A Bad Day

It's been seven months now, and I have an inkling of what I'm doing (ha). Sometimes days go by and I don't need advice - really. And I'm starting to see some things differently. For one thing, suicide is such a big deal. I end up talking about and dealing with this way too much. Two of my patients now have made attempts and been hospitalized, both were overdoses which, frankly, we providers classify as low-lethality. It usually doesn't kill you. If you want to die, you should jump off a high place or get a gun. And now I feel like I should backspace over all that and erase it, but no, it's the truth. I need to say these things so that I don't cry. And I guess that's the point - this is heavy stuff. There have been days I leave my office and feel as though my body is full of mercury. And I'm not the one that's suicidal! I can only imagine...and I do, I imagine because I think that's important. And at the same time, I realize that I can't truly fully experience what they do. I have no trouble getting up and feeling good about lies before me each day. They go weeks, months, without a single day feeling that way. I am just surprised by how many times each day I discuss suicide with a person. As in, do you feel suicidal? Yes, I do. How often? What's in those thoughts? While I listen, I'm toting up their past in my mind - have they felt this way before, have they attempted before, what did they use, etc. Then we get to the really ugly parts - Have you thought, gee I'd like to do this next Tuesday? (and that sounds like planning a dinner party, which absolutely makes me go cold) and finally, Do you have a gun? Have you looked for spots to jump when you drive over Pennybacker bridge? I have one patient that I asked to remove a gun from the house.

This is exhausting. I can't seem to do this and shake it off. And I want to quickly say, I'm not whining. I love my job, and I intend to keep doing it and get better at it. It's just, JFC, I am slayed by how much I have to deal with suicidality and how difficult it is emotionally. Sometimes I wonder, gee, is it me? Is is some quirk that I ended up with these people? I kind of thought this would be easier....you know, the perception those of us that have been in the trenches of mental hospitals have is that private practice is the easy route - the mildly depressed and anxious. And you know what? That's just totally screaming wrong. People out in the community have significant issues. This is no small potatoes - let me just say Robin Williams. I heard on the radio driving home that he had killed himself. Oh god, we didn't save him. Think of everything he could've done if he'd stuck around.

I had a particularly bad day recently. Let me describe it. I'm going to change up a few details to protect identity. First of all, one of my patients came in manic. A manic person is dangerous, they are impulsive, make poor choices (have unprotected sex, buy new cars, walk alone at night) and if they have suicidal or self-harm tendencies, that can be a bad mix. So the first order is cool them down and protect them. That's hard in an outpatient environment. I need them to use good judgement to follow my instructions, and they don't have that now. What I try to do is hand them a sample medication to knock the mania on its ass - a good stiff antipsychotic usually does the trick. Don't really trust them to get to the drug store. But that messes up the day - they take more time than a 30 minute followup. So I start the day behind already.

Then I have a new evaluation that was a borderline personality. Fit it to a T - the history of drama-filled relationships, F'ed up childhood, the dependency and poor coping in life, the rushing from this to this to this to fix her. It was hard to listen to, and then there's the thought in the back of my mind: these patients rarely make any improvement. I have only an hour for new evals and it's hard to cover everything in most cases. This person was killer - I had to interrupt several times, "Gee, I'm sorry, but I have to move on and ask you some questions or we won't finish". Frankly, she wasn't capable of following that simple instruction. Finally I wrap things up and discuss a few medication options and she then reveals, Tah-Dah! - she already knows what she needs! She read about it in a magazine and sounds like it's just the drug for her. And it's a new antipsychotic. Funny, when I say that word, most patients don't react too well, they hate the idea of psychosis. I explain to her that none of her diagnosis fits the criteria for that drug. But, but...she protests. It sounds like it would help me. I said, it's not FDA approved from your diagnosis. It's unethical for me to prescribe it and I won't. You are free to leave and see another provider, no charge. Jesus. She decided to go with what I recommended. As I'm checking her out, our receptionist tells me that she got a strange call and had to refer him to me. A guy goes thru the process to book an initial eval, gives all the info (which is a lot), then at the tail end - Tah-Dah! - reveals that it's actually for his wife, not him! And she doesn't want help, so he's going to trick her into coming to the appointment! Of course, Angela tells him we won't accept that. He'll have to get agreement from me to have the appointment booked. I listen to this rambling voicemail, and this is the ridiculous part - he won't say what's going on. I suspect that his wife is using drugs or alcohol but JFC if you want help, at the very least tell me what's going on. I call him back and leave a message saying, look I suspect she has a substance abuse problem and you need to consult with an interventionist, not with me. I refer him to two places that have interventionists on staff. Luckily, he doesn't call me back. I am always highly suspicious when an adult calls to make an appointment for another adult - even if it's a college student - it just immediately tells me that the person isn't really motivated to seek treatment for themselves. Let mommy do it. And that never goes well.

Alright. Think that's enough? Well, the day goes on and three of my follow-ups are struggling with suicide so we have to talk about that in some detail. See the first paragraph of this blog. That alone would be enough for one day, but there's more. I have another new eval at the end of the day, and he's pretty much in crisis. Panic attacks, can't sleep, missing work. Cries thru much of the hour. We get about 1/3 of the way in, and he starts asking me rather strange questions. Would you stop writing things down? Can you keep a secret? I explain the limits of confidentially - namely, if I believe you are at risk to harm yourself or others, I can call the police, and if you are abusing a child or elderly person, I have to turn you in. OK, not a show-stopper yet. He keeps hinting around, finally spills it. He did some illegal activities in the past. And we move on.

So there it is. That's what a bad day looks and feels like. I think next time I'll explain what a good day is like - I have those too. Really.