We've Never Had This Day Before

I remember the moment I figured that out. I couldn't have been more than four or five at the time. I was on the back porch of my grandparents' cottage, hanging out with my grandfather. By "hanging out," I mean "prattling about things that are perfectly obvious to everyone but five-year-olds while Nonno was trying to read the paper." Nonno and I "hung out" a lot in those days at the cottage: I was younger enough than my siblings and cousins that having to include me probably sucked the fun out of whatever it was that they got up to, and I had a range that I wasn't supposed to stray beyond without being with someone else. The beach and the local candy store were outside my proscribed range. What was left was digging through the basement for interesting toys discarded by my older cousins and bothering my grandfather. (Now that I think about it, I don't know where all the other adults would have been at the time -- I guess if all the kids and cousins were busy entertaining themselves, they were probably napping. I wonder why Nonno never found refuge in a nap? Maybe because I was bothering him. If he were still alive, I'd ask him.)

Anyway, I was left with a lot of time to think things over as a little kid, and I remember the day on my grandfather's back porch when it occurred to me for the first time that even though it was Tuesday, it wasn't the same exact Tuesday as last Tuesday, and that next Tuesday won't be the exact same Tuesday as this one. I remember sharing this with Nonno, really marveling at my new, more sophisticated understanding of the universe, and being sort of disappointed and frustrated at how underwhelmed he seemed. "But Nonno, it's a totally different Tuesday!" trying to impress upon him that I had just figured it out. Right that minute. All by myself!

We never had this exact day before.

I remembered this at some point during my day today in the Nuthatch for a couple of reasons. First, hospitals run on routine. The cast of characters may change, but the order of show does not. Everyone -- staff and patients -- depends upon it. So it's pretty easy to become inured to the fact that this is, actually, not the exact same Saturday as the one before. It's a new day and new things can -- and do -- happen every now and again.

But also, in that moment on the porch, I actually had made a pretty important step in my cognitive development. It was an instance of very ordinary genius among many, many instances of ordinary genius that about every healthy, normally developing child will make. My understanding of the universe had actually become more sophisticated and my five-year-old self was probably right to be impressed that growing human brains stumble upon this sort of wisdom each and every day all by themselves.

Adults in many ways are just big children, and maturation isn't something you just do once and are done with -- it comes and goes with the circumstances. One of the ways we assess mental health is by trying to observe how mature or sophisticated or flexible someone's reasoning is (which is why you should be concerned if someone in a white coat starts asking you questions about things like what you would do if you found an addressed, stamped envelope on the ground near a mailbox). Assessing cognition against a developmental yardstick can give you some clues about someone's mental health at that moment.

This is why you don't hear a lot of patients in psychiatric hospitals make jokes. Not because psychiatric patients don't have senses of humor, or because they are too morose or catatonic, but because the ability to form and then tell a joke (as opposed to simply saying something humorous)is a pretty sophisticated maneuver, cognition-wise. And if you're in a state of decompensation that requires you to be locked in a psychiatric hospital, your sense of the relationships between things and between people is not likely to be as finely-tuned as it might. It's so rare, that I can think of only one time, in six or seven years, when a patient told an actual joke.

Until today. Given all of the above, I hope you'll forgive me that I laughed out loud at this from a guy in a wheelchair, "Hey, I'm a sit-down comic!" after a few of us chuckled at something merely funny that he had said. And, as my laughter subsided, he turned to leave, saying, "That's my time -- you've been great! And don't forget to tip your waitress."

Ok, he didn't actually say that last part, but I really wish he had.

(Bonus points to careful readers -- Hi Mom! -- who remember that I've already posted about the other time a patient made an actual joke. I'm repeating myself, I know. No need to point it out.)

The Golden Ratio

Here's a quote from Wikipedia: "In mathematics and the arts, two quantities are in the golden ratio if the ratio of the sum of the quantities to the larger quantity is equal to (=) the ratio of the larger quantity to the smaller one."


