Tag Archives: consultation liaison

Mental State Examination: Looking, Listening and Asking

Mental State Examination: Looking, Listening and Asking
By Paul McNamara @meta4RN
Adapted from the original work of Jenni Bryant @JenCLNinja
RN, RPN (NPC) RGN (BDH), MRN(MH), BN(UNE), MN (Research) (UoN), FACMHN

Every Australian undergraduate nurse is introduced to mental health and undertaking mental state examinations/assessments. However, only about one in every twenty nurses will specialise in working in mental health. For the majority of nurses (ie: those not working in mental health) undertaking a mental state assessment can often become a forgotten skill. This, in turn, deskills the nurse and disadvantages the patient – it’s not holistic care if mental health isn’t considered along with the medical/surgical/maternal aspects of care. As the adage says: there is no health without mental health.

If you’re not accustomed to incorporating mental state examinations (MSE) into your everyday role, it can feel a bit intimidating. Nurses I’ve worked with sometimes feel that they’re not adequately equipped to assess someone’s mental state. Of course they are – as long as they have a bit of emotional intelligence (self-awareness, self-regulation, social skills, empathy and motivation), and break down mental state examination to the three core skills that Jenni Bryant identified in her original powerpoint presentation: looking, listening and asking (adapted, online version available via www.slideshare.net/paulmcnamara).

This online version is in response to a few people requesting to have a print-friendly version (here: MSE), and/or something they’ll always have “in their pocket”, via internet-connected smartphones. The meta4RN.com website readily acknowledges that .edu and .gov websites have more credibility. However, many of those websites are not device-agnostic, so don’t render as well as meta4RN.com does on smartphones and tablets.

It’s a good habit to document a brief MSE for all your patients, not just those with a diagnosed mental illness. Mental state can and does change over a shift, day or week – it’s important to notice and communicate changes.

A comprehensive mental state assessment will include a full history: medical history, psychiatric history, medication history and personal history (developmental, relationship, education, employment, social). As history is static, there is no need to make this part of your “everyday” regular MSE.

A MSE is a snapshot as the person as they are at the time. A well-documented MSE conveys this impression for the reader. Using non-judgemental language, direct quotes of what the person says, and finding the right descriptors/adjectives makes for good MSE documentation. No need to worry about sentence construction. Dot points are fine.

Hopefully the following info will assist.

Mental Sate Examination (Looking, Listening and Asking)

General Description (Looking)

Level of Consciousness
drowsy, alert, sleeping, fluctuating

grooming, makeup, posture, clothing, obvious physical deformities or characteristics

eye contact, rapport, level of activity (do you see psychomotor agitation or psychomotor retardation? if so, describe it), body language, mannerisms, specific activities

Speech (Listening)

smooth, hesitant, interrupted, staccato
easy to interrupt/redirect?
are responses prompt or delayed?

fast (pressured), slow, or unremarkable?

soft, loud/pressured, unremarkable.

flat, monotonous, restricted range, expressive

the capacity to maintain a normal progression from one stream of thought to the next: over-inclusive, poverty, circumstantial, perservation or blocking?

assess for abnormalities of form of speech, not form of thought eg stammer/stutter, dysarthia, expressive or receptive aphasia.



Affect (Looking)

An objective assessment of facial and bodily expression of mood state.
Is affect appropriate to content? (congruent)
Assess the range, appropriateness, intensity and quality of affect
Rapid shift from one emotive response to another? (lability)

Some Useful Adjectives:

sad, tearful, angry, irritable, elated, euphoric, frightened, despondent, animated, expansive, cooperative, ingratiating, distressed, discouraged, anxious, hostile, guarded, anxious, calm, ambivalent, dysphoric, euthymic, suspicious, fatuous, bewildered, perplexed

Mood (Asking)

A subjective assessment of mood state:
How has your mood been lately?
How do you feel within yourself?
What has given you happiness, joy or enjoyment recently?
Are you a good person?
Have you been feeling guilty or sad?
If 10 is as good as you ever feel and 0 is as low as you go, where on the scale have you been over the last couple of weeks?

