The Violent Patient

On the New York Time's Well blog recently, nurse Theresa Brown wrote a piece entitled "Feeling Strain When Violent Patients Need Care," in which she talked about caring for a very threatening, potentially dangerous patient suffering from cancer. This patient, a large 300 pound man, had a reputation for causing havoc in the hospital. He had been banned from one ward for tearing a light fixture off the wall and fighting with hospital security. He had "slugged" a family member at the nursing station and threatened to kill a nurse. In spite of all this, he apparently was not in custody at the time that Ms. Brown was caring for him, which meant that he was not a prisoner in shackles and there was no dedicated law enforcement professional watching over the situation. Understandably, Ms. Brown was afraid.

What some people might not appreciate or been aware of, was that she was also embarrassed about being afraid. Working in the health care field, and in nursing in particular, meant that one could be exposed to volatile situations at any time. Being a professional meant being able to stay calm and poised enough to manage these situations, and this is where the author of this piece felt lacking. She felt she should have been tougher, more unflappable, or somehow invincible to this very concerning patient's intimidating demeanor. Ultimately she was replaced on the case by a male nurse. We never find out what happened to the patient, whether he actually did commit acts of violence during that admission, or whether he calmed down with the male nurse and cooperated with the care he needed. We also don't come to any resolution about what a health care professional should do in a situation like this. This is not a question the narrative was meant to answer, apparently.

As always in story like this, the most interesting part to me were the comments that followed. Over the next two days nearly one hundred people wrote in, mostly nurses and doctors and other health care professionals, to talk about the multiple incidents in which they were bitten, scratched, spat upon, cursed, hit and kicked in the emergency room, on the psychiatric unit, and in the intensive care unit. Half way through the comments I found myself wondering what the incidence of post-traumatic stress disorder must be among health care professionals after a few years of routine work. (I don't know the answer to that question.)

I was also impressed by the range of thoughtfulness that some commenters brought to the situation. Some quickly speculated that the patient might have been a veteran or someone equally traumatized, who would naturally have responded with aggression when startled awake in the middle of the night by a stranger. Others speculated that he might have been having an unexpected reaction to a medication, or been in the midst of a delirium. Some suggested that a CT scan should have been done to make sure his impulsivity and temper weren't due to a malignant brain metastasis. Clearly, these health care professional readers were setting aside their own personal experiences to consider the cause of the patient's emotional reaction and behavior. This was heartening to me.

Other comments were less sympathetic, implying that hospitals should be more liberal in their use of physical and chemical restraints and that assaultive and threatening patients should be prosecuted consistently.

I felt rather fortunate after reading this piece. I've worked with patients known for this kind of violence, but I've been comfortable doing so knowing that safety and security were a necessary and essential condition to providing treatment. I've always felt safer in most correctional facilities I've worked in than in some more traditional clinical settings. Even so, I rarely have had to deal with patients who were so angry or potentially dangerous that I wasn't sure I could treat them even in the correctional setting. That's not good because in most cases there is no one else to turn the patient's care over to when you're the only shrink in the building. This is how I've managed to handle it:

If the patient starts the appointment calmly but escalates during the interview, the first thing I do is slow down. I want time to listen, to think, to make sure the patient knows that I'm hearing him and am concerned about what he's saying. This also helps me listen better. I set my pen down and stop taking notes. I look at the patient. I make sure he knows he has my full attention. If he allows me, I will ask questions to get more information or to clarify something he has said. I repeat what he's told me, and ask him if I am understanding him. If and when he says 'yes', things chill out immediately and we negotiate a treatment plan.

If this doesn't help, or if I start to feel I can't listen safely, I tell the patient I feel uncomfortable or worried. It's not waving a red flag in front of a bull to admit that you're scared. You'd be surprised how many temperamental men (I only treat male prisoners) have no awareness whatsoever that they are talking way too loud or gesturing too broadly or behaving in a way that attracts attention. The nearest correctional officer usually notices first. If I see an officer glancing in to check on me that gives me a nice opportunity to point out to the patient that his behavior is arousing the concern of custody. That always works.

