The Nurse and the Mental Patient; a Study in Interpersonal Relations

the Nurse and the PatlMit A Study in Interpersdnaf Relations Shows the Importance of the nurse- /?^//e/)^; /-e/a^/o/7s/7/^ in contributing p<3^^::^ ent mmm'"' iWORRiS S. SCHWARTZ >^ THE NURSE AND THE MENTAL PATIENT A Study in INTERPERSONAL RELATIONS By MORRIS S. SCHWARTZ, Ph.D. EMMY LANNING SHOCKLEY, R.N. M.S. in Nursing Education With the assistance of CHARLOTTE GREEN SCHWARTZ, M.A. • • Sydney John Wiley & Sons, Inc. New York London PUBLICATIONS OF RUSSELL SAGE FOUNDATION RussfU Sage Foundation was established in 1907 by Mrs. Russell Sage the Jot improvement oj social and living conditions in the United Stales. In carrying out its purpose the Foundation conducts research under the direction of members of the staff or in close collaboration with other institutions, and supports programs designed to develop and demonstrate productive working relations between social scientists and other profes- sional groups. As an integral part oj its operations, the Foundation from time to time publishes books or pamphlets resulting from these activities. Publication under the imprint the of Foundation does not necessarily imply agreement by the Foundation, its Trustees, or its staff with the interpreta- tions or conclusions of the authors. 20 19 18 17 16 15 © 1956 Russell Sage Foundation Printed in the United States of America PubUrf,ed as a John WUey & Sons. Inc.. paperback tuthonzed by RusseU Sage Foundation ISBN 471 76610 Library of Congress Catalog Card Aumba: sG-ygjs Contents Foreword by Walter E. Barton, M.D 5 Preface by Esther Lucile Brown, Ph.D 9 Introduction ^3 PART ONE RECURRING PROBLEM SITUATIONS •"ear and Patient Assaultiveness 21 (2iL^EAR and Patient Assaultiveness (continued) .... 44 NThe Patient Is Demanding 7^ The Patient Is Withdrawn 9^ "^The Patient Is Hallucinatlng, Delusional, or Self- Preoccupied 113 6. The Patient Has Eating Difficulties 139 ^^^;^ The Patient Is Incontlnent 149 8. The Patient's BEHAvnoR Has A Sexual Connotation . 157 C^^ffHE Patient Is Suicidal 167 SoH The Patient Is Extremely Anxious 182 PART TWO lnterpersonal processes common to problem situations The Nurse and THE Patient—An Illustration . 201 Understanding the Patient 218 231 ;; Communicating with the Patient [4." Relating to the Patient 244 rj5r Conclusion 282 Index Introduction to the Paperbound Edition number IN the decade that has elapsed since this book was written, a of new and exciting developments in the care of hospitalized mental patients have emerged. These developments have accompanied radical reconceptualization of the nature of mental illness and the conditions and modes of intervention necessary for its alleviation. These changes in thinking and practice have inevitably resulted in a different kind of social context within which the nurse-patient rela- patient. tionship is carried on and a redefinition of the role of nurse and other What is expected of each and of both in interaction with each stands in sharp contrast to the expectations of a decade ago. What are some of the new ways of thinking about the nature of the diflBculty that brings a patient to the mental hospital and keeps him there? There has been increasing acceptance of the idea that non- organic mental illness is not a disease entity lodged within the patient. Rather, it is seen as a pattern of difficulty that the person manifests in relating to himself and others that creates and maintains anguish for himself and trouble for others. This pattern of difficulty is seen not only as a product of what a patient "is" but of what he does and what others think about him and do to, and with, him. This line of thinking — further maintains that, if the patient's difficulties are to be alleviated his thinking and behavior changed — not only must the patient do something about himself but personnel who are part of his daily social environment must develop attitudes and behavior toward him that best fit his needs and are most appropriate for his current and chang- ing condition. These ideas have led to the attitude of increased hopefulness about patients and to the expectation that most patients need not become TIIE NURSE AND THE MENTAL PATIENT chronic. Once the beHef had been abandoned that there was something endemic in the mental patient that inevitably kept him ill, mental hospital personnel could entertain possibilities of early release and work on the assumption of short-term hospitalization. What have been some of the changes in the conception of who could be helpful to the hospitalized patient, how help might be of- fered him, and what might be instrumental in eflFecting a therapeutic result for him? There has been increasing agreement with the idea that it is not exclusively or even primarily the doctor who "gets the patient well!' Instead, compared with a decade ago, there is more widespread acceptance of the idea that any one or several of a large number of persons in the patient's social environment might con- tribute to his recovery. It is now