Neurovegetative signs and symptoms:

Thoughts (Asking & Listening)

coherent? rational? sequential/linear?
amount – poverty, flight of ideas, vague
continuity of ideas – incoherent, blocking, circumstantial, tangential, irrelevant
disturbance in meaning or use of language – neologisms, word salad

delusions, obsessions, compulsions, suicidal ideation, phobias, paranoia, preoccupations?
Do you feel safe here/at home?
Are you able to project your thoughts onto others?
Are other people able to insert ideas/thoughts into your head?

Perception (Looking, Listening & Asking)

Hallucinations = false sensory perception that occurs in the absence of a stimulus.
Can affect any of the senses:
Have you been experiencing any unusual sensations that you can’t easily explain?
Do you any special powers?
Sometimes when people are really stressed they hear voices/noises, but there’s nobody there. Has that ever happened to you?
You seem distracted by something I can’t see. Can you help me understand what you’re experiencing?

Ideas/delusions of reference
Do you have any unusual experiences when watching TV, or listening to music?
Do you ever feel that the TV has special messages just for you?

Illusion = misinterpretation of sensory stimulus
eg: responding to a pyjama top on a chair as if it were a cat; being startled by something out the corner of their eye.

Cognition (Asking & Listening)

time, place, person, situation
Clock Drawing Test [brief frontal lobe assessment]
please draw a large circle, then insert numbers to make it look like a clock.
now draw in the hands to show ten past eleven

MMSE: Mini Mental State Examination
– screening [ie: not diagnostic] tool for cognitive impairment – best for mild to moderate
– does not differentiate between delirium and dementia
– used to detect impairment, to follow course of illness, to monitor treatment response
– affected by education, intelligence, age, literacy, culture and inter-rater reliability

MMSE alternatives include:

MoCA: Montreal Cognitive Assessment
ACE-R: Addenbrooke’s Cognitive Examination
RUDAS: Rowland Universal Dementia Assessment Scale
KICA: Kimberley Indigenous Cognitive Assessment

Insight & Judgement (Asking & Listening)
Insight = to see one’s self as others do
Judgement = capacity to make reasoned decisions

Does the person recognise symptoms (eg: confusion, hallucinations) as symptoms?
Is the person aware that they are ill and understand the effects and implications?
Is the person seeking assistance/information or rejecting help?
Good, partial or poor? As evidenced by…

Risk (Asking & Listening)

Estimation of risk will be influenced by the person’s history (ie: previous experiences, behaviours and exposures) – the static factors.

Risk is best explored after rapport has been established, and the person knows that you are a safe, non-judgemental person. If somebody discloses intent/plans of harming themselves or others, thank them for trusting you, and let them know that it is too important a matter for just the two of you to handle alone. You’ll arrange for support.

The suggested questions below are for dynamic, “here and now”, factors only

Risk to Self
Do you still have “the fighting spirit”?
Do you ever think, “what’s the point in going on?”
What’s keeping you going?, what makes life worth living?
Have you thought you would be better off dead? How strong are these thoughts?
Have you thought of suicide?
Have you made a plan? [if “yes”, does the person have access to means?]
When would you do this?
What can I do to help you to stay safe?

Risk to Others
You seem pretty angry.
Are you able to express that anger safely?
Do you feel like acting on that anger?
Do you feel like hurting someone?
Are you safe to be around at the moment?
Am I safe with you? What about the other staff and patients here?
What can I do to help you to stay safe?

Alcohol, Tobacco & Other Drugs (Asking & Listening) 

Most substance abuse is contextual
Give “permission” for honest answers

“Sounds like you’ve had a lot of stress lately. How have you been coping?”
“You’ve got a lot of stuff going on at the moment… are you drinking or smoking more than usual?”
“In FNQ plenty of people use the bottle shop or a bit of choof or speed to try to manage stress. How about you?”

Quantity. Frequency. Recency. Route.


