Psychiatry & Psychotherapy Podcast - Reducing Inpatient Violence in a Psychiatric Hospital

Episode Date: March 7, 2019

In this episode of Psychiatry & Psychotherapy, Dr. David Puder dives into the critical issue of inpatient violence with special guests Dr. Gillian Friedman and Nate Hoyt, MS4. Explore the latest evidence-based strategies to predict, prevent, and manage aggression in psychiatric settings. Discover key insights on: Risk factors for inpatient violence, including diagnoses and history of aggression. Effective de-escalation techniques and innovative interventions like Safewards and environmental modifications. The role of pharmacotherapy, staff-patient relationships, and alternative approaches in reducing violence and improving outcomes. Join us as we reimagine safer and more compassionate care for both patients and staff in psychiatric hospitals. By listening to this episode, you can earn 1.5 Psychiatry CME Credits. Link to blog. Link to YouTube video. Instagram: dr.davidpuder Twitter: @DavidPuder Facebook: DrDavidPuder

Welcome to the Psychiatry and Psychotherapy Podcast, the podcast to help you in your journey towards becoming a wise, empathic, genuine, and connected mental health professional. I'm your host, Dr. David Puter, a psychiatrist who splits his time practicing psychopharmacology, individual and group psychotherapy, medical director of a day treatment program, medical education research, and teaching, residents, and medical students. All right, welcome back to the podcast. Today, on popular demand from questions, from the audience, from people who have emailed me.

We are going to be talking about impatient violence on the psychiatric unit, how to predict if someone is going to be violent, how to kind of address. And we're going to try to move into the practical area of it pretty quickly, talking about how to de-escalate potentially violent patients and how to not have to just inject people with, you know, out of end and howdall, but maybe how to talk them down,

how to establish a therapeutic alliance, something that I've talked about frequently in this podcast. And lo and behold, now it gets applied to a certain situation in the inpatient setting. So today, I have the great pleasure of being joined by Jillian Friedman. She is the medical director of San Jose Behavioral Health. She's worked as an attending psychiatrist for 16 years. She's currently mostly working at three different hospitals and is credentialed in seven. She has a background in a fellowship in women's health where she did a lot of chemical dependency for women who are pregnant.

And she also has a background in assertive community treatment where you go into someone's home and work with them in their home. Can you tell me a little bit about that piece first and then maybe we'll... Yeah, yeah. That's really my love in psychiatry is following a group of people who... These are people who have not been very well served in the traditional health care system that we have, where you make an appointment, you get to the appointment, and that's when you get seen. And if you don't get to the appointment, you don't get treatment.

Right. So people in an assertive community treatment program, nobody is lost to follow up unless they truly disappear. Okay. You go out and find them wherever that is. Often there's a split. You try to have people, especially to maximize the efficiency of the physician's time, you try to have them come into the office if they can, but you go out to them if they can't. Okay.

And the team sees them at least once a week, sometimes more if necessary. So it's finding for people who have severe and persistent mental illness, it's being able to help them before they have a decompensational. that leads to a hospitalization or another acute event. Wow. Okay. So we will sort of pick your brain for the nuggets of wisdom that you have on how to de-escalate patients because I imagine in that setting is where you really started learning

because that's like the when you're, it's almost like an impatient acuity. It's like a hospital in the community sometimes. Yeah. Wow. I'm also here with Nate Hoyt, who is on a previous episode. regarding the Dark Triad and a fourth-year medical student, really been helpful in doing some of the literature review. We're going to attach to the podcast an article that we will have written

by the time this thing is done. And so, Nate, welcome to welcome back. Thank you. So let's start off a little bit talking about why this is important to talk about. Why is it important to train staff? on how to de-escalate violent patients and how common is it? So maybe what has been your initial experience when you first started in hospitals? Like, is it more frequent when you first start?

How it's handled? Do you train the staff? Like, what's your sort of general approach? Well, you know, there's a great variety of hospitals out there. And some hospitals have been doing this for a very long time and they have their own systems that really work well. And then others have systems that can be improved. And this is something that people are very motivated to improve. People don't want to be scared on the inpatient unit.

They don't want to be frightened that they are going to be injured. And so some of that is having the system set up in a way that promotes safety. And some of that is having people have skills. If people feel that they have mastery, that they know what's going to, what to do. in an emergency, then they're going to feel safer and they're going to perform in a way that promotes safety better. Yeah. Nate, take us through a couple of the statistics on how common it is for violence to occur

inpatient settings. Oh, yeah. Okay. So one of the articles that Dr. Friedmanson over beforehand was very useful, they pointed out that there was almost one in five acute psychics. psychiatric patients have committed at least one act of violence while hospitalized, but there's this important distinction to make that actually a small percentage of these patients are repeat offenders and something that the literature calls recidivistic assaulters. And these individuals, which make up

maybe about 6% of those aggressive patients, are responsible for 10 times more aggressive acts. inpatient than those who offend less frequently. So there's actually a small percentage of psychiatric patients that are responsible for a greater amount of the violence. Yeah. And one of the statistics that came out of one of the studies that was really, it was like, wow, that's really high is that 75% of nursing staff work at psychiatric hospitals will at some point in their career report that they were assaulted.

75%. And sometimes these cause disabling injuries. One in four psychiatric nurses reported that they had some sort of disabling injury from one of these. So I think the need to have a clear outlined protocol like you were saying is necessary to protect the staff and also to protect the patients. because often what I also learned was that most incidents occur patient to patient. So what are some of the things, Jillian, that you see as things that can predict future violent episodes? So I'm in a setting where a lot of the violence that occurs is because people come in a very acutely psychotic state. So you've had a previous podcast where you were talking to Dr. Cummings, who was in a different type of inpatient setting, a more forensic setting where people have been there longer

and they have other legally related psychopathology. So there might be more in that case of people who have more predatory violence on a chronic basis. But in the setting that most of us work in, in regular acute infatology, patient hospitals, it's going to be weighted more the other direction where people are more frequently violent when they're having an acute episode of an exacerbation of psychosis, particularly if there's also mania with it. People have then two things going on at once. They have delusions, often paranoid delusions, that are also fueled by an increase in impulsivity.

Yeah, so we talked about in the violence episode that there's three types. There's the predatory violence, which is kind of like the psychopath or the antisocial. That's a planned, deliberate attack. And then there's the impulsive act, which could be from someone with borderline personality disorder or mania. Or mania. Yeah. And then there's the psychotic violence. which is like the schizophrenic who has command auditory hallucinations to hurt someone

and then maybe also some delusions that people are out to get them and the staff are the you know and then sometimes when you have a manic patient you have both if somebody who has the delusions that people are out to get them and then they also have the highly increased impulsivity yeah so when you're doing when you're meeting with a patient for the first time when you're observing them, what are some things that increase your concern that this could be a violent person or could be a violent action could take place?

So some of it is just the physical agitation that you see. When you're talking about people who are, and this is particularly in relation to mania. And one of the things that I think that it's easy as an early career psychiatrist or a resident to the trap that people get into sometimes is with patients who are, I'm sorry, just a little diversion about mania. Yeah.

Is the liability of somebody who is having an acute manic episode. So you can, somebody can come in and you develop in that moment an alliance with them and a relationship with them. And it feels to you like their agitation is calming down. but then you can introduce something into the situation and not understand that if they are acutely paranoid also, that that may be interpreted in a different way. So here's an example for me from like the Stone Age when I was a resident. In the emergency room, having a patient who was very paranoid, also very manic, again, pacing, you can see their increasing.

physical movement, maybe the tone of voice, the volume is increased, the rate is increased, they're cutting you off, there's an emotional, angry part to it. And then, you know, the over the course of the length of an evaluation that a resident does in the emergency room, you know, there was a, it seemed like an alliance built, and then the patient, was a considerable amount calmer, but we had to have labs done. She hadn't allowed labs done. And, you know, in my enthusiasm as a resident, I thought, well, I'll draw the labs because she's got this comfort with me.

