Healing through Communication: The Practice of Caring
Advancing caring as an intrinsic part of nursing, the author of this volume offers a theory of caring that is grounded in both clinical practice and existing theory. Author Carol Leppanen Montgomery describes the qualities and behavioral manifestations the caregiver needs to communicate caring and the unique qualities of the health care system that shape the communication of caring. She then lauds transformative effects of caring while admitting the emotional risks caregivers undertake. Finally, a model is presented that describes the support necessary to sustain this level of communication and to help caregivers cope with the emotional demands of caring.
Demonstrating the depth and complexity of caring communication, Healing Through Communication is a valuable resource for caregivers in all the helping disciplines, especially nursing, allied health, ...
- Front Matter
- Back Matter
- Subject Index
Part I: The Concept of Caring
- Chapter 1: Putting the Caring Back into Health Care
- The Significance of Caring in Health Care
- What is Caring?
- The Limitations of Psychological Models
- Chapter 2: Theoretical Foundations of Caring
- Communication Theories Related to Caring
- Theories of Caring
Part II: The Theory of Caring
- Chapter 3: Caring Begins with the Caregiver: Predispositional Qualities of the Caregiver
- Person Orientation versus Role Orientation
- Concern for the Human Element of Health Care
- Person-Centered Intention
- Transcending Judgment
- Hopeful Orientation
- Lack of Ego Involvement
- Expanded Personal Boundaries
- Chapter 4: Caring in Action: Behavioral Qualities
- Empowerment through the Mobilization of Resources
- Being Present with the Patient
- Creating Positive Meaning and Hope
- Chapter 5: Caring Unfolds with the Client: Relational Qualities
- Deep Emotional Involvement
- Self-Awareness and Purposeful Use of Self
- Inter Subjectivity
- Aesthetic Qualities
- Transcendent Qualities
- Chapter 6: Caring is Contextual: The Health-Care Environment
- The Intense Nature of the Health-Care Context
- Team Participation
- Patient Participation
- Chapter 7: The Distinct Nature of a Professional Caring Involvement
- Self-Awareness and Purposeful Use of Self
- Lack of Ego Involvement
- Empowerment through the Mobilization of Resources
- Contextual Support
- Level of Skill Development
Part III: The Effects of Caring
- Chapter 8: The Transformative Effects of Caring
- Effects on the Caregiver
- Effects on the Patient
- Chapter 9: The Emotional Risks of Caring
- Experience of Personal Loss
- Emotional Overload
- Chapter 10: Coping with the Emotional Demands of Caring
- Personal Resources That Sustain Caring
- Contextual Resources That Sustain Caring
- Chapter 11: Implications for Practice and Education
- Reclaiming the Value of Caring
- Promoting Caring Communication in Education and Practice
To my son David, and to the memory of my mother, Claire Harcourt Leppanen
Copyright © 1993 by Sage Publications, Inc.
All rights reserved. No part of this book may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher.
Quotes from Montgomery (1991a) are reprinted by permission of the publisher.
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Library of Congress Cataloging-in-Publication Data
Montgomery, Carol Leppanen.
Healing through communication: the practice of caring/Carol Leppanen Montgomery.
Includes bibliographical references and index.
ISBN 0-8039-5120-5 (cl.).—ISBN 0-8039-5121-3 (pbk.)
1. Caring. 2. Medical personnel and patient. 3. Patients—Psychology. 4. Caregivers—Psychology. I. Title.
[DNLM: 1. Communication. 2. Professional-Patient Relations. 3. Caregivers—psychology. W 62 M7867h 1993]
01 12 11
Sage Production Editor: Tara S. Mead
At one time, medical advances and technology seemed to promise deliverance from the threat of our own vulnerability and mortality. As Daniel Callahan once noted, however, this promise has yet to be fulfilled. Mortality rates are still the same as they have always beeb—one per person.
So, while science and technology still struggle to buffer the onslaughts of illness, debilitation, and death, these threats continue to be a part of our human existence, and we are still faced with our own mortality. We have controlled such scourges as polio and the whooping cough, but new plagues, such as cancer and AIDS, continue to touch the lives of most individuals. Even those who practice every preventive control strategy are not invulnerable, and none of us is immune from the threat of loss of our loved ones.
