My Secret Weapon: Psych Notes Pocket Guide

Please let me introduce you to Psych Notes Clinical Pocket Guide. I often refer to this as my "secret weapon" while I'm at my internship, because it contains all kinds of great assessment tools, disorder overviews, intervention techniques, and a lot of other useful information for professionals who work at an inpatient psychiatric hospital.

I am constantly referring to it when I conduct biopsychosocial assessments, interact with new patients, or write notes in patient's charts. I think this is a great tool for anyone who is entering the field of psychiatry, whether it be nurses, therapists, social workers, etc. The notebook is dense, but really compact (note its size compared to a computer mouse), making it great for portability. 

Psych Notes is divided into seven distinct sections including basics, assessment, disorders/interview, drugs/lab, drugs A-Z, crisis, geriatrics, and tools/index. This makes it incredibly easy to locate the information I need.

The basics tab contains an overview of various psychological theories including psychodynamic (pictured), psychosocial, and interpersonal. Additionally, biological aspects of mental illness, issues related to confidentiality, HIPAA, and patient's rights are also covered.

I frequently use the assessment tab, as it guides the components I must cover during a biopsychosocial interview of incoming patients.

Because the DSM is a bit cumbersome to reference (especially when time is of the essence), the disorder overviews are particularly helpful when trying to evaluate a patient's presenting symptoms, and a possible diagnosis.

Considering the low cost, I think Psych Notes is a great investment to students or new social workers to the field of mental health. Plus, it's water proof, which really came in handy last week when I spilled coffee all over my desk!

















The entire notebook is also available to download via Scribd. Enjoy!

Psych Notes - Clinical Pocket Guide Scanned

How to Engage a Difficult Patient

Alyssa* is a 45-year-old Eastern European female admitted to the inpatient psychiatric unit for being a danger to others and for being gravely disabled. Alyssa’s landlord contacted Santa Monica Police after she threatened to kill tenants living in her building. Law enforcement brought her to the hospital after she verbally threatened to stab the police with a knife hidden in her nightstand. Upon arrival, Alyssa was extremely paranoid and claimed that numerous individuals are plotting to kill her. Upon a Biopsychosocial assessment, Alyssa threatened the social worker numerous times, stating that if she wasn’t discharged immediately, she plans to sue the hospital and have the treatment team arrested.

The above vignette is a common example of the type of patient I see on the inpatient unit at Harbor UCLA Medical Center. As a social work intern, interacting with patients who believe they do not belong on the unit is incredibly challenging. When interviewing or assessing newly admitted patients, it is not uncommon for patients to verbally threaten me, make snide or rude comments, or sit in silence. To be fair, it is completely understandable that patients are frustrated, angry, or embarrassed when they are legally required to stay at the hospital.

After trying a number of different ways to engage with patients like Alyssa, I now have a few go-to strategies that strengthen rapport, and ultimately, increase my ability to help patients during their stay.

1. Encourage Med Compliancy: While this might be controversial, I often tell patients that a surefire way to expedite discharge is through medication compliancy. This is a great way to align patient goals with those of the treatment team, as patients tend to stabilize much quicker when consistently adhering to medication regiments. Plus, there is no question that length of stay for those who take medication is shorter than those who don’t.

2. Alleviate boredom: Whether it’s retrieving a bible, a magazine from the hospital gift shop, or requesting the occupational therapist to play a song during exercise group, finding small ways to alleviate boredom allows me to form an alliance with patients.

3. Contact Collateral: Contacting patients’ family or friends can be a great way to connect with a difficult patient. Because patients do not always have change for the payphone or have access to the phone at the nursing station, I will often bring patients back to my office to make a phone call. The sentiment is definitely appreciated, especially when a patient is calling long distance.

4. Catch Patients Doing Good: Due to the nature of the inpatient milieu, the treatment team often focuses on patients who are either disrupting the unit, or refusing the take their medication. I have found it to be extremely important to “catch” patients who exhibit good behavior. Verbally reinforcing these instances is not only a chance to build rapport, but also shows the patient that the treatment team genuinely wants to see improvement.

5. Internet Research: Whether its providing patients with a brochure to an outpatient care provider or looking up an address so they can write a letter, conducting quick internet searches for patients can help link them to outside resources.

*Patient identity has been concealed.

You Say Mercedes, I say Mental Illness

"God is playing jai alai and you are the ball" 

Dan Neil, a Wall Street Journal reporter recently wrote this catchy description for a review of the new Mercedes CL63 AMG. While I thought this was a cute way to the describe how it feels to accelerate in the coupe, I could not stop thinking about how well these words describe the psychotic symptoms of mental illness, specifically the delusional and hallucinatory symptoms of schizophrenia and other thought disorders.

As an intern for Harbor UCLA Medical Center for the past three months, I have been exposed to a number of patients who are battling severe and persistent forms of schizophrenia. Patient's minds are often transfixed or paralyzed in nightmarish, violent, or persecutory states. Extreme distortions of reality can often have scary and real consequences.

For example, a patient was recently admitted to the inpatient unit after experiencing harrowing ideas of reference. Chorus lyrics from a rap song spoke to the patient in such a way, that he exhibited homicidal ideation towards members in his family. The patient internalized the lyrics and started to believe he was a God-like figure. He reasoned the only way he could preserve his status was to kill members of his family. Fortunately, the patient was admitted before he acted on any of these thoughts.

Another patient, also suffering from schizophrenia, held highly persecutory beliefs concerning her family. The patient was extremely paranoid, and believed her family worked for the FBI and they were plotting to kill her. The patient became distrustful of everyone around her, including her family and the treatment team.

As evidenced by these examples, patients succumb to an outside force that is much larger and stronger than themselves. As one does with a jai alai ball, these patients are figuratively swung around, flung high, and slammed by a disorder that pirates their perception of reality.

