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Chapters reproduced on the web The
Paradox of Psychiatric Nursing:
Making a Difference by Attempting to Change
Nothingby
Ben Davidson B.A., R.M.N.
Abstract
In chapter fifteen, Ben Davidson introduces the third set of means by which
one may develop an ethical practice, clinical supervision. The use of colleagues
to provide feedback about your style of work and the form of your interaction
with clients is invaluable in psychiatric nursing. It may take many forms however,
including individual supervision with a line manager, peer group supervision with
colleagues, an external facilitator coming in to enable in-depth discussion of
the work, and so on. If resources allow, however, it may be that there is no better
form of supervision than from someone actually in the room watching your interaction
with clients. In this chapter a form of 'live supervision' is described where
the supervisor, or 'support worker', makes comments on the process of the interaction
during the session, in a way that allows the client, as well as the 'active' worker,
the best chance to use any insights that emerge.
Introduction Recently I attended an interview
for a senior clinical post in a nursing development unit. I had to choose an aspect
of my practice to present in a ten minute slot to the three interviewers and the
group of six candidates for the post. I decided to use a case study. It was hard
to find a piece of work that seemed exactly appropriate, harder still to condense
it into that time, but there was an example that outshone the rest. I worried
that the life stories of the clients involved might distract attention from the
particular aspect of my practice I wanted to convey, so I decided to highlight
from the outset what aspect of my clinical practice the case study demonstrated.
There were two main themes. The first theme related to the approach we take as
psychiatric nurses. Do we join with psychiatrists in attributing mental pathology
to events, processes and people, in working on someone's illness, in treating
a problem? Or might our role be something different, to validate a person's experience,
to facilitate a negotiated view of their situation as the natural upshot of their
life history (Smail, 1984 pp.12-13), to try simply to be with them in that situation?
My second theme was essentially a practical application of the first: In the light
of the tension between the two roles described, how should we view, and manage,
a mental health crisis? I have reworked the presentation I gave so as to publish
it in its current form, as I believe the material is important and may be of wider
interest.
Some Background
I work at a Mental Health Day Centre. We are a community resource owned and run
by an inner city Social Services department. The central thrust of our work is
large group facilitation and provision of a therapeutic milieu, in a homely building
in Kennington, South London, with crisis intervention available for clients during
periods of mental breakdown. This crisis intervention is conducted, as is other,
preventative work undertaken at the Centre, through drop-in's and sessional therapeutic
work, as well as through outreach support and practical help for people in their
homes. We also undertake welfare work: Getting people benefits, housing repairs
and so on. The approach taken to our clinical work is based on systems theory
and group analysis. What this means in practice is that we rely on the relationships
within the group, client-client as well as client-staff relationships, to generate
healing. Such relationships also provide the backdrop for our use of an innovative
form of family therapy, employed to good effect even with people in psychotic
states. Ours is a group of clients who mostly don't like
hospitals. Generally we manage to keep them out. They like, instead, our attempts
to empower them to believe in their own strengths, our attempts to understand
and validate their experience, our attempts to work with them analytically - but
with a light touch (Phillips, 1995) - and as a large group. It is a cohesive large
group. The point of this paper really is to show what
it is like to work in this way with people in attending to their mental health
needs. I hope to convey something of the experience of adopting a systems approach,
seeing and relating to people and their problems always within a larger context.
