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Jill Presnell
Nov 19, 2012


[The individuals and situations described below are an amalgam of years of encounters and represent common presentations. Potentially identifying information has been removed or changed to protect confidentiality]

It’s 5:30 am. I receive a desperate phone call from the unit. Would I be willing to come in “for even a few hours” to cover for a therapist who called in sick. I have a little more flexibility with my hours because I’m currently a per diem therapist. I agree to work from 7am to 1pm. My husband and I planned a date for this afternoon.

I enter the report room at seven with my characteristic positive attitude. This stands in sharp contrast to the war-weary looks of staff who are on their second or third twelve hour shift. There are eighteen patients and five of us: two nurses, two therapists (my cohort will be working with the only adolescent), and one of my favorite psychiatric technicians. We read notes on each patient from the last twenty-four hours. “Patient participating in groups.” “Patient denies SI/HI.” “Patient in good behavioral control.” (what exactly is good behavioral control??)

After the nurses divvy up the patients and decide who will handle discharges and admits, we head up to the floor. The BSU milieu is one of the more welcoming I’ve seen. It’s nicely carpeted with yellow beige wallpaper and a decorative border running along the top of the walls. The rooms are laid out in a figure eight with a cozy lounge in each loop. The nurses’ station is an open arch between the lounges and the charting area sits in a room behind it. There is an intensive care area (ICA) behind a Plexiglas window on the other side of the chart room. This area is much less cozy.

The patients are scattered about. Some are watching TV. Some are lying in their rooms. And a few are circling the nurses’ station with no particular purpose but want to be around staff. There is an underlying sense of waiting; for discharge, for phone calls, for the doctor, for breakfast... for something. I generally like to take this time to be out on the floor chatting with patients, completing psychosocials, or doing some one-on-ones. Today I am scheduled to start the first hour monitoring patients in the ICA.

Two patients occupy the ICA. A middle aged man whose visual, auditory and cognitive experiences don’t mesh with reality and a college-aged kid who was brought in by his girlfriend after holding a gun to his head while he was high on “Bath Salts.” He signed the voluntary admission form only after it was explained he would be involuntarily admitted if he didn’t. Not a threat, a reality.

I decide to start by introducing myself to the kid. He offers a suggestion of what I could go do with myself and then rolls over in bed. I get the sense he isn‘t up for a chat. The older man is much more approachable. While he is certain that several of the staff are involved in a conspiratorial plot, he doesn’t believe that I am one of them. I spend the next half hour with one foot in his world. My approach is to refrain from directly challenging any of his delusions. I empathize with associated feelings, listen for statements I can link to reality, and am honest with him when I don’t understand. He seems to enjoy the interaction.

The nurse scheduled to relieve me is late. She has been working on two early morning discharges. When I emerge from the back, I see my supervisor, an amazing, upbeat woman who is scheduled to be off today but like so many of us in mental health, she sacrifices her personal time for the team. She sees me and asks if I would be willing to run over to the 6th floor of the hospital and do a consult. It’s quarter to nine. I am scheduled to run a group at ten. Crisis assessments take me an average of two hours and consults a little less. But this is a “slam dunk” consult. A young woman overdosed and continues to have suicidal thoughts. It won’t take long.

When I arrive at the girl’s room, I see that she is having blood work drawn. Her mom and husband are in a race to get to me. With the girl’s permission, I talk to them first. Mom urgently begins sharing the story before we even get to the private conference room. Apparently, after her daughter was stabilized, mom insisted that her daughter be brought here by ambulance from over two hours away. Several closer treatment centers had been willing to accept the patient. Mom says she wanted a psychiatric unit associated with a medical hospital. My impression is that she is embarrassed by what her daughter did. Hiding her daughter two hours away would ensure no one found out.

Mom informs me that her daughter had a genetic chemical imbalance which came from the “psycho” ex-husband’s side of the family. Mom instructs me on the medications her daughter needs and firmly asserts that “at least thirty days” of inpatient is required. The husband sullenly shares stories of sudden mood changes and impulsive, dangerous behavior. It takes all my therapeutic tools to control a demanding mom, encourage a frightened spouse, focus a chaotic conversation and manage a therapist who is having some negative counter-transference issues. Though neither says anything directly, the tension between mom and husband is palpable. After thirty minutes of listening, questioning and redirecting, I finally get a chance to talk to the patient directly.

