When every word matters by Jaime Lavid

WHEN EVERY WORD MATTERS

Public Domain Compilation of articles about communication with persons who may be experiencing psychotic symptoms

Title: When Every Word Matters Compiled by: Dean Amory Dean_Amory@hotmail.com Publisher: Edgard Adriaens, Belgium eddyadriaens@yahoo.com Cover Illustration by Tamara Adriaens ISBN:

978-1-291-64271-1

This book has been compiled based on the contents of trainings, information found in other books and using the internet. It contains a number of articlesindicated by TM or ÂŠ or containing a reference to the original author. Whenever you cite such an article or use a communication model in a commercial situation, please credit the source or check with the IP -owner. If you are aware of a copyright ownership that I have not identified or credited, please contact me at: eddyadriaens@yahoo.com

WHAT DO I SAY?

What do I say to you When you're almost as smart and powerful as God And I but a humble, stupid worm?

How do we communicate When you know past and future, And know what others are thinking or saying anyway?

What can I tell you When you can read my most intimate thoughts And all I say is so utterly boring?

How can I make you understand That I am not your enemy, But your loving partner, reaching out to you?

WHEN EVERY WORD MATTERS

How to communicate with someone who may be experiencing psychotic symptoms?

Introduction The practical benefits of applying the techniques explained in "When Every Word Matters" go far beyond communicating with persons who are suffering from a psychosis. "When Every Word Matters" is about creating and expressing an attitude of empathy, which will prove useful every time when the way we see and experience things is different from the way our interlocutors do. Giving feedback, delivering bad news, dealing with criticism, conflict resolution, crisis communication, dealing with complaints, negotiating, intercultural communication, dealing with unreasonable requests, mediating, coaching, motivating and influencing people, ... are some of the situations in which this attitude may make all the difference. In fact "When Every Word Matters" teaches us a way of being in this world which will enhance our communication and hence our relationships with all the people we meet with. The present document is a compilaton of public domain publications by the very best experts in the field? Amongst which : -

Professor Tony Jonn, Rose Mc Cabe Stefan Priebe Xavier Amador Geoff Brennan Gary Winship Christina Theodoridou Marshall Rosenberg Liv Monroe Peter M. Sandman

Index 1. about the first episodes of psychosis What is psychosis? Typical and early signs of psychosis Is psychosis a diagnosis? What is the first episode of psychosis? Early onset of psychosis Young adults and new onset psychosis Later in life new onset psychosis Short term psychosis Trauma and it's relationship to psychosis The adverse childhood experience Causes of psychosis - Risk factors - Early warning signs - Substance use

2. Psychosis first aid guidelines How do I know if someone is experiencing psychosis? Common symptoms when psychosis is developing How should I approach someone who may be experiencing psychotic symptoms? How can I be supportive? How do I deal with delusions and hallucinations? How do I deal with communication difficulties? What if the person doesnâ&#x20AC;&#x2122;t want help? What should I do in a crisis situation? What if the person becomes aggressive? How to de-escalate the situation. About these guidelines

3. Communication and psychosis I: Itâ&#x20AC;&#x2122;s good to talk, but how? Summary Declaration of interest Studying communication What should I say now? Interventions to improve communication Concluding remarks References Source

4. Communication and psychosis II: Key Tips in communicating with a person who has psychosis Reflective Listening I'm not sick, I don't need help LEAP : Listen, Empathize, Agree, Partner

5. Nursing a patient with a severe psychotic illness About these guidelines Information about psychosis - What is psychosis? - Different types of psychotic disorder - What causes psychosis? - Prognosis: do people get better? - What are the treatments? What the generalist nurse or healthcare officer can do - Communication (engagement) - Observation (contribution to assessment) - Reassure, encourage and support the positives - Reduce stress and conflict - Look out for depression and suicidal thoughts - Medication - Coping with common side-effects of medication - Administering medication

6. Communication skills for nurses and others spending time with people who are very mentally ill Source Dedication Acknowledgements Preface Contents Inpatient nursing care and interaction. Nurse patient interaction Interpersonal and communication skills The nursing process, Isobel Menzies - Lyth, and primary nursing Outside the mainstream: Laing, Berke, Mosher and Barker Milieu therapy and modified therapeutic communities

Psychotherapy, solution focused therapy, person-centered therapy and pre-therapy Expressed Emotion, psychosocial interventions and cognitive behavioral therapy Potential lessons from dementia care Summary and aim of this work This study of interaction - The interviews - Analysis Moral foundations -

Notice, do not ignore Encouraging, supportive and gentle Empathy and concern Honesty Don't intrude Respect

Preparation for interaction and its context - Observe first - Consult case notes - Consult friends and family - Choose the right nurse - Choose the best time of the day - Choose location - Set appointment in advance Being with the patient (Relationship building, maintaining and assessment) - Be with, sit with, be available, offer conversation - Introduce self, explain role - Light, casual, normal conversation - Focus on person - Here and now as topic - Joint activity - Humor - Apathy / withdrawal specific — Comfortable silence — One-sided conversation — Be creative - Hallucinations — — — —

Tolerating and making allowance for auditory hallucinations Not too much too fast Say their name Be creative

- Thought disorder — — — — — — —

Acceptance and listening Name themes Writing Send away to think Remind, prompt to topic Keep it simple Clarification

- Agitation / over activity — Positive feedback — Set interaction limits — Reduce stimulation - Upset / Distress — Reveal self — Limit unnecessary interaction - Aggression / Irritability — — — — —

Get them sat down Get the patient to write Maintain clarity Choose topic in which they are expert Avoid

Nonverbal communication, vocabulary and timing - Slow pace, patience - Slow speech - Simple vocabulary - Short sentences - Repetition - Use silence - Quiet, not loud or shouting - Tone of voice - Writing and drawing - Less vs. more gesticulation and movement - Touch / close vs. no touch / distant - Short interactions - Frequent interactions - Persistence - Aggression / irritability — Choose language — Non-verbal non-threatening

Emotional regulation - No anxiety - No frustration or irritation - Optimism Getting things done - Suggest, not order - Give reasons - Be flexible - Break down task into small steps - Avoid, defer or postpone tasks - Maximize task choice and attractiveness - Prompting - Positive feedback, encouragement - Assist, do part of the task - Assertiveness - Delusions — Semi-collusion for greater good - Thought disorder — More gestures Talking about symptoms - Apathy / withdrawal — — — — —

Hearing and respecting the experience Mutually explore causes Negotiating and agreeing a care plan Structure, routine and purpose Step by step

- Hallucinations — — — — — — — — —

Hearing the experience Hearing the effect on the patient Hearing to assess safety Respecting the experience Stress management Negotiating and agreeing a care plan Distract Bolster coping Casting doubt and challenging

— — — —

Acceptance and listening Explore to understand the person Explore delusions to assess risk Monitor delusions for incorporation

- Delusions

— — — — — —

Don’t deny or dismiss Gently question, cast doubt Directly challenge the delusion Don’t collude Ignore the delusions Find workarounds

- Thought disorder — Acceptance and listening — Explore how it affects them - Upset / distress — — — — — — — — —

Acceptance and listening Give time alone Stay calm and neutral Don’t close them up Persist to find out cause Explore solutions Take action to relieve cause Distraction Assess suicide risk

- High arousal — — — — — — — — — — — — —

Hear the patient, listen Exercise, physical activity Distract, calming activity Request lowered arousal Relaxation Don’t argue or confront Relationship leverage Give choices, empower Explain what the rules are and the reasoning behind them Describe consequences Forceful containment Debrief later Advance directives

Lessons for practice - Summary of findings - Novel findings? - Barriers to nurse-patient communication - Psychotherapy and the acutely ill psychotic patient - Some implications Appendix – the interview schedule References

7. Nonviolent Communication - Introduction - Steps - Violence provoking or life alienating communication - diagnosing - denying responsibility - demanding - NVC: purpose, background, what NVC is not - Components of an NVC expression - observation - feeling - need - request - 2 Ways of moving toward connection - honestly expressing own feelings and needs - empathically listening to other’s feelings and needs - The four ears: how we choose to hear difficult messages - Awareness, not content - Creating the internal space that nurtures learning and connecting - Creating the community space that nurtures learning and connecting - Taking responsibility for our feelings - Need versus request - Requests versus demands - Giving and receiving gratitude - Comparison of Jackal and Giraffe Language - Enriching “feeling” literacy - Feelings mixed with evaluations - Non Feeling Expressions - Feelings inventory - Needs inventory - Human Needs -

Life and contribution Autonomy and choice Connection and Interdependence Joy and Celebration

- Template for writing public policy letters

8. Empathy in Risk Communication Column Table of Contents The Essence of Empathy: Sort-of Acknowledgment Empathy and the Kinds of Risk Communication Ten Elements of Empathic Communication 1. Feeling and Attitude: Empathy Isn’t a Strategy 2. Candor and Humanity: Being Real 3. Deflection: You – I – They – Some People – It 4. Questioning: “How Does That Make You Feel?” 5. Listening and Echoing: “I Hear You” 6. Agreement: “I Think You’re Right about That” 7. Kinds of Empathic Statements: A Typology 8. Kinds of Interpersonal Statements: Another Typology 9. Proactive Acknowledgment: “Some Things You Should Know about Me” 10. Performatives: “I Hope the Situation Will Improve Soon” Some Examples from Earth Afterword by Jody Lanard

1. About the First Episodes of Psychosis Early identification and evaluation of the onset of psychosis is an important health concern. Early detection and intervention improve outcomes. Psychosis may be transient, intermittent, short-term or part of a longer-term psychiatric condition. It is important to understand the range of possibilities, both in terms of possible diagnosis associated with psychosis and the prospects for recovery. This NAMI website is a resource guide for your increased understanding of assessing, treating and living with new onset psychosis, including strategies to help the return to school, work and daily life. What Is Psychosis? Psychosis (psyche = mind, osis = illness) is defined as the experience of loss of contact with reality, and is not part of the person’s cultural group belief system or experience. Psychosis typically involves one of two major experiences: A. Hallucinations can take the form of auditory experiences (such as hearing voices); less commonly, visual experiences; or, more rarely, smelling things that others cannot perceive. The experience of hearing voices has been matched to increased activity in the auditory cortex of the brain through neuro-imaging studies. While the experience of hearing voices is very real to the person experiencing it, it may be very confusing for a loved one to witness. The voices can often be critical (i.e. “you are fat and stupid”) or even threatening. Voices also may be neutral (i.e. “the radio is on”) and may involve people that are known or unknown to the person hearing the voices. The cultural context is also important. For example, in some Native American cultures, hearing the voice of a deceased relative is part of a healthy grieving process. B. Delusions are fixed false beliefs. Delusions could take the shape of paranoia (“I am being chased by the FBI”) or of mistaken identity (a young woman may say to her mother, “You are an imposter—not my mother”). What makes these beliefs delusional is that these beliefs do not change or modify when the person is presented with new ideas or facts. Thus, the beliefs remain fixed even when presented with contradicting information (the young woman continues to believe her mother is an imposter, even when presented with her mother’s birth certificate and pictures of her mother holding her as a baby). Delusions often are associated with other cognitive issues such as problems with concentration, confused thinking and a sense that one’s thoughts are blocked. These experiences can be short lived (e.g. after surgery or after sleep deprivation) or periodic (as when associated with a psychiatric condition or persistent like bipolar disorder or major depression). Some typical and early warning signs of psychosis include -

Worrisome drop in grades or job performance; New trouble thinking clearly or concentrating; Suspiciousness/uneasiness with others; Decline in self-care or personal hygiene; Spending a lot more time alone than usual; Increased sensitivity to sights or sounds; Mistaking noises for voices; Unusual or overly intense new ideas; and Strange new feelings or having no feelings at all.

These signs are particularly important when they are new or have worsened in the last year and if the individual has a close relative that has experienced psychosis. Learn more about psychosis risks by visiting the Centre for Early Detection, Assessment and Response to Risk. Behaviour and thought processes are often impacted by delusions or hallucinatory experiences. People experiencing new onset psychosis may report trouble organizing their thoughts, feeling as if they are dreaming while awake or wondering if their minds are playing tricks on them. Hallucinations can distract a person’s attention and executive functioning (the ability to prioritize tasks and make decisions) may also be impacted. Agitation or withdrawal often accompanies these experiences, which can be experienced in a variety of ways but are often anxiety-provoking or terrifying. At times, people experience these altered perceptions of reality

with indifference or resignation, or they simply “fall into” the psychosis and lose interest in external reality. Shame and humiliation of being different often complicate the experience and make getting help more difficult. Is Psychosis a Diagnosis? No. Psychosis is like fever—a very important symptom. When a person has a fever, it could be from a virus in the respiratory system or a bacterial infection of the urinary tract. These are two very different causes of fever and each cause requires different treatments. The reduction of fever is one way to know the condition has been addressed properly. While we understand less about the three-pound “universe” that is the human brain than we do about infectious disease, the same broad principles apply. The goal of a comprehensive evaluation is to determine if there is an underlying, reversible medical cause of the condition and—if there is none—to determine the psychiatric diagnosis. After the symptoms, the associated history and relevant workup have been put into a diagnostic framework, the next step is to develop a collaborative and comprehensive plan with the person to address the symptoms in the context of this diagnosis. A comprehensive plan attends to the person interests and strengths and looks to school, work and relationships as the person’s goals dictate. What Is a First Episode of Psychosis? A first episode of psychosis is the first time a person experiences a psychotic episode. The first such episode often is very frightening, confusing and distressing, particularly because it is an unfamiliar experience. Unfortunately, there are also many negative stereotypes and misconceptions associated with psychosis that can further add to this distress. You are not alone if you are having this experience (estimates place the risk of psychosis at about three in 100. Help is out there both for the individual and the family, and this help comes in many forms. By exploring this web resource, you are already looking at the issue and seeing how your resilience and coping strategies can be employed to best deal with psychosis. Psychosis is treatable. Many people recover from a first episode of psychosis and never experience another psychotic episode. Finding support and resources is essential to managing the experience, whether it is shortlived or lasts a good deal longer. Early Onset of Psychosis When young children report hallucinations in the context of poor school performance social withdrawal or exhibit other odd behaviours then a diagnostic evaluation is required. The caregiver will assess the child, perform laboratory tests and may request developmental or psychological testing to help make a diagnosis. This could include neurologic problems, bipolar disorder, or childhood schizophrenia, which is a rare, but real, presentation. Schizophrenia typically occurs in a window of the mid- to late-teens to the early 30s (this age range is a few year later for females, often the presentation is early- to mid-20s as opposed to the teen years). Symptoms of schizophrenia in school-age children are rare, and this is unexpected and traumatic for the family while they are seeking help and assessment. As this is an uncommon condition, local caregivers may struggle to put together a comprehensive plan. A teaching hospital with a department of child and adolescent psychiatry would be a good place to begin. The National Institute of Mental Health (NIMH) has a research and clinical service centre in Bethesda, Md., to better understand childhood schizophrenia, while providing state-of-the-art care to children in care. This program offers diagnostic and treatment options to children who have had the onset of psychosis prior to the age of 13. Children aged 6-18 are eligible to enrol. Young Adults and New Onset Psychosis Young adults are the most common age group to be at risk for their first episode of psychosis. The experience of psychosis impacts young adults at a developmentally vulnerable time. This is a stage of life that usually

challenges young people to develop more independence, establish an identity, create intimate relationships and move away from the nest of the family home. Typically, young adulthood focuses on the external world and friends, while parents often serve a valuable—but less central—day-to-day role. Yet, if a young adult is having problems organizing his or her thinking or is distracted by hearing voices, functioning at a high level of independence will be problematic in many cases. Psychosis often impacts individuals in college years, and the culture in a college setting is not typically geared towards seeking help. Having a psychotic process separates the individual from peers and can impair social connections. The loss, or threat of loss, of social contacts adds stress to the person experiencing these symptoms. It is often scary and activates feeling of shame when one is having these experiences that are so difficult to discuss. This leads to isolation and may reinforce the power of the inner experience as withdrawal from external contacts occurs. With a young adult away at college, parents may think they are supposed to keep some distance in order to support independence in a college-age child, and may not have adequate information in order to appreciate the onset of psychosis. Psychosis requires intervention as soon as the person or the family realizes the seriousness of the situation. University counselling centres are increasingly aware of the need to get support and assessment to students experiencing this challenge. Young adults and families can be encouraged by the development of resources intended to help meet their unique needs. NAMI offers some resources, including NAMI on Campus, NAMI groups on some college campuses, and StrengthofUs.org, a social networking site specifically for young adults living with mental health conditions. These both offer young adults access to information and peer support from other young adults with a shared experience. Later-in-life New Onset Psychosis When the first presentation of psychosis is over age 40, this presentation raises the need for intensive medical evaluation. The probability that there is a detectable medical cause of psychosis increases with age, with increased use of medications, medical illness and surgical procedures. Delirium, which can present with psychosis (coupled with change in level of consciousness), is common in individuals who have other risks (i.e., post-surgery, on multiple medications) or neurologic vulnerabilities ( e.g. dementia, Parkinson’s disease, cognitive decline). Multiple neurologic and medical conditions can present with psychosis later in life, and many of these are reversible. Short-term Psychosis A brief psychotic disorder that lasts between one day and one month and is typically associated with severe stress or the post-partum phase is considered short-term. The return to a non-psychotic state is common in the condition. Trauma and Its Relationship to Psychosis Traumatic events impact body, spirit and brain. Research has demonstrated biological as well as psychological effects of traumatic events. The type of trauma as well as the developmental stage of the person and their brain also makes a difference in terms of how a traumatic event may manifest in the person’s experience. The field of mental health has moved towards a more sophisticated understanding of how traumatic events can influence a person’s experience, and a movement towards trauma informed care has been a focus of SAMSHA for years. This is an important departure as NAMI was founded in part by mothers who were falsely blamed for the neglect and reason their children had developed schizophrenia. The “schizophrenogenic mother” theory posited that cold and neglectful parenting caused schizophrenia. This “one size fits all” conceptualization blamed mothers and did not rely on empiric evidence. The relationship of traumatic event—of all kinds—and the development of psychiatric illnesses is emerging and reveals a significantly more complex story. We now know that the brain is plastic—it responds to its environment and that the way that environmental experiences manifests in a given person with their genetic makeup remains an important area of inquiry. The Adverse Childhood Experience (ACE) study demonstrated a relationship between self reported adverse childhood experiences and multiple adult health problems, spanning both physical and mental health concerns.

The researches noted higher rates of many health problems that correlate with the number of adverse childhood experiences in a large HMO population, including heart disease, lung disease, hypertension and mental health concerns including suicide. ACE were not limited to a few of the subjects followed---more than one fourth of individuals were exposed to substance abuse in the home and over two thirds of the sample reported at least one adverse experience. One individual in 10 had more than five adverse experiences and this population had more health concerns of all kinds later in life. Traumas impacted both health outcomes and also adult life choices— including substance abuse, domestic violence and sexually transmitted diseases. This is a powerful and provocative study and promotes more research in this area. There is no simple if A then B in this compelling area of inquiry. Neuro-developmental conditions like psychosis have many possible influences than span genetic, stress and environmental aspects. It does appear that adverse experiences are more common in people with psychotic disorders, yet a trauma history is not present in many individuals with psychotic disorders. In a review of two large data sets researchers found a relationship between multiple adverse experiencing and the later development of psychosis. “Experiencing two or more traumas significantly predicted psychosis and there appeared to be a dose response relationship.” For more on this research review, visit “Cumulative Traumas and Psychosis: An Analysis of the National Co morbidity Survey and the British Psychiatric Morbidity Survey” Shevlin et al., Schizophrenia Bulletin 2008 34 (1). The experience of psychosis can also be experienced as traumatic. The experiences can have many manifestations but terror and fear are key elements of traumatic experiences and these are common responses to the onset of psychosis. As the field goes forward, integrating awareness of the interaction of experience on brain and body development will improve approaches to individuals experiencing psychosis. Causes of Psychosis Risk Factors When it comes to psychosis, the interplay between genetics and the environment is not yet fully understood. Researchers are continuing to explore the underlying genetic risks associated with psychosis. Research suggests that a wide range of environmental factors (such as birth injury, severe stress, sleep deprivation, maternal infection in the second trimester, head trauma and substance use) may trigger an underlying genetic risk and lead to an episode of psychosis. There is no one gene or stress that causes psychosis. Like asthma and diabetes, vulnerability to psychosis likely is the interplay of genetic risk and environmental factors. Much more needs to be understood about this interplay. The mapping of the human genome in 2003 begins what promises to be a long and challenging process to better understand the relationship between genetics, the environment and mental illness. Of the many conditions that have psychosis as a symptom, schizophrenia is the best-studied in terms of the interplay between genes and environment. For example, using careful population records in Europe, researchers have shown the relative correlations of how the condition travels in families. Having first-degree relatives (parents, siblings) with schizophrenia increases your risk of having schizophrenia. For example, if you have an identical twin that was diagnosed with schizophrenia, your overall risk would be in the range of 50 percent. If you have a parent with the condition, you would have about a 10 percent chance of developing the disorder. These are probabilities only, as there have been no developments in determining any one person’s risk with scientific precision. There exists no single gene test for illnesses associated with psychosis, such as schizophrenia. There is evidence that vulnerability to psychosis may be increased in individuals who have a gene variant and who also smoke marijuana. It is best to avoid this substance, especially if you have any risk factors for development of psychosis.

Early Warning Signs For some psychiatric conditions that later develop psychosis symptoms, there is often a prodromal (early) phase. In this phase, the following may be noted: -

Isolation and withdrawal Loss of interest in peers Declining self-care/hygiene Change in thought pattern including disorganized thinking Preoccupations/paranoid thinking Lack of motivation

Getting a comprehensive assessment of these symptoms is important to understand the possible explanations for the change in the personâ&#x20AC;&#x2122;s behaviour. Substance Use For many individuals, the use of substances increases the risk of developing psychosis. In general, the younger the person and their developing brain are, the greater the risk posed by the use of substances. Substances known to have links to possible psychosis include: -

Marijuana/hash/THC Methamphetamine (including crystal meth) PCP/Psilocybin/Peyote /Mescaline LSD Ketamine

Prescribed medicines may also produce psychosis: - Steroids - Amphetamines/stimulants

2. Psychosis First Aid Guidelines • How do I know if someone is experiencing psychosis? • Common symptoms when psychosis is developing • How should I approach someone who may be experiencing psychotic symptoms? • How can I be supportive? • How do I deal with delusions and hallucinations? • How do I deal with communication difficulties? • What if the person doesn’t want help? • What should I do in a crisis situation? • What if the person becomes aggressive? • How to de-escalate the situation. Source: The MHFA Training & Research Program Orygen Youth Health Research Centre Department of Psychiatry The University of Melbourne AUSTRALIA www.mhfa.com.au How do I know if someone is experiencing psychosis? It is important to learn about the early warning signs of psychosis (see box) so that you can recognize when someone may be developing psychosis. Although these signs may not be very dramatic on their own, when you consider them together, they may suggest that something is not quite right. It is important not to ignore or dismiss such warning signs, even if they appear gradually and are unclear. Do not assume that the person is just going through a phase or misusing alcohol or other drugs, or that the symptoms will go away on their own. Common symptoms when psychosis is developing: Changes in emotion and motivation: Depression; anxiety; irritability; suspiciousness; blunted, flat or inappropriate emotion; Change in appetite; reduced energy and motivation Changes in thinking and perception: Difficulties with concentration or attention; sense of alteration of self, others or outside world (e.g. feeling that self or others have changed or are acting differently in some way); odd ideas; unusual perceptual experiences (e.g. a reduction or greater intensity of smell, sound or colour) Changes in behaviour: Sleep disturbance; social isolation or withdrawal; reduced ability to carry out work or social roles (Adapted from: Edwards, J & McGorry, PD (2002). Implementing Early Intervention in Psychosis.)Martin Dunitz, London.) You should be aware that the signs and/or symptoms of psychosis may vary from person to person and can change over time. You should also consider the spiritual and cultural context of the person’s behaviours, as what is considered to be a symptom of psychosis in one culture may be considered normal in another.

How should I approach someone who may be experiencing psychotic symptoms? People developing a psychotic disorder will often not reach out for help. Someone who is experiencing profound and frightening changes such as psychotic symptoms will often try to keep them a secret. If you are concerned about someone, approach the person in a caring and non-judgemental manner to discuss your concerns. The person you are trying to help might not trust you or might be afraid of being perceived as “different”, and therefore may not be open with you. If possible, you should approach the person privately about their experiences in a place that is free of distractions. - Try to tailor your approach and interaction to the way the person is behaving (e.g. if the person is suspicious and is avoiding eye contact, be sensitive to this and give them the space they need). - Do not touch the person without their permission. - You should state the specific behaviours you are concerned about and should not speculate about the person’s diagnosis. It is important to allow the person to talk about their experiences and beliefs if they want to. As far as possible, let the person set the pace and style of the interaction. - You should recognise that they may be frightened by their thoughts and feelings. Ask the person about what will help them to feel safe and in control. - Reassure them that you are there to help and support them, and that you want to keep them safe. If possible, offer the person choices of how you can help them so that they are in control. - Convey a message of hope by assuring them that help is available and things can get better. - If the person is unwilling to talk with you, do not try to force them to talk about their experiences. - Rather, let them know that you will be available if they would like to talk in the future. How can I be supportive? Treat the person with respect. You should try to empathise with how the person feels about their beliefs and experiences, without stating any judgments about the content of those beliefs and experiences. The person may be behaving and talking differently due to psychotic symptoms. They may also find it difficult to tell what is real from what is not real. You should avoid confronting the person and should not criticise or blame them. Understand the symptoms for what they are and try not to take them personally. Do not use sarcasm and try to avoid using patronising statements. It is important that you are honest when interacting with the person. Do not make any promises that you cannot keep. How do I deal with delusions (false beliefs) and hallucinations (perceiving things that are not real)? It is important to recognise that the delusions and hallucinations are very real to the person. You should not dismiss, minimise or argue with the person about their delusions or hallucinations. Similarly, do not act alarmed, horrified or embarrassed by the person’s delusions or hallucinations. You should not laugh at the person’s symptoms of psychosis. If the person exhibits paranoid behaviour, do not encourage or inflame the person’s paranoia. How do I deal with communication difficulties? People experiencing symptoms of psychosis are often unable to think clearly. You should respond to disorganised speech by communicating in an uncomplicated and succinct manner, and should repeat things if necessary. After you say something, you should be patient and allow plenty of time for the person to process the information and respond. If the person is showing a limited range of feelings, you should be aware that it does not mean that the person is not feeling anything. Likewise, you should not assume the person cannot understand what you are saying, even if their response is limited.

Should I encourage the person to seek professional help? You should ask the person if they have felt this way before and if so, what they have done in the past that has been helpful. Try to find out what type of assistance they believe will help them. Also, try to determine whether the person has a supportive social network and if they do, encourage them to utilize these supports. If the person decides to seek professional help, you should make sure that they are supported both emotionally and practically in accessing services. If the person does seek help, and either they or you lack confidence in the medical advice they have received, they should seek a second opinion from another medical or mental health professional. What if the person doesnâ&#x20AC;&#x2122;t want help? The person may refuse to seek help even if they realise they are unwell. Their confusion and fear about what is happening to them may lead them to deny that anything is wrong. In this case you should encourage them to talk to someone they trust. It is also possible that a person may refuse to seek help because they lack insight that they are unwell. They might actively resist your attempts to encourage them to seek help. In either case, your course of action should depend on the type and severity of the personâ&#x20AC;&#x2122;s symptoms. It is important to recognise that unless a person with psychosis meets the criteria for involuntary committal procedures, they cannot be forced into treatment. If they are not at risk of harming themselves or others, you should remain patient, as people experiencing psychosis often need time to develop insight regarding their illness. Never threaten the person with the mental health act or hospitalisation. Instead remain friendly and open to the possibility that they may want your help in the future. What should I do in a crisis situation when the person has become acutely unwell? In a crisis situation, you should try to remain as calm as possible. Evaluate the situation by assessing the risks involved (e.g. whether there is any risk that the person will harm themselves or others). It is important to assess whether the person is at risk of suicide [please see the MHFA Guidelines for Suicidal Behaviour. These can be downloaded from www.mhfa.com.au.]. If the person has an advance directive or relapse prevention plan, you should follow those instructions. Try to find out if the person has anyone s/he trusts (e.g. close friends, family) and try to enlist their help. You should also assess whether it is safe for the person to be alone and, if not, should ensure that someone stays with them. It is important to communicate to the person in a clear and concise manner and use short, simple sentences. Speak quietly in a non-threatening tone of voice at a moderate pace. If the person asks you questions, answer them calmly. You should comply with requests unless they are unsafe or unreasonable. This gives the person the opportunity to feel somewhat in control. You should be aware that the person might act upon a delusion or hallucination. Remember that your primary task is to de-escalate the situation and therefore you should not do anything to further agitate the person. Try to maintain safety and protect the person, yourself and others around you from harm. Make sure that you have access to an exit. You must remain aware that you may not be able to de-escalate the situation and if this is the case, you should be prepared to call for assistance. If the person is at risk of harming themselves or others, you should make sure they are evaluated by a medical or mental health professional immediately. If crisis staff arrives, you should convey specific, concise observations about the severity of the personâ&#x20AC;&#x2122;s behaviour and symptoms to the crisis staff. You should explain to the person you are helping who any unfamiliar people are, that they are there to help and how they are going to help. However, if your concerns about the person are dismissed by the services you contact, you should persevere in trying to seek support for them

What if the person becomes aggressive? People with psychosis are not usually aggressive and are at a much higher risk of harming themselves than others. However, certain symptoms of psychosis (e.g. delusions or hallucinations) can cause people to become aggressive. You should know how to de-escalate the situation if the person you are trying to help becomes aggressive. Take any threats or warnings seriously, particularly if the person believes they are being persecuted. If you are frightened, seek outside help immediately. You should never put yourself at risk. Similarly, if the person’s aggression escalates out of control at any time, you should remove yourself from the situation and call the crisis team. When contacting the appropriate mental health service, you should not assume the person is experiencing a psychotic episode but should rather outline any symptoms and immediate concerns. If the situation becomes unsafe, it may be necessary to involve the police. To assist the police in their response, you should tell them that you suspect the person is experiencing a psychotic episode and that you need their help to obtain medical treatment and to control the person’s aggressive behaviour. You should tell the police whether or not the person is armed. How to de-escalate the situation: • Do not respond in a hostile, disciplinary or challenging manner to the person; • Do not threaten them as this may increase fear or prompt aggressive behaviour; • Avoid raising your voice or talking too fast; • Stay calm and avoid nervous behaviour (e.g. shuffling your feet, fidgeting, making abrupt movements); • Do not to restrict the person’s movement (e.g. if he or she wants to pace up and down the room); • Remain aware that the person’s symptoms or fear causing their aggression might be exacerbated if you take certain steps (e.g. involve the police). About these guidelines Purpose of these guidelines These guidelines are designed to help members of the public to provide first aid to someone who may be experiencing psychosis. The role of the first aider is to assist the person until appropriate professional help is received or the crisis resolves. Development of these Guidelines The following guidelines are based on the expert opinions of a panel of mental health consumers, carers and clinicians from Australia, New Zealand, the UK, Ireland, the USA and Canada about how to help someone who may be experiencing a psychotic episode. Details of the methodology can be found in: Langlands RL, Jorm AF, Kelly CM, Kitchener BA. First aid recommendations for psychosis: Using the Delphi method to gain consensus between mental health consumers, carers and clinicians. Schizophrenia Bulletin 2008; 34:435-443 How to use these Guidelines These guidelines are a general set of recommendations about how you can help someone who may be experiencing psychosis. Each individual is unique and it is important to tailor your support to that person’s needs. These recommendations therefore will not be appropriate for every person who may have psychosis. Also, the guidelines are designed to be suitable for providing first aid in developed English-speaking countries. They may not be suitable for other cultural groups or for countries with different health systems.

Although these guidelines are copyright, they can be freely reproduced for non-profit purposes provided the source is acknowledged. Please cite these guidelines as follows: Mental Health First Aid Training and Research Program. Psychosis: first aid guidelines. Melbourne: Orygen Youth Health Research Centre, University of Melbourne; 2008. Enquiries should be sent to: Professor Tony Jorm, Orygen Youth Health Research Centre - Locked Bag 10, Parkville VIC 3052 Australia email: ajorm@unimelb.edu.au

3. Communication and psychosis / I: It’s good to talk, but how? Rose McCabe and Stefan Priebe Summary Communication between clinicians and patients is at the heart of psychiatric practice and particularly challenging with psychotic patients. It may influence patient outcome indirectly or be therapeutic in its own right. Appropriate conceptual models, evidence on effective interventions and specific training are required to optimise communication in everyday routine practice. Declaration of interest None. This work was, in part, supported by the Medical Research Council (grant GO401323) Rose McCabe is a senior lecturer at Barts and the London School of Medicine and Dentistry. Her research focuses on linking treatment processes, particularly therapeutic relationships and interactions, with outcome. Stefan Priebe is Head of the Social and Community Psychiatry Research Unit at Barts and the London School of Medicine and Dentistry. His research addresses concepts, processes and outcomes in mental healthcare. Clinicians communicate with patients. In psychiatry, this is arguably the main part of what they do in their daily practice. Yet, does it matter how they communicate? Both the General Medical Council and the Royal College of Psychiatrists highlight the role of good communication in achieving therapeutic relationships. Effective communication, and the related construct, the therapeutic relationship, may have an impact on patients’ engaging in treatment in the first place, following treatment suggestions, satisfaction, symptom severity, referral to other services and willingness to file lawsuits.1 It may even be therapeutic in its own right. The therapeutic relationship is negotiated and reflected in patient–clinician communication and appears to predict outcome in different samples and settings across mental healthcare. If communication may be influential in patient outcome, there is a challenge to understanding how these processes work in psychiatry. This may feel especially difficult when communicating with patients with psychosis whose contributions may appear to be inappropriate both in their content and placement in the interaction. The first step is good research. Studying communication Communication is difficult and cumbersome to study. A typical approach involves recording the interaction. Videotaping one session can be the minimum. This is easier in a clinic setting than in various community settings. Audio taping alone is problematic given how much information is contained in non-verbal aspects such as posture and gaze. A long gap in a consultation has a different meaning if the clinician is writing notes in that gap or has eye contact with the patient and is not responding to a patient’s question. Most methods involve transcription, ranging from basic (content only) to highly detailed transcripts (content plus intonation, pauses, overlap, gaze, etc.) followed by time-consuming and labour-intensive analysis; linking one-off consultations with long-term clinical outcome is inappropriate given the complexity of treatment processes. It is likely that a series of consultations need to be studied to establish factors that have an impact on clinical outcomes. Simpler methods may need to be developed to capture intermediary outcomes of communication so that they can be assessed in pragmatic studies with sufficiently large samples. Setting aside the methodological problems, a key conceptual issue is that, even in the social sciences, there is no definitive model of ‘good communication’. A focus of positive communication throughout healthcare is patientcentredness. One component is shared decision-making. People with schizophrenia have a slightly stronger

preference for shared decision-making than primary care patients. Among those with schizophrenia, younger people and those with more negative views of medication want more participation. Some research has been carried out on shared decision making in relation to antipsychotics. Seale et al audio taped psychiatric consultations and interviewed psychiatrists about their negotiating styles. In interviews, psychiatrists were committed to achieving concordant relationships with patients although they felt there were obstacles particular to psychiatry, mainly if the patient was deemed too ill to make decisions and the patient’s honesty about their medication use. Analysis of the consultations themselves showed how side-effects may remain unaddressed (by offering no response, changing the subject or disagreeing with the patient’s interpretation of the experience) or be acknowledged through sympathetic and supportive listening. What should I say now? In a detailed study of how psychiatrists and patients communicate about psychotic symptoms in out-patient consultations, patients repeatedly attempted to raise the content and emotional consequences of their hallucinations and delusions. Psychiatrists frequently avoided engaging with these concerns, leaving both patients and doctors very uncomfortable. One patient asked ‘Why don’t people believe me when I say I’m God?’ to which the doctor, after initial avoidance, replied ‘What should I say now?’ In ‘normal’ interaction, avoiding sensitive issues that might expose conflicts of opinion is typically a good strategy. This might also apply here where the clinician avoided a confrontation about beliefs on which agreement was unlikely to be reached. Yet, in interactions with patients with psychosis, initial avoidance by clinicians seems to lead to explicit confrontation and disagreement about the very reason the patient is there. With patients who are not well-engaged, this might lead to further disengagement during treatment. Despite the fact that communication about psychotic symptoms is a frequent challenge and regarded as fascinating by many clinicians, there is little systematic, theoretically informed training on how clinicians should respond. Many state that the recommended approach is not to ‘encourage’ the patient to talk about their symptoms because it amounts to inadvertent collusion about the illness. Because the patient is uncertain about reality, the clinician might feel that they should be firmly rooted in reality and respond to the God question with ‘because it is not true’. There are alternative ways to respond. For instance, a client-centered approach might respond to the emotional content of the patient’s statement with ‘You feel misunderstood and puzzled by it’. A cognitive approach might ask for evidence about the belief. One could take the patient’s perspective with a response like ‘Why should people believe you? They did not believe Jesus either’. Further responses are possible using other therapeutic approaches. Yet, most psychiatrists are not specifically trained in this nor is there much theoretical debate on such a core aspect of everyday communication with patients with psychosis. Communication is not only technical. It also involves emotions, particularly when communicating about profoundly disturbing experiences. Jaspers6 discussed the challenge of communicating with another person whose experience is so remote from the ‘normal’ realm to render it ‘non-understandable’. However, in order to establish ‘non-understandability’ the clinician first has to try to understand the patient’s experiences, which requires communication about symptoms, emotions and their meaning for the patient. Clinicians themselves may need to be supported in their response to patients’ disturbing experiences. Communication involves at least two people and so far we have considered only the role of the clinician. However, doctors and patients construct the interaction together so how are patients with psychosis communicating? It is clear that patients are representing concerns that have been discussed many times before. They raise the same issues time and time again, often expecting that the clinician will disagree. It may be important to understand if (and how) patients are breaching ‘normal’ communicative practices both for understanding the disorder and identifying appropriate ways to respond.

Interventions to improve communication In medicine generally, alerting clinicians to the patient’s concerns/ emotions and changing clinicians’ beliefs about communication have led to communication change. However, interventions to improve communication, and in turn outcome, in psychosis are rare. A simple communication checklist completed by patients before seeing their clinician improved communication and resulted in treatment changes. An intervention structuring patient–key worker communication elicited the patient’s satisfaction with a range of life domains, their needs for care and wishes for different help. Patients receiving the intervention had a better quality of life, fewer needs for care and higher treatment satisfaction after 1 year. It remains unclear, however, whether the structuring, focusing on the patient’s view, the forward-looking emphasis on treatment changes or a combination of these factors was crucial to the intervention’s success. Finally, an intervention to increase shared decision-making with in-patients with schizophrenia did not take up more of the doctor’s time, increased the uptake of psycho education and increased involvement in medical decisions. As in medicine generally, different approaches have been tried on a more or less ad hoc basis without explicit theoretical frameworks specifying key communication processes and the pathway through which they may influence health outcomes. The current state of the art cannot begin to address the question ‘Does one size fit all?’ (Which is unlikely). Different clinicians may have different communication styles and strengths which might have to be enhanced rather than eradicated. Also, a particular clinician’s communicative style may suit one patient and not another. Future research might address matching the right patient with the right clinician to achieve the best possible communication. Concluding remarks If psychiatrists want to make better use of everyday communication as a core component of their trade, the ambition must be to develop better competence and skills to maximise its therapeutic effect, preferably based on sound conceptual models and evidence derived from them. Some of the required skills may be generic, whereas others are likely to be specific to communicating with patients with psychosis. Jaspers stated that ‘the ultimate thing in the doctor–patient relationship is existential communication, which goes far beyond any therapy, that is, beyond anything that can be planned or methodically staged’ (p. 798). Thus, not all aspects of how psychiatrists and patients communicate might be identifiable in research and teachable in the classroom or individual supervision. Yet, the challenge is to advance the state of the art to reveal as much as possible so that patients benefit from communication that is, either indirectly or directly, therapeutic. Clinicians may also benefit from enriching their therapeutic options and professional expertise. Rose McCabe, PhD, and Stefan Priebe, FRCPsych, Unit for Social and Community Psychiatry, Barts, and the London School of Medicine and Dentistry, Queen Mary, University of London, UK Correspondence: Dr Rose McCabe, Unit for Social and Community Psychiatry, Newham Centre for Mental Health, London E13 8SP, UK. Email: r.mccabe@qmul.ac.uk First received 11 Dec 2007, final revision 11 Dec 2007, accepted 14 Feb 2008

References 1 Cruz M, Pincus HA. Research on the influence that communication in psychiatric encounters has on treatment. Psychiatr Serv 2002; 53: 1253–65. 2 Castonguay LG, Beutler LE. Principles of Therapeutic Change That Work. Oxford University Press, 2006. 3 Hamann J, Cohen R, Leucht S, Busch R, Kissling W. Do patients with schizophrenia wish to be involved in decisions about their medical treatment? Am J Psychiatry 2005; 162: 2382–4. 4 Seale C, Chaplin R, Lelliott P, Quirk A. Sharing decisions in consultations involving anti-psychotic medication. A qualitative study of psychiatrists’ experiences. Soc Sci Med 2006; 62: 2861–73. 5 McCabe R, Heath C, Burns T, Priebe S. Engagement of patients with psychosis in the consultation: conversation analysis study. BMJ 2002; 325: 1148–51. 6 Jaspers K. General Psychopathology (trans. J Hoenig, M Hamilton). Manchester University Press, 1959. 7 Hinshelwood RD. Suffering Insanity: Psychoanalytic Essays on Psychosis. Brunner Routledge, 2004. 8 McCabe R. Specifying interactional markers of schizophrenia in clinical consultations. In Against Theory of Mind (eds I. Leudar, A. Costall). Palgrave Macmillan, in press. 9 Van Os J, Altamura AC, Bobes J, Gerlach J, Hellewell JSE, Kasper S, Naber D, Robert P. Evaluation of the Two-Way Communication Checklist as a clinical intervention. Br J Psychiatry 2004; 184: 79–83. 10 Priebe S, McCabe R, Bullenkamp J, Hansson L, Lauber C, Martinez-Leal R, Ro¨ ssler W, Salize H, Svensson B, Torres-Gonzales F, Van Den Brink R, Wiersma D, Wright DJ. Structured patient–clinician communication and 1-year outcome in community mental healthcare. Cluster randomized controlled trial. Br J Psychiatry 2007; 191: 420–6. 11 Hamann J, Langer B, Winkler V, Busch R, Cohen R, Leucht S, Kissling W. Shared decision making for inpatients with schizophrenia. Acta Psychiatr Scand 2006; 114: 265–73. Source: BJPsych: The British Journal of Psychiatry (2008) - 192, 404–405. doi: 10.1192/bjp.bp.107.048678

4. Communication and psychosis / II Key Tips in communicating with a person who has psychosis Since psychosis directly affects a person’s ability to perceive, interpret and communicate information, family members have to learn new communication skills. A few key tips in communicating with a person who has psychosis: Psychosis generally makes people much more sensitive to emotional tones and stimulation. It will help to keep the environment as low-key as possible, and to speak to the person with a kind, matter-of-fact voice.     

Use short sentences. Don’t try to go into long explanations. Be concrete and specific. Avoid abstractions and generalities. Be careful about word choice to avoid communicating negative judgment. Provide consistent, sincere praise and positive feedback. After you speak, give the person plenty of time to digest the information and respond.

If there is something particularly important you are trying to communicate, use simple words and repeat the same language rather than using different language. Don’t argue with people about delusional beliefs. Remember that their perception of reality is just that to them: reality. Directly confronting delusions usually causes people to become defensive and less prepared to consider alternatives. Don’t “go along with” or agree to delusions, either. Learn reflective listening techniques. Agree to disagree. Approach delusions in a spirit of shared inquiry. Don’t push if the person starts to get upset. Reflective Listening No matter how hard it is to understand what a person is saying, there is ALWAYS a grain of truth. When a person is experiencing psychosis, their communication gets mixed up, but through reflective listening you can find a common ground. The steps in reflective listening with a person who has a psychosis:      

Listen to what they’re saying. Look for elements of reality. Ask yourself what they are feeling, or how you would feel in the situation. Ask clarifying questions only. Comment about the feeling, without stating any judgments about the content. Give the person time to respond. Comment about feeling again, and maybe gently begin to reframe/create a shared context. Give the person time to respond. Begin to identify “common ground”- reality you can agree on, or a way of addressing the feelings the person is having.

Here are a couple of examples: Example 1 - Person with psychosis: “God told me he doesn’t want me to take my medicine.” - Family member: “How did God tell you that?” - Person with psychosis: “God created the world in seven days, and on the seventh day He rested, and I can’t rest on this medicine”.

Family member: “Wow, resting is so important. You must be totally exhausted if you can’t rest.” Person with psychosis: “Yeah, they put me on this really high dose.” Family member: “How about if we talk to the doctor about doing something to help you rest.” Person with psychosis: “Can you talk to him for me?”

Example 2 -

Person with psychosis: “Everybody in town is after me.” Family member: “That sounds terrifying to think everybody’s after you.” Person with psychosis: “It IS terrifying.” Family member: “No wonder you’re so upset. What led you to feel that everybody’s after you?” Person with psychosis: “There are all these cars outside.” Family member: “Hmm, that’s interesting (going to look at the cars). Gee, there’s a shopping center across the street. Do you think that might be part of why there are so many cars?” - Person with psychosis: “Well, maybe… but I still think people are after me.” - Family member: “It sounds like you’re feeling really scared. What can we do to help you feel safe?” “I’m Not Sick, I Don’t Need Help” The book by Xavier Amador, "I’m Not Sick, I Don’t Need Help", is particularly useful for families trying to communicate with a person who does not accept that they are ill. Amador makes several key points: Sometimes it is actually better for people not to accept a psychiatric label, if they have negative beliefs about what that label means. By using their language rather than insisting that they accept a particular diagnostic label, they are more likely to choose treatment. Usually adapting to medical diagnoses such as psychosis and schizophrenia involves a process of “de-stigmatizing”, re-thinking what those labels do and don’t mean. Amador also points out that people with schizophrenia (and psychosis in general) often experience cognitive problems which are not immediately obvious. In particular, he discusses “anasignosia”, a brain condition in which individuals are unable to recognize medical symptoms. He hypothesizes that this may be a significant factor for some people who “lack insight” about their illness; they may, in fact, be literally unable to recognize the symptoms. Amador reinforces the importance of reflective listening, and offers the “LEAP” model: “Listen, Empathize, Agree, Partner”. The bottom line is to listen for what the person finds motivating, empathize with them, find common ground you can agree on, and partner with them to address common goals.

