Saturday, October 13, 2012

Female Continuing Care Unit: Where Validation and Acceptance Lead to Healing and New Beginnings

Unit logo after becoming FCC.
Though it has been a long time since my last blog post, I will pick up where my last post left off --Dorothea Dix Hospital.  When I walked up the front steps at Dix that first, full day and was preceded up the steps by a bright red cardinal, I had only an inkling of the task I was undertaking and no thought at all of being at Dix beyond the 30 hours a week for 60 days that was spelled out in my initial contract.  As it turned out, though, I usually worked more than 60 hours a week, often thought about the work there when I was elsewhere, and had my contract repeatedly extended. Ultimately, Dix, its patients, and its staff were the primary focus of my attention for 28 months.  While the challenges were for me at times profound, I now look back on that time as some of the most satisfying of my 35 years in psychiatry.
As the attending psychiatrist for the long-term female unit, I initially was faced with learning about each patient--why they were there and what had been done to treat them so far.  I met regularly with the other members of the staff who had in most cases been working there for several years, and slowly but surely I gained a relatively complete picture of  each person involved and how the unit was functioning to provide services to women reputed to be among the most seriously mentally ill in North Carolina.
On my first day I was told by one of our health-care technicians that I was the first psychiatrist in 15 years to ask her name.  This did not seem to me like a good omen.  I came rather quickly to realize that if I was going to have an impact on the lives of our patients, I was going to have to develop a close working relationship with the other members of our entire staff, not just those with professional credentials.  I invited everyone who wished to share ideas with me to talk with me in my office, and many changes suggested by staff members were subsequently implemented.
For the first four months there was a lot of chaos that included on an almost daily basis having someone put in four-point, leather restraints due to her otherwise uncontrollable violent behavior.  A water fountain was being torn from the wall about once a week, and the glass in the nurses station was being broken out about once a month.  The unit usually sounded to me more like the lobby of a large train station than a hospital.  I asked that our staff members strive to lower voice volume and whenever possible to avoid shouting from one end of the hall to the other.  And as our staff  lowered the volume, it at least became easier to tell whether a commotion was coming from patients or from staff.  Over time, as requested, the sound level did become more like a library and less like a train station.

Each patient who wanted a CD player was given one along with CDs of the music she wanted to hear. An attitude of validation and acceptance was modeled and encouraged. Staff members were asked to respond to patient requests with "Yes" if there wasn't a good reason to say, "No;" and if there was a good reason to say, "No," then they were encouraged whenever possible to say, "Let me check with the treatment team, and I'll get back to you."
After four months, it became obvious that significant changes had begun to occur.  Patients were no longer being placed in restraints; and significant violence including destruction of hospital property was a thing of the past.  Several patients who had been expected to live in the hospital for the rest of their lives improved enough to be released to less-restrictive living arrangements.
One example is a woman who had been hospitalized for over half her life and regularly stated that she hated doctors. For months on end she would scream almost incessantly, refuse to take medications, refuse to walk, and would only rarely leave her room. Gradually a cordial relationship was developed with her, thus allowing her treatment team to subsequently negotiate with her to establish an effective treatment strategy.  It is my understanding that she is now living quite happily in a group home, walking with a cane, and taking responsibility for management of her chronic medical conditions in a way she previously could not. Another example is a woman who also screamed a lot and had 2 to 1, arm's length observation 24 hours a day.  She was thought to have HIV dementia, but by changing several of her medications and interacting with her using the principles of validation and acceptance, the symptoms of dementia cleared and psychotic symptoms improved so dramatically that within six months she was transferred to a semi-independent living facility where she has continued to do quite well.

In the spring of 2010 it became necessary for our unit to move from one section of the hospital to another, and the opportunity was taken to change our name. Staff members and patients nominated new names for the unit, and three subsequent rounds of voting narrowed our choice of over fifty submitted possibilities down to the one we chose, Female Continuing Care Unit. The hospital administration allowed us to officially change the name; and incorporating numerous staff and patient suggestions for changes in our new space, we partially remodeled the area that became our new home. Both staff and patients seemed to take pride in how we had evolved. Many staff members were involved in planning appropriate, off-campus weekend activities; and there seemed to be in many ways a sense of being a caring family.

This was our unit philosophy:
Validation and Acceptance Can Lead To Healing and New Beginnings

We believe:
  1. All people make sense all of the time (at least they make sense to themselves) and that everyone deserves our best effort at understanding. 
  2. Sometimes people “speak” with behavior rather than words and still make sense; again, at least to themselves.
  3. We ourselves might speak and act in similar or even more difficult ways to understand if our lives had taken similar paths.
  4. Speaking softly and in a kind manner to others can help us arrive at a place of better understanding.
  5. Really listening with compassion to the concerns, hopes, and dreams of others in order to understand rather than to win an argument or to control them may be the ultimate way to show respect and caring.
  6. Partial gains are important, and it's important to maintain our patience even when it's hard to do.
  7. Martin Luther King, Jr., was correct in his assessment that “Darkness cannot drive out darkness; only light can do that.   Hate cannot drive out hate; only love can do that.
  8. Our work is about loving as best we know how.

My time working at Dorothea Dix Hospital was for me a great joy, and I was very sad when the decision was made to a close an institution that has meant so much to so many over its long, illustrious, trail-blazing existence.  I will always cherish my relationships with all the people I came to know during that time of team-building and collaboration that I believe truly led to healing and new beginnings for many of the women we served.

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