And it's one of two, I've only had two instances in my career where somebody's actually, you know, laid their hands on me. That was one of them because we brought in the, and even though we talked about it, and she knew in advance that when she had a paranoid interpretation when I brought the phlebotomy supplies in and she thought that I was you know taking stuff for gene testing and that I was stealing her DNA and and you know she grabbed my hair it was it was oh wow yeah so it was something that I learned then it was nice to learn those things as a resident but I learned to have respect for the fact that people who are in an acute psychotic state or acute manic state are not going to interpret things

in the rational way that you're going to interpret them. And even if you've said this in advance, you just have to be more vigilant in those cases. And to expect that somebody, nobody likes to have their blood drawn, but somebody who's acutely paranoid might have a reaction to that. And you need to at least have other people with you. Yeah, that's a good reminder. And it kind of illustrates the complexity of what we're talking about. Like you could think that things are going well. You've connected with the person.

Then you add in this next element. And it's like all of a sudden the delusions come back. And so she grabbed your hair and you were able to get free. You was able to. Yeah. Wow. That sounds like that would have been pretty scary as a resident. but a good learning experience.

Yeah. Yeah, I remember one time I took away, we had detox someone off of their Xanax, and at time of discharge, we decided to destroy their Xanax so that they couldn't have it all because they would be at risk for overdosing. So we had it burned,

and I was the one that told the patient this, and she charges me, like straight up, you know, four days into admission, we had some sort of alliance going, and she charges me. And I, like, turn and I just run, and I, like, get in the door, and I shut the door to the resident room. And she, like, is banging on the door. You-hoo.

And she's cussing me up a storm, you know, and I'm just like, oh, my gosh. But, and she was, like, you know, 45, you know, not in any form of shape that you would imagine, like, but could do some damage because she was just all of a sudden, full of fury. Yeah, people, I mean, you have to have empathy for the, for the situation that they're in. They don't know. Internally, it really feels to them like it's normal inside and it's everything outside that is

abnormal, right? So they really do sometimes feel, you know, when people say, you know, you don't have any right, to hold me here. There's nothing wrong. I'm brought here for no reason. Inside their head, that's how it feels. So you have to be able to put yourself, if you were feeling trapped and cornered

and it felt to you like there was never going to be any way to get out, you wouldn't have the same responses either. Yeah, yeah. And I think that's an important step. And it's harder to do sometimes with someone who's extremely angry. or aggressive. It's harder to have the empathy.

It's normal to get defensive. It's normal to want to protect ourselves. And I think it takes some practice and some wisdom and skill to remain in that empathic stance of like, yeah, that would be really hard that this woman's meds were taken away. And this was like how she treated her anxiety. And, you know, this is all she knew to treat her anxiety. So I think that gets down to, in terms of safety, there is, and I got us away from it for a little bit, but I think there are two,

you can divide it. There's, what do you do to be best able to predict that this might happen? Okay, so there are certain times that people are going to be more susceptible, and we'll go into, you know, like kind of like other risk factors too, but certain times also, if when they're first there and they don't understand why they're there and they're very, like the first two or three days of a hospitalization are more labile for somebody who is acutely psychotic or acutely manic. And then also when things that are, that they're likely to get angry about are likely to happen. So they're having their, in California, the second, the longer involuntary hold is called a 50-250 hold.

And California aggressively protects people's rights. Everybody has a hearing. And people who don't, what feels normal on the inside to them, so they're expecting in that hearing, of course the hearing officer is going to say, sure, leave the hospital today. And so no matter how much they're, you know, we try to prepare them for that, when that happens, sometimes that's a point where people are very angry. How do you try to prepare them? Well, it depends on how, again, what state of the hospitalization they're in, right? So somebody who is screaming all night and, you know, punching at the fire extinguisher and is probably not going to be able to sit down with me and send. say, okay, so let's talk about what might happen in the hearing.

Okay. But sometimes, you know, a few days in, they have had some medication, they've had some other treatment, and they can have that conversation, even if they're still considerably manic and still considerably delusional. And they can, and so we can say if you, you know, and I'm very straightforward in presenting people what their rights are. There's a patient's rights advocate who's kind of like your attorney, their only job is to argue that you should win your hearing and be allowed to leave. And I provide them all of the information because we want them.

If they stay there, we want it to be for the right reason, right, the right legal reason and the right therapeutic reason. So let's talk about what would happen if you win and you know, you and I have a disagreement about whether you should. should stay in the hospital, but you might win. So what would then be the next step for you? And then we can kind of get into, if the person is going to leave the hospital, what would be the safest discharge that they could have? And then let's talk about what would happen if you lose, because I want us to be on good terms no matter what happens.

And sometimes that's effective. Okay. And so you said that we're talking about times in the hospitalization when they're more prone to be violent. Are there any other times that come to your mind? So you talked about the early on when things change, when they're coming back after they lost their court hearing. Yeah. Sometimes it's often it's around discharge early on.

And sometimes you have somebody who, for whatever reason, is in a state where even if they've heard it before, you know, they don't, either they don't remember that they've heard it before from you, you know, that the discharge isn't going to happen today. Or they're very in this moment focused, and they are not able to, even if they did remember it, it's not, to them, emotionally pertinent to the moment. And so sometimes there is an escalation around, especially with the physician, I mean, it happens with other staff too, but most people know that the ultimate order for the discharge comes from the doctor. So it can be very focused on the physician.

People who have difficulties, for instance, they have had a head injury and that impairs their ability to control impulses. You may tell them today and then tomorrow they're going to bring it up again. And maybe they're especially frustrated that day. and there can be some, for instance, the one physician attack in my current hospital that has occurred, has been with a patient who had done quite a lot of organic brain damage from dextramothorfen, like really bad chronic dextramothorfen abuse. So he just did not have the impulse control at that point. It wasn't any different from the conversation that had happened the day before.

But I think having those conversations where there are staff around and being prepared for it is important. Sometimes if you have somebody who is like recently I had somebody who was going to be discharged back to jail and really didn't want to go back to jail. Yeah, I had one of those instances as well. We were discharging him and basically the police were waiting outside to take him back. he lunged at the psychiatrist and screamed at the top of his lungs. And it was very frightening for us all. So I had been talking about this with the patient for days, right? But part of the reason that the patient was in the situation the patient was in

was that the patient did not have very good ability. Sometimes it feels to people, even when they do have options, it feels to them based on their life experience, that they feel kind of star-crossed, to use the Romeo and Juliet term, that the stars have aligned so something bad is always going to happen to me. And every time I try to make it different, it turns out badly. And you're piling on something they don't want, a bad outcome on top of their feeling that their whole life just goes bad for them.

So even though I had been talking with the patient for several days, you know, you don't know the eventual outcome, but the first step is going to be they're going to take you back into custody and then it will get determined in the legal system. As it got closer, the patient was just more and more upset about it. And I could, so part of that identifying that it's going to be a difficult situation is, The day before, the patient is much more intrusive with me, saying, well, can't I go back to things that I'm not going to have any ability to decide about, but it's a signal that the patient's getting more emotionally wrought. Then on the day of discharge, several people are able to identify that the patient is having more difficulty. So this is the other part of that is there's got to be a culture in the hospital where everybody from, you know, the recreational therapist to the nurse to the doctor to the, you know, to the cleaning crew if they see something, understands that safety and it's a see something, say something culture. There's psychological safety to report things up the chain to have open communication in the team.