L.E.A.P Four steps to successful communication (source: Dr. Xavier Amador, I’m Not Ill, I Don’t Need Help): 1) Listen to your loved one. Sounds simple enough, but more difficult then you would think. When you listen the goal is to gain an understanding of what your loved one wants, feels and believes in. The goal is to not just to listen but to learn. To listen without learning is pointless. You want to gain a full understanding of their experience, not yours of the illness and treatment. 2) Empathize Empathize with your loved one regarding their experiences with the illness and treatment despite how out of touch with reality they may sound to you. This would include listening and empathizing when they tell you they won’t take medicines. If you want someone to seriously consider your point of view, be certain that they feel you have considered theirs. 3) Agree Agree on a common ground. Work on observations together, while remaining neutral, to discover what motivation the person has to change. Common ground always exists between the most extreme opposing positions. “What happened after you stopped taking your meds?” vs. “This happened because you stopped taking your meds”. 4) Partner Partner with your loved one. The aim of this step is to help you collaborate on accomplishing the goals you have agreed on. 1) Listen 1) What to learn by listening a) Their beliefs about having a mental illness. b) Their attitudes on medications. c) Their concept of what they can and cannot do. d) Their hopes and expectations for the future. e) Cognitive deficits caused by the illness. 2) How to listen effectively to someone with a mental illness. a) Set aside a time to talk Set aside time to talk, such as after dinner, going for walk, while smoking etc. During difficult times, sit close to the person, not face to face (can increase paranoia), and attempt to share a couple of words without pressure or an agenda. If you are the type that insists of getting something accomplished then let your accomplishment be that you were just there. Although this seems pointless, it builds trust and openness. What to do during difficult times 1) Sit side by side other than face to face. 2) Avoid direct eye contact. 3) Identify with rather than fight with family member. 4) Don’t rationalize, Share mistrust. 5) Postpone (temporarily) psycho-education. 6) Reassure.

7) Leave them alone if necessary. b) Agree on an agenda. If this can’t happen, then just listen, but learn! Your loved one may be tired of hearing what he or she can and cannot do. When they learn you will not do that, they may be more apt to talk abut “hot topics” (medicines). To establish agenda follow lead of your loved one. If they are pontificating on that they won’t take medicines then ask, “I would really like to understand what it is about meds you don’t like”. Don’t second-guess at this point just listen and empathize. c) Listen for beliefs about the self and the illness. Find out what they want out of life without being judgmental. If they want to work, don’t tell them it is unrealistic. Listen! And Believe! Attempt to learn if they even believe they are not ill and what medications/therapy do for them (both positive and negative). d) Don’t react! I’m not saying ignore, just don’t give your opinion. Empathize with the experience instead of telling them it is not true. Use a statement like “anything is possible” I’m not saying agree with delusions just don’t disagree. With exceptions to urgent matters, but be assured it is urgent. e) Let chaos be. There will be times when your loved one does not make sense or is out of touch with reality. Don’t interrupt or attempt to fill in the blanks. You can still get the information you need by letting them just talk. f) Echo what you have heard. Make it a point to assure them that you have heard them this can be done simply by repeating it back to them in your own words. If they feel you understand them, they are more likely to be open to your opinions later. g) Write it down. Complete Attitudes and Beliefs checklist. Do this after the conversation. Unless it would cause defensiveness in your loved one. “Would it be ok if I use this form I have?” 2) Empathize 1) Your listening will naturally lead to empathy. When someone you are working with is in pain it is hard not to empathize. It is however easy to tell someone what you think is best also because your care and think you know what is best. The former will ultimately lead to a real interest in your thoughts; the latter will lead to resentment and frustration. 2) What should I be empathizing with? a) Any feeling your loved one is willing to talk about. b) Frustrations about pressures to take medicines and personal goals not met. c) Fears about medicines, being stigmatized, and failing. d) Discomfort attributed to medicines (i.e. weight gain, feeling groggy, tired, stiff) e) Desires to work, get married, have kids, return to school and to stay out of the hospital. 3) How to empathize. a) Use reflective listening. Reflecting back statements and feelings in the form of questions.

b) Recognize your loved one’s point of view. c) Establish that loved one’s point of view is only one point of view. d) Supply an alternative, in non-parental manner. e) Anticipate setbacks. f) Talk about yourself. g) Talk in fashion that allows your loved one to “save face”. h) Maintain a positive attitude. i) Use admiring and approving statements. j) Provide education about negative symptoms. 4) How not to empathize. a) Telling your loved one they are not ready for a goal they have set for themselves (i.e. work, school, sexual relationship) and focusing on “maintenance” Telling your loved one he/she needs to be on medicines to get better and he/she will always have to take them. b) Focusing on the labels of illnesses. c) Imposing your standards of living on them. d) Taking a parental stance/controlling privileges such as money or driving. “Ex. I told you if you would have taken your meds this wouldn’t have happened”. 3) Agree 1) Having listened and empathized with your loved one’s frustrations, goals, etc., you will ultimately have something that you all can agree on. It won’t be everything and it may not be much, but if the door is cracked put your foot in it (i.e. wanting to work, they may feel they have not because they have been in the hospital although you may feel it is due to symptoms you can both agree it is good to work and to stay out of hospital). 2) What to do when you notice the door is opening and defences are down. a) Normalize the experience (i.e. I would feel the same way if I were in your shoes) b) Discuss only perceived problems. “I can’t sleep because of the shadows” You may recognize this as paranoia or hallucinations; however you need not use those words. c) Review perceived advantages and disadvantages of treatment. If they miss a disadvantage feel free to point it out. (I understand that medicine also makes you gain weight). d) Correct misconceptions if possible, such as assuring neuroleptics (I try to avoid the term anti-psychotics) are not addictive and MI is not caused by upbringing or illicit drugs. e) Reflect back and highlight perceived benefits. (I understand the medicines suck, but it sounds like you feel if you take them you stay out of trouble with the judge). f) Agree to disagree. This can be important when your loved one feels threatened by you. You can agree to disagree. Point out disagreements can be non-threatening such as in sports or politics. g) Remember the goal is to collaborate and not pontificate. 4) Partnership 1) Once you have established an agreement work together on how it can be completed on their terms (i.e. how they believe they can return to work or stay out of the hospital.) 2) If possible attempt to agree on goals that are reachable.

5. Nursing a patient with a severe psychotic illness About these Guidelines For general nurses and healthcare officers Nurses play a central role in the assessment and treatment of patients with severe, psychotic mental illnesses. Nursing such patients is a skilled job that requires special training. Sometimes, general nurses or healthcare officers without mental-health training may augment the care provided by mental-health nurses. This section provides information to help them to do that. It covers two topics. • Information about psychotic illness. • What a generalist nurse can do to contribute to assessment and treatment. It does not cover specialist topics such as how to assess hallucinations and delusions. Information about psychosis What is psychosis? The word psychosis is used to describe a broad range of mental disorders that affect the mind, where there has been some loss of contact with reality. These types of disorders can vary greatly, though certain types of symptoms are characteristic. They include unusual and often extremely distressing experiences such as the following. • Disturbances of thinking: thoughts become confused and may seem to speed up or slow down. Sentences are unclear or do not make sense. Patients may feel as if their thoughts are being put into their head and are not their own thoughts. They may have difficulty concentrating, following a conversation or remembering things. They may then appear to be unresponsive or uncooperative. • Delusions: false beliefs that seem real to the patient and are not amenable to logical argument. They are often very frightening. For example, a person may believe that their food is being poisoned. Common themes for delusional beliefs are persecution, punishment, grandiosity and religiosity. For example, someone acutely ill may believe that he is Jesus. • Hallucinations: patient sees, hears, feels, smells or tastes something that is not actually there. For example, they may hear voices that no one else can hear. Food may taste or smell as if it is bad or poisoned. Hearing voices is a very common symptom of schizophrenia. The hallucinations can range from occasional voices through to an almost constant barrage of derogatory comments from a large number of different voices. • Changed feelings: patients may feel strange and cut off from the world. Mood swings are common and patients may feel unusually excited or depressed. Their emotions may seem dampened — they feel less than they used to or show less emotion to those around them. Different types of psychotic disorder There are different types of psychotic illness. These include the following. • Substance-induced psychosis: use of, or withdrawal from, alcohol or drugs may be associated with the appearance of psychotic symptoms. Sometimes the symptoms remit as the effects of the substances wear off. Sometimes the illness lasts longer. It is possible for a patient to both have a more long-term psychotic illness and to misuse substances. It is not possible to tell from the symptoms alone whether someone has a substance-induced psychosis or whether they have another psychotic disorder. It is a mistake to think that because a prisoner is a drug user they cannot also have a severe psychotic illness such as schizophrenia.

• Brief reactive psychosis: psychotic symptoms arise suddenly in response to a major stress in the patient’s life. The patient makes a quick recovery in a few days. • Organic psychosis: physical injury or illness, such as a brain injury, encephalitis, AIDS or a tumour, may cause psychotic symptoms. • Schizophrenia: psychotic illness in which the symptoms have been continuing for at least 6 months. The symptoms and the length of the illness vary. • Bipolar disorder (manic depression) and psychotic depression: psychotic symptoms appear as part of a more general disturbance of mood. When psychotic symptoms are present, they tend to fit in with the person’s mood. For example, someone who is depressed may hear voices telling them they should kill themselves. Someone who is unusually excited (manic) may believe that they have special powers and can perform amazing feats. What causes psychosis? Schizophrenia is probably caused by a combination of biological factors (such as a family history of schizophrenia) that create a vulnerability to experiencing psychotic symptoms. The symptoms often emerge in response to stress (e.g. breakdown of a relationship, being held in solitary confinement, bullying), drug abuse or social changes in vulnerable individuals. This theory of causation is known as the ‘stress–vulnerability model’. It helps to explain why psychosis is usually an episodic problem, with episodes triggered by stress and patients often quite well between episodes. It also helps to guide management. International studies show that once a person has schizophrenia, the environment in which he/she lives can help them to stay well or can make them worse. In a calm environment and one where people provide plenty of support and encouragement, those with schizophrenia will suffer fewer psychotic episodes than if they are surrounded by people who push, frighten or criticise them. Prognosis: do people get better? Schizophrenia usually begins in early adult life but may occur at any time in an individual’s life. Those who develop schizophrenia at a very early age do not tend to do as well as those whose illness begins in middle or old age. Although for some schizophrenia will be a life-long concern, others experience only one episode of the illness and never have a further episode. Generally, 20% of people recover completely, 35% are stable for long periods but have some further episodes of psychosis, and 45% experience long-term problems requiring continuing care. One-quarter of the latter group deteriorate more severely and rapidly and need very high levels of care and support. When someone is in a very distressed, acutely ill state, it can be hard to believe that they will ever get better. Realistic hope is one of the most important treatments a nurse or healthcare officer has to offer. What are the treatments? • Assessment: first stage of treatment involves assessment, usually over some time. Mental-health specialists need to develop an understanding with the patient of how and why these symptoms affect them. A range of measures may form part of the assessment, eg the ‘Delusion Rating Scale’ and the ‘Belief about Voices’ questionnaire. • Medication: along with other forms of treatment, medication plays a fundamental role in recovery from a psychotic episode and in the prevention of future episodes. The monitoring of side-effects is critical to avoid or reduce distressing side-effects that can lead to a patient being unwilling to accept the medication central to their recovery.

• Counselling and psychological therapy: having someone to talk to is an important part of treatment. A person with acute psychotic symptoms may need to know that there is someone who can understand something about their experience and provide reassurance that they will recover. As recovery progresses, different forms of psychological therapy can:   

help the patient and those caring for them (on ordinary location) learn how to keep stress levels low in order to prevent further episodes help the patient and those caring for them (on ordinary location) recognise early warning signs that a further psychotic episode is developing and help the patient learn ways of reducing the impact of hallucinations and delusions.

• Practical assistance: treatment often also involves assistance with employment, education, finances and accommodation. What the generalist nurse or healthcare officer can do 1. Communication (engagement) (The section on communication was adapted from ‘The guide to communicating with people who have serious mental health problems’, developed by Katie Glover when she was at START, a Homeless Mentally Ill Initiative Project in London.) In order for the healthcare team to help the patient, the patient has to feel that the team is on their side and be prepared to communicate and, at least to some extent, to cooperate with the team. A trusting relationship with any member of the healthcare team is therefore important to the success of the treatment. Building such a relationship is especially hard with a patient who is psychotic as, at least in the acute stage, they may believe that you intend to harm them. When you talk to the patient, it is likely that you will have to adapt your usual communication style as the patient’s memory, concentration and tolerance levels may all be reduced. • Talking with someone with a severe mental illness: 

   

Never leave someone who is mentally ill to guess your intentions or the intentions of other members of the healthcare team. Their imagination will run riot. Always explain why you, the doctor or other person wants to talk with them. Try to ensure that the environment is comfortable and safe for both you and the patient. Ask where in the healthcare centre the patient feels safe/OK to talk. Remember that social interaction can be very stressful for the patient and be prepared to acknowledge this: ‘I can see how hard this is for you. I appreciate you making the effort to talk to me’. Be warm and friendly but also prepared to spend time in silence. Always be aware of cultural issues. If you are not sure, ask. Finding out as much as you can about the patient’s culture will help communication.

• Talking with someone who is hearing voices. If you are not sure someone is hearing voices at this particular time, ask them. If they are, do the following:     

Acknowledge the difficulty and distress that voices cause. For example, ‘It must be really difficult for you having this conversation. I really appreciate you making the effort’. Do not challenge the fact that the patient can hear voices. They are real to the patient. However, you can say in a gentle and matter-of-fact way something like, ‘It’s your brain playing a trick on you just now’. Talk clearly and slowly if necessary and be prepared to repeat questions. Be prepared to take longer even for a simple matter. If someone is obviously in distress, ask them if they have had enough. Be prepared to come back later.

• Talking with someone who mentions their delusional beliefs:  



Show some understanding of the person’s feelings, eg ‘It must be really scary to think that someone else is controlling your thoughts’. Do not argue about the strange ideas but do not pretend to agree with them either. Focus instead on how the delusions make them feel and then change the subject to something neutral or pleasant in real life (eg what is for dinner?). If the conversation is distressing to the patient or to you, it is OK to say, ‘I’ll talk to you later when you’re feeling a bit better’.

• Relating to someone who is withdrawn or isolated:    

Be prepared to sit with the patient in silence. Doing practical tasks close to the patient can be comforting. Sharing activities without talking can also be helpful. Gently encourage other activities which are not too demanding (eg watching television, washing dishes, playing a board game). Be prepared to keep trying. It can take a long time for some people to respond.

• Talking with someone who is angry or aggressive. People with schizophrenia are usually shy and withdrawn. However, they may also become aggressive, especially when they are experiencing fear or paranoia (feeling that they are being persecuted and that other people are out to get them) or voices (voices can, rarely, command a person to injure others). To reduce patient fears and the potential for aggression, it may be helpful to do the following: — Give the patient space. Do not crowd them. — Inform the patient about what you are doing and intend to do. — Tell the patient that you do not mean them any harm. — Talk calmly and evenly. — Talk to the patient in a quiet environment. — Continually reassure them. — Keep your hands in view. — Keep your movements to a minimum. — Ask them why they are upset. 2. Observation: contribution to assessment Nurses and healthcare officers may spend long periods with patients. Your observations of the patient’s behaviour are a very valuable part of the assessment. General information about conducting observations is provided in Observation. In psychotic illness, helpful observations include the frequency, intensity and duration of ‘positive symptoms’ and the extent of ‘negative symptoms’. Positive symptoms include:

Negative symptoms include:

• • • •

• • • • •

Hallucinations. Delusions. Thought disorder. Paranoia.

Lack of motivation. Social withdrawal. Emotional withdrawal. Difficulty in forming relationships. Lack of spontaneity.

Make your observations as concrete and objective as possible, e.g. ‘Spent all morning in bed. Appeared to watch television in afternoon but showed no reactions to the programmes or to changes of channel by others. Unresponsive to efforts to hold conversation’ (rather than ‘withdrawn’). 3. Reassure, encourage and support the positives People with a psychotic illness are likely to feel confused, distressed, afraid and lacking in self-confidence, both during the acute phase and for a long time afterwards. The illness has probably caused them to lose control of their thoughts and to feel overwhelmed by the world around them. As they recover, it is common for patients to: • sleep for long hours every night (or during the day) for 6–12 months after the psychotic episode • feel the need to be quiet and alone more often than other people and • be inactive and feel that they cannot or do not want to do much. It is helpful to explain to the patient what is happening to them, e.g. that psychotic symptoms usually appear as a response to severe stresses (see What causes psychosis above) and that additional sleep and inactivity is the body’s natural way of slowing down to allow the brain to recover following the shock of an acute episode. It is also helpful, as the patient recovers from the most acute stage of the illness, to encourage them to resume activities gradually that they have been able to do and have enjoyed in the past. Encourage the patient to help with simple jobs around the healthcare centre or to chat with you or to join in any art or other therapeutic activity on offer. If the patient refuses, do not pressure them but make it clear that they are welcome to come when they feel able to join in. Make it clear that they are welcome simply to sit in the company of others and watch or listen to people without joining in more actively. You may find that the patient likes to listen to loud music a lot of the time. This may be a way of drowning out distressing voices or thoughts. Earphones or a Walkman may be helpful. Most importantly, it is helpful to relate to the patient as a human being who has interests and strengths separate from his/her psychotic symptoms or lack of them. This may be crucial in rebuilding some self-esteem and hope for the future. Find out what the patient’s interests are and, if you can, discuss them with the patient. If the patient has contact with family members who are supportive, try to arrange a visit. It may be very helpful for the family members to have information about psychosis. This can be provided by an organisation such as the National Schizophrenia Fellowship (for details, see Resource directory). 4. Reduce stress and conflict Because environmental stress plays such a prominent part in triggering episodes of psychosis, reducing such environmental stress is an important part of both treatment and prevention. The particular kind of stress that studies have found to be detrimental to patients with schizophrenia consists of high levels of ‘expressed emotion’. This means: • hostility: not only just bullying or physical aggression, but also angry shouting • emotional over-involvement, eg ‘Can you tidy your cell for me?’ and • criticism, eg calling a patient ‘lazy’, blaming him/her for being uncooperative. Staying calm and using the communication tips in Communication/engagement above will be helpful. Ensuring that the patients are in an environment safe from bullying is also important. If the patient returns to normal location when the acute episode is over, residential managers should be aware that the way the patient is treated by staff and prisoners will significantly affect the likelihood of relapse. Additional patience and ‘giving leeway’ may be required. 5. Look out for depression and suicidal thoughts People who have psychotic illnesses are at significantly higher risk of depression and suicide. They tend to have low self-esteem, to feel hopeless about their lives, to misuse drugs and alcohol, to lose their social role and be unable to attain their personal goals. In addition, some may hear voices telling themselves to kill themselves.

If the patient expresses depressed or suicidal thoughts to you, do the following. • Listen to their feelings, but also point out that help is available. • Express appreciation of the patient’s feelings and the fact that he/she confided in you. • Let the doctor and mental-health nurse know and consider opening a 2052SH form (in Scotland, an Act to Care form). • Distract the patient by involving him/her in pleasant, low-key activities. • Help them to be with someone by whom they feel accepted. • Let the patient know that you accept and care about them. • Consider whether any stressors can be removed that might be depressing the patient (eg worries about going back to a location on which he had been bullied). 6. Medication If you become aware that a patient is not taking the medication, do the following: • Remind them calmly that the medication helps to keep them well. • Ask if they are having any side-effects. • Let the doctor or mental-health nurse know that the patient is refusing to take the medication. Medications used for mental-health problems Information for non-specialist nurses General Nurses may be involved in administering psychotropic medication. This section is a brief guide to the main types of drugs used to treat mental disorders. The aim is to help you answer simple questions that patients may ask, and to know what to do if the patient does not turn up to collect their medicine. Further training is needed to help you recognise and deal with the side-effects of medication. The things to remember are the following: • • • •

A patient can only be given medication they have agreed to take (consent). Consent must be voluntary and reflect a continuing agreement to take the medication. Patients can change their mind about taking medication. When information is given to a patient about their illness and medication, it can increase the chance of consent being given. • If a patient refuses to take the medication, you should record their views in the notes and report the fact to the prescribing doctor.

MEDICATION Anxiety and insomnia Benzodiazepines What are they? Benzodiazepines are drugs used primarily to treat symptoms of the following. • Severe anxiety, eg tension, feeling shaky, sweating and a difficulty in thinking straight. The drugs, known as anxiolytics and (misleadingly) minor tranquillisers, include diazepam (Valium), lorazepam (Ativan), oxazepam (Serenid) and chlordiazepoxide (Librium). • Short-term problems with sleeping. Drugs known as hypnotics include loprazolam, nitrazepam (Mogadon) and temazepam (Normison). Benzodiazepines also have muscle-relaxing properties and some (e.g. diazepam) can help the following: • Epilepsy: particularly ‘status epilepticus’. • Symptoms of alcohol withdrawal (usually chlordiazepoxide). When someone has been heavily dependent upon alcohol, giving benzodiazepines during withdrawal may help prevent very serious, even life-threatening symptoms such as delirium tremens. Side-effects Common side-effects Drowsiness, sleepiness and an inability to concentrate during the day. Rare but important side-effects • Patient becomes aggressive, excitable, talkative or disinhibited. Ask the doctor to review the medication. • Rash: if this occurs, patients should stop the drug and see the doctor. When are they not helpful? Benzodiazepines are not ideal for the treatment of anxiety and insomnia because they only give symptomatic relief, do not treat the underlying illness and are addictive. They should not be taken regularly for more than 4–6 weeks. Taking them once per day or every other day (for insomnia) or irregularly, eg for 1 or 2 weeks for panic attacks, reduces, but does not eliminate, the risk of addiction (for more efficacious and longer-term treatments, see the guidelines on Sleep problems, Panic and Generalised anxiety disorder). Benzodiazepines should be avoided wherever possible during pregnancy, childbirth and breast-feeding. They can sedate the baby and cause breathing problems. They should not be used routinely to deal with sudden stress (eg bereavement, imprisonment) (see the guidelines on Bereavement and Adjustment disorders).

Important notes about benzodiazepines General • They are commonly traded illicitly on the street and in prison. Ensure that the drug goes to, and is taken by, the person for whom it is prescribed. • If a patient misses a dose, do not give two or more doses together next time. • They add to the effect of alcohol. Advise patients who may be released that alcohol is best avoided. • Many people become addicted to benzodiazepines because of legal prescribing by their doctor. Withdrawal • Benzodiazepines should not be stopped suddenly if they have been taken regularly for more than 4–6 weeks. • Withdrawal should never take less than 6–8 weeks — and often much longer • Withdrawal symptoms can include anxiety, tension, panic attacks, poor concentration, difficulty in sleeping, nausea, trembling, palpitations, sweating, and pains and stiffness in the face, head and neck. • The risk of suicide and self-injury increases during withdrawal and the regular monitoring of the suicide risk is required. • During withdrawal (especially if it occurs quickly), the patient may behave unpredictably and pose a management problem. Advise officers that this may be part of the withdrawal syndrome. They should deal with the patient as calmly as they can. It may be possible to postpone adjudications until after the withdrawal is complete so that any improved behaviour can be taken into account. Individuals withdrawing from benzodiazepines may benefit from help with anxiety-coping skills. Help lines and organisations providing support for those wishing to withdraw from benzodiazepines is provided below.

Beta Blockers What are they? Beta Blockers include oxprenolol (Trasicor) and propranolol (Inderal). In lower doses, they can help treat the physical symptoms of the following. • Anxiety, eg palpitations, sweating, shakiness. They do not affect the psychological symptoms (eg worry, tension and fear). • Heart conditions such as hypertension (high blood pressure), angina and arrhythmias. Side-effects Common side-effects Fatigue, cold extremities. Rare but important side-effects Rash or itchy skin, dry eyes, very slow pulse. Advise the patient to consult the doctor immediately. Important notes about Beta-blockers People with asthma should not take them. • There is no evidence that they are addictive but they should be stopped gradually because of the likelihood of rebound tachycardia. • If the patient misses a dose, do not give two or more doses at once. This may cause more side-effects.

Hypnotics What are they? Hypnotics are used as a short-term treatment for insomnia. • Non-benzodiazepine hypnotics include chloral hydrate, chloral betaine (Welldorm), clomethiazole (Heminevrin), promethazine (Phenergan), diphenhydramine (Nytol), zaleplon (Sonata) and zopicline (Zimovane). Promethazine and diphenhydramine are antihistamines. Chlormethiazole (Heminevrin) can help agitation and restlessness as well as alcohol-withdrawal symptoms. Side-effects Common side-effects All hypnotics: drowsiness, dizziness, reduced reaction times during the day. Rare but important side-effects • Chloral: rashes/blotches, wheeziness (especially if the patient has asthma). • Antihistamines: wheeziness (especially if the patient has asthma), palpitations/fast heart beat. • If any of the above occur, advise the patient to stop the drug and consult the doctor immediately. Important notes about hypnotics • They are commonly traded illicitly on the street and in prison. Ensure that the drug goes to, and is taken by, the person for whom it is prescribed. • They may cause addiction if taken regularly for longer than 4–6 weeks and should be taken in as low a dose as possible for the shortest time possible. Taking them only when required or every few days (eg on alternate nights) can be a useful way to use the drugs safely. • It is recommended that chlormethiazole is taken for no longer than 9 days if used to help alcohol withdrawal. • If dependence occurs, withdrawal symptoms can include anxiety, tension, poor concentration, difficulty in sleeping (‘rebound insomnia’), palpitations and sweating.

Antidepressants What are they? Antidepressants are used to improve mood in people who are feeling low or depressed. Certain antidepressants may also be used to help the symptoms of panic disorder, obsessive-compulsive disorder, social phobia, bulimia nervosa, post-traumatic stress disorder (PTSD) and chronic pain syndrome. All these drugs seem to be equally effective for depression at the proper dose, but they have different side-effects. If one drug does not suit a patient, another may be tried. There are three main types of antidepressants. • Tricyclics (TCAs): include amitriptyline (Typtizol), amoxapine (Asendis), dothiepin or dosulepin (Prothiaden), Imipramine (Tofranil) and lofepramine (Gamanil). • Selective serotonin re-uptake inhibitors (SSRIs): include citalopram (Cipramil), fluoxetine (Prozac), fluvoxamine (Faverin), paroxetine (Seroxat) and sertraline (Lustral). • Irreversible monoamine oxidase inhibitors (MAOIs): include isocarboxazide (Marplan), phenelzine (Nardil) and tranylcypromine (Parnate). A special kind of MAOI is known as a reversible inhibitor of monoamine oxidase type A (RIMAs). These include moclobemide (Manerix). There are, in addition, a number of other antidepressants, such as venlafaxine (Efexor), mirtazapine, nefazodone, reboxetine and trazodone. Side-effects Common side-effects • TCAs: sedation, dry mouth, blurred vision, weight gain, constipation, sweating. • SSRIs: insomnia, stomach upsets, sexual dysfunction. • MAOIs: blurred vision, dizziness, drowsiness, dry mouth, constipation. • RIMAs: dry mouth, nausea, headache, dizziness, insomnia. Rare but important side-effects • TCAs: skin rashes: stop medication and consult the doctor immediately. • SSRIs: skin rashes: stop medication and consult the doctor immediately. • MAOIs: urine retention: refer to the doctor immediately. Sweating, blurred vision, skin rashes, headache: stop medication and consult the doctor immediately. Important notes about antidepressants • If a patient misses a dose, seek them out and ask how they are. Ask the staff too. It is possible that the patient has not come to collect the medication because he/she has become more depressed, with increased lethargy, hopelessness and an increased risk of suicide. • If a patient misses a dose, do not give two or more doses next time as this may increase side-effects. • They may require at least 2 weeks before their mood starts to lift and 6 weeks before a full effect is achieved. Some changes (eg increased appetite, energy levels) may occur before this. Inform the patient about this lag in effectiveness. The risk of suicide may rise during this time. Careful monitoring is required.

• With TCAs, overdose attempts are serious and often fatal due to cardiac complications. The symptoms of overdose include: agitation, confusion, drowsiness, difficulty in breathing, convulsions, bowel and bladder paralysis, dilated pupils, and disturbances with the regulation of blood pressure and temperature. • Tranylcypromine (a MAOI) by virtue of its amphetamine-like properties has a high abuse potential. Take extra care to ensure that the drug is given to, and taken by, the right patient. • With MAOIs, dietary restrictions are necessary to prevent a tyramine-induced and potentially fatal hypertensive crisis. Tyramine is found in many common foods. Patients should not take any other drug at all (including over-the-counter cough and cold remedies) without consulting a doctor. If a throbbing headache develops, medical attention should be sought immediately. • Most people may need to continue taking antidepressants for at least 4 months and some may need to continue for 12 months or more, especially if they have been depressed more than once, to reduce the chance of relapse. • Antidepressants should not be stopped suddenly, even if the patient feels better. Their depression may return. In addition, they may experience ‘discontinuation’ symptoms. At worst, these could include headache, restlessness, diarrhoea, nausea, ’flu-like symptoms, lethargy, abdominal cramps, sleep disturbance and mild movement disorders. These are usually short lived and can even occur with missed doses. • Despite the discontinuation symptoms, antidepressants are not addictive because they do not produce craving for the drug, or tolerance (ie needing more of the drug to get the same effect).

Antipsychotic medication What is it for? Antipsychotic drugs are called neuroleptics or, misleadingly, major tranquillisers. They are usually used only for the treatment of severe psychotic illnesses such as schizophrenia, mania and major depression with psychotic features. Their side-effects are common and often serious. They can also be used to help manage confusion, dementia, behaviour problems and personality disorders, or, in smaller doses, to help treat anxiety, tension and agitation. They have an initial, rapid, tranquillising (calming) effect. Their effect on psychotic symptoms, such as delusions and hallucinations, may not appear for several weeks. There are two main groups of drugs. • ‘Typical’ or classical antipsychotics: include ‘low-potency’ drugs, such as chlorpromazine (Largactil), which are used in hundreds of milligrams per day, and ‘high-potency’ drugs, such as haloperidol (Serenace) and fluphenazine (Moditen), which are used in tens of milligrams per day. • ‘Atypical’ antipsychotics: such as risperidone (Risperdal), olanzapine (Zyprexa) and clozapine (Clozaril). Clozapine is an ‘atypical’ antipsychotic that has, to date, a unique effectiveness with patients who have not improved with other antipsychotics (drug-resistant schizophrenia). Some typical antipsychotics are available as long-acting ‘depot injections’, such as fluphenazine decanoate (Modecate) and haloperidol decanoate (Haldol). Antipsychotic drugs have different side-effects to each other. If one drug does not suit a patient, another may be tried. Side-effects There is a wide range of side-effects. Many are common. They can cause significant impairment in functioning and may be the reason why some people stop taking their medication. They occur most commonly with the high potency typical antipsychotics. With appropriate advice and management, side-effects can be minimised. If a patient is distressed by side-effects, advise them to have a discussion with the doctor or mental-health nurse. Common side-effects • Constipation, dizziness, drowsiness, dry mouth, appetite increase, blurred vision. Movement disorders, known as ‘extrapyramidal’ side-effects, include shaky hands, feeling shaky, involuntary movements of the face, neck, eyes and tongue. Also, akathisia (acute feeling of restlessness in the legs, constant pacing). Rare but important side-effects • Fever and muscle stiffness could be ‘neuroleptic malignant syndrome’, which is rare but potentially fatal. Stop medication and call the doctor urgently. The patient should be cooled, and the body fluids and serum electrolytes monitored. Anticholinergic medication will be needed. • Skin rashes: stop medication and consult the doctor immediately.

Depot injections It is sometimes necessary or helpful for antipsychotics to be given as ‘depot’ injections. A depot injection is a long-acting injection usually given into a buttock. The injection releases drug over several weeks, so the patient does not have to remember to take tablets at regular times each day. Depot injections are no more or less effective than tablets or capsules. They should only be given where essential, as they are painful to receive. The administration of depot injections should be preceded by an assessment of the patient’s mental state and general physical health, including side-effects.

Important notes about antipsychotic medication • It is essential that medication is taken regularly to avoid a recurrence of psychotic symptoms. If patients fail to turn up for their medication, make contact with them to assess why they have not taken their medication. Report this to the prescribing doctor or mental-health nurse. • Sedative antipsychotics may impair mental abilities. If alertness is impaired, advise the patient to avoid operating machinery or driving. • Remind patients, especially anyone who is taking clozapine (Clozaril), to report the sudden appearance of signs of infection (sore throat, fever). A complete blood count should be done immediately to check for the development of agranulocytosis.

Anticholinergic medication What are they for? Anticholinergic medication includes procyclidine (Kemadrin) and orphenadrine (Disipal). These drugs are used to reduce some of the extrapyramidal side-effects of antipsychotic medication. Acute dystonia and Parkinsonism respond quite well, tremor responds less well, akathisia responds poorly and tardive dyskinesia can be made worse by the drugs. These drugs should not be prescribed routinely for all people taking antipsychotic medication, but only after symptoms arise. Withdrawal of anticholinergic drugs should be attempted after 2 or 3 months without symptoms, as the drugs are liable to misuse and may impair memory. Side-effects Common side-effects • Dry mouth, constipation, blurred vision. Rare but important side-effects • Urine retention: contact the doctor. Important notes about anticholinergic medication • Patients may trade them and may try to obtain an extra dose. • Drugs have a mood-elevating effect and, when taken on their own, in the absence of antipsychotic medication, may also cause muscles to become stiff or, if enough is taken, to go into spasm. • Take steps to ensure that the drug is given to and taken by the individual for whom it is prescribed.

Mood stabilisers What are they for? Mood stabilisers are drugs used to help prevent mood swings (feeling ‘high’ or ‘low’) in people who suffer from a bipolar illness (sometimes called manic depression). They include lithium carbonate (Camcolit), sodium valproate (Epilim) and carbamazepine (Tegretol). Lithium is also used in severe, recurrent depressive illness and in aggression. Carbamazepine and sodium valproate are also used to help control epilepsy. Carbamazepine is also used to relieve the symptoms of trigeminal neuralgia (a painful condition of the face) and in a number of other illnesses such as alcohol withdrawal or alcohol dependence, schizophrenia and withdrawal from benzodiazepines. Side-effects Common side-effects • Lithium: nausea, diarrhoea, metallic taste in the mouth, weight gain, increased thirst, difficulty in concentrating. • Carbamazepine: drowsiness, dizziness, stomach upset, visual symptoms (eg seeing double). • Sodium valproate: nausea and vomiting, sedation, diarrhoea/nausea. Rare but important side-effects All three drugs can cause serious disorders. A range of blood tests is required for monitoring. • Lithium: blurred vision, shaking and trembling, confusion, slurred speech, nausea and vomiting, diarrhoea, skin rashes. Advise the patient to stop taking the medication, to drink water and to see the doctor immediately. • Carbamazepine: leucopenia, aplastic anaemia and agranulocytosis. Advise patients to report any symptoms of fever, rash, sore throat, infections, mouth ulcers, easy bruising, paleness of skin, weakness, bleeding or small purple spots on the skin. • Sodium valproate: rash, impaired platelet function (patient bruises without reason and bleeds easily), impaired liver function (the patient feels sleepy, is sick, loses appetite, the skin may look yellow). Stop taking the medication and see the doctor immediately. Important notes about mood stabilisers • It is essential that these drugs are taken regularly. If lithium is stopped suddenly, there is a very high chance that the illness will return. If the patient misses several doses, they may need a new blood test to check their blood levels. If carbamazepine or sodium valporate is being given to help control fits or blackouts, missing a dose can cause the fits to return. • If the patient does not turn up to collect their medication, seek them out and ask how they are. Ask the staff too. It is possible that the patient has not come to collect the medication because he/she has become more depressed, with increased lethargy, hopelessness and an increased risk of suicide. • If a patient misses a dose, do not give two or more doses next time, as this may increase side-effects. If a patient misses two or more doses, refer them to a doctor for blood level checks. • Remind the patient of the importance of reporting and responding to early symptoms of lithium toxicity. Make sure he/she has a copy of the information sheet on lithium toxicity (it is on the disk ). The most common cause of lithium toxicity is dehydration, which may occur during hot weather or physical exertion. Other

causes are urinary tract infection and illnesses that cause vomiting and diarrhoea. These may occur despite regular blood tests. â&#x20AC;˘ Remind patients taking carbamazepine of the importance of reporting immediately any fever, sore throat, infections, mouth ulcers, easy bruising, paleness of skin, weakness, bleeding or small purple spots on the skin. â&#x20AC;˘ Remind patients taking sodium valproate of the importance of reporting immediately any jaundice and abdominal pain.

Drugs used for treating attention deficit hyperactivity disorder (ADHD) The most commonly used drug in ADHD is methylphenidate (Ritalin). It is a stimulant and should be used along with educational, social and psychological help. Methylphenidate can help a young person’s abilities to concentrate and reduce over-activity and destructive behaviour. It is usually available from specialist centres only, and from general practitioners under ‘shared care’ agreements with specialist centres. It is also sometimes used to help narcolepsy (a sleep disorder), depression in the elderly and for ADHD in adults. Side-effects The main side-effects are nervousness, lack of sleep, lack of appetite and stomach-ache. These can sometimes be reduced by changing the dose or changing the times of the doses. Sometimes the drug can slow down the rate of growth, although the young person will still end up the height they would have done. Less often, side-effects such as feeling sick and skin rashes can occur. Important notes about medications for ADHD • Methylphenidate is a stimulant drug. It can be addictive, especially in adults. Take especial care that the drug goes to and is taken by the person for whom it is prescribed. • As methylphenidate is a stimulant, it is best not to give it after 4 pm as it may interfere with sleep.

Coping with common side-effects of medication Some side-effects occur commonly with more than one type of drug. It is important for patients to know that all drugs have unwanted effects, that these vary from individual to individual and depend on the type of drug and dose being given. Sometimes the side-effects disappear after a few days or weeks, while other side-effects are more troublesome and persistent. It is very important that the patient reports any unwanted effects the drug seems to be having to his/her doctor. The unpleasant effects can often be eliminated, reduced in severity or made more tolerable by a range of simple strategies. The strategies the doctor may suggest include the following. • • • • •

Changing to a different medication. Decreasing the dose. Taking the drug in several, smaller doses spread through the day. Taking the medication with appropriate food. Taking extra medication to counteract the side-effects.

Strategies that you can advise to help patients deal with side-effects include the following: Side-effect

Strategy for coping with it

Appetite (increase)

Eat a diet low in fat and high in fiber. Avoid sugary or fatty foods. Drink low-calorie soft drinks.

Constipation

Increase exercise. Increase fiber in diet. Increase fluid intake.

Dizziness

Get up slowly from lying or sitting. Avoid excessively hot showers or baths. Avoid alcohol, sedatives or other sedating drugs (eg marijuana).

Drowsiness Take medication in a single dose before bedtime (talk to the doctor about this first). If you feel sleepy during the day, you should not drive or work with machinery. Dry mouth Ensure a regular fluid intake. Limit alcohol and caffeine (both enhance water loss). Use sugarless gums, fruit pastilles and lollies (sugar will promote dental decay). Suck on ice cubes. If it is very bad, ask your doctor about artificial saliva (Luborant).

Stomach upset Take medicine after food. Consult with the doctor. Sensitivity to sunburn Avoid the midday sun. Regularly use sunscreen and wear a hat, sunglasses and shirt. Ask your doctor for a prescription for sunscreen.

Administering medication: general issues The main issue in administering medication in a prison setting is how to make sure that the right medication goes to, and is taken by, the right patient at the right time. All psychotropic medications and many medicines used for physical conditions (eg analgesics) also may be used as currency on the wing. Patients may sell or give them to other prisoners or be pressured/bullied into doing so. There is also the possibility that patients may save medication and then use it to overdose. Other issues, common to administering psychotropic medication in any setting, include the following: • How to provide information about the medication and its side-effects to all patients, and also those with communication difficulties who may not understand the instructions. Information tends to increase compliance. • What to do about those patients who are not capable of managing their own medication, eg those with learning disability. • How to encourage ‘compliance’ or concordance without infringing the rights of patients to refuse medication they do not want. This is a particular issue with antipsychotic medication especially depot injections. Possible solutions A major response to the problem of reducing trading and the hoarding of medication is to supervise consumption of medication — giving it only ‘in sight’ and not ‘in possession’. This solution may, however, bring its own problems. For example, giving medication in sight rather than in possession may: • mean that the dose is given at the wrong time. For example, a sedative could be given at 4.00 or 5.00 pm and so be ineffective in helping the individual sleep at night • turn medication into a battle ground between patients and healthcare staff and • make it difficult or impossible to give medication twice or three times per day. The decision about whether any particular medication should be given in possession or not is an individual one. It will depend upon the timing of the dose, the number of doses needed per day, the patient’s ability to understand his/her medication, the risk of abuse, etc. Whether medication is to be given in possession or not and the reasons for the decision should be documented in the notes. Systems and policies about medication Effective programmes for administering medication include the following: • Tracking and monitoring system that records whether patients are turning up for and taking their medication. Actively seeking out those patients who are considered to be at risk without their medication (including those on antipsychotics, mood stabilisers and some on antidepressants) who do not take it. • Regular reviews of medication. Reviews will ideally take place in a clinic, be multidisciplinary, and include the prescribing doctor and administering nurse/HCO who together review compliance, the behaviour of the patient with regard to medication and the patient’s own report of his/her progress. • Regularly scheduled patient educational groups related to the use of psychoactive medications. These are important and can reduce the need for in sight administration of medications, with all its attendant problems. They also increase compliance. • Policy on ‘in possession’ medication including flexibility within the policy. • Awareness by all who are involved in administering medication of the need to obtain patient consent and of what to do if a patient refuses to take the medication.

6. Communication skills for nurses and others spending time with people who are very mentally ill Source: Len Bowers, Geoff Brennan, Gary Winship and Christina Theodoridou Illustrations: Geoff Brennan - Copy editing: Richard Humm - © 2009, City University Dedication This work is dedicated to our 28 interviewees, on whose expertise it is based, and to all those engaged in caring for the acutely mentally ill Acknowledgements This work was in part supported by a grant from the Square Smile Appeal of the Lord Mayor of the City of London, 2001-02, Sir Michael Oliver The resources of City University London, and East London Foundation NHS Trust also supported the work Managers and staff of East London, Camden and Islington , and Central and North West London NHS Foundation Trusts, welcomed our research, helped identify their most skilled practitioners, and made their time available. Preface You, talking to me?! As often, when faced with new ideas, novel theories or revolutionary concepts, the first thought is, “Surely this has been done before – and if not, why not?” Many of the work practices evolved by the 28 expert nurses in this study seem obvious, but it is clear that the reality on many – or most – psychiatric wards is one of non-communication and mutual incomprehension. This research, when translated into a ‘guide’ or ‘handbook’ for nurses, should provide a very useful if not essential part of their education. The way that expert nurses dealt with - or rather related with - patients seemed to lead to better outcomes for the patients and for the nurses. So, if we could promote the nursing practices described in this work it is likely to lead to improved outcomes for service users and much happier staff. Strikingly, many of the nurses did not describe just using language but spoke of a range of different mediums, including non-verbal communication and, most excitingly, other more creative methods. Students and staff should not only read this but be actively encouraged to feedback (anonymously if they prefer) how they get on putting these principles into practice but also to identify the factors that prevent or make it difficult for them to do so. This will enable dialogue and learning to continue. For many of us, this reminded us that there had often been that special nurse, that one person, that “somebody who was there for me”; someone who did do it and did put it into practice. Compiled by members of SUGAR: Service User Group Advising on Research, City University London. 17th December 2009.

Contents Inpatient nursing care and interaction This study of interaction Moral foundations Preparation for interaction and its context Being with the patient Nonverbal communication, vocabulary and timing Emotional regulation Getting things done Talking about symptoms Lessons for practice Appendix â&#x20AC;&#x201C; the interview schedule References

Inpatient nursing care and interaction Acutely mentally ill people present their conversational partners with a perplexing range of behaviours and challenges to normal social interaction. Their mood might be one of euphoria and elation, with thoughts running through their head at speed, skipping from topic to topic as a spun stone skips over water. Or they might be deeply depressed, full of thoughts of guilt and painful emotions, with both speech and movement considerably slowed. Alternatively all their emotions might be flattened, dampened, unresponsive or incongruous. They might be obsessed with strange ideas and interpretations of the world and what is going on around them, with these beliefs often about a hostile world. Coupled with these delusional beliefs may be auditory or other hallucinations, commenting on what is going on around them, instructing, abusing, or generally interfering with their ability to think. In addition to the distraction caused by hallucinations, their thinking processes and verbal abilities might also be directly affected by a variety of thought disorders. They may be irritable, incongruous, unpredictable, and perilous conversational partners until their illness stabilises. Some people experience only one acute episode of the conditions currently called schizophrenia and manic depressive psychosis, which then gratifyingly resolves over time and never recurs. Others experience periods of wellness in between relapses and recurrences, whereas yet others have the conditions chronically with continuous symptoms, and experience exacerbations on top of this. All such people generally receive help, care and support largely in the community. However during periods of acute illness, when they are at higher risk of coming to harm, harming themselves, or possibly harming others, when they have little in the way of social support, when they live in a rejecting and stigmatising community, they are likely to be admitted temporarily to an acute psychiatric ward (Bowers et al. 2009). A proportion of these admissions are compulsory using mental health legislation. Such admissions are most likely to last about three weeks in the UK, and allow their condition to be assessed, appropriate treatment given, their physical healthcare and daily living needs to be attended to, and their safety maintained (Bowers 2005). Although psychiatrists regularly visit and see patients, and occupational therapists provide structured activities, most of the 24 hour care for patients is provided by a mix of qualified and unqualified nursing staff. However advice and information is scarce on how nurses should interact with acutely psychotic patients so as to effectively keep them safe, assess their needs, deliver treatment and provide physical healthcare. In the following sections we review the recent development and history of inpatient care in order to pull together what information exists. Nurse-patient interaction Over the past fifty years there have been a number of research studies about nurse-patient interaction on acute psychiatric wards, coupled with theoretical work about the nature of psychiatric nursing derived from neoFreudianism. On the plus side, the work of the nurses is generally highly regarded by patients (Rogers, Pilgrim, & Lacey 1993), and nurses can relate many critical incidents where their interaction with patients has been highly valuable (Cormack 1983;Flanagan & Clarke 2003). The nurse-patient relationship is generally seen as central to the provision of good inpatient care, and the widespread acceptance of this is generally due to the

work of Hildegard Peplau (Peplau 1991). However there have also been several reports of low levels of actual nurse-patient interaction, with 8% of nursing time spent in interaction with patients (Altschul 1972), 15% (Sandford, Elzinga, & Iversen 1990), 19% (Tyson, Lambert, & Beattie 1995), 21% (Sanson-Fisher, Poole, & Thompson 1979), 7% of nursesâ&#x20AC;&#x2122; time in potentially therapeutic interaction (Whittington & McLaughlin 2000), and patients spending only 4% (Hurst, Wistow, & Higgins 2004) or 6% (Martin 1992) of their time in interaction with nurses. One of these studies showed that as staffing numbers increased, staff-staff but not staff-patient interaction increased (Sandford, Elzinga, & Iversen 1990). These figures are quite variable, indicating that some places at some times have up to three times as much nursepatient interaction as others, nevertheless nursing has generally been intensely criticised for low levels of interaction. This has resulted in a low valuation of the time consuming and complicated case management work also carried out by ward staff which does not involve direct nurse-patient interaction (Deacon 2003). Another effect of this critique has been a concentration on interpersonal skills during nurse training, exercises to improve communication (Star Wards 2009) and more lately, centralised audits and policies that require a documented minimum of 15 minutes one to one nurse patient interaction for every patient during the course of a nursing shift (Healthcare Commission 2008).