  • Alcohol
  • Tobacco
  • Cannabis (choof, gunja, yarndi, weed, dope)
  • Amphetamines (speed, goey)
  • Methamphetamines (ice, crystal meth)
  • MDMA = methylenedioxymethamphetamine (ecstasy)
  • Opioids (codeine, morphine, methadone, heroin)
  • Benzodiazepines (benzos: diazepam, oxazepam, nitrazepam/moggies, temazepam/normies, alprazolam/xannies)
  • Hallucinogens (LSD, magic mushrooms)


That’s it. Hopefully you’ll find it as a handy memory-prompt/word-finder/confidence booster when providing holistic patient care.

There is a printer-friendly version here:

There is a slideshow version here:

The short URL for this page is: meta4RN.com/MSE

As always, your feedback is welcomed in the comments section below.

Paul McNamara, 22nd July 2016

Defending Mental Health in Nursing Education


The Guardian (UK ed), 29 Sep 2014

There was an article in The Guardian (UK edition) recently where a nurse described how ill-equipped they felt to support patients experiencing mental health difficulties. The article included the startling information that, “My nursing course, which I think was excellent, contained no more than three days structured education on caring for patients with mental health problems.”

Umm. That wasn’t an excellent nursing course. That’s a crap nursing course.

Look, us Aussies like to tease the Brits about their weather and cricket team every chance we get, but I’m not accustomed to criticising their nursing courses. The truth is, I do not know enough about nursing courses in the UK to hold any strong opinions about how good or bad they are.

That said, I wonder what the general public would think of hospitals being staffed by nurses who had undertaken, as reported, a three year nursing course that includes only three days of teaching in mental health. I am glad that doesn’t happen in Australia.

Dumbing Down is Dumb

Since July 2000 most of my work has been about supporting mental health care in the general health settings as Consultation Liaison CNC (more about that here) and as Perinatal Mental Health CNC (more about that here). These roles have direct clinical input, but also have a lot to do with supporting general nurses and midwives to feel more confident and become more skilled at providing direct clinical care to people experiencing mental health difficulties. It’s inevitable that they’ll need these skills – a significant proportion of people who access general hospitals and/or maternity services also experience symptoms of depression, anxiety etc. Dumbing-down mental health education for general nurses and midwives is dumb.

elistIn August 2012 a Mental Health First Aid (MHFA) instructor proposed using MHFA as inservice education for hospital-based nurses. I mounted my high horse to defend the depth and quality of nursing education sprouting the opinion that MHFA is not suitable training for RNs. My rant went along the lines of it’s great training for many community and professional groups, but it’s inadequate for those working in health role. Undergraduate nursing programs have more than the 12 contact hours that MHFA offers, and we should re-awaken/build-on that education. Nurses in particular need to know a bit about:

  • symptom detection
  • meanings/implications of diagnostic groups
  • medication effects and side-effects
  • the biopsychosocial model of mental health
  • social determinants of health
  • risk assessment/management
  • emotional intelligence and therapeutic use of self

confpresTo give MHFA their due, they have never claimed their training to be an alternative to formal nursing education (others have). MHFA does a good job at informing first responders, but does not address mental health in a manner suitable for a frontline clinician. There is a community expectation that nurses and midwives will have a depth of understanding of mental health beyond that of the general community, beyond basic fist aid.

This conversation started off as a discussion in the workplace, then became a topic of discussion on the Australian College of Mental Health Nurses e-lists, then morphed into a conference presentation and, more recently, was articulated as this journal article:

Happell, B., Wilson, R> & McNamara, P. (2014) Undergraduate mental health nursing education in Australia: More than Mental Health First Aid. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.07.003

Happell, B., Wilson, R. and McNamara, P. (2014) Undergraduate mental health nursing education in Australia: More than Mental Health First Aid. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.07.003

Anyway, I guess there are two points to this blog post:

One: Quality Control
Let’s make sure that we continue to defend the quality and depth of undergraduate nursing and midwifery training in Australia. We must never let it slip like the UK example of just three days training in three years. That is woefully inadequate.

