Psych Nursing: A unique field of nursing.

Patti_RN

My car rolled to a stop at the curb about a half-block from Bev's group home; soft instrumental music filled the interior and cool air blew softly on my face as enjoyed the peacefulness of the moment. I was pleasantly lost in thought and busy scribbling notes about my previous patient. Bang! Bang! Bang!! A fist hit my side window and jolted me into attention and fear. A contorted, red face filled the window and a loud stream of profanities drowned out the music. It seemed that the mouth was the largest feature of this distorted face, a face that was mere inches from my window--a face comprised of a twisted mouth and fierce, wild eyes. I then saw other details... flashes of nicotine stained teeth that suffered from years of neglect; teeth broken from previous accidents, dark gaps where teeth were missing from assaults... a face lined with the wrinkles of a person much older... jagged scars on the chin and brow--permanent reminders of torturous experiences. Blazing orange-dyed hair reflected the emotional charge of this frantic, angry person. This was Bev. Bev was one of my favorite psych patients.

Psych, or mental health nursing, is not your typical nursing experience. Patients usually suffer from medical conditions as well as mental health issues, but a psych nurse's focus is on caring for the mind. In my years as a psych nurse, I can't remember ever starting an IV, inserting a urinary catheter, reading a monitor strip, or ever being burdened with back-to-back med passes. Instead, I talked to my patients. Talked and talked and talked. I learned about their lives, their dreams, their delusions and their desires for the future. Often their hopes are of simple things most people would consider basic expectations: wanting to live independently in their own apartment, wanting to be free of erratic mood swings, wanting to find a job, to have friends, and to reconnect with family who abandoned them. (Dealing with a seriously mentally ill relative is too much for many people to handle.) Sometimes I'd have a hard time figuring out what was real in their lives and what was imagined--my patients couldn't separate the two, themselves. Schizophrenic patients don't lie; they really believe they really were a child actor who played a bit part on Lassie, or that they invented plastic toothpaste tubes. Mental illness can be genetically linked just like coronary artery disease and hypertension can be genetically linked. Psychiatric problems also can be insidious, appearing without cause or warning. It can happen to anyone.

Bev's life began like yours or mine. She was the second of three children. Bev loved animals and seemed to attract all the strays in her neighborhood. She fed them, bathed them, and found homes for them. Deb's sister describes her as a once happy person who made it her personal mission to make people laugh. Bev was a talented first base player on her high school's softball team. She proudly kept a yellowed, creased newspaper clipping in her room at the group home; the clipping described Bev's ability to catch wild throws and tag runners out. Next to that clipping was a black-and-white photo of a girl with an enormous, genuine smile, wearing a pale, starched dress, with blond ringlets tumbling from her wide-brimmed straw hat. Several years later, something inexplicable happened. Bev's sister says that 'she snapped.' Bev doesn't recall anything leading up to the incident--in fact doesn't recall anything besides standing with a kitchen knife in her hand, the blade coated with glistening red, and seeing her own mother's hands and arms covered with blood. She still cries when she talks about it. Bev spent the next 20 years in a state hospital for the criminally insane. There, her hallucinations became more constant; her demons remained. Bev was haunted every moment--every waking and sleeping moment. Bev spent more than two decades living in her own personal hell.

Many patients were locked away in institutions for years. Some hospitals were caring, friendly places where staff genuinely cared for the patients. Others were horrible places where brutality was common and there was no treatment for the patients' illnesses. Even where treatment was given, the psych meds of that era were generally ineffective, so patients had no relief from their internal horrors.

I rolled the window down an inch and firmly told Bev to get herself under control. Almost like flipping a light switch to the off position, Bev's demeanor changed. She wiped the spit from her lips, and with embarrassment (and lack of social finesse) used her sleeve to wipe the little wet spots from my driver's window. "I've been waiting for you... for hours..." her voice was soft, but with a slight edge of disappointment rather than anger. "I know, Bev, it's hard to wait. You were really looking forward to my visit, but it's not 2 o'clock yet. I'm actually 15 minutes early." Her eyes dropped to her wrist where tan skin outlined the place her watch used to be. Another resident took her watch and Bev had no money to buy another. This is a major setback for a woman whose life is regulated by predictability and precisely scheduled activities. "Bev, I'll be there in 5 minutes." Bev nodded and shuffled away. Her frame hunched, her head hanging in shame because of her outburst. I finished my short paragraph then waited an extra minute or two before moving the car 100 feet to her house. One of Bev's goals was to learn to deal effectively with disappointment and learn patience; forcing her to wait allowed her to practice restraint and to concentrate on her emotions. It felt a bit cruel to make her wait, but it's a skill she needed to learn. I told myself it was better for her in the long run but I still felt twinges of guilt.

Psych nurses usually don't see progress measured by leaps and bounds. Small goals are identified and worked on until improvements can be noted. These, little, 'baby steps' are often weeks or months in development, but are reasons for celebration and delight when the milestone is finally reached. Sometimes years of mistreatment caused the problem, so it can take years to undo the damage. Sometimes the damage is done exclusively by the illness so the time it takes for progress can be a mystery--you just have to keep trying.

