Psychological aspects of bowel care

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Psychological aspects of bowel care

• By courtesy of
• Christine Norton PhD MA RN
• Nurse Consultant (Bowel Control)
• Professor of Gastrointestinal Nursing
• St Marks Hospital Kings College
• London, United Kingdom

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Ms CR

• 32 years old, severe diarrhoea (Crohns)
• Out shopping with 5 year old daughter
• Urgency, could not hold on, accident
• No public toilet
• Unhelpful assistant
• Eventually used staff toilet
• How to cope? How to explain to daughter?
• I want the floor to open and swallow me

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Werner-Beland, 1980Nurse with SCI

• "Do you know what it feels like to lose control
  over one of the first functions over which one
  gains mastery in life? . The very act of messing
  the sheets because of involuntary bowel activity,
  or, its reverse of having to have one enema after
  another to be rid of the stuff was almost more
  than I could cope with. Nurses would say things
  like, "I don't know why you are so upset. It's
  just an enema." I wanted to scream I have
  crapped on my own for 36 years! You just don't
  understand! I am dead!.

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Cavet, 1998 People dont understand

• Detailed study of people's experiences of living
  with faecal incontinence
• Powerful social rules associated with this area
  of life meant that families (of teenagers with
  faecal incontinence) faced public distaste,
  embarrassment, ridicule, general ignorance and
  very limited opportunities for discussion
• Negative effect of this social climate,
  compounded by the invisibility of the condition
  and the pressures on all young people to conform
  to very narrow stereotypes of bodily perfection.

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Effects of poor control

• Restricted world, boundaries constrained by
  toilets, need to conceal
• Living on a leash
• Keep control by staying close to safety
• Envy of others freedom
• Major constraint on quality of life

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Quality of life bowel problems

• Life often revolves around toilets
• First concern when go anywhere new
• Horror of queues
• Avoid places and activities in case no toilet
  available
• Chained to the toilet
• (Chelvanayagam Norton 2000)

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Normal bowel control

• Complex learned voluntary skills, such as
  languages and driving, become incorporated once
  learned inaccessible to conscious effort (Leder,
  1990)
• Know how but cannot access individual
  components. Body harmoniously understands
  without conscious effort (Merleau-Ponty, 1962)
• Bowel control is voluntary, but subconscious

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Reaction to excreta

• Innate or learned aversion?
• Smell linked to lower animal functions
• Can learn to repress disgust (nurses, sewerage
  workers),
• Context-specific, arbitrary features determine
  response? (OK at work)
• Cope with own infants
• Differentiate biological disease / atypical
  social functioning (which attracts blame) (Turner
  1984)

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Bladder bowel control

• One of first socialisations in childhood
• Incontinence is naughty socially unacceptable -
  embarrassment
• Elimination used as an expression of hostility
  aggression, verbally physically
• Infant learns that witholding or performing can
  produce a reaction (Loudon, 1977)
• All connotations of bowels negative

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Loss of control

• In dysfunction loss of organic silence become
  aware of body functioning
• Conscious effort interferes with autopilot
  functioning
• Cycle of anxiety and hypersensitivity
• Difficult to regain control as it was learned in
  pre-conscious memory era
• Difficult to communicate and teach

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• Toilets are not available in many places
• Anxiety can trigger urgency
• Vicious circle develops urge ? panic ? urgency ?
  more panic ? incontinence ?panic more next time

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