s narrative. Journal of Psy- March). Putting the person first.
chosocial Nursing and Mental Health Mental Health Today, pp. 31-34.
Services, 40(7), 42-50. McLeod, J. (1997). Narrative and psycho-
Barker, P., & Buchanan-Barker, P. (2005). therapy. Thousand Oaks, CA: Sage.
The tidal model: A guide for mental Stevenson, C., Barker, P., & Fletcher, E.
health professionals. London, UK:
(2002). Judgement days: Developing
Brunner-Routledge. an evaluation for an innovative nurs-
Barker, P., Jackson, S., & Stevenson, C. ing model. Journal of Psychiatric and
(1999). The need for psychiatric nurs- Mental Health Nursing, 9, 271-276.
ing: Towards a multidimensional theory Vaughn, K., Webster, D.C., Orahood, S.,
of caring. Nursing Inquiry, 6, 103-111. & Young, B.C. (1995). Brief inpatient
Brookes, N. (2005). Phil Barker: The tid-
psychiatric treatment: Finding solu-
al model of mental health recovery. In tions. Issues in Mental Health Nursing,
A.M. Tomey & M.R. Alligood (Eds.), 16, 519-531.
Nursing theorists and their work (6th Zeldin, T. (2000). Conversation: How
ed., pp. 696-725). St. Louis: Mosby. talk can change our lives. Mahwah, NJ:
Buchanan-Barker, P. (2004). The tidal Paulist Press.
model: Uncommon sense. Mental
Health Nursing, 24(3), 6-11.
Buchanan-Barker, P., & Barker, P. (2004).
Ms. Buchanan-Barker is Director, Clan
Unity International, Newport on Tay,
More than a feeling. Nursing Standard,
Fife, Scotland, and Dr. Barker is Professor,
19(11), 18-19.
School of Nursing and Midwifery, Trinity
Chen, C.P. (2005). Morita therapy: A
College Dublin, Dublin, Ireland.
philosophy of yin/yang coexistence.
The authors disclose that they have no
In R. Moodley & W. West (Eds.),
Integrating traditional healing practices
significant financial interests in any product
or class of products discussed directly or
into counseling and psychotherapy (pp.
indirectly in this activity, including research
221-232). New York: Sage.
support.
Clay, S. (2005). A view from the USA.
Address correspondence to Philip J.
In P. Barker & P. Buchanan-Barker
Barker, Professor, School of Nursing and
(Eds.), The tidal model: A guide for
mental health professionals (pp. xv-xvi).
Midwifery, Trinity College Dublin, 24
D’Olier Street, Dublin 2, Ireland; e-mail:
London, UK: Brunner-Routledge.
Phil_Barker@ukf.net.
Cook, N.R., Phillips, B.N., & Sadler, D.
33