Help! How to cope w/ rude, bratty ED and PD young pts

[bagwash]

Sorry if this is an old topic. Couldn't seem to find the "search old forums" button.

I work (as an RN) in an eating disorder ward. We get a lot of young (!4 to 25yo) pts who are mostly straight-out anorexics but also a substantial portion of mixed ED types as well (restricters who also vomit/binge/ substance abuse/use laxatives etc). Many pts also self-harm and have personality disorder traits...

Of these sad, deeply disturbed girls, a small but very influential subset also seem to suffer from a sense of grandiose, almost narcissistic entitlement. This combined with their ambivalence about treatment and the irritability/mood swings caused by re-feeding creates a volatile combination.

I should add here as a quick explanatory note: virtually all our pts are voluntary.

I find these pts unbelievably rude at times--treating the staff like idiots employed solely for their amusement, giggling and running down the team and programme in whispering tones in a pathetically schoolgirl manner (more appropriate to ten year olds) and generally sneering and expressing their withering contempt without restraint. I guess it doesn't help that your average ED is a perfectionist +++ and they expect everyone else to attain the same high standard they consider essential to the simplest tasks.

They are also control freaks e.g. tonight I was doing their BPs etc when the girl I was checking felt it necessary to inform me that I was on the wrong page (as I hadn't turned over from the previous pt's page yet). I assured her it was all under control, but felt like saying" Please don't feel you need to supervise me!".

Anyway, the above behavious are pretty much standard fare, especially at the meal table where we eat with them and encourage normal eating behaviours and where we get all the expected "give me a break!" protests and looks that could kill at 2 paces. Guess that's what we get for being "the food police". More spectacularly, every so often we are treated to a full-blown tirade when we have truly enraged one of the pts in the "Little Princess" category e.g by expecting her to take a modicum of responsibility for behaviour.

Yes. I am burned out! We get no support from management or debreifing. Many of these pts seem totally ungrateful and unaware that we are "busting a gut" (sorry--Aussie expression) to try to get them better and keep them safe from falling into the category of 20% mortality from their disorder. Sometimes I think they see us as mere servants--like waitresses (hence the "I'll have what I want and I'll have it now, or there'll be trouble!" attitude) or as low-grade maids/nannies, rather than as caring, overworked professionals deserving of respect.

Any suggestions on how to cope with brattiness?

[BSNtobe2009]

I don't think there is anything you can do but continue to be encouraging.

Just remember what you already know...eating disorders are mental disorders and when they are in the hospital receiving treatment the nurses and other medical staff that are there to help them...are seen as the enemy.

To some degree, the personalities are very similar to those going through drug withdrawal....their bodies are getting re-introduced to food and nutrients when it has been very deprived, they will say and do anything to get you to leave them alone while they contemplate how to get rid of their next meal without anyone knowing, and they see you as the person that is another step in taking away their ritual, and that is why they are so rude. A junkie will treat someone that takes their next fix away the same way.

They are in the process of losing what is most precious to them...control over their bodies.

[Meerkat]

I am a former anorexic with stable recovery for the past 11 years. Lots of the girls I was in the hospital with acted the same way.I think you should try what the staff did with those girls when their behaviour was obnoxious: ignore them!

When they say something snotty, no response. Don't give life to their behaviour.

They are losing the only thing they can control (food intake) by seeking treatment...so they are probably trying desperately to get control in other areas.

During group, however, that kind of disruption is not acceptable. Offer them 'room time'.

[EmerNurse, BSN, RN]

Not a psych nurse, but having had a few teenage girls (thankfully w/o such problems, thankyoulord), I have to say that some of the behavior you describe sounds like a typical teenager to me.

Underneath their mental issues and behaviors, are also the same irritating, attitude-generating teenage behaviors. I don't allow my kids or their friends to be obnoxious, even if they have issues. Your patients are fighting to keep behaviors that meet their perceived needs, my kids might be fighting to keep their phone privaledges(sp?). Not a perfect analogy by any means, but the attitudes you describe sound very much like those I get.

Just an observation - I have no answers for you - but keep the faith. These patients are not attacking YOU or challenging YOU personally - they're attacking the situation they hate. Try not to let it get to ya.

[bagwash]

Thanks Emernurse, Meerkat and BSNtobe;I appreciate your feedback.

The analogy with a junkie wanting his/her fix makes a lot of sense. Mind you, I worked in drug and alcohol (you guys call it chemical dependency) for over a decade but rarely encountered this kind of hostility! At least, not this pervasive, sniping, relentless hostility.

I guess the bottom line is that they're in treatment because their parents have put them under duress to come in, not because they want to be there.

