So long, it's been good to know you...

Last day. Lots of paperwork completed. Ate a huge unhealthy lunch from my favorite restaurant just to say....whatever. Still caught up in all the stories at morning meeting, the problem solving, the distribution of caseloads. Elizabeth and I ate lunch, as we often do, watching The Young and The Restless. One last time. The staff gave me a collage of pictures of themselves, with signed messages. I took some pictures, too: of morning meeting, of people getting coffee, of Elizabeth at her desk. At mid-day one of the nurses knocked on my door and said the clients wanted me to tell them myself that I am leaving. So I stepped out and did that. It was the guys in the lobby: Chick and Slick, Ricky, all the guys who've held doors for me and greeted me in the morning with "How're you doin"? They asked when they'd see me again and I said I was planning to come to the annual Christmas party. Evie called. She'd missed the women's group yesterday and wanted to say goodbye. And Terri stopped by, ditto. The case manager, Rick, had written me a long note with his email address on the staff collage. He asked me if I could recommend him for a raise, sort of teasing. I said I didn't know how much my word was worth here anymore. He asked, "then what should I do to get a raise"? I said, "Stand on your head." In the afternoon, Elizabeth was still dealing with how the hospital wants to handle Shawna, and with two clients who got drunk last night and crashed their car into a ditch. She reminded me that I had to turn in my keys and my cell phone. My purse felt much lighter. I cleared out my desk and ran the gauntlet of a few more hugs and got into my car, with my plants and my clock. Then I drove the long way home, the long drive I've been hating, thinking nostalgically about how I won't be doing that anymore. And I played with my dog. And made some dinner. And now.... So long for a while.

Tears

I have a hard time summoning, or allowing, tears. I barely cried at my father's funeral. So it may not be apparent to my clients how deeply their expressions of feeling reach me. Today the women's group dyed and decorated Easter Eggs. Olan gave us a dozen eggs she'd already hollowed out, so they can even keep them if they want. A client I fell in love with when I first came to this job joined the women's group only a couple of months ago. She, as far as I know, has few friends, and has had a very hard time staying free of psychosis. I hospitalized her more than once, and have been through some very tough times with her. At the time, she was very stressed out by money issues. Now she has some income and is stable. She's also been given bi-weekly shots of psych meds, and that seems to be working very well for her. I was very surprised that she came to women's group more than once. Today she arrived without prior knowledge that we would be dying eggs. I thought she would think that was foolish, but she got into it as much as anyone, and when she was leaving, she turned around and gave me a hug. I can't adequately express what that meant to me. I took Angela into my office after group to sign some papers and do a med fill. She told me that her therapist and I had brought her "from zero to 60" in being able to socialize and avoid isolating herself. She started to cry, grabbed a tissue, and left. And in the morning, Ricky said he had a card for me that he'd left at home. He was happy to learn that it is tomorrow that is my last day. I have never had such a hard time leaving a job.

Three More Days

My official going away party was today, but I'm working through Thursday. My emotions are very unsettled and I don't like being the center of the party. It was lunch, with jokes. so that was fun, I guess. Of course, I'm moved by all the feelings coming my way from the case managers, the nurses, Elizabeth and even people outside of our office. The case managers went to great lengths today to dismantle and bring me something that I've always wanted. I can't say what it is because, although it has no monetary value, they sort of "took" it without asking permission. Thinking of them all working as a team to do that is the best part. I've told several of the clients that I'm leaving, but chickened out today and put a farewell sign on my office door. That way I won't have to tell them in person, but will be around long enough to say so long to each one. I'll see my colleagues again, I'm sure, but it won't be the same. It is less certain that I'll see the clients I've become close to in this past year and a half. There is a way in which I've seen nurses suddenly detach from a patient, even one who's had a long stay and whom they've bathed, helped to walk, changed dressings and IVs for and shared stories and confidences with. One evening they're sitting by the bed talking about their children; the next morning they're all business as they present the discharge paperwork and call for a wheelchair. I understand that better now. Shawna is in the hospital on the long-term ward, and that is a relief. Harry is in jail, also long-term. But will I really not see Danni again? Stacy? Angela? Chick and Slick? Lily and Paul and Dylan? Bev and Terri? Three more days. Thank you to everyone for your kind posts. After Thursday I'm going to take a break. Then I'll figure out whether I feel I can reasonably continue to write here. Thanks for cheering me on.

