IamA psych nurse working in both an acute unit as well as a maximum security unit AMA!

Fellow psych RN here. What do you do to keep from becoming jaded toward Axis II (borderline, repeaters, etc) patients with parasuicidal behaviors who are unwilling to help themselves?

Sometimes I think that not becoming jaded is one of the biggest challenges a psych nurse faces. The best thing you can do is to educate yourself on why they illicit the behaviours they do. Most patients with borderline personality disorder have been severely abused from a young age, and self-harm is one of the ways in which they cope with their inner pain. The more understanding you have, the easier it is to look past the challenging behaviours. If you can change the thought of them being unwilling to help themself, and rather see it as them being unable to help themself(yet!), it's much easier to deal with the frustration.

I strongly recommend Linehan, M. M. (1995). Understanding Borderline Personality Disorder:The Dialectic Approach and Batemans Handbook of Mentalizing in Mental Health Practice.

What is the absolute worst you have seen?

A patient opened her abdomen with a small scissor, nicked her intestines and were found with half her guts in her hands on the floor. You could smell the shit in the corridor outside. I've had nightmares about that one.

A less gory one is having to force feed an anorexic patient with a history of abuse. Seeing the terror in her face as she was held down by the staff and hearing her scream while we forced an NG tube down her nose is something which I'll remember till I die. She was down to 30 kg and would've died if she didn't get any food, otherwise I would've never done it. We tried to motivate her for a week to eat, but it was clear that she wasn't able to do it. When she got better, she thanked us for it, however the experience was horrifying.

Did the first person survive? That sounds horrifying. Have you had to witness much suicide? I'm glad to hear the anorexic girl eventually got better. Do you know how she's doing now?

She survived. Although I'm not certain for how much longer. She's had a lot of serious suicide attempts, and it might just be a matter of time before she succeeds.

I'm not sure how the patient with anorexia is doing. She was discharged some time ago and haven't been back, which is usually a good sign though!

-What made you decide to go into your line of work?

-What are the big misconceptions about what you do, or what psychiatric hospitals are like, or are the movies/TV fairly accurate?

-Have you ever needed to use that alarm and why?

• I have two friends who are schizophrenic, and seeing their struggles made me want to become a psychiatric nurse. I got a job in a housing complex for psychiatric patients and found out that I've got a knack for talking to people, so I decided to go for my nursing degree, which I havent regretted for a moment.
• The biggest misconception is that we are prison guards, who just drug patients to keep them quiet. It's also a much less dangerous job then many people think. Most of our patients are only a danger to themselves. Movies like to play up the dramatic side, which is understandable. Most of the day consists of me talking to people and drinking coffee, which would make a boring movie.
• I've used the alarm lots of times. Sometimes when I've gotten attacked. The last time I used it, it was because I discovered a patient trying to hang themselves in the bathroom and I needed someone to get a scissor to cut them down. Luckily we got there in time and he survived.

I really don't have a question, but as someone who's suffered with depression and knowing a couple of people who have Schizophrenia I think what you're doing is really cool.

You seem to care a lot about your patients and your job, so thank you.

Happy holidays :) Don't forget to be awesome.

Happy holidays! Thank you for the kind words.

My son is an ER nurse and he tells me some sad and strange stories.

Mental illness just seems to leave people on the street hurting themselves and sometimes others.

My question is - from your perspective what can be done in a practical way to better handle the issue of mental illness leading to a revolving door in and out of hospitals?

1. Education. Everyone should have some knowledge about what it means to have a mental illness, and where they can find help.
2. Money. There just isn't mental health resources out there. Those who get treatment are often severely ill, to the point where they are visible in society. That's when they end up in the ER. Most people suffer to themself. If there were enough resources we could help people before they get to the point of needing hospitalization.
3. We need to think about the importance of self-worth. It just isn't enough to get people on drugs and talk therapy, if they just stay at home and watch TV in the meantime. The importance of having a job to go to cannot be underestimated, but many are reluctant to hire people who have a mental illness. Which is a damn shame since most of the patients I meet can work, with just a small amount of assistance.

What's the most awww work-related moment you've had so far?

What do you consider the biggest success of your profession?