maintained that it is the therapeutic team, as individuals and as a group, that brings about therapeutic results. While the authority of the psychiatrist in the mental hospital setting has been maintained, his "magical" powers of cure have been put into realistic perspective, as has the potential contribution of other personnel. The latter— nurses, aides, social workers, and psychol- ogists—are no longer seen as adjuncts to treatment; they are held to be as central as the psychiatrist in the patients' improvement. The patients, too, are viewed as significant instruments in their own recovery. This means that social structural reorganization and the utilization of group processes, as in the development of therapeutic milieu and communities, play as important a part in recovery as specific procedures, such as drugs, electroshock therapy, or individual psycho- therapy. In this view of help, the patient is not "given treatment"; that is, he is not dealt with as a passive recipient of the staff's ministrations but is enlisted as an active participant in his own treatment and that of his fellow patients. These rcconceptualizations of the nature of the difficulty designated as "mental illness" and of the kinds of structures, processes, and procedures that might help patients have resulted in the creation of new organizational forms within the mental hospital and in some instances of institutions that are so different in their conception and structure that they are scarcely recognizable as mental hospitals as previously defined. For example, the concept of the mental health center has INTRODUCTION TO THE PAPERBOUND EDITION been used to create a complex of services that includes twenty-four hour care, day care, evening hospital, out-patient care, and a halfway house. In addition, the mental health center has sought alternatives to hospitalization for persons referred to it. In contrast with a decade ago, hospitalization is not viewed as the necessary first choice for helping an emotionally disturbed or psychotic person. With a range of treatment alternatives, personnel can select the treatment that seems most appropriate, given the patient's needs, diflBculties, and family situation, radier than be compelled to hospitalize the person because no other alternative is available. Institutions that house and treat the emotionally disturbed are now being viewed as resocialization or reeducational centers, rather than as settings whose primary function is to give medical treatment, as in a hospital. This especially is true for those settings that have been organized into therapeutic communities. Here concern is focused on the social organization of the institution, on the values and norms that predominate, on the prevailing types of interpersonal relationships, on the emotional toning that characterizes the institution and relationships therein, and on the impact of all these on the progress of the patient in learning new patterns of relating to, and feeling about, himself and others. Even the more conventionally organized mental hospitals are tend- ing toward more open and flexible social organizations and role defini- tions for patients and staff. In general, the conception of the mental hospital as a relatively isolated, self-contained unit is being abandoned, and the barriers between the hospital and the community are breaking do\vTi. Thus, community members are given the opportunity to come into the hospital in various roles, in greater numbers, and with increasing frequency. Conversely, mental hospital personnel are moving into the community in order to use its resources for their patients. Inside the hospital the emphasis is less on cure and permanent re- turn to the community and more on releasing patients rapidly, even though they have obvious limitations. The concern is not so much with recidivism as with having patients remain out of the hospital when- ever and as long as they can. During their hospital stay patients have TIIE NTJRSE AND THE MENTAL PATIENT greater freedom of movement within the hospital as well as outside. There is a continuing push toward open doors and a deemphasis on surveillance and prisonlike procedures. And patients are being given more and more responsibility for themselves and their fellow patients. As a consequence of this "opening up',' both staff and patients are more exposed to the "normal" world and both have to respond to, and come to terms with, this world just as the outside world now has to deal more often with the members of these institutions. The past decade has seen a growing recognition of the detrimental effects of the mass features of mental hospitals. Attempts are being made to counteract or eliminate these mass phenomena by individual- izing patient care. Thus, large hospitals are being decentralized into a number of relatively autonomous smaller units. Within these decentralized units, wards are organized so that a small number of patients is the responsibility of a single staff member.

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