Wednesday is Three-Day Day, Part I

I'm sure this varies from state to state, but here in this state, when someone signs himself into a psychiatric unit, he does so with the condition attached that if he believes he is ready to be discharged, and we do not, we have the right to hold him an additional three business days after he has notified us in writing of his desire to go. If we still don't feel the patient is ready for discharge after the time is up, and he won't retract the three day letter, we have the option at that point to file papers with a court asking for a hearing to commit the patient to our care.

Now, it often happens that patients sign these three-day letters over the weekend -- either all the word find puzzles have been filled in, so there's nothing else to look forward to but smokes, or they were brought here from some emergency room over the weekend and never throught they should have been admitted in the first place. Monday being the first full business day after the weekend, many of these three-days expire at 5pm on Wednesday. So tomorrow with be a big day for discharges, court papers, and intense negotiations with the patients. There are many strategies on both sides of this transaction, but I won't go into that now.

For now, I'll say that tomorrow I've got two three-day's expiring. What's at issue is not our opinion about whether these patients could benefit from further hospitalization, or even whether they need further hospitalization. It's whether we believe we would be putting either the patient or someone else in imminent risk of serious harm by unlocking the front door. In practice, though, what we really figure is whether a judge will likely believe us when we say that the patient is a danger to herself, or the patient when she says she's not.

Of tomorrow's two, one patient is quite paranoid, argumentative and lives in a homeless shelther for mentally ill women. She's here apparently because she's been cheeking her meds, and attacked her roommate in the middle of the night. She denies all of this. In fact, she denies having a mental illness, and states her only problem is that she needs to see a dentist, and why aren't I helping her with that?! The other is a middle-aged guy with a history of a few near-lethal suicide attempts, who has a vague and and convoluted story about some money having been stolen, resulting in his wanting to kill himself.

Anything can happen with a three-day -- despite what you've planned for and expected, at the last minute the doc can decide to discharge or file papers, the patient can retract, the patient can say she'll retract, and then not. Sometimes a patient gets a reality check from someone on the outside ("No, you can't come home until you've been back on the Zyprexa for another week, and if you promise to stop calling the FBI's field office every day.") and retracts under duress.

My prediction for tomorrow? One will retract and one will not. We won't try to commit either. One walks, one doesn't. Any guesses?

Stay tuned,

Madeline

What Time Are We Leaving?

It hasn't been a terribly tough day today, but it has been a kind of tough week. Some staff are out on vacation, so everyon'e got an exrtra load. And Friday's can be difficult for some patients because they're anticipating how bored and neglected they'll probably feel over the weekend. Different staff, not as many groups, no meetings with treatment teams. All there is to look forward to is smoke break and maybe a card game or two. Some patients seem really not to care, and in fact seem to prefer really being left alone.

Other patients, though, metaphorically grab on to your pantleg as you're trying to get out the door, making any bid they can for more attention. At the same time, you're feeling in a particular hurry because it's Friday, you're tired, it's been a long week and there's still a little summer left, so wouldn't it be great to get out of here early. Your main motivation, though, honestly, is to get out the door before the "Friday at 4 crisis".

Today I got a little lucky -- none of my patients (at least so far -- it's only 4:20) have become suicidal or demanded discharge at the very end of a Friday. The Friday at 4 suicide threats are a much bigger plague for outpatient therapists. My patients are already in the hospital, afterall, and the evening staff really can handle it. On the other hand, the sudden demand for discharge can wreak a little more havoc if the patient is basically stable and able to take care of him or herself. It's a tough spot to keep someone in a psych. hospital over a weekend essentially against their will if your main justification is that it's your turn to bring the limes to margherita night, and you didn't have time to pick them up last night. In this case, it's usually easier to just go ahead and do the discharge paperwork, because you'd probably spend more time arguing about it with the patient if you did't. And you can avoid all the other patients seeing that you're still here, and looking vulnerable, and start circling with their own crises like a pack of lunatic wild dogs after a wounded bunny.

No, the worst of it today was one patient coming up with six or seven very pressing issues that she's "freaking out" about, but in reality, at least five of them really can until Monday. And another patient came up to me as I was unlocking the the unit door to leave. She had a towel and a toothbrush in her hand, and she asked me if she had time to take a shower as if I were going to be taking her with me.

Enjoy the weekend,

Madeline

Like a Train Wreck

Studying psychosis is a little like looking at a train wreck -- as much as you might be shocked and horrified, you are also deeply curious, perhaps even morbidly so. All those parts bent, twisted, mangled and strewn about. Utter chaos. You look at the pictures over and over again, knowing something pretty bad happened, and hoping something in the photo will help you figure out exactly what.

