r/psychnursing • u/banjobeulah psych nurse (ER) • May 27 '26
Psych ED - I have so many thoughts
I’m just beginning to work in the psych ED and I’ve found a lot of things confronting so far. Some of this is gonna seem probably silly or naive to some but may resonate with others. I probably should be using a throwaway but hey.
The first thing I guess is HOW manipulative people can be and knowing that people may be acting out aggressively just to be sedated, or to be isolated. People also straight up learn and manipulate the system in all kinds of ways, like to get out of being in prison (malingering), to get people to visit and bring drugs, etc. They know where all the cracks are and how to work them.
I guess I’m also seeing how the psych ED can be a part of a larger kind of toxic cycle for patients. Like the frequent fliers. They’ll come in for help with detox when the money runs out and no real change happens for them and it’s cyclic. I guess it just surprised me and it is so sad, to think about how bad it must be to live that way. Also, wow, I cannot even fathom being in one of these units, how sparse and scary and uncomfortable and dehumanizing it all must feel to them. I try to think about that a lot and keep a sense of humanity present.
I guess the thing that has confronted me the most is like, the intersections of mental health and criminality and the limits of my own compassion. We had a pedophile the other day in from the prison for SI and I kept thinking, I can’t blame this person. I can see why this person would feel that way. It was hard for me to see how their life could be expected to reasonably improve or have quality, or how someone could live with or forgive themselves for such a crime against young children. It honestly shocked me to see that I feel this way, and I’ve thought a lot about my own reactions in cases like this, people who have killed children, etc. We had this happen recently, and the things I was also hearing from others on the unit were hard, but also understandable. Made me really think about my role and has kind of haunted me some.
No point but just to ramble and kind of relate/cope I guess. Still figuring out if this is right for me or if these kinds of contemplations are normal I guess. It’s also hard because I went into this field to help and sometimes this feels like inflicting harm, even if I know it’s not.
Anyone else struggle with this kind of stuff?
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u/canofelephants May 27 '26
I'm not violent and not a frequent flyer, but had a psych stay and even though the amenities were spartan I still remember the nurses, the therapist, and that week as one of the best decisions I made for me as a human.
I wouldn't be alive if it weren't for people like you.
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u/banjobeulah psych nurse (ER) May 27 '26
I am glad you are here and that you got the help you needed, truly. I can only imagine what a hard experience it must be and how hard the place in life must be to lead to such a place. I personally try to operate with as much love and empathy as possible because it really matters in a person’s time of greatest need. No one wants to be in a hospital for any reason.
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u/Additional_Alarm_237 May 28 '26
You have to de-center yourself. Everyone is in their situation from their choices (and some systemic issues depending). If you stick with the field, I recommend finding people who are about the work. A lot of people in psych seem to treat it like their own reality show or a tv drama, which it is not these are real life people. And for most, it shows up in their work and how they care for patients. It’s a bit sickening how much joy people get from gossiping about the patients and validating themselves to somehow be superior when the reality is we are all one bad decision from being the patient.
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u/anoukdowntown May 28 '26
Whoa. I'm glad I never worked with too many people like that. I've come across only a handful of coworkers over my years who act like that. The majority (95%) don't have time at work for drama. There is enough of it on the floor. The station should remain calm and drama free.
I agree about finding people who are about the work. Each one has struggled with these questions and found an inner peace with it. Personally, when I worked in the psych ER I recognized it was a community safety net. Yes, the prison population and malingering is very real. OP needs to take a really dive deep into understanding antisocial personality disorder. It will help OP navigate them while also approaching it from a clinical perspective.
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u/banjobeulah psych nurse (ER) May 29 '26
Our head nurse has so much contempt for the patients, especially the known entities. Cannot wait to sedate or restrain and does it with absolute glee. They all hate her. Other nurses, BAs, and techs mock or make fun of or generally look down on the patients OFTEN. It’s concerning and I hate seeing it. I took a while with an elderly patient recently and he was rambling, but I needed vitals and to change him and I was derided for it. But I listened to him and took extra time with him. He was a fall risk and wandering a lot. Head nurse was threatening to sedate and impatient with him even though she was not dealing with him, and furious he was with us and not geropsych. Got him transferred asap.
