communication techniques?

[andisayd]

I work in a high functioning psych facility where basically everyone is schizophrenic or schizophrenic affective/depressed. I understand communication technique isn't a one size fit all but are there any "real live" tips. I know you arn't suppose to play into their delusions and give back answers that redirect them or bring them back into reality; but when you have a guy who is responding to AH commands and not eating and the only way is to play into their delusions... then what? Like sometimes they would be AOx4, super high functioning then a day later we have to 5150 someone and send them to a higher care facility :l

[Jules A, MSN]

I love this population and one of the best things I can offer is to be kind and low key. Their instincts are often very well honed and they seem to be able to sense who is there to help them, even if they aren't able to accept your help, and will respond better than if you come in afraid, disgusted by their presentation or antagonistic. I'm normally pretty high energy and talkative but this requires a complete change to a calm approach. On numerous occasions, not always but sometimes, I have been known to calmly walk in an ED room with a floridly psychotic patient when 5 police officers are unable to enter the room without resulting in a physical altercation. I liken this to their sense of my non-threatening affect and kind intention. "I wouldn't do anything to hurt you. I am trying to help, what can I do to help you feel more safe?". Sometimes it works and many times it doesn't.

Things I try to do and some of this can depend on whether you have a previous relationship with the patient is figure out on a basic level their concerns. If they are afraid someone is trying to kill them I will say "you know this is a locked unit and I promise I will help keep you safe". I rarely support their delusions but also rarely argue or try to reorient them. Something like "I know you see snakes over there but I do not see that. Why don't we move over to this side of the room so we can continue talking an an area where you feel more safe".

With regard to food and medication as we all know the packaged things can be helpful such as leaving their pills in the packets so they can see the name, dose and open it themselves. A sealed bottle of Ensure is often my best friend and I will offer it to anyone afraid to eat our food. If they will eat cookies, I get them cookies. I encourage staff to allow whoever the patient trusts to be their primary caregiver this isn't the time to try to set those kind of boundaries although keep in mind even the most psychotic patient can still have a behavioral component.

Most importantly if they remain avoidant to interactions with you don't force it, make it short and sweet. There will be times when I say I have to ask you two questions and then I promise I will leave you alone. If this works, fine, if not leave them alone anyway you have enough to complete a thorough assessment based on the interaction. Lastly if they tell you to get out of their room immediately get out and I usually acknowledge their statement "Absolutely I will leave you alone now but if you need anything please call". There is no reason at all to push that envelope because it is setting you up for assault and the patient up for distress, aggression and possibly legal charges. Good luck this is another challenging but amazing population to work with.

[midazoslam]

Couldn't have said it better, Jules A. Working with people who are exhibiting psychotic symptoms require compassion, understanding and the opportunity to feel safe. "Playing into" delusions, or "reality orientating" are not best practice methods; rather, acknowledging the person's distress, informing them that you do not share the same belief but understand their fear can often boost the rapport with the person.

Of course there are hits and misses, and this does not work for everyone. Clinical judgement, nursing intuition and empathy should guide us in all interactions.

Good discussion!

Midazoslam