BEHIND THE LOCKED DOOR: A Psychiatric NursesaEUR(tm)s Story

By Gregg M. Schultz RN

One man, not sure where his next job would come from, is employed by God where he will compassionately care for society's least fortunate--the mentally or emotionally ill, when they transition into the psychiatric hospital system. I am that man. This is my story of working in the psychiatric system, usually in a hospital setting.

This volume is a telling of twenty-nine years of caring for and about people who, but for the grace of God, could be me or my family. It is a telling of surviving and thriving in often difficult circumstances. Starting as a mental health worker in 1988, I received my registered nurse license in 1993 and continued as a psychiatric nurse until I ended compensated employment in 2017.

This is a telling of covering the naked and treating the self-inflicted wounds of the bloody. The whys and logics of many of the disorders encountered are addressed in caring and often wry commentary. The actual workings of the psychiatric hospital, and my observations of that environment are presented.

Life as it is actually lived, often at its most visceral level, is on display here. I frequently make reference to a person's WIIFM (what's in it for me) as a dominant factor motivating the behavior of people, both the patients and the hospital staff. I do not spare myself when addressing WIIFM as a behavior motivator. There is caring for wounded hearts and how to manage those whose hearts are beyond either wounding or caring.

The legalities, as well as the realities, of how the mental health system works and the protections for those who are a danger to themselves or others or unable to care for themselves are presented here, and I deal with the realities of psychiatric hospitalization and dispel the nonsense of a seventy-two-hour psychiatric hold.

There is triumph and tragedy presented here in a uniquely engaging style by a true storyteller.

• Language: English
• Publisher: Christian Faith Publishing, Inc.
• Release date: Mar 30, 2023
• ISBN: 9798887515441

Book preview

Chapter 1

A Greased Tussle

I was walking the halls of the county hospital psychiatric unit where I worked as a registered nurse. My reverie was broken by hollering close by the doors that enter the unit. There was no time to wonder—just go! I used the middle of the hallway, staying away from doorways; somebody might swing something at me or try to grab me. In the psychiatric unit, you have to anticipate the unexpected, and I don’t like being ambushed, so I am cautious even when rushing to noises. Somebody was in trouble, too; now hurry!

Rounding a corner, a patient that I had been working with. He’s not a bad guy; we got along pretty well. He’s bigger, younger, prison muscles. Nobody my middle-sized, middle-aged self could handle alone, and there he stood, half a head taller than me, in complete glistening sable glory.

Not a stitch of clothing, he looked like a well-oiled bodybuilder sans Speedo. He was headed for the exit doors, and I was first on the scene. I shouted his name. This would get his attention, interrupt whatever his plan was, and my loud voice would bring many more staff in emergency response mode.

Reaching him, he looked down at me. A feral look in his eyes but a slight look of recognition and a little compassion toward me also. I was watching him but also looking through the door windows, prepared to wave off anyone approaching to unlock those doors to come onto the unit. He knew me. For the past few days, I had been his psychiatric ICU nurse behind an internal set of locked doors. I had, at times, given him little packets of petroleum jelly, at his request, because it was winter in Michigan, and heated air dries the skin. Dry skin is especially ashy and is most obvious the darker your skin is. His legs could be seen from a room away, and I was constantly handing out lotion. He wanted petroleum jelly, not lotion. A matter of personal choice, I suppose. We have had a few talks in the course of his stay. Hey, he’s a nice guy.

He pushed me away with a flat palm to the chest. I grabbed the arm, and the method became obvious. He was covered in petroleum jelly from neck to toes. Laughable if it was not that he was police hold from the county jail, and he had an escape plan, I guess. I never found out if there were clothes and a ride waiting outside or not. The opportunity to talk never arose again.

