THE VALUE OF THE USE OF DIALOGUE AND SELF IN RECOVERY
Daniel B. Fisher
John F. Sweeney
EXPECTED LEARNING OUTCOMES
After completing this chapter, the student will be able to:
1. Define the term self
2. Define components of recovery
3. Identify the principles of dialogue
4. Describe ways to develop greater self-awareness
5. Define therapeutic communication
6. Discuss the key concepts of therapeutic communication
7. Explain the significance of therapeutic communication to establish and maintain therapeutic nurse–patient relationships
8. Identify techniques of therapeutic communication
9. Describe barriers to effective therapeutic communication
10. Describe the foundations of Emotional Connection, emPowerment, and Revitalization (eCPR)
11. Describe the five intentions of eCPR
In this chapter, we describe the role of nurses in helping relationships. We integrate three important trends in mental health care: use of self, the recovery paradigm, and the dialogical practice.
DIALOGICAL RECOVERY OF LIFE
Before the emergence of the voice of the person with lived experience, the focus was on the actions of the helper in the recovery context. Today we propose that the focus needs to shift to the capacity of the person in distress to experience his or her power to heal and recover. We are calling this Dialogical Recovery of Life (Fisher, 2015). This means that all actions by the person assisting need reframing in light of how well they enhance empowerment and vitality in the person who is distressed. We call this implementation of Dialogical Recovery of Life, Emotional CPR (eCPR).
Dialogical Recovery of Life is a synthesis of the uses of dialogical practice (Seikkula et al., 2006), recovery principles (Fisher, 2008), a trauma-informed approach (Mollica, 2009), and uses of self (see the following discussion). Taking a Dialogical Recovery of Life approach to healing not only benefits the person who is experiencing extreme emotional states (clinically described as psychosis), but also aids the growth and healing of those around him or her as well as the practitioners. This also applies to people experiencing states of lesser emotional distress, as well as to conditions of addiction. The following is a summary of ways that taking the Dialogical Recovery of Life approach can be of assistance to everyone who is emotionally distressed:
DIALOGUE is a uniquely suited process for bringing recovery to self and others. Dialogue enables people to see their world, and the world around them, through a new construct. This refreshingly broadened point of view enables them to hope, dream, and plan for the future.
Trauma is any process that interferes with these life-sustaining dialogues and interferes with the life. Trauma cuts people off from intimate relationships, and the nourishment of personal growth. When personal growth is impeded by trauma, recovery becomes challenging. To protect themselves, people often retreat to safety within. If, after prolonged retreat, they still feel unsafe, they only consider one version of reality—their own—and fall into a more negative place. They become psychotic, and/or suicidal, either passively by withdrawing from life, or actively by attempting to end their lives.
Drugs and medications are a temporary way out of this crisis situation. However, an overreliance on medication can lead to overdependence and a deceleration of personal development.
People need to connect with others who can support or identify with them. This human dialogue is the key to interpersonal relationships and can often sit extremely well with the initial crisis where one is taking medication.
A combination of eCPR and the Open Dialogue is well suited to reestablishing connections between the person in distress and his or her natural network. Just as eCPR helps a person to connect one-to-one with another person, Open Dialogue helps a person connect with his or her network. Many people with experience in dialogical practices have noted their own increased clarity of thought through their engagement with others in this process. Open Dialogue can expand options and points of view by enabling participants to become aware of new dimensions to their lives. In the interplay of dialogue, new meanings are generated that the participants had never previously dreamt of. This brings new ideas to life, which can then infuse lives with renewed meaning. This weaving together of different worlds goes beyond a single personal perspective and opens new horizons. By thinking more complexly, a person in distress can think beyond delusions.
Recovery research has shown that someone needs to reach the deepest self of the person in distress. It often takes someone who has been there and found a way through. It takes someone else with a strong sense of empathy to bestow hope to the person in despair. It takes a very human person who can fully believe in the other’s capacity to recover his or her life. This is the essence of eCPR. This is why it is called heart-to-heart resuscitation.