Yeah. And so that's something that you've built and fostered in your leadership. And so people communicate, okay, someone's been agitated, someone's escalating, and that gets to you through texts or through, you're on the unit most of the day. I'm on the unit most of the day and then people can always get me. And sometimes it's letting somebody else there who knows where I am, like which meeting. man to come and get me. So the nurse who was starting to prepare the patient for discharge was able to tell that this was different from what the patient had. And the patient actually was making some statements that were concerning to the nurse. So they got in.

And at that point, we, you know, even at that point, the CEO got involved to make sure that we had. And so we're going to, you know, when the police arrive, we're going to have this number of people on the unit. And we're going to offer the patient some medication. Okay. And if the patient is feeling like, because we certainly don't want them also to be, to start doing anything aggressive towards somebody else or toward themselves in the process of not, you know, our responsibility doesn't end when the patient leaves our door. Right. Right. So there's a process that's going to take a few hours. And we want them to be, to have as many tools. Sometimes medication is a tool. And, you know, I can say, you know, would a little bit of lorazepam before you leave help you? Yeah. Okay. So coming back to the things that you notice that are warning signs and that your staff has been trained to notice, are there any of, um, are there any, uh, are there any, uh, other things that come to your mind that you've trained them to notice or that you start to notice if someone is escalating.

So you can catch it early on. So one of the biggest things is how does the person respond to other attempts to verbally de-escalate? Right. So if the person is pacing around and yelling, getting into arguments with peers and you try some things to, to try to do it and it doesn't work for very long, then you know you have to increase your toolbox. So increasing the toolbox could be getting the person to a point, to a place where there is a lower amount of stimulation.

It could be using some things like we've headphones that patients can wear with music. So other calming sensory things. It could be offering some medication. And I want to make a distinction between offering medication and involuntarily medicating somebody. You don't want it to get to the point where you have to involuntarily medicate somebody. So using something that's going to be therapeutic earlier on is a much, much, much better option than having to ever live. your hands on someone, which means that you have to have it available, which means doctors have to write the order to have it available.

So sometimes the person comes on the unit and there's a lag between the time they get on the unit and the time that they're going to have the psychiatric evaluation with the psychiatrist. In most hospitals here that I work in, that evaluation could occur anytime in the first 24 hours. but they need to have tools available immediately. So that was one of the first things when I came on as medical director that I was looking at in terms of safety is do we have all of the tools? And part of the tools is do the staff members know what to do when somebody is, you know, to verbally deescalate or to give them some options for, you know, lower sensory environments? but also one of the tools is do we have a system where whoever is writing the admission orders knows please prepare and write some medications that can be used if the person needs them to be able

to stay safe? That's good stuff. So you, so it's, what I'm hearing a lot of is there's a team approach. There's multiple people with eyes on that have some tools in their toolbox that they can use. so the nurses can on their own, hey, let's go to a quiet room, hey, put on these headphones, what kind of music do you want to listen to? And then, you know, offering, hey, do you want to take a pill to calm you down? It makes me think of one incident just recently I was covering in the chemical dependency unit

and those very agitated patient had already been throwing things and not directly attacking anyone but getting pretty close. and everyone was thinking that this patient needed to be discharged. And I went and saw the patient. And it seemed to me like the patient was going manic for some reason. The patient was coming off of drugs. And sometimes what I've noticed is that it's like they were in a mania and then the mania leads them to use a lot of drugs.

And then as they're coming out of the drugs, it's like it uncovers what was underneath. And so with this particular person, I spoke to the person. and offered her some olanzapine sublingual. And she was more than happy to take it. So we got it started and then, you know, transfer her to the higher acuity unit.

And she did, you know, she did better without needing to force anything on her. And a lot of that just came from me, just staying with her, actually giving her the pill, showing her what was on the label, explaining what it was. Any stories that come to your mind,

similar or like in particular? And this kind of brings up a good point too that very often on an acute inpatient unit, we don't have, we have multiple pathologies, like you said, this patient had both mania and chemical dependency issues going on simultaneously. So, and especially in the hospital that I work at where there's not a psychiatric emergency, we're freestanding psychiatric hospitals, so there's no emergency room there. So everybody who gets to us,

and we get people from more than half the counties in California, there's a shortage of psychiatric beds, so people can be traveling hours. By the time they get to us, they've already failed to clear in an emergency room. So it is, I mean, not that it never happens, but it's uncommon if somebody comes in, under the influence of drugs or alcohol, and they make it all the way to us, it's uncommon

that that's the only thing that's going on. It's usually that complicating some other underlying psychiatric condition, whether it's depression, whether it's mania, whether it's another psychotic disorder like schizophrenia. More commonly in our hospital, it's mania or schizophrenia or another psychotic condition. Yeah, and you've shared with me your hospital was fairly acute. you're taking Medi-Cal, Medicare. Private insurances. You're taking some private insurance, but the acuity of your hospital is fairly high.

And part of that is that we are a large facility. We have 80-bed facility, and we don't cherry-pick for psychiatric reasons. There are some things we can't manage medically because we don't have other medical units there. I have to be a little bit careful if somebody has something that could put them in medically in hot water quickly. But for the most part, we're not saying we're only going to take the easiest patients. Yeah.

And some patients that arrive from an ER, although they were medically cleared, still have medical issues, which is, you know, I don't know how you guys screen or if you screen carefully. the ER notes, but I remember one patient particular came in, and she was actually having a miscarriage once she hit the unit. And it was quite frightening to her because she was also psychotic. She had been walking around in the freeway and been doing dangerous things that were obvious. Obviously there was something really off, and then by the time she got to us,

and it was about a four-hour drive from where she was in an ER to our, in patient hospital. And by the way, whenever I tell stories, I always change a couple variables. Yes, I do too. To protect, to protect patient identity and HIPAA. The other thing I wanted to ask you here is you shared with me when we were at coffee that you're on the unit most of the day and you're watching what goes on on the unit from your office. You have some sort of ability to kind of see what's going on in the unit or describe how to that works. And I was thinking about this as I was preparing to come here. I really do think that it is helpful to be on the unit. We have a paper chart system as many freestanding psychiatric hospitals still do. So I can chart anywhere.

I do my notes on computer and then we put them in the chart so we have kind of a protected system for that. But I can do that on the unit. It depends on how the hospital is set up. Often in other hospitals where I work where there's no way to do that. There's not any space to do that, the computers that I need to use for the electronic medical record to put my note in our back in my office, which is off the unit. But I do think that as much as it's possible to be on the unit, because your 15-minute interaction with somebody that day may not be characteristic of what's gone on the rest of the day. So if you're not on the unit,

and I still get surprised by things, even though this is my philosophy and I am on the unit most of the day, I don't go into the patient's room when I'm doing the interview. Most of the time we have a separate interview room. So I still get surprised by things that I hear from the nurses,

for instance, as the day shift of the nurses is closing out, And I'm, so it hammers home to me that you need to get more information than just your own interaction with the patient. And what kind of patient load are you taking? And do you have your other physicians take that you're the medical director of? So we have a hospitalist psychiatry system. So we have people who are there, you know, for anywhere from, you know, four to ten days at a time. and they're working 16 hours during,

so they're there, the majority of the time, the patients would be awake. And I do that too. And sometimes people, you know, they'll have a Saturday and Sunday off in the middle. And then another team comes in. This is a less common, but becoming more common system in psychiatry, but it does work because inpatient stays are usually short.