All we have left when control strategies fail us, and breakdown occurs, are the compassion and caring that we extend to one another. Unfortunately, during our fascination with the promise of technology, we lost sight of the importance of this human element.
In our culture, caring is viewed as frivolous compared to the real work of curing. Our cultural heros are those who represent power—the power to save us from the invisible demons that seem to cause our suffering. Yet each day, a very different form of heroics is shown by those who stand by and care for those for whom technology has failed: the disabled, the chronically ill, and the dying. [Page x]Our society shuns these victims, for they represent our failures and loss of control. As these victims are shunned, the efforts to help them create a meaningful existence are also ignored and devalued.
In this book, I would like to shed light on this underacknowledged, but very important, part of health care and to recognize caring as being more than mere sentiment. I will at least begin to address the complexity and depth of insight that is required of those professionals brave enough to get involved beyond their professional persona, and who use their hearts as well as their science to heal. It is my hope that this text will inspire caregivers to give a voice to and advocate for what Jean Watson would call the private and invisible world of a patient. I also hope that both students and seasoned clinicians will be reinspired to find meaning and joy in their work, as I have been reinspired by my work on this project.
The use of the terms client and patient was considered in terms of their implications. It has been fashionable in some disciplines to substitute the word client for patient because of the paternalistic implications of the role of the patient in the health-care system. On the other hand, the term client might seem artificial in some settings, because it seems to deny the vulnerability and special status afforded to those who are truly helpless. Therefore, both of these terms are used throughout this text, to represent both connotations of the experience of being a recipient of health-care services.
I am extremely grateful to Trish Jones, my dissertation chair, for her belief that scholarship should make a difference in the world. Her courage in taking risks and her unrelenting, but supportive rigor have been a great example. I also wish to thank the rest of my committee: Al Goldberg, Carl Larson, Karol Merten, and Janet Quinn. A postbaccalaureate training grant from the Division of Health and Human Services funded the dissertation research, and the research committee, through the Center for Nursing Research at the University of Colorado, funded the continuation. Joanie Rogers Jackson, Debby Sandella, Pauli Sarasoli, Kay Vaughn, and Denny Webster all provided helpful feedback about the manuscript and the developing theory.
The Center for Human Caring at the University of Colorado School of Nursing has provided intellectual stimulation, especially with the ideas of Peggy Chinn, Sally Gadow, Janet Quinn, and the founder, Jean Watson. Similarly, I wish I could acknowledge those countless students, workshop participants, and colleagues who stimulated my thinking and provided me with new ideas about caring.
Many nurses with whom I have worked in the past have taught me so much and made me proud to be a nurse. The two that stand out in my mind are Charlene Miller and Kay Davis. Recently, I had the good fortune to discover the work of Rachel Corday, an artist whose vision has helped me to appreciate caring and spirituality in a whole new way.[Page xii]
Finally, my most important debt of gratitude goes to the participants in this research. Their stories, their insights, and the sheer depth of their practice went far beyond what I had expected to find when I started this project. These individual caregivers are the heart and soul of this book.
The following story is from “Ode to the Psychiatric Nurse” by Rachel Corday (tape and manuscript available through the Boulder Alliance for the Mentally 111).
From her room one day, Cooper hears David screaming. David is still a boy and when he screams, it is like a terrified child who cannot be consoled.
“I pulled myself to my feet,” Cooper says, “for my voices weighed heavy against my brain like an iron slab. I pushed them away by crawling out from underneath and found my way to David's door. He screamed again in a wail as I got to his room. I saw then something I had never seen on the ward.
“Mrs. Harrington, the nurse, was there and had pried David away from the wall where he had pounded his head over and over, the way he did at these times. Nothing, it seemed, could stop him. And he would keep on until the aides restrained him or until he had knocked himself unconscious. But Mrs. Harrington had stopped him in time, although his blood ran down the wall.
“She held him against her breast and he bled against her uniform. She sunk with him to the floor as she braced him with her body.
“‘David, David,’ she said, ‘no, no, it's alright now.’
“She surrounded him in her arms as if to hold him everywhere.
