Journal of Psychiatric and Mental Health Nursing, 1999, 6, 335^337

Commentary

An encounter with the work of AnnieAltschul: reflections from down under

I would be lying if I were to claim that Annie

Altschul has been an inspirational ®gure in

guiding me through my career as a psychiatric

mental health nurse. I may at times tell some

`untruths' but I am not a liar. So I will tell you

about how I came to read the work of Annie

Altschul when I was not at all interested in

reading anything to do with psychiatric mental

health nursing

I want to share with you my ®rst experience of

working in psychiatric mental health nursing. Part

of this re¯ection includes my ®rst encounter with

the work of Annie Altschul. The year is 1973 in a

large psychiatric hospital in Auckland, New

Zealand (down under). At that time the training

for psychiatric nurses was a three-year hospital

based programme which included on-site training

interspersed with theory `block' times. Ideas and

`understandings' about psychiatric mental health

nursing in this country were guided mostly by

what was happening in England and to a lesser

degree Australia. There were few psychiatric

mental health-nursing scholars and nursing prac-

tice was grounded in the medical model with little

attention to the needs of the local community.

At the commencement of our training we had

three months in theory (prelim) before being

allocated wards. In the classroom the texts

referred to by our tutors where mainly medical

ones. We were taught a lot about the disorders

and the `treatment' (electroconvulsive therapy

and medication) but little about how to actually

`be' with people who had a mental disorder. I

have no recollection of any texts with a nursing

focus being recommended. It wasn't until I took

myself into the deep and dark corners of a local

bookshop that I discovered a small (and hence I

assumed manageable) book called Psychiatric

Nursing by A. Altschul. I was instantly attracted

to this book because of its size and knew it would

be easy to carry around (very important when you

are a student not to look too overburdened with

large textbooks). On ¯icking through the pages I

saw chapter headings that I could very easily

relate to. In particular I was drawn to headings

that referred to care of disturbed and violent

patients, nurse±patient relationships and nurse±

patient interactions. I was a little intrigued by the

name of the author as well.

My ®rst placement after the three-month

`prelim' was in the female security ward where I

was to stay for 15 months of my training.

Here I had what was for many of us encounters

with sta� and people with mental illness that

helped to shape our understandings of human

behaviour in ways that none of us could have

anticipated. Ask any psychiatric nurse where they

had their ®rst clinical experience as a new student

and they will often tell you about times of great

laughter as well as profound grief and sorrow. We

were cast out into a world where few of us had

any idea about what to expect or how to behave

let alone write about the behaviour of others. It

was a scary time yet somehow there was a tinge of

excitement at the thought of actually meeting

some `real' patients.

Already, having been on this ward for only one

day I had come close to being assaulted by a

rather large and somewhat overbearing female

patient. This situation had caused me some dis-

tress and I was desperate to ®nd some meaning

behind this encounter to help me understand and

cope with future situations. At that time forma-

lized peer review or clinical supervision were alien

concepts and most of us were left to drown our

re¯ections down at the Inner Circle, a pub in

Avondale, which was one of the local watering

holes frequented by psychiatric nurses.

It was my ®rst morning duty in female security

and I was keen to make a good impression. Apart

from the fact that this required me being on time I

was determined to appear calm and collected. Not

at all phased out by the things that I had heard

# 1999 Blackwell Science Ltd 335

Editor:

Phil Barker

Submissions address:

Department of Psychiatry, University of Newcastle UponTyne, The Royal Victoria Infirmary, Queen Vicoria Road,Newcastle Upon Tyne NE1 4LP, England

about this ward and the people in it (sta�

included). The charge nurse always kept new

students in the corridor away from the dayrooms

where he could keep an eye on us and I was no

exception.

Entrusted with making the morning tea I

`bounced', into the kitchen, not a care in the

world, bright as a button to put the zip on. A

very tall athletic looking woman wearing a nightie

and dressing gown was standing next to the zip,

arms folded, staring at me as I blossomed in. I

knew instantly who this person was (famous

reputation around the hospital) and instinctively

knew that I was in trouble as I reached over to put

the zip on. I could see by the look in her eyes that

she was very angry but was unsure if it was

because of me. I knew that I had to get out of

this tiny kitchen very quickly but despite wanting

to turn and run I sensed that this would not be the

best course of action. I spoke to her and commen-

ted on how nice her hair looked before easing out

of the kitchen. I had survived. Some months later

when I asked this same woman why she had not

attempted to harm me she simply said `because

you knew'.

