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Hi everyone, I used to be here quite a bit but haven't in a while due to working full-time, having to move twice (don't ask), and other stuff. But when I started struggling with this issue last week I figured the folks here could provide some input and hopefully insight.

I work as a mental health therapy aide on an inpatient unit. Last week a young woman was admitted experiencing full-blown mania for the first time. Of course she's a pain in the ass to the staff and other patients, and she's refusing meds. In addition to all that goes along with mania (which I know I don't need to tell anyone here), she's feeling very scared and paranoid, because her family tricked her into going to the psych ED and then had her committed.

What's really bothering me is comments the staff are making along the lines of "She's so arrogant" and "I know she's having a tough time, but she needs to tone it down; she could do that." HELLO?!? If she could "tone it down," do you think she'd need to be inpatient? And isn't part of mania having that inflated sense of self-esteem? And didn't they teach you this in nursing school? And how about a little EMPATHY?

I know I need to keep some professional distance and be careful not to over-identify with her. I keep trying to (gently, diplomatically) make the point that what we're seeing is the mania, not necessarily the real person, and she doesn't have any control over it at the moment. I'm not out about being bipolar myself - on my own experience, and the advice of people I trust, I don't think that would be a good idea - so I can't say, "I've been there, you haven't, and you don't know what the hell you're talking about." But it is so incredibly frustrating.

Anyone been through anything like this, or have any ideas/comments/suggestions? I'd be really happy to hear.

P.S. Sorry this is so long - I guess partly I just needed to vent.

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When pnurses burn out, it always goes very badly.

I was in the hospital for suicidal depression, and was tricked into by my family as well (I wasn't comitted, but I was underage so I had to be there against my will). I admit I was a total pain in the ass. I refused to do a lot of the stupid stuff they make you do as an inpatient because the only reward for doing it was being able to go outside and smoke - and I didn't smoke. I was incredibly mad at being there, and SSRIs don't exactly kick in a week. The only way I got out was lying to the pdoc.

I was ready to be discharged - as in stuff packed up and waiting to sign the papers. One of the nurses came up to me and said "I don't think this program did you any good. You just think nobody can help you and they aren't good enough for you anyway."

I sat there dumbfounded. What I should of said was "You know, hopelessness is a symptom of depression. Don't they teach that in nursing school - or did you miss that day?"

My sympathies are with the young lady. I can't imagine how horrible it must be to be scared out your mind with no insight and having to deal with a bitchy staff.

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zenbean,

I'm a nurse, and when I was in school, this is exactly how our students reacted. The general attitude was like "this guy is a jerk" and "he is so obnoxious and arrogant" and "he never shuts the hell up and makes trouble all the time". Granted, these were students who never interacted with mentally ill patients before and barely understood mania. They viewed the actively manic patient as a case of a crap personality, a jerk.

The psych staff, however, did understand mania, and they would tell us students "this patients behavior is because of his mania". Even though staff knew this, they couldn't help emotionally reacting (i.e. judging and finding the patient bothersome/offensive). So, the psych staff would on one hand be like "he's manic and that's why he is this way" but on the other hand they were like "...and it is annoying as hell and really hard to deal with".

A staff member even said: "I know it's horrible, but I can't wait for when he falls into depression", because he was a lot less annoying when he would slow down and isolate and cry a lot (this was a small unit and the patient in question was a long term resident with very severe bipolar disorder that never went into remission... it was really really sad, the man was like in his 40s and had lived in the mental institution since he was a teenager). So, basically, even though the staff knew the patient was this way because of mania, they couldn't help but emotionally react/judge. And they secretly wished he would fall into depression so he would go isolate and cry.

Sad. But, I guess it is only natural, they're just humans.

Speaking personally, I found it pretty easy to view his behavior as a symptom of his illness. I did find it really annoying and I felt angry when he would do destructive/meddlesome things and cause trouble on the unit... but, logically, I knew it was all because he was mentally ill. So, like the staff, I understood... but emotionally, I still reacted and judged. The other students didn't seem to understand that as much and a lot of them really believed he was a crappy person.

