WORKING WITH TEENAGERS IN INPATIENT HOSPITALIZATION. A SYSTEMIC LOOK AT NURSING THOUGHT AND PRACTICE

Summary

Systemic thinking has caused a revolution in clinical practice, through the paradigm shift (Kuhn, 2000) from the individual and internal medicine to relationships and broader social networks. The application of systemic beliefs in the working environment of the Adolescent Psychiatric Inpatient Care Unit (AICU) provided the opportunity for a fuller consideration of the therapeutic reality, offering interesting cases and reflections on the interaction between young people and the health care team members. Moreover, the systemic practice offered the tools and techniques for applying the theory into the everyday clinical practice.

**Key -Words: ** teenagers in inpatient hospitalization, systemic thought, nursing practices

** Introduction**

According to  first order cybernetics , the patient/therapist system is perceived as a given objective which can be studied, separated and manipulated. On the other hand,  _second order cybernetics _ perceives the relationship as an inseparable system, as a therapeutic process the outcome of which depends on the quality of interaction (Heylighen, 2001). The concept of  autopoiesis , introduced by Maturana & Varela (1987), provides the operational autonomy for the systems and therefore renders problematic the notion of therapeutic guidance. Yet once both the therapist and patient are perceived as subsystems of the undivided therapeutic system, the reductionist separationofguidance / non-guidance becomes obsolete. Thus we do not speak of the possibility of one system affecting another autonomous system, but of a new condition determined by the therapeutic relationship and defined by the context in which social events unfold (in our case, the nursing facility).

In this sense, therapy is a meta-condition (a higher-level condition) of co-construction of meaning (Bruner, 1990), with the use of language as a basic taxonomy tool and the mediation of complex communicational processes (Watzlawick et al, 2011).

Based on the above, the therapist is not perceived only as a guide but also as a fellow-traveler who, depending on the circumstances, guides, treads along or follows the teenager along the recovery path.  The purpose of treatment is not so much a guide as to invent together ways to build roads.

Nurses accompany teenage identifications sometimes as alternative parenting models, or as authentic substitutes for physical absences or even as transitional objects of teenage compulsions. The therapist and the patient work together to build a therapeutic -via speech- reality. This translates as a dispute towards power, which was the result of the different knowledge possession (Foucault, 1980), as well as a shift of the therapist from a  knowledge  position to a  **curiosity ** position and ultimately an  irreverence ^[1] position against the predetermined shapes of knowledge and practice (Cecchin, 1992)

The old, entrenched and largely functional patterns (of direction and control) remain naturally dominant.^[2] However, they are now more open to post-review and dynamic revision. The change of position (and viewpoint) allows the evaluation of attitudes not -exclusively- as a linear outcome of basic and unvarying personality attributes, but mainly as a result of cyclical relations of interaction between individuals (Selvini et.al, 1980).

Although this perspective is a "narcissistic blow" to the complacent therapeutic omnipotence, it can liberate the system’s dynamic balance inasmuch as it allows a  **self reflexive ** consideration as free as possible from the myths of causal explanations. The self (Tsekeris, 2010), is rather reflectively re-created, necessarily intertwined with the 'real world' and dialectically reassembled through a continuous, reciprocal and synergetic (chaotic) self-organizational interaction of the  _ego _ with:

1. the emerging social structures;
2. the significant others (real, imaginary, or implied). It is now clear that the systemic thinking and practice does not replace previous models but expands them, proposing new flexible approaches of the therapeutic reality in which behavior is not a result of the static characteristics of personality, but of the complex and interactive relationship with the Other and the context.

The  theory of complexity  refers to systems that exhibit complex, universal behaviors as a result of the local interaction of components or constituent factors whose behavior is determined by relatively simple rules (Cohen & Stewart, 1994).

In a static, “homeostatic" world, therapists can agree to observe, interpret, classify on the basis of prefabricated patterns that describe how a "normal" teen must be. And as they possess the ability to determine the degree of a specific adolescent’s divergence from the norm, the therapists can easily suggest ways for restoring balance.