In inpatient psychiatry, your group is in the golden ratio if the ratio of sociopaths/narcissists/help-rejecting complainers to everyone else in your group is 1:4 or smaller. (Sociopath, narcissist, and help-rejecting complainer are not mutually exclusive categories, so the math here would entail counting the number of individuals in which one or more of any of those features are in evidence. By narcissism, I'm meaning the inability to contemplate the existence of any perspective than one's own, by the way.) I've been working on this calculation for years now, over hundreds of groups on psychiatric units, and I believe that I have finally found the answer. I'm thinking about writing a scholarly paper, and maybe getting something named after me -- Piaget's Stages of Cognitive Development, Prochaska and DiClemente's Stages of Change Model, Freudian slip, the Francesca Principle of Why All Your Groups Sucked Today and You Feel Like the Very Life Has Been Beaten Out of You. It's catchy; I like it.

Now I'm not saying that sociopaths, narcissists and help-rejecting complainers don't belong in nuthatches -- sometimes they do. I'm also not saying that they're not just as deserving of compassionate, competent mental health care as anyone else. Of course they do. I am saying that they can be darned tough to deal with in groups, particularly if there isn't enough of everyone else to neutralize the toxic effects.

It can be particularly tough for me because I'm only working in this hospital one Saturday every other week. The average length of stay is only eleven days, so I don't know most of the patients and they don't know me. I have no fund of good will upon which to draw, and I don't know ahead of time who's going to take up which kind of role in group. More importantly, the S/N/HRC's tend to see me as someone new to test, deride, or manipulate. Usually it's fine -- I've been through it many, many times before, and they don't often come up with much that I haven't heard before.

It's generally stuff along the lines of "the doctors/nurses/social workers/milieu staff/maintenance/food/groups, etc., in this hellhole suck and I'm going to keep interrupting you and/or talk to my neighbor about it, making this group suck, and then I will complain about that, too." Or "my problems are so very, very different/more important/more interesting/more complex/more painful than you or anyone else in this room, heck, the universe! can possibly understand, so how, oh how, can you expect me to divert my own or anyone else's attention away from all my misery for even a moment when I'm in such misery." Or "I'm feigning some mental health crisis in order to avoid jail/being fired/kicked out of my house, and if I can convince you that I really am sick and not malingering, I think I can get you to take pity on me and call my probation officer/boss/girlfriend and get them to take pity on me also." None of which will generally have anything to do with what the group is actually about, so if you're in the Golden Ratio, you can engage EE who's actually interested in your group, and the S/N/HRC's will either be quiet, play along or leave.

If you're not, the S/N/HRC's will join forces and gang up on you and EE will either be cowed into silence or leave themselves.

For some reason today, the S/N/HRC:EE ratio in my groups was unusually high, and the more the groups derail, and the more attention they can grab, the more gratifying it is for them and the more it sucks for everyone else. I didn't have a very good day. The rest of the staff seemed stressed out and disgruntled also, so I'm guessing the Francesca Principle doesn't apply just to groups. I'm glad to be home finally.

And that's the point to remember -- it's fairly obvious, but I suppose it bears saying. I get to go home, and I have a home to go to. And I have many other things to amuse me besides torturing social workers, nurses, milieu staff -- and by the way, other psychiatric patients -- with my BS shenanigans.

I'm a Rules Girl

And thank you to you too, Rebecca, my other reader.

Part of the problem with getting myself to blog are the groundrules I've set for myself: only blog about things that have happened in the last couple of days, and no material about other staff or complaining about the hospital in general. The reasoning behind the first rule is that it would be way too easy to just store up a bucketful of amusing anecdotes in my head and write them all down when I get a chance. That feels a little disingenuous to me -- the immediacy is the whole point to a blog, right? The problem is that thought-provoking things don't happen to me everyday. At least they don't happen everyday that I happen to have time and energy to write about it after work. Or they provoke the same thoughts you've already heard.

As for Rule #2, well that's just fair play (and self-preseveration). But I have to admit, the groundrules do end up limiting the available material. Not that I'm necessarily withholding lots of little gems from several months ago, or bursting with juicy rants about the Nuthatch. But you know, I don't work alone -- very often other people are a big part of what goes on here. For better or worse, there have been a number of significant staff changes here in the last several months, and the adjustment takes up a lot of my mental energy. But telling you about it would probably be against the rules, so you'll just have to take my word for it.

