Who's Afraid of the Big, Bad Psych Patients

by rn/writer Guide

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If you want a room full of nurses to become very quiet, mention working on a psych unit. Some will express interest. Others will quietly edge away. But neither group is likely to be aware how "normal" psych has become and just how many people actually have a diagnosable disorder.

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    Who’s Afraid of the Big Bad Psych Patient?

    Whenever I tell people I use to be a psych nurse, I usually get one of two reactions. “That’s so interesting—tell me more.” Or, far more often—“Yikes! Psych freaks me out. I could never do that.”

    It’s no wonder. Very few of us had more than a brief flirtation with psych during nursing school. In class, we were introduced to Freud and Jung, Maslow and Erickson. We learned about normal brain function and the myriad ways it can falter. We covered a long list of diagnoses and the signs and symptoms that went with them. And we made lists of meds. Lots and lots of meds. Next up—the psych ward where we made hesitant contact with patients, attended group sessions, and did our best to conduct therapeutic conversations. Remember active listening?

    But psych is a complex area and we barely had time to scratch the surface. Add to this the fact that we didn’t want to say anything offensive (So, how does it feel to be psychotic?) or set anyone off, and it’s easy to see why we were relieved when the nurse locked the ward door behind us on the the last day.

    It seems so rational, even somewhat sensible to be afraid of psych patients, but is the fear justified?

    Consider that there are approximately four million people in the US with severe mental illness. Out of that number, just 40,000—one percent—are violent. And, according to Jeffrey Swanson, a professor at Duke University, that violence is mostly mild behavior—shoving, pushing, punching—more associated with resisting someone else’s control than intending to cause them harm.

    The stark reality is that mental patients are 13 times more likely to be the victims of violence than the perpetrators. Limited resources, rough living, and the fact that they aren’t the most credible witnesses, turn folks who struggle with mental illness into attractive targets for criminals and opportunists. Often, patients are their own worst enemies, forgetting (or deciding not to take) meds, giving away money and possessions, and choosing unscrupulous or unstable companions.

    But none of that makes the news. The mentally ill people we hear about are the crazed gunmen or the serial killers. With extreme criminals providing the “face” of psychiatric illness, it’s little wonder that even the word “psych” freaks people out.

    In reality, if you want to see what a typical psych patient looks like, take a peek in the mirror. That isn’t meant to insult, but to illustrate how “normal” mental illness is.

    According to the Kim Foundation, in any given year, approximately one in four American adults will suffer from a diagnosable mental illness. Unfortunately, many people will not actually be diagnosed, and of those who are, many will not request or receive treatment. Nevertheless, a quarter of our population lives with one or more psychiatric afflictions. What could be more ordinary than that?

    Let’s take a step back from the machine gun-toters and the axe-wielders and recognize them for the statistical anomalies that they are. Much more common are everyday people who struggle with mood disorders (depression, bipolar disorder), anxiety disorders (panic disorder, obsessive-compulsive disorder, PTSD, generalized anxiety disorder, and a variety of phobias), conduct disorders, substance abuse, eating and body image disorders, ADHD, autism spectrum disorders and Alzheimer’s disease.

    It’s a rare person that doesn’t know someone affected by one of these maladies and many of us know half a dozen or more. (Pssst. And some of us are that "one in four" affected people.)

    Do we hold all of these people at arm’s length? Not usually. We often learn to keep a bit of protective distance, but we still interact and encourage the afflicted ones to seek health and make better decisions. That’s similar to what happens on a psych unit. Doctors, nurses, techs, and other professionals try to establish a caring connection, offer a listening ear, and help the patient navigate through treatment choices and through their often challenging lives.

    But isn’t it frustrating to work with such messed up people? It can be. But “messed up” is a relative term. Some mental patients are fairly sane people who have been steamrolled by insane circumstances, time and time again. If you knew all that they had dealt with over the years, instead of shying away, you’d be proud to know them, and you’d see them for the resilient survivors they are.

    Other folks have been tuned to a different frequency for most of their lives, but you can still see a spark of humanity in their eyes. Even the hostile, edgy ones have a good days mixed in with the not-so-good.

    As far as the fear of “setting someone off” goes, when you work in this milieu, you learn ways to help patients deescalate. Or at least how not to push their buttons. This is a fantastic life skill to practice on a psych ward, but it can come in handy anywhere.

    Another frequent bugaboo connected with psych is the idea of tip-toeing on eggshells when it comes to talk of suicide. When, at first, I was taught to ask patients outright, “Are you thinking of harming yourself? Do you have a plan?” I thought it was, pardon the expression, insane to ask a fragile mental patient such a loaded question. I assumed they’d either lie or become angry or both. Imagine my surprise when they almost always told the truth and expressed relief that someone had mentioned the elephant in the room.

    Once the subject was broached, we could discuss the emotional triggers that sparked thoughts of self-harm and strategies for patients to get their needs met without drama or damage. They were happy someone cared enough to ask and often agreed to contract (make a deal) to keep themselves safe. They would agree to say a particular word as a signal that they needed a one-to-one conversation or they’d write rather than cut or they’d even ask us to put them in the quiet room where they could calm their racing emotions with our help.

    Some nurses have expressed reluctance to deal with a population so given to (and good at) manipulation. Initially, you get suckered in. A lot. But then you learn. And pretty soon you get to a point where you don’t even get riled up any more. When someone tries to play one staff member against another or take unearned privileges, you say things like, “No, you can’t break the rule, but thanks for asking. We have lovely parting gifts for you. Thanks for playing our game.” You laugh. They laugh. No hard feelings.

