? about personal responsibility

[MQ Edna]

In our psyche rotation, we were discussing the problems w/recividism (sp?) We were told one of the major problems was that when inpatients (bipolar, schizophrenia, depression often w/dual addiction) are released, they're feeling better and take their meds as long as their 'samples' hold out, and then they often stop taking them, become acute and are readmitted. My question to those who work in this field, is when does personal responsibility come in to play? My feeling is, we expect diabetics to test their blood sugars and be compliant w/their meds, in short to take responsibility for teatment of their disease...some of my fellow classmates, feel that they are ill, and shouldn't be held responsible for following through with their treatment plan and perhaps should have their hand held throughout the continuem of care. So, when do you say "we've done all that we can, now it's up to you? Here are phone numbers, resources for meds, shelters and food..."? I realize as a nation we need to take care of those who don't have the ability to care for themselves, but yet we also say we have the right and freedom to chose...and some of these folks chose to live on the street, or not take their meds...when does our responsibility end and the patients start? In AA and Alanon, isn't this called enabling? Or is my complete ignorance in the Psyche field showing through?

[purplemania, BSN, RN]

Tough question and it has been fought many years, even in the political arena. I think everyone has to decide where to draw the line and still be comfortable with how you practice. The same phenomena occurs in nursing med-surg patients who are non-compliant or leave AMA. Consider the homeless: some people think it is enough to let the homeless decide for themselves while others feel the homeless should be institutionalized and others are in between. No good answers but at least you are caring enough to question the status quo!

[TitaniaSidhe]

I think in part some of the explaination comes from the fact that society today views being a user of illegal drugs or alcohol as having less stigma than mental illness. By mental illness I am not speaking simply of depression, or personality disorder type DX. but the biggies such as Bipolar, Schiz & Schizoaffective. This is sad but true. I feel in part that some of the patients we see in & out so frequently self medicate with illegal drugs & alcohol rather than take their psych meds b/c they actually feel this is more like being "normal."

Now then on the opposite side of that you have the mallingers who are in my opinion misdiagnosed. In truth the are actually addicts with personality disorders of which no amount of medication shall make any difference. They constantly are non-compliant with OPT & meds, go back out on a snort using whatever drugs they use, then come back for admission claiming depression with suicidal ideation. They have been through countless rehabs but the behavior persists & as long as they claim to be suicidal or made some lame gesture such as scrathing their wrist they know they will get admitted. I mean any psych nurse worth her salt knows the truely & severly mentally ill when she/he see it.

The majority of the dual diagnosis patients I see at our hospital are not truely Schiz or Bipolar. They are in fact simply addicts who refuse to grow up & take responsibility for the actions & face the consequences of such. I do believe the greatest diservice we do to this particular group of patients is to not tell them the truth, ie: you are of course depressed after losing your job, wife, children, family, friends, home & using several hundered $$ of crack cocaine. Shall we now look at the fact that had you not been sitting with that stem in you mouth in some God forsaken crack house you may still have all those things you have lost. Does you choice to use not have a direct impact into the losses in your life. If you deal with your addiction problem maybe you will not have this depression b/c your life situation will improve? Instead we tell them oh you are depressed & suicidal, here take this Prozac or Zoloft or Effexor, or whatever, it will make you feel better. We never really deal with the root of the problem. Behavior mod is really the only way to deal with addiction. The person themselves must wish to change. They must be allowed to fall flat on their face hard to come to the realization that they need to change. The enabeling we do does not help them it only serves to keep them using & stay sick.

Now some may say this sounds a bit harsh but, allow me to say I have been clean since 1989. No one picked me up, they allowed me to fall & fall hard. I then made the decision I had a prob & sought help in dealing. The help I sought was not in Psych or even health care, although detox sometimes requires hospitalization for safety. The help I sought was from others who had fought the same battle & won. I went solely & still go solely to 12 Step Program & have maintained abstinence since 1989. It was no easy but it does work if you really want it. There are many who will help for nothing in return, just because you have asked for the help. All these in & out SIMD & polysub abuse Dx. are only playing the system & playing a game.

Only my opinion & thanks for listening. Good question by the way. Really cool that you even thought to ask it.

