Written by Per Terje Naalsund
The crossing of cultures
The therapy room and the hospital is very different environments. As a therapist I am not really concerned with the question of what’s the matter with my clients. What interests me is how they are and whether I am able to find a way of being with them that will let them allow themselves to feel how it is to be with me. What informs my work is the quality of this openness to different feelings, in the client but also in me. For me, to be able to open up in this way, it is important that I take care of myself and take my own reactions to what happened in this meeting seriously.
In hospitals the matter is quite different. Something is always the matter with patients, that’s the reason they‘re allowed in. But I believe that doctors and nurses see this differently. The doctors job is primarily to fix the patients. The nurses’ job is to give care, assisting of course the doctor in the treatment of the patients, but also caring for the patient as a human being who being hospitalizied often will be in a kind of existentially distress.
Nurses are in a position where these two cultures cross each other, but the support they are being given by the professional systems around them seems to be very one-sided, as if the therapeutic, biological and humanistic wisdom of care and self-care falls short of the cost-effective management of operational procedures.
I wanted to talk about this with one of my favorite therapists, Julianne Appel Opper. She is a psychotherapist, supervisor and trainer well-known in the gestalt therapy community for her courses such as: “Interbodily processes in therapy”, “Working creatively”, “Shame in therapy” and more recently on professional self-care in the health professions.
She is known for her ability to bring body-to-body communications into the field of psychotherapy and supervision, and to show how it influence the relationship between the therapist and the client as well as the unfolding of the therapeutic processes. I’ve been to a number of her workshops, and every time I have felt like I’ve learned a lot more about how I can care more for myself as a therapist working in the health care field.
The health-care systems we are in
«It is hard to be able to care in an uncaring system,» Julianne tells me. «On Saturday I gave a webinar for supervisors, and thanks to one of the participants, we looked into the important role of our work settings. We explored how hard it is when it is about money and about being quick.» Just as in Norway, German hospitals are run like they’re businesses and they are taking decisions based on which operations bring more money. «I was told how nurses feel like they have to run, and there is only one nurse for so and so many patients,» she tells me, but adds that this isn’t only about today’s health care. We live in times where care for oneself has a hard time being established: «In the social and cultural field it is also about being efficient, young, fit and strong.»
The wider field that influences us
The health care crisis seems to be part of a wider crisis. Since the Covid pandemic there seems to be a surge in systemic break downs in our health service systems, not only in Norway, but internationally as well. Especially nurses, but also more and more physicians, want to leave their present workplace. Some cultural transition is going on where we are losing faith in our ability to influence the systems we are a part of. It is remarkable that we now can read about nurses in Norway that leave their permanent position at hospitals and instead hire out their work force to the hospitals who now are desperate for personell.
Talking to Julianne about this, brings us out of the hospital setting and into the feelings we all harbour these days: «We are in several wars at the moment and I think that this also shakes us. Yesterday, at an event of the New York Gestalt Institute about “War and Grief”, people said that this is not my world anymore!» Julianne tells me.
Thinking about this complexity, I can’t help saying to her, that I think we all feel that something has to change, but that we can’t see how it can come about, and therefore we today don’t feel like we are in a movement towards something. In my world the willingness we have to care for others are of critical value. The protests of nurses towards the system they are a part of also brings some hope.
The atmospheres we breath in
«So what could we do about the situation of nurses? Could a new social movement begin there?» I wonder.
«You know the work of nurses isn’t valued enough. Neither by the payment, by offering groups, by supervision, by care, nor by being able to sit together and to talk to each other of what you carry,» Julianne says.
When talking to Julianne my rather abstract concerns is made more vivid through her descriptions of the situations nurses are in. «What happens when a nurse enter a hospital room?» she asks. «This body also enters atmospheres,» she says. «These atmospheres could be of pain, of bitterness, of trauma and despair, of loneliness. The patients struggle with questions as ‘Why me? How will I live with this illness? Will I die?’ This implicit body-to-body-communications enter the nurses without their cognitive control,» she tells me.
