The first year in any healthcare setting, no matter whether you’re a newly minted MD, an RN or a shrink, is like entering something out of Alice in Wonderland because you have no idea who the important players are, where the dangers lie, and what your actual duties may be. The best advice I can give to anyone planning to spend some time on a psychiatric ward or in a psychiatric hospital or even a GM&S (general medical and surgical) hospital, is to find a trusted mentor or someone with many years of experience and sit at their knee. Their experience may provide you with an invaluable history of the unit or the hospital and this can be very helpful to you. How it will be helpful is up to you and your creativity.
Some personnel, unfortunately, may have many years of experience but they have developed an eye for psychopathology rather than for potential strength. There may, also, be considerations of keeping beds full to maintain the financial footing of the institution or just plain keeping things the way they’ve always been and looking to newcomers as potential problems.
Some newcomers will be greeted enthusiastically, others will be viewed with a jaundiced eye, as staff wonders what havoc you might wreak in your assigned area. But even these skeptical few may, unexpectedly, turn to you at one point in the future for some help or guidance. It happens and when it does the relationship changes. I had it happen and it occurred quite suddenly when I thought I was going to receive a dressing down by a head nurse.
You are an interloper and you will be tested many times, sometimes in situations, in hindsight, which placed you in real physical danger. How you extract yourself from these situations will depend greatly on your ability to see the potential as well as the safe routes out of it. I did manage to see that safe route out on several occasions. In one situation, I had been sent to do psychological testing on an isolated floor in a hospital with a patient who was actively psychotic. Despite his illness, he managed to make the right decision.
His actions helped me make the decision to take him out of that locked room where we both were and back into the safety of the Dayroom downstairs. The head nurse knew I would be going to a secluded floor, through a locked stairway and locked doors. Up there, no one would hear me if I needed help and still she watched, speechlessly, as I left the safety of the downstairs ward.
As I prepared to administer the testing to him and he began looking at the Rorschach cards I presented, each card was perceived as a squashed bug with blood around it, even though the card was printed only in black and white. Calmly, he said, “I think you’d better take me downstairs before I do something.”
Immediately upon hearing that suggestion, my internal safeguards began to work overtime and I slowly got up from my seat and told him, “Okay, let’s go downstairs now.” Before we could reach the safety of the Dayroom, however, remember that we had to pass through those locked doors and a locked staircase where only the two of us would be. It was, to put it mildly, an experience I will never forget.
How had I, a green member of the staff, been permitted to take a potentially murderous and psychotic patient off the unit to a secluded area — and all alone? You see, it’s sometimes payback time for little things you did and never realized they were going to bring on serious consequences. I had committed one of these imaginary hospital felonies by accepting a lunch tray from a staff member.
Staff was all eating from lunch trays (actually meant for only patients) in the nursing station and I was invited to take one, which I did. I thought it was a kind gesture, but just then the head nurse came in, glared at me and called me into a medication room. Once there, she laced into me about “stealing” patient food and how she could report me for it and I would be in serious trouble. I tried to explain, but I was cut short. I had been warned and it must never happen again. Shortly after this dressing down, I was to be shown the upstairs area where I would do the testing on this patient. Get the picture?
But this patient would be leaving once his psychosis had been managed and he was stabilized. It was another patient, who had been there for over 10 years, who would prove to be the most memorable one who helped me learn to be a psychologist with a new appreciation of institutional helplessness.
During his time in the hospital this particular patient had received little in the way of evaluation or psychological treatment. In fact, he was viewed as a patient who would never leave and would never benefit from any programs because he was mentally retarded, a frighteningly large man who towered over the tallest staff members. Besides such a formidable body, he had a psychiatric illness. The fact that he was huge could have played a role in this lack of attention to his mental health needs. Curiously and unbelievably, this giant with his massive muscles was shy. Standing over 6’7” in stocking feet, he was an impressive figure on any ward of a hospital.
How had he come to this place and where had he been? Curiously enough, I had been to a facility where he spent his first years through his teens. It was one of the sorriest hospital settings I could have imagined. It didn’t even seem like a hospital. Where else would a nurse bathe a patient’s inflamed foot in a vegetable crisper from a hospital refrigerator that held medications?