Back to the immediate question: have you ever seen or participated in a greased pig contest? Let me also digress and say that real gang up on a guy doesn’t go like the karate or fight scenes from the movies. We deal in the real world in the psych unit. The staff are the gang. In the flicks, our protagonist is surrounded and disposes of his attackers one at a time, while the rest of the gang waits their turn to get thrashed. Not a good idea! This was not an entertainment venue, and he was not a protagonist. We played pile-on and take care of business. Optimally a gang of five in a bad situation is a good number. One for each limb and a spare for whatever is needed. In the real world, you make do with however many you’ve got and make sure that the patient is kept free from injury. In these situations, the patient has the right to be kept from injury, a benefit seldom extended to the staff by the patient.

For as far as he had thought it out, he had a good plan. No clothing to get a grip on and a greased slippery hide, my grip slid right off him. It was quite a towel tussle, but we got him behind a locked door, and he was discharged back to jail after that stunt. Nobody hurt, and it was all in the kind of day that a psychiatric nurse can have. Although that one was the only one of that unusual variety I have ever experienced.

A psych unit deals with people operating at a more visceral level than most people do. The common conventions of wearing clothes and not doing harm to yourself are more fluid with folks requiring psych hospitalization.

But behavioral disorders that result in depriving folks of their freedoms either voluntarily or involuntarily require a special sort of person to care for them. I am one of those. I am a psychiatric nurse, and this is my story.

This is a raw and visceral story. It is how it is. Told by one who has covered the naked and cleared the blood but, most importantly, cared for wounded hearts. A telling of pathos, compassion, and sometimes victory.

Chapter 2

Out of Rope

Like the best in many fields, I was forced to find my calling because I ran out of any other options. I did, however, wake up one day and tell myself, I want to become a registered nurse. I was thirty-six years old, a beaten-down failure at everything.

Nurses have been referred to as angels of mercy. I am the perfect definition of an angel. I was created, not born into the profession, and I am a male. Maybe in some literature, you might find an ever existent or female angel, but not in the sixty-six books of my Bible, the two named angels being Gabriel and Michael.

I felt like I was a failure at everything I had done in life. I was at the end of my rope. It is said when you reach the end of your rope, tie a knot and hang on. Believe it or not, it’s a good starting place for a person who chooses to become a professional (caring) nurse. Let me further explain that there are two types of nurses: the starters and the start-overs. The first group, generally women, make the choice early in their lives to become nurses. I applaud and appreciate this group. The second type are twenty-or-so years older in life and are looking for a second start in life.

Maybe the kids are grown and kind of independent; maybe the marriage is on the rocks. Many have tied that knot in life’s rope, and nurse’s school is where they are hanging on at. I am this type of nurse.

I’ve already said, I did not spring full formed into a world that appreciated the many benefits I could offer it as a nurse. I was born and bred in one of the rust-belt states; where I’ve always lived was one of the belt holes. A bit of a dreamer and a will-o’-the-wisp when I came of age, I thought I wanted the American dream: a house, a car, a dutiful Stepford wife waiting with supper ready, and my two and a half kids happy to see me when I got home each night. I really was every woman’s nightmare, a man-child vague in every way. She had her own agenda when we married after my twenty-first year. It lasted, in name only. Another twenty-one years.

After graduating high school, I found auto plant work. It was stultifying. At eighteen years old, pushing a broom for a handsome rate of pay at a Chevrolet foundry, I would ask myself if, in sixty-two years, as I am lying on my back, looking up at a coffin lid closing over my face, What would you do over again now that it is too late? My reflections would go back to that American dream, with the understanding that I did not want to be bored at work, and then a little background nudging emotion from when I was thirteen years old and discovered that my mother had been a mental patient in a notorious state hospital some years ago. I overheard her say that she would be hospitalized for months, come home, get pregnant, return to the hospital. Repeat cycle times four. I was number 2. Over the years, as I thought about my earliest memories, those memories began to make sense.

You’ve got to do something with yourself in life, and the Vietnam War was going on.

Maybe if I had been drafted like my grandpa in the First World War and my dad in the second, I would have had some time to season and had some sense knocked into me. There was a draft lottery system at that time, and my number came up, much to my mother’s joy, so high that the Russians would have to be one state away before I was drafted. So no army for me. I eventually lit upon the idea of going to college to become a psychologist. It was that nudge about my mother, who, I might add, was a highly educated high school chemistry teacher. She made me take her class; I was a disappointment to her. I had no mind for chemistry.

