Who's Afraid of the Big, Bad Psych Patients

rn/writer, RN

Whenever I tell people I use to be a psych nurse, I usually get one of two reactions. "That's so interesting--tell me more." Or, far more often--"Yikes! Psych freaks me out. I could never do that."

It's no wonder. Very few of us had more than a brief flirtation with psych during nursing school. In class, we were introduced to Freud and Jung, Maslow and Erickson. We learned about normal brain function and the myriad ways it can falter. We covered a long list of diagnoses and the signs and symptoms that went with them. And we made lists of meds. Lots and lots of meds. Next up--the psych ward where we made hesitant contact with patients, attended group sessions, and did our best to conduct therapeutic conversations. Remember active listening?

But psych is a complex area and we barely had time to scratch the surface. Add to this the fact that we didn't want to say anything offensive (So, how does it feel to be psychotic?) or set anyone off, and it's easy to see why we were relieved when the nurse locked the ward door behind us on the the last day.

It seems so rational, even somewhat sensible to be afraid of psych patients, but is the fear justified?

Consider that there are approximately four million people in the US with severe mental illness. Out of that number, just 40,000--one percent--are violent. And, according to Jeffrey Swanson, a professor at Duke University, that violence is mostly mild behavior--shoving, pushing, punching--more associated with resisting someone else's control than intending to cause them harm.

The stark reality is that mental patients are 13 times more likely to be the victims of violence than the perpetrators. Limited resources, rough living, and the fact that they aren't the most credible witnesses, turn folks who struggle with mental illness into attractive targets for criminals and opportunists. Often, patients are their own worst enemies, forgetting (or deciding not to take) meds, giving away money and possessions, and choosing unscrupulous or unstable companions.

But none of that makes the news. The mentally ill people we hear about are the crazed gunmen or the serial killers. With extreme criminals providing the "face" of psychiatric illness, it's little wonder that even the word "psych" freaks people out.

In reality, if you want to see what a typical psych patient looks like, take a peek in the mirror. That isn't meant to insult, but to illustrate how "normal" mental illness is.

According to the Kim Foundation, in any given year, approximately one in four American adults will suffer from a diagnosable mental illness. Unfortunately, many people will not actually be diagnosed, and of those who are, many will not request or receive treatment. Nevertheless, a quarter of our population lives with one or more psychiatric afflictions. What could be more ordinary than that?

Let's take a step back from the machine gun-toters and the axe-wielders and recognize them for the statistical anomalies that they are. Much more common are everyday people who struggle with mood disorders (depression, bipolar disorder), anxiety disorders (panic disorder, obsessive-compulsive disorder, PTSD, generalized anxiety disorder, and a variety of phobias), conduct disorders, substance abuse, eating and body image disorders, ADHD, autism spectrum disorders and Alzheimer's disease.

It's a rare person that doesn't know someone affected by one of these maladies and many of us know half a dozen or more. (Pssst. And some of us are that "one in four" affected people.)

Do we hold all of these people at arm's length? Not usually. We often learn to keep a bit of protective distance, but we still interact and encourage the afflicted ones to seek health and make better decisions. That's similar to what happens on a psych unit. Doctors, nurses, techs, and other professionals try to establish a caring connection, offer a listening ear, and help the patient navigate through treatment choices and through their often challenging lives.

But isn't it frustrating to work with such messed up people? It can be. But "messed up" is a relative term. Some mental patients are fairly sane people who have been steamrolled by insane circumstances, time and time again. If you knew all that they had dealt with over the years, instead of shying away, you'd be proud to know them, and you'd see them for the resilient survivors they are.

Other folks have been tuned to a different frequency for most of their lives, but you can still see a spark of humanity in their eyes. Even the hostile, edgy ones have a good days mixed in with the not-so-good.

As far as the fear of "setting someone off" goes, when you work in this milieu, you learn ways to help patients deescalate. Or at least how not to push their buttons. This is a fantastic life skill to practice on a psych ward, but it can come in handy anywhere.

Another frequent bugaboo connected with psych is the idea of tip-toeing on eggshells when it comes to talk of suicide. When, at first, I was taught to ask patients outright, "Are you thinking of harming yourself? Do you have a plan?" I thought it was, pardon the expression, insane to ask a fragile mental patient such a loaded question. I assumed they'd either lie or become angry or both. Imagine my surprise when they almost always told the truth and expressed relief that someone had mentioned the elephant in the room.

Once the subject was broached, we could discuss the emotional triggers that sparked thoughts of self-harm and strategies for patients to get their needs met without drama or damage. They were happy someone cared enough to ask and often agreed to contract (make a deal) to keep themselves safe. They would agree to say a particular word as a signal that they needed a one-to-one conversation or they'd write rather than cut or they'd even ask us to put them in the quiet room where they could calm their racing emotions with our help.

Some nurses have expressed reluctance to deal with a population so given to (and good at) manipulation. Initially, you get suckered in. A lot. But then you learn. And pretty soon you get to a point where you don't even get riled up any more. When someone tries to play one staff member against another or take unearned privileges, you say things like, "No, you can't break the rule, but thanks for asking. We have lovely parting gifts for you. Thanks for playing our game." You laugh. They laugh. No hard feelings.

You might be amazed how many people you know--nurses among them--who either struggled with mental illness in the past or still do so today. Counseling, meds or both have allowed them to progress to the point where you would never be able to tell psych issues are or were a part of their lives unless they told you.

I'll leave you with two important truths about psych. One is that psych patients are just like the rest of us, only more so. And the other is that no matter what kinds of patients you work with (and who your co-workers are), you will always find psych training useful.

Law creates barriers to getting care for mentally ill

Working to Reduce Mental Illness Stigma | The Kim Foundation

NAMI: National Alliance on Mental Illness | NAMI: The National Alliance on Mental Illness