Here's the really fascinating part: We all read newspapers and watch TV, so we know that those guys at the NTSB can sift through a tangled wreck of a train and catagorize an amazing amount of detail. Every wreck is different, but also the same. What looks like chaos to you and me actually follows a pattern. Steel bends and twists in certain ways. Glass cracks and shatters in its way. Insulation bubbles and melts in the way that it does, fire follows its own rules. And so on.

And like a train wreck, psychosis. Most people have some idea of what a psychotic person sounds or acts like. But when you sit yourself down with a psychopathology textbook, you are utterly amazed that people who have studied these things have an dizzying array of ways to describe when someone doesn't make sense. Ideas of reference, tangentiality, circumstantiality, clanging, neologisms, derailments, perseveration, thought blocking, thought insertion, thought broadcasting, logorrhea, aphasia, word salad. And so on. You sit there in the lecture hall gaping in disbelief that people who are that crazy can be crazy in just the same way that other people can be that crazy.

I once had two patients at the same time who both believed that Elvis is still alive and has a very special, personal affection for each of them. The government conspiracy is rarely just a government conspiracy; it's always the CIA or the FBI. Never the Department of Agriculture, the Public Health Commission, or the trash collector. Even though most of us have far more contact in our lives with the trash collector, and the trash collector probably has a legitimate reason to be out to get us ("Putting six months' worth of newspapers out on the same day! I'll fix her wagon!") he never is in the mind of a paranoid.

So I shouldn't have been surprised today when one of my patients -- a nice enough middle-aged lady how seems to have had a psychotic episode as a side effect of some other medications, and who seems to be pulling herself together really nicely -- said to me, "Yes, now I understand exactly what's happened to me. All these stressful things like I told you yesterday, my back injury, leave from work, financial pressures, teenage daughter, and then those medications. Yes I understand now. The only thing I still don't understand is whether I'm staff here or a patient. But I talked it over with my husband. Tom, dom, hom, lom, mom. I talked it over with my husband and he's picking me and Tom over there up and taking us all home. Driving away home. Oh well, been there, done that. Been there, done that. Been there, done that." Indeed.

Cheers,

Madeline

Up is Down and Down is Up

An interesting phenomenon, I've noticed, is that the crazier the patients are, the more sane they think they are, and the more sane, the crazier.

I did a group on one of our less acute units today. These patients might be suicidal and/or character disordered, but they don't generally get special messages from the TV. They mostly have homes, families and jobs, and are not usually delusional in the clinical sense. One of the patients, like many others, is a young, bright, college-educated woman, who for some reason becomes suicidal every few months and comes in to the hospital. In today's anxiety management group, she was expressing her frustration at how irretrievably crazy she believes herself to be and exclaimed, "But who gets anxious before parties?!" Well, anyone who has parents, in-laws, or has been to high school.

Contrast this with a patient I had a few weeks ago on the acute unit. Also like many of his cohorts, young, bright and talented. When he doesn't stay on his meds, the voices take charge and he comes into the hospital. Prior to this admission, a bird had died in the yard of his group home and he respectfully buried it out back. Then he came up with the idea that the bird perhaps could be revived. He exhumed it and brought it up to his room. When the group home staff told him he had to get rid of the as-yet-unrevived bird, he, as we like to say, could not be redirected. Right up to his discharge, he insisted that he saw nothing odd about this.

CPR on dead birds: sane. Wigging about social functions: crazy. Keeping carcasses in your bedroom: sane. Avoiding family gatherings: crazy. Sometimes up is down and down is up here in The Nuthatch.

Peace out,

Madeline

Update on Manny

I went to see Manny the next day (see Thursday's post). I had heard earlier in rounds that he had taken some meds the previous night (since he's been refusing meds in the hospital, we're having a tough time believing him when he tells us he'll get back on his meds at home -- both he and his father are not understanding that that's why we can't discharge him). Big progress! Then the morning nurse reported that he had gone up to the med room window asking to take his morning meds. The nurse handed him his pills and some water and he walked away.

"Whoa, Manny, I thought you were going to take your meds this morning?" the nurse said, trying to call him back.

"I am."

"Well, I need to see you take them, ok, buddy?"

Manny turned around, the story goes, pulled his balled fist out of his pocket and opened it, revealing the pills. "See? They're right here. I'm going to take them home."

I spoke with Manny later in the day, and told him how sad it had made me the day before that we had had such a tense conversation with his father. He jumped right up out of his chair and left the room. I gave him about fifteen minutes and tried again. I told him that it had upset me that he had said in the meeting that no one was listening to him, and when I tried to give him a chance to talk, his Dad shut him down. He wasn't really able to say much, but he did make eye contact a few times, so I think he heard me, and is maybe beginning to trust me a little, little bit.

