DOI: 10.31038/PSYJ.2022424

Abstract

Self-experience in nursing leads to an expansion of personal and professional scope. Emotionality, empathy and perception become, as it were an instrument, more precise and coherent to use. Self-awareness raises questions, as well as directing one’s gaze to wherever the entanglement is located. Where patterns are repeated over and over again or internal laws require compliance it becomes clear why, and what of it should remain the same or be changed. Self-experience raises awareness and reduces psychodynamic symptoms.

Keywords

Nursing, Self-awareness, Affect resonance training

Good nursing depends on the ability to experience childlike reactions without ceasing to be an adult. This ability can be strengthened and promoted [1]. This usually requires training, supervision and self-awareness. This enables openness, thoughtfulness, consideration, attention and creative thinking in a challenging work environment [2]. Through mechanisms such as bonding or identification, we get infected by the feelings or states of others. By letting in, we learn to empathize, to have compassion as well as setting boundaries and by that we tempt to develop a proper self. During the process of self-awareness, conflicts of one’s own are re-activated and are therefore, as Steinberger [3] writes “…subjects to constant self-control. The ability to mobilize one’s own conflicts or affects, thoughts and feelings from the past is the key to understand the patient, it is fundamental to be able to empathize”. Self-experience goes against the belief in speed. It takes time to develop its effectiveness, it needs a safe and clear space in which the knots and entanglements along the life story become visible. Usually no new memories are generated. Memories are often given a different meaning, a different reference. The network is being rebuilt. In the context of self-experience, Quinodoz emphasizes that apparently incompatible parts such as fear of being incomprehensible, being flooded or not to be able to hold up one’s own barriers, are conscientized and made accessible and useful. This is important in the context of nursing because personal and interpersonal experiences as well as being in a caretaking position, one’s own experiences and dynamics are always triggered. Past, damaging relationship patterns and experiences of patients are relived. The intensity depends on how severe current mental disorders are. Patients thereby reveal existential needs, abilities as well as anxieties that run the risk of making no sense whatsoever if they are not interpreted the right way. In a caretaking position to understand these states, behaviors or scenes and being able to deal with them without getting lost is a main goal. Especially people whose neediness, anger or even hate, anxieties and forlornness have taken almost unbearable measures, need an opposite who is able to deal with it. Understanding is therefore fundamental for a relationship-oriented work.

Relationship is a Highly Effective Factor

The course and intensity of mental disorders are best predictable if different sources of information are brought together. In order to maximize the chance of a prediction it requires a deep understanding, including all its complexities, of the past and the current condition of the patient. The most effective tool this regarding is the patient-nurse bonding [4]. The forming and perception of relationships have become a highly acknowledged and effective factor in the work with mentally ill people. For a long time already these bondings were seen as a significant element of the setting in the health care system. However, it was only through the systematic research of psychodynamic processes that it became evidently and undeniable how fundamental this sort of relationship is.

Nurses experience most of their interpersonal contacts in open social space, where unconscious processes are more difficult to identify due to the amount of information perceived simultaneously. The emotional impact of these interactions is considered rather unpredictable due to their complexity and the rapidity with which they unfold [5]. Them who are not aware of the power and presence of these unconscious processes, run the risk of being pushed into the restaged role of a spear carrier by the patients. Using basic psychoanalytic skills such as transference, countertransference, containment, as well as identifying more complicated psychodynamic processes such as “projective identification” [6-9] are a strong basis for relationship-oriented work. By transference it is meant, that the patient transfers old expectations and feelings to whom is offering a boding. The idea of using this to relieve suffering dates back to Freud [10]. Countertransference indicates what is triggered by the patient in the caretaking person [11]. Building on this, Melanie Klein describes that children project unbearable feelings onto their minder, sometimes to such an extent that this minder unconsciously identifies with these feelings and consciously assumes that these are his or her own feelings. Identification then means that the baby’s original fear became the mother’s fear, which in turn makes feel the baby her (inherited) fear. These dreadful conditions in the child thus appear to be confirmed (projective identification). Klein also emphasizes on the important observation that children need to learn and practice to build up an inner acceptance for loving and hating others at the same time. Upon this, Bion [12] was able to design his “Container/Contained-Model”: Containing suggests that at the moment of occurrence, the patient’s projections ought to be taken up kept by oneself at first, not to operate with them. It means to help the patient to slowly and step by step become aware of these transferences and projections and to keep them in their conscious mind. Children (and later on as adults as well) internalize feedbacks, reactions and correlations of and about their behavior and upon this they create their subjective world. What occurs, how this can be understood, which solutions become visible and tangible, depends on the inner possibilities the caregiver has to offer and the bigger the neediness is the stronger is the dependency. If these caregivers cannot offer enough support (containment), the child creates connections which could cause lifetime long psychological suffering if they are not comprehended accordingly.

