Chapter 23

GETTING THE PATIENT'S POINT OF VIEW

WHAT DETERMINES THE POINT OF VIEW

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.

Jim's father is the ash man. His world is in the alleys and basements. His pastime, cheap movies, and the park on Sundays. When he is not working he is too "dead tired" for anything heavier than the Sunday Supplement or perhaps the socialist club-rooms, where he talks about the down-trodden working man and learns to hate the "idle" rich. He spends his money on food and cheap shows and showy clothes. He talks loudly, eats ravenously, works hard, is honest, and wants something better for his children than he and the "old woman" have had. His music is the street-organ, the movie piano, and the band--some of it excellent too--but none of your dreamy stuff--good and lively. And his son, Jim, is true to type.

After the Armistice Jim and Richard, who have fought for months side by side, go to Paris together. Richard may "have a fling" at Jim's amusements for the sake of playing the game and "seeing how the other half lives" and all that--but before long we shall find him in the high-class theaters and restaurants, visiting the wonderful art collections and libraries, riding in luxurious automobiles, and staying in the best hotels he can find. And even though Jim may have saved Richard's life and Richard is eternally grateful, and loves Jim as a "dandy good scout," their ways will inevitably drift apart when the one big common interest of fighting together for a free world is over. They will always remember each other. Jim will decide that a "highbrow" can be a real man, and Richard will ever after have a fellow-feeling for the "other half" and think of them now as "folks." But Jim is not at home in Richard's neighborhood and circle; and Richard is a fish out of water in Jim's. The point of view of each has been largely determined by his heredity and his environment.

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.

GETTING THE OTHER MAN'S POINT OF VIEW

Our points of view are very frequently merely hereditary or acquired prejudices, hence altogether emotional rather than rational. We only with great difficulty see things through another man's eyes. It necessitates comprehending his background fully, and standing exactly where he stands, so mind and eyes can both look out from the same conditions that confront him. And this is only possible for the man or woman possessed of a vicarious imagination. Such an imagination, however, can be cultivated.

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.

After all, the law is very simple. Each man is the result of the things he puts his attention chiefly upon; and he puts it naturally upon the things which his forebears and his surroundings have held before him. The rare person and the trained person can assert the "vital spark" of his own personality and tear attention away from the easy direction and force, and hold it somewhere else. So he can change his points of view by learning that there are other vantage grounds which direct to better results. With some one else to lead the way and give a bit of help, or with the urge of desire to understand the new viewpoint, or by the drive of his will, he can change his own.

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.

Let us try just a few experiments. Hold your pain and suffering from your appendix operation, and disappointment because you can't be bridesmaid at your chum's wedding, up close to your eyes, and you cannot see anything else. They crowd the whole field of vision. Look at the world from the eyes of a spoiled woman of wealth who for twenty years has had husband, friends, and servants obedient to her every whim. She has grown selfish and demanding. What she has asked for, hitherto, has been immediately forthcoming. Now she is ill, and she naturally considers the doctors and nurses mere agents to secure her relief from discomfort. She is willing to pay any price for that--and still she is allowed to suffer. From her point of view it is utterly unreasonable, inexcusable. What are hospitals and nurses for, anyway? And she is carping, critical, and disagreeable. Her attitude is as sick as her body. How could it be otherwise?

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 on the world from the eyes of the immigrant who has lost all his illusions of the land where dollars grow on the street and where everyone has an equal chance to be president, and if you do not cringe in abject humility, you are not unlikely to be insufferably self-asserting, considering that the world has robbed you and that now it is your turn to get all that is coming to you. So you make loud demands in a rude, ordering voice. The nurse is there to wait upon you--and finally you will have your innings.

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.

One can often judge very truly a patient's real character by his reaction to his sickness. On the other hand, frequently it only indicates that he has not yet properly adapted himself to a new experience and a trying one. We hear so often, "Why, she's a different person these days, since she's feeling better. It's a joy to do things for her." She was the same person a while back, but had not learned to accept discomfort. Any of the following list of adjectives we hear applied to our patient again and again by the nurses:

unreasonable stubborn lazy deluded cranky resistive unco-operative will-less hipped obsessed hypocritical of mean disposition excitable fearful exacting dissatisfied undecided wilful self-centered morbid doubtful demanding retarded abusive depressed spineless self-satisfied

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.

We must admit that the highest type person, when sick of any physical illness, does not deserve such descriptive terms as these. But they are the rare folks, few and far between; while the great mass of us have not acquired more than enough self-control and thoughtfulness for the ordinary routine of life. We are weakly upset by the unexpected. If it is a pleasant unexpected, we are plus in our enthusiasm, and people applaud; if the unpleasant unexpected, we fall short, and people deplore our weakness. If we learn our lesson of self-control and adaptability, and gain in beauty of character through experience, it has served a purpose. But the nurse deals with the average of human nature, and she finds their reaction faulty. Very often, if she is observant, she will discover that a patient responds in a very different way to some other nurse, who somehow finds that "trying" sick woman charming or thoughtful, likable or sweet. Of course, it may be because the other nurse weakens discipline and caters to the patient's whims; but it is just as likely to be because she has tempered her care and her strictness with understanding. She has grasped the patient's point of view; and with that start, the chances are 50 per cent. more in favor of the patient grasping and acceding to the wise nurse's point of view.

