The one lesson I learned working in a psych unit

I was incredibly nervous going into my first day in the inpatient child/adolescent psychiatry unit. “Was this where the truly psychotic kids are? Am I going to be safe here?” I wondered as I casually introduced myself to the staff on the floor. After a morning of sitting in on group therapy led by psychologists and occupational therapists, I calmed down. Against the backdrop of the soothing soft pastel colors, I began to forget that I was in a hospital and not an outpatient clinic.

I was expecting to see the stereotypical patient mumbling to them or trying to injure themselves in the dark corner of the hospital floor. However, I found that the hospitalized psych patients were shockingly normal. Though some kids were rough around the edges, there was nothing immediately threatening about the majority of them. They were the standard middle and high schoolers that had many of the same concerns expected for their age. They had issues relating to their parents, stress due to schoolwork, and drama with their friends. They weren’t so “crazy.”

A 15-year-old shared her concerns about her depressed mood following a recent break-up. She had thoughts of committing suicide but knew she wouldn’t actually act on it. She told her parents who brought her in. She described her stressors and they echoed similar experiences that I had faced in high school. Hearing her story made me think the patients in the psych unit must all be similar to their peers, but had simply gotten caught up in life stress. As she shared her mood symptoms, I began to check off the symptoms needed to diagnose depression. Proud of myself for identifying a textbook case of major depressive disorder, I excitedly presented the case to my preceptor and left with a sigh or relief.

Day two was drastically different.

Five minutes into group therapy, an agitated 12-year-old patient started running around. “Some kids just can’t sit still. He’ll calm down,” I thought to myself as I tried to redirect him. I focused on getting other children in the group to share what brought them to the unit while the 12-year-old started pacing back and forth and fixating on me. He stared blankly at my bright blue necklace. Before I could react, he ran over and grabbed me by my necklace. He began to pull me down by the neck while jerking violently at my necklace. I struggled to gasp for air as a behavioral health tech tackled him down, and a nurse called for security.

He swung me off my stool, and my head hit the floor. Pain and shock followed.

While I was assessed in the ER, I became upset at myself for letting my guard down. The 12 year old was quiet and depressed just yesterday. I had no idea that he would be manic today. I became distressed that I hadn’t taken more caution to see the attack coming and avoid it. The patient who had attacked me was diagnosed with ADHD, bipolar disorder and oppositional defiant disorder. Impulsive behavior, psychotic episodes and acting out towards authority figures are not uncommon in those conditions. I felt that I should have better predicted his actions due to his diagnoses.

It took a couple of weeks and involvement in a psychotic break, but the stigma I held towards mental illness slowly began to fade. I stopped viewing it as just a deviation from normal behavior. In the days following the attack, I learned more about the subtleties of the patients’ conditions. I saw that not all depression presented the same and that psychosis was often completely unexpected. I came to understand that a patient’s diagnosis didn’t make their behavior predictable and that I couldn’t hold myself responsible for the 12-year-old’s actions. Just as in other areas of medicine, a patient can easily be misdiagnosed and therefore receive improper treatment.

I learned many valuable lessons on the inpatient psychiatry unit. The biggest one was that will continue to resonate with me lifelong is that mental illness affects everyone differently. A person’s depression can affect them drastically differently than their family members who previously received the same diagnosis. People’s mental illnesses are just as unique as them. As a medical student, I often want to apply textbook knowledge to take inventory of a patient’s symptoms and assign a diagnosis. I have to take a step back and realize that there is so much more behind mental illness than a DSM code. I’ve come to learn that even when stressors, strengths, and weaknesses are shared, it can have a different effect on each person.

The similarity between all of the patients I saw was that they could all be helped in some way. While psychiatric evaluation and medications were the keys to their improvement, empathetic listening often played a large role in many of their treatments. I have great admiration for those who dedicate their lives to helping the mentally ill. I hope to approach all of my future patients with the same nonjudgmental and patient attitudes I witnessed in many of the staff I worked with.

The author is an anonymous medical student who blogs at Naked Medicine.

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