I introduce myself to the very young woman and tell her I’d like to speak to her alone. She quickly glances at her mom and then asks if her husband can stay. Getting the message, mom shoots an angry look at the spouse and leaves the room in a huff. When mom is gone, the girl tears up. I encounter another pained soul; minimized past violations emerging through drug use, cutting, and ruminations on death (sometimes just knowing she has this powerful choice eases her sense of powerlessness). I feel I’ve got a pretty good initial picture of what’s going on in this girl’s world. With some coaxing and encouragement from her husband and me, the patient agreed to be admitted (if the doctor feels it’s necessary).

It’s now ten to ten. I’ve been here an hour and I still have to call the doctor, write the note, and obtain the patient’s signature on the admittance forms. I know that if I don’t get back to facilitate group then it won’t be run. I’m the only therapist on the adult unit. [Discussing why the nurses don’t run groups is a whole other blog] I whisk myself to the nearest private phone and give a quick and dirty overview to the psychiatrist on call. She’s going to be admitted. I’m going to run group. I’ll get her to sign the paperwork later. It’s not like she’s going anywhere.

I arrive at ten after ten. Patients pack into the “TV lounge” for group while I situate the couches, loveseats and chairs into a circle that will accommodate twelve of us. As I begin explaining the process of group, a woman stops me with the comment “Jill, take a breath. You’re talking really fast and your body looks tense.” Everyone laughs. It’s not unusual for me to comment on someone’s speech or body language during group. I guess it’s having an effect. I thank her, take a breath, a ground myself in what I’m doing now. Therapy group.

Despite constant interruptions (members called out to see various doctors, pages going off overhead, vacuuming being done in patient rooms), the group is working well. Members talk freely to each other. They express feelings and challenge each other. It’s not difficult for me to keep this group in the present experience. About half-way through, the adolescent therapist interrupts to tell me that there is someone to be seen in the ER. She reminds me that she’s not scheduled to cover the ER. She has one adolescent so she’s doing no groups. I have seventeen adults. I feel irritation pushing through my face. I reply that it will be about fifteen minutes (we have twenty minutes to get to the ER after receiving a page).

I begin the process of closing group. We review what has been brought up and anything members found helpful. Right as we’re finishing, I sense a stirring. One woman has begun crying. I should have remembered. This woman has a pattern of becoming emotional at the end of group, wanting to retell the story of her ex-husband’s cruelty to her. I had planned to bring this up at the start of group. I didn’t. I’m annoyed with myself.

Quick, directive, closed ended statements corrals the woman into making positive reflections. She’s not happy about it. Before heading to the ER I locate the woman’s nurse in the charting area and inform her that the tearful woman may need to talk. The nurse isn’t happy about it. I grab my things and head to the ER. There are now two patients to be seen, neither of whom is “quite ready.” I suddenly think of my date with my husband at two o’clock. I feel it starting to drift away. I’m not happy about it.

I decide to go back to the sixth floor and get paperwork signed. As I arrive on the unit I am blitzed by the patient’s nurse who irritably wants to know when we will be taking the girl because they need the room. I reply that I am just getting the paperwork signed and make a hasty getaway. Everything goes smoothly with the young woman. She seems to understand the process and signs willingly. As I walk back to the elevators, I feel pleased at having completed something today. My revere is interrupted quickly by the sound of someone calling my name. It’s the young woman’s mother. She was out smoking when I was in her daughter‘s room. It crosses my mind to pretend I don’t hear her. This option is dismissed through the realization that she will reach me before the elevator does. I turn around and greet her.

Mom announces desperately (and a little too loudly) that she has something important to tell me about her daughter’s suicide attempt. I make several very quiet attempts to explain that her daughter is being admitted and any additional information should go through the unit. [Where is that elevator!?!?] The woman will not be put off. She begins berating her son-in-law, not so subtly blaming him for her daughter’s problems. It strikes me that mom’s blame has shifted from the “psycho” father to the “emotionally abusive“ son-in-law. I wish her luck as the elevator arrives. She continues talking and follows me in. This woman does not pick up social cues.

She is now asking for my opinion “as a professional” about something that I “can’t let her daughter know.” Her poorly veiled attempts to get me to align myself with her stirs that counter-transference pot. I look the woman directly in the eye and firmly announced that I will not make any such promise and that anything she told me pertinent to her daughter’s treatment will be written in her daughter’s chart. The elevator reaches the ER floor and I step out. She begins to follow but I explain, a little too harshly, that I am in a hurry and have two patients waiting. She tears up. I feel a twinge of guilt. I pause, give mom a gentle smile and nod which she returns. Off to my next crisis.