I'm surprised how often an angry inmate will suddenly pull himself together and calm down once you tell him you're scared. Some of them are quick to apologize, or emphasize that---in spite of what they might have done in the past---they have never laid hands on a woman.

Lastly, I know when to recognize when I need to take a break. If I find myself wanting to cut the patient off or getting annoyed---too annoyed to listen---I know it's time to call it a day and try again another time. These are the times when mistakes get made. I can ask the patient if we can take a break and come back to the discussion later in the clinic session, or on another day. I explain that things have gotten heated and I really want to make sure I'm taking the time to think about his care.

If none of this works, I still keep trying. I will make sure I have any necessary security in place, and explain to the patient why it's needed. If someone is available, I may ask another health care professional to sit in the room with me. And make sure an officer is outside the door. In extreme cases, it might be necessary to put the person in handcuffs and a waist chain for the appointment.

Hospitals aren't used to doing any of this, or can't. But when 15% of all US nonfatal on the job injuries take place in health care settings, through patient assaults on staff, it's time to take de-escalation training seriously.

Seeing Alzheimer's Through Art

William Utermohlen is an artist who died in 2007, twelve years after being diagnosed with Alzheimer's dementia in 1995. His story is discussed in this article in Urban Times. The art that he created during his descent into dementia very graphically tells the tale of his disease.

1996

1997

1998

1999

2000

'All right,' said the Cat; and this time it vanished quite slowly, beginning with the end of the tail, and ending with the grin, which remained some time after the rest of it had gone.

'Well! I've often seen a cat without a grin,' thought Alice; 'but a grin without a cat! It's the most curious thing I ever saw in my life!' 

~Lewis Carroll, from Alice's Adventures in Wonderland


[sorry, accidentally had Comments turned off... fixed it]

Shrink Rap has Become Part of the Problem

I'm taking a break from Shrink Rap for a while and leaving the blog to ClinkShrink and Roy.  As I mentioned in my post on "A Matter of Perspective," sometimes people come to an impasse where they simply can't hear what the other has to say in the way that it was intended, and on certain topics, I think I've hit that place with a handful of our commenters.  I feel unhappy when I try to express myself and my words get twisted and distorted so that meanings and intentions that are attributed to them are far from what I ever meant to convey.  I understand that some commenters feel the same way when they try to get me to hear their points of view, and so I believe we are at that impasse of irreconcilable differences. 


At moments, the comments over the past few weeks have been outright mean.  There is a respectful way to disagree-- one that has a chance of getting heard-- but some of this has turned into name-calling.  As Rob says, I could use a thicker skin when it comes to blog comments.  I have been struggling over the past couple of weeks because I write something, it gets shot back at me as something I never dreamed I was saying, and I've been left to ask myself why I want to write for readers who are so angry with me?  If they don't like what I have to say, why do they read my blog?  If they have a better ideas, why don't they write their own blogs?  It's as if Shrink Rap has become a magnet for those who've had bad experiences with psychiatry --- and you know,  that's always been fine, we've learned a tremendous amount from our readers-- but lately I feel as if we're not just a forum to allow open conversation on the good, the bad, and the ugly about psychiatry-- but that we've become punching bags. This is not why I've decided to take a break, but it started to move me there. 

I spoke with a friend last night who mentioned she's been following what's happening on Shrink Rap.  She wanted to know, "What's wrong with those people?"   Other real-life (as opposed to blog life) friends comment that readers won't be happy until I declare that involuntary hospitalization is absolutely the same as Nazi concentration camps without qualification, and I've had other real-life folks contend that I'm catering to the Axis II's (not my words).  


I love Shrink Rap, but part of it's mission is to explain psychiatry and to de-stigmatize mental illness and it's treatment.  What transpires in our comment section has not been successful lately: if anything some (and please, I mean some) comments fan the flames for the worst stereotypes of patients with psychiatric disorders.  They do nothing to further the cause.


