Dealing with the non-violent mentally ill

[03RN]

The day I first posted in this thread I had a schizoaffective patient lash out after she got into an area she wasn't allowed in. She refused to leave and when another nurse tried to direct her out she swing.

I was watching and as so as that happened I walked over with much speed and took her by the arm. She swing and kicked but as soon as she was through the door I let go and she stopped.

She is not violent. She is frustrated and due to her medicine non compliance she is disorganized and not able to communicate effectively. She is paranoid but not aggressive.

She will be committed then told she either takes meds by mouth or she receives IMs untill she complys.

Schizoaffective and schizophrenic patients are similar enough I'm going to lump them in together. I normally treat them similar but still person to person.

Sometimes they are responding to internal stimuli. Auditory hallucinations sound scary but most patients are honest about them. In school I had a little old lady tell me the voices we're telling her to kill me. She promised she wouldn't.

Typically the patients don't act on the voices and they want to take meds to make the voices go away. They might be kinda scary when they are talking to the voices they hear but almost never violent.

They may not follow directions that well but that's because there are louder voices they are hearing.

[Josh Runkle]

This was my first thought. Mostly a joke, though.

In all seriousness, people with non-violent mental illnesses are not a threat 99% of the time, and unfortunately, they are treated as if they are. The difficulty for the responder is that it is very difficult to discern what is going to turn into sudden violence. Often there are few warning signs and it can be sudden.

Also: responders often get spooked up over stuff that sounds worse (like schizophrenia), but daily to recognize warning signs of things that sound more common (like Bipolar Disorder) but have transitioned from Mania to Psychosis.


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[Nephrology]

This was my first thought. Mostly a joke, though.

In all seriousness, people with non-violent mental illnesses are not a threat 99% of the time, and unfortunately, they are treated as if they are. The difficulty for the responder is that it is very difficult to discern what is going to turn into sudden violence. Often there are few warning signs and it can be sudden.

Also: responders often get spooked up over stuff that sounds worse (like schizophrenia), but daily to recognize warning signs of things that sound more common (like Bipolar Disorder) but have transitioned from Mania to Psychosis.


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I really need one of those patches.

Re: the mentally ill, I agree with most everything that's been posted here. I actually worked the swing shifts both sat/sun this past weekend so I have some recent experience fresh in mind.

One thing I learned early in the ED is that posture and body language go a LONG way in establishing productive communication, even with the seriously mentally ill.

Adopting a relaxed posture (arms uncrossed and relaxed at your sides, gentle smile/warm or welcoming facial expressions, etc) goes a very very long way in de-escalating people who are agitated or in preventing a conflict from evolving in the first place. Same goes for tone of voice and demeanor. Being calm, polite, and gently concerned for their well being goes a long way, even in the delirious or psychotic. If you can, don't stand over them - try to meet them at eye level (if they seated, squat or sit next to them). Sounds dumb, but this goes a very long way too.

Another tactic I use often is to employ open-ended questions and to take their concerns very seriously, no matter how crazy they sound. When they say "My neighbor is spying on me for the Soveit government," ask them why they think that's true. Express genuine empathy for the stressors that they describe. As has been stated by others already, these hallucinations are extremely vivid and persuasive to those who are experiencing them. The emotions they evoke are just as genuine as the emotions that we experience, and their stressors just as real as ours. Taking their concerns seriously can go a long way in establish rapport, and, in contrast, rejecting their lived experience out of hand is a great way to totally fuck yourself.

Two patients i've seen in the past immediately spring to mind. The first is a guy who came in because he opened his closet and thought that there were two people in his suit hanging in the closet and were convinced they were there to ambush him or do him harm. I asked him if he had ever seen those people before and why he thought they were there to hurt him. I asked him if he's ever seen anything like this before and if he said no, and over the course of the night (and after a titch of haldol), he eventually expressed concern that the people he saw were not real and was connected with the appropriate psychiatric care.

