PSYCHOLOGICAL PROBLEMS OF PHYSICALLY ILL PERSONS
Patrice E. Rancour
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Describe how mental and physical health are interrelated
2. Define suffering
3. Identify the key concepts of suffering
4. Explain how compassion fatigue can impact the nurse
5. Describe and apply mental health care concepts to physically ill patient populations
6. Demonstrate understanding of the nurse’s role in addressing end-of-life issues
7. Describe the role of the mental health liaison/consultation nurse
8. Apply the nursing process from an interpersonal perspective to a physically ill patient with mental health issues
Complementary and integrative therapies
Critical incident debriefing
All nursing practice is predicated on viewing the whole of a person as a mental/physical/spiritual unity. Providing care to a patient whose primary diagnosis is a physical illness would be incomplete without attending to the mental, emotional, and spiritual experiences captured within that illness experience. In fact, many physical illnesses offer the patient an opportunity to heal far beyond the merely physical. And this opportunity exists at the crossroads of where therapeutically conscious nurses meet their patients.
Consider this statement: “Every nurse is a mental health nurse.” In every interaction that nurses have with patients who are experiencing physical illness, whether in the home or inpatient or outpatient medical–surgical settings, the nurse must care for the whole person by also rendering competent mental health care. Doing so can often make the difference between successful or unsuccessful outcomes for the patient and his or her family.
This chapter addresses the concept of suffering as it relates to the therapeutic use of self and its impact on the nurse. It describes the most common issues that affect the mental health of physically ill patients, end-of-life care, and the role of the mental health liaison/consultation nurse. It concludes by applying the nursing process from an interpersonal perspective to promote the mental health of patients with physical illness.
SUFFERING AND THE THERAPEUTIC USE OF SELF
SUFFERING is often defined as the experience of distress or pain, which can be emotional, mental, spiritual, or physical. It is often synonymous with words such as agony, torment, and torture. Several theorists have addressed this concept as it relates to mental health.
Theoretical Views of Suffering
Recall from Chapter 2 that suffering is a key concept identified by Joyce Travelbee’s interpersonal theory of nursing. Travelbee built her theory on the works of existentialists including Viktor Frankl, noting that his work, Man’s Search for Meaning (Frankl, 1959), played a significant role in the development of her own theory. Frankl believed that in a world over which humans have little control, the way a person chooses to respond to his or her experience determines whether and how that person survives and/or thrives. These beliefs were the result of his observations while being incarcerated in a World War II concentration camp. He noticed that some of the prisoners lived while others did not, although camp conditions were the same for all of them.
Travelbee’s definition addresses suffering as ranging from simple mental, physical, or spiritual discomfort to extreme anguish. She also describes phases beyond anguish, which include the malignant phase of despairful not caring, and a terminal phase of apathetic indifference (Travelbee, 1971). Travelbee insisted that suffering is a key element in the exploration of illness. Therefore, suffering can be addressed within the scope of the nurse–patient relationship through therapeutic communication. (See Chapter 2 for a more in-depth discussion of Travelbee’s theory on suffering.)
According to Travelbee, suffering can be explored within the nurse–patient relationship.
These concepts were further expanded by Shinoda Bolen, a physician who practices Jungian psychology (Shinoda Bolen, 1996). This school of thought emphasizes the individual psyche and the quest for wholeness through the uses of symbolism, archetypes, and spiritual principles. Shinoda Bolen built on these concepts by contending that illness can often be experienced as an archetypal descent into the underworld. She likened common occurrences such as receiving a life-threatening diagnosis or passing through the threshold of the treatment center (e.g., hospital entrance, etc.) to being ferried across the River Styx. Once the patient’s needs during the healing journey are met, and teachings are received, the patient’s identity is then transformed (healed) and the patient returns to his or her community.
Frequently, nurses are witnesses at the crossroads of such experiences. Thus, nurses can employ the therapeutic use of self to suggest ways so that the patient can reframe these periods of physical suffering into opportunities for expansion. When this happens, patients are better able to bear the burdens of such suffering because they are being assisted to find meaning in experiences that otherwise would be experienced as futile, mundane, or merely banal (Rancour, 2008c).
