"When you get those rare moments of clarity, those flashes when the universe makes sense, you try desperately to hold on to them. They are the life boats for the darker times, when the vastness of it all, the incomprehensible nature of life is completely illusive. So the question becomes, or should have been all a long... What would you do if you knew you only had one day, or one week, or one month to live. What life boat would you grab on to? What secret would you tell? What band would you see? What person would you declare your love to? What wish would you fulfill? What exotic locale would you fly to for coffee? What book would you write?"

Tuesday, March 1, 2011

Schizophrenic Transference

So this past weekend at work during report from the day shift aides, upon walking by a certain room, I receive the knowledge of, "This one is from the (local psychiatric hospital). You have to be really careful with her, she is combative at times and even if she acts nice she will turn on you in an instant." And then the aide then proceeded to show me her scratch wounds on her arm.


I've received these warnings before during report and from nurses. So far, during the past five years of work, I have never been hurt by a patient.


These are my strategies:

- avoiding patients I know may hurt me

- asking for another person to come in the room with me when I have to go in or can't avoid room anymore

- "talking the patient down" when they get excited, violent, anxious, angry, etc.

- maintaining a calm atmosphere the whole time I am in room, without showing my anxiety/fear.

- explaining everything before you do anything to patient or touch patient in any way. And, introduce self and anyone with you when entering the room.

- And last but not least, using defensive strategies when physically threatened to protect myself but not hurt the patient at the same time.  (This is hard).


It's hard to protect yourself, protect your patient, and maintain a facade of calmness and at the same time come across as someone that will not be pushed around and is here to help you.


So, I'm a wimp, may I add. And I don't like working with psychiatric patients in the first place. But, for now, and maybe later, it's my job. So, as said above, I do have a couple tactics that I learned in my psychiatric clinical/class and learned by personal experience.


So it came time in my shift that I could no longer avoid this patient, I had to go in to see her. I didn't know anything about her other than what I got in that very short report. So, I used all my tactics. I introduced myself, I used my calm voice, I told her I was here to take her vital signs and her blood sugar. She said that was fine. We chatted a little...mostly about Yale, Harvard, cows, water, pencils, cheese and her friend Jenny. I replied with lots of therapeutic responses...I agreed with everything she said and showed interest and treated her with respect. I'll add here that she was in her 60s. We said goodbye and that was that.


Then it came time, a couple hours later, for me or my coworker to go and give the aide a break that was sitting with her from the psychiatric hospital. Because I am not brave and did not want to sit with her for thirty minutes, I sent my coworker in, but I said I'd be in to check up on her multiple times. I stayed nearby the room, helping nearby patients, and I could hear the patient (Lets call her Jane- not real name) getting very upset, and loud. I went in to help my coworker and as soon as Jane saw me she said, "Oh, good. You're here, I trust her! (me)." So I used my calm voice and I asked her what the problem was. She said my coworker was working with Satan and needed to leave. Me and coworker determined she needed to be changed (her bed was soiled), so I calmly told her we would be changing her. At the same time, I kept her focused on me and not on my coworker, and held eye contact and conversation. After we were done, my coworker said it was best if I stay in with her for the remainder of the break, and she would do some extra work on the rest of the floor. Well from then until 20 minutes later, It felt like 20 hours later.

This is where the art, blessing and curse of transference comes into play. As psychology terms go, transference is when your patient views you as someone they already know, unconsciously or consciously. If you act like their mother, they will unconsciously treat you like their mother. If you act like the sister they have hated their whole life, they will subject those feelings of hate onto you. So you can see how it can work for you both ways. Well, my situation is a little different. Due to the fact that I can not find any actual term for this phenomenon, I will call it "Dementia Transference" or "Schizophrenic Transference". Schizophrenics (Like Jane) make things up in their mind, they have delusions, hallucinations, people talk to them in their head.. Before their illness, it is common for them to have been very intelligent people. In their mind, what they say goes. They tend to be very paranoid of "outsiders" and are convinced of whatever the "voices" want them to believe. Sometimes these voices are good, but most times they are harmful and detrimental. They tell the patient to hurt other people or hurt themselves, etc. So I name it "schizophrenic transference" because I found out very soon into the conversation that Jane thought I was her daughter, "Lauren".

