At work today I, not for the first time, experienced a trivial clash of ideology with some of my work colleagues. I was handing over an experience with a patient who is at this time experiencing vivid visual and tactile hallucinations, appearing to be focused almost exclusively around animals, reptiles being the most common.
In this instance, he had called me to the toilet where he was having problems. I entered and pulled the door closed to provide privacy. He explained that he was having a problem. A lizard was in his boxer shorts and it was obviously causing him concern and discomfort. As I stood there, he repeatedly folded and unfolded his boxer shorts, as if searching for something that he felt but was unable to actually get hold of. As if the lizard was continually evading him, in conflict mentally with what he senses told him.
For those who have never experienced anything even vaguely similar, this is almost classic psychotic hallucination. It’s actually rather rare. A pure sensational experience that does not evoke fear or terror, but something that causes confusion and sensory disorientation. Oh, it can be so much worse, but thankfully not in this case. The patient in question is a nice guy.
In handover, this caused some dismissal. In mental health nursing, and the approach to patients experiencing such hallucinations there are two schools of thought. Those who think that a nurses role is not to dismiss such personal experiences, and those that think that to go along with such things is to perpetuate such unreal experiences as to do so is to the detriment of the patient.
The latter viewpoint is easy to understand if rather blinkered. After all, the nurse of this viewpoint cannot see, in this case, a lizard nesting in the patient’s boxer shorts. It’s simply not there and the very idea that a lizard could be there in a men’s toilet, on an inpatient unit in a British seaside town during the bank holiday weekend is ludicrous.
During the handover one staff member indicated that they would tell the patient to simply not be silly, and dismiss such things.
Personally, the attitude of the ‘dismissive’ nurse may indicate several things. Firstly, a lack of experience beyond the mundane. What is attainable within the reach of our basic human senses.
Secondly an inability to accept the experience of the individual as important. In other words, if they cannot perceive or accept something, then it does not or cannot exist.
This is rather sad really, but hey.
The other type of nurse, let’s call them, them ‘empath’, has the ability to accept that just because they cannot directly experience that someone experiencing hallucinations, it does not mean it does not exist. My partner, a nurse of much longer experience than I, describes it as saying to a patient, “I cannot experience what you are experiencing, but that does not mean I don’t believe that you are experiencing it.”
I, from my own point of view know exactly what they are experiencing and so am unable to dismiss it. In my early years I experimented with several common substances that had a psychoactive effect, basically magic mushrooms and LSD. This coupled with a naturally accepting and non-judgemental attitude to others has firmly put me under the ‘empath’ type of approach to mental health nursing. I cannot dismiss anyone suffering in the way the patient described above is shown, because I have experienced very similar sensations and hallucinations, while temporarily under the influence of psychoactive chemicals. I know what it feels like to have my sensory input taken out, twisted about and mixed with imagination and sometimes even a large dose of irrational fear.
Each person experiences the world about us in a unique and subjective way. And thats without including the effects of mental illness on such personal perspections. So to dismiss the experiences of a mental health patient simply because we cannot personally experience the same, is both irrational and to be honest rather cruel.
It’s the same as telling a devout believer in any divine concept that what they believe is simply not true because you do not share such beliefs. Or that someone suffering from colour-blindness is wrong because they cannot see the world about them in the same colours that you do.
Being artistic I also tend to see things in such terms. A child drawing a three dimensional object will be restrained by their concept and ability to translate something three dimensional onto a two dimensional medium. They will develop such an ability, but at an early age, they have not gained such a perceptional ability. Would you tell a child drawing a box as a simply square that they were wrong, just because you have gained the ability they lack? The answer is no.
The sad thing when dealing with adults who cannot accept that they cannot experience is that they won’t really change their attitude without experiencing such a profound change of perception personally, and even if they do, it still won’t be the same. Its individual, it’s personal and so by definition, unobtainable by anyone else.
Despite the patient described above being noted as experiencing a classic case of psychotic hallucination, another patient with a similar condition will not experience the same sensations. To some it might be little demons dancing around his tea cup, another will see a mark on a wall gaining some distracting but profoundly moving connotation. Another will feel the pain of an onion as it is cut and denote such pain as causing the cutters eyes water, while yet another will see electronic implants or insects under their skin. To that person these things are as real as any experience we so called ‘normal’ people perceive, but just because we don’t experience them, does that not make them real to the individual who does?
The answer once again is no.
On a similar point, I listened to a black female police officer in the Louisiana police force which was involved in the killing of an unarmed black teenager. She felt that the lack of empathy and understanding of white officers with the black community continues to lead directly to the ease of taking such an fatal reaction when in situations of conflict. She noted that fear is an aspect of this. A lack of understanding and of course it is a common fact that we fear what we do not understand.
So is the dismissive reaction to the intrapersonal experiences of a mental health patient going through a psychotic episode a reaction with an aspect of fear? And so as described, causes in some an extreme emotional reaction and makes that person react in an extreme way. Something that is in fact a abnormal reaction, an extreme reaction.
The foundation of stigma towards people with mental health problems is fear. That the sufferer may act in an unpredictable way that may endanger others. One of the founding principles of the modern Mental Health Act, originally developed in 1983, is that the person under assessment may be a danger to themselves or others. If they are seen as a danger in any shape or form, they will be Sectioned, along with all that entails, even if they have actually not behaved in any overt manner that may support this fear.
But in the minds of the everyday person, that fear is based around the possibility that every single person, given the right set of experiences may end up suffering a mental illness, and in our culture, particularly Western, civilised society, we are consumed with conformity, or self control, because we have been conditioned that anything that breaks the accepted norms of that society is not normal, will lead to the individual being isolated, cast out by their peers and even being brought to the attention of professionals.
I read once that it takes two people to have a mental illness. One to experience it, another to say they are experiencing it. A schizophrenic alone on a desert island is not a schizophrenic, it’s just a man on an desert island. It takes the judgement of others to label that person as not acting in a so called normal way. Society creates stigma by not accepting the behaviour of anyone who is perceived as different, who behaves in anything other than the accepted manner of that time in history.
In The Crysalids, the profoundly insightful English author John Wyndham describes such a world where any form of physical abnormality is persecuted as being an abhorrent affront to God and destroyed. This, in my opinion is exactly the same concept as those white police officers reacting in the extreme to the black community due to lack of understanding and acceptance.
It’s commonsense really. To have empathy for another, who have to have a glimpse of what its like to walk in their shoes. Obviously as subjective beings, true interchangeable experience with another is impossible, but empathy is about acceptance through understanding isn’t it?
The argument that to follow the delusions of another perpetuates the delusion is also rather arrogant. It denotes that by dismissal and the imposition of the personal point of view over another, it renders the sufferers reality as not real. It presumes that the dismissal of such things can undermine psychosis.
If that is the case, why does psychiatric medicine need drugs? Don’t bother with Clozaril or Respiridone, all it takes is a stern dismal to not be silly, there’s nothing there, pull yourself together and shake it off. There! Sorted!
This is obviously not true.
If every mental health professional took LSD as part of their training and experienced the pseudo psychotic state that it leads to, everyone would gain empathy for those who suffer from these conditions and that conversation I had in handover, would not have occurred. After all, and rather ironically, drugs such as cannabis and opium had widespread use in the early days of psychiatry to create a temporary psychotic state.
In the end, the nurse being confronted by someone living with such hallucinations should not be expected to believe in fairies or demons, or that black is white and white is black. The nurse should however accept that the patient does. And react accordingly.