Monday, January 7, 2008

Effective Communication

By Sudipa Sarkar
Introduction

A case of personal communication happened when my cousin sister, who was suffering from severe form of anorexia nervosa, had been hospitalized for near about 3 months and 2 months respectively with a pause in between. My cousin sister was suffering from a chronic failure to eat and this became a great life-threatening issue for her when her weight decreases to 48.5 pounds from her original weight of 121 pounds with a height of 5 ft 4 inches. She was a good student in her class but on the onset of her illness she gave up all her enthusiasm for her studies or any willingness for getting good marks in class. She was also a good, promising and talented student for her dancing teacher. Despite of her previous futile six treatments, she had been readmitted into hospital once again due to the extreme severity of her health condition in question. Due to the prolonged duration of the disorder, it leads my sister became socially isolated. It seems that she did not have any willingness to communicate with any one around her. She was showing a symptom of continuous acute depression along with her fatal decision about eating pattern all the time. She even became very reluctant about performing her daily necessities. It seemed that she had lost any positive feelings about herself and hence the willingness to survive as well. Her parents, yet separated but supportive, also put a great emphasis for her betterment and tried to help her to cope up with it properly. But it became all ineffective as my cousin sister was either just non-responsive to their action or showed an intense level of irritability or aggression towards them. In the meantime, she has been assigned to a new nurse. However, the nurse initially also failed to change her behaviour pattern over the food by changing the diet schedule. But she changed her treatment pattern by emphasising and involving a great amount of exemplary communication between themselves, leading to a real success story in time.

Personal Clinical communication incident

At the initial stage, my cousin sister refused to take sufficient diet required for her system, though she consumed a minimum amount of food after her staying at hospital for so long time. But while eating, she was always either slow or not able to finish all the food in her plate. The nurse in question did not force her or ask her about her action, rather affirmed her to be with whenever needed. Then, after few days, the nurse tried to explore the probable cause behind her action and hence externalize the condition by including social, emotional, personal, intellectual, familial and physical aspects into account. She tried to build up a trust and faith on her by empowering the rapport with my cousin sister. This seemed to develop a one-to-one relationship between them by encouraging my cousin sister to take a little interest about the presence of the nurse in her room. Few days later, when my sister was sitting beside the window with an unfinished food-plate in her hand, the nurse informed her that she would leave early today, which is followed by a immense query in my cousin sister’s face and asked her, “Why?” The nurse replied very normally that she needed to meet her fiancĂ© as she didn’t meet him for quite a long time. This action of the nurse was pre-planned and working as one of her investigation factor for exploration of the underlying reason. This sentence left my cousin sister’s face with a pale colour and the nurse noticed her sudden change in facial expression. At this time, my cousin sister was looking more anxious and unusually silent than she was before. The nurse took the clue and asked her empathetically, “Don’t you want me to leave now?” After a significant pause, my cousin sister replied, “Surely you can go, I would better stay all alone.” But as soon as the nurse started to pack up her things and seemed to leave the place, my cousin sister shouted in a real unusual manner, “Cant you stay with me today? Is it so necessary for you to meet your fiancĂ© today itself? Can’t anyone be here for me?” These three sentences with an intense amount of emotional anxiety provided the nurse with