Therapeutic Communication in Mental Health Nursing

Aesthetic and Metaphoric Processes in the Engagement with Challenging Patients

Shira Birnbaum

• Publisher: Routledge
• Year: 2017
• Print ISBN: 9781138244290
• eBook ISBN: 9781351998024
• Edition: 1
• Topic: Social Sciences
• Subtopic: Health Care Delivery
• Index: Social Sciences

Awarded first place in the 2017 AJN Book of the Year Awards in Psychiatric and Mental Health Nursing.

This book introduces an innovative technique for therapeutic communication in mental health nursing, expanding the toolkit for nurses seeking to engage challenging patients who have not responded to more conventional therapeutic methods. Linking nursing communication to current research on metaphor and figuration, it is illustrated with accessible clinical examples.

Metaphor is a key component of talk-based psychotherapies. But many of the patients whom nurses encounter in the inpatient setting are not good candidates for talk-based approaches, at least initially, because they are violent, withdrawn, highly regressed, or otherwise lacking a vocabulary to convey thoughts and feelings. This book offers specific clinical examples of an approach called the "gestural bridge." This is a method for structuring games and physical activities which connect metaphorically to a patient's personal themes, activating narrative and observational agency and enabling an exchange of meaning to begin at a time when conventional language is not available. Rooted in what nursing theorists have called the "embodied" or "aesthetic" way of knowing, this approach is both specific and easily grasped.

Drawing from contemporary work in literary theory, semiotics, metaphor theory, cognitive science, philosophy, linguistics, psychoanalysis, and the arts, Therapeutic Communication in Mental Health Nursing is important reading for advanced-level practitioners, students, and researchers interested in communication and relationship-building in nursing.

1Introduction¹

Sara was one of those remarkable patients, familiar in psychiatric and mental health work, who eats objects that shouldn’t be eaten. Batteries, keys, bottle caps, paper clips, knives, nail clippers, Christmas-tree garlands, broken zippers, pencils, chips of plaster and linoleum, coins of all varieties, and all manner, it appeared, of screws, staples, washers, and nails. You could see some of this array in her abdominal X-rays – a radio-opaque detritus from the forest floor of a lived life. Some of these items passed through Sara’s digestive tract. Others lingered, necessitating emergency endoscopic procedures or, on multiple occasions, surgery to remove portions of perforated bowel.

A middle-aged, developmentally disabled woman, Sara had been living in a city park and eating from trash cans. Police responded to 911 calls from commuters at a train station where she was found gesturing aggressively and causing a disturbance, and she was taken to a local medical hospital for treatment and evaluation. In the emergency room, radiological scans identified a key, lodged in her esophagus, and dozens of other unusual objects in her stomach and intestines. Multiple endoscopic procedures were performed to clear the gastrointestinal tract, and, once medically stabilized, she was transferred to a nearby psychiatric facility. Over the course of about a month, psychiatrists there sent her out for emergency surgical treatment four more times, X-rays revealing, each time, bizarre new ingestions. A portion of her intestine needed to be surgically removed. From that smaller psychiatric facility, she was delivered, in wrist restraints, to our sprawling admissions department, and, soon thereafter, to one of our general psychiatry units.

At the time we first met her, Sara didn’t know her birth name, couldn’t give a birth date, and offered no social security number or previous address. She claimed, first, to be 28 years of age. Then 48. Then 31. She had no known relatives and couldn’t remember either parent’s first or last name. There were no school records, previous fingerprinting, or other potentially identifying documents. She reported her birthplace as Philadelphia and knew the name Louisiana, claiming to have lived with her mother in the woods there for some period of her childhood. She’d chosen a name for herself with a sound she found pleasing, and, so, Sara is what we called her. During her previous psychiatric hospitalization, she had been diagnosed with schizophrenia, psychotic disorder, foreign-body ingestion, and mild mental retardation. How she’d stayed alive over the years, given the history, we couldn’t fathom.