So it's not that, It's not very different from having a situation where there's a regular 8 to 5 psychiatrists during the week and there's a weekend psychiatrist. So it's not a larger number of doctors that the patient interacts with. So I will see anywhere from 14 to 17 patients as part of my, and then I have the administrative part of my job. the doctors who are there for on the adult units, we'll see usually in the range of 23, 24 patients in a 16-hour period. Okay. And we also have an adolescent unit.

And so that caseload for the adolescent doctor is a little lower. It's 17. Okay. Good. You mentioned the importance of gathering extra information other than what you may just get from your interaction with a patient. And going through some of the articles, specifically, CalVAT really stresses this idea of like an organized violence assessment.

I know CalVAT's kind of designed more for forensic hospitals, but there were some other studies where non-franic hospitals were using different kinds of assessment tools just to see if they could predict violence. Have you come across any assessment tools that? Yeah, one of the hospitals I work at uses the, the Brossette score. Now, I normally know what's going on even without the Rosette score, but the hospital does find it very useful, especially for the nurses in handing off one patient to another nurse. It's kind of a quick and dirty way of giving them an idea. Overall,

this is what you're getting. So I think it's a good idea. I think it's especially good idea. So, I mean, the nurses and the, you know, they're called different things at different hospitals, mental health techs, behavioral health associates, the non-nursing behavioral health staff really do need some, you know, some as much assistance in knowing what they're getting. And I think that the process is useful. And Nate, tell us a little bit about what you learned about some of the predictors of violence. So there are a lot of different studies that have tried to attach different risk factors to violence. Some of the ones that we were able to uncover were probably the most significant one was a prior history of aggression, specifically violence within one month. Also, the male sex is associated with greater aggression inpatient settings, certain psychiatric diagnoses,

and we've already touched on some of them already today, but schizophrenia was the top one diagnoses of personality disorders or impulse control disorders. Also there was bipolar and schizoaffective came up in some studies. Substance use disorder was a really high secondary diagnosis and a lot of aggressors. And one study showed that about 50% of aggressors, had a secondary diagnosis of substance use disorder.

And we've kind of touched on that. Also younger patients, specifically younger than 32 years of age. Something interesting that came up was about 67, in one study, 66% of assaultive patients in another study had a history of being abused as children or prior abuse in their past. Yeah, so there's some just general risk. factors, and I think it's important to look, especially at the history of violence. So there's, there are some hospitals that will do for, for patients that they know who have

been there repeatedly, they'll do certain alerts. So there's one hospital where, you know, if I'm seeing a patient, it will automatically pop up. This patient has a history of assault here in the health care set. So there are there different levels? One is knowing how serious is the violence that the person has engaged in when they've been ill in the community, right? Do they have, has any of it led to, I mean, these are all sorts of things that I ask in an assessment. Okay. But has it led to have they had legal consequences of having violence before? Sometimes I ask the question, what's the most violent thing you've ever done to somebody else? Oh, okay.

Yeah. Are there any other questions you ask? This is in the history. I always ask if people have had, in addition to knowing, so I want to know in the history, you know, I want to know how many hospitalizations they've had, how long the illness, like what was the first time you were ever hospitalized. Have you ever been at a place that is a longer-term locked facility like a state hospital? That's a different level of pathology.

I want to say pathology, illness. It's a different level of illness sometimes. When people have had, they don't, their condition doesn't clear within the time that we have in an acute psychiatric hospitalization and they need to have further treatment in a longer term facility. Have you been arrested? People who have had a lot of criminal justice contacts in jail is often different from prison. So there are just like five questions, but they give a lot.

of information. Okay. And then also previous violent acts. Okay. And then another interesting thing from the CalVAT. I think it was the CalVAT, yeah, the CalVat was they talked about medical conditions that can increase the risk of aggression. And they list psychomotor agitation, acesthesia, pain, delirium, intoxication, withdrawal,

complex partial seizures, sleep issues, abnormals, abnormalities. and glucose, calcium, sodium, thyroid, and cognitive impairment. Do you have any nuggets of pearls of wisdom for us in those categories, things you've seen? So I think that acathesia is a big risk factor, especially if somebody is already, you know, manic or psychoticate, then, you know, some of the medicines that we use can produce acathia. I think that helping the doctors at the facility deal better with acathia. Yeah. Talk me through, okay, how do you assess if someone has aceshesia?

What do you see and what do you hear from them? So if anybody has ever had acethesia, I have had acetheia once in response to compasine given in the emergency department. And I have to tell you, I would rather have continued. vomiting. It was the most uncomfortable experience. I was disabled for the entire time that it lasted. And I can certainly see if I were in the hospital and I were already in a compromised position in terms of my impulse control, I can understand how that would lead me to be on the verge of wanting to do something every second. Yeah, since you've had that first-hand experience, Like, what was that like?

What did you feel in your body? It's a feeling that you have to move constantly, no matter what position you're in, you're uncomfortable, you feel like you have to move, but moving doesn't relieve it. It is if you thought of this internal restlessness that was constant and you could never do anything about it, and it is unbelievably uncomfortable. Were you able to move and get relief from it? I was able to move. and I was compelled to move, but it didn't relieve it.

Okay, so this is not someone sitting calmly. Can you sit calmly? I was able to sit calmly. It just felt unbelievably uncomfortable. Okay. Yeah, I sort of describe it as an internal and external restlessness. And when I was at a forensic lecture, they talked about this being one of the things that people get sued because of,

if a patient gets discharged and on the discharge note, there's like, you know, this person's restless, they're pacing, and then they get discharged without treatment of that. And then they go do something that harms themselves or harm others. Then lawsuits are, there's a higher potential lawsuit. I don't know if you've heard the same thing or if you've had any experience with that sort of. Yeah, I haven't had an experience with that, but I could see how that would be the case. I certainly have had the experience where I, I have to say, you know, we need to treat this because this person is going out of their mind.

When you think about treating it, what's your first go-to? So, propranolol is effective for a lot of people. I often see propanol prescribed ineffectively for acethesia. So somebody who has significant acethegia needs a scheduled propranol dose. Yeah. 10 milligrams of propranolol three times a day as needed is not going to be sufficient. So 20 milligrams three times a day? Is that kind of where you start? I may start for a day lower than that just to make sure there's no hypotension if people are on the border.

But yeah, that's, and then you might go higher. Yeah. Clonopin? I often go to Ben's Tropine before clonepin, but depending on the case. So if it's somebody who would get other benefits from Clonopin, whom I'm not as concerned about. So in the inpatient setting, this is sometimes people, if somebody has had a substance dependence issue, they're very, very reluctant to use benzodiazepines. I guess my feeling is everybody's got to get acutely better first. Yeah.

And so there are some, if somebody is really, psychotic and somebody's really manic. Safety is more important. You can deal with the other part later. In treating mania, I think antipsychotics, mood stabilizers, and benzos. Those are the three sort of big guns that we have there. Now, when I was on with Dr. Cummings, he talked about metasapine, Remmeron. I've tried that since, and it's helped a couple of my outpatients.

Usually outpatient, it's a lesser degree because I'm going slower. but I've had patients come in and they have anxiety and they're on some sort of antipsychotic or, you know, compasine and, yeah, acesia. So it needs to be in everyone's mind when we're treating these population. Right. And if somebody has significant acethesia,

it can't be just a PRN medication. It really needs to be a scheduled medication. You have to consider that. Absolutely. Yeah. Absolutely. Because once the PRN is gone, if you haven't changed the antipsychotic,

they're still going to have acesia. Right. And you don't want somebody to have to come up, somebody with, it's as much, it's just like when somebody has a psychotic episode, you wouldn't prescribe the antipsychotics PRN. I mean, you might have those additionally, but you would have something scheduled

so that their entire treatment for it wasn't reliant upon they're having to come and ask the nurse. First of all, recognize that that's what's going on with them and then come and ask the nurse. Yeah. Most people have no idea what's going on when it happens. I had one patient who came into my partial program with pretty clear acesia. And I didn't have them stay in group. I wrote a script and sent them out immediately to go get the script and to go take care of it.

