by Charles O'Meara, RN
Some people love baseball, others find it boring. Some people love jazz or classical music and can't stand hip-hop while others have the opposite view. We're all the same, but a little bit different, too. That's why they make (and sell) so many flavors of ice cream. These preferences and dislikes are called personality traits and they don't disappear when someone is diagnosed with mental illness. Yet they seem to. I've read literally hundreds of pages of notes in hundreds of patients' charts over the years and I often spot huge gaps in their history, mistakes in their timeline, contradictory diagnoses, vague anecdotes and lots of other stuff that serves no purpose and doesn't help the patient. In psychiatry patients' personalities are often overlooked, unknown entirely or discounted during treatment. Sometimes we don't see the person, only their symptoms. Unfortunately, in psychiatry, those symptoms can easily overshadow a patient's personality. Firestarting, predatory sexual behavior toward other patients, violence, throwing things, intentionally ignoring the staff when they ask that a patient turn their music down at two in the morning, self mutilation, suicide attempts and so on. You can't exactly trivialize or gloss over that stuff. Nor should it be trivialized. But when patients become out of control emotionally and mentally, it's important to discover what increases their anxiety level and what reduces it. That's a win-win for everyone. Whoever or whatever you were before you became mentally ill doesn't necessarily change once your symptoms are formed. If you were a stingy, nasty, bigoted, budding white supremacist at sixteen or seventeen, that's not going away just because you develop major depressive disorder or schizoaffective disorder. What it does mean is that when your symptoms are uncontrolled, these things are likely to influence and color your behavior to an even greater degree. A white supremacist schizoaffective patient who believes that extraterrestrials are reading his thoughts may take this to the next level and decide that those extraterrestrials are black and come from a planet populated by black creatures who are out to persecute whites. If you're a teenager with major depression who excels at tennis, you might become absolutely furious if other patients on a psychiatric unit talk so loud you can't enjoy the tennis match on TV. You might even punch one of them. And when that incident is reported to the oncoming shift or written up in a doctor's or nurse's note, it sounds, well, pretty odd: "patient. B. became enraged when patient S. kept talking during the tennis match. Pt. B then took off his shoe and struck patient S. in the face multiple times." When you read about "crazy" behavior related to crimes in the newspaper and ask "Why would someone kill another person over a bottle of soda?!?!" The answer is that it wasn't over a bottle of soda. It was about something deeper. When I was a head nurse on a psychiatric unit we often had to deal with problems affecting roommates. We spent a fair amount of time figuring out how to move two patients from this room into different rooms and what to do with the new admission. Psychiatric patients whose symptoms are poorly controlled often have problems getting along with other. If one person has to have the lights off at bedtime and the other likes to have them on, that's becomes a problem. Throw some paranoia and mania and delusional thinking into the mix and you might have to literally go into that room and physically separate the patients when it comes to blows. So you learn to put the patient who sleeps with the lights on in the same room as another patient who sleeps with the lights on. Obvious? Sure, but you'd be surprised how often this sort of thing is overlooked in favor of the staff on a psych unit engaging in a power struggle - and I'm sorry to say that from my experience this might include anyone, doctors, nurses, nurses with a lot of fancy degrees, unlicensed staff, housekeepers, you name it. Too many times I've seen 'problem' patients dealt with as children with the staff shouting some variation of "Because I said so and I'm in charge, that's why!" The key to solving situations like the above is using a carrot on a stick. If you know the patient values something - perhaps a weekend pass - and they're about to throw a stapler, quietly reminding them about the consequences and losing that weekend pass works a lot better than yelling. If a patient hates going to a particular therapy group for whatever reason, the solution isn't to punish them, it's to find out why they don't want to go. And just as I don't approve of staff yelling at patients and saying 'Because I said so' neither do I approve of patients yelling at staff and saying 'It's none of your business!' (And for the record I also don't approve of supervisors and hospital higher ups who haven't done one-to-one patient care in decades saying 'because I said so'.) To a large extent, we are a product of our upbringing. If you were raised to be positive and go for the gold and never give up and be a good upstanding citizen, chances are a lot of that will stay in place when you become mentally ill. Once your symptoms are controlled, you'll probably still hold those values. You may end up working in a soup kitchen, although your mania annoys everyone around you. But hey, at least you're focused on something good as opposed to murder and mayhem. If, on the other hand, you were raised in poverty by a single mom who left you alone and brought strange men back to the apartment when she was drunk and loudly had sex with them while you sat hungry and afraid in