Buildings that were out of the late 19th Century, indoor hall lighting with 25 watt bulbs and almost absent staff. The patients swarmed around you as you tried to walk through the open Day Room. Walking, you found there was no room around you as the group reflected your every step. It could have been unnerving if it wasn’t so incredibly sad. They needed human touch, caring and they were hungry for any little bit of it they could get. I’d be leaving, but they wouldn’t and that made it even sadder for me. They were prisoners and they had committed no crimes and their “sentences” were indeterminate.
A small play area contained the remnants of rusty swing sets and broken seesaws in a grimy field of dusty earth. No grass, no trees, not even a regular road led into this forlorn place. The one-lane road ran along the edge of a pond that was more like a flood retaining pond than anything else. Nothing poked through the sleek, black surface and it was a perfect setting for a horror movie.
The hospital is closed now and I could never understand how it was permitted to remain open anyway. Maybe it was local political pressure because of the jobs it provided or, perhaps, there were even parents who did visit their children here and wanted them close to avoid a lengthy trip to one of the other state facilities.
But this was a place where children were taken decades ago; some as young as four years of age. They would be deposited by parents who were told it would be “better if you left them here” rather than trying to manage them at home. For most of the children, once the parents were gone, there would be no further contact, no greeting cards, no presents, and no visits. They were alone and, probably for that reason, many of them called the nurses on the wards “mom.”
This was the fellow I was to see now and he was someone who was staying at this place forever as he had remained at the other hospital since his fourth birthday. He never spoke up for himself and he would never, ever be leaving.
Social workers had never even been given paperwork on him for any type of BV (brief visit) to a group home or boarding facility. He went to school on grounds but seemed to just while away the time doodling in a coloring book. The teachers marked him present and moved him on to the next level. It was all so mechanical.
I felt as though I was somehow transported into an act in “Sling Blade” although this guy hadn’t killed anyone as far as I knew. But I wasn’t so sure he wouldn’t if provoked sufficiently. I would be incredibly wrong, but that would be later for me in my new-found education. Several things about him were to shock and amaze me.
No one showed interested in his case until he began to wreck the ward where his bedroom was and the panicking nurse frantically called my beeper begging me to come over to calm him down. I’d never seen him before, I didn’t know who he was and I’d never even heard of this patient. All I knew was “he” (no name given) was out-of-control and was destroying his room and much of the common area outside of it. I was walking in blind knowing absolutely nothing about this guy and I was supposed to be the “rescue squad” for this emergency. This is part of the inherent stupidity that post-grad education can instill in you when you’re green and think everything can be talked over. It can’t and staff can place you in danger.
I wondered if I were showing a bit too much bravado when I went alone. Of course, I had to go alone because we had no safety personnel in that hospital and no one to accompany me. I didn’t even think of the security guards who patrolled the grounds but stayed off the wards.
Again, looking back, it may have been an extremely foolish move on my part and not a very good choice on the nurse’s part. She could have called the hospital police for assistance, but she didn’t. I think she may have been concerned that she had made a few bad moves herself leaving him on the unit with her alone when his outburst began. The rooms were on a second floor level, again, separated by long corridors with locked doors at either end and no chance of anyone hearing calls for help, should that be necessary. Calmness, you quickly learn, is one of your best defenses.
As I approached the nurses’ station after unlocking the heavy door to the unit, I asked where the patient was and I was told, by an obviously frightened and timid nurse, that he was, “Out there.” Looking into the large dayroom, there were wrecked bookshelves, overturned chairs, a planter on the floor, a broken fish tank but no patient in sight. I still didn’t know what he looked like or even his name. Where was he? I looked to the nurse for guidance and she nodded her head in the direction of a bedroom. You usually would never go alone into a patient’s bedroom. It can be a trap.
Walking over to the bedroom, cautiously, I came upon a very large male dressed in clothing which was obviously too small for him and he wasn’t wear any shoes. He was, to put it mildly, quite frightening. He stared at me. No words were uttered as I looked around his room and saw books and bed clothing strewn about.
