Let’s imagine a scenario. You are the head nurse in an ER or a psych ward. A man comes onto the unit escorted by police in handcuffs. He had been arrested for brandishing a samurai sword at a bus stop and threatening passersby. The police disarmed him, put him in shackles and brought him to your psych ward for evaluation.
Momentarily, the cops are going to transfer custody of this still clearly agitated man to the psych nurses who work under you. The man shows every sign of becoming physically aggressive the moment the cuffs come off. His narrowed eyes are casting furtively to the left and right and he is muttering incessantly to himself about people who have it coming to them and how he is going to finally give them what they deserve.
He is not responding directly to questions but just acting out in a paranoid yet threatening manner. You have no idea how long it’s going to take for this guy to come down from this psychotic state on his own. He needs to be dealt with, handled, right now. He poses an immediate danger to everyone’s safety, including yours. You can’t allow other people to be harmed by this guy no matter what his problem is. You have to ensure the safety of staff and patients alike.
But you’ve read about how people who have been restrained and injected with antipsychotics against their will deeply resent that treatment and were left with psychological scars from having that happen to them. In addition, a mandate has recently come down from the government banning coercive treatments like forced drugging and electroschock.
Oh and don’t forget, he is the not the only person on the ward. Other patients need to be tended to, and there is always the potential of another person coming to the ward right after this guy. You simply can’t allow this man to carry on his show and dominate limited staff resources all shift long. So what do you do in thirty seconds when the cuffs come off that guy?
A very good post. I am a registered nurse and have taken care of psychotic patients (in a subacute setting only).
Some people may resent this when the psychosis ends… well look at it from another perspective. Medical personnel, doctors, nurses, your family, and civilians resent it when psychotic people who frequently become violent and dangerous stop taking their medicine, because it is just as much a violation of the rights of other people in society to frequently be subjected to a person in an agitated mania prone to violence/homicidal impulse…or a deeply entrenched psychotic delusion that everyone around them is trying to murder them resulting in this psychotic person “acting out in self defense” by attacking those who are nearby.
Either this person needs to live in a cave somewhere they can go psychotic/homicidal/violent without hurting other human beings, or alternatively they need to accept that they have this disorder and must take medicine to keep self, family, and other members of society safe.
IMO it is not a valid argument to say it is a violation of a persons’ rights to use major tranqulizers against a persons will who is acting out in a dangerous violent way against other people. When your medical disorder poses a threat to the rest of society, you do not have a choice in the matter of treating it while acutely severely symptomatic. Either leave society all together (i.e. live in the woods) or accept that society is going to occasionally force you to take medicine in order to protect its other members from the effects of your illness.
Look at it like this. Not to compare severe bipolar or schizophrenia to pedophilia…but, just for arguments sake, imagine a person with a sexual attraction/sexual assault against children who frequently takes jobs where he is trusted with protecting children. THis person knows he has this problem (sexual attraction to children, impulsive sexual attacks against children) but he refuses to do anything to curb his antisocial mental/behavioral problem. In fact, he just lets it all hang out and actually seeks out positions where he will be in contact with children, showing a total complete disregard for the safety or interests of the rest of society (the children he will attack, the parents of the children he will attack.
If society puts this guy on a list, tells all his neighbors he is a pedophile, is it a violation of this mans rights? Doesn’t this man have every right to find a job where he is a schoolteacher, a gym teacher, a coach, a scout leader? It is a violation of his rights to tell the neighborhood he is a pedophile, right?
Perhaps it is… but, it is a much bigger violation of rights of inevitable victims to allow this man to just walk around undetected where he could ruin more lives. The end does justify the means. It is a violation of rights to disclose his personal history, but it is a much bigger violation of rights to allow this man to walk around raping people.
Again not to compare mental illness to pedophilia, but when you have a certain brain problem which makes you a danger to the very society you live in, you have an obligation to that society so as to minimize the risk you pose to them. if you won’t comply willingly by taking at least minimum medication to prevent dangerous psychotic behavior, it is justifiable for that person to be forced into compliance at least until he or she is reasonable enough not to be a danger to himself or others.