Okay, you ask, what does this have to do with becoming a nurse? A journey of a thousand miles takes some steps, and we will hurry through a bunch of them. I worked, went to college, and got a BA in history and psychology in three years. I did not go to graduate school, my excuse being that during the war, everyone wanted an educational deferment, and there were like a million applicants for every grad school opening. There is a saying that with a degree in the humanities, you better be able to ask, Do you want fries with that? So having a wife in tow and after four years of marriage, we started a family. I sold a whole lot of cigarettes and gasoline, even reaching a position of district manager for an oil company. In high school, I pumped gasoline and was always super impressed with that exalted position in life. I left that position because my employer decided to sell truck stop pornography through all outlets, and my Christian faith would not permit me to do that. Eventually unemployed in 1988, I washed up on the shores of the county hospital, where my education qualified me to work as a mental health worker.

The staff that work in psychiatric settings are not the brutes of the movies, and I have never seen any men in white shirts and pants with a black belt. If I had shown up wearing such a combination, I probably would have been sent home to change. At the time I started, we were expected to dress normally, which meant a button-down shirt and slacks, no blue jeans except on casual Friday. Brutishly direct they are, however. I was dismayed in my six weeks of orientation to hear my mentors walk up to a patient—a complete stranger—introduce themselves, and then ask, Are you feeling suicidal? Do you have any plans or thoughts of hurting yourself or anybody else today? Not generally how I have approached people for the first time. But then I never tried selling used cars or fireworks either. Surprisingly I have not had anyone take offense at such an introduction. I have used it innumerable times since then. But only in the clinical setting. Probably just felt nice on the receiving end to know that someone cared enough to ask.

By the way, I was trained then by the best, and they had done their homework on their patients before they went out and introduced themselves with such a seeming off-the-wall query.

Let me explain that the staff workers in the psychiatric units are classified as nursing staff members, whatever their title may be. For the purposes of this book, everyone in this role I will refer to as mental health workers, or MHWs for short. They take their direction from registered nurses and legally function under the licensure of the registered nurse, whom I will generally refer to as RN. This also makes the RN responsible for how the workers carry out their assignments. We will get back to this. Let me also say that there are a bunch of other people who work in or on the psych unit who also are not nursing staff and do not report to the RNs. I cover them under The Other Players write-up.

Michigan, at any time, is a tough place to earn a living. In 1988, I was happy to land a job earning $8 per hour. RNs at that time were paid $12 or so an hour. What I found really nice was that I was full-time at forty hours a week and paid by the hour. That means I would be paid overtime if I worked in excess of eight hours in a day or over forty hours in a week. Considering that I had just done the last thirteen years as a salary-slave manager, sometimes working in excess of sixty hours a week for an unchanging salary. There was a lot of overtime posted. A competitor had hired away many of my new employer’s workers. That’s what made room for me! Further, I was eager for that OT pay, as I had lots of time to fill. What I also had—it never leaves me—is hubris. Coming from a businessman’s world, I was used to a lot of back-and-forth consideration when decisions were made. I learned quickly to curb this side of my worldview. Patient-care imperatives are not a democratic process, and I learned that my input had its proper place, which is kept to myself.

Desperate gratitude makes for a quick learner.

Given my cockiness and an attitude that was shared by some of us MHWs that we had more education than the RNs, a reckoning was soon to come to me. I dared to point out to a nurse somewhere that I thought she was in error. The next day, when I was called in to see the nurse manager, conspicuous by its absence was an inquiry as to my point of view. When I got my tail out from between my legs, I came to a couple of realizations: (1) the nurses ran this hospital; (2) if I lost my job, I was in trouble.

I was at a significant crossroads in life. I had to have the goods that would make me employable. Some sort of licensure in which the paper would be hired. Just as long as I get the paycheck. A quick assessment of my situation revealed a good job, as long as I could keep it. Time on my hands. The hospital would back me with tuition reimbursement as long as more education was work-related. Not very likely that I could get a plumber’s license. Most importantly, I liked my job and wanted to stick around.

