Gestural bridge activities – the metaphoric representations which I have described in this book – are a form of communication which begins not with prior assumptions about the care or compassion our patients might need, or with ready-made manuals about “correct” methods for displaying them. Rather, the activities described here emerge from a far more complex source – a unity of reason and imagination, feeling and thought – which philosopher Mark Johnson has called “imaginative rationality” (Johnson, 1987) and which many writers in the psychoanalytic tradition have long identified as a core of creative therapeutic work (Arieti, 1976; Borbely, 2008; Modell, 2003; Rothenberg, 1988). Elliot Eisner, a painter who became one of the leading educational theorists of the last century, noted that literacy comes in many shapes and sizes; to support someone to become literate means to grow the capacity to encode and decode meanings constructed across the great variety of forms which humans use to represent the contents of our consciousness (Eisner, 1996). A related claim might be made for nursing: it involves a multiplicity of literacies, some of them having to do with cultivating imagination and metaphorical reasoning as a means for exploring and evaluating new possibilities for patients.

What lessons might be harbored in the stories here regarding the ways we are educated to be professional nurses, the ways we sensitize our ears to patients’ voices and learn to reach inside ourselves for connections and associations not previously articulated? How might nurses promote this more “poetic” mode of understanding (Gibbs, 1994) so that it can be brought more consistently to bedside practice? I suggest, in this chapter, a few general principles. These are not so much about skills or specific knowledge content as about overall orientation and disposition. They are a way of looking at things.

At the point of Wendy’s re-hospitalizations, nurses would get saddled with the order to wash her – by force if necessary. Anyone who has bathed a homeless, incontinent, and grossly psychotic patient knows well the hazards. Combative resistance in a slippery, wet room can be frightening and dangerous both for the patient and for the nurse. But to get into a shower room with Wendy was to realize the principle which Florence Nightingale, in her 1859 classic Notes on Nursing (Nightingale, 1859), placed at the core of our profession: that the body itself is the source of understanding and communication, the ultimate repository for every way we know and tell. Wendy wailed like a banshee about Nazi gas chambers, rendering achingly clear, as I restrained her, the degree to which she was living the suffering of her concentration-camp-survivor parents. Her rage at my offers of fresh clothing and a diaper (“Don’t waste a new one, you stupid cunt!”) cast into high relief her punishing self-explorations about the nature of entitlement and waste in a world of suffering and deprivation – the question of how much might be too much for one person to ask. Wendy raised her fists to punch me when I offered to clean and trim her fingernails, as she swore she had been using them as can openers. An obviously delusional statement on its surface, it gave poignant reflection to the quandary she had posited between her own body and the rest of the world: what does it mean to survive and “make do” in a place where resources are scarce, where there is cruelty and absence and want?

At the advanced level, psychiatric nursing increasingly consists of practices divorced from body experience: we dispense prescriptions for psychotropic medications to be administered by others, we take seminars in leadership and management and pile certifications alongside our titles. At the level of the floor-duty nurse, meanwhile, staffing shortages and burgeoning documentation and paperwork demands mean that physical care tasks – once the nurse’s domain – fall, increasingly, to nursing assistants and support technicians. This is moving our profession in the wrong direction – away from the direct relational work at the core of good nursing.

Which brings us to the second principle – about taking seriously the potential meaning-content of patients’ bodily gestures and behaviors, encountering respectfully and not dismissively the great diversity of narrative forms in which people might be telling stories.

Norton, my patient, rolled on the ground in a bizarre, grotesquely disturbing manner – a perverse choreography of slow-motion contortions. He crawled, coiled, twisted. His taut, trim body had the persistence of a wind-up toy: finding himself in a corner, he’d switch direction. This behavior made him an easy target for other patients’ frustrations and anger – a temptation made all the worse by his mumbling in a gibberish nobody understood. We nurses did our best to keep him clean and fed. We monitored for bruises and exhausted all means to engage him to sit still, especially when visitors or inspectors came, as his ridiculous prone displays made it seem we were neglectful. There had been months of medication trials and evaluations by neurologists and specialists in catatonia and other extreme schizophrenia manifestations. Still, he crawled like a snake on the floor.

