How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 61
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There have been several publications on applying cognitive behavioural techniques on acute inpatient wards to
people suffering acute psychoses (Clarke & Wilson 2009) plus a report on our own work in this area (McCann
& Bowers 2005). The full range of CBT techniques are not applicable to acutely ill patients as they require the
ability for introspection unavailable to patients in florid psychotic states. Despite this, lower level and more
simple techniques, such as relaxation training, and coping strategy enhancement have been applied in the
inpatient setting leading to higher level interventions such as relapse prevention work and psycho education
once the psychosis has stabilised (Forsyth et al. 2009). In descriptions of these techniques, however, the
interactions utilised in florid states of psychosis are poorly described and many of the pioneering research
studies in this area actively excluded people with florid symptoms. An adaptation of CBT and so called
“Mindfulness” techniques taken from meditative philosophies has also been adapted for people with psychosis.
Acceptance and Commitment Therapy (ACT) has been said to prevent the rehospitalisation of psychotic patients
(Gaudiano & Herbert 2006), but again the interventions seems to assume a level of functioning that is often
beyond a person with florid symptoms. These interventions are extremely novel and have yet to gain a wide
implementation or examination.
These ways of ameliorating psychotic symptoms do provide one available framework for therapeutic
interactions between nurses and patients. Reducing expressed emotion is more widely applicable and can
provide a backdrop or context to all interactions between professionals and patients on the ward.
Potential lessons from dementia care
While authoritative and detailed writing about communicating with acutely psychotic patients is scarce, a
considerable amount is available on communicating with those suffering from dementia. While not everything is
transferable due to differences in the nature and experience of dementia and acute psychosis, some things
clearly are applicable, and there is great potential for cross fertilisation. One work (Killick & Allan 2001)
highlights the skills used in starting conversations, maintaining them, and ending well with good feelings and a
sense of completeness. Many ways to bring conversations to a positive end are offered: take time; give cues
verbal and nonverbal (have to go in a minute, other tasks waiting, sit on edge of chair); thank for conversation
and say what you have enjoyed, perhaps summarise content; leave time to hear their feedback if they want to
make some; develop an ending routine that can be reused with the same person again to generate habit; say
you'll come back and are looking forward to it; leave a card; tell them when you will be available again.
Validation therapy (Feil 1993) is a more theoretically inspired approach that aims to help people with dementia
deal with developmental tasks carried over from previous phases of their lives. However most of the fourteen
techniques of validation therapy (factual questions, rephrasing, using polarity, imagining the opposite,
reminiscing, using ambiguity, mirroring, tone of voice, linking the behaviour with unmet need, identifying and
using the preferred sense) can be utilised to some degree or other in conversations with the acutely psychotic.
Fundamental to both these works is an understanding of the experience of dementia, what it does and doesn't
change, what people with dementia might feel in different situations and contexts. As such it demonstrates an
acute sensitivity. It is hard to think of any such professional account of acute psychosis. Most accounts are
objectified (i.e. accounts of behaviour and symptoms) rather than truly phenomenological. Therefore a good
starting point might be patients’ accounts of being ill or user poetry, whilst acknowledging that such accounts
can be distorted by the illness itself. Again, interestingly, nearly all approaches to communication with people
suffering from dementia draw upon Carl Rogers’ psychotherapeutic ideas and values.
Summary and aim of this work
Previous work does have some significant guidance to offer the practicing psychiatric nurse who is caring for an
acutely psychotic person and who wants to communicate with them effectively and therapeutically. The goals of
that interaction would be to keep the patient and others safe, accurately assess their mental state, deliver
appropriate treatment (physical, psychological and social), and ensure that their physical health and needs are
catered for. The foremost things the literature offers is the importance of basic listening and communications
skills, coupled with a set of attitudes and values that sees the person and their experience as important and to be
understood as well as possible. Ways of working have been developed that allow nurses to spend at much of
their time as possible in contact with a small number of patients, so as to develop these processes. Some
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