Before I get too far gone, I want to note that I was wrong, and the nurse was right. I got the chewing out I deserved. There were some things I did as an MHW that I would not have tolerated in an MHW when I took on the responsibility of a registered nurse.

I worked from the autumn of 1988 until the spring of 1993 as an MHW in a full-time capacity. I attended nurse’s school while working as an MHW. The next twenty-one years, I worked as a full-time psychiatric registered nurse.

As a person new to working with the mentally ill, things went along as well as could be expected. I did something right and something wrong every day. One has to learn the right ways, and that takes experience, which takes time. On top of that, you are dealing with people’s lives. I had heard from some motivational PhDs once that on any job, the first year, the job owes you.

The second year is about equal, and the third year, you owe the job. I recommend that anyone who is wise and reads this both bears it in mind and keeps it to themselves in any applicable situation. Bosses and HR do not appreciate this sage advice. Don’t ask how I know this.

The focus of this narrative is not biographical except as is circumstantial to the narrative, so I am not pinning subject matters to a timeline. What I learned as an MHW carried on through my career and was a good foundation for a psychiatric nurse. I will come back to my nurse’s training a little further on, but now let’s talk about patients as their care is the reason for this story.

Chapter 3

Surviving and Thriving

My first and most basic assessment that I do with anybody I encounter is to determine what their WIIFM is. A term of my own invention, it stands for what’s in it for me. In the psych unit, it is my survival tool. Which goes to show where my personal WIIFM is at.

From the moment of arrival to the unit, a person is going to engage in defensive tactics. People who are not patients generally have socially acceptable ways to meet their needs. Not always but that is another story. The person arriving as a patient, especially those on their first time around, cannot be expected to act in any usual way, so we had to be prepared and attempt to put the patient at ease until we figured out what was going on with them and ease them through the admission process. The wise practitioner will come across as firmly nonthreatening. I was often involved because many of our patients came in on an involuntary basis, with paperwork that had to be checked for completeness, legality, and then the petition paper had to activated by a registered nurse. Consequently I was the first impression that the person had of the place they had been brought to. We all know that first impressions are lasting. A sense of orderly, friendly, calm can allay a lot of concerns that a person who finds themselves now a patient in a strange place may be experiencing.

As an admitting nurse, I also had to do a lot of threat assessment for any hidden agendas or secondary gains that the newly admitted patient might harbor. Listening and looking for clues in the initial interactions, it does not hurt to ask the patient flat out why they are being hospitalized. You’d be surprised what they will admit to. If you but ask.

I was not the only person they were meeting. In an uncomplicated admission, a staff member took over the first part of the admission process. The staff I worked with had the same innate understanding of WIIFM factors as I did, even if they used different terminology. With few exceptions, they are kind and caring. I always bore in mind the adage There but for the grace of God go I and treated people the way I would want to be treated. I was not unique. Our patients could be anyone from a screaming hellcat to a catatonic person. I will add here that I never took anything for granted. People can change in a hurry if they think there is something in it for them, or they get panicky. As far as catatonia goes, I always understood that this shutting down is a rage reaction, and I had better be prepared to deal with it if they came out of it.

So what types were admitted involuntarily? Street people with nothing, to those who seemingly had the world by the tail. Occasionally it was a battle as soon as the police escorts removed the cuffs. The doctors put a stop to that, however, by refusing to accept people who were causing problems in the emergency room until they were calmed down. So we got a few that were heavily sedated on arrival. There were those who attempted to bluff and bluster. We were violating their rights as a citizen. Lawyers, street gang affiliates, their mother, etc. would be invoked as a possible contact, and you’ll be sorry. Terrified people expecting the worst that Hollywood could conjure to those just happy to have a warm place with food.

