Joe had attended college briefly and worked part-time as a disc jockey for a local radio station. Fired from the job after repeated sobbing outbursts, he ran out of money and became homeless following eviction from a rental apartment. Police found him wandering along the side of a road. Hospitalized for psychiatric care, he was started on medications and then released. Unable to access supports from among locally available community service options, however, he rapidly decompensated and was soon returned for inpatient care following a series of suicide attempts by drug overdose. In the new setting, Joe confined himself to a corner chair near a window in the day room. When he wasn’t slumped under a winter coat as the TV blared, he wandered the small hallway, tearful or, sometimes, in full-throttle sobbing. Multiple medication trials did not break this odd cast, even after many weeks. Disappointment and despair set in among the clinical staff.
If anyone attempted to strike up conversation, Joe would launch into a bizarre fusillade of sobbing complaints: I can’t read, I can’t think, I can’t see straight, he would insist tearfully. My legs hurt, my arms feel heavy, I can’t remember things, I can’t listen to music, I don’t enjoy anything. Staff and patients alike found these punishing tirades disturbing and began to avoid Joe, as nobody wanted to set off another barrage. The facility had recently seen a suicide attempt; the attending psychiatrist, wary about copy-catting, placed Joe on close-monitoring status, specifying that he spend some time each day talking privately with a nurse as yet another round of new trial medications was started.
They teach you in nursing school to “establish rapport,” and that, very simply, was the starting objective for the nursing team. I invited Joe to join me in one of the activity rooms. But every day for a week, our meetings were chaotic and unpleasant, as Joe sank deeply into any available chair, teary-eyed, and sooner or later began torturing his arms and thighs with alarmingly compulsive scraping gestures of his fingernails. Between sobs, he fired off the familiar I-can’t-see-I-can’t-think-I-can’t-focus, and so on. Though I documented faithfully my nursing intervention – “supportive counseling and empathic listening” – I didn’t feel my “counseling” was particularly supportive, and my listening didn’t feel the least bit “empathic.” I certainly could see why the staff found Joe so difficult to tolerate.
The facility had a sunny backyard. Perhaps a little fresh air and sunshine, I thought, might help this guy. So, one day, I took our sessions outdoors. The heaving sobs, the fingernail scraping, the litany of this and that gone wrong – it all came predictably as Joe slumped his shoulders and sank into the park bench.
Presence alone, as we’re taught in nursing school, has the capacity to soothe and console. “Therapeutic use of self,” I reminded myself. But outdoors, as indoors, I felt again the uniquely unpleasant sensation of being compressed, inundated, by Joe’s aggressive brand of misery and incessant harping. You’re not supposed to look away from your patient – that’s Nursing Communication 101 – but I found myself gazing guiltily at the quiet, tree-covered hill beyond the fence, my eyes seeking relief in a more open vista.
People caution you not to “take your work home.” But one night, a strange memory came to me of an episode, years earlier, when a small bat had flown into the window of my ninth-floor New York City apartment. Panicked and desperate, it frantically slammed itself against walls and knocked pictures off their hooks. Several of us had exhausted ourselves in the effort to trap and free it. I thought now about the frenetic tone of someone who is exhausting himself – and everyone around him – trying to locate himself in an open, unfamiliar space. My mind traveled, too, to the story from classical mythology of Pan, the Greek god, who has the body of a man and the head and legs of a goat. Pan is so ugly that everyone retreats from him. One day, he comes across a nymph named Syrinx. Falling instantly in love, he chases her, but she runs away, seeking refuge in a river, where her sisters hide her by transforming her into a reed. As the wind blows, a melody is produced. Pan stands, mesmerized. Not knowing which reed is Syrinx, he grabs a handful and ties them quickly together side by side. Forever after, their music in the wind – the music of Pan’s pipe – evokes for him the presence of his lost love. Our word for “syringe” is derived from this story, as is our word for “panic.” More importantly, as the philosopher Ernst Bloch once noted, the ancient story speaks to our fundamental understanding of sound’s remarkable capacity to evoke form, or, as Bloch states poetically, “to trace, in the invisible, the outlines of human longing” (Bloch, 1985, p. 197). Which brings us to the nursing intervention that suddenly registered itself in my mind.
