How Do I Approach This?

Keely-FutureRN · Dec 22, 2005

Hmm. That's a tight spot there.. I'm not a nurse (yet:p ) but if I were you I would set the example of how to appropriately give report without adding judgements. You are doing a great job in being the patients' advocate and it is unprofessional and insensitive for your coworkers to be doing that.

Keely

Thunderwolf, MSN, RN · Dec 22, 2005

Sometimes, not only do we need to educate our patients, but our staff as well. I see this type of staff behavior as "psychiatric prejudice". Sadly, even folks who work psych fall prey to it. Becoming a mentor and role model for others is not always easily managed when staff may be resistive. The approach needs to be nonconfrontational, in the spirit of education, and is done quite often during the course of one's care. The key element is that you wish to have the key offenders to hear and digest your message...hopefully, to change their own behavior. Often, change needs to occur one person at a time...when you are one on one with him/her. Otherwise, you face the group mentality...which is resistive to change.

I wish you the best.

Glad to have you out there in the trenches.

rn/writer, RN · Dec 22, 2005

Psych is a tough specialty. When I worked it, I much preferred the kids to the adults. They were honestly manipulative (an oxymoron, but true) and many of them were mostly normal young people living in grossly dysfunctional situations. For the most part, they had a good sense of fair play and responded well to structure and consequences. Only a small percentage were organically mentally ill--that is had mental illness that originated in their own chemistry or wiring. The rest were behaviorally mentally ill, meaning that they had lived in crazy-making "homes" with inconsistent or addicted or selfish parents and had developed some crazy-making strategies of their own. Unfortunately for them, crazy-making doesn't go over well in school or in society or even in the very homes that produced them and so we were give the dubious honor of trying, during a very short stay, to produce order out of their chaos.

The population you are talking about is these kiddos ten, fifteen, twenty years from down the road.

Again, there are some adults with biological diagnoses. Bipolar disorder, schizoaffective disorder, organic brain syndrome, intrinsic depression, and other disorders. But, by far, the greater number of patients are those I call the behaviorally challenged. They have learned crazy thinking and they live crazy lives. Meds can help, but many won't take them.

Borderline personality disorder is a very popular diagnosis, not because something funky got into the water supply and damaged a whole bunch of people but because BPD is a mild form of sociopathy. Many kids raised in the wreckage of dysfunctional adult lives learn pathological ways of dealing with responsibility and relationships. They don't know how to connect in a happy, healthy manner so they copy the destructive strategies they see and learn to do whatever it takes to get a reaction from otherwise preoccupied grown-ups.

People with BPD don't have much of an inner landscape. They have a very poorly developed sense of identity because they were emotionally starved/neglected or subjected to painful interaction during the stage when kids are supposed to get their needs met (without begging) and see themselves reflected in their parents eyes as lovable, adorable, special little beings. BPD patients weren't given this positive self-image. Many don't feel that they show up until and unless someone else is reacting negatively to them. THAT is what feels normal to them and it is also their proof that they exist. This is why many of them are extremely demanding, argumentative, manipulative, and unreasonable. Each of these things is pretty much guaranteed to get an emotional response and that tells them they are alive.

Some BPD patients are extremely co-dependent, calling their partner at work 20 times a day or smothering their children or just living soap opera lives in general. When they're not creating drama, it's like the light goes out and they disappear. Then they need to start something new to feel alive again.

This is a relentless condition for psych workers to deal with because it is so intractable. First, the problem originated in a behavioral response that may have seemed appropriate at the time, but has created far more problems than it ever solved. Second, the psych world is geared toward sickness and not toward health. It's much easier to write a prescription than to tell a patient she is not accepting responsibility for her poor choices. Third, we don't offer a behavioral approach to BPD, but even if we did, this population would not be inclined to accept it. They'd probably be like alcoholics or drug addicts, many of whom have to reached the depths of desperation to consider treatment of this sort and who may relapse a dozen times before it "takes." BPD is a fear-based, terribly ineffective coping strategy that takes on a life of its own and renders its occupant unable to connect with others in a healthy way. Empathy is an extension of the care we give ourselves. These people have nothing to offer because they have nothing to begin with.

