Bullwhip

Ah, not feeling guilty because I'm not studying. Best feeling in the world. Even if I'm sick. Yes, I worked two days last week and everyone on the unit was sick. Seems to be just a cold, and I haven't missed any workouts yet.

Got another job offer, one of the docs at work. I'm starting to realize that I won't have any problems finding work. I knew that intellectually, but it's another thing when six months before you're available, offers come in. What I don't want to do is just take what's offered, I want to find the best fit possible for me. The day before Xmas was really awful on the unit - we even had a "code purple" in the admit area right at shift change (of course at shift change). That's when people are getting aggressively out of hand and we need extra staff to either restrain them or just a show of force. Our PICU (Psych ICU) has 10 beds, and the types of patients that are in those beds is very important in terms of what kind of day it will be. We had three young antisocial men, which is absolutely terrible. One is bad, two is awful... We ended up moving the "best" one over to the open side because the three of them just created an untenable situation. Too much hitting and threats and tempers flaring, which makes the nurses get in the med room and sharpen the needles. And a few of the other patients on there, not young men, were intensely psychotic. It was a rough day, and I wasn't even assigned to the PICU. Just the overflow of dealing with all that affected every single staff member. And this disturbs me - about half of my patients simply weren't improving, in spite of being on antipsychotic meds for at least two weeks, some more than a month. They seemed fine until you questioned them closely -- then the delusions came out, "Well, since I'm a doctor, they said that I can write my own prescriptions..." This came from a patient that was decidedly not a physician, and was in fact on court-ordered medication. Meaning we will hold you down and apply it via an injection if you don't swallow this pill. Not that physicians can't have mental health disorders - one of the saddest cases I ever saw in New Jersey was a psychiatrist that was hospitalized with major depressive disorder after his wife had committed suicide. I watched him waste away over a period of months.He blamed himself for her death.

I had a really odd dream. It was after the doc made me that job offer, I dreamed that I was at work as a Nurse Prac, and it was my first day. And get this, I had a venomous snake with me that I used to bite the patients to provide their meds. All the docs had their own snake, but since I was new, my snake was very badly behaved. He kept trying to bite the other docs and slither across the table as we were in treatment team meetings. I would grab him back and apologize. Talk about weird.

So moving the young anti-social man over to the open side turned out to be a really bad idea, he ended up calling 911. Now that has happened before (obviously) but since this guy is antisocial, he is as slick as, well, a snake, and super skilled at gaming people. The EMS team that responded was two newbies, so they were quickly sucked into Mr. Gamer's web. We spent at least two hours on that. Finally, the medical director insisted that the patient not be transported to the emergency department. His little game was foiled after all, but all of us were stressed and angry. What a waste of resources. Why doesn't someone so clever put their skills towards good instead of just jacking everyone up? The eternal question with the antisocial. And honestly, I would say that he's more borderline personality disorder than anything else, but I've noticed that there seems to be a gender bias when it comes to those two diagnoses. Men are classified as antisocial, women as borderline. He was a yawning black hole of attention-seeking behaviors all day long. For example, when I gave him his meds, he comments on how cool my nails look. I say thank you in a brusque way, I've already pulled on my no-nonsense schoolmarm persona, which I find works best with these types of patients. He moves on to initiate a conversation about his anxiety (right, he's sooooo anxious) -- he's appealing to my expertise and desire to offer therapeutic communication. I don't take the bait. The next time I see him, he's got a strange marking on his face that he applied with a magic marker. I don't even remark on it. Each interaction, he rachets up the "look at me" stuff. That's clearly borderline to me.

One of the super-psychotic patients was in group therapy when they were asked to write down their goals to be ready for discharge. It was so interesting, I copied what they wrote (with minor changes to preserve privacy). This is how the psychotic brain works. He wrote:
"Can live with Ma,
like John Wayne,
living for Dragnet,
miles away with Old Yeller,
and my bullwhip."
What's interesting to me is that you can sort-of see the grains of truth in there - maybe living with his mother is an option, sounds like she lives in a rural area, is Old Yeller his dog? Would he watch Dragnet on TV? But that last line is a little disturbing.

I've started my supervision work for my therapy skills and finding that works. Rob is my supervisor and I think we "click". I have three patients that I see regularly now, with three different diagnoses. I've already had to ask Rob, does just therapy work for this particular disorder? Because I so badly feel this patient needs medication too, it feels like I'm hamstrung in terms of helping them. Yes, he was quite reassuring, and offered some specific approaches that I should use when meds aren't in the picture. But man, I am so glad that I will be able to do both in the future. It just feels like I'll be able to offer well-rounded, comprehensive care.

I'm reading all kinds of great stuff while I'm off. Some of it applied to my job. One of the books is about psychological masquerade, when patients look mentally ill but it's due to an "organic" disorder, such as a brain tumor. (I dislike that term "organic" because mental illness is organic, too.) Another book is a memoir of a bipolar woman. And I'm reading Margaret Atwood's Positron series, which is a disturbing view of the future. I had to order Christopher Hitchens' last book, on mortality. Having a Kindle is the best.

But by far, the most exciting thing about having time off is going to yoga more than once or twice a week. I can usually get there three or four times now, which just makes life so much better. It's funny, I want to recommend yoga to every single patient. I do always talk about overall lifestyle choices - I think that's one of the keys to good mental health - and I mention yoga, but I don't tell them how actually rabid I am about it.