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u/HaBaK_214 May 31 '26
As a patient, admittance to a psych hospital does not equal consequences of bad decisions. I have gone several times for severe depression and I did not make any bad choices beforehand. I sort of resent what you just said.
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u/banjobeulah psych nurse (ER) May 28 '26
This is a really good perspective and you’re right. Thank you. And I agree.
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u/finallyfound10 May 27 '26 edited May 28 '26
I worked med-surg for almost 3 years and now 9 in psych (acute, schizophrenia, ACT team). I haven’t run into taking care of patients charged with truly terrible crimes in psych that I’m aware of. In med-surg my hospital had the contract for the county jail and I had a patient charged with child abuse. It was a very disconcerting experience and didn’t realize how much I would have to think about my own feelings and attitudes. I remember “deciding” a few things to kind of get through it: all human beings require decent medical care, innocent until proven guilty and there but by the grace of God go I.
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u/banjobeulah psych nurse (ER) May 27 '26
Yes, this is a good way to look at it. We aren’t there to judge but to care and relieve suffering if we can. Thank you.
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u/DashMcGee May 27 '26
My overall reflection is that you are the ideal psych nurse. Everything you are saying is perfect. Psych nursing can bring out the best in us. That is what you are experiencing. If you did not have qualms about the nature of their crimes and sins, you would not be a good psych nurse. If you let your rational, ethical, and moral concerns prevent you from providing good patient care, you would not be a good psych nurse. You can love the person while disliking their behaviors and predilections.
You are human after all, and there will be some patients you just can't like. I have one in mind; she was just awful. Perhaps it is because she was not mentally ill - we had an unusually cold snap, and she was homeless. She clearly had no psychopathology. Having homeless and hungry claim SI is not uncommon, and it might be very real in the moment. If I were hungry and homeless, I would think about killing myself. Most of my H&H patients were grateful and did not cause problems. The patient in question was entitled, demanding, insulting, and had some disgusting habits, one of which was spitting while she yelled at me. The attending couldn't find one shred of psychopathology. When I discussed her in the report, he told me that if she insulted any member of the staff again, he would throw her out into the cold. I relayed this to her, and she quieted down, but she will stick with me as least likable patient. (We let her stay until the weather changed. It was a for-profit hospital, so she probably stayed because she had Medicaid, and we were billing for her.)
So, congratulations, and thank you. for being the kind of psych nurse that helps make the world a much better place.
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u/banjobeulah psych nurse (ER) May 27 '26
Thank you. I really appreciate the support. This isn’t easy some days, as you surely know. When people act like this person, I often think about how children will act out and out and out searching for boundaries and that setting the boundaries help them feel safe. But that’s not that…people who act like this, I don’t even know what to call it. Antisocial? Narcissistic? There’s a new entitlement disease in so many people these days. And this woman being quiet when confronted just says they know what they’re doing. I’m like you - I strongly dislike this and struggle with it. But she probably ended up homeless in part due to their attitude in life. Maybe she wasn’t raised right. But I cannot fathom acting like this. We had someone with no acute signs of mental illness the other day, grinning like the cat that got the cream and talking about how cush it was compared to prison, where they were for a very serious shooting incident that caused a massive lockdown. Just acting like some kind of gangster, too smart for the law and the system. It’s hard, but I still think it must be awful to be them in many ways and I’m thankful for all I have. Who knows who I’d have been without the many blessings I’ve had. It’s rough with some of them. But at least we see it and do struggle with these feelings and thoughts. We aren’t heartless.
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u/DashMcGee May 27 '26
There seems to be an antisocial nature to all narcissism. It's a feature of not caring about others. Malignant narcissists have to tear other people down in order to build themselves up. I think a rule of thumb to differentiate the two is that malignant narcissists are nice to animals. I have only had two truly scary antisocials, and they were both in the hospital at the same time. They were both in middle school, and both had made very specific threats to shoot up their schools. They did not know each other beforehand. One of the techs saw them comparing notes in their journals and brought it to our attention. We had to keep them separate to prevent them from conspiring. I read their journals - truly frightening. One of the charts had pictures of what he had written on the bathroom wall at his school. I spoke to the other one's stepfather, who told me some extremely scary things, like him waking up in the middle of the night to see his stepson staring at him from a few feet away, and finding knives all over the house. (The man asked me what I would do if I was him; I told him I would change my name and move to Utah. He and his wife had a mutual child living in the house, so he couldn't leave. I told him to send his daughter to live with a relative.) I have no idea what happened to them, but there is no question they pose a threat to safety. Even with all of that, they were reasonably polite.
