Conversations with patients: Violence on a psychiatric unit
In these essays, I feature interactions I have had with my patients that I have found to be meaningful and thought-provoking. Any details about the patient’s identity have been modified to protect patient privacy and confidentiality.
Kristin came into my care after a 3 week hospital admission to an inpatient psychiatric unit. When unwell, Kristin held delusions that she was the wife of Jesus and stopped sleeping and eating. She did not remember much from her hospital stay but she recalled feeling really happy and motivated in the weeks leading up to it. A feeling she had never had before and missed now that it was gone.
After her discharge, she struggled with depression and anxiety. She had moments where she would become very agitated and suicidal. With the support from the First Episode Psychosis clinic, medications and time, Kristin has fully recovered and is now in a relationship and back to work.
In my care, Kristin has also been processing what had happened to her. She told me of a memory from the inpatient unit that has continued to bother her. The memory was this:
She is approaching the front desk calmly when a nurse tells her she is bothering other patients. Kristin does not understand and begins to protest. Kristin is then cornered by several nurses and security guards, restrained to her bed by her wrists and ankles, and she is given an injection against her will. She is deeply traumatized by this event, saying, "it was an inappropriate use of force for just bothering people."
Whenever she recalls this event, she becomes angry and can not settle for several hours.
I offered to go over her hospital records with her when she was ready, to see what was documented, and she gave me permission to go ahead.
The nursing notes detailed that she was shouting about being possessed and running in and out of other patients' rooms. She was tearful and agitated and would not return to her room to settle down with the nurse. The nursing notes also documented an attempt to console her and to give her oral medication to calm down, which she refused and continued to run down the hallway yelling.
Kristin sat in a stunned silence. "But she said I was only bothering people," was her first response.
This is such a difficult experience. I have worked on the inpatient psychiatric unit for years and have witnessed many times the disinhibited, uncontrollable behaviors of someone in the throws of their mental illness. I suggested to Kristin that we wait until the next meeting to discuss further if she wanted, and that it might also be helpful to hear my thoughts as a care provider in this challenging setting.
By the next appointment, Kristin had been trying to come to terms with several things. First, how little she remembered. Second, how what she remembered was completely the opposite to what the nurses experienced and third, if she had been given a chance, could she have calmed down on her own?
An inpatient psychiatric unit is an extraordinary and complicated place. It is a place of healing, while being a place of chaos. I wanted Kristin to appreciate that the risk for injury and violence is much higher in this setting, and so we do not have the luxury of much time before stepping in when someone is disinhibited and escalating. I wanted her to know that as scary as it sounds, she was assessed to not be in control, and that this happens in psychotic illnesses. Clinical judgement therefore has to be made quickly to ensure minimal physical and psychological harm to staff and patients. All who work on the unit know this and are vigilant, as safety is our biggest responsibility and priority.
I also wanted Kristin to know that the care staff are trained in methods of de-escalation and that force is used as an absolute last resort. There are also measures in place in hospital to ensure restraints are only used when necessary and not for too long. Patients in physical restraints are seen more frequently and the order to use them expires within 24 hours so their need is reassessed.
I can not imagine what it would be like to see the world and yourself in a way that differs so dramatically from how others see and experience you and your intentions. And then to be met with force or violence on top of that and the sense of helplessness and confusion that Kristin described. There was harm, and Kristin needed to talk about this. I also needed to hear it.
What I wanted Kristin to know is that force is unavoidable in some cases, and may cause harm, but not for nothing. Because there too was healing. Where these two seemingly irreconcilable concepts come together are in the complex, tragic and triumphant process that is recovery.
**It is important for me to acknowledge that there are instances of unnecessary and excessive use of force on patients with mental illness in and out of hospital settings and that I do not condone this. This essay speaks only to this one case.