Conversely, in the fluid world of  complexity  there is no way of knowing how a “normal” teenager must be.  What we do know is that we must remain  available  and  curious  to understand the distinct reality of each teenager. We (nurses), with our knowledge and values, operate as prototypes of possible options and not as possessors of the one and only road to the "truth." We use  collaborative dialogue  as an invitation for a potential path towards change, while maintaining the therapeutic responsibility as protection against arbitrary interpretations and abusive practices. This condition protects the therapeutic relationship from the risk of extreme arbitrariness^[3] where all versions are just as good as the others, without at the same time allowing the effortless return to the naive "knowledge" of the past.

According to Anderson (2013), a  cooperative dialogue is a communication process with the following characteristics:

● It is a natural, spontaneous activity that takes place at all times;

● It includes the collaborative design, which invites, learns and respects the other person's experience;

● Each dialogue is unique for the specific participants, situations, circumstances and agenda;

● The differences in intensity, clarity, uncertainty, etc. are necessary for a productive dialogue;

● The dialogue is multidimensional;

● Each session –discussion and relationship– is part of the participants’ past, present, and future;

● The dialogue implies a multiplicity of voices, present and absent;

● The context is the backdrop for the debate: the historical, cultural, organizational and relational context.

● The cooperative dialogue premises:

○ To talk, listen and respond;

○  Complete trust and the ability tobe open to the opinions and diversity of others;

○  Not to assume that you know what the other person means, not to fill in the gaps or the elements of the story of another person with what you think lies behind the story;

○To make sure that you understand the other person’s perspective as best you can. Understanding does not mean agreement;

○ Time for internal and external debate;

○ Time for interior and exterior reflections;

○ The use of pauses and silences as opportunities for reflection, internal debate and preparation before talking.

Thus in the context of cooperative dialogue we propose alternative explanative patterns and look for differences, exclusions, and twists that could cause a first crack, however miniscule, in the concrete wall of the narratives of the disorder.

Application of systemic ideas in everyday practice

In every organization there are two channels of communication flows. The  _formal _ and the  informal.  The formal channel is reflected in the official organizational chart and the institutional roles of people (Patient, Physician, Psychologist, Nurse, Head, Subordinate), the unofficial one concerns the informal communication among members. According to Allen et al, (2007), the informal network of communication is most important for the formulation of the dynamics within the organization.

Taking the above into consideration, we believe that the transformation of informal communication into formal helps to manage emotional reactions and impulsive actions, gives voice to negative feelings, satisfies the  sense of justice,  demystifies and de-dramatizes reactions, clarifies misunderstandings and above all recognizes the teenager patient as a person, in accordance with the philosophy of Rogers (2012).

From the very beginning of its operation, of the  _AICU, _ working in small groups was used widely in the therapeutic process. Teen group meetings are created ad hoc as processes for crisis management, expressing emotions and resolving conflicts.

There is no clear structure in these group meetings^[4]. Apart from the basic rules of civil social interaction there are nospecific procedures, strict targeting and formal or implied agendas, and of course no invitation or exclusion procedures. Everyone is free to join or withdraw from these group meetings at all times, even during the session. This basic element in standard group treatment changes as and when circumstances so require. Group meetings have taken place in the Multipurpose (recreation) room, the nurses’ office, the Head Nurse’s office, the refectory, the children's rooms, the courtyard, day or night, with 2 or 10 kids — wherever and whenever they are needed.

We believe in the direct use of small ad hoc groups as an effective mechanism for resolving conflicts and regulating emotions. Essentially it is as if there is a potential, unscheduled group meeting that has been running from the very beginning of the unit’s operation. The only thing that changes (or is it what remains permanent?) is the constant rotation of members in a never-ending apposition of narratives and persons who weave the thread of Ariadne in the space-time continuum, creating a sense of intimacy and safety even for the most isolated group members.

The adolescents’ narratives^[5] are followed by silences. Glances of support alternate with interjections, emotions change, long-repressed voices emerge in consciousness. All this abolishes the silence of the mental disease, liquidates the ultimate dysfunctional reality and ultimately renders the burden of psychic pain it more manageable. This  reframing ^[6] process allows a "safe" approach even to the deepest wound^[7] as it clothes with reason even the most intimate and repressed experience, that of nakedness and sexual abuse. All this takes place in an environment of safety and empathetic understanding which is promoted through the following mechanisms: ● Acceptance of the teenager as who he/she is (Rogers, 1995); ● Absolute freedom to express thoughts and emotions, even the most negative ones about the treatment group; ● A non-judgmental attitude; ● Self-disclosure.