I hope also to show how psychotherapy is essentially, 'an obstinate attempt of
two [or more] people to recover the wholeness of being human through the relationship
between them.' (Laing, 1967 p.53). In preparing this paper for publication, however,
it seemed it might be helpful to provide some basic themes about systemic family
therapy, some of the techniques used. I have hesitated to do this as I am keen,
first and foremost, to convey something of the experience of working in this way,
rather than distracting the reader's attention by over-conceptualising it. Working
therapeutically, after all, demands primarily an ability to be in tune with one's
feelings and other aspects of one's own experience in relation to clients, as
a way of beneficially accessing and bringing to light their experience and the
way it influences their conduct. All too often we use ideas and theory as a crutch
because we are daunted at the prospect of relying on our feelings, and then we
censor and modify our experience in line with what we think we ought to be experiencing
according to such ideas and theory. Nevertheless, a theoretical base from which
to practice and a proper understanding of what the work involves is also important,
so for a comprehensive text on family therapy and systems theory, useful both
as an introduction and for reference purposes, I would recommend Skynner's 'One
Flesh: Separate Persons - Principles of Family and Marital Psychotherapy' (1976),
and ask the reader in the meantime to forgive my necessarily sketchy account of
some basic concepts and techniques which follows. In
the work I describe below, two systemic concepts and techniques are pivotal -
homeostasis and paradox. In relation to homeostasis, perhaps the simplest way
to explain what lies at the heart of this concept is to say that 'nature balances
automatically what we do not balance consciously' (Skynner, 1976 p.12). If a family
has come to invest in the myth that 'in this family we never have arguments',
it may be no surprise that conflict, hostility and jealousy, for example, get
acted out unconsciously or expressed through other means. There may be a high
prevalence of gastric or other somatic complaints in the family, as a means of
concretising such feelings. Or conflict may come to be represented as occuring
between the family (us) and some outside agency such as social workers, members
of another race, grandparents (them), as a way of externalising rage and envy.
Alternatively, one member of the family may come to contain the banished feelings
on behalf of the whole group, and even be seen as abnormal, or formally diagnosed
as having psychological problems or otherwise scapegoated as a result. An adolescent
displaying a ferocious temper and sexual precociousness may be expressing the
repressed sexuality and anger of some other, possibly more powerful individual(s),
or possibly those repressed feelings of the whole family group. Viewed solely
in the context of how a balanced individual might be expected to act, she may
appear as though she is disturbed. However, in the context of the family system
of communication and expression of affect, her conduct may be seen more appreciatively
as representing (in exaggerated form) perfectly normal feelings which are otherwise
denied throughout the group. And although their relatively repressive states of
being will be less problematic for the other family members as individuals, the
attention to manners and etiquette they display as a group, may more realistically
be seen as equally exaggerated. My suggestion, that families
may simply 'come to' such an arrangement as this, ignores the operation of power
within a group, as also it ignores the distress and pain experienced as such roles
become increasingly polarised, entrenched and pathologised. In such circumstances,
it may be that the services of a family therapist, operating from a model which
takes into account the communication, or patterns of information exchange within
the whole group is required, in order to restore equilibrium to the system. While
polarisation of roles and feelings may be quite normal (after all, we do all have
different ways of being, feeling, expressing ourselves etc.) there are occasions
when the 'homeostatic' mechanisms which keep members of the system in balance
cease to be effective, and some intervention is required to restore equilibrium.
In the account that follows, the role of paradox in such
intervention is a central theme. A 'paradoxical injunction' is one where a message
is given which promotes change by prescribing that things should stay the same
(paradoxically). The reader will be familiar with some situation where, in exasperation
at a defiant child, a parent tells it to do the opposite of what is required,
having seen that the child's need to express defiance is greater than any other
emotional consideration: "O.K., that's it, that was your last chance - you
have taken so long to sit down to eat you are not going to get any dinner now."
Which, of course, is a risk - a sharp child (or one with no appetite) might see
through this device and insist that such an arrangement suits him fine, he didn't
want to eat anyway. However, if the intervention was well-judged, the child's
defiance wins over and the child insists that as he is now seated he is entitled
to food immediately. Just so in marital or family therapy! 'Well it does seem
as if the two of you are having the most awful time of it, and these problems
certainly are very, very serious indeed - four different professionals is it you
said you've seen now over the last year? - but I have to say that, from what I
have gathered in this interview, there is really nothing I have to offer that
you would be able to use to improve the situation. I really think you're just
going to have to find a way of living with this thing. [Long pause; give some
sign the interview is about to end, eg close the file, make as if to stand up.
Then...] Unless... No, its hardly even worth wasting our time talking about it....'
cue response from patient. The form of paradox used in
the following account is far more subtle than the above (although the example
given is Robin Skynner's, from a public lecture, not mine!). In a form of intervention
Skynner refers to as 'reactor analysis' (op cit, p.188) the therapist lowers his
emotional defences and allows the family attitudes to affect him, allows himself
to be sucked into the communication system. As Skynner describes, such therapists
'...operate rather like the fishermen of the Gilbert and Ellice islands ... where
one member of the team dives into the tentacles of the octopus while the second
follows immediately behind and, by a sharp tug on the leg of his companion, raises
them both swiftly to the surface where they can be disentangled. For equally cogent
reasons the reactor-analysts also operate in pairs, one standing by to rescue
his co-therapist as he is about to vanish into the "dear octopus" of
the family's pathology.'