Two: Speak Up 
If you’re a nurse or midwife with strong opinions about a subject, it doesn’t hurt to discuss these opinions online. As per this example, a discussion held online morphed into a conference presentation and a journal article. For me, anyway, the difference between it being a rant and a paper was the interest and input from a couple of Nursing Academics: Brenda Happell (@IHSSRDir on Twitter) and Rhonda Wilson (@RhondaWilsonMHN on Twitter).


Happell, B., Wilson, R. L. & McNamara, P. (2013). Beyond bandaids: Defending the depth and detail of mental health in nursing education. Paper presented at the Australian College of Mental Health Nurses 39th International Mental Health Nursing Conference Perth, Western Australia, Australia. Abstract in International Journal of Mental Health Nursing, Vol 22, Issue Supplement S1, pp 11-12 http://onlinelibrary.wiley.com/doi/10.1111/inm.2013.22.issue-s1/issuetoc

Happell, B., Wilson, R. L. & McNamara, P. (2014) Undergraduate mental health nursing education in Australia: More than Mental Health First Aid. Collegian (In Press) http://dx.doi.org/10.1016/j.colegn.2014.07.003


Thanks for reading this far. As always, your feedback is welcome in the comments section below.

Paul McNamara, 21st October 2014

Short URL: meta4RN.com/defend

A Mental Health Nurse in the General Hospital

MHCBelow is a copy of the blog post I was invited to submit at My Health Career. The website is targeted at high school and university students considering or pursuing a career in health, guidance officers, career development professionals, and others working in or with the health care sector.

To see the post where it was first published online, and/or to have a look around at the My Health Career website, please visit www.myhealthcareer.com.au/nursing/mental-health-nurse-paul-mcnamara


A Mental Health Nurse in the General Hospital

Paul trying not to look too much like a goob.

Paul trying not to look too much like a goob.

Paul McNamara has extensive experience providing clinical and educative mental health support in general hospital and community clinical settings. He holds hospital-based, undergraduate and post-graduate qualifications, is Credentialed by the Australian College of Mental Health Nurses (ACMHN), and has been a Fellow of the ACMHN since 2007. Paul is a very active participant in health care social media, and is enthusiastic about nurses embracing “digital citizenship”. More info via his website meta4RN.com

There is an odd little sub-speciality of mental health services called “consultation liaison psychiatry”. This waffly, jargon-ridden mouthful of syllables is usually abbreviated to “CL”. What is CL? Easy – just think of it as “general hospital mental health”.

I’m a mental health nurse on a CL team. The only ward in the hospital I don’t visit is the mental health unit (the mental health unit already has heaps of mental health nurses – they don’t need me there). It’s the rest of the hospital I serve: the surgical wards, the medical wards and the maternity unit.

General hospital patients are more at risk of experiencing mental health problems than the general public – being sick is stressful. It works the other way around too: people who experience long-term mental health difficulties are more at risk of becoming physically unwell – being under lasting emotional stress can take a toll on the body.

Nurses, doctors, social workers and other allied health practitioners will phone CL when they have concerns about the mental health of a patient. Sometimes all that is required is a bit of information and clarification about medication or follow-up services available in the community – we do that over the phone. More often, we are asked to meet with the patient and determine what, if any, mental health matters can be sorted-out while they are in hospital.

The most common mental health problems experienced in the community are anxiety and depression – it’s the same in the general hospital – a lot of the people I meet with are experiencing either or both of these conditions. There are other mental health problems like eating disorders and deliberate self harm that sometimes require input from both the medical/surgical team and the mental health team concurrently. Helping-out with planning and providing support and care of these patients is a pretty big part of my job.

Sometimes it’s not the person in the pyjamas (the patient) who needs our support – sometimes it’s the communication, the systems and the clinical staff who benefit most from CL input. This can be in the form of structured education sessions or, more typically, in the form of supporting discussion, reflection and problem-solving on how best to meet the needs of the patient within the limited resources available in the hospital. In this aspect of the job, a CL nurse will try to help the clinicians involved step-back from the busyness and pressures of the hospital ward and take “a balcony view” of what is happening. By taking ourselves out of the chaos of a busy shift and calmly looking back at things with a bit of distance, sometimes we can see how we can “do business” in hospitals a little more constructively.

