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.

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?

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.”

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.

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.

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.

All the more so in psychiatric nursing, where our patients’ mysterious, sometimes disturbing gestures and psychotic delusions challenge us to reach into the deepest inner dictionaries of connectivity and understanding. To pay attention to these, to be open to meanings embodied even in bizarre presentations, is to call upon Freud’s groundbreaking articulation, more than a century ago, of the human capacity for an understanding which is at once generous and intellectually rigorous (Birnbaum, 2015).

Paul Ricoeur, the French philosopher of language who wrote extensively about psychiatric illness and psychotherapy, suggested that to work with the mentally ill, fundamentally, is to reintroduce into the linguistic community those who have been excommunicated from it (Ricoeur, 2012). This book claims for nurses a key role in achieving that re-introduction – deploying a specific kind of technique at a particular moment in the clinical process.

How might we describe the nursing interventions deployed in the encounter with Sara? They were empathic and generous, as any nursing interventions should be. But our games and playful activities with her – the call-and-response-style pointing and identifying, the floor-sweeping and surface-wiping, the naming and dancing, and so on – cannot be classified wholly as therapeutic communication in the way nurses generally understand it. There were no uniquely identifiable listening techniques, no set of structured responses, no interactive verbal scripts demonstrating emotional availability, validation, or compassionate presence in the moment. Our intentions were not conveyed by posture, tone, or facial expression. We gave no praise, offered no words of encouragement or reassurance. Nobody talked about their feelings. Nor could our encounters be classified in the same category as talk-based psychotherapy, with its long-range goal of promoting durable insight and conscious self-awareness.

Gestural bridges are sensory-based play activities which cast psychological ideas in an analogic physical form. They deploy metaphor as a bridge that facilitates initial contact with a patient’s private themes before conventional language is available to characterize and convey them. Gestural bridging provides tools that support a patient to order and organize some of the problematic elements which remain private, unnamed, and untamed in his or her felt world – to create a representation for some of his or her internal ideas. Without conventional speech, it builds a shared space of contact and meaning exchange between patient and nurse. Inviting the patient into an indirect kind of conversation – what cognitive linguists have sometimes called a “conceptual metaphor,” (Fauconnier & Turner, 2002; Lakoff & Johnson, 1999) – it creates conditions for movement forward into treatment alliance.

It is the goal of this book to describe the gestural bridge in a way that makes it accessible and understandable for mental health clinicians, particularly nurses, who work with very challenging and persistently ill patients who have not responded to conventional treatment approaches. In subsequent chapters, I discuss the philosophical and developmental underpinnings of this technique and illustrate its use with examples drawn from a variety of care settings.