Guardedness in Communications between People Experiencing Acute Psychosis and Mental Health Nurses A thesis presented to Dublin City University for the Degree of Doctor of Philosophy By: Sean Boland (RPN, RGN, Fam. Ther. (FTAI), MA) June 2016 Supervisors Dr Evelyn Gordon Dr Mark Philbin School of Nursing and Human Sciences 0 Declaration I hereby certify that this material, which I now submit for assessment on the programme of study leading to the award of Doctor of Philosophy is entirely my own work, and that I have exercised reasonable care to ensure that the work is original, and does not to the best of my knowledge breach any law of copyright, and has not been taken from the work of others save and to the extent that such work has been cited and acknowledged within the text of my work. Signed: ______________________ Date: 31st August 2016 Student ID No: 56124562 i Acknowledgements I would like to extend my deep gratitude to the nurses and those who have experienced acute psychosis, without whom this study would not have been possible, and to the staff and management of the research site and Shine who assisted with the recruitment process. I would like to posthumously express my deep appreciation to my initial supervisor, Professor Chris Stevenson and to Dr Evelyn Gordon and Dr Mark Philbin for their encouragement, guidance, patience and sharing of their wisdom throughout the course of conducting this study and writing this thesis. Last but by no means least I would also like to extend my thanks and appreciation to my wife Susan, my children Jack, Anna and Connal, friends and colleagues for their support and patience throughout my journey through doing this study, as significant study time was put ahead of family time. ii Operational Definitions Acute Psychosis The term acute psychosis is commonly used among mental health professionals when referring to the presence of certain experiences that are occurring for a person. Experiences, what clinicians consider hallucinations, delusions, thought disorder and abnormal behaviour, and is believed as central features of the diagnostic terms schizophrenia, bipolar disorder and paranoia. The term also indicates that there is an increased intensity and severity attached to these experiences that leads to families and some who experience these experiences, to seek help from mental health professions. Service Users/Patients/Clients Within public mental health services the term patient, client and service user is used interchangeable when referring to those who attend these services and it is noted that they are also used interchangeable in the literature. In terms of clarity those study participants who had experienced acute psychosis are referred to as ‘service users’ or ‘service users experiencing acute psychoses’. Where appropriate other attendees of mental health services that have a different diagnosis, for example depression will be referred to as ‘patients’. Nurse In the main the term ‘nurse’ will be used instead of mental health or psychiatric nurse. Communication In relation to this study the term communication refer to the process of service users/patients and nurses interacting and conversing with each other. iii Table of Contents Declaration i Acknowledgements ii Operational Definitions iii Table of Contents ix Abstract Chapter 1. An Overview of the Thesis 1 1.1 Introduction 1 1.2 Background and Rationale for the Study 1 1.3 Study Aims, Methodology and Methods 2 1.4 Thesis Outline 3 1.5 Summary 3 Chapter 2. Literature Review: Psychosis and Communications: Main Understandings and Approaches Available to Mental Health Nurses Working in the Irish Mental Health Services 4 2.1 Introduction 4 2.2 Psychosis: A Contested Concept 4 2.2.1 Prevalence and incidence 5 2.2.2 Medical/Psychiatric Perspectives on Psychosis 8 - Classification of Psychosis 11 - Biological/Biomedical Signs and Symptoms – What is seen and experienced 13 - Treatment of Psychosis from a Biological/Biomedical Perspective 16 2.2.3 Biopsychosocial Approaches to Psychosis 19 - Stress-Vulnerability Model 20 2.2.4 Psychosocial perspectives for Psychosis 23 - Dialogical Approaches 24 - Cognitive behavioural approach for psychosis 28 2.2.5 Alternative Explanations of the Causality of Psychosis 31 - Trauma 31 - Spirituality 32 - Critique of Biomedical Psychiatry 34 2.2.6 Subjective Experiences of Psychosis 35 - Service User and Family Subjective Accounts 36 2.2.7 Psychosis – Voluntary Support Organisations 39 - Hearing Voices Movement 39 2.2.8 Lay Understandings of Psychosis 41 2.2.9 Summary of Psychosis: A Contested Concept 42 2.3 Communication between Nurses and Service Users 44 2.3.1 Introduction 44 iv 2.3.2 Nurses and the Therapeutic Relationship 45 2.3.3 Communication Challenges 45 - Dual Role – Custodian