frequent flyers

Yes it does get frustrating and many staff get burned-out from the "personality disorder" clients. All clients need help, and you should not focus more energy on one client or type of client than another. The Personality disorder client (i.e. Borderline client) will demand all of your energy and the rest of the staff's energy to give them all attention, whether it be positive or negative. The reason it gets frustrating is that these clients do have an understanding on what they are doing, but like you said, they refuse to take "personal responsibility" for their actions. Other clients may not be able to express their needs to staff as well as other clients. This can be hard to determine which client needs more priority over another client during your shift. Gaining the experience comes within time. Try to ask other nurses, the treatment team, and the other staff at your facility for more insight on how to handle personality disorder clients better. You can also read up on this type of client in the DSM, the internet, other books, etc.

A big problem in an adult psych/CD unit I worked on was people trying to stretch their budgets until their next benefit check arrived. About two to three weeks after welfare and SSI checks went out, there would always be a surge in "suicidal" patients checking into our ER. Often, these patients would leave AMA if not discharged the day the check was to arrive. When we talked to them about financial responsibility in regard to AMA discharge, the reply was often along the lines of, "It doesn't matter. I'm not paying the bill anyway."

In one case, I overheard a patient on my unit talking on the phone to a friend, saying "I'll keep telling them I want to kill myself for a few more days. By then, my check will be in." I notified his psychiatrist, who discharged him on the spot.

Unfortunately, frequent flyers are a way of life, especially in psychiatry. Even if a patient has presented in your ER umpteen times saying he/she wants to die, the hospital will usually be reluctant to assume the potential liability of what happens afterward if they turn the patient away and this was the one time the patient was truly serious. Normally, if you have a vacant bed, you're stuck.

All places have frequent fliers. We have a set of vacationers too. It is frustrating from a taxpayers point of view. It costs $800.00 a day to just be admitted to a bed on our unit. If you want meds, labs, consults, treatments--all extra charges. It really burns me up if I think of it like that.

So, I try to think of it in a different way. I look at it like I know the patient so admitting them won't be hard. I know what to expect from them, they know what to expect from me. I always think that it could be much much worse and I imagine having to admit my worst patient. The frequent flyer fills a bed so if the worst patient tried to get in, she would have to be admitted elsewhere. So I use all my psych skills on myself--imagery, rational emotive therapy. Guess that stuff really does work.

Some of our more familiar clients are blunt with me and tell me, they are here to rest after coke binge, being kicked out, no money left, need a break from the hubby etc. I try to think of them like family. You don't have to like them, just let them stay for a few days til they are on their feet then off with them. We are family to some of these people. We have been the only caring and almost mentally healthy people they know. When you have been kicked out, where do you go? These people have no one else.

I firmly believe in tough love so a lot of this clashes with my own personal beliefs. I believe in personal responsibility. I also believe that I would make myself sick if I let it get to me all the time. I don't try to do a lot of therapy with the ones that don't come there for that reason. I do the basic review of meds, side effects and mood/hallucination checks. Lots of times, I don't even sit down for these interactions. That leaves me time for the ones that are craving to be heard. You don't get much satisfaction from fakers but when you feel you have made a small difference in someone's life just by listening to them, it really makes me feel like I have done a good job and that validates my choice of careers.

It is frustrating dealing with borderlines, but has anyone heard of EMDR or theophostic ministries approaches? The work being done with both of these approaches is amazing and similar. We get discouraged in our field because we do not see a lot of progress. I feel discouraged as a nurse because I have seen the way these therapies work (I am being trained in EMDR -eye movement desensitization and reprocessing), and yet it seems as if the medical profession does not much want to know they exist. When they are recognized, the drug companies have a lot to fear because these therapies actually change people.

I have seen EMDR done on 10 clients and I have seen no real change or only short term improvment.

I have been using with adolescents the sort of algorhythm that EMDR uses without any bilateral stimulation to help kids get into the present and try to figure out why they are acting the way that they are and I think that it could be used to avoid restraints. First I ask how the kid's body feels--tight relaxed hot cold tingly - in pain etc. Then I ask what emotions they are feeling- and have them rate them just like we do pain from 0-10. Angry, sad, happy, frustrated, etc until they find one that fits. Then ask what are they saying to themselves as a person starting with an I statement- I am discouraged. I feel powerless. I feel defective. I am bad. I should have this or that. This is what Francis Shapiro refers to as the negative cognition. Then how would they like to feel. I can get power. I am learning to be good. I can learn to have hope etc until one fits. This is what Shapiro calls the postive cognition. Then you have them rate it from 0-7 about how true it feels to them. And in doing this you have to ask the kid to be truthful and accept his answers because if you don't ask for truth and ask for the correct answer--it will not work. Often the kid will then calm down enough to follow directions. It is a way of getting into the here and now about how their body, emotions, and cognitive mind. There is a lot more to this, but it does calm kids down. It is much more powerful than it sounds. There is so much more in EMDR to help kids access positive resources so they can get through difficult situations.

Janet Kurz RN