To mitigate the dangers her behavior posed, Sara was placed under a continuous staff surveillance protocol. Legal permission was granted to deny her access to private storage space, clothing with pockets, zippers, buttons, or snaps, eating utensils, and personal possessions such as toothbrushes and combs. She was started on medications to control psychosis and impulsivity. Staff cleaned her teeth by rubbing them with towels and dispensed small quantities of shampoo into her palms when she showered, under supervision. She continued to attempt to grab objects, however, including employee ID badges, pens, syringe covers, and scraps of paper, and she turned aggressive toward the staff attempting to stop her or block her way. She required frequent sedating medication and was moved to a safety room, separated from the general patient areas, after another patient passed near her in a hallway and handed her some coins, which she swallowed. Over the course of the next few weeks, she required multiple additional trips to the emergency room. Her bowel perforated; she became feverish and septic. Multiple surgical procedures again followed, including removal of her gall bladder and portions of her colon. She spent a month in a coma. Then, again medically stabilized, she was returned for psychiatric treatment. This time, there was a medical warning in the chart, with a phone call from one of the surgeons to the hospital medical director: further surgical procedures could not be performed safely. The swallowing had to stop.

On the unit, Sara was bedridden in the beginning, a massive surgical incision bisecting her severely distended abdomen and covered in heavy layers of gauze and tape. We observed her for signs of fever, tended to her wound, and attempted to discourage her from picking and eating the dressings. We confined her to a sparsely furnished room from which all decorative items and trash containers had been removed and door hinges tightly bolted. We counted our supplies – the gauze sponges and tape rolls and gloves and ointment applicators and caps from saline bottles – as if on a surgical unit, so that none of it would wind up in her throat or stomach. We administered enemas to discourage straining and ease the abdominal distension so her surgical wound might heal. We rubbed her skin with lotions to make her more comfortable. A hand-off communication checklist was developed for shift-change, as incoming and outgoing staff together, three times a day, inspected her room for any of the multitude of stray objects that can shake loose from routine hospital procedures. A schedule was established for periodic X-ray evaluations to track her rate of new ingestion.

Foreign-body ingestion, as it is formally known, poses intense and multifaceted management challenges for hospitals and group homes, and there are no therapeutic or pharmacological interventions proven to significantly or durably reduce swallowing behaviors in patients. The behavior is widely documented among the developmentally disabled and well known in borderline personality disorder. Some patients who swallow objects are clearly psychotic or delusional, but many seem remarkably high-functioning, which surprises you when you see them in the throes of an episode – aggressive toward anyone who gets in the way of the compulsion, in that moment, to ingest. It is virtually impossible to build a care environment free of risk, unless you keep someone in shackles, and reports appear frequently in medical and nursing journals lamenting the enormous costs and clinical challenges posed by this elusive, tenaciously complex syndrome. But here was Sara, gracious, friendly, remembering to say “thank you” when served her medications, muttering to herself quietly and glancing into the air, scanning overhead, seeming to be hearing something, with long graceful hands and meticulously clean fingernails, charming in her blue bedroom slippers and floral-print housedress, her hair in neat cornrows, smiling broadly like a jack-o-lantern with her few remaining teeth and asking, politely: if somebody has an MP3 player with speakers, would you mind, please, playing some Bee Gees?

As the weeks passed, Sara’s surgical wounds healed, though slowly, as her abdominal distension was not resolving. She began hoisting herself out of bed more frequently, and her confinement began to frustrate her. As her strength returned, so did her aggressive episodes. Staff worried when she began pacing in her room, graduating to slamming herself against walls, rolling on the ground and, within a few weeks, pushing furniture around the floor for hours on end: one day the bed had to be positioned against the wall; the next day, closer to the bathroom door; the day after that, in the corner by the window. The constant motion loosened screws and compromised joints; officers from the Safety department came to inspect, advising a new room-search protocol that included a daily walk-through and visual inspections of all the corners, backs, and undersides of the bed, the dresser, and the side-table, and so on. Sara begged to come out to the shared patient areas, to socialize in the TV room, to sit in the unit porch and throw bread crumbs to the birds outside, to join church services in the hospital chapel and drink coffee at the unit-wide morning meeting. She begged for music, for writing utensils, for art supplies. Increasingly, she needed to be sedated to prevent violent conflicts, as the staff were not authorized to meet these growing demands for independence and activity. The treatment team was stuck. No choice seemed safe. We nurses shook our heads. What is there to do with such a person, who is so utterly likeable and yet so dangerous to her own safety?

