the tendency to pathologize behaviours that seem natural to me

Thunderwolf, MSN, RN · Jul 25, 2009

A good case example where inpatient case management is important to ensure proper after care followup...ie linkage with counseling and/or other community resources.

Thunderwolf, MSN, RN · Jul 25, 2009

"Pathologicalizing the normal" or viewing illness everywhere and/or in almost anyone.

This not an uncommon phenomenon seen in many mental health care providers.

Many are aware of this tendency (and appropriately stop)

....and many may not be aware of doing this (and continue).

I understand your concern and applaud you in your awareness of this.

Much has to do with clinicians trying to stay on one's toes sort of speak when working with very mentally/emotionally ill patients. Often, it can be very hard to separate from this type of vigilance...therefore, viewing pathology everywhere in almost everyone. It entails some insight on one's part to be aware that one may be committing this error and the need to shift back out of it...because it is not appropriate. In some cases, pathologicalizing the norm can become pathological itself....because it ceases being functional and adaptive when used this way by a clinician. I'll explain my rationale a bit more below.

The truth of the matter is that pathology is nothing more than normal behavior/thinking/feeling becoming not normal. Even in saying this, I ask: what is normal?

I prefer to use the terms of "functional" and "adaptable" to explain what being normal is.

When the person begins using normal (sic) behavior/feeling/thinking in a non-functional and/or in a maladaptive way and he/she begins to experience distress (as well as maybe creating distress to those around him or her), it has turned pathological...otherwise meaning, it has turned into an illness. Much may also depend upon the context in which this occurs. Behavior (in all of its dimensions) does not exist in a vaccuum...there is a context. Therefore, a thorough history is very important. The context is the foundation in which the house of Norm or Abnorm is built upon.

So, when conducting a psych eval or assessment...along with exploring symptoms, it is important to explore these other areas...functionality and adaptability and context. Things do not happen out of the blue in most cases. There are reasons.

When clinicians begin pathologicalizing what is normal (sic), they begin losing genuine perspective....clinically as well as personally.

This is one major reason why clinical supervision becomes very important in clinical practice. It not only serves our patients best, but keeps the clinician better aware and better prepared in reducing these errors in perspective and in judgement.

What ever you decide for yourself with regard to your career (leaving psych or staying in it), you have my very best.

Great post.

Peace

Whispera, MSN, RN · Jul 25, 2009

Sometimes staff members become burnt out and start thinking just because someone is admitted with a psych disorder, everything thought/felt is part of the illness. People like you, who question this, are needed, to advocate for the patient. Don't give up just because the others don't agree with what you're thinking...maybe you're the one who's correct.

zuzi · Jul 26, 2009

Hey everyone - this is my first post on allnurses.

Hey welcome to AN!

Sometimes in my clinicals, I find that the nursing staff pathologize behaviours that seem totally natural to me.

Ie. A suicidal patient thinks no one is helping her since she was admitted, and the staff think she's paranoid!

Could be or could be not! IF her ideation "no one help me" has many other behaviors or clinical s/s that came to sustain this type of ideation... could be AND paranoid but not only....is much more close to a depression state to be

To me it seems totally natural that you would feel like no one was helping you in this situation.

Well as soon you try to comit a suicide...everything related to "normality" need to be analyzed very precautious... for a futher consequence of your nursing decisions

Meds haven't kicked in yet, (how many days of medications???? did you call the doctor for updates???)

and the facility I'm at has no formal counseling available with psychologists or social workers, and nursing staff are too busy to have conversations of more than two or three minutes with each patient.

She's suicidal and she has no one to talk to! (where are family members, phones call, what is her PLAN OF CARE???)

The patient is lucky if she sees a doctor once a week.

All we have done to help her is to put her on a locked unit, which probably seems really threatening to her.

At this time is A HELP for her!

I know she needs to be kept safe from herself, but in many ways, the unit seems punitive rather than therapeutic to me.

Try to see the true in another way... write the atributes for "punitive" in THAT REAL facility not in a dream one.

I'm not being manipulated, I just know I'd feel the same way.

Is not about manipulation... is probably that you are much more affective-sensitive instead to logical thinking.

I'm thinking about switching to med-surg, which would cost me at least a year and maybe more of extra training.