The therapist is
a reactor in that he does not direct, so much as follow, or react to the emotional
currents at play. He is an analyst in that he respects the potential of patients
to discover their own way forward if only their motivation and insight can be
harnessed. The means by which such harnessing occurs is the relationship between
co-therapists (or active and support workers in the case of the model in operation
at the Day Centre). The active worker dives in to the current of emotion and communication
between the family members, specifically not censoring or having to think about
his response - that is the job of the support worker, who 'tugs his leg' at appropriate
junctures, and then initiates a conversation between the two of them as to his
(the active worker's) emotional response, the roles the family participants are
taking, the feelings that are getting expressed, those that are not getting expressed
and so on, thereby eliciting insight in the clients. If the reader is able to
recall a time in childhood when a parent discussed your conduct or character with
another adult, in your presence, all the while excluding you from the conversation,
that may give something of the flavour of such interactions. Although our experiences
of such interactions are usually painful, as they were occasioned perhaps through
a parent's feeling angry and rejecting, it is possible, I hope, to imagine how
such a powerful form of relationship may be harnessed therapeutically in the patient's
interests. In particular, where the active worker's emotional engagement with
the family dynamics prompts him to want to intervene directively or prescriptively,
the support worker is in a position to give that small tug (if they are working
well together) and draw the former's attention to his mistake (subtly prescribing
to the clients that they should not change - or at least should not be made to
change), while at the same time drawing their attention to the way in which roles
are being adopted and feelings shared. And so to business:
I am Marjorie's key-worker at the Day Centre. Marjorie is a neatly-dressed, 59
year old, white woman, who has a forty year psychiatric history, most of that
time on high doses of neuroleptic medication, but without apparent side-effects.
She presents as highly dependent on her carer, John, who, during the open door
drop-in's we run twice weekly, will prepare her food, organise her medication
and sort out the change she needs to pay for her tea. She is also, somewhat paradoxically
it may seem, very intelligent, keenly aware of her environment and sometimes quite
engaging. She was in psycho-analysis for a number of years in her twenties. John,
who has been Marjorie's carer and partner for about thirty years, is a 74 year
old, small-framed, white man. He has led a colourful life, is widely-travelled
and looks intriguing with his long, silver-grey hair in a pony-tail, a meticulously
shaped goatee and a perpetual look as if there is a party in his head. He used,
in the years after the second world war, to be a nurse at a mental hospital. He
can be very patronising and controlling. He might greet us with a review of Marjorie's
progress, talking to us about her as if she is not there: "She's been very
up and down this week, haven't you Marjorie." A crisis
developed in the early Autumn last year as Marjorie became more dependent, quite
angrily so at times, insisting John get her things and complaining about the care
he was giving her. The arguments ranged from a low-level bickering during drop-in's
to quite heated outbursts and exchanges. Marjorie was violent on several occasions
at home. A psychiatrist had intervened by changing and increasing the strength
of Marjorie's medication. He had John's support in focussing his treatment this
way. They both saw Marjorie as the problem, or at least as having the problems.
It was surely no co-incidence though that in the Summer
it had emerged that John, or Janet, as he wanted from then on to be known, was
becoming a transexual. Janet began dressing in women's clothes and would talk
candidly about the breasts she was developing as a result of her hormone treatment.
At first we staff denied our anxiety about the couple
and blamed our feelings of unease on the uncompromising way Janet asserted her
transexuality, interpreted by us as a need to shock. But this disabled us in responding
to the wider situation and emerging crisis. Things continued
this way for some time until Janet accompanied Marjorie to a Women's Group at
the Centre and asked to become a client in her own right so that they could attend
the Women's Group together. Although it was presented as a strategic ploy to gain
admission, this request seemed also significant as a statement from Janet regarding
her status. We took the opportunity to respond creatively and decided our response
should include Janet, even though she was technically too old to access our services.
Rather than give a full description of the sessions with
Marjorie and Janet (or rather Beverley as she came finally to be known), I shall
draw out some of the difficulties and highlights in the work, relating them back
to my principle theme of the psychiatric nurse's role: Pathologisation versus
validation.
