Sunday, December 09, 2007


I was recently informed by an ER patient that I need to take sensitivity training.

The patient was educated, articulate, dignified, and clearly suffering from a mental illness. The mental illness wasn't the presenting complaint, though; a small physical injury was. When I stopped by, as part of my routine rounds, and identified myself as the chaplain, the patient requested prayer, but didn't give me the chance to offer it. Instead, I became the audience for a long, winding, alternately convincing and bizarre narrative about family history, the injustices this person had suffered at the hands of police and paramedics, and the events leading to the ER visit.

The patient wasn't white. This is important.

I sat and listened; that was clearly my job in this situation. When the medical staff entered the room, I left. When I went back in, the patient was ranting to a nurse about how the doctor had been racist. The doctor had called the patient by first name; the patient found this disrespectful.

Trying to help, I said, "That's how we do it here; he'd call any patient by first name. I'm sure he didn't mean to offend you." But the patient was on a roll. The doctor was racist; police were racist; paramedics were racist; the nurses were racist.

The nurse gave me an imploring look and said, "I'll go find the doctor." I followed her out of the room and asked if she wanted me to talk to the doctor too; she said, "No, that's okay. He just has to go back in there and make nice."

I went back into the room. The patient was talking to someone on a cellphone. I left, and wound up in the middle of a cluster of nurses who were muttering about the patient.

"You know, that makes me angry, being called racist."

"It's a symptom of mental illness," I said. "Has to be. Something's wrong there."

Everyone agreed, but the staff was still angry about the accusations. This was all complicated by the fact that the patient had been discharged, but showed no signs of leaving. The doctor had evidently suggested a security escort, which wasn't going to make the patient feel better about anything.

I went back into the room. The patient, off the phone now, had spread a bewildering collection of personal items out on the countertop and was arranging them haphazardly into small piles. Things kept falling onto the floor. "I need to get all of this organized so I can go get my money." I offered to help pick up the things on the floor, but the patient said, "Oh, no, my lawyer's going to fly in and lift all the fingerprints from that. We can't touch it."

"How about if we wear gloves?" I asked, but the patient -- while moving things back and forth on the counter -- said that we had to leave everything where it was. The nurse came back and started explaining discharge instructions.

"You're standing up! You're talking down to me!" the patient said. "You're racist!"

I'd been standing the whole time. "I've been standing; I'm sorry if that bothered you -- "

Whereupon the patient whirled to face me and said, very calmly, "What you need is, what do you call it? Sensitivity training. That's it. You don't know what it's like to be black."

"That's true," I said, "I don't," whereupon the patient treated me to a long lecture about racism.

The nurse left. The patient calmed down. Through the open door, I could see three security guards (two of them white), and my heart sank. But the patient had evidently forgotten about lawyers and fingerprints, and gave me permission to pick up the things on the floor. "Oh, it's fine if you do that. I don't have a problem with you. Have you seen my driver's license? I think the ambulance people stole it."

I was trying to lift a very large plastic bag of personal belongings. Was this well-dressed, well-groomed person homeless? "I can't pick this up," I said.

"Neither can I. I can't lift anything."

So a helpful, smiling security guard stepped in to give us a hand. Perfect! Exit patient, with a helpful, smiling security escort. An audible sigh of relief went up from the nursing station, and the nurses started teasing me. "Hey, Susan, so you need sensitivity training, huh? Yeah, of course you do, because you're so insensitive."

"Well, I've had that training through church, but I guess it didn't take."

"Yeah, you must've flunked."

"Hey!" a tech called. "I found the driver's license! It was on the floor!"

"I'll take it out there," I said.

"No," said the tech, "I'll do it," and did. But a few minutes later he came back, fuming. "So I hand over the driver's license, and then I say, 'You can't smoke in here because it's a hospital,' and what response do I get? 'You're racist!' So I say, 'It has nothing to do with race! You couldn't smoke in here if you were purple or yellow or green!'"

"It's a symptom of mental illness," I said again, weakly.

"Yeah, I know, but it still makes me angry. One of the admitting clerks came up to me when I was out there and said, 'You know, I've been called everything, but being called racist really made me angry!' And I said, 'I know! Me too!'"

Later, I talked to a nurse, who observed ruefully, "When people say things like that, nobody's as nice to them, and then of course they think it's because of racial issues."

"It's a self-fulfilling prophecy," I said.

"Yes, exactly."

Meanwhile, I was frustrated by our complete inability to address the psychiatric issues. This patient lives out of the area and hadn't come in because of psych issues, which made them off-limits. And it would only have made things worse to tell the patient, "No, we aren't racist; you're mentally ill."