(luckily in canada, student loans are 40% forgiven for nurses because of the nursing shortage)

Give you much more chances in psych, if you will feel ok with stay do it, may be later you will see in a diferent way

Jules A, MSN · Jul 26, 2009

There are just so many subtle issues that as a student you might be missing. Personally I happen to think that most suicide attempts are manipulative. Keep in mind that many patients with a history of suicide attempts have cluster B traits also. As a student you will be a natural target. I'm not saying this is the situation but just keep an open mind and consider that the nurses with years of experience might be on to something. If you really think this milieu isn't therapeutic perhaps this facility isn't a good match for you. Good luck.

Swandive · Jul 27, 2009

So, this patient continues to say that she doesn't feel like she's receiving help.

She understands why she was placed on a psych hold after a suicide attempt, but she feels like she needs counselling.

Her family is in a different city, she's new to this city and doesn't have friends here, or school, or a job, or anything.

I really think isolation led was one of the key factors in her depression, and as one of the most high functioning pts. on the unit, she can't relate to the people around her. She could try to figure out if there's a way to get counselling on the unit - ie. having a private counsellor come in to talk to her. Her dr. would have to okay it, and she'd have to pay this counsellor probably upwards of $100/hr. She's also not getting out of bed, and probably not really up for going through the phone book and interviewing potential counselors.

How do you usually address a hopeless sense of isolation in a pts plan of care? Part of it is definitely that she needs to have more internal emotional resources for dealing with stress or sadness, but the girl also has old abuse issues, etc. and probably does need to talk to a therapist. I feel really bad that our facility has no way to address this. I've been emphasizing that her time on the inpatient unit is a time of physical and emotional rest, and that it's not a time to tackle big issues. But she just seems lonely, and her affect is getting flatter, and she's getting out of bed less.

mikayla0813 · Jul 28, 2009

So, this patient continues to say that she doesn't feel like she's receiving help.

Does this patient have an AXIS II diagnosis? Sounds a lot like Borderline Traits to me, but could be wrong...I've seen many, many patients (especially female) try to get attention with these maneuvers, especially those who have abuse histories.

She understands why she was placed on a psych hold after a suicide attempt, but she feels like she needs counselling.

This is an inpatient facility with no psychologist/social worker? Odd...Is she not in any kind of group therapy? Again, her penchant for "needing to talk" may be a plea for attention. Negative attention is better than no attention.

Her family is in a different city, she's new to this city and doesn't have friends here, or school, or a job, or anything.

I really think isolation led was one of the key factors in her depression, and as one of the most high functioning pts. on the unit, she can't relate to the people around her. She could try to figure out if there's a way to get counselling on the unit - ie. having a private counsellor come in to talk to her. Her dr. would have to okay it, and she'd have to pay this counsellor probably upwards of $100/hr. She's also not getting out of bed, and probably not really up for going through the phone book and interviewing potential counselors.

Even if her meds haven't kicked in, her depression should be treated in her plan of care, i.e. not allowing her to sleep all day, making it a goal for her to interact with her peers, or perhaps playing a game with her peers to draw her out of her self-imposed shell.

How do you usually address a hopeless sense of isolation in a pts plan of care? Part of it is definitely that she needs to have more internal emotional resources for dealing with stress or sadness, but the girl also has old abuse issues, etc. and probably does need to talk to a therapist. I feel really bad that our facility has no way to address this. I've been emphasizing that her time on the inpatient unit is a time of physical and emotional rest, and that it's not a time to tackle big issues. But she just seems lonely, and her affect is getting flatter, and she's getting out of bed less.

An inpatient facility is really not the place to address these old abuse issues unless she expected to remain there for a while (months). Opening up that can of worms if she's just there for stabilization will actually make the presenting problems more severe. The plan is usually to stabilize, then the social worker should have some type of continuity of care planned for her to visit with her local MHMR or therapist. This sense of isolation can be addressed by having the patient journal, locking her door during the day so she can't sleep all day (sounds harsh, but it works), having her work on coping skills on a daily basis. Ask her what 5 coping skills might be for her and see what she comes up with. If they are appropriate, have her practice these. If they are not appropriate, try to come up with some together. Above all, don't try to tackle her BIG issues with her (big red flag for manipalation). If she attempts to try to talk to you about abuse, refer her to the psychologist i hope you have on your unit.

