Learning From Patients: The Story of Ray

April 1, 2021
April 1, 2021
By Leigh Ann Bradley, Director of Coaching, HealthStream

Every coach with a clinical background has a patient who has made a significant impact on his or her life--one who, while in the role of patient, has been the teacher. Ray* was that patient for me. While I had been a practicing nurse and psychotherapist for many years, I was relatively new to the world of nursing on a locked psychiatric ward. Ray was sent to our locked unit because he had become behaviorally unmanageable; his mother, acting as his primary caregiver, was no longer able to reason with him. Ray was an Hispanic man in his early 30’s. He was significantly developmentally delayed and dealt with anger, frustration, and fear by banging his head on any available hard surface. As a result, he had cut himself over one eye, suffered intracranial swelling, and had developed a disfigured “cauliflower” ear. When Ray arrived on the unit, he had been heavily sedated by EMS workers; he was placed in soft restraints for his safety and the safety of those taking care of him.

Patient-Centered Communication

I met Ray on his first day on the unit, and we began to communicate. Communicating with Ray meant helping him to understand that I was not there to hurt him. He was able to speak and expressed his fear of needles (he had been sedated using intramuscular injections). We established some ground rules with each other. If he could control his head-banging, injections would not be needed. But, Ray’s developmental disability meant that our agreements were sometimes short-lived and quickly forgotten in what he perceived to be threatening circumstances. At the end of each encounter, regardless of outcome, other staff and I thanked Ray and expressed belief in his ability for improvement. Medications Ray routinely took to control seizure episodes gradually began to assist in his behavioral control, but Ray’s “go to” method of expressing fear, anger, or frustration continued to be head-banging. 

Staff were baffled as to how to deal with this continued behavior; we had tried behavioral reinforcement of all kinds, including using food as a reward and bargaining by offering privileges in exchange for not banging his head. We worked together as a team, so that one person’s efforts would not be unwittingly undermined by those of another. Although well-meaning, professionals will often “undo” each other’s hard work by failing to adequately communicate what is being done and why. 

While these behavioral efforts were important in teaching Ray new ways of coping, under stress they failed to work. One day, one of the male clinicians suggested that perhaps a wrestling helmet, one with holes cut out over the ears and designed for impact, would be useful. We presented Ray with his helmet, telling him it would help to keep him safe, and he loved it. He did not want to remove it for any reason. And, interestingly, once Ray began wearing his helmet, we were able to tie positive behaviors with it, and his incidence of head-banging diminished dramatically. While in Ray’s case, we required a helmet to jump start our effectiveness in consistent communication, it was the model for communication, based on the HealthStream principles of RELATE™, which made the difference in the long term. 

* name changed to protect the identity of the patient.

Making a Difference, Long-Term

After a time, Ray’s behavior had improved to the point of allowing him to be discharged. His mother, an elderly woman, felt she was no longer able to take care of him, and she continued to be afraid of his potential for head-banging. Ray was placed in a small group home with other developmentally-delayed males. He did well. Several of us continued to think about and inquire about Ray. We learned that the interior of his wrestling helmet had become worn to the point of rubbing his head. We bought a new helmet, and two of us took it to him in the group home. Imagine my surprise when, on greeting Ray, he addressed us pleasantly and was not wearing a helmet. In fact, when we presented him with his new helmet, he placed it in a corner. He told us he did not want to wear it, didn’t need it, and no longer wanted it as it reminded him of his old behaviors. What I learned that day is that all interactions mean different things to different people, and while Ray’s helmet and our staff were important for a time in his life, Ray had moved on.

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