2.12.2008

His Crime

After a quick repair job on my car that failed to bring me to the psych unit last week, I made it back up to middletown, thermostat edging dangerously towards the red. I had to administer a fluid bolus in the parking lot before our customary breakfast in the community cafe. During our morning discussion, I reflected on something I mentioned in a previous discussion, on the preeminence of relationships, sexuality and attachment in forming the psychoses that lead the patients I had contact with to their commitments. One of my classmates turned to me and said "you realize you're on a sex offender unit, right?"

::facepalm:: riiight, it all makes sense now. It's kind of funny that I didn't realize this until now. Not all of the charts I reviewed were for sex offenders. Due to the limited availability of beds, patients with different diagnoses were housed in that unit just because there was no other place for them. Arsonists, violent offenders and psychotics with self-care deficits were housed among them, so I mistook the distribution for being representative for forensic psych as a whole.

On the unit, I continued to have positive interactions with staff and patients alike. I had a rematch in my battle of wits with the jolly psychologist, where he reminded me of the role of campylobacter jejuni in guillan-barre syndrome. Fun stuff.

The patient I'm following for my case study was, as usual, busy with groups. I spent most of the morning pulling information out of his chart for the Big Care Plan (tm). As valuable as care planning is, I can't help but view it as busy work, since the care planning we're doing involves interventions and assessments that we're not actually doing with our patients, no matter how well-adjusted they are. The other thing is that since this is an observational experience and we're given patients who are relatively stable, a lot of the assessments in the big care plan simply don't apply. No, he doesn't seem to be hallucinating. No, he doesn't appear to be employing any coping mechanisms. Yes, he does appear to be on the same planet as us. I could have picked a much more interesting patient on my own.

There's another thing. As helpful and friendly as the unit staff have been, being introduced to a patient by staff actually hinders as often as it facilitates. I've had great luck just walking into the day room and chatting up the occupants, playing a quick game of cards or just listening to them or letting them show off the awsome new CD they just got from the thrift store. When a staff member walks up to them and says something like "hey, do you feel like talking to a nursing student?" they usually get negative responses. I wonder if it has anything to do with the normal socially constructed image of a nurse...maybe some of the patients secretly suspect it's a trick or a put-on. At the very least, the prospect of being introduced to a pretty, young, student nurse might be perceived as disturbing to someone in treatment for paraphilias, or at least suspect.

When the cohort got together later to eat lunch, I was invited by the instructor to present my case to the group, since I was talking to her about it and she seems to dislike it when the cohort is bifurcated (an admirable quality in an instructor). I started rambling extemporaneously about everything I knew about the case. It's a shame I can't go into detail here, it's a pretty interesting case, but the all-powerful health insurance portability and accountability act prohibits me recounting the personal details of patients and sending them zipping about the airwaves. It seems like a fine enough line in the milieu!

Anyway, I got some guidance on something I posted about earlier, how it seemed to me that the wording in the chart that the patient "admits" to masturbating regularly somehow placed that behavior in a pejorative light. The instructor explained that the significance of that wording was actually that the patient has reached a level of comfort with the health care team that he can discuss that particular matter openly. Whether or not his denials of sexual fantasies about children can be taken at face value, however, remains to be seen.

Of course, at the first mention of "masturbation", my cohort erupted (tee-hee) into fits of giggles and crude humor. I'm all for giggles and crude humor, but I was put off by the breach of decorum during what seemed to me to be a perfectly legitimate discussion (one that had now gotten completely off-track and could not be followed). The instructor pointed out that their reaction indicated that they had not reached the level of comfort with that aspect of their sexuality that he had. When I asked if by "he" she meant me or the patient, she replied "both".

The cohort reacted with incredulity and disgust when I said that I felt that I could identify with my case study patient. I was expecting that reaction, and even constructed in those few short moments a tirade to respond with. Would they be so judgemental if confronted with a diabetic who is dying from non-compliance? A CABG blown by one too many cheezeburgers? Sometimes I have to question the motivations of my comrades at times, their compassion frequently seems limited and those limits frequently seem rigid. Maybe it's a maturity issue. I was thinking to myself "oh really? You're so great that there's no possible way you could ever identify with someone who has done something horrible? No way you could identify with someone who's ill?" I dunno. I get worked up over nothing sometimes.

The rest of the cohort decided to watch a video, so I excused myself and returned to the unit. I'm thankful for the easy time, but I'm really not interested in being educated on the subject of mental illness by the main-stream media, no matter how entertaining the presentation. Even if most of the patients were in groups or vocational rehab therapy, I figured I could at least talk to the nurses on the unit about their jobs.

As luck would have it, my case-study was on the unit and had nothing to do for a while, so we walked the grounds for a bit (his level of restriction allows him to walk around outside the unit without an escort, I can't be "responsible" for him), and he answered some of my questions about his therapy between drags on his cigarette and short episodes of anxiety posturing. He referred to the reason he was committed only as "My Crime". He didn't need to go into detail, I knew all the details already from his chart. I was more interested in what was important to him, what he finds helpful, and what he's looking forward to in the future. He identified the group therapy as being particularly helpful to him, and he goes to a lot. In addition to AA (mandated because he was under the influence of ETOH when he committed his crime), he attends a sex-offender's group, a male survivors of rape group, a trauma group, dialectical behavioral therapy group, and probably some others I don't know about. I'm disappointed that I haven't been able to attend any groups lately, but the therapists usually balk at the suggestion, even when the patients invite me to attend. Most likely, the only group I'll be able to attend will be AA (which is also the least interesting to me).

When I returned to the group, I discovered that the video-playing device was not operable, so those hours were spent in discussion. I can't say I'm sorry I missed it, the crazy people had more interesting things to say. That might sound harsh, but, well, I already KNOW what they think.

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