So I'm going to break the other rule and tell you a story from several months ago. We had 50-something year old woman with schizophrenia here last spring. She was pretty catatonic when we admitted her -- she stared into space and not much else. It might help you to know that some of the side effects of antipsychotic medications can be things like high cholesterol and diabetes. She was on a medication as an outpatient that seemed to be working for her just fine, but she was having some metabolic changes that could be problematic down the road, so her doctor took her off that medication and started a new one, which didn't work.

Enter Laura, staring into space. Laura then spikes a fever and stops eating and drinking. She starts antibiotics, but also becomes incontinent of urine and feces. At this point, she will also neither stay dressed nor stay in her room. She screams if anyone approaches her and resists all attempts to drape her with a sheet or johnny. I develop this trick where I walk up to her holding a johnny open and basically just wrap her up in it before she knows what's really happening. We can usually get her to keep it on long enough to get her into her room and put someone outside her door so that she can't come out again. I have a similar trick when I go into her room and hold a sheet up in front of me so that she can see my face and I can see hers, but nothing else. I'll talk to her like that if she won't let me drape the sheet over her. I do my best to make it clear to her that I will absolutely not meet with her if she is exposed.

I'm not sure what she actually understands. She's no longer catatonic, but still severely decompensated. Her eyes dart back and forth, she looks at me suspiciously, she rocks forward and back. She looks at times as if no matter how hard she concentrates, she just can't get words out of her mouth. Often she throws me out of her room. Her low-grade fever persists, as does her incontinence.

Weeks go by. Her outreach workers call often and are very troubled by the continuing bad news. They've never seen her like this before. The unit staff cannot believe that a few weeks ago this lady was living in her own apartment with two roommates -- they figure her for a nursing home for sure. Finally the infection clears up and her antipsychotic meds have a chance. Little by little she gets dressed and may answer a few questions before saying to me, "What do you want? I don't have to talk to you!"

After a month or so, we start to get nervous that she won't get back to herself and be able to leave the hospital. We start to think about whether we need to apply for a state hospital bed or have her screened for a nursing home. The outreach workers are devastated -- this just isn't Laura. How could she disappear just like that? And why can't you bring her back? In the end we decide to put her back on the first med that gave her the metabolic syndrome -- when (if) she's recompensated, we can review the risks with her and she'll be able to give or withdraw her informed consent to be on this medication.

More days go by and she starts to show some real improvement. She is still pretty paranoid and doesn't like to leave her room. She talks to me sometimes in a whisper because she's afraid that others can hear. One day she asks if she can make a phone call. I tell her that of course she can and can I help her in some way. She says yes, and I motion for her to follow me to the patient phone. She tries, but she just can't -- she can't bring herself to leave her room. This goes on for days -- can I call someone for you and give them a message? Who? Who is it you want to call? Maybe I can get the number for you if you don't remember it. We creep closer and closer to the door. One day, she leans over the threshold and peers out, looks up and down the hall. No, nevermind, I don't want to make the call. Ok, maybe tomorrow if you want.

Finally, she comes with me out into the hall and down the corridor to the phone. She looks around a few times, to see who might hear. I dial for her and she waves me off. She can take it from here.

I don't go too far, though, because I want to listen in. "Mom?" she says. "Hi, it's me, Laura. Yeah. I'm fine. I'm in the hospital. How are you, Mom?"

I almost burst into tears right on the spot. It's moments like that that really keep me going. Like the time when Andy flirted with a girl (see January 26). The absolute, stunning, searing, heartbreaking humanness of it. Forgive me if I've said this before, but I've figured out that one of the big appeals in working with this population is the ability to connect with certain universalities of human experience in a very simple and direct way. Maybe it's because so many of my patients, in terms of their ability to get along in the world, are pared down to basic survival that these universals are that much more striking to me. Like being playful with another human being or wanting to talk to your Mom. Nevermind that Laura's pushing 60 herself, and can barely work up the courage to leave her room after six weeks of staring, streaking, peeing, pooping, screaming and swearing. She just wanted to talk to her Mom.

Happy Thanksgiving, if I don't see you before then.

Madeline

I came to believe that there's no one out there. No one but Weeza, that is. Weeza who took the time to comment on my blog, which I appreciate. Thank you, Weeza. Then a family gathering disabused me of the notion. They said they read the blog. You said you read the blog. So this goes out to my aunt -- you know who you are.