    You might be amazed how many people you know—nurses among them—who either struggled with mental illness in the past or still do so today. Counseling, meds or both have allowed them to progress to the point where you would never be able to tell psych issues are or were a part of their lives unless they told you.

    I'll leave you with two important truths about psych. One is that psych patients are just like the rest of us, only more so. And the other is that no matter what kinds of patients you work with (and who your co-workers are), you will always find psych training useful.

    http://www.jsonline.com/news/law-cre...135387808.html
    http://www.thekimfoundation.org/
    http://www.nami.org/
    Last edit by Joe V on Jan 2, '12
    nursing_n00b, CosmicHymns, sharpeimom, and 18 others like this.
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    rn/writer joined Dec '04 - from 'In the heart of the heartland'. Posts: 11,700 Likes: 14,794; Learn more about rn/writer by visiting their allnursesPage


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    32 Comments so far...

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    I remember my psych instructor (a fantastic instructor and human being) walking up to someone on our psych unit - a unit I was terrified to be in, as it housed the most ill as they got stabilized on meds/therapy - and just said, "Hi, my name is Susan (not her real name), what's yours?" She proceeded to talk to this man who'd been mumbling to himself and trying his hardest not to bang his head against the wall (literally) just like she'd talk to anyone else. It was fascinating to watch, and we learned a lot in the 60 or so seconds she spent engaging him in conversation. Some of it was 'therapeutic communication', and some of it was regular talk. We were so wrapped up in thinking "Holy-gosh-this-is-psych-everything-I-say-has-to-be-therapeutic" (and there is definitely a time for that) that we had forgotten that sometimes people just want someone to say hi.

    Great article. As a postpartum depression survivor and family member of folks with varying degrees of other disorders, thanks so much for writing it.
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    The first 3 min of my psych rotation a 300 pound guy started posturing like a gorilla and staring at me. I edged behind the nurses station and he pounced on another male nurse punching him in the face. Next thing I know, the 60 year old female nurse that was sitting at the desk somehow gets the pt in a headlock, and starts talking to him in a calm voice about how it isn't nice to hit people and slowly brings him to the ground without a struggle.

    I was both impressed and terrified at the same time.

    Kudos to all psych nurses that know what they are doing!
    RNperdiem, CBsMommy, exnavygirl-RN, and 2 others like this.
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    I hated my psych clinicals. It felt like a prison, without the inmates being shackled. Most of the people I had to talk to for my stupid assignments obviously did not want to talk to me, for they'd gone through the drill before. Psych is placed with LTC in areas I will work in. It's at the level of "if all else fails".
    rn/writer likes this.
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    I enjoyed working in a psych hospital. I learned so much about people and patients in 5 years that I had not learned in my previous 23 years of nursing...sad, but true.

    You said alot with your words "In reality, if you want to see what a typical psych patient looks like, take a peek in the mirror. That isn’t meant to insult, but to illustrate how “normal” mental illness is" problem is you will rarely, if ever, get a nurse to admit being treated for a "mental illness". It will be called anything, but...
    VivaLasViejas likes this.
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    Wonderful article. Very informative and intelligent. I am a pre-nursing student, still miles away from my dream but you do not have to be there to understand this.
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    I work in psych. I too had an "image" in my mind of what working in a locked psych unit would be like. It turns out, it really isn't all that bad! I really do enjoy it and I quickly realized that although I do not want to work in psych (I am a nursing student), the knowledge I have gained will be invaluable anywhere I take my nursing career.
    CBsMommy likes this.
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    They say to always ask about suicidality if you suspect it, but I have rarely seen a doc ask. Never seen a psychiatrist ask. Why?
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    When I was in nursing school I was TERRIFIED of the psych patients. I literally talked to only one patient during my entire rotation, and only for a whole of 2 minutes. I stayed as far away as I could.. and eventually the rotation ended. To which I was entirely thankful.

    Well.. what do you know. I graduated and was hired into a residential psych treatment center. It is awesome. I have learned SO much. I do not fear the patients anymore, am no longer afraid of them, no longer afraid of saying anything to them, and no longer afraid to ask them about suicide/self-harm, etc. It is an amazing experience.

    To everyone terrified of psych.. just jump in. Say "hi" and talk to your patients. It truly isn't as bad as it feels like it might be!
    designer-mommy and CBsMommy like this.
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    Quote from canoehead
    They say to always ask about suicidality if you suspect it, but I have rarely seen a doc ask. Never seen a psychiatrist ask. Why?
    Really? I've seen lots of them ask. Besides my nursing exposure to psych, several relatives went through some rather severe mental illness challenges, and this was almost always one of the first things talked about.

    As a nurse, I didn't always want to be in someone's face about it, so I would ask things like, "Are you feeling safe right now?" "Anything on your mind that I should know about?" ""How are you doing with the urges (to cut or whatever they were into)?" Or evn just, "Want to talk?"

    It surprised me at first that anyone answered these questions (and the more direct ones, as well) honestly, but in retrospect, I think my asking gave them permission to voice what was going on in their heads. It opened the door, so to speak, and then they could walk through it.

    A lot of my patients learned that drama/acting out got them the attention they wanted and needed, but it took some modeling and some coaching to get across the idea that they didn't have to do crazy things to get assistance.

    Some of them felt a profound sense of relief that they could get help simply by asking or even just responding to someone else's inquiry about their emotional state. This was a revelation to many of them and cleared the way for the beginning of trust.
    nursing_n00b likes this.


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