SELF is defined as the entire person of an individual; an individual’s typical character and an individual’s temporary behavior; and the union of elements (body, emotions, thoughts, and sensations) that constitute the individuality and identity of a person (Merriam-Webster, 2011a, 2011b). An awareness of a sense of the self is core to a human being’s personal identity (Gallop & O’Brien, 2003). From an early age, individuals become aware of physical, psychological, social, and cultural similarities with others. Insights into these similarities and dissimilarities emerge as individuals begin to understand the unique, interactive, and shared experiences of themselves and others that occur across one’s life span. The sense of self develops from early childhood experiences and continues as the individual transitions from family, school, social, and work life toward old age. SELF-REFLECTIONS are triggered by the developmental and incidental encounters with others as the individual moves along in life. Whether joyful, neutral, or painful, the processes of feedback from others, self-discovery, learning, experience, travel, and memory forge insights into the complexity of life as an individual and shared reality. This experience of the self represents a lifelong journey of discovery of personal identity.
The concept of self refers to a person’s entirety that develops throughout the life span as the person experiences similarities and differences with others and gains insight into his or her identity.
Carl Rogers, although not a nurse, is one theorist who addressed the concept of self. Rogers is known as the founder of person-centered counseling. He contends that when listening to another, some major conditions are imperative in supporting development in the other. These core conditions are as follows:
Congruence (the mind being in tune with the body)
Empathy (being able to put yourself in the other person’s shoes emotionally)
Unconditional positive regard (not judging anyone and having a positive and supportive attitude to them; Rogers, 1951)
According to Rogers, these elements, when present in the therapeutic relationship, would lead patients to develop these conditions in themselves. Contemporary psychiatric-mental health nursing understandings, skills, and treatment approaches have been influenced by his philosophies.
Carl Rogers, the founder of person-centered counseling, identified three core conditions needed to support development of the other person: congruence, empathy, and unconditional positive regard.
It is one thing to become more aware of one’s own self, and it is altogether another to be able to assist others to explore the dimensions of their own sense of self, reality, and connection to the world. The term therapeutic use of self primarily came from the work of three theorists writing about the one-to-one nurse–patient relationship, namely Hildegard Peplau, June Mellow, and Ida Jean Orlando (Lego, 1999). Lego synthesized the work of these early theorists to provide a seminal definition of the concept therapeutic use of self as:
The relationship between a psychiatric nurse and his/her patient, formed for the purpose of brief counselling, crisis intervention, and/or individual psychotherapy. The emphasis is on the interpersonal relationship between the nurse and the patient, with all its vicissitudes, as opposed to physical care of the patient. (1999, p. 4)
Peplau’s theory (see Chapter 2 for more information) developed over a 40-year period and was enhanced by research focused on barriers to interpersonal closeness and her reflections on clinical observations (Coatsworth-Puspoky, Forchuk, & Ward-Griffin, 2006; Lego, 1999). Drawing on Peplau’s theory, Karen Lee Fontaine defined the therapeutic use of self as “using one’s personhood to provide psychiatric nursing care” (Fontaine, 2009, p. 168). Fontaine notes that a distinction has to be drawn between the therapeutic use of self in a one-to-one nurse–patient relationship and its use within a specialized milieu that focuses on the shaping of group behaviors within a therapeutic community.
In addition to Peplau, other nursing theorists such as Joyce Travelbee (1971), Annie Altschul (1972), and Phil Barker (1998, 2001b) have described the nurse–patient relationship. Still others have suggested that psychiatric-mental health nurses define the development of a therapeutic relationship with their patients as a foundational aspect of nursing care (O’Brien, 2001).
IMPORTANCE OF THE THERAPEUTIC USE OF SELF
A phenomenological study (a study designed to describe the lived experience) by Moyle (2003) recounts two aspects of an effective therapeutic relationship valued by patients during treatment for depression. These are “being with the patient” and “the need for comfort,” in contrast to two alternative approaches perceived as nontherapeutic—“focusing on the physical” and “lack of comfort” (Moyle, 2003). These alternative approaches were experienced as avoidance of emotional engagement through the nurse’s business and emotional coolness within the context of maintaining professional boundaries. While subscribing to a positive view of the therapeutic use of self as nurturing, caring, insight developing, and behavior challenging, Moyle suggests that overinvolvement can be detrimental.
