Came very close to calling this one ‘Why nurses hate their patients’ but felt that would be an overstatement. Sometimes, as I may have suggested before, nurses are not full of unconditional positive regard towards their patients.
Their are many reasons nurses often feel negative towards their patients; being diagnosed with bipolar disorder, not being unwell enough, talking too much, not talking enough, talking back, being non compliant, vomiting down the back of a nurses jumper and of course being too clever for their own good.
Sometimes we really really hate smart patients.
Funnily enough this is not always because nurses are as thick as mince.
Nurses are incredibly guilty of the Fundamental Attribution Error.
In social psychology, the fundamental attribution error (also known as correspondence bias or attribution effect) describes the tendency to over-value dispositional or personality-based explanations for the observed behaviors of others while under-valuing situational explanations for those behaviors. The fundamental attribution error is most visible when people explain the behavior of others. It does not explain interpretations of one’s own behavior – where situational factors are often taken into consideration. This discrepancy is called the actor-observer bias.
Mental health nurses have been taught about this, but entertainingly we do not think it applies to us. For the sake of argument suffering from a diagnosed mental illness can be considered, sometimes, to be a situational explanation.
I have seen a trained nurse accuse a patient of deliberately lying in wait so he could steal another patient’s biscuit. You might think this is possible, it is. An average patient is capable of devious levels of cunning that would impress Mr Fox. In this case though the biscuit stealing patient suffered from advanced dementia. His capability to plan anything was … severely compromised. Another sign of the patient’s poor cognitive state was the fact he stole one of those horrible Nice biscuits, frankly I would rather risk the Maltesers.
Normally though if someone is suffering from a readily identifiable illness we will take that into account when judging their behaviour. If you have been screaming about your clothing being full of bugs all morning, your mental state will be taken into consideration when we find you standing naked pushing your jumper out the two inch window gap.
Intelligence then.
For a working definition shall we say the ability to logically think about a situation and gauge it’s likely consequences. Not brilliant but it will do for now.
Most nurses like intelligent patients. As long as they are not too argumentative of course. But we would much rather argue with smart people than morons.
What nurses really do not like is the feeling they are wasting their time. Particularly with patients who just do not want to be helped. Though this can also apply to others whose symptoms do not currently appear to be severe.
Some, particularly intelligent, patients give an appearance of control of their symptoms. We end up with statements like:
“They deliberately chose to take that overdose because we were discussing discharge!”
Generally the nurse will say this with a tone of personal offence.
This kind of thing is bad enough normally. Now imagine a patient who can intellectually discuss their reasons for self harm or attempted suicides, discuss why they are not effective coping strategies in the longer term and may even have extremely good control of other parts of their lives.
Plainly, the Slaphead nurse thinks, if the patient can a) be clever, b) hold down a good job most of the time and c) discuss their symptomology they must be able to 1) choose not to self harm.
This problem, in my limited experience, is most prevalent with respect to patients suffering from borderline. But I have seen exactly the same failures of thinking applied to people with depression (should just pull their socks up), bipolar just choosing to be bad) and even dementia (faking to avoid a court case).
So in short.
If you are a patient, clever and ill with a slaphead nurse you might just want to remind your nurse that as well as clever you are also ill and this should be taken into consideration.
It is far too late for me to reread this so please forgive any terrible slips where it might appear I condone slapheadery.
It’s arguable that much of the DSM/ICD type of classification of mental disorder results from the fundamental attribution error as defined above, especially when it comes to personality disorder. Also, slaphead nurse attributing intentionality to somebody who is ill (and probably therefore regressed) might do well to look at the psychodynamic literature, especially the greatly respected and very readable Donald Winnicott, originally a paediatrician, and also Freud’s ‘The Psychopathology of Every-Day Life‘. It’s not necessary to agree with every word. The point is that underlying drives will give the appearance but not the reality of conscious intentionality. But that of course applies to slaphead nurse as well as to irritating patient.
There needs to be a sociological name for this phenomenon – failure to recognise that correctly identifying the problem does not make it magically go away. It’s the flaw in CBT, as well, that leads me to sit there going “well, obviously it’s irrational and self-defeating. And?”
To be fair to nurses, psychiatrists are just as guilty, maybe even more so. Most of the nurses I’ve met have made some actual effort to be nice, which is more than can be said for shrinkypoos.
I think what’s important is the difference between understanding things intellectually and understanding things emotionally. It can’t always be assumed that the former indicates the latter.