and Helper 47 - Risk and Vulnerabilities 47 2.3.4 Communication Models and Approaches available to Nurses 52 - Some General Models Available to Nurses 52 2.3.5 Models and approaches regarding Talking to Service User’s Experiencing Psychosis 57 - Peplau’s Interpersonal Relations Theory 57 - Bower’s Approach to Communicating with Acutely Psychotic Service Users 59 - Forchuk and Jensen’s Approach to Nursing Service Users with Disturbing Voices and Beliefs 61 2.4 Summary 63 Chapter 3: Methodology: Classic Grounded Theory 65 3.1 Introduction 65 3.2 Underpinnings Ideas 65 3.2 The Role of Literature in a Grounded Theory Study 65 3.4 Overview of grounded theory 67 3.4.1 Debates within Grounded Theory 68 3.5 Rationale for Using Classical Grounded Theory 71 3.6 Classic Grounded Theory: Methodological Framework 73 3.6.1 The Coding Process 73 - Substantive Coding 74 3.6.2 Constant Comparative Method 75 3.6.3 Theoretical Saturation 77 3.6.4 The Core Category Emergence 77 3.6.5 Memo – Writing 78 3.7 Summary 79 Chapter 4: Methods: Applying Classic Grounded Theory Methodology 80 4.1 Introduction 80 4.2 Aims and Objectives 80 4.3 Design and Procedures 80 4.3.1 Inclusion and Exclusion Criteria 80 - Inclusion Criteria for Service Users 81 - Inclusion Criteria for Nurses 81 - Exclusion criteria for Service Users 81 - Exclusion Criteria for Nurses 82 4.3.2 The Research Setting 82 4.3.3 Gaining Access 82 4.3.4 Participant Recruitment 83 4.3.5 Participant Profiles 84 - Figure 1 Nursing Participants Profiles 84 - Figure 2 Service User Participants Profiles 85 4.3.6 Data Collection 86 4.3.7 Some Reflections on the Interviews 86 4.3.8 Tape Recording the Interviews 87 4.4 Sampling Method 88 4.5 Data Analysis: Generating the Theory 89 v 4.5.1 Open Coding 89 4.5.2 Process of Identifying the Main Concern 90 4.5.3 The Process of Identifying the Core Category 91 4.4,4 Theoretical Saturation 92 4.5.5 Theoretical Memos 92 4.6 Ethical Considerations 93 4.6.1 Gaining Ethical Approval 93 4.6.2 Restraints Placed on the Study 95 4.6.3 Providing ‘Safe Measures’ for the Participants and Researcher 96 4.6.4 Informed Consent 97 4.6.4 Maintenance of Dignity 98 4.6.6 Risk to Benefit Ratio 98 4.6.7 Anonymity and confidentiality 100 4.6.8 Ethical struggles 100 4.8 Summary 101 Chapter 5: The Theory: Guardedness in Communications between People Experiencing Acute Psychosis and Mental Health Nurses 103 5.1 Introduction 103 5.2 The Main Concern: Establishing Permissible Communications 103 - Figure 3. The Key Components of the Main Concern 104 5.3 The Core Category: Guardedness in Communications 104 - Figure 4. Core Category and Sub-Core Categories 105 5.4 Overview of the Theory: Guardedness in Communications between Service Users Experiencing Acute Psychosis and Mental Health Nurses 106 - Figure 5.Evolution of the Theory 107 5.5 Summary 108 Chapter 6: Raising Guardedness 109 6.1 Introduction 109 6.2 Raising Guardedness 109 Figure 6. Raising Guardedness 110 6.2.1 Learning Guardedness 111 - Becoming Guarded 111 - Enacting Institutional Communications 117 6.2.2 Experiencing Risk 124 - Enacting Distrustfulness 118 - Experiencing hostility 129 6.2.3 Keeping Conversations Light 134 - Using re-assurance 134 - Playing the Game 139 6.3 Summary 143 Chapter 7: Lowering Guardedness 145 7.1 Introduction 145 7.2. Lowering Guardedness 145 Figure 7. Lowering Guardedness 146 vi 7.2.1 Developing Safety and Trust 146 - Making Connections 146 - Observing and timing – choosing a safe place 153 - Trusting the Other 160 7.2.2 Conversing about issues of Importance and Concern 166 - Creating joint understandings 166 - Easing worries 170 7.3 Summary 176 Chapter 8. Discussion of the Findings 177 8.1 Introduction 177 8.2 Guardedness in Communications’ as it relates to Therapeutic Communications 177 8.3 Guardedness in Communications’ as it relates to Collaboration 180 8.4 Guardedness in Communications’ as it relates to Socialisation and Therapeutic Relationships 184 8.5 Guardedness in Communications’ as it relates to Trust and Distrust 190 - Experiencing Hostility 192 - Observing and Timing: Choosing a safe Place 193 - Trusting the Other 194 8.6 Summary 195 Chapter 9. Implications and Conclusions 196 9.1 Introductions 196 9.2 Demonstrating Trustworthiness in this Study 196 9.2.1 The ‘Fit’ of the Theory ‘guardedness in communications’ 196 9.2.2 The ‘Workability’ of the Theory ‘guardedness in communications’ 197 9.2.3 The ‘Relevance’ of the Theory ‘guardedness in communications’ 198 9.2.4 The ‘Modifiability’ of the Theory ‘guardedness in communications’ 199 9.3 Some reflections on the Study and Personal Learning 199 9.4 Limitations 200 9.5 Implications for Practice 201 9.5.1 Implications for Nurses Working in Clinical Practice 201 9.5.2 Implications for Management and culture of Organisation