The trouble is that they look for all the world like spoiled, trouble-making brats. Brats because they are stuck at a childish level. Spoiled because nothing seems to get through to them. Trouble-making because that's their main tool for interacting.

I think you will find your co-workers, not uncaring, but discouraged by the grim statistics for the borderline population. As a group, borderlines can suck up 90% of the staff's energy and produce 1% improvement. It's definitely disheartening. Add to this that the BPD patient's behavior is DESIGNED to irritate and annoy and you have a group of patients that will relentlessly reproduce the crazy-making chaos that made them what they are today.

Concentrate, if you can, on the people for whom you CAN make a difference. Set very firm boundaries with BPD patients. Do some subtle behavior mod by giving more and better acknowledgement to healthy interactions than to manipulation and complaining. Learn all you can about BPD and ways to "bullet-proof" yourself to the kind of frustration it is their calling to generate. And share what you learn with co-workers.

In my opinion and experience, BPD is a horribly debilitating condition and it's made worse by understanding that this was not inborn, but created. It's all so unnecessary. The sad thing is that the prognosis is very poor. Hence the staff's distancing responses.

I won't say your co-workers attitude is correct. Only that it is all too understandable.

Thunderwolf, MSN, RN · Dec 22, 2005

Miranda, your post was wonderful, as usual.

I might add that BPD and burned out staff can often inflame each other.

It is when we resume the therapeutic role as clinicians, without down grading ourselves into our personal negative passions, is when improvements can occur. I used to work inpt and outpt psych. I was even a psychotherpist for several years at a CMHC. BPDs, like Paranoids, can detect dishonesty a mile a way. Being mindful of this is important when you provide care to either one. You are most correct in that it is sociopathic in nature....for many male sociopaths are diagnosed with Antisocial Pd, whereas females are often diagnosed with BPD. Miranda, I agree much with what you have posted. However, I can not help but feel that you yourself have been burned out by a few here and there. Understandable. BPD folks are trying...that is their job. Our job is to be behavioral role models for the brief time we have them inpt. One of my most memorable inpt BPDs was a frequent flyer who was a social worker. She knew what BPD was by the nature of her profession, met and acted out all the criteria, but would be adamant that she was not BPD. I, like you, set the boudaries. As a counselor and psych nurse then, I was often very straight forward in my approach. Eventually, she got it...after multiple admits, mutiple episodes of take downs and restraints, and multiple no nonsense 1:1s. Eventually, she showed significant improvement and was able to become gainfully employed again. BPDs are a lot of work. As a psych nurse, this is expected and should not really be much of a surprise. It is part of the turf. Each diagnosis demands a different approach. BPD intervention and treatment really needs to be seen as no different. BPD, as well as most other PDs, often mellow out with age. The exception is Histrionic PD, which often can worsen with age. I guess my ex-counselor days is kinda showing through here. Sorry for that.

Miranda, you're wonderful.

I enjoyed reading your post.

Wolfie

(an ex-outpt counselor who you used to send your inpt BPDs home to)

elkpark · Dec 22, 2005

I agree with what rn/writer and TW had to say. I would also throw in, for my 2 cents' worth, a little different perspective.

You will find, as you continue in psych, that it is a very tiring, draining specialty, emotionally as well as physically. (In fact, I recall from some of your other posts that you are finding that out already.) One way of blowing off some steam and frustration is to joke (privately) about the esp. frustrating and difficult clients. Sure, it sounds awful to the "uninitiated" and it certainly should NEVER be done where clients or family members could overhear. (Black) humor is a fairly universal coping skill in healthcare (think of all the terrible "nicknames" EMS and ED staff have for clients), and it ain't pretty but it works. I have come to the conclusion, as an "old psych hand" (10 years as staff nurse, 11 years as psych CNS), that joking about the really frustrating clients (IN PRIVATE) is healthier than bottling up your frustration and then having it negatively color or influence your therapeutic approach to the client. Those feelings have to go somewhere! I believe firmly that the (psych) people who are really setting themselves (and their clients) up for trouble are the ones who insist that they don't have any negative feelings about the clients (because that would make them baaaaad people!) -- Newsflash: We all have them. The healthy, constructive, responsible thing to do is recognize that and deal with them.