Grand Finale... of sorts

Yesterday I picked up the phone and it was Danni, in tears. "I just thought you would want to know that my uncle died last night," she said, and I said, "Oh no. I'm so sorry." Danni's uncle was more a father to her than her own father has been. They lived quite near each other and she saw him almost every day. He's been sick for a long time. I remember once when she answered her cell phone during a session with me. I was patient when I heard her say, "Chocolate, with sprinkles." It was her uncle asking her what kind of ice cream she wanted. He just happened to be passing a DQ. Danni asked if I thought she should go back on meds. I told her she should let herself have all the feelings she was having, to give it a day or two and if she couldn't sleep or felt unusually anxious, to call us back. I told her to give my love to her family. I think that's not "correct" professionally, but I can't always deny my own feelings. And I guess of everyone I've worked with here, she's Number One. Today I gave myself to paperwork. I don't want to leave Elizabeth with a pile of scut work to handle, so I'm trying to get a jump on the April papers. I was bleary-eyed by 4:00 when I heard a commotion at the front of the building. People were arguing. I heard Olan's voice. Then I heard her say, "Shawna, stop!" I ran to the back of the building to look for Elizabeth. Shawna was discharged from the state hospital yesterday, despite continuing to cut herself while she was there, despite my telling them that she seemed not at all at her baseline when I saw her last week. Within four hours of coming home, she was drinking, and by early evening she was calling on call to report that she'd been cutting. Couldn't find Elizabeth right away so I called to Pru and Mike, "Olan needs help!" and ran outside myself to see what was happening. Shawna was striding away from the building, a plastic bag swinging by her side. Two people I didn't know were running after her, calling her name. When I caught up to them Shawna stopped and looked surprised. She raised a can of beer to her mouth and took a gulp. Then began an argument. "You all are calling the police right now, aren't you? You're going to send me up, and I'm not going," she said. The two strangers, who turned out to be neighbors who had been trying to take her to the hospital, tried to talk with her, but she just kept walking. One of the neighbors told me that Shawna had been drinking and cutting herself all night and all day today. they tried to take her to the hospital, but she wouldn't get out of the car. So they brought her to us. I tried to talk to her then. I said that we couldn't guarantee that the ER wouldn't send her to the psych hospital but that her cuts needed to be looked at. She was dripping blood despite the bandages she had wrapped around her arms. Elizabeth came out of the building and joined us for a discussion in which we all tried to justify our positions and Shawna heard nothing. It occurred to me that Elizabeth, I, the neighbors, Pru and Olan all were performing for each other: look, see, I'm trying so hard to do the right thing for Shawna. And Shawna was the ringmaster who didn't care what any of us said or did. Eventually, Shawna started marching for the overpass she had threatened to jump from before. Olan stayed beside her. Elizabeth asked me to fill out a commitment form, and I ran inside to do that while she called the police. The cops were there by the time I ran back out with the form. It took little convincing for Shawna to get in the police car, but before she left she asked her neighbor to get her some cigarettes. We all were shaking by the time she was driven off. Elizabeth's face was bright red. Several of us stood out in the sunshine on the parking lot, just letting our pulses settle down. Mike asked me how I could give this up. And I felt simultaneously that it was a good thing to give up and that I would miss it. Something like being a fireman, I suspect. You are right at the center of the action. Good. Bad. We'd been in touch with the hospital and with the unit that ultimately decides the placement of individuals in the population we deal with. We'd been assured that we will not have to take Shawna back if she is let out any time soon, any time without having had a full course of ECT. I don't know who I am more angry with: the doctor who discharged her, or Shawna, who refuses to see the care that is offered to her by her children, her neighbors, by us. The staff keep saying to me, "You're really going to leave all this"? I guess their constant consciousness of my leaving is a sign that I have been important to them. Truly, I am sad to leave them, sad to leave others, too. I took the women's group to lunch yesterday and we had a very good time. One of the women took me aside to ask if I was leaving because she had told another staff member that I had said in women's group that I, too, am on antidepressants. "I was worried that you were leaving because I'd told your secret." I had to reassure her that it wasn't a secret, that having a psychological condition that needs treatment should be no more shaming than having a cold or any other illness. No doubt, I will miss all of this.

Winding Up...And Down

I saw Danni's name on the doctor's list today so I waited and watched for her to come in. When I heard her voice, I invited her into my office. Her boyfriend stayed out in the waiting room. "He's not my boyfriend anymore," Danni said, "he just brought me today because I needed a ride. We're friends now." She told me she has a new guy now. She said she hasn't used drugs in two weeks and that her new boyfriend doesn't do drugs. She said she realized that the boyfriend in the waiting room and she were bad for each other and that eventually everything they did was about drugs. She hasn't taken any psych meds in over a month either, and she says her moods are pretty stable and that she feels "happier than I've ever been." I told her that is great. Then I said I'll be leaving my job soon. I said I'd always be rooting for her and that I thought she would could have a big life, that she's capable of getting whatever she wants. I told her she could call me for a referral to therapy or a support group and that I'd always be interested in how she was doing. She said, "Oh, I'm happier than I've ever been. I mean it." Then her eyes filled and her face lost expression. "What's that about, Danni?" I said, and the tears flowed. "I don't know," she said, "I think it's tears of happiness." She asked if she could hug me and she went out to see the doctor. Later, as a couple of the case managers were writing reports and asking me for help with how to word things, Cindy said, "what are we going to do for a thesaurus"? Terri stopped in and asked if she could hug me because "I won't get many more of these." And in the afternoon Doris called from the hospital. She's getting out tomorrow. I'd stopped to see her briefly yesterday. We don't know each other well. She isolates a lot and doesn't talk to many of us. Today she said she thought she could use some counseling. I was surprised, in a warm way. I told her we could talk about it on Monday and she said okay. I'll have to tell her then that I'm going. I have two more weeks of getting ready to go. It's hard!