The Work
Difficulties From the time I first met this couple
nearly two years ago, up to the point I just reached in my account, I resisted
seeing Marjorie as 'the problem'. Increasingly, however, John/Janet/Beverley was
the problem, so far as I was concerned. She was controlling, pathologising, shocking
and in more or less complete denial of any need herself whilst evidently in the
middle of probably the most traumatic event of her life, which she shared compulsively,
in intricate detail and at length with anyone who would listen. All the while
she would laugh off both Marjorie's and anyone else's difficulties about the gender
reassignment as other people's oversensibilities, not her problem. All sense of
vulnerability, dependence and need in the relationship appeared to be vested in
Marjorie. When I advised that they needed help to look together at the issues
contributing to their current difficulties as a couple, Beverley expressed considerable
ambivalence, insisting she was attending the sessions to help Marjorie with her
problems. Although I offered, in the spirit of maximising client choice, to see
Marjorie alone to give her support, I was glad that we all finally agreed they
would be 'family' sessions. For some time though, despite this systemic emphasis,
I retained my view that the problem was Beverley's, a response every bit as pathologising
as the psychiatrist's. We used the family therapy technique
described above: I would engage directly with Marjorie and Beverley while a 'support
worker', my colleague Jackie, was also in the room, sitting slightly to one side
of me in a position where she could watch the interaction between the three of
us and offer live supervision when necessary. This co-working relationship is
difficult in many respects, not least of which is the fact that one's practice
as active worker is under constant scrutiny and critique, in front of the client.
It is of course also difficult to establish adequate trust with one's co-worker
to allow the feedback to flow smoothly and to work with it.
I would often ask Beverley and Marjorie to review the session just before it ended.
On one such occasion Marjorie had said what she thought we had covered in the
session and how she felt about it. Beverley then took her turn. However, Beverley
did not talk about how she felt, but about Marjorie. Despite several prompts from
me, Beverley insisted on reviewing where Marjorie was at rather than presenting
her own response. At a point of near exasperation with Beverley, where I had all
but told her she was jeopardising progress by refusing to own her feelings, Jackie
stepped in to remind me I had said the session would finish with Marjorie and
Beverley's feedback, but now I was lecturing rather than listening to Beverley.
I apologised and allowed the session to finish. On another occasion, in contrast,
Beverley had acknowledged not only how hard she was finding the gender reassignment
and people's attitudes to her, but also how she felt nervous and unsure how to
respond to Marjorie's anger. What an admission of vulnerability from Beverley,
what a breakthrough! "Marjorie, how do you feel
the session has gone?" "I don't think there'll
ever be any change, he just mocks me all the time Ben."
I tried to coax some optimism out of Marjorie, angry at her fatalism, touched
by Beverley's disclosure and scared that Marjorie was pushing them back again
into their polarised positions. Again, Jackie intervened: She reminded me how
Marjorie had said she was feeling; she suggested that difference was normal and
healthy in any relationship and it was fine for Marjorie to be feeling pessimistic;
she advised me to accept how Marjorie felt; and she told me that we now had to
finish the session. Again, I apologised, echoed how Jackie had summarised Marjorie's
position, and ended the session on that note. On both these occasions I had been
drawn, by my own need to make things better, as well as by Beverley and Marjorie's
fear of the confusion they faced, into trying to resolve things. I had on each
occasion identified a problem: Beverley's denial of her needs; Marjorie's refusal
to feel anything but helpless and fatalistic. On each occasion I had responded
much as the partner in their relationship would characteristically respond - with
anger towards Beverley and her denial in the first case (much as Marjorie felt),
and with an attempt to control Marjorie's experience, to get her seeing things
more positively, in the second (acting much as Beverley would). Together, Jackie
and I then produced an alternative response to these circumstances, which was
in each case to highlight what was happening and, at the same time, just to allow
the situation to be. Highlights
The highlights of my work with Beverley and Marjorie were the occasions of positive
change in their relationship. These seemed to occur just when my absorption in
their relationship was at its greatest and when differences between them manifested
in the relationship between Jackie and I (Skinner, 1976 p.275), with me becoming
more problem-oriented toward them and Jackie restoring a more neutral approach,
as described above. Such breakthrough and change in the couple's attitude to themselves
and to each other usually took the form of acknowledgement and acceptance by Marjorie
and Beverley of the role reversal in their relationship. A good example was when
Beverley eventually shaved off her goatee. I had mentioned some time before how
much harder I found it to relate to her as a woman while she sported such an impressive
beard, and both Jackie and I remarked on the change at the beginning of this session.