On the other hand we have the reflective speech of the therapeutic group: explanation, experience, example, apology for any wrong practices and the healing power of forgiveness. Yalom (1983) believes that groups in a hospital context last as long as a session. For us there seems to be a continuous group since the beginning of the  AICU .

The concept of  circular causation , a milestone concept of systemic thinking, allows us to move away from the unproductive game of recriminations and conflict. The relationship is not linear, it gets co- constructed in the (dense)^[8] period of hospitalization and unreels spirally in space/time. The fundamental skill of  **empathy ** becomes an objective for processing, like the disclosure of individual responsibility for the relational gaps in the here and now  of every teenager’s life.

The coordinator of group meetings will look at  _the differences that make a difference _ (Bateson, 1972). He/she will try to harvest information from a dataset, find the different perspectives of teenagers, synthesize the different voices of the group, look for the exceptions, the cracks in the solid narrative of the disease. The purpose here is to highlight a different discourse for yesterday, recast the story of pain, fill mnemonic gaps, provide hope and, of course. consolidate a sense of continuity for adolescents suffering from an unbearable lack of meaning.^[9]

The concept of  scapegoat  helps us assume a critical stance towards our preferences in taxonomies, classifications along the axis of DSM 2^[10]. Why is it that some children are more engaging than others? Why are we prepared for more concessions and greater tolerance to some teenagers? Can beauty and intelligence as a Halo phenomenon (Nisbett & Wilson, 1977) blur our judgment? Is it the tragic stories of some children? Is it that they look like us? Is it that we share a common fate?

What is the nurses’ role in all this? Systemic wisdom tells us that when we see a child, deep down our stories meet: the voices of  significant others  inside our heads; our own wounds and our own gaps; the impasses we have experienced, the solutions we gave, our choices and our errors.

Our actions have, of course, a multitude of effects. We develop special relationships with some children, we become their person of reference, but we do not cease to be members of the treatment team. Our presence is completed at the end of our eight-hour shift, but the child remains within the framework after we are gone.^[11]

The  AICU , like all similar organizations, is based on the basic precepts of Behaviorism (reward, punishment, operational learning,etc.) in an effort to put deviant behaviors under control. Behaviorism has some advantages which are important in clinical treatment of acute incidents. The main advantage is that it acts effectively within a short time. On the other hand, modern developments in psychoneurology^[12] dispute much of what we take for granted. The "difficult" children aren't necessarily "difficult" because they want to be, but because they cannot help it. Their brain is not able to correctly perform the complex task of emotional regulation, resulting in a reduced ability for social interaction. The comforting thing here is that the brain has the ability to learn new ways of interaction using the mechanism of neuroplasticity^[13] (Rakic,2002).

What is needed is to give  _voice _ to the teenagers’ actions of impulsivity and then help them acquire problem-solving skills (Green, 2008).

The  _revolving door _ phenomenon (Haywood et.al, 1995), frequent re-admitted incidents and the adjustment difficulties of some adolescents in other environments^[14] brings skepticism as to whether rewards and punishments can bring about substantial and sustained change in the lives of teenagers. Most children who are hospitalized in the  _AICU _ have been subjected to reprimands and punishment from different contexts (home, school, legal system) with rather poor results in terms of changing behavior. The specific teenagers seem to have developed an  _immunity to punishment _ (Lewis, 2015).

Construction of meaning

Life could contain its  meaning,  of course. Faith helps in that sense — the belief in the indestructibility of the soul, in the afterlife and in heavenly reward. Christians believe that all these exist, but not here and not now. By contrast, the existentialist philosophers such as Nietzsche and Kierkegaard (McDonald, 2005) do not believe that life has any substantive meaning (May, 1961). The way they see it, meaning is one’s personal responsibility and duty. Meaning is what each of us attaches to life.