Health care work is like this... you see and deal with a lot of things that are emotionally jostling or upsetting, but you have to learn to control your reactions and not express them. Not just in mental health is this true, but in all healthcare. Patients will curse at you and treat you like crap, or they'll be really noncompliant and disrespectful, and you have to not react and treat them neutrally.

A lot of nurses... you just have to ignore them. For patients in an inpatient unit, it's really tough because you're so vulnerable. Thing about nursing is that it is a really hard job, corporations exploit the hell out of nurses, and so you end up with this situation where a lot of people are doing the job who are miserable and/or undereducated and never wanted to be nurses anyway and definitely don't want to be nurses after having to take care of ridiculous patient:staff ratios.

It's really not the nurses fault, I believe the fault is in the corporations which exploit this job, PURPOSEFULLY understaff out of greed (nursing shortage is a myth, long term/subacute facilities and many hospitals PURPOSELY understaff). It's sort of impossible to care when you are being treated like a machine. In these kinds of places a lot of nurses work straight 8, 12, 16 hour shifts without much of a break because the patient: staff ratios are so appalling. They don't have time to care, because the job is constructed in such a way that they can't do a good job. They can't find any sort of pride or foster any empathy or sense of accomplishment in their work because they are being exploited.

Then, there are some nurses who shouldnt be nurses... they do it because it is a good secure job and they really don't care at all about helping people and find no sense of satisfaction from that.

But the biggest problem, IMO, is that working conditions have always been pretty terrible, and a lot of jobs are so awful that the staff are burned out as hell.

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One of the best lessons my pnurse did when I was first admitted was put me in charge of taking a (still manic) guy out for his first outing outside the hospital. It was hard! He talked and chattered adn ran off and when I came back (after hospitalization, now not manic) I bitched.... loudly. She looked right at me and said, "And now you know how your family feels."

Empathy cuts both ways.

Anna

As a bipolar, I can state that my bipolar is extremely annoying and empathy is not always possible, probably. Nor do I expect total empthay from all my providers, as long as they don't bitch to my face, I think I'm okay.

I think you are over identifying.

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I can reply to this from two views.. kinda or something...

I have been inpatient a few times and have seen how patients are treated... not always the nicest to say the least. I can understand that the people working there are doing just that, working. Its a job to them...... but its the patients lives! If they were all doing good they wouldn't be there!

Also.... I have a friend who works in the mental health field... he works at a residential facility. He didn't know my DX.. but after a 4 hour drive and listening to him say schizo this and schizo that and how "they" were always such a pain in the ass to them.... and sometimes he just wonders what the heck goes threw their head......

I decided to ask him if he really wanted to know what goes on in their mind... of course he said yes..... So I told him a bit.... he asked me how I would know that... and I told him my DX.... he shut up after that.. and has since decided the mental health care field is not for him. "I've realized I will get no where working in mental health." :)

"Why don't these people make my day easy.... I gave up MY Christmas day to work there and try to give them some form of a Christmas when no one else gives a shit about them." Umm can I just say how wrong that statement is on sooo many levels?;)

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OW - Thank you much for your thoughtful response on the pressures of nursing.

However, I believe anybody who goes into pnursing needs to understand right off the bat that their patient population is by definition annoying, ungrateful, and non-compliant (and this goes at least double for adolescents). Nobody is cured in the hospital, especially not with insurance the way it is and patients being kicked out in a number of days. I am going to guess that being a pnurse is the least rewarding field to specialize in.

But from what I understand about nursing (please correct me if I'm wrong) it is most definately a choice. Chosing any other field than pnursing gives you more options, more job security, and more money. I think pnurses need to approach their job with their eyes wide open and get the skills to go into another part of nursing if they feel they can't handle it anymore. In more medical specialities you will at least run across a polite, grateful patient once in a while. A burn-out nurse has more potential to harm patients (who by definition have trouble handling stress) on a psych ward than just about anywhere.

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i still believe that the most help i ever received was from a psych nurse on an inpatient unit during my first crisis admit.

i got amazing treatment and probably much better overall care from a partial program more recently. but the intensive help that i got when in crisis for hte first time ever and completely scared and clueless was beyond compare.

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First off I LOVE the "bipolar double agent" phrase, boy does it ever fit.