A patient knitted a pink hat with a lot of frills on it for one of the older male nurses as a thank you when she was discharged from the unit. He wore it with pride the whole day.

Wow, that's a good question. I think the nursing profession has been very good at standing up for patients rights throughout history, which is something to be proud of.

How much negligence have you witnessed in this field of work? Is it as rampant as it has been perceived in the past?

A lot has happened since the old days of psychiatry, when there were no real treatments and patients were mostly locked up because society didn't want them. The most negligence I've seen is maybe spending a bit too much time in the breakroom instead of with patients.

Also while it probably can't be called negligence, I dislike some of the attitudes I see towards patients with personality disorders and self harm/suicidal acts, as some view them as a nuisance and attention seekers, which I do not agree with.

I have worked in a state hospital as a Social Worker. Have found that patients are too often told they have a brain disease. Generally its a series of life events that led to their hospitalization. Most of the staff in these establishments believe that a patient's success in the community upon discharge is primarily based on whether the patient is compliant with their medication. There is a large body of evidence that suggests viewing mental distress as a brain disease increases social stigma. Any thoughts?

Why not both? Most of the time its a combination between difficult events and a vulnerability in the brain. I agree that the focus too often lays on the medication aspect, but the reason for this is that it's very important. I think if we can get to the point were people don't treat mental illness differently from a physical illness, we've eliminated the stigma. The problem right now is that we treat a disease in the brain, differently from a disease in the lungs based on fear and lack of knowledge.

Have you heard that 3rd world countries have much better patient outcomes and use a lot less medications, usually only using drugs for acute episodes? Any thoughts why affluent countries would be unwilling to try the activities of daily living and support that have proven so beneficial for patients in less affluent countries, rather than insisting on escalating drug cocktails for life?

Haven't seen any studies indicating that 3rd world countries have better outcomes, so if you could link some I would much appreiciate it!

I think we often turn to medication because it's very easy to give someone a pill, instead of supporting them in their daily life. Costs a lot more resources, and takes more time. I think it's also due to the medicalization of psychiatry, where we put a bit too much trust into theories around neurotransmitters and think too little about the conditions people are living in.

Are suicidal tendencies always associated with depression? Have you, or anyone you know of, ever encountered someone whose life was so bad they coolly chose to end it even without being depressed?

Not always. Many patients with borderline personality disorder struggle with constant suicidal thoughts. Statistics say that around 90 % of those who kill themself was diagnosed with a mental illness at the time of their death. Can't say I've dealt with any suicides in "healthy" people.

Does it ever feel overwhelming? Have you ever had a day where you were close to quitting? What happened?

A patient which I worked very closely with almost managed to take his life. He ran off while on a walk with another staff member, took a massive overdose of paracetamol and hid for long enough that administring antidote(mucomyst) wasn't very effective. He spent a week in the ICU. I honestly thought that if he died, I probably wouldn't last very long because of how deeply it affected me. Luckily he made it, but it showed me the importance of learning ways to cope, because losing patients is a real risk. I still struggle whenever something similar happens, but not to the same degree.

As someone who suffers mild schiphrenia(I failed to spell that right.), severe OCD, suicidal thoughts and anorexia, I just want to thank you. Although I've never gotten help and still go unmedicated at 15(If I make it to 18, I plan to get help...my parents are. Eh. Haha.), I think it's an amazing thing you do. I don't think I could have seen the things you did and still be sane! That was probably way more details then you needed, but oh well! Haha.

I go through all the drama associated of people with mental illnesses, think we aren't 'capable' and stuff like that, and knowing that at least SOMEBODY believes in us is a wonderful thing.

My parents, unfortunately, are one of those who stereotype mental illnesses. They say people who commit suicide, cut, and starve are idiots. And that because the zoo I volunteer at knows I'm not mentally sane, nor physically well, that they should NOT keep me on the program. It's hard dealing with it from my PARENTS of all people.

But seriously, thanks. For believing in people most people don't. :) You're doing a great thing! Sorry for my rambling haha.

I'm very sorry to hear about the lack of support you have from your parents. Maybe you can see if there are anyone you can talk to at school, like a guidance counselor? You shouldn't have to face this alone. Take care of yourself!

How long did you have to go to school to get where you are now?

