3/3/09

I am completing my Practicum hours on the Children and Adolescent Unit at Brylin Hospital under the supervision of the director of programming for the unit. After months of playing phone tag, filling out paper work, and having drug testing and background checks done, I started working on the unit today!

My supervisor suggested that I follow a Mental Health Technician around so that I may become gently acclimated to the environment and the routine on the unit. I arrived at 9:30am. The children range in age from 6-17 and are separated into two groups. Group one 6-12 and group 2 over 12. Group one was in the middle of TA or therapeutic activity time which consisted of playing ping pong, beach volleyball, and card games. Group 2 was "in school" Everyday time is set aside for the children to complete schoolwork and there is a teacher on hand to assist with any problems. For group two, two hours is alloted, for group one only one hour. Schools are expected to send work for each child. Monday-Friday involves a regular schedule involving meal times, hygiene times, group activity, down time, meeting with case managers and doctors and visitation.

Through out the day, I followed the techs around and observed the children's behaviors and interaction. Today there were two patients in need of 1:1, which means they are assigned a staff member who must be within an arms length of the child at all times. This occurs when the child is an immediate threat to himself or others. One of the children who was on 1:1 today was given a PO before I arrived which is an oral sedative, in this case Thorazine. While I was there I witnessed a nurse administering an IM or Intravenous Medication to the same patient. Before the injection the patient was out of control, running through the hallways, assaulting staff. Afterwards his affect became flat and he was very lethargic. He ended up leaving group activity to take a nap.

Many of the patients on the unit at this time have had previous hospitalizations at Brylin. Some seem to genuinely enjoy their time spent in the hospital. One wing on the unit is called SOAP. I forget the exact meaning of the acronym but it is specifically for children who have been sexually abused or have themselves been perpatrators. I was well warned about one girl from this wing who was admitted in August, however her behavior today was not at all indicative of previous difficulty. She was very sweet and docile. Overall, all of the children on the unit were relatively well-behaved today.

I had the opportunity to review some of the charts containg patients' histories. I also sat in on the nurses' meeting when they were changing shifts, which was interesting. My supervisor took me to admissions to review the file of a potential patient.

I was given my name badge and universal key. I am excited for my next experience on the unit.

3/5/09

My second day at Brylin started at 9 am. I was surprised how many patients had been added or discharged in the course of two days. I met the little boy who's file I reviewed in admissions. I was taken back by how sweet and polite he appeared to be. One of the staff assured me that he was in his "honey moon phase" that almost all patients experience. I again sat in on the TA groups. Group one was particularly active. Group two was working on friendship bracelets, a skill that they can use as a relaxation technique after leaving the hospital. I also sat in on a social work group with Group 1. The social worker tried to engage all of the children in a board game that addressed appropriate responses to different situations and encouraged the children to talk about emotions. I spent a good portion of the day shadowing and talking to one of the mental health technicians. I was curious about the types of treatment available. I specifically asked whether or not Group two was involved with any Cognitive Behavioral or Talk therapy. She said not really. There were two patients discharged while I was there, so I saw a little of that process. Also one of the patients had a visit from her mother and mother's fiancé. Schedules vary from day to day so I met a few staff members that I had not met on Tuesday. I had the opportunity to interact with a couple of patients in Group two after lunch during a second session of TA. The most common diagnosis in this group is depression. Due to the structured nature of the daytime hours, the patients are generally better behaved. I may set up a few hours in the evening so that I may observe more severe behaviors.

3/10/2009

I arrived at the hospital at 9 am and stayed until 4 pm. I spent most of the day observing group one. Again I was very inquisitive and interested in the backgrounds and intentions of the staff members. I discovered very quickly that one of the Mental Health Technicians had never worked on the children's unit. It's amazing how quickly the children can single out new staff. One patient in particular was pushing limits. I witnessed some of his inappropriate behaviors last week, but nothing like today. He was throwing chairs, insulting staff with vulgar language, refusing to leave the group, clinging on to table legs. There really is no system of reinforcement or punishment in place.

One of the therapeutic activities today was a form of music therapy. The recreational therapist played songs and provided the children with paper and oil pastels. They were instructed to use the material however they liked. Drawing pictures or writing words. I noticed that there is a lot of modeling of behavior that takes place. One patient observed the pattern that another was drawing and began to copy it in another color on her own paper. Also one of the staff calmly informed one of the patients that his behavior was inappropriate and that he was being rude. Later on, while playing a board game, the same patient told his opponent that he was being rude.

A patient tried to steal my master key, I firmly told him to never touch my key. He then sweetly gazed into my eyes and told me, "You're too dumb to really work here."