It is unfortunate some people find forced injections and seclusion rooms to be traumatizing… but what is the alternative? Allow a wacko to run around the ER with a knife while doctors and nurses run away? Allow a full on pscyhotic manic person to wander about the streets screaming and attacking random people?
I read a story once of a person with a psychotic illness who heard voices telling him to eat his grandmother. So he did that. He killed her and cannibalized her body. When this person came down from their psychosis, they probably would have *wished and begged* for the opportunity to be injected with some strong cold haldol so that he would have been prevented from doing that. If only it were available to him, that is… which it wasn’t…
I am not trying to be a jerk, but it is TOTALLY unreasonable to argue against forced treatment for emergent psych crisis where a person is a clear cut danger to others. I am against forced treatment when people are not a danger to others, I am even pro assisted suicide… but this is a different situation.
If we were talking about a non-psychotic criminal, there would be no argument about “forced jailing” because we would feel as if purpose of intent and understanding of consequences makes it justifiable to force people into isolation (prison) against their will. Meaning to say, “he knew what he was doing but killed those people anyway…lock him up in a cell for a million years by himself”.
Prison isn’t supposed to be about emotion, it is about protecting society. We put criminals in jail because they have proven themselves antisocial and so the punishment is about protecting society.
Acute psych exists to protect both the patient and society, it is not a prison but it serves a similar function.
It is unfortunate some patients feel like they are being punished, like they are in prison, but there is no other alternative. It sucks bigtime that some people have diseases which make them brandish knives and try to kill people, but life isn’t fair. Some people have terminal cancer and will die, some people have multiple sclerosis and can’t move. Some people have severe bipolar and occasionally have to be forced to take IM shots of drugs so that they don’t kill people. It’s another horrible thing that exists in this world but there’s nothing else to do. It’s not an option to allow this person to run around machete-ing bystanders.
By: itsthewooo on December 3, 2010
at 9:54 pm
With that said, which i do think probably makes me seem like an uncaring jerk… i think we are describing the problem incorrectly. “Forced treatment” is not the problem… the problem is SHITTY treatment. Meaning to say, the doctors and nurses suck.
The crucial factor in how a patient perceives his or her psych care is probably determined by how caring, kind, compassionate were the psych nurses/aides who were taking care of them. Which not enough psych nurses are.
If I were the nurse in that situation (and I am a nurse and have been in this situation before), I would get the PRN medication and I would explain what I was doing to the patient and why I was doing it. I would be as calm as I could and as non-threatening as possible. I wouldn’t do anything without first telling the patient what it was, why I was doing it, what the effects are, and why it is necessary for me to do this.
I would expect this psychotic and delusional patient to curse me out anyway, to attempt to hit me, to spit on me, to kick me, regardless of what I said… but I think the sort of care the nurse / aide gives can mean the difference between a patient feeling violated and a patient (when down from their psychosis) walking away feeling like the nurses / staff did what they had to do in that moment. If you are a bitch nurse with an attitude like “I am in control and you will do what I say” of course the patient is going to feel like you are violating them. If you try to get on their level and understand what they are going through and explain things so that they feel more control, it’s less likely that patient will feel traumatized.
The problem is that in acute psych nurses and orderlies are burned out or never gave a shit in the first place and so they treat the patients like non-humans, and the patients perceive the treatment as like that of a prisoner in a jail.
You can only take getting kicked, punched, and spit at for so long before you lose your compassion and start acting like a prison warden. When 24/7 you deal with antisocial behaving people, you start treating them like criminals (whether it is justified or not). It is unfortunate, but a reality that burnout is super duper high in acute psych / emergency med.
In my line of work I frequently deal with dementia psychosis, which is certainly far less dangerous than mental illness psychosis… but i am quite familiar with the scenario of a confused, agitated, combative patient. I reorient as much as possible and explain to the patient why I am doing what I am doing, and why it is necessary. They get pissed off but it is for their own good/safety. The difference with dementia psychosis and schizophrenic/bipolar psychosis is that the schizophrenic or the bipolar will eventually regain their cognition and feel the capacity for regret/understanding of the things they did and how crazy they were (and with that comes either gratitude or resentment for the treatment they received). The dementia patient is permanently altered cognition and lives only moment to moment. They want to get you one hour, the next hour they completely forgot it all and are looking for lost family members and want you to help them.