3 years to get a bachelor in nursing, then 2 years to get my master in mental health. You can work in my position with just a nursing degree though.

What state do you work in? Did you volunteer somewhere during college to get a better chance at getting hired? Or was it easy to just get a job right out from graduation? I ask this because I'm trying to be a nurse, possibly hospice, and I live in CA where it's basically impossible for graduating students from CA to get a job in CA without any experience first.

I work in a country in Europe. I worked as an assistant at the institution during nursing school, and was offered a job afterwards. I'm also male which is highly sought after in psychiatry.

What is the craziest thing that you've ever seen? and what is the craziest story that you ever heard from being there?

I see a lot of crazy, most of it from the staff and some of it from patients. Something recent is when an older woman with schizophrenia went off her clozapine(very potent anti-psychotic) cold turkey, which gave her a massive rebound psychosis. She was having conversations with over 10 voices at the time who were trying to hurt her. She would wince as though being physically hit by the voices, and she was so paranoid she'd chase everyone out of her room. She believed she was in a concentration camp, and was terrified. Ended up having to inject her with IM olanzapine against her will, which finally gave her som peace.

1. How can I help someone who needs help psychiatrically and refuses to get it?

2. What should I do to get into this type of field? I'm thinking about being a psychiatrist.

3. Not a question, but thank you for doing what you do!

1. You can't. You can only encourage them to seek help, and support them in their decision. Unless they are severely delusional, suicidal or a danger to others, in which you can contact emergency services and have them committed. But this is a drastic step, which might destroy any relationship which you have with this person, even though it might be needed.
2. To become a psychiatrist you'll need to finish med school and complete a residency in psychiatry. Try /r/medicine or /r/psychiatry for tips. If you want to see what it's like, see if you can get a job as an assistant at a psychiatric hospital.
3. You are very welcome.

I don't know if you're familiar with this TED talk, by Jon Ronson, but it basically is about a man who fakes psychosis in order to avoid going to prison, only to be kept in a psychiatric ward for many years before being discharged.

What is the likelihood of a sane person being mistaken as a psychotic today, and what would it take for him/her to convince the doctors and nurses that he/she is indeed mentally-sound? Or has the diagnostic criteria been improved upon, so that instances like this won't happen again?

It's actually quite often where we have to try to find out if someone is psychotic. Usually it's young people who are admitted for the first time against their will. After a while you get a knack for teasing out psychotic symptoms like delusions or thought control. There are also other characteristics that are pretty hard to fake. I've seen people fake hearing voices to get admitted, often to get drugs, and honestly it's quite easy to spot. You get this gut feeling after a while, where you just know if someone is actually psychotic, or suicidal for that matters.

I don't think you'd be able to fool us, but I can't be sure, we might have some actors in the unit.

What's a typical day helping patients like? A good day? A bad day?

Worst case you saw in a patient?

A good day is a day which I'm able to build a good relationship with a patient and get them to trust me. Where we are able to joke around and interact in a good way, regardless of whatever issues the patient has. As I usually say, just because you are suicidal doesn't mean you can't have fun.

A bad day is any day where I have to use force, be it to get a patient to take medication or restraining them. It feels like we've failed whenever we have to resort to those means. Although sometimes, it just isn't possible to break through a patients psychosis or delusions without forcing them to take medications. Still sucks.

Some of the worst cases I've seen is in the security unit where you have patients on the highest doses of the heaviest antipsychotics and they are still psychotic and delusional to the point where they are a danger to themself or others. They shuffle around corridors in a daze, terrorized by things we cannot see. It's heartbreaking. Schizophrenia is a shitty disease.

Is there a movie/series that represents mental illness and psych care accurately?

Alternatively, what movie/series has the most bullshit pseudoscience in terms of psychology? I'm talking '2012' levels of bullshit i.e. "the neutrons have mutated", or something similar.

I've got to say I've stopped hoping that my profession will ever be portrayed accurately. However I really enjoy movies with a mental health theme, and I'd recommend Black Swan, Girl Interrupted, Shutter Island. Actually, come to think about it the first season of Homeland is quite accurate when it comes to showing bipolar disorder, especially Carries manic breakdown.