Interpersonal and communication skills Curriculum changes in psychiatric nurse education in the 1980s gave much greater emphasis to training in interpersonal skills. These advances were swiftly overtaken by further nursing education changes (Project 2000) during which nurse education in the UK was brought into the University sector and the first half of training became a common foundation programme (CFP) for all nursing specialities (i.e. psychiatric nursing combined with general nursing, childrenâ&#x20AC;&#x2122;s nursing etc.). Whilst this new model brought greater academic breadth and rigor to nurse training, it also adversely impacted on intense, small group interpersonal skill development in psychiatric nurse training. The interpersonal skills which are taught to nurses are based on social psychology research into communication and social skills (Hargie 2006) merged with ideas from counselling psychology and the psychotherapies (Egan 2002;Heron 2001;Rogers 1961). These skills are not specific to mental illness or psychotic disorder, instead including generic listening skills (eye contact, body orientation, attention, prompts, use of open questions, reflection, paraphrasing, summarising, probing, demonstrating empathy, etc.), coupled with basic problem identification and solving approaches. Since the 1990s many psychiatric nurses have additionally been trained in de-escalation as part of courses in the prevention and management of violence and aggression (Lee et al. 2001;Wright 2003). De-escalation skills are generally poorly defined, but include (Stevenson 1991): non threatening postures, calm and quiet tone of voice, careful use of interpersonal space, mirroring, open questions, etc. These interpersonal skill areas clearly overlap, and although both are applicable to acutely psychotic patients, neither is specifically elaborated in any way for its application to patients who are in such a condition or state.

The nursing process, Isobel Menzies-Lyth, and primary nursing By the 1970s and 80s, traditional psychiatric nursing care was perceived to be overly custodial, unsystematic and task oriented. These concerns were shared in the general nursing field, where there was similar dissatisfaction. In psychiatric nursing this discontent was fuelled by a psychoanalytic study and interpretation of general nursing working styles by Isabel Menzies-Lyth of the Tavistock Institute (Menzies 1960). So powerful was this analysis that it remains regularly quoted to the current day, and is still well read by psychiatric nurse educators, often circulated as multiple generation, faded, difficult to read photocopies. The essence of that analysis was that task allocation, the system by which nursing care activities were shared out during a shift of work, was a social defence against anxiety. Task allocation was the giving of fixed tasks to individual nurses, such as doing the observations, medication, baths, dressings, meals, etc. Such an allocation of work meant that care for the individual patient was fragmented, as their needs would be met by many different nurses during the course of the shift. Menzies-Lyth argued that such fragmentation was unconsciously motivated to prevent meaningful relationships between nurses and patients, and thus defend nurses from the anxiety provoked by dealing with pain, deformity, death and dying. Psychiatric nurses read this as equally true in relation to acute

inpatient care, the anxiety in this case being provoked by the psychic pain and fragmentation of the acutely mentally ill person. This concern and awareness converged with new developments in the organisation of nursing care in the US: nursing models, the nursing process and primary nursing. The order in which these arrived in the UK, and their penetration of psychiatric nursing practice, has varied over time and across the country. However it would be fair to say that the nursing process was the first and most influential of these developments. It was a method of nursing work that sought to systematise and improve practice through the implementation of a cyclical process of assessment of patients’ needs, planning care, implementing that care, and evaluating it. Early nursing research in the UK did demonstrate that when the nursing process was implemented, the quality and continuity of care improved. It was eventually universally used in nursing, forming part of the move towards individualised care (McFarlane & Castledine 1982). The nursing process continues in use today, shaping the documentation and practice of in-patient psychiatric nursing, although the degree to which it has been successful, or as successful as it could be, remains open to question. Amongst community psychiatric nurses, the nursing process has been subsumed within the care programme approach, which is a multidisciplinary commitment to a shared care plan. Nursing models (Meleis 1985) flowed out of a pre-occupation with trying to define what nursing was, and what made it distinct from the activities of other healthcare occupations. Such theorising was associated with the move of nursing education into the University sector and the initiation of degree and higher level degree courses in nursing, coupled with aspirations towards a higher professional status. A multitude of such nursing models were produced, nearly all of which were based upon general nursing practice, with the intention that such models could shape nursing curricula as well as the practice of nursing – particularly the assessments and care plans being formulated through the use of the nursing process. Some of these models, particularly that of Peplau previous mentioned, were imported and applied to psychiatric nursing in the UK, again emphasising the interpersonal nature of psychiatric nursing and individualised care. Models reached the height of their influence in the 1980s, but are now mostly absent from both education and the practice of mental health nurses in the UK, with the exception of the Tidal Model which will be discussed further below. It has been argued elsewhere that any such models have to start from what psychiatric nurses actually do and contribute to acute inpatient care if they are to remain influential, rather than seek to arbitrarily redefine nursing work as something else (Bowers 2005). Primary Nursing was the last of the great US nursing innovations to jump the Atlantic. Associated with the name of Marie Manthey (Manthey 1980), primary nursing was a way of organising the nursing team across shifts so that one qualified nurse was always in charge of the care of a fixed number of patients, whether the nurse was present or not. That nurse carried out the nursing assessment, drew up the nursing care plan, reviewed and evaluated that care, and was responsible for interdisciplinary liaison and communication with the patient’s family. When the primary nurse was not on duty, other nurses (who were primary nurses for other patients) acted as associate nurses and delivered the care as prescribed by the primary nurse. This organisation gave the primary nurses considerable autonomy and responsibility, and again enhanced individualised care and strengthened the nurse-patient relationship. Only a small number of wards in psychiatry made a thorough implementation of primary nursing (Bowers 1987;Bowers 1989;Ritter 1985), but reports were generally positive. Before any more widespread implementation could occur, the UK government mandated that every patient should have a ‘named nurse’ (Department of Health 1991). Such allocations were carried out and remain so today, however the specific responsibilities of the ‘named nurse’ were not defined by policy, thus the role became titular and the opportunities presented by primary nursing proper were lost. Sadly, none of these three innovations was specifically elaborated for how individualised care was to be delivered to acutely psychotic patients, or how a nurse-patient relationship was to be built up across the divide of cognitive deterioration, suspicion, delusional beliefs and sometime coercive treatment. So although they thrust nurses into such relationships, they were left to devise on an ad hoc, learn by experience basis, how to actually do it.

Outside the mainstream: Laing, Berke, Mosher and Barker Arising out of the phenomenological and existential philosophies of the 1950s and 60s, coupled with general systems theory, Laing argued that psychoses were the product of dysfunctional family communication and upbringing and represented and sane response to an insane society. Leaving mainstream psychiatry, Laing set up

his own residential treatment centre in Kingsley Hall, in the East End of London. Laing’s writings drew upon these philosophical sources coupled with many ideas from psychoanalytic psychotherapy, in particular those of defence mechanisms in order to explicate the experience of psychotic breakdown (Laing 1965). While such accounts might, if true, help us to understand what a person suffering a psychotic breakdown experiences, they do not lead to clear recommendations on how to communicate or treat them, other than conveying that understanding. The main account of treatment at Kingsley Hall supports the idea that communicating such understandings was the treatment, in addition to allowing and facilitating the psychotic process to take its course. Laing’s stance never received wide acceptance in psychiatry, let alone by psychiatric nurses, although it does have some supporters. The concepts and the language in which these ideas are conveyed are not easy to understand, nor do they have ready, easy or certain applicability to dealing with the acutely psychotic person. However the idea of being with the psychotic person and trying to grasp or understand their experience was well received by psychiatric nurses, although difficult to put into operation and not well described in the psychiatric nursing literature. One of Laing’s co-workers, Berke, went on to found the Arbours Centre, a charitable institution which still offers treatment in this form today. Treatment at the centre has been described in a number of papers and books, and consists of tolerating the extreme emotions of the patient in an accepting manner, being with them, and expressing understanding of them in psychoanalytic terms (Berke 1987). Some elements of therapeutic community practice are also present, with regular community meetings being held. Therapy is seen in terms of a working through of psychic pain, and the therapists live and eat together with the ‘patients’. The Arbours Centre does offer that rare thing, a fully explicated model of how to interact with acutely psychotic people. However it is not one that can readily be followed in an acute psychiatric ward where the backbone of treatment is through medication, stays are short and often compulsory, nurses and their superiors are not in psychoanalytic therapy, and the psychotic experience is not viewed as one of personal growth and development but rather something that prevents and disables such growth. In addition, the Arbours literature does not seem to explain how they deal with violent incidents, inter-patient bullying, serious self harm and other disturbed behaviours that tax the abilities of psychiatric nurses. However the kindness, respect, warmth and egalitarianism shown by Arbours staff to their residents are very clearly transferable. While there does not exist a clear historical link to psychiatric nursing practice, these human values are very much a part of psychiatric nursing as they are of the Arbours approach. In the US, dually inspired by phenomenological philosophy and by contact with Laing and Kingsley Hall, Mosher created Soteria method. This was remarkably similar to the Arbours centre, but without the psychoanalytic orientation (Mosher 1999). Thus the focus is on being with the ill person and building a nonintrusive empathic relationship, without the use of neuroleptic drugs. However there was still a longer term attempt to develop a meaningful understanding of the psychotic experience based upon the person’s interpersonal circumstances and history. Soteria House itself only operated for a few years, although it has more recently been replicated in Berne, Switzerland, and does have some evidence for its efficacy (Calton et al. 2008). The model cannot really be claimed to have influenced psychiatric nursing practice in the UK, and is not completely distinct from that of Berke (interestingly articles from one do not cite the other). Just as with the Arbours model, its value base and focus on empathy does have common ground with psychiatric nursing practice, and provides a model to guide the encounter with acutely psychotic individuals. However once again, how difficult behaviours and reluctant patients are dealt with is not described, leading to the suspicion that the approach would not be applicable to acute psychiatric wards and their patients without considerable modification. It is difficult to conceive of hostile, paranoid, non-insightful and highly deluded patients being willing to freely stay in such an environment, let alone engage in some proffered therapeutic process. An attempt to import some of these ideas and ideals into acute inpatient psychiatric nursing has been made by Barker with his Tidal Model (Barker 2001). This attempt at defining a nursing model specifically for psychiatric nursing is difficult to tie down and summarise. Metaphors of tides, water and ships are prevalent, sources drawn upon are diverse, and the ideas are often contradictory and jostle side by side with each other. Yet for all its flaws, the model does get some way towards expressing the nub of actual psychiatric nursing practice and interaction with patients. That is, listening to the patient narrative and understanding of the situation, and hearing that with respect, things which represent the beating heart of psychiatric nursing. The model is humanistic and person centred in Rogerian sense, which is why it is accepted, recognised and welcomed by many practicing nurses. However other than this core emphasis, interactions with acutely psychotic patients are not further defined or described, and issues around psychiatric coercion and difficult patient behaviours are not clearly explicated.

Milieu therapy and modified therapeutic communities A rather different stream of psychiatric practice that has permeated acute inpatient psychiatric nursing practice was that of therapeutic communities, a British innovation associated with the work of Maxwell Jones in the 1940s (Jones & Bonn 1973). The common attributes of such communities are (Kennard 1998): an informal and communal atmosphere; group meetings central as fora for sharing information, decision-making, feedback, and generating cohesion; shared work of maintaining and running the community; shared authority and a flattened hierarchy; a therapeutic role for residents; and underpinned by moral values and beliefs about the interpersonal and social nature of psychiatric difficulties, therapy as a learning process, and basic equality. Therapeutic communities have had a major impact on the care and treatment of people with personality disorders, drug and alcohol dependencies, and criminal behaviours. However for a period they were also adopted by some leading acute psychiatric wards in a modified form. Certain elements of the therapeutic community ideal spread to nearly all acute psychiatric wards for a period, especially the notion of a weekly community meeting with some shared governance and therapeutic learning responsibility, coupled with the idea of egalitarianism between staff and patients and evidenced by the abandonment of nursing uniforms. Attempts to implement this approach on acute psychiatric wards are not without major difficulties, particularly in relation to acutely psychotic patients. Acutely ill patients are often not able to communicate easily, and are not in a fit condition to assume responsibilities towards running a community. In the case of psychosis, the idea of social causation, and social learning as an effective therapeutic method, are both open to serious question. Nevertheless, acute psychiatric wards in the UK are populated by more than just those suffering from acute psychosis, and even those patients usually make a recovery during their stay making them fit to engage with therapeutic community activities to some degree. Thus the therapeutic community notion continues to be present in psychiatric nursing practice to some degree, and from time to time is rediscovered and reimplemented or re-energised (Mistral, Hall, & McKee 2002). Similar and parallel innovations in the US came to be known as milieu therapy (Gunderson, Will, & Mosher 1983). The concept of milieu and milieu as a form of treatment was broad and never completely fixed, and drew on multiple sources. Patient involvement was drawn from therapeutic communities proper; validation or being with the patient was drawn from Mosher and Laing; finally the idea of structure encompassed rules, routines, hierarchy, herding or group care (in the Goffman sense, but non-pejoratively), and behavioural modification systems of every hue, and drew on a similarly wide range of sources, from Bettelheim, through Menninger to the work of Ayllon and Azrin, and Paul and Lentz. There was thus a sense in which milieu therapy ‘meant everything to everyman’, incorporated a wide range of treatment modalities, and therefore specific recommendations on practice or on interaction with acutely psychotic patients were rare. The literature argues, with a degree of weak research support, that intensive milieus with high levels of staff-patient interaction, patient involvement in decisions and responsibilities, and with an ideology that psychosis was meaningful and needed to be worked through, had good outcomes for non-chronic sufferers of schizophrenia. However none of this literature gets down to the actual detail of the nature of staff-patient interactions.

Psychotherapy, solution focused therapy, person-centred therapy and pre-therapy The psychotherapy literature might be thought to offer some helpful indicators on how to interact with acutely psychotic patients. Unfortunately the vast majority of the psychotherapy literature of any sort has been written about the treatment of non-psychotic people and about outpatients. There is little specific writing or advice about the inpatient care of people with acute psychoses. In the sole book about inpatient group psychotherapy (Yalom 1983), the main potential therapeutic processes are identified: instillation of hope, universality, imparting of information, altruism, corrective recapitulation of the family group, development of socialising techniques, imitative behaviour, catharsis, existential factors (death, freedom, isolation and meaninglessness), cohesiveness and interpersonal learning. Although his work is now of some vintage, being over 25 years old, it continues to be rediscovered and applied from time to time (Grandison et al. 2009). While Yalom does talk about offering patients support, valuing them, respecting and understanding their experience, all applicable to interactions with psychotic patients, the therapeutic processes he identifies are all considered to be the way in which group psychotherapy operates for ‘higher-level’ (i.e. not acutely psychotic) patients. Of this 312 page book, only 12% is devoted to talking about group therapy with

acutely psychotic patients, and the recommendations consist of structured small group activities of the type routinely conducted by occupational therapists and nurses (Remocker & Storch 1977). There is little specific advice on interaction with patients in these states, other than that they should be ‘supportive’. Yalom thus takes us no further forward than Laing, Berke, Mosher and Barker. Alongside Yalom, a variety of sources recommend the use of ‘supportive techniques’ with acutely psychotic patients, emphasising acceptance, affection, partnership, optimism, respect, empathy, reassurance, encouragement, advice and problem solving (Lakeman 2006). Whether such approaches constitute a therapy (i.e. used in the belief that they will produce symptom reduction or permanent change) can be questioned; and they can perhaps better be understood as normal expressions of care, or even a moral stance towards those in any psychological distress. As such, they are definitely applicable as a ways to talk with and spend time with those who are acutely psychotic, and can be readily integrated into everyday psychiatric nursing practice. Early behaviour therapy research during the 1950s and 60s did examine staff and patient responses to the psychotic behaviour of long stay inpatients who were considered to be chronically ill. In particular the research looked at how other patients and staff acted so as to reinforce (or not) the expression of psychotic symptoms (pacing, aggression, psychotic talk, shouting). Observational research did show that symptomatic behaviour in this patient groups was sometimes positively reinforced by nurses, although appropriate behaviour was also particularly well rewarded by qualified nurses and other patients (Gelfand, Gelfand, & Dobson 1967). Intervention studies showed that such behaviours could be substantially by nurses via positive attention to normal behaviours and ignoring the symptomatic behaviours (Ayllon & Michael 1959). Thereafter such approaches to care of chronically ill patients were widely used in token economies or other behavioural rehabilitative strategies. However these patients were not necessarily acutely psychotic. Their behavioural disturbances may have more been a product of the institutional environment than their illness. Simple suppression of psychotic symptoms might be achievable through behavioural reinforcement. However suppression is not equivalent to therapeutic change, and generalisation to settings outside the hospital is completely unproven, as is any endurance of change past the time as which the behaviour therapy ends. Moreover, suppression of symptoms and the failure of staff to listen to the psychotic experience might well accentuate patient sense of difference, exclusion, loneliness and stigmatisation, thereby making depression or even suicide more likely. Thus it is sad to read statements that nurses’ efforts to listen to and understand the patient are to be considered intermittent reinforcement of psychotic behaviour (Gelfand, Gelfand, & Dobson 1967). Solution focused or brief therapy has also been applied, albeit rarely and with little in the way of evaluation, to acute inpatient care (Macdonald 2007;Vaughn et al. 1995). This type of therapy is geared towards helping patients find and implement their own solutions to their problems whilst monitoring their own progress and the impact of changes they are making. In order to function, this type of therapy requires patients to be able to engage in meaningful dialogue, and as this is not possible for some acutely psychotic individuals, it is therefore not universally applicable. In addition some contortions are necessary to apply it within the framework of compulsory detention, and it only caters for strictly therapeutic conversations geared towards problem solving. However it does provide a formula or approach that facilitates meaningful and acceptable dialogue between nurses and patients, shaping a collaborative and positive relationship. The influence of Carl Rogers’ person-centred therapy (Rogers 1961) has been enormous. Not only have specific techniques such as summarising, paraphrasing and reflecting, entered nursing through communication skills training. The values and attitudes which form part and parcel of his humanistic approach have been adopted by psychiatric nurses and many others. These attitudes include: warmth, genuineness (congruence), unconditional positive regard (acceptance, caring, or prizing), empathic understanding, and non-judgmentalism. These attitudes or fundamentals of human person to person care have probably been more influential than the psychotherapy with which they are associated. As a psychotherapy, the evidence for a positive impact on people suffering from psychosis is poor. The approach might make people feel accepted and understood, but being accepted and understood does not necessarily lead to therapeutic change in psychosis. However the processes of listening, accepting and demonstrating empathic understanding does provide a framework and some suggestions on how to communicate with acutely psychotic patients who can engage to some degree in dialogue. However no specific advice is offered on how to respond to delusional material, thought disorder, hallucinations etc., beyond seeking to understand what that feels like and convey that understanding. The pre-therapy of Prouty and colleagues is specifically designed for use with those suffering acute psychosis, and draws upon Rogers for its inspiration (Prouty 1994). The method consists of five techniques: situational

reflections, facial reflections, word for word reflections, body reflections and reiterative reflections. These methods do not require verbal ability on the part of the patient or dialog with them. Instead they create ‘contact’ with the patient, with contact construed as the elicitation of some form of person to person recognition and interaction in the real world, as opposed to the withdrawn inner world of the patient’s psychosis, or alternative self-awareness (contact of the person with themselves). Some authors make large claims for the therapeutic impact of pre-therapy (Pörtner 2002) with little evidence other than personal experience. Most of the accounts simply do not translate to acute psychiatry – they are with institutionalised chronic patients, and much of the recontacting is about getting past the institutionalisation, not the psychosis (Pörtner 2002;Van Werde 2005). The institutional care described is of a poor quality, and many of the patients described clearly do not need hospitalisation. The patients are constantly very ill and handicapped – equivalent to high support hostel residents, perhaps, in the UK, and the management are weak and distant. The basic nursing described is deficient and applying pre-therapy masks the issue. Nevertheless these are five useful techniques for use with withdrawn and generally uncommunicative patients suffering from acute psychosis. In addition, the whole approach usefully underlines the importance of being with the patient, knowing who they are and what their interests and pre-occupations are, rather than doing things to them. For nurses who are psychotherapeutically informed, the nurse-patient relationship is seen as the focal encounter in the process of therapy. Psychotherapeutic approaches in mental health nursing (Winship et al. 2009), have been realised in the high quality practice in at least some institutions. In particular, the focus has been on the nurse as therapeutic agent who applies psychotherapeutic interpersonal skills across a range of therapeutic encounters, either in individual practice, group therapy or in the psychotherapeutic milieu as a whole. Mostly psychoanalytically inspired, such approaches to psychosis can be characterised as more assertive and combative than those inspired by Rogers (Jackson & Williams 1994). It has been shown that nurses can assume a much more active role in the formal psychotherapy process without compromising their potency in the milieu. Attempts have been made at integrating the role of nurse and therapist in so far as nurses carried an individual case load seeing patients for sessions at least twice a week and sometimes up to five times a week where necessary (Bell 1997;Jackson & Crawley 1992;Jackson & Williams 1994;Ritter 1984). The approach of the nursing staff was not psychotherapy per se, and the nurses were not employed as psychotherapists, but intensive supervision, a high level of teaching and psychotherapeutic training can ensure that the patients receive a substantial psychotherapeutic intervention. However none of the literature from this tradition can be summarised into a set of simple recommendations on interaction strategies with the acutely psychotic, instead requiring for its application a high degree of training and education, and dedicated therapist-patient sessions.

Expressed Emotion, psychosocial interventions, and cognitive behavioural therapy Up until the 1980s, the most effective treatment to reduce symptoms and the risk of relapse has been treatment with neuroleptic drugs. Two strands of research have made a significant difference to this picture, demonstrating that psychological and social interventions can reduce symptoms and relapse too. Although it is unlikely that these treatment methods will replace medication, they do constitute a way of delivering significant additional benefit to patients. The first strand of research that demonstrated that this was possible focused on the family care environment, showing that hostility and criticism of the ill person (high expressed emotion), exacerbates the illness (Tarrier et al. 1989). The second strand of research successfully applied existing cognitivebehavioural therapy techniques to the management of reduction of the symptoms of schizophrenia. This research showed that the intensity with which delusional beliefs were held, and the disruption caused by hallucinations could be reduced through a form of verbal questioning, belief modification, and experimental reality testing. The resulting therapeutic techniques, often called together ‘psychosocial interventions’, are mostly offered to patients when they are well and living in the community. However there have also been endeavours to implement them on acute psychiatric wards, with some evidence that they have a positive effect (Drury 1994;Drury et al. 1996a;Drury et al. 1996b). With respect to high expressed emotion, this has been identified as present in staff (Van Humbeeck et al. 2001) and associated with high levels of symptomatology (Kuipers & Moore 1995) although the direction of causality has not been established. Given that in family environments expressed emotion is known to precipitate relapse, it is a reasonable deduction that staff should ensure the tenor and content of their interactions with patients is warm and nonjudgmental rather than hostile and critical. Strikingly, these ideas take us back to Carl Rogers. Given the challenging nature of the behaviours of acutely psychotic patients, following this recommendation might be more difficult than it first appears.

There have been several publications on applying cognitive behavioural techniques on acute inpatient wards to people suffering acute psychoses (Clarke & Wilson 2009) plus a report on our own work in this area (McCann & Bowers 2005). The full range of CBT techniques are not applicable to acutely ill patients as they require the ability for introspection unavailable to patients in florid psychotic states. Despite this, lower level and more simple techniques, such as relaxation training, and coping strategy enhancement have been applied in the inpatient setting leading to higher level interventions such as relapse prevention work and psycho education once the psychosis has stabilised (Forsyth et al. 2009). In descriptions of these techniques, however, the interactions utilised in florid states of psychosis are poorly described and many of the pioneering research studies in this area actively excluded people with florid symptoms. An adaptation of CBT and so called “Mindfulness” techniques taken from meditative philosophies has also been adapted for people with psychosis. Acceptance and Commitment Therapy (ACT) has been said to prevent the rehospitalisation of psychotic patients (Gaudiano & Herbert 2006), but again the interventions seems to assume a level of functioning that is often beyond a person with florid symptoms. These interventions are extremely novel and have yet to gain a wide implementation or examination. These ways of ameliorating psychotic symptoms do provide one available framework for therapeutic interactions between nurses and patients. Reducing expressed emotion is more widely applicable and can provide a backdrop or context to all interactions between professionals and patients on the ward.

Potential lessons from dementia care While authoritative and detailed writing about communicating with acutely psychotic patients is scarce, a considerable amount is available on communicating with those suffering from dementia. While not everything is transferable due to differences in the nature and experience of dementia and acute psychosis, some things clearly are applicable, and there is great potential for cross fertilisation. One work (Killick & Allan 2001) highlights the skills used in starting conversations, maintaining them, and ending well with good feelings and a sense of completeness. Many ways to bring conversations to a positive end are offered: take time; give cues verbal and nonverbal (have to go in a minute, other tasks waiting, sit on edge of chair); thank for conversation and say what you have enjoyed, perhaps summarise content; leave time to hear their feedback if they want to make some; develop an ending routine that can be reused with the same person again to generate habit; say you'll come back and are looking forward to it; leave a card; tell them when you will be available again. Validation therapy (Feil 1993) is a more theoretically inspired approach that aims to help people with dementia deal with developmental tasks carried over from previous phases of their lives. However most of the fourteen techniques of validation therapy (factual questions, rephrasing, using polarity, imagining the opposite, reminiscing, using ambiguity, mirroring, tone of voice, linking the behaviour with unmet need, identifying and using the preferred sense) can be utilised to some degree or other in conversations with the acutely psychotic. Fundamental to both these works is an understanding of the experience of dementia, what it does and doesn't change, what people with dementia might feel in different situations and contexts. As such it demonstrates an acute sensitivity. It is hard to think of any such professional account of acute psychosis. Most accounts are objectified (i.e. accounts of behaviour and symptoms) rather than truly phenomenological. Therefore a good starting point might be patients’ accounts of being ill or user poetry, whilst acknowledging that such accounts can be distorted by the illness itself. Again, interestingly, nearly all approaches to communication with people suffering from dementia draw upon Carl Rogers’ psychotherapeutic ideas and values.

Summary and aim of this work Previous work does have some significant guidance to offer the practicing psychiatric nurse who is caring for an acutely psychotic person and who wants to communicate with them effectively and therapeutically. The goals of that interaction would be to keep the patient and others safe, accurately assess their mental state, deliver appropriate treatment (physical, psychological and social), and ensure that their physical health and needs are catered for. The foremost things the literature offers is the importance of basic listening and communications skills, coupled with a set of attitudes and values that sees the person and their experience as important and to be understood as well as possible. Ways of working have been developed that allow nurses to spend at much of their time as possible in contact with a small number of patients, so as to develop these processes. Some

additional therapeutic or interactional techniques have been described, such as supportive psychotherapy, pretherapy, solution-focused therapy and psychosocial interventions, all of which harmonise well with the fundamental attitudes and values of Rogersâ&#x20AC;&#x2122; person-centred therapy. A further few can be readily borrowed from developments in caring for dementia patients. These, and the ventures from outside of mainstream psychiatry, all emphasise the importance of deep respect for, and interest in the acutely psychotic patient as a fellow human being. However while these sources do give us some useful tools, there is a sense in which they do not go far enough. The literature does not really tell us how best to spend time with the deluded or hallucinating patient. There is an over emphasis on dealing with those patients who are comparatively well, and certainly on those that are cooperative, insightful, and friendly. However many acutely psychotic patients on acute wards can be deeply unwell, severely deluded, suspicious, hostile and aggressive, and incredibly challenging to spend time with, let alone provide care to and treat. Here the literature and previous work seems to be silent, hence this research was undertaken to discover if there were untaught, traditional or self-developed skills amongst nurses identified as being highly skilled with acutely psychotic patients.

THIS STUDY OF INTERACTION The interviews The aim of our study was therefore to seek to identify nurses’ skills and methods in working with acutely psychotic patients which were not already well-known or formally taught. We were looking for traditional practice learnt perhaps from watching others, tacit knowledge not previously formulated, and to draw upon expertise gained through experience. We worked with the managers and nursing leadership of three London mental health NHS trusts to initially identify a few practicing qualified psychiatric nurses who were acknowledged experts in working with acute psychotic patients. We then interviewed them, also asking them to nominate others whom they knew and thought of as particularly expert, a strategy known as snowball sampling. The nurses identified were currently working in community and inpatient posts, and we collected 28 in total. Just over half (53%) of the sample were female, with most currently working in the community (75%). Roughly equal numbers came from each of the three Trusts involved in the study. The interviews were all digitally recorded and transcribed so that we could analyse them with the aid of specialist computer software (N6). Our interviews were semi-structured, in that they consisted of a framework of fixed questions, however the interviewer had freedom to follow leads and diverge from the schedule when appropriate. We devised the questionnaire based on our experience, round table discussions about the nature and pattern of acute psychosis, reviews of research instruments to measure illness severity (Theodoridou et al. 2008), and on parallel work to construct our own scale (the Nursing Observed Illness Intensity Scale). The full interview schedule is in the appendix to this monograph.

Analysis All interviews were firstly read in detail by the Principal Investigator (LB). Initial coding followed the structure of the interviews, where subjects were asked in turn about communication with apathetic and withdrawn patients, then hallucinating patients, deluded patients, thought disordered patients, agitated or overactive patients, upset and distressed patients, and irritable or aggressive patients. All statements by subjects were then coded at a finely grained level under each of these categories. These were then grouped under each symptom area into eight preliminary domains: preparation-context; initiation; style-approach-values; content-durationfrequency; metacontent (talk about the symptoms not aimed at reducing or ameliorating them)-therapy; selfmonitoring; coerce-assert-persuade; and task accomplishment. These code headings were then assembled in a large table (symptom areas as columns and preliminary domains as rows) and discussed with the research collaborators, the City University MH research team, and Dr Rose McCabe as an external expert in the area. Several plans for higher level groupings of the data were examined and discarded at this stage. The division of strategies into core versus periphery was discarded because the dispersion of codes meant that any ‘core’ was extremely small. Division into basic, intermediate and advanced strategies was also abandoned, as there were no criteria within the data on which to base such distinctions. Instead some of the preliminary domains were merged, others kept and some divided to produce seven themes, whilst acknowledging significant overlap. In terms of presentation, it was decided to present the common themes across symptom categories first, followed by material which was specific to the patients presenting specific symptoms. Codes were determined to be common themes if they existed across at least three symptom areas. The pattern was followed for all domains except ‘talking about symptoms’, which generally contained only specific material. As the analysis progressed, it was possible to collapse a number of existing codes into larger categories. However some codes remained as being mentioned by only one interviewee, and unless they were judged as yielding a particularly valuable insight, they are not included in the analysis below. The next five chapters cover the main findings from the interviews: moral foundations; preparation for interaction and its context; being with the patient; nonverbal communication, vocabulary and timing; emotional regulation; getting things done; and talking about symptoms. Identified communication strategies are introduced by subheadings, and are further subdivided where necessary. Numbers in the brackets indicate how many interviewees mentioned the specific strategy; for example 15/28 means that 15 of the 28 interviewees spoke of the strategy or method concerned. Illustrations have been provided (all by Geoff Brennan) to aid understanding.

Moral foundations There was considerable cohesion in subjects’ responses under this heading, with most being generic across all symptom domains. Five different aspects of the moral stance that nurses took were apparent and well represented in the interview data. Notice, do not ignore (19/28) This was expressed in a variety of responses to patients’ behaviours, including not ‘forgetting’ about apathetic patients, ‘allowing them to be left out’ or ‘leaving them to rot in their beds’, giving as much attention to the negative symptoms (apathy/withdrawal) as the positive (all others); talking to patients about their hallucinations and delusions, rather than ignoring them, changing the topic when patients brought them up, or ignoring the patient as ‘too unwell to try and engage with’, as ‘even if it’s nonsensical it is still communicating’; giving ‘extra attention’ to those who are anxious or agitated, rather than less, not ‘sending them to their room and just leaving it’. Noticing meant not dismissing patients’ symptoms, overtly writing them off to patients as ‘not real’ or ‘symptoms of your mental illness’, as ‘dismissing their reality would be a big no, no I think on the whole’. The consequences of so doing are to generate antagonism and a sense of abandonment: ‘to dismiss their symptoms out of hand is going to make it very confrontational and they’re not going to feel that you're listening to them or helping them in any way … destroying a relationship’. Ignoring symptoms meant that nurses would preclude understanding ‘how, what their experiences are and how the symptom is affecting them in their function and in their emotional state’, and this in turn meant that no therapeutic work could be undertaken. In addition, noticing symptoms prevented nurses from making mistaken assumptions about patients’ experiences: ‘what people describe as hearing voices or hallucinating is often, what we consider those things to mean isn't necessarily what the patient or the client considers them to mean’. Encouraging, supportive and gentle (23/28) Being gentle with patients meant ‘not shouting’, but rather going to the patient giving him or her quiet advance notice and suggestions about what they might like to do, having a low emotional content and a slow, quiet approach. It also meant not being rushed, but ‘respecting the pace at which it is comfortable’ for the patient concerned, and avoiding any sense of ‘force’, ‘argument’ or ‘pushiness’. One respondent referred to a ‘sandwich’ technique, in which the patient is listened to and heard first, nurtured, prior to suggestions being offered about helpful things to do, or what needs to be done now. Being supportive was also about not being ‘domineering, or taking control, telling people what’s good for them’, but using a more passive, sympathetic and suggestive style of approach such as ‘just put it into that, let’s see if this helps’. Similarly, when information is needed ‘you don’t bombard them with a lot of questions, you perhaps just gently tease things from them’. Encouragement was also about feeding back positive judgements, evaluations, reassurance and reminders: ‘highlighting their abilities and their skills and the positive issues that they can look forward to will make any tasks easier, increasing their self confidence and motivation’. Others emphasised the combination of ‘understanding’, ‘sympathy’ and ‘encouragement’ to do things. Sometimes the degree of support rises to the point where nurses do things for patients where they simply cannot do them themselves, for example washing them. Being encouraging, supportive and gentle means giving patients ‘space’, taking ‘time’ and requires ‘staff availability’, however not doing them was recognised by nurses as likely to exacerbate anxiety and hence other psychotic symptoms. Empathy and concern (19/28) “Let them know that you’re genuinely, concern, show genuine concern, be empathetic to them. Be there for them, getting them to know that you’re concerned about their wellbeing and you’re, you want to help them and support them at the difficult times, for them to get better.” This was seen as a fundamental element of every approach to patients, and was talked about in a number of different ways, including seeking to ‘understand more what the patient is going through’, being ‘compassionate’, ‘empathetic’, warm’, ‘expressing concern’. More everyday terms used were being ‘motherly’ or ‘friendly’, and definitely not expressing boredom in response to patient symptoms or distress. Without this ‘caring attitude’ it was recognised that patients would not trust

the staff, and without that it was much more difficult to help them in any way at all. The way these things were demonstrated by nurses behaviours were in ‘tone of voice’, ‘giving time’, being responsive to patient distress, offering help and by verbal statements of concern, even in the face of aggressive and other challenging behaviours. An approach of ‘love, empathy, concern and kindness’ was viewed has having the potential to eventually dissolve patient anger and alienation, and would be remembered and appreciated by them as they improved. Honesty (10/28) “Being honest with them, letting them know what I am prepared to do and what I am prepared not to do and what I cannot do. Honesty and being straight and upfront with them.” This involved such things as telling the patients that they might hold certain delusional ideas, but these are not shared by the staff, then negotiating around that difficulty. Explaining truthfully why you want patients to undertake a particular task, such as taking medication, or being truthful and giving away some information about yourself in conversation with patients. It also involved honestly admitting when services had failed or gone wrong, not pretending to understand what patients were saying when they are thought disordered, telling patients the real reasons they were legally detained in hospital even if they did not want to hear them, being realistic on the limitations of psychiatric treatment, being truthful even in the face of patient anger, and in particular being genuine about expressing care and concern to patients. Don’t intrude (20/28) “You have to judge how, I think how frequently you approach somebody or how you talk to them or how it’s, it’s a case of being and acknowledging that as well that you don’t to, you don’t want to intrude, you don’t want to be intrusive but you really want to be there for them to talk to. You really want to be someone that they can come and ask questions or, but you know, it’s using your judgement in that way.” Nurses recognised that psychotic symptoms could be experienced as deeply ‘private’, personal and ‘intimate’, and that to speak of them was ‘almost like talking about sexual fantasies’. In their eyes this partly accounted for patients being unwilling to talk about their symptoms, or being very guarded in what they were willing to say. Thus patients could perceive too much detailed questioning about their symptoms as threatening or transgressing the boundaries of allowable conversation between relative strangers. For withdrawn or distressed patients, any attempt to interact ran the danger of being more intrusive than the patient could tolerate, thus nurses spoke in terms of making themselves available for the patient to choose to converse: ‘acknowledging that they’re upset and if there’s anything I can do, that will give them room to actually if they want to talk’. Or being careful to adhere to the normal etiquette around knocking on doors and entering rooms, keeping any conversational attempts short, rather than ‘prying’ or ‘trying to tease lots of information out of the person’ or ‘imposing your presence on them’, and limiting the numbers of people participating in or witnessing the conversation. Other expressions of this low key approach were ‘being visible without being intrusive’ and ‘not harassing’ patients. All of these were ways in which nurses sought to moderate the perceived intrusiveness of their attempts to interact with patients. When nurses had pushed too far or intruded too much, they then knew that they had to tolerate the patient’s angry response: ‘not taking offence if someone says, I don’t want you to be here, please go away or in slightly more direct terms than that.’ “And not really pushing them to communicate very deeply about what’s going on, cos often some of those ideas can be really deeply held and really frightening to hold, so therefore I don’t really push them to expose those ideas very quickly”. Respect (22/28) “You respect them. You never think, even if in your head you’re thinking this is total rubbish. Delusional nonsense. You must not let that seep out into your perception of them as a person. Or the way in which you’re interacting with them.” To the interviewees, respect meant not making fun of or laughing at patients, their behaviour, or their delusions, even while admitting that ‘there’s something quite comical sometimes’ and that

‘any member of the public would be laughing’. One interviewee reported: ‘when I see it, trust me, I deal with it, I don’t like it. You should never disrespect people’s beliefs even if you know that they are delusional beliefs.’ It also meant a commitment to trying to establish and hear the patients’ point of view, rather than just control their behaviour through verbal instructions; being polite and apologetic to angry and agitated patients. One subject explained that this was the opposite of a confrontational and authoritarian style, and that the same thing can usually be communicated in ‘a respectful quiet manner’. Respect was also about not being condescending, critical, demeaning, treating patients like children or ‘making them look silly in front of their friends’. Instead it is about giving them as much independence and responsibility for themselves as possible, while at the same time acknowledging their personal reality and symptomatic experiences. “This man for example, he would write things out by hand. And I’d get them typed up. And they were very delusional. But what was fascinating if you read them, and he had certain beliefs about how nurses should interact with patients. He wanted to give the ward something as a professor of ethics. So I got them typed up. And when they were hand written they looked complete, it was all big writing. But when you typed them and read them, although they were delusional, you could make sense of them in a weird sort of way. And I think by treating him with respect you can get to a core of something he’s trying to communicate, and I think it’s that level of respect, it’s that level.”

Preparation for interaction and its context Again, most of the material under this heading was generic to patients exhibiting all symptom areas. However some of the specific choices were differently nuanced, and these are described below where relevant. Observe first (20/28) Before choosing to try to interact with a patient, it was recommended that the nurse ‘observe’ or ‘read’ the situation, ‘gauging how somebody is’. This would allow the patients level of distraction by hallucinations, mood, agitation, irritability or other symptoms so that the appropriate approach can be made. To do this required nurses to ‘have some experience in reading into presentation, symptoms and how to deal with each presentation’, looking at their behaviour, facial expression, movement, perspiration, respiration, hygiene, neatness and other nonverbal cues. It was accomplished by ‘being peripheral … taking a seat, watch for a bit, get a sense of what’s going on, how that person’s impacting on other people’. Such observation, reflection and assessment continued once conversation was started, so that the nurses’ responses could be continually adjusted to the patients’ behaviour: ‘one moment she was charming, the next moment she was quite aggressive and I think that, I noticed the longer the conversation was going on the more it, she was inclined to become aggressive just because of the impatience’. One nurse referred to this as ‘treading very carefully’ because patients could respond in unpredictable ways due to their symptoms. Consult case notes (9/28) The previous case record was a source for three very useful pieces of information. Firstly the patient as a person, their ‘background’ and interests, thus yielding potential topic for conversation or type of activities that they would be more likely to respond positively to, or which could be used to counter some of their symptoms. Secondly, it provided information on what interventions and approaches ‘had worked in the past or hadn’t worked in the past’ with this particular person. Lastly, the record provided information on the level of risk posed by the patient, whether they had been violent in the past and to what degree, what things are likely to ‘make the person more irritable’, or whether ‘their bark was worse than their bite’ and they could be approached with a greater degree of confidence. “You have to gather as much information as you need in order to have any kind of contact or interaction with a patient with any diagnosis”.

Consult friends and family (9/28) Either to provide information on patients usual interests in order to utilise this to facilitate conversation, build relationships and set achievable goals for improvement, or in order to elicit support and help for the patients themselves. It’s about trying to hook in to see if there are any hooks in what they're interested or what they’ve been interested in in the past, ring their parents to see if you can find out”. Choose the right nurse (16/28) Sometimes it was important to choose the right nurse to make the approach. This was perhaps particularly important in choosing who would lead on trying to de-escalate tense situations, but was also relevant for choosing who would be more likely to be able to ‘give reassurance’ to a distressed patient, calm an agitated patient, or win co-operation from a reluctant patient for medical investigations or whatever. The relevant issues for such a judgment were the nurses’ age, gender, culture/ethnicity, relationship with the patient, available skills, and sometimes intangible elements to do with the interpersonal styles of individual nurses and how they fit with the patient concerned. “If someone’s very distressed or there’s been very bad news then that’s certainly appropriate time for nurturing … if you’ve got someone who’s able to do that at that point then often more experienced member of staff or someone in, older. So even someone just, who they get on well with. So hopefully you’d be looking at who was, who you consider the most appropriate person to be.” Choose the best time of day (14/28) Nurses noted that symptoms could ‘alter quite a bit even during the course of the day’, and ‘that would alter what you can do with them’. Energy levels could also fluctuate, influencing the likely success of trying to get a task or activity completed, as well as engage successfully in conversation, or patients could be more relaxed at certain times. Nurses therefore looked for ‘windows of opportunity’ to get things done. Choose location (22/28) Selecting the right environment for conversation was deemed to significantly affect the likelihood of success. Several aspects were mentioned, the most frequent being trying to secure a location that did not over stimulate the disturbed and symptomatic patient. Corridors on the ward were considered particularly problematic, because ‘there’s lots of other stuff going on’ and ‘you’re dead in the water’. Too much stimulation from other activities, people, noise and conversations was thought to exacerbate psychotic symptoms such as irritability, overactivity and hallucinations: ‘the wards are so chaotic that if in your head you’re very chaotic at that time, then obviously the chaos of the ward and the hustle and bustle of every day living is going to be, it’s going to be, exacerbate those symptoms’. Drawing the patient into a low stimulus environment was thought to be particularly important for angry patients who needed to be de-escalated and calmed. A further gain from getting them into a quiet area was removing them from an audience, and reducing the possibility that patients might see any conversation as a ‘show of strength’ and making sure that they don’t have to ‘back down’ in front of others. However nurses also had to exercise caution about their own safety in such circumstances, as it was not wise to be completely isolated with a potentially violent patient. For other patients, perhaps those who were upset, distressed or were going to talk about their delusions, the privacy of the location was a critical aspect of success. Basic comfort with regard to heating, lighting, fresh air and seating also needed to be considered, and where possible this could be adjusted to the requirements of the patient concerned. Territorial aspects of the environment could also be used to enhance the potential of success. Going into ‘their space’ such as day rooms and bedrooms, rather than taking them into offices which might be associated with ‘probing’ professional psychiatric interviews. Asking the patients what they would prefer was another useful strategy. Choosing the right place also had to be done with regard to the needs of the individual patient.

“So you pick your area where you're going to meet them according to where they feel comfortable and reasonable obviously, but, for example, if somebody hears things from the TV you wouldn’t want to be in a room where that’s happening. If someone’s fearful of something coming from outside you might think that their bedroom might be a more peaceful space than maybe somewhere else. So an awareness of how they feel about where they are.” Set appointment in advance (9/28) Rather than formal appointments, this was more about giving patients advance notice about when the nurse was going to spend time with them or complete a task with them: ‘I would go maybe 20 minutes, 30 minutes beforehand, and explain to them what’s going to happen’. This advance notice allowed patients to psychologically prepare themselves, ‘so that actually they can prepare themselves for being disturbed and I think that shows that you're respecting them’ and avoided sudden surprises or springing things on patients, a scenario that was more likely to elicit anxiety or noncooperation. Setting a time for talking with patients could also allow them to contain their anxiety over the interim: ‘it’s this idea that actually I’m a secure base and I will be coming back, I won’t be leaving you, it’s more you’re trying to establish that with them’.