Someone told me today that she couldn't eat lunch because all her teeth have fallen out because they are Medicaid teeth. How do you respond to that? I said "Oh darn" (which is one of my stock phrases, along with "Fair enough" and "Well, to be continued"). "F*** you," she replied. Wrong answer, apparently.

I seem to be saying the wrong thing a lot lately, or at least my patients seem to think so. I have one guy -- he's a kid, really, who has an obsession with crafts and a hair trigger. It's an unsettling mix. He's big. Hulking big. With a boyish face, blond hair, red cheeks, and an awkward demeanor. Remember Mikey from Recess? He huddles over his various drawings and pictures, very intent. Cute, right? Just a big lunk of a guy, gentle giant, right?

Wrong. He's holding a basket full of lego and he asks to speak to one of the unit staff. I ask him what he needs, and he repeats the staff members' name as if I'm very, very dense. I tell him that I can try to help him if he needs something urgently I can try to help him, but otherwise he either needs to be in group or in his room. (That's the rule -- no goofing around or hanging around the nurses' station during group time.) Without missing a beat, he raises his fist with some plastic lego-like thing in it and makes like he's going to wing it at me! I was so surprised I think I actually ducked. He takes off down the hall, punches the phone, kicks some stuff, punches some stuff, swearing a blue streak.

Just about anything can set this kid off. Yesterday we're sitting together for just a few moments, and I tell him that he'll be going back to his crisis stabilization bed when he's ready to be discharged from us. "Who said that? I'm not going there!!"

"Your case manager told me it's all arranged."

"No way," he's yelling now, "I'm not going there!! That f***ing b**ch!! I f***ing hate her." Slamming of furniture and kicking commences as the yelling and cursing escalate, including demands to sign out of the hospital, return to mother's house and some nice, juicy bits about how much I suck. Ooops, said the wrong thing again.

At this point, you have to some quick thinking to do. Hopefully, you've already made the right decision about where to sit. Some people advise that you, the professional, should be sitting closest to the door so you can make a quick exit. Sound advice, but certainly not protective in every situation. First of all, positioning yourself between a patient and a door can make many patients feel trapped and nervous, especially patients with trauma histories or paranoia. Many patients are afraid of other people enough that if they start to lose control, it is more likely because you scare them and they want nothing more than to get away from you and return to their favorite activity -- usually lying in bed with the covers over their head. You want those patients close to the door.

Secondly, you might want to avoid turning your back on someone who's punching, kicking and throwing things, such as you might have to do were you to try to exit the room. Also, we have an obligation to the patients' safety as well as our own, and leaving an out of control patient in a room by himself only accomplishes the second thing. If you leave, someone has to go back in, probably with reinforcements. See above re: feeling trapped. As Sun Tzu says in the Art of War, a trapped enemy will fight to the death. He advises giving your enemy an exit to avoid unnecessary bloodshed on both sides.

In some rooms you can actually position yourself so that you and the patient are equidistant from the door. That's the best, I think. That way, you can try asking the patient to leave the room (he or she may very well cool off if you can just get the conversation to end and, if not, the commotion out there in the hallway will hopefully draw the attenting of the aforementioned reinforcements). And if he or she won't leave, you can walk out yourself (moving quickly enough to get out of the way of any flailing limbs or projectiles, but not so quickly as to add to the general air of tension and fear).

In the above situation, I started with telling the patient that the conversation would be over if he couldn't speak respectfully to me and control his behavior. Which SO did not work. Then I told him the conversation was over, and he actually walked out on his own. Stomped down the hall, slammed the door to his room. Of course, within minutes, he cooled right down and was back in the dayroom with his crafts.

I have to admit, I'm a little afraid of him. (Did I mention that he's BIG? And impulsive? He's like a 6-foot, 275-pound 6-year-old.) It's not a good feeling. Especially since people who are intimidating generally are pretty good at exploiting fear in order to, well, intimidate. And he uses his ability to intimidate in order to have unlimited access to arts and crafts projects. Not wealth, not power, not drugs, not sex. Popsicle sticks and glue.

I know when I put it that way, I sound pretty silly to be intimidated, but you really had to be there.

