Is a level of behavioral health nursing missing?

[Tommyd2]

I've only been in behavioral-health nursing/tech'ing for a couple of years now. I've noticed that many nurses are excellent at comforting and caring for psychiatric patients with suicidal or depression diagnoses, but notice that a majority of nurses do very little with patients with borderline and aggressive diagnoses. I've seen nurses, techs and some social workers do all in their power to avoid contact with borderline and aggressive patients. Certainly there is a sense of fear with particular patients under these diagnoses, but are we doing them or society any justice? Are we providing behavioral health that will allow them to become more social and even-tempered in society by simply avoiding them and strictly giving them ordered meds?

I've read a recent article that mentioned a particular (general) hospital organization that sold it's behavioral health operation to a focused, behavioral health hospital organization. The municipality where the facility is, was ecstatic about the new owner organization's potential to serve their community. The mentioned that there are psychiatric patients in their community that are under-served. They mentioned how patients either can get the psychiatric care they need or likely end up in the prison system.

It appears to me that there is a missing piece in behavioral healthcare today. While we are great at managing suicidal ideation, some bipolar, depression, some mania, some schizophrenia, we are not great at preventing violence and crime in society which certainly must include some mental-health component . Traditional healthcare won't allow the tools necessary to provide behavioral health for aggressive patients, sociopathic, or psychiatric patients with criminal tendencies. A full hospital organization that does not have distinct separation of patient satisfaction scores (ie. does not exclude customer satisfaction scores from a mental health unit) will always, in my opinion, will never be able to provide proper mental health care to those patients with aggressive or violent components of their mental illness.

Many of us have seen shows like "scared straight". Those types of behavioral programs have apparently been successful at curbing attitudes and keeping kids out of the prison system. I would like your feedback on whether or not you think there is some merit in having a "scared-straight" type mental health unit or separate psychiatric facility that is monitored and co-sponsored by municipalities (health and corrections divisions) to attempt to truly provide care to aggressive or violent mental health patients to keep them out of the prison system and perhaps prevent further school shootings, hate crimes, and the like.

[Munch]

I don't understand what you really mean by scared straight kind of psych facility? You can't scare mental illness out of someone. What would be the difference between a regular psych facility and a scared straight psych facility?

[Tommyd2]

Medicating aggressive patients is a temporary fix. Behavioral health involves not only meds but consults, groups, and other activities. Do you just throw meds at the aggressives? Programs must have some rewards and punishments/consequences for aggressive behavior. I'm thinking of more of the military type style of the scared-straight type programs. Again, we're talking about the aggressive psych patients. Most of your general hospital with psych units won't even accept the patients I'm talking about. Thanks for your inquiry and opinion.

[idkmybffjill]

No. I don't think that type of program would be remotely helpful.

It seems the idea is that all aggressive behavior displayed by mental health clients is just some type of "misbehavior" like they are middle-class teenagers doing drugs and fighting because they want to impress their friends. That's not the case generally from my experience. Often, it's because their mental illness is affecting them in a way that makes it difficult for them to actually control their anger or in a way that makes them believe that their acts of aggression are necessary. For instance, a patient who become aggressive because they have persistent delusions that anyone near them is an FBI agent coming to kill them isn't going to magically "see the error of their ways" because you shove someone in front of them to yell and scream at them and tell them they are going to end up in prison if they don't go straight. It doesn't work like that.

Also, many mental health patients don't go commit crimes because it's fun. Usually, it's because they are deep in a crisis or as a result of other factors like poverty, unemployment, homelessness and substance abuse (which are exacerbated by their mental illness). I bet crime rates among those with mental illness would decline a lot more if proper resources were provided outside of inpatient facilities and if the stigma surrounding mental illness was dispelled than you would see with a scared straight psych unit.

Plus, studies show that scared straight programs actually increase criminal activity. Staff at the Department of Juvenile Justice have called those programs "ineffective" and "potentially harmful."

[Sour Lemon]

Irrational people are not going to respond in rational ways.

