Distressed or depressed patients
When they are with someone sympathetic and supportive, crying can be one of the most healing experiences for patients. The act of crying releases tension and dilutes painful feelings and thoughts. This effect can be made even more beneﬁcial if they’re with someone who is accepting of them and the state they are in.
For understandable reasons, staff can want to urge patients to stop crying, perhaps because it saddens the member of staff or they feel crying prolongs the patient’s distress. It’s certainly true that when someone is crying a lot it’s hard to have a conversation. But if the essence of conversing is about communicating rather than speciﬁcally talking, then it’s clear just what powerful communication is going on. The patient is conveying unambiguously how much emotional pain they are in. And the staff member who sits alongside them, gently and supportively, is conveying that they recognise this and care about them. Two of the most difﬁcult aspects of being with very distressed patients are coping with them crying and balancing being optimistic with not belittling the genuine, often overwhelming challenges they’re facing.
The following can help
- Staff don’t actually need to say anything. Patients ﬁnd it comforting just to have someone sitting with them
- People really appreciate being told they can take their time, however hard this feels for staff on a super-busy shift. It’s deﬁnitely better to say nothing than to ask a patient to stop crying!
- Patients really appreciate being given time to stop crying, at their own pace. Some may then want to talk about what’s going on for them. Others may feel it’s been helpful enough just to have ‘got it out their system’ and not want to talk at that stage.
- Anything you can do which helps the patient feel better about themselves, their coping skills and their problem-solving abilities will be really beneﬁcial. For example, asking them if they’ve experienced something like this before, what have they found helpful? If they’re very stuck, becoming one stage removed can free things up a bit, eg asking them what they might say to a friend in a similar situation.
- Trying to avoid going off to get mountains of tissues or distracting the patient so they stop crying; going with the ﬂow and being comfortable with the tears without feeling that you are responsible for making them stop. Sometimes staff may want the tears to stop because they feel uncomfortable or awkward. But if the patient is comfortable enough to cry in the company of someone else, this should be supported rather than suppressed.
Q. 1 What might a patient feel if you ask them to stop crying? Examples:
- It’s wrong, inappropriate or ‘weak’ to cry
- you don’t recognise how serious the causes of their distress are
- you feel embarrassed or awkward with someone who is crying
- you’ve got old-fashioned views about “what men are like”!
- you don’t accept them as an individual, complete with vulnerabilities as well as strengths.
Q. 2 What phrases do you use, or might you use in future when a patient is crying? Examples:
- Take your time
- I’m sorry this is so painful for you
- You let it all out. It’s best to have a good old cry
- It’s OK. Have a tissue.
- It’s not surprising that you find talking about this so distressing.
- What would you find helpful right now?
Patients who are or become depressed.
Being ill is a depressing experience, everyone knows this because we’ve mostly all been there. However, if you have a long term condition such as diabetes or a cerebral vascular accident (stroke) this is stressful and can lead to depression and anxiety. And of course people without chronic physical health conditions also develop depression.
A report published by the Academy of Medical Royal Colleges No Health Without Mental Health is quite clear ‘patients with any form of long term physical illness have an increased risk of depression.’ They add ‘Over half of all cases of depression in the general hospital setting go unrecognised by physicians and nursing staff’. This means that as frontline staff we are in a great position to recognise when someone may be becoming depressed or is depressed and we can ask for them to be referred to the liaison psychiatry service, and get them help.
Great, but is someone going to tell you they’re depressed? Not always. Men in particular (sorry to sound sexist but the evidence backs this up) find it difficult to say they are down or depressed, they can see it as a failure or an admission of weakness or they’ve never learnt the language to talk about their feelings – the same for some women.
How do we recognise depression?
You can’t give a blood test or an x-ray to see if someone’s depressed. The answer is simple: look and listen (anyone remember the Green Cross Code?) Often it can be the patient you’re finding it particularly difficult to establish a rapport with, they don’t smile, don’t chat with you and whenever you ask them to do something like get out of bed to mobilise they say ‘I can’t be bothered’. Instead of getting fed up and thinking the patient is being un-cooperative start looking for other signs of depression and also listening to what they’re saying.
How they may look:
o Sad depressed and anxious
o Slow in moving and thinking (the brain and body literally slow down)
o Speak in a flat, slow, monotonous way
o Look unkempt, untidy
o Aren’t interested in appearance and personal hygiene
What they may say:
o ‘I’ll never get better’
o ‘Life is always going to be like this’
o ‘My family would be better off without me’
o My pain will never go away, this is my life now’
o ‘I’m worthless, no good to anyone’
o ‘I can’t go on like this’
o ‘I want my old life back, I can’t do this’
If you see changes in a person’s appearance and behaviour for no obvious reason, discuss your concerns with the team and think about a referral to liaison psychiatry. If a patient makes negative, hopeless statements as above, again discuss with the team and refer for a mental state assessment to liaison psychiatry.
Have patience with the person they do not want to be like this – they are really struggling.
Sometimes the person may seem depressed but actually it’s anxiety driving their behaviour, so it’s always worthwhile checking if they’re anxious about something – have a look at the next section on anxiety, ask the person if they’re having any of the physical signs of anxiety.
The second counter-intuitive thing is that someone can appear very agitated and restless, anxious but they’re actually depressed – it’s called an agitated depression. You’re not expected to diagnose this. Call in the experts – liaison psychiatry, but support the patient by listening and reassuring them that we can help them; they have a psychological condition that we can treat.
Mental Health First Aid England Handbook www.mhfaengland.org
Academy of Medical Royal Colleges (2009) No Health Without Mental Health London: Royal College of Psychiatrists
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