One More Time

I drove upstate this morning to meet with the state hospital people for the last time, at least in my current capacity. The meeting was fine: Henry is back in their hands and we all agreed that we are out of ideas for what to do with him. His psychiatrist said he doesn't think Henry is either depressed or psychotic, that he's just playing them for a roof over his head. Yup. I saw him on the ward later and he asked me, "Please, miss, can't you find an agency to give me some money"? Right. Just get in line. Meanwhile, the doctors think he's been selling his meds for crack. Shawna is there, looking not so great. I took her out for a walk. She confided that she is still cutting surreptitiously, even while being watched. The cut she showed me is not healing (due to being reopened and deepened again and again) and is becoming a permanent cleft in her arm. I couldn't betray her confidence, but did have to indicate to the staff that I don't think she's at all ready to be released. They know what's going on: asked me if she'd been out of my sight at all on our walk. I said no. I hadn't been able to tell her that I'm leaving my job. I was afraid of how she might react. I did tell the women's group. They were pretty philosophical. Terri was doing a hilarious routine about the night her roommate set the house on fire. "We're all mentally ill," is what she says she told the firemen when they were at the door. She said she could prove it: "Just look at my roommates," she said, "one is warming her hands by the fire she set and the other one is wearing her hat and purse, waiting to be told to leave the house." She had everyone cracking up. I've asked Pru to take over leading the group and they all like her, so I think that should go well. We are going out to lunch again next week and Pru will go with us to begin the transition. My new job is for sure as of today and has some exciting possibilities attached to it. I don't expect to continue to write about it here. We'll see. I leave my current job in the first week of April and then will have several -- needed and welcome -- weeks off to contemplate....

Outside of Everything

Today someone asked if we thought she should report another client who had said she enjoyed having her parakeet masturbate on her hand. I said no. And someone else said he was glad he was "outside of everything." I asked, "what do you mean"? He said, "Outside of the hospital, outside of prison... you know, outside."

Hopping Mad -- With One Bright Spot

They took him! I could hardly believe my ears when I picked up the phone Wednesday morning and heard a social worker at one of the psych hospitals tell me that they had Ray. "He seems quite disoriented," she said. I had to remember to avoid sarcasm as I told her the story of what had happened among Ray and his roommates. "Aha," she said, and I breathed a sigh of relief for having someone there who gets it. "This boy does not need the hospital," I said, "he's just looking for a way out." Now I hope they get him out of there before the weekend. At their weekly meeting, the state hospital told our representative that Shawna is doing beautifully since they've had her journaling. "She's got great insight," they said. Right. Been there. Had her journaling. It won't save her life. The thing is, they act as if we don't know our clients, don't bust our butts for our clients, don't look for every possible solution to their depressions, their delusions, their manias. Five minutes at the hospital and they've got the cure. This is supposed to be teamwork, but too much of the time they don't want to hear what we've got to say. The bright spot is that Danni called and I happened to be the one answering the phone. She said she'd moved out of the house where Pru was looking for her, so it wasn't Danni who refused to come to the door. She'll be in today to see the doctor, and I will see her too. I had been thinking that I'd feel terrible to leave the job without seeing Danni.

What Would You Do?

Morning burst upon us with a problem among housemates. Jim is a guy with end-stage emphysema, and he is still smoking. He's beginning to think now, though, that he might really die. So he's been on edge. His housemate Karl is frequently hospitalized for self-harm. Everyone seems to forget he exists until he burns his arm with cigarettes or makes his fingertips bleed. The two of them were in a dither about Ray, a much younger guy who shares the house with them and who describes himself as "just plain lazy." He stays in bed most of the day, does not clean up after himself (his room is full of dirty dishes) and is careless about showers and such. His case manager has tried everything to light a fire under him and nothing has worked. Karl and Jim, they admitted, had been up most of the night sharing a bottle of Jack Daniels and dissing their roommate. "I just can't take it any more," Jim said, and put his head down on my desk and cried. "I'm sorry. I'm really sorry for what I did to cause this," Karl said mournfully. I told him he hadn't done anything and he seemed disappointed not to have a leading role. I said I'd get Ray to come in and talk to me and see what could be done to change things at their house. When Ray came in he said he wanted to go to the hospital. "Why?" I asked. "Because I don't feel safe in my house." I told him that was not a reason for going to the hospital. "I want to go to the hospital," he insisted. I said I wouldn't send him, that there was no good reason to. I said his housemates would not hurt him. I said I knew both of them well and they had never done anything like that. "Then I'll say I'm going to hurt myself. I'll call the police myself," he said. I told him he could do that but that I wouldn't recommend it. We went round and round like this until he asked to use the phone to call a friend to come get him. While he was at the phone, I slipped out to get a sandwich. No sooner had I placed my order than the nurse was calling me to say that an ambulance and two police cars were in the driveway. What should she tell them, she wanted to know. "Tell them that my assessment is that the client is full of b.s. Let them take him for another assessment at the local hospital, I don't care." so she did, and they did, and I don't know whether he got sent up to the psych hospital or not. But if they took him, after turning down Shawna and some other really sick people, I'll be hopping mad. Pru went to see Danni today. She knocked on the door and saw a curtain move. Whoever looked out at her decided not to answer, even after Pru knocked and knocked again.

This Just In

Another night with Shawna calling on-call at midnight, being sent to the ER, being sent back home, threatening to kill or hurt herself, then retracting the threats. Mike looked beat this morning, as he was the one on call. These relentless episodes have led us to send her to the state hospital involuntarily and to request that her case be reviewed. We believe she cannot be maintained in the community and should have long-term hospitalization. Tomorrow Elizabeth and I will go up there to, in part, make the argument. It's exhausting. At least she is (we believe) safe for the moment.

Weekend Report

Over the weekend Shawna either took rat poison or decided to say she did. She was hospitalized but showed no internal bleeding so they've sent her home. I dread the next event. When I talked to her last week she was unable to acknowledge her children's concerns for her, saying that none of them care about her. In all the time I've known her I've not found her able to look at things from someone else's perspective. I just don't know what any of us can do for her. The homeless count is now three. One says he's being taken in by a friend. Another remains in the hospital, waiting for the home fairy to work her magic. The third got into the hospital over the weekend because he had nowhere else to go, but they know his tendency to try to manipulate the system and they sent him back to us today even after we said over and over again that we have no bed for him. So he's on the street and I expect we'll have more news of him tomorrow. Henry also has been heard from again. He's in a hospital, the one you can check into voluntarily, which he apparently did as soon as he was released from prison, no doubt because he, too, had nowhere to go. We're not just working without a net. We're flying through the air without even a trapeze.