“‘David,’ she said, ‘no, no.’[Page 136]
“Then she came to rest with him against the wall. She rocked him and pressed her cheek against the side of his head. Her face was as if enjoined with him, so intensely was she with him, so perfectly did she care. And David heard her.
“‘It's me, David, stop now. You know me. David, David, David.’
“And he became still and his shoulders dropped and his head rested onto her breast as if it had belonged there all along.
“‘Yes,’ she said. ‘It's alright now. No one's going to hurt you. I have you.’
“The aides were there, and someone with a shot. But no one moved in the silence, but stood inside the doorway, their arms fallen to their sides. They gazed across the room at David's stillness, and at Mrs. Harrington as she rocked with him, as if to some ancient rhythm.
“She did no more than gently close her eyes as David's blood upon her cheek mixed with her tears and dropped onto his back and spread into a circle of stain that had in mind some pattern of its own to make. Some memory that, suspended in time, would return and return again.”
Appendix: Guidelines to Prevent Becoming Involved in a Destructive Way[Page 137]
What is it about this person that I am overinvolved with? For example, am I fascinated with the pathology or the symptoms? Do I identify with the problem?
(The problem with these questions is that if you answer “yes,” it does not necessarily indicate the wrong kind of involvement. For example, identification with a client is not a problem unless it is a destructive identification. Those who are most at risk might answer “no,” as they are probably unaware of the needs that are driving the relationship with the client).
Is something about this client's personality or situation getting me “heated up”?
(This is okay and can provide motivation for advocacy. The danger arises when we get caught up in principle at the expense of the client by making the client a “cause.” Another danger is that this may be our battle, although we may not be aware of it and may think that it is the client's need.)
Is my ego getting caught up in this situation? Will this case prove my abilities or worth as a clinician? Have I, as a helper, become [Page 138]the focus of this experience rather than the client? Do I think I'm the only one who can help?
(It's hard to admit when we get our egos caught up in our work. One caregiver explained that she will get a swelled heart rather than a swelled head when she has a caring experience.)
Can I stand back and look at this situation from a variety of perspectives? Can I hear the team's point of view, the family's?
(If we become too immersed in the client's inner world without an alternative perspective, we will no longer be a resource for that person.)
Might I be unwittingly using this relationship to work out some pain from my own personal history?
(While helping others with similar problems can be a very healing practice, it requires that we have healed ourselves. For this reason, and many others, many people in the human service fields find counseling, psychotherapy, or other healing work helpful.)
Am I acting as “The Lone Ranger,” rather than trying to mobilize a team response?
(Successful caregivers will see themselves as part of a team even if they have to create one from community/client resources.)
Am I empowering this person by doing the very least possible for the person so that I don't take away any of the client's potential?
(This may be difficult because it means allowing yourself to watch someone struggle to solve problems instead of just taking over yourself and doing it for the person.)
Do I believe in the inherent competence of this client? Do I feel a sense of hope for the client?
(Every client has strengths and inner resources that have not yet been mobilized. If we become immersed in the client's own sense of de-spair [Page 139]and helplessness, then we will probably diminish them and create the client's dependency on us and on the system.)
Have I utilized all existing resources on behalf of this client. Have I created some if there aren't any?
(Remember that when caring, you strive to be like a conductor of an orchestra, bringing all the resources to life, rather than being the main resource yourself.)
Do I have a preconceived idea of what I would like the outcome to be for this client?
(While we all have to be professionally accountable for outcomes, to take this on as though we really know what the best outcome for this person should be is arrogant. While we do the best we can, successful caregivers strive just to make a difference for the client, no matter how small it might seem, rather than to try to control the client or what happens to the client.)
Am I avoiding my own life by becoming so caught up with this client or with my work in general?
(Sometimes, when we are in a personal crisis, it can be helpful to temporarily lose ourselves in work, but to allow work to become part of a pattern of avoidance is the antithesis of caring.)
Is there a sense of harmony, or a beautiful feeling, even in the face of tragic circumstances, or do I feel emotionally drained without a sense of meaning?
(This is probably the most challenging question, for which there is no easy answer. You should always strive to make sense out of what you are exposed to and make use of all the spiritual, philosophical, and psychological resources that can help you do this. If it is just too much, then it is okay to back off emotionally and distance yourself in whatever way you can.)
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