Underestimating Psych Patients

Angry white man with tattoos on arm sitting on black leather padded chair

The Unpredictability Of Psychiatric Patients

There are some patients who are very unpredictable, despite knowing them very well and believing that everything will be all right on future encounters. These patients are unpredictable because they are either suffering from psychosis, borderline personality disorder, antisocial personality disorder or under the influence of drugs. A common mistake that many psychiatrists and other healthcare workers make is letting their guard down when around psychiatric patients with whom they previously have interacted with.

Whether you are a friend, family member or healthcare worker, you can never let your guard down around mental health patients. This does not mean that you should be rigid and not flexible or relaxed around them; just don’t lose your guard. This is because mental illness, personality disorders or traits are very unpredictable; they can often cause a person to change at the snap of a finger.

I personally had this happen to me recently with a chronic psychiatric patient suffering from schizophrenia. The nurse had called to inform me that the patient was pacing in the hallway, which is an early sign of agitation for him. As I made my way upstairs to the respective unit, the nurse called again and warned me to be careful as the patient was near the hallway next to the unit door; at first he warned me to stay out of the unit.

About thirty seconds later, he told me that I could come onto the unit. As I slowly unlocked the unit door, the coast was clear for a few seconds, until the patient appeared in the hallway looking straight at me. He started walking towards me in an agitated manner and not making any sense in what he was saying. My immediate inclination was to turn back towards the door and leave the unit as I had no way of making my way to the nurse’s station for more clarification of the situation.

The mistake I made is that I decided to bravely stand in the hallway and attempt to understand the patient as I figured, “What the hell, I’ve talked to him before when he was agitated and he never did anything!” But this time was different. As soon as he arrived next to me, he lunged for the keys that I was still holding in my hands without realizing. I was then struggling to hold onto my keys as he was diving deeper into my palms to snatch them.

At this point I knew that I couldn’t wrestle or fight with the patient because as healthcare workers, we are trained to defend ourselves but not actually engage in fights with patients. It is then that the unit staff came rushing onto the patient and retrieved the keys after a brief manual hold. The keys were returned to me. The point of the story is that I made the mistake of believing that this psychotically agitated patient who I had multiple previous encounters with, likely would not do anything on this encounter as well.

But I was wrong! This is evidence of the unpredictability of psychiatric patients and why you should never underestimate their potential for harm towards others. Always trust your intuition for it is there to guide you when your logical mind gets in the way. Even though logical, your mind does not always place you in the best positions in life and that is where your intuition steps in to protect and guide you. I was lucky that I came out of this situation unharmed!

Have you had any experiences that have gone wrong with psychiatric patients?

Are you Ready? (This is Defeating Stigma Mindfully)

Psychiatric Patients Have Their Reasons

Middle-aged brunette woman yelling with strings attached to face

Psychosis Or Personality?

When it comes to understanding psychiatric patients, many times it can prove to be quite a challenge; their behaviors leave you scratching your head, “is it their psychosis or are they just being oppositional?” Sometimes it’s fairly obvious that a patient is so psychotic that their behavior suffers as a consequence. But then there are times when it’s hard to tell whether their improved psychotic symptoms are still contributing to their behavior, or they are being oppositional.

Patients have many reasons for being oppositional:

  • They don’t like the psychiatrist or the treatment team
  • They don’t believe that they have a mental illness
  • They don’t like taking medications
  • It’s simply their personality
  • They’re angry at the world and are taking it out on the treatment team

. . . and the list goes on. Sometimes you’ll never understand a psychiatric patient’s behavior. And many times, you will never be able to discern between psychosis and personality, because they’re often intermixed. This is when the field of psychiatry becomes challenging and even frustrating for many clinicians.

It’s like a child or significant other who starts changing their behavior in a negative manner; they leave you wondering at what point did something go wrong! And you continue to gently probe and offer your assistance and guidance, only to be shut down with resistance and oppositional behavior.

Becoming frustrated in the field of psychiatry comes with the job, but the frustration must always be concealed from the patient and dealt with privately. Showing a patient that you are frustrated will influence the therapeutic alliance, almost always in a negative, counterproductive and potentially destructive way.

The solution is patience, dedication and professionalism. You will not always understand the behavior of a patient and that’s okay! As long as you continue working with them in a safe, professional, caring and compassionate fashion, then that’s what matters most! Psychiatric patients have a very good eye for being able to tell which clinicians are kind, honest and caring, and which are in it for other reasons.

The stigma that revolves around “he’s crazy” or “she has lost it” is something that we need to eliminate. These kinds of statements only promote division, hatred and more suffering, and these are the last things that patients need; especially patients who are mentally ill! Don’t add to the stigma.

Are you Ready? (This is Defeating Stigma Mindfully)

Hostile Work Environment

Hands holding yellow angry face illustration in front of brick wall

The Hostile Nature Of Some Psychiatric Patients

You will find that there any many psychiatric patients who have a hostile nature. If things don’t go their way, they will take it out on you if you catch them at the wrong time of day. There are many reasons for this: they may be disorganized, psychotic or have a personality disorder such as narcissism or antisocial traits.