Julianne’s point isn’t only about the impact this has at the moment inside the hospital room, but how these experiences which especially nurses are exposed for, influence the life world of nurses:
«A nurse inhales these unspoken messages, involuntarily, like a virus, and they stay in the body for some time. Some of the body-to-body-communications we also carry in our bodies after we exit the situation. It gets imprinted in our system, where it comes into contact with our own traumatic reactions that we might hold in our bodies. We can’t help how it then colours our own self organisation and our perception of our selves and the world around us.»
She gives an example from her daily practice. «Many times as a therapist I am sitting with a body in the chair in front of me who wasn’t cared for as a child, and who had to learn not to expect and need care, and what my hands then receive is the message that I should “stay away”. Afterwards, when I go to my lunch break it is intriguing how I can carry this with me for some time. When somebody wants to pass by on a narrow sidewalk, I notice that I still hold a «go away» in my system. It is as if I had not left the co-created field of “the world is not a friendly place” with my client.»
The same happens to nurses coming out of hospital rooms. «I am concerned,» Julianne tells me, «of whether nurses take the time to breath out what they just inhaled? I can see them being very busy in the head: “Next, I’ll have do this and this, and this…” and in parallell the body gets loaded with potentially traumatic bodily communications, a bit like a zebra trying to ignore the many lions all around, holding so many impulses for action in the body.»
Who cares for the carers?
I can’t help asking her, from some deep need inside myself, where is the place for people that care for others? Today’s culture is on the one side very frightening to us, with growing fear of what the future will bring with war threaths, climatic turning points and the disruptions of our work life through the application of artificial intelligence and by rigid control and management systems. On the other side this fear seems to be countered by a strong concern for our own individual health, wealth and safety. It seems like people that choose to be nurses are in danger of extinction because we don’t care enough for them. Who cares for the carers?
Julianne looks at this from another perspective: «What motivates us to become a nurse or therapist? I believe that there is something important about this motivation. I see this as shaped by early experiences. We very easily get stuck in the role we had as children in the family of origin. Were we brought up to comfort and please, to avoid conflicts and be kind, to be in service of others? This is a well-known theme in psychoanalysis. Karen Maroda in her book “The Analyst’s Vulnerability” questions when healthy self-sacrifice develops into submission. If the nurse/therapist carries on working from this “child-like position”, setting boundaries does not come natural and exactly here lies the danger of burning out!
«So the helpers need to be confronted with their helping instincts?» I ask her.
«Maybe confronting is not a good word,» she answers, «but acknowledging the possibility that I am doing this work to feed my inner child is important. If I am into giving what I myself did not get as a child, I can easily stretch myself far too far, trying to do the impossible again and again. If I give endlessly, I also easily swing into a strict or harsh reaction where I say “No more!”
A second layer in these processes is that we are wired of needing to feel as a good child. If this did not happen enough, then this need stays open and colors our adult behavior. Then, we are driven to do good things endlessly so that we can feel as a good person.
There is another important third layer that we can’t help reacting to traumatic bodily communications. We inhale the energies of “I need help right away!», and this makes us run and do the impossible. For some these voices echo traumatic situations from our past.
As we talk about this, I can’t help feeling very grateful towards all the people out there that are helpers. «If we didn’t have this child in ourselves that know how to help others, who would be the helpers then?» I ask her.
«In the health care systems these ‘children’ get used too easily,» she promptly says.
Julianne makes me think of how helpers often are strained by helping systems that would have collapsed without their help. Today’s body of helpers comply with the professional systems around them, especially the computer systems we all seems to have to obey, and then with the family systems they are bound to, where their «inner child» is busy caring not only for their children, but also for their own parents and maybe doing the caring that their partner skips as well. Their life can be a 24 hrs busy-ness of doing «good».
Individually tailored self-care
«Could we as therapist contribute in any way?» I inquire. «Is there any qualities of gestalt therapy for instance that could be of help?»
«I can only speak for myself,» Julianne says, «I have weekly supervision. There is a saying: ‘Every good mother needs a good mother for themselves’. As therapists we can contain, hold and care when we are contained, held and cared for.»
She thinks a bit: «What else can I say? I am 64 now. With age I can acknowledge my own trauma and what bodily processes come up when I sit in traumatized fields.»