[Munch]

Where I live in NY state and in other states they have mental health courts. Its a problem solving court with the end game of treatment and not incarceration for mentally ill people that commit crimes. They are usually mandated to some type of program and appear in court in front of the judge usually once or twice a month for progress reports. If they successfully complete the treatment recommended to them the charges are dropped fully or down to a misdemeanor to a felony.

I think this is a better solution than trying to scare people straight. People with mental illness a lot of time are responding to internal stimuli or their violence is directly related being mentally ill(voices told them to push someone in front of the subway car or they believe their neighbor was trying to poison their food so they shot their neighbor with a shot gun). If they weren't mentally ill its possible they wouldn't be violent. So I don't believe a scared straight type psych treatment would work. They aren't able to correlate their actions resulting in negative consequences so telling them they might wind up in jail would be pointless.

[Munch]

Irrational people are not going to respond in rational ways.

Exactly. Showing a mentally ill person jail is a consequence for their actions it might not click. A mentally healthy person understands what consequences await if they get violent with someone else, they are able to connect the dots. Unfortunately it just doesn't work like that for someone who is in a mental health crisis not thinking rationally.

[Tommyd2]

Thanks for feedback. You have some good points. You have mentioned schizophrenia in your response. By all means schizophrenia wouldn't be a diagnosis that would match a scared-straight/military style type program.

[elkpark]

Exactly. Showing a mentally ill person jail is a consequence for their actions it might not click. A mentally healthy person understands what consequences await if they get violent with someone else, they are able to connect the dots. Unfortunately it just doesn't work like that for someone who is in a mental health crisis not thinking rationally.

It doesn't even work with lots of people who don't have any kind of psychiatric illness -- many, many people just don't have the ability to think far enough into the future to make choices now based on potential consequences they may face at some point in the future. Plus, we know from behaviorism research that random, delayed punishment (i.e., you might get caught and go to jail at some point in the future) is one of the least effective means of changing behavior.

And, yeah, as already noted, the "scared straight" programs have not been particularly effective or successful.

[AutumnApple]

The place I work at insists we don't use a "scared straight" theme with our care. There are no punishments, no corrective actions........

For example, we do not say "If you throw that book, you will go to the quiet room." Instead it's "If you throw that book, it will be unsafe for the rest of us." They go to the quiet room to settle down but, the idea that it is a punishment is hopefully removed.

I don't think we do enough. Even places like mine that make a conscious effort to not be that way............truth is..........

Well, we put them in the quiet room, talk to them then let them out and all is done. So, in essence, even though we try to achieve a different understanding with them, our actions still mirror a "scared straight" facility. We're not going that extra step further.

[Oldmahubbard]

Certainly there are teens, or young adults, who are in the prodrome of schizophrenia. In theory, they can be helped before things get bad.

Unfortunately, they are difficult to identity and substance abuse must first be ruled out. Easy to say in a textbook, but quite hard to do in practicality.

It is important to know that most mentally ill people are not aggressive, but when they are, the aggression is very unpredictable.

Many schizophrenics wind up in jail (or prison) due to minor crimes. Panhandling, trespassing, petit larceny. A very small percentage commit extremely violent crimes, but it is not more than than the non mentally ill population.

With regard to character disordered persons, such as borderline or antisocial personality disorder, treatments are quite limited.

Antisocials, in particular, commit a majority of the crimes. There is a spectrum, and a degree of psychopathy, but those at the higher end of the spectrum are untreatable with current methods.

Any form of treatment is likely to make them worse.

Thankfully, there are large, ugly concrete buildings with razor wire where they can be housed. Permanently if needed, which it often is.

[Gentleman_nurse, MSN]

I think I understand your point and suggestion. Do you mean counseling principles of holding patient's accountable or programs using confrontive therapeutic techniques especially for conduct disorders? Yes, they do exist.

I'm not judging the merits of your ideas, just offering something else to consider. Most people think about the clinician, the intervention, and the patient. They forget about variability. The same patient treated by two different but competent clinicans using identical interventions may result in different outcomes.

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