Quality of Overwhelming

It is often hard for patients to accept help. The combination of urgent, existential need for help that is inextricably linked to the doubt whether they even are to be helped at all is an all too common life experience. In emotionally overwhelming situations, it can be difficult for patients to differentiate between inner and outer reality. If the subsequent projections are particularly violent or cruel, it is an important indication of the patient losing his or her ability to symbolize and feeling exceedingly overwhelmed. Under these circumstances memories, experiences and current emotions become fuzzy. Patients undergo such strong and intense states of emotion that these cannot be put into words. They act them out and present them in a scenic, interpersonal manner. This can be very challenging and even devastating for the whole team considering all groups of professionals. Patients suffering from severe personality disorders tend to activate multiple emotional states simultaneously. An inexperienced counterpart can be confused and overwhelmed by the situation. The important thing in this context is to understand the intensity and the features of these states of distress and confusion through self-experience in order to be able to ascertain what is going on in whom [13].

Aiyegbusi and Kelly remark the fact that the more unstable, unadjusted and critical the patients are experienced, the less positive feelings or empathy they receive. Without a compassionate and reflective attitude towards the patient there is neither the possibility of a delimitation from him nor a bonding with him. In order to keep oneself safe one might incline towards the idea that complex behavior can be treated (controlled) without having to understand the context or circumstances. It is then when in team meetings it is claimed that there are to be taken educational measures instead of looking for an appropriate treatment. If on the part of the caretaking persons no skills are acquired in order to deal with these grudges to be able to digest these attacking projections, interactions of clinical processes and procedures come into play which undermine the containment function. Succeeding the frightening sources – i.e. the patients – are rationalized and treated very strict and rigidly.

During or after severe breakdowns or in exceptional states of distress, patients are existentially dependent on being caught and handled by someone able to prevail his caring function throughout ardous emotional situations. Self-experience helps to remain self-reflective, insightful and to keep an intersubjective thinking [14,15]. Unprocessed trauma reactivates a vast force and is projected onto and into the nursing staff by patients. This way patients subconsciously tempt to reduce their own dreadful fear. They often experience the respective institution as unwelcoming, uninterested and uncomprehending. People with severe mental disorders are often not able to keep internal conditions (such as emotions or thoughts) to themselves neither can they talk about them. Instead, they tempt to act them out in an explicit manner. If there are many reproaches and complaints from the patient, they must be classified by the one encountering them. Do they concern the other person? Are they aimed at the institution? Or all of it together? A common reaction of defense when a situation becomes rampant, is to escape into structural and procedural processes in order to build a (seemingly) safer framework. However, this makes the team emotionally inaccessible and tears them apart from the patients. This can trigger feelings of isolation and create an inadequate, debilitating and sometimes even re-traumatizing environment for patients. In addition, due the fear of patients being harmful to themselves or to others, as well as through mistakes or misjudgments on behalf of the team, a conduct of blaming each other, paranoia and rigid defense-positions might arise, instead of enhancing openness and exchange. Another unpleasant side effect, which is often encouraged by schemes which do not lay their focus on psychodynamic, is the feeling of guilt on behalf of the patient. On behalf of the caretaking professionals, the before mentioned elements or this type of “work culture” are risky components which could cause Burnout and might lead to moral decline.