I'm sure the patient's encountered genuine racism in the past, and now sees it everywhere. Something -- personal history, the psych issues, a combination -- has left that patient oversensitized to the possibility of prejudice. The medical staff, meanwhile, were reacting far more defensively than they usually do to insults, insisting to me and to each other that they aren't racist. The patient's obsession had sparked some collective psychodrama, some group wrestling with anger and guilt, in the nurses and techs.

And I was in the middle, having very little luck communicating with either side. The patient's accusations didn't worry me, because I really did see them as symptoms; but precisely because I viewed them that way, I had trouble empathizing with the reactions of the medical providers, who were taking this symptom far more personally than they take most others.

Which means, I guess, that I really do need sensitivity training.


  1. Odysseys of George12:35 AM

    Hi I enjoyed this very much. TQ

  2. I'm not sure what it is about being called a racist that pushes so many buttons.

    I know kind of how they felt, though. I had a little girl attack me at work once. Hairpull followed by headbutt. And you know - you really and honestly do know - that it's just one of those things. It's not acceptable, it's not right... but it happens and there's not a whole lot you can do about it except lock yourself in the office and cry. Sure she did it, but it's not something you can really hold her responsible for. It's not malicious.

    And as badly as I react to that, a verbal assault on my character would be a lot worse. There are staff where I work who can just shrug off far worse attacks than a little girl's headbutt, but I can't do it. Maybe you have the ability to do that with verbal attacks. I'd bet that tomorrow, people will have had time to assimilate the experience and will be able to look at it more like you could. At least I'd hope so, because you're right that it's the illness speaking. When they calm from the sting of the insult, they'll see that.

    Meanwhile, I wish I could be half so automatically generous of spirit.

  3. ... or not.

    Gripping episode.

  4. You know, just because someone has suffered mistreatment and bad luck doesn't mean they aren't also an asshole.

  5. Thanks, George and Martin!

    EL: I'm much more sensitive to physical injuries than verbal ones: I wouldn't deal well at al with a headbutt, even from a child!

    Patrick: Mistreatment and bad luck are one thing; illness is another. I think that to be considered an asshole, a person has to have volition over whether or not to act otherwise -- and it wasn't clear to me that this patient did. One of the most painful things about all illnesses, including mental ones, is how they compromise free will.

  6. Susan, as you pointed out you were in the middle. That is an extremely difficult position to be in and I think you handled it very well. You were in a different role so you were able to develop a different perspective. I hope that when the nurses and doctor got home they were able to calm down and thought differently about the patient. Maybe it is just me but when I have a reason for someone's bad behavior, no matter what, it is always easier to let it go.


  7. You were in a difficult position, especially if you literally aren't allowed to bring up psychiatric issues if the patient doesn't. That seems kind of odd to me, but hospital polocies are often weird. I she had a physical illness that she didn't come in for, would you have to ignore that too. Say they xray for broken ribs and find a lung tumor. What would happen then? I think psychiatric illness should be treated by the same standard. Not that any of this is your responsibility.

    Sometimes matter of fact comments and questions can help. "It seems like it's hard to trust people or get organized right now. That could be a symptom of an illness. Do you take medications for those things?" Sometimes people have no insight without feedback, but plenty when reminded. Again, not that it was the case here.

    As a psychiatric social worker I get used to being called names or accused of racism. You're right, it's not personal. My one physical attack really got to me though.

  8. Anonymous6:01 PM

    I'm sure the patient's encountered genuine racism in the past, and now sees it everywhere. Something -- personal history, the psych issues, a combination -- has left that patient oversensitized to the possibility of prejudice. The medical staff, meanwhile, were reacting far more defensively than they usually do to insults, insisting to me and to each other that they aren't racist. The patient's obsession had sparked some collective psychodrama, some group wrestling with anger and guilt, in the nurses and techs.

    Susan, please remember you're only there a few hours a week. I'm thinking, in your perception, that maybe the patient had long-term issues with a valid history. Who really knows. Maybe this is the way this individual "confronts" awhat he perceives as "the system".

    I'm interested in the ED staff. I'm sure they're trained to set boundaries and ignore unsubstantiaded claims -- except, they, too are subject to feelings of frustration, and perhaps, collective guilt.

    It sounds to me as if the patient worked that just a little (alot?).

    And you, with you're compassion worn on your face, are a ripe target.


  9. Actually, a lung tumor was a terrible analogy, I'll try again.

    What if someone came in with a possible broken bone and it was evident that they had asthma as well? Not inpatient-type asthma, just mild asthma that was interfering with their life and could be very simply treated with a prescription and advice to follow up with their primary care doctor. This mild level of paranoia, concentration impairment and disoorganized, delusional thinking is just as simply addressed with antipsychotics and the same advice.

    Why can't it be treated like the asthma would be?

    And now this is me not ranting about stigma and non-parity of care for what we know now are brain diseases. :) :) :)

  10. Hi, Mary! Thanks so much for your comments.

    I agree with you completely. But unfortunately, the issue's far more complicated than it should be. I'm wary of raising psych issues with the medical staff because I got yelled at once when I tried to; that incident made it clear that psych issues don't get dealt with unless they're the primary complaint.

