Millions of people come into contact with the mental health system every year, and many thousands wind up in the institutional system of care. Institutionalization can be a stultifying and frightening experience, involving physical and social isolation, loss of autonomy, and further disruption of already damaged life routines. When we take the nursing oath, we accept for ourselves a moral obligation to humanize what is inhumane in this situation and this system and to engage wholly in the work of restoring patients’ access to maximal independence, safety, dignity, and self-regulation, even when they have not responded to previous attempts at engagement or treatment – and even when their outward behavior challenges and troubles us deeply. This book is an effort in that direction. It describes a form of therapeutic communication which has not been theorized previously in psychiatric nursing but which seems to hold promise as a means for engaging acutely ill institutionalized patients who have not responded to more conventional therapeutic approaches.
I have called this method the “gestural bridge,” and I have given examples of how it was deployed to engage patients at times when they were particularly difficult to “reach” clinically. A gestural bridge can be said to represent an instance of what some cognitive linguists have called “conceptual metaphor” (Lakoff & Johnson, 1999). It is a way of taking a complex, abstract idea and giving it a form, without using words, by mapping it on to commonplace, readily accessible body-based schemas of experience and understanding. The idea receives a tentative, ad hoc representation in the form of a game or physical activity, rather than in conventional language.
In each situation described here, a patient was violent, aggressive, withdrawn, bizarre, or unready or unwilling for other reasons to participate in formal talk-based therapies or group programs. An activity was developed. It called for many of the traditional nursing competencies – caring, compassion, composure, patience, perseverance, and so on. But it contained little in the way of conventional therapeutic language and format. Words of encouragement were not spoken. Absent were the usual overt offers of empathy or support, the acknowledgment and the validation, the praises for good effort. Feelings were neither identified nor talked about, and conscious insight was not a goal for the patients. There was no specific care plan and no list of objectives read off from a psychiatric diagnosis. Rather, the aim was simple engagement, and the activity looked more like a game than like conventional psychiatric nursing.
Appearing to be game-like or play-like, however, did not make the activity frivolous or unserious. On the contrary, each of the interventions described in this book was structured in a specific and deliberate way. It linked to something personally significant to the patient – casting in the structure of its gestures and motions a theme the patient seemed to be holding inside. It invited the patient to encounter an idea in a wordless, sensory vocabulary that was familiar and non-threatening. But it provided the nurse, at the same time, with a means to point to new directions for feeling and thought. Straddling what is private in one person and what could be shared in common with another, the activity set in motion, between patient and nurse, a simple organizing image, a metaphor, which enabled the patient to begin experiencing a problem in a new way and to create what philosopher Paul Ricoeur has called new “frameworks of connection” (Ricoeur, 1977).
By reconfiguring the stream of sensory and mental experience, even in a small way, the games and activities described here effected a shift in what philosophers and psychoanalysts, after Freud, have sometimes called the “representability” or “figurability” of an idea (Castoriades, 2007; Botella & Botella, 2005, 2013). At a time in a patient’s life when he or she is unable to articulate or give voice to complex feelings or needs, this approach offers the ultra-gentle nudge of a transitional dialect, an initiation into language – without quite being language itself. It begins the process of tearing what might be say-able from what has not been said previously.
Let us review what happened in each of the examples offered here. With Sara, games and activities were developed which suggested in multiple small but repeating ways the separation of inside from outside. These activities “spoke” to her, without words, about borders and boundaries. With Joe, a listening game activated themes of space and place, suggesting that a sense of enveloping safety and belonging is attainable and might be built by multiple means. With Donald, our activities played on themes of yearning for entry and exit, of wanting to take in and break out – allowing him to have these as a mental experience before mastering a language for expressing them in words. With Valerie, we developed activities which provided an external, concrete structure, a vocabulary of shape and form which substituted for conventional words but pointed to the possibility of narrative-making. With Aaron, finally, our activities engaged themes of order, rhythm, and reciprocity; they were a way of reminding him about something he was missing.
In none of the encounters described here did the patient need to verbalize conscious understanding. There was no discussion about the mental associations which may or may not have been triggered during the course of engaging in the activity or game, about the movement of meanings across sensory modalities, or even about the feeling of having been cared for. Might we have talked to Donald directly, for example, about his yearning to break free from confinement? Or sat down with Sara to consider, together, her struggles with objects that had perforated her bowels? Of course not. Such conversations would have led nowhere. They might actually have been damaging, since the patients showed clearly that they were not ready for talk of this type. Rather, in each case, the behavioral response itself was the measure of the activity’s effectiveness. We saw, in Aaron, the calming effect of rigorously ordered music, and in Joe, a dawning sense of comfort and belonging, the feeling of being surrounded by a personal space. We saw, in Donald, the cessation of violence and a new willingness to engage with clinical programming. In Sara, we could measure a reduction in self-harming behaviors, as with Valerie we witnessed a remarkable narrative emergence. In none of these situations, however, did we need to talk to the patients directly about what was happening. Writer Albert Rothenberg has noted that to try describing a metaphor in literal terms is to strip it of some of its power, deprive it of some of its vitality (Rothenberg, 1988). So, too, for the kind of play involved in a gestural bridge.