the next room...well, there's certainly a chance that you might become a bitter, angry, lonely, hostile person whose mania expresses itself as murder and mayhem. Getting to know patients as people means that they feel more comfortable around you and are more willing to open up as well as listen when you speak. For doctors, nurses, therapists and so on, it means less stress and a greater chance of helping the patient to improve their life. So, the big question becomes: how do we get to know patients better? The results of my extensive research in this area have revealed the following secret: you ask them. One of the reasons I went into psychiatric nursing is because it's one of the few truly wholistic forms of western medicine. There are no blood tests to detect schizophrenia. No PT scan or MRI can tell you whether a patient is suicidal or not. An x-ray won't detect deep feelings of self-loathing and depression. In psych, you have to talk to patients to find out who they are, where they came from, what motivates them, what scares them, etc. Oh yeah, you also have to listen to them as well. And then you have to pass the information on to the rest of the staff. So the problem is two fold. Firs,t how do we 'get to know' mentally ill patients as people? Second, how do we share that information without violating someone's privacy? Unlike many other 'sick' people, psych patients usually have a tendency to drift in and out of treatment, moving from hospital to hospital where the goal is to patch them up, calm them down and get them out the door as quickly as possible. They move in and out of this program or that program, out of one halfway house and into another, visit a therapist in one town then move and visit a therapist in another town. And each time they appear at a hospital or therapist's office or whatever, they are a blank slate, an unknown entity, a collection of symptoms. I don't want to dwell on HIPPA and generally stupid privacy laws, but I will say that when you are dealing with the mentally ill, the rules thought up by bureaucrats, don't work. Patients with mental illness sometimes intentionally lie about their identity Other times they are whacked out of their skull and believe themselves to be someone/something other than they actually are. In other cases they literally can't remember the answers to your questions. Often they do not have family members or friends who can vouch for them or corroborate basic information. Are they really the niece of a very, very, very well known TV celebrity?' (yes, it turns out, the patient I'm thinking of was indeed the celebrity's niece and I thought it was a joke when that very famous celebrity was on the phone when I picked it up.) Obviously it's not OK to walk around town and say to everyone you meet 'Guess who's back in the loony bin? Yup, Carl Pimplenipper! They found him eating dog poop in the park again! He should go back to live with his parents at 1234 Imaginary Address Avenue in Phoneyville.' On the other hand, you can take just about anything to a ridiculous extreme and the privacy police have definitely done that. What about the other part of the problem, getting to know the patients by talking to them? Sometimes clinicians - doctors, nurses, therapists, all of us - don't even bother to ask questions. Or, if we do, we forget the details and/or write a half-assed note in the patient's chart. An incident where a patient states they become immediately paranoid if they see a woman wearing a hat because their hat-wearing grandmother beat them is recorded as "Pt states she has issues with grandmother." I remember a patient who was sitting on the ward watching the local news when he suddenly jumped up and began screaming that "The TV told me my father's dead!" He was subdued and sedated. It turned out that his father was mayor of the patient's hometown for a number of years. When he died, they announced it on the evening news. The staff didn't know this. So the patient was assumed to be delusional. On a more positive note, I had patient who kept telling the staff "Freddy Fixit Day is coming! Three more days to Freddy Fixit Day!" We all had a jolly good laugh about it, even some of the other patients. Then someone from the patient's home town brought in a newspaper clipping about Freddy Fixit Day. I have learned over time that making an effort to learn something about a patient helps tremendously in treating them. For example, often patients won't take their medication and it causes an impasse. Staff becomes frustrated and we get head butting: take your meds/no/take your meds/no/i said take them/i said no/etc. Me, I take them aside and say something like "OK, what's going on? You don't like being here, I know that. Hospitals are not fun places. But there are some good reasons why you should at least try the medication. Are you afraid of it? Did you hear something bad about it? Are you worried about side effects? If you have any questions, ask me and I will get you the answers." Then I drop the subject and walk away and about seven times out of ten they approach me within a day or two and want to talk about the meds. So, to sum up: 1. Clinicians need to learn how to interview patients, how to listen, how to gather information. 2. Clinicians need to learn to accurately and fully document the results of the interactions they have with patients. 3. That information needs to be shared. 4. Don't serve the patient broccoli if they tell you they hate broccoli. |
charles o'meara, r.n.I have worked as a registered nurse for more than two decades, ninety percent of that time as a psychiatric nurse. Archives
June 2017
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