24 April 2010

What I Learned on the Psych Ward

One of the early lessons I learned as the Team Leader of an adolescent psych unit is that teenagers crave limits.  They hate limits.  They push and push and push. . .but, in the end, they want to know what's right and what's wrong.

My first shift staff and I could always tell when another shift had been lax in enforcing the milieu's routine.  The kids would be hyperactive, demanding, and making frequent visits to the time-out room at the staff's direction.  A few questions here and there and we would discover that a new staff member on another shift had bent the rules, or a PRN nurse had tried to undermine the authority of the staff, etc.  

Like clockwork, one of the kids would "go off."  A fight would break out, or someone would start beating the wall of his/her room, etc.   When verbal re-direction didn't contain the acting out, staff would physically intervene with a "take-down" and remove the kid to the special care unit to cool off.  In order to discourage other episodes of acting out, additional staff from the adult unit would arrive and help us to settle things down.  In a very short time, the unit was back on track and all was well.

In our Team Leader meetings we would discuss this phenomenon at length and all agree that the maintenance of milieu routine was vital for unit safety.  Despite this, some staff--nurses and therapists mostly--continued to bend the rules, disrupt routines, and reveal treatment team plans for discharge and visits.  In other words, they were the parents who could not say "no" and mean it.  Their inability to stand up to the limits-pushing by the kids endangered the unit and our patients' successful treatment. 

Another lesson I learned early on:  do not hire education, psychology, sociology, or social work majors for milieu staff positions.  They tended to see themselves as Messiah figures who would save the kids by just listening to them and trying to understand them.  Of course, the kids manipulated the living daylights out of these suckers.  Instead of hiring self-anointed saviors, I hired business majors and athletes--people who understood the need for rules and discipline but who also encouraged the kids to do their best given their circumstances.  It also helped to have four or five 300 lbs. football players around when our gang members decided to "get buck."

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  1. I agree with everything you said here..that was my experience when I worked in adolescent psych, too.

    At the time I worked there, I was a Criminal Justice major...they don't fall under any of your categories, but there were a LOT of us working there. CJ majors, of course, tended to be quite limit-oriented and consistent. And ready to execute a tackle if need be!

    Much of our "leadership", though, was quite clueless. The ones who were the best supervisors? Regular people who didn't have sociology degrees!

  2. Very interesting post. I have always believed that the explosion in the number of cases of sexual abuse that began in the late 60's was the result of the widespread disregard of sexual morality and the systematic undoing of all the laws governing poronography, adultry, sodomy, etc. Neither celibacy nor homosexuality caused the abuse. People need rules. A society that constantly bends the the rules is a disaster waiting to happen. Anarchy is not pretty.

  3. Lamont - Another possibility is that prior to the 60's people just didn't talk about this stuff. I am friends with an 80 year-old former nun. She left the convent because the priests who oversaw the place treated it like their own private brothel. The rapes she suffered weren't the result of anarchy or drugs, or immoral living on her part. And, there were plenty of rules. No anarchy there. I could go on about other families from my very religious, church-going neighborhood where beatings & incest were fairly rampant... I don't think the adults in these cases were ever much into the 60s counter-culture, though they sure did mess their kids up something. And the kids - yeah, they used a lot of drugs. It was the only escape they could find short of leaving home. So, I don't blame them for their "immorality", I cry for some of the places their pain led them.

    Anyway, this is a little far afield from the very excellent observation that certain categories of institutionalized, mentally ill patients *really* need structure if they are to function at all, even within their confined universe.

    But, it should be noted, those patients, regardless of age, will always need the type of structure Fr. Philip discusses. Typical adolescents need structure yes, but they also need freedom if they're going to develop their critical faculties. It's a much trickier balance to strike. You can't necessarily do a take-down on your 14-year old, much as you'd like to, because s/he's being impossible.

  4. I was working on the computer help desk at the Austin State Hospital at the time that I converted to Catholicism. Although I didn't normally have patient contact, the very first time I attended an Ash Wednesday Service was with the patients there at the facility. The sounds in the room were what I would expect to hear in purgatory. They understood better than I, who we all are. It was a humbling gift.

  5. so I just gotta ask...

    would you hire ME??

  6. Mom, as a staff member, yes. I had a lot of trouble with the RN's.

    Two of my best staff members were mothers.