When I arrive at the ER I’m informed that the patients are medically cleared. I call the floor to let them know that there are two evaluations pending. The charge nurse for the day, a gentle natured unflappable woman, assures me that there are no Ativan drips available for my use. I tell her about my date at one o’clock. She patches me through to the adolescent therapist who reminds me that she’s not scheduled to cover the ER. She didn’t know who would be covering after me and suggests I “just leave at one.” If no one is scheduled, the remaining patients “will have to wait.” I remind her that a patient in the ER takes precedence over unit work and that crisis evals are part of every therapist’s job. She sardonically suggests that, if it was part of our job, I should stay until it’s done. I consider suggesting something to her but, as a professional, think better of it.

I review the ER notes for each of the two patients. One is a regular who generally comes in when he has gotten into a fight with a girlfriend, has been kicked out of/evicted from his residence or has criminal charges pending. I happened to know that today it was the last situation. He had apparently come in last night stating that he was having suicidal thoughts but upon learning that we would have to send him to another hospital he decided that he felt “safe enough” to go home and would return if he felt unsafe again.

He’s back this morning due to feeling unsafe. During the interview, I ask if he followed through with any of the outpatient counseling we had set up when he was last discharged. He hasn’t: “They didn’t set up any transportation.” “They won’t give me a case manager to manage my appointments.” “They didn’t call to remind me about the appointment.” He has never followed through with outpatient treatment. He lives crisis to crisis and relies on the system to put out his fires.

With gentle but weary eyes (he trusts me), I ask him how much he wants things to change. He insists he really wants to feel better. I ask it if he wants it like a drowning man wants air. He desperately insists that he does. I tell him frankly that I don’t believe him. He looks hurt. “If you wanted it that badly, you would find a way to get to an outpatient appointment. You would stand on your head and sing the star spangled banner if there was a chance it would help.” He pleads with me. I tell him if he is admitted then I expect him to be at every group and that I am gonna “kick his butt” if he’s not; reiterating that I believe he has what it takes to find a way through but that I won’t work harder than he does. A sad, childlike smile forms on his face. I doubt my statements made a difference but I refuse to lose hope in anyone. The psychiatrist on call today is different from last night. Based on the patient’s specific plan with intent, past attempts, impulsive tendency’s, and pending negative stressors, this doctor admits him.

Beginning the paperwork, I give report to the nurses and leave a message for the Medicaid HMO case manager who will call me back “within an hour.” I will be gone within an hour. I will be on a date with my husband. [sigh]

A note at my station says that my supervisor called. She called from home. She answers with her typical upbeat tone and tells me that she will come in to relieve me a little after one. She apologizes that she will be late. There is no guilt trip. No self pity. I wonder to myself how many hours she’s worked this week. I will stay. I detect relief in her voice but she assures me that it would be okay if I wanted to get home. I’m resolute. She tells me that she has found another therapist who agreed to come in at five. Upon hanging up, I call my husband. “You do what you’ve got to do hon.” I apologize as I say that I would probably be too tired to have our date tonight. It was a date…you know what I mean…a planned, dinner to cigarette date.

Over the next several hours, more emotionally hurting folks arrive in the ER. A man who was brought in by the police on an involuntary warrant had been ripping up the floor boards of his house looking for wire taps and cameras. He has been seeing men looking in his windows and knows people have been searching his house while he was out. The police dropped him off and left. No information was shared. No one knows if they were state or local. I have to track them down.

A woman, brought in by her wife, has become increasingly depressed. She now spends her days sitting in front of the television chain smoking and staring blankly. She is tearful and practically mute. No suicidal thoughts. Her wife feels frightened and frustrated. It was a tough sell to the insurance. After all, she’s “not a danger to herself or others.”

When my replacement arrives, there are two more patients waiting. The just-out-of-undergrad crisis work wisely brought an extra large Dunkin’ Donuts coffee. She’s got a lot of potential. Her empathy and intuition make up for her lack of experience.

I give her an overview of where I am at then head over to the unit. I still have to do group notes. Wait…what happened in group? It seems like days ago. By the time I get home, it’s a little before six. My husband has dinner waiting. I eat on the couch. My mind still whirling over the day’s events. I’m scheduled to fill in for the partial therapist tomorrow. But that’s okay. It’s only for “a few hours.”

Jill Presnell is a Counselor in Northeastern Pennsylvania as well as an advocate for the provision of recovery oriented mental health services.

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