Applied Psychology for Nurses

We can acquire habits of thinking and habits of feeling as well as habits of doing.

But the other habits, the bad ones, are not acquired with effort. We fall into them. Hazy thinking is easier than clear thinking. Suppose you are by nature rather oversanguine or overdespondent, and you make no genuine attempt to evolve that nature into poise. Directing will to do what desire opposes is too difficult, and you go the way of least resistance. So easily are the bad habits formed; but only with tremendous effort of will and persistence in refusing their insistent demands can they be broken or replaced by helpful ones.

The nurse meets in her patients numberless habits which retard recovery of body and make for an unwholesome mental attitude. Some patients have the complaint habit, some the irritation habit, some the self-protection habit, some the habit of impatience, some of reckless expression of despair, some of loss of control, some of incessant self-attention. The nurse who can arouse an incentive to habits of cheer expression when the least cause of cheer appears, who can by reason, or if that is not possible, by suggestion; by holding out incentives, or by making some privilege depend upon control—this nurse can help her patient to displace habits of an illness-accepting mind by habits of a health-accepting one. Above all, let her beware of opening the way to habits of invalidism. Some people acquire the “hospital habit” because it is easier to give way to ill-feeling, however slight, and to be cared for with comfort, than to encourage themselves to build up endurance by giving little attention to minor ailments.

We have touched upon only a few of the laws of the mind. The nurse can help develop saving mental habits and wholesome attitudes while she helps to strengthen sick bodies; she can make a cure a little more certainly lasting who will remember that:

1. Adaptability is essential to life and health.
2. There is no neurosis without a psychosis.
3. Suggestion may be a powerful factor for health.
4. What we attend to determines what we are.
5. Thought substitution is possible.
6. Habit is a conserver of effort.
7. Will is a saving power.

Life would be a very simple proposition if the mental machinery always worked right. But this is peculiarly subject to damage both from without and from within. From without it may be damaged by the toxins of food, as in the acute toxic psychoses; by the poison of drink, as in the alcohol-produced psychoses, such as acute alcoholic hallucinosis; by lack of muscular exercise, resulting in a deficient supply of oxygen to burn up the accumulated toxins from energy-producing foods; by the infections, which may result in the infection-exhaustion psychoses; by wrong methods of education, and by surroundings which demand too severe a mental strain in the struggle toward adjustment. These damages from without we class roughly as environmental.

There may be disorders of any or every function of the intellect, disorders of feeling, and perversions of will. Some of the most commonly met we list below.

From this limited survey of the mind’s disorders we realize that every departure from the normal mental attitude tends to associate itself with one of the following five states of mental disability.

• Depression,
• Exaltation,
• Perversion,
• Enfeeblement,
• Deficiency.

Hyperesthesia is abnormal sensitiveness to stimulation.

Anesthesia is loss, either temporary or permanent, of any of the senses.

Perversion is morbid alteration of function which may occur in emotional, intellectual, or volitional fields.

Example: The odor of a rose causing an acute sense of physical pain.

An illusion is a false interpretation of a perception.

The normal mind is quite subject to illusions, either due to a faulty sense organ, or to a preconceived state of mind which so strongly expects or presages something else than reality as to misinterpret what the senses bring.

An hallucination is a perception without an object.

There are possible hallucinations of every sense. Nonexistent objects are seen, touched, tasted, heard, or smelled.

Hypochondriasis is a state characterized by persistent ideas of non-existent physical disabilities.

The hypochondriac has every known symptom of indigestion, or of heart disease, or is threatened with tuberculosis—all in his mind; and whatever the disorder he seizes upon, his attention hovers there, while the ideas of that particular disability persist and strengthen.

A flight of ideas is an abnormal rapidity of the stream of thought.

Every perception so immediately is linked with some association of experience that expression is swift and often incoherent. One word will follow another with amazing rapidity, words suggested by sound association, usually, rather than by that of meaning.

Example: “Made a rhyme, had a dime, did a crime, got the time, bring some lime.” This association by rhyme is quite common. But the associations of meaning are not uncommon.

Example: “Made a rhyme. Mary was a poet. Mary had a little lamb. Where’s Mary?—Mary!—No Jim—Jim, all my children—calling, calling, calling,” etc.