A couple of memorable admits for me:

I corralled the worker whose turn it was to do the admission, and we went to see the patient. We walked into the room and had to look up to see his face and just kept looking up until we got to his visage. Now I was pretty much middle-aged average for a man in every respect. The worker was my height and of a lean build. The guy we were looking at was pushing seven feet tall. Think the movie The Green Mile. The worker whispered to me, If he goes off, we are dead. Now a man charms with his words, and that worker was a charming fellow. I confidently introduced myself as Nurse Gregg and wondered what it would feel like to have my arms torn off. I then let Mr. Worker take over while I handled paperwork, staying close by. We never had trouble from this guy in the unit. Evidently his WIIFM did not involve using that immense size to intimidate others, which could have been reported back to his county court.

Oddly enough, when it was time for him to go home, two sheriff deputies from his county showed up that were as big as him. I don’t know what they feed ’em there, but I wish I could patent it.

The other was around 1990. I was the worker. I got my nurse license in 1993. I was staffing the intensive care area. The nurse brought in a distraught lady wearing a trench coat. I introduced myself. I was wearing my customary slacks and button shirt. She saw she was not in immediate danger. I asked if I could hang up her trench coat. While not immodest, she was not wearing a dress but a slip. Professional women used to dress like that. Quickly getting her a gown to wear, we proceeded. Her story was that she got home from work, removed her dress, and lay down on the sofa to rest. From nowhere, she was disturbed by police knocking at the door.

They told her to get her coat, You’re coming with us. She was cuffed and brought over. After some reassurance, it also helped that it was a quiet night. She admitted that she had all the movie horrors of psychiatric treatment centers in expectation. We reviewed her copies of her paperwork, finding that her estranged husband had filed the petition. She also told me that the statements of the petition were not factual.

He wanted me out of the house for a few days, she surmised.

The psychiatrist released her the next day. Her last words to me were inquiring how this petition process worked again. She might be trying it herself real soon. Her WIIFM on arrival was basic survival. On departure, I suspect, a good divorce lawyer.

Caring for the Heart

The one thing that everyone arriving in the psychiatric unit has in common is a heart. I don’t mean the pumping organ slightly left of center in the chest. I am referring to the heart of a person’s emotional self. With some exceptions caring for this part of the person who comes in as a patient is not given enough consideration when care planning is done. Maybe such a care plan is not a realistic expectation. A good care plan spells out how to care for a patient’s needs in the specified areas and can be modified if results are not being achieved as planned. It is much more difficult to plan to care about a person’s needs. To care plan for a patient is mechanical, and maybe science. The best practitioners, I have found, also are artists of the heart.

It does not matter how they are packaged, whether big or small, scary formidable, or negligibly insignificant, nattily dressed, or unbathed. They are one size and shape when it comes to their heart (there are exceptions; these will be dealt with later). Most patients arrive scared, angry, and defensive. They all want to know that somebody cares about them. It is the old saying you get a lot further with honey than vinegar with shoe leather on it, and it looks like this: a ready smile, a perfect stranger, in passing, stops to ask if you are okay, and is there anything they can get for you? Sometimes it is going the extra step of not just saying you can’t do something but the stopping to explain why and then offering alternatives that might meet your needs.

Frequently it is someone that cared enough to ask you to try a little harder, like when you just want to be left alone on the pity pot in your psychiatric hospital bed, and they don’t ignore you, continue to nudge you, and then spend some time with you after whatever it was that you were required to do.

These care artist staff members have also learned balance in their lives. Their ability to care does not come at the expense of themselves. They are mature enough, have professional boundaries, and will not burn themselves out in doing their jobs. They have benefited from experienced workers and now teach others that will take their teaching. These are the true therapeutic heart of the psych unit.

I have said that there are exceptions. There are the patients whose agenda overrules their heart; perhaps they did not have much heart to start with. I don’t know. They are the ones who, maybe, are here simply because they have been swept up out of an unstable situation, made so perhaps by themselves. They may be predators looking for easy victims. They may be just plain sociopaths who seem to be incapable of caring about or empathy for others.

I have learned the hard way to be extra cautious around the sociopath. They should be treated the same way as all