Being with the patient (Relationship building, maintaining and assessment) There was a roughly equal balance under this heading between material that was generic, and that which was specific to dealing with patients exhibiting specific symptoms. Be with, sit with, be available, offer conversation (16/28) “They might be not be very nice, but just be around and say or even I appreciate you won’t talk to me, fuck off, I appreciate that fair enough, but you know who I am, I’ll be around if you want to interact” One way nurses did this was ‘letting them know that you are always available when you are around’, in other words telling patients that they are available and allowing them to make the approach, giving them the freedom to select the member of staff that they felt most comfortable with: ‘remember that I'm always around, and probably in your own good time, when you feel that you're ready to come to me, feel free to do so, but I will always, I will also be looking out for you.’ It also meant being consistent in that availability and accessibility, giving time even when the patient is not able to utilise the time to communicate effectively. This was spoken about as ‘investing time’, implying that the return on that investment might come later rather than immediately. A more active way was to make that availability more prominent by ‘sitting down in the room where they are’, ‘just be in the room a little while’ before saying anything and ‘occupying the same space’. There could be a thoughtful attentiveness about this presence: ‘sitting in the room with somebody and trying to think about ways that soothe them’, and ‘allowing them the space’ to say what is on their mind. This process could not be ‘forced’, as ‘pressurising the patient isn’t helpful,’ instead nurses had to wait for the right moment, when patients were ready to talk, ‘going into their space and being with them’. Slightly more assertive is to directly offer conversation, such as by saying ‘do you want a chat?’ or ‘can we go and talk about this’. “And in a way it might just be about being there regularly and saying, I'm going to keep a check on you every ten minutes or so because I'm a bit worried about you, and so just a genuine concern for that person and just seeing how they're travelling regularly.” Introduce self, explain role (12/28) “You introduce yourself and what you are there for, and you make them understand they can come to you for help or if they want to discuss their condition or medication or whatever you’re there to do for them. So you develop a relationship.” Having approached or made themselves available to

the patient, nurses would wait for that ‘little second that they look at you and recognise you are there’, and use it to greet the person and introduce themselves (by name), building a rapport by explaining what they are there to do. The nurses communicated that they were there to understand and help in whatever way possible, detailing what kind of help that might be, how patients can access it and trying to show ‘the advantages of talking’. Explaining their role also involved explaining what the hospital and ward were for, how they were run, and how work was conducted there, giving information about what they could expect from the services including ‘what they would not do’ as well as what they would. Light, casual, normal conversation (10/28) “You address them the way they would like to be addressed. You talk to them the way anybody and everybody would like to be talked to. You talk to them as individuals, as human beings, with respect.” This could mean being ‘respectfully curious’ about the patient, learning about their background and experience, what is important to them and what interests them. Depending on their response or interests, this could start or continue with chat about ‘general things’ – television, sport, football, soap operas, the current news, weather, events local and national, etc.: ‘you can always find a gateway to build a relationship and trust’. Thus nurses and patients can end up chatting about ‘all aspects of their lives’ or ‘anything that is going on’. The starting point was for nurses to treat patients as ‘ordinary people’ and engage them, if possible, in ‘normal conversation’. Focus on the person (21/28) “I think you need to look at ways in which you can find out what they're like and if possible that involves finding out, I guess from people who know them and trying to key in things that they may have potentially previously enjoyed, or had some kind of meaning for them and try and engage with them with those things.” More specifically, this meant putting to one side for the moment the psychiatric problems and symptoms, instead focusing upon patients as, first and foremost, people rather than specimens exhibiting curious behaviour. Not focusing on the hallucinations, the voices, the delusions and the thought disorder, instead discovering ‘the person past the symptoms’, all the other aspects of the person that don’t necessarily have anything to do with their psychiatric status. ‘Trying to find out about the person, what did interest them before everything shut down.’ Knowledge gleaned from other sources (by questioning friends and relatives, or by reading the case notes) could be used to try and create social contact with patients who were disengaged, for example commenting on the football team a patient supports and trying to stimulate or draw them into making a verbal response. Newspapers and news items were other topics utilised by nurses to initiate conversation, draw patients out and learn about them, their points of view and thoughts about the world. Horoscopes, radio programs, TV, films, soap operas, magazines, music, friends, family, children were all other readily available topics for conversation and finding out about the person, whilst setting to one side their psychiatric problems. Asking open questions was a critical technique in drawing patients into person-centred conversations, or simply making comments and awaiting a response. Focusing on the person could also mean exploring their everyday worries and feelings, their natural responses to being away from home and in hospital, or querying and responding to their normal physical needs around eating, drinking and sleeping. Not just talking about the symptoms, but about all aspects of their care such as ‘social care, housing and the things they want to change’. “Building a relationship is a long drawn process as well, just always trying to talk about a more varied topic of things, because it’s all well and good to acknowledge that every time they see you they don’t want to always be talking about voices or talking about what their positive symptoms are. Just looking at other things.”

Here and now as topic (4/28) “I’m thinking of inpatient wards where, it’s a pretty awful environment, I think, and what you see around you is quite crazy in itself, and then to have somebody who’s there, feeling very withdrawn and looking at this scene that they’re facing and that’s, it’s quite an absurd scene area, and they are seeing people who are quite unwell, and who are saying really odd things, and yet we’re trying to help make that person better and to be more normal, so to speak, and so I guess just noting what you see. And I guess, in a way it’s saying, well yes it’s, this experience, it is very odd. It’s very strange and it’s frightening.” Somewhat related to focusing on the person rather than the symptoms, was assisting the patient to focus on their here and now experience, or using the ‘here and now’ as a topic in its own right. Here, once again, props could be used, such as ‘books, the television, what is going on in the room’, ‘paintings’ on the ward walls, ‘factual things’ such as sounds and colours on the ward, rather than abstract, theoretical or symptom based conversation. This method could be adopted in order to help with orientation to time (time of day, day of the week, month or season of the year), place (X hospital, N ward), or person (nurse so and so, the ward cleaner, hospital porters, other patients, or celebrities, politicians etc in the news). Joint activity (22/28) “Sometimes I might start off doing something myself. And then, then I’d invite the person to join me if it was appropriate, it may not be appropriate at that time, it may be appropriate at another time. But I might start off by doing something just to, so that, that person, I suppose, has the time just to work through their distress and if the person is then able to come and do something with me, that’s good.” Another much spoken about way to get socially engaged with patients was frequently recommended: joining what they are doing, or initiating something and asking them to join in. Playing games for example, such as ‘scrabble’, ‘pool’, ‘card games’, and ‘playstation’; or being with them and assisting whilst they care for themselves – having a shower or a bath, hair care, shaving, doing their laundry, making a phone call, all provided opportunities for social interaction and relationship building, both verbally and nonverbally. Two specific activities were mentioned a great deal, so obviously had proved useful to many nurses: 1. ‘Going for a stroll, just going to the shop’, or if appropriate to the individual patient, walking up and down the ward with them. getting away from the environment of the ward, where possible, was seen as beneficial and aided communication. 2. Eating meals with the patient, or more commonly a possibility, making or assisting them to make a snack or a drink. A more common standby from the past, smoking a cigarette with the patient, was only mentioned once in the interviews. “The writing, writing things down, because I've found that that slows the thinking down. Painting, drawing, sensory things as well just like taking someone into the garden, gardening, just doing something, actually something, I think the thing about that is something that actually connects them to something in the environment, something very, very concrete and something that's actually slowing the thought processes down.” Humour (10/28) “I think a bit of humour goes a long way as well. Even if you’re feeling really down you can still, peoples’ humour seems to be retained somehow and just sharing a bit of a laugh about what’s happening and, just can be a bit of lightening of the load for people and it can build trust as well because I think, if you can laugh with somebody you, it feels a bit more candid. You don’t feel like you’re necessarily just speaking jargon and you’re just representative of the system but that you’re, if you laugh together, you’re human to human rather than, type of staff member to patient, in a way.”

The addition of humour was seen as an expression of ‘friendliness’, as having the capacity to diffuse tension, anger and anxiety. The fundamental concept here was that the nurse was trying to raise a smile from the patient, rather than utilising patients or others as the butt of mutual humour. Because expression of humour might be interpreted as belittling or disrespectful, nurses expressed a degree of caution about recommending it, indicating that the content, timing and fundamental relationship had to be right for this to work well. Without the pre-existing ‘good relationship’ it was not felt that humour could readily be risked, and being able to use humour appropriately and well was regarded as a ‘sophisticated’ technique. More simple uses of humour, such as ‘telling a joke’ were less risky. Interestingly, utilising humour was mentioned in relation to all symptom areas except delusions and hallucinations, perhaps reflecting the acute sensitivity of patients to criticism of these symptoms. In talking about their own ‘sense of humour’, nurses also meant their need not to take personally or necessarily too seriously all of the things patients said, particularly their hostility. “I’m not saying make light of the situation. But you can be a bit more jovial about a situation. But that’s something that you would have to have established a very strong relationship with before you could do that.” Apathy/withdrawal specific Comfortable silence (9/28) Sitting with the patient, communicating attention nonverbally, and ‘waiting for them to make the first move’ or simply ‘just being with somebody and being able to accept being with somebody in silence’, as well as making a greater use of pauses in silences in what conversation is achieved. “Maybe just sitting with them first of all, just so that they’ve got the physical presence of somebody there for a while with them first of all.” One nurse mentioned sitting with a patient for 30 minutes without them talking. To accomplish this requires ‘not having any expectation that anything’s going to happen quickly’, ‘tolerating silence’ and guarding against ‘hammering out questions’ because of ‘your own anxiety’. “And just having silence at times but not in a kind of dynamic silence … trying to find a kind of a medium so that people are not feeling bombarded, but at the same time you’re not just sitting ignoring each other. So feeling you’re engaging with someone and trying to get that fine tune to a level that’s comfortable.” One-sided conversation (3/28) Here the nurse makes all the effort and all the running, sitting next to the person and chatting regardless of the non-response of the patient ‘just like I’m having a conversation with them and they’re just not answering but, and I can keep that up actually for quite a long time’. All the time the nurse keenly attends to and watches the patient seeking the smallest response, maybe a ‘flicker of a glance’ or a ‘smile’. Be creative (1/28) “So clients I've known, for example, who might be into music but they're just too withdrawn or apathetic to request or organise music in their room, I might get the radio for example and maybe say, well look N, if you want to switch it off, I’ll go away and I’ll come back in ten minutes see if it's still, and do something like that.”

Hallucinations Tolerating and making allowance for auditory hallucinations (3/28) Even when just trying to have a normal chat with the hallucinating patient, nurses recognised that they had to make allowance for the reality of the patient’s experience. This could be about acknowledging the potential for the patient to be distracted, as the voices might be like ‘a radio that can’t be switched off’ and ‘lucid answers’ to questions should not necessarily be expected. Thus ‘patience’ and ‘pragmatism’ around expectations, coupled with open acknowledgement of the hallucinations as something potentially impacting on communication were all requirements for a reasonably successful conversation. Not too much too fast (5/28) Too much stimulation, either through trying to convey ‘excessive amounts of information’ or trying to communicate with the patient in a very noisy place with lots of people around, were seen as things that hallucinating patients would not be able to cope with. This was perhaps another way in which conversations had to ‘accommodate their needs’. Failure to attend to these needs might have negative consequences for the patient, resulting in more ‘bizarre behaviour’ or even aggression. Say their name (2/28) Given the distraction of hallucinations, nurses recommended using the patient’s name more than usual in order to get their attention back: ‘just saying their name, just to get them back in the conversation again’. Be creative (1/28) “I remember once … we had a young girl who was incredibly suspicious and she locked herself in a room for ages and every time we went in to see her, she’d become incredibly hostile because she was so paranoid and we wouldn’t give up really. So it was a case of I’d go in to see her maybe once every half an hour. She wasn’t on observations but, and just pop my head through the door and just say, did she want a drink and constantly try and play it down and it took a long time and then eventually we put some music on and we just went in her room and danced with her and it seemed ridiculous but it was something that she was able to respond to. So I think it’s a, it’s difficult, it’s about being creative. It’s about trying different things, if something doesn’t work then it’s not just saying, well that, that person is really disturbed and you can’t get through to them. It’s about trying different things and that’s what we do. It was, it worked for her and every time she became extremely distressed, she’d put music on and she’d dance.” Thought disorder Acceptance and listening (15/28) Going along, being patient, waiting for sense to emerge over the longer time period, without ‘straightaway feeling you have to say something’. In using this technique the patient is kept going by responses such as ‘oh yeah’ and nods of the head. Some nurses said they ‘enjoyed that aspect of the mind’, ‘had some affinity with it’ and found the process ‘creative’. Listening over the longer term enabled nurses to identify ‘themes giving you an insight into who that person is, and what’s most important for them as well’. Further understanding could then develop as to how the thought disorder was affecting them and interfering with what they might want to do. Nurses could also then ‘tune in to how they were feeling’, enabling the identification and treatment of distress, and/or better risk assessment. Being prepared to listen for some time also made possible a social connection for the patient that might be ‘quite rare for them’. Such opportunities also allowed the patient to ventilate and let off steam. The difficulty in attending and listening to a thought disordered patient was also commented on, as ‘”while there is no connection between their ideas … you need to be completely the opposite, maintain your brain in gear and listen to what they say’. “I follow people's tangents that they go on, I'll just go with them on the ride essentially. And often I think people on the surface are not making much sense, but even in thought disorder I think

sometimes people will, the connections they make between a word or a thing seems to be able to, I seem to be able to be able to follow that link and just stay with it in a sense.” Name themes (2/28) Once themes have been identified through listening, these can be named and attempts made to further discuss them with the patient concerned. Doing this might ‘help them to retain some order in their disorder’. “So if there's religious themes there and you've covered a whole range of areas that have some kind of religious element to it, or like naming that in some way. Or maybe there's a theme around crucifixion, you can say, crucifixion seems to be coming up a lot in what you're talking about, and then that maybe gives a framework by which people can understand themselves as well.” Writing (5/28) Asking patients to write down what they wanted to say, and bring it on a piece of paper. Nurses suggested that this ‘slowed the thinking down’ and helped patients realise what they wanted to communicate. Send away to think (2/28) When attempts to understand what the patient says completely fail, they can be asked to go away and think about what they want to say and return when things are clearer. Remind, prompt to topic (10/28) If the patient thought blocks, then they can be prompted with ‘what they’ve just said’. alternatively if he or she goes off on a tangent, questions can be repeated or ‘gentle reminders’ given about the topic of the conversation: ‘just keep repeating the question and bringing them back to it’ or saying ‘can we just come back to this?’. Once again nurses mentioned difficulties in staying focused themselves when patients ‘jump from topic to topic’, so the use of reminders was helpful to nurses as well as the patients they were speaking with. Keeping the conversation on track was ‘like guiding someone through a very dark place, or a jungle’. “I think the technique as much as anything else should be quite, should be guided. This is what we’re talking about, stay on this thread and guide them through”. Keep it simple (6/28) For example choosing an easy topic of conversation rather than a complex one, and being prepared to change topic in response to patients showing difficulties in communication. Alternatively this could be about helping the patient avoid complex social situations that they are not able to deal with, such as demanding group activities, or ‘not bombarding them with lots of information or choices’, ‘too many new, too many complex ideas’, right down to simplifying the language used, not using ‘flowery’ words and being concise. Clarification (5/28) Mixed opinions were expressed here. Some thought that when nurses did not understand they should ask the patient to clarify what they meant, and that when nurses were trying to convey information they should check that the patients had understood it. Others thought that doing so put patients under more pressure, exacerbated their problems in communicating, and were not ultimately helpful.

Agitation/over activity Positive feedback (3/28) Giving positive feedback, recognition on what the patient is doing well and what they are accomplishing, as opposed to being critical. “Give them positive feedback when they are able to sit down with you.”

Set interaction limits (3/29) Nurses recognised that patients with these symptoms could be very demanding and request more staff time than could possibly be given to them. They therefore suggested that if this was an issue, limits should be placed on how often the staff would converse with the patient, and/or on the duration of those conversations: ‘before … I tell them I go five minutes and five minutes only, or ten minutes and ten minutes only’. Reduce stimulation (3/28) Excessive stimulation was seen as likely to make the agitated or overactive patient worse. Such stimulation could come from nurses trying too hard to make contact with patients, for example by following a pacing patient, placing such a patient on special observation, or asking them to do more things. Upset/distress Reveal self (2/28) Being prepared to mention one’s own experience of distressing events, not to look for sympathy for oneself, but in order to establish a good rapport. “That's really upsetting, I know when somebody died, when my uncle died I was really upset about that. I wouldn't be adverse about saying, there's a shared humanity here that we have, we share some of this experience and what you’re going through is really human and normal, and it's important that we are here together to just survive this.” Limit unnecessary interaction (2/28) At the point at which someone is acutely distressed, it is not a good time to be asking too many questions or trying to communicate too much information. Aggression/irritability Get them sat down (4/28) Nurses suggested that if you could get the patient to sit down with you, then this had a calming effect that enabled more reasonable conversation: ‘you can't feel quite so pumped if you're sat down talking to someone’. Get the patient to write (2/28) Communication through writing was seen as a possibility, a way for the patient to express themselves without the risk of them losing their temper in a closer interaction with staff: ‘getting them to write down their frustrations and the reasons why they’re becoming angry’. Maintain clarity (3/38) Making sure that the patient had a good understanding of what was happening and what you are doing, preventing as far as possible any misunderstandings that might heighten or trigger the release of anger. So, for example, nurses suggested checking with the patient how they understood what was going on and why you were talking with them, in addition ‘even if you think they're not listening, or can’t hear you is to continue to explain to them about why you're doing it and actually what you're doing.’ Partly this was about recognising that irritability and aggression affect the ability to concentrate, listen and take in information, and this ‘makes them more irritable and aggressive’, so extra effort has to me made to keep everything clear by the use of copious explanations. “They’ll probably make assumptions about what you are saying, so I think it’s really important to let them know exactly what you're saying, check that they’ve heard you.”

Choose topic in which they are expert (1/28) Try to engage the patient in a conversational topic of their interest, in which they have more expert knowledge so that ‘he's the master of it in a way, and he retains a sense of pride’. Avoid (3/28) Past a certain point it was recognised that it was safer to give such patients ‘space’ and not to ‘spend time’ with them until they were in a calmer state – or unless needed to de-escalate potential violent situations.

Nonverbal communication, vocabulary and timing As we specifically asked interviewees not to give us the ‘textbook communication skills’ few of them mentioned such basic skills as showing attentiveness through posture, facing the patient, eye contact, use of ‘mm’s’ and ‘ah’s’, head nodding etc. The majority of themes were generic to a degree, although there were differences across the symptom domains. These are indicated in the text below, with techniques specific to one domain presented at the end of this section. Slow pace, patience Particularly for patients exhibiting apathy and withdrawal (14/28), nurses were keen to ‘give someone quite a lot of time’ and ‘respect the pace at which it is comfortable’. They explained that patients could be cognitively compromised and ‘not be working as fast and able to make the connections’. A hurried, rushed and ‘pushy’ approach was seen as not likely to be successful. Similar comments were made about being patient with hallucinating patients (7/28), particularly in terms of allowing them time to complete tasks. For thought disorder too (10/28) it was necessary to be ‘patient in conversation’, ‘go slowly’ and ‘give them more time to talk’. One nurse likened being thought disordered to being on holiday in a foreign country where you do not speak the language ‘you just have no idea what somebody’s saying and they have no idea what you’re saying’ and noted how frustrating that was and how much patience is required on both sides. Slow speech As well as taking things at an overall slow pace, some nurses talked about speaking slowly, particularly with patients who were hallucinating (2/28) and especially with those who were agitated or overactive (7/28) ‘not picking up on their rapid flow of speech’ and ‘being quite measured in how I’m going to respond to them’, ‘slowing the pace down’. “I think you need to keep cool and the slow pace. The faster he goes or she goes, the slower you should go, try to calm people down”. Simple vocabulary (5/28) Avoiding ‘medical jargon’ and ‘technical terms’, ‘talking naturally’ and ‘using simple language’, because ‘to somebody that is hallucinating the concentration span is so small’. The aim was to reduce the burden of ‘cognitive work on the part of the client’. Short sentences (12/28) Similarly, in order to make misunderstandings less likely, nurses recommended the use of short sentences, again on the grounds that ‘the cognition isn't working so well and the level of concentration and their ability to work out communication is much reduced’. Others expressed this as being ‘clear and concise’.

Repetition (9/28) Using lots of repetition was viewed as useful for the same reasons, so that if the patient failed to understand at one moment because they were distracted, they might be able to grasp what was being said the next. “Repeat repeat repeat … I think you should never assume they understand what you’re trying to communicate. I think you should take it for read that you’re going to have to repeat it. You might have to write it down. You might have to say it over and over again. In several different situations, you might have to get somebody else to say it”. Use silence (2/28) Allowing long pauses was recommended as a way to elicit some response from certain patients. “Slowly, softly, empathically, sympathetically and allow them time to talk when they’re ready and if you need long silences, then you have long silences. It’s a tool for your trade.” Quiet, not loud or shouting Although mentioned for thought disordered patients (1/28), this seemed to be particularly important for agitated/overactive (10/28) and aggressive/irritable patients (9/28). This had a potential ‘calming effect’ on patients and was considered to help them ‘listen a bit more’ by requiring them to be silent themselves and concentrate. Doing the reverse, mirroring the loud voice of the patient or shouting was reported as being likely to make patients more agitated, and it was pointed out that it was possible to be assertive without ‘raising your voice’. As the following excerpt shows, it was even possible to use this technique during telephone conversations: “I watched a colleague of mine coach a client on the phone once, they put it absolutely magical, he was trying to help this client deal with the housing, and the client kept swearing at people, and my colleague was just sitting there, reading the paper with his feet up on a desk looking so relaxed, and every now and again he would just, it was like a conductor conducting an orchestra he would just, lower, lower, just like that. And it was wonderful watching the client just moderate his behaviour, to these very gentle interventions from the worker.” However in extreme circumstances then it could be allowable to try shouting: ‘if the aggression is at that level that somebody's actually trashing something then you can just shout, stop, and then that can actually help sometimes as well’. Tone of voice (3/28) A sympathetic, empathetic and caring tone of voice was mentioned in relation to dealing with upset and distressed patients. Writing and drawing (4/28) These were seen as options when verbal communication was not proving effective, or to open a second channel via which information could be conveyed and exchanged. Diagrams and pictures could be drawn, writing down information for the patient to take away with them and look at it when they were able to concentrate or to use as a reminder to do certain tasks: ‘if they've got something written in front of them that can help them as well to remember what they’re supposed to be doing and when they're supposed to be doing it.’ Less vs. more gesticulation and movement Movement and gesticulation were other available channels for communication. With thought disordered patients (4/28), instead of giving instructions verbally, a combination of showing what they needed to do with gesticulations might prove more effective: ‘you might need to get alongside them and model what to do’. ‘Eye contact’ and ‘facial expressions’ could also be part of this process. However for agitated or overactive patients, the nurses advised precisely the opposite, be ‘still’, ‘not fidgeting’, ‘slowing down movements’: ‘just don't gesticulate too much or things that can often can raise feelings of agitation’.

“You have to be so un-agitated. You have to be like a block of ice really, like a block of stone, and that’s tone of voice, eye contact, where you place your hands, how much you move around, quick movements, the whole bit. You are like this great big boring slab of humanity in the face of this excited dot.” Touch/close vs. No touch/distant Nurses were cautious about advocating the use of touch. For apathetic withdrawn patients, one nurse suggested that ‘sometimes actual physical contact or reassuring physical contact, just by touching somebody’s hand or physical touch can be important’ however they also acknowledged that ‘if you come and sit too close to somebody who’s not ready for that, that can be incredibly intimidating’. In relation to hallucinations another nurse mentioned that ‘people when they’re very psychotic are, probably their spatial, their need for space is probably a little bit larger than normal, not true of everyone but it could be’. Interviewees were more likely to recommend or view touch as positive for patients who were upset and distressed (8/28): ‘and sometimes just putting maybe your hand on their shoulder to support them while you talk to them calmly’. However even here two nurses expressed caution, with one saying this had to be appropriate to the relationship’ rather than just the normal behaviour of the nurse concerned, and another saying that ‘it’s such an emotive thing … some people don’t want to be touched’. When it came to aggression and irritability, they were clear that personal space should not be ‘encroached’, and patients should not be touched (3/38). Short interactions (19/28) Somewhat in contrast to statements about patience, and giving adequate time to people without rushing them, nurses also emphasised the need for brief and focussed interactions. Perhaps the duration of the interaction reflected its purpose, with task and information seeking/giving likely to be shorter than relationship building and assessment interactions: ‘you really have to be very focussed on the task that you’re doing, so kind of very brief in your interventions’. Or perhaps it was that even gentle and slowly-paced interactions could still be conducted briefly, for example one nurse spoke about ‘small doses’ and ‘give the patient time’ within the same response. Keeping the interaction short was about fitting it to the individual patient, making it ‘tolerable for the person’, within their cognitive capacity or not adversely impacting on their mental state, for example ‘over simulating’ the overactive patient, engendering distress in a thought disordered patient who cannot understand what is being said, or igniting aggression from someone who is highly irritable ‘because usually, when people are very irritable, agitated, going on about things actually increases their irritability’. However changing mental state during interaction could also indicate a need for the nurse to change strategy rather than curtail the interaction: ‘usually been that when people are very agitated or feeling irritable or aggressive it’s usually because they’re quite distressed or frightened or disturbed by what’s going on around them, or the environment that they're in, so it’s usually a sign to maybe change something or do something a bit differently for them, or your interaction with them’. Brevity was also about making the interaction tolerable for the nurse, ‘trying to spend a length, any significant length of time with them would probably not work, and I think I would probably end up feeling frustrated’, and a pragmatic means to end a conversation that might otherwise have no reasonable end point: ‘and listen to them, but not forever because otherwise you’re one nurse, or one mental health professional down in the team because they will take you away for the full day’. Some of the nurses spoke about setting these boundaries by giving the patient timings in advance: ‘from the outset saying, I’m just going to see you for 15 minutes, and then trying to get into a conversation with them’. Frequent interactions (15/28) One way to provide time to patients whilst keeping interactions short was to increase the frequency of contact, ‘consistently going back’ and ‘building up a regular pattern so there is a familiarity there’. Nurses indicated that with this strategy it was necessary to remember the content across contacts, developing continuity despite fragmentation, and continuing (or reinitiating) tasks started

during the previous interaction. Frequently going back enabled nurses to check on patients’ safety, and could be reassuring for them, developing a sense of security. Persistence (16/28) This communicates interest and commitment to the patient, being persistent and not giving up despite any lack of progress demonstrated concern for the patient. Such persistence could be rewarded by the patient starting to respond verbally, ‘become open’, ‘start to trust’ the nurse, or ‘come out more from her room and joining activity groups’. Constant persistent offers of contact, without ‘getting exasperated’, enabled nurses to seize on those occasional moments when the patient concerned was receptive. Not giving up over the longer term was also important for aggressive or otherwise difficult and disruptive patients. “It will take dips, and just not to give up and try other ways or restart again. Trying to build that relationship and always being open with them after an aggressive period, and explaining things to them after a period where they’ve been quite aggressive.” Aggression/irritability Choose language (4/28) Just a few hints were given as to how to modify language to deal with irritable patients. Saying ‘you sound very grumpy’ was seen as more acceptable and less likely to give offence than accusing someone of being irritable. And talking in terms of ‘we or us’ was seen as more likely to lead to a resolution than ‘me and you’ or just ‘you’, as this makes people feel less isolated, for example ‘it would be good if we could all come to an agreement or an understanding about how we can make this situation better or different or less irritating for you, or less dangerous and frightening for those of us here’. Sentence and question construction could also be undertaken in less rather than more confrontational ways: ‘I can go in and say why did you hurt the nurse, instead of that it’s like I was kind of saying what happened that the nurse got hurt, tell me how that nurse got hurt?’ Non-verbal non-threatening (14/28) Nurses recommended the use of ‘open hands, open gestures’, and refraining from any gestures associated with ordering, commanding, hierarchy and authoritarianism, such as: ‘wagging your finger’, ‘staring people out’, ‘pointing at people’, ‘folding arms’ and ‘standing with hands on your hips’.

Emotional regulation Warm and genuine concern for patients was critical to all interactions with patients, and was presented under ‘moral stance’. In this section we present other material related to the emotional experience, presentation and self-regulation of nurses. Most of this ran across all symptoms domains, but potential problems seemed to be most acute around nurses’ reactions to aggressive and irritable patients. Low levels of negative emotion or responsivity were deployed by nurses as a dampening mechanism that provided the social environment patients seemed to require in order to settle and reduce their psychotic symptoms. No anxiety (26/28) Not being frightened or scared by the expression of psychotic symptoms, whether they be thought disorder, hallucination or whatever, instead expressing to patients a calm, confident, knowledgeable response, such as ‘I’ve met a lot of people who have these experiences, and it’s almost like, I’m not frightened by you having this and I’ve come across it before’. Being ‘calm’ and ‘relaxed’ was also important in the face of agitation and overactivity, both of which could be made worse by tension and anxiety in the nurse, indeed one nurse said it was not a good idea mirror patents agitation, or ‘be drawn into it’. Nurses also had to be able to emotionally ‘contain peoples’ distress’, by being calm, rather than ‘feeding into situations, making a drama out of it in terms of someone’s disclosed

something and it’s, oh my God that must have been terrible, how dreadful’. It was important to convey the message that the nurse could ‘tolerate’ the patient’s distress, ‘being calm and receptive’, as ‘quite often distress is related to something that might well be very difficult to hear as well’. Across the psychotic symptom spectrum, ‘seeming relaxed around the experience’ was said by nurses to be likely to ‘help reduce it’, in addition modelling ‘good behaviour’ for the patient by communicating that you are ‘comfortable’, ‘confident’ and ‘secure’. Acute anxiety can warp nurses behaviour towards certain patients ‘they are terrified, they’re paralysed by her agitation because they know anything, anything even slightly provoking will cause this massive explosion. So it makes people not be honest with her, or give in to her very quickly where it’s not necessarily the right thing to do, so it’s hard’. In crisis situations, where patients are shouting and waving their arms around, it is quite natural for nurses to be frightened, however it was reported to be better if they ‘model a more effective way of dealing with it and be able to stay calm … and to emotionally selfregulate’. It could take nurses years to learn this skill, but once they could ‘channel any anxiety or navigate that anxiety into quite a peaceful state’, ‘steady’, ‘appear unfazed’ and ‘in control’, they were more likely to be successful in de-escalating such situations. However this was found to be extremely difficult by some, and one nurse reported that with one terrifying patient ‘it was actually a supreme effort to not make my fear of him very obvious’. Nurses’ anxiety was not just about patient behaviour, it was also about failure, particularly failure when on display in the ward day room with patients and trying to interact with difficult and challenging patients, a feeling of ‘pressure to do well’. Not being anxious in this situation meant being able to take the risk, and being willing to publicly fail. No frustration or irritation (25/28) As with anxiety, reducing the expression of frustration was said to be important across the full symptom spectrum, but was particularly relevant to dealing with aggressive and irritable patients. The sheer amount of time and energy it takes to accomplish a simple task, for example obtaining a patient’s menu preferences for the next day when he or she is thought disordered, can generate considerable frustration. Such responses could generate a kind of vicious cycle within the interaction: ‘people that spend too much time with people that are thought disordered become irritable and start to then reinforce that irritability onto them which makes them more thought disordered’. There were similar risks of getting ‘irritated or tired around someone who’s overactive’, or frustrated around the long term struggle that can be required to engage with the apathetic and withdrawn patient, or get them to do something, ‘not taking offence if someone says, I don’t want you to be here, please go away or in slightly more direct terms than that’. In these and other similar situations it was considered important not to ‘take things personally’, but instead understand that ‘what you’re seeing is likely to be symptoms of their illness’. In this way it was possible to resist the temptation to ‘pressurise’, ‘cajole’ or ‘rush’ patients. When patients are being angry for what seems like no good cause to the nurse, it can be difficult not to get irritated and angry in response. One example was given where nurses responded emotionally to racist abuse, and it was stated that ‘fighting irritability with irritability is just not going to work’, instead this was likely to ‘escalate the whole situation’ and was considered to be the ‘ultimate unsuccessful technique’. In these already tense, difficult and threatening situations, nurses had to pull off the feat of monitoring their own emotional responses, being ‘careful about how the person’s made them feel’ and refraining from ‘antagonising them more’ by getting ‘inadvertently into anger and aggression yourself’. Examples given were ‘losing your temper’, ‘shouting back’, and ‘being rude back’, with one nurse warning ‘just be careful of all of these kind of things when people are angry, it can bring out all sorts of demons in the other person can’t they?’ Optimism (7/28) “If you're feeling optimistic then it’s more likely over a period of time that that will rub off on the patient. Whereas if you're going in there and you're thinking there’s no hope for this patient, then the likelihood is that nothing will change.” Maintaining an optimistic stance was judged valuable, and to accomplish this, nurses had to generate their own belief that the person could improve. This was easier if the whole ward team were ‘going in there optimistic’, communicating and instilling hope for the future.

Getting things done When a person is acutely psychotic, they can be very difficult to manage. It is the nursing task to make sure that deluded, hallucinating, overactive, agitated and sometimes distressed people get sufficient sleep, get up in the morning, wash and attend to personal grooming, wear appropriate clothes, eat and drink sufficiently, etc. In addition attempts have to be made to build a relationship with them, foster social contact between patients, engage them in organised activities. At the same time nurses have to ensure that they take their prescribed medication, don’t leave the ward without permission, see various visiting professionals such as psychiatrists, avert or diffuse arguments between patients and prevent them from harming themselves. Suggest, not order (24/28) “But if you're just going in and using one blanket expectation for all and not really thinking about why it might be hard in one way for one patient and hard in a different way for a different patient then actually I think that, that means that they're maybe only complying because they may be frightened not to or intimidated into complying and actually it probably doesn’t help build the relationship and ... mean that they can achieve their next goals. So, yeah the inability to think about them differently and individually and work out what works best for that, I think that means that you’re more likely to get resistance and more likely to get people who maybe just comply because they’re a bit afraid not to.” The nurses reported that suggestions were better than dispensing orders, because they were more likely to elicit cooperation and helped to grow the relationship with the patient concerned. So, instead of telling people to get up or wash, the verbal formulae for ‘putting across a suggestion’ that were more likely to work were: ‘it’s 8 o’clock in the morning, are you going to get up now, do you want to have a shower?’; ‘this is usually the time where we do this and do you want to do that?’; ‘would you like to eat, would you like a change of clothes?’. This was the opposite of ‘being bossy’, ‘pressurising’ people, being ‘too domineering, or taking control, telling people what’s good for them’, telling them ‘what to do’. Even asking could be tricky on occasion, as ‘ if you ask them to do something that just by the mere fact that you’re asking them to do something they will become irritable’. Critical approaches, coupled with unrealistic targets for what patients could accomplish, with an undercurrent of anger and irritation from the nurse, were not likely to be successful, and might ‘provoke patients’ or evoke ‘resistance’. Worse still was ‘shouting’, ‘manhandling’, ‘threatening’ sanctions such as withdrawal of leave, and physical force such as ‘grabbing by arms and dragging and that’s just, that’s just terrible, trying to force people into things’. “Unsuccessfully has been to try and take over, and not really allowing the patient to think but sort of imposing a plan on them … very unsuccessful. I can think of an occasion where I did get very, very caught up in the patient’s anger and abuse, and she was extremely agitated … I’d rather it hadn’t have happened, because it was totally unproductive and it made me really think, I’m never doing that again because it didn’t make me feel any better, it didn’t make the client feel any better, it didn’t achieve anything.” Give reasons (15/28) “Things are really bad at the moment but it’s really important that we keep you hydrated, we keep you with some food because we are working to really help you and improve things for you. It’s important that we keep you physically fit as well because things are really difficult at the moment. So you’ll be trying to persuade them that we’ve got to try and do something about their physical health as well.” To generate motivation for and compliance with necessary tasks, nurses would give reasons and rationales for the behaviours they wished to elicit from patients. So the need to take medication and what effects and advantages it might have would be freely discussed with patients, as would the benefits of eating regularly, drinking enough fluid, having a bath, etc. Some really fundamental and obvious things might need to be spelled out for the patients, such as ‘eating and sleeping can help you cope with this challenging, distressing situation’, and getting dressed might help because

‘keeping up your everyday activities is going to help you through this, whereas if you let things slide you’re going to feel worse’. In other words, explaining exactly why the task is important and what will be achieved by doing it, and how that will help the person restore a normal pattern of activities and shape to their day: ‘showing them the link between the physical and the emotional and how they all interact and interplay with each other’. One nurse referred to this operational psychiatry as ‘some kind of talking economy’, with desired behaviours being purchased by nurses through interactional investment. Be flexible (21/28) “If it's going to bed and you're really wired and irritated, it's unlikely you're going to be able to go and fall asleep. So maybe there's some middle ground that you can find where you go, well maybe you're not going to go to sleep, but maybe you can go and read in the, not read probably, listen to music on your headphones in the smoking room. I don't know, I just think rules and tasks are only of limited use, they need to be meaningful for people.” As part of the discussion process, the patients point of view about the task can be explored, so that they can feel heard and valued, and so that the timing or precise content of the task can be adjusted to suit their wishes. This generated a participative relationship ‘so that you're not just imposing something, but they're actually taking part in it’. Talking about the task also allowed the identification of factors that might be preventing the patient from doing it: ‘I guess I skirt around the outside it a lot, to see what it is that’s blocking it’. Understanding the patient’s reasoning process meant that nurses could sometimes find workarounds, or ways of both getting the task done and satisfying the patient at the same time, reaching ‘common ground’. Flexibility could also be shown by giving a degree of choice to patients: bath or shower; tea or coffee; now or in half an hour; with me or with another nurse, etc. Giving such options meant that the interaction was much less likely to be taken as or descend into an argument, and in addition the task could be made more attractive by offering different foods if the patient wasn’t eating, or varied bath accompaniments (shower gels, soaps, towels) if they were reluctant to wash. Negotiation could also be a valuable tool, offering a range of potentially more desirable options in return for a degree of co-operation. Care had to be taken, however, to only promise what could actually be delivered, otherwise the longer term situation could be made worse. “If we’ve got somebody who doesn’t like sleeping in her bedroom when she experiences certain types of hallucinations and she prefers then to sleep on the mattress on the floor. And that’s fine, I think, for that period of time until the woman or the person then feels safer and you, I wouldn’t necessarily try to change that.” Break down task into small steps (13/28) “I find it’s probably simpler to break down the task into simple little bits. And so instead of saying, OK this morning, well what we intend to do is to either, maybe get your laundry done, it’s probably easier to say, could you just put your dirty clothes here. And then from there, can we take them to the laundry room? And then from there, washing powder, so just breaking the task into little bits, and trying not to get into any more complex conversations during that time, that would distract them from the task.” Taking any task in ‘clear, slow steps’, or ‘bit by bit’ was thought to be advantageous, as ‘giving them too many things to do or too much pressure’ was unhelpful. Another example given, in addition to doing the laundry quoted above, was taking a bath, which could be broken down into collecting the towel and toiletries, going to the bathroom, running the bath, getting in etc., or going to bed broken down into turning down the sheets, taking off your shoes, then the rest of your clothes, putting on the pyjamas, etc. This mode of approach meant that it was easier for patients to understand what was required and to succeed at what they were trying to do. One thing at a time meant that the patient ‘did not have to remember a sequence of tasks’ and cooperation was thus less cognitively demanding, whereas ‘anything too complex is just going to be bound to fail’. Some tasks could be broken down into smaller disconnected bouts of activity, in recognition of the fact that patients might not be able to concentrate over a sustained period. For example conducting a systematic mental state examination or rating scale could be done over several short sessions over the course of a day, rather than over a single continuous period of time. Another sense of ‘step by

step’ as mentioned by nurses was that of gradually increasing expectations about what patients would do, as they recovered from their acute symptoms: ‘so it went from the non verbal, well it went from the isolation, to the non verbal, to watching TV together, to talking, to coming out and eventually eating in the dining area … it was a very gradual and a slow process over a matter of, couple of months’. “To make a bed for example, and to ask them in terms of helping me precisely what I want them to do, so it’s not just, oh help me make the bed. It’s, can you get the pillow out of its pillowcase? Can you put the pillowcase on? Really breaking down tasks and making it very simple for them to be able to understand and achieve, and, yeah so very focused, very specific and probably not anything that’s going to go on for too long.” Avoid, defer or postpone tasks (13/28) Somewhat similar to choosing the right time of day, there were times that it was better to avoid when trying to complete a task with the patient, for example when he or she is especially agitated, irritable or upset: ‘just leave the tasks that I know are going to cause conflict’ or ‘calm them down before you actively involve them in things’. So non-essential tasks could be avoided and postponed to later in the admission, and even essential tasks such as getting the patient to eat and drink could be carefully timed to maximise the chance of success: ‘but they might be hungry later on and I will be able to give them some sandwiches, some toast, some biscuits, or whatever is available’. Maximise task choice and attractiveness (16/28) Ordinary everyday tasks can be made more attractive with some care and preparation. For example one nurse described making bathing easier for patients: ‘if you say, I’ve run you a bath and I’ve put lots of nice soaps in it … I’ve got this really nice new bubble bath and I’ve got some nice clean towels’. This approach to improving patients’ hygiene was recounted in almost identical terms by several of the nurses. Alternatively if the important thing is to get the patient engaged in any activity, then having a wide range of things to do can assist in finding something that he or she can respond positively to, ‘just offering something that might interest them’ and ‘you’ve got to offer them choices’. “I had somebody who was very withdrawn, wasn’t interested in any communication, but had a dog and just trying to sort out a dog has made him come out of the shell and from the little things, the door will open”. Prompting (10/28) Being with the patient while the task is getting done, and giving gentle reminders and prompts, almost like a form of coaching: ‘shall we do this now’. Even more basically, some patients might need reminders to continue to eat and consume the food on their plate, or drink what is in the glass in front of them on the table: ‘it’s trying to gently remind them to keep on course with the task they’re doing rather than going off all over the place, without pressurising them, to gently remind them oh, you were having your dinner’. Such prompts are ‘just a reminder to bring somebody back into the here and now, rather than whatever else is happening, the other distractions in the persons mind’. As an alternative, a written list of instructions can be provided: ‘if they’ve got a simple task like making a sandwich, if you write it out in five statements … they can keep going back and looking at it, and seeing what they're supposed to be doing’. The prompts and reminders help patients stay on track when they are overactive and their thoughts skip from topic to topic too fast, or when thought disordered or distracted by hallucinations. Positive feedback, encouragement (13/28) Recognition of the difficulties patients experience and praise of their progress towards accomplishing a task, were critical ways to keep them motivated to complete the task in hand: ‘it’s positive reinforcement, you do something good, you make that person feel good about what they do, I think that works’. Constant reassurance that they are doing well, coupled with acknowledgement of the effect their mental state has on their ability to do such mundane tasks. Highlighting their abilities and successes can help energise patients, as ‘even if it’s only a very small goal, to the patient it might be really, really big’. All this has to be accomplished without being patronising,

communicating any sense of superiority, of belittling the patient in any way, instead being ‘very appreciative of how difficult it is’ and expressing gratitude for their efforts and work. Assist, do part of the task (6/28) Instead of abandoning patients to complete the task themselves, once they had agreed, nurses suggested that with some patients it was a good idea to render further assistance: ‘the main thing would be to do things with them’. Finding the right level of assistance to provide was considered to be a ‘fine balance between being caring and encouraging people to take action without actually taking the action for them’. Starting to give assistance also ran the risk of eliciting passivity from the patient and frustration from the nurse at the slow pace of progress, with one nurse confessing ‘I would probably end up doing all the things the agitated person should be doing … so my strategies are pretty useless’. Of course it is somewhere between very difficult and impossible to judge what an acutely psychotic patient is capable of doing at any one moment, hence nurses move forward step by step on a pragmatic basis, trying to elicit from the patient the most involvement they can. Assertiveness (18/28) “I mean it’s a very difficult thing to do but it’s something again, I’m sure in Mental Health Services we get heavily criticized for, that somebody was too agitated to eat or drink for three days. And obviously that’s going to have such an impact on their physical well being. So I’d have no qualms at all about restricting somebody’s access, stopping somebody, sitting them down, trying to encourage them very strongly to have a drink. Obviously to take medication if that was necessary which it probably would be. Try and get them to have something to eat.” Despite nurses’ reluctance to order patients to do things, and their desire to suggest action, give rationales, be flexible and search for consensus, there were occasions when it was necessary to be more forceful. This was typically in relation to giving prescribed medication, but also about ensuring patients drank fluids or ate some food (preventing dehydration or malnourishment), or kept clean enough not to become objectionable to other residents on the ward. This might mean being more assertive, instead of ‘shall we?’ statements, being ‘prescriptive’ such as saying ‘we will’, ‘we are’ and ‘it is going to happen’ becomes the format of communications:’ just saying, you should have a shower because you really smell and just doing that, and then it’ll just happen, and people can sometimes really respond to that’. Constant reiteration and request, ‘keep going on about it’, is another strategy, even though ‘it can feel a bit like a broken record in terms of having to ask people to do things and insist’. Explanations or rationales as to why it is necessary to eat or drink yield to descriptions of what will happen if the patient does not co-operate. Alternatively, nurses may try to use their relationship with the patient as leverage: ‘take it for me, or trust me, I really think you should take this medication’. Instead nurses might quietly ask another patient to have a word and encourage action, or allow confrontations over personal hygiene to take place during patients’ meetings on the ward, thus beneficially utilising peer pressure. If something really important is at stake, then several staff might be assembled in a show for force to clinch the issue. Or being more assertive might mean intruding on the patients personal space in order to overcome their withdrawal, touching them in order get them to drink or take medication, maybe even guiding the cup or the tablets in their hand up to their mouth, thus one way or another ‘forcing the issue’. Nurses said that to do these things made them feel ‘uncomfortable’, uneasy and ‘dirty in a weird kind of way’; nevertheless they accepted that was a ‘moral responsibility’ to ‘cross that threshold’. It does not mean that gentleness and the search for co-operation were abandoned completely. At every stage the patients’ difficulty was verbally recognised and appreciated, their smallest of moves towards co-operation met with warmth and encouragement, respect for them maintained, and every step of increased assertiveness by the staff taken with deep and overt reluctance. Nurses experienced the most agonising dilemma as keeping patients clean. Food, fluids and medication were a given and seen as urgent issues of high importance: ‘if somebody really needs to eat because they’re dangerously unwell, then I think sometimes your tactics you use have to be much more forceful really, in terms of how you, maybe physically encourage somebody to stand up and walk with you to the kitchen.’ However cleanliness was more difficult, as ‘how much do you infringe someone’s human rights to get them into the bath?’ One nurse told of seeking legal advice on the issue for a patient who was agitated and overactive and wouldn’t let anyone near her, but who was menstruating, with the result that she was restrained and given a shower.