Example: In hypochondriasis, as given above.

Ideogenous pains are either pains born of an erroneous idea, or mental reproductions of pains now having no physical cause.

A suggestible person, learning that his grandfather died of an organic heart, conceives the idea that he has inherited the trouble, and begins to suffer cardiac pains; and as long as the idea persists the pain is felt.

Compulsive ideas are ideas which intrude, recur, and persist despite reason and will.

Example: The compulsive idea of contamination may lead its victim to wash and rewash his hands at every contact with matter, until finally, though they are raw and sore, he is incapable of resisting the act.

Disorientation is a state of mental confusion as to time, place, or identity.

Amnesia is pathologic forgetfulness.

Example: As sometimes found in the infection-exhaustion psychoses, when the entire past of the patient may be wiped out for the time. Cases of permanent amnesia are known.

Aphasia is a defect in the interpretation or production of language.

A delusion is a false belief which cannot be corrected by reason.

A somatic delusion is one centering upon alterations in the organs or their functions.

Example: Absence of a stomach, inability to swallow.

A nihilistic delusion is one which denies existence in whole or part.

Example: Mother denies the existence of her child.

A delusion of reference is one in which the deluded individual believes himself an object of written, spoken, or implied comment.

Example: The actors on the stage are directing their remarks directly against the victim in the box.

A shut-in personality is one that habitually responds inadequately to normal social appeal.

Sense of unreality is one of the commonest psychic alterations through which customary sensation states are displaced by unnatural and usually distressing ones.

Morbid inhibition is an abnormal, negative activity of the will.

An obsession is an idea which morbidly dominates the mind, constantly suggesting irrational action.

Obsessed patients may consistently step in such a way as to avoid the juncture of the flagstones on the pavement; may insist on removing their shoes in church; may hail each person met on the street and tap him on the arm; may refuse to ever leave the house without an open umbrella; or may try to attack every man they see, not because they want to hurt or kill, but because they are obsessed to the performance of the action.

A tic is a useless, habitual spasm of a muscle imitating a once purposeful action.

Motor tics, such as habitual jerking of the arms, shrugging the shoulder, contorting the face, shaking or nodding the head, snapping the fingers, etc., are very common among nervous children, and even in many otherwise normal grown-ups.

Distractibility is an abnormal variation of attention.

The common inability of the hypomanic patient to hold his attention to any subject when another is open, is very like the distractibility of the child who turns to every new interest as it is presented.

It is with these patients as though not only initiative were lost but also the power to follow another’s lead. But their independence asserts itself in opposing every suggestion and in acting so far as possible contrary to it.

Mutism, as used in psychiatry, is an abnormal inhibition to speech.

Patients sometimes speak no word in many months. To all appearance they are true mutes. Then suddenly something may remove the mental blockade and they talk.

Compulsive acts are acts contrary to reason, which the will cannot prevent.

A seemingly quite normal patient will sometimes grab a vase from a stand in passing, and dash it to the floor. Something “urged” him to do it, and he could not resist. Others will tear their clothes to shreds, not in anger, but because they “could not help it.”

Psychomotor overactivity is abnormal activity of both mind and body, contrary to reason and uncontrolled by will.

Psychomotor retardation is an underactivity of both mind and body in which consciousness is dulled and the body sluggish.

A neurosis is a disorder of the nerves, which may be functional or organic.

Psychosis is the technical synonym for insanity.

Borderland disorders constitute a group in which mental perversions do not yet so dominate reactions as to make them irrational.

Twilight is neither night nor day; the feelings of the hysteric are not insane, but the actions may be.

Insanity is a prolonged departure from the individual’s normal standard of thinking, feeling, and acting.

Mania is insane excitement.

Melancholia is the inability of the mind to react to any stimulus with other than gloom and depression.

Melancholia may be of the intellectual type or of the emotional type. The patient who tells you constantly that he has murdered all his children, that he is a criminal beyond the power of God to redeem, who seems chained to his delusions, yet shows no adequate feeling reaction, no genuine sorrow, we call a case of the intellectual type of melancholia. Another patient misinterprets every normal reason for happiness until it becomes a cause of settled foreboding. The mother, whose son fought safely through the war and is now returning to her, feels that his coming forecasts calamity for him. He had better have died in France. She is of the emotional type of melancholia.