These hostile patients are extremely difficult to work with, because they won’t allow you to get close to them on a personal level. On the one hand, you want to help them to overcome their symptoms and get discharged; on the other, you feel threatened and start to lose interest in helping them.

Persistence is key with these patients, but at the right time. If you keep insisting on meeting with them on a consistent basis without spacing out your requests, they will only distance themselves even more from you. They may even start to verbally or physically threaten you.

The threats make no difference, because you can always inject them with an antipsychotic or anxiolytic. But you don’t want to develop a relationship that revolves around hostility and injections; this won’t help the patient in the short or long run. You are there to establish a therapeutic alliance with the patient.

It can be very frustrating to observe hostile patients defeat themselves in their own treatment. But one has to understand that sometimes their mental illness is so bad, that their judgment becomes way too clouded. With a poor judgment and a shaky insight, it also becomes more difficult to establish a therapeutic alliance.

But patients also need to understand that psychiatrists are there to help them; we are not their enemies or punching bags. Without our help, patients are only cornering themselves into a deeper hole. Deeper holes never turn out with positive results. Therefore, patients need to take it easier on their psychiatrists and allow themselves to be helped.

But it’s also important to keep in mind that not all psychiatric patients can take it easier on their psychiatrists. Many are too psychotic to make such a decision, even if their personalities do not align with their oppositional behaviors. It’s important for a psychiatrist not to forget how a mental illness can influence a patient’s reaction towards them.

Both parties bring important contributions to the table: the patient provides their insight into how they view the world and their illness; the psychiatrist provides his knowledge and understanding on how to better help the patient. It’s a win-win situation when both parties cooperate and form a strong therapeutic alliance!

Are you Ready? (This is Defeating Stigma Mindfully)

Stuck Within A Psychiatric Institution

Psychiatric patient standing on gray mesh surface

Imprisoned By Your Mind

To be institutionalized means that a patient has been in a psychiatric institution for such a long period of time that they have become used to it. They no longer have any interest in leaving the hospital because they have become too comfortable; their family has become the staff working on the unit.

Even if a psychiatric patient is qualified for discharge, they still may not want to leave; it just doesn’t matter anymore. Too much time has passed; they have lost the sense of what it feels like to live in society. The thought of leaving their comfort zone sounds terrifying; they prefer to remain locked up.

Imagine the government banging on your door and saying, “we are knocking down this house, you need to pack your bags and go. You have one week!” This is how some psychiatric patients feel when discharge becomes an option. Even though they may be asymptomatic and functional, they view the idea of discharge as “packing up my bags and starting from scratch.”

Most if not all psychiatric patients enter an institution with displeasure and discomfort. Their daily goal is to get one step closer to discharge; every day brings new hope. But there is a threshold upon which a patient has either lost hope or has become too comfortable with their new environment; this is the point of no return.

Once a patient crosses this invisible line, it becomes very difficult to get them to accept the idea of discharge. Some patients will actually regress and become symptomatic again in order to avoid being released. Some even start to improve and then will say things such as, “I don’t want this treatment anymore because I want to remain psychotic.”

Some patients have been mentally ill for so long, that if they start seeing their symptoms go away, they become uncomfortable. Their mind has become so used to their illness that they view sanity as a threat; an unfamiliar territory. So they start to become noncompliant with medications, forcing psychiatrists to obtain court orders.

The reality is that for many chronic psychiatric patients, they want to remain psychotic and institutionalized. This is their reality; their way of viewing the world. They have established their routines and their way of living. And if you step inside their world and start making plans for them, they start to see you as an intruder who is interfering with their life.

The dim reality as viewed by one person is paradise as viewed by another.

Are you Ready? (This is Defeating Stigma Mindfully)

Talking With Psychiatric Patients

Female psychiatric patient holding mirror

Words By The Mentally Ill

Psychiatric patients are very unique individuals from many different walks of life. There is no such thing as a typical patient. Patients cannot be standardized and identified based on appearance or behavior. Even if it were so, the unpredictability of psychiatric patients would make them outliers in as little as a few hours.

A psychiatric patient is not always someone who “was crazy ever since I can remember.” Many patients previously held impressive jobs and were functioning members of society. They were able to attend work, pay the bills, raise a family and even treat patients themselves!

Each patient has a unique story somewhere within them; you just have to access it beneath the many layers of psychopathology. What makes it difficult in talking with psychiatric patients is their unpredictability in behavior and speech. Sometimes they shower you down with words, while other times, you feel like you are talking to a brick wall.

Just because it might be difficult to talk to them, does not mean that you should get discouraged and lose hope. Many family members also struggle to talk with patients who are their relatives. Imagine how difficult it is for a mother to see her son institutionalized and refusing to eat or drink water?

Family members suffer the most; wouldn’t you if that were your son, daughter, father or mother? But we cannot give up on them. We are all in this together in helping psychiatric patients reach a functional level that is appropriate for living a safe and healthy life in society.

Always keep in mind that psychiatric patients may be difficult to talk to; expect it. And don’t get angry with them. It’s so easy to become frustrated after they consistently pull your hair out, but remind yourself that they are mentally ill human beings who are not in their right state of mind!

Don’t make their life harder than it has to be. Treat them with respect and care.

Are you Ready? (This is Defeating Stigma Mindfully)

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