I totally identify with this post - as a chemical dependency counselor and an addict/bipolar (co-occuring) person I am scared, literally scared, to go back to work in the field. It's a lot of work to work in the field and have mental illness...lots of boundaries to set up and it's a good idea to have a strong support system to bounce things off of when things get crazy and confusing.

There's lots of double standards...lots.

I adore working with addicts as well as people with mental illness - no bones about that.

When I was doing my internship at a medical model treatment center I would sit there and burn with shame and embarrassment when the therapist (upon hearing someones behavior or diagnosis) would say things like "oh that's borderline, that's bipolar" and he would always make a point out of those two dx. The staff including the pdocs would laugh at the pts during the staff meeting and then I would watch them while they conducted rounds or groups and feel like they were total two faced jerks. I left my internship wondering if that's how I had to act and talk in order to blend in with the rest of my staff/co-workers. Hence the beginning of the feeling like a "double agent"

On one hand since working in the mental health/addiction field I totally get that people need to vent how the pts affect them and found myself torn between the "us and them" mentality - I either had to get into therapy to work these issues out or get out of the field or just say fuck it and leave... it was a powerful thing to deal with.

I found it hurting myself the way I worked with both pts and the staff. I don't know if I'm too sensitive or need more training or just not cut out for the politics of this field or what but I still get stumped at how someone can maintain total neutrality and not join in with the staff in venting about the pts - to flat out making fun of them in cruel ways. I had huge periods of self loathing on weekends off and wondered what the hell was I doing working in a field I loved and talking about pts that way...as I was a pt in wards for many times over.

So after awhile of joking about the patients with other staff members about certain pita pts and feeling that "two faced" feeling while conducting groups or 1:1 with my patients... I waited for an opportunity to present itself so I could quit and not have it be centered around me being "bipolar and too weak to cut it in the working field"

The opportunity came and I bailed. The weeks preceeding my little bail out though were soooo stressful I almost ended up in the psych ward - I would come home shaking and pissed, have to call my AA sponsor on the way home (as soon as I'd get in the car I'd hit speed dial) and just vent vent vent how I felt about being two faced... On one hand I was totally compassionate about the pts and I'm good at what I do, on the other hand I found myself prostituting my own compassion and beliefs on how mentally ill should be treated that I was at my wits end because I could not marry the two - I could not be the compassionate counselor AND be a counselor who laughed about pts being a PITA and such...

I have been in therapy since and haven't worked in the field since. I chose to go back to school and finish a degree, one class per semester and on purpose so it will take longer for me to go back to work.

I've been offered my old position with fewer pts and doing mostly groups and I have turned it down - it was a shabby place to work (public funding) and although the main perpetrator of all the mean gossipy backstabbing crap is gone, I'm still gun shy. The fear of being found out is greater now because I share very openly in AA meetings that I have bipolar disorder...it's just part of my life and I don't hide it in AA.

hearing the comments hurt - both as a person with bp and I hurt for them because I knew how the others really felt about the pts... but as time has gone by I realized a few things - that some of the sickest people work in the field of mental health and treatment and unless they have both compassion and education, then they are not going to be effective.

People with paranoia already feel like it's all about them... I hated watching the staff tell the pts "oh no we're not talking about you" when they WERE!! There's nothing more fucked up than messing with someone's reality, it's sick and wrong. That's one thing that I wouldn't participate in and it felt awkward. I'm just glad I always had paperwork to work on, that way I could stay away from my co-workers and still be in the fray at the same time. It's a hard line to walk.

Disclosing that I have bipolar disorder will put me at a disadvantage because the staff/co-workers will treat me as a lesser person (watched this happen) and if I don't disclose it I feel like a hypocrite and a "in the closet" bipolar. Or god forbid I'm having a great day and they say "oh don't mind her, she's having some mania" or...well you get the picture. I just want to be a worker among workers - and sure, come to me if you want insight on what it's like to have bipolar...but don't laugh at me behind my back because I dared to be honest and vulnerable. But it's a reality.

It's acceptable to have depression and anxiety and even ADD in the mental health field, but in my experience - and maybe I haven't found a healthy place to work yet - once you mention that a counselor has a personality disorder (why is there such a stigma, it's stupid) bipolar or schitzophrenia you automatically distance yourself from your coworkers and are undermined and talked about and are left out of staff decisions because you are "just like a pt"

And in the treatment field if you are a recovering addict/alcoholic it's okay to be a counselor but not okay to have mental illness.