3/16/2009

Today was a difficult day. I arrived at 11 am and stayed until 515 pm .There were multiple outbursts of aggression among the patients. One of the patients who has a history of OCD was playing Monopoly with two other patients and myself. The player before him rolled double sixes and mistakenly moved his piece 13 places. This was a surprisingly strong trigger for the patient with OCD. Accusations of "cheater!" rang through the air, and before I could de-escalate the situation the little boy was throwing himself at the other player and punching with all his might. Astonishingly, the other patient (who has frequent aggressive outbursts) did not retaliate. Staff quickly intervened and separated the boys. Perhaps ten minutes later one of the staff members decided to hold a group session with group one to discuss conflict resolution, using this incidence as an example of how the situation may have been handled more appropriately. I did not think that this was such a good idea seeing as the two patients who were involved were still angry and asked to participate. During the group session another conflict arose with two different patients over a stuffed animal. The language that flew out of this small child's mouth made my ears bleed. Thankfully there was no real physical confrontation despite the multiple threats made against one another.

Two of the boys from group two who are roommates in the SAAOP ( this is the actual acronym tho I still do not know exactly what it stands for) hall had multiple conflicts today. One of them is well known for his perpetual instigating. The other became fed up with being made fun of and refused to allow his roommate to enter their room during "down time" ( down time is the hour after lunch where the patients are to find a quiet activity to do in their rooms, they can nap, read, write letters, do puzzles etc...) The two were separated, the instigator was sent to the seclusion room, but allowed to keep the door open. I am unsure how the situation escalated because I was reading through files at the nurses station, but the child who was being picked on repeatedly started acting out, screaming and throwing his furniture. From what I gathered, his anger was justified. His actions were not. The staff called for a nurse to administer either a PO or IM. A social worker intervened and talked the patient down. He verbally expressed how frustrated he was with the constant insults from the other patient and the situation. He agreed to take a PO ( medication administered orally). In my opinion he was rational and cooperative and therefore did not need the medication. He was not a danger to himself or others at the time the medication was given. I have never studied pharmacology and I am not aware of all of the uses and misuses/ effects and side effects of the drugs that are prescribed. I wonder how many of the nurses and staff members are educated in this area.

Right before I left there were more aggressive outbursts surrounding dinner time and who would be allowed to go down to the Bistro and who would be forced to eat in the lounge or their room.

Everyday that I have been at Brylin I have met new staff members. Some of them seem to genuinely care about their jobs and the patients. Some of them don't.

3/18/2009

I was at the hospital from 11 am until almost 7 pm today. They day started off relatively mellow. The children were well-behaved. After lunch I discovered a patient jumping up and down flipping his light switch on and off. When I asked him what he was doing, he told me he was trying to wake up his roommate. The little boy had been given an IM the night before and refused to wake up this morning. When he finally was awoken by a nurse, he was angry, defiant, and uncooperative. He dumped his medication and the glass of water that she handed him on the floor. He was reluctant to communicate and shouted profanities at the staff. Upon returning to his room, he found his roommates copy of Robinson Crusoe and ripped all 200 pages out, one by one. My supervisor intervened and locked up the rest his books in the closet. She spoke calmly to the boy having the tantrum and asked him if he was making a safe choice in behaving this way. She also asked him why he chose not to use his words to express his anger. A little while later the same child was laying on a beanbag chair in the door way of the calming room. I spent a little time talking to him and trying to get him to move himself and the bean bag out of the hallway and into the calming room. Later on he approached me and asked if I would play Sequence with him. I didn't know how to play, so he taught me. It is incredible that such a young person can have so much anger.

It is a lot to take in. Observing the interactions not only between patients and staff members, but also among the two groups. Today was a big day on the unit because we were having company. A couple new doctors and some board members were coming to tour the unit. Instead of downtime after dinner, the children were allowed to go to the lounge and play board and video games. All children fight over video games. However there was very limited conflict among the gamers today. The visitors came and left.

The little girl with Aspergers who has been on the unit since August had a violent episode and had to be restrained. During her episode (which required the attention of three or four staff members) one of the Group One boys threw himself on the ground and demanded that I bring him a knife. Also during the episode, a girl from Group Two was sitting alone on the stairs, I asked her if she was ok, she told me she just wanted the voices to stop.

I am only given a glimpse into what some of these children are dealing with.

3/19/2009

I was at Brylin from 10 am to 2 pm today. When I arrived group one was working on completing a caring frame with one of the social workers. The caring frame is a worksheet designed to help the children think about ways that people can show that they care for one another. They were encouraged to come up with a list of people that care about them. During TA I played ping pong with a few patients. I also went with them to lunch. A number of patients are being discharged today. I think that it is difficult to not become emotionally attached to the children who stay here. Tuesday will be a whole new ball game.