What are some of the most obscure cases that you have ever had to work with, witnessed, and/or seen? Also, how profoundly were the other patients affected to some of the other incidents you elaborated on? Were they affected greatly by it, so much as to hinder their path towards a healthy mental state?

Thank you for establishing this AMA.

Edit: Missing Word

I've worked with someone who was diagnosed with dissociative identity disorder, which was previously known as multiple personalities. I can understand why people are skeptic towards the diagnosis because it feels very unreal to talk to someone who mid sentence turns into someone else. It was very interesting.

When we've had a serious episode on the unit which other patients have witnessed we always have a debriefing with both staff and patients. Most patients are actually very understanding, and a great support for eachother. I cannot guarantee that someone hasn't been affected negatively though. Luckily, when you are very sick you are often mostly concerned about yourself and in your own head so often the other patients don't even notice when there is something going on.

Have you ever been in a potentially life threating situation with one of the patients? Hope this isnt an inappropriate question. Happy holidays to you all! :)

Actually I don't think so. I've been in situations where I've gotten hurt, but never more than a bruise or a bite mark. Our alarms means that help is only a few seconds away, so if I'm in a threatening situation I don't hesitate to press it. We also search all our patients for dangerous objects when they are admitted, to make sure they don't bring knives or other weapons into the unit.

What is your best "success story" regarding a patient?

I got a patient with complex PTSD, history of self-harm, anorexia and borderline personality disorder to tell me that she was having a tough time. She'd been tortured by her parents her whole childhood and taught that any sign of weakness would lead to her being beaten. It took me a month to get her to trust me enough that she could talk to me, instead of resorting to her usually coping mechanisms of cutting or dissociating. It might seem a bit silly to count a conversation as the biggest success story ever, but I've honestly never felt more successful as a psych nurse.

As a counselor who spent 9 months working on a acute psych ward: that is amazing! What an awesome moment.

It is so exciting to hear from an individual in psych nursing who is actively working against becoming jaded - such a challenge. Unfortunately, that was not the norm where I was, and it was super sad,especially for those really trying to make a positive difference.

It's hard not to become jaded or cold, when you face so much suffering and trauma day in and day out. It's a shame that it's such an effective coping mechanism, because I think it distances you from the patients which makes it harder to connect. But I find that the more I learn and the more I understand, the easier it is to stay empathic.

Are psychiatric hospitals different? There are a lot of stories around internet about mistreatment, abuse and abandon of parients from psychiatric hospitals. Do you personally know about such hospitals where patients are treated in unhuman ways, and are disposed on the street like animals for example? Do you know hospitals that on the contrary do care a lot about their patients, even if they are unable to complain?

I think there will always be cases of abuse in places where people have power over other people, but I think we've come a long way since the early days of psychiatry. I can only speak for my hospital, but I've never witnessed any form of abuse, and I think most of the people who work there go above and beyond in helping patients.

But we only have to go back 40 years and people were still being lobotomized, and it was viewed as a legitimate treatment. I think it's very important to be aware of what a vulnerable position the patients are in, as we've seen before, when you are "crazy" your complaints can easily be dismissed. Therefore it's very important to have strong rules governing what can be done, and independent comissions who look into any hospitals practices.

How do you reestablish care and a therapeutic relationship after being attacked by a client?

I work in a non-secure residential psychiatric facility and about two weeks ago I had an incident where I was attacked by client for the first time. Thankfully I was not seriously injured but it was still very frightening. Since the incident I'm finding that I am unconsciously on edge around him and he can obviously pick up on this.

Since he will be living at the facility for the foreseeable future what is the quickest way I can put this incident behind me?

Talk to him. Tell him how you feel. You might discover that he feels bad about what happened as well.

Hi! Thank you for this AMA. I salute you for handling this difficult job and educating people like myself who know nothing about it.

Was there a moment that you were thinking this job is the worst mistake of your life and you just wanted to walk out and never return? (Obviously, a moment that didn't last, but still). If not, what do you think could bring you to your breaking point?

Honestly, never. I love what I do. But losing patients is hard, and I'm sure there is a limit to how many I can lose before I can't handle it anymore.

It's amazing that you truly love what you do! Most people wish they could feel like that even one day of the week...