Another guy I saw was convinced he had been beaten up by a likely fictitious person. This guy was billed as aggressive (had assaulted a couple officers in the field) and was in soft restraints when I met him. I asked him more about this person and what happened to him, and in the most compassionate tone I was able to muster I told the patient that he did not deserve to be treated like that and that he had a right to feel safe and protected, and that we were going to do everything we could to keep him from harm. He broke down in tears and was extremely cooperative for the rest of the night.

These two anecdotes stick out because they were success stories, but obviously it doesn't always work out that way. I know that compassion fatigue is a real thing, so I do apologize that my advice boils down to "be compassionate," but I've found that simple empathy can go really far with the severely mentally ill. I'm tired and post-call so sorry if the above was rambling, but hopefully helpful to some.

edit: Didn't read 03RN's post before so sorry that I basically ended up repeating a lot of what he already said... but at least we're consistent!

Not disjointed, and I hope you continue to add more as you can. Congratulations on the newly expanded family, and thanks for taking time away from all your new responsibilities to help us out.

The only thing I'd say is difficult to translate over to LE is sitting on the ground. I will squat if they are seated (which sucks because of my knee, but whatchagonnado?) and make sure I've got enough room to stand up and move back if they start to stand or move where they can lunge.

If you can seat them in your car car or on the hood or something or something that might help. It also might be helpful to ask how you can make them more comfortable, within reason. Putting them in the driver's seat as often as possible (without of course jeopardizing your own safety/professional duties) goes a long way.

[Nephrology]

Bipolar, schizophrenia, schizoaffective, drug induced psychosis, behavioral are probably what will cause you as law enforcement problems. Another one might be a boarder line who displays self injurous behavior (the most staff intensive patients we get).

To expound on this a little bit, patients with personality disorders (including Borderline Personality Disorder) are extremely challenging because for all intents and purposes they look, walk, and talk just like regular people most of the time. Also, unlike frank mental illnesses like schizophrenia or bipolar disorder, patients with PDs suffer from maladaptive behaviors that they learned early in life, and not (to my knowledge) from an organic disorder of the brain that can be readily corrected with medications.

Also, patients with PDs can be very high functioning, and only have their disorder surface when exposed to certain triggers or in certain contexts. Patients with Borderline, for example, often engage in self harm, impulsive spending sprees or drinking/drug binges, etc, but can be intelligent enough to try to cover up or mitigate the consequences of these choices. My guess is that most LEOs who make contact with personality disordered individuals probably would have no idea that they even have a mental illness to begin with (vs. the much less subtle screaming, naked homeless guy with schizophrenia...).

As some of you may remember, I dated a woman with borderline PD for a year and a half, and it ended with police intervention and a no contact order. I definitely got way closer to that one than I would have ever liked, but it was a very educational experience...

[03RN]

To touch on something's nephrology mentioned.

Be empathetic. Which is different than sympathetic.

Ask questions but don't ask "why". "Why" will often escalate an agitated person. It sets them back and puts them on the defensive. It is not conducive to therapeutic communication.

Are their complaints valid? I've had a pt billed as paranoid because he thought people were video taping him in the group home. Turns out someone was.

Now whenever we get report about some outlandish claim that everyone chuckles about I ask for the case worker to investigate or I call the police department or the ED.

The mentally ill are often taken advantage of. That doesn't make there behavior ok but it helps to treat them.

[Josh Runkle]

Are their complaints valid? I've had a pt billed as paranoid because he thought people were video taping him in the group home. Turns out someone was.

I got dispatched to a “anaphylaxis - multiple bee stings, patient has already self administered 2 epi pens”...turns out it was a psych patient who hallucinated about the bees but still took the epi pens.

A week later I had a guy run in yelling that there were a bunch of bugs in his ear and he could hear them buzzing, but he never saw them go in. I thought he was a psych patient but I irrigated his outer ear just to humor him. Sure enough...there were a bunch of bugs in his ear.


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