This is about important things, meaningful relationships, values, ideals, dreams and hopes. Meanings look both ahead and back in time. They come from the past as invisible threads that bind us to our ancestors. They are myths and narratives of family history, ghosts and shadows, happy and sad moments distant and remote,  formed into patterns of relationships and behaviors through narratives, names, name of locality and maps that afford a sense of continuity and sufficiency.

Sometimes, however, some  **traumatic ** events in childhood cause rupture and discontinuity, dispersing all sense of trust and security to the four corners of the soul.

"Nothing is as it was before. What would fill the existence with love and certainty is now a source of unbearable pain, anxiety and abandonment.”

What follows for the child is a desperate attempt to survive, and this is bound to cut. the complexity of emotions down to the basic primordial emotions of the body in an attemptto keep together what has remained after fragmentation and disintegration. The child clams up to fend off psychosis, freezes internally to keep a bleeding wound in check while the void, the absence of internal objects (Matsa, 2008) hovers inside him: the chasm which swallows insatiably the meanings, the significant things in life which do not find somewhere to cling on to and crumble endlessly. This is the price to pay for this incredible pain of memory not to be lived again (Miller, 2003).

So slowly but surely the child stops feeling so as not to remember, causes pain so as to feel, seeks destruction to pretend that that she/he exists, uses consolations to warm up, tries to kill himself or herself to remember (and remind!) that only the living have such an option.

The vast majority of hospitalized children have had a traumatic childhood and adolescence. Sexual abuse in particular has several negative impacts on children. It injures the body and soul permanently and leaves persistent scars that resist both time and treatment. Especially sexual abuse within the family brings about the maximum negative impact, destroying all sense of security and confidence ,  the basis for healthy relationships. To cope with the pain and confusion, the child builds cognitive patterns that describe himself in the darkest colors of obsolescence, self-blame, shame and anger:

Dad is good; what he did to me must be my fault

I'm not worthy of love

Relationships hurt

If I trust, I would be exploited

These patterns, the products of bipolar childhood thinking but also of the need to survive in a harsh environment, become permanent along the path to adulthood. All sorts of relationships (friendly, sexual, professional) are crammed into this narrow, emotionless mold. Pervasive eroticism, seduction, manipulative maneuvers, dramatization, obsolescence and idealization, everything serves the single need to confirm the basic patterns of self-worthlessness.

Relationship-forming is not a matter of choice in this case. These children will connect in the only way they learned in the abusive environment they grew up in. They convince themselves that that they are worthless, diabolical, with a sly and sinister side which is there to punish. They are now certain that they came to life in order to destroy and be destroyed. All this adjusts behavior into a self-fulfilling prophecy which, sooner or later, will cause maximum fear, loneliness and abandonment.

In this way, the other person is not invited in the child's life as a companion, friend or classmate, but as a spectator to the tragedy of fragmented existence. He/she does not become a helper and fellow-traveler but a wave-breaker of emotions, an object of grief, envy, lust, worship, hatred, idealization and devaluation. Every so oftenthe  nursing group  becomes the object of these archaic associations — sometimes as an idealized mother and sometimes as a deadly Medusa, as a partial symbol and a chimerical figure of an internal world divided in two, just as the primary object was once split.

Relations are often gauged in terms of endurance and distance. How long will you last next to me? If you're near me I'm in pain, and if you go away I'm afraid! As a result the deep existential pain of rejection is constantly triggered by the failure to form relationships of emotional attachment and substance. Added to the deep pain of abuse is the daily pain of lack of meaning. And a drop, a large or small drop from the daily routine is all it takes for the glass to overflow. Then the pain becomes unbearable as it explodes with violence against the unworthy self (Gustafson, 1986). Self-injury, risky behaviors, suicide attempts.Even death does not seem so horrible, at least no more than an unlivable life (Linehan, 1999). Treatment at this stage is not verbal. It is more like treatment through presence:

I'm here for you, and I can bear both your pain and my own fear of responsibility.

I do not judge: behind what you are doing (which is understandable under the circumstances) there is a wounded soul which needs care. The words and the techniques can wait.

