therapist investigate important parts of the client’s environment. Any number of comments and questions can be used to gather information and to facilitate the client’s self-awareness and growth. We have found that the client shares a significant part of himself when he permits the therapist, through photographs, to become involved in his personal experiences. The therapist, on the other hand, may gain useful therapeutic information. Also, family photographs, while they most often portray good times, open the doors for investigating not-so-good times as well. Variations in the use of photographs in therapy sessions are being tried in our clinical setting. For exampie, we have asked clients to take pictures or have pictures taken with greater regularity, particularly during times of stress. The discussions based on those photos seem to make clients more aware of the important aspects of conflict situations, and that allows them to anticipate and prevent minor crises. We have asked clients to select and analyze favorite photographs, and then we discuss the characteristics consistently portrayed in the pictures to help them clarify their values and goals. We also have directed them to write funny, sad, angry, and affectionate captions for apparently meaningful photographs, to build up more flexible perceptions of the significant others in their lives. The promising variations appear limitless. There are some difficulties with the process. A major one is the cost, especially for those who are poor. In addition, many clients tend not to choose photographs at random when requested to do so, but screen them carefully. Also, men, unlike women and children, seem disinclined to respond to the approach. Another problem is that it is almost impossible to generalize about cases because of individual preferences and experiences. However, in spite of the apparent ambiguities and limitations of the technique, its potential appears to add more to the clinical process than it detracts.
INTEGRATING
MENTAL
HEALTH
CONCEPTS INTO A CURRICULUM FOR NURSING STUDENTS Kathleen Charles Lawrence
A. Magill, Winkelsteln, Oberlander,
UTraditionally almost exclusively
RN., MEd. M.D. M.D.
nursing school on the care
curricula have of the physically
focused ill. Care
Miss Magill, who was lead instructor in medical-surgical nursing at Mount Sinai Hospital when the program was established, is now assistant director of continuing education and training at the Bronx Municipal Hospital Center. Dr. Winkeistein is associate clinical professor of psychiatry and Dr. Oberlander is a clinical associate in psychiatry at the Mount Sinai School of Medicine, City University of New York. Please address reprint requests and inquiries to Dr. Winkeistein at the department of psychiatry, Mount Sinai Hospital, 100th Street and 5th Avenue, New York, New York 10029.
642
HOSPITAL
& COMMUNITY
PSYCHIATRY
for patients with emotional problems was studied separately in psychiatric nursing courses, which dealt mostly with the gravest types of psychopathology. The emphasis on crisis intervention furthered that trend. Because they were taught in such a piecemeal fashion, the students tended to compartmentalize their knowledge and often failed to understand that illness may have multiple causes and may require varied and concurrent forms of nursing intervention. Thus nursing students and graduates administered either physical or psychiatric care and rarely considered the patient as a whole person. Recognizing the need for more comprehensive patient care, several of our faculty members in the Mount Sinai Hospital School of Nursing’s medicalsurgical department attempted to integrate emotional health concepts into the general nursing curriculum.1 Experienced liaison psychiatrists, who were affiliated with the clinical departments where our students were assigned, enthusiastically agreed to participate in the program. Thus specific clinical problems could be discussed in detail by instructors, students, and psychiatrists involved in the actual care of the students’ patients. Our aims were to develop in the students an ability to identify mental health concepts, to utilize these concepts in the administration of comprehensive nursing care, and to evaluate the outcomes of such patient care. Over a two-year period, one of the psychiatrists conducted a series of five weekly one-hour sessions for groups of approximately 16 students each who were rotating through medicine and surgery. We used a semistructured format for our sessions. During the sessions, themes were introduced, sometimes at the instructors’ or students’ request, and were illustrated with clinical data involving patients known to the group. Later the sessions were supplemented by smaller patient-centered conferences conducted by liaison psychiatrists on the individual patient units. Some of the topics discussed in the weekly sessions included the emotional responses of patients to hospitalization and illness, the different roles of the surgeon and nurse in patient care, psychological aspects of mutilating surgery, and the dying patient. Other subjects were pre- and postoperative emotional reactions, psychological aspects of abortion, the meaning of the “difficult” patient’s behavior, and the nature and therapeutic value of communication between nurse and patient. As in many other consultant-consultee situations, students were free to accept or reject suggestions offered by the psychiatrist or other group participants. Meetings were nonauthoritarian in structure, and thus, in responding to a particular theme, participants were free to explore their own feelings and those of others in a relatively nonthreatening, supportive environment. In
1971
the
Mount
replaced by a baccalaureate City College of the City
Sinai
School
program University
of
Nursing
closed
and
was
in the Nursing of New York.