Most of us, at an early age, learn to soothe ourselves when we feel lost. We linger in hot showers and wrap ourselves in plush towels. We snuggle under blankets, embrace furry pets, and slather on floral-scented lotions which envelope our bodies in comforting, familiar associations. We conjure shapes and surfaces of texture and temperature and scent which remind us about companionship and enclosure. Joe’s gestural patterns – the sinking deeply into chairs, the wrapping under absurdly seasonally inappropriate winter coats, the scratching to heighten sensations at the body surface – all these, I realized, could be read as a kind of frantic effort to evoke for himself a feeling of enclosure, of boundedness in space. The more I reflected on it, the more it seemed we were all feeling cramped around Joe because something about his lurching tirades and constant tearfulness amounted, essentially, to an aggressive projection of force against surfaces.
Anyone who has cradled children in lullabies or attended choir services in large cathedrals knows viscerally the unique feel that sound exerts on the body’s membranes. Sound by itself, as the Pan story reminds us, has the capacity to create form and texture – to manipulate air into shapes that soothe and surround with minutely felt gradations of pressure and motion. Joe had worked in radio: he’d come to us from the world of sound. It made sense, now, to consider that sound itself might form the basis of a more productive means of making contact with him.
Next time we sat outside, I asked Joe if he’d ever incorporated nature or animal sounds in any of the radio shows he had done before his hospitalizations. He remembered using whale recordings, and I told him that I wanted him to think, now, about those old recordings, and to try listening to the sounds outside us. I scooted alongside him, and we turned our faces outward together.
At first, we heard the rumbling of an airplane engine overhead. Then, we heard the heaving groans of the facility electrical-power generators. We heard the crackle of truck wheels scraping gravel at a construction site down the road. We heard the whine of flies, the Morse code of woodpeckers, the hurrying trill of wrens and fleetingly, beyond that, the distant bustle of traffic. The cosmos cooperated with this experiment, thankfully, offering rich sequences of varied and nuanced noises. Given the specific assignment of listening, it was clear, Joe could still himself, at least for a short period, as my sitting alongside him served as a wordless initiation of collaboration and synchrony.
The following day, we tried again. I began pointing to each sound as we heard it. This time, I asked Joe not just to listen, but to try envisioning the location of each sound and to imagine, much the way a blind man uses a cane, the three-dimensional physical space between the sound points – to translate, in a sense, from the auditory to the visual and tactile experience of geographical space. For a week of these brief interventions, lasting no more than 10 or 15 minutes each time, we played this “blind-man” game. We mentally constructed all manner of spaces – cubes and domes and so on – from cricket chatter, ambulance sirens, bird calls and whatever else was available. Step by step, in this way, I re-acquainted Joe with his capacity to hear, and, indirectly, to sense in other ways – to see and feel the spaces around him. And in a more general sense to deploy the mind’s eye and remember what might, constructively, be done with it. Joe continued to cry silently.
By the second week of this activity, however, I noticed that the subject matter of Joe’s speech started gradually to broaden. He began speculating about measurable distances such as the number of yards to the nearest highway and the square footage between bird calls. He lowered the volume of his voice. The crying diminished. He began telling me about playing the guitar (both of us had taken lessons), about his family, about apartments he’d lived in or visited over the years. The themes made sense: sound, space, the familiar surfaces of people and place – all following along a widening trail of ideas set out by the activity of our listening, seeing, and imagining together. By the third week, the sobbing stopped. The complaining stopped.
I continued to document the nursing intervention: “supportive counseling and empathic listening.” But these phrases described inadequately the inchoate but palpable shift I had observed. In the vocabulary of sound – in the delicate mutuality of our seeking it, without my using words to pin him down or trap him in conversations he wasn’t ready to have – Joe seemed to be grasping a sense not only of location, but of being located. Of possessing within himself a capacity to narrate a personal envelope.