These things are what people who work in the field experience and it's a lot of work to overcome over personalizing things to be an effective worker among workers.

As usual I have talked too much...but that's my input FWIW...

Thanks for bringing this up as it really helped me a lot to see that a.) not alone and b.) other peoples input

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A couple of things: First of all, a lot of people in the psych field are often interested in it in the first place because they and/or family members have MI. So especially if they have had family with MI, it resonates with all the difficulties they had with that relative growing up, which can really impact their treatment of those patients. And it also means many of them are somewhat unstable and impulsive themselves, and don't watch what they say, or how they act, as carefully as they should.

Now my dad was friendly with several of his patients, especially his bipolar patients, because they reminded him of his father. He also felt strongly that if *he* refused to socialize with people with MI, it undermined the whole premise of his profession. My dad is also mildly bipolar himself, but mostly hypo-manic, so he has always been a high achiever, unlike myself.

But he also had patients he warned us to never let into the house, and said if they appeared at our door, to call the police. This isn't because he hated them, but because he was worried that if they were angry at him (and I think many of us have been angry at even the best p-docs and t-docs at times), that they would take it out on his children. He also taught us how to answer the phone (never say our name, even if were patients we knew and were friendly with; always ask who it was before we gave the phone to our dad). Again, this is not because he hated them, but because he wanted to protect us.

But, I never, ever heard him, his nurse practitioners, or the psychologists he worked with say anything negative about a specific patient. He would not tolerate it. He said that MI people often seemed really annoying, but that was a symptom, not who they were. He would be straight forward with them about the fact that they were manifesting an annoying symptom, but he never equated it with their underlying personality So it is possible for psych workers to be accepting of really annoying behaviors. It has taught me to be frank about both my own and others behaviors, but to not hate any one who was being a pain in the ass.

I dislike people for who they are, not for their MI. ;)

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Thank you for all the thoughtful responses. I KNEW you guys would have a lot to say about this, and it's all really helpful.

I probably should've said in my original post that I like and respect almost all of my coworkers. I know how difficult their jobs are, and I know no one is purposely trying to disparage any patients. And it's true that we all often end up working very long hours. So Persephone's points are valid. But in a way, knowing that they are well-meaning and relatively educated people makes it even harder to listen to some of the comments without reacting. And yes, I realize I may be over-identifying - I want them to understand the patients because I want them to understand, and have sympathy for, all of us who deal with this. I know there's no way that anyone without a mental illness can understand what we go through, but I think professionally trained people often think that they do. On the other hand, I agree that a lot of psych nurses, especially the ones with long experience, are awesome. On our unit, they are often the ones who are the best advocates for the patients.

Anyone who's worked in this field (or in an ER, which I've also done) knows there's a lot of sick humor around it, and a lot of that is necessary, I think, to then be able to go out and face patients who are obnoxious/threatening/totally lacking insight. I guess the crux of this particular situation is the insistence of some of the staff that this patient could change her behavior if she chose to. If you don't understand that someone in the grip of a serious mental illness isn't capable of that kind of choice, you're missing something BIG.

And yes - lots of burnt-out nurses continue in the field - just hanging on until retirement. This is bad news for patients, and bad news for the nurses themselves. In the short time I've worked on this unit (just under two years), there have been a lot of really difficult situations, including staff being seriously hurt and a patient being killed shortly after discharge, and there has been NO support from management. No counseling, no debriefing, really not even an acknowledgement that these things happened and might have impacted staff. So it's hardly a mystery why people burn out.

A lot of what Tempestia says resonates with me, especially the fact that there's an "us/them" mentality. When you're both us and them, it can get really sticky a lot of the time. I feel like my ability to understand what the patients are going through makes me better able to support them in the ways they need, which is why I continue to try to deal with it.

As for reporting them to management, I just don't feel like that's an option. It would be abundantly obvious who had made the complaint, and I can't afford that kind of bad blood with my coworkers.

OK - I went too long again - I have a habit of doing that. Thank you all so much for the responses, you've given me a lot of food for thought.

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