And, you know, gave them good ways to follow up with me if it didn't resolve. So this is something very serious. Okay. Okay. My other thought with aceshesia is we have to be aware of when we insert another medication that's not an antipsychotic, it may change the metabolism of the antipsychotic and increase it. An example might be Prozac with risperol. Prozac can increase the risperol dose considerably. And so, you know, how the P450s work, when we add a second medication on the antipsychotic, you know, does it increase the level of the antipsychotic?

everything that's on that list is something that I have seen contributing to agitation and aggression in patient setting. Right. I mean, delirium is like, I've seen that many, many times, just pulling out lines, throwing things, attacking the staff, biting the staff. Either delirium that they come in with or delirium that is acquired. So, for instance, divalprox is a wonderful medication in a certain number of people. It's going to produce hyperamonemia. if you start to see somebody, and sometimes people get a delirious-like picture even without

hyperamoneemia. So just something you have to be aware of is if you've started it and a few days later the person is starting to get worse, then you have to assess whether that's not the right medication for that person. With that, that's a nice pro. Is there any sort of other clinical things that you'll see in that person that make you think that I should check an ammonia level? Yeah.

So when somebody starts to look delirious, it's a different picture from, you know, when somebody is manic or psychotic, you see a more organized delusional picture. If somebody is not remembering your name or they're not remembering, you know, kind of suddenly, if this is a change, not remembering what day it is, they appear confused. They're looking like they don't know what's going on. they're starting to talk about, so I had one case where it was a really kind of manic-aggressive guy and he started to not know what day it was. His first question to me was, am I a Tyrannosaurus Rex?

That's not the same picture that he had come in with. And so it wasn't, he got much better when we changed the medication from dival proxed to lithium, that acute stuff that was going on changed. He started to not know what day it was. His first question to me was, am I a Tyrannosaurus Rex? That's not the same picture that he had come in with. And so it wasn't, he got much better when we changed the medication from dival proxyl lithium. That acute stuff that was going on changed.

Another thing that you have up there are complex partial seizures. And so that sometimes happens. It's not as frequent on the inpatient unit. But having a medication that addresses that if that is going on, it's very difficult to pick up sometimes because a regular EEG has terrible sensitivity for complex partial seizures. Okay. So, you know, doing an EEG is not necessarily going to give you...

When they're not having the episode, or when they're having the episode. Even when they're having the episode, the sensitivity is very low of the EEG for complex partial seizures. Okay. Cognitive impairment, we've already given some examples. Yeah, and I see a lot of the withdrawal, especially because we're in the meth capital of the world here. A lot of withdrawal from methamphetamines, causes large amounts of anger, irritability. You know, they usually want to sleep for a couple days, but when they're up, they're angry.

Yeah. And other substances also alcohol. And we go through these trends in medicine. Right now there's a big trend to use non-benzodiazepine agents for alcohol withdrawal, which I think is great if it's working. but if somebody's still having withdrawal symptoms, again, everybody's got to get through the first few days. And you can deal with whatever.

You shouldn't be so afraid to use benzodiaz-a-day as it means in somebody. If they're having withdrawal symptoms, it's more important to treat the withdrawal. Yeah. Okay, so the next, we've talked about, you know, be cautious of environmental factors that could contribute to aggression, like a lack of supervision, structure, waiting in lines,

crowding, excessive noise, poor staff teamwork. Let me give you another example of an environmental factor recently. So this is, again, going back to the importance of see something, say something. So I had somebody at one of the hospitals assault somebody because part of the person's picture was whenever anybody would use the phone on the unit, that person thought whoever was using the phone was making a report about him to, it was a very paranoid interpretation. The appropriate environmental intervention for that patient was move him to a room that wasn't close to the phone.

So environment can be the physical structure of the hospital. It can be how long do you have to wait in line in the cafeteria, but it also can be how close is your room to the phone. Tell me about the patient who was barking. So, yeah, this was a patient who came in just in a very, again, mania, mania with a lot of psychosis. And the patient also had mild developmental disability, which was, didn't necessarily,

it was separate from the psychotic disorder, but it also made some of the interventions more difficult because there was a reflexive rigidity to anything that you would suggest that was separate from the psychotic condition, the manic condition. So one, in addition to being very verbally aggressive toward peers,

and that's one of the other things you have to be careful with on an inpatient unit is that even if somebody is not doing anything that is physically aggressive to somebody else, if what they're doing is going to provoke aggression from other people, then you probably need some sort of intervention with them to protect them from being assaulted. So one of the things that we thought would be effective for this person would be if he could get away from the stimulus of the inpatient unit and also get away from the peers that he was being somewhat provocative with. And at a certain point, he started barking.

He had part of his psychotic system sometimes was that he thought he was a dog. So the barking was part of that. And the nurse, the charge nurse at that point, that was the point where he thought this person really needs to get away from. So we have a quiet room and he said, let me show you to our special barking room. And then that got some, you know, the patient was able to go cooperatively and stayed in there for a period of time and was able to decompress. Yeah, that's really classic. So we have... Oh, and in terms of the violence history, one intervention that is...

So we talked about risk assessment includes what's the violence history. One of the things I've seen be successful at some hospitals is they have... Because you don't want to be reinventing the wheel every time. If something is effective for somebody, have it in the record in a way that it pops up. So at one of the hospitals I work with in the electronic medical record system, they've said, okay, here's the aggression care plan for this person if they come in and we're seeing a lot of violence or potential for violence. And it has there. So if I'm a new doctor rotating there, I can see, okay, chlorpromazine really works for this person and Zyprexa really doesn't. Okay.

Yeah. Yeah, that's good. Okay, so I want to go into de-escalation strategies. And in this one paper, Richmond, 2011, which we'll have a link to in the article we write, it talks about first engaging the patient verbally, second, setting up a collaborative relationship, and third, verbally de-escalating.

And for the verbal de-escalation, they talk about this verbal loop, where you start by listening to the patient, and then you find ways to respond that agrees with or validates the patient's position, which is empathy. And then third, you tell the patient what you want them to do. Like take med, sit down, and you basically repeat this over and over. And one of the things that was a huge takeaway for me,

having a history of doing this, but one of the things that I learned in reading this article actually was that it may take a dozen times to do it. this. And so that may sound like that takes a lot of patience. It does. And each cycle may take one minute. So you're listening, you're empathizing, and then you come back to, okay, I need you to sit down, I need you to take this medication. And you do it over and over again. And actually, they said, like, the people who have gotten good at this, it may be the seventh or the tenth time that you're doing it, that the patient says, okay, and sort of calms down enough.

and follows through. So that was a big takeaway for me. Any thoughts on that in particular? So I think, and of course what is possible in your physical environment is going to be dependent on the situation that you're in. If I can do it in a way where there is staff supervision, I think just sitting down makes a difference. To have the conversation sitting down rather than

standing up towering over the patient, if the patient is able to sit down at that point. But things that if you have to get into a discussion with somebody where you're going to disagree, to do it in a way where it feels more to the person as if you're putting yourself on the same level with them rather than being this towering figure commanding them, helps facilitate what you've talked about there. And if there's anything in what the patient is saying that you can agree with and reflect back to the person, so I hear you saying that this is what you're concerned about.