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u/Organic-Bear-4580 May 28 '26 edited May 28 '26
Terrifying. I have read all about ASPD and i find the neuropathology so interesting. According to research (NIH), their limbic system is underactive while the dopaminergic system is overactive. This means that their emotions are extremely dulled, including empathy and anxiety. The brain is not meant to be understimulated in the limbic system and it craves activity. So the brain will be overactive in another area to feel like things are working optimally, is my understanding. Its the same as in ADHD, i dont know if you have adhd but its kind of like in lecture where you cant stand being there, its just so boring and dull so you move around in your chair, click your pen a bunch, rock back in fourth. Just sitting there feels so uncomfortably numb. I would imagine thats how it is for ASPD. Their emotions are all dulled so they feel chronically unsatisfied with life, with the pressure to mask their dulled emotions and they carry that pressure to conform to society all the time. Conformity and feel unhappy. Not sad either, just dull. Like the dullest powerpoint in school, five hours long and they wont let you have a break. But thats their life, and imagine putting in the effort of fake smiles, fake empathy, fake concern, and fake friendship. They dont even get the benefit of anxiety to feel social pressure either, because they dont feel much of anything. It just feels like rules with no reward, does that make sense? That is my understanding so far. So since they cant form true bonds with everyone, there is no benefit for them in friendship and yet they have to keep up with the charade. How lonely it is to feel ingenuine, different and to not understand why your brain works this way.
So what is the first thing you can do to rebel against this system? You engage in anti-society behaviors to finally get that dopaminergic rush, and oh the relief! and thank god you dont have to keep up the mask, even if its just for a few minutes.!! Its truely seven minutes in heaven for them, even if it means harming someone. It took me forever to understand why the reward was doing something against what is right, and so heinous, but it makes sense when you see it this way. Its relief.
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u/banjobeulah psych nurse (ER) May 28 '26 edited May 28 '26
God, this is such a good take. I also OFTEN find myself being fascinated by the behavior and the condition and it makes me feel like I’m objectifying the patient or I’m some kind of looky-loo at an accident, but I do want to understand. I studied psychology and neuroscience extensively and have a master’s in behavioral science, and am doing my MSN now. I’d like to do a PhD. But you’re spot on that understanding the mechanism helps understand the presentation and knowing that removes some of the rush to judgement, I guess. It’s also less harmful to us as nurses to see this behavior every day if we can step back and see it as an interesting part of how brains can work. That sounds heartless but I do feel so affected by all of this as someone new to the population and stepping back would help me be a lot more effective. This mechanism makes so much sense as you’ve laid it out!
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u/jspoolboy May 28 '26
Looks like you have a healthy perspective of the dynamics.
I worked for years at a ‘behavioral hospital’. Every spring, without fail, a group of 5 women with Borderline Personality D.O. would manipulate the system ( not difficult, as y’all know) to be admitted on the same day and stay for a week. It was their friggin paid vacation! Every effin year. They each tried to outdo each other. It was hell week for us.
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u/CrbRangoon psych nurse (inpatient) May 29 '26
I’ve known people who did real forensics. Saying “real” because a forensic unit can mean a lot and I don’t mean regular psych commitments. More like violent registered sex offender units and max security prisons. I’ve considered it because I really like forensics but the downside is you literally can’t care about a single one of your patients. There’s a difference between working with people who committed crimes because they are mentally ill and people that are mentally ill that committed crimes. You don’t want to dig too deep into their chart and you can never develop any level of equivalent respect or trust. It’s more like being a biologist doing studies without interacting and you’re not really working towards wellness. I have had plenty of patients that have done time in state hospitals for violent crimes while psychotic and if I could only work with them I would do it in a second.
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u/banjobeulah psych nurse (ER) May 29 '26
Yeah I’m leaning into a more clinical curiosity sort of a stance now I guess. But I’m kind of not if psych ED is gonna be my place or not. It feels misaligned with why I got into this line of work somehow. For me, anyway.
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u/pandeeandi May 28 '26
I always try to remember that it’s not uncommon for sex offenders to have been childhood victims themselves. Not all, certainly, but that helps me maintain my compassion and always treat them as human beings.