Another psychotherapist, Miriam Goodman, suggests one can transform suffering by attending to it and, as a result, grow in compassion with others:
we carry this mistaken belief that enlightenment means we do not suffer anymore. But it is possible to suffer with a calm, loving heart. These two are not mutually exclusive. Enlightenment for me is about growing in compassion, and compassion means “suffering with.” Enlightenment has something to do with not running from our own pain or the pain of others. When we don’t turn away from pain, we open our hearts and are more able to connect to the best part of ourselves and others—because every human being knows pain. (Platek, 2008)
Goodman’s view suggests that nurses work on their own healing by refusing to turn away from the pain of others; that nurses recognize their call to service as the way they have decided to manifest their own purpose in the world.
Unless nurses have a relationship basis for their practice, what Travelbee calls “the therapeutic use of self,” it is fairly easy to medicalize normal human experiences such as birth, illness, and death, and the subsequent pain and suffering that accompany them. When this occurs, the humanity of the experience and the potential for healing by transformation and self-actualization can be lost. Compassion as the essential human trait becomes replaced with pharmacology and the starkness of procedure. Vigilance toward making one’s own self a therapeutic tool is often one’s best defense in a world that too often depends on technology alone to save individuals from the inevitability of the human condition.
Adopting such a perspective encourages the patient and the nurse to seek meaning in traditionally painful experiences such as illness, thereby helping each bear the ordeal of the patient’s suffering. Within the context of the relationship, the patient is not only able to survive, but to thrive as well.
Suffering and Its Impact on Nurses
It would be an error in judgment to believe that nurses are not affected by the suffering of their patients. Providing care to people who are ill and in pain challenges nurses to be mindful of their own mental health and the mental health of their colleagues. The provision of mental health care is especially challenging because one needs to remain vigilant for the unconscious tendency to allow tasks and procedures to distract and distance one’s self from the suffering of those for whom one cares. The very nature of the therapeutic use of self transports the nurse directly into the very heart of suffering so that its effect on the caregiver becomes inescapable (Pendry, 2007).
Nurses need to understand that COMPASSION FATIGUE, and its cousin, burnout, may interfere with caring, and is an occupational hazard that does not constitute a character defect. When nurses begin to exhibit symptoms of such occupational stress or recognize it in others, a rapid response is necessary to help the nurse achieve rebalance. Such symptoms can include reduced ability to concentrate, preoccupation with traumatic patient experiences, rigidity, powerlessness, guilt, anger, shock, depression, insomnia, nightmares, irritability, social isolation, appetite disturbances, despair, hopelessness, frequent bouts of physical illness, headaches, gastrointestinal problems, and other stress-related symptoms (Boyle, 2011). These symptoms can be escalated when nurses work in environments that do not address moral dilemmas (usually end-of-life scenarios that nurses may find morally compromising), and can also intensify into lateral violence against one another. This occurs when nurses feel powerless to control their own scope of practice within an organization and, without recourse, begin to redirect their anger toward one another.
CRITICAL INCIDENT DEBRIEFING is a structured response to compassion fatigue whereby trained staff assist nurses to express and process feelings in a structured way after particularly stressful patient contacts. Such sessions can help nurses acknowledge the special nature of the work in which they are engaged and to regain balance. Reaching for balance also includes ensuring that nurses are eating healthy foods, getting rest and exercise, and making sure that other parts of their lives are also in balance.
Developing such self-awareness helps the nurse identify the physical, emotional, and spiritual needs that he or she has, and to give oneself permission to get these legitimate needs met. Box 20-1 lists questions to assess compassion fatigue and ways to intervene. Doing so frees the nurse to participate in the dynamics of a therapeutic relationship more fully with the patient. When one loses the connection to the meaning of one’s work, one loses the energy to accomplish it.