[Thunderwolf, MSN, RN]

There are alot of factors why people are noncompliant in maintaining their health. Denial remains a big problem. Why a Schiz or Bipolar goes off meds may be quite similar to a diabetic who does the same thing or a person with pneumonia stops taking his/her antibiotic because now feels better. Axis I diagnosed folks may be quite different than Axis II diagnosed folks in their rationale. Substance use complicates it more so, considering that 80% of antisocial PD's abuse substances, 50% of Schiz and Bipolar do, as well as 30% of depressed and anxious folks. Another factor is COST, COST, COST, such as "Do I buy this medication or do I pay rent or buy food?" Many truely sick Axis I folks can't afford the new meds, especially the atypicals. Another factor is general poor management skills. Now really, who enjoys balancing a checkbook? Balancing meds, appointments, supports, meals, etc can be quite difficult for folks who remain symptomatic. Another factor may be the amount of meds the patient has to take on a daily basis. Sometimes, you simply forget taking the medication. Another factor may be that we are kicking out of the hospital folks sooner and sicker and less educated than before. Another factor is if that person has a competent case manager in the community who actually does case management. Not all case managers are the same, nor all community mental health centers...sort of like nursing homes (not all nursing homes are alike). Another factor is that the person's family members may be just as ill as the patient, and may even encourage noncompliance. Some folks don't like the stigma which still remains and choose not to be one. And true, some patients may chose to remain ill because the hospital provides three hots and a cot. There are many reasons and no real good answers with our current system. Maybe a paradigm shift is in order. Do other folks have any ideas?

[CliveUK]

In the field of psychiatry, I don't think you can ever say "OK that's it, we've done all we can". It's the nature of the beast, and I would be strongly opposed to any measures which, basically, punished patients for having the temerity not to agree with the psychiatrist. They already have to cope with mental health legislation, without having any further sanctions and restrictions placed on their lives.

[nancynurz]

This has always been difficult for me. I can understand the high number of substance abusers in psych-- if you have the choice to experience side effects like blunted emotions, weight gain, diabetes, muscle stiffness, tremors, drooling, etc., or your can get high-- I understand the choice some make. Some patients are flat out lonely and sadly, their hallucinations are company. I have seen patients become functional but they are then able to recall severe abuse or just plain see how little they have accomplished in life. They prefer to be lost in their illness. Think about the smokers who carry their portable O2 or smoke through their trachs, the diabetics who want insulin rather than change their eating habits, the morbidly obese who want the CPAP & refuse to admit their weight causes their apnea and joint pain . . . I think everyone is negligent with personal responsibility for their health in some way; just some are more obvious than others. You do your best to teach and then support them. I've seen some patients make complete turn-arounds, you never know when kindness and a non-judgmental front (no matter what you may feel inside ) may make the difference.

[StuPer]

I would add to some of the very pertinent and accurate comment made by Thunderwolf, and that is that there is a marked difference between mental and non-mental chronic illness. A person who refuses to take, monitor, or mantain a diabetic regime is able to make that descision based on (admittedly poor) intact cognitive reasoning. Most people suffering with serious chronic psychotic illness are rarely totally symptom free, any mistake deliberate or otherwise in their treatment regime will immediately make it increasingly difficult to make the next rational descision, its the old stone on a hill, once rolling its very difficult to stop.

You may say on the other hand that people who abuse alcohol and other drugs are a waste of space and resources. The thing to bear in mind is that you don't just wake up one day and say..... "Im bored.... uuurg.... I know I'll get into crack cocaine". Many people in this scenario are victims of domestic/childhood violence/sexual abuse... others have been psychologically abused to the point where they only feelings of self-esteem come from the feelings they get when high. There are few people who resort to this lifestyle out of choice... and once in there the drugs themselves make it very hard to escape. TitaniaSidHe you have my respect for you successful struggle, but I'm sure your aware there are many who live the life you once did who do not have your strength. Your asertion that behaviour modification is the only way is correct, but everyone needs to be aware that their interactions with this client group could have a direct bearing on someone feeling it maybe worth getting off the drugs. Encouragement without patronisation, support without dependency, consistency and DBT will go along way to helping people make the change. Even the most frequent flyer to the ED in an intoxicated state can make a change, they just have to feel its worth it, and that is better than what they have.

regards StuPer