There's more to her than mental illness




Regardless of what specialty we choose in nursing, we all have defining moments that shape our practice. Some are heartwarming, others heartwrenching. Many positive and negative interactions have influenced my practice over the last 23 years. One special patient continues to remind me to remain patient-centered and provide nonjudgmental, holistic care.

Cari L. Allen, RN
Cari L. Allen, RN

One day, I was performing an intake assessment on “Annie” who was being transferred for inpatient psychiatric treatment following a suicide attempt. She had been described as agitated at the transferring facility, requiring PRN medication and restraints. Staff had been assaulted physically and verbally. The nursing handoff was peppered with words such as “manipulative,” “attention-seeking,” and “uncooperative.” Reading through the clinical evaluation, I saw evidence of an extensive history of abuse, multiple suicide attempts and self-injurious behaviors.

The transport staff brought Annie into my office. While sitting with her, I asked several questions that were met with angry responses or an obscene gesture or shrug. I continued the interview and offered her something to eat and drink, a blanket and the opportunity to call a support person to be part of the interview.

When I asked Annie about her home life, childhood and trauma issues, her demeanor changed. The anger turned to a deep sadness. Annie recounted numerous abusive atrocities she experienced throughout early childhood and more recently. I could not imagine having to live through those experiences. “I am sorry that all of these things have happened to you,” I said. “You didn’t deserve to have that happen.”

Her aggressive and angry edge began to dissipate. “Thank you,” she said. “No one has ever said that to me before.”

Annie has been offered help by many healthcare professionals over the years, and while I don’t believe I was the first to say those words to her, I believe she was responding to the fact that the message was delivered with genuine kindness and sincerity.

As we finished the interview, she said, “I didn’t mean to hurt those people, you know. All I have is my rings that they wouldn’t let me keep because they said I would hurt myself with them. I have three babies who were taken from me and those rings are the only things that keep me going some days. I hope to give the rings to [my children] when they are older. They are gone now just like my babies. Thank you for being kind to me.”

The next day I stopped at the transferring facility and tried to track down the rings without success. I saw Annie several times over the next few days. She was no longer having episodes of anger or violence, but instead was experiencing despondency and a debilitating depression.

Surprisingly, about a week later the transport company delivered an envelope to me with the rings inside. I took the rings to Annie. She grabbed my hands and began to cry. “Thank you,” she said. “These are my hope.”

I have taken many de-escalation courses over the years, and the bottom line has been that aggression is a way to communicate when all other communication has failed to address fears or meet needs. If we keep that in mind rather than labeling or judging when an individual’s behaviors are escalating, we can make strides to break down barriers and facilitate healing.

I have heard healthcare professionals say they could never work with psych patients. But no matter what specialty you work in, at some point you will care for someone in a psychiatric crisis. It may not even be a patient, but possibly a patient’s loved one or a co-worker. Mental illness does not discriminate, and while strides are being made, stigma still exists.

My interactions with Annie early in my mental health career allowed me to learn the value of accepting people where they are in their journey. The key to developing and maintaining rapport is speaking from the heart while being mindful of therapeutic boundaries. Ask yourself what fear the person has that is not being addressed, and how you can keep him or her safe while addressing the person’s needs. •

To comment, email editor@nurse.com.


About the author

Cari L. Allen, MSN, RN 

Cari L. Allen, MSN, RN, is a trainer/auditor for Sunflower Health Plan in Kansas. After eight years in nephrology, she developed a serious contact dermatitis and needed to find a specialty where she could avoid plastic, latex, vinyl and nitrile. Fortunately, she found psychiatric nursing.

13 responses to “There’s more to her than mental illness”

  1. My mother, also a nurse, told me that any patient who is complaining, angry or uncooperative are really “just scared. Many of them are scared to death.” I found that
    to still be true after 56 years of nursing.
    This is an important issue that you are addressing. Thanks.

  2. HI,
    I just wanted to comment about the early part of Cari’s article, where she is given report including words like attentio-seeking, manipulative, etc.
    I am often stunned when getting report about “how problematic” my patients are going to be. I’ve been lucky to somehow ignore that and it almost always turns out that I have great patients and we develop fun and caring relationships. I often offer to take on the “hard’ patients because it always turns that they are now. It is unfortunate how easy it is to color the on-coming nurse’s evening by providing opinionated reporting that is often reflects the “passing on” of bad information that becomes a predictor of the patient’s behavior because of the attitude that nurses then take into the room. Most patients just want to know that someone cares about them and their behavior changes very quickly to the positive.
    Daniel Scheffer RN

  3. Thank you for sharing this very powerful story. My husband prays with people in our church and you never know the “story” in peoples lives. We all have a story, sometimes more tragic, painful and even confusing or bizarre at times than other peoples. Before you judge, remember its not your story…its theirs and it has meaning and influence on their life, with lasting impression that shape and mold who they are and how they believe or respond to events. Our job as healthcare providers is to offer compassion and healing.

  4. Your compassionate response touched Annie through your genuine acknowledgement that she is valuable and did not deserve what had happened to her in the past. “Aggression is a way to communicate when all other communication has failed to address fears or meet needs.” this is a very important observation and something to remember, especially when we are the objects of the aggression. Get curious, this may not be the time to ask questions, at least within yourself acknowledge what your gut says might be the need or the fear.

  5. I love you Cari!! This woman used to be my supervisor and is quite honestly one of the most wonderful women I have ever known. Working is psychiatric care has always been an honor for me. Thank you Cari for such a great story!!

  6. Thank you Miss Cari for this beautiful message…something we need to know, reflect, and be mindful of everyday not only as nurses but humankind.

  7. In health care we tend to use negative words to describe our patients. The best example is a sweeping generalization of “non-compliant”. Who’s in charge of their care? Us or them? Why are they “non-compliant”? Often it boils down to two things; communication and relationships. If we listen more than we talk we can break it down into why they can or can’t perform something. Or identify alternative therapies that are also effective. That’s a ramble but working with nursing students I want them to not judge and look through the lens of the patient. “My hope” is that all patients have their own “rings” to pass on! Thanks for all nurses do!!

  8. Thank you for sharing. I so agree that taking the time to listen and be present with most people brings out the best. I try to purge words like “manipulative” and “non-compliant” from my vocabulary.

  9. I have encountered anger and aggressive behaviours in patients and did not realize that all other avenues of communication had been tried to meet needs and ego (?) and this resulted in the behaviours. Great information to use. Open up other avenues of communication that are appropriate to setting and offer my attention and listening skills to facilitate this. Don’t expect someone else to do what I am not willing to, have neglected to do ( in this case because of ignorance on my part), or used the non compliant excuse as a wall to effective input on my part. I am not a lazy nurse and am glad I have a better understanding of ” noncompliance and manipulation “, thanks to this author.

  10. This article is very informative. Every healthcare professional should always try to be empathetic. As a young nurse, I was hoping to avoid psychiatric patients. What happened was the first unit worked was Med-Surg. Almost every patient who I cared for had some type of psychological issue. These unresolved issues showed up in the evenings or especially at night.

  11. Thank you Cari for such a thoughtful assessment of how mental illness can effect both the patient and those caring for a patient in crisis. The person in crisis is simply facing a difficult season with the need for a listening and understanding ear (and warm heart).

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