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.

Some of the most common of these sick reactions with which the nurse must deal are enhanced suggestibility, repression, oversensitiveness, stubbornness, fear, depression, and irritability. And each one demands a different method of approach if real help is to be given.

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 DELUDED PATIENT

If the patient's mind is temporarily clouded through infection or suffering, he may be reacting to a delusion, an obsession, a fixed idea of disability, a terrifying fear. Sometimes he persistently refuses food, and gives no reason for it. The unthinking nurse is tried, puzzled, and irritated. In other ways, perhaps, the patient seems quite normal. But, after all, the explanation is very simple. He probably is as confident that the food is poisoned as you are that it is as it should be. No arguing would convince him, for, to his mind, the nurse is either a complete dupe or an agent of the people whom he knows are plotting his death. And urging him only strengthens his conviction.

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.

These deluded patients live in a world we often do not sense, a world whose reality we do not appreciate. The nurse, after much experience, finds that there is a key to every resistance, to every lack of co-operation, to abnormal attitudes and actions. She realizes that a powerful emotion of desire or fear, of love or hate, of ambition or self-depreciation, of hope or despair, of faith or distrust, unchecked by reason or judgment through the years, has provided a soil upon which emotional thinking alone can grow. The patient is a mere puppet of the suggestions of emotions which may not be at all pertinent to the facts.

NURSING THE DELUDED PATIENT

The nurse soon realizes the uselessness of attempting to argue a patient out of his delusions, of trying to convince him that the things he sees and hears and perhaps tastes and feels, are but hallucinations. Her very insistence only fastens his attention more firmly upon the false conclusion or makes him more convinced that his mind is giving him a true report from the senses of sight and hearing and taste and feeling. But often a quiet disregard of the delusions while the nurse goes on her way and holds her patient to his routine, consistently and confidently, as she would in case they were not true, will eventually cause him to question their reality just because no calamity results. The nurse acts as if these delusions and hallucinations were non-existent in reality, and when the occasion arises, through the patient's questioning, she urges him to exert his will to act also as if they were not true; to try it and see what happens. Arguing, also, she finds, usually antagonizes or makes the patient stubborn. He cannot prove by her logic his point, but he "knows" from inner experience that he sees what he sees, hears what he hears, and knows what he knows. The fact that the nurse does not is merely annoying evidence that she is blind, deaf, or stupid to these things of his reality. He knows he is lost and damned, or tainted; that he is King George, Cæsar, or the Lord, as the case may be; or that his internal organs are all wrong. He "feels" it and the nurse can't--therefore, he alone has true knowledge of it. In the end, the wise nurse who never disputes with him, but leads him on to action which utterly disregards these things, may bring about a gradual conviction in the patient's mind that a man couldn't do what he does if all these things were true; and the delusion slowly may lose its force or the hallucination fade away. Many patients drop them from their lives entirely. Many others in whom dementia is not indicated, or in whose cases it is indefinitely delayed, can come to an intellectual realization that all these things are fantasies, and do not represent reality; that despite their continued, frequent, or occasional demands upon feeling life, they can be consistently ignored. These psychopathic individuals may act as they would if the delusions never came henceforth to their consciousness, and so be enabled to live a comparatively normal life.

THE OBSESSED PATIENT

A patient who is suffering from obsessions must carry out certain abnormal actions, or be wretched. She cannot do otherwise. It is as though she were forced by some outside agent, though the forcing is actually from within. When the nurse realizes this, and the more essential fact--that many patients, who have not true obsessions, yet have a tendency toward obsessed ways of thinking and doing--when she comprehends it almost as she would if she were the victim, then she is ready to help the patient by gently making the action impossible, and at the same time diverting attention.

THE MIND A PREY TO FALSE ASSOCIATIONS

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.

The nurse can only sense the strength of the influence of heredity and environment and habit of thought, which would give the explanation of many things in her patient's attitude. Nor can she realize just what shade of meaning certain phrases and words have for her charge. To the nervously overwrought person the most innocent reference--father, sister, wife, home--may bring concepts that are unbearable. The association of the word may make for deep unhappiness, of which the nurse knows nothing. But she _can_ learn that all these things _do_ influence attitude, can appreciate the difficulty of her patient's effort at adjustment, and do all in her power to make that adjustment possible. If the patient is reasonable she can appeal to her reason. If she is too sick for that, the nurse can use happy suggestions. If the mind is deluded and obsessed she can use firm kindness. She can learn what loss of privileges will affect the rude and unco-operative patient, and may be allowed to try that. She can sometimes help the patient to self-control by making her realize that after each outburst she will be constructively ignored.

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.