significant sign and she affirmed her to say, “Ok, I will be here with you. Do you need me here to talk?” “Yes, I need a friend to share my pains.” After that incidence, my cousin sister told the nurse that how she was deprived by her boyfriend because of her own cousin sister, who, according to her boyfriend, is much more attractive because she is slim enough and also possesses a good image over the peer group. And also her boyfriend refused her to take away in any social party by emphasising his embarrassment regarding her bulky presentation. While discussing it with the nurse, my cousin sister also affirmed about her emotional insecurity about her parent’s separation as well as her social anxiety and emotional dependency on her boyfriend. The nurse didn’t put much stress but acted as a good empathetic listener and allow her to ventilate properly and took all the relevant notes regarding her mental condition that might help in externalizing the illness by considering the conflicts in her daily life. Later on during her treatment, there seemed a noteworthy change in her behaviour pattern in the presence of that nurse. She now agreed to depend somehow on the nurse regarding her diet. She didn’t make much argument about the quantity of her food or she was not so frequent with her unfinished food as well, but she made complain if she found that the food contains more fat contents than usual. She eventually showed a gradual resistance power against her loneliness and hence the onset of depression. At this point, she also tried to shift her focus into some positive activities, like doing embroidery, etc. She also showed a good deal in communicating with other nurses in her room and tried to concentrate on her daily necessities. It seemed that she was developing positive self-esteem with a positive self-image. However, the prevalence of mood disorder followed by depression sometimes lead her to go down to her to the lane of loneliness and caused partial social isolation. It was partial as because it seemed that even if she was down intensely, she like the nurse’s presence in her room. At that point of time, the clinician showed a great enthusiasm by offering her support and partnership by saying, “Ok, till this time before we meet, you fight alone with your pain, now I am here with you, let me allow to be with you in your fight…let’s see what we can do together”, followed by an understanding of her condition in an empathetic manner, confirming her perception about my cousin sister’s feelings, “I can understand what is going on with you…”. It seemed that the nurse’s effort to provide continuous positive feedback with the exposure of reality helped my cousin sister to idealize and rationalize with the stressors in her life, and hence weakening the internal anxiety. My cousin sister seemed to be secure with the presence of the nurse. Later on the treatment process, in a one-to-one session with the nurse, while idealizing the context of illness, my cousin sister was asked to choose between life and death and she choose life as her answer. The motivation to lead a life in a positive manner was observed during the conversation. Now while she was improving on her diet, she was encouraged to undergo cognitive therapy by emphasizing her role in society as a social agent. My cousin sister did provide a good response in the therapy session followed by a pleasant communication with her parents, which was comprised of general discussion about the family members and minor discussion about anorexia nervosa symptoms, but not anything about the underlying cause or treatment policy. Since this time, my cousin sister was encouraged to build a view on personal-self as well as about others. She started doing shopping of beauty accessories and dress materials accompanied by the clinician. Also she was encouraged to join in a dance group as she already developed 99 pound weight and her behaviour pattern was almost normal. She also showed her enthusiasm to start her study once again. Moreover, it seemed that she developed a significant level of positive self-esteem, self-confidence and a positive self-image which helps her to further progress in life with a positive view of life as a whole.