Onward and Upward

Today I received the proposal for the new job I've interviewed for. It looks good. I'll call them tomorrow. It looks like things may move quickly now. My heart is light and heavy at the same time. Pru came in to meeting and reported that Shawna cut herself again last night. This morning she was playing bingo at the center. One of our young, hard-to-treat guys is homeless after a few nights in jail. No one in his family, which is large, will take him. A guy who gets belligerent when he doesn't get his way got very paranoid about Mike and was threatening him out on the parking lot while the doctor weighed whether to commit him. Cindy finally found a home for Mert. I counseled a few of my colleagues about their clients and a couple of their own problems. And I explained to someone at the state hospital that even after all these weeks we do not have housing for the man who has been ready for release for over a month. I will not miss that kind of stuff. But I will miss my clients and my colleagues a lot. And I know that once this tie is broken, only a slender thread will remain: it's the intensity of our days and the hard-to-believe nature of so much of what we do every day that binds us more than friendship or anything else. When I stop sharing that it will be like losing our common language.

Are We Having Fun Yet?

Not really. Maybe it's the drab winter days. Or the increasing number of people we can't house. Or the co-pays that are starting creep in for people who are already stretched to the max. The ECT treatments that I arranged for Shawna are going to cost her about $25 each in co-pay. That may sound reasonable, but not when her entire monthly budget is $750. She, like so many of our clients, needs a lot of dental work, too, and that isn't covered at all. When we offer to take them to the dentist, as we are obliged by the state to do regularly, about 90% of them say, "no thanks," year after year. Fuel costs are going through the roof, with many of our clients trying to heat flimsy trailers or run-down houses. I've been at this for less than two years and even I can see what's been chipped away. It feels like we're on a sinking ship, with everyone on the shore shouting, "Row harder!" Things are moving toward my next job. Paperwork is being done. The wheels are slowly turning. I wonder, though, if it will be much better. Sorry to be so down. I've spent most of today doing therapy, and that's what I came for, but it isn't what these people need most.

Made It Through the Night

Phone rang at 11:30 pm last night-- case manager telling me Shawna had called the on-call. So I got up and walked out to the kitchen to call Shawna. She told me all was well, but I could hear her daughter in the background saying, "Come on , Ma, tell her the truth." So Shawna eventually told me she had cut herself, but that it didn't require medical care and that she now felt much better. I fought my sleepiness to try to assess the situation. I knew that Shawna can be trusted to decide when her cutting is severe enough to need stitches, but I could hear her daughter's anxiety. After talking with both of them, I asked Shawna to contract for safety through the night and to come in to the center in the morning. I got her daughter on the phone and told her what I'd had Shawna agree to, and also said that if Shawna did anything else dangerous, or threatened to do such a thing, her daughter should call 911 right away. They didn't call, but I didn't sleep well nonetheless. Pru brought Shawna in right after morning med run. Shawna looked beat and said she hadn't slept much and that Pru had waked her up. I was thinking that that was later than I'd been able to sleep, trying to push back my frustration with Shawna for bringing so much anxiety into the lives of her children, into our lives. I talked with her a while. She told me her kids were mad at her and that made her feel bad. I said I didn't think they were mad, but that they were frustrated, and reminded her of how much they rush to meet her when she is sober: taking her out to lunch, sitting up at the kitchen table to talk with her. I asked her to keep that vision in front of her and to remember what is possible. I scheduled an appointment for her to be assessed for and have further ECT treatment. It is far from her home, but is the closest place that does ECT. The doctor's office told me she will have a co-pay of a bit more than $25 a session. She has about $600 a month to live on.

I don't know if her budget can sustain that. And that makes me mad all the more. She absolutely NEEDS this treatment. What kind of healthcare system would put so many barriers in the way of getting it.

Help Me Make It Through the Night

On the drive to work this morning I was trying to listen to a book -- a mystery I was hoping would distract me from being weary of my job. The cell kept ringing with case managers calling in to tell me they were sick or would be late, or about clients who needed meds that weren't in their med boxes. Elizabeth was at meetings so again I was at the helm of our rickety ship. Pru called and said she'd just left Shawna's where she'd gotten Shawna to agree not to cut herself or otherwise harm herself until at least 11:00 a.m. Part of the agreement was that I would call her. She's been asking for me any time she calls on-call. There were just three of us at morning meeting, and a slew of clients in the waiting room, lining up to get their checks. It was so noisy that I had to slip into Olan's office to use the phone to call Shawna. She had been drinking all weekend. We had talked several times on Friday and I'd thought I'd left her in a pretty good place. But she lives in such a web of emotions with all of her kids and their friends and the attendant dramas that things change just about every hour. She gets mad when they won't buy booze for her. They get made when she wants to drink. Some of them use drugs. Some steal. Some eat all the food in the house and never wash a dish. And Shawna says she can never assert herself unless she's fueled up on alcohol. I talked her into getting something to eat this morning and said I'd call later. When I reached her around noon she said she was just tired. Tonight we're back to zero. She'd found a way to get alcohol without the kids (and pointed out to me that she was being independent, as I'd suggested....not exactly what I'd had in mind). Now she was furious with them that they'd not helped her. I tried to say that maybe they think not getting liquor for her is the best way to help. But she wasn't receiving very well. So I asked her to call me if she feels like hurting herself tonight and she reluctantly said she would. All evening I've been ping-ponging between worrying that she will hurt herself in some serious way and worrying that I'm fostering too much dependence on me. Another sleepless night, I'll bet.