Kevin was about the same age as Norton; they’d known each other for years. This is an interesting fact about psychiatric care: inpatient and outpatient programs and facilities, short-term and long-term, voluntary and forced, public and private, are organized geographically into a regional system of care, so cohorts of chronically and persistently ill patients often run into one another repeatedly across multiple settings over periods of time. A social history evolves between them which transcends any specific episode of treatment or institutionalization. Kevin approached me angrily one evening as I struggled to coax Norton out of a puddle of chicken in which he was twisting on the dining-area floor.

“I myself had felt the darkness of the soul. I myself was drowned in the depths of the sea. I myself was like the worm and the snake, without the strength to walk and the breath to speak.”

“Okay,” I said. “What’s up?”

“Don’t you know what he’s saying to you?” Kevin hissed, pointing to his old acquaintance in the puddle. “Just look at his shoulders! Look at how they squeeze together! Can’t you see he’s squeezing his heart? Can’t you see he’s showing you how much it hurts?”

I looked at Norton. His shoulders indeed were squeezing. And then I looked back at Kevin. “Blind you are,” Kevin said, “and blind you shall be.” And I could see that, in a certain way, he might have been right, not necessarily in his specific interpretation of Norton’s communications, but in the generosity and plain reasonableness of his noting the possibility of meaningfulness.

The narratives of the world are numberless, wrote the French semiotician Roland Barthes (1977). In languages spoken or written, in images fixed or moving, in gestures, motions, myths and legends, in movies and theater performances, in paintings and stained-glass windows, in complex orchestral compositions and in the simplest, most plaintive ancient melodies – in every age, in every place, in every society, there is no people without the impulse to tell. So plentiful are the forms of narrative, Barthes wrote, it is as though almost “any material were fit to receive man’s stories” (Barthes, 1977, p. 79). And so it is for our patients. Their meanings are not limited to what words can express. They speak to us in a multiplicity of ways, some more readily accessible than others, some stunning in their grotesqueness, some perhaps disgusting or acutely disturbing. But each needing and deserving of our attention and engagement.

To become a psychiatric nurse means to embrace this perplexing diversity of forms and to listen, respectfully, to what might be harbored there. Instead of hurrying to contain a patient’s bizarre presentations – packaging violence, or aggressive preaching, or foreign-body ingestion, for example, in boxes labeled “symptoms” or “behaviors” needing merely to be managed – this approach calls us to engage these presentations as actual ideas, as the suggestions of a story that wants to rise to the surface of tell-ability. It is normal and natural, of course, to find some behaviors frightening and some stories appalling and deeply disquieting. But if we subject our emotional responses to the scrutiny of thoughtful reflection, they may become, potentially, a source of knowledge, discovery, and richer, more respectful understanding.

Nursing culture is a culture of efficiency. We pride ourselves on being “goal-directed” and “solution-focused.” On action plans that strive toward specified aims. We identify a problem, list its operational objectives, execute plan elements, and document the achievements or failures to achieve stated aims, and so on. Knowing in advance what exactly we’re aiming for, we are able to check our work. This is the kind of logic than enables self-assessment and high standards. It is the basis for accountability. But gestural bridging calls for a slightly different kind of logic. It is a logic of letting go. It asks not only that we strive toward a specified aim, but also – every so often – that we refrain from striving. This is the third principle embodied in the interventions described here: that we allow the mind to venture and stray sometimes from the instrumental logic of objectives-based planning and thinking.