Psych is very unfulfilled for the nurse. All of your patients either hate you or are apathetic. You are frequently attacked. Few psych patients appreciate good nurses, but all psych patients remember the shitty ones . Unlike med surg, no one has a good experience int he psych hospital. All psych hospital stays are tragic for the patients. No one wants to be there. They are all forced to be their either by themselves or family or by the law. No psych patient appreciates his care, at best they are bittersweet and have an ambivalence for it.
In short… the key to making acute psych treatment less adverse for patients is very delicate, skilled nursing staff with excellent communication/compassion… but that’s like finding a unicorn in the dessert because the nature of psych murders the spirit of most all nurses.
By: itsthewooo on December 3, 2010
at 10:21 pm
Hello again, Itsthewoo,
Here is the thing, I don’t disagree with you. I am impressed with the persuasiveness of your experiences and commentary. I know I will probably catch flak from some of my readers for saying so, but, I too know the dark side of mental illness. I know about the violence and the spitting and threats. I have been in psych wards, group homes and facilities where I lived with or witnessed some scary incidents. I’ve had mentally ill people tell me they were going to slit my throat or sexually assault me.
Right in my neighborhood, there is a man who sleeps in the bushes somewhere nearby and can sometimes be found wandering the park, yelling at no one and everyone. People freeze in place when he walks by and pull their children close. I’ll write a post about this guy one day, and some of the other psychotic people I run into in this city…
Anyway… The problem is that the methods we use to restrain and control people who are out of control are traumatizing. If you are not going to shoot someone up with tranqs, then what do you do? Tear gas? A tonfa to the head? Tazing? Rear naked choke? If not four-point restraints, then what? A chain on a wall? You are absolutely right. You can not allow a deranged person to run amock slashing and beating on people because you are too afraid you are going traumatize the guy and violate his rights. What about your right not to be subject to being assaulted by a psychotic person? You have to balance the public good. Since he isn’t in a cave out in the middle of nowhere, and because he is a danger to society in his mental state, you have to step in and do something.
In this I sympathize wholly with you, with LE, and outreach workers who have to deal with this sort of thing. Now, in the future, maybe we will invent a phaser with a stun setting. You shoot the guy with the beam as he raises his hand to you and he crumples quietly on the floor and wakes up with a headache that will soon pass. Or, some kind of force-field projector where you could hold the guy in a traction field. But unfortunately at this point in time, we have limited options. Thanks for your comments and for sharing your experience here man.
By: Jane on December 4, 2010
at 9:02 am
Flak, well, you might say so. Very briefly: I don’t think anybody has to accept that they have a disease that doesn’t exist. So, yes, forced “treatment” is an issue. First, someone would have to prove to me that I am diseased. Then, when they’ve successfully done that, they can go get the Haldol. As long as they can’t, if they shot me up with Haldol (or whatever else of that kind), they’re, well, not even punishing me, but actually torturing me. Big time. And I’d find it even more appaling, if the person to torture me at the same time they’re doing it, tried to tell me it only was for my own good. Huge double bind. And what all abusers do. It’s the same atrocity as that which drives many people to the point where they end up at a psych ER, in handcuffs.
I’ve had some debates on the net with psych staff in the past. What struck me each and every time was their outstanding ability to create double binds. Double binds and mystifications (Laing). One after the other. Is that something they get especially trained in? So that they better can provoke the “symptoms” that are necessary, if they want to “treat” (= torture) people?
What I would do? I’d do the same thing Loren Mosher did, and ask the person if there wass anything I could do for him.
By: marianbg on December 5, 2010
at 5:13 pm
Did Loren Mosher say anything about whether or not the “Is there anything I can do for you” approach always works 100% with all psychotic and threatening or violent people? Did he have a back up plan for when the answer to that question is “Frak you!” followed by a swing to the face?