“What happened?” He stared. I asked again, this time rephrasing the question. “What about telling me what just happened?” In a low, mumbling, hardly audible voice in words that came out haltingly, he told me that he was hungry and they would not give him money to buy any candy. I had to look up at him and now I was in a scene from “Cuckoo’s Nest.” Was that a shiver I saw? Maybe he was just so filled with rage that I was about to be flung into the outside area. What was going to happen? Time wasn’t compressed; it was drawn out and five minutes felt like an hour as I waited. Everything was in some kind of slow motion and I was caught in it.
Since everyone on the ward was down in the dining room eating lunch where he had been just a half hour before, I was confused. If he had just come back from the dining room, why was he hungry and what was the reason that he wanted money for candy? It didn’t make any sense and no one offered to clear it up, certainly not the frightened nurse hiding in the nursing station. Why hadn’t she come into the room with me, I wondered? She knew this guy and I didn’t.
Calm, I told myself, calm and just be as gentle as you can be. “Okay, you’re hungry and what else happened?” He began to tell me that staff had thrown away a videotape that he enjoyed watching. The tape was “Frankenstein” with Boris Karloff. One can only wonder how this tape had such special meaning for him because, if you read the original story by Mary Shelley, you begin to appreciate the viewpoint of the monster. Read it and see what you think. It’s really not a horror story in the usual sense.
Did this patient view himself as a monster? If he did, he had more cognitive abilities than they were attributing to him. He also had a greater degree of sensitivity that was not being recognized. Was he responding to staff cruelty? Yes, some of them can be very cruel and Nurse Ratched could be a role model for them. I’ve seen them laughing at autistic patients who were licking ashtrays.
I now knew that I had to talk to the nurse on the unit and I told him we would have to see how we could solve this problem for him. I asked him to wait in his room and he did.
The nurse related a story of how, for several years now, this patient had gone to the dining room with the rest of the residents, stood in line with his tray to get his meal and then proceeded to go directly to the large garbage cans and dump the entire contents of his tray into it.
He would then ask to be returned to the unit. The nurse in charge, not wanting any confrontation with him, would give him a few dollars to go to the small store on grounds where he would buy candy and perhaps a hamburger. All of this would be eaten alone on grounds, seated behind a building. This day, however, one thing had changed and that was that the staff had thrown his video away. I’ve always said “good from bad” and here it was without them knowing it. It was a move that would eventually save him from this living hell of a hospital.
Now I had to determine three things; why he was dumping his trays and how to solve that problem and why the staff had thrown the video away. The second was easier to find out than the first and the third was relatively easy to uncover. The first problem, however, would require several months of behavioral treatment to resolve. The solution would involve me and a social work intern who was working with me. The result would be spectacular.
Why had the staff thrown the video away? Without doing adequate investigation, they came to the conclusion that he had been urinating in his clothing closet and therefore they decided to dump the contents into the garbage. The contents, of course, being not only his clothing, but his precious video and comic books and everything in there. Nothing was to be saved.
After a bit more tentative investigation on my part, we discovered that the culprit was his roommate, not this patient, who was urinating in the closet. He had chosen not to urinate on his own clothing but those of this patient.
Let me ask you a question. If staff was sleeping in the nursing station at night and they locked the bathrooms on the unit and you had to urinate and they wouldn’t open the bathroom up, what would you do? Many staff members had two full-time jobs, so they slept at one and this was it.
The reason for the locked bathrooms? Patients could easily hang themselves while the staff slept, so the easiest thing to do was lock everyone out of the lavatories.
In order to have a better idea of just what was happening in the dining room, I accompanied the entire unit down to the dining room to observe for myself what was happening. Like in any high school lunchroom, there were the small groups with the rough, prison-smarts leader, the ones who were keeping themselves on the edges and those who just put their noses into their plates. It didn’t take long for me to notice that this patient stood timidly in line with his head down and his eyes darting to either side.