If you don't mind me asking, how do most patients pass? In a psych ward, the most logical explanations would be suicide, eating disorder-related complications or OD. Are there any other common ways for psych patients to sadly lose their battle?

Other than the things you mention, some patients who've been on antipsychotics for a long time(especially the older drugs) get metabolic syndrome and heart complications. But suicide is the most common.

What one change (however major/minor) would you make to the way people with mental health problems are supported/treated do you think would have the most benefit?

Just remove the stigma, and we'd solve so much. People wouldn't be afraid to talk about their struggles, they wouldn't run from those trying to help and the shame which drives so many of these conditions would vanish.

What is your approach to individuals with borderline personality disorder and psycopaths (antisocial personality disorder)?

Treat others the way you wish to be treated, and most of the time you'll do alright. I try to see past the diagnosis(which in the case of antisocial personality disorder and borderline personality disorder carries a lot of stigma) and treat them like regular people. I use mentalization based techniques, and I'm very transparent when it comes to my thought processes.

I work in the mental health field as well. We have many folks who aren't court ordered who are non-compliant, and go through a sort of revolving door of psyche hospitalizations, because they are so resistant to treatment. What are your views on court enforced medication?

Sometimes it's necessary. It sucks, but some people just don't have enough insight into their own condition that they can take care of themself. We should strive to minimize the amount of court enforced medication, but it would be foolish to think that it can disappear completely.

How often do you use four point restraints?

Rarely, but it depends on the patient population. Sometimes we get patients who are very psychotic and aggressive, where we'll have to put them in restraints many times a week, while other times it can go months before we use them.

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It's strictly illegal for staff to have any sort of relationship with patientsoutside of the hospital.

As someone who has spent time under a 5150, I'd sincerely like to thank you. The nurses had such a big impact on me, I wouldn't have gotten out as soon as I did without them. You sound like a really great nurse, I appreciate it

You are very welcome! I hope you are feeling better.

do you have any experience with clinical licenced social workers? anything to share about your opinion of that profession? also what do you think about hispanic populations? ever worked with them? thanks for doing this AMA!

They are heroes. Doesn't matter how much you improve a persons mental state while they are inpatient, if their living conditions outside will just send them back. Social workers help find people places to live and work, which is just as important as anything else we do.

I'm so glad to see that new healthcare legislation will bring parity to mental healthcare.What are your thoughts on this? have you seen any effects clinically or administratively yet?

I work in a country with socialized healthcare, but I'm very happy that the US is finally coming to it's senses.

How many of your patients have kids, or a partner? I can't imagine being forced to call emergency services to have someone commited. It must be painful.

Many. In fact most. And just about everyone has family. We offer family talks to anyone who is close to the patient, as we know it can be incredibly difficult.

:(.. Thanks. You mentioned coping mechanisms earlier, which have you learned so far?

Talking to co-workers, working out, getting a therapist of my own(I really recommend this).

What are the worst self-inflicted injuries you have had to deal with?

I've seen cuts to the bone on both arms and legs. A patient who swallowed lots of razorblades. A patient who injected ammonium chloride. People get creative.

Have you ever seen somebody committed who clearly should not have been?

Sometimes patients with borderline personality disorder get involuntarily committed after parasuicidal acts or self-harm, which really only makes things worse. They get more triggered, and it often leads to even worse self-harm.

Do most of the patients socialize with each other and if so in what ways?

Yeah, most of them do. Playing cards, pool, talking or just watching TV together. Sometimes we have group therapy sessions as well. Patients are encouraged to interact, however they are also told that they can't discuss eachothers treatment or illness just because they often have enough to deal with themselves.

Which patients do you find to deal with the hardest in regards to your own mental health?

Manic patients without a doubt. They ask for a hundred different things, talk at the speed of light about nonsensical thing, and all you can do is tell them no, while trying to help them get better. Makes for a lot of agitation both amongst the patient and the staff.

Are you happy with your life?

I spend a lot of days in a psych hospital, what do you think? ;)

What type of training did you go through? I am currently in nursing school and trying to decide where to work. Being a psych nurse seems like it would be an interesting and fun job.. but I was also thinking about doing life flight!

Clinical practice for 2 months during nursing school, then a new grad program for the first 2 months at the unit.