Looking back at the story about Sara, we might remember that our approach did not start with a psychiatric diagnosis and follow down a list of associated goals and measurable objectives, as nursing interventions generally and rightfully do. Rather, it began with a simple turn of phrase – overheard in an ordinary conversation during wound dressing. In the small answer to a small question about where a swallowed item had lodged, we stumbled, suddenly and unexpectedly, on the suggestion of an inner configuration of thought. A door opened into consciousness. And from that small gateway, we were able to imagine a new form of interpersonal contact.

Some information sits for years at the margins of self-awareness. But it isn’t lost. We’ve all had the experience of an image popping up suddenly, a sense that dawns all at once. Passing someone in a hallway, for example, calls up the resonating awareness of tobacco smell on an old friend’s breath. Hearing a melody emanating from a passing car, we summon the face of an old school classmate who sang so beautifully on the park bench under the corner oak. These are not necessarily mere passing sensations. Rather, in some cases, they are amenable to be put to use. None of the ideas in this book could have been derived from a diagnostic manual or followed logically from conventional nursing-care objectives. Rather, they were generated by reference and association, by the wandering of meanings in the body.

To linger inside an idea is to allow ourselves to feel for its echoes, to note the contours it evokes in our own pool of memory and thought. This mode of arriving at an intervention is not the traditional professional mode of the nurse, though it is well known in art and, of course, in psychoanalysis, where transference and counter-transference are regarded as a primary source of information and treatment is expected to require an investment of utmost patience over periods of many years. To be open to the more distant sources of understanding is to access and make available, in our work, more of ourselves than is required by conventional approaches to therapeutic communication. It is to behave as the artist behaves – and to respond as the artist responds to the pulls and tugs of symbol and suggestion. It is to harness what has sometimes been called an aesthetic attitude – an innate human capacity, as I have argued here, inscribed in our earliest engagement in play and communication.

All of us, from time to time, experience a sudden flip in our perceptions of things – a flash moment, so to speak, that shifts our vision and generates connections between elements which become, forever onward, inseparable in our minds. Here was the ordinary and familiar thing – the game of sorting cards into grid-like configurations of columns and rows – sparking the shock of recognition, the moment of singular coherence when diverse aspects of understanding coalesce into a resolute whole, binding themselves by the instrument of an effective metaphor. So it is for the insights which come to us about our patients. They arrive, at times, with a sudden and bracing simplicity.

Professional training and credentials give order and discipline to our thinking. But they can’t make us good nurses. Care plans are important, since practices grounded in reasoned judgment have a greater chance of hitting the mark than choices made hastily and without evidence or previous trial. But they don’t offer much guidance in our struggles with patients who have not responded to conventional treatments. An ideological commitment to caring is also important, as our work would be impossible without it. And it is crucial, of course, to understand the treatment norms connected to specific diagnoses, since interventions randomly targeted are pointless and, worse, potentially harmful. But, as the stories in this book illustrate, some of what nurses know derives not from any of these, but, rather, from an everyday capacity for imagination to meander across the sense modalities and wait for a moment when pieces might fall into place.

This is the “vision” which enables the blind, figuratively, to see, and the parent to sense naturally how to speak, in the gestural language of a warm embrace, to her infant’s outstretched arms. It is the fundamental ability of thought to make itself felt, to announce its presence across the face of the body. It is the same innate human proclivity which transformed sounds, for Joe, into the sensation of physical boundaries, and dollhouse furniture, for Valerie, into spoken words. It forms the metaphoric basis of literature and art, as we have seen previously.

Which brings us to the fifth principle: that the body itself is an instrument not only of feeling but of thought. It is a source of judgment. This is something we grasp tacitly – as when, faced with a choice, we ask “what does your gut say?” or, confronting a decision, we assess that “it feels right” or “seems like a good fit.” This is a concept well known in the arts. The creation of a poem, a painting, or a melody depends upon the artist’s ability to attend to highly nuanced qualitative relationships in a medium, as Elliot Eisner has written (2002). In music, the medium is sound; in the visual arts, it is form; in dance, it is movement. And so on. The artist working in each of these media must attend to properties and potentials specific to that medium and to the work as it unfolds, making moment-by-moment judgments by consulting somatic experience, asking “how does this image feel now, at this moment?” “Does it hang together?” “Does it satisfy?” These questions do not yield to recipe and algorithm, as Eisner has suggested. They are questions only the body can answer.