“Right this is what I see at the moment, we feel as a team that this might help you and this is what we’re going to do. So it’s being very directive … taking control of the situation because they are not able to do that for themselves.” Delusions Semi-collusion for greater good (3/28) Where tasks were really important, such as delivering the food/fluids/medication trio, some nurses were willing to lean a little bit towards colluding with patients delusions, by not challenging them, not taking a position on them, or expressing neutral comments that were ambiguous as to whether they expressed understanding or agreement. In other words bordering on allowing the patient to believe that their delusional system was accepted to some degree. This was recommended with extreme reluctance: ‘it may not be a, the intervention that people would recommend, but sometimes you have to go down that route, I think, just to get the person, who is pretty deluded to work with you’. One example given was of a patient who believed he was a member of the royal family, but who hadn’t washed for some time. The nurse concerned said he did not believe royalty would allow themselves to get so dirty that they smelled, instigating the patient to have a shower. “If you’re trying to achieve a task and the task is important, so if it’s something to, for instance, trying to get them to, let’s say, take their medication for one thing. Then if whatever their delusion is, and how they’re expressing it, if it doesn’t pose any danger then, in a way, not acknowledging it but going along with them, just nodding and saying, OK, just for the short term, for them to achieve that task.” Thought disorder More gestures (5/28) Instead of using language, which these patients can find difficult to understand and process, nurses suggested that desired tasks could be modelled, indicated, or described through gestures in order to enhancer successful communication: ‘being more visual and demonstrative about it’.

Talking about symptoms This section includes everything the interviewees had to say in relation to talking with patients about their symptoms, or interacting with them in ways to reduce their symptoms. Although there was some overlap between domains, we present this material separately by symptoms, as there were specific nuances to these approaches that required careful description. Every one of the interviewees mentioned the value of medication, either regular prescriptions, as required doses, or in some cases coerced rapid tranquillisation. This is not explored in detail below. They also mentioned a number of formal psychotherapeutic approaches as applicable, including: cognitive behavioural therapy, solution focussed therapy, hearing voices groups, relaxation training, anxiety management training, anger management training, motivational interviewing, systemic family therapy. As these are all well described in textbooks, and the interviewees did not add any detail about their specific application to acute psychosis or inpatient work, these have not been further described. However there were a number of techniques the nurses did describe which would be claimed by one or other of these therapeutic approaches. As these were described in detail and repeatedly by nurses, with specific applications to acute psychosis or inpatient work, these are described below. Apathy/withdrawal Hearing and respecting the experience (9/28) The emphasis for apathetic and withdrawn patients was not so much the endeavour to get them to describe it, but instead to observe, recognise, acknowledge, respect and try to understand it. This meant not pushing too hard, tolerating silence whilst still spending time with the patient. Patients

could still also be asked about their feelings and experience: ‘I would look at actually getting them to describe their feelings and how they feel, what’s going on for them within’. Respecting that experience involved not putting such patients under pressure ‘to be what they are not’ by an approach which is ‘too animated’ or ‘forcefully’ putting them ‘in social situations that they might not handle at that point’. It also meant not ‘ignoring’ the apathy and withdrawal as if it were not there, but talking about it, ‘acknowledging how they’re feeling’ and approaching them for durations and activities that they could reasonably tolerate. Several of the nurses spoke about apathy and withdrawal being meaningful behaviours with reasons, and stated that ‘you had to acknowledge that’ and try to ‘understand the position they are in’ because ‘it’s always a different reason for why they are withdrawn’. “I think it’s important, if they are withdrawn there might be reasons for it, and you need to understand what reasons they are. They might be scared, they might be worried about any environment, they might not know what’s going on, and so you have to respect that.” Mutually explore causes (7/28) Nurses indicated there were ‘hundreds of reasons’ why someone might be in this condition, and in addition to acknowledging and respecting it, it was necessary try to ‘to work out from them why or explore the reasons with them, why they’re feeling the way they’re feeling’. One way of getting to this information was by suggesting a task or activity to them, and then exploring their feelings about it or reasons for declining: ‘say think about what might be beneficial, exploring why they haven’t done that, exploring why, if there’ve been concerns why do they think other people are concerned’. Alternatively nurses might offer the interpretation that their experience is a ‘symptom of the illness they may suffer from’. Negotiating and agreeing a care plan (7/28) Nurses said this was far preferable to using force or trying to coerce the patient to do things. Instead they advised negotiation, ‘forming a plan with the patient’ and they argued that this approach based on ‘kindness’ worked better. Such a plan had to be realistic in terms of what was expected from the patient given their mental state. Such agreements ‘to try to do something together’ could not necessarily be reached quickly with apathetic and withdrawn patients. One nurse described several days of trying to maximise and increase contact with such a patient who was virtually mute, in an unwashed and dishevelled condition and spending all of her time in her bedroom. By utilising every possible opportunity, eventually the patient spoke to her, and once communication was established a care plan was written and discussed with her, which she agreed to. Only then was it possible to get her into the bath on a consensual basis: ‘just that relationship that existed between me and her enabled me to actually succeed in that’. Structure, routine and purpose (5/28) A number of different means to accomplish this were reported, including establishing a reward structure of some sort, utilising desired activities such as going for a walk, out to the shop, leave opportunities or progress towards discharge. Alternatively plans and timetables for the day could be agreed, diaries of activity kept so that progress can be made visible. Rating scales could be used and the results placed on a wall chart in the patient’s room for the same reasons. Step by step (6/28) Managing a slow, staged build up of activity and social engagement on the part of the patient. One nurse described spending two months working with a patient who initially was completely isolated and could only communicate nonverbally, through gradually venturing out of their room to eating in the dining room and watching television together. Another nurse referred to this a ‘graded exposure … which can sound very technical, but it's just getting them to do little bits at a time, and they can see that they can build up to the goal’.

Hallucinations Hearing the experience (24/28) The patients experience can be explored by observing the impact voice hearing has on them, noticing their distraction, their talking back to the voices and their body language. However their experience can also be explored by asking such questions such as: ‘how loud’, ‘how long does it last’, ‘how many voices’, ‘what do they say’, ‘how frequently does it happen’, ‘is it saying anything about me’, etc., in order to ‘try to get to the heart of their experience’. Some nurses used structured questionnaires in order to systematically understand what patients were experiencing. That understanding could extend into interpretations as to what the hallucinations might represent for the patient, such as ‘some bereavement that they didn’t address and manifesting itself at some level’, or ‘a reflection of some kind of relationship they’ve had’. Conversations might have to be timed to periods when the patient is not actively hallucinating, or the patient might not wish to talk about them, in which case this needs to be respected. “In some ways, I guess it’s tied in with the talking about what’s going on and the thinking level with the hallucinations as well, and sometimes I’ll just sit down with somebody and we’ll have quite, for want of a better word, crazy conversations about whatever’s going on that are very left field, and just about, what that persons beliefs are, and just exploring the terrain of, all right, so you think this is possible and you see this stuff, and the implications of it and the symbolism of it.” Hearing the effect on the patient (17/28) The interviewees stressed that it was important to be calm, accepting and not frightened of these strange experiences related by patients. Patients themselves could find their hallucinations frightening, so to hear their experience calmly ‘gives people some relief’, and ensures they are ‘not alone in their personal hell’. The voices patients hear can be persecutory and abusive, causing them great distress. Visual hallucinations could also be frightening, with one nurse describing a patient who was reluctant to go to bed as he saw eyes all around him and thought he was a ‘sitting duck’ in bed. Nurses recommended talking with patients about the impact their voices were having on them, in a calm and confident manner, as a first step towards offering help. Some nurses suggested concentrating on the emotional impact of the voices more than anything else, as ‘feelings are very real and the consequences of the feelings are real’. Hearing to assess safety (9/28) Hallucinations could posed safety risks for the patient or those around them. Examples given included ‘voices that are telling them that the food is poisoning them’, becoming so distressed by the voices that ‘they are a serious risk to themselves’, be unpredictable, ‘suddenly lashing out and attacking’ someone, especially in the case of auditory hallucinations that command them to do things such as harm themselves or others: ‘telling them to jump off a building’ or ‘telling them to kill such and such a person’. Nurses needed to hear about and explore the nature of these hallucinations in order to work out how best to help the patient and keep everyone safe. Respecting the experience (15/28) Respecting equals openly talking about it and acknowledging its impact on communication, the disruption, distraction and difficulty that the experiences causes for the patient: ‘you’ve got to acknowledge it and make it real, although you can’t experience it you’ve got to act as if it’s happening in the room’. Not respecting meant ‘ignoring the hallucinations and talking about something else’ or saying things such as ‘snap out of it’ or ‘threatening them … if you respond or talk to the voices, that means you stay in the hospital longer’. Totally dismissing the patients experience was also not respectful, saying things like ‘you have got an illness and these are all not real and let’s try and not talk about them’, or it’s ‘all tricks in your mind, it’s all in your head’, or ‘it’s just not real, it’s not happening’ This ‘invalidates their experience’, adds to the person’s distress, simply doesn’t work, is not helpful to the patient and pushes them ‘away from services’. Such approaches were said by one nurse to be linked to biological medical model that sees hallucinations as essentially meaningless and irrelevant psychotic phenomena. “I think people can be quite dismissive of people who are experiencing voices and think that there’s’ no point, that

actually somebody’s too unwell for you to try and engage with them and I think that’s thoroughly wrong. I think it doesn’t matter how unwell or psychotic somebody is, you can, there’s a glimmer of being able to engage with them on some level. ” If put on the spot by a patient, instead of contradicting the patient’s experiences, nurses recommended simply saying ‘you may see, hear or smell so and so, but I don’t’, thus acknowledging their experience without affirming or confirming it, or the beliefs that are attached to it. Colluding with the patient’s hallucinatory experience, perhaps by agreeing with their interpretation of it, was not seen as at all helpful or respectful. Stress management (6/28) Several nurses identified a link between stress and the experience of hallucinations, and suggested ‘identifying the external stressor’, taking action to ameliorate or remove it, and teaching relaxation skills or deep breathing exercises to the patient experiencing the stress in order to reduce their response to it: ‘trying to get them to relax and be able to switch off anything which is happening internally … like a low level meditation, and however they got themselves there whether it was through music or doing relaxation techniques, I’d always aim to try and get them to, where they’d be able to have no internal talk or hallucinations happening’. The focus here would not be so much on the hallucinations themselves, but ‘why this has happened at this time in your life, what do you think is going on?’ Negotiating and agreeing a care plan (6/28) The nursing response to hallucinations needs to be negotiated with the patient concerned. Some are not distressed by the experience, and do not want the nurses to do anything, others wish ‘to ride through the experience and discuss it afterwards’. By discussion and negotiation, strategies that patients have used successfully in the past can be supported by nurses during the current admission. With some patients it is possible to agree a graded response based upon the intensity and severity of the symptoms, with an agreement as to when additional medication will be used. Distract (15/28) Patients could be distracted from their hallucinatory experiences by ‘talking about something else or doing something else’, and suggestions included ‘talking and walking’, ‘watching TV’, ‘listening to music’, having a ‘game of pool’ and ‘reading a book’. It was noted that patients are very individual in what they find helpful in these circumstances, so the strategy has to suit them of be discovered through trial and error. “So I think there are times to talk about hallucinations and how they affect you but I think that engaging in different activities like playstation, football, their interests, getting them to socialise with other people … can be really useful.” Bolster coping (10/28) In addition to distraction techniques, nurses mentioned the use of earplugs as helpful to some patients, asking the voices to go away for a fixed period of time, or telling them to go away. Being in a room with others can help some patients with their hallucinations, but makes others worse. Normalising the experience helped some by reducing their anxiety, letting them know that it is ‘not uncommon’ to hear voices. Casting doubt and challenging (8/28) Nurses described several ways of gently (and sometimes more strongly) challenging patients experiences with voices. For example, oblique reassurance, not directly contradicting what the voices were saying, but alleviating concern nevertheless. The example given was of a patient whose voices had told him police and gypsies were outside wanting to get him, to which the nurse responded ‘well, there aren’t any in here at the moment, are there?’ Similar example was given about how to respond to a patient experiencing persecutory voices, with the nurse talking ‘to really reinforce their own sense of self and who they are and know they’re not this most appalling person

which the voices are trying to convince them that they are’. One nurse described using one sense to cast doubt upon the hallucinatory sense. A patient was seeing snakes all over, and was encouraged to touch the floor and the walls, ‘so they could feel the solidness’ and realise that they weren’t there, getting temporary relief. Others spoke about openly doubting what the voices were saying, or their reality, by remarking gently on how strange the experience was or occasionally, in appropriate cases, direct authoritative contradiction could bring the patient some relief of anxiety and perplexity. Delusions Acceptance and listening (18/28) Nurses responses reflected the fact that patients had a need to talk about their delusions, ‘so giving them that space to talk about them, and to feel that you're actually listening to them I think is very important’. This importance to listen derived from the fact that ‘for that person their world is real, what’s happening to them is very real’. Many nurses enjoyed or were fascinated by patients strange ideas about ‘what was happening to them, their family, the government or the country, … so I like listening’. One nurse gave the example of a patient who believed he was a member of the Royal Family (who had even had an official card printed for him and had on one occasion tricked the Police), ‘and he told me everything about it ... and nothing that he said was true … but talking to him about what he believed to be the truth built a relationship’. Another remarked that ‘sometimes it just pays to be quiet and listen and see that stuff come past’ after relating the case of a patient who had ‘grandiose beliefs about his part in the world and the Iraqi conflict’ and spent all his time ‘shouting his beliefs at me’. The interviewees also recommended attending carefully to the emotions engendered by the delusions, mentioning fear, elation, anger, distress and upset as possibilities. Exploring those delusions was not always just a matter of passive listening. In addition it required nurses to ask about how the delusions started, how intensely it is believed, what sense they make of it and how it relates to their background, upbringing and culture. Such enquiries could be quite extensive, as delusions were usually part of a whole belief system that could take time to unravel and understand. In order to make this telling safe for patients, it was necessary for nurses not to leap in with contradictory evidence or identify glaring holes in the argument, instead listening with ‘attentiveness’, ‘respect’ and ‘not disagreeing with the delusion, but maybe thinking about the effect of the delusion on somebody’. Seeking to ‘pick holes in them’ or ‘show they are wrong’ during conversation ‘is going to have an atmosphere of threat to it’ and is an unsuccessful strategy, as ‘we all hold our beliefs strongly and defend them’. “Just taking the heat out of them by listening, and respecting the emotional impact of them is a good way to take some of the sense of isolation away that comes with thinking differently to other people.” Explore to understand the person (16/28) Accepting and listening to delusional material was a way to generate a deeper understanding of the patient and their experience. Nurses spoke about this as getting to grips with the ‘texture’ of patients delusions, how they all ‘link together’, what the underlying ‘concept’ ‘or ‘symbolism’ might be, ‘tuning in to the underlying feelings’, ‘learning what it actually means for them’ and understanding how delusional systems may have a protective function. Occasionally this level of understanding was capable of generating interpretive insights, linking delusional material to the past or current real experiences of patients, ‘making sense of it’ in ways that could sometimes be shared with the patient concerned. “It’s to not necessarily just chuck it in the medical box as a symptom, so therefore we are, or down medication, but to try and unlock it really. What might be the idea, why are they experiencing that? Where’s that come from?” Explore delusions to assess risk (7/28) Interviewees realised that delusional beliefs had the capacity to be linked to actions that risked the safety of the patient or others. They therefore specifically explored the potential for such actions to occur. One nurse gave two clear examples of this. In the first case, a patient had delusions about a

woman living in the flat below, that she was making noises that were ‘threatening to him or sexual towards him’, and the nurse explored what contact the patient had with her, and asked what was the likelihood he was going to act on those beliefs and in what ways that might be. The second example was of a patient who believed he was on a mission that meant he should jump out of a third story window, and the nurse explored how important the mission was, and whether the patient was making any plans about beginning the mission. Monitor delusions for incorporation (9/28) Occasionally nurses get incorporated into patients’ delusion systems in a negative way, becoming part of the conspiracy against them in some way. This could result in patients becoming hostile and antagonistic towards the nurse concerned, and when this did occur, care had to be swapped to other nurses who were not incorporated in the delusional system in this way, because contact could lead to the patient becoming distressed, or in extreme circumstances, violent. Nurses suggested this could be averted by ‘constantly checking’ with the patient, ‘being mindful’ and evaluating ‘how you are perceived, how you are seen’. Sometimes it was necessary to explain in great detail why you wanted to ask certain questions before asking them, or maybe even checking with the patient first whether you could ask them, so as to minimise and feeling of threat or loss of control. Staying ‘neutral, professional and appropriate’ was important, as was not insistently arguing with them that their delusions were false. Don’t deny or dismiss (23/28) The nurses were generally agreed that it was not helpful or successful to deny the delusion, ‘shout at the patient saying it was not real’, or disrespectfully dismiss it, ‘belittling’ them: ‘oh don’t be so stupid, that’s not true’, ‘that’s total rubbish’ or ‘it’s just your mental illness’. Doing this was said to ‘completely break down any sort of relationship’, sometimes make the patient angry, turns the nurse into an ‘adversary’ and ‘can make the person stop communicating’. Alternatively, with someone who is ‘fragile and vulnerable or where the delusion is particularly sensitive or protective of patients’ emotions, a denial can ‘shatter’ them, make them ‘distressed’ or precipitate ‘depression and possible self-harm attempts’. In addition not listening ‘doesn’t really take you anywhere’, prevents proper understanding of the person, and a correct assessment of the level of risk. Gently question, cast doubt (18/26) Introducing questions or doubts about the delusional beliefs could be done and might be helpful. However the nurses indicated that you first needed to have a good, trusting relationship with the patient concerned, and that the strongest and most central parts of the delusional system should be left alone whilst doubt is introduced around the edges, with less strongly held and perhaps less emotive beliefs. This work could not, therefore, easily be done early in the patient’s admission before confidence in the staff had been established, the delusional system was thoroughly known and good relationships formed. At this point, slightly challenging questions (not direct contradictions) could be introduced, say through expressing puzzlement about the gaps between the delusional belief and the evidence, or gaps in the patient’s explanations, such as ‘when did they do it’, ‘how did they do it’, ‘why did other people do this’, or by suggesting alternative explanations, or by getting them to test the beliefs out. These interventions should be targeted at ‘little points of movement’ or ‘ambivalance’. Directly challenge the delusion (9/28) A smaller number of nurses suggested that there were occasions when this could be helpful. When a delusion was linked to an intention to harm another person, then a stronger challenge was absolutely necessary. However another nurse related an occasion when one member of the nursing team directly challenged a patient’s delusions, and the challenge led to discussions and the first cracks on the overall delusional system and a step towards recovery. The pre-existing relationship with the patient was a very important foundation for this intervention. In fact a longstanding nurse-patient relationship in which the same delusional system had been recounted many times sometimes enabled nurses to be dismissive of delusional talk with not great impact: ‘she phones me quite often from the ward when she’s unwell, and says, oh I’m off to Monte Carlo with my millionaire husband, and I can now say to her, yeah whatever; I’ve heard it all before’. With yet other patients,

delusions could be soft and malleable, enabling nurses to argue and present evidence that was quickly reassuring for the patient, by checking under beds, in rooms and cupboards etc., for the threats the patients believed were there, or demonstrating that the things with which patients were preoccupied were not actually occurring. Reassurance in such cases tended to only work on a short term basis, ‘because it comes back very quickly’, but was helpful to the patients concerned. Don’t collude (17/28) Agreeing with the patient about the veracity of their delusions, perhaps in order to avoid difficult or tense conversations, or for fear of what might happen if they challenge the delusion, or to get the patient to go along with a particular course of action. This was not seen as acceptable behaviour. Many nurses indicated that this was primarily a matter of being honest with the patient. While not wanting to dismiss or deny their delusions, nurses could not allow themselves to confirm them either. So if a patient put them in a position where they had to express a judgment, the nurse would say things like ‘I understand that these are the thoughts you are having’ but that the belief was not shared. In this way nurses could maintain themselves as a ‘reference point’ for patients. Ignore the delusions (6/28) With fixed and longstanding delusions, some nurses indicated that it was better to ignore them and give up on any attempts to change them: putting them on the back burner and not putting an emphasis on them sometimes can be really useful as well’. Instead they suggested ‘looking again at what might be meaningful activities in his day, and what he might like to do, and being positive about other activities’, ‘making the most of bits that aren’t affected by the delusion’. Find workarounds (9/10) When the delusions are of an intensity of nature that they interfere with patients’ daily lives, particularly basic functions like eating, drinking and washing, then ways to work around the delusion have to be found. Several nurses spoke about dealing with patients who thought the food and/or drink was being tampered with or poisoned, and suggested allowing the patient to select his own food, tasting it first for them, or providing it as supplied in sealed containers that the patient can undo themselves. Thought disorder Overall, thought disorder was not clearly understood by all the interviewees, and advice on how to deal with it and respond to it as a topic rather scant. Several interviewees considered that thought broadcasting and thought insertion (with related delusional ideas) were thought disorders. A number of different suggestions were mentioned by only one interviewee as opposed to several, including: distracting the patient; reminding them they have got through this experience before; not challenging the thought content; explaining the physiological cause; and helping family and friends to understand. Acceptance and listening (15/28) Nurses answers did not so much focus on thought disorder as a topic of conversation or a therapeutic target; instead they circled around what it was like to try to engage in normal conversation with a patient who was severely thought disordered. In this regard it was noted that ‘the conversation can veer very quickly to all kinds of places’ and ‘cover some very whacky themes’, nevertheless to stay with the conversation meant ‘you could have a social connection with a person when perhaps that’s quite rare for them’. To accomplish this required nurses to give plenty of time for the patient to express themselves, be ‘calm’, ‘non threatening’, ‘not putting too much pressure’ and ‘not bombard them with questions’. “I follow people's tangents that they go on, I'll just go with them on the ride essentially. And often I think people on the surface are not making much sense, but … even if you range over many topics you often will, it will fall around particular themes which then gives you an insight into who that person is, and what's most important for them as well. And also how that style of thinking is affecting them as well, and what's preoccupying them and how that might get in

the way of them doing what they want and what they value in the world, and how they might live what they value.” Explore how it affects them (4/28) Some interviewees tentatively suggested trying to explore with the thought disordered patient the effect it was having on them, and on their relations with others. Upset/distress Acceptance and listening (25/28) Nurses’ responses on this topic emphasised giving time in a quiet, private environment, ‘allowing them to be upset’ and ‘just being with them’, eventually moving to asking ‘if they want to talk about it’ or suggesting that it might ‘help to talk about it’. Gentle prompts and questions then allowed nurses to draw out from patients their thoughts, feelings and the events which were distressing them. Taking a distressed person to a private place could also usefully prevent other patients from also getting distressed in sympathy. Time had to be spent with someone in being with them and hearing them, before it was possible to move on to talk about coping, otherwise ‘the person can feel invalidated’ and that ‘you are trying to push their feelings away, sweep it under the carpet’. The interviewees were also careful to state that patients’ wish to speak should be respected, and that they shouldn’t be put under pressure to expose the causes of their upset, or as put by one nurse: ‘not prying’. Being with some ‘in silence’ and ‘not saying anything’ can be perfectly acceptable ways to respond, instead ‘waiting until they are ready to talk’. If a person is upset and angry, too many questions might ‘increase their distress’. Give time alone (3/28) If it was what the patient wanted, and an offer of comfort and listening came too soon or was rejected, a distressed patient could be given some time alone, ‘but not indefinitely’. Stay calm and neutral (4/28) Hearing upset was difficult, but in order to patients to be able to share the depths of their feelings, nurses had to be able to tolerate the distress without becoming ‘uncomfortable’ themselves. If the nurse themselves can’t contain their response to the patient’s distress, then the patient will feel less able to be distressed, and communication is hindered. If the nurse responds with overly sympathetic distressed feelings, it can unhelpfully amplify the patient’s distress as opposed to helping resolve it, or patients can feel they ‘have to protect’ the nurse ‘from their distress’. The correct response was therefore ‘remain calm and show you are interested’. Don’t close them up (11/28) Perhaps because it is hard to tolerate distress, the interviewees noted that acceptance and listening were sometimes avoided. They therefore suggested that responses to the distressed patient should not include fatuous reassurance, such as ‘stop crying, don’t worry, everything’s going to be OK’, or ‘it’s not that bad, you’ll get over it’. Nor was it acceptable to dismiss how someone was feeling, make light of it or try to coerce a better mood through shouting at them or ‘telling them to pull themselves together’. “And I think you’ve got to be careful, as the practitioner, you’re not shutting them up because you’re finding it difficult to be around.” Persist to find out cause (7/28) While patients should not be put under pressure to reveal all, nurses did recommend gentle persistence in order to find out what underpinned patients’ distress. Overcoming reticence could be done by repeated contact and offers (‘putting in opening gambits every now and again’), spending time in silence with the upset person (‘understanding that it might take quite a long time to get to the bottom of it’), finding the right place on the ward, or just homing in on the right moment when the patient was ready to talk.

Explore solutions (9/28) These can either be offered as possibilities by the nurse, or the patient can be asked what support would help them: ‘how can we make this better for you?’ A helpful move could be to ask if they have felt this way before, and what has happened previously, what has helped and what hasn’t. Alternatively, to elicit their own ideas, the patient could be asked ‘what would you tell a friend in your situation?’ Take action to relieve cause (6/28) If it is something causing the distress that the nursing team can remedy in some way, then appropriate action can be taken. No specific examples were given. Distraction (6/28) Involving the patient in various activities was recommended as a way of distracting them from their distress: walks, meals, self-care activities, socialising with fellow patients were all things mentioned by interviewees. Assess suicide risk (2/28) Two nurses suggested that distress might indicate raised risk of suicide, and that risk needed to be re-evaluated and assessed when patients were upset. High arousal Many interviewees gave mixed responses under both agitation/overactivity and aggression irritability. It was therefore difficult to treat these two areas separately, and they have been merged and considered together under this single heading. Hear the patient, listen (26/28) Nurses indicated that it was a mistake to prejudge the aroused patient, or to think of them as being bad, or badly behaved. Instead the correct approach was based on the assumption that ‘something has made them feel that way, and it’s trying to discover what that something is’. So, when the person concerned may be ‘pacing’, ‘snappy’, ‘hostile’, ‘cross’, ‘looking at you in an intimidating way’, ‘shouting and hitting the walls’, ‘threatening verbally’, or ‘screaming’, the first question is ‘can you tell me what’s going on?’ This gave an opportunity for patients to ventilate and communicate their feelings, which was sometimes all that they required to recover their equanimity: ‘sometimes people just need to go blah and get it all out of their system … it gives them a chance to just spew out a bit of info and feel a little less isolated with that, they may be carrying the world's survival on their shoulders according to what their beliefs are, so that's incredibly daunting’. Many different causes for high arousal were mentioned, including ‘fear’, ‘anxiety’, ‘being bullied’, mood disorder, auditory hallucinations, ideas of reference, real failures on the part of psychiatric services and workers, conflict between patients, ‘somebody’s said something, looked at somebody in the wrong way, has taken away something that they’ve been expecting such as having a cigarette or going out for a walk or having their leave, seeing the doctor, not seeing the doctor, not being discussed where they said they were going to be discussed, family not coming up to the ward’, or ‘distressed, frightened or disturbed about what’s going on around them’. There were some cautions and provisos in relation to this recommendation to listen and find the reasons behind the high arousal level. One nurse suggested that with some patients, exploring the cause of their arousal could lead to an increase, even a sudden increase in their anger: ‘you can turn the heat up really quickly, without meaning to’. Sometimes the patient is unwilling to co-operate with this process of exploration, with one nurse recounting how a physically strong and fit martial artist paced up and down the ward muttering curses and imprecations, and rejected any attempt to speak with him by walking away, resulting in ‘total failure’. Exercise, physical activity (4/28) A few nurses indicated that physical exercise, either by allowing the patient to ‘stomp around outside’ or by gym based activities and exercise, would use up ‘their excessive energy’.

“I’ve had a client before who when he's felt the mania coming on, he's gone running, because he was a runner anyway, so he'd go and jog for three or four miles, and come back and feel a lot calmer about things.” Distract, calming activity (9/28) If a patient is becoming irritable or agitated, it can sometimes avert escalation, or even resolve the situation, if they are distracted by engagement in other activities. Nurses suggested ‘watching a movie’, ‘playing pool or table tennis’, ‘a jigsaw puzzle’, ‘listening to music’, ‘looking at the paper’, ‘walking or pacing’, cup of tea or coffee, converse about other non stressful topics such as their ‘family or job’ or recent nice events on the ward. Request lowered arousal (6/28) When a patient is becoming more irritated and agitated within the course of an interaction with staff, they might not be fully aware that they are raising their voice and starting to shout. It is possible at this point to ‘just ask them to, I am here, I am listening and I want to help you to think but actually I can't really understand what you're saying when you're shouting, you might want to sit with me or you might want to talk to me more quietly and then maybe I can think about what you're saying’. Relaxation (7/28) Simple relaxation techniques could be offered and taught to patients, including slow, deep breathing: “I've seen nurses do relaxation techniques that I would never have thought that someone that agitated would be able to manage and they have managed it so yeah, as I say I was quite surprised, I didn’t think at that level of arousal that relaxation would work but it did’. Don’t argue or confront (14/28) Becoming aggressive, raising one’s voice with all the accompanying body language, was widely reported to be counter productive. This was referred to in different ways, including being ‘threatening’, ‘inflexible’, ‘confrontational’, ‘over challenging’, ‘laying down the law’, ‘too hard’, or ‘pushy’. Relationship leverage (7/28) A pre-existing good, trusting relationship with the aroused patient can help any crisis calm down much more quickly. Nurses recounted specifically referring to and using their previous relationship with the patient who is aroused, reminding them who they are and how long they have been working together: ‘you can refer to your relationship you have with them, you can say we, I know this is something that keeps cropping up and really rubs you the wrong way, I remember we spoke about that … people are less likely to try and take a swipe at you for a start’. Give choices, empower (14/28) Once the initial complaint or issue had been thoroughly explored and defined, the interviewees spoke of the necessity to involve patients in decision-making and finding an acceptable resolution. Such resolutions could result in issues being raised with the patient’s consultant psychiatrist or other practical changes. Involving patients and giving them options gave them ‘routes out of the situation’, and meant they were not placed in ‘a psychological corner’ from which they might come out fighting. Finding compromises and solutions through negotiation meant that nurses had to be ‘flexible’ rather than rigid about ward rules, what could and could not be done. Where the high arousal was a consequence of psychiatric symptoms, it was not so easy to find ways to solve them, other than enhancing the patients own coping strategies or other interventions as explored in previous sections, whilst waiting for treatment to take effect.

“If you give them a choice at all time, they may remain very agitated but at least then it can be channelled hopefully in the most, safest way.” Explain what the rules are and the reasoning behind them (15/28) To the aroused, irritable patient, any constraints on their behaviour can elicit angry outbursts. Nurses gave examples such as asking the patient to go to bed at a reasonable hour, eat, wash, wear sufficient clothing, not expose themselves, not come into the ward office, not shout be abusive or racist, not threaten or bully others, not leave the ward, not damage the furniture and fittings, etc. Demands from patients could also be unrealistic given the workload of the ward or other constraints. The nurses stressed that it was most important to explain to patients why these boundaries existed, and to explore with patients ways that their needs and desires could be met without the rules being broken: ‘it’s just giving them reasonable boundaries but most importantly saying why you’re giving them the boundaries’. Several nurses mentioned that instructions could be given quite forcefully, without the nurse themselves leaking any anger, frustration or irritation: ‘firm but not threatening’, ‘assertive but not aggressive’. It was possible to be forceful ‘without shouting at someone who is already irritable and aggressive, and telling them what they’ve got to do, it can provoke patients’. “Honesty and empathy and if that means that you’re trying to get somebody to avoid doing something that they want to do then you have to explain that that’s what it is you’re trying to achieve for them.” Describe consequences (5/28) Nurses also stated that it was sometimes necessary to explain to patients what would happen if they continued to behave aggressively or became physically violent. These nurses suggested that patients could feel ‘out of control’ and needed the staff to show competence, confidence, and the ability to contain their behaviour. They spoke of explaining ‘consequences’, ‘repercussions’ and being a ‘little bit inflammatory, a little bit threatening’. References in the text made clear that these consequences included severe containment methods (restraint, coerced medication, seclusion). Forceful containment (16/28) In acute situations, where necessary to preserve the safety of patients and those around them, nurses spoke about manually restraining the highly aroused patient, given sedating medication (by injection if necessary), or placing the patient in seclusion. However three nurses’ recounted incidents where they had seen patients restrained too quickly, before any discussion had taken place with them about why they were angry, and objected to this, considering it to be poor practice. Debrief later (7/28) When there has been a violent incident, then at a later point, perhaps the next day, this needs to be explored and discussed with the patient concerned, ‘you need to try and let me understand what’s going on, how can we stop that from happening again’. This process involved asking the patient what had happened, to give reasons for behaving the way they did, and exploring with them what the consequences were for others and themselves, all with a view to increase the patient’s empathy, understanding, anger management skills and social skills in conflict expression. Perhaps also identifying trigger points where interventions could be made by the staff and patient together at an earlier stage, should the situation be repeated. This was also an opportunity for the staff to explain to the patient why they did what they did (for example, seclude the patient for an hour), in an attempt to prevent the patient from ‘holding any grudges’. If there has been a conflict between two patients, then a similar process can be undertaken: ‘I’ll always get them to sit down and talk to each other’. Advance directives (8/28) Outside of a crisis situation, when the patient is relatively well, not agitated, overactive, irritable or aggressive, then is the time to negotiate what to do and how to handle the situation should it recur. The patient can then choose what he or she feels is the best strategy that is most likely to succeed. One nurse gave a detailed account about how such an advance directive could be negotiated, with

the nurse utilising the patients history and case record, reminding the patient what had happened before, and tempering their suggestions into a realistic applicable plan about what should happen in the scenarios most likely to recur: ‘how do you want us to work with you in that situation … how would you want us to approach you … what happens if you say no?’ If such negotiation and planning has already been done and the patient is highly aroused now, then the advance directive should be implemented. The presence of such a planned strategy makes the situation much more predictable for the patient as well, and there ‘not quite so scary for them’, and because of that, less likely to end in a struggle of some kind.

Lessons for practice Summary of findings Analysis and reanalysis of the interviews found that the interaction techniques reported divided into seven natural domains: the moral foundations for interacting; preparation; being with the patient; nonverbal aspects; emotional regulation; getting things done; and talking about symptoms. The moral foundations incorporated a complex mix of sometimes countervailing imperatives, such as notice and do not ignore the patient, nevertheless avoid intruding and respect their privacy. Also included were values emphasising warmth, care coupled with a high degree of respect and an absence of harshness even under the most challenging circumstances. Honesty was seen as important, particularly in relation to restrictions on patients’ liberty and the quality of the service they received. Interactions were shown to commence prior to meeting the patient, as careful preparation was deemed to increase the chance of success. Such preparations included wide consultation of records and other people who knew the patient concerned, careful observation, consideration of the best time and location to initiate interaction and choosing the right nurse to make the approach. Simply being with acutely psychotic patients was shown to be a complex activity that could require a considerable number of different adjustments, approaches or interactive techniques. The basic spine of these included simply sitting with the patient or spending time with them, whilst offering light normal conversation, supplemented by the nurse introducing him or herself, focusing on the patient as a person rather than on their symptoms, using props, the local environment or what was happening on the ward as topics, and engaging in a joint activity, spiced with appropriate humour. Where the patient was apathetic and withdrawn, interviewees talked about developing a comfortable silence, or engaging in a one-sided conversation. If the patient was hallucinating, this had to be tolerated and made allowance for in the conversation, and simpler topics chosen; if thought disordered themes could be named, reminders and prompts to the topic given, clarifications sought, things kept simple or the patient could be asked to communicate through writing. For the agitated or overactive patient reducing stimulation, setting interaction limits and giving positive feedback were considered to be helpful. When patients were upset or distressed, normal conversation was generally felt to be inappropriate, similarly in some cases it was judged best to avoid patients who were currently irritable or aggressive. However in the latter case choosing a topic in which the patient was an expert was judged a wise move, whilst at the same time getting them sat down and maintaining clarity. There was a perhaps surprising quantity of new recommendations about nonverbal communication, vocabulary and the timing of interactions. A slow pace, slow speech, short sentences, simple vocabulary and repetition within and across interactions were recommended. Tone of voice should be both caring and quiet, interactions being short and frequent, with persistence shown in efforts to communicate. There were times and occasions when touch and greater use of gesticulation were judged appropriate, and times when they were not. Writing and drawing were acknowledged as useful alternative communication media. Particular care was recommended with aggressive and irritable patients, with a non-threatening nonverbal stance being required and a cautious choice of the language used.

Whilst communicating, or in order to do so effectively, nurses had to regulate their own emotional responses to what patients were doing and saying. They deemed it most important not to display any anxiety in the face of acute psychotic symptoms, patients’ psychological distress or their overt hostility and aggression. Being calm and receptive in the face of such patient behaviours was deemed more likely to reduce them – becoming anxious more likely to amplify them. Similar recommendations were given about becoming frustrated or irritable with patients uncooperativeness, lack of progress or resistance to actions which would benefit them. Finally an optimistic outlook was considered valuable and motivating for patients (as well as fellow nurses). Attempting to get things done with patients (e.g. get them to get up or go to bed, eat, drink, wash, take their medication etc.) required a whole range of additional and different interaction techniques, including making suggestions rather than ordering patients to do things, giving reasons for the task, being flexible, maximising choice, prompting, encouraging, giving positive feedback, rendering assistance, and in some circumstances being assertive and forceful. When resistance was based upon delusions, a degree of collusion was allowed by some nurses if balanced by the patient’s needs for care. For thought disorder, using gestures as a means of communicating what was to be done was considered helpful. Talking about symptoms with patients was the single largest domain in the interviews. Absolutely fundamental to all symptom areas was the need for nurses to hear what patients’ experiences were, accept them, and seek to enter and understand their effect on patients with caring and respect. This was clearly a foundation for nursing practice, and was the starting point for all other interactions about symptoms. Following this, for apathetic or withdrawn patients, it was judged helpful to mutually explore causes, agree a care plan, develop a routine and purpose, and then take a step by step approach. For hallucinating patients, stress management, distraction, bolstering coping and in some cases casting doubt or challenging the hallucinatory content were considered good approaches. Gentle questioning or direct challenge were also sometimes deemed appropriate for the deluded patient. Collusion was not recommended, however sometimes it was considered appropriate to ignore the delusions or find workarounds so that patients’ needs could be met. In the case of upset and distressed patients, interviewees talked about staying calm, keeping patients talking, persisting to find out the cause, and taking action to relieve the cause or exploring other solutions with the patient. Responses on agitation, overactivity, irritability and aggression were not clearly distinguishable and were therefore considered together. The expert nurses recommended exercise, distraction, relaxation, avoidance of confrontation, explaining the reasons for actions and rules, negotiating advance directives and forceful containment. Novel findings? This study set out to uncover any tacit or traditional knowledge amongst practicing nurses about how to communicate well with those in a state of acute psychosis. The first assessment of the results must therefore be on what or whether anything new has been discovered. How much of the material above simply repeats the content of nurse training, reflecting the zeitgeist of psychiatric nursing practice, and how much hidden expertise has been uncovered? How much is the above information novel, and how much is an elaboration of the recent knowledge history covered in the introduction? The pattern of responses and themes in the interviews does indicate that the contents are not widely known. While some techniques were present in two thirds of the interviews, many others were only present in one third or less. And those interviewed were nurses considered to be particularly expert at dealing with patients suffering from acute psychosis. This does not prove the contents are new or undocumented material. It does prove that there is likely to be a considerable number of the techniques described above which are not known by most psychiatric nurses (and therefore not utilised). The low numbers of expert nurses reporting some techniques also indicated that further interviews might yet find additional material of value. Those low numbers additionally indicated that our findings might be of significant use to nurse educators in the future. We specifically asked our interviewees not to tell us about ‘textbook communication skills’, as these were felt to be already widely known by nurses and a significant part of nurse training. These were still mentioned in passing by most nurses, supporting our assumption that they are well known and have been well assimilated into practice. However our research interest was to move beyond

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. Rogersâ&#x20AC;&#x2122; 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. Rogersâ&#x20AC;&#x2122; 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 patientâ&#x20AC;&#x2122;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 on the fact that nurses had to deliver nursing care to people who are in a very psychologically disabled condition. Information on how best to accomplish these was virtually absent from any part of the literature, yet forms a very considerable part of the findings of this study. Barriers to nurse-patient communication A wide variety of recommendations were made by our interviewees about interaction with patients, but it is legitimate to ask how compatible these are with the realities of daily life on the wards. Only half of nursing staff in face to face contact with patients receive any systematic training whatsoever (Bowers, Jones, & Simpson 2007). On many shifts there may be only one or two qualified nurses on duty (48% of all daytime shifts, unpublished data from 136 wards), accompanied by a mix of health care assistants and student nurses. The qualified nurses have to answer all phone calls to the ward, manage the visits of other disciplines, supervise the junior staff in their activities, respond to patient requests, queries and crises, and spend a significant amount of time giving out medications. Taking into account the time required for writing up nursing notes, taking handover from the previous shift and giving it to the next, this leaves precious little time for anything else, even on a well staffed shift.

Thus having uninterrupted time to sit down with a patient and respectfully listen to their experience, is at a premium. Such times are more likely to occur on night duty when demands are reduced because many patients are asleep, or at weekends because of reduced demands to service other professionals visiting the ward. Opportunities at other times are a scarce resource. The reality of interactions between patients and staff is that they tend to be brief, and conducted on the fly in the midst of other activities. This can be an asset in certain circumstances, and our interviewees did point out that joint activities were ways to develop conversation with patients, and that some patients mental state did require interactions to be short and to the point. However interactions are conducted by those with minimal or incomplete training far more frequently than with a qualified nurse – a situation that causes considerable frustration to those who have assiduously trained for three years to practice as a skilled and qualified psychiatric nurse. This is not to say that no time is ever available, nor that there are some wards and teams where the time that is available is wasted in doing nothing or staff making social conversations with each other. An efficiently managed and hardworking staff team can make the best of those opportunities which are available. And the fact that our expert nurses could talk about a wide range of techniques and skills demonstrated that they had acquired these in practice and they were feasible. The environment of the ward can also provide obstacles. If quiet privacy was the best location for meaningful conversation, then appropriate rooms had to be available. Yet many wards in outdated buildings would find such provision a challenge. And even if such rooms were available, for a nurse to go with a patient into such a room removed one person from general supervision of the ward and patients – an important task to be able to provide instant support to patients with fluctuating and unpredictable mental states, to prevent aggression, bullying, selfharm and absconding. Trying to converse within the ward day room or public areas meant that passers by could overhear what was being said, making both parties self-conscious and guarded. Meanwhile the nurse was open to being approached and interrupted by other patients with requests and demands. Another way of regarding these competing pressures is to consider the nurses’ tasks. Their first priority was to keep patients safe, and this meant keeping them on the ward when necessary, and keeping a constant supervisory eye over every patient and every area of the ward. That observation enabled them to complete the second task of assessment – monitoring the condition and behaviour of patients to inform other members of the team, enabling correct treatment and diagnosis. The third task, that of giving treatment, centres currently mainly around giving medication, involving four lengthy medication rounds each day, inlcuding persuading reluctant patients to take their medication, checking that they have been taken, answering questions and assessing for side effects, plus a lot of communications with doctors and pharmacy about medication changes, discharge medications, leave medications, etc. Lastly comes making sure that patients eat and drink sufficient for their health, have clean clothes to wear, take baths, shave, cut their nails, etc. Interaction takes place alongside these tasks, but not a great deal of time is left over for general conversation to build relationships. Structured therapeutic interactions are possibly amongst the last in a long line of priorities. It also needs to be recognised that the psychotic experience itself represents a very real barrier to effective communication. It is an alien, abnormal and private experience, thus accessing it from outside and understanding it are problematic. Cognitive processing is compromised: the patient’s concentration, memory and ability to understand are adversely affected, thus acquiring or giving information is difficult. Inpatients are frequently hostile, mistrustful and angry because of their confinement on the ward, the restrictions placed on them, close living with other people, mood changes, delusions and hallucinations; all of which pose challenges to nurses’ efforts to establish and maintain a supportive relationship. Strange, bizarre and frankly funny beliefs, talk and actions by patients mean that maintaining overt respect requires effort and delicate balancing. Lack of interest, inertia, apathy on the part of patients mean that undaunted and excess energy is required from the staff, not just once, but over and over again. Moreover, our interviews of staff grossly oversimplified the interactional challenge by considering symptoms groups separately. In the real world patients experience combinations of symptoms (e.g. thought disorder, delusions, apathy and irritability) and their experience changes over time, even during the course of a single nursing shift. Getting interaction just right for the patient, the moment and the task therefore takes great skill and artistry, and the challenge should not be underestimated. Psychotherapy and the acutely ill psychotic patient Our interviews failed to uncover any new psychotherapeutic methods. All that were mentioned were applications of already known methods, mainly client-centred therapy, solution focused therapy, and cognitive behavioural therapy. Client-centred therapy was only applied in terms of its value

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base, and was not formally embarked upon as a matter of systematically producing reductions in psychotic symptomatology. With the other two types, psychotherapy with acutely ill patients tended towards simplistic and basic applications of the most fundamental techniques. The impression given from the interviews was that these were delivered in an ad hoc and sporadic manner by individual clinicians, rather than being an overall framework within which the whole nursing team worked. This observation remains valid even though interviewees occasionally mentioned wards where, for example, hearing voices groups were held regularly. Strikingly absent was any mention of psychoanalysis or the associated idea of defence mechanisms, although these might provide a rich resource for understanding and construing patient behaviours. The nursing focus to a far greater extent was focused upon being with patients in a supportive way as a moral necessity and duty to those in psychological distress.. Beyond that, the priorities were keeping patients safe, assessing their mental state, delivering medical treatment and physical care. Communication was a vehicle to accomplish these important goals, through establishing relationships and finding ways to negotiate and manage the hurdles posed by psychotic symptoms. Psychotherapeutic strategies to directly counteract or reduce symptom were a much smaller part of the overall picture of daily nursing care. There is little in the way of evidence for the efficacy of any psychotherapy for inpatients with acute psychosis. The only studies which have been conducted are those utilising cognitive behavioural approaches, and although these have reported good results, they are insufficient in number and size for a high level of confidence in their findings. Trials with inpatients present enormous difficulties. When patients are very ill, they often do not have the capacity to give informed consent. Cooperation with therapy can be poor, and inpatient stays are relatively short. Even the implementation of psychotherapeutic ideas into the general practice of inpatient psychiatric nursing can be difficult (McCann & Bowers 2005). Nevertheless this is an important area for further development and research as, if effective applications can be found and proven, they might pay big dividends in reducing patientsâ&#x20AC;&#x2122; length of stay in hospital and separation from their normal everyday lives. Some implications What would be the outcome if all nurse-patient interaction was informed by and applied the techniques reported by this study? They would certainly seem to enhance the possibility of cooperation and collaboration between nurses and patients. If so the delivery of medication, accuracy of assessments, and physical health status of patients might all be improved. It also seems logical to conclude that aggression and violence might be reduced, either through the easier accomplishment of necessary tasks with patients, or through more effective and rapid de-escalation with irritable, agitated and aggressive patients. As the risk of suicide amongst inpatients is as much of a problem with psychotic patients as it is with those who are depressed (Bowers, Banda, & Nijman 2009) it is a possibility that better communication would reduce social isolation and hence risk. Finally it might be supposed that patients who are in receipt of such a highly skilled approach might have a greater satisfaction with the care they receive and potentially be more willing to be admitted to hospital on subsequent occasions, without the use of legal detention. Whether this broad range of benefits can actually be delivered remains a matter for further research. The contents of this book are derived from interviews with expert practicing nurses about interaction with acutely ill patients within service delivery settings. However the authors have increasingly come to recognise that what is described here could be widely useful to other professionals who have to deal with acutely mentally ill people (police, ambulance personnel, social workers, general practitioners and psychiatrists), and to family and friends of the mentally ill, many of whom have few sources of concrete advice on how to deal with the situations they face in their daily contact with people who suffer psychotic disorders. Increasing the skill set of nurses who deliver care to patients in inpatient wards will require some changes to nursing education. Pre-registration nursing education will need to move beyond the basic communication skill set which is currently taught. While the content of this still remains very valid and applicable, this research has described additional techniques and strategies which it would be valuable for every nurse to have readily available in their â&#x20AC;&#x2DC;toolboxâ&#x20AC;&#x2122; of social skills. However, in order to spend time with disturbed patients, such nurses also need to have a thoroughgoing knowledge of psychopathology and psychiatric symptoms, coupled with the best possible understanding of what it feels like to be psychotic. During training, much of which takes place in

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practice, it would be highly valuable for students to seek out patients who were able to describe this experience for them. This could usefully be supplemented by wide reading of patient accounts, patient poetry, art, etc. Health care assistants also have a great deal of contact time, but no training in communication skills at all. It could be most valuable to services and the patients they care for if some of the expert practices described here could be taught to this group of workers. Finally, we reflect as authors that in our experience, consistently applying these techniques requires the thickest of skins covering the deepest of hearts fed by the largest of passions.