Healing is a very complex process that occurs within the framework of the relationship and is affected by multiple variables, many of which exist outside of the nurse’s control or awareness. As the relationship includes the nurse, the nurse needs to pay attention to his or her own needs for the relationship to remain therapeutic. For example, if the nurse is tired, frustrated, defensive, angry, anxious, or sad, and is not aware of these feelings, the likelihood is high that such feelings will be acted out within the context of the nurse–patient relationship rather than being worked through properly. When this happens, the nurse is unable to accurately perceive what the patient needs and how to meet those needs. As a result, the nurse is in danger of meeting his or her own needs at the expense of the patient. Debriefing with a colleague can provide support, feedback, and insight.
Within the context of the therapeutic relationship itself, experienced nurses understand the value of simultaneously moving in close and letting go. In other words, seasoned nurses understand how to stay attached to the process of providing care (under their control) and to let go of the need to control the outcome (not under their control). The experienced nurse does not allow feelings for the patient to undermine expert clinical judgment, but always reviews his or her own reactions to the patient, and uses that knowledge to monitor for counter-transference, which can interfere with quality patient care.
BOX 20-1: COMPASSION FATIGUE: ASSESSMENT AND INTERVENTION
• What physical, mental, emotional, social, and spiritual signs and symptoms of compassion fatigue do I most commonly exhibit when I am distressed?
• Who/what has helped me in the past to prevent such compassion fatigue?
• Who/what has helped me in the past to heal such compassion fatigue once it presents?
• Are there any new beliefs or practices that could help me prevent or heal compassion fatigue?
• Adopt healthy lifestyle behaviors to ensure that I can successfully inoculate myself against stress in general (healthy nutrition, exercise, social support, sleep hygiene, etc.).
• Once compassion fatigue is identified, get help as soon as possible from identified resources.
• Reach out to colleagues who exhibit signs and symptoms of compassion fatigue and recognize this as a part of legitimate mental health care rendered in the work environment.
Compassion fatigue can make colleagues vulnerable to burnout as well. Responding to the emotional exhaustion of co-workers in compassionate ways helps to forge strong interdisciplinary teams. According to the Quality and Safety Education for Nurses (QSEN) project, this is an example of a knowledge base, attitude, and skill set which is a prerequisite to delivering safe care as part of a health care team (QSEN project, 2015).
The therapeutic use of self places nurses at risk of compassion fatigue because they are directly involved in the patient’s experience of suffering.
SPECIAL ISSUES RELATED TO MENTAL HEALTH AND PHYSICAL ILLNESS
Nurses are routinely involved in procedural interventions such as collecting vital signs, administering medications, and performing treatments for individuals with physical illness. In addition, nurses also continually assess the mental health of their patients by regularly assessing patient orientation, comprehension, memory, cognition, mood, and reasoning judgment. These areas are vital, for example, when determining potential cognitive dysfunction related to prescribed therapies or the capacity for informed consent. However, assessing a physically ill patient’s mental health is additionally important because stress, loss, changes in body image, or pain can impact the patient’s physical status as well as place the patient at risk of developing depression, anxiety, or delirium, the most common mental health comorbidities of physical illness.
Impact of Stress
Just as patients with schizophrenia and bipolar disease present with physical illnesses, numerous patients without identifiable mental health disorders must contend with mental health distress that occurs during the course of their physical illness. This distress may be secondary to the physical illness itself. Additionally, it may be the result of the hospitalization and treatments required. As much as 75% to 90% of all visits to primary care providers are due to stress-mediated causes (American Institute of Stress, 2015). The role of prolonged exposure to unremitting stress is implicated in the inflammatory responses associated with many chronic diseases. As such, teaching patients stress management skills to promote resilience is well within the scope of nursing practice.
Adverse Childhood Events and Stress
The impact of mental health on physical health has been identified in numerous research studies. One research study, known as the Adverse Childhood Experiences (ACE) study (www.cdc.gov/violenceprevention/acestudy/pyramid.html), demonstrates this strong relationship. This research addresses the relationship between ACE and adult health (Anda et al., 2006). It documents that unhealthy adult lifestyle behaviors, such as tobacco use, alcoholism, poor nutritional choices, sedentary lifestyles, and stress, contribute to at least 50% of all morbidity and mortality in this country. According to the study, these lifestyle behaviors may actually originate as behaviors designed to reduce stress in people who, as children, were victims of sexual, physical, or emotional abuse.
