Mental Illness

On my current placement I am treating a young man whom through a self harming incident attempted to, and succeeded, in emotionally hurting their family. This patient has a long history of mental illness in addition to a poor relationship with their family. As a result of their injuries they will be in hospital for a significant period of time and will suffer from the consequences of the burns for the rest of their life. Reading the patients history (ie social problems, problems with the law, drug history) prior to them being admitted to the ward I pictured the patients family as being ‘typically dysfunctional’ ie unemployed parents, drop out children, heavy drinkers etc. However when I met the family I was surprised at how ‘normal’ they were. This immediately made me realise that we should never ‘categorise’ patients before we meet them.

Keeping this in mind I went in with the physio to see the patient for the first time. As they had only just recently been extubated they were on a ‘cocktail’ of medications and were quite drowsy and ‘out of it’. That day we had no problems treating the patient and there was no hint of the behavioural problems highlighted in their notes. The next day however and for the days to come the patient was very verbal – lots of swearing etc – and did not want physio as it was painful. As with all of these types of patients we provided lots of education explaining why physio was necessary etc.

The patient was causing numerous problems for the nursing staff by being verbally aggressive, non-compliant etc. This resulted in a ‘companion’ or full time nurse being stationed in the patient’s room to prevent them from self harming again. Last week comments made by the patient became very inappropriate toward myself asking personal questions etc. At the time I just ignored these and when we had left the room my supervisor said that was the right thing to do and they explained the patient is trying to go beyond a ‘professional relationship’ so that they will be able to manipulate myself in the future. I thought about this and it made a lot of sense as I had witnessed the patient saying some horrible things to their family – again trying to hurt them emotionally. For this sort of patient I realised you have to be very distant and professional as due to their mental illness they have an altered sense of what is appropriate and lack inhibition or a sense of embarrassment/shame in what they will say to you.

Unfortunately whilst it is good to build rapport with patients as it allows them to trust you, you must adapt the way in which you relate to every patient. For patients that suffer from mental illness you must be very clear and outline in black and white what you will accept them saying during a treatment session and what is not allowed. For the above patient a behaviour contract has been written up with the aid of the clinical psychologist. Whilst this has not stopped their inappropriate behaviour there is now a structured and consistent method to deal with the situations which will hopefully improve the patient’s behaviour. I also reflected on how difficult this must be for the family, not only from the guilt they must feel, but also that no matter what sort of upbringing someone may have mental illness when uncontrolled can have devastating consequences for all. This is my first encounter with self harm and a family involved, if anyone has had any patients in a similar situation and has any strategies to deal with inappropriate language prior to a behavioural contract being drawn up please feel free to share them, as it was very awkward at times treating this patient. Thanks.