We also spend a lot of time “undiagnosing” (this is a “neologism” – a made-up word – I heard recently via Sydney psychiatrist Dr Anne Wand). The people we “undiagnose” the most are those who are experiencing grief. There can be a lot of grief in general hospitals, but we try to be careful not to confuse the emotions of grief (sadness, anger, temporary despair etc) with a psychiatric disorder. Grief emotions are often really uncomfortable but they are part of what makes us who we are. We don’t want to “psychiatricise” or “psychologise” the human condition. Grief is not something to be simply fixed; grief is a part of life – a difficult part of life – that is usually successfully navigated without psychiatric input. Support from loved ones and/or social workers and/or specific counselling services can help.

So, that’s an overview of what it is to be a mental health nurse in a general hospital. It’s a varied role where we spend nearly as much time with the general hospital nurses, midwives, allied health staff and doctors as we do with the hospital patients. The role involves direct clinical care, collaborating with colleagues and providing education. For more information on the speciality please visit my website or the consultation liaison nurses special interest group section of the Australian College of Mental Health Nurses website.


Print Version (PDF): CLnurse

Thanks to Amanda Griffiths of My Health Career for inviting me to submit this overview of consultation liaison nursing.

As always, your comments are welcome.

Paul McNamara, 2nd May 2014


Trying to Stay Focused

PatientFocused Some days it feels like a cruel conspiracy.

Those are the days when it feels like the time and space I have made to speak one-to-one to the patient* is in the middle of a sports arena. The patient and I walk into the middle of the empty playing surface and make our preparations for meaningful discussion, for emotional catharsis, for education, for counselling, for disclosure, for discovery, for therapy.

Then the grandstands of the arena start filling with people with loud voices. These people are not providing frontline care, so we would like to think of them as supporters. However, they all seem to think of themselves as coaches. They each have their own special area(s) of interest and shout well-meaning advice from their seats in the grandstand.

It gets very rowdy and distracting. SystemsFocused So many supporters coaches. So many systems**.

Systems are what makes airlines so safe – apparently that’s why hospitals have become so system-focused over the last couple of decades. I think it is a bit silly that public health systems try so hard to align themselves with profit-making airline systems. The cost of a regional hospital redevelopment ($454m) is about the same cost as two Boeing 787s (source), However, they serve very different purposes: the hospital is filled with critically ill people aiming to become less unwell or die with dignity. Commercial jets are filled with tourists and business people going on a planned journey. The hospital is a place of unknowns: discovery, diagnosis, treatment, trials and strong, unpredictable human emotions. A commercial jet is a trumped-up bus that travels at a scheduled time on a scheduled route between clearly defined destinations, carrying only people who are wealthy and healthy enough to travel long distances.

Hospitals and airlines have such very different clients, expectations, control and outcomes – can they really teach-each other much about systems?

Nevertheless, I understand the rationale for systems, and will make no effort to argue against them. Still, wouldn’t it be nice if there was one healthcare system? As it stands in my workplace, the emergency department has a system (EDIS) that does not speak to the ICU system (MetaVision), which does not speak to the general hospital system (ieMR), which does not speak to the mental health system (CIMHA). And that’s just within one hospital – imagine how fragmented it gets when we start thinking of the primary healthcare and rural/remote outpatient sectors.

I understand that some of these systems, some of these competing demands, are very important – but not all of them are. For example, it is not important that a clinician spend time away from their patients to transpose a bit of information that is in one hospital system into another hospital system –  this is a matter of dumb systems.

Which is why nurses and other clinicians know that sometimes the safest, most compassionate, and most ethical thing to do is to turn their back on the distractions created by dozens of disjointed systems, and make the priority to simply be with the patient.

Why? Because we are trying to stay focused – patient focused.