Argh! This is something that drives me absolutely mad. I generally intellectually know that my behaviour is strange/unhelpful etc. I can also maintain a decent level of functioning, even though subjectively I feel terrible. This leads to doctors and nurses assuming I am fine, when I am indeed a complete mess, I’m just good at hiding it.
I also get fed up of psychs and nurses treating me as if I’m stupid because I am ill or displaying “stupid” behaviour (e.g. self harm).
So much so in the past, that on recent admission I tried to lay down some guidelines – treat me as an intelligent adult, don’t hide things from me, understand that I find it hard to be honest about how I feel etc. Now my psychiatrist is suggesting because I described myself as intelligent I must be narcissistic and because I tried to make some rules, I must show traits of OCPD! She is so convinced of these traits from this one conversation, she has changed my diagnosis to focus on my “unhelpful personality traits”, but as I only show a couple traits of a few different PD diagnoses she can’t be more specific. It all seems a bit ridiculous. She doesn’t seem to consider the fact that I may not have been my usual self during that conversation because I actually have another conditon! She also doesn’t seem to understand everyone could show a couple of these personality traits and that doesn’t make them ill.
Anyway rant over. I need to write a full post on this, but haven’t had time yet since I came out.
How about your psychiatrist’s unhelpful personality traits? People do tend to accuse others of the things they do themselves. You might think it worth contacting PALS and/or writing a formal letter of complaint to the Trust Chief Executive (stick to the facts rather than rhetoric or your psychiatrist can say: “See what I mean?”). Psychiatrists on a power trip who are unaware of their own motivations are a bloody menace. A psychiatrist I greatly respect once said on a course I was attending: “All persons who enter any health care profession do so in order to address the unresolved needs of their own Child”.
I hope you’re doing well now.
My ever-so-lucky sister was under the power of a psychiatrist head of department with narcisstic personality disorder (kindly diagnosed by his colleagues). Thankfully he was suspended from practice, though I think he has his practicing rights back again, just not near my sister.
Morning, nephron. Driving sleet here. The worst instance of this I know of was the case of a psychiatrist who gave ECT (just called “treatment”) to everyone, including people diagnosed as suffering from an anxiety state. Those who queried this got more. Staff who expressed disquiet in meetings found a rumour spread that they had been telling patients not to have ECT. Eventually, I heard on the grapevine that this medic had been sectioned.
Late response, but I’d just like to say that it was 33 degrees here today, brightly sunny, dry, with a light breeze. Perfect.
Oh gosh! I think that might be my consultant, except mine is a woman. It now seems she has shifted her idea to narcissistic rather than ocpd and I’m fairly convinced she has it herself!
I was told I had Narcissistic PD by a Clinical Psychologist, who seemed very narcissistic to me. When I saw her straight after seeing the psychiatrist once, she asked what he had said, and when I told her she burst out ‘Oh no, you must have got that wrong – I didn’t tell him to say that, that isn’t what we discussed. I will have to speak to him.’ Ermm ok?! It was strange, because it couldn’t have been much less like me really.
I make a habit of telling every new doc (SHO or consultant) or nurse on first meeting that I very often seem well when I am not. That I learned to cope that way for years, and that switching it off isn’t possible even if it’s not helpful. I also point out that I am very articulate and good at explaining exactly what’s up with me because giving complete technical explanations at the drop of a hat is my job. I spend 8 hours a day, 5 days a week at meetings, writing documents or talking to people to either find out about stuff or explain stuff to them. Therefore, even when very ill I am good at this.
I find that situating it in the context of “I’m good at this, beacuse it’s my job and I have practice” works, as well as the explanation about not being able to switch off the “I’m fine” exterior, because I am deflecting the emphasis away from “look, I’m smart and capable and articulate and that doesn’t go away when I’m sick”, which pisses people off for some reason on to “measurable” phenomena.
Unfortunately though if someone refuses to listen there’s buggerall that can be done about it.
Into The System – you need to get an Advocate asap. Seriously.
I tried exactly the “this is my job, I can do it in my sleep” thing and it was seen as narcissistic behaviour!
I’m trying to work out the whole diagnosis thing… it’s all a big confusing mess in my head at the moment.
Do you have an advocate yet?
DeeDee’s right! It sounds as though you’re being made to feel confused by a narcissistic bully. You could also tell your GP you want a second consultant opinion – but don’t let yourself get isolated or the bullying will increase. You need somebody to help you with this who knows what they’re doing. Urgently.
