Acute psych unit with no "talking" therapy?

Domestika · Feb 12, 2011

Come on, acute psych nurses. I know you're out there. :)

opossum · Feb 14, 2011

I too am curious as to what happens on other psych units - I'm a new grad about to begin work on a unit at the state psych hospital.

I'd love to hear about the "milieu" (my new word of the day!)

Seawitch · Feb 14, 2011

I'm not a psych nurse - but I just can't imagine that happening. What happens to those who are responding to voices and those who are manic? Is it for people that are depressed or sufferring from Post Traumatic Stress to reduce the stimuli??

I'd be interested to hear more.....

Davey Do · Feb 14, 2011

What an interesting situation! Interesting being the relative term here- I'm not saying that the situation you described, Domestika, is a good one. However, it is an interesting one.

It seems that the type of therapy that goes on in the Unit you work with is focused on medications. I understand the reason for, and appreciate, your enquiry. Your belief that medications are only a portion of the Treatment Approach is a School of Thought held by many. And, oh, how I could go on and on about Easy Fixes and Happy Pills or Taking the High Road!

Before I pontificate further, please allow me to answer your question, "Is this the norm?" In my nearly 30 years of experience in working State and Community Hospitals and Mental Health Clinics, I have to answer "No. This is not the norm".

Group and Individual Therapy are typically seen as essential parts of the Treatment Process. Emotional Discomfort needs to be dealt with through a Processing Type of Therapy if the Individual can ever be expected to grow and develop through Conscious-Changing Efforts as a result of Illuminating Revelations.

Or the Individual can just take a pill in order to deal with our Emotional Discomfort. Like David Gilmore of Pink Floyd sang, "I have become- comfortably numb." Sole use of medications do not DEAL with Emotional Pain. Most Psychotropic Medications merely mask the symptoms.

Now, before I am perceived as being totally Anti-Pharmacological, I have to state that I am not. I believe that medications can be used as a bridge to better health. But Therapy based soley on medications is like a house built on sand: The first big wave, or crisis, that comes along will topple that seemingly well-established residence.

I thank you for allowing me to express my views on this subject and wish you the best in your endeavors.

Dave

rn/writer, RN · Feb 14, 2011

For many (if not most) acutely mentally ill patients, meds and talk therapy are like the right foot and the left foot. Which one do you use for walking? Why, both, of course. The meds help to regulate moods, suppress urges, and eliminate psychosis, among other things. The stabilized patient can then make use of group and individual therapy to heal emotional wounds and address unhealthy ways of thinking.

I'd be interested to find out what the insurance companies think of this "meds only" approach. My guess is that they'd balk at paying inpatient rates for a management system that could be implemented on an outpatient basis. Part of the rationale for inpatient admission is the frequent exposure to group and individual therapy and the patients' interaction with each other and with staff. If the milieu is not going to be used as a tool, why insist on such an expensive form of treatment?

Strange, indeed.

mentalhealthRN · Feb 15, 2011

The idea is that when a patient is hospitalized into an inpatient psych unit they have decompensated to the point where they are a risk to their own or others safety,or they are so depressed that they are what we would call passively suicidal to the point of neglecting their ALDs and such. Not functioning enough to be safe. They are there to be stabilized. This is done via meds--new meds, dose changes, d/c of meds, etc.-- and providing a safe, secure, supportive and monitored environment. Any medical pathology contributing to or causing the behaviors/symptoms can also be looked into--ie delerium, brain cancer, CVA, TBI, UTI, AIDS delerium, porphyria, etc. This is not the point at which psychotherapy is appropriate or generally very productive. Not to say that supportive conversations should not be happening between the patient and nurses, mental health techs, social workers and docs but its not truly psychotherary. Its more along the lines of just theraputically supportive conversations. Groups tend to be more like the ones the recreation therapy staff does with things like relaxation, guided imagery, etc. Think of it in terms of Maslow and his hierarchy of needs model. The patient needs to be stable enough to move on to therapy. They need to have their psychosis symptoms or anxiety or depression stabilized with meds. For some this may be getting rid of the symptoms totally or with other more severe cases getting to the point where the symptoms are stable enough to function with. ie--the voices were very bad on admit--telling the person to kill themself and others and the pt responding to the voices....then once the anti-pscyhotics are back into the system long enough the voices subside to the point of no longer being threating and a lot less intrusive. Or a manic patient letting meds kick in so the pt can slow down enough to listen. or anxiety settled enough for the pt to relax and sleep and function. So basically the idea of the initial admit is to stabilize. Then depending on the pt they will move to a partial hospitalization, to intensive outpatient therapy, outpatient therapy or if they seem to be making very slow progress towards stabilization they may need to move to a long term facility--like the state programs. These levels of care after the hospitalization for the acute symptoms are where the therapy can really begin or resume. Make sense? Hope this helps.

Domestika · Feb 15, 2011

Thanks for all your great insight!

MentalhealthRN: I definitely understand what you're explaining about people needing to be stabilized before they will benefit from psychotherapy. And there are many people on the unit who I don't believe would benefit at all from psychotherapy in their current state. However, there are patients on the unit who have reached a level of stability that I think is conducive to talk therapy (ie. the 21 year old woman who has been on the unit for three months stabilizing her schizophrenia medication and is now moderately reality-based). She can carry on a conversation and mostly understand what you are saying, but there is no teaching going on. She is still only assessed for signs of efficacy of her meds.

There are also patients who come to the unit after a suicide attempt, or in advance of a possible suicide attempt, who I think could really benefit from some therapy. They are more or less mentally competent. They can carry on a "normal" conversation and have insight into their issues. Yet they are treated in the same way as the severely psychotic: assess for med efficacy; adjust as needed.

