How to Coach Yourself and Others Coaching and Counseling in Difficult Circumstances | Page 97

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these basic skills and describe expert practice specifically with acutely psychotic patients. This
presents particular challenges which are not covered in basic communication skills training, namely
how to cope with and respond to patients who are apathetic or withdrawn, hallucinating, deluded,
agitated or overactive, thought disordered and irritable or aggressive.
Our introduction demonstrated that nurse-patient interaction was both highly valued and considered
to occur insufficiently frequently. The recommended practice structures (models, nursing process,
primary nursing) and policy (audits and good practice guides) for psychiatric nursing all seek to
make improvements to interaction frequency, style and content. Yet as we have also seen, these
efforts to improve psychiatric nursing practice do not deliver information on how they are to be
implemented with the most seriously and acutely ill patients that nurses cope with on a daily basis.
The value base and approach common to all psychotherapies and summarised so well by Carl
Rogers was found in our introduction to be present in diverse sources of expertise in dealing with
acutely ill psychiatric patients. It was central to mainstream therapeutic approaches such as
psychosocial interventions and cognitive behavioural therapy, through to the work of Laing, Berke
and Mosher, generally considered to be fringe or even anti-psychiatric movements. It was also
present in new innovations in dementia nursing care and the therapeutic community movement.
These values were also clearly reflected by our interviewees and formed the foundation or basis for
their approach to acutely psychotic patients. The interviews clearly demonstrated the primacy of
listening to patients, linked to respect and care/concern. Rogers’ terms seem to have disappeared,
but the value and attitude base remains similar. These probably represent universal moral elements
of care for the mentally ill and psychologically disturbed.
However our findings also move beyond these basic values in several ways. They articulate the
reality that nurses do not always wait for patients to willingly engage in interaction concerning their
symptoms and problems. Inpatient psychiatric nursing is a practice that mixes both active and
passive stances, and while nurses will sometimes wait for patients to approach them they will also
notice patients and seek them out in order to engage with them. The warmth, empathy, interest and
acceptance articulated by Rogers are present in the interviews, but they are located within a context
that shows that their deployment is a special challenge with acutely ill patients who are
unpredictable, angry and sometimes rejecting or aggressive. Rogers’ idea of congruence,
genuineness or honesty was present in the interviews, but perhaps with a more factual capacity in
relation to the realities of inpatient care where nurses represented a whole service provision
structure (the hospital) and legal framework of coercive detention. Thus what they had to be honest
about was, yes, their feelings of care for and warmth towards patients, but also the reality of the
whole panoply of the service which was provided (from hotel services through to the
multidisciplinary psychiatric team) and the reality of the patient’s legal status (sometimes
vehemently rejected by them). Finally, the interviews add another element not in any of the
voluntary, therapy based models that presuppose the patient wants to participate. That is that active
and passive approaches to acutely psychotic patients have to be judiciously mixed so as to recognise
the intensely personal and private nature of psychotic experience. Related to the active element
were a huge range of other interactional issues based o