*Clarification re using the word “Patient”

In mental health over the last couple of decades nomenclature has changed from “patient” to “client” to “consumer” or “service user”. I understand the rationale for this – it is to move away from the passive (i.e.: “patient” as someone that the “expert” diagnoses and fixes) to participant (i.e.: “informed “consumer” of a service). In my current role I provide mental health assessment, support and education in a general hospital – the people I see are, in this context, first-and-foremost medical/surgical/obsetric hospital inpatients. It is these people’s physical health that had them admitted to an acute general hospital as “patients”, hence my use the word here.

**All the systems named in the “Systems Focused” cartoon are real, as is the claim that using each one is VERY IMPORTANT.

Tech Tip

I used an easy-to-use iPad app called Notes Plus to draw the cartoons. As you can see, my artistic skills have pretty-much plateaued since kindergarten, as has my spelling. Nevertheless, I think the cartoon might have been a little better and a lot easier to draw if I had used a stylus – that’s what I would recommend if you plan to do something similar.


As always, your thoughts/feedback is welcome in the comments section below.

Paul McNamara, 6th April 2014

Perinatal Mental Health: A Good News Story

diabetes, for instance

diabetes, for instance

Most health messages are such a downer, surely there are many people who will either switch-off from the message, or become unduly alarmed. Compare health marketing to commercial marketing and it’s no wonder obesity is rising. Put frankly, Coca-Cola and McDonalds have better ads: they’re full of fun and optimism:

Things Go Better With Coke!  

McDonalds – I’m Lovin’ It! 

Don’t get me wrong: depression is a bugger of a thing, and perinatal mood disorders are especially poorly timed. Looking after a pregnancy/baby is tricky enough without tossing in anxiety and/or depression.

However, at the risk of sounding all Pollyanna about it, there are some good news stories we can talk about when discussing perinatal mental health. Here’s a small list of things I’d like mentioned in every antenatal class/similar forum for parents-to-be/new parents:

IMG_0328[1] 6 in 7 new mothers and 19 in 20 new fathers will not experience perinatal depression. Are there any other gambles that give you better odds?

[2] Symptoms are usually easy to recognise. There’s even a free online anonymous self-scoring tool available: justspeakup.com.au/epds

[3] If somebody is not sure how to start a conversation about mental health with their midwife, doctor or child health nurse, there’s a handy online tool to help build a checklist of things to mention: docready.org

[4] Information and resources are easy to find. In Australia the “big five” are:

[5] Support is easy to find too:

[6] There are a range of treatment options: it’s not a matter of  “one size fits all”.

[7] If required, there are some medications that can be used in pregnancy and/or breastfeeding.

[8] Recovery rates for postnatal depression are very good.

[9] Some places have access to specialist perinatal mental health clinicians.

[10] Mental health clinicians are not interested in stealing the baby. In fact, mental health clinicians seem quite pleased with themselves when they get to see parents and infants connecting and communicating with each other.

[11] If attachment between parent and baby does not happen as easily as expected (this happens a fair bit with anxiety and/or depression), there are video guides to help, for example: Baby Cues Also, in some towns and cities (especially those with a perinatal and infant mental health nurse), there are clinical staff who can help with this communication/attachment/bonding stuff too.

What’s This About Exactly?

During the week a couple of new mums declined referral to see a nurse (me) from the consultation liaison psychiatry service because they had preconceptions about how negative the experience would be. It’s not absolutely necessary for every parent to see a mental health specialist, of course, but I think we (that’s “we the health professionals”) should start fishing-around for ways to better describe the good news stories about perinatal mental health.

diabetes, that is

diabetes, that is

If Coca-Cola and McDonalds can convey a sense of fun and optimism out of the products they sell, surely we can convey a sense of fun and optimism out of the services we provide. We have something that’s much better than the offerings of either Coca-Cola or McDonalds, so let’s reorientate the language and recalibrate expectations by using positive language.

Maybe when perinatal and infant mental health (PIMH) services in Queensland are re-established, we can re-launch with an upbeat attitude and slogan:

 PIMH for a healthy head-start!