A second mission of Shrink Rap is that it gives me a creative outlet, a place to write, a place to vent, a place for thoughtful discourse about things that are important to me.  Lately it is a lot of work to watch my every word and very disheartening to still be misunderstood.  Just like my day job, you say?  No, much harder.  My patients come to get well and they understand that I'm in their corner.  None of them analyzes the nuances of every word that comes from my mouth.  This is good: I talk a lot and sometimes I say impulsive things.  My patients are wonderful people, I love working with them, and this is why I love my work enough to want to write about it in my free time.

Many people have commented, or sent me messages and emails, saying they don't understand the hostility and they like Shrink Rap.   To all of you: Thank You.  I will be back, I just find that it's consuming too much of my thoughts and dampening my mood, so I'm going to step back for a little bit.  


I want to say it one last time.  If you feel you've been wounded by the psychiatric system, Please Complain.  Don't do it in the comment section of a blog-- that doesn't change the world.  Try these suggestions: 
http://psychiatrist-blog.blogspot.com/2011/06/please-complain.html or start your own blog.  If you want to tell me that no one will listen to you because you're a psychiatric patient, I don't believe that.

Please no comments on this post.  

Back soon.

Antipsychotic Use for Elderly Nursing Home Residents: OIG Report

There have been some recent reports about the increasing use of atypical antipsychotics on both ends of the age spectrum. The US GAO (Government Accountability Office) issued a report in December finding higher rates of psychotropic use, including antipsychotics, in foster children compared to nonfoster children (3-4 times higher). Recommendations for increased vigilance and monitoring were made.

In May 2011, the US OIG (Office of the Inspector General) issued a report entitled, "Medicare Atypical Antipsychotic Drug Claims for Elderly Nursing Home Residents." This report examined claims from a six-month period in 2007, finding that 14% of nursing home residents had at least one claim for an antipsychotic, amounting to over $300 billion. Eighty-three percent of these claims were for off-label conditions (e.g., agitation, insomnia), and 88% were associated with a dementia diagnosis. Atypical antipsychotics carry a warning about using them in elderly patients with dementia due to an increased risk of heart attack and stroke.

So, there was a hearing in November before the Senate Special Committee on Aging about this issue. The hearing itself can be viewed on their website, as well as links to the testimony provided.

This is an important issue, because as our population ages and develops more dementia, the pressure to manage the resulting behavioral problems with pills rather than with patience, understanding, and adaptation. Medications can have a role, but cannot be the only solution and should not be used excessively. Some quotes follow.

I believe that behavior itself is not a disease. Simply put, behavior is communication. In people whose ability to communicate with words is limited (such as patients with dementia), communication tends to be more nonverbal (i.e. behavioral). Our challenge is to figure out what they are trying to say, and if they are in distress, to identify the underlying causes and precipitants. Many of the behaviors that are commonly observed in patients with dementia and that are often labeled as difficult, challenging, or bad, such as agitation, wandering, yelling, inappropriate urination, and hitting are typically reactive, almost reflexive behaviors that occur in response to a perceived threat or other misunderstanding among patients who by the definition of their underlying illness have an impaired ability to understand. ...

Patients with dementia often have trouble comprehending their environment, resulting in misperceptions that are often perceived as threats. In most instances, the key to behavior management in dementia is environmental modification, especially the human environment, which may be as simple as changing our approach and our response in order to prevent and minimize distress.  The fundamental basis of health care is caring for others. The fundamental basis of caring is love, acceptance, and respect for persons.