School
of the
(Continued
on page
645)
4
‘4
1
0
(Continued
from
page
642)
At one of the meetings on the emotional aspects of mutilating surgery, the discussion was stimulated by the group’s concern for a patient who experienced severe depression following an emergency ileostomy for perforating diverticulitis. It soon became evident that the students’ initial reactions to an artificial opening in the abdominal wall for the passage of stool were similar to those feelings experienced by many patients and their families-shock, disbelief, and bewilderment. It was an emotional strain for them to care for patients who had undergone stomal surgery. The students recognized that the usual reactions of a patient to such surgery often reflect fear that it is performed only as a last resort and is horrible beyond the realm of emotional adjustment. When they observed and discussed the surprising inner strengths that most patients exhibit in response to mutilating procedures, such as mastectomies and amputations as well as stomal surgery, students became more comfortable with and supportive of such patients. In another meeting, the emotional reactions of a patient to elective abortion became the focus of discussion. (Abortions were being performed for the first time in the hospital at the request of the patient. ) Again, the reactions within the group seemed to mirror those of individual patients. The fact that elective-abortion patients were often the same age as the students clearly stimulated the group’s identification with them. Intense anger toward the physician who performed the procedure, toward the patient who sought it, and even toward fellow students who favored legalized abortions was openly expressed and discussed. The students eventually realized that perceiving and understanding patients’ attitudes, which may be different from their own, facilitates good nursing care. The group generally agreed that those who were unable to achieve such insight might express their own negative attitudes in subtle forms that would demoralize a patient. In a session concerning the dying patient, we discovered that most of the students had never experienced prolonged contact with a dying person. Some had never attended a funeral. The emotional impact of seeing and caring for a dying person was overwhelming at times. Some students denied that their patients were that close to death; others expressed anger over our helplessness in the face of incurable illness. Others adopted the philosophy that death was a merciful termination of terrible suffering, and some thought that illness and suffering had redemptive powers that would help one find happiness in a life after death. One instructor gently reminded the group that a dying patient was still alive and desperately needed the love and concern of those closest to him-his family, nurses, and physicians. Eventually the students came to an uneasy recognition that, even in the face of incurable illness, one can still do much to relieve a patient’s suffering. Subsequently, when deaths did occur on the units, many group members were able to talk more freely about
their feelings and to be supportive of one another and to surviving family members. Instructors were alert to the needs of those students who appeared least able to cope with the discussion of death and gave them added support. At no time was it necessary to remove students from assignments involving dying patients. From the start students participated actively in the group sessions. Questions concerning the application of mental health concepts to nursing-care situations were included in all examinations. The students generally did well with those questions and, in anonymous evaluations of our sessions, commented favorably on their experience. Most important, direct observation of students indicated that they frequently used the services of the liaison psychiatrists and applied mental health concepts with growing effectiveness in the administration of nursing care.
THE USE OF HOME VISITS TO AVOID HOSPITALIZATION IN A PSYCHOTIC CRISIS Bruce
Granovetter,
M.D.
UThe crisis team at the Tremont Crisis Center in the Bronx feels that many psychotic crises can be resolved without hospitalization and often in a remarkably short time. The team uses a combination of treatment approaches and makes home visits when necessary. The following case illustrates how effective the team’s approach can be. Mrs. B’s son-in-law contacted the crisis team on her behalf. Mrs. B, a 54-year-old woman of Italian descent, had not set foot from her apartment for three and a half years. She wanted psychiatric help, but she would not leave her apartment. The crisis team sent three of its members to see her. They were greeted by Mrs. B, a trembling, disarrayed, and tearful woman who hid behind the door until they had entered. She told them that she was terrified to go outside her apartment. She did not permit anyone in her family to visit her because she felt they were involved in a conspiracy against her. She also accused her roommate of being a member of the conspiracy; she shared the apartment with Mrs. D, a diagnosed chronic schizophrenic whom Mrs. B had met four years before, while both were hospitalized in a state institution. Mrs. B also did not permit the radio or TV sound to be turned on because she was afraid of it. Everything in the house with a name or number on it was covered with adhesive tape or wrapped in opaque plastic, including the contents of the refrigerator and cabinets. Also, she allowed no newspapers in the apartment. Mrs. B told the team members that a month before
Dr. Granovetter is a first-year resident at the Tremont Crisis Center, a track of the department of psychiatry of the Albert Einstein College of Medicine in the Bronx. His mailing address is PH E, 221 West 82nd Street, New York, New York 10024.