She seems thoughtful, and then grounds herself in her professional interests: « We must be aware that self-care is individual! There is no program fitting everybody. I have been saying for many, many years that it is good to learn a body vocabulary. To have an understanding how we hold processes in the neck, in the jaw, or for example in our knees. At the self-care webinar the other day, we explored what had been challenging this week and which of the processes we still sense in our bodies and if so, where in our bodies? We then looked into what these body parts need.»
I recognize that the point about knowing our bodies not only seems foreign to our rather rational, enlighted Norwegian culture, but also is a knowledge that struggles to cross into the more mainstream psychotherapeutic cultures from body psychotherapy.
The relational body orientation of Julianne’s methods opens for instance for the insight that care can be intrusive: «At the webinar we also looked into the processes of self and care and how our bodies might struggle with receiving care. Especially in our work with traumatized clients, we should be aware that impulses for self-care can not develop. Naturally, when in pain, we would look for comfort, and we look for it from our parents. But when a child have received bad, damaging behavior by a parent, the source for being comforted when in pain is also taken from this child. So the traumatic behavior enters the body together with a loss of a parent being available to comfort and care. Self-care then is far away and it can be shaming to receive what you never had.»
There is an abundancy of self-care exercises for nurses on the internet. There is also someone who writes about self-care fatigue. I can’t help thinking that having to do self-care in itself can induce stress and the feeling that you yourself is responsible for the stress you’re feeling. «Isn’t self-care something else than doing what’s scientifically proven is good for you?» I ask her.
«I think that we have to tailor self-care. One self-care doesn’t fit all bodies. Individual self-care needs space and time, and few people seems to have enough space these days. We look into our cellular phones and are on Facebook, Instagram, LinkedIN. Then there’s no space to sense what kind of state am I or where I hold tension in my body. Self-care is to have an inner dialogue with ourselves as a living body.
The other day I mentioned the metaphor «Nervenkostüm», the nerve costum, to a client. She had Covid and was very exhausted. Even though she had no energy, she was still determined to go back to work the next day. ‘Wow!’ I thought. ‘What do I say?’ I asked her in what kind of state her nerve costume was? She immediately said: ‘My God, there are so many wrinkles in this fabric’. Then, I asked: ‘Do you think that it is good for your costume to be packed in and to go on a business trip?’ She replied «No! That’s not good for the costume.» And then we talked about: «What might be good for the costume? She had ideas to lie it on a bed so that the wrinkles could stretch and to hang it in fresh wind. She emailed me: “I am not going. I am staying on sick leave”. And I went: ‘Yes! Yes!’
So self-care is like kindly asking the costume: How are you? What can I do for you? Do you need fresh air, or do you need to move? Or do you need to be softly touched where your wrinkles are? I believe that this can be a dialogue we could learn and practice. Maybe. Hopefully. What would you say?»
The lightness of nurses
Julianne’s question to me makes me think about what we need to listen to ourselves. We probably need some «third» element, whether it is a professional listener or some sort of a medium, like this metaphor «the costume of nerves», that makes us tune in. Julianne thinks this third element has to have a quality of playfulness as well:
«I believe that it is not easy listening to oneself in company with bodies that are anxious, traumatized, afraid of everything, which are in freeze or in a running/survival mode: ‘this, this, this,.» Julianne says. «This energy doesn’t allow space to listen to ourselves anymore. The danger is that the traumatic communication also turns us into zebras, who can only run. When we adjust in this way, playfulness becomes out of reach. As therapists we need to find ways to stay a bit lighter than our clients. This also sends the message that I can be with you.»
I am thinking about this. We need to stay a bit lighter. I guess this is what nurses bring into the hospital rooms. They are a bit lighter than the pasients they meet. To me this is a talent nurses have and that they need to have to be able to enjoy their work. The crisis we are in might have something to do with this ability. Do we give them the professional support they need to keep going on being lighter?
Per Terje Naalsund is an Norwegian Gestalt psychotherapist, editor of Gestaltterapeuten, and trainer at the Norwegian Gestalt Institute.
You can read more about Julianne Appel-Opper at her website: http://thelivingbody.de/