To look at the abdominal X-ray of a patient who ingests foreign objects is to feel oneself in the presence of a harvest. It is a harvest of observations, fragments of passing experience, like the collected shards of something barely glimpsed, remembered partially or fleetingly. The paper clip and the crucifix, the wristwatch and the dime, the nametag with the pin on its back – they appear on the screen plate like references loosely connected to one another, as in a collage, insinuating something which might be made coherent, perhaps, if seen some other way; they point to some almost-vanished recollection that might, in time, be retrieved by the mental operation of piecing back together. Every day, one of the hospital staff psychiatrists came to the unit to evaluate Sara. Why, she’d be asked, had she swallowed such-and-such a thing? How did she come to get her hands on it? When was the last time it happened? Is there any intent to do it again? Sara stared blankly at these queries, as if the words themselves mystified. I thought about this at her bedside one morning, perplexed as I sat, wiping her face with a warm washcloth. I had dressed her oozing abdominal wound, wrapping the waste inside-out in a latex glove and encircling it in my palm where she couldn’t get a good look at it. I asked the whereabouts of a quarter I knew she’d swallowed some weeks previous. “It’s a part of me now,” she pronounced, gazing at my face squarely. “No one can take it away.”

In nursing school, as in programs for any of the other therapeutic disciplines, we learn that the framing of a question can determine, to a large extent, the quality of the answer. For months, there had been no progress in our understanding of Sara, despite the daily interrogations about why and when and how. But a question about where, suddenly, opened a universe – revealing, remarkably, a grotesque emotional achievement: nameless and without the reference points of home and family and literacy and memory, Sara had turned herself into her own container, a portable corpuscular purse for her own stored data. She had made things “mine,” in a sense, by making them “me” – transcending, by way of this unique mental operation, the separation of inside from outside.

The next morning, I woke up early, giving myself time to rummage through my children’s bookshelves. I found an old picture book about human anatomy, and I brought it to work, storing it at the nursing station. From that point on, every time I dressed Sara’s wounds or administered her medications, I brought the book with me to her bedside, and we sat together to look at the illustrations. This is your digestive tract, I showed her. This is your esophagus. This is your stomach. Here are your intestines. I held her hands over her belly and her chest and her throat, and so on, to show the locations. I taught her about lungs, how to feel for chest expansion, helped her find her heart, taught her to feel for the pulse. Every day, I quizzed her about what was inside as I indicated what was outside, and it became a kind of ritual between us: tell me the name of the thing under this gauze pad I am taping on you, show me where the food goes, show me where it travels inside. Other nurses joined. The direct-care staff, inspired and perhaps emboldened by the novelty of these strange didactic scenes, began stuffing small radios into their pockets and encouraging Sara to dance in her room, narrating body moves as they demonstrated – “this is your right arm shaking up and down,” “now we bend to the left,” “hands on hips,” and so on. Sara began to invent housekeeping chores for herself – wiping the windows and the floor tiles, dusting along the wall edges. Staff allowed her to use towels at first, and then, eventually, a broom from the housekeeper’s closet. Together, over a period of months, we built with Sara the metaphorical outlines of an inner landscape, a sense of being embodied, and we enabled her, at the same time, to achieve an intimacy and a mastery of the spaces that were, irreducibly, outside her. We shored up the partitions and made solid the borders eroded by her years of swallowing.

The facility had a particularly compassionate psychologist who started meeting with Sara twice a week. He developed a series of what are called “exposure” exercises, sitting with her in a special therapy room and placing around the table an assortment of objects, starting, in the first weeks, with items too large to fit in her mouth and moving progressively, over time, toward smaller and smaller things. A recreational therapist scheduled time in the gym so that Sara could run around, which we hoped might reduce her need to shove furniture. The gym staff got her a large rubber ball to toss and kick, its outer surfaces quietly repeating, with each touch, the message of separation of me from not me.

Repeated X-rays began to reveal that Sara’s swallowing had slowed. She could go for several months without new objects appearing in the abdominal scan. Gradually and in steps, restrictions were lifted: Sara was allowed in an activity room for 30 minutes, first once a day, then twice a day, with one crayon at a time. Then, church services. Then, for 20 minutes at a time, joining the morning and evening unit meetings for coffee in the company of other patients. Then the outdoor porch, with supervision. Eventually, a year and a half after her admission, Sara was able to have a roommate, another patient with a long history of swallowing who had been placed on similar restrictions regarding clothing and personal belongings.