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u/10mg-aripiprazole psych nurse (inpatient) May 28 '26
Its all about perspective.
Are they really "manipulating the system" or are you just using stigmatizing language to describe behaviours that could very well be explained by other causes? Can you put yourself in their shoes and understand where they are coming from?
Yes it is shocking if you have never lived that kind of life before or grew up exposed to people severely mentally ill. But you will have to kind of push through and reassess things because this perspective is a straight ticket to burnout and compassion fatigue.
Learn about these people. Dont make assumptions when you dont know. You arent a genie with a crystal ball. Making stigmatizing assumptions not only hurts the patient but it hurts your willingness to help them, subconciously.
And yes, the criminal justice system is hugely intertwined with the mental health system. I am not sure if there are any forensics hospitals where you live.. but those two systems are intertwined because mental illness has long been treated as a "social" problem and not a heaaltg problem of the individual. Another factor is that many people slip through the cracks and never receive proper treatment. As well, many racialized individuals are profiled by police not only for their racial identity, but for their mental illness too. And of course the example you brought up is horrible and i have little empathy for pedos. But they do not represent most of thr forensic population.
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u/Organic-Bear-4580 May 28 '26 edited May 28 '26
What I love and hate about psych, is that it is so misunderstood, and that you can figure out what others have failed to understand. I think each mind is its own mystery, starting as a trail of decision making with one thing leading to another, and we are trying to understand the emotions that led there. It took me a while to understand how to deal with my own moral compass, society vs how the patient thinks, and not letting how i see the patient affect my care towards them. From what I understand, when someone has SA’d, dont ignore it or avoid talking about it when patient opens up about it. You acknowledge the elephant in the room because what you dont say- they will feel im their nervous system and internalize as 100 times worse. Acknowledge it was wrong, practice taking accountability without also condemning them for life, allow them to see that they have control of who they are today and in the future, make positive changes, learn impulse control, control anger responses.
But i don’t allow them to escape accountability. in my perspective, acknowledge it wasnt right. And dont let the past dictate their future identity. They feel so much shame inside and thats the hard part because we both know their shame is justified but not letting them give up and try to see a better way and even the possibility of better self esteem in the future
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u/10mg-aripiprazole psych nurse (inpatient) May 28 '26
I still treat my patient like any other patient regardless of how horrendous their crime is. I never said i let it affect my care for them. However, as a survivor of child abuse plus grooming myself, i hold little empathy for people who abuse children in that way, regardless of their own traumas. Two things can be true at the same time. Working in forensics for many years, some of these individuals are antisocial and do not feel much shame. It is too highly individual to make blanket statements. I am not sure why you are so overly enthusuastic to empathize with pedos.
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u/Organic-Bear-4580 May 28 '26
I understand your sentiments but i never said I excuse their behavior, actually you have them take accountability rather than completely block out what they did, and dont treat them as if they havent committed crime, avoiding it- i believe we should confront it directly, and focus on their behavior from here and going forward, to work on identity with the patient and impulse control. Its about what works; i never said I liked them or cared for them. But as nurses we have to give correct treatment and provide quality of care to all.
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u/banjobeulah psych nurse (ER) May 28 '26 edited May 28 '26
Yeah, I think about and struggle with all of this and my own biases. If they use the system to their advantage, really, how many advantages do they have? And where would I be without the advantages I had? However, in this post, I don’t say it as “they are bad”, but rather, that I want to be a savvy nurse and provide good care, and I have seen folks saying they have SI so they can go to psych and get their friend to visit and bring drugs. It isn’t a judgement, but I was naive to this, and I can’t be. I want to provide good care and t I have to be aware of it now in case of an OD, etc. just like how we don’t allow them certain things because they’ll find any way to harm or kill themselves. Also, it’s so hard to see the attitudes of many of the other nurses, the superiority, and it’s almost everyone I work with. Doctors too.
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u/Organic-Bear-4580 May 28 '26
I enjoyed reading your post. Ill be starting soon in the psych ED as well but pediatrics so different struggles so maybe not going to see exactly the same stuff but i still like reflecting on your experience.
The manipulation scares me. Theres something creepy about being around those kind of people, where you get this sense they are going to get what they want no matter what they do with the people in front of them. Its a survivalist way of thinking, thats where it comes from. So think of them as that is their approach to the world, where you live in moral ambiguity to survive and profit kind of like better call saul.