Aiygebusi and Kelly assume that being constantly confronted with people going through severe emotional pain can be experienced as afflicting and also frightening. Being exposed to this can also provoke intense inner states which, without professional coaching and schooling, can be perceived as very disruptive and thus have to be warded off appropriately. This can create the most challenging situation in nursing professions, being attacked, denigrated or threatened. It takes the development or strengthening of the inner capacity to endure on one hand, as well as to remain flexible on the other hand. For some patients contact or closeness is only to be established via pain and aggression. If such an encounter gets to emerge a caretakers’ unprocessed trauma, sadomasochistic alludings among the staff can be an attempt to gain back control over their own feelings. Accordingly, unconscious requests from patients in seriously severe conditions, to enter into their dynamics can generate powerful, sadomasochistic projections amongst the nursing staff. If these projections are recognized as such, they can provide important clues of how internalized relationships are organized within this patient and thus it can be reacted accordingly upon it.

From a psychoanalytical perspective, according to Berliner [16], masochistic aggression indicates suffering in order to be loved. That being so, suffering suggests a link towards someone else and thus implicates proximity. Suffering can also be regarded as a longing for autonomy. In this case the suffering person fantasizes to feel on a more equal level (‘I can take the pain’). If patients see no other way than to accept the sadism of a certain caregiver, they will merely take it. In order not to lose this caregiver, an inner arrangement is created to make sadism somehow bearable. On this matter masochism is the internalized sadism, which was previously experienced with another important person to this patient, which is now turn against himself. This is how abuse is interpreted as care and aggression as love. So what masochism means is to love a person who’s endowments are abuse, disinterest or suffering. Masochism remarks that experiences as of how it feels to be loved, to be paid attention to and to be taken care of, through the powerful mechanisms of introjection, identification and the emerging internalized legislators (superego), the sadism of the loved ones transformed into something that is experienced as one’s own and is charged libidinally.

It can be affirmed that the more deficiencies there are in a system, the more authoritarian and controlling it becomes trying to minimize the risks [17]. For people in big institutions in which the number of interactions are numerous and scope of power is incomprehensible, it is often difficult to maintain an adequate sense of individual identity within the working-context. The power of large-group-dynamics often causes feelings of vulnerability, pressure to adapt, being determined [18,19]. Institutionalized health systems, with their rejection of fear or anxiety are therefore a current example. According to Evans, it can be observed that institutions dealing with recovery shift these feelings of deficiency or inferiority into phantasies of omnipotence of how much or how quickly the risks of a breakdown, violence or suicide/murder can be prevented. The danger that “magical solutions” (e.g. ten therapy units or eight weeks of treatment for severe or chronic disorders) or that hatred and rejection will promote is particularly critical when those who are primarily confronted with the anxieties or dreadfulness of the patients, are suddenly made responsible for them – and this usually affects the caretaking professionals.

Autonomy and Good Practice

The capability of being good to others includes inner acceptance and the ability or insight of being dependent on others. To internalize this constructively is an important step towards autonomy and good practice for nursing professions. This is where the potential for stabilization, recovery and healing lies. In order to be able to perceive one’s own sensations in a retrospective and prospective manner, concepts as of emotion-response training (ART) are required, through which self-reflective behavior as well as reflecting on others can be practiced [20]. As for German-speaking areas, Johann Steinberger’s team has been working on this topic in the Viennese nursing school at the Otto Wagner Hospital for already ten years. Emotion-response training as a self-experience is an essential component training. Through this training, consisting of self-experience and two stages of supervision, there can be seen significant improvements in the capability to empathize and more openness towards actively forming liaisons. In addition, it was found that the emotion-response training enhances a clearer differentiation between perception and communication.

In nursing professions, it is worked, felt and communicated with as well as within in bodies. A great deal of the perception of what we are and what we aspire is shaped by the unconsciousness. In order to understand oneself and the world, the amount of information perceived has to be reduced categorized. People long for categories as well as for mutuality and separation in order to be able to be in proximity. Unconscious communication occurs in a quick and complex matter without a veil of adjustment. A bonding establishes rapidly and might in some cases be a riddle over years. Like the life-shaping rhythm of the heart and blood, there is a melody of the psyche within everyone which has an unstoppable and effective sound. We know how contagious yawning can be, but the question Hustvedt [21] proposes is “what about the contagiousness of emotions which are documented over a long time span and over various contexts and different parts of the world?” (P. 337f). Unconscious communication delivers and receives on all channels simultaneously. It is hard to let body and psyche/mind talk simultaneously. Often there is an inclination towards a certain position whilst communicating. In an attempt to use the biopsychosocial model in reference to communication, it can be seen the effort it takes to think of these different systems as correlating or as a conjunction.