Problem is I saw a second consultant before first consultant declared her diagnosis. First consultant says that second consultant agrees with her diagnosis and backs her up, but as far as I am aware second consultant agreed there were “personality traits”, but I’m pretty sure she didn’t think I had a full PD, especially not narcissistic.
As for advocate – not yet. I only got her actual diagnosis out of her today. Just had vagueness until now. Looking at the ICD-10 and DSM and seeing what actually fits or not and then going to decide on action.
Still get the advocate. And good luck!
If you kick up a fuss, repeatedly, and get good representation (ie advocate) you are likely to get somewhere. it doesn’t matter what the “rules” are. If you take what they give you they won’t change anything. Squeaky wheel.
I was silly and assumed that my psychiatrist and the nursing staff in the hospital would appreciate an articulate engaged patient interested in educating herself and participating her care.
I was wrong. All they really wanted was for me to shut up and swallow whatever they thought I should swallow.
In the hospital they wanted to give me something I’d never heard of, called symbyax (prozac + zyprexa, I think). I asked for the package insert and was told “you don’t need to read that. It only tells you about side effects.”
sigh.
Anyways…I am absolutely the worst patient because I have a professional background, including degrees, in psychology. It means they can’t get away with telling me just anything. It also means I know when they are lying to me. It means I know what questions I should be asking. It means I can’t be shoved off with the old “you have a chemical imbalance” explanation for everything. It also means that they never believe anything I say because “she knows how to game the system.”
I don’t know what to do about it. I either acquiesce and be a “good patient” or I stand firm for my right to direct my own treatment and get labeled and treated as a trouble-maker.
I don’t know what to do about it. I either acquiesce and be a “good patient” or I stand firm for my right to direct my own treatment and get labeled and treated as a trouble-maker.
*Sigh* Sing it.
That reminds me, I haven’t had my care plan since my last appointment. Cynical side says this is because I successfully argued that I don’t have frigging BPD, and he’d rather not give me a care plan than allow me to have a say in it.
Yep. As a patient, I’ve found having an opinion on your own care is never a good plan, unless you want to end up being diagnosed with Difficult Patient Syndrome. Luckily as someone who has done this in the context of eating disorder treatment, pretty much any opinion I had that differed to the professional “help” I was getting, was cast aside as a symptom of my illness, as apposed to a combination of logic and research. Obviously I was disagreeing in order to hang on to my ED behaviours, not because I wanted to take responsiblity for my own life, or express my own beliefs. It was just those awful control issues rearing their head again.
Lola x
My psychiatrist often describes me as a difficult patient, but mostly in a spirit of friendly exasperation. So I guess that’s OK.
unless you want to end up being diagnosed with Difficult Patient Syndrome.
I have that.
Yes, expressing an opinion is dangerous. It frequently does seem to lead to Difficult Patient Syndrome, and somehow that means you end up with the words Borderline Personality Disorder splashed all over your notes…. Lola has a flowchart somewhere on her site which explains the process of getting a BPD diagnosis very well.
Check out DSM-5 301.83 BPD (reformulated Borderline Type). Although DSM-5 in general seems very waffly, here the focus has changed from how others find the patient to how (s)he feels. If so, I hope I’m not being over-optimistic in saying the new description seems much less open to misuse/stigmatisation.
I hope so. It is a genuine problem, and I have no problem with the diagnosis per se – I have a problem with the way it is viewed. Although I think they could have renamed it – I prefer the ICDs term Emotionally Unstable PD – at least that is vaguely descriptive, Borderline is just misleading, and confusing. The MIND info still states that the Borderline refers to being on the border of psychosis, which is outdated to say the least. Out of interest, since in the UK we officially go by the ICD, how much of an impact will the DSM changes make?
Well it seems to be having an impact here and certainly people do tend to speak about BPD rather than EUPD. There’s probably an MSc dissertion at least in studying and enumerating the relationship between DMS and ICD; I imagine the WHO in due course will produce something very similar but not quite the same, which appears to be the form.
You’re perfectly right that the word ‘borderline’ is out of date and misleading. There are several PDs the APA proposes to drop that could be subsumed under the general heading of EU Type, e.g histrionic PD (my late mother, I’m sorry to say), which 50 years ago was called ‘hysterical personality’ and regarded as a neurosis. In any event, an attempt at empathy has to be better than a tick box approach with the danger of the Fundamental Attribution Error, as in the disgraceful incident lackofinsight relates below.