In the 21st century, the term patient began to be replaced with terms such as client, service user, person with lived experience, or survivor of psychiatric-mental health services as a result of a gradual paradigm shift from a biomedical to a social psychiatric viewpoint that placed greater emphasis on increased patient autonomy. Before this shift in viewpoint, the more medical model approach resulted in patients being disempowered. With this greater emphasis on patient autonomy, patient involvement and collaborative care planning were taking place.
Being there for someone and being involved and supporting people through mental distress and emotional challenges are not easy. Many find it tiring and exhausting and a very adequate amount of supervision is required. The term compassion fatigue was first introduced by Joinson in 1992 (Hunsaker, Chen, Maughan, & Heaston, 2015). Of course, this work can also at times be stressful. As miners often work underground in dusty environments, they are therefore at risk of developing lung diseases. Therefore, it is not an unreasonable hypothesis that psychiatric nurses would be at risk of burning out in their practice, given their constant exposure to emotional distress. In a paper that reflects on student nurses’ mental health, Morrissette (2004) contends that being in stressful psychological environments can be psychologically damaging. Work on terms such as burnout, staff engagement, and work engagement is currently increasing. People are slowly realizing that if individuals are not supported in their work, that is, they are not given adequate resources, then they are more likely to suffer from burnout and disengagement, and this is not good for either the patient or the staff. A leading nurse academic, Jean Watson, spoke about the curative factors, identifying that there were key themes involved in the caring process (Watson & Woodward, 2010).
CONCEPT OF RECOVERY
The consumer/survivor movement in the English-speaking countries in the 1970s and 1980s laid the foundation for recovery through empowerment (National Empowerment Center [NEC], 2006). Instead of an emphasis on illness, there is a shift to the capacity of the person in distress to use his or her crises as growth opportunities. The terms mental health and recovery (a view that encompasses the whole person) are coming to the forefront. For example, in Ireland, new inpatient units are being renamed as mental health and recovery units instead of psychiatric units. Such a change initiates a gentler and more embracing sense of a unique personal recovery journey, thus transforming a pure biomedical model of care into one focusing on dialogue and a shift in patient–therapist power relations. In the United States, recovery, too, is a major focus. The Executive Summary of the President’s New Freedom Commission on Mental Health cited a need for transforming mental health service delivery with recovery as the goal of this transformation (President’s New Freedom Commission, 2003). The Commission also emphasized that the transformation to a recovery-based system needs to be driven by persons with lived experience of recovery. In addition, the Substance Abuse and Mental Health Services Administration (SAMHSA) in their National Consensus Statement described “mental health recovery as a journey of healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her potential” (NEC, 2006). Thus, the term recovery is now used more frequently.
RECOVERY is a process that includes a person’s lifestyle, work, and aspirations. It is about the person’s quality of life, not about the illness. SAMHSA has identified 10 fundamental components of recovery:
Individualized and person centered (based on unique strengths and resiliencies, needs, preferences, experiences, and cultural background)
Empowerment (authority to choose from a range of options and to participate in all decisions)
Holistic (mind, body, spirit, and community; all aspects of life)
Nonlinear (continual growth, occasional setbacks, and learning from experience)
Hope (NEC, 2006)
Barker’s (2001a) Tidal Model provides a meaningful way of empowering both the nurse and the patient to work therapeutically toward recovery (Buchanan-Barker & Barker, 2006, 2008). Barker’s Tidal Model is the first mental health recovery model developed conjointly by psychiatric-mental health nurses and people who have used mental health services. It is also the first recovery-focused model of psychiatric-mental health nursing recognized internationally as a significant middle-range theory of nursing (i.e., a theory that is more concrete and less abstract in scope). This model has been used as the basis for interdisciplinary men.
To establish a meaningful interpersonal relationship, the nurse needs role competence (skills for practice), role support (effective supervision), and a commitment to engage therapeutically (Lauder, Reynolds, Reilly, & Angus, 2000). In other words, claims suggesting it is someone else’s job, there is not enough time, no one supports or coaches me, or no one values my efforts will inhibit the nurse from engaging or taking professional accountability for the quality of the therapeutic relationship that he or she has with a patient.