~Jonathan M. Evans, MD, MPH, FACP, CMD
Vice President, AMDA−Dedicated to Long Term Care Medicine

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Medications are used often as the first intervention because family members, care givers, nurses and doctors in ALL settings lack information or training regarding alternatives.  To merely target this one class of drug as the “problem to be fixed” will have the unintended consequence of increasing the use of other, equally risky medications, such as benzodiazepines, anti‐seizure medications and sedative‐hypnotics, all of which have side effects that include confusion, falls, and risk of death.  Furthermore, if the focus is only on the nursing home, we will create barriers to access for care that patients and families desperately need.  In some states, such as California where consent rules regarding the use of any psychoactive medications in nursing homes are in place, some nursing homes have declined admissions because of a “history of behavior problems requiring psych meds”, creating real challenges for caregivers and often requiring patients to stay for long periods in the acute care hospital. The solution to this challenge is not a short‐term fix, but rather a two‐fold strategy that involves systemic application of non‐pharmacological behavioral interventions as the first line of treatment, with close monitoring for appropriate and limited use of medications when the non‐pharmacological approaches have not worked.

~Cheryl Phillips, M.D., AGSF
Senior VP Advocacy, LeadingAge

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Despite the severity and frequency of these symptoms, there is currently no FDA approved therapy used to treat BPSD [behavioral and psychotic symptoms of dementia]. As a result, many types of medications, including atypical antipsychotics, have been used “off-label” in an attempt to mitigate these symptoms. In 2005, the FDA examined this issue and found that the use of atypical antipsychotics in people with dementia over 12 weeks helped to reduce aggression, but was also associated with increased mortality. ...

The Association recommends training and education on psychosocial interventions for all professional caregivers. Specifically, the Alzheimer’s Association believes “in making the decision to utilize antipsychotic therapy the following should be considered:

 Identify and remove triggers for behavioral and psychotic symptoms of dementia: pain,
under/over stimulation, disruption of routine, infection, change in caregiver, etc;

 Initiate non-pharmacologic alternatives as first-line therapy for control of behaviors;

 Assess severity and consequences of BPSD. Less-severe behaviors with limited
consequences of harm to individual or caregiver are appropriate for non-pharmacologic
therapy, not antipsychotic therapy. However, more severe or “high risk” behaviors such
as frightening hallucinations, delusions or hitting may require addition of antipsychotic
trial;

 Determine overall risk to self or others of BPSD, and discuss with doctor the risks and
benefits with and without antipsychotics. Some behaviors may be so frequent and
escalating that they result in harm to the person with dementia and caregiver that will in
essence limit the life-expectancy and or quality of life of the person with Alzheimer’s
disease; and

 Accept that this is a short-term intervention that must be regularly re-evaluated with your
health care professional for appropriate time of cessation.”

~Tom Hlavacek
Executive Director, Alzheimer’s Association of Southeast Wisconsin

A Matter of Perspective

 

Often, when two people can't get along, it seems like the issue is one of communication.  People say things that are ill-phrased, or the person hearing a statement assumes an intention that is not meant to be.  Sometimes, a well-worded conversation fixes the problem, often with words such as, "I'm sorry that upset you.  I never meant it to come off that way and I meant to say X."  A misunderstanding, it happens all the time.  I sometimes suggest that people read the book Difficult Conversations by members of the Harvard Negotiation Project.  The book talks about the value of feeling heard, and how it is important to understand the intentions of the other party.  You can't imagine how often I hear stories about people that sound a little off, and when I ask why someone would say or do those things, I hear theories of how the other party is jealous, or just enjoys watching my patient suffer, or is manipulative, or sometimes the stories have quite complex theories dating back to an event that occurred long ago and doesn't seem that memorable.  Now the theories could be right, people are jealous, or manipulative, or sadistic, but often I can think of alternative explanations that would explain the same story, and I do think that it may be valuable to ask someone their intentions when things go wrong.


Sometimes, people hit a place where nothing can be said that is right by either party.  There are irreconcilable differences.  One person may talk of their heart-wrenching distress and weep their story, while the other hears it as "there he goes again trying to get my attention with his tears," and the crying party feels like their honest and sincere attempts are useless on someone with a hard heart. You can find your own variations on this theme, I'm sure.