So an example might be there was patient recently, inpatient units generally don't allow people to have cell phones. There's a privacy issue with that. You could take pictures of who's there. You know, and for a variety of other reasons. So that's something that's always put into storage and it's not going to be available to the person. And everybody's unhappy about that. You know, I would be unhappy if I didn't have my cell phone for, you know, an extended number of days.

This person who was very manic really wanted to, it's that his music was on the cell phone. And it was the music that he liked. So one of the things in this verbal loop was, okay, when we meet, as long as it's safe, I'll bring my cell phone and you can pick one song and we'll play the song. Okay. And that ended up being, so if there's anything, sometimes people will say if there's anything that you can agree to and what the person wants, agree to that.

Yeah, for one thing that comes to my mind is sometimes patients want food brought from the outside and so just writing a simple nursing order for that to take place is like makes all the difference for them and sort of calms down that that feeling of being from home maybe being separated from their loved ones. That's good. He goes into this or there's this other article, Fishkind 2002, which is really talking about the Ten Command for Safety. And I think it would be worth going through each one and kind of talking about any stories that are coming up to our mind. So the first thing is respect personal space.

And so this is keeping two arms distance, at least from the person. You know, it's not getting too close. So if they do strike or if they do kick, you have enough room to move away. And understand, you know, a lot of patients have been sexually abused. And so space is very important. You know, like are you blocking the door? Are you blocking their exit?

Are you towering over them, like you said? Are you sitting calmly? Yeah, any thoughts that come to your mind other than... Not in addition to what you've said about that. Okay. And the second one is do not be provocative. You know, so don't have your fists clenched. Don't have closed off body posture.

You know, your arms crossed really tightly. Don't excessively stare the patient down, which can be a provocation for dogs. animals alike. Any other sort of things that you do to decrease the threat? Yeah, I think this is really important. And also just tone of your voice. So I have, it's most difficult with patients that you are getting emotionally provoked by.

And there's a certain prognostic value to what we call likability. So if somebody just, if somebody is both provocative towards you, and just not very likable, it's much more difficult to maintain this. So what I know, I have to find that one likeability nugget for the patient, and that allows me to be better at this. But if I'm having difficulty with that,

that's my internal cue. I'm having difficulty finding what I find likable about the person that I need to have help from other people. So, for instance, I'm much more careful about my tone if other people are with me. So try to take a staff member in with me. And that all comes from being aware of your own emotional response. That's good, yeah. Kind of understanding your own sort of countertransference or the reaction,

the total reaction that you're having based on your past experiences and the current situation at hand, right? So we both are reacting to composite of those things. And if the person is incredibly, like, triggers us in a unique way, then it's like, okay, how can I get, you know, other staff involved? Or what do I have to do to prepare myself for the fact that my natural inclination is going to want to be to use a tone that's not going to be helpful? So, I mean, looking at it strategically, it's not that I don't have a right to be angry at this person, right? Sometimes, but it's not strategically beneficial. Yeah, yeah.

So maybe processing it with your colleagues separately, you know, like your frustration, but then, you know, when you're with the person really trying to think what's going to be best for them, their outcome, their situation. That's good. Okay. The third thing is to establish verbal contact. So they recommended one person, a trained person, you know, someone who's been trained maybe at doing the three steps of the verbal loop of listening to the patient, finding ways to respond that agree or validate with the patient,

and then telling the patient what you want and being able to do that multiple times. So someone who's been trained to do that 10 times in a row, having a one person sort of who's been trained to de-escalate people to be with a person. And then other people, if there's other staff around, have them not be as well talking to the patient. So that was one of the recommendations.

The second part of that is to explain who you are and your goal is to keep everyone safe. So maybe you explain that to the patient like, hey, I'm doctor so-and-so, I'm here, or I'm nurse so-and-so, and I'm here to keep everyone safe. And I'm here to hear what your concerns are, what you need, what your desires are. So, yeah, any thoughts on that particular part? Yeah, I'm in that situation a lot. Okay. I'm a person who has to come in and help reestablish safety.

And that is exactly what I say. Tell me exactly what you say. So let's say I'm a patient. And I'm like, hey, I want to leave. My unit, yeah. I want to go. I want to go home. So I come in and I say, I'm Dr. Friedman.

I'm the medical director here. And my job right now is to make sure that everything stays safe here on the unit. So, and normally I do have staff there because I want to have things safer for me and for the patient. And then the patient will say what the, you know, I need to leave. It's I'm being held here illegally. And then I say, well, here's the process for that. I can understand that you don't want to stay here. You will have a chance to have a hearing about that.

And in the meantime, we need to be able to keep things safe. or sometimes the person has all sorts of other things that they want to have addressed and it's impossible to address them while the person, well, and so that is what I say. I said those are all very legitimate things to have addressed. Right now we're in a situation, though, where we have to deal with safety. So we have to establish safety first before we're never going to get to being able to work on any of those things if we can't get to a safe spot. Yeah, that's good.

Okay, number four is be concise. So use simple language, simple vocabulary, bite-sized pieces of info. So don't use complicated grammatical structure. Try to bring it down to maybe a third or fourth grade level because when people are really stressed, that's the level the brain goes down to. And then persistently repeat the message that you want repeated. So any thoughts on how you use simple language? Just the way that you described it a second ago. go, it was clear. It was, hey, I'm the medical director. I'm here to keep you safe. Here's your

rights. Any other things that you would not do that you would do in other situations? Because I come from a family of English teachers, I'm always having to check my language and see if I'm, you know, and if I find that I've used a word and it is unclear, then I'll say, is it clear what that word means? And then I'll, I'll revive. from there. Yeah. Yeah. So you're thinking about the person you're speaking with

and you're thinking about how to put things into words that they would understand and not using any medical jargon or psychiatric jargon. And part of that is empathy, right? Because you're thinking into their experience and what they're going to be able to understand and you're watching them. And if you say something that it seems like it didn't get in, they don't understand it, then it's like, okay, how do I rephrase this in a more simple way?

And how do I assess for understanding? Okay, number five is identify wants and feelings. So one of the examples that they gave was, even if I can't provide it, I would like to know so we could work on it. Yeah, and, you know, this can be really simple sometimes. So recently we had patient who, and people have a tremendous amount of adrenaline

when they are sometimes in an acutely psychotic state. So this is somebody who, with a broken hand, scaled a fence on the patio that I've never seen anybody scale. Wow. And eloped from the hospital. So when the person returned, there were several transports had come to our hospital and then ended up being brought somewhere.

the cell phone had gotten at another facility, and he was very worried. Even though he's not going to use it on the unit, he wants to know where it is. He wants to know that it got from, and this was continually agitating him. I don't, as the physician, have any ability to contact the facility, but somebody does. So just saying, okay, let me write down exactly what you're telling me where it is. Here's the person that I'm going to give it to. at our hospital. And they'll call the other facility

and find out if it's there and locate it. And that calmed things down. That's good, yeah. And that's showing you're really using your team, you're explaining things clearly, you're trying to meet his concerns, his desires. That's good. Number six is listen closely to what the patient is saying.

So through body language, verbal acknowledgement, and repeating back to their satisfaction what they're saying. And also, there was a quote that said, to understand what another person is saying, you must assume that it is true and try to imagine what it could be true of. So this, when I read this, I was just like, oh, their empathy is again. I mean, so much of this is like empathy, careful listening, you know, and so many of those topics I've covered in the,

the Therapeutic Alliance series I'm going through in this podcast as well. And for psychotic patients, sometimes if what they're doing that is unsafe is based on a delusion, there's also sometimes the technique is called entering the delusion with them. So, you know, they're swallowing things because those things have certain religious or protective value. And swallowing, you know, in the case I'm thinking of it wasn't an inpatient case. case, but metal, you know, swallowing metal has this kind of spiritual value. So the way that I address it with the person is, okay, given that metal does have this spiritual value, is there any way

it could have a protective force for you without having it inside your body? It's not challenging it. It's entering it. Yeah, yeah. I tend, um, to not want to disagree directly with a delusion because it provokes agitation and it doesn't really help. Yeah, by definition, a delusion is a fixed false belief. So to that person with the metal, I might say something like, it would be, I hear from you that it feels very safe to have metal with inside you. And that there's something very scary about not having that. So it's empathizing with the distress that's there. without necessarily co-authoring that they need the metal to save themselves.