Hysteria is a nervous disorder based upon suggestibility, and capable of imitating most known diseases.

Example: The impulse to kill, quite regardless of who may be the victim.

Psychopathic personality is a term much used today to designate an hereditary tendency on the part of the individual to mental disorder.

The neuropath is the individual with an inborn tendency to the neurosis.

Neurotic is a term broadly employed for the nervous in whom emotions predominate over reason.

Neurasthenia is a nervous disorder characterized by undue fatiguability.

Psychasthenia is a nervous disorder characterized by a sense of unreality, weakness of will, self-accusation, and usually by phobias and obsessions, all subject to temporary correction by reason or influence from without.

Hypochondriasis is a disorder characterized by morbid attention to bodily sensations, and insistent ideas of bodily disorder.

Phobia is a morbid fear or dread.

When we realize, too, that we are born with certain inherent tendencies of temperament, which are too often of the melancholic or overcholeric type, our wonder grows that we are not doomed to defeat at birth. Were it not for the possibilities in the germ-plasm of choosing the much of good also in our heredity, often enough to overbalance the bad, and for the proved power of environment and training to modify or even altogether overcome the harmful parts of our birthright, there would be little hope for many.

What will decide whether a human being can resist, successfully, bad tendencies in heredity, or in environment, or in both, and keep a reasonably balanced mind? It demands insight, ambition, will; and if these remain the body can be forced to saving ways of health, and body and mind can largely make their own environment. But with heavy handicaps of heredity or environment, or both, and poor insight, or lack of desire, or weak will, nothing can save the mind from neurotic taint or worse—nothing but obedience to some one strong enough to control the habits of that life, until self-control is born. And there is a hope that it can be born in the most neurotic or neurasthenic, so long as the mind is sane.

Attention naturally follows interest. It can, however, be held by will to the unappealing, with the usual result of transforming it into a thing of interest.

One of the laws of the mind we have already stressed is that what we attend to largely determines what we are, or shall be. The interests which secure our consideration may be the passive result of emotional life, the things which naturally appeal, which give us sensations that the mind normally heeds; or they may be the active result of our will which has forced application upon the things which reason advised as worth acquiring.

Some of the most charming people we shall ever know are those temperamental children of happiness whose interests are naturally wholesome and externalized, whose natures are spontaneous and joyous, and who live as they feel, seemingly never knowing the stress of forced concentration. With them attention follows feeling, feeling is sweet and true, and volition simply carries out what feeling dictates. And life may not be complicated.

But neither of these two groups can long withstand the stress of a world they only feel and have never attempted to comprehend. The irresponsibly happy ones are too often crushed and broken when life proves to bring loss and failure and disappointment; the morbid probably will cease some day to enjoy their melancholic moods, and be unable to find their way out of them. If both had learned to control attention, they might have been saved. The happy, care-free child of the light is at desperate loss when the sun he loves is obscured, if he has not learned to look upon the far side of the clouds to find that there they glow golden with the rays temporarily shut from him. Because clouds were not interesting to him he never attended to them—and now he cannot. If the pessimistic, morbid one had looked away from the shadow to the sun it hid he, too, in the end might have seen with sane eyes and lived so wholesomely as to find all the good there was in life. Willed attention, rather than spineless feeling distractibility, might have saved him.

I am an undisciplined child and I want only candy for my lunch. It is not good for me. Milk is what I should have. I don’t want it. You may deprive me of the candy and force me to drink the milk, and I can do nothing but submit. But I rebel within, and I am only more convinced that I “hate” it and want candy, and that you are my natural enemy because you force the one upon me and deprive me of the other. If I were insane and so, of course, could not be reasoned with, this might be inevitable. But it would be unfortunate. In that case, if possible, do not let me see the candy; let only the food it is best for me to have be put before me, and perhaps eventually I shall come to want the more wholesome thing—for it is better than the hunger.