    This is probably, at least in part, because the hospital where I volunteer doesn't have a psych ward. If we wanted to work up this patient for psych issues, we'd have to call in a psych social worker who rotates among all the hospitals in the area. That person can't prescribe meds, and this patient lives elsewhere and doesn't have a local doctor who can.

    Psych patients in the ER are a sore issue: it can take hours for the social worker to show up, and still more hours if the person needs to be hospitalized and we have to wait for a bed at one of the two mental-health hospitals (one for people with insurance, one for people without), and then wait even longer for transport. We've had patients stuck in limbo in our ER, with nothing the medical staff can do for them, for up to an entire day. This is frustrating when people with dire physical complaints need those beds.

    Under these circumstances, we tend to limit psych attention to patients who a) want it or b) pose threat of harm to self or others, the classic criterion for hospitalization.

    This patient was in neither of those categories: would surely have kicked, screamed, and accused us of racism if we'd suggested psych treatment, and hadn't done anything warranting a legal hold.

    There's also the fact that -- as one of our former staff chaplains reminded me repeatedly when she listened to my stories about trying to find social services for patients -- the ER isn't a "one stop shop." It's supposed to be for emergencies; the fact that it often operates as a walk-in clinic, especially for patients without insurance, isn't something the medical providers advocate and certainly isn't something they want to encourage.

    Our ER, like everybody else's, is strained to its limits, and Reno has pretty piss-poor psych services even for people who live here. Since this patient didn't, I'm fairly sure that the attitude of the med staff, if I'd asked (which I didn't), would have been, "The patient can take care of that in the patient's home town."

    Please keep in mind that since I didn't ask outright, a lot of this is interpretation based on previous incidents. But it's worth noting that the nurses agreed with me about the psych issues, and no one said anything about addressing them.

    One of the reasons I volunteer in the ER is that it gives me a chance to interact with populations (specifically psych patients and addicts) to whom I wouldn't have access otherwise, and who need what I can offer, especially when the med staff can't offer anything except, "We're calling every hour to check on whether they have a bed for you." I'm sad that I can't do more, and at least some of the med staff are probably sad that they can't do more.

  11. I'm a chaplain intern in a mental hospital, and from your description I think you're right on about there being a mental problem. Working with these folks is challenging. Sounds like you're doing good work.

  12. Susan, thanks so much for your wonderful answer. You are a blessing to those patients because you understand them.

    We have many of the same problems here. There are only two on call (night and weekend) social workers for about 2000 patients at our agency. Transport can take hours because they don't use ambulances usually, the police are called to transport and their least favorite non-emergency job is transporting psychiatric patients, so they won't do it unless and until everything else is done. What's more, all the psychiatric units REQUIRE most patients to be medically cleared guessed it, the ER.

    The ER staff hate us and our patients.

    I wish I could start a clinic with a lab and pharmacy just for clearing psych patients as well as an ambucab for them. Police are used mostly because they are "free" but if course it actually costs money, nobody tracks it though so nobody's budget looks bad. And paranoid people have an easier time if they are not actually taken away in a cop car and locked up. And every mentally ill person maintains more dignity if it does not appear that they are being arrested because they are being handcuffed and taken away by the police.

  13. Hi again, Mary! Yes, psych patients here need ER medical clearance, too, and I can't say that the med providers are very fond of most of the patients (they seem to get along fine with the social workers, though).

    We used to have social workers dedicated to the ER. They were let go in a round of budget cuts. It was a really bad decision.

    I'm completely with you in wishing that these patients had a place they could go, right away, that was devoted to their needs. Our homeless-services center, at one point, had gotten some funding to set up a mental-health and substance-abuse triage clinic (specifically to relieve pressure on local ERs), but I haven't heard anything about it for a while. If it happens, it will be a godsend.

    I've gotten flack from medical staff for spending so much time with patients they don't consider a priority (not that I neglect anybody else), and on one occasion I was told point blank not to visit a patient, a homeless frequent flyer, who's consumed a vast amount of hospital resources. The nurse who told me not to visit this patient loathes him. I told the nurse I was going to visit anyway -- and I would have, too, except that the patient remained blissfully asleep for my entire shift.

    It's a fine line. I see myself as being there, in part, to advocate for the patients nobody else likes (and I've said that to med staff), but I'm a volunteer and have no leverage. That gives me freedom, but also means that I can't afford to rock the boat too much -- not, without leverage, that I'd be able to do that even if I thought it wise.

  14. Prudence4:21 AM

    Now, that is one tough situation. It can be really frustrating trying to deal with a person who firmly believes he's being victimized. Patience is a virtue, but it also has limits.

    --- Prudence


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