I've started to wonder if I have perhaps come to this place with our Shrink Rap commenters.  I feel like I say something and the response indicates that my comments were misinterpreted.   I try to clarify, it just gets worse, and our comment streams now end with readers insulting the blog, me (apparently I'm someone's nightmare shrink and jail would be preferable--which leads me to wonder why such a person would read our blog), and my choice of topics to discuss.  If I talk about an observation I've made, people get angry because of a scenario they've extrapolated that to, which was never what I meant in the first place.  Attempts to clarify seem to be futile.  I don't feel heard, and clearly, some of the commenters don't either. 


And sometimes I feel like readers don't want a discussion at all.  A story is written in, and I often sympathize with the story because our readers write in about very touching, and often tragic, difficulties.   They also sometimes seem to feel that it is the Shrink Rappers' obligation, job, or destiny to right the wrongs they see in psychiatric practice and I do believe we've let these readers down.  Sometimes, I feel terribly bad for the person who has been victimized, but I'm also aware that I've heard only one side of the story, and I may talk about what the other side might be.  And while I don't believe people should suffer, I do sometimes feel that it's helpful to see other perspectives.  It enables a search for a solution to occur with a more thoughtful dialogue.  But it also means that I sometimes sound unsympathetic in that my answers are read as "Yes, but..."  From my point of view, that's part of the discussion, and if you want to say something and want us to respond with absolute sympathy, having heard half of a story that often demonizes our profession, and you don't want to know how the other side might look at it, then I don't think Shrink Rap is the place to come.   I am not likely to write a post about how psychiatrists are all evil and manipulative control freaks who want only to incarcerate, abuse, and poison their patients.  And it's not that I don't believe there may be evil shrinks out there, or stories of abuse, or nasty and disrespectful nurses, and I certainly do believe there are psychiatrists who practice quick, uncaring psychiatry for the sake of a bigger paycheck, but sometimes I want to consider other possible explanations.


Let me give an example from recent posts.  I put up an article from USA Today on how involuntary commitment is so unpleasant and that if it were more humane, it might not be so awful.  I put it up because I agree with it.  People wrote in to talk about the abuses they've suffered, and that is fine, it's what I expected.  But several people complained about being searched, and how it was offensive and insulting and given their past histories and diagnosis, this was inappropriate.  I understand their pain and humiliation, but what doesn't get mentioned is the perspective of others when things go wrong.  The patients are new to the unit, the staff has no idea who is dangerous and who is not, and psych units can be very unpredictable places.  Some of the policies are made as reactions to bad things that have happened, and often patients have assaulted other patients, or the staff, and suicide attempts (and completions) are not that uncommon.   A patient might be insulted at being searched, but is he also insulted when searching is not done and he's stabbed by another patient who came in with a knife taped to his leg?  Wouldn't that lead to the same "unbelievable" cry?  And to read our blog, one would think that no psychiatric patient might ever care about the safety of the hospital staff or their right to be concerned about it.   It's not that I don't empathize with commenters' suffering, it's that I'd rather there was just a token nod to why it may be necessary.  Why does a four-year-old have to remove and x-ray her flip-flops to get on a plane.  Do we really think she's going to blow it up?  No, but perhaps we think that if they stopped x-raying children's flip-flops, then a terrorist might then use them as a vehicle for a bomb.  Or maybe it's all ridiculous and we should be a little bit more thoughtful about our security procedures.


One commenter was distressed about being strip-searched and made the statement that other hospitals don't all do this.  Not my field of expertise, but it does seem to me that if one can say "I understand why it's done, I want you to understand how damaging it is," and then go on to say that other institutions don't do this and propose other, less damaging means of addressing the same issue (?metal detectors, drug dogs, pat downs, body scanners, whatever) perhaps there is some power to this.  Maybe you get people looking and they say Wow, the institutions that don't strip search patients actually have a lower violence rate (I don't know this, but we do think it's possible that there would be less violence if patients aren't enraged).  But someone is going to read my comments about staff and patients being in danger as meaning that I think it's fine to violently rip people's clothes off them, and for the record, I don't.  