Sometimes You Have to Say Uncle

I was asked to referee a session between a case manager and a client today. The two have worked together for several years, but the tie that they created is wearing thin. The client has been acting out with booze and drugs in ways that hurt his family, and the case manager is mad: she sees years of her effort with her client slipping away just because he won't do what's "right." This was supposed to be a meeting in which the case manager would lay down the law for the last time before handing the client over to someone else on the team. We'd already arranged a client exchange for next week. But the case manager needed to leave feeling that she was still in charge. This is a very willful client, however, and within minutes the meeting had turned into a showdown with both of them talking at once and nobody listening. I stood up and stared them down until I had their attention and could finally say, "Let's leave it for today." The case manager got up and left without another word. I looked at the client and said, "We can meet next week with the whole team and see where we go from here. But I don't want to hear another word about what happened any time before this afternoon. We're going to start over." It was so important to the case manager not to "lose" to the client. I was afraid she'd feel over-run by me. I talked to her about how you have to know when to "fold 'em," when you are no longer the one who can bring out the best in a client. No one should be your life's work. That's why we work in a team. The victories are most often unexpected and usually are arrived at by having the work of several people converge in a fortunate way. It was a demanding day. I was starting to hate my job again. The highlight for me was a short visit with Angela who is doing wonderfully well. We talked about the music we're listening to lately and about how women's group had gone. She said she wants to have the group meet at her house when the weather gets warm. She has a garden. If things were less hectic. If hospitals collaborated and didn't toss people out as soon as they can. If there were day programs with interesting, challenging things for clients to do, and emergency funds to help them when they are in a bind. And affordable housing. And shelters for when someone is in a crisis. And healthcare industry that was first and foremost about health care.....

The Return of Miss B

I just realized that today was the first anniversary of the Women's Group. We had our weekly meeting today. Wish I had noticed it was our anniversary earlier so I could have told them. The other day one of the nurses asked me if I would be willing to have Miss B join our group. I said sure, thinking that there was no way in the world that the independent Miss B would join our group. She was, for a time, the client who taught me the most about the limits of what I can and cannot do. I've written about her before (giving her a different name that I can't remember now). She is exactly my age, pretty, smart, articulate. I like her very much. When we first met, she was frequently psychotic, and wildly so. She'd pace around the waiting room yelling at the staff, cursing each of us in turn. We did nothing right in her eyes. The police came in on several occasions when she physically threatened staff or destroyed her own furniture and clothes. I was on a mission to help her keep her home, which she was about to lose for lack of money, and to keep her stable. It didn't work. We hospitalized her several times and it took a while to get the right mix of meds into her and bring her back to her baseline. The last time I saw her in the hospital she poked my shoulder and backed away from me. "I know you," she said, "don't you come near me." For the past six months or more she has remained at her baseline. It's not just the meds, not just her compliance in taking them. It is that she inherited some money and her financial stressors lightened up a lot. That's key: she's not worrying about being homeless every minute as she was before. Miss B. is a very independent woman, who has wanted nothing from our agency except meds. So we've left her alone this time, and after a period when we had someone go to her home every day to observe her taking her meds, we've gradually made her more independent with managing them herself. Now she was going to come to women's group? I didn't think so. But when I got there to open the door, she was standing right next to it. Three other women turned up and we talked about their kids, some of whom they've lost custody of and aren't allowed to see. We talked about what it feels like to know you are getting out-of-control manic. We talked about the loss of love. We planned our next lunch out: March 30 for Terri's birthday. And we laughed some, too. Miss B. sat taking it all in, and about halfway through she started to tell just a little bit of her own story. And at the end of the group she said, "I really enjoyed this." Will wonders never cease. I went to an exercise class tonight. The instructor said he used to work in mental health until all the budget cuts and the increasingly tight reins of managed care got to him and he gave it up. Sometimes I wonder what I was thinking to enter the field when so many of the pros are leaving. At least the women's group is bright lately. And there's Miss B.

Street People

Mert behaved exceedingly badly at the shelter where Cindy had miraculously found a 30-day bed for her. So she is homeless once more. Pru picker her up in pouring rain on Saturday night and drove around trying to find a place for her. No dice. She finally dropped her in front of a house in Crack Town and wished her good luck. Mert turned up this morning, looking for her check, none the worse for wear -- although she's pretty far gone as it is. Pru had quite a weekend. She stopped at Shawna's, slopping through a sea of mud to be greeted by Shawna -- a very drunk Shawna -- at the door. "Don't call the police on me again," Shawna begged, her little niece hiding behind her, peeking out at Pru. Pru said she wouldn't as long as Shawna didn't threaten to kill herself. Shawna promised. And Pru said there was at least one sober adult in the house so she didn't call child protective services. This time. It does get passed down, generation to generation. Genes sometimes, I guess, but also it's a matter of people growing up in chaotic, ill-functioning households. Makes it hard to dream. A guy named Skeeter who uses any drug that comes his way was reported as having been very high on Saturday. This morning he called and asked if anyone had seen his wallet. He spoke v e r y s l o w l y. "Nope," I told him, after asking around, "Did you check your car." He said he would. He called every couple of hours to ask if anyone had seen his wallet. In the afternoon he said he also needed meds, but Pru had reported leaving meds with him for today and tomorrow. Some time after four o'clock he called once again. "Found my wallet right here in the house," he said, "My meds, too." Guess he came to. I'm seeing hardly anyone for therapy these days. As hard as it is to make progress with some of the clients, I miss that work with them.