Which brings us to the sixth core principle: about the interplay of feeling and thinking – of impulse and restraint. My patient Clement had recently been moved to a supervised apartment. The expansion of community placement options such as this answers decades of earlier failed attempts to deinstitutionalize the chronically mentally ill. I felt a sense of moral duty, both to Clement and to the reform movement his apartment represented. I wanted this to work. I wanted Clement to have independence and autonomy, to secure the same freedoms and rights for himself, despite his illness, as are expected for everyone else. So, every two weeks, as part of an outreach team, I checked on him – delivering his oral medications, administering his decanoate injections, ferrying him to the grocery store, and inspecting his cabinets and countertops for evidence of any relapse into heroin and alcohol. But every time I looked, the pantry was bare. Not a crumb to be seen.

I had taught Clement to make a budget, to list healthy foods and find them on the supermarket shelves, to switch the stove on and off, to wash dishes with soap, to order grocery delivery, and so on. But the dumpster at the back of the nearby Panda Wok restaurant remained, despite all my work, his primary source of food. I felt awful. I stepped up the frequency of my visits. I reassured him about my caring presence and availability. I promised persistence and began routinely checking his weight and vital signs and asking about nausea, vomiting, and breaks in the skin. I bought him fruit-and-vegetable smoothies, which weren’t cheap, hoping to inspire some interest in alternatives to greasy Chinese food. I feared he might succumb to food poisoning, develop hypertension, cut himself on broken glass or, worse, be bitten by a rat. But nothing changed, the weeks passed, and I escalated into an alarm state as I documented in my progress notes the ongoing reiteration of life-skills teaching.

This is the sixth lesson: that empathy calls out for accuracy, feeling calls out for thinking. Warmth, compassion, and perseverance, the traditional nursing values, are a source of pride for our profession, and emotional connection is a key to good nursing. But the impulse to feel strongly and the desire to act compassionately call out, as well, for the taming discipline of reason and thoughtful reflection, for a commitment to restraint and precise targeting in the kind of care we perceive our patients to need. The approach described here asks that we take responsibility not just to give care, but also to take care. That is, to be careful – and to make sure that our feelings of concern, forceful though they might be, do not become possessive or territorial – do not obliterate the patient’s world of ideas by folding it into our own professional narrative about nursing empathy and love.

Nursing theory, in general, tends to claim far-reaching results for our work, and much of our professional literature describes what are taken to be fundamental and sweeping life changes in patients following relatively brief interpersonal encounters (Birnbaum, 2015). These claims no doubt hold true in many cases, and most of us can describe personal experiences which seem to bear them out. But they project, as well, our own deeply held desires to derive meaning from our work, feel efficacious in the face of human suffering, and claim a place for ourselves among the clinical disciplines. More realistically, as the stories here demonstrate, nurses might claim for ourselves something perhaps less grand but nonetheless crucial for our patients and for the work of our clinical teams. Bridging interventions are a unique nursing contribution not because they are the whole of treatment, transformative or curative in and of themselves, or because they are the end of treatment, solving a problem once and for all, but, rather, because they unlock a door – they open a transitional space in which patients can begin communicating with others. They enable other forms of therapeutically rich relationships to be launched.

Many of the clinical relationships which benefitted our patients were enabled to begin, in large part, as a direct result of the initial “bridging” work which nurses performed and which transitioned the patient into readiness for treatment. In this sense, “bridging” acknowledges that nursing, however unique in what it offers and contributes, is bound in a tight and mutually nurturing symbiosis with the work of other clinical disciplines. We tend to forget this sometimes, and collaborative teamwork, with some exceptions, is not yet built into the curriculum of most programs where nurses are trained.