Sacred in the Simple…

As you probably know, I work at the State Hospital. Most of my patients have severe schizophrenia and bipolar disorder. My unit is one of the six most acute units in the hospital where there are often assaults of staff and between patients. It is often a very stressful place to be as I am hypervigilant about where I am positioned in relationship to very mentally ill patients, making sure I have other staff with me when I meet with patients to promote safety for myself and other patients. With assaultive patients, staff are often called to help physically subdue a patient to prevent others and the aggressor from getting hurt. Unfortunately, during these times, staff are often injured while trying to keep a patient from assaulting themselves and others. We’ve had some very serious injuries including fractures, concussions with loss of consciousness, bites, cuts requiring sutures, and of course the emotional and mental toll of watching our friends and co-workers succumb to violence. Not to mention, the staff of color are frequently called derogatory racial names and often the female staff are sexually harassed. I feel the weariness in myself, and I am not on the unit constantly throughout the day. Already twice this week, I’ve had a patient threaten to kill me.  My staff bear the majority of these traumas. They are all heroes in my opinion. I know that title can be overused, but I don’t know too many others, except firemen, policemen, and paramedic/EMT’s who could put themselves in constant danger for the welfare of very mentally ill people whom they don’t even know. My staff know these patients are someone’s mother, father, sister, brother, uncle, aunt,  grandparent, cousin, and friend.

Every week, part of my job is to meet individually with each patient to assess their mental state and the symptoms of their mental illness. I meet with them to determine if they are responding to their medications, continuing to have disorganized thinking, or having symptoms of depression or anxiety, and all of this helps me to make appropriate decisions about which medication and what dose they might need. Every week, I have to document about each patient. Documentation isn’t just filling in checkboxes. It’s writing a 5 to 9-page Word document (single-spaced) about their entire care for the week. Topics are not only what I’ve already mentioned, but it’s objective information about their mental status including their appearance, behavior, mood, affect, thought process (whether it’s linear or disorganized), if they have hallucinations or delusions, and their level of insight into their illness and legal situation. Most of the time, I’m able to take another staff with me to talk quietly about all the things I just mentioned. Sometimes they don’t want to talk except at their doorway or in the hallway. Sometimes the patient will tell me to go away in not-so-nice ways, but it’s not personal. It’s just mental illness speaking. Most of them, no matter how violent or angry they arrived at the hospital, are some of the nicest people you’d ever want to meet when their mental illness symptoms improve even a little.

There have been times when I get to meet with the patient in a different way than just sitting in a chair across the table from them. Instead of feeling like something that has to be done to get all my work finished for the week, meeting with a patient sometimes looks like something all people might do all the time.

One day I need to see a patient named Al (name is changed). When Al arrived at the hospital only two weeks prior, he was expressing delusions and appeared to hear voices. He was very withdrawn into himself. After a week of a small dose of antipsychotic medication, he was a different man. He was interactive with staff and peers, smiling, and funny. When I spotted Al, that day, he was playing SkipBo with two other peers. I asked if I could sit down and they all said yes. Immediately, Al insisted I play with them. I declined politely but Al took six cards from the main deck and handed them to me. He wasn’t going to take no for an answer! He had a big grin. I noticed they weren’t playing SkipBo using the normal rules. I noticed the normal stockpile you’re supposed to deplete to win the game wasn’t part of this game. In the middle of the table, the stack of cards to draw from was probably three different sets of SkipBo cards all stacked together. I was a little worried so I gulped and asked, “Do all those cards have to be gone before the game ends?” Gratefully he said no. He said everyone needs “six cards, wait no seven,” handing me a seventh card, “and when you run out of cards in your hand, the game is over.” As we went along into the game, I realized they were making up several rules as they went along. The patient across from me went through all the cards in his hand but then picked up seven more cards, continuing to play. About two rounds later, I finally ran out of cards in my hand. They declared me the winner! He talked most of the time to his rather quiet peers, not noticing they weren’t responding to him. This entire process took about 30 minutes.

This experience was not just time spent playing games with my patient. Those 30 minutes I could have spent documenting, ordering medications, or reviewing chart notes. I chose to focus on Al for those 30 minutes. I learned so much about Al. I learned about his family background and some of the difficulties he had to endure in foster care. About his more current condition, I learned the strengths and weaknesses he’s experienced, his thinking process, and what changes he’s gone through mentally since arriving at the hospital. His focus and attention, whether or not he seemed to be listening to voices, and if he was having delusional thoughts. I looked at what he was wearing to see if it was appropriate for the weather conditions and whether he was paying attention to his hygiene. These are all important when assessing the patient’s condition mentally. Playing a simple game and not trying to direct those three patients to play by the written rules, was a learning experience for me. We can learn about someone while doing the most simple activities with others. The sacred in the simple. I learned, I can’t control other people and can learn so much about people when you really watch how they think about things. I remembered I can’t expect certain behaviors if they’ve never learned them. It’s not my job to change their entire situation. I help behind the scenes by changing his medications so he can eventually function in the world. I listen to what he is saying, even if it doesn’t make sense to me. This means developing a relationship with Al. He now trusts me. He knows I care about him and am not trying to make him into what I think he should be. Since then, he’s confided in me about other parts of his life and asked my advice instead of me having to give my advice unsolicited. I think this is a lesson for life. Thanks Al for allowing me to be part of your life.