Madeline

The Apple Doesn't Fall Far From the Tree

Often I enjoy meetings with patients' families. I like the appreciation they show when they can talk to someone who seems to understand their kid (or brother, sister, whatever) , or who can help them understand their kid and his or her illness. Especially when I'm working with patients whose illnesses are really chronic -- schizophrenia, for example.

One of two things often happens. Either I'll hear that anxious edge in their voice soften when I respond relatively matter-of-factly to a description of how Johnnie came to be in the hospital.

They: "Well, Johnnie stopped taking his meds three weeks ago, and started decompensating. He was doing ok for a while -- he barracaded himself in his room, covered the windows with black plastic bags, and started sleeping with a butcher's knife under his mattress. We tried to get him to come in on his own, but he refused. We finally had to put our foot down and call the police last night when he ran out into the street without his clothes on, waving his knife around and trying to cut his own tongue out."

Me: "Guess he didn't want to get blood on his shirt."

I think these families brace themselves for the shock, horror or pity that they just can't seem to get used to, and so are relieved when they can talk to someone who underresponds.

The other thing that often happens, especially for families who are trying to get their heads around a new diagnosis, is that they come in fairly overwrought and. In addition to being agrieved and angry, they haven't found the internal logic of this kind of craziness yet. It's as if Johnnie really were being controlled by aliens. I can help them see that it's just like that for Johnnie, too -- that some problem in his brain is making all his thoughts, and everything he sees and hears and touches so jumbled and overwhelming that the only possible explanation he can come up with is that he's possessed. And that the last thing that will be helpful to Johnnie is to try to convince him that he's not being controlled by aliens, because then he'll believe you're controlled by the aliens, too, and he definitely, definitely won't let you give him his meds. On the other hand, you also don't want to humor him about the aliens, because then he'll dig in and his delusional system, as we call it, will become both more elaborate and entrenched.

I give them tips and tricks: Try to respond to the emotional content, not the literal content, as in, "I can see how upsetting it is for you to believe you are being called back to the mother ship. How can I help you feel less frightened?" or Agree to disagree, then redirect, as in "I know you believe the mother ship is sending you messages, but I'm having some trouble believing that. So what would you like for dinner?." They often find these things helpful.

But then there's that third category of family. The ones who are just plain nuts themselves. These interactions are rarely gratifying for the clinicians or therapeutic for the patient. There's denial, paranoia, grandiosity, sabotage of treatment, control issues, hysteria, you name it, all writ large. We've given up on the idea of the "schizophregenic mother" causing schizophrenia, but it's pretty hard to discount the role of nurture in mental illness all together.

Such was my family meeting today. I have this young, paranoid patient whose father came in insisting that we discharge Manny. He does this pretty much every day, in fact. Today, the doctor joined Manny and me for a chat with Dad.

"It was those special ed. teachers who made Manny sick when he was 8, you see, with their intellectual terrorism. You don't know my son," says Dad, "only I know my son, and only I can cure my son. I have rights, I brought him here and I can take him out." When Dad is reminded that Manny is an adult who signed in voluntarily, and so Dad's consent is not required to treat Manny, Dad ups the ante.

"Manny? He's sick," he says, "he knows nothing. How can you listen to him?" Clearly he's in no mood for tips and tricks from the social worker.

"Well, Mr. Manny's Dad," the doctor and I tag-team in saying. "Help us understand what you're saying. Manny got sick at home and you brought him to the hospital so we could help him. Now you're saying that Manny is well enough to leave the hospital, even though he's the same as when he came in. As you yourself say, he's sick, and he got that way while he was at home with you. Can you help me understand why you feel so strongly about his discharge?"

That didn't help matters much. Manny's Dad said to me: "I see you smiling. I know why you're smiling; it's because you're nervous," he says in a patronizing tone and puffing up his chest.

All right, that's it. I put my hand up and say, "With all due respect to you, Mr. Manny's Dad..." Sure sign of trouble if you have to start a sentence with "with all due respect."

The conversation ended badly. Mr. Manny's Dad had to be escorted from the building. I realize the guy's bananas, but if you could see this kid -- young man, really -- trying to get a word in edgewise, then being shut down by Dad, ("I'm the father. I speak for Manny.") you'd understand why he sleeps on the floor between the bed and the wall, and pretty much just stares at the wall the rest of the time, and you'd be pretty pissed off at this guy, too. Maybe you would've been able to finesse Mr. Manny's Dad better than I did, or maybe you'd've been able to convince your attending doc that Dad needs to be pink papered into a hospital himself, but sweet Jesus, please not here. If so, I would've liked to have seen it.

Madeline

So, my day today...