Contiguity as well as language, in fact every getting into contact, unleashes memories. Concrete physical contact in a familiar setting which appeals to openness, generates a profound psychological response which, if it can be discussed, can enable important changes [22]. Concerning self-awareness, however, sensory touch needs the translation from emotion into language with all the possible interpretations as well as the awareness of the complexity and interweaving of these processes. The therapeutic slogan which unfolded upon this regard is that reflective, emotional, ideally open talks can be a meaningful and tangible reduction. Starting with self-experience in one’s own encounters and acquisitions and later on in the context of nursing, the developed consciousness is to be treated with special care. According to Quinodoz, language can open up a path to physical experiences on a very young psychological stage of development. Via the free associative speech, it is possible that traces of memory are forgotten. Memories, which strongly influence the body, indicate that no or insufficient words have been found for them. This can be understood as an indication the point where irritation has scratched into life history (there were no words yet) or how strongly it had to be repressed (the words must not be true). By fantasizing and remembering in the context of a secure relationship, emotions can be transformed into symbolic thinking and neuronal patterns can be (re) activated and changed. In this context, Kradin [23] refers to a connection between placebo-reactions and a person’s ability to bond. In his model, the physiological effect of a placebo presupposes an internalization and evaluation of interpersonal significant experiences that have been repressed and are therefore unconscious. In concrete terms, this means that an encounter or its particular manner triggers a related somatic reaction. Babies are unable to distinguish physical from psychological conditions at the beginning. Babies may feel physical pain and simultaneously have the feeling of being hated, or not to be able to distinguish frustration from the whole-body state of hunger. Hustvedt raises the question, whether a simple classic conditioning is also a form of memory. Where and how does a memory become a somatic reaction (and vice versa)? Where does desire, a thought, flow into the body? Where is a physical reaction ultimately a repeating narration of a past experience? Sensory as well as memorized memories or evaluations model and offer structure and framings. Thus memories are or become something like an opportunity to fulfill a life plan [24]. Outspoken memories help detecting formerly established connections which can subsequently be enhanced or discarded and rebuilt.

Language as a Medicine

Language is the preferred tool in self-experience. There are remarkable features of therapeutic speech, hearing and performing [25-27]. “Language as a remedy” is an effective platform upon which one is enabled to get closer to oneself. Lorenzer even considers therapeutic speaking to be equivalent to an “operation of speech” (p. 98). Language also represents a Zeitgeist. It has long been observed that human functions are engaged to the most modern metaphors. We find ourselves situated within processes, we possess memory and capacity and are in need for updates. In institutionalized healthcare systems particularly, there is a propensity towards a mechanized use of language, which can be useful due to its sophistication and reliability on one hand, but on the other hand it can be an obstacle for the development of relationships, for it tends to be rigid and excludes metaphors, imagination and intuition. Words such as reactions as a symbol emphasize on a certain reality, make other realities disappear and thus form personal, social or political processes [28]. Learning a ‘psychic technique’ and using it as a tool, makes it seem comprehensible, handy and applicable. This has major advantages. It provides security, it can be standardized, it is comprehensible, deductible and provable – it is “neat”. Neatness has high priority in hospitals. “The recognition of a shared involvement and the associated acknowledgement of a shared fear of what is to be discovered is reduced by the idea of having a right theory, a proper technique,” emphasizes Steinberger. However, he argues further, technology can be equated to a framework within which the respective idea of encounter and relationship is embedded. “Technology and metapsychological ideas build a frame of reference for the displacement and thus the description of the invisible. The reiteration and reduction of fear is based on the ability to abstract and generalize, and to find a broad purpose in language for dealing with our concerns”. Relationship and getting involved are terms which sound opposing towards technology and tools. Scarvaglieri takes into consideration that self-experience via psychotherapeutic speaking and being in a relationship, might untie mental processes and thereby effectuate changes. According to Quinodoz, language which transcends the rational and the informative, brings to light buried inner images and fantasies and lets physical, psychological and historical memories resurrect. Hence Steinberger adds, that the sensory impressions we selectively take in and react upon, are always placed alongside our psychological understanding as well as in response to clarifications and interpretations of feelings. He emphasizes: “This ability to comprehend develops as a result of labeling or by using language as a displacement employing metaphors (language), so as not to be at the surrendered by one’s own impulsiveness and the behavior resulting of it. In order to be “objective”, we have to be deeply “subjective” in our understanding. Without influence, there can be no understanding and no impact on the construction of reality”. Words determine something and help us to live interacting with each other. Depending on which words are spoken at what point, they can either hit with force or fizzle out in empty space. The use of metaphors, images and analogies helps to get in contact with the ability and capacity of symbolizing. This in turn strengthens and opens your own inner space.