This attitude on the part of the nurse presupposes that her own attention, while with her patient, is upon him and upon securing his health, and not upon her tiredness, or boredom, or headache, or the party tonight, or the man who has asked her to go to the theater with him tomorrow. She, surely, must learn to direct her thoughts where reason suggests, and to gain new interests through willed attention, or as a nurse she is less than second rate. Nor can she get the best results until she can turn with a single mind to the patient at hand as the immediate problem to be solved. And probably neither nurse nor doctor does any better service, except in saving life itself, than in keeping the patient from thinking constantly of himself and his ills. For it seems of little use to have made some people physically well, if they are to carry through prolonged years the curse of constant self-attention, self-centeredness, an ingrowing ego.

1. Attention naturally follows interest.
2. Attention may be held by will where reason directs.
3. New interests grow out of willed attention.

   A fourth we shall stress before considering the use the nurse can make of them:

4. The thing to which our chief attention is given becomes the most important thing.

Do not contradict this too quickly. Don’t say that nursing gets your chief consideration because it is, of necessity, your profession; but that you love your music infinitely more, and look forward to that through all your hours on duty. If this merely proves that music is distracting your attention, you are doing your nursing as a means, and not as an end; you give it probably all the attention necessary for good work, but your real desire is music. Your chief attention is directed toward that goal. Hence music is to you the most important thing. If your will is sufficiently trained to keep you from consciously thinking of it, still you are dreaming of it and working for it. You may make a very good nurse, but you will never be as excellent a one as the woman from whom nursing demands first and chief attention.

For the nurse herself in the care of patients let us draw some conclusions from these laws of the mind’s working:

1. Have a goal in view for the patient’s health of both body and mind.
2. Work toward instilling in your patient a health ambition—a pride in health.
3. Remember that overcrowding the mind defeats your purpose of making one clear impression.
4. Win interest by any legitimate means to the next step toward the goal, and only the next.
5. Work for attention to hopeful, courageous, and happy things.

The point of view of any individual depends upon temperament, present conditions—mental and physical—and the aim of the life. That is, it depends upon his inherited tendencies plus a unique personal something, plus all the facts of his environment and experience, plus what he lives for.

Richard and Jim both live in Philadelphia, Richard on Walnut Street and Jim on Sansom Street. Richard’s father is of the best Quaker stock, with hundreds of years of gentle and aristocratic ancestry behind him. He followed his father and his grandfather into the profession of medicine, and is a well-known specialist, alert, keen, expert, and deservedly honored. He is at home in Greek and Latin, French, and the sciences. He selects at a glance only the conservative best in art and music and literature. His world is a gentleman’s world, a scholar’s world, and the world of a scientist and a humanitarian. And Richard, his son, is true to type.

But suppose Jim isn’t true to type. From the time he was a mere youngster the ash-man life did not appeal to him. In school he liked the highbrow crowd; he “took to” Latin and literature. He has a feeling of vague disgust when he sees a vulgar picture, a shudder when the street-organ grinds. There is something in Jim different. He isn’t in tune with either his immediate heredity or his environment. The contribution from some remote ancestor has overbalanced the rest, and Jim becomes a professional man.

Or perhaps Richard breaks his father’s heart. Instead of following the trail already made, he cuts loose, frequents vulgar resorts, hates his school work, becomes a loafer and a bum—and, finally, a second-rate day laborer. Again, what he is himself, his “vital spark” has been stronger than immediate heredity and environment, and has broken through.

You hate my father. He injured yours—unjustly, to your mind, of course, for yours can do no wrong. From my point of view this father of mine is a great, good man. From your point of view he is wicked and cruel. We are both honest in our emotion-directed opinions. Until you can know my father as I know him, and I can know yours as you know him, we shall never agree about them. But I can learn to understand why you feel as you do, and you can learn to understand why I feel as I do. I can put myself, in imagination, in your place, and see that other man as my father, and pretty well grasp your point of view, and you can likewise get mine.