VOLUME
26
NUMBER
10
OCTOBER
1975
645
INTEGRATING
MENTAL
HEALTH
CONCEPTS INTO A CURRICULUM FOR NURSING STUDENTS Kathleen Charles Lawrence
A. Magill, Winkelsteln, Oberlander,
UTraditionally almost exclusively
RN., MEd. M.D. M.D.
nursing school on the care
curricula have of the physically
focused ill. Care
Miss Magill, who was lead instructor in medical-surgical nursing at Mount Sinai Hospital when the program was established, is now assistant director of continuing education and training at the Bronx Municipal Hospital Center. Dr. Winkeistein is associate clinical professor of psychiatry and Dr. Oberlander is a clinical associate in psychiatry at the Mount Sinai School of Medicine, City University of New York. Please address reprint requests and inquiries to Dr. Winkeistein at the department of psychiatry, Mount Sinai Hospital, 100th Street and 5th Avenue, New York, New York 10029.
642
HOSPITAL
& COMMUNITY
PSYCHIATRY
for patients with emotional problems was studied separately in psychiatric nursing courses, which dealt mostly with the gravest types of psychopathology. The emphasis on crisis intervention furthered that trend. Because they were taught in such a piecemeal fashion, the students tended to compartmentalize their knowledge and often failed to understand that illness may have multiple causes and may require varied and concurrent forms of nursing intervention. Thus nursing students and graduates administered either physical or psychiatric care and rarely considered the patient as a whole person. Recognizing the need for more comprehensive patient care, several of our faculty members in the Mount Sinai Hospital School of Nursing’s medicalsurgical department attempted to integrate emotional health concepts into the general nursing curriculum.1 Experienced liaison psychiatrists, who were affiliated with the clinical departments where our students were assigned, enthusiastically agreed to participate in the program. Thus specific clinical problems could be discussed in detail by instructors, students, and psychiatrists involved in the actual care of the students’ patients. Our aims were to develop in the students an ability to identify mental health concepts, to utilize these concepts in the administration of comprehensive nursing care, and to evaluate the outcomes of such patient care. Over a two-year period, one of the psychiatrists conducted a series of five weekly one-hour sessions for groups of approximately 16 students each who were rotating through medicine and surgery. We used a semistructured format for our sessions. During the sessions, themes were introduced, sometimes at the instructors’ or students’ request, and were illustrated with clinical data involving patients known to the group. Later the sessions were supplemented by smaller patient-centered conferences conducted by liaison psychiatrists on the individual patient units. Some of the topics discussed in the weekly sessions included the emotional responses of patients to hospitalization and illness, the different roles of the surgeon and nurse in patient care, psychological aspects of mutilating surgery, and the dying patient. Other subjects were pre- and postoperative emotional reactions, psychological aspects of abortion, the meaning of the “difficult” patient’s behavior, and the nature and therapeutic value of communication between nurse and patient. As in many other consultant-consultee situations, students were free to accept or reject suggestions offered by the psychiatrist or other group participants. Meetings were nonauthoritarian in structure, and thus, in responding to a particular theme, participants were free to explore their own feelings and those of others in a relatively nonthreatening, supportive environment. In
1971
the
Mount
replaced by a baccalaureate City College of the City
Sinai
School
program University
of
Nursing
closed
and
was
in the Nursing of New York.