What are your ideas for upbeat slogans and messages? Please add them in the comments section below.

Paul McNamara, 25th January 2014

Nursing’s Peculiar Privilege

Dear Reader: please don’t read this blog post if you are offended by strong swear words or find talk of suicide a trigger for unsettling/risky thoughts. Kind Regards, Paul.

Who is Going Behind the Curtains?

Working over Christmas and New Year made me especially cognisant of one of the peculiar privileges that we nurses have: we spend a lot of one-to-one time with the person who is medically/surgically recovering after a suicide attempt. My current role is Consultation Liaison Mental Health Nurse – a role that provides mental health assessment, support and education in a general hospital (more info about the role here). When the person is admitted to the general hospital after a non-fatal suicide attempt we are asked to be involved in planning and providing their care.

There are few things more privileged and more important than spending time with the person who is alive after deciding not to be. I do worry that this role is sometimes delegated to the least qualified (and lowest paid) member of frontline clinical care: the Assistant In Nursing (AIN) when there is “nursing special” in place (i.e.: when there are concerns that the person may abscond and/or harm themselves again).

Naturally, being an AIN does not mean you are incapable of sensitive, compassionate, safe care. I just think that “going behind the curtains” to assist in holding and containing the often very strong emotions of the person who has survived suicide is incredibly important. I don’t feel comfortable that someone without mental health qualifications or clinical supervision is tasked with sitting at the bedside for hours at a time. It may not be good for the either the person/patient or the AIN.

Suicide rates per year. Chart courtesy of www.mindframe-media.info

Suicide rates per year. Chart courtesy of http://www.mindframe-media.info

Parallel Processes

In clinical supervision we often explore the parallel processes and how they apply to our clinical work. When working in perinatal mental health I aimed for the therapeutic relationship to be a template for the parent-child relationship: kind and nurturing, responsive and interactive, empowering, educative and enjoyable. The idea being that, at some level, the qualities/values that inform the therapeutic relationship can then have a knock-on effect for the relationship the parent has with their baby. Not many perinatal mental health clinicians have an abrupt, cold, clinical style of interacting with their clients: they tend to be warm, gentle communicators.

When nursing the person who has survived suicide we need to think about parallel processes again. Julie Sharrock (a rock star of consultation liaison nursing) first introduced me to the phrase “holding and containing” as a part of the therapeutic relationship. Traditionally the notion of holding and containing has been attributed as a function of the inpatient setting/building: a place to keep people safe. Julie introduced it to me as a way to keep people safe, by reframing it as a concept for interpersonal therapy. That is, we nurses can assist and model the act of holding and containing difficult emotions.

For the person who has unexpectedly found themselves alive and in hospital after intending to end life, we may need to hold and contain the person physically for a short time, but (to my way of thinking) it is even more important to support the person to hold and contain their thoughts and feelings.

Thoughts are slippery, and prone to be dropped.

Feelings are brittle, and prone to cracking.

Holding and containing such difficult-to-secure, fragile things is fraught: the clinician needs their thoughts and emotions held and contained too. Its a parallel process: as I’ve discussed previously we need to nurture the nurturers.

Suicide rates per age group (2010). Chart courtesy of www.mindframe-media.info

Suicide rates per age group (2010). Chart courtesy of http://www.mindframe-media.info

Profound Moments

Some of the most profound moments of my working life have occurred while supporting the person who has survived suicide.

The incredibly dark humour: “I’m such a fucking loser I can’t even kill myself properly!” said the very nice man. He was not laughing out loud, but smiling at the grim absurdity of his situation. He was alive, but physically worse-off than when he decided to die: now fractured, urinating through a tube, receiving fluids and antibiotics via an IV line. More wounds. More pain. Yet, despite the extra physical insults, he was pleased that he had survived.

The worry: “Is my brain OK? I feel really agitated and confused.” asked the lady who had been in intensive care for a few days. Her brain was OK in the long-term, the distress she was experiencing was mostly short-term stuff:  delirium is really common amongst ICU patients. Hypoxic patients aren’t so lucky: they sometimes never recover the former function of their brain.