Exemplary incident

The case described here may be cited as an exemplary communication incidence to employ a narrative but empathetic approach to unmask the underlying causes of the disease and hence by the method of externalization helping the patient to focus on the devastating nature of the disease, identify the cognitive factors associated with it and hence enable to arrest it. As their study with anorexia nervosa patients, Rosen JC, Reiter J, Orosan P. (1995) concluded that anorexic eating behaviour is supposed to develop from the feelings of fatness and unattractiveness, hence resulting cognitive bias influencing the victim’s self-evaluation, thinking pattern and corresponding eating behaviour. This theory synchronizes with the case of my cousin sister when she ventilated her pain and thus her cognitive framework related to self-evaluation and self-image which is intensely affected by her emotional trauma concerning her interpersonal relation to her boyfriend. The cognitive influence along with other factors like emotional, environmental or physical leads the situation for the treatment of anorexia nervosa complicated. This is not possible only to try bringing the necessary changes in diet, but an overall concern to the problem at an individualized level is mandatory. However, it seems that there is nothing more than an obsessive thinking pattern concerning weight gain, but in most of the cases, individual suffering from any kind of eating disorder, there is a strong underlying emotional conflicts need to be resolved fast. In a study conducted by Marjo J. S. Zonnevylle-Bender et al mentioned that there is a significant deficit in the area of emotional information processing for the patients suffering from anorexia nervosa. This also supports in the case of my cousin sister, showing a distorted pattern of emotional functioning related to her close interpersonal relation and communication with parental figure. The lack of good communication among family members may affect an individual in almost all aspects of life, including cognitive, behavioral, social, emotional, physical, and spiritual and it can only be modified by considering the overall improvements in environmental domains i.e., society/culture, community/ neighborhood, school, peer group, and family/extended family, resulting an increased effectiveness on positive changes in behaviour pattern as well as coping pattern with different kinds of life-stressors. According to Korsch et al. (1968), there is a strong correlation among doctors’ or caregiver’s communication style and patient adherence to the recommended treatment policy. Hence, in case of mental health issues, this communication style not only affects the adherence, but helps in developing the trust for the caregiver enhancing the belief of understanding their problem from the patient’s perspective and to establish a strong belief about positive outcome as well. The severity and extended form of the disease is not only associated with the eating behaviour of the client and hence the treatment is not limited into only changing the eating behaviour pattern. It is multi-faced and multi-dimensional in nature by including various factors ranging from personal to social. As the different complexities may trigger or act as a cause for the development of this disease, so the case of anorexia nervosa must be handled with greatest care and empathy being very flexible about perceiving the client view of the world and self. In a cross-sectional study with patients suffering from anorexia nervosa, Tozzi Federica, et al mentioned about three common factors contributing to the recovery of the patient would be supportive nonfamilial relationship, therapy and maturation considering the subjective accounts of the development of anorexia nervosa along with factors fostering recovery. So it is important to focus on the individual cause for the development of the disease rather than considering it in generalized fashion. To gather information at personal level and to handle the case in individualized pattern, the empathetic communication pattern will always prove to be exemplary as it is with the case mentioned here with my cousin sister. It helps her to facilitate with the crisis of her illness without being threatened about her condition in any negative pattern. The nurse came up with an immense but rational respect for her, which made her feel secure at her point of view and let her ventilate her inner anxieties. The nurse always showed her understanding of perception empathetically and rationalizing the distortion in her thinking pattern by providing her positive feedback all the time. Moreover, it is because of an outcome of a good communication between the caregiver (here the nurse) and my cousin sister helps to regain stability not only in personal level, but also social level like enhancing family interaction, participating in social network, say, dancing group, , showing motivation to start study once again, for example, and hence to divert her feelings and attention towards negative self to positive self by encouraging to pursue a broader perspective to see the life. In a study on the treatment of anorexia nervosa, Hilde Bruch suggested that if the treatment only intends for behaviour modification over the eating habit, it may result an temporary output, whereas, the proper treatment should include the process enabling the patient to develop a personal identity and a sense of self-dependence. Exemplary communication style helps in not only to the recovery process as Janet Treasure (2006) mentioned in her research paper but also it helps in improving the quality of life of the individual. In the case of my cousin sister, the good and healthy communication style of the nurse influenced my cousin sister to develop her perspective in a more broadened way which affected her interaction with her parents after a successful intervention by the clinician. It helped my sister to relate to her parents in future communication and being able to receive any required feedback about her life in general. However, due to her prolonged treatment pattern, she was admitted hospital before, but only using exemplary communication style employed the effective onset of her treatment for her illness. Thus, the above-mentioned case study affirms that an exemplary communication style associated with empathetic view, positive feedback and continuous positive support are always helpful and needful for clients to facilitate with the required behaviour change and hence to get back into the root of the life once again.

Conclusion

As anorexia nervosa has deeper impact on and individual as well as in the environment than it is generally noticed at its superficial level, so it is always essential to help the patient to identify the inner conflict. When an individual under such stressors developed as an outcome of the disease itself is exposed to the self-identification and self-retrospection process, it multiplies the stress for the patient if the environment is not exemplary for the individual himself, hence, worsening the condition with futile result at the end. This happened with my cousin sister in her previous treatments, whereas, the significant improvement came into account when the situation had been modified by employing exemplary communication method. At its ease, it is the exemplary communication inducing from non-familial support group that helps patients to neutralize the underlying anxiety related to their disorder. Thus it enables them to identify their crisis in a positive fashion resulting in the development of motivational force to cope up with their conflicts and to lead a better life with a broadened perspective.
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