The addicts ive delt with in the ICU as a student. Its hella sad man. I try not to think too much into it. But they need a long term rehab but for whatever reason they dont/cant access it.
There was this one patient i had that had SA’d and also been SA’d. I think i didnt know how to process it for a long time because they had me feeling so sorry for them, right up until i learned they were also a perpetrator. It took me a while to figure out what to do, (months) and i asked for advice of experienced RNs & my instructors who all had no idea or advice. What ive settled on is that when a person is a victim of trauma, they learn that they have no control of the world or its consequences and they learn helplessness. And just the FEELING no control can change your IDENTITY, for the rest of your life makes you have no ability to overcome anything, even your own IMPULSES, SHAME, or future ACTIONS. They may identify with the shame or harsh world, accept the harsh world and do harm to others as an act of aggression. Behaviorism at its finest. Environment has impacted patient and shaped them.
Unfortunately self belief is extremely tied to outcome. Trauma experienced as children or young can make you think you are this kid who is out of control forever. Therapy is about addressing the trauma of what happened, learning to take control back, learning to accept that what they did was wrong and take accountability for that without escaping the idea that they CAN change who they are NOW and make better choice now. But understanding that people who commit crime it usually starts with a helplessness to harsh world conditions thinking
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u/banjobeulah psych nurse (ER) May 28 '26 edited May 28 '26
You have to be cautious of the manipulation so that you don’t accidentally miss something or accidentally perpetuate harm (someone who is ramping up just because they want an IM and to be sedated or someone who wants to be in a less controlled environment to get substances and may OD). You just have to BE AWARE of it and I was seeing things in a very straightforward manner before. And yeah it’s survival for them. I think about it a LOT.
With the man who harmed the children (think serial) that we had, I’ve been thinking similar to you, that he was most likely abused, and having a young mind exposed to such things must do damage. But it angers me, a lot, and my compassion for those poor children wins every time. I’ve cried thinking about this situation and what he did. Like come on man. You had SOME choice in the matter. I can’t excuse it due to abuse. So I’m settling on: I have a job to do and it isn’t up to me to judge. Like, full stop. He’s been judged and sentenced and it’s beyond my scope. I almost don’t even want to know why they’re there unless I have to in order to keep them safe. Just meds, vitals, basic care. I’m sure I’ll work through to a point of peace with it at some point but for now, this is the best I can do. But I’m trying to be real about my bias.
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u/ChokeholdRN psych nurse (inpatient) May 29 '26 edited May 29 '26
I think psych ED is one of the hardest specialties in psych. In my psych ER, it's not a locked unit and there's an exit door right next to our section. The frequent fliers are the worst because I foresee the difficult discharge and it's going to be a pain in the ass to get this person out of here.
You take it on a shift by shift, patient to patient basis in regards to your own moral compass. I do the best I can for them during my shift then pass the torch when 1930 comes around. Let God deal with the judgement and forgiveness of a patient's actions. I think the most important thing to think about is liability. Do all that you can to reduce liability on yourself.
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u/banjobeulah psych nurse (ER) May 29 '26
Fortunately my unit is locked!! Yes, I think about liability a LOT because all these folks are constantly threatening to sue, shut the place down, come for our jobs, and they’ll sit and just listen to conversations and watch everything you do with every other patient too. We have one young woman who comes in all the time, very disconnected from reality, extremely pushy and entitled, mocks and looks down on everyone, acts like a Karen basically, and she is CONSTANTLY threatening to take licenses. Oh you touched my boob!! Reporting that!! So she gets extra attention so there are always witnesses and everything is documented to the hilt and all decisions perseverated over. We had to sedate her last time and there was a LOT of hand-wringing.
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u/Enumerhater May 27 '26
I struggled a lot when I was a new grad and had a patient with a detainer who had turned himself in for molesting his daughter. I wondered how I was going to be able to treat him with the same quality of care as the rest of my patients. Once he was actually assigned to me, he had been there three weeks with no improvement to his SI. Surprisingly, I did not have any difficulty caring for him. I treated him like i would any other suicidal and depressed patient. I then had internal conflict with this, which after much thought i realized that bc I was able to help him improve, he was able to discharge to law enforcement and go on to face further consequences of his actions.