Stress, when not addressed in childhood, results in poor stress management and lifestyle choices later in life. Such stress and unhealthy behavioral choices then contribute to the development of chronic illnesses. These chronic illnesses then increase the likelihood of increasing inflammation and subsequent psychosocial distress, setting up recurring feedback loops. Developmentally throughout the life span, nurses are in excellent positions to intervene in such cycles and to interrupt the cascade effect they can produce.
Consider the popular truism: “While genetics loads the gun, lifestyle choices pull the trigger.” Thus, for example, focusing exclusively on calorie counts with morbidly obese individuals who cannot seem to shed their weight, or tobacco users who cannot seem to stop smoking, lacks the more holistic approach needed to address such public health problems.
Adverse childhood events have been shown to lead to unhealthy lifestyle behaviors that contribute to the development of chronic diseases later in adulthood.
Mind–Body Interactions and Stress
Stress is well known to be directly linked to many chronic illnesses prevalent today and is often considered the primary cause of many illnesses (Cohen, Janicki-Deverts, & Miller, 2007). Chronic stress can trigger insulin-resistance diseases such as diabetes, autoimmune diseases such as asthma, and cancers due to unremitting immunosuppression resulting from perpetually high circulating cortisol levels. Such relentlessly high cortisol levels contribute to chronic inflammation in the body (Kiecolt-Glaser, 2009). These levels interfere with the immune system’s ability to repair itself and can contribute to a cascade effect of neuroendocrine, immunological, and metabolic problems resulting in the numerous chronic illnesses so prevalent today (Cohen et al., 2007).
Scientists such as Candace Pert have described the biochemical molecule responsible for translating psychoemotional phenomena into anatomical–physiological phenomena and vice versa (Pert, 1997). These molecules, called neuropeptides, which are located throughout the entire body, are concentrated in select areas such as the hypothalamus and the gastrointestinal tract. PSYCHONEUROIMMUNOLOGY is the study of the complex relationships between the immune, nervous, and endocrine systems, and these relationships are mediated through neuropeptides.
COMPLEMENTARY AND INTEGRATIVE THERAPIES provide healing strategies that target the psychoneuroimmunological basis for health and illness. They are often employed prophylactically to keep the system in balance in order to promote or restore health. These therapies use physical, psychological, energetic, spiritual, and nutritional means to strengthen a person’s capacity to heal. While allopathic approaches to healing tend to be disease-focused, complementary and integrative approaches are more holistic in nature.
The National Center for Complementary and Integrative Health (NCCIH; nccih.nih.gov) is part of the National Institutes of Health. The NCCIH classifies these practices into two subgroups:
1. Natural products, which include herbal supplements, biological, nutraceuticals, essential oils, and dietary supplements.
2. Mind–body therapies including:
Meditation, mindfulness, and transcendentalism
Movement therapies such as Feldenkrais, Alexander technique, Pilates, Rolfing, and Trager
Relaxation techniques, such as breathing exercises, guided imagery, progressive muscle relaxation, and hypnotherapy
Tai Chi and Qi Gong
Energy therapies such as Healing Touch and Reiki
Whole systems of healing, such as Traditional Chinese Medicine, Ayurveda, Naturopathy, Homeopathy
Increasingly, the population is using these modalities to promote health, prevent illness, and to counter the side effects of allopathically prescribed treatments. For example, acupuncture is used to treat chemotherapy-induced nausea and vomiting. Many people turn to these healing approaches because of dissatisfaction with the current allopathic (medical) model. An integrative approach to patient care incorporates and customizes the best of complementary practices with the best of allopathic practices.
Stress can disrupt the functioning of the nervous, immune, and endocrine systems. Integrative approaches to healing can restore homeostasis.