Every place I've worked in psych over the years, I've encountered (and exhibited, to some extent) the same behaviors you describe. It's human nature, and can be a constructive way of helping each other cope with v. difficult and frustrating clients and situations, if that's the intent. (Or, it can just mean that staff are bitter and burned out and should find another job, but we're going to assume, for the sake of this discussion, that's not the case here.) As long as it stays in the report and/or break rooms, and your colleagues are not approaching the clients with the same attitude you describe in report, I would not be too concerned or condemnatory. I realize mine will probably be a minority position on this thread, but I can live with that! :chuckle

Meerkat · Dec 22, 2005

Hmm interesting thoughts on this. Elkpark, I admire your honesty, brutal as it is. And it does make sense. As I said our nurses are GOOD. Perhaps it is just their way of coping with the frustration. I'm learning all about that. I guess in some ways, I was coming into the psych specialty, thinking, in some deep drevasse in my mind that perhaps I could be the Psych Patient Whisperer (is you know what I mean...the reference to the Horse Whisperer--the guy who had psychic communion with horses)...In this short time I have d/c'd patients who swore up and down and sideways that they would think twice before self mutilating, that they wouldn't swallow a mess of pills, and thinking that *I*...the *born* psych nurse practically single handedly got THROUGH to them! A hero fantasy, I guess. But BAM! A week later they are back! So with that in mind, I can understand the frustration in psych nursing...and maybe the references are just what elkpark said....blowing off steam. Thanks for the support.

rn/writer, RN · Dec 22, 2005

Miranda, your post was wonderful, as usual.
I might add that BPD and burned out staff can often inflame each other.
It is when we resume the therapeutic role as clinicians, without down grading ourselves into our personal negative passions, is when improvements can occur. I used to work inpt and outpt psych. I was even a psychotherpist for several years at a CMHC. BPDs, like Paranoids, can detect dishonesty a mile a way. Being mindful of this is important when you provide care to either one. You are most correct in that it is sociopathic in nature....for many male sociopaths are diagnosed with Antisocial Pd, whereas females are often diagnosed with BPD. Miranda, I agree much with what you have posted. However, I can not help but feel that you yourself have been burned out by a few here and there. Understandable. BPD folks are trying...that is their job. Our job is to be behavioral role models for the brief time we have them inpt. One of my most memorable inpt BPDs was a frequent flyer who was a social worker. She knew what BPD was by the nature of her profession, met and acted out all the criteria, but would be adamant that she was not BPD. I, like you, set the boudaries. As a counselor and psych nurse then, I was often very straight forward in my approach. Eventually, she got it...after multiple admits, mutiple episodes of take downs and restraints, and multiple no nonsense 1:1s. Eventually, she showed significant improvement and was able to become gainfully employed again. BPDs are a lot of work. As a psych nurse, this is expected and should not really be much of a surprise. It is part of the turf. Each diagnosis demands a different approach. BPD intervention and treatment really needs to be seen as no different. BPD, as well as most other PDs, often mellow out with age. The exception is Histrionic PD, which often can worsen with age. I guess my ex-counselor days is kinda showing through here. Sorry for that.
Miranda, you're wonderful.
I enjoyed reading your post.
Wolfie
(an ex-outpt counselor who you used to send your inpt BPDs home to)

Yeah, I'm a little burned out. Partly by patients. Partly by family members whom we have decided to "love from a distance."