In this critical phase the care of the nursing team is priceless: the warmth of a hug, care and attention, the mirroring of emotions, the containment.  Containment  is defined as placing a limit around an experience or feeling. The experience or feeling is subject to management or refusal, it could be maintained or passed on, and it could be experienced or avoided, so that its results could be alleviated or strengthened. Bion (1970) describes the relationship between content and container, indicating that the container could act as either a filter or a sponge, to manage difficult feelings, or could become a rigid frame that prevents or limits – thus making the content something which may be experienced as a threat or as salvation.

The Nursing team has the heavy load of becoming the object of teenage impulsions, often acting as a lightning rod for their overwhelming negative feelings. The  **good-enough mother , ** according to Winnicott (1960),is able and willing to accommodate in her "hug" ( holding ) the entire destructiveness and hatred towards the child's primary object (symbolically the female breast). In this way the nursing team is the metabolite of painful feelings by preventing the onset of  acting out .

With the above processes hospitalization becomes for teenagers a restorative experience of signification, of meeting with the other person and identifying with better standards. The ultimate goal of nursing intervention is to help adolescents become competent for real, meaningful relationships through the practical assurance that they deserve love and acceptance. As aptly phrased by Paris (2008), “ People cannot find lasting love, or  a good person , until they feel deserving of love ".

[1] Of course, as Cecchin warns us, before we dispute a theory we should first get to know it very well.

[2] We must not forget that from an institutional standpoint, the nursing team doesn't work based on the political and institutional gap but within the larger physician-centred health model  specified by the political requirements of the statutory organs of the State (Government, Department of Health, Hospital Administration, etc).

[3] As stated by Schweitzer & Schlippe (2008), treatment reduction entails the risk of arbitrariness and the (subsequent) deficiency in discussion (p. 99).

[4] The adolescent group meetings are not therapeutic teams in the standard sense of the term. They are more like opportunities for conciliation and interaction based on the here and now, i.e. in the everyday reality set by the context. Of course, in the daily operation of  AICU  there are also formal groups, e.g. focus groups.

[5] Bulimia can be a lifeline in the deep sea of emotional emptiness in some cases.

[6] During an adolescent team meeting, one of the girls reported obvious feelings of shame and guilt over her arrest for prostitution outside the Omonoia Police Department. The Coordinator reframed the incident, saying that " Only a deeply moral person like you would choose to hustle outside a police station ".

[7] Although coordinators try of course to focus discussions on the here and now and on the relationships amongst adolescents.

[8] Dense in the sense of the disproportionate burden of communication messages and emotions in respect to a normal teenager's life.

[9] One particularly useful exercise for groups of teenagers is the Tree of Life, which comes from the Narrative School. The Tree of Life has been used successfully in the treatment of childhood trauma in particularly hard and violent environments (e.g. wars, and AIDS pandemics) ... more about the Tree of life can be found on http://dulwichcentre.com.au/the-tree-of-life/

[10] Axis 2 of DSM includes personality disorders.

[11] As regards the Person of Reference, I had once developed a special relationship with a "difficult" child who felt so safe in my presence alone that he slept peacefully when I worked the night shift. I considered my presence therapeutic for the child and highly productive for the placement. It wasn’t long before I realized the living hell that the child (as well as my colleagues) experienced when I was not working. All nurses have similar stories to tell from their experiences.

[12] For example, we now know that human behavior is formed in the prefrontal cortex and that many of our adolescents belong in clinical classifications (ADHD, ODD, PTSD) showing deficits in normal development and functionality in the corresponding brain area.

[13] Neuroplasticity refers to the ability of the brain to recreate nerve synapses and restore functionality.

[14] For example, upon returning to the home or school after being discharged.

Sources

Greek

Miller, A. (2003). Οι φυλακές της παιδικής μας ηλικίας ή Το δράμα του προικισμένου παιδιού, Athens: Roes.

Schlippe, A.,V. Schweitzer, J. (2008). Εγχειρίδιο της συστημικής θεραπείας και   συμβουλευτικής, Virginia Ioannidou (ed.), University Studio Press.

Foreign

Anderson, H. (2013). Collaborative-Dialogue Tips For Optimizing The Possibility. Retrieved November 18, 2015, from http://www.taosinstitute.net/Websites/taos/images/ Resources BriefEncounters/2013-10_ Brief_Encounters_-Dialogue_Tips_-_Harlene_Anderson.pdf.