Marjorie had not noticed though, until Jackie and I commented on Beverley's appearance,
that the beard had gone, despite the fact that Beverley had shaved it off early
that morning. Beverley tried to laugh this off and related how Marjorie had failed
also over the previous three years to notice her developing breasts. She acknowledged,
finally, in a rare outburst of emotion, how angry this lack of recognition had
actually left her, and how her derisive laughter belied this. She also disclosed
how rejected she felt by others and how awful her appearance now seemed to her,
"like an old hag". Apparently as a result of expressing her own vulnerability,
she managed to start taking Marjorie's more seriously. This included a willingness
to hear Marjorie's expression of anger, outrage and hurt that she (Beverley) had
kept her hormone therapy and gender reassignment secret for three years under
the pretext of some sort of test to see if she (Marjorie) noticed. Marjorie also
made breakthroughs. For example, she acknowledged how when she referred to Beverley
as 'he' she wanted to hurt her because of her anger about the changes Beverley
had imposed, without consultation, on their lives. Then, increasingly, she explored
and learnt how she could be less dependent and how she could look after Beverley.
Awkwardly and with rather closed questions at first, but with increasing confidence
and skill, Marjorie would ask Beverley how she felt about things, whether she
hadn't found aspects of her gender reassignment, interactions with people and
aspects of their relationship together difficult to handle. And perhaps the most
impressive example of her move from dependency to taking charge was in the role
she took in recounting the history of their relationship together. Marjorie evidently
felt proud at the increasing sense that theirs was a unique and impressive story
of a life together. She asked whether I might write about the work I had done
with them some day, and when I told her recently that I was writing this paper,
she asked (and then requested in writing) for her real name to be used.
Commentary It is easy to caricature psychiatrists
as representing a force of pathologisation, while as nurses we do something much
more creative. But this oversimplifies things to a ludicrous degree. This was
the point about my practice that I wanted to convey, that it is much easier for
all of us to find a problem in our clients and try to get rid of it. I, certainly,
find it a constant struggle to act from the position I described earlier: Validating
a person's experience, facilitating a negotiated view of their situation as the
natural upshot of their life history, trying simply to be with them in that situation,
attempting to change nothing (Laing, 1989). When I manage to do it though, often
with supervisory help as described, it seems to me that, paradoxically, attempting
to change nothing makes the most significant difference: In these circumstances
even the most traumatized clients begin to accept their experience and begin to
unfold as people (Davidson, 1992 pp.202-3). In the case in point, it was when
I was most absorbed in my relationships with Beverley and Marjorie, when I managed
just to be there with them, attempting with Jackie's help to change nothing, that
this sort of unfolding and growth took place; stagnation turned to breakthrough.
It was possible for me to maintain this approach by using (live) supervision to
help maintain an awareness of disequilibrium in our relationships, and using it
also to help retain a focus on strengths and away from 'problems' in the couple's
system. Our plan had focussed on validation, and validation
is what we managed to offer. In particular we validated Marjorie's experience
of anger at the changes she was undergoing, anger at being kept in the dark and
anger at not being taken seriously; we validated Beverley's experience of the
difficulty of gender reassignment, her need to retain some semblance of psychic
control in the face of these changes (which led to her difficulty in accepting
she had needs) and her onerous responsibility of looking after a highly dependent,
needy partner while she wanted to develop her own life for a change; and we validated
their experience as a couple, especially as their relationship was, surely now
more than ever in their thirty year history together, stigmatised and lacking
in social validation: A psychiatric patient and her ex-nurse carer, living as
man and wife; an elderly couple below the poverty line, facing death; two women,
one a transexual, in a relationship together. We also
managed to draw on strengths in Beverley and Marjorie's past experience together
to help them through the current crisis. We helped them to see how this crisis
emerged organically out of their life together and out of the roles they had adopted.
