Critical Mass

Apparently, putting a dozen troubled little boys and a couple of adolescents together causes a spontaneous reaction. Between two wards, you can only separate so many volatile patient pairs. There are obvious laws about male and female patients not sharing the same room, but other laws also limit the age difference between roommates to 36 months. Then, there's also a law or hospital policy preventing a patient who has a history of sexual misconduct from even being in the room at the same time as the roommate, so at night they have to take turns sleeping out in the common area. In case you're not adequately disturbed, keep in mind I've been working with kids. On one ward, there's a 9-year-old who has a history of sexual misconduct, and the other ward has a 13-year-old in the same love boat... er, same boat (I'm sure that's an example the type of twisted humor you develop to help cope with the knowledge of what's been done to these kids and what they in turn do to others). The 9-year-old is annoyed with not being allowed in the (single-occupancy) bathrooms at the same time as the 7-year-olds. My preceptor described "insight" as the ability to appreciate the consequences of one's actions and the effect of those actions on others. I'm seeing a lot of patients, even older kids, who are totally clueless about cause and effect of their actions.

Anyway, all this logistic juggling is made worse by the fact that both wards are near capacity. Several kids on the more full one decided to lose their cool today. It was a rough afternoon. I learned I am not naturally gifted with the patience to deal with the loud, outbursting types of patients day in and day out. One little boy had a penchant for loudly screaming a couple octaves higher than should be possible and slamming doors repeatedly. Another decided to make it his personal mission to attack a younger kid who's kind of an outcast and just mopes about all day. Then there is a teenage girl who has borderline personality disorder (alternates between desperately clinging to you and beating the crap out of you, not always figuratively). Bradley, a boy she knows, was admitted today. So, with the aggravation of little boys screaming and the desire to show off for her newly-formed soul mate, she reverted to her coping method of choice: regressing to the maturity level of a three-year-old. On the way back from one of several trips to the seclusion room and after a boat load of meds, she yelled, "It's ok, Bradley, it's ok! I'm calm now! It's ok, Bradley!" She's screaming this, mind you.

While I'm discussing totally odd behavior, there was a certain teenage boy admitted for combative, defiant behavior. He was one of the first patients I saw here, and the doctor said to imprint him in my mind as a classic case of bipolar, which is apparently overdiagnosed these days. During his stay on acute, this guy had one or two run-ins with staff, being physically aggressive and just defiant. I saw the staff bodily drag him to the seclusion room; if all you could have seen was his face, you'd have though he was just enjoying a competitive sport. No wild psychosis glinting in his eye, no hatred seething out of his pores. They asked him at one point why he was acting this way and he said, "I don't know. It's fun." His behavior eventually leveled out, so he was transferred to the residential unit, which allows more freedoms while still providing intensive treatment. Last week, he decided it would be a good idea to fill his toothbrush holder with feces. I'm not sure if that was "fun," or if there was some other driving force. My attending said it was a subconcious way of testing others' acceptance of him. "Here's a part of me, what do you think of it?"

Not all the patients are so oddly colorful, however. One was a teenage girl who was just dealing with several stressors and started cutting and having some suicidal thoughts. Her family is supportive, and she just needed some quick inpatient therapy before being set up with outpatient follow-up. She had a positive outlook on life in general and got along with people well and should be fine.

Back to cutting and other self-destructive behavior. Cutting and similar actions are distinctly different from suicidality. Cutting is not an action meant to harm or kill; it's like sighing long and hard at a complex problem. It's an emotional release. It's a way of transferring abstract, intangible, inner distress to a tangible, concrete, external locus. It does some other things, too, but that seems to be the consistent theme amongst cutters. They probably won't have thought it out in such detail, though.

As a poor analogy, think of suicidality and cutting as being like flames and smoke. They often coexist, but it depends on what's being heated, and they are two separate entities. Smoke and flames are simply the obvious signs of the combustion process, which is what really needs to be stopped. Similarly, putting an end to the angst and depression leading to suicidal ideation and cutting is the only effective treatment for them. If you want to treat the symptoms, the best action you can take to prevent these thoughts/actions directly is to equip the patient with healthier coping mechanisms. You can't cure suicidality. You can't cure cutting. You can't cure suicidality. You can't cure cutting. Should I say it again? You have to cure the underlying cause. If I seem emphatic on these topics, it's due to personal experience with both. I should specify that's past experience, so don't go locking me up.

Speaking of personal experience, it's both a benefit and a detriment. On the one hand, I'm non-reactive when patients relate suicidality and cutting, which facilitates their sharing, plus I understand their thought processes fairly well. One the other hand, I feel detaining most of these patients is such overkill (no twisted pun intended). I keep thinking, "so they cut themselves and want to die, what's the big deal? I had the same thoughts and I'm still here. (And I walked five miles to school in the dark barefoot in the snow uphill both ways and in my day...)"

So as not to leave on a negative note, consider this: this sentence has seventy-five letters... q.

Scott