Bev was sitting on her front porch when I stepped onto the sidewalk. Her smile was genuine and her blue eyes glistened and danced. It was as if she had no recollection of her outburst less than 10 minutes before. She jumped to her feet and greeted me warmly. Bev was almost childlike in her innocence and trust. In contrast to her occasional angry tantrums--tantrums that drive others away, her naï¿½ve trusting nature draws opportunists to take advantage of her. Besides the missing watch, she has loaned money to others who have no intentions of repaying her--often multiple times to the same people. Unscrupulous store clerks would routinely overcharge her and pocket the couple dollars they cheated from her. Bev not only suffers from mental illness, her mind is clouded from years of self-medication, alcohol abuse, lack of stimulation, and even the side-effects of anti-psychotics that keep her on a relatively even keel--an even keel for a woman who once viciously attacked her mother for no apparent reason.

Many of those who suffer from mental illness try to chase the demons themselves with alcohol, street drugs, and risky behaviors. The worst illness must be schizophrenia. Reality and hallucinations swirl together in frenzied images. Separating imagined terrors from the reality is impossible. Voices scream. Noises echo. Faces contort. People threaten. Because children are fearful, teenagers are amused, and uneducated adults misunderstand the mentally ill, some of the taunting is real, much of the screaming and laughter is genuine, and hallucinated torment is confused with the real torment. Some memories are imagined while real memories are blurry or forgotten. It's hard to know yourself if you don't know your experiences. It's hard to create relationships when much of what you share about yourself is delusion. It's hard to know what you're capable of if your personal memories are a mixture of fantasies and black holes.

When I first met Bev, she was unpredictable, often angry and argumentative, and usually unkempt in appearance and hygiene. She was difficult to connect with because every comment was an accusation. Most interactions were unpleasant because she seemed to feel entitled and was exceedingly demanding. Her social skills were virtually absent and she had the combined foul odors of dirty hair, perspiration, cigarettes, and household cleaner (which she used to scrub her skin to keep germs from invading her body). Positive changes in her personality came in large part from changes in her medication regimen. Different medications allowed her to be receptive to suggestions and advice--which improved her demeanor and allowed her to adopt normal personal care habits. In time, Bev became less angry, friendlier, and her behaviors became less bizarre.

Anti-psychotic medications are more effective than they were decades ago. Still, finding the right medication is often an exercise in trial and error. The miracle cocktail that works wonders on one patient simply multiplies the mental demons of another. If a med doesn't work, the patient needs to be weaned off over several weeks before they can begin taking another, and the patient needs to be on the new med at least a couple weeks to judge the effect. Finding the right medication can take months or longer. Sometimes medications work beautifully for years then inexplicably stop doing their magic. Depending on the individual patient and the type of mental illness that plagues them, some patients' mental health may improve to the point they are not discernible from 'normal' people who have only minor quirks and idiosyncrasies. Others, with more serious conditions like schizophrenia continue to be haunted to varying degrees, unable to work, maintain relationships, or control the emotions as we expect in our society. Like all of us, they long to connect, to be productive, to be wanted and valued, and to be 'normal'.

Bev apologies for the cigarette smoke wafting in my face. I offer to switch places with her so I'm upwind. As much as I dislike cigarette smoke, I was tempted to excuse this social infraction, but again, Bev's behaviors needed to be shaped so she could more easily get along with others and have friendly interactions with other people. She needed to learn to be sensitive to others and control emotional outbursts that drive people away. Blowing smoke in someone's face--no matter how unintentional--does not endear the smoker to others. It's taken three years for Bev to become somewhat sensitive to other people's comforts and rights; she needs to practice this new skill. We switch chairs.

Most people with very serious mental illness won't ever be 100% mentally healthy. There are countless comparisons that can be made between medical and mental health issues. Just like a patient with a chronic, debilitating medical condition, a person with schizophrenia can live with the disease for a long time, improve with treatment, see a reduction in their symptoms, and transition to a higher level of functioning. But, unlike a person with a medical problem, the mental illness itself often prevents the patient from acknowledging they actually have an illness. They sincerely believe others conspire to victimize them, to steal their money, to lock them away, to coerce them into taking mind-altering drugs, and do so by accusing them of being crazy. They trust no one; getting them initial psychiatric help is often next to impossible. This, combined with the expense of care in a population with no money, no insurance, and often little social support, treatment is not optimal if it exists, at all.

Bev continues to live in a group home. I no longer work as a psych nurse, but I do keep in touch with Bev. Sometimes I'm amazed at the progress she's made. Other times I'm saddened by the cruelty of her illness and how it's robbed her of living a life that's in any way normal or typical. In one of my more hopeful moments, I commented to Bev that she was doing well; I complimented her on her efforts and perseverance. She paused, looked at her surroundings--the porch littered with cigarette butts, the living room full of silent, sullen patients all staring at a TV that blared in the corner--then she asked, "Will I ever get out of here and live on my own? Will anyone ever really care for me?"

Maybe someday soon psychiatric meds will bring miracles. Maybe schizophrenic patients will be symptom free by taking a monthly injection or a daily pill. Maybe love and companionship will be part of life for these patients. Until then, nurses play a major part of their social lives and are a large part of the patients' hopes for the future.

"Bev, I care for you. Let's walk to the restaurant and get some pie and ice cream." The apple pie was probably the highlight of her week. Psych nurses really do make a difference in their patients' lives, differences that might seem insignificant by other measures, but are profound for the patient.

Psych Nursing: A unique field of nursing.

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