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APPENDIX – The interview schedule In this interview we are particularly interested in hearing about the ways experienced staff communicate with patients during their spells of acute psychosis. We want to hear about the verbal and non verbal techniques you use (or those you have witnessed others using). We’d like to hear about the ones you think work and those that don’t (or those that sometimes do!). We don’t particularly want to hear about the textbook communication skills things like paying attention to people, giving feedback, reflecting, etc. – unless you have a particular angle or different use (or view) of such things. 1. Can you tell me a bit about your experience of looking after acutely psychotic patients? What sort of things do you like or not like about it? The following questions I am about to ask fall into seven domains. First I’m going to ask about patients who are apathetic or withdrawn, then I’m going to ask in turn about patients who are hallucinating, deluded, thought disordered, upset or distressed, agitated or overactive, and finally aggressive or irritable. Is that OK, are you clear about that?

First domain. Patients who are APATHETIC and/or WITHDRAWN 1.1 If you want to just spend some time with a patient who is very apathetic and/or withdrawn, how do you go about doing that? 1.2 How do you try to build a relationship with a patient who is very apathetic and/or withdrawn? 1.3 Do any of these things (or anything other kind of communication or conversation with them) reduce the degree of apathy/withdrawal? 1.4 What about when you need to accomplish some kind of task with a patient in this condition, say get them up in the morning, get them to have a bath, or eat something, or take their medication? 1.5 Are there any other strategies you use or have tried with apathetic and/or withdrawn patients? 1.6 Is there anything else you’ve seen others try, successfully or unsuccessfully? 1.7 Is there anything that shouldn’t be tried with people who are apathetic and/or withdrawn? 1.8 Is there anything else you can tell us about working successfully with patients who are like this? I’d like to ask you now about patients with positive symptoms – firstly about those who are hearing voices or who have other sorts of hallucinations.

Second domain. Patients who are HALLUCINATING 2.1 If you want to just spend some time with a patient who is hallucinating, how do you go about doing that? 2.2 How do you build a relationship with hallucinating patients? 2.3 Is there a way of talking with them that might reduce their hallucinations during the conversation? 2.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 2.5 Are there any other strategies you use or have tried with actively hallucinating patients? 2.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 2.7 Is there anything that shouldn’t be tried with people who are hallucinating? 2.8 Is there anything else you can tell us about working successfully with patients who are in this state? I’m now going to ask you a similar set of questions about very deluded patients.

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Third domain. Patients who are DELUDED 3.1 If you want to just spend some time with a patient who is deluded, how do you go about doing that? 3.2 How do you try to build a relationship with those patients? 3.3 Is there a way of talking with them that might reduce the extent of their delusions or their preoccupation with them? 3.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 3.5 Are there any other strategies you use or have tried with very deluded patients? 3.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 3.7 Is there anything that shouldn’t be tried with people who are deluded? 3.8 Is there anything else you can tell us about working successfully with patients who are in this state? We are about half way through the interview now.

Fourth domain. Patients who are THOUGHT DISORDERED 4.1 If you want to just spend some time with a patient who is thought disordered, how do you go about doing that? 4.2 How do you try to build a relationship with those patients? 4.3 Is there a way of talking with them that might reduce the severity of their thought disorder? 4.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 4.5 Are there any other strategies you use or have tried with very thought disordered patients? 4.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 4.7 Is there anything that shouldn’t be tried with people who are thought disordered? 4.8 Is there anything else you can tell us about working successfully with patients who are in this state? Can we talk now about agitated and/or overactive patients?

Fifth domain. Patients who are AGITATED and/or OVERACTIVE 5.1 If you want to just spend some time with a patient who is agitated and/or overactive, how do you go about doing that? 5.2 How do you try to build a relationship with those patients? 5.3 Is there any way of talking with them that reduces their agitation or overactivity? 5.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 5.5 Are there any other strategies you use or have tried with agitated and/or overactive patients? 5.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 5.7 Is there anything that shouldn’t be tried with people who are agitated and/or overactive? 5.8 Is there anything else you can tell us about working successfully with patients who are in this state?

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Sixth domain. Patients who are UPSET and/or DISTRESSED 6.1 If you want to just spend some time with a patient who is upset and/or distressed, how do you go about doing that? 6.2 How do you try to build a relationship with those patients? 6.3 Is there any way of talking with them that reduces their upset or distress? 6.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 6.5 Are there any other strategies you use or have tried with upset and/or distressed patients? 6.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 6.7 Is there anything that shouldn’t be tried with people who are upset and/or distressed? 6.8 Is there anything else you can tell us about working successfully with patients who are in this state?

Seventh domain. Patients who are IRRITABLE and/or AGGRESSIVE 7.1 If you want to just spend some time with a patient who is irritable and/or aggressive, how do you go about doing that? 7.2 How do you try to build a relationship with those patients? 7.3 Is there any way of talking with them that reduces their irritability? 7.4 How about accomplishing some kind of task with such a person, say getting them to wash, or go to bed, or eat a meal. How do you go about doing that? 7.5 Are there any other strategies you use or have tried with irritable and/or aggressive patients? 7.6 Is there anything you’ve seen others try, successfully or unsuccessfully? 7.7 Is there anything that shouldn’t be tried with people who are aggressive and/or irritable? 7.8 Is there anything else you can tell us about working successfully with patients who are in this state?

One final, last question. 8. Is there anything else you can tell us about communicating with and interacting with acutely psychotic patients? Many thanks for your time in completing this interview. That’s been really helpful

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Peplau, H. E. 1991, Interpersonal relations in nursing: A conceptual framework of reference for psychodynamic nursing. Springer, New York. Pรถrtner, M. 2002, "The pre-therapy prject at Sint-Amandus," in Pre-therapy: reaching contact-imapired clients., G. Prouty, D. Van Werde, & M. Pรถrtner, eds., PCCS Books, Ross-on-Wye, pp. 123-153. Prouty, G. 1994, Theoretical evolutions in person-centered/experiential therapy: Applications to schizophrenic and retarded psychoses Praeger, New York. Remocker, A. & Storch, E. 1977, Action speaks louder Churchill Livingstone, Edinburgh. Ritter, S. 1984, "Does the team work?", Nursing Times, vol. 80, no. 6, pp. 53-55. Ritter, S. 1985, "Primary nursing in mental illness", Nursing Mirror, vol. 160, no. 17, pp. 16-17. Rogers, A., Pilgrim, D., & Lacey, R. 1993, Experiencing Psychiatry: Users' Views of Services London: Macmillan. Rogers, C. 1961, On becoming a person. Sandford, D. A., Elzinga, R. H., & Iversen, R. 1990, "A Quantitative Study of Nursing Staff Interactions in Psychiatric Wards", Acta psychiatr.scand., vol. 81, pp. 46-51. Sanson-Fisher, R. W., Poole, A. D., & Thompson, V. 1979, "Behaviour Patterns Within a General Hospital Psychiatric Unit: An Observational Study", Behaviour Research and Therapy, vol. 17, pp. 317-332. Star Wards 2009, Talkwell. Encouraging the art of conversation on mental health wards Bright, London. Stevenson, S. 1991, "Heading Off Violence With Verbal De-Escalation", Journal of Psychosocial Nursing, vol. 29, no. 9, pp. 6-10. Tarrier, N., Barrowclough, C., Vaughn, C., Bamrah, J., Porceddu, K., & Watts, S. 1989, "The community management of schizophrenia: a controlled trial of behavioural intervention with families to reduce relapse.", British Journal of Psychiatry, vol. 153, pp. 532-542. Theodoridou, C., Bowers, L., Brennan, G., & Winship, G. 2008, "The measurement of psychotic acuity by nursing staff", Journal of Psychiatric and Mental Health Nursing, vol. 16, no. 3, pp. 234-241. Tyson, G. A., Lambert, W. G., & Beattie, L. 1995, "The Quality of Nurses' Interactions with Patients: An Observational Study", Int.J.Nurs.Stud., vol. 32, no. 1, pp. 49-58. Van Humbeeck, G., Van Audenhove, C., Pieters, G., De Hert, M., Storms, G., Vertommen, H., Peuskens, J., & Heyrman, J. 2001, "Expressed emotion in staff-patient relationships: The professional caregivers' and residents' perspectives", Social Psychiatry and Psychiatric Epidemiology, vol. 36, pp. 486-492. Van Werde, D. 2005, "Facing psychotic functioning: person centred contact work in residential psychiatric care," in Person-centred psychopathology, S. Joseph & R. Worsley, eds., PCCS Books, Ross-on-Wye, pp. 158168. Vaughn, K., Webster, D., Orahood, S., & Young, B. 1995, "Brief inpatient psychiatric treatment: finding solutions", Issues in Mental Health Nursing, vol. 16, no. 6, pp. 519-531. Whittington, D. & McLaughlin, C. 2000, "Finding time for patients: an exploration of nurses' time allocation in an acute psychiatric setting", Journal of Psychiatric and Mental Health Nursing, vol. 7, pp. 259-268. Winship, G., Repper, J., Bray, J., & Hinshelwood, R. D. 2009, "Collective biography and the legacy of Hildegard Peplau, Annie Altschul & Eileen Skellern; the origins of mental health nursing and its relevance to the current crisis in psychiatry.", Journal of Research in Nursing, vol. 14, no. 6, pp. 505-517. Wright, S. 2003, "Control and restraint techniques in the management of violence in inpatient psychiatry: A critical review", Medicine, Science and the Law, vol. 43, no. 1, pp. 31-38. Yalom, I. 1983, Inpatient group psychotherapy. Basic Books, New York.

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7. Nonviolent Communication: A Model for Social Change Adapted from Marshall Rosenberg, Ph.D. and Liv Monroe "In every moment, each of us is trying to meet our needs in the best way we know how." (Marshall Rosenberg) ---=oOo=--"Out beyond ideas of right and wrong, there is a field, I'll meet you there" (Rumi) An Introduction to Nonviolent Communication Nonviolent communication is founded on language and communication skills that strengthen our ability to remain human, even under challenging conditions. NVC guides us in reframing how we express ourselves and hear others. Instead of being habitual, automatic responses, our words becomeconscious responses based firmly on an awareness of what we are perceiving, feeling and wanting. NVC is a Language of Compassion Rather Than Domination, which helps us to resolve conflicts by focusing our consciousness on what we are observing, feeling, needing, and requesting. It leads us toward a quality of connection among people where everyoneâ&#x20AC;&#x2122;s needs are valued and get met through compassionate giving out of the joy of contributing to another human being. The potency of NVC is in its pragmatic simplicity. In any moment, there are two ways to enhanceconnection & understanding: (1) vulnerably express our own feelings & needs, or (2) empathically listen to the feelings & needs of the other. These are radically different choices than we are accustomed to experience when we are in conflict:namely, fight, submit or flee. With practice, NVC helps us navigate within ourselves to transform blame & judgment, where neither our own needs nor those of the other person are likely to be met, into a mutual awareness of human needs. Nonviolent communication uses the metaphors of giraffe and jackal to describe communication that is either life-serving - communicating to connect -, or violence provoking communication. Nonviolent communication is a model of being conscious of what one values and is courageous enough to live accordingly. The model involves the following steps: 1. Objective Observation (observation without judgment) a. Concrete actions I observe, without analysis b. When I (see, hear, remember, imagine, etc.) 2. Honest Feelings (from inside oneself) a. How I feel in relation to these actions b. "I feel" 3. Universal Needs (no reference to a specific action, place or person) a. The life energy in the form of needs, desires, wishes, or values that creates my feelings.

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b. "because I am (needing) 4. Specific, Present, Doable Requests (detailed, ideally 40 words or less) a. a. Clearly requesting that which would enrich my life and the life of my community without demanding. The concrete actions I would like to be taken. b. b. â&#x20AC;&#x153;Would you be willing toâ&#x20AC;Śâ&#x20AC;? Violence Provoking or Life-Alienating Communication At the base of all violence is a kind of thinking that attributes the cause of conflict to wrongness of others, with a corresponding inability to think in terms of vulnerabilities (what one feels, fears, yearns for, and misses). Violence comes out of fear and a belief that some people deserve certain treatment. Jackal encourages this -kind of thinking by incorporating the following into our everyday language: A. Diagnosing (instead of respecting): Judging and implying wrongness or badness of those who don't share or live up to one's values. Note that it is important to have and make value judgments, i.e., determinations of what one values. Moralistic judgments such as the following are violence provoking. 1. Name calling, fault finding, criticism, put downs, or praise 2. 2. Evaluations, interpretations, analysis, diagnoses, labels (classifications . keep one from seeing the humanness and individualness in others) 3. 3. Concept of deserve (certain actions or people deserve punishment, others deserve reward, e.g. merit recognition) 4. 4. Any shame inducing language or behaviour. B. Denying Responsibility (instead of taking responsibility): Blaming others or attributing the cause of one's own actions and feelings to external causes. 1. 1. Blaming others for how one feels, rather than recognizing that feelings are caused by whether or not one's needs are being met, for example: a. a. Saying, "you made me mad," to someone who arrived late. b. b. Believing that someone "hurt you" when they forgot your birthday. 2. 2. Obscuring choice by using words that blame others for one's actions. a. a. Dictates of authority ("I lied because the boss told me to.") b. b. Other's actions ("I hit my child because he ran in the street.") c. c. Vague forces ("I cleaned my room because I had to.") d. d. A diagnosis ("I drink because I am an alcoholic.") e. e. Group pressure ("I smoke because all my friends do.") f. f. Rules, laws, policies, regulations ("I have to suspend you for this infraction because it's the school policy.") g. g. Social or sex roles ("I can't throw a ball because I'm a girl.") h. h. Uncontrollable impulses ("An urge to eat overcame me.") 3. Any guilt inducing language or behaviour.

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C. Demanding (instead of requesting): Attempting to control others by threatening, bossing, manipulating, or shaming. If the denial of a "request" results in punitive action, the request was really a demand. When a person perceives a demand the only choices they know are to submit or to rebel. Demands include the following violence provoking language. 1. 1. Words like: have to, must, should, had better 2. 2. Threats of punishment or blame (punishment extracts a high price) 3. 3. Promise of reward or praise (reward is dehumanizing) 4. 4. Any fear inducing language or behaviour. “Judgments & violence are tragic expressions of unmet needs.” (Marshall Rosenberg) “To observe without evaluation is the highest form of human intelligence.” (J. Krishnamurti) Thinking & Language that Alienate Us from One Another - Diagnoses, judgments, labels, analysis, criticism, comparisons, etc. - Deserve thinking (i.e. that certain behaviours merit punishment or rewards) - Demands (denial of other person’s choice; intention to punish those who don’t do it) - Denial of choice or responsibility (had to, should, supposed to, they made me do it, etc.) Purpose of NVC - To inspire compassionate, heartfelt connection so that all needs may be valued - To connect to the life in ourselves and others - To be inspired and to inspire others to give from the heart Background of NVC - Developed by Marshall Rosenberg during the Civil Rights era; influenced by Carl Rogers - Centre for Nonviolent Communication: web: www.cnvc.org, email: cnvc@cnvc.org, - phone: 1-818-957-9393 What NVC is not … - NVC is not about being nice; it's about being real. It's not about stifling intensity, but transforming it. - NVC is not about changing other people or getting them to do what we want. It's about creating connection & understanding. - NVC is not a technique or formula. It's a process that helps guide our consciousness to a new awareness. 4 Components of an NVC Expression 1. OBSERVATION “When I see/hear/notice…” (free of judgments, labels, diagnoses, opinions, etc.) 2. FEELING (free of thoughts) “… I feel …” Examples of feelings when needs ARE met: Affectionate Confident Engaged Excited Exhilarated Grateful Inspired Hopeful Exuberant Joyful Calm Refreshed

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Examples of feelings when needs are NOT met: Annoyed Angry Disgusted Uneasy Detached Tense Embarrassed Tired Sad Vulnerable Scared Pain 3. NEED (universal human needs free of strategies) “… because I need/value …” Examples: Beauty Autonomy Empathy Mourning Honesty Love Meaning Safety Respect Community Contribution Mutuality Authenticity Transparency Acceptance To be valued Play Support 4. REQUEST (free of demands) “Would you be willing to …?” 2 Ways of Moving Toward Connection 1. Honestly express your own feelings & needs - Ongoing awareness of feelings & connected needs in present moment - Willingness & courage to express those feelings & needs (vulnerability) Example: “When I see you read the newspaper while I’m talking, I feel frustrated because I’m wanting to be heard. Would you be willing to close the newspaper for 5 minutes and hear my idea?” 2. Empathically listen to other’s feelings & needs - Qualities of empathic listening: presence, focus, space, caring, verbal reflection of feelings & needs - NOT advising, fixing, consoling, story-telling, sympathizing, analyzing, explaining, … - No matter what is said, hear only feelings, needs, observations & requests Example: Are you feeling … because you need …? The “4 Ears”: How We Choose to Hear Difficult Messages EXAMPLE #1 Person A: How dare you walk out of the room when I’m talking! You inconsiderate S.O.B.! You just can’t stand to hear the truth. 1. Person B (blaming A): Me the S.O.B. … how about you! You’re the one who started all this in the first place. You are so self-righteous telling me I’m inconsiderate. You’ve never thought about another human being besides yourself! 2. Person B (blaming himself): Oh, I’m sorry. I didn’t mean to be disrespectful. It’s just that I don’t know what to do. I never know what to do, or what to say. I feel so worthless! 3. Person B (sensing his own feelings/needs): When I hear you say that, I feel hurt because I’m needing respect and to be seen for who I am. And I really need some space because I’m in a lot of pain right now… Would you be willing to tell me what you heard me just say? 4. Person B (sensing A’s feelings/needs): Are you feeling angry and wanting respect and to be heard? EXAMPLE #2 [Mother has a 1-1/2 hour coffee with a friend… her first time away from the children in 3 days.] 6-Year-Old: Mama I don’t want you to go! What could be more important than being with me?! (tugging at her leg, crying loudly) 1. M (blaming child): Let go of my leg! Be quiet! You’ve got no reason to cry … I’ve been with you all day. You always make this so hard! When all I want to do is have a few minutes to myself!

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2. M (blaming herself): Oh, my gosh, I’ve really upset you! Why do I always do this?! … Why am I so selfish? … I’m such an awful mother. 3. M (sensing her own feelings/needs): Honey, I’m really feeling exhausted and needing to just have some personal time to connect with my good friend, Betty. Would you be willing to let Mary (the babysitter) hold you? … 4. M (sensing her child’s feelings/needs): Are you feeling sad and wanting to be held? … Are you feeling hurt and needing to know that you are precious and loved? … 4 Ears: 1. Blaming others (attacking) 2. Blaming ourselves (submitting) 3. Sensing our own feelings & needs 4. Sensing others’ feelings & needs Blaming is the realm of the jackal. The jackal part of us sees the only choices as fight, submit or flee. More than likely, the jackal doesn’t even see choices, but responds in a habitual or automatic manner. We are each responsible for how we hear what other people are saying. Connection is the realm of the giraffe. The giraffe part of us knows that there are two ways to connect in any moment: to sense our own feelings & needs, or to sense the feelings & needs of the other person. The giraffe is also keenly aware of the choices she is making in every moment. It’s About Awareness not Content by Gregg Kendrick, Certified Trainer Learning NVC involves a different kind of "understanding" or "learning" … very little learning from the head or making sense of concepts … more learning from the heart, learning with my whole being, expanding my awareness … it's not a linear progression, but spiraling more deeply & more expansively. This kind of learning does not happen very meaningfully by talking or reading about NVC. It happens most powerfully when we seek to connect with one another and with ourselves … when we engage in and witness the experience of NVC. The learning happens in the struggle and the longing to connect. I am often more empowered to engage in NVC when I remember that it is not about getting it right, but about moving toward the connection that I want (what Marshall calls "growing progressively less stupid"). Amidst these experiences, each one of us is learning what we are ready for. In the same exercise or experience, we may each be learning something very different. I find that I am nearly always surprised. If I am willing to share my experiences, I often notice that my own learning seems to deepen as it is received by the other person or people that I am with. Creating The Internal Space That Nurtures Learning And Connecting I have found that my learning of NVC happens more fully when I create a place in myself that supports that learning: - a place of spaciousness … we're discovering what's already there, not putting more stuff in - a place of awareness of self in this moment … noticing my thoughts … my body sensations … my feelings … my intentions … my needs … my choices - a place of openness … finding where I am tense or distracted, and “letting go” to a place of being alert, yet relaxed … not doing, but being - a place of choice … where there is no “have to”, no “should”, no “supposed to” … there are only choices

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Some strategies that may enhance your learning : - Think back why you continued reading this document until here. Remember these intentions often and take responsibility for their fulfilment. - Pause often to notice what is going on within you … connect to your own feelings & needs - Express your needs and ask for what would fulfil them. - When another person is speaking, focus on their feelings & needs. - When another person is speaking, pause or check in to see if they are complete before expressing what is wrong, remembering that each of us are trying to get our needs met in the best way we know how - … only you are responsible for your intentions, your feelings, your needs, your choices … … only I am responsible for my intentions, my feelings, my needs, my choices … Creating The Community Space That Nurtures Learning And Connecting We are each co-creating and contributing to the quality of the community space that holds us, whether we are conscious of it or not. What my intention is, where I focus my attention, and the choices I make … each of these becomes a part of the texture of the space. In my experience, certain qualities in that space support connection and learning among us: - a space of remembering our common intention for coming together … to connect with one another … to learn and grow in our understanding of that connection and in the process of NVC that takes us toward it - a space of inclusiveness … where each person is invited and given the space to be heard … where your needs matter as much as my own • a space of authenticity … where I vulnerably express my own feelings & needs as best I can - a space of empathy … where I strive to hear feelings and needs no matter what is being said … where I give each person plenty of space until that person has been fully heard - a space of conscious choice … where I strive to hold our common intention, the needs of each person, and my own needs as I choose how to best meet these needs … where I honor the choices of those around me - a space of compassion … where there are no judgments, no right or wrong, no demands, no punishments or rewards … only people trying to get their needs met in the best way they know how stirred up in you. - Remember: we are all doing the best that we can Some strategies that may enhance your learning : - Get empathy. Empathy is the fuel we need to connect. - Find an empathy buddy & meet at least weekly. - Participate in an NVC practice group. - Meet with an experienced mentor who can nurture your growth - Participate in a 7-day or 9-day NVC immersion training - Strive to live NVC throughout your life: at home, in your workplace, in the organizations in which you participate - Pause often to notice what is going on within you … connect to your own feelings & needs - Meditate on needs • Love your jackal … he has many gifts for you Observation Cues: - “When I see …” - “When I hear …” - “When I recall seeing/hearing …”

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- “When I imagine seeing/hearing …” Examples: “When I see you reading the newspaper …” “When I hear you say, ‘I’ll never amount to anything,’ …” “When I remember seeing you hit the table with your fist, …” Observation Check: - Is my observation free of evaluation? - Can my observation be recorded by the lens of a movie camera or the mike of a tape recorder? - Does my observation contain words such as “always,” “never,” “whenever,” “constantly,” etc.? … am I using these words factually or evaluatively? Taking Responsibility for our Feelings We take responsibility for our own feelings by connecting them to the need within us that is either being met or not met. For example, "I am disappointed because I would like companionship." Contrast this expression to the more common way we often blame others for our feelings: "You never want to spend time with me … why are you so selfish." When we blame others for our feelings we tend to stimulate feelings of guilt in the other person. If we express our needs we have a better chance of getting them met. Need vs. Request Need: Universal human quality without reference to place, person or time Request: A specific strategy to meet a need that usually involves a particular person doing something at a particular time EXAMPLE I have a need for companionship. I can imagine that need being met by making a particular request of you: "Would you be willing to meet with me at 2pm today at Williams Restaurant for a cup of coffee and conversation?" If you say "No," then I may try other dates or times or places with you that might work. Or I may ask someone else to meet me. For every need, there are an enormous (i.e. infinite) range of possible strategies that could meet that need. Self-full vs. Selfish vs. Selfless Selfish: I only value my own needs Selfless: I only value others' needs Self-full: I value my own needs and others' needs equally The Path to Emotional Liberation Stage 1, Emotional slavery: We believe we are responsible for the feelings of others. Stage 2, Obnoxious: We no longer want to be responsible for the feelings of others … and often express it with anger Stage 3, Emotional liberation: We accept responsibility for our own intentions & actions, but not the feelings of others. We respond to the needs of others only out of compassion & a desire to contribute, never guilt, fear or shame. Requests Versus Demands By Gregg Kendrick, Certified Trainer

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Only after a connection has happened between people (i.e. a mutual understanding of each person's feelings & needs) do we seek to find solutions. ("Connection FIRST, then solutions") We are more likely to get our needs met when (1) we are conscious of our needs and (2) we explicitly make a request that may fulfill our needs. ("Ask for what you need.") REQUESTS vs. DEMANDS In making a request, we honor a "NO" as much as a "YES." For example, are we willing to try to understand what a person is saying "YES" to while they are saying "NO" to us? Do we value the other's needs in that moment as much as our own? Example: You: “I’d really like to understand your needs so we can work this problem out. Would you be willing to talk about it right now for 5 minutes? Mary: “I don’t want to talk now.” You: “Are you exhausted and want to get some rest?” Mary: “No, I just want to sit here & be left alone.” You: “So you want to just be with yourself right now?” Mary: “Yeah, just leave me alone.” You: “I want to trust that we’ll work this out soon … would you be willing to talk this afternoon after lunch?” Mary: “Maybe so, but not now.” You: “OK … I’ll check with you after lunch.” Request Cues “Would you be willing to …?” Request Check Requests are clear, positive, and immediately "do-able". They offer a tangible solution to meeting needs in the moment. Examples: Clear: “Would you meet me for coffee at 3:30 tomorrow at the Downtown Coffee Shop?” Vague: “Would you have a conversation with me sometime?” Positive: “Would you be willing to explore with me what needs of yours are met by smoking?” Negative: “Would you stop smoking?” Do-able: “Would you be willing to tell me what you just heard me say?” Not do-able: “Would you listen to me?” Connecting Requests - Did the person hear what you wanted to communicate?: "Would you be willing to tell me what you just heard me say…?" - What's going on in the other person after hearing what you said?: "Would you be willing to tell me how you feel after hearing what I said …?"

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Giving And Receiving Gratitude By Gregg Kendrick, Certified Trainer Gratitude or appreciation is recognizing when a person has contributed to our life or to the lives of others. Expressing Gratitude In NVC, we express gratitude in 3 parts: 1. What specifically did the other person do that enriched your life? 2. How do you feel now as you recall what they did? 3. What need of yours was met by what they did? Note that these three parts are simply the first three parts of any NVC expression: observation, feeling, need Example: "When I remember you asking if I could use some help this morning, I feel grateful because I value mutual support among our team." Receiving Appreciation In NVC, I receive appreciation joyfully, even with awe, as I hold in my awareness this power that flows through me to enrich life for others. It is often hard to receive appreciation fully because it is hard to recognize this beauty & power within us. This is a very different experience than the way we often respond to compliments, through false humility or a feeling of superiority. False humility: denies the importance of the appreciation; e.g. "It was nothing." Feeling of superiority: Thinking "I am better than others because I received the appreciation or compliment.” Appreciation vs. Compliments Appreciation: what's alive in ourselves (feelings & needs met) stimulated by the other person's actions Compliment: a positive judgment of the other person e.g. "You're really great!" "Good job!" "You are a kind person." Compliments, though positive, are still judgments of other people. They are often used to manipulate the behaviour of others. “…the more you become a connoisseur of gratitude, the less you are a victim of resentment, depression, and despair. Gratitude will act as an elixir that will gradually dissolve the hard shell of your ego — your need to possess and control — and transform you into a generous being. The sense of gratitude produces true spiritual alchemy, makes us magnanimous — large souled.” (Sam Keen) Hunger for Appreciation We tend to notice & express what's wrong rather than what's right. We are all hungry for our intentions to enrich the lives of others to be recognized. Exercise: "What appreciation might someone give you that would leave you jumping for joy?"

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Everyone has choice and is responsible for their own actions, words, thoughts, attitudes, beliefs, and even the feelings their thinking causes. 1. No one can make another person do anything. 2. No one can make another person happy, sad, angry, or hurt. 3. No one can cause another person's response. We are not responsible for what happens to us, but we are responsible for our response to it. 4. We can't change other people but we can change how we respond to them.

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3-Ds of Jackal

- 3-Rs of Giraffe

Jackal is about DESERVING.

Giraffe is about REMEMBERING

Who deserves punishment or reward?

We are all interconnected though unique.

Who or what is right or wrong?

People enjoy most, enriching life.

Jackal is for CORRECTING.

Giraffe is for CONNECTING.

Diagnosing:

Respecting others and self,

judging others or self as good or bad, right or

knowing we all are acting to meet our needs

wrong; categorizing; analyzing; criticizing; Inducing Shame

Denying Responsibility:

Taking Responsibility

blaming others, including use of language that

for our own actions, beliefs, feelings, and

obscures choice, such as "I had toâ&#x20AC;Ś";

thoughts

Inducing Guilt

Demanding

Requesting

as though there is one right way, threatening or

and accepting "yes" or "no" as the answer,

punishing those who don't follow one's desires

as a gift

Inducing Fear

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NONVIOLENT COMMUNICATION Jackal language (1) versus Giraffe language (2) 1. Clearly expressing how I am without blaming or criticizing 2. Empathically receiving how you are without hearing blame or criticism OBSERVATIONS 1.1. What I observe (see, hear, remember, imagine, free from my evaluations) that does or does not contribute to my well-being: "When I (see, hear) . . . " 1.2. What you observe (see, hear, remember, imagine, free from my evaluations) that does or does not contribute to your well-being: "When you see/hear . . . " (Sometimes dropped when offering empathy) FEELINGS 2.1. How I feel (emotion or sensation rather than thought) in relation to what I observe: "I feel . . . " 2.2. How you feel (emotion or sensation rather than thought) in relation to what you observe: "You feel . . . " NEEDS 3.1. What I need or value (rather than a preference, or a specific action) that causes my feelings: " . . . because I need/value. . . " Clearly requesting that which would enrich my life without demanding 3.2. What you need or value (rather than a preference, or a specific action) that causes your feelings: " . . . because you need/value. . . " Empathically receiving that which would enrich your life without hearing any demand REQUESTS 4.1. The concrete actions I would like taken: "Would you be willing to . . . " 4.2. The concrete actions you would like taken: "Would you like to . . . " (Sometimes dropped with offering empathy)

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Enriching Feeling Literacy

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Feelings Mixed with Evaluations

"Victim Verbs" abandoned

intimidated

smothered

abused

isolated

stupid

accepted

invalidated

threatened

attacked

invisible

trampled

blamed

left out

tricked

betrayed

let down

unheard

caged

manipulated

unimportant

cheated

misunderstood

unseen

cornered

neglected

untrusted

criticized

overpowered

unwanted

distrusted

overworked

dumped on

patronized

hassled

pressured

ignored

put down

inadequate

rejected

insulted

Non Feeling Expressions Feelings are not likely expressed after the following phrases: I feel like...

I feel that...

I feel it...

I feel as if...

I feel you, he, she,

I feel I, they, we...

Thoughts, evaluations, judgments, and criticisms usually follow these phrases.

Feelings inventory A = feelings likely to be experienced when our needs are being fulfilled B = feelings likely to be experienced when our needs are not being fulfilled

A absorbed

astonished

concerned

elated

expectant

adventurous

blissful

confident

electrified

exultant

affectionate

breathless

contented

encouraged

fascinated

alert

buoyant

cool

energetic

free

alive

calm

curious

engrossed

friendly

amazed

carefree

dazzled

enlivened

fulfilled

amused

cheerful

delighted

enthusiastic

gay

animated

comfortable

eager

excited

glad

appreciative

complacent

ecstatic

exhilarated

gleeful

aroused

composed

effervescent

expansive

glorious

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glowing

interested

moved

relieved

touched

good-humored

intrigued

optimistic

satisfied

tranquil

grateful

invigorated

overjoyed

secure

trusting

gratified

involved

overwhelmed

sensitive

warm

groovy

joyous-joyful

peaceful

spellbound

wide-awake

happy

jubilant

pleasant

splendid

wonderful

helpful

keyed-up

proud

stimulated

zestful

hopeful

loving

quiet

surprised

inquisitive

mellow

radiant

tender

inspired

merry

rapturous

thankful

intense

mirthful

refreshed

thrilled

B afraid

despairing

gloomy

miserable

terrified

aggravated

despondent

guilty

mopey

tired

agitated

detached

heavy

nervous

troubled

alarmed

disappointed

helpless

nettled

uncomfortable

aloof

discouraged

hesitant

overwhelmed

unconcerned

angry

disgruntled

horrified

passive

uneasy

anguished

disgusted

horrible

perplexed

unglued

annoyed

disheartened

hostile

pessimistic

unhappy

anxious

dismayed

hot

puzzled

unnerved

apathetic

displeased

humdrum

rancorous

unsteady

apprehensive

disquieted

hurt

reluctant

upset

aroused

distressed

impatient

repelled

uptight

averse

disturbed

indifferent

resentful

vexed

beat

downcast

inert

restless

weary

bitter

downhearted

intense

scared

withdrawn

blah

dull

irate

sensitive

woeful

blue

edgy

irked

shaky

worried

bored

embarrassed

irritated

shocked

wretched

breathless

embittered

jealous

skeptical

animosity

broken hearted

exasperated

jittery

sleepy

dislike

chagrined

exhausted

keyed-up

sorrowful

dread

cold

fatigued

lazy

sorry

grief

concerned

fearful

lethargic

sour

hate

confused

fidgety

listless

spiritless

lassitude

cool

forlorn

lonely

startled

cross

frightened

mad

surprised

dejected

frustrated

mean

suspicious

depressed

furious

melancholic

tepid

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Needs Inventory Autonomy

Self Expression

being "seen"

creativity

choice (to choose one's dreams, gods, values)

goals to generate, to create

choice (to choose one's plan for fulfilling one's

growth

dreams, goals, values)

healing

individuality

mastery

self-empowerment

meaning

solitude

production (to be causal) teaching

Celebration

Social Emotional (Interdependence)

aliveness celebrate the creation of life and dreams fulfilled

acceptance

celebrate the losses: loved ones, dreams, etc.

acknowledge

(mourning)

affection

communion

appreciation

humor

being heard

play,

being liked

pleasure, delight

closeness

ritualizing the sacred

communication serving

Integrity

community

authenticity

companionship

giraffe honesty

connection

meaning

consideration

purpose

contribution

values

contribution to the enrichment of life

vision/dreams

empathy support

Mental

emotional freedom

awareness

emotional safety

clarity

giving

consciousness

intimacy

discrimination

love

information

oneness

reflection

reassurance

stimulation

recognition

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thinking

relaxation

understanding (to comprehend)

reliability understanding

Nurturance

respect

air bonding

Spiritual Energy

exercise

aesthetics

food

beauty

movement

being, beingness

protection from life-threatening forms of life

grace

(viruses, bacteria, insects, predatory animals)

harmony

rest

inspiration

sexual expression

order

shelter

peace

EXPRESSING IN GIRAFFE When I (hear, see, remember, imagine,) …. I feel … Because I (want, need) …. And would you be willing ….. ?

RECEIVING IN GIRAFFE When you (hear, see, remember, imagine) ….. Are you feeling …. Because you are (wanting, needing,) ….. And right now would you like …. ?

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HUMAN NEEDS

• Life and Contribution o Power to serve life: to make life wonderful for others and self o Ability to do what is necessary to live: to control one's own life, mastery, capability, and competence o Physical need for safety, nurturance, and nourishment: air, balance, caring, comfort, exercise, food, harmony, movement, physical affection, procreation, protection (including from viruses, bacteria, insects, and predatory animals), shelter, rest, tenderness, touch, and water

• Autonomy and Choice o Freedom to choose: ones own actions, dreams, feelings, goals, plans, thoughts, values, and visions and to honor this freedom for others o Self expression: authenticity, creativity, growth, healing, identity, individuality, integrity, teaming, meaning, production, and solitude o Mental need for knowing and understanding: awareness, clarity, comprehension, consciousness, discrimination, honesty, information, making meaning, reflection, stimulation, thinking, and truth

• Connection and Interdependence o Love and belonging: to love and to be loved, mutual caring and sharing o Give and get relationship with others: affection, being heard and seen, bonding, closeness, companionship, communication, community, consideration, empathy, fairness, friendship, inclusion, intimacy, interconnection, justice, openness, support, and warmth o Emotional need for compassion and being compassionate: acceptance, acknowledgment, appreciation, emotional safety and healing, nurturance, reassurance, reliability, respect, sexual expression, tolerance, trust, and understanding

• Joy and Celebration o Fun and enjoyment of the aliveness in each of us: aesthetics, beauty, delight, grace, harmony, humor, inspiration, laughter, mourning, order, play, pleasure, ritual, and vibrancy o Celebration of one's integrity: of one's wholeness, of all the parts that make up oneself, and of being an essential part of a larger whole o Spiritual need for oneness with all beings: passion, peace, love, purpose beyond self, meaning for life, and unity

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Template for writing public policy letters 1. Objective Observations Write your observations of what your issue is, what other people (this may include research reports) are saying about the issue, without analyzing and without judgment. Inform your reader as clearly and precisely as possible as to what the issue is, without interpretation or analysis

2. Feelings and Needs Divide into triads. Read your description of your issue to two other people. Obtain any feedback about clarifying your observations so that they are free of interpretations and analysis. Ask your two partners to "guess" what you might be feeling and needing in relation to the issue: " Are you feeling ______ because you are needing ______?" Even if they are wrong in their guess, they will help you clarify what you are feeling and needing. Spend about 5 minutes per person on clarifying feelings and needs. Refer to appendices if necessary.

3. Requests In triads, try to formulate clear, specific doable requests of the person you are writing to - the more succinct these requests are, the better! Acknowledge that you understand the organizational network the person is embedded in and that your request is made cognizant of this. You may also request a written response by a given deadline, to make sure you can conclude your work within the planned timeframe. A valuable request might be: asking to consider a specific alternative plan or proposal.

4. Expressing Appreciation On your own time, as you work on the draft of your letter, experiment with a closing paragraph based on expressing appreciation for how the person you are writing to is already doing something to enrich your life or the life of your community. Rosenberg's model of expressing appreciation involves: a. The actions that have contributed to our well-being b. The particular needs of ours that have been fulfilled c. The pleasureful feelings engendered by the fulfilment of those needs In writing these letters, you have the ability to write, rewrite and edit to make your writing really clear and focused. You should write your letter in a narrative flow in which the sequence of observations, feelings, needs and requests are embedded. Speaking NVC is even more challenging, as it requires being very aware of how one responds in the moment. The power of the model is from communicating observations, feelings, needs and requests as a coordinated flow of communication consistently in both expressing and empathically receiving communication.

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8. Empathy in Risk Communication by Peter M. Sandman - with an Afterword by Jody Lanard

Everybody agrees that empathy is crucial to risk communication. Vincent Covello, for example, argues that caring/empathy accounts for fifty percent of trust; the other fifty percent, he says, is shared about equally by dedication/commitment, honesty/openness, and competence/expertise. He often quotes an old saying to the effect that people (especially people who are upset) don’t care what you know until they know that you care. So if you do care, showing you care is obviously crucial. What isn’t so obvious is how to show you care, how to express your empathy. Advice from a risk communication consultant to “be empathic” or “show you care” is of limited value without specifics about how. Too often it leaves clients thinking they’re supposed to check off some kind of empathy box – say something like “we are all so sorry for your loss” or “we don’t blame you for being upset” and then move on to the topic at hand. Or it just leaves clients rightly wondering what exactly they are supposed to do. Nor is the consultant’s advice to “just use your intuition” very helpful (or very empathic). Our intuition about empathy is often wrong. We need guidelines. And the guidelines can be profoundly counterintuitive. When a stakeholder is recounting how upset he or she is about something your company has done or plans to do, it might be tempting to murmur sympathetically, “I know how you feel.” That sounds like it should be an empathic thing to say. Yet every risk communication practitioner soon discovers that it doesn’t feel the least bit empathic to the recipient. The invariable response is an angry, “No you don’t!” Paradoxically, “I can’t imagine how that must feel” makes people feel more understood than “I know how you feel.” Clearly there must be more to expressing empathy than just telling others you feel their pain. It turns out people are often very proprietary about their pain. They don’t take well to strangers who claim to feel it. It’s theirs! And yet they don’t take well to strangers who seem oblivious to their pain either, or who deny that they’re feeling it, or who tell them they shouldn’t be feeling it. For example when there’s a terrorist attack, an infectious disease outbreak, or some other crisis, officials sometimes think the empathic thing to do is to reassure the frightened public. “We have the situation under control,” they may announce (whether it’s true or not). “There is no cause for alarm.” But experienced crisis managers know that this sort of empty reassurance isn’t reassuring. Instead of making people feel understood, supported, and cared for, it makes them feel abandoned, alone with their fear. “The situation looks pretty bleak right now” is actually a more empathic piece of crisis communication than “everything is under control.” Of course you don’t just say the situation looks bleak and stop there. You tell people what you’re doing to protect them, what they can do to protect themselves, how much you hope things will improve, etc. But starting with a worried acknowledgment of how bad the situation looks so far is a huge empathic improvement over starting with a cheery expression of overconfidence and a false claim that there’s nothing to worry about. Even if there really isn’t much to worry about, and your goal is to help people calm down rather than gear up for the emergency, it’s still essential to empathize with their concern, not to trash it. But “I know how unnecessarily upset you are” isn’t the way! The dilemma of empathic communication, in other words, is finding a middle path between two mistakes: being oblivious to your stakeholders’ feelings and intruding on your stakeholders’ feelings. Much of what has been written about empathy focuses on not being oblivious, so novice risk communicators are likely to think obliviousness is the only problem. They’re likely to suppose that the vague admonition to “Be empathic!” means they should keep pointing out what their stakeholders are feeling (“You’re upset”), that they know what their stakeholders are feeling (“I can tell you’re upset”), and that they appreciate how their stakeholders came to feel that way (“I understand why you’re so upset”). There are worse ways of intruding (“You’re stupid to be upset,” for example) – but this is still intruding … and it thus falls short of the empathic ideal.