The therapeutic use of self can be burdensome. For some, the notion of the emotional burden of nursing suggests that the therapeutic use of self as a nursing intervention may be problematic (Smith, 1988, 1989; Smith & Gray, 2001a, 2001b; Smith & Lorentzon, 2005). The therapeutic use of self can be burdensome if the nurse does not receive adequate support and clinical supervision. For example, a psychiatric-mental health nurse may often experience an emotional burden from his or her sharing one’s presence with a person rather than by retreating into task activity or psychological distancing of the self; that is, not getting involved with the person’s issues at times of personal painful distress (Finfgeld-Connett, 2006). Also, establishment and maintenance of an effective interpersonal relationship require skilled personal disclosure by the nurse where appropriate, in which the therapeutic use of self is akin to Smith’s understanding of the emotional labor of mental health nursing (Smith, 1989; Smith & Gray, 2001a; Smith & Lorentzon, 2005). Mitchell and Smith (2003, p. 109) suggest that “the concept of emotional labor provides a means of describing and understanding the often invisible work employed, among others, by those in the caring professions. It involves using emotions and the appearance of emotions to provide security and confidence in others.” Trying to meet the needs of patients in distress over a prolonged period can take its toll on the psychiatric-mental health nurse. In short, the emotional labor of psychiatric-mental health nursing requires resources of resilience, perseverance, compassion, and access to clinical support.
Clinical supervision provides an objective view crucial to therapeutic relationships. Without adequate support and clinical supervision, the nurse may experience role strain and uncertainty about what he or she is likely to encounter in the clinical setting and may feel overwhelmed. One way in which such role strain may be manifested is by physical and emotional distancing from the person through activities such as being too busy, engaging in tasks, or avoiding accompanying the person through the painful episodes of distress. Using the four stages of Peplau’s interpersonal theory, Forchuk investigated the behavior of nurses and patients during the outcomes of each stage. The results showed that psychiatric-mental health nurses were competent and did assist patients therapeutically to traverse the four stages of the nurse–patient relationship as described by Peplau (1952; Forchuk, 1991a, 1991b, 1992, 1994; Forchuk & Brown, 1989; Forchuk et al., 1989).
Another study by Welch (2005) demonstrated that psychiatric-mental health nurses experienced “trust,” “sharing of power,” “mutuality,” “self-revelation,” “congruence,” and “authenticity” as their true self at pivotal moments of a therapeutic relationship. The psychiatric-mental health nurses interviewed gained a sense of mastery of the essential art of interpersonal nursing (Welch, 2005). There is evidence that mental health service users can articulate what they seek and value from psychiatric-mental health nurses in the context of a therapeutic relationship.
Patients have expressed a desire for the nurse to be able to “relate to me,” “know me as a person,” and “get to the solution” (Shattell, Starr, & Thomas, 2007). To be effective, patients wanted a nurse to treat them compassionately with respect, sensitivity, caring, and support. They wanted to be listened to and provided with companionship and to have confidence in the nurse’s skills to interact effectively with them. Specifically, it meant providing emotional support; having appropriate knowledge, training, and experience; and having a capacity to challenge verbal and nonverbal cues honestly and congruently (Shattell et al., 2007). To relate in a human-to-human manner, to know a person intimately, and to apply the therapeutic use of self require the psychiatric-mental health nurse to assess the professional boundaries between the patient and the nurse.
Despite shorter admissions, an individual’s journey through a period of mental distress toward recovery can be lengthy. This requires that the nurse be skilled with focused compassion and a willingness to challenge and support a person through a period of mutually disconcerting exploration. These existential challenges affect one’s ways of knowing how to relate to others and events and turn them into new ways of relating to self, others, and the world (Shattell et al., 2007).
SELF-AWARENESS is a necessary component of the therapeutic use of self. A self-awareness program for undergraduate nursing students was devised to assist in the development of therapeutic relationships with their patients (Kwaitek, McKenzie, & Loads, 2005). The course was developed, drawing on the work of Benner and Wrubel (1989), on the primacy of caring in professional nursing and on Dawn Freshwater’s (1999) work on psychotherapeutic application of emotional intelligence of the psychiatric-mental health nurse described in the following. It used the exploration of clinical vignettes to focus on four key themes: “knowing self,” “knowing others,” “unknowing,” and “presencing.” Through exploration of these dimensions of the self, particularly related to what was unknown about self or others, participants gained insights into their personal ATTITUDES and conscious and unconscious ways of human relating. The development of capacity to reflect on the self and the personal impact on others form part of what is referred to as “emotional intelligence” (Freshwater & Stickley, 2004). This realization is key to understanding one’s unconscious ways of responding to others that are complementary to, yet distinct from, intentional, interpersonal interactions. The notion of “doing for” a person and the conscious experience of “being with” a person at times of mental anguish or distress need to be cultivated in the nurse to facilitate a therapeutic healing process. Recognition of the nurse’s own unconscious need for approval, respect, and love through the caring process constitutes a necessary, if at times painful, journey of self-discovery, without which the nurse will be unable to relate empathetically to others (Freshwater & Stickley, 2004).