Another commenter asked if I do this to my patients, this 'yes, but' thing.  Sometimes I do.  If a patient is telling me a story about an interaction with another person that sounds unlikely to me, I may ask the patient why he thinks he got the reaction he did.  Would it be honest to sit there and listen to something that doesn't sound right without challenging someone to think about it in new ways, or to propose some other possible explanations?  Let me give an example from a recent Shrink Rap topic.  If a man talks about how his adult son has estranged him and he has no idea why and he presents theories that sound unlikely (my son wants to control me, he's jealous, he always favored his mama,  you name it), and I have a sense of what might be part of the issue from other things he's told me, I might ask, "Do you think the fact that you don't approve of his wife and the way that they are raising their children might be making him uncomfortable?"  Or I might ask if the son may have found it difficult to get his approval when he was younger, or if how the father used to treat him before he stopped drinking might be a part of this.    But it a patient doesn't want to hear this, if they need me to be all in their court, and if they insist I'm wrong (and after all, I wasn't there, so my theories may well be inferior theories), I back off.   The truth is that no matter how troublesome the patient's behavior is or has been, they are my patient, they are the one I am obliged to help, and sometimes I feel around for the best way to do this.  No, I don't always get it right. 

I don't know if this helps, but I suspect it will inflame things.  Commenters may say I'm getting defensive again, and they'd be right.  I read some of the comments and think, "You'd say this in my living room?" Because if you're someone who might behave in this manner, there is no way you'd be invited in to my living room.

Follow Up on Sam and Our Survey

Remember Sam, the student who applied for a competitive internship and didn't know whether to check yes or no for the question about whether he has a psychiatric disorder?  If you forgot the discussion, you can read it here: http://psychiatrist-blog.blogspot.com/2011/11/tell-me-ethical-dilemma.html


I thought I would let you know that Sam checked yes on the box that asked if he had a psychiatric disorder.  I thought I would also let you know that Sam was chosen for the competitive internship.  
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Last week we asked readers who have been certified to psychiatric units if they would want to be involuntarily hospitalized again if they became ill and imminently dangerous again.  63 responses, one person hit submit without answering, and here is the final tally:




Summary See complete responses

If you became psychiatrically ill again and presented an imminent danger to yourself or others, would you want to be involuntarily hospitalized again?
	Yes 20 32% No 42 67%

When Adult Children Shun Their Parents

Over on Shrink Rap News, a post will be going up about my random thoughts about adult children who essentially divorce their parents.  In the families I'm talking about (and I know many), these aren't extreme situations--the children did not suffer from abuse, neglect, or deprivation at the hands of their parents.  When they were children, the parents tried to be attentive, caring, and to provide for them as best as they could (which was sometimes rather well).    The parents likely made mistakes, because parents are not perfect,  but the issues are current ones...and often ones the parents themselves can't articulate.  In these cases, the adult children have severed ties even though the relationship was close, and they themselves might say they had good childhoods.  Why the estrangement?  I suppose it's different in each case, and often there are issues with parental divorce, the relationship with the child's spouse, a sense that the parent is too critical, too judgmental, or perhaps too intrusive and controlling.  The adult children may feel they are being used or manipulated.  I talk about some of my theories, and they may well all be wrong.  None of it science, just what I've gathered from listening.  If you'd like to read my thoughts, I invite you to surf over to CPN's Shrink Rap News.  And, of course, I'd like to hear your story.  You can check over there sometime around noon.

If you're interested, I'll also direct you to a website run by someone dear to me:  MOTHERRR! -- about rebuilding mother-daughter relationships.  While my post talks about estrangement from the vantage point of the parents, this site looks as mother-daughter difficulties from the perspective of the adult child.