“You are the biggest fucking cunt that has ever existed in the whole world!”, said the man after being told he was unable to leave hospital. I was filling-in paperwork that would mean he was an involuntary patient as per the Mental Health Act. I didn’t think I was being particularly nasty. The mental health act is handy because there are times when I need to say, “It seems to me that you don’t have the capacity to keep yourself safe at the moment. So,  I’ll take some of the responsibility of keeping you safe for now. Naturally, we will hand the job back to you when you come good.” Using that framework, filling-in the paperwork for the mental health act is sometimes the most nurturing thing I can do. That’s why i was genuinely surprised, not offended, when he said, “You are the biggest fucking cunt that has ever existed in the whole world!” I asked, “Really? Worse than Hitler?” He laughed and said, “Yeah, Definitely.” I laughed too. Take that Hitler.

The person who had two high perceived lethality, but fortunately non-fatal, attempts to take his life in the fortnight before we met reworded Shakespeare’s famous opening line to Hamlet. Instead of saying, “To be, or not to be, that is the question”, he said, “After what I have experienced in hospital, I now think that it is better to have a difficult life rather than no life at all.” I was so pleased to hear him think that way, and at the same time felt so sad for those people who do not have the opportunity to reconsider: those people that bypass the hospital wards and go straight to the morgue.

These are profound moments in the lives of people.

Nurses, myself included, have the peculiar privilege of being with the people who are experiencing the most important days of their life: the first few days of life that they planned not to have.

Let’s not take that peculiar privilege of nursing lightly.

In Closing

Talking and thinking about suicide can be distressing. Australians can access support via:

 Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

MindHealthConnect www.mindhealthconnect.org.au

phone_hotline-40Outside of Australia and not sure where to get support? Google usually displays a red telephone icon and your country’s suicide support phone number when searching for a suicide-related topic.

As always, comments and feedback on the blog post is welcome. Suicide can be a sensitive topic to comment on, and this blog is the public arena; so, before wording your comment, please check-out this: Mindframe guide

Paul McNamara, 19th January 2014

A Picture is Worth a Thousand Words

Car vs Bike Wounds: even an illustration that completely lacks artistic merit can convey a lot of information more effectively than a page full of text.

Gingerbread Person Pic “Car vs Bike Wounds”. Even an illustration that completely lacks artistic merit can convey a lot of information more effectively than a page full of text.

This week at work we have been discussing the roll-out of the ieMR (integrated electronic Medical Record). At present it is not integrated with the existing mental health system (CIMHA: Consumer Integrated Mental Health Application), the existing emergency department system (EDIS: Emergency Department Information System) or the existing intensive care unit system (CIS: Clinical Information System). Let’s not be too distracted by that though – apparently there is an integration team beavering away in a back room somewhere: they’re teaching these hospital systems to talk to each other. Once that’s sorted-out the ieMR will be the best thing since bung fritz.

A hospital file diagram such as this can assist in conveying an understanding of the patient's experience.

A hospital file diagram such as this can assist in conveying an understanding of the patient’s experience.

A different thought crossed my mind though – will the ieMR make the bad art of gingerbread women/men, genograms and other diagrams obsolete?

I hope not – even my hastily drawn-on-an-envelope examples used on Twitter during the week and in this post convey meaning quickly and easily (hopefully). Don’t get me wrong – I’m all for typing words into a digital archive (in fact, I’m doing it right now!), but there are times where it is clearer to communicate with an illustration. I hope this is not lost as we transition to an electronic medical record.

The patient is the expert. The clinician asks them about their family and draws a genogram to organise information. Sometimes genograms explain a lot.

The patient is the expert. The clinician asks them about their family and draws a genogram to organise information. Sometimes genograms explain a lot.

Does your hospital/health agency have an electronic record that easily allows illustrations still? If so (or not) I would be grateful to hear from you in the comments section below.

Paul McNamara, 21st September 2013