Thursday, March 24, 2005

Delusions & Plans

I had a patient today with the most horrifying, absurd and imaginative delusions I've come across. They involved male genitalia, a Western European ethnic group, canine excreta and an unusual substitute for water. We're taught to "redirect" patients having delusions and focus them on other, less inflammatory ideas. Also, we're supposed to reassure the patient that they are safe and that the delusions are a symptom of their illness. This is really hard to do and my patient wasn't responding to any of this redirection business. The only way I found to distract the patient was to have the patient help me fill out a survey that itemized just how depressed the patient was. The patient loved the survey. I decided talking about depression was slightly more therapeutic than talking about the maligned ethnic group and what they do to male genitalia.

However, one of the questions concerned killing yourself and my patient admitted having "suicidal ideations" and had a plan to carry them out. Having a plan is considered to be the #1 warning sign as it suggests the patient is serious and not just enjoying the idea of no longer existing.

"OK," I said. "Hmmm. Well. Could you just hold on? I'll be right back" [nursing student flees and returns moments later with a real live psych nurse] "Ummm, could you just repeat to Nurse X what we were talking about." The patient did tell the nurse what the patient told me (to my relief) and it was duly noted. So that was my first suicidal patient. Pretty awful.

My best friend in the program worked in psych before coming to the program and is accustomed to leading group therapy sessions and implementing "cognitive behavioral therapy" (helping people adjust their thinking/processing methods to be more positive and adaptive). Today, our clinical instructor actually let my friend lead a session and she was amazing. I couldn't believe how well she managed a group of about 15 people including about equal parts of dementia, schizophrenia, depression and substance abuse. She had them read cards with positive thinking statements ("I can learn to be peaceful!") and say how these statements related to their lives. If they said they couldn't relate to the statement, the rest of the group was encouraged to help the person figure out that at least in some small way, they did embody the positive statement.

You would think this would be a total disaster, no? It wasn't. It was great! The patients (especially the subtance abuse patients) spend so much time focusing on how miserable they've been and how miserable they are, that they're not used to saying nice things about themselves and others. I was really surprised and so proud of my friend.


Anonymous SWG said...

Unlikely RN -

I've been reading your blog for the past few months, in anticipation starting the accelerated program at the SON in June. As you can imagine, and probably understand I am excited and nervous! I would love to be able to chat about your experiences there.

9:49 AM  
Blogger Ilan Muskat said...

Wow. That's almost a heartwarming story at the end right there.

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