Someone else also mentioned the cost involved in providing "out patient" services to inpatients. And I think this is a big part of it. When I asked my clinical instructor why there was no therapy side of things on the unit she said that "people are here just to be stabilized. Once they get back into the community they can contact counseling services". I think it's disasterous to provide treatment just to the point where the person isn't going to kill themself or others, send them back out to the community and expect them to locate and attend counseling for a problem most of them don't believe exists. Granted, some of them have "case managers" who try to help them connect with services, but the severely mentally ill often have no insight into their illness and simply go back into the community, decompensate and then come back to the unit for another med stabilization. Round and round we go.

Although I have no experience, I have a hunch that some of these revolving door patients would be back on the unit less frequently if they were learning some coping skills while they were here. It's kinda frustrating to watch! It's definitely given me a better idea, as a student, of what I want out of my future work. I want to not only stabilize peoples' mental health with medications when needed, but also impart information, support and skills that will help them grow as people and develop more insight into the role they can take in their own mental health.

mentalhealthRN · Feb 15, 2011

Interesting.... a pt on a "acute" psych hospital unit for 3 months? Wow. That is part of the problem. That person should be transferred if they are not able to be discharged-- to a more appropriate facility. One where she would get therapy. Yes you are right. I think it is a combination of both the coverage of outpatient services in an inpatient acute setting for insurance purposes as well as what I was speaking of before. The idea that they are they short term to be stabilized. However, this is assuming the premise that the patients are actually there only during the acute phase/exaserbation of their illness. Once they are stable they need to be discharged. There are partial hospitalization programs where they go like a job to tratment. Daily -Mon-Fri all day, like 8 to 5 --intense and they get therapy, but sleep at home. There are CDT Programs for those who are SPMI and that group gets a case manager as well. So I guess the biggest issue I see in the place you are at is the LOS for those folks (length of stay). I am suprised they are getting covered that long and that the Utilization Review nurses aren't making the docs d/c them sooner. I do get your frustration though. I found that in inpatient often those that are more stable and don't have groups or anything to do get into trouble more often due to being "bored". You can, however, as a psych nurse do some informal talk with the patients. I call it therapuetic support. And maybe suggesting optional groups to the manager. We opened the gym in the evenings when we could and let them shoot hoops. They loved this and it was a great outlet for those that were anxious, manic, etc...... and they would sleep better. You could try suggesting something like that. The other thing is talking to the social workers about having materials available for the clients who have done DBT prior to their stay and can work independently on worksheets specifically for DBT (Dialactical Behavioral Therapy) sometimes they will have stuff for the pts to do. Also you can suggest journaling to the clients. They usually don't allow pens and such but will sometimes if not a violent patient and they sit in a common area where staff can monitor for safety. Journaling helps a lot of patients I found.

Domestika · Feb 15, 2011

I should mention that I'm in Canada, so things are organized a bit differently than in the U.S.

Three months is a pretty lengthy stay on this acute unit. She would have been gone a week or two ago but her discharge plans were changed at the last moment because someone she previously had a conflict with was discharged (from another acute unit) into the same rehab house as she was meant to go to. So things have been delayed a bit while they try to find another set up for her. And I should mention that her psychiatrist says that she presented to the unit with the most severe schizophrenia he has ever seen, so her stay was always going to be a lengthy one.

But there does seem to be a real lack of "in between" services. The acute unit is for stabilization and discharge is sometimes difficult to set up. Some people are discharged back into the community with no supports other than "here are some phone numbers and your prescription. Remember to fill it." Some people go to supported living facilities or into extended care. There is one patient on the unit who has been there for more than a year because they haven't been able to find an appropriate facility for her (that will take her). She is geriatric, quite mentally ill even when "stable", has severe COPD and needs help with her personal care (staying clean, etc.) Oh, and she has been aggressive in the past. So she takes up an acute bed. Not a perfect system.

Thankfully the unit does have an OT during the week who holds the community meeting, supervises crafts and does genuinely interact with the patients and does things like teach them the guitar or piano. They also get some gym time every few days. But they don't go out of their way to involve people in these activities. It's written on a board on the unit and sometimes there's an announcement that the activity is beginning, but the people who are a bit more isolative or shy simply don't attend any activities whatsoever. And as a result, they have next to no interaction. It's disheartening to see nurses say "Oh, so and so is the same. Still guarded and superficial, didn't talk to me, remains flat, isolated" etc. Because you know that the nurse probably went up to them, asked how they were, didn't get a response and that's their whole "assessment". That's all the interaction the nurse will probably have with that patient on her 12 hour shift. I think it takes more work than that. Actual work.

I'll look into your suggestion of finding some materials I can provide them with, even just Health Canada printouts on their particular illness and coping strategies or something. I'm just a student right now so I'm still learning all the skills myself. I don't always know what to suggest or even how to respond to their questions and concerns. But I'm doing my very best to offer my ear to anyone who wants to speak into it and I make it a point to constantly be on the floor, walking around, making myself available if anyone wants to engage. I'm only one person and I'm just a student, but I figure maybe I can still make a difference. There might not be formal therapy, but just having someone to vent to and talk to can help relieve some of the stress of being on the unit and coping with illness.

Seawitch · Feb 15, 2011

I think the no talking would suit people with PTSD. I know of a few Vietnam War vets who can book in for a couple of weeks a year - just to do nothing and have some low stimuli time.

If I had to tell a person with mania to be quite I'd end up manic myself.