Bateson, G. (1972). Steps to an ecology of mind: Collected essays in anthropology, psychiatry, evolution, and epistemology. University of Chicago Press.

Bion, W. R. (1970). Attention and Interpretation. London: Tavistock Publications.

Bruner, J. S. (1990). Acts of meaning. Harvard University Press.

Cecchin, G., Lane, G., & Ray, W. A. (1992). Irreverence: A strategy for therapists' survival. Karnac Books.

Cohen, J., & Stewart, I. (1994). The collapse of chaos: Discovering simplicity in a complex world. New York: Viking.

Foucault, M. (1980). Power/knowledge: Selected interviews and other writings, 1972-1977. Pantheon.

Friedrich Nietzsche (Stanford Encyclopedia of Philosophy). Retrieved November 15, 2015, fromhttp://plato.stanford.edu/entries/nietzsche/.

Gustafson, J. P. (1986). The complex secret of brief psychotherapy. Norton.

Heylighen, F., & Joslyn, C. (2001). Cybernetics and second order cybernetics.  Encyclopedia of physical science & technology , 4, 155-170.

Haywood, T. W., Kravitz, H. M., Grossman, L. S., & Cavanaugh Jr, J. L. (1995). Predicting the  "revolving door" phenomenon among patients with schizophrenic, schizoaffective, and affective disorders.  The American journal of psychiatry ,  152 (6), 856.

Kuhn, T. (2000). The Structure of Scientific Revolutions. The University of Chicago Press. pp. 24–25. ISBN 978-1-4432-5544-8.

Lewis, K. (2015). What If Everything You Knew About Disciplining Kids Was Wrong? Retrieved January 22, 2016, from http://www.motherjones.com/politics/2015/05/ schools-behavior-discipline-collaborative-proactive-solutions-ross-greene

Linehan, M. (2009) Dialectic Behavioral Therapy. Retrieved January 22, 2016 from http://www.psychiatrictimes.com/articles/marsha-linehan-dialectic-behavioral-therapy-0

Maturana, H. R., & Varela, F. J. (1987). The tree of knowledge: The biological roots of human understanding.. New Science Library/Shambhala Publications.

May, R. E. (1961). Existential psychology, New York: Crown Publishing Group

McDonald, W. (2005). Kierkegaard, Søren | Internet Encyclopedia of Philosophy. Retrieved December,11, 2015 fromhttp://www.iep.utm.edu/kierkega/.

Nisbett, R. E., & Wilson, T. D. The halo effect: Evidence for unconscious alteration of judgments.  Journal of personality and social psychology,  35(4), 250, 1977.

Paris, J. (2008). Treatment of Borderline Personality Disorder: Guide to Evidence Based Practice, Guilford Press.

Rakic, P. (2002). Neurogenesis in adult primate neocortex: an evaluation of the evidence,  Nature Reviews Neuroscience  3 (1): 65–71. doi:10.1038/nrn700.PMID11823806.

Rogers, C. (2012). On becoming a person: A therapist's view of psychotherapy. Houghton Mifflin Harcourt.

Selvini, M. P., Boscolo, L., Cecchin, G., & Prata, G. Hypothesizing— circularity— neutrality: Three guidelines for the conductor of the session.  Family process , 19(1), 3-12, 1980.

Tsekeris, C. Reflections on reflexivity: sociological issues and perspectives. Suvremene teme , (3), 28-37, 2010.

Watzlawick, P., Bavelas, J. B., Jackson, D. D., & O'Hanlon, B. (2011). Pragmatics of human communication: A study of interactional patterns, pathologies and paradoxes. WW Norton & Company.

Winnicott, D. The Theory Of The Parent-Infant Relationship, IJPA, Vol. 41-pps, 585-595, 1960. Retrieved Octomber 12, 2015, from http://icpla.edu/wp-content/uploads/2013/09/Winnicott-D.- The-Theory-of-the-Parent-Infant  -Relationship-IJPA-Vol.-41-pps.-585-595.pdf.

Yalom, I. D. (1983). Inpatient group psychotherapy. Basic Books.Systemic thinking has caused a revolution in clinical practice, through the paradigm shift (Kuhn, 2000) from the individual and internal medicine to relationships and broader social networks.