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So before you go any further in this article, please reconsider your anchoring frame, your mental model of what “being empathic” means. It’s not enough to pay attention to stakeholder feelings. It’s not enough to show we’re paying attention. We have to find ways to do it respectfully and gently. The Essence of Empathy: Sort-of Acknowledgment The essence of empathic risk communication is understanding what your stakeholders are feeling, and then finding a way to sort-of acknowledge what they’re feeling – without trespassing on their emotional property. I wrote “sort-of acknowledge” instead of just “acknowledge” because you’re dealing with emotional dynamite here. Your acknowledgments have to be gentle, unintrusive. In fact, your acknowledgments may have to be deniable, especially by your stakeholders themselves. People who show you how they feel may really want you to show them that you get it (that you “get them”) – and still need to deny their feelings. For instance, people who are frightened may not want to admit it, and therefore may not want you to notice it too overtly. It isn’t kind, or wise, or empathic to push your stakeholders to acknowledge the feelings you’re sort-of acknowledging, or even to acknowledge your sort-of acknowledgments. Empathic risk communication, in other words, aims to get your stakeholders’ feelings “into the room” without making your stakeholders feel exposed or pinned down. You find a way to signal what you think they might be feeling, and to validate that it’s a pretty understandable way to feel. If you’re reading them right, they will feel more understood, better able to bear their feelings, and thus better able to cope with the situation. They may or may not tell you you’re right. They may even tell you you’re wrong, and insist that you back off – which of course you should do. If you were reading them right in the first place, they will nonetheless feel more understood, better able to bear their feelings, and thus better able to cope with the situation. All this is symmetrical. The relationship itself may not be symmetrical. You may be Goliath to their David, the embodiment of a powerful multinational corporation graciously consenting to listen to their concerns; or you may be David to their Goliath, a lowly corporate supplicant desperately seeking access to their community and a “social license to operate.” (You may be one of these in your mind and the other in theirs.) Either way, empathy is symmetrical. If your stakeholders understand you better, and find ways to sort-of acknowledge what’s going on for you, that too will improve the interaction.

What is it, exactly, that needs to be sort-of acknowledged? How your stakeholders feel about the situation – their feelings of anger, fear, unfairness, betrayal, etc. This includes not just the emotions themselves, but also the judgments that intermix with those emotions – their belief that X happened or Y is going to happen, that X was a calamity or Y will be an injustice. It also includes what they wish would happen or fear might happen. How your stakeholders feel about you – mistrust, for example, or dislike, or envy. Once again, this includes judgments as well as emotions – their belief that you did X or you’re going to do Y. Who your stakeholders imagine you are (both in your role and as a person), and how they imagine you feel about the situation and about them – their sense that you don’t like them or don’t trust them; their sense that you’re a callous corporate lackey, an east coast elitist, or whatever they think you are. Some of what you’re sort-of acknowledging is objectively true. Maybe the situation really is unfair, or you really have acted in an untrustworthy way, or you really are an east coast elitist. Some of it is partly true. Some of it is neither true nor false; it’s a matter of opinion, more about values than facts. And some of it is flat-out mistaken. You can’t sort-of acknowledge that you’re an east coast elitist if you’re actually a Midwestern populist; empathy doesn’t mean agreeing with falsehoods. But you can still sort-of acknowledge that it looks that way to them (or if that’s too intrusive, that it might look that way to some people). And you can still sort-of acknowledge the things you have been doing, or have been accused of doing, that might give that impression.

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Importantly, some of what you’re sort-of acknowledging is projection. If I’m angry at you, and not comfortable admitting it even to myself, I may project it instead, and thus imagine that you’re angry at me. (And I may try to get you angry at me; projections are often self-fulfilling.) Or if I wish you’d just go away even though I know we have to complete our business together first, I may imagine that you’re trying to get away before our business is done. Or if I’m afraid I’ll say something stupid, I may imagine you’re thinking I’m stupid. I am projecting my feelings, wishes, or fears onto you. So your sort-of acknowledgments may have to be multi-level. You need to sort-of acknowledge the projections, and also what might underlie the projections. Take the first example. Assume a stakeholder is angry at you and is projecting the anger, imagining that you’re angry at him or her. (Let’s also assume the stakeholder is wrong in this case, although as a rule when stakeholders are angry at you it’s a good bet you’re probably angry back.) To sort-of acknowledge the projection, you might say something like this: “I wonder if I sound angry. I think I may be coming across as angry.” To sort-of acknowledge what underlies the projection, you might say something like this: “A lot of people might get pretty angry about what our company has been doing. I think if I lived in this neighborhood I might feel pretty angry right now.” Here’s what you don’t say: “I have figured you out. You’re angry at me, and that’s making you think I’m angry at you.” You don’t say that partly because you might be wrong, but mostly because even if you’re right it’s far too intrusive a thing to say so overtly. This all sounds pretty shrinky. It is pretty shrinky. The best guidance I know about how to do empathic risk communication comes from Leston Havens, a Harvard psychiatry professor. His 1986 book Making Contact: Uses of Language in Psychotherapy was written to help psychotherapists communicate empathically with their patients. But it’s as close as you’re going to come to a bible on empathic stakeholder relations. Although I have met Les only a handful of times, my wife and colleague Jody Lanard did a psychiatry residency under his leadership at Cambridge Hospital. What follows is in large measure Sandman’s take on Lanard’s take on Havens’s genius.

Two warnings about this column, before I delve more deeply into empathic risk communication: Don’t expect a cookbook. I promise to offer more concrete, practical recommendations than the vague advice to “be empathic” or “show you care.” But I can’t turn empathy into a checklist, and I’m not going to try. In fact, some of what follows is heavy going, especially toward the end of the column. Readers who don’t like abstractions – and shrinky abstractions at that – may want to skim quickly past #7 and #8 below. Although much of the thinking behind this column comes from the field of existential and interpersonal psychiatry, I am not implying that risk communicators are in a therapist role vis-à-vis stakeholders-as-patients. Stakeholders don’t come to us for help with their psychological problems; we are neither authorized nor qualified to tinker with their psyches – no more so than vice-versa. But trying to understand other people is fundamental to all relationships, even (maybe especially) relationships that are largely antagonistic. Showing that you’re trying to understand is also fundamental. We can borrow from psychiatry without imagining that we are psychiatrists, and without picturing our stakeholders as patients.

Empathy and the Kinds of Risk Communication I routinely distinguish three main kinds of risk communication. I start with the distinction between a risk’s “hazard” (how much harm it’s likely to do) and its “outrage” (how upset it’s likely to make people). Based on this distinction, I categorize risk communication into three tasks: When hazard is low and outrage is high, the task is “outrage management” – reassuring excessively upset people about small risks. “Calm down.” When hazard is high and outrage is low, the task is “precaution advocacy” – alerting insufficiently upset people about serious risks. “Watch out!” When hazard is high and outrage is also high, the task is “crisis communication” – helping appropriately upset people cope with serious risks. “We’ll get through this together.”

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Empathy is important in all three kinds of risk communication, but not necessarily in the same way. Empathy is obviously crucial to outrage management – when people are upset about a risk even though you’re pretty confident they’re not actually very endangered. Under those circumstances, the toughest part of the risk communication job is to reassure your stakeholders that the technical risk is low. Especially if you’re responsible for causing the risk in the first place and have an economic interest in dissuading them from objecting to it, your stakeholders have good reasons not to believe your reassurances, even when your evidence is strong. In this situation, establishing an emotional connection is incredibly difficult and absolutely essential. Whether you think of it as “showing empathy” or simply as acknowledging people’s grievances and concerns, it’s a prerequisite to progress. Without an empathic approach, it is virtually impossible to tell people that they are wrong to be upset about some situation or wrong to blame you for it. The role of empathy in precaution advocacy is quite different. Unlike outrage management, in which people are upset (often about you) and need an emotional bond to help them calm down, precaution advocacy is all about talking to people who are apathetic. Your job is to make the issue interesting. There’s no need to be endlessly expressing your understanding and compassion for people who are barely paying attention. But you’ll need all the empathy you can muster to figure out how to get them to pay attention. The empathic challenge in precaution advocacy isn’t in how you communicate your fellow-feeling; it’s in how you feel your way into your stakeholders’ state of mind so you can appreciate why your issue isn’t firing them up and what might have the capacity to fire them up. You don’t have to show them you understand their apathy – but you will have to understand it deeply if you’re going to have much of a chance to overcome it. Sometimes, moreover, what looks like apathy about a risk is really something else entirely. Two possibilities of special relevance to empathic communication: Denial can masquerade as apathy. Far from being apathetic, stakeholders may be so upset about a risk that they have tripped a psychological circuit-breaker to protect themselves from unbearable feelings. Terror about cancer, AIDS, or nuclear holocaust, for example, may hide behind denial. When stakeholders are in denial, it is very important not to misperceive them as apathetic. Excessive outrage about a precaution can masquerade as insufficient outrage about a risk. Employees who can’t stand the face mask you want them to wear, for example, may claim that they’re not worried about the solvents or the asbestos. This is quite common, and often missed. It takes empathy to detect these two situations. And it takes empathic communication to address them. What about crisis communication? In February 2007, a Canadian risk communicator wrote to my website Guestbook, suggesting that in an emergency people have more important priorities than empathy – that they need “leadership, someone in control of the situation telling them what’s going on and what they can do, an army-general-like approach, clear instructions, clear respectful orders.” (See “Are empathy and compassion really what matters in mid-emergency?”) My answer, in part: There have got to be moments when people are in extremis, know they’re in extremis, have already come to terms with the situation emotionally, and just want practical help – information about what’s going on and instructions or advice about what to do. When that’s the situation, “empathy” means noticing that that’s the situation and not wasting precious time trying to show you care. But I think that’s very much the exception. Even in the middle of an emergency, most people need emotional support, not just practical help. And our ability to absorb and respond to practical help often depends on our getting the emotional support up-front. Paramedics and EMTs, for example, are often in situations where seconds count; even so, they find time to murmur words of support to the patient and the patient’s family. Ditto for 9-1-1 operators. Even surgeons are learning to find ways to demonstrate their humanity before the patient goes under.

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Narratives by survivors of the 9/11 attack on the World Trade Center frequently emphasize the empathy and compassion shown by firefighters, police, and their fellow survivors as they struggled to find their way to safety. They emphasize the practical help too. It’s not either/or. The most famous quotation to come out of 9/11 was what New York City Mayor Rudy Giuliani told a reporter who asked how many people had died in the Twin Towers. “The number of casualties,” he said, “will be more than any of us can bear.” Why did his words resonate so deeply? Giuliani was saying, in effect, that the attack was unbearable. He was bearing it, but with difficulty – and he let the difficulty show. That’s what helped New Yorkers (and the rest of us) bear it too. Interestingly, Giuliani’s speeches since then have expressed the view that it was his strong, calm leadership that rallied New Yorkers after the attack. I think it was his empathy and compassion. Of course it was important that he didn’t fall apart. But the unexpected blessing was that we could all watch him struggling, successfully, not to fall apart. Watching Giuliani hold it together helped millions of us to hold it together too. Empathy in a genuine crisis is different from empathy when people are understandably but unnecessarily upset about a small risk. Since the crisis is genuine, presumably you are upset too, not just your stakeholders. So you can go beyond sort-of acknowledging their feelings to showing that you share their feelings – and that you too are struggling to bear it all and carry on. This is what Mayor Giuliani did so magnificently in the crucial period after the 9/11 attacks. In a crisis, empathy should be deployed to help you guide people, to help you help them cope with the crisis – not to reassure them falsely. Crisis managers who imagine that showing empathy means over-reassuring people, “emphasizing the positive” or “calming them down,” are way off the mark. But so are crisis managers who neglect showing empathy in their haste to tell people what to do.

Specific elements of empathic communication. 1. Feeling and Attitude: Empathy Isn’t a Strategy Empathy is first and foremost a feeling. In Salinger’s Catcher in the Rye, Holden Caulfield’s alienation was grounded in his belief that other people “don’t get me.” The Martian verb in Heinlein’s Stranger in a Strange Land was “grok”: “I grok you.” You actually can feel some of your stakeholders’ pain, and that can help relieve the pain. As Les Havens puts it: Contagion of every affect [emotion] has been reported by therapists: anxiety, depression, anger, excitement, ecstasy, even affectlessness…. Often if the therapist of a depressed person feels depressed himself, the patient improves. It is as if the therapist has relieved the patient of his despondency. It is a dangerous sign if a worker does not become depressed while caring for a suicidal patient; he may not have come close enough to aid the suffering person. Nor is it just therapists who feel spontaneous empathy. Havens references a photograph of people “who twist in unison while observing a pole-vaulter clear the bar.” Similarly, I have noticed that when my risk communication seminars dwell on atomic radiation (and fear of atomic radiation) as an example, many of the men in the audience cross their legs. Feeling your way into other people’s feelings is a capacity we all have, though of course not all the time. Old couples and young lovers sometimes can complete each other’s sentences; Havens says empathic therapists sometimes can (silently) complete their patients’ sentences. When I say empathy is a feeling, I don’t mean to imply that it has to be intuitive. Some people really are intuitively empathic; they sense what’s going on for those around them, and they sense how they should respond. Other people’s empathy is more analytic; they assess the cues others are putting out, figure out what those cues are likely to signify, and consciously decide how to respond. Sometimes the intuitively empathic people think theirs is the only way, and resist articles like this one that try to come up with guidelines for being empathic. “If you have to think about it,” some readers may be saying to themselves, “it’s not empathy.”

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That may be the case for those of us who are intuitively empathic. They may have little need for guidelines; the guidelines may even get in the way of their intuition. But more often than not my clients have a pretty good understanding of what’s going on for their stakeholders (whether they got there intuitively or analytically) – and still don’t know how to communicate that understanding. I’m writing for them, mostly. When feeling fails, at minimum empathy is an attitude: You are genuinely trying to get how your stakeholders feel. Empathy is not a strategy. I am not telling you to fake empathy, and faking empathy is hard anyway. If you think your stakeholders are being foolish or treating you unfairly, it’s probably going to show. If you wish you didn’t have to spend time with them, it’s probably going to show. Above all if you haven’t a clue why they’re doing and saying what they’re doing and saying, and don’t really care to find out, it’s probably going to show. The recommendations that follow are ways to make sure the empathy shows … if it’s there. You can’t use most of these recommendations when all you’re feeling is hostility toward your stakeholders. Not that empathic risk communication is reserved for use with stakeholders toward whom you have only the kindest of feelings. You’re usually going to be ambivalent. My clients often say of their stakeholders, “I know just how they feel. I’d feel the same way in their shoes.” Even though they mean it, they still have a tough time hanging onto their empathy when the stakeholders start berating them at a public meeting. Use all the techniques you know to hold onto your empathic attitude. Keep reminding yourself that you’d feel the same way in their shoes. Count to ten. Find a confidant you can rant and rave to about what jerks they are. Write angry letters you never send. And then try to feel your way back into their shoes. On a bad day when all you’re feeling is hostility toward your stakeholders, don’t imagine that these recommendations are going to help. When you’re feeling partly hostile and partly sympathetic, then some of them ought to help. So what should you do when all you’re feeling is hostility? Take a break if you can. Get somebody else to take over for a while. Do whatever works for you when you need to recover your equanimity – and your empathy. Then these recommendations will help again. 2. Candor and Humanity: Being Real When all you’re feeling is hostility, you’re not going to be able to act like an empathic risk communicator. When your feelings are mixed, when empathy and hostility coexist, consider the possibility that you should let some of the negative stuff show. Psychotherapists don’t share all their feelings with their patients, and risk communicators shouldn’t share all their feelings with their stakeholders. But it’s important to share enough of what you’re feeling to come across as real. It is very, very hard to communicate empathically if you’re not also being real.

Les Havens teaches his psychiatry students that getting angry at patients is occasionally the most empathic thing they can do. Losing control is never the right thing to do, but deciding to let some anger show sometimes is. One time when a patient was making racist and anti-Semitic comments in a group session, Havens leaned toward the patient and said, with deliberate anger in his voice: “That makes me really angry. If you don’t stop that right now I’m going to leave the room.” This helped the patient regain control over his own leaking emotions. And it established that Havens wasn’t an impersonal, impervious therapist-doll, but a real person who was really offended by what the patient was saying. Similarly, I have occasionally advised clients to go ahead and express some of their anger at their stakeholders. Maybe they’re questioning your competence and your integrity; maybe they’re costing your company or your agency hundreds of hours and millions of dollars. Of course you’re upset. You may very well be as outraged as they are! But while they’re freely expressing their outrage, you’re struggling to suppress yours, to hide it even from yourself. Almost inevitably it leaks out – usually in the form of cold courtesy. You may tell yourself that’s what it means to act professionally, but to your stakeholders you’re probably coming across as uncaring or even passive-aggressive, certainly not as empathic. Letting some of your anger show is very likely an improvement over converting it into frigid, obviously hostile courtesy.

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It’s possible to carry “being real” too far – and end up being really unprofessional. But most professionals are overly preoccupied with looking professional, and insufficiently attentive to looking human. It’s rare for the public to end up thinking some risk communicator or crisis manager was too emotional, too involved, too personal. It’s quite common for people to think he or she was too controlled, too calm, too uncaring. So while “too emotional” certainly exists, it’s mostly a theoretical problem. “Too controlled” is by far the likelier problem. And that kind of robotic control is incompatible with empathic risk communication. Anger may be the hardest emotion to express empathically. That’s why marriage counselors spend so much time working on how to fight fair. Other emotions are less fraught. But some of my clients have trouble getting themselves to express any emotions. Consider these two stories, both of them about government environmental protection officials, both of them, interestingly, women. In the first example, the official failed to express compassion; in the second, she succeeded in expressing hurt. At a public meeting, a mother was testifying about her daughter’s leukemia: how awful it is to watch your child sicken and wonder whether it might be the emissions from the nearby waste treatment plant, and all the experts can say is they don’t know, they’re not sure, there’s no proof. She was weeping, and many in the audience were tearing up … but not the hearing examiner, who remained calm, aloof, unruffled. I’m sure she thought that the leukemia had nothing to do with the waste treatment plant, and I guess she thought that showing compassion for mother and daughter might be tantamount to conceding a connection. So her only reaction came at the end: “Your five minutes are up. Thank you for your input.” You could hear the audience gasp. At a different meeting, an agency spokesperson was being given a hard time by angry townspeople. After a few hours of hostile rhetorical questions, she asked for a break. “I need a few minutes alone,” she said. “What’s happening tonight is important and legitimate, and I really want to hear all your criticisms and bring them back to my agency. But it’s hard for me. I don’t want to start crying. That would be terribly unprofessional. I just need some time to pull myself together.” When the hearing resumed after the break, the criticisms continued, but the tone was much more substantive instead of personally hostile. Do you think the first official was more professional than the second? Maybe so. But the second was a lot more empathic – and the second ran a much better meeting. On one level, perhaps, being real can be seen as the opposite of being empathic. Havens divides Making Contact into two main sections, “Empathic Language” and “Interpersonal Language.” Empathic statements, he writes, are “credulity operationalized.” The goal is to be “taken in” by the other person, and thereby to understand the other person’s perspective as if from the inside. By contrast, interpersonal statements are “skepticism operationalized: the goal is not to be taken in, not to allow the patient to settle assumptions or projections upon the therapist.” Put differently, empathic statements help the patient – or the stakeholder – feel understood, validated, even held; interpersonal statements help the patient/stakeholder feel like a real person in genuine contact with another real person. They are yin and yang. But like most people I use the word “empathy” more broadly than Les Havens does. Another book that has had a profound impact on the way Jody and I see risk communication is Martin Buber’s I and Thou. (Havens often cites Buber too.) Buber argues that “I-Thou” relationships are authentic because they treat others as real, whereas “I-It” relationships (which he says are far more common) objectify others for one’s own purposes. Because “I-Thou” relationships are necessarily mutual, they require being real, as well as accepting and validating that the other person is also real. Much later in this long column I will return to Havens’s useful distinction between empathic statements and interpersonal statements. For now, I want to see them all as part of an empathic, “I-Thou” whole. You shouldn’t have to choose between candor and empathy, between being yourself and showing you care. Quite the contrary. Even though candid statements about how things seem to you are obviously distinct from empathic statements about how things might seem to your stakeholders, the essence of risk communication is to find ways to combine the two. Your goal as a communicator is very often to change your stakeholders’ minds about something. So empathy alone won’t accomplish your goal; at some point you’re going to need to tell them what you think and why. But candor alone probably won’t accomplish your goal either. If you’re not attuned to their perspectives, they’re profoundly unlikely to accept yours.

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A core task for risk communicators is to learn how to disagree empathically. When the anti-inflammatory drug Vioxx was pulled from the market in October 2004 because of cardiac risk, pharmaceutical company executives immediately started trying to differentiate Vioxx from their other antiinflammatory products that were still on sale. Here are two quotations, both aimed at protecting other products by disagreeing with the public’s tendency to paint with a broad brush. The second one used empathic language that acknowledged the way many laypeople saw the situation; the first one didn’t. (Which perspective is turning out to be more accurate medically, the public’s or the pharmaceutical industry’s, is a separate issue.) “It is important to note that the results of clinical studies with one drug in a given class are not necessarily applicable to others in a class.” – Peter Kim, president of Merck Research Laboratories “It’s hard to comprehend how two drugs in the same class could be so different. But they are each in a subclass of their own, and those different chemical structures translate into a different safety profile.” – Mitch Gandelman, Vice President of Pfizer Here’s another example, showing how an unempathic disagreement can be converted into an empathic disagreement, integrating candor and empathy. In early 2005, when surviving Southeast Asian fishermen started to fish again after the devastating tsunami that had wrecked most of their boats, they had trouble finding customers. Fearing that the fish might have fed on the bodies of people who had drowned, their surviving friends and relatives were reluctant to eat the fish. So officials were at pains to explain that there was no risk of disease from eating the fish. Dr. Lee Jong-wook, then Director-General of the World Health Organization, tried to set a good example. While visiting a fishing village, he told a CNN reporter that the widely held perception that the fish were contaminated by the human corpses washed out to sea was wrong. Dr. Lee said: “Fish is a good source of protein and I am eating fish every day. No problem.” In a post-tsunami column on “Talking about Dead Bodies,” Jody and I wrote: It’s that perky “No problem” that sounds so out of touch with people’s normal feelings. How much better if Dr. Lee had said something like this: “I must admit I hesitated before I ate the fish. I couldn’t help wondering what the fish had eaten. But the experts tell me it is safe, and I want to do everything I can to help the local fishing industry recover. So I am eating the fish.”

3. Deflection: You → I → They → Some People → It One key way to make your acknowledgments less intrusive, to convert them into empathic sort-of acknowledgments, is to deflect what you say away from the stakeholders you’re actually talking to. Deflection is what you’re doing when you say “a lot of people might get angry” instead of “you’re angry.” And deflection is what Jody and I thought Dr. Lee should have tried. What he actually said (“I am eating fish every day. No problem.”) sounded oblivious to people’s fears. “You are afraid to eat the fish” would have felt intrusive. “I must admit I hesitated before I ate the fish” uses deflection to find the empathic middle. Of course if Dr. Lee felt no hesitation whatsoever about eating the fish, he shouldn’t claim otherwise. In that case, maybe he could have talked about a colleague who hesitated and then overcame the hesitation. Or he could “some people” it: “I sympathize with some people who feel uncomfortable eating the fish. They can’t help wondering if….” Years ago, Jody taught me what she called the “I – you – it – some people” framework to control the extent of the deflection. Thinking the framework through for this column, I revised it to “you – I – they – some people – it,” in order from most to least intrusive. Suppose for example you’re in the middle of a controversy over groundwater contamination from your factory. Although the evidence shows a very low probability of any health effects, some of your neighbors insist the

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contamination is deadly. You suspect that part of what’s going on is an unacknowledged worry about property values, which may be fueling people’s resistance to the reassuring health data. (Of course other things are fueling it too: mistrust of your company, scientific uncertainty, etc.) You want to raise the property values issue without being too intrusive. Here are some of your options:

Undeflected:

You

“You’re not really worried about health! You’re afraid your property values might be affected.” Deflected:

“I was in a situation like this when I lived near an industrial park. What worried me even more than the health effects was the possibility that my property values might be affected.” More deflected:

They

“One of your neighbors was talking with me last week about this situation, and the thing that worried him the most was the possibility of an effect on his property values.” Still more deflected:

Some people

“Some people in a situation like this would probably be worried about their property values.” Most deflected:

“It’s possible there could be some concern about property values here.”

Lots of variations and combinations are possible. Consider this example: “I wonder if some people here tonight might also be worried about their property values.” Talking about what “people here tonight” are thinking is pretty intrusive for a public meeting. But making it “some people” reduces the intrusiveness; “I wonder if” and “might also” deflect it further.

Deflection serves two empathic purposes. First, the more you deflect what you say, the less likely it is to provoke denial. People can more easily accept that it’s possible there could be some concern about property values than that they themselves are actually more worried about property values than health. Second, deflection makes it easier to keep the issue on the table (or at least in the room) even in the face of denial. If you tell me I’m worried about property values and I tell you I’m not, we’re at loggerheads. It’s hard to go on to talk about property values. But if you say only that there could be some concern about property values, I can say “not for me there isn’t” (or perhaps just say it to myself) and the property values topic is still on the table. It’s best to avoid provoking stakeholders to express their denial. So if you decide to say that some people in a situation like mine would probably be worried about their property values, you should just let the statement hang there. Don’t add “What about you?” – which might easily force me to say, “No, not me.” Of course deflection isn’t an excuse for dishonesty. If you were never in a situation like this, don’t say you were. If you haven’t talked to a neighbor who was worried about property values, don’t say you have. Why not just deflect everything you say to the max? Because deflected statements are less clear and less powerful than direct statements. You deflect when you have to, as much as you have to, to avoid intrusiveness. But if a person is already “owning” a viewpoint or a feeling, then intrusiveness is much less of an issue and you can respond or ask questions more directly without much risk of provoking denial. Thus if I have already told you I’m worried about property values, it’s not necessary and not especially empathic to deflect my worry onto

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“some people.” Better to echo my worry back at me (“I can hear how worried you are about property values”) or ask me to amplify (“Has anything happened yet that made you think property values might be going down?”). But if you’re sensing that I might be worried about property values even though I’m claiming to be worried about health, then it’s too intrusive to just tell me how you think I feel. If you do, I’m likely to take offense, even (perhaps especially) if you’re right. How dare you accuse me of feeling that way! How arrogant of you to think you know better than I do how I feel! Those reactions will of course distance me all the more from being ready to notice and acknowledge my worries about property values. To avoid pushing me further and further into denial, you need to deflect what you say. The example I’ve been using, “worried about property values,” is a stand-in for a whole range of content that stakeholders may not want to acknowledge openly – content that empathic risk communicators should therefore sort-of acknowledge in deflected ways. Not surprisingly, most of what needs to be deflected has a strong emotional component. Anger often needs to be deflected, because people so often deny they are angry. People who are angry at you may angrily (or coldly) deny it if you call them on it too overtly, especially if their anger is masquerading as righteous indignation. “I’m not angry,” they’ll insist, their teeth clenched. “I’m just right!” Some people will deny even their anger at third parties, and excessively intrusive efforts to get them to admit it will only drive it further underground. (Unacknowledged rage at terrorists and at specific ethnic groups, for example, may underlie some unwise counterterrorism policies.) Again and again in risk controversies, I find that my clients are reluctant to acknowledge their stakeholders’ anger at all. They want to pretend that everything’s fine. On those rare occasions when they do acknowledge the anger, their acknowledgments tend to be too explicit and unempathic, focused on insisting that the anger is misplaced. “There’s no good reason for you to be so angry at our company.” I try to persuade clients to “sort-of acknowledge” the anger, to deflect the anger empathically: “A lot of people have told me this decision makes them feel angry at our company.” But it’s a tough sell. I try to explain that deflection helps people move past their anger – whether they acknowledge it or not – and become more willing to at least consider the company’s position. It’s hard for people to move past their anger while they’re feeling “accused” of being angry. And of course it’s even harder for people to move past their anger when the object of that anger doesn’t even seem to have noticed it yet. Fear also belongs on the shortlist of emotions that are likely to need deflection. Some people who are afraid want to hide that fact from others; some need to hide it even from themselves. Telling them they’re afraid, and especially telling them they should stop being afraid, will tend to push them more deeply into denial. Once again, deflection can help. “People often tell me they find it frightening to discuss plans for a severe flu pandemic” is likely to feel more empathic than “I know this frightens you.” But despite its lack of deflection, even “I know this frightens you” is more empathic than “Don’t be frightened” or “There’s no reason to be frightened.” From child-rearing to surgery, this truth is firmly established: To help people bear their fear, or to help them begin to let go of their fear (if the fear is excessive and letting go is appropriate), first help them accept that it is okay to be fearful. When H5N1 bird flu first arrives in a country that hasn’t yet experienced it, poultry sales typically plummet for a while. Most governments have overtly expressed disdain for their citizens’ initial reaction of avoiding chicken. But when Nigeria had its first known human case of avian influenza in early 2007, an official news release expressed respectful empathy for the temporary fears of normal people. It started by gently deflecting those fears onto “other countries”: [W]e have observed that in other countries experiencing their first human H5N1 cases, there has been widespread fear of poultry and poultry products, with a concomitant drop in consumption and sales. For a short time, that may happen in Nigeria too. It is entirely understandable that the population may be overly worried about all chickens, not just sick chickens. [Nigeria Avian Influenza Crisis Management Center, Bulletin 29] Deflection isn’t reserved for just anger and fear. Emotions in the “sadness” family – misery, depression, etc. – are also common responses to risk that people may not be prepared to acknowledge directly. So are emotions in the “ego injury” family – hurt, rejection, resentment, envy. Even positive emotions may need deflection. (Think

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about what it takes to signal empathically to an emotionally unexpressive friend that you know he or she cares about you.) And of course we’re not talking about pure emotions here. What needs to be deflected usually has a cognitive component as well as an emotional component. In the example I started with, your stakeholders were perfectly willing to acknowledge that they were worried. What needed deflection was how much of their worry might actually be about property values rather than health. Deflection is a core skill of empathic risk communication, and it is greatly underutilized. But it’s not for every situation. As I mentioned earlier, when people are well-aware of what they’re feeling, sometimes you can just go ahead and express empathy directly, without deflecting at all. Here is an example. A few weeks after the attacks on the World Trade Center and the Pentagon, a small number of people started receiving letters laced with weaponized anthrax spores. Several died. People throughout the country became afraid that they too might encounter such a letter. Many were reluctant to open their mail. Although some officials responded with ridicule, most tried to keep their reassurances respectful. Timothy Paustian, a microbiologist at the University of Wisconsin, quickly updated the anthrax section of his online microbiology textbook. The no-nonsense factual information he provided certainly didn’t ridicule people’s fears about their mail; it simply explained why the fears were probably unfounded. But it fell short of empathizing with fearful readers. Jody revised the new section using risk communication principles, and Paustian posted her revisions. Here is one before-and-after excerpt. Jody’s version addresses “you” the fearful reader without deflection, but nonetheless with empathy: Before: However, it will be very unlikely that you will receive one of these letters. Think about how many pieces of mail go out and how many people there are. Your chances are very low. After: You know it’s unlikely that you will receive one of these letters, but you’re still scared. You know how many pieces of mail go out, and how many people there are, but you can’t completely shake that inner worry. You know your chances are very low, but you find yourself reaching cautiously for the envelope, and you feel … just a little nuts. Welcome to the human race. In each situation you need to figure out which content is on the table already, which content is comfortable enough that you can raise it directly, and which content is too private and unacknowledged, too fraught, to handle so intrusively. For the content that you think is fraught, use deflection to get it into the room.

4. Questioning: “How Does That Make You Feel?” Questions aren’t always empathic. Sometimes they can feel too intrusive, more like an interrogation than a conversation among equals. The most intrusive questions don’t even feel like questions, but rather like patronizing or disdainful accusations: “Aren’t you really more worried about property values than about health?” But at a very fundamental level asking people how they feel is more empathic than not caring how they feel or telling them how you think they feel. As a rule, people like to tell their stories. They even like telling their stories to people they don’t like … and sometimes end up liking them more as a result. I am constantly surprised how reluctant my clients are to ask their stakeholders (especially their unhappy stakeholders) any questions at all. For example, I have sat in on dozens of planning sessions over the years to set the agenda for a public meeting. Invariably I suggest making a handful of phone calls to regular attendees to ask them what they want to talk about this time. My recommendation is seldom followed. Maybe it’s a control thing. A lot of my clients really want to do their own agenda-setting. They don’t mind guessing what their stakeholders want on the agenda – but if they actually ask, they’ll feel bound by the answers they get.

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Risk communication practitioners may not like asking questions, fearing that they’ll be stuck with the answers. But if the answers are likely to be honest, getting them onto the table will probably do more good than harm in the long term, even if the answers are sure to be hostile and the interaction is sure to be unpleasant. Asking stakeholders why they mistrust you, for example, or why they oppose your proposal, is a good way to get their objections out into the open. Even if you haven’t got a good response, or they don’t want to hear your response, just ventilating their grievances will reduce their outrage a bit, so the conversation can focus more productively on the disputed extent of the hazard. The rule of thumb here: If people are upset, you’re usually better off letting them get it off their chest. You’re better off if they’ve had a chance to vent, if you’ve heard what they’ve got to say, and if they know you’ve heard it. Letting people criticize you is itself an empathic thing to do. So find a way to ask the question. But sometimes your stakeholders aren’t likely to answer your question honestly, especially a question about feelings. They may be denying or projecting some of what they’re feeling. They may be confused about how they feel. Or they may be thoroughly in touch with their feelings but disinclined to share them with you – maybe they think it would be rude or tactically unwise to do so; maybe they think it’s just none of your business. A question that’s likely to get no answer, or an evasive answer, or an inaccurate answer, is probably an unwise question to ask. It’s very likely to force the truth more deeply into hiding, and it’s very unlikely to feel like an empathic interaction. So think about revising your question to make it more empathic. Here are some guidelines for empathic questioning: Make sure the question doesn’t presuppose a particular answer. “Aren’t you worried about property values?” presupposes that you are. “Are you worried about property values?” leaves the question open. Try deflecting the question. “Do you think some people are worried about property values?” is a less intrusive question than “Are you worried about property values?” By asking your stakeholders what they think others might be feeling, rather than what they themselves are feeling, you’re making it safer to give an honest answer. You’re inviting your stakeholders to project their feelings onto others so they can express them without acknowledging them. Try putting the question in the form of a statement (“I wonder if you’re worried about property values”) or even a deflected statement (“Some people might be worried about property values”). By asking the question indirectly rather than directly, you’re making it both easier to answer (your stakeholders feel less under scrutiny, less on-the-spot) and easier not to answer (your stakeholders can let it slide without giving a false answer or explicitly refusing to answer). Indirect questioning also allows people to use your statement as a jumping-off point for what is really on their minds, if they want to. If you are close to correct, they might start out, “Well, it’s not property values, exactly, but let me tell you about….” A series of indirect questions feels more like a conversation and less like an inquisition than a series of direct questions; through successive approximations it takes you closer and closer to your stakeholders’ actual concerns. Try to ask open-ended questions, which usually feel less intrusive than specific questions, and therefore tend to elicit more (and more honest) information. “How does that make you feel?” is almost a burlesque of a typical psychotherapist’s question – but it’s actually a pretty good question in some situations, a lot less intrusive than “Are you angry about that?” If your open-ended question might be too vague, you can combine it with deflection: “A lot of people might be angry about that. I wonder how it makes you feel.” (If you stick to the first half, you’re back to putting the question in the form of a statement.) Think about how much to say about yourself. Revealing some of your own thoughts and feelings is certainly more “I-Thou”; it establishes that you’re a real person too. It can help make questioning feel more empathic – and more an exchange among equals instead of an interrogation. It sets an example and implicitly asks for reciprocity: “I’ll show you mine if you show me yours.” But it might also distort your stakeholders’ responses to your questions. Compliant stakeholders may say they agree with you, even if they don’t. Oppositional stakeholders may say they disagree with you, even if they don’t. Moreover, the focus may shift from your stakeholders’ experiences, opinions, and emotions to yours – and to what they think about yours. It’s a judgment call. Keep rethinking whether there’s too much of you, or too little of you, in the interaction. And bear in mind which error you tend to make more often: inserting yourself too much or keeping yourself (your “self”) too hidden.

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Don’t start with the hardest questions. Although telling you how they feel is usually what makes stakeholders feel most understood, most empathized with, questions about feelings are also the most intrusive questions. Fact questions are much safer (unless the facts themselves are embarrassing or controversial). But fact questions that call for a one-word or two-word answer don’t launch much of a conversation. The best questions ask stakeholders to narrate a story: “What did you do when the sirens went off?” “What happened next?” Such questions open the door to an emotional answer without demanding one. Later when the bond between you is stronger, you can consider following up with questions specifically about their feelings. Give stakeholders permission to be reticent. “If you want to tell me, I’d be grateful to learn more about why you feel that way. But I can understand that you might not want to talk about it right now.” Paradoxically, most people are likelier to talk about loaded topics after you’ve said they might not want to. (This is an example of the seesaw of risk communication.) Sound like you want to learn. Questioning feels empathic when the questioner gives the impression of honest curiosity – of wanting to know the answer. If your questions feel perfunctory – if you sound like you already know the answer or don’t really care about the answer – your stakeholders won’t experience the questioning as empathic. Less empathic still is if you sound like you’re trying to catch your stakeholders in a contradiction or an admission, if you seem to be collecting ammunition or scoring points rather than trying to understand. Of course the best way to sound like you want to learn from your stakeholders is by actually wanting to learn from your stakeholders. Just as you can’t express real empathy if you don’t feel empathic, you can’t express real curiosity if you’re not curious. Questioning isn’t something you do to check it off on a list. You do it because you want to understand your stakeholders better. Look for role models, people who know how to ask questions empathically. Jody points out that one of the best exemplars of empathic (and interpersonal) questioning is National Public Radio’s Terry Gross. In the service of her genuine curiosity, and her desire to make interviews come alive for listeners, she does a superb job of asking open-ended questions, converting questions into statements, using deflection, revealing pieces of herself, asking permission before an intrusive question, etc.

5. Listening and Echoing: “I Hear You” If you’re going to ask questions, you should shut up and listen to the answers. Obvious though that is, it’s not always done. In fact I don’t always do it myself. Far too often I ask a good question, then become impatient with the response I’m getting and interrupt to answer my own question. Pretty dumb. And certainly not empathic. Listening isn’t the same thing as daydreaming. So practice your active listening skills. To show that you are really listening, nod your head from time to time, keep your face responsive (smile or frown; furrow your brow in effort or raise your eyebrows in surprise), murmur an occasional supportive “uh-huh,” maybe even take a note or two. As a rule, don’t interrupt. If you don’t understand what the speaker is getting at, it’s important to say so and ask a clarifying question – even if it requires interrupting the flow. But every time you’re tempted to do that, ask yourself first if you’re really trying to “get it” or if you’re actually just trying to prove you get it, or showing off, or reasserting control. Sometimes my clarifying questions genuinely help my clients bring me up to speed. Sometimes they just frustrate my clients and delay the process of getting me briefed. And when the speaker falls silent, don’t be in too much of a hurry to fill the silence. Allow a few seconds to pass. Ponder what your stakeholder has just told you, and how you might want to respond. See if he or she finds something to add, or if somebody else decides to jump in. I urge my clients to structure most public meetings around listening to what stakeholders want to say. There are exceptions, meetings where the audience really comes to listen and you’ve got a lot to tell them. But much of the time you wouldn’t be meeting at all if you didn’t have to, either because some law or policy requires it or because some stakeholders are anxious to give you a piece of their mind. People come to such meetings largely in order to vent their thoughts and feelings, and until they have done sufficient venting they are in no mood to listen to you. The underlying purpose of the meeting, then, is to let them vent, let them listen to each other vent, and let them see that you, too, are listening and trying to understand.

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The meeting is at least partly a pressure relief valve for stakeholder outrage. Instead of allowing the pressure to build until there’s an explosion, you want to help your stakeholders vent their outrage. That should relieve the pressure a little, for a little while. A good meeting, however, aims at more than just temporary relief. To relieve the pressure for more than a little while, listen to what your stakeholders are saying, learn from it, and figure out what your company or agency needs to do differently. So an empathic meeting doesn’t start with three hours of official PowerPoint presentations, followed by “public input” from 10 to 11 p.m. just before adjournment. In an empathic meeting structure, you start by asking people why they came. As they voice their questions and concerns, you write them all down on a flipchart. (Better yet, ask somebody else to write them down, so you don’t have to turn your back or dilute your attention.) Then you go back over the list: “This one is on the agenda already. This one we can add to Cindy’s presentation at 7:30. This one I’ll answer right now. This one a lot of people want to respond to, so let’s add an open discussion of that to the agenda. This one we can’t deal with tonight, but if the person who raised it will see me during the break, we can schedule a time to talk about it….” It’s uncomfortable to adjust your agenda in real time to what the people in the room want to talk about. And you’re entitled to reserve some time for things you want to talk about, things you think people need to know even if they don’t realize it yet. But if a key purpose of the meeting is to listen to people’s outrage, and if no other purpose is likely to get accomplished until you’ve made some progress on that one, then it’s self-defeating to make your stakeholders listen to you before you listen to them. A strange thing happens when you go into a meeting determined to listen to outraged stakeholders. They start wanting to listen to you. That wasn’t their goal on their way in the door, but after an hour or two of telling you how they feel and what they think, they begin to wonder how you feel and what you think about everything they’ve been telling you. (This is yet another risk communication seesaw. If you weren’t listening so hard, they wouldn’t want you to talk.) “Well!” someone is likely to pronounce. “What’s your reaction to all this?” The first time you’re asked to talk, it’s probably wise to demur: “There are people who haven’t spoken yet, and I’m learning so much tonight.” (You can’t say this last phrase unless you really mean it; it’ll come out sounding sarcastic and obnoxious.) But eventually there’s a consensus that it’s your turn. Now what do you say? You echo. As I pointed out at the start of this column, “I know just how you feel!” isn’t an empathic echo. It sounds more like a claim to omniscience than an effort to learn. And it’s intrusive, virtually guaranteeing that your stakeholders will respond by pushing you further away: “You can’t possibly know how we feel!” Even “I hear you” claims too much (and it sounds so Sixties). A far better way to transition from listening to responding is something like this: Let me see if I’ve heard you right. I’ve been listening hard this evening, and it seems to me that most of the people who have talked are focusing on three main issues. A lot of people really want us to do X, they’re very worried about Y, and they think we were wrong to do Z. Why is this a better echo than “I know how you feel”? For one thing, it deflects the echo from “you” to “a lot of people.” But even more important than that, it’s tentative, provisional. It tests whether you “get it” instead of claiming you do. That makes it easy for stakeholders to correct any misimpressions. It also makes it easy for stakeholders to revise or reinterpret their earlier comments. They don’t have to say they changed their minds; they can just say you’re a little off. Echoes should almost always have some kind of conditional language: “Let me see if I’ve heard you right….” “I think some people probably feel that….” “I wonder if some of what I’ve heard tonight means that….” In an angry public meeting, it often makes sense to hold your tongue until your stakeholders have done some venting and are ready to hear from you – then summarize what they’ve been saying in one big tentative echo. In a calmer meeting, or a smaller conversation, you should do your echoing as you go along. Note that you don’t have to agree with a stakeholder’s viewpoint in order to echo what the stakeholder said. It’s very useful to find things you can agree with, and I’m going to turn to that topic in a minute. But it’s crucial to echo even the things you disagree with. Save your disagreement for later, but don’t imply you agree either. If

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stakeholders are saying your company is dishonest, your probably don’t want to use an echo like, “Our company is dishonest”; that might imply you think so too. Nor do you want to start an argument: “Our company is not dishonest!” Nor do you want to pretend you didn’t hear what your stakeholders were telling you. “You think our company is dishonest” is a candid, straightforward echo that can’t be misinterpreted. But it’s awfully intrusive. Add some deflection, some conditional language, and some specifics, and you come up with something like this: “It sounds to me like some people here tonight think our company was dishonest when we said….” Echoing is very empathic, but it’s not as empathic as listening. Don’t interrupt to echo. (I make that mistake a lot.)

6. Agreement: “I Think You’re Right about That” The notion that agreeing with people is an empathic thing to do isn’t as obvious as it might seem. Sometimes disagreeing is the empathic thing to do. The essence of empathy is to make other people feel understood and respected (respected in the sense that you have made the effort to “get” their position) – not necessarily agreed with. Facile or insincere agreement is going to come across as facile or insincere, not as empathic. I have a close family member who almost never expresses disagreement directly; when he thinks I’m wrong but doesn’t want to discuss it, he says, “You’re probably right.” I don’t experience that as empathy but almost as dismissal. He doesn’t care enough to argue. If in fact you disagree with what a stakeholder is telling you, trying to fake agreement will actually get in the way of showing you understand and respect what he or she is saying. Nonetheless, finding and focusing on areas of agreement is an empathic thing to do. Of course it won’t help much if the areas of agreement are peripheral. Finding something unimportant to agree about may occasionally be a useful icebreaker in difficult negotiations, but often it comes across as sarcastic and trivializing: “Well, at least I can agree with you that 8 a.m. is too early for our next meeting.” You need to look for areas of agreement that will feel to your stakeholders like significant concessions – which means they may feel to you like significant losses. Let’s assume your stakeholders are berating you. Maybe it’s a low-hazard, high-outrage risk controversy and they’re angrily (and fearfully) telling you how arrogant and dishonest they think your company or agency has been. Maybe it’s a high-hazard, high-outrage crisis situation and they’re fearfully (and angrily) telling you how badly they think your company or agency has prepared to cope with the crisis. Almost inevitably when other people are giving you a hard time, some of what they say is true; some of it is exaggerated but has at least a germ of truth; and some of it is nonsense – garbage. When they’re done venting and it’s your turn to respond, which of these three do you tend to focus on? If you’re a normal human being, you focus on the garbage. “That’s garbage!” you explode. And then you give two or three examples of things your stakeholders said that are demonstrably untrue. Whose outrage are you managing when you do that? Your own. Who are you empathizing with? Yourself. To empathize with your stakeholders and address their outrage instead of yours, try to focus your response on the criticisms that have some merit. “Yes, we did screw X up. And we weren’t as candid as we should have been about Y.” I’m not advising you to agree with criticisms that are false. That won’t work. (And you won’t do it anyway.) But if you listen hard for criticisms you can honestly agree with, odds are you’ll find some. If you want to do empathic risk communication, focus a large part of your response on those. You shouldn’t let the areas of disagreement go completely unmentioned. If only to establish that you’re not conceding the truth of accusations you think are false, you need to find a way to correct the record (as you see it). It’s useful to have a corner of your website, for example, that addresses accusations you think are false and says why you think so. But at least as big a corner of your website should acknowledge accusations you think are sound. You may even decide to take up some of the points of disagreement in real time, responding to stakeholder comments at a public meeting. But at least as much of your response should be devoted to conceding the truth of some of what your stakeholders have said.