Altschul discussed the relationship between the

new and inexperienced nurse and the patient

recognizing the dynamics in the ®rst encounter:

`The new nurse experiences fear and misgivings,

and this very insecurity is communicated to the

patient, who, in the presence of one inexper-

ienced member of the sta�, may become frigh-

tened. Because he is frightened he may become

aggressive. It is therefore very often the new

nurse who has to bear the brunt of the violent

patient and who requires some reassurance and

support.' (Altschul, 1973, p.175)

What I read about in Altschul's book made a

lot of sense to me. It was easy to read and very

straightforward. The language was uncompli-

cated and inclusive. I could understand what she

was writing about and this helped to validate the

feelings that I had as a young 18-year-old student

nurse working in a tough and sometimes uncom-

promising environment. The above passage high-

lighted the need to recognize and explore the

feelings that in¯uence and sometimes compromise

the therapeutic relationship.

In this instance the female patient had sensed

my fear and uncertainty despite my behaviour to

try and disguise this. She had probably seen it all

before, many times. I had not acknowledged the

feelings that I had before coming to work in this

ward or discussed them with anyone. I had been

scared, anxious and totally unprepared on my ®rst

day in this ward. Truth be known I had probably

been down at the Inner Circle the night before

drowning my anxieties!

Unfortunately I had not read this chapter

before going to work in this ward. However, I

did take the time to read the chapter and the book

after this incident. I learnt a lot more in the

process. Some of the areas that Altschul wrote

about that particularly interested me were about

the importance of knowing thy self, boundaries

in the nurse±patient relationship, appropriate dis-

closure of feelings and issues around interpreting

patient's behaviour.

I wonder if Annie Altschul wrote at that time

how it was for her hoping to connect with some of

us out there. Much of what she wrote about at

that time connected with me and helped me to

understand a little about the complexities of

human interactions and the role of the nurse in

this very demanding yet rewarding area of

nursing. Even looking at this book today I am

struck by the relevance this writing still has. I am

not sure if Annie Altschul was ahead of her time

given that this work was ®rst published in 1957.

However the issues and concepts discussed at that

time are still recognized as key concepts today.

Any psychiatric mental health nursing book that

you open today discusses these areas of nursing.

Altschul also broached the sometimes not so

easily talked about topics such as the complex

issues involved in `touch', about giving advice to

patients, controlling aggression (in sta� and

patients) and attitudes of sta� towards patients

and colleagues. Another controversial area today

is the importance of good supervision and

Altschul recognized this as an essential part of

supporting nurses in their practice.

Altschul captured the essential concepts that

are part of psychiatric mental health nursing and

wrote about them candidly. Many writers and

theorists have also developed and explored these

same concepts but what was unique about

Altschuls approach was her ability to express

these ideas in a nursing context at a time when

the medical model was dominant, and to chal-

lenge this was very di�cult. To be able to articu-

late the nursing `voice' and the role of the

psychiatric mental health nurse is something that

we are still trying to do today in our profession.

Commentary

336 # 1999 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 6, 335±337

In 1973 I was appreciative of the opportunity to

read about the work of Annie Altschul. At that

time I began to raise my awareness about what

was involved in nursing people who had been

diagnozed with a mental illness. My con®dence as

a new student nurse was enhanced by the oppor-

tunity to re¯ect on these concepts that Altschul

wrote about. Since then I have developed my

learning and expanded my thinking to take

account of the New Zealand context of psychia-

tric mental health nursing. This means dealing

with concepts such as culture, gender and sexu-

ality in relation to my current work and personal

experience. For all of us working in psychiatric

mental health nursing it is important to have a

beginning place, a platform from which to expand

the horizons of our thinking. I am grateful for the

chance discovery of a very small but in¯uential

book that gave me the opportunity to do this.

CHRIS WALSH

Senior Lecturer

Co-ordinator Postgraduate Certi®cate in

Advanced Nursing (mental health)

Department of Nursing and Midwifery

Victoria University

PO Box 600

New Zealand

Commentary

# 1999 Blackwell Science Ltd, Journal of Psychiatric and Mental Health Nursing 6, 335±337 337