We talked also about how the crisis might merge into their future together: If
Beverley should die first, Marjorie might now manage independently and Beverley
could go to her death more integrated a person, with needs as well as capabilities.
My individual approach failed to maintain a wholly systemic
view of Beverley and Marjorie's situation, veering toward an idealisation of Marjorie's
role and denigration of Beverley's. With the involvement of a support worker,
however, a more truely systemic view was maintained, with much greater overall
neutrality regarding the question of whose was the 'healthier' role. As a self-regulating,
homeostatic system ourselves (helped in part by the supervision and the help with
our relationship we received from our manager), Jackie and I together saw Marjorie
and Beverley's ways of experiencing emotion, and their interpersonal functioning,
much more as complementary and inter-dependent.
Epilogue
Shortly before giving the presentation I met with Beverley and Marjorie to make
sure they were happy with my discussing them and to ask them for help with a review,
three months on, of the work we did together. They invited each other to respond,
demonstrating the best of listening skills and respect, helping each other out
as they talked. Characteristically now, according to colleagues, Marjorie took
the lead, saying they listened to each other more, although sometimes needing
reminders. "Yes," said Marjorie, "Beverley
listens to me more. But she does forget sometimes."
"And when I forget, Marjorie, you remind me," laughed Beverley.
Then, looking at me, Beverley added "And I remind her, too, when she doesn't
listen to me, you see." Beverley then again showed
her vulnerability, asking me to tell the interview panel how much more difficult
it is to go through a gender reassignment than people imagine. She lectured me
in rather an abstract way about these difficulties though, as if they were not
her own, and Marjorie raised her eyes to the heavens. Not everything had changed.
But perhaps that was the most humbling aspect of this experience: By working consistently
simply to be with Beverley and Marjorie, rather than trying to get something to
change, certainly some things remained as they had always been. They will still
no doubt both fall back on patterns of relating that they have each learnt early
in their lives and practised for many more decades than I have been around. But
at the same time Jackie and I had made it possible in some paradoxical way for
quite a dramatic change to take place. The change was a restoration of balance
and flexibility in their relationship. It felt very natural now for Marjorie to
be taking something of a lead and for Beverley to be concentrating to some extent
on her neediness. Beverley's account of difficulties
in relation to transexuality was in full flow. But these were difficulties my
interview panel should be informed about for their education. Beverley had stopped
short of expressing them as problems she was finding it hard to manage, or could
do with some support in talking through. She caught onto the irony of this and
finally paused. Marjorie added, semi-automatically, "I still have no idea
how to help Beverley choose her dresses, she drives me mad, I don't know what
to do. And I don't think my psychiatrist should decrease my medication Ben."
Marjorie and Beverley glanced at each other, then at me, a self-parody of stuckness
in their respective roles, and the three of us giggled.
Acknowledgement I should like to thank Ms.
Jackie Adeosun for her skillful use of the support-worker role in the above intervention.
I wish also to acknowledge the training, encouragement, supervision and support
given to me in the work described above by Mr. Nicholas Watts CQSW, Project Manager,
Cowley House Community Mental Health Day Centre, Directorate of Social Services,
London Borough of Lambeth, England. Cowley House has now closed due to cutbacks
in the local government Social Services budget. References
Davidson, B. (1992) What can be the relevance of the psychiatric nurse to the
life of a person who is mentally ill? Journal of Clinical Nursing, Vol 1 No. 4
pp.199-205 Laing, R. D. (1967) The Politics of Experience
Ballantine, New York Laing, R. D. (1989) Did You Used
to be R. D. Laing? recorded in Tougas, K., Shandel, T. & Feldmar, A. Channel
Four, London & Third Mind Productions Inc., Vancouver.
Phillips, A. (1995) On Flirtation Faber and Faber, London.
Skinner, A. C. R. (1976) One Flesh: Separate Persons Principles of Family and
Marital Psychotherapy, Constable, London. Smail, D. (1984)
Illusion and Reality: the Meaning of Anxiety, Dent, London.
© The Author
Revised version published in Nursing Times (1997) 93[25] pp.52-54 as 'Making a
Difference Through Acceptance'
Please let me know what you
think. Also, any enquiries concerning reproduction should be sent either in writing
to the following address, or by E-mail by clicking on my name:
Ben
Davidson, 8 Elsie Road, London SE22 8DX., England.
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