Until next time,

Madeline

Sense-Making

I don't know why I haven't blogged lately. Maybe I got into a space in which I didn't want to think about my work all that much. A big part of that may have had to do with my caseload changing, so that I was working less with the manics and schizophrenics and more with the trauma patients. With the trauma patients, I'm much less likely to be able to take that "Gee whiz, aren't people fascinating" stance that made blogging sort of fun. Also, the stories are much harder to take: rather than the more mundane tragedy of bad luck resulting in some psychotic disorder, I was wading around in life stories that were -- are -- horrific. It's frequently observed that people who work with trauma survivors have to have some tolerance for the horrors that human beings can inflict on one another. We don't dig around much in patients' trauma histories on inpatient units all that much -- that tends to be more destabilizing -- but you can't avoid knowing about your patients' stories.

I think the steam went out of the blog around the time I got these two patients in particular. One had been abducted and assaulted a few years earlier by a group of men and was left tied to a doorknob for several days. By the time she had been discovered, her legs had become gangrenous and both had to be amputated below the knee. The other was a very sweet middle-aged woman who had been in an incestuous relationship with her father from prepubescence through adulthood, and was struggling with having decided to end all contact with him. What observation can I make about the universality of human experience with that kind of material? There's no poignance here.

Maybe I'm putting too much pressure on myself to be entertaining or have some point. Maybe it feels more exploitative and invasive to use these stories as material. Afterall, a decompensated schizophrenic has a really tough time hiding her illness, while a trauma survivor goes to extraordinary lengths to hide hers. Maybe I've taken on the survivor's coping strategy of protecting myself from the inevitable shocked and disgusted recoil from others when they hear the stories.

Don't feel sorry for me -- I love my work, and I have plenty of folks to whom I can turn when I need to dump this stuff. But I do admit to having higher aspirations for this space than merely dumping. And the coming-to-terms and sense-making processes are much more difficult with this population. So why wouldn't I want to just go home at the end of the day instead of spending another hour or two mulling it all over? As I wrote this last paragraph -- in fact this whole entry -- I had hoped some answer to that question would emerge. But it hasn't, so I'm going home.

Peace,

Madeline

Guest Blogger Coll: Well, Duh continued

Coll posted this in response to my last post, "Well, Duh." Thanks, Coll -- response follows.

Coll said: I think that there are a lot of reasons that working in this field is wonderful for some of us, and awful for others, and I think what you say is part of that.

When you study psychology and mental health, they usually teach it to you as if it's a science; and certainly a fair amount of it is. But when you come into contact with patients, it's also about who you are, and I think that makes it as much an art as it is a science. Me, I love that. I love that both sides matter.

It didn't take long, out of school, to understand that it's a myth that only people who have their shit totally together can do this work. That was a major relief, trust me. It's even better when I see that some of the stuff that could get underfoot in my life can work for me on the job.

My social life has involved some trainwrecks; let's say, some ... difficult women, with resultant whiplash of the heart on my part. Nothing I feel very bad about, but enough give me an interesting story or two. Now, I find myself working very comfortably with an inpatient group of women.

It can be tricky; I'm a male working on a ward full of women. The estrogen alone can make me crabby every month. But it has been four years, now, and it's generally been a good experience, both for me, and, I hope, for them. At least, for the most part, they trust me, and believe I'm working to keep them safe and help them work to get better. And that's no small thing.

On my first shift, there, I took a group of them out for a smoke break. One of them looks at me, and asks, "So, how's it feel to be out with six crazy women?""Well, it's more efficient than college," I said. "Then, I did it one at a time." I'm smug about being able to come up with that quip on the spot, but I also think of it as the start of a working arrangement with people who don't always have much reason to trust men. I like them, with occasional exceptions, and I hope that the fact that they can see that helps the work.

And I've noticed something. I've noticed that whatever lingering part of me has this wish to help women who don't really know how to take care of themselves ... that part of me gets to do it where it can be channeled into something useful. And, because it's not my personal life, I don't seem to get tangled up in my own stuff. That's not as simple or as easy as I make it sound, but if you work in this field, and you've thought about yourself, as you have, M, you probably know what I mean. Hope so, anyway. So, when I run into it away from work, I don't get pulled in. Or I haven't so far. And, like you, I keep learning things about myself. I love that.