At first I played along. I really just wanted to get out of there unscathed, so I just talked to her, I nodded and smiled, answered questions. I tried to dig a little deeper to find out more about the "role I was playing". I found out that she thought I was Lauren because we shared common traits (brown hair and "crooked glasses" (as she put it-lol) and she thought I was pregnant, as Lauren must have been. [I'm not pregnant, I'm just fat, I guess] ). I found it interesting stepping into this person's life…or past life, I guess, and taking a look around. I see it like walking right into a person's mind, but walking in blind. You can see what is around you, what you are learning but not whats coming. That's where this starts to get tricky. Its all good and well pretending to be someone if it helps your patient, but what about when that relationship, the relationship between Jane and Lauren, and "me", goes bad?

I could tell she had mood swings, I knew that much. I knew she was starting to get agitated. Her IV was starting to hurt her, and I don't blame her for getting upset about this because it was bleeding and did look painful but at the time being, there was nothing I could do about it as an aide other than talk her out of pulling it out. She kept reaching for it, telling me that "mommy knows whats best" and "let mommy do what she wants". I tried to recover the situation- I carefully grasped her hands so she could not pull the IV- And played it off as if we were holding hands and tried to get her hooked on another trail of conversation. That worked for about ten seconds before she was back to IV. I tried the usuals, "Its helping you get better, It needs to stay in." or "I'll have your nurse come in and look at it". Then she started crying and told me "Remember when you were little, and you cried and you wanted something? I always gave It to you. Now give your mommy what she wants." . I didn't know what to say, except for "I can't let you touch your medicine." And surprisingly, she gave up after that. Another example: Jane- "remember when I taught you latin when you were three? You knew Latin when you were three." Me- *nods* Jane: what does "somethinginlatin" mean?" me: I don't know. I forget. Jane: YOU'RE SUPPOSED TO KNOW LATIN, THAT'S WHY I TAUGHT YOU!"

Then a "third" person came into the room, a person that I could not see, but she could, in her mind. I knew the situation in her mind was escalating when she wanted me to show this person my ID in order for me to remain "acceptable" to stay in the room. I guess I was granted acceptance by this mystery person. We then proceeded to stare at the clock that she thought to be a camera. We "took pictures". She told this third person about "me" [Lauren] and I could tell that this person was one of her voices that was telling her to do things.

Luckily, my time was up and the 1:1 attendant came back.

This isn't the first time I have encountered a situation where my patient thought I was someone else, usually a granddaughter or daughter of theirs. I've heard many of times that it is morally unethical to "play along" as a professional healthcare member, and that it is our job to "reorient them" and tell them I am their nurse aide and you are in SuchandSuch Hospital. But I've seen a lot of people get upset when we try to reorient them. It is a very thin line to walk on, and the line is made of ice that you can easily fall through at any moment. Letting transference happen can get you many places- you can learn a lot about your patient. Its like taking a ride on a flashback memory train of the patient's, and you are a fly on the wall watching their memory unfold and then suddenly you are called upon for information that only "Lauren" would actually know, not me. Then the patient gets mad and you are SOL either way.

So that's my experience with transference, schizophrenics and psychiatric illnesses. Yes, I did do a good job with her (besides the questionable transference), but I did not like being in there one bit. That's what I don't understand. How can I hate the thought of psychiatric nursing so very much and yet be so good at it? I guess that's another different blog. So anyway, I am back on the blogging machine! Lol. I (hopefully!) passed my test, and tomorrow begins my 10 day spring break and I will be a blogging monster, for I have many posts written down that I want to share. So keep checking back! Thank you for reading another long (and hopefully not boring) post!

As always, with immense amounts of love,

~A Writer in a Nurse's Body

PS- I feel sorry for whoever "Lauren" is out there. Her childhood was probably less than pleasant.


crimsonlight said...

Wow I loved reading that. I'm a psychology student, and I haven't learned about that yet!

Philimar said...

that's really hard to work with such special patients and dangerous too