On the ward floor, staff noted that Joe started waking for breakfast and joining the staff-and-patient morning group meeting. He attended first one and then more of his assigned group programs. The scratching gestures had ceased. Removed from close monitoring, Joe was able to begin earning points toward a less restrictive level of supervision – to gain more independence and grounds privileges. Soon, he began attending regularly scheduled sessions with his doctors and therapists; he enrolled in music classes. Everyone on the staff felt that medications had worked, programming had worked, nursing had worked. He even made a few friends. As his schedule filled, he and I stopped our regular meetings. There was no longer a need for them. His therapist told me a few weeks later that he was looking for an apartment, preparing for re-entry into community life, and, more importantly, eager to reconnect with family, friends, and work, feeling optimistic for his future prospects.
Making contact when words are not available
It is not difficult to notice that the stories of Sara and Joe share a common thread, despite their outward differences. Each begins with a patient who is isolated and suffering, unable or unwilling, for one reason or another, to enter productively into conventional therapeutic programs or treatments, who is alienated from the day-to-day world of ordinary human conversation. Then, something happens between patient and nurse. An interaction changes things. It begins with the nurse’s alertness to a pattern, gesture, or other element of behavior which is specific and unique to the patient, but which lends itself to reconstruction in the form of a simple, time-limited game or activity. The game or activity is direct and straightforward – easily grasped. It requires no jargon-laden theoretical elaboration, no translation, no complicated manual of step-by-step instructions. It is playful and accessible. Anyone can do it. It incorporates many of the traditional therapeutic competencies – the show of attention, of empathy, of patience and confidence and compassion, the sense of genuineness and emotional availability, the commitment to establishing a protective interpersonal sanctuary, a holding environment, which is nourishing and stable. But the activity’s most important feature is precisely something else: it embodies a specific logical subject matter distinct from these other attributes. It gives body-based physical form to a specific but abstract idea. It creates a representability for something the patient has been unable previously to name – something which now can be shared, in the form of a conceptual analogy, in the play between patient and nurse.
In the encounter with Joe, as in the encounter with Sara, we can identify a specific logical transformation. Emerging from Joe’s distinctive relationship with music and sound, a “blind man’s” listening game became an alternative, viscerally based vocabulary for suggesting to him, without words, the themes of safety, mutuality, and the possibility of invoking the feeling of a safe, enveloping surface of personal space – something akin to what psychoanalyst Didier Anzieu called “the skin ego” (Anzieu, 2016). Starting with his appreciation for music and sound – with his personal idiom rather than with more conventional therapeutic language – the game invited him into an activity which expressed, to some extent, what was plaguing him, but in an alternate, sensory vocabulary that was accessible, familiar, and non-threatening. Over his aggressive and disturbing emotional flailing, his grasping for boundaries and containment, the game cast a new, plainer structure, the suggestion of a more orderly and coherent representation.
We attain what is possible, it is sometimes said, by extending what is given; we employ the known to invent what has not been known previously. The activities described here embody this common-sense principle. Starting with elements of the patient’s own communicative system, but recasting them in an accessible, body-based vocabulary which can be shared and elaborated by someone else we were able to initiate our patients into an exchange of meanings, around themes of keen interest, but without rushing them into conversations they were not ready to have or group programs they were not ready to endure. This transformation is what I am calling the “gestural bridge.” The capacity for therapeutic communication of this type has not previously been theorized in nursing. But it has been the subject of considerable attention in other disciplines, particularly cognitive linguistics, philosophy, art, and psychoanalysis, and it has roots, as will be seen, in the earliest communicative encounters of infants and children. This is the subject of the next chapter.
References
Anzieu, D. (2016). The skin-ego (N. Segal, Trans.). London: Karnac.
Bloch, E. (1985). Essays on the philosophy of music. New York, NY: Cambridge University Press.
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