How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 60
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reflections, facial reflections, word for word reflections, body reflections and reiterative reflections. These
methods do not require verbal ability on the part of the patient or dialog with them. Instead they create ‘contact’
with the patient, with contact construed as the elicitation of some form of person to person recognition and
interaction in the real world, as opposed to the withdrawn inner world of the patient’s psychosis, or alternative
self-awareness (contact of the person with themselves). Some authors make large claims for the therapeutic
impact of pre-therapy (Pörtner 2002) with little evidence other than personal experience. Most of the accounts
simply do not translate to acute psychiatry – they are with institutionalised chronic patients, and much of the recontacting is about getting past the institutionalisation, not the psychosis (Pörtner 2002;Van Werde 2005). The
institutional care described is of a poor quality, and many of the patients described clearly do not need
hospitalisation. The patients are constantly very ill and handicapped – equivalent to high support hostel
residents, perhaps, in the UK, and the management are weak and distant. The basic nursing described is
deficient and applying pre-therapy masks the issue. Nevertheless these are five useful techniques for use with
withdrawn and generally uncommunicative patients suffering from acute psychosis. In addition, the whole
approach usefully underlines the importance of being with the patient, knowing who they are and what their
interests and pre-occupations are, rather than doing things to them.
For nurses who are psychotherapeutically informed, the nurse-patient relationship is seen as the focal encounter
in the process of therapy. Psychotherapeutic approaches in mental health nursing (Winship et al. 2009), have
been realised in the high quality practice in at least some institutions. In particular, the focus has been on the
nurse as therapeutic agent who applies psychotherapeutic interpersonal skills across a range of therapeutic
encounters, either in individual practice, group therapy or in the psychotherapeutic milieu as a whole. Mostly
psychoanalytically inspired, such approaches to psychosis can be characterised as more assertive and combative
than those inspired by Rogers (Jackson & Williams 1994). It has been shown that nurses can assume a much
more active role in the formal psychotherapy process without compromising their potency in the milieu.
Attempts have been made at integrating the role of nurse and therapist in so far as nurses carried an individual
case load seeing patients for sessions at least twice a week and sometimes up to five times a week where
necessary (Bell 1997;Jackson & Crawley 1992;Jackson & Williams 1994;Ritter 1984). The approach of the
nursing staff was not psychotherapy per se, and the nurses were not employed as psychotherapists, but intensive
supervision, a high level of teaching and psychotherapeutic training can ensure that the patients receive a
substantial psychotherapeutic intervention. However none of the literature from this tradition can be summarised
into a set of simple recommendations on interaction strategies with the acutely psychotic, instead requiring for
its application a high degree of training and education, and dedicated therapist-patient sessions.
Expressed Emotion, psychosocial interventions, and cognitive behavioural therapy
Up until the 1980s, the most effective treatment to reduce symptoms and the risk of relapse has been treatment
with neuroleptic drugs. Two strands of research have made a significant difference to this picture, demonstrating
that psychological and social interventions can reduce symptoms and relapse too. Although it is unlikely that
these treatment methods will replace medication, they do constitute a way of delivering significant additional
benefit to patients. The first strand of research that demonstrated that this was possible focused on the family
care environment, showing that hostility and criticism of the ill person (high expressed emotion), exacerbates
the illness (Tarrier et al. 1989). The second strand of research successfully applied existing cognitivebehavioural therapy techniques to the management of reduction of the symptoms of schizophrenia. This
research showed that the intensity with which delusional beliefs were held, and the disruption caused by
hallucinations could be reduced through a form of verbal questioning, belief modification, and experimental
reality testing. The resulting therapeutic techniques, often called together ‘psychosocial interventions’, are
mostly offered to patients when they are well and living in the community. However there have also been
endeavours to implement them on acute psychiatric wards, with some evidence that they have a positive effect
(Drury 1994;Drury et al. 1996a;Drury et al. 1996b).
With respect to high expressed emotion, this has been identified as present in staff (Van Humbeeck et al. 2001)
and associated with high levels of symptomatology (Kuipers & Moore 1995) although the direction of causality
has not been established. Given that in family environments expressed emotion is known to precipitate relapse,
it is a reasonable deduction that staff should ensure the tenor and content of their interactions with patients is
warm and nonjudgmental rather than hostile and critical. Strikingly, these ideas take us back to Carl Rogers.
Given the challenging nature of the behaviours of acutely psychotic patients, following this recommendation
might be more difficult than it first appears.
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