As for Mind not keeping up, that doesn’t surprise me. My wife used to be a Mind advocate but felt that tha policy she was required to follow lacked rigour and was not necessarily in the patient’s best interests (a pretty experienced bipolar patient herself). She went off with a group that parted company with Mind on this called the Care Forum.
I work as an advocate on several psychiatric wards. What’s even worse than attributing a patient’s behaviour to their personality is attributing it to their “illness”. The other day I saw a patient in tears because the consultant would not listen to her during a review and her CPN had failed to show up for the third time running. The consultant told me she was crying because she has “diurnal mood variation”. I see this type of thing all the time, it must be a horrible feeling to have your right to an opinion on anything denied like that!
My main gripe with the BPD diagnosis is that whether given correctly or not, it has the potential to become a self-fulfilling prophecy due to the way that health professionals tend to view people who’ve had the label applied to them.
I won’t deny that some people do fit the model and in that instance it can be helpful but if it is given incorrectly it is pretty difficult to argue against it without further incriminating yourself. Cue inappropriate treatment.
I never have that problem because it’s quite obvious to everybody that I is a bit fick innit.
I want to comment, but have been struggling to construct anything which isn’t an angry rant.
I’m seen this from both sides – both in handover/wardrounds/daily b******g about whichever patient/client/service user has annoyed the CMHT this week, and at the sharp end of services…
My personal favourite was being accused of being “too intelligent” to be mentally ill, so I must be making it up…
Could point out that if I really am just being manipulative, then I suck at it, since all I ever manage to do is make MHPs angry, therefore I can’t be that intelligent…
But as Lorna put it, the flaw seems to be the general:
” failure to recognise that correctly identifying the problem does not make it magically go away”
It’s even funnier when they realise that not only am I (generally) capable of stringing whole sentences together, but I was(am) also training to be a mental health nurse. Then despite being in the grips of crisis and therefore incapable of all but one word: yes/no/don’t know (OK that’s 2 words) answers I was expected to write my own care plans…
I’ve also been told that I clearly lack insight into my actions, yet at the same time should understand said actions have consequences – this is a paradox I still fail to get my head round. Yes generally I’m perfectly capable of weighing up pros and cons and deliberating consequences to actions. When I’ve just done something “stupid” it’s a fair-bet I wasn’t thinking things through, since executive function seems to get taken over by the crazy sometimes…
This is why the general insinuation that I realised ODing in december would cost me my place on my course, and did it anyway, is fairly well galling. It was sometime later when that little consequence set in, and only then because other people brought it up (damn reality-mongers…).
I guess though for (generally) rational, thinking MHPs in can be quite a scary thought that (generally) rational, thinking, intelligent patients/clients/services users can be caught in the grips of total irrationality/lack of thought/crazy calling all the shotsness – it probably (consciously or sub-consciously) sits better to believe in other reasons for the behaviour.
Besides as a species, we are terribly egocentric. I know plenty of people who struggle to view anything which occurs as not done solely for their benefit/annoyance…
I’m pretty sure an Angry Rant is a valid response here
I guess though for (generally) rational, thinking MHPs in can be quite a scary thought that (generally) rational, thinking, intelligent patients/clients/services users can be caught in the grips of total irrationality/lack of thought/crazy calling all the shotsness – it probably (consciously or sub-consciously) sits better to believe in other reasons for the behaviour.
That’s a very interesting point, actually. It’s probably terrifying to think that People Like Us can turn out Like That. So the instinct to put distance between them kicks in.
I have a similar conversation with non-professionals – “those nutters”/”I am one of those nutters”/”No you’re not”. People Like Us, by definition, cannot be People Like Them, so when Someone Like Us shows up acting Like That, there must be some other reason.
Something I try to get across to people who are not mentally ill when I talk about my illness, is that although they may know me as a normal person, I _am_ really mental when I am ill – I do need to be in hospital, I am incapable of finding my own arse with both hands and a map, I really am severely socially, intellectually and emotionally impaired.
I then point out that although I can be very acutely ill, I am still a normal person. Yes, I suffer extreme symptoms, but that doesn’t make me some sort of weirdo. I am a “nutter”, and furthermore, the vast majority of “nutters” are normal people like me.
This approach seems to work well.
I’ll go further and say this is the root of all victim-blaming. It’s a defence mechanism. “If she brought it on herself, then it won’t happen to me if I’m better than her.” And if they can’t find some way in which the mental patient brought it on themselves or deserved it, then they can’t be a real mental patient at all. Because otherwise, it could happen to anyone, and that’s terrifying.
