How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 59

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acutely psychotic patients, and the recommendations consist of structured small group activities of the type
routinely conducted by occupational therapists and nurses (Remocker & Storch 1977). There is little specific
advice on interaction with patients in these states, other than that they should be ‘supportive’. Yalom thus takes
us no further forward than Laing, Berke, Mosher and Barker.
Alongside Yalom, a variety of sources recommend the use of ‘supportive techniques’ with acutely psychotic
patients, emphasising acceptance, affection, partnership, optimism, respect, empathy, reassurance,
encouragement, advice and problem solving (Lakeman 2006). Whether such approaches constitute a therapy
(i.e. used in the belief that they will produce symptom reduction or permanent change) can be questioned; and
they can perhaps better be understood as normal expressions of care, or even a moral stance towards those in
any psychological distress. As such, they are definitely applicable as a ways to talk with and spend time with
those who are acutely psychotic, and can be readily integrated into everyday psychiatric nursing practice.
Early behaviour therapy research during the 1950s and 60s did examine staff and patient responses to the
psychotic behaviour of long stay inpatients who were considered to be chronically ill. In particular the research
looked at how other patients and staff acted so as to reinforce (or not) the expression of psychotic symptoms
(pacing, aggression, psychotic talk, shouting). Observational research did show that symptomatic behaviour in
this patient groups was sometimes positively reinforced by nurses, although appropriate behaviour was also
particularly well rewarded by qualified nurses and other patients (Gelfand, Gelfand, & Dobson 1967).
Intervention studies showed that such behaviours could be substantially by nurses via positive attention to
normal behaviours and ignoring the symptomatic behaviours (Ayllon & Michael 1959). Thereafter such
approaches to care of chronically ill patients were widely used in token economies or other behavioural
rehabilitative strategies. However these patients were not necessarily acutely psychotic. Their behavioural
disturbances may have more been a product of the institutional environment than their illness. Simple
suppression of psychotic symptoms might be achievable through behavioural reinforcement. However
suppression is not equivalent to therapeutic change, and generalisation to settings outside the hospital is
completely unproven, as is any endurance of change past the time as which the behaviour therapy ends.
Moreover, suppression of symptoms and the failure of staff to listen to the psychotic experience might well
accentuate patient sense of difference, exclusion, loneliness and stigmatisation, thereby making depression or
even suicide more likely. Thus it is sad to read statements that nurses’ efforts to listen to and understand the
patient are to be considered intermittent reinforcement of psychotic behaviour (Gelfand, Gelfand, & Dobson
1967).
Solution focused or brief therapy has also been applied, albeit rarely and with little in the way of evaluation, to
acute inpatient care (Macdonald 2007;Vaughn et al. 1995). This type of therapy is geared towards helping
patients find and implement their own solutions to their problems whilst monitoring their own progress and the
impact of changes they are making. In order to function, this type of therapy requires patients to be able to
engage in meaningful dialogue, and as this is not possible for some acutely psychotic individuals, it is therefore
not universally applicable. In addition some contortions are necessary to apply it within the framework of
compulsory detention, and it only caters for strictly therapeutic conversations geared towards problem solving.
However it does provide a formula or approach that facilitates meaningful and acceptable dialogue between
nurses and patients, shaping a collaborative and positive relationship.
The influence of Carl Rogers’ person-centred therapy (Rogers 1961) has been enormous. Not only have specific
techniques such as summarising, paraphrasing and reflecting, entered nursing through communication skills
training. The values and attitudes which form part and parcel of his humanistic approach have been adopted by
psychiatric nurses and many others. These attitudes include: warmth, genuineness (congruence), unconditional
positive regard (acceptance, caring, or prizing), empathic understanding, and non-judgmentalism. These
attitudes or fundamentals of human person to person care have probably been m