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There is little room for empathy in an endless rebuttal. Be particularly careful not to find yourself busily rebutting minor factual errors and exaggerations when you should be conceding the truth of a basic proposition. I worked some years ago with the complaints department of a U.K. railway company that almost made a fetish of these sorts of rebuttals. A passenger who wrote that her train was 90 minutes late would get back a huffy letter documenting that it was only 83 minutes late – with no acknowledgment that 83 minutes is as unacceptable as 90. Nothing empathic about that! In a typical risk controversy, your stakeholders are going to get a lot of technical things wrong. They’ll probably get most of the process things right. This is a rule with plenty of exceptions, of course. Still, more often than not they’re right (or mostly right) that you have been arrogant and unforthcoming, but wrong (or mostly wrong) that your dimethylmeatloaf emissions are giving the neighbors cancer. You will be tempted to spend all your time insisting that there’s no proof your emissions have had any effect on the neighborhood cancer rate. And to be sure, it’s a point you need to make. But if empathic risk communication is one of your goals, try to start by conceding that you have been arrogant and unforthcoming, or that you have sometimes been arrogant and unforthcoming, or at least that you might sometimes have come across to some people as arrogant and unforthcoming.

7. Kinds of Empathic Statements: A Typology Havens divides empathic statements (as opposed to interpersonal statements; we’ll get to those next) into four categories: imitative statements, simple empathic statements, complex empathic statements, and extensions. Imitative Statements Imitative statements are a close cousin of what I earlier called echoes. Havens writes: “Thus ‘How can I decide?’ might be said to the doubtful person; ‘What hope is there?’ to the depressed one; or ‘Where does one find the courage?’ to fearful ones.” Notice how these statements are made less intrusive. They’re reframed as questions, and they’re deflected. “Where does one find the courage?” is a lot easier to hear than “You sound frightened.” Even so, Havens warns that imitative statements should be bland. The goal is to comfort by our presence, not to startle by our prescience. Not everyone knows that minds can be read or that only a few people are so creative and unique that their thoughts could surprise anyone. Many people are deeply private; they believe their thought should never be known.… Here’s a slightly longer example: One day Jeanne seemed especially still and distant. I mused aloud, “What is one supposed to do?” To my surprise, she crisply replied, “Right!” and after a long pause, “I don’t know what to do. I never know what to do.” I had put myself in the midst of her uncertainty, verbalized it for her, and shared her desperation by my tone. At the same time, there was no implication that she should know or decide, as many ways of calling attention to her indecision might have suggested. Similarly, you can echo your stakeholders’ emotions, their situation as they see it, without suggesting that they should see it or handle it differently. “A Superfund cleanup in the neighborhood – how to bear it?” On the day I was drafting this section, doctors and parents in Perth, Australia were worried about an upsetting disease cluster. Four very young children had died suddenly from streptococcal illness; three of the four also had seasonal flu. Health Department officials openly (and appropriately) expressed their own frustration and anxiety in the media. Communicable disease director Paul Van Buynder, for example, said, “We are desperately trying to get to the bottom of what’s causing these illnesses.” But many local doctors, inundated with worried parents, didn’t want the parents to be concerned. Consider this typical quotation from the head of the Western Australia Council on General Practice, GP Steve Wilson: “If a child is sitting up, taking fluids, cooing and kaaing and looking fairly well, there’s no cause for concern, because the vast majority of these infections will just be straightforward viruses and not the flu.”

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Australian media carried lots of technically correct but unempathic statements like Wilson’s – statements that failed to empathize with the understandable alarm of parents facing the specter of a rapidly progressing fatal illness of mysterious origin. How hard would it have been to say something like this instead? It is scary to hear about these four sudden deaths of children. Of course it is alarming. How to tell whether a child’s minor symptoms might be the start of a nightmare! How can any parent be sure? Here are the symptoms parents should look for…. If those are the symptoms you’re seeing, get your child to the doctor NOW. But if a child is sitting up, taking fluids…. Instead of invalidating parents’ understandable fears, officials can put themselves into the midst of those fears, and only then offer helpful (and reassuring) guidance. Empathic imitation of the stakeholders’ feelings comes first, setting the stage for differential diagnosis (is it a routine cold or a flu that might morph into this fatal disease?) and reassurance (it’ll usually be the former).

Simple Empathic Statements The simplest of simple empathic statements aren’t even statements, but gestures, facial expressions, and the like. There are also empathic sounds, of which the psychiatrist’s “hmmm” is an obvious example. Havens comments that you can often tell what school a therapist went to by these sounds; Jody tells me Les is famous among his students for the precise tone of his gentle, inquisitive “hmmm?” The simplest way to show empathy in words is a single adjective: “Wonderful!” “Frightening!” According to Havens, “When we follow a person’s narrative in an empathic way, we find ourselves automatically producing these exclamations.” You just have to decide to express them rather than suppress them. Accented adjectives like “How awful!” are a little more dangerous. Havens warns that they can sound insincere and patronizing if they’re not spontaneous. Translations go further, putting the stakeholder’s feelings into words. Once again, deflection is usually called for. “It was terrifying” or “wasn’t it terrifying?” or “Anyone would be terrified” is a lot less intrusive than “You were terrified.” But “you must have been terrified” may be okay, even though it uses “you,” because it validates the feeling rather than accusing the stakeholder of it. “You must have been terrified” pretty clearly implies that anyone would have been. Havens writes: “We are saying it [the feeling] is natural, understandable, and shareable.” Effective translations should also leave the stakeholder free to correct or deny your interpretation, or to confirm it, or to ignore it altogether.

Complex Empathic Statements Havens’s chapter on complex empathic statements starts with “no one….” statements – “no one understands,” for example, or “no one did the right thing for you.” The “no one” formulation is in some ways a variant on deflection. Thus, “no one understands” postpones identifying who in particular has failed to understand. That’s probably more useful for a therapist whose patient feels mommy and daddy didn’t understand than for a company whose stakeholders feel management doesn’t understand. Don’t use “no one” to refer to your own failures and omissions.

“No wonder” statements don’t have that limitation. “No wonder you’re angry at us” (or, if you need to deflect, “No wonder some people are angry at us”) is a good way to get the anger into the room and validate it at the same time. The validation, of course, makes it less likely that stakeholders will deny the feeling. As Havens writes, “no wonder” is “a denial of denial.” “God knows….” statements make it possible to say intrusive things without actually intruding. “God knows this community has endured enough already.” It’s God who knows, not you. “God forbid….” statements let you raise unpleasant possibilities while empathizing with your stakeholders’ desire not to consider them. “God forbid, if the chlorine sphere should explode….” These are also ways of expressing thoughts about which your

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stakeholders are ambivalent. Havens uses the example of a patient who both wants and fears to get out of a bad relationship. See how these three complex empathic statements variously capture the ambivalence: “God knows you must want to escape.” “God knows you must want to escape.” “God forbid you should want to escape.” In early 2003, when the U.S. government raised the terrorism alert from yellow to orange, the Federal Emergency Management Agency reiterated its preparedness advice for citizens to stockpile some food, water, batteries … and duct tape, to help seal off a room in case of certain types of chemical or bioterrorist attacks. The media reported that a few people had actually sealed off some of their rooms. Homeland Security Secretary Tom Ridge needed to point out that this was a premature overreaction. Notice how he integrated complex empathic statements into his February 14 response: God forbid, there may come a time when the local authorities or national authorities or someone will tell you that you’ve got to use them but, for the time being, we just don’t want folks sealing up their doors or sealing up their windows. Unfortunately, dealing with that kind of possibility is part of the new reality we live with. While a few people may have overreacted to FEMA’s duct tape advice, millions responded with derision instead, and “duct tape” became the punch line of thousands of jokes. (Overreaction and derision are both predictable responses to scary precautionary advocacy.) As far as I know, Secretary Ridge didn’t offer an empathic response to the scoffers. He could have said something like this: Even though there are situations where duct tape could save lives, it sounds so lame, so laughably inadequate. God knows how terrifying it is to think about another 9/11, not to mention things even worse than 9/11, like a widespread chemical or bioterror attack. And no one in the government has anything better to offer than duct tape? Of course duct tape is only one item on a list of recommended precautions. Still, I wish we could give people more and better ways to protect themselves. No wonder there are jokes on Letterman and Leno! In August 2003, North Carolina had a case of Eastern Equine Encephalitis (EEE) that attracted significant media attention and frightened some people. State Epidemiologist Jeff Engel found empathic ways to resonate with people’s fear, validate people’s fear, educate people’s fear, and moderate people’s fear. Here he is in the August 24, 2003 Fayetteville Observer: Dr. Jeff Engel, a state epidemiologist with Health and Human Services, said the state has documented “only 12 or 13 human infections since 1964.” The most in one year was three in 1989…. Though human infections are rare, Engel emphasized precautions. “Fear is appropriate. I mean, my God, here you have a mosquito that can kill,” Engel said. “What we are trying to do through you guys, the media, is use that fear in a positive way. We are trying to get information out there.” After the story ran, the local Wal-Mart sold out of insect repellant. Engel’s empathic statements generated preparedness, not panic.

Extensions Extensions echo/imitate what your stakeholders are saying, but they add things your stakeholders aren’t saying but may well be thinking – often by extending what has been said in time or in space. If a patient says “It has been difficult,” for example, Havens writes that the therapist might say “It has been difficult for a long time” or “It is not only difficult at work but at home.” According to Havens, extensions let you probe the limits, extending until your stakeholders indicate you’re wrong. He illustrates this with a short dialogue: P:

I did want to die.

H: It may still be what you want. P:

I don’t know.

H: The pain continues.

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I feel so terrible.

H: It may not be possible to imagine any time free of it. P:

I thought if I died it would stop.

H: That might be the only time. P:

No, now I feel I will be better.

Extensions make more of a contribution to the dialogue than Havens’s other sorts of empathic statements. They don’t just echo what the stakeholder is saying or not-quite-saying; they go on from there – in baby steps – to probe what else you think might be going on. Although Havens doesn’t say so, they’re a sort of hybrid between empathic statements and interpersonal statements (see #8 below). When Havens writes about empathic statements, his focus is on how to get closer to other people’s unacknowledged feelings and how to express that closeness without intruding too far. Empathic statements neither endorse nor dispute what others are feeling, just gently get closer to what they are feeling. In risk communication, this helps get your stakeholders’ feelings closer to the surface and, with luck, “into the room” – but not quite “onto the table,” since that would probably be too intrusive. Getting stakeholders’ feelings into the room is useful partly because it helps your stakeholders feel understood, partly because it helps you address their feelings and the issues that give rise to them, and partly because it helps everyone disentangle stakeholders’ feelings from the substantive issues that the feelings may be distorting. Sometimes it is possible to go beyond bringing your stakeholders’ feelings into the room; you can actually put them on the table. This is too intrusive for everyday use – but when it’s used appropriately it can be breathtaking. In the wake of the December 2004 tsunami, Malaysia’s New Straits Times published a superb January 17 editorial on the post-tsunami fear of eating locally caught fish. The editorial acknowledged (in a segment I’m not quoting) that eating the fish was only minimally risky, but argued at length that the fear was natural and inevitable. Notice the editorial’s use of deflection; it describes the public’s feelings very explicitly, but framed in terms of how “Everyman” and “people” are bound to be feeling – never “you” the reader: Primal fear has dealt a double-whammy to the fishing industry. Finally putting out to sea again after repairing their boats and reassembling lives so rudely shattered and washed away by the December tsunamis, they now find no one wants to eat the fish they catch because … well, who knows where they’ve been, what they’ve seen – and eaten? The finger-in-a-fish-belly rumour that cut Penang’s fish sales in half in recent days was too obviously waiting to happen, and too predictable to be true. As with all urban myths and legends, someone was bound to find a way to express, in the simplest and most graphic way imaginable, Everyman’s deepest dread. Let us not, therefore, dismiss these notions too disdainfully. The revulsion people feel at the very thought of eating an animal that has recently eaten a human being is not superstitious but primal. It is not irrational but subrational; it stems from the deepest and darkest recesses of the conscience, where resides, perhaps ironically, what it means to be human…. So this is a scare that must run its course…. [New Straits Times, January 17, 2005]

8. Kinds of Interpersonal Statements: Another Typology Havens identifies three kinds of interpersonal statements: projective statements, counterassumptive statements, and counterprojective statements. In Havens’s terms, all three are interpersonal rather than empathic because they operationalize skepticism rather than credulity. That is, they assert something different from what your stakeholders are trying to assert, rather than just repeating or clarifying or even extending what your stakeholders are trying to assert. They move the conversation to a different place. They are therefore more real, even more “I-Thou” than empathic statements; they are communications from one authentic person to another. But in a broader sense interpersonal statements are still empathic, because the focus is still on your stakeholders, not on you or “the objective situation.” It’s a bit like the old joke: “Enough of me talking about myself, now you

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talk about me.” Empathic statements represent your attempt to understand the way your stakeholders see things. Interpersonal statements represent your attempt to explain your “take” on the way your stakeholders see things. Empathic statements can take you only so far. To really explore how things look to your stakeholders, you have to put more of yourself on the line.

Projective Statements Projective statements are the simplest form of interpersonal speech. The word “projection” here has nothing to do with Freudian projection (in which people attribute characteristics from one person or situation to another). A projective statement is simply a declarative sentence. You’re projecting some new content into the dialogue. But the purpose of a projective statement isn’t mostly to convey information. Its purpose, Havens says, is to evoke. “A mark has been placed and the patient is stimulated to add, correct, or erase.” A projective statement is a gentle probe. Havens illustrates this with a short dialogue. The patient is talking about some past event. “It was a nice day in August,” the therapist says. The patient disagrees: “No, it was raining. I remember mother said it would be clear.” “Then your sister got mad,” the therapist prompts. This time the patient adds rather than disagreeing: “She said mother was crazy.” As Havens points out, this is how people (empathic people, anyway) usually talk to each other. People make empathic exclamations, ask questions, and listen in silence to reveries and associations; yet perhaps the most powerful engine of verbal intercourse is the statement of fact or possibility. Stakeholders who will quickly grind to a halt if you listen silently, who will get defensive or evasive if you ask questions, may tell you everything you need to know if you probe with projective statements. In Havens’s illustrative dialogue, for example, the projective statement “It was a nice day in August” leads naturally to the response, “No, it was raining. I remember mother said it would be clear.” Two things are crucial about projective statements. First, as I have already said, they should keep the focus on your stakeholders. The value of your statement is in what it evokes, not what it says. And second, they should be hypothetical, tentative, conditional. You’re probing for a response, not taking over. You’re willing to be wrong, happy to be corrected, content even to have a particular probe ignored (you’ll try another). Your pursuit of truth – your stakeholders’ truth – is a series of successive approximations, like tacking a boat. If you have any doubts about whether this conditionality is clear to your stakeholders, add some explicitly conditional language to your projective statements: “Maybe it was a nice day in August.” “I’m guessing it was a nice day in August.” “It sounds like it might have been a nice day in August.” Havens summarizes this eloquently: “Projective statements are free offerings meant to be taken, amended, or set aside…. The evocative powers of projective statements are directed both at finding the other and, by means of the hypothetical element, testing what has been discovered.” Let me reiterate Jody’s excellent advice to listen to Terry Gross interviews on NPR. If you listen to Gross’s program, Fresh Air, listen for projective statements – and the responses they evoke from her interviewees.

Counterassumptive Statements Your relationship with your stakeholders differs in many ways from a therapist’s relationship with a patient. But there are also similarities. Among the similarities is this one: Just as patients make false assumptions that can get in the way of the therapy, stakeholders often harbor false assumptions that similarly complicate their interaction with you. (Of course you often harbor false assumptions about your stakeholders that also get in the way.) In both cases the assumptions may be unstated, maybe even unexamined. In both cases confronting the

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assumptions directly will probably do more harm than good. “Counterassumptive statements,” Havens says, “shake assumptions without making them a matter for debate.” I think this is sometimes the wrong approach for risk communication with stakeholders. In fact, I have argued that it is extremely difficult to correct a misimpression just by pointing out the contrary truth. See for example my discussion of the “Donkey” strategy in “Games Risk Communicators Play.” In our handout on “Anchoring Frame Fundamentals,” similarly, Jody and I argue: You cannot correct misimpressions by ignoring them. You need to address them explicitly, acknowledging that they are widespread and why they seem convincing. Only then is it useful to explain why they are, surprisingly, mistaken. Take us with you from X to Y. Don’t ignore that we think X and just keep insisting Y-Y-Y-Y. But when stakeholders’ false assumptions are barely conscious or deeply embarrassing, it may be more empathic to use counterassumptive statements. One of the most common false assumptions in the patient-therapist relationship is the patient’s assumption that the therapist is incredibly wise and competent, even omniscient. A therapist who wants to shake that assumption might, Havens writes, “make it a point to forget the patient’s name” or “stumble clumsily while showing the patient out” or say something along the lines of “I hope I don’t make a bigger mess of things than your last doctor.” There are less extreme ways to accomplish the same goal. When Jody was seeing patients, she often emphasized regretfully what a weak and uncertain science psychiatry is, how far behind chemistry and physics, basically “in the dark ages.” I often say similarly deprecating things to my clients about risk communication. And I urge my clients to say similarly deprecating things to their stakeholders about, say, toxicology or epidemiology or quantitative risk assessment. Any (or all) of three things may be going on when an epidemiologist says something self-deprecating about epidemiology at a public meeting: For those in the audience who overvalue epidemiology and expect miracles, she is using a counterassumptive approach to gently “shake” people’s mistaken belief that an epi study is likely to come up with a clear answer. Without directly challenging the false assumption and thus provoking either debate or denial, she is recalibrating people’s expectations. She will probably want to combine her interpersonal counterassumptive statements with empathic statements that gently help bring the false assumption into the room: “Communities sometimes think an epi study is sure to give them a definite answer. If only we could! It’s such a natural thing to hope. But….” For those in the audience who are contemptuous or suspicious of epidemiology (and may not be saying so), she is conceding that they are partly right. I’ll talk more about this sort of proactive acknowledgment in #9. People are of course likelier to cut her some slack if she acknowledges epidemiology’s limitations than if she seems to be overvaluing it herself. More importantly, they are likelier to notice where epidemiology can be of value. For those in the audience who are ambivalent about the strengths and weaknesses of epidemiology, she is riding the risk communication seesaw. Each time she says something favorable about her profession, ambivalent people move toward the negative seat on the seesaw; each time she says something critical, they move toward the positive seat. By oscillating from one to the other, she can slowly help them move toward the fulcrum – that is, toward a realistic appraisal of what epidemiology can and can’t accomplish. Of course your stakeholders’ false assumptions aren’t just about whether epidemiology can save the day or whether you’re omniscient or incompetent. Your stakeholders may have false assumptions about whether you’re greedy or altruistic, for example, or whether you’re honest or dishonest. Or as I wrote near the start of this column, they may have false assumptions about whether you like them or trust them, or whether you’re a callous corporate lackey or an east coast elitist. Your stakeholders’ false assumptions may not be about you at all, but about the situation, or even about themselves. Havens writes at length about dealing with patients’ false assumptions about themselves – patients who see themselves as inadequate or fragile or super-successful and want (or at least expect) the therapist to confirm that self-perception. The therapist’s job, he writes, is to “lightly undercut” the expectation. “The person expecting praise should feel a little unsure, and the person expecting to seem foolish should feel mildly praised.”

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Counterprojective Statements Counterprojective statements are arguably a special kind of counterassumptive statements. They aim to “lightly undercut” a specific sort of false assumption, one that started with someone else or some other situation and is now being “projected” onto you or the current situation. Such psychological projections come up all the time in therapy. In fact, they are a big piece of how therapy works. Patients project onto the therapist conflicts from their past. For example, they may unconsciously expect the therapist to act as their parents once acted. The therapist uses the projection to help the patient work on the past conflicts; the goal is to disentangle the past from the present so the patient can put the past into perspective and move on, instead of reenacting the same plays over and over again. Something similar happens sometimes in risk communication. People’s interaction with you probably isn’t their first contact with “evil, dishonest” corporations or “bureaucratic, incompetent” government agencies. You remind them of other times in their lives when they felt mistreated by big organizations, and perhaps also by more personal authority figures – including, yes, their parents. They may project onto you their reactions to these past contacts. And so you may have use for counterprojective statements. Havens’s prototype is when somebody stubs a toe on a piece of furniture. The normal response to the pain of stubbing your toe includes “anger toward the object, blaming it, even wanting to kick the offending object again.” The anger then gets generalized and projected, so anybody standing nearby is likely to be resented. Havens continues: The treatment of such small, paranoid psychoses is, first, empathy with the pain and then alliance against the object. A friend can be quickly made by kicking the offending object for the injured person…. Just as certain exclamations, “How painful!” or “That must have hurt,” are the prototypic form of empathic speech, so another exclamation, “That damn chair,” is the prototype of counterprojective speech. Or, in a therapy example, the patient is projecting onto Havens other people’s failure to provide needed help. He keeps putting the projection back where it belongs: P:

Why don’t you clarify this? You know me very well. I’m confused.

H: That’s right. P:

I can’t do it alone.

H: Neither your boss nor your girlfriend has clarified things either. P:

They haven’t.

H: Everywhere you look, no one helps. P:

But you’re supposed to.

H: I suppose your parents were too. P:

They didn’t.

H: No wonder you want someone to take their place.

In my safety communication consulting, I often point out to clients that adult employees started out as children who felt overprotected by their parents: “Don’t play with your feces” … “don’t touch the stove” … “don’t ride your tricycle in the street” … on and on to “don’t major in humanities” and “don’t marry that jerk.” Outrage at (parental) precautions is at least as fundamental in people’s psyches as outrage at risks. On the job, many employees project their childhood intolerance of parental protectiveness onto the safety manager, whose warnings are all too reminiscent of the mommy they thought they’d finally escaped. The simple counterprojective solution is to remind employees where some of their irritation comes from: “You’ve been overprotected a lot.” Since that’s too intrusive, deflect it: “Sometimes people on the shop floor tell me I remind them of their parents, always warning them about some risk.” Or merge your counterprojective purpose with some of the empathic approaches discussed in the previous section: “Here comes that meddling

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safety manager [you] again! I’m always sounding like somebody’s mommy – be careful about this, be careful about that. God forbid I should leave you alone to get the job done!” Though he classes counterprojective statements as “interpersonal” rather than “empathic,” Havens notes that counterprojective statements are also empathic, “because they involve the expression of the patient’s strongest feelings.” But counterprojective statements go on to help reattribute those feelings to their correct objects, rather than letting them stay misattributed to you. I do a fair amount of work with mining and oil companies in developing countries – countries with a long history of colonial exploitation. When a western multinational corporation arrives in an African village, it is a safe bet that many stakeholders will project their feelings about colonialism onto the company. Of course the projection may be accurate; the company may in fact be yet another colonial exploiter. But assume for the moment that it isn’t. Assume that the company intends to behave responsibly and responsively, that it is capable of behaving responsibly and responsively, that it will share the profits from its resource development activities with the people whose resources are to be developed, that the village is really going to end up better off than if the resources weren’t developed (or at least better off than if they were developed by a different company). So the projection is inaccurate. But the projection is nonetheless inevitable. To succeed in establishing a good relationship with the village and securing a “social license to operate,” the company will need to voice the loathing of colonialism that is animating the village and contaminating the interaction. It will need to say, not “That damn chair!” but something equivalent to “That damn colonialism!” It will need to make counterprojective statements. But that’s not all it will need to do. The company will also need to acknowledge the ways in which it really does resemble the colonial exploiters of the past. I want to turn to that next.

9. Proactive Acknowledgment: “Some Things You Should Know about Me” I have urged mining and oil companies in the situation described above to come as close as they can make themselves come to saying something like this: For centuries people who looked a lot like me have stolen resources from people who looked a lot like you. So when we come here today asking your permission to let us drill, you’d have to be a fool not to feel a lot of anger and a lot of suspicion. Are we going to do it to you again? And I have to admit a painful truth: If we could do it to you again, there’s a good chance we would. A lot of people think that’s the nature of capitalism, to do whatever the company can get away with. I hope I wouldn’t be a part of anything like that, but there’s no reason why you should trust that I wouldn’t – and I can’t even claim that my company wouldn’t, if it could. What’s important here is that whether we want to or not, we can’t act like colonial exploiters anymore. You’re too powerful – powerful in your own right and powerful in your allies, all the activists and NGOs and socially responsible shareholder groups that are watching us like a hawk. So the question isn’t whether or not we’re going to exploit you again – and get away with it again. We can’t get away with it anymore. The question is whether or not you’re going to forgive us for the history of past exploitation and let us do business with you. There are still pros and cons to letting us come into your village, of course. It’s still debatable whether the benefit to your people will outweigh the harm. Even with a company that’s trying to be socially responsible and a community that’s empowered, resource development is a dirty and disruptive business. Some things haven’t changed: We come, we harvest your resources, we make money, we leave. Even though some of the control and some of the profits have moved from us to you, it can still feel a lot like colonial exploitation. This is more than a counterprojective statement. It acknowledges that there is truth to the projection. When Havens writes about interpersonal statements, he’s focusing on ways to address another person’s incomplete or inaccurate or poorly understood perceptions without directly confronting them, without overtly disagreeing. Unlike empathic statements – which echo, amplify, clarify, or extend what the other person is feeling and thereby help bring it “into the room” – interpersonal statements contribute another perspective: yours. Counterprojective statements in particular actually dispute what your stakeholders are feeling (and projecting onto you), though gently and indirectly so as not to launch a debate.

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But what do you do when your stakeholders’ perceptions are accurate? Especially when they’re negative perceptions about you or your organization, I don’t think it’s enough just to bring those perceptions into the room. And it’s certainly not right to dispute them. You owe your stakeholders confirmation. If they’re speaking their minds, no problem – then the empathic response is agreement (#6) or at least partial agreement. But often your stakeholders won’t speak their minds. They rightly (or somewhat rightly) see you as a colonial exploiter, but they’re too courteous or too embarrassed or too cautious or too strategic to say so. Then empathic risk communication requires you to say so for them. This isn’t in Havens’s typology. For want of a better term, let’s call it “proactive acknowledgment.” Suppose for example your state health department has withheld information about a local bird flu outbreak. You were pretty sure it was a low-pathogenic strain, not the dreaded high-path H5N1, but until you knew for sure you didn’t want to reveal the outbreak at all. Now it’s come out. Sure enough, it’s a low-path strain just as you expected. But even so, you can tell that people are feeling mistrustful, upset that your agency sat on the news, and worried that if it had turned out to be a high-path strain the delay could have been deadly. They’re not expressing their concerns overtly, but you can sense the ill-feeling. We’ve talked about a variety of empathic ways to get that feeling into the room – empathic statements along the lines of “Some people might feel we withheld potentially important information.” But such statements leave unstated the fact that “some people” would be right! I think that fact deserves to be acknowledged. Honesty requires that it be acknowledged. Empathy requires that it be acknowledged. And your own self-interest requires that it be acknowledged – partly so you can more readily apologize, explain why you did what you did, and talk about what you might do differently next time; and partly so your stakeholders can more readily put their feelings and your behavior into perspective and begin the process of moving on. It’s not all-or-nothing, of course. Your agency had its reasons for withholding the information; you may even feel that your reasons justified what you did (though I would tend to disagree). Since there are two sides to the issue, proactive acknowledgment doesn’t necessarily mean prostrating yourself in a total mea culpa. You might say something like this: When we first learned of the outbreak, our agency made the debatable decision to wait to announce it until we could firmly establish which bird flu strain was involved. There are probably some people here today who feel that was the wrong decision. Some people inside our agency felt that way too; it wasn’t an easy decision. Even though we were pretty confident it was a low-path strain, if we’d turned out wrong we would have lost valuable warning time for nearby poultry farms. And being completely candid is usually the best policy. But we were worried that announcing the outbreak without knowing the strain could start a shockwave of fear and end up having huge, harmful, and unjustified effects on poultry markets. So we waited. We turned out right this time – it was a low-path strain, with no human health implications. Still, by deciding to wait we forfeited some of the public trust we have earned in years past, and for that we apologize. And here’s what we plan to do next time a situation like this arises…. This example embodies many principles of risk communication and crisis communication – sharing dilemmas, acknowledging opinion diversity, apologizing for misbehaviors. From the perspective of empathy, what’s important about the example is that it doesn’t just bring stakeholders’ mistrust and disapproval into the room. It validates those reactions and expresses partial agreement with them. My clients generally find proactive acknowledgment profoundly counterintuitive, almost incomprehensible. Albeit reluctantly, they get that it’s important to acknowledge the truth (or partial truth) of accusations that people are actually leveling against them, when in fact those accusations are true (or partially true). The only alternative would be a dishonest denial, and they know that’s unwise as well as wrong. And after a short struggle they get that it is useful to respond empathically to people’s unarticulated feelings, to bring those feelings into the room. The only alternative would be to let the feelings stay underground, where they’re likely to distort everything else that’s happening in the organization’s stakeholder relations. But they rarely get that it can make sense to plead guilty before they’re accused. Isn’t that doing their detractors’ dirty work for them? And yet the principle that underlies proactive acknowledgment is one of the best-established principles in all of social science. It goes back to research in the 1950s by Hovland and others into one-sided versus two-sided

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argumentation. (As art rather than science, it goes back at least to Aristotle.) In a nutshell: When an audience is uninterested and uninformed, and likely to remain uninterested and uninformed, one-sided arguments are more persuasive than two-sided arguments. But when an audience is aware of information that supports the other side, or is interested enough to acquire such information later, then two-sided arguments are more persuasive. In other words, you should plead guilty before you’re accused when you’re talking to people who are likely to hear you accused sooner or later – and especially when you’re talking to people who are already accusing you in their minds. When stakeholders are thinking but not saying something negative about you, a lot of their energy is inevitably focused there – energy that could be better used elsewhere. They keep thinking it, muttering it under their breath, no matter whether they’re trying to keep themselves from saying it or trying to find the courage to say it. When you acknowledge it proactively – say it for them – you free up that energy. Once again, you’re not necessarily (and not usually) just plain pleading guilty. At worst you’re probably pleading guilty with extenuating circumstances. More likely still, you’re acknowledging a few senses in which you’re guilty, while clinging to your plea of overall innocence. Even lawyers, for whom one-sided communication comes most naturally, understand the value of admitting the other side’s best arguments in their summation – the jury’s already thinking about those arguments, and they’ll loom all the larger if they’re not conceded and put into context. And lawyers understand the value of mentioning the other side’s best arguments in their opening statement as well – the jury’s surely going to hear those arguments soon, and they’ll hurt less if they’ve already been previewed and put into context. Yes, there’s a heritage of colonialism and your mining company might still act like a colonial oppressor if it still could, but the shoe’s on the other foot now. Yes, it wasn’t transparent to suppress news of that low-pathogenic bird flu outbreak and you can understand why people might mistrust your agency because of it, but you really didn’t want to provoke an unjustified international boycott of your state’s poultry. Sometimes, of course, you’re completely in the wrong, and what’s called for really is a proactive total mea culpa. It would take something like saintliness to decide to own up proactively to misdeeds no one is ever likely to know about unless you come clean. But all it takes is wisdom to confess proactively before they inevitably catch you or when they already know you’re guilty. Parents know (and so do wise children) that proactive acknowledgment in such cases provokes forgiveness and reduces punishment. But most of the time there is truth on both sides. Acknowledging the part of the truth that’s not on your side doesn’t come naturally. But it shouldn’t be that much of a stretch when you sense that your stakeholders already have that part of the truth in mind anyway and you realize that it will loom far larger if it isn’t acknowledged than if it is … or when you predict that your stakeholders are bound to find out eventually and you realize that they will feel totally betrayed if you weren’t the first to tell them. I did a consultation today – literally in the middle of final editorial changes in this column – with an oil company whose newly hired CEO was involved in a big accident at his previous company. The major question on the floor was what the new CEO should say about the accident. I argued that he should raise the topic proactively, assuming it to be in stakeholders’ minds – and that once it’s under discussion he should never be the one to change the subject. And I argued that he should concede proactively, without waiting to be asked, that he feels responsible. Of course he can’t depict himself as legally responsible; he doesn’t believe he is, and he’s involved in litigation where he’ll be claiming he isn’t. But he needs to tell people what he has learned, what he would do differently if he had it to do again, and what he will do differently in his new job. Above all, he needs to confirm people’s unspoken belief that a tragic accident on his watch is a blot on his record. Even when you are mostly in the right, and even when your stakeholders are mostly on your side, there are still points of divergence. I sometimes call these the “yes buts.” (The term as applied to risk communication originated with Caron Chess.) When my clients tell me their stakeholders are likely to support a particular position they’re taking, I ask them whether there are any aspects of the position that their stakeholders will see as negatives. Those are the “yes buts.” Unexpressed “yes buts” can often keep a plan from going forward, even when most people are mostly in favor. If stakeholders are raising the “yes buts” on their own, fine; acknowledge them. But if for some reason stakeholders are harboring “yes buts” they’re not raising, I urge my clients to raise the “yes buts” themselves. Most importantly, I urge my clients to proactively acknowledge the validity of the “yes buts” that are valid. If you’re doing empathic risk communication, “Here are the downsides of our proposal….” is the sort of thing you

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should find yourself saying often. A client that has proposed a major new development in a forested area is currently preparing a public summary of its proposal. Of course the summary will explain how development will provide jobs and help the economy; of course it will cover the “conservation easements” that aim to balance the parts to be developed by guaranteeing that much of what’s left will remain forest forever. Of course the summary will explain why my client thinks its proposal is a good deal for the public. For the sake of empathic risk communication, the summary should also lay out the counterarguments – not just the ones my client can rebut, but also the ones it must simply concede are real disadvantages of what it wants to do. In any future influenza pandemic, one of the most readily available strategies to slow the spread of the disease will be frequent and thorough hand-washing. This sort of hygiene advice will inevitably sound painfully inadequate, which it is – and in some cases (on the bus, for instance) difficult to implement as well. To maximize the impact of their hygiene recommendations, pandemic communicators will need to acknowledge the “yes buts” that people may be feeling (often without saying so, sometimes without even realizing it consciously): “I know this doesn’t sound like much of a response to the most serious national health threat in decades, but….” “At the risk of sounding like a kindergarten teacher or even your mother, let me suggest….” “I realize that it’s hard to do in some situations, but whenever you can….” “Here is an obvious but often-ignored infection-fighting strategy we try to drum into new medical students….” If your stakeholders are ambivalent, as they often are, proactive acknowledgment also makes sense in terms of the risk communication seesaw. In talking with clients and prospective clients, for example, I often make a point of referring to myself as “expensive” or sometimes “exorbitantly expensive.” They have to know what I charge. If they’re privately aghast at my hourly rate, my proactive acknowledgment gets it into the room without forcing them to plead poverty or express disapproval – and that makes the rate a little less objectionable. Maybe it will help them feel more comfortable telling me my price is too high for them; maybe then they will counteroffer, or at the very least tell me “no thanks” instead of just disappearing. And if they’re ambivalent about my hourly rate, my proactive acknowledgment that it’s high increases the likelihood that they’ll say to themselves, “yeah, but maybe he’s worth it.” Similarly, every time I write a long column (like this one) I make sure to mention at least once how damn long the column is. I’ve already decided not to keep it short; I want to say everything I’ve got to say, and I’m more committed to being thorough than to being user-friendly. But at least I can admit it proactively. It’s not like you won’t notice if I don’t mention it. Okay. Let’s summarize: If it’s negative and it’s false and your stakeholders are accusing you of it – find a time and place to correct the record but don’t focus on it too much; searching for points of agreement (#6) is more useful. If it’s negative and it’s false and your stakeholders are thinking about it but not raising it overtly – use counterassumptive and counterprojective statements (#8) to try to correct the error without confronting it, and use deflected empathic statements (#3, #7) to get the feelings into the room. If it’s negative and it’s true and your stakeholders are accusing you of it – admit it. That’s agreement (#6). If it’s negative and it’s true and your stakeholders are bound to find out – admit it. That’s proactive acknowledgment (#9). If it’s negative and it’s true and your stakeholders are thinking about it but not raising it overtly – admit it. That’s proactive acknowledgment too (#9). If it’s negative and it’s true and your stakeholders will never know unless you tell them – see your clergyperson. (My opinion on ethical dilemmas isn’t a professional opinion; I’m a risk communication expert, not an ethicist.) There’s one possibility not on this list: If it’s negative and it’s true and you learn that your stakeholders are about to accuse you of it. Opinions differ on this one. There’s a case to be made for just-in-time acknowledgment, preemptive acknowledgment. It’s a bit like turning yourself in moments before the cops knock on your door; maybe you’ll get a little time off for being proactive. But there’s also a case to be made for

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waiting till the accusation is made, since you know it’s coming, and then doing your acknowledgment thing. Sometimes stakeholders can find preemptive acknowledgment all the more infuriating. It can look like you had a slick, well-rehearsed plan to go public only if you were about to get caught. One way to make this judgment call is to ask yourself what’s in your own mind. If you’re thinking, “that’ll take the wind out of their sails,” your preemptive intention is more hostile than apologetic. It’s probably better to give your critics the satisfaction of catching you fair and square – wait and let them raise the issue. (When they do, be sure to acknowledge and apologize promptly; there’s nothing to be gained by evading or protesting.) But if you’re thinking, “it’s time to own up and face the music,” then there’s a good chance your acknowledgment will be experienced as proactive, not preemptive.

10. Performatives: “I Hope the Situation Will Improve Soon” Havens ends Making Contact with a short section on “Performative Language.” The concept of performative statements was introduced by philosopher J.L. Austin, particularly in his influential 1962 book, How To Do Things with Words. The basic concept is obvious once it’s pointed out: Some statements don’t state a claim but rather perform an action. The Wikipedia entry on “performative utterance” has a wonderful list of typical performatives. Here are some of them: “I now pronounce you man and wife.” “I christen you….” “I apologize.” “I accept your apology.” “I divorce you, I divorce you, I divorce you.” “I promise to be there.” “This meeting is now adjourned.” “The court is now in session.” “I sentence you to death.” Of course performatives don’t automatically happen. Havens quotes Austin’s example of the performative “I appoint you…,” which isn’t valid “when you have already been appointed, or when someone else has been appointed, or when I am not entitled to appoint, or when you are a horse.” Similarly, consider the performative “I apologize.” The apology may be insincere, or sincere but not believed, or believed but not accepted. Apologizing doesn’t necessarily resolve the other person’s grievance. Nonetheless, apologizing isn’t just claiming to apologize. It’s apologizing. It does what it says. Some performatives are more complicated, because they both state a claim and perform an action. When a baseball umpire calls a runner “Out!” he is simultaneously judging that the ball reached the base ahead of the runner and causing the runner to go back to the dugout. And when a beloved spouse murmurs “I love you” she is simultaneously claiming to have a particular feeling and arousing that feeling (in herself and her husband both). Similarly, as Havens explains, “I admire you” is on one level a claim that may be true or false; but on another level it’s a performative, because it tends to make you feel admired. “I admire how generous you are” is more complicated still. It states two claims, that you are generous and that I admire generosity; as a performative it makes you likelier to feel generous and likelier to feel that your generosity is a good thing. “I hate how self-sacrificing you are” appraises the same behaviors very differently, and will have very different performative impacts. Performatives are powerful interpersonal statements: They establish an “I” that is appointing, apologizing, umpiring, loving, or admiring. Performatives can also be powerfully empathic statements, especially when enacted on behalf of stakeholders. Probably the most powerful empathic use of performatives is to express hopes, wishes, regrets, fears, and worries. “I hope the situation will improve soon” is a performative statement because the statement doesn’t just claim as a matter of fact that if you looked inside my mind you would find hope. It expresses the hope. It performs

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hopefulness. The statement itself hopes. (By contrast, the statement “I eat” doesn’t eat; it merely claims that I do.) I am amazed at how seldom my clients tell their stakeholders their hopes and wishes. Even if your hopes and wishes are quite different from those of your stakeholders, expressing them is still humanizing; it establishes that you are a person who has hopes and wishes. If they are hopes and wishes your stakeholders share, then expressing them builds commonality. And if they are hopes and wishes your stakeholders share but cannot easily acknowledge, expressing them is profoundly empathic. “I wish we were back in a pre-9/11 world.” “I hope someday our enemies will agree to live and let live.” “If only we could just nuke ’em all.” (There are some hopes and wishes that your stakeholders daren’t acknowledge and you daren’t acknowledge either. One or more of these three may well be in that category.) Achievable hopes are well worth expressing. In fact, every time you are tempted to make a promise, consider whether you’d be wiser to downgrade it to a hope. And every time you are tempted to say you’re “confident” about some good outcome (getting the fire under control quickly, for example), consider whether it would be more accurate, more credible, more sustainable, and more empathic to change “confident” to “hopeful.” But expressing unachievable wishes is even more valuable than expressing achievable hopes. “I wish I could give you a definite answer” is more empathic than “I simply cannot give you a definite answer.” “I wish that damn accident had never happened” is more empathic than “I know you wish the accident had never happened.” “I wish we could take every conceivable precaution” is more empathic than “It’s foolish to imagine we could take every conceivable precaution” (and more honest than “we’re taking every conceivable precaution”). Regrets are unachievable wishes about the past. And so expressing shared regrets is also extremely empathic. The actual word “regret” has lost its empathic power from overuse in legal contexts; “management regrets to inform you…” doesn’t sound regretful or empathic anymore. “I wish we had realized…” does. So does “If only we had realized….” Finally, fears and worries are the flip side of hopes; they are what we hope won’t happen. Not surprisingly, then, expressing shared fears and worries is a powerful way to show empathy, especially if they are feelings that your stakeholders have trouble expressing for themselves. Choose your words carefully. If you say you’re “concerned” when stakeholders are terrified, it’s going to sound minimizing rather than empathic. If you say you’re “terrified” when stakeholders are merely concerned, you may frighten them more than you intended, or they may start worrying empathically about the state of your emotions. Needless to say, the first error is a lot more common than the second. But in a frightening situation, even official expressions of concern are more empathic than the conventional (and conventionally false) insistence that “There is no reason for concern.” Bottom line: When you are about to claim that there is no reason for concern, consider acknowledging instead that you (too) are concerned. Then ask yourself if you are actually worried. If you are, try to force yourself to say “worried.” Performatives can be deflected and qualified as much or as little as you think best, depending on how “deniable” they need to be to avoid over-intrusiveness. Thus “I admire how generous you are” can morph into “Everyone admires that kind of generosity” or “It’s admirable how generous that was.” “I wish I could give you a more definite answer” can become “Many people wish there were a more definite answer” or “We all wish there were a more definite answer” or “I think we all probably wish there were a more definite answer.” Some Examples from Earth Empathic statements, counterassumptive statements, counterprojective statements, performative statements – all that obscure jargon from psychiatry and even philosophy. (Yes, glad you noticed. This is itself an empathic statement.) What does it mean down here on earth? I hope you will collect your own down-to-earth examples – from media stories of risk controversies; from Terry Gross interviews; from your own interactions with family, friends, colleagues, and stakeholders. Figure out what makes them empathic. If you like thinking in categories, figure out what category they’re in – or make up a new category if you need one.

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If you find (or create) a really good example of empathic risk communication and you don’t mind sharing it, please email it to me at peter@psandman.com. If I get a good collection, I’ll add an appendix of “Some Examples from Earth.” Afterword by Jody Lanard In the wondrous age of Google searches and tags, I would tag this column Risk Communication, Empathy, Havens, Buber, Sandman (although Buber is mentioned only briefly). What is a reductionist seat-of-the-pants risk communication consultant like Peter Sandman doing on a list with psychiatrist Leston Havens and philosopher Martin Buber? What are Havens and Buber doing in a risk communication publication at all? In the genealogy of risk communication, other important influences are far more obvious than Havens and Buber: The psychometric paradigm of risk perception, developed by Slovic et al., which underlies Sandman’s most famous formulation, “Risk = Hazard + Outrage.” The profoundly influential work of Kahneman and Tversky on the framing of decisions, prospect theory, and judgment under uncertainty (heuristics and biases). But at its deepest roots, our philosophy of empathic risk communication springs from the ideas of Leston Havens and Martin Buber. In Peter’s column, he tries for the first time to bring Les Haven’s work to life for students and practitioners of risk communication. It almost feels like an oxymoron, to try to operationalize empathy. Les Havens was brave and brilliant enough to do this in his 1986 masterpiece, Making Contact: Uses of Language in Psychotherapy. A Boston Globe reviewer called the book a “grammar of empathy.” Les Havens was one of my most beloved teachers in the years surrounding the book’s publication. When I introduced Peter to Les’s work in 1985, I cautioned him, as my fellow students and I always cautioned each other, that Les’s teachings could not, should not, be turned into a cookbook or checklist for communicating. Nevertheless, it often seemed like novices were doing exactly that, when they practiced using some of Havens’s difficult approaches. This sometimes led to scorn from more advanced practitioners or from closer “disciples” of Dr. Havens – a very unempathic response to abashed students taking brave baby steps! In the 1960s at Princeton University, Peter passionately studied the work of Martin Buber with his beloved professor, Buber scholar Malcolm Diamond, and with philosopher Walter Kaufmann, who later translated Buber’s masterpiece, I and Thou. Another Buber scholar, Robert E. Wood, discussed the “fraught” issue of trying to analyze and use a complex structure such as Buber’s: The attempt at analysis, though indeed fraught with the very serious danger of destroying the immediacy of experience, likewise puts us in a position of being able eventually to experience the immediate more profoundly…'. [T]here comes a time when, through persistence in analysis, along with attention to immediacy, immediacy itself is deepened. The musical score, as Buber observes, is not the same as the musical performance; and yet we may add that an understanding of the score may eventually enhance the appreciation of the performance. — Robert E. Wood, in Martin Buber’s Ontology This applies as well to the work of Leston Havens, and to future attempts of risk communicators to embrace this work. I think it was courageous of Peter to take the risk of trying to operationalize empathy, to build guidelines but not a cookbook around the difficult thinking of Havens and Buber. I hope you will take the comparable risk: the risk of trying new approaches that might feel stilted or forced at first, even if they feel stilted or forced at first. I believe it will help your efforts at Making Contact. Copyright © 2007 by Peter M. Sandman

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