The Role of Nursing in the Provision of Integrative Care
To address the impact of stress on patients, nurses need to assess the patient and family carefully. Questions that can help focus the assessment include the following:
What is the patient’s perception of the current stressors he or she and family are presently facing? “Of everything happening to you right now, what seems to be the hardest?”
How do the patient and family typically cope with stress? “When you have faced difficult times in the past, what has worked the best for you?”
What resources are the patient and family missing that could help them in the current situation? “What is it that you think you need to help you get through the current situation?”
Within the context of the therapeutic relationship, the nurse uses active listening skills to assist the patient and family to identify their feelings and put them into words to foster communication. A statement such as, “You sound scared. Would you like to talk about it?” demonstrates concern for the patient and allows the patient the opportunity to share his or her feelings if he or she wishes. Providing empathetic responses to distressed patients and families, such as, “I understand how difficult this is; you don’t have to go through this alone,” helps to validate their emotional distress and to provide support. The nurse collaborates with the patient and family about those people or resources that can assist them to successfully navigate the current situation. For example, the nurse could ask, “Is there someone from your faith community you would like for me to call for you?” Again, the nurse demonstrates a concern and interest in the patient.
Nurses may also offer mind–body interventions within the context of the therapeutic relationship. As the immune system has the capacity to learn, these interventions are designed to induce relaxation responses during which the immune system can repair itself. The subsequent release of ENDORPHINS, which are chemicals in the body that are responsible for producing a sense of well-being and are potent mood elevators, lays the groundwork for subsequent healing responses.
Nurses can incorporate many integrative therapies into their nursing care to tend to the whole person. However, the nurse needs to assess the patient’s health beliefs and practices before implementing specific therapies. Box 20-2 highlights appropriate assessment questions and provides suggestions for interventions.
The use of complementary and integrative interventions with patients presenting with physical illness can provide teachable moments whereby nurses can use their counseling skills to influence not only the patient’s mental health, but physical health as well. Nurses interested in learning more about such integrative practices can search the Internet for numerous clinical, educational, and research resources that are available (e.g., www.wholehealthmd.com, www.imconsortium.org, nccih.nih.gov, www.consumerlab.com, www.naturalstandard.com, mindbodyhealth.osu.edu, herbs-supplements.osu.edu). In addition, many nurses become licensed and certified in complementary and integrative therapy practices to extend the reach of their healing into areas such as the patient’s bioenergy field, tapping into the mind–body connection to evoke a healing response, use of somatic modalities such as massage therapy, and making use of more psychospiritual approaches in their work (Rancour, 1994, 2010). The holistic benefit of incorporating such modalities into nursing care practice is that their healing benefit extends not only to the patient, but to the nurse as well (Rancour, 2008a, 2008b, 2008c).
Loss and Grief
Physical illness changes people’s lives often in ways that are not readily self-evident to anyone except the patient. Consider the many losses that are inherent in illness: loss of well-being, autonomy, time, body parts and functions, money, relationships, jobs, a predictable future, mobility, freedom from pain, body image, lifestyle, role changes, and time, to name but a few.
The normal response to all such loss is the healing, yet painful, experience of grief. It can manifest itself in many ways, such as shock, denial, anger, anguish, and deep sadness. A grief model, developed by Bailey, a hospice nurse, illuminates the trajectory of the grief journey (Bailey, 1986). This model is highlighted in Box 20-3.
Nurses need to assess for signs and symptoms of the grief response in all patients facing illness. Acknowledging the validity of these feelings is important to promote working through them. Otherwise, these feelings can interfere with the patient’s ability to adhere to a treatment regimen and recover. For example, a patient who is newly diagnosed with diabetes continues to deny the illness despite his or her symptoms. As a result, the patient is likely to experience increasing morbidity from failure to come to terms with the necessary lifestyle changes required by the diagnosis. If the nurse is not attending to the patient’s grief response, diabetic teaching is likely to be ineffective as the patient resists it.