And your thing is it's a little bit different, but I think it's good as well. It's like, okay, is there a way that's not going to be harmful towards you to maintain this sort of belief in the same way that swallowing metal is going to be harmful towards you? Number seven, agree or agree to disagree. And mainly it's to find things that you can agree with. So there's three things you can agree with. One is you can agree with the truth. Two is you can agree with the principle behind the statement. So, for example, I believe everyone should be treated respectfully.

The third one is agree with the odds. For example, there would probably be other patients who would be upset also. There would probably be other patients who would be upset also. So you're sort of normalizing that they're going through, could be experienced as distressing by someone else in the third example. Something that is similar to this, that chairman in my department in residency said, is you can always find something, you can always find something to apologize for if the person really feels wronged, you can at least say, I am really sorry that you are having this

experience and that it's so difficult for you here. it's certainly not our intention to have your stay feel uncomfortable to you. Yeah. Or you can say, I think other people in your situation would also find this situation uncomfortable. And I actually, you know what, I agree that our food here isn't the best. And I agree that there are a situation, you know, that we don't have all the TV stations, we don't have, you're not allowed to have your cell phone. So there's a lot of things about being here that are very intrinsically frustrating.

So yeah, agreeing with the truth. And I heard another expert person who was de-escalating people, you know, like there would be VA patients who would be really upset about their care at the VA. And he would just go straight to, yeah, I agree. You don't even know half of it. There are so many more things that you could be frustrated about the VA here. And I am like totally with you in that. And the patients would be like, what?

they would be shocked. You know, you've just like kind of aligned with them, you know? So, and, you know, this is also good for just arguments in general, right? If you are having arguments with your significant other, try to find the parts that you can agree with and agree with them. You know, like, hey, I agree I was late today. And I agree, now that I see it from your situation, I agree that that was upsetting. You were planning, you were expecting, and it's hard when we have expectations.

that are met. It's understandable that you would be upset. So find anything that you can agree with, and that can be de-escalating. Okay, let's move on to eight. Lay down the law and set certain limits. So you lay down the expectations for expected behavior as a matter of fact, not as a matter of threat.

So you can say on our unit, we don't attack each other, we don't harm each other. you know, the staff won't do that to you, and we expect you to not do that to us. I do that with my kids. I say, you know, Daddy doesn't physically hurt you, and so we don't physically hurt each other. And again, tone of voices is very important for this. Yeah, tell me about, like, what would your tone sound like when you were doing this? Yeah, it sounded pretty much like my tone right now.

So one of another... My tone was probably a little bit too authoritative. Well, there are instances where I use a little bit more parental tone on the adolescent unit, but mostly not. Mostly, you have more power. Most of us want to go louder and sharper. You have more power going softer and lower. Hmm. I like that.

Okay. Number nine is offer choices and optimism. So you propose alternatives to violence. You can offer kindness like blankets, magazines, access to phone, food, drink. Choices in optimism. We've talked about how you give choices. One way I do it is you give two choices that you're both okay with. So you could take this medication now or you could wait half an hour and take it.

Or you could take this medication or this medication. or you could, you know, you could either go to your room right now and calm down, or we could open the door and you could go outside in our place. I don't know. Any other kind of choices that you give? Yeah, no, that's a really good technique. The other thing I do is, I think this is, this also comes from parenting is, well, how about we do this right now and then in half an hour we can do this,

you know, the thing that the patient wanted to do. Yeah, with my kids, when it's bedtime, it's like, okay, we can either go to, your room and we could read stories or we could go to your room and play for three minutes before we read stories. So it's kind of like either way you're going to your room, we're moving you in that direction. What do you think, Nate? Now that makes perfect sense. Yeah, ideas from sales come to mind where the salesman will, you know, say, do you want to sign for this now or do you want to, you know, look at another option? And basically, do you want this today or do you want it Wednesday? You know, that kind of an idea where it's two options where the sale gets made either way.

Yeah, yeah. I've heard of that for dating too. It's like, okay, do you want me to pick you up at five tonight or do you want me to pick you up at seven? Maybe not the best way for consent, but, okay. Yeah, any other thoughts from that? No, I think we can go on to the next one. Number 10, debrief with the patient and the staff. And any stories come to your mind on debrief.

and the importance of debriefing? So I was going to bring this up independently if we didn't. Debriefing is critical because the idea is that you're continuously learning from the situation that happened to see if you can improve the system and also to see what, so the system in general, but also the further interactions with that specific patient. And so we tried this, what needs to be. And so every day the first meeting of the hospital is, debriefing any incidents that occurred the, and by incident, it could be, it doesn't necessarily

mean something that led to, you know, involuntary medicine or something that led to an incident is we had this difficult interaction with the patient and, you know, to prevent things from happening or to make things, to help facilitate things going better. What do we need to change in our strategy? And we've also implemented. if there is, if things do escalate to the need for locks occlusion or restraint, we don't have that many restraints, but if, or involuntary medication, if somebody, if it continues, or even one-to-one observation, if the one-to-one observation continues, I mean, if people need one-to-one observation, they need it.

but every hour the nurse has to do a little assessment about what's the justification for this. And it's an opportunity to say what needs to happen in this patient's care to move them to a situation where we're not. Because having somebody there watching you all the time becomes a patient's rights issue. It's an intrusion into your privacy. So it should be necessary if it's going on. We don't think about that often on psychiatric inpatient units, but people do have a right to their own privacy if they're in a condition that they can be safe.

So that intervention might be a change in the behavioral plan or that intervention might be that we have to reevaluate the medication strategy. Perhaps the medication strategy is not treating all of the symptom clusters that need to be treated or perhaps it's not progressing quickly enough. Yeah, that's good. And I also think that debriefing can be important because it really does help the staff, especially young staff, understand what's going on, understand how the situation was handled, what we can learn from it. And things that may be not so traumatic for us, you know, like later on in our careers can be very, very troubling to the staff. And so, yeah.

One thing I'm curious about is how often do you have to give involuntary medications with all the approaches that you take? Is it like a daily thing with the really acute patients or is it? No, it's a daily thing. It, um, there are times, so I work the high acuity, all-male unit. So I have the unit where if you're causing a problem anywhere in the hospital, you get sent to my unit. Okay, okay. If you're male. So there may be instances where people, for the first few days of their hospital,

there have been instances where somebody has required involuntary medication three days in a row. Yeah. Right? Yeah. If you're doing your job, you get them to a situation quickly where that's not the case. Right? That's what I mean by something like that is an opportunity to evaluate what needs to change. How often do you need to reese a patient and basically force meds against their will?

So, okay, Reese is important if it is something, if medication is, if there's nothing you can do, and it really, right, Reese should always be a last option. For people who are not in California, we should probably explain what a Reese is. RIS is our term for a capacity hearing to see whether the person has the capacity to refuse. Mm-hmm. Yeah, so how many of those, like, how many patients initially refuse meds that you're able to convince to take the meds and not need the Reese hearing versus how many times do you need to go to Reese? Most of them. And actually, I say, when I'm having the discussion about it, I say, look, I really want us to be able to come to an agreement that is cooperative. I don't want to have to go to a hearing. and argue to do something against your will.