Full Moon Arisin'

And I'm on call again. Didn't think I was until I actually got called to talk to a client who wanted me to tell the doctors at the medical hospital not to send her to the psych hospital because she'd taken a whopping overdose. "I was just angry," she told me, "I'm not angry anymore." Of course, I explained that they couldn't take her word for it and would have to send her to the hospital for evaluation. "If you're really back to your old self, as you say you are, you'll be out before the weekend," I said. Mike is being his sweet self again. He's started growing a vegetable garden from seed, on all the windowsills: beans, tomatoes, peas. He says he was annoyed last year when the case managers kept being turned down by nurseries when they asked for a few donations of plants. He told me he's also making sure that the clients in the men's group have their cars in running order by June, when he intends to start taking them fishing again. "Like we did last year, we'll go out and catch what we can, and we'll come back to the center and cook it up, along with the vegetables we're growing. And we'll do that as often as we can in the warm weather," Mike says. Is he great or what?

Tax Cuts Are Nuts

My turn to talk to the state hospital team today. Right away they asked what we are doing to get one of our clients out of there. He's been ready for weeks, but we have nowhere to house him. "This man cannot stay here forever!" the resident exclaimed to me, "You know what they say: if you stay in the hospital long enough, you get sick." I told him that we have put this client on the waiting list for every shelter in the county, as well as for our tiny residential program. I told him that the other night one of our clients slept in a truck because there was no bed anywhere for him, and that we have another homeless client we are trying to place. He said, "Have you tried the YMCA"? I had to work not to laugh-- even if we had one, this client couldn't afford it. "The client's entire income is $153 a month. If you can find me a bed for him that costs only that much, I will take him there immediately," I said. As I left the meeting I turned to say, "I hope all of you vote," and one of the doctors said, "Amen." Their jobs are hard, too, I know. They made a point of telling me to let Shawna know that they were very glad to see how quickly she snapped out of her suicidality, and that her drinking again after a month of sobriety should be viewed as a typical step in the course of recovery rather than a failure. It was good to see that expression of care for her. I told Olan, her case manager, who said she'd relay the message. Later I happened to pick up the phone when Shawna called, asking for Olan. "Hi, Shawna, it's me," I said. "Oh hi. I guess you heard I messed up," she said. And that gave me a chance to say, "Actually, I heard you did very well in pulling yourself back together. All the docs at the hospital thought you were terrific."

A Few Good Women

Women's group was down to two today. If I don't call to remind some of the members, they forget to come. We talked about last week's lunch and how we'd like to do that again. And we talked about being in the hospital, and which hospitals are preferable. Sally said she missed the hospital diversion beds we used to have, where people could sign in for a few days respite from whatever was causing them stress. Budget cuts. (And more coming from the feds, it looks like. We had our client Dylan sleeping on the steps in front of our building last night after his case manager, Rick, had exhausted every possibility for a bed. Rick was back at it today and got him a room in a boarding house. When I left he was rounding up blankets and towels. I walked past Dylan and said "You're lucky to be working with Rick. He's going the distance and then some for you." Dylan said he knew he was lucky and was grateful that Rick "stands by" him. Mert is also homeless -- in a motel til her money runs out, which will be in another few days.) Evie said she'd continued to write poetry since we'd written Haiku and Tanka in our group a couple of weeks ago. She'd like us to do another writing day. We talked about other "themes" that might enliven things and decided that next week we will ask everyone to bring in something that means something to her and tell the group about it. I look forward to that. Evie is enthusiastic and said she'd call some of the other women. The state hospital sent Shawna home today. Elizabeth and I talked about how we haven't had a suicide among our clients (knocking wood, of course) and speculating that with the hospital bounce we will soon have one. Then what will they say? Most of the day, though, was spent on paperwork. Reams of it. Catching up so we can pass our recertification review. A lot of it is redundant and boring to do. Yesterday I signed a stack of paper at least 8 inches high as part of what I must do to be accepted as a therapist by insurance companies. That will take at least three months to process, and in some cases six months, I'm told. Can't start a new job until that's accomplished. Nice to see land on the horizon, though.