This sense of unknowing is explored in the deliberate creation, valuing, and usage of inter- and intrapersonal space in the therapeutic relationship (Stickley & Freshwater, 2006). It is cultivated through experiential learning using art, creative therapies, role modeling, and clinical supervision as an alternative to propositional knowledge. Failure to acknowledge interpersonal space by being busy with tasks creates the risk that the nurse may compound alienation, prejudice, and the replacement of meaningful dialogue. What is termed “phatic” conversation or social chit chat, though of benefit in the early stages of a professional relationship, may be overused at the expense of authentic, shared interaction (Bloor & Fonkert, 1982).
Dealing with a patient’s distress could become unidimensional unless considered from the patient’s perspective of a therapeutic nurse–patient relationship. Early attempts by psychoanalysts to delve into the chaotic existence of a patient tended to rely on the techniques and expertise of the therapist to shape the reframing of mental distress (Shattell et al., 2007). This gave way to the later human-to-human theories developed by psychiatric nurses such as Hildegard E. Peplau and Joyce Travelbee. Both advocated for greater power equity in the therapist–patient relationship. A warm, secure, trusting, and companionable relationship is the type sought by contemporary service recipients in a mental health setting (Shattell et al., 2007). Specific characteristics in the nurse valued by patients included a capacity to relate to the patient as a person rather than as a patient, the instillation of hope, and the building of authentic rapport. Although the art of effective listening, mutual understanding, touch, and self-disclosure were prized, these could be undermined if a nurse withheld the commitment to time, presence, and genuine effort to understand the person’s needs and perspectives (Shattell et al., 2007). This then leads to the following question: What could be the indicators of an effective therapeutic relationship? A number of writers (Dziopa & Ahern, 2009; Stockmann, 2005) have identified the qualities or constituents of such a relationship. These are identified in Table 3-1.
It is one thing to identify the constituents of the therapeutic relationship, but altogether another to attempt to define the role of the psychiatric-mental health nurse and the needs and preferences of the patient for such an encounter. Table 3-2 links the stages of Peplau’s (1952, 1997) interpersonal process with contemporary views of patients and the interventions identified through clinical studies. It provides exemplars drawn from the wide body of research that has engaged with and explored the application of Peplau’s theory in the everyday practice of the psychiatric-mental health nurse over the past 50 years since it was first formulated. In general, contemporary views of patients reveal that they want and feel the need to be in control of their own recovery. They feel positive when being listened to and when given a choice of treatments if appropriate.
Different skills need to be applied by the psychiatric-mental health nurse as he or she accompanies the patient through the therapeutic journey across the four stages of Peplau’s interpersonal therapeutic relationship.
Positive Components of the Self
Therapeutic interaction is facilitated by certain components. The most important component the nurse brings to any interpersonal relationship is self. This is body and mind and unique life experience. Patients view the relationship as the cornerstone of inpatient care (Forchuk & Reynolds, 2001). Three factors are thought to contribute to the development of the professional relationship: (a) caring characteristics of the nurse, (b) how the relationships were conducted, and (c) implementation of the goals during the therapeutic meetings.
EMPATHY is often another core principle highlighted in relationship literature. Empathy is not simply active listening but more a recognition of the person hearing what the other is saying while being able to occupy a shared space. Empathy can be defined as putting yourself in the other person’s shoes, or seeing the world through the other person’s eyes.
DEMONSTRATED QUALITIES IN A NURSEb
Conveying understanding and empathy
Presence, unconditional positive regard
Empowerment, self-esteem building
Maintaining clear boundaries
Patient-centered goals and objectives setting, value clarification
aFrom Dziopa and Ahern (2009).
bFrom Stockmann (2005).