So I have that discussion after the person has been refusing medications. And a lot of the time that does work. Okay. And we come to something, well, I'd be willing to take this. I wouldn't be willing to take that. I mean, it's got to be reasonable. Like you said, you have to have choices that you are also okay with. Yeah.

We often have patients who are like floridly manic, who it's, you know, the only way to... Right. treat them is to give them that's against their will. And often once they come out of their mania, they're thankful that we did that, but in the short term it's pretty tough, you know, to do that to someone's autonomy.

But I don't know. Do you have any thoughts on that? It is, okay, so here's the way that I feel about that, that people who are that manic and that psychotic are going to have, they're going to have other interference with their autonomy because the behavior is dangerous. You know, we're doing it because it's physically dangerous, right? The standard for the legal standard for giving somebody medications against his or her will is much higher than the legal standard for hospitalizing them, right? It's a greater intrusion into their privacy and their personal being.

So you really need to be able to prove that there's no other attempt to reach a voluntary agreement that has worked. That there's no other reasonable medication choice other than the one that you're suggesting that the patient would be more amenable to. And if sometimes on the day, sometimes the, they're more cooperative with the patient's rights advocate than they are with you as the physician. And you shouldn't see that as an affront or as a bad thing. If the patient meets with the patient's rights attorney or advocate, some counties it's not an attorney. And that patient says, you know, I would take Risperdall. I'm just not going to take this other. And maybe you've suggested it to them before.

They've said, no, if they're saying yes now, that's not a bad thing if they actually follow through and take it. Yeah. So you've got to put your ego aside and say, we all want the same outcome, which is that we come to a place where we have a cooperative agreement. Coercive things will work if it is something that's going to get, going to change. if somebody is acutely manic and the medication is going to make them unmanic. But in general, a cooperative agreement is always better in the long run.

Yeah. And how much time do you have to spend with a patient on average to, like if they're really against taking medications? Like how much time are you spending with a patient to build that alliance to the point that they would take the medication? Yeah. If somebody's not taking medications, that's like the, the top of the hierarchy, and they really need them to come out of the, of the, that's the top of the hierarchy of needs. So that is most of my inpatient visit with them that day and maybe the next day until, and it's focused on, you know, we're going to have to have things safe

and I just don't see a way of doing it without some medication. So like, are these like five, 10 minute interactions, 15, 20 minute interactions? Somewhere, somewhere, somewhere. between. Okay. Sometimes the person won't meet with you for five minutes. Right. Yeah. It depends on the...

Yeah, for sure. Well, thank you. That's really helpful. I think before we close, I think we should talk about some of the other articles that were interesting. Oh, yeah. Nate, why don't you take us through any of that jumped out to you as like,

wow, that's interesting. I wonder how that happened. Yeah, so we've talked so far about a lot of traditional methods, medications, rare restraints, seclusion, things like that. But then there are a few studies out there about some less traditional methods. One of the studies comes to mind, the study that you sent over about a place in Blackpool, England, the acute inpatient psychiatric facility started taking their patients one day a week to the zoo and reported some pretty amazing things after a year.

So before this year started, they were having about 182 aggressive incidents in patient. And after this year of taking patients to the zoo once a week, the incidents dropped down to 126. That's a really big increase. I'm sorry, but really big decrease. And then they also noticed some other interesting things that happen, like average length of stay reduced by 50% reduction in SAF, taking sickness. time of more than 50%. So a lot of really amazing things. It almost sounds too good to be true coming from a very simple thing that might be difficult to do in the U.S., obviously. But what are

your thoughts about a less traditional things like that? Because it really shows that there's a balance. There's a balance of positive experiences and then what we think of as the experiences that people find confining or, you know, where they feel that they are, control is being exerted over them. I think, you know, from a medical legal standpoint, I don't think anybody could do this. In an acute inpatient setting in the U.S., you couldn't take somebody out of the hospital

where the person could, you know, has the potential to run off. But it does illustrate that you have to think of things that are going to be positive experiences for them as well. Yeah, what this made me think of was when some of the reforms came in the history of psychiatry, you know, where, I mean, it sounds really bad, but they used to put chains around, you know, the mentally ill. And so Pinell, when he came in and he, you know, opened the windows and had them gardening and had, you know, visits and good food and healthy, you know, exercise.

And, you know, patients got better. And I think it's a mindset change more than just going to the zoo. It's like, okay, the culture is shifting. The culture of, you know, these are people. These are people who struggle like we do. So maybe just increasing the morale of the culture of the unit, I think, changed a lot of these different things. This is why you see yoga, pet therapy. These are things that.

Yeah, yeah. They come from our hospital, yeah. Yeah, and those kind of things, you know, help people feel, you know, like humans. Again, so I think that would be my sense of, like, it wasn't just the zoo, right? It was like the culture shift. And whoever allowed for the zoo to take place, that was a great leader, right? And so it was like maybe something to do with that great leader and the leadership and the culture shift and everything that happened from that, you know. rather than just being a singular, you know, going to visit animals once a week.

But that would be my sort of take on, you know, what would happen if we randomized control trial this in multiple settings, you know, it would be like, well, probably not the same results. Yeah, I think you're absolutely right. How else would you get staff so much more enthusiastic about coming to work that they're taking less sick days in a year? I mean, that's got to be a culture shift, yeah. Yeah.

Any other studies you want to highlight before we wrap this up, Nate? No, I think that's there's the important things. And, you know, anything else we'll just cite in the document that we put online. Okay. Yeah. Gosh, this has been a really great episode. I've learned a lot in this. And it's a good reminder to me as well when I'm covering the unit to really, to not just jump to, you know, simple solutions,

but to really engage the patient in that therapeutic alliance, engage the patient with empathy as a human who struggles and as a person going through difficult situations. And how can we allow patients to have the most autonomy in the midst of, you know, one of the most difficult situations in their life, you know, being psychotic, being manic, being severely suicidal? So those are the things that I really appreciated from going through this with you, Dr. Friedman. Thank you. Yeah. Any last thoughts you want to share, Dr. Friedman? I just want to jump off of what you said there. This is another very wise thing from the chairman in my department when I was in residency on the inpatient unit. And I think this is still true.

You know, we are in the era of biological psychiatry for several decades now. However, all psychiatry is about the relationship. That's really good. really good. Nate, any sort of big takeaways that you've had in reading this and going through it? Yeah, I think that building off of that, this idea that emphasizing the relationship and really paying attention to what the patient wants, you know, we're oftentimes wrapped up with ideas of how can we stop the patient doing what they're doing. And interesting studies, looking at what patients think about the inpatient setting, usually come away with them reporting,

feeling very controlled, stifled, things like that by the traditional methods. And in this idea, and we've touched on it a lot today, partnering with them, trying to empathize with them, putting a lot of intention and thought into de-escalating as much as possible before going to involuntary meds and things like that really make a difference in how patients feel and bring back a sense of humanity. Yeah. So we will have a link in the bottom of the show notes to different places you can interact with the material.

I really appreciate it having you on, Dr. Friedman. We'll have you on again and get some more wisdom from you and practical experience and kind of the mixture of science and just years of doing this and doing it well. And one of the reasons why I had Dr. Friedman on was because we're in this professional Facebook group together. And yeah, it just someone had posted a job offering at, I think the place that you worked at. And someone else commented on it that Dr. Friedman is the best person you could possibly have as a boss. and it's just like that like collegiality of like multiple people jumping on board and saying the same thing that made me think like okay I want to have I want to have Dr. Friedman on so thanks for coming on and thank you for having me okay Thank you.