Don't Jump

By 8:40 this a.m. we were dialing 911. And that was the least of it. Shawna had come in yesterday (when I was off) saying that she felt suicidal. She was given some medication, observed in the office for several hours, and taken home. When Pru went to her home to observe her meds this a.m. , Shawna said she was suicidal again, so Pru brought her into the office and seated her in the waiting room while we had our morning meeting. Ten minutes into it one of the other clients was banging at our door to tell us that Shawna had walked up to the overpass next door to our office and had said she was going to jump. Olan, her case manager, ran out immediately. Others rushed to get the clients inside, away from the action. The police responded quickly. Shawna was in no mood to cooperate so it took four men to get her into the car and off the hospital. Elizabeth notified the state that she was on her way up. THEN... the state hospital staff called in a fury: how could we have told them in yesterday's weekly meeting that all was well with the clients on our list and now, one day later, we were sending them a second client. (One had decomped yesterday, threatening to kill his family and his dog.) They wanted to know why we didn't see these things coming. In each case, as I told them, the client had started to use drugs or to drink, and each has a history of almost instant decomp when using. I explained that we have seen each of these clients every day, that we are keenly aware of their fragility, that we ARE doing our jobs. Their doc then called our doc to ream him out about the care we are giving to our clients. What's more, they had us call the police and tell them not to bring Shawna to them but to take her to the county hospital to be medically checked out, a real insult to our professional judgement. But wait-- it gets worse.... A couple of hours later Shawna called from the hospital to say she needed a ride home. I was shocked! Mike called the ER to inquire whether they were actually ready to release someone who'd been trying to jump from an overpass only a few hours earlier. Yes, they said, that's what they were doing. I was ready to let it happen, tired of being second-guessed by everyone. But then Lorraine walked in and when I told her what was going on she tracked down our doc to tell him about it. He called the ER. The ER doc said he was releasing Shawna because she was heavily intoxicated and he attributed her suicidal gesture to alcohol use. Our doc tried to set him straight, telling him about the last few days, and summarizing the last few years of her treatment, including recent suicide attempts. The ERl doc said he'd reconsider but made no promises. Later, we learned that he'd been persuaded to see things our way when Shawna called to ask us to bring her a carton of cigarettes: obviously she was being sent upstate. The doc railed and ranted the rest of the day. I just thought about how I really don't want to meet with the state folks next week. It's sad for Shawna, of course, but hard not to note that she told 15 people in the waiting room that she was going to jump from the overpass. Fifteen would-be rescuers.

Lunch with the Girls

Today was the women's group lunch that we had set up a few weeks ago. I was very much looking forward to it, although as I drove to work in the rain I was wondering who would show up and whether I could get hold of a big enough car. At morning meeting I asked what vehicles were available and whether anyone would like to come with me. The vehicle at hand was a big old van. Happily for me, who had not driven the van before and did not know exactly where the restaurant was, Cindy said, "I'd love to come. What time"? An hour before we were scheduled to meet at the center, I spotted Bev in the waiting room. She smiled and waved. Twenty minutes later Terri turned up in a crisis, her hair in a tangle, her eye make-up smeared around her eyes. I did some ad hoc therapy with her and she decided it would be best for her not to go with us today. As I walked her to the door I saw that Evie and Stacey were sitting together, all dressed up, with lipstick on and clips in their hair. We waited a few more minutes for Angela and our newest member, Sally and then Cindy loaded everyone into the van and we drove off. I was looking at the snow geese in the fields, and the new construction on the highway, thinking about how seldom our clients leave our little community. Even for me, getting away from the center in the middle of the day felt like a real outing. The restaurant was great. Bev had picked it because they make chicken fried steak; she'd been wanting to go back there for more than a year, the last time her sister was in town. It took a while for everyone to narrow down our choices. After we'd ordered Angela whispered to me that she'd had one of the exotic drinks pictured on the menu and that it had been delicious. We stuck with iced tea today. The food arrived and Sally picked up her fork to pitch in. Angela asked, "does anyone want to bless the table"? "Oh, oh, I'm sorry," Sally said. I assured her it wasn't a big deal. We joined hands around the table and Angela made the blessing, and then everyone was chattering and eating, and asking for more tea, and stepping out for a smoke with each other, and telling each other about movies they'd liked. It was so ordinary, and so wonderful. Everyone wants to do lunch again soon. As Cindy said to me, "You have to do these things. They're important. They give you back your sense of purpose."

Monday, Monday

Walk in the door and two people rush over to me while I've still got my sunglasses on and my lunchtote in my hand. One wants to tell me a story and the other wants to show me a letter he got from his landlord. Sometimes I come in smiling; sometimes I just come in. Early spring is the time when my own spirits fall. We're not there yet, but I feel that kind of chemical letdown that is depression. Hard to rally for the client who curses you because she's called for a phone number and you don't have it memorized, or the client who gets picked up drunk on the street in the afternoon, thus losing his spot in the only place we could find a bed for him. Or the client who needs to talk to the nurse right now because she needs to change next week's appointment and her anxiety about it is so high that she can't wait another minute. Tomorrow the women's group is going out to lunch. Their case managers have been telling me that they are excited. I'm looking forward to it also, I think. I hope it will be fun for everyone. (I hope I can get to use a van or we won't be going anywhere.)

A Million Little Pieces

Danni's specifically avoiding me. I feel bad, too, that one of the last things I left her with is the James Frey book about overcoming addiction that even Oprah now says is built on lies. Several people I know thought he was a hero and I had hoped he could be one for Danni. Just another scam. The theme at work today was "how the hell can we..." I wonder when people will wake up to the world I've been living in and see how fragile our hold is on our clients and their wellbeing. First they closed the hospitals. Then they reduced the number of crisis beds in the state. Then they took away funding to meet client emergencies such as not being able to pay the rent or the utility bill. Now they're taxing people who don't have enough money to go to lunch at Applebee's to pay co-pays on their meds, and not covering some meds at all. We can't keep this world spinning with scotch tape and string. The doctor was going off about politicians who say, as he's heard in person, that it is too expensive to medicate "these people" who won't be contributing to society anyway. Elizabeth was going off about not wanting to be a motel clerk for all the homeless clients. Lorraine was going off about how we have to keep the paperwork up to date on the meds or people will get hurt. When we asked for a volunteer to run some meds over to someone who was unable to come in today, no one spoke up. They are all so burnt. Me too, me too. I told Elizabeth today that I may be leaving soon. She was great about it, even though I know it may add to her workload for a while. I couldn't be there knowing I was planning to leave and keeping it from her. She is really a star in administration. I admire her fair-mindedess and her toughness. Leaving her will be hard. I can't even think about leaving some of my clients yet.