It's just a bit tiresome when "kids" as old as 25 (!!) are still acting out their teenage rebellion fantasies (but still living at home when not in hosp., expecting mum and dad to fulfill their every need). Somehow I don't think hospital really helps them with their attitude problem. Being around their fellow ED pts just seems to result in a race to the bottom, i.e. a competition to be the sickest.

In fact a senior psychologist I spoke with told me the evidence shows that treatment doesn't really work (at least, not any more effectively than no treatment). Bit demoralising to know that, but I think I remember reading it's pretty much the same with chemical dependancy. Everything depends on motivation. However, treatment does help keep them (ED patients) alive during the medically dangerous process of refeeding.

As for coping with them, I do generally go for the option of ignoring the worst, most childish behaviour, but wonder if I wouldn't be better off telling them more often that rudeness isn't acceptable. It just never seems to work for me when I do try this! Not having kids of my own, I guess I haven't quite perfected the right tone of voice for such things.

Thanks BSNtobe for the point about normal teenage behaviour. I don't remember feeling it was OK to be obnoxious and disrespectful when I was around that age, but I guess times have changed. I do find it wierd that kids now have such a sense of superiority, yet seem to remain immature and dependant for so much longer than back in the "old days". (I'm 47, so going back a bit of a way).

[IMustBeCrazy]

I find it very surprising that your institution doesn't have a Behavioral Intervention Program available to use.

Snottiness is one thing, but when you have a ringleader/mob mentality, the milieu has then changed from one of healing to abuse. Axis 2 diagnoses seem to run rampant in the eating disorder camp, which is another big argument for forming BIP's.

The problem is, until you address the untoward behavior by incurring some sort of time-out or other consequence, this behavior is going to snowball, including more and more patients until it is truly a hostile environment for not only staff but patients. It's the classic "inmates running the asylum" analogy.

Some people balk at BIP because they feel that it is punitive. I argue that it is a necessary component of a therapeutic environment. These pts need to learn new boundaries, many have not been subjected to or held accountable to such. Therefore it is imperative that this be available for staff to use in order to enforce positive behaviors.

[bagwash]

Sounds like a great idea, Imustbecrazy.

I'm not too familiar with Behavioural Intervention Programmes as such, but I get the general idea--consequences for unacceptable behaviour.

Currently we have none, where I work, except for some limiting of privileges resulting from poor eating behaviours. Reprimands for brattiness from us ordinary RNs don't necessarily mean anything to them--except perhaps to provide yet another oppurtunity for them to be rude and display their defiance to all the other pts. They have no respect because we have nothing concrete to back us up.

I think you're right, some of these young people have never had limits put on them, and they desperately need them. No wonder they have no self esteem, as growing up in such a structureless environment doesn't give anyone a sense of genuine worth.

Sometimes I think they really need chores (not ones that involve energy expenditure of course!) to give them a sense of responsibility. It would be good to have a system where the pts earn trust and privileges. They won't get any rewards for curling up in a foetal position and cutting themselves, nor for beligerantly expressing every bit of anger they feel (whether justified or not) out in the real world. You have to wonder about the destructive long-term effects of hospitalisation, where these behaviours attract extra attention, and therefore reinforcement.

[IMustBeCrazy]

Sometimes I think they really need chores (not ones that involve energy expenditure of course!) to give them a sense of responsibility. It would be good to have a system where the pts earn trust and privileges. They won't get any rewards for curling up in a foetal position and cutting themselves, nor for beligerantly expressing every bit of anger they feel (whether justified or not) out in the real world. You have to wonder about the destructive long-term effects of hospitalisation, where these behaviours attract extra attention, and therefore reinforcement.

Exactly!

Actually, I think it is therapeutic to expect this population to keep their rooms tidy, change their own linen, etc. Often, due to their illnesses, they are used to being waited on/catered to, which IMO is a large part of why they have developed the Axis 2 in the first place.

Reward structures work very well. Think of this population as a group of preschoolers in terms of their needs. They haven't developed past the need for craving a great deal of attention, however they can get it, which often is negative attention. When they are admitted, they are on (for example) Level 5. With compliance to their treatment plan, RESPECTFUL attendance in groups etc, they "earn" their way to Level 1 which affords the maximum in privileges. If they relapse in behavior, they immediately lose a level (or possibly go all the way back to level 5 for cutting/physical harm) etc.

[bagwash]

Yep, sounds great, but unfortunately, I don't think it is ever going to happen, in our unit. The sad part is that I now think the only way I can survive in this unit is to be a lot more distant, more rigidly "professional" and to keep my guard up at all times, except with the pts I know are truly interested in recovery and able to behave respectfully.