Gestural bridging harnesses the imaginative tools associated more often with poets and artists than with conventional nursing-care planning and understandings of patient care needs. It represents a form of aesthetically grounded therapeutic communication which has links to play therapy with children and with some of the themes which figure centrally in psychoanalytic approaches to treatment. For the most part, our professional has relegated poetry and art to the periphery – cast these as decorative and enriching, good for patients and perhaps an aspect of professional self-care – but not really central to our everyday professional work. The approach described here, on the contrary, restores the aesthetic to a central place in nursing.
In Listening to Patients, their book on phenomenological approaches to patient care, Thomas and Pollio (2002) suggest that thoughtful nursing grows not out of pre-conceived and computer-printable care plans but, rather, from an attunement to individual subjectivity and personal meanings in the patient’s experience of illness. There have been multiple calls in recent years for a revival of the “aesthetic” in nursing practice – for creative approaches rooted in the “embodied experience” of nursing in real situations (Chinn & Kramer, 2014; Chinn & Watson, 1994; Hartrick, 2002; Hartrick Doane and Varcoe, 2013). Kagan, Smith, and Chinn (2014), along these lines, have emphasized the importance of commitment to the liberation of personal agency in the nurse–patient encounter. Gestural bridging is a metaphoric process of therapeutic communication which exemplifies these ideals as it connects psychiatric nursing to some of the foundational principles of other psychotherapeutic disciplines.
Nurses are particularly suited to developing interventions of this type because of our rich and unique access to patients. We spend more time with patients than do any other kind of clinician, which means we have more of a chance to get to know them – provided we make the most of it. We see patients in everyday situations rather than in scheduled “sessions,” which means we develop an intimate understanding of their personal habits, rhythms, and responses in “real time.” We engage with their bodies directly, in ways that bring us information unavailable to others in the clinical setting. For the most part, we are not bound to manualized treatment protocols and are free to respond to patients as situations and context demand. We could and should be making far better use of this special access to knowledge than is currently the norm.
Advocacy in a changing policy context
We are living in an era of fiscal restraint and widespread public- and private-sector downsizing. Policymakers and healthcare administrators promise a commitment to patient recovery and to high-quality mental healthcare. But cost-cutting measures continue to result in significant adverse changes in the staffing and task structures of many psychiatric treatment settings, eroding clinicians’ capacity to do the intensive, collaborative, interdisciplinary work that professional duty demands and that patients deserve. In both the public and the private sectors, we see almost the same story: as a result of these changes, it is becoming increasingly difficult for nurses to do the kind of creative, thoughtful nursing we want and are trained to do. In this context, our future is bound with that of our patients. Advocating for them – for the most vulnerable, the most challenging and, often, the most publicly despised – we advocate for our own professional integrity and capacity. It is incumbent on us to take up this effort – to work for a robust, adequately financed, appropriately staffed and integrated system of care that ensures patients’ access to creative and thoughtful treatment and maximizes their chances of getting out – and staying out – of restrictive institutional settings. I can only hope that this book contributes to making a case in that area.
If you are a nursing student or a new psychiatric nurse, you most likely have not realized yet the full scope of the personal and professional challenges you will face on the job. Little in your training can prepare you for the disturbing, often heart-rending, and sometimes frightening situations you will encounter, or for the complexities and frustrations of interdisciplinary clinical work. Under immense strain, you’ll have to maintain a commitment to unwavering civility and intellectual curiosity and an attitude of utmost respect for your patients and their capacity and creativity. Apply yourself to this challenge.
References
Botella, C. & Botella, S. (2005). The work of psychic figurability: Mental states without representation. New York, NY: Routledge.
Botella, C., & Botella, S. (2013). Psychic figurability and unrepresented states. In H. Levine, G. Reed, & D. Scarfone (Eds.), Unrepresented states and the construction of meaning: Clinical and theoretical contributions (pp. 95–121). London: Karnac.
Castoriades, C. (2007). Figures of the thinkable. Stanford, CA: Stanford University Press.
Chinn, P., & Kramer, M. (2014). Knowledge development in nursing: Theory and process (9th ed.). New York, NY: Elsevier Mosby.
Chinn, P. & Watson, J. (Eds.). (1994). Art and aesthetics in nursing. New York, NY: National League for Nursing.
Hartrick, G. (2002). Transcending the limits of method: cultivating creativity in nursing. Research and Theory for Nursing Practice 16(1), 53–62.
Hartrick Doane, G. & Varcoe, C. (2013). How to nurse: Relational inquiry with individuals and family in changing health and healthcare contexts. New York, NY: Wolters Kluwer.
Kagan, P.N., Smith, M.C., & Chinn, P.L. (2014). Philosophies and practices of emancipatory nursing: Social justice as praxis. New York, NY: Routledge: Taylor & Francis.
Lakoff, G. & Johnson, M. (1999). Philosophy in the flesh: The embodied mind and its challenge to Western thought. New York, NY: Basic Books.
Ricoeur, P. (2012). The rule of metaphor: Multidisciplinary studies of the creation of meaning in language. Toronto, Ont.: University of Toronto Press.
Rothenberg, A. (1988). The creative process of psychotherapy. New York, NY: W.W. Norton.
Thomas, S.P., & Pollio, H.R. (2002). Listening to patients: A phenomenological approach to nursing research and practice. New York, NY: Springer.
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