I spent sixteen years of my twenty-five year nursing career as a Psychiatric
Nurse. In Arizona, they call it Behavioral Health. I worked in private facilities
for adolescents, where they had a private chef, to registry work with adults-
also in private Behavioral Health facilities, to the Arizona State Hospital where
I worked on all of its Forensic Units. I spent more time in Geriatric Forensic and
Adolescent Forensic than I spent with adults. Any call-offs by scheduled Registered
Nurses could mean that any nurse could be floated to any unit at anytime.
When I first went to the State Hospital, as a registry nurse, I admit that I
was terrified by the looks in the eyes of the patients. We would describe it
as “looking off.” I spent my first day grateful to be in the medication room
preparing medications and not on the floor being terrified. Patients would cue
up to receive scheduled medications at a door at the med room which had a top
that could open, while the bottom of the door was locked. This was to prevent the
possibility of a newly admitted patient from charging at the medication nurse.
A staff member stood beside the patient to help identify them, many or most had
removed their admission wrist bands.
I cannot describe the first few minutes of that first day, starting with the
sound of doors being locked behind me. Fear welled up inside of me. By the end
of the first day, I had been chased around the unit by a new patient (who had
been in and out of physical restraints all day.) New patients were not stabilized
on their medications and staff did not know their “cuing behaviors.” Cuing behaviors
are predictable movements within certain patients that would proceed an attack on
other patients or staff member-such as pacing, increased verbal assaults, facial
expressions. As a medication nurse, the faster a nurse could draw up IM medications,
the safer the staff would be. Staff would dislike a “slow nurse” who put them at risk.
Chaos could break out at any time, over anything. When one patient “blew” it was
like the popping of popcorn; others would follow suit. Soon a “riot” would have
broken out on a unit. One of the jobs of the floor staff was to monitor for cuing
behavior and when observed, notify the charge nurse or med nurse so an oral liquid
form of the medication could be offered to the patient. If the patient refused, it
would more than likely lead to a “show-down” and sadly, physicians orders for a
Seclusion and Restraint would be issued for the patient, so that they could receive
their medications IM. Seclusions and Restraints follow strict safety guidelines for
the patients: continuous monitoring of vital signs, bathroom needs and a re-assessment
for compliance every two hours. Remember at a state facility, if compliant per
verbal agreement, the patients were allowed back into the general population. Many
of these patients had already had a brush with the law or community and were determined
to be a danger to themselves or to others. Some were petitioned and some were court
ordered until “competency” could be established (if facing legal charges.) Some patients
could not understand the charges against them and had to be prepared to go before a judge
by virtue of role-play undertaken by professionals.
Malingerers, who had broken the law, but were there to avoid “real jail” were easily
weeded out by behaviors. Occassionally, a patient had become so “institutionalized,”
that they were terrified of leaving a “step-down” unit and going into a monitored
living environment outside of the high metal fences and barbed wire. Such a patient
could easily try to “cheek” their medication as to allow the fullness of their mental
illness to resurface. By “cheeking” I mean not swallowing their medication-hiding them
in the mouth, until they could “stock-pile” it.( which in itself is dangerous should
the patient decide to try an attempt at suicide.) Not taking medication would lead to
the de-stabilization of the patient. Erratic behavior and violence were not far behind.
There was a protocol to ensure that patients could not “cheek” their meds. Every now and
again, a patient would “outfox” the staff, anyway. Every shift that a mental health
professional stepped onto the floor of a Forensic Unit was an act of courage and bravery.
It is needful to make a distinction between “non seriously mentally ill” and “seriously
mentally ill.” Also, to make a distinction between someone with suicidal ideation versus
homicidal ideation. “Non seriously mentally ill” could be cyclothymic, bipolar along with
personality disorders. Also, poor impulse control, poor insight in various combinations.
Seriously mentally ill, could cover the gamut: sociopaths (antisocial personality disorders)
with homicidal ideation, Paranoid Schizophrenia; a combination of diagnosises rendering them
incapable of holding down a job. I believe that many homeless in Arizona are mentally
ill. They fell through the “criteria-cracks.” They were too ill to get out of the relentless sun in the summer where dozens yearly would die from heat stroke. The summer before I left Arizona, the good citizens went around to the homeless passing out bottles of water. I often wondered why emergency lodging was not provided for these people, for the water would run out. They looked too shabby or scary to hang out in the air-conditioned mall. They would more than likely be chased away by mall security for frightening the shoppers and ruining their spending day.
While the conversation ensues about guns and the mentally ill, it is my belief that people who display poor impulse control, who hate & fear are just as dangerous as the seriously mentally ill, in a “perfect storm. It is my concern that people who are not knowledgeable about the differing degrees of mental illness do not put everybody into one lump. There are “Patient’s Rights” to consider. The mentally ill have these rights, as well they should. In Arizona, there is petitioning process available. I suspect that those who observed Jared’s behavior were afraid of him. They would be afraid to petition him, even his parents were probably justifiably afraid of him. They would not want the repercussions of having petitioned him not knowing what he might do when he came out. Most of the community probably recognized the possibility that he had “homicidal ideation.” Police can be called in to pick up and take to an assessment facility those who need mental health services but are not willing to seek them on their own.The criteria in Arizona is “danger to self or danger to others.” Someone could have called the police anonymously to ask them to monitor a person behaving strangely within their neighborhood or community.
It is my hope that this blog will help America not to further stigmatize people who have already been stigmatized. Americans always seem to need a new underdog to kick-about. I hear the words, “nuts” and “crazies” bandied about. It is NOT OKAY! Rather use the terms “disturbed” or “seriously mentally ill.” Talk about “suicidal or homocidal ideation.” I pray that the people who are seeking a solution, find an effective, compassionate way to deal with mental illness as it relates to gun ownership. We do not need any more cruelty in our minds or our conversations. We do not need those in need of our help to
be hiding fearfully in the shadows. We do not need the seriously mentally ill to feel paranoid about being discussed in a perceived “threatening” way. This might prove counterproductive. All of the seriously mentally ill are not in “the system.” Our civility in this specific matter, itself, could save lives.