Starting to Feel It

Things are great, the semester is winding up, but man I sure am glad it's almost over. It feels a little ungrateful to complain - I mean, I'm so lucky that I'm able to go to grad school.  But I basically took too many classes. And the delay starting clinical just compressed everything starting in October into this miserable so-busy-all-day-long Monday thru Friday gig. Like I said, I couldn't even schedule a haircut in the the month of October or November. (Actually, I just got that done today, after I had my first final exam. Yes, I can finally breathe.) I'm working as a therapist on my own now at one of my clinical sites and finding my way as a new clinician. It's exciting and humbling, and I don't take it for granted. As I told someone recently, I have a proper sense of terror when I close the door and it's just me and my client, looking at each other. It's one of the hardest things I've ever done, I can say that. As Ken says, it's a puzzle. People tell you what's on their mind, but you have to figure out so much more - like, what do they not fully realize about themselves? What are they hiding from themselves (and trying to, from you)? What formative event have they left out that needs to be discussed? In the last - I don't know, maybe 20 years - the psychiatric community has found proof that many of our disorders are rooted in genetics and neurochemical/structural makeup - it's not all "bad parenting", although that is a factor. And how do you assess that? It's not like I can do a head CT in the office, and the differences at this point are rather subtle. Diagnosis is hard work - makes me appreciate the TV show House all the more. For instance, one of my therapy clients came to me with a very specific diagnosis in mind. And it took her almost the full session to reveal this. She has a set of expectations now around this, and we have to discover this territory together. But I certainly can't dismiss her ideas - even if I flatly disagreed (which I don't). Because she is the expert on her own inner life. I'm just someone who's a trained guide. Hope it's worth the money (ha).

I have realized that I certainly don't want to work at the state hospital on the kids' unit. I like the vast majority of the patients - but the subset of kids that don't really belong there (those with severe conduct disorders that basically disrupt the environment completely) have ruined it for me. This facility is not the place for them, but unfortunately placement is such a problem in Texas that they end up there anyway. And I can't be a part of that. The other kids - those with treatable psychiatric illnesses - I really liked them. I look forward to working with kids in the community that need help. (And yes, I know that theoretically Conduct Disorder is treatable but not at ASH. We are not staffed or trained to treat that.)

I've managed to work some fun into the semester. Ken and I saw Duncan Sheik perform at the Paramount and it was such a treat. I've been a huge fan since 1993, with his big #1 hit Barely Breathing (which he did a smooth-jazz version of as an encore), but it was nice to introduce Ken to him. Duncan was so funny and generous and just what you want a singer/songwriter to be for you, up on that stage. He sure has a wicked self-deprecating wit. I love how he said to introduce one song "Have you ever noticed how every sensual....seductive....arousing....hot....(this went on for a while)...thing is better in the anticipation?" Anyway, it was funny. I obviously am not as good a raconteur as he is! And he sang my favorite song (Wishful Thinking).

Let's see....what else happened....AIDS Walk Austin was fun. Beautiful day, good cause. My biggest baby had to evacuate for the hurricane in NYC. Is that weird or what? We live in Louisiana (yes, we survived Katrina) for 20-odd years, and Dani goes to New York and is hit with a hurricane. We flew her home the day before it hit, and it's a good thing because it was a nightmare. We had to send her back after a week because classes resumed at NYU but she went back to a freezing cold dorm with no heat or hot water. Luckily, late the next day it was fixed but we were a little frantic. She spent a really shivery night.

The diagnostic bible of psychiatry (DSM-5) has been updated and it's quite controversial. We've been talking about it in class all semester. I didn't realize that I was getting involved in a profession that has such controversy surrounding it, but I am. The public is questioning pathologizing that may be going on - is hoarding really a psychiatric disease in its own right, or just a case of OCD? Is severe bereavement the same as clinical depression? Are kids over-diagnosed with bipolar disorder (yes)? Are the drug companies in bed with mental health providers, seeking to smooth over every bump in the road with a pill? One of the things I like about working now as "only" a therapist, before I graduate and have prescriptive authority, is that I'm forced to treat patients without turning quickly to drugs. My personal belief is that drugs are needed in some cases, but are probably over-prescribed in general. My goal is to not be in that camp. The other part about prescribing is do it right. I've already seen several patients that were prescribed a low starting dose of anti-depressant by their family doctor, and followup wasn't really done. They are still on that dose, and not feeling better after months. The doc wrote a quick prescription without a thorough psychiatric exam (maybe as part of their standard 15-minute office visit), and didn't titrate the dose. If you need psychiatric care, you need to see someone fully qualified in that arena, or expect sub-standard results. Just my biased opinion, folks.

And another biased opinion is something that I've changed recently. As a result of my experiences on the kids' psych unit, I no longer support legalizing marijuana. I can't tell you how many kids I've seen that think that's the answer to all their problems, but what is does is just suck all the motivation out of their brain. I have no problem with adults smoking a little here & there, but its effects on the developing brain are scientifically documented as terrible. And yes, I know that if it's legal, then you have to be 21, but how many of you drank alcohol before it was legal? Yeah - all of you. Me too. And the other thing is the brain is still in a high state of development until about age 25 or 26. I've always supported legalization, but I have changed my mind. I think society has to protect these vulnerable teenagers that choose this horrible thing that frankly, puts them in a fog and robs them of a future. The other thing is that I read the cartels don't really grow marijuana any more because the in-state cultivators have basically taken over the market. Ever watch Weeds on Showtime? So that's not a good reason any more to make it legal.

This last pic is just two cute kittens from the shelter. Don't you just want to kiss that little pink nose? We are still consumed with kittens there. It's been the worst year ever. If anyone out there wants a kitten, please please please visit the Austin Animal Center. Open every day from 11-7. http://austintexas.gov/department/animal-services