School
of the
(Continued
on page
645)
4
‘4
1
0
(Continued
from
page
642)
At one of the meetings on the emotional aspects of mutilating surgery, the discussion was stimulated by the group’s concern for a patient who experienced severe depression following an emergency ileostomy for perforating diverticulitis. It soon became evident that the students’ initial reactions to an artificial opening in the abdominal wall for the passage of stool were similar to those feelings experienced by many patients and their families-shock, disbelief, and bewilderment. It was an emotional strain for them to care for patients who had undergone stomal surgery. The students recognized that the usual reactions of a patient to such surgery often reflect fear that it is performed only as a last resort and is horrible beyond the realm of emotional adjustment. When they observed and discussed the surprising inner strengths that most patients exhibit in response to mutilating procedures, such as mastectomies and amputations as well as stomal surgery, students became more comfortable with and supportive of such patients. In another meeting, the emotional reactions of a patient to elective abortion became the focus of discussion. (Abortions were being performed for the first time in the hospital at the request of the patient. ) Again, the reactions within the group seemed to mirror those of individual patients. The fact that elective-abortion patients were often the same age as the students clearly stimulated the group’s identification with them. Intense anger toward the physician who performed the procedure, toward the patient who sought it, and even toward fellow students who favored legalized abortions was openly expressed and discussed. The students eventually realized that perceiving and understanding patients’ attitudes, which may be different from their own, facilitates good nursing care. The group generally agreed that those who were unable to achieve such insight might express their own negative attitudes in subtle forms that would demoralize a patient. In a session concerning the dying patient, we discovered that most of the students had never experienced prolonged contact with a dying person. Some had never attended a funeral. The emotional impact of seeing and caring for a dying person was overwhelming at times. Some students denied that their patients were that close to death; others expressed anger over our helplessness in the face of incurable illness. Others adopted the philosophy that death was a merciful termination of terrible suffering, and some thought that illness and suffering had redemptive powers that would help one find happiness in a life after death. One instructor gently reminded the group that a dying patient was still alive and desperately needed the love and concern of those closest to him-his family, nurses, and physicians. Eventually the students came to an uneasy recognition that, even in the face of incurable illness, one can still do much to relieve a patient’s suffering. Subsequently, when deaths did occur on the units, many group members were able to talk more freely about
their feelings and to be supportive of one another and to surviving family members. Instructors were alert to the needs of those students who appeared least able to cope with the discussion of death and gave them added support. At no time was it necessary to remove students from assignments involving dying patients. From the start students participated actively in the group sessions. Questions concerning the application of mental health concepts to nursing-care situations were included in all examinations. The students generally did well with those questions and, in anonymous evaluations of our sessions, commented favorably on their experience. Most important, direct observation of students indicated that they frequently used the services of the liaison psychiatrists and applied mental health concepts with growing effectiveness in the administration of nursing care.
THE USE OF HOME VISITS TO AVOID HOSPITALIZATION IN A PSYCHOTIC CRISIS Bruce
Granovetter,
M.D.
UThe crisis team at the Tremont Crisis Center in the Bronx feels that many psychotic crises can be resolved without hospitalization and often in a remarkably short time. The team uses a combination of treatment approaches and makes home visits when necessary. The following case illustrates how effective the team’s approach can be. Mrs. B’s son-in-law contacted the crisis team on her behalf. Mrs. B, a 54-year-old woman of Italian descent, had not set foot from her apartment for three and a half years. She wanted psychiatric help, but she would not leave her apartment. The crisis team sent three of its members to see her. They were greeted by Mrs. B, a trembling, disarrayed, and tearful woman who hid behind the door until they had entered. She told them that she was terrified to go outside her apartment. She did not permit anyone in her family to visit her because she felt they were involved in a conspiracy against her. She also accused her roommate of being a member of the conspiracy; she shared the apartment with Mrs. D, a diagnosed chronic schizophrenic whom Mrs. B had met four years before, while both were hospitalized in a state institution. Mrs. B also did not permit the radio or TV sound to be turned on because she was afraid of it. Everything in the house with a name or number on it was covered with adhesive tape or wrapped in opaque plastic, including the contents of the refrigerator and cabinets. Also, she allowed no newspapers in the apartment. Mrs. B told the team members that a month before
Dr. Granovetter is a first-year resident at the Tremont Crisis Center, a track of the department of psychiatry of the Albert Einstein College of Medicine in the Bronx. His mailing address is PH E, 221 West 82nd Street, New York, New York 10024.
VOLUME
26
NUMBER
10
OCTOBER
1975
645