I don't know if you worked with kids at all, but one thing I always thought was interesting was that there is no such thing as a borderline diagnosis under the age of 18. Why? Because the immaturity, inconsistency, moodiness, and self-centered outlook that makes us all love borderlines so much is pretty much typical for an adolescent.

Your approach with the BPD social worker is commendable. One of the things I found most discouraging was the lack of a unified, structured response at my old hospital. The "talking cure" is NOT effective with BPD patients. They'll talk your ear off and justify and rationalize and excuse and argue and complain and whine and wheedle and cajole. What they won't do is change their behavior if that hasn't been required of them. Who would? It's a cushy deal (at least in appearance) to be a perpetual child who is not to blame for anything. I always thought we were doing these folks a great disservice just to medicate them, stick 'em in a couple of groups, and send 'em on their way. But as I said in my earlier post, I do believe most of them would have checked out AMA had we asked anything more demanding. I'd love to see a 12-step program for BPD, but I'm not holding my breath.

Thanks so much for your kind words. The affirmation means a lot to me.

chris_at_lucas_RN, RN · Dec 22, 2005

We really do have good nurses on our unit, but I do not like hearing, in report, them say stuff like 'she's psycho' or that one is a whack-job' and the whole borderline borderline borderline thing for every female who walks in the door. The eye rolling, the "he's BACK AGAIN???' comments...My grandma was acutely schizophrenic and I really would hate to think that people would talk like that about her. One day in report, I smiled and said, 'Not, crazy...he is ILL' and I got more eyerolls. Any thoughts?

We have a psych ER in our facility (PCSU = psychiatric crisis stabilization unit), and a wonderful set of docs who rotate through so that somebody is there all the time, sometimes two of them.

One in particular has lately been prone to make very reasonable statements about the etiology of patients' symptoms. On the one hand, we have staff who are immersing themselves in gallows humor and sometimes are just plain disrespectful--not to the patients, but you never know who is listening, do you?

The other night I was assigned to PCSU (I'm a fulltime float), and he came in from assessing a very overweight, very borderline "frequent flyer." His words were golden. To no one in particular, and almost as if it were his way of dealing with the stress of the job he said, "That patient has such a long sad history of abuse from early childhood. So often we forget that their symptoms grow out of their attempts to survive intolerable situations." (I just love the guy, can you tell?)

As for myself, I am sometimes tempted to join into the "humor." Let's face it, when we are tired, and frustrated, or just tired and frustrated (LOL), we can be a hair cynical. On my better days (which fortunately outnumber those other ones), I work hard to be genuinely concerned and warm toward my patients. I treat them well. I just keep my mouth shut when the other stuff is going on, unless I believe it is being overheard, and then it is more to protect the patients than anything else.

I also make a point of being as kind to my colleagues as I can. (For a couple of them, the best I can do is just be quiet.)

The combo seems to result in a more harmonious team, a more cohesive and therapeutic unit and, maybe by coincidence, less of that kind of talk about patients.

Thunderwolf, MSN, RN · Dec 23, 2005

Excellent input everyone. We are blessed, you know, to have a very fine bunch of psych and ex-psych nurses here. I just needed to say this. I feel blessed as a Moderator.

Thank you all.

Swanee · Dec 26, 2005

Provide education and use colleages for support. Is this the nursing report? Who is making the comments, other nurses or mental health workers? Address them individually and discuss your concerns because that type of behavior trickles down to the patients and they sense the disrespect. Good luck.

kadokin, ASN, RN · Dec 27, 2005

Here's a thought, your co-workers need a lesson in compassion. Must confess I don't always use the best of language in report. (Sometimes clinical terms just FAIL to paint a picture of some of our very sickest pts).

-Tell your co-workers about your grandmother. This may get them to thinking about how they sound when they get "slangy"

-Continue to set a good example by NOT using those derogative terms when discussing pts. Be as clinical and specific as you can w/your language.

-You are a good pt advocate

-Remember not to take yourself or your situation TOO seriously