Grace, Understanding, and Rational Detachment

I have spent a good bit of time working with difficult populations in my life. Through the course of my career, I have found myself breaking up fights in an inner city mission in New Orleans. I have had a knife pulled on me in a male housing unit of a homeless shelter and I have been punched, bitten, pushed, and thoroughly cussed out by patients that were entrusted to my care. I have had the unfortunate experience of having to assist placing an individual in a hold in order to administer medication to calm them and I have been the observer of some overall pretty bizarre behavior. To those that work in psychiatric care and other difficult work environments, these circumstances become the norm. Over the years, as I have offered support to staff and others, I have reached the conclusion that there are two main factors that contribute to staying healthy and continuing to work effectively with challenging individuals. The first is good self care. If a person does not engage in effective self care practices, their shelf life working with inpatient psychiatric patients and in difficult populations is pretty short. As caregivers we are kind of like buckets. We are constantly pouring out to help others, but if we don’t have anything going back into our buckets they becomes empty and we experience burnout. Burnout puts us into a position where we are apathetic about the work that we do and it makes it impossible to offer good care and to truly connect with a person in a healthy therapeutic way. We have to find ways to keep that bucket full or we will find ourselves becoming a burned out sarcastic shell and ceasing to have any real therapeutic usefulness. Self care is also a commitment to the individuals that we work with. Generally speaking, difficult populations are also often vulnerable populations. Even though their behavior is often challenging and struggle for staff to manage, they still deserve for us to offer the best care possible. This can not happen if we are burned out. Another quality I have noticed that is a contributor to success in working with difficult populations is a concept called “rational detachment.” Rational detachment is the ability to not take things personally in your work environment. People who have developed the ability to rationally detach can deal with difficult individuals and not take in personally. People have different ways of developing the capacity for rational detachment. Here are a couple of suggestions for developing the ability to be able to effectively rationally detach. First, if you expect a psychiatric patient to behave like a neuro-typical person, you are setting yourself up for failure due to your own expectations. It is important to also realize that the people, no matter how aggressive or inappropriate they may behave are considered to be a vulnerable population. Sometimes, just by stopping to consider where that person has come from can help us approach a difficult person from place of empathy. For example, I know that in my own work, I struggle with personality disordered individuals. Many of these individuals feel as though they are attempting to emotionally bleed you dry. Their sense of neediness and attention is often very high. Unfortunately, these types of individuals are usually met with one of two responses. Either they draw caregivers with bad boundaries in to enable them to the eventual burnout of the caregiver or they are met with an abrasive response from caregivers that is disconnected and characterized by over developed boundaries. People either feel sorry for the individual or they distance themselves from the individual. Neither of which is very therapeutic. The solution to this is empathy. Empathy is attempting to understand the feelings of another. It serves to preserve a boundary as the person engaging in empathetic behavior never forgets that the other person’s problems are not their own. This boundaries allows them the choice to engage therapeutically to help someone. Empathy begins with getting out of ourselves and simply trying to understand the patient’s point of view. For instance, personality disordered patients typically are rough for individuals to care for. Borderline personality disorder in particular can be emotionally rough to deal with. Yet, if you stop to understand where the behavior comes from, it can allow for a little more grace when dealing with the person. Borderline personality disorder often comes from environmental factors such as abuse. Among individuals admitted onto an inpatient psychiatric unit, roughly 60-80 percent of them have trauma and abuse histories. For all women units, 80 percent or more of the patients have trauma histories. Furthermore, in my state of Kentucky, we have twice the national average of child abuse being reported, so our numbers of inpatient individuals who have experienced significant trauma are likely even higher. If you take a child that begins to be abuse or molested at the age of 8 or 9, that child experiences great confusion. At this stage in their life, adults are supposed to care for them. They are still under the emotional umbrella of their parents. It doesn’t help that children at this age also have a smaller worldview and are typically a bit more self-centered. So, when this child begins to experience abuse, they don’t ask the questions: “Why me?” They ask the question: “What did I do to cause this person to do this to me?” This question and the taking on of the blame for what someone else did begins the process that leads to maladaptive coping. Shame takes root. The person may engage in self harm behaviors or suicidal ideation because they see themselves as worthless or have internalized some sense of self hatred. The child no longer feels like they have any control in their lives. They spiral emotionally into a place where they are merely trying to survive. They experience rejection with extraordinary, almost life threatening pain, and they see life as something that “happens to them” rather than them being an active participant. Their sense of self is fractured as their human development is stunted by the abuse. This leaves them feeling needy and being dependent upon the approval of others as they lack the ability to approve of themselves. Often, they may find themselves dealing with long stints of abuse that last for months and even years before they can escape it. All the while the trauma they are experiencing continues to accumulate. In an effort to protect themselves, they develop maladaptive coping such as manipulation and a penchant for creating chaos. Their developing brains can develop changes from the trauma they are experiencing leading to PTSD, flashbacks, and unwanted emotional intrusions leading to acting out behavior. So, what started out in childhood as an attempt to cope with horrendous conditions becomes maladaptive coping in adulthood. No individual chooses this for themselves. Had we gone through similar events in our lives, we likely would have some of the same behaviors that our patients have. Unfortunately, as caregivers, we are placed into the position of having to work to help that person put the pieces back together and work to repair the damage that someone else has done. If we can see past the difficult symptomology and truly try to see what has caused those symptoms, we might find ourselves surprisingly compassionate towards that person, for in many cases, it is truly miraculous that some people survived the horrors that they did. Seeking to understand rather than seeking to judge is a key to compassion, empathy, and ultimately to rational detachment. Our job must be seen from a place of perspective. Rational detachment requires of us a clear understanding that an individual’s behavior towards us is not personal, but rather a symptom of their illness. It also requires of us to maintain the boundary that recognizes that an individual’s problems our not our own. If we are able to do those two things, then we can engage in compassionate and empathetic care that is empowering and we can negate some of the more challenging emotional responses to caring for difficult populations. Self care and rational detachment serve as the foundation for offering good care. We must not neglect these two things if we hope to make a difference in the world and to have staying power in our work environment.-

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