Let us not forget that what we see depends on whether or not our eyes are normal, on where we look, or on what kind of spectacles we wear. Two things we can change—where we look, and the spectacles. If our eyes were made wrong we probably cannot change that, but we can often correct poor vision by right artificial lenses. There are people doomed to live in most unattractive, crowded surroundings who make a flower-garden of charm and sweetness there, or, without grounds, keep a window-box of fragrance. The normal person can pretty largely either make the most impossible environment serve his ends or get into a better one. So we can usually look to something constructive, helpful, attractive, or beautiful; and we can refuse to wear blue spectacles.

We nurses soon realize that there are just about as many points of view as there are people, and that if we would help cure attitudes as well as bodies, and so lessen the tendency to sickness, it behooves us to learn to see what the other man sees through his eyes or by the use of his glasses, from where he stands.

Look about you from an aching mind and body, after days of suffering and sleeplessness, and unless you are a rare person and have a soul that sees the sunshine back of everything—you will find the world a place of torture. Look out from despair and loss of the ones you love best, or from failure of will to meet disaster, and everybody may be involved in bringing about your suffering, or in effecting your disgrace.

Look out from the resentful eyes and smarting mind of the negro who is just beginning in a northern city to realize that his boasted “equality” is a farce, and you will try to prove to the white nurse that you are as good as anybody. You are impossible; but back of all your bravado and swagger and rudeness and complaint of neglect because of your color, you realize that you cannot measure up. You know you belong to a different race, most of whose members are daily giving evidences of inferiority; and you are sure that the nurse is thinking that.

Look from the eyes of the “new rich,” or the very economical, and you are going to get your money’s worth out of your nurses.

The nurse who can get back of her patient’s forehead and put her mind there and let it work from the patient’s point of view, will learn a saving sense of humor, will be strict without antagonizing, will clear away a lot of mental clouds and help to make permanent the cure the treatment brings.

Unpleasant terms they are, and condemning ones if accepted as final. When the nurse realizes that under the same conditions she would probably merit them herself, she becomes more anxious to remove the conditions, and less bent upon blame.

Shall we not remember that our trying, cranky, stubborn patient is a sick person, and learn to treat that stubbornness or crankiness as a symptom indicating her need, just as we would a rising temperature?

When we can meet her attitude with comprehension, and, if necessary, with quietly firm disregard, then we are beginning to be good nurses.

Old Isaac Walton wrote a book many, many years ago called “The Complete Angler.” He was a famous amateur fisherman, and he says there are only three rules to be observed and they will bring sure success:

1. Study your fish.
2. Study your fish.
3. Study your fish.

If the angler follows these directions, he is not apt to offer the wrong bait. When he knows all their little peculiarities, he will know how to catch his fish. The “complete angler” has an unlimited patience and an infinite sense of repose and calm. He never hurries the fish, lest they become suspicious of his bait. And he proves that these three rules work.

The nurse who accepts every patient as like every other, and treats him accordingly, will never be a great success. The nurse who “studies her fish” and learns their psychology, will be a therapeutic force. She will know the why of the way that patient acts.

The writer recalls one such case of a patient who had to be tube fed through many months, though a tray was set before her three times a day—and as regularly refused. Then one day she was seen slipping food from off another patient’s tray and eating it greedily, not knowing she was observed. When questioned, though she had never before given a reason for refusing food served to her, she said that “they” had nothing against Mrs. B., so wouldn’t try to poison her. Her reasoning was excellent when one accepted her premises. She had bitter enemies. They were not enemies of Mrs. B. and would not harm Mrs. B. Therefore she dare not touch her own food, but could eat Mrs. B.’s if no one knew.

Sometimes a nurse reminds a patient of some one in the past who has complicated her life in an unhappy way, so she distrusts or dreads her or is made constantly uncomfortable in her presence. In such a case, if the nurse reports her patient as resistive, or fearful or cringing, or distrustful, she is really misrepresenting her; for under another’s care that patient may show an entirely opposite reaction.

But the point we wish to make is this: There are some sick reactions which the nurse, if she recognizes as such, can help the patient to transform into wholesome ones. At the very least the wise nurse can learn to simplify her own difficulties by accepting the unpleasant patient as possibly the result of her illness, and refusing to allow her trying attitude to get on her nerves. The patient may be reacting normally to the stimulus her untrained and toxic brain received. And when the nurse can see into the other’s mental workings, get her point of view, she is ready to give fundamental help.