We nurses came to believe we had done some of our best work with Sara – a work of dogged restraint, self-discipline, and almost infinite patience, marked, above all, by a willingness to recognize in her pathology a kind of creativity, something imaginative, albeit grotesque and distorted. Creating physical experiences that gave a form and simple physical representation to a specific idea – reflecting and reinforcing a separation of inside from outside – we had connected to Sara’s primary themes, her literal themes of taking in, of making mine, but reconfigured them, setting them, to some extent, on a new course. We “spoke” to Sara – in activities and motions – about borders and boundaries. And though we never fully halted her swallowing, we did, finally, measurably slow it, enabling her to regain a small amount of dignity and independence.

Creative processes in nursing work

What, if anything, was distinctive about the nursing interventions which had worked in this situation to ease Sara’s suffering? I decided I would try to pinpoint their specific characteristics. This book, the by-product of my reflections, is about the deployment of metaphoric reasoning in psychiatric and mental health nursing. With examples drawn from the treatment of severely chronically mentally ill patients in a variety of settings, I describe episodes in which psychiatric nursing teams reached past ordinary language and deployed, instead, unconventional methods more akin to art, in key respects, than to traditional nursing practice. Rooted in metaphor, symbol, reference, and analogy, they harnessed the creative and imaginative tools and aesthetic attitude of the artist and the poet rather than the methods more conventionally associated with professional nursing-care planning and understandings of patient care needs. These interventions do not match a box from “column A” to a box from “column B,” the nursing action to a preconceived need or objective read-off from a diagnostic list. Rather, they represent a form of aesthetically grounded therapeutic communication which has roots in play therapy with children and is familiar in psychodynamic and psychoanalytic circles but which has not previously been theorized as a part of the nursing toolkit. These methods added significantly to the patients’ treatment by opening doors for a therapeutic alliance to begin where previous efforts at engagement had failed.

Psychotherapy privileges the spoken word, and traditional music and art rehabilitation therapies presuppose patients’ capacity to cooperate in groups and participate in communicative exchange. None of these can proceed, however, when patients are dangerous, uncooperative, or highly regressed. In the earliest stages of psychiatric hospitalization, with the most severely ill patients whose behaviors make talk-based therapy impractical or impossible, sensitive relationship-building has to come first. At its core, relationship-building is about language. It calls for identifying a specific communicative channel which might enable initial interpersonal contact. In collaborative, multidisciplinary treatment planning of the type which characterizes most inpatient settings, front-line nurses are the personnel to whom this task often falls. We spend far more time observing and interacting with patients than do most other kinds of clinician, which makes it possible for us to achieve a level of intimacy and familiarity, early on, which other clinicians often lack. Moreover, our time tends to be flexible. Not bound by advance scheduling or a need to bill for particular hours of service or sessions of a prescribed length, nurses watch situations unfold in “real time” and can grasp opportunities to build understanding in moments of patients’ greatest receptivity.

Some of us might be licensed or trained to conduct manualized therapeutic protocols such as cognitive behavioral therapy or dialectical behavioral therapy, but since most of us are not, our opportunities are wide-ranging for nuanced interventions that emerge directly from patients’ observable modes of relating – and, equally importantly, from our own often under-utilized capacity for creative and sensitive engagement in the clinical encounter.

Symptoms, in mental illness, are regarded as signs of disease. But they are also communications. Fragmented, perhaps bizarre, they are pieces of a hieroglyphic-like system which may be decipherable if we take them seriously as salient and meaning-bearing – as windows into the patient’s private dialect (Laing, 1969). We nurses are well poised to listen to these symptom dialects, as our profession has been rooted, from the start, in an attunement to the body’s speech. We register in our ear canals the poignant whoosh that air makes as it searches the recesses of the collapsing lung. We feel the quickening of our own pulse in tune with the throbbing of a patient’s frightened heart. We breathe the saltiness of wounds and find, in those inhalations, surprising moments of mute kinship. Our work trains us in the great diversity of human vocabularies – in the body’s plaintive, hesitant whispers, its whines of self-absorption, its joyous declarations and deep-seated groans of anguish – in all its multitude of strange and subtle p...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Acknowledgments
• 1 Introduction
• 2 The gestural bridge
• 3 Metaphor, play, and the representation of ideas in body-based analogy: meeting people where they are
• 4 Garden-variety analogy
• 5 The house as a grammatical form
• 6 Rhythms and regularities in a musical bridge
• 7 Nursing knowledge and nursing art: implications for learning and professional development
• 8 Conclusion
• Index