I think the ideal of course should be non-violent means whenever possible. But some and I stress some people put their own self into a double bind when they become mentally ill and they are around people in a civilized society where some people don’t take kindly to being threatened by a man with a samurai sword just because ‘The Man’ is conspiring to keep this guy repressed, (according to his own rants).
I think it is a serious and potentially very dangerous mistake to assume that a kind word or an inquiry into the subjects wants or needs is going to be all that is required to talk someone down from being both psychotic and threatening, which was the scenario that I wanted to play with in this post. Great if you are the only nurse on the ward, but when you have other staff as well as patients to look out for, you have to have a more assertive backup plan ready to go for when the kind word does not work and you are still in danger thirty-five seconds later.
By: Jane on December 7, 2010
at 11:46 am
Jane, of course it isn’t always enough. Still, usually incidents like the one you refer to don’t last very long, given that people understand that the “psychotic” person indeed is threatening to “act out” because he’s terrified. Self-defence, exactly. So, don’t threaten him additionally (with incarceration, restraints, Haldol, etc.), but do everything to make him feel safe. Loren Mosher also used to tell people, they were free to leave if they didn’t want anybody to do anything for them. That is, he did the opposite of threatening them with incarceration. Don’t start telling people in distress, you’re going to “help” them (if they want your help, or not), that they’re sick and need your “help”, and all that bs. It’ll only upset them even more (and righteously so). Don’t try to fool these people. They’ve got a sixth sense for, if you mean what you say, or not. And nothing is worse than lying to someone in distress.
Anyhow, if words can’t do the job, there are (at least in most countries, must admit that I don’t know about the U.S.) laws that allow for someone to be prevented from doing harm to themselves or others, while there is immediate danger for this to happen. What these laws don’t allow for, is to anything to the person that either in duration or intensity exceeds the actual threat. So, you may not shot someone up with any psych drugs, as these remain active in their body, also after the person is no longer a threat to anyone. You may not electroshock them, as also the “effect” of ect exceeds the period of time, the person is an actual threat. And you may not keep them locked up, restrained, or anything of that kind for a sec longer than what they are an actual threat. (These laws have got nothing to do with any special mh legislation that actually is a violation of human rights.)
Loren Mosher said, they handled dangerous situations simply by outnumbering the person, and holding on to them for the rather short period of time it takes truly skilled staff to make them calm down.
By: marianbg on December 7, 2010
at 12:50 pm
“What these laws don’t allow for, is to do anything to the person…” it should have read.
By: marianbg on December 7, 2010
at 12:53 pm
Another thing: you need guts to work in the field. If you’re afraid of the guy, and no matter how huge an effort you make to hide it he’ll know, he will inevitably translate your fear into him actually being a danger, a threat, and it will reinforce his desperation and aggressivity.
Interesting read on the matter: http://www.isps-us.org/articles/stockholm.htm
By: marianbg on December 7, 2010
at 1:14 pm
I would imagine so. But restraining someone is itself a controlling act. You put your hands on me, you are trying to control me, I am going to shrug your hand off me or worse if you insist on touching me, which I how I felt and reacted when it happened to me. I am pretty sure the trauma was going both ways. To go to work and subject yourself to someone who is both enraged and psychopathic puts you in danger. You are absorbing their energy as surely as they are sensing yours. The things I said to the psych nurses would be chilling for most people to hear. To go home from work to face your family and carry on, having heard earlier in the day direct from someone’s mouth to your face that they intend to stalk and kill you later on in life when you’ve forgotten the incident, as payment for what you did to them on the ward. People need counseling for burn out and stress after they’ve had to deal with acute patients for awhile.
By: Jane on December 12, 2010
at 1:39 pm
I’d say, they need to change their attitude towards their “patients” — and to do that, they’d need to first change their attitude towards themselves, and drop the self-deceit and self-hatred they engage in. That would reduce both violence in general, and threats to stalk and kill them remarkably.
Psychopaths very rarely end up at a psych ward. They usually end up in prison.
By: marianbg on December 12, 2010
at 3:59 pm
Most psychotic people aren’t violent.
By: shinxyblog on January 8, 2011
at 8:25 pm
I tend to agree with you, Shinx. Thanks for visiting.
By: Jane on January 9, 2011
at 8:36 am