I don't need crazy at home; I gave at the office.

Madeline says: Thanks, Coll. I remember having these conversation with my own therapist while I was in graduate school in which I would worry that I was too crazy to be a social worker. I'm sure you would agree with me, Coll, that you do have to have your shit reasonably together to work with psychiatric patients if you want to to be effective and responsible. I'm going to challenge you a little, though, because I think we all get a little tangled in our stuff from time to time -- whether we act upon whatever we get caught up in, or whether we bring it home with us -- or not. I think it's an inevitability. But believe me, nobody -- but nobody -- has their shit totally together.

One of the more obvious ironies you clue into here in the real world (as opposed to grad school) is that if you're worrying about whether you're crazy, you're probably not. Neurotic, yes, but not crazy. One of the less obvious ones is that spending your time ruminating on whether and to what extent you are crazy is both a total luxury and a total waste of time. Postmodern rhetoric as to whatever "crazy" might actually mean aside, (I've gotten tired of the recurrence of cheesy song titles and lyrics in my posts, and am now switching to the phrase, "postmodern rhetoric" as my leitmotif (while simultaneously winking at both the reader and postmodernism itself with witty, self-referential asides, thus reassuring us all that I remain a postmodern girl; I think it'll make me seem smart)) I'm not the least bit concerned if my patients are crazy or not -- I'm concerned with whether they can function or not. Craziness vs. sanity is totally irrelevant. I'm just looking for people's lives to work for them a little better.

I like to tell myself, when I remember those conversations with my therapist, that I didn't mean "crazy" in the severely impaired sense, but rather as self-deprecating short-hand to express actual anxieties over specific vulnerabilities that could get in the way of me and my patients. Or maybe I was just wasting my therapeutic hours staring at my navel. Who's to know for sure? As they say, what you see depends on where you sit.

Madeline

Well, Duh

Have you ever made a discovery about yourself that, once having discovered it, seems so bloody obvious that you even feel a little silly about it?

I've known for some time that I have the tendency to get into relationships in which I bear the bulk of the responsibility for the relationship itself. In other words, I do all the talking, feeling, consoling, cajoling -- I do all the relating because my beloved of that moment is so guarded, reticent, angst-ridden, or whatever else his bag might be that if I didn't do all the relating, we wouldn't be a couple so much as two people just sharing a newspaper. Not to worry, though. I've long since come to the conclusion that I don't want to have to work that hard for the privilege of giving up first dibs on the crossword, and my personal relationships reflect this feat of self-knowledge.

I bring it up because it only just recently occurred to me that my professional life more or less requires that I engage in the very same relational habits at work that I've banished at home. Take Andy, for example. Remember Andy? Wordless pacing guy? Well, Andy finally got his state hospital bed. With some luck, it'll be a step toward home and a return to some kind of functioning. I felt a little like I imagine a mother feels when she sends her kid off on his first day of school: some mixture of excitement, sadness, pride and fear. I think Andy was just relieved to be getting a new hallway to pace. I helped him get some of his things together and wished him luck and good care. He nodded and asked for an envelope. I got a feeling of deja vu.

As a therapist, as a social worker in particular, I'm trained to think about mutuality in the therapeutic relationship, about subverting the authority inherent in being the one with the license. Power with, not power over and all that. That's all well and good, but postmodern rhetoric isn't going to get me very far with an inpatient population of decompensated schizophrenics. Sure, I've always got an eye on enhancing self-efficacy, but these relationships are anything but mutual. A guy like Andy's got so much chaos in his head that he needs cues from other people to figure out how to respond to the world. He needs a cheerleader and a coach, and I get a lot of satisfaction out of being able to do that for people like him.

The only thing that's surprising about any of this is that it took me so long to see that the pattern. And I have to admit to feeling a little dim-witted for not having seen it sooner. Why, it's just as plain as the nose on my face.

I suppose I've hidden this from myself for the obvious reason: I don't really want to have to ask myself if I've made a healthy adaptation, or if I've just transferred the pathology from one area of my life to another. I think for now I'll take the "if it ain't broke, don't fix it" approach and just call it an interesting observation.

Ciao,

Madeline