We -- the treatment team, which consists of me (the social worker), the attending psychiatrist and the nursing staff -- have really been in a quandary about this one patient of ours, I'll call him Arnie. Back in the day, Arnie apparently was a Real Bad Dude -- lots of jail time, long history of IV drug use, dishonorable dicharge from the Army for going AWOL a few times, family has all but disowned him. He has a dementia, an underlying bipolar disorder, and is still given to getting into fights. He's perfectly amiable now, but it takes a little bit of doing to really connect. He shuffles from foot to foot and is constantly gesturing with his hands. He mumbles badly, often just to himself, and has a quick laugh. But if you get in his face, he'll get back in yours. Given his history, only having gotten in a couple of fistfights on our unit is pretty good. He's what we call easily redirectable and every few days I coach him through putting his hands in his pockets and walking away if he's annoyed.

He was in a state hospital for a long time, sent there via the criminal justice system, because he had deteriorated enough to not be safe with a general prison population. He was court-committed, and so petitioned the court to let him go, as he had done several times before. Last fall they did. He told the judge that he'd be going to his sister's and everyone but the judge understood that that wasn't going to happen, so he's been on the streets.

Or really in psych hospitals mostly, because he doesn't have the wherewithall to keep himself together out there -- gets into fights in shelters, uses cocaine or heroin, doesn't take his meds -- and ends up getting picked up by the cops, who bring him to a hospital rather than the station. Now, I work in a private, acute hospital. What that means is that, among other things, our job is to stabilize patients and discharge them. We don't provide longterm care (if we can help it), so the almost three months that Arnie has been with us is a long time. But Arnie doesn't have anywhere to go, and has no one to look out for him, and his current strategy of trying to commit some petty crime so that he will be arrested and sent back to jail where everything is predictable just really isn't working out. As evidenced by the stitched up lip he came here with.

None of the various state agencies that might be called upon want anything to do with him. Remember that he used to be a Really Bad Dude? Well, he's managed to get himself kicked out of practically every group home, agency, rest home, program in the state. Nevermind that he can't get himself out of a paper bag right at the moment, they remember the time he set fire to the living room and he's persona non grata. Too young for a nursing him, too physically well for a department of public health bed, has an organic brain condition so the department of mental health won't take him. So he's mine. You'd think, given his history, that I'd have a hard time mustering up much sympathy for a sociopath like him, who is reaping what he has sown. But sociopaths are often quite charming, and dammit, there's something about this guy I really like.

Here's the kicker: Arnie wants to leave our hospital. Badly. Keeps putting in papers to make us decide whether to just unlock the front door or ask a judge to commit him to our care. Then just when we're about to go to court, he withdraws the papers. He's done this four or five times now. We don't want to go to court because he can pull it together for brief periods of time when there's something in it for him, and we're afraid the judge would find him competent to take care of himself and order us to release him. Which would let us off the hook for trying to find someone to take care of him. You'd think it would be a no-brainer. But as much as he keeps saying he wants to go to court, he can't seem to bring himself to do it, either. In the meantime, I've still got three or four rest homes I haven't called, and someone just gave me the number of some big state mucky-muck who might be able to pull some strings somewhere.

Madeline

My First One

Welcome to The Nuthatch, as in loony bin. I don't know why, but I prefer nuthatch to loony bin when referring to my place of employment: a psychiatric hospital. I often leave here at the end of the day with some story, observation or question swimming in my head -- this can be pretty intense work. So I'm hoping that this blog will help me sift through all that, and be entertaining to read. You'll let me know.

Right off the bat, I want to be clear about a few things: it's not my purpose to either romanticize or demonize mental illness in general, or people with mental illnesses. My patients can sometimes be pretty crazy, confusing, infuriating, tragic or gosh-darn-it funny, either wittingly or unwittingly. Just like everybody else. When I'm talking about my day among friends, I try to be careful to point out that I'm not meaning to make fun of crazy people. I think that comes across in person, but in writing, I'm not so sure it will. It'll be a challenge. So to be clear up front: I think that recognizing that crazy people can inspire the range of responses in us that anyone else would is humanizing for us and them. And if those of us who care for folks with mental illnesses can't laugh and/or cry about it from time to time, we become wooden, saccharine and/or sadistic. And that helps no one. So if you find a bit of trench humor offensive, this might not be the blog for you.

Second: I'm not here to either defend or detract from the psychiatric profession, or the mental health profession more generally. We live with a number of tensions -- dialectics, if you will -- that maybe I will blog about. Things like, to what extent are we a safe place for people who are unable to keep themselves safe, and to what extent are we a prison; or at what point are we trying to help people lead more functional lives, and at what point are we making value judgements about what "normal" is and what "sanity" is; or is diagnosis reductive and dehumanizing, or is it a tool that is useful in communicating with patients and each other. To name a few. These are the ambiguities with which we live and that are part of what makes our work interesting and challenging. In other words, I don't have a point to make about psych hospitals, I just want to tell you about my day.

So that's my first post. Whew. Next time, I'll make good and in fact tell you about my day.

Madeline