Which, you know, is understandable, but dear God, people, GET OVER IT.
Mental! This is amazing! I love you even more! When is our marriage? I need to buy that dress.
Seriously, I am so late to this party, because I’ve been so busy taking care of my own mentalness, but this is so what I am always trying to get at. Remember this post? Yeah, this is what I was trying to get at. I have so much to say.
I think that the Fundamental Attribution Error is a big reason for why I have been diagnosed, formally and informally, with BPD so many times and why I have been called “manipulative” and “histrionic” so many times. And because mental health care is so very charming, only mental health care professionals have ever expressed interpreting me this way. I may appear to have BPD in what I do outwardly: my self-injury and eating disorder, having panic attacks in inconvenient places at inconvenient times, and asking for help from supposedly the wrong people in supposedly inappropriate ways, thereby crossing boundaries. So they label me with BPD and assume it is a personality disorder (oh how reprehensible!) that motivates these things. That I am trying to find a savior or trying to garner pity and attention for myself or whatever BPD motivations supposedly are. Then I try to explain that no, it honestly hadn’t occurred to me that having a panic attack in a hallway would make me conspicuous and I really was trying to be invisible even if I happened to be doing quite a poor job of it. But they don’t want to hear my explanations, they want to stonewall me to tough-love the BPD out of me, and my explanations probably seem like an attempt at keeping my supposed web of lies and manipulation intact. It is apparently inconceivable to them that I was doing these things sincerely, that I really did need this help, that I was out of my mind with desperation to feel better and I was begging for help from anyone I thought might have some to offer because I hadn’t yet received any “help” that actually helped me.
I also suspect that when I resist their platitudes and point out the inadequacy of their CBT and make the same pedantic distinctions that they do, but in the opposite direction, they are making the Fundamental Attribution Error again. They have their conceptual framework and theirs is automatically “right” because they are the professionals. Then I come and disagree with their framework, so therefore I am “wrong”. And if I am “wrong” it must be because I am still ill. I’m not actually wrong, I am just recognizing more nuance in the world than they are. But because I am more intellectually engaged and think about these things more critically than they are, I get trapped as they refuse to let me leave because I am “ill” until I agree with them, of course I am only trying to hold on to my eating disorder rather than trying to find something actually helpful. And it is more important for me to think about the coping skills and all than it is for them because I am the one whose sanity depends on their success, I am the one whose mind will splinter if they prove inadequate, and when they are presented to me, they look terribly inadequate. But that isn’t an excuse for any of that, just perhaps a reason for why I am more motivated to think critically about these things than they, presuming that they are able to think about these things critically if they wanted to.
If I am generally holding things together well enough to seem relatively normal on the outside while being acutely unwell on the outside, for me that means that my mind is constantly frantic with streams of profanities. I am only just barely holding it together. Because I am spending so much energy holding myself together enough to be presentable, I don’t have enough energy to hold myself together also in an actually healthy way.
I find the therapists and counselors to be the most guilty of all this because they are the ones doing most of the “talking through things” stuff and teaching me stuff. In the places I’ve been, nurses are more to give pills and ask about side effects and such and psychiatrists to choose the pills.
Aaron Beck did a study where his hypothesis was that more intelligent patients fared better with cognitive therapy. My hypothesis would be that the most intelligent and least intelligent patients fare worse, with average to high average faring best. His study actually showed a slight correlation of more intelligent patients faring worse, but it wasn’t statistically significant. Instead of actually opening up to the idea that he might be wrong, he discussed a bunch of reasons for why he might still be right despite what his data showed. I have a pdf of it and I can email it to interested people.
My main gripe with the BPD diagnosis is that whether given correctly or not, it has the potential to become a self-fulfilling prophecy due to the way that health professionals tend to view people who’ve had the label applied to them. I would add that it becomes self-fulfilling also because of how the professionals tend to treat the patients that they have labeled with BPD, on account of how they view them and fit all of their actions into the conceptual framework of BPD. I do think some people probably do fit the BPD diagnosis and that some of the distancing and tough-loving may be helpful, but when they do that to someone who is acutely unwell, I think that is very damaging.
“Mental! This is amazing! I love you even more! When is our marriage? I need to buy that dress.”
Yes. I feel it as well. But it must be secret. No one can know about us! Can I trust to your discretion dear heart? My insides are knotted like a tangle of lusty limbs.
Your comment here pretty much covers the next post I am planning to make in the sequence. Your previous post regularly wanders around the back of my head.