3/24/2009

The dynamics on the unit have changed. There are far fewer patients in group one. I sat in on a SW group that focused on self-esteem. The worksheet was entitled. "I like myself from A-Z" and the patients had to come up with positive adjectives describing themselves for each letter of the alphabet. I also sat in on an MHT group. The topic was "Changes" the patients were encouraged to think about and discuss one thing that they would like to change about themselves. I felt that the leaders of the group were under-prepared for dealing with some of the issues that this topic brought to surface. I spoke with my supervisor about this and she explained to me how challenging doing group activities in an in-patient setting is and reasons for this. On thursday morning I will be sitting in on a meeting for the unit that I am excited about.

3/26/2009

So the multi meeting that I sat in on was really interesting. Mainly the discussion was between the social workers and the doctors. I learned some terms used in social work and found it interesting that people can speak different languages when discussing the same topic in the same room. I stayed for a full day and we had a birthday party for one of the patients.

4/2/09

 Having not been to the hospital in exactly one week, it was strange to not recognize many of the patients. One patient that was there the first week has returned. This seems to be a common practice, children having multiple stays at the hospital.  The patients that I find the most interesting are the ones that do not have immediately apparent difficulties or disorders.  

4/7/09

 I started the day at the multidisciplinary meeting again. I think that it is important that the doctors ask for in put from all of the people who interact with the children. The nurses, TA, SWs. It was interesting to hear background on some of the patients before having met them. One of the doctors described to me a patient with severe anxiety problems and told me that she is highly intelligent and very interesting to talk to. He told me that I should seek her out.  Unfortunately I had only limited contact with the patient he described throughout the day. I like to stay and watch the chaos that sometimes insues during a shift change. Today was particularly chaotic.  There is lots of huss and fuss among the staff regarding lay-offs in the company.  This is strange to me seeing as I feel the unit could use more qualified staff. The director gave tours to representatives for Parent Advocates and representatives from the Children's Psychiatric Center.

I have been observing the progression of a patient that has been described as "toxic" and a "budding borderline" She slept the majority of the day and while awake exhibited extremely bizarre behaviors that I had never seen from her before. Such as zoning out and attempting to bite staff members. I was told that she has become increasingly aggressive and tried to attack other patients.  Another patient that was discharged in a previous week has returned. I am unaware of the details of the grounds for her hospitilization, but she is struggling with the beginning of an eating disorder, which many of the staff feel should be the primary concern for treatment, however this facility is not equipped for handling such a problem.

I sat in on a social worker group that was intended to address appropriate ways of handling anger. The worksheet first discussed not so appropriate ways that many of us deal with anger. One of which was throwing things. The social worker asked how many of the patients throw things when they get angry. One eight year old patient contributed, "I throw things! You can throw grandmas! You just kill them and then you throw them!"  During the multi meeting it was discussed that this particular patient has repeated thoughts of harming others.  The doctor explained to me that many people are tormented by intrusive negative thoughts. Through treatment and therapy they can lead "normal" lives, but they must deal with the torment. He shared a story about a patient of his that had obsessive thoughts of harming others. The patient worked as a saftey inspector for a major airline. When questionned whether or not he had thought about purposefully damaging a plane, he responded "Oh no, I could never do that!" yet he suffered from recurrent thoughts of wanting to harm others.

I spent some time trying to coax a patient off of the floor in front of the nurse's station and back into group. His complaint was that he was soooo tired and only wanted to go to his room and sleep. After a while, my supervisor told me that if he wanted to be uncooperative, we would just have to leave him on the floor and step over him. It's obvious that this patient thrives off of individual attention, so it makes sense to leave him if he is not at risk of harming himself or others, earlier in the day he had stolen a pen and gauged both of his forearms with it before a staff could retrieve it from him.

It is exhausting just being on the unit.

4/14/09

    The multi meetings generally last for an hour, today it lasted two hours. There were a lot of patients discharged today.  There is such a bizarre mix of emotions surrounding discharging patients on this unit, especially for those who have been on the unit for a while or are destined to return.

It was also one of the days where staff take patients off the unit to the YMCA. This happens almost every Tuesday and Thursday. There is no defined system of choosing who gets to go, and it is almost always an issue for at least one patient who doesn't understand why their name was crossed off the list. If you are on 1:1 or do not have appropriate foot wear, or if you misbehave you cannot go. The main restriction however is that the van can only transport six patients.  

The director has attempted to implement a reward system for one of the patients who has been on the unit far longer than the average stay, with little promise for discharge or being moved to a long term care facility at the moment. The challenge is finding age and developmentally appropriate rewards for the patient.  She will have three goals per day, achieving these goals will result in a reward. She will carry her b-mod plan with her on an index card so as to avoid confusion with the changing of shifts. 

  It's spring break, so instead of going to "school" the children were allowed to watch a recently released movie, Bolt. I played a board game with a couple of the patients, unfortunately one became frustrated easily and refused to finish the game.