When identity confusion and mental illness presents to our Behavioral Unit

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By Debbie Moore-Black RN

We were not well versed. We nurses on Behavioral Health.

I finally left ICU nursing after 33 years. I was close to retirement and I thought Behavioral health would be so much easier than ICU.

But the old comparison of apples and oranges held true. There was no comparison of ICU to Behavioral Health.

We admitted a female patient 33 years old. She was angry. She had random outbursts along with hitting patients and staff members. No reason and no cause.Her first day she let us know she was a female. Though she presented herself with a typical male attire, with very short cropped hair, she demanded we call her Lisa.

The next day she was a male. And Lisa became Tommy. By the third day Lisa, then Tommy now became they/them.
It was confusing to the staff and to be safe we would call the patient by the last name. The outburst continued. Random spitting and hitting of staff and fellow patients, that we were forced to put the patient in isolation. Basically to protect the other patients and the staff from Lisa or Tommy or They/them.

We had a mandatory zoom meeting from the social workers. They felt the staff needed to be educated. It almost felt as if it was a reprimand though. We were a busy unit. High acuities with varied diagnosis’ of schizophrenia, paranoid schizophrenics, bipolar, psychotics. These patients usually were non- compliant with their medications upon discharge. They did not go to therapy… our unit was a revolving door.

During the zoom meeting, the social workers insisted that we call the patients by their perceived pronouns. That we must respect their pronouns. But every day with Lisa was a challenge. There was no rhyme or reason to what the pronoun was for the day.

I interjected to the social workers, “but right now we have a patient insisting we call her “your majesty, the Queen of England”, another patient was Jesus, and a female patient was pregnant with the baby Jesus. So where do you acknowledge the patient with their pronouns or with their bizarre titles? Where do you draw the line?”
We added that the patients were expressing delusional thoughts such as being Jesus, the Queen of England, the FBI.
Where do you clearly tell the patient that this is a delusional thought? That this is not reality.

The social workers agreed that those titles were of delusional thinking …. But as other nurses piped in: where do you draw the line.If a patient is one day a female, the next day a male and the next day a they/them is this also delusional ideations? The social workers agreed that calling a patient Jesus or the Queen of England would encourage their delusional thoughts.

So it was decided that we would not acknowledge those delusional thoughts but we would acknowledge a patient’s pronouns even if it changed every day. I would be the first to say I am not knowledgeable about gender pronouns and identity but would it possibly be fair to say that there is definitely gender identity confusion? And if so when did this start? Maybe during childhood? Maybe during some traumatic event?

It became clear that with all due respect we would only call the patient by their last names.
The reality was if we called them what they wanted us to call them for that day, the random outbursts, anger, screaming and physical assaults would continue. And we had to somehow keep a level of calmness in this very volatile behavioral health unit.

Lesson learned: that although ICU patients were complex and challenging there was usually an algorithm to match their disease process.

In Behavioral Health there was no algorithm. There was no finite answer.

Debbie Moore-Black is a nurse who blogs at Do Not Resuscitate.

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