He went up to receive his food and then wheeled on one heel and marched directly to the garbage cans and asked a staff member to take him back to the unit. It took all of 10 minutes or so for this entire action to take place. I now knew what was wrong. He had a terrible case of social anxiety and it had never been recognized or treated. His treatment plan included only psychotropic medications to keep him calm and there had been no other form of therapy. They’d not given up on him; they never started on any real treatment plan. He was a loser from day one at this place.
I had to have a plan to help him and I decided to enlist the aid of the dining room staff (who were very friendly toward him) and the ward nurse. She was now willing to be an accomplice in anything that would keep him calm. I asked the dining room supervisor to call the unit 15 minutes before the residents were to go to lunch. This would give me 15 minutes with this patient in the dining room with no one else there. The supervisor agreed and the calls began to come on a regular basis for lunch, the only meal for which I was on the hospital grounds.
The first day, beginning to get my sea legs for this endeavor, I took him, alone, down the corridors and staircases to the dining room where three kitchen staff stood behind the steam tables. He took a tray, we went up to the server, she filled his plate, and I proceeded to lead him to a table where he would be facing out a window with his back to the dining room door. It was through this door that the other residents would file in to pick up their meals. As he sat down, I was preparing how we could have a distracting interaction that would help him to feel more comfortable while eating in the company of someone else. What could I talk about? How would he answer? Would he get angry? What was going to happen? All of this ran through my mind as I maintained a composed appearance or so I thought. Who knows how I looked? Why didn’t they ever talk about this stuff in my doctoral classes? They actually left a lot of practical stuff out.
I didn’t have to wait long before he asked me, “Am I just like you?” As he asked, he ran his index finger down his arm pointing to the thick hair on it and then pointing to my extremely smooth skin. “Yes, you are,” I assured him and then we began to talk about sports. He asked me several other questions that indicated he had concerns about how people perceived him and whether or not it was okay if he wished to be something other than who he was. He wished he’d been born different. Who couldn’t have that wish if they were leading his existence? Sounded pretty normal to me.
We talked of many things during those brief meals and he asked about comic books and whether I could get them for him, if he could get another Frankenstein video and even about dinosaurs. He offered to give me the $40 he received each month for his PNA (personal needs account) if I would just get comic books for him.
This provided an opportunity for me to do a bit of financial management with him. I told him that he should only pay the amount that someone spent on comic books and that they would have to provide a receipt and the nurse could help him with this. We needed authority figures to stand up and help him in all these efforts. Certain staff members were taking all of his money for small purchases that didn’t even amount to $5 or $6. He was, consequently, left with nothing and would have to appeal to the nurse for a dollar or two to buy something to eat. It was eye opening.
The work did not go uneventfully and, in fact, one outstanding point shall forever remain in my mind. I was asking a rehab worker if she would include him in a mall shopping group and if he could be considered for placement on a unit where he would ultimately be discharged to a supervised residence. I will never forget the reaction this received from the rehab worker. “I have been in rehab for 25 years,” she said pulling herself up in her polyester pants suit, “and he will never leave this hospital.” I told her I didn’t agree and I determined that my plan would not include her participation.
The months passed and I worked with him and the social work intern who took my place until I was scheduled to leave the hospital. He had made excellent progress and by this time we had him involved in a group and he was going on regular shopping trips to the local mall with other residents. He had even made his first purchase in a mall store. It was a pair of sneakers for which he had saved up.
I left the hospital and I heard nothing further about him since I had no interaction with hospital staff any longer. It would be several years later, while standing in line at a store that I would see the result of that work years ago. A familiar voice called out to me. I turned and there he stood with a worker beside him and a shopping cart in front of him.
The young woman came over to me, told me he often spoke about me and she whispered to me, “He is one of our best residents.” I acknowledged him (something we don’t normally do in the community) and told her I was glad. She said he had been discharged to the residence and was doing extremely well. Part of his plan included his participation in a sheltered workshop and there, too, he was one of their best employees.
I will never forget this patient “who would never leave” the hospital. Wonder if the rehab worker was there when he was discharged. She’d probably try to take credit for it. He deserves all the credit because he had to be brave enough to trust and to try and he accomplished more than some of us could under similar circumstances.