Outsiders might stigmatize these experiences as crazy, ridiculous or downright nonsensical. But to victims of mental illness, these experiences are tangible and overpowering. What is even more frustrating, is medicine to treat thought disorders does not suppress or eradicate delusions or hallucinations; patients simply have to learn to live with them.

Photo credit: Jamespot

Shockingly Unshocking: Observing Electroconvulsive Thearpy (ECT)

Last week I did something that I never thought I would do; I watched a doctor administer ECT to a patient suffering from Bipolar Affective Disorder. ECT is often administered to patients who are treatment-resistant to other, more traditional forms of treatment such as medication.

The patient receiving ECT was resistant to a variety of MAOI med cocktails and other anti-psychotic drugs. Because his delusions (increasingly present in his manic state) were becoming unmanageable, the medical team decided ECT would be the most effective therapy in controlling the patient's delusions. I was present for patient's 14th session.

Prior to observing ECT, I was extremely anxious about witnessing a violent seizure, largely because of preconceived notions I gained from watching this scene in One Flew Over the Cuckoo's Nest:

The reality of the procedure could not have been more different from this scene. The tongue plate inserted into the patient's mouth (to prevent the patient from clenching their teeth or severing their tongue) was the only similarity.

In the operating room, every detail is controlled, with the procedure lasting only five minutes. The patient is put under an anesthetic and remains unconscious for the duration of the procedure. Once unconscious, the patient is administered medication to enter a fully paralyzed state (with the exception of the feet), and then administered a seizure-inducing medication. Two electrodes are placed on the patient's temples, to which the doctor is able to administer the electroshock waves to the patient's brain.

Successful ECT elicits a 15-30 second grand mal seizure. Researchers are still unable to determine why ECT is effective at treating individuals with severe mental illness, but its benefits have been widely documented.

What was surprising about the ECT session, was how little the patient moved throughout the procedure. If it weren't for his toes wiggling back and forth, or the EEG spitting out a brainwave scan, I probably would not have noticed the patient received ECT at all. 

The reason I felt it was important to document this experience is twofold.  

1. Misconceptions about ECT are rampant. So many of us cringe when we hear someone suggest ECT, often because we automatically think of the media's portrayal of what ECT used to be.  
2. If administered correctly, ECT can be one of the most painless and effective intervention methods for patients suffering from extremely debilitating illnesses.

 

Many of us are are biased towards ECT because we too often associate the therapy with violent and negative outcomes. I hope this post elicits a more positive perception of an intervention that has been misconstrued for decades.

UCLA MSW Field Internship: Exposure to the Other Four Senses

Trying to describe my internship at an inpatient psychiatric unit, feels like trying to explain stage-fright to someone who has never been on a stage... or better yet, someone who doesn't even know what a stage is.

I have interned only two days at UCLA Harbor Hospital, and I can already tell I have my work cut out for me. The psych ward is staffed with two doctors, four residents, three to six nurses (depending on the shift), and two to three clinical social workers. The ward has 24 beds (12 of which are currently in use), a nursing station, two seclusion rooms, a cafeteria, and a place for patients to lounge. The office I share with my supervisor is tucked behind a hallway on the floor of the ward. The office door is always bolted, and the office comes equipped with a panic button (something I hope I never have to use). 

The image I just described might sound familiar. Nearly all of us have some notion of what a psych ward looks like, probably due to Hollywood's portrayal of them in the classic film, One Flew Over the Cuckoo's Nest, or more recent films, Girl, Interrupted and Gothika. I have to say that Hollywood does a pretty good job of depicting what a typical psych ward looks like: a white, sterile environment, with patients wandering the halls in hospital gowns.

While these films accurately depict the scenes of a typical psych ward, they only offer a loose sense of what it is really like to be present and interacting with patients in the unit. To give a more compelling idea of this reality, I'd like to push beyond the sense of sight by detailing how my other four senses (hearing, smell, touch, and taste) are actively engaged in the psych ward.

Hearing: The most shocking part of working in the psych ward are the sounds I hear: patients screaming, singing, shouting, rambling, crying, mumbling, etc. I was quick to learn about Code Green (combative person/elopement risk/person with internal disaster), when an unruly patient burst into rounds and had to be restrained by security and the nursing staff. Later that day, I encountered one patient who, according to the nursing staff, had been belting out lyrics for six hours straight, and had to be moved into seclusion so she wouldn't disturb other patients. Lack of sound is surprisingly shocking as well. In contrast to the patient who was singing, I met another individual who has not uttered a single word for over a year.

Smell: Being a state hospital, UCLA Harbor receives its fair share of homeless individuals. Regardless of whether the patient is homeless or not, patients are encouraged to shower everyday. However, no one is forcing them to do so. As you could imagine, it's not the most pleasant to conduct a psychiatric intake interview when someone hasn't showered for multiple days or weeks. On the bright side, all hygiene is documented in a patient's chart, so at least I know whether or not they have showered prior to when I interact with them.

Touch: Physical interaction with patients is limited, nonetheless, it happens. A patient, for instance, reached out to shake both of my hands, and held them for what felt like an eternity. His hands were shockingly cold, dry and frail. Moments later, he volitionally fell on the floor. When I grabbed his arm to help him up, I was shocked by how light his body was.

Taste: I'm not sure if it's the hand sanitizer stations, the lingering smell of rubbing alcohol, or the combination of both, but I seem to barely have active taste buds by the time lunch rolls around.

I can say, with confidence, that I have never had such eye-opening experiences in such a short amount of time. Who knows what the next 8 months will bring, but I certainly welcome the challenges that will no doubt come my way.

Photo Credit: loojie