BOX 20-2: COMPLEMENTARY AND ALTERNATIVE MEDICINE (CAM) THERAPIES: ASSESSMENT AND INTERVENTION
• Determine the patient’s belief about what made him or her sick and what he or she believes would heal the sickness. “Tell me about why you think you became sick and what you think will heal you.”
• Assess the patient’s current use of complementary and integrative therapies. “What healing practices, beliefs, preparations, or herbs do you currently use to help you heal?”
• Assess the patient’s willingness to explore new healing practices based on whether or not the current healing practices are helping him or her cope. “It sounds like your pain is getting worse. Would you be willing to try something new to see if we could get better results from the medication?”
• Provide evidence-based information on the clinically demonstrated effectiveness of complementary and integrative therapies, how to locate credentialed practitioners, and how to assist patients to become savvy health care consumers of these services. “Looks like that massage helped you maximize the benefit from your pain medication. When it’s time for you to go home, let’s check with your insurance company to determine if they have any licensed massage therapists on their provider network that you can be referred to after your discharge.”
• Integrate as many evidence-based modalities into your practice as possible by becoming credentialed in modalities that add value to the care you provide. “While we talk about how you can cope with fatigue since your heart attack, if you like, I can give you a Reiki treatment to boost your energy level.”
• Teach patients the value of inducing the relaxation response (meditation, prayer, Reiki, etc.) as a means of assisting them to reduce circulating cortisol levels on a regular basis, thereby reducing systemic inflammation which contributes to disease. “What do you usually do to relax?”
BOX 20-3: BAILEY’S JOURNEY OF GRIEF MODEL
• Loss occurs
• Protest: Characterized by shock, numbness, confusion, anger, and physical symptoms
• Searching: A preoccupation with what will or what has been lost, presence of vivid dreams
• Despair: Anguish, depression, social withdrawal, hopelessness, and slowing down of thinking and behavior
• Reorganization: Bursts of energy, intermittent interest, indifference, fatigue, detachment, apathy, and survivor guilt
• Reinvestment: Integration of the old with an emerging new way of life; learning to live with the loss
From Bailey (1986).
Nurses who understand the nature of deep emotions such as denial, anger, and intense sadness are better able to develop plans of care that incorporate attention to these emotions in addition to providing disease-related treatments. Assisting patients to identify what they are feeling helps to minimize the potential for acting out. In addition, the ongoing use of active listening skills such as reflection and paraphrasing dynamically facilitates grief work. Active listening skills also provide ego strength and indicate confidence in the patient’s ability to ultimately adapt (Rancour & Cluxton, 2000).
Nurses also need to consider the family, because just as patients grieve their losses, so too do their families. High rates of morbidity and mortality often occur in family caregivers as well as those who lose life partners. Providing family-focused care signifies the nurse’s recognition that family members will be at varying stages of their own grief cycles in coping with and adapting to the patient’s illness. In addition, the culturally competent nurse will address these responses in such a way that he or she communicates an understanding of and empathy with families whose culture and spiritual outlooks—and therefore whose mourning and its rituals—are different from his or her own.
Grief and loss affect not only the patient but the family as well. Active listening skills are important to help patients and families identify their feelings and put them into words.
Body Image Changes and Stigma
In a culture that prizes youth and beauty, there is little room for individuals whose physical illnesses create diversions from some imagined or idealized norm. Many losses that prompt grief responses may involve changes in body appearance and/or functioning. Experiences such as chemotherapy-induced alopecia (hair loss), amputations, or ostomies can provoke body image disturbances with subsequent stigma. Difficulties adapting to one’s changed body can create self-esteem issues, making acceptance of one’s new body and its altered functioning a challenge. For example, when does a young woman mention to her new dating partner that she has had a mastectomy? Often, patients are angry about what is happening to them, asking “Why me?” When seen as a grief response, the nurse can help the patient reframe his or her relationship with the injured or changed body part from one of anger to one of forgiveness and even compassion that can be visualized as being sent to the injured body part (Rancour, 2006; Rancour & Brauer, 2003). Box 20-4 highlights appropriate assessments and interventions for dealing with changes in body image and the attendant stigma.