It is important to keep on speaking (this includes moments of silence), even if it comes awkward or complicated situations between the participants. Only then suitable boundaries and proper containment can be established, as in two sides to a coin. It takes awareness of what is being spoken out and what is to be held back. It needs clarity about who is the one speaking and who is the one listening, and what this might represent and imply. There has to be paid attention to behaviors that communicate something in place of language. It takes practice in order for language to lead to freedom of action. In order to be able to communicate, it takes openness for whatever unfolds, as well as the augmenting the ability to understand and to be understood. Complicated situations might require having to soak in a lot and consequently react to it in appropriate dosages of words and actions (containing). So, it is important to raise awareness as well enhancing ones listening skills. Narrating and listening are subjects to continuous transformation. There is always the possibility to illuminate or recognize different elements of an experience. A rational, deliberate nuance can prevail on the front for a long time, until a symbolic or previously unconscious and unlinked aspect is suddenly perceived. It is beneficial to find a mutual exchange whereas there can be shared laugh even over serious, difficult or sinister topics. “Growth…”, Steinberger emphasizes (2019),”… also implies reflecting about feelings of inhibition, shame, ignorance”. He continues to emphasize: “…. it is also important to enhance the ability of accepting new thoughts as well as being able to stand ignorance”.

Nursing encounters are complex and take place in a wide variety of contexts. Deconstructing one’s own ideas and basic attitudes as well as one’s profession helps to achieve a more comprehensive experience in the work context. “To handle complex work situations reflectively, to face oneself as well as the others acceptingly, to recognize ambiguities of situations and the fact that there may exist different solutions to one problem, as well as withstanding the pressure of having to act in order generate solutions” are set as main achievements. Misconceived and unbearable fear provokes the search for a certainty in which there can be found classification (‘this is how it is’) and reiteration (‘it stays this way’), in order to be able to secure the perceived truth. However, if fear can be understood as an information carrier and thus establish a connection between all those involved in the arising situation, it might imply that by making use of the fear employing comprehension and classification, it could ultimately expand the leeway. Self-experience means allowing, accepting and respecting subjectivity, enjoying it and making use of it, for the emotional impact in the working environment can be perceived to be more complex. Thus the structures of the relationships tempt to incline more towards respect, empathy, authenticity, clarity and openness.

If in collective reflection in a familiar environment, openness, emotional self-revelation, criticism and discussion are constructively accepted, the participants will enhance their ability to engage in dialogue, and there will be more space for discussions and there will be less fear of asking questions or of being questioned [29]. The better the nurses’ own difficult experiences are treated, the less damaging interactions there are to expect. The more precisely the understanding and acceptance is of oneself, the more precisely it can be differentiated between one’s own reactions based on one’s own experiences and what ultimately has more to do with or results from the other person, as well as being understood. Every encounter and every relationship has its unique quality, which only results from the presence of the people taking part at that time. The psychoanalytic model offers a constructive framework in order to recognize and comprehend subjective and unconscious beliefs, roles or structures within oneself as well as in patients and thus being able to deal with them. So it aims to achieve acceptance, transformation and growth. Steinberger on this: “The influence on the patient unfolds from the realization the therapists conceive about themselves and through this being able to develop a different approach towards the patient”. If there is success creating a link between the current behavior of patients and their life history, disregarding its fierceness, more positive evaluations and subsequent more positive attitudes towards the patient can be observed. Following the paradigm of keeping out private matters out of professional matters, it can now be summarized that if private and professional issues are combined in a specific way, it leads to strengthening and preservation of relationships and actions in caring professions.

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