Swandive · Jul 28, 2009

Thanks Mikayla.

I especially appreciated your comment about how opening BIG cans of worms is a redflag for manipulation - as a student, I hadn't thought of it that way at all, but it makes sense.

I just feel like a jerk because we have no psychologist or social worker to refer her to while she's here. If she wants to talk, there's no one appropriate. No group therapy, either. Her stay is probably going to be 3-5 weeks long. When she's discharged, she has the option of being treated by our outpatient team, which includes dr.'s, nurses, an MSW and a psychologist. Which is free, because we're in Canada. We have social workers who come in with dogs that the patients pet and brush, but they aren't allowed to talk to the social workers about their lives...

She doesn't talk to the other patients at all. The RN I'm working with says we shouldn't get her out of bed, because she needs "rest" while adjusting to her new SSRI, and the inpatient stay is for physical and emotional rest.. But it's been this way for almost a week. When do we start paying attention to her ADLs? The RN will ask her to shower, and she'll do it w/o complaint, but doesn't make her come to meals or anything, so she's basically not eating. The drill on this unit for a missed meal is that if you do, there's a table with juice on it, and you can have as much juice as you want.

mikayla0813 · Jul 28, 2009

I just feel like a jerk because we have no psychologist or social worker to refer her to while she's here. If she wants to talk, there's no one appropriate. No group therapy, either.

Seems like that is a big disservice to the patients, but maybe I'm just spoiled because of the way the facility I work at is set up. I would have her keep a journal of all these thoughts that she wants to "talk" about so she will have a point of reference when she is discharged and ready to speak with a therapist. Keep encouraging her to seek a therapist upon discharge but also let her know that you are probably not the best one to speak with her regarding abuse issues and try to change the subject.

Her stay is probably going to be 3-5 weeks long. When she's discharged, she has the option of being treated by our outpatient team, which includes dr.'s, nurses, an MSW and a psychologist. Which is free, because we're in Canada. We have social workers who come in with dogs that the patients pet and brush, but they aren't allowed to talk to the social workers about their lives...

Pet therapy is excellent!!

She doesn't talk to the other patients at all. The RN I'm working with says we shouldn't get her out of bed, because she needs "rest" while adjusting to her new SSRI, and the inpatient stay is for physical and emotional rest.. But it's been this way for almost a week. When do we start paying attention to her ADLs? The RN will ask her to shower, and she'll do it w/o complaint, but doesn't make her come to meals or anything, so she's basically not eating. The drill on this unit for a missed meal is that if you do, there's a table with juice on it, and you can have as much juice as you want.

I'm sure her weight is monitored? Her labs are also probably drawn on a regular basis since she is on meds? If these values stay WNL, I wouldn't be too worried. If she is borderline, making an issue of the eating may actually worsen the symptoms. If she is depressed, as soon as the meds start working, she will more than likely begin eating again.

You sound like you really care and the facility you're at is lucky to have you!

Swandive · Jul 28, 2009

I don't really think she's borderline/axis II, because she doesn't seek attention at all.. She doesn't talk on the phone with family or friends - didn't even notify anyone of the attempt. Her dx is major depression + PTSD, and it seems pretty right on.

She never comes to the nurse's stn. When we check in on her, her only complaint is that she wants to talk to a therapist. She hasn't tried to bring up "big" issues with me or other nurses. She herself stated that she knows we're not the appropriate people to talk to- she just wants someone appropriate to bring this stuff up with. She doesn't try to talk about it with the other patients.

I can understand how it's a long, uncomfortable wait until discharge to see a psychologist or MSW.

She doesn't "push" the therapist issue- if we ask her what would make her more comfortable, she says talking to a psych/MSW would - but she understands it's not possible. She doesn't get angry about it, or complain.

I guess I'll just keep working on coping skills / ADLs? And emphasize that coping skills + taking care of herself in terms of ADLs will make her stay more comfortable while we wait for meds to stabilize. Eating would help her mood, etc. The IP unit is a good time to practice coping skills - because it's an environment without the resources she may want, so she can work on managing at times when she feels like there are no resources available.