I Saw a Man Who Wasn't There

Things just aren't settling down. I'm watching one case manager after another moving toward the verge of burn-out, all for good reason. Fifteen minutes before closing Mike called and said he had just left Art's house where Art had told him that his voices woke him up this morning and told him to walk into traffic. Lorraine and Pru and I were there and we all got chills because Art did walk into traffic about a year ago and subsequently spent many weeks in the hospital with broken bones and internal bleeding. I was on call the night it happened and I won't soon forget seeing him in his hospital bed. Lorraine, who has a long and good relationship with Art, called him and asked if he could resist the voices. He said he could for a while, and Lorraine told him if they start to get to him he should call 911 and then call us, and Art said he could do that. Last week, Del was delivering Art's meds and Art said he was having a terrible time with his (deceased) brother who kept telling him all sorts of trash. Del asked him where his brother was and Art pointed at a corner of the living room. So Del faced the corner and said, "Brother, I can't see you and I can't hear you but Art says you are wearing him down and I'm asking you to please let him rest for a while." And Art said it worked very well. As we calmed down about Art, Del walked in very frazzled. He'd picked up a client from the hospital and had spent all day trying to find him a bed. The guy is homeless, penniless and very vulnerable-- this is no tough guy. Del called all 12 shelters in the county. No luck. He took the guy to the homes of various friends, and turned up nothing. We talked about telling him to spend the night in the waiting room of the ER. Really. We had no place to put him. And this is happening more and more frequently. We are where the buck stops when the hospitals push them out. We are the ones mandated to find homes for them and there just aren't enough of them, and none that are free.

The Most Depressing Day of the Year

At least four different people told me today that they had heard that January 24th is the most depressing day of the year. Apparently, all had been listening to the same radio station this morning. The rationale is that a) you're losing your holiday cheer (long gone for me) b) the days are still short and c) you can't quite see spring coming. I don't know if that's where to put the blame, but I can attest that the folks I work with, including me, are low on energy and patience for the stuff that is so usual in our jobs. For instance, today I was assigned to find a place to live for a client who soon will leave the hospital. He has less than $150 a month in benefits. He is okay with going to a drug and alcohol supervised setting, but there is no space available. He is not eligible for shelters due to past legal issues. He has no family, no friends. As we have no respite or crisis care homes, where are we to put him? And the hospital is pressuring us because they cannot justify keeping a patient just because there is nowhere else to put him. I'm sure they are also being pressured about keeping patients beyond the necessary time. Update on our client who has been in prison because her son stole things, her husband pawned them and she wore them: her husband drove to the prison to bail her out on Friday. She got into the car and as he drove off she jumped out and ran into the woods. Once the guards had helped her husband retrieve her, she was committed to a psych hospital. I've not seen her decomp before, but apparently when she does, it takes months to bring her back. Last time she poured boiling oil on her legs and spent months in the hospital. Jackson is becoming homeless. The relatives with whom he has been staying, last in a string of relatives, have given him until the end of the week to find new digs. But where? We have no supervised place to give to him, and without that he is sure to be in jail or the hospital in no time at all. Spinning straw into gold. I just wish I had the formula. I'm being considered for a job that pays much more than what I make now, and would involve no on call, no trips upstate to the hospital, no looking for homes for the homeless: just doing therapy and supervision with a non-chronic population. Sounds like heaven.

Loves Me, Loves Me Not

Rain all day. Cassie knocked on my door and asked if she could see me for a minute. She came in and sat down across from me. "Rae is not doing well," she said. She went on to tell me that Rae is unable to stop thinking about the co-worker she'd fallen for months ago. A few weeks ago he told her that he has a love interest elsewhere and Rae was crushed. Even though she could easily find other work in her chosen area, she is unwilling to do that. Instead, she is wearing sunglasses to work, she told Cassie, so that no one will see her cry. We also suspect she is drinking to excess. Nobody does well with unrequited love. And in this instance we are talking about someone who has few friends, no family relationships to speak of, and a history of major depressive disorder. As difficult as Rae can be (she has substantial anger issues) my heart breaks for her. I told Cassie I had intended to see Rae for therapy this week anyway and that I would give her a call. I did call Rae later in the morning. She sounded very grateful for the call. I said I'd just wanted to remind her of our appointment and didn't say anything about what Cassie had told me. "Oh thank you," she said, "I'm having a tough time. It will be really good to talk to you." Who doesn't need someone to listen now and again?

Medicare Woes Take High Toll on Mentally Ill - New York Times

Medicare Woes Take High Toll on Mentally Ill - New York Times

TGIF

Manned the office today again. Elizabeth was to be out all day and I'd agreed to come in, and was glad to so that I could make up for some of the hours when I leave early to conduct workshops and groups. Got everyone to cover the growing med observation list, which seems pretty big now. We observe people only when we can't trust them to take meds on their own. Even if we come by every day and leave the day's meds for a person, some people will either forget to take them, or will flush them because they don't want to take them. Hence the popularity of bi-weekly shots (which burn painfully) for people who are hard to bring to baseline or are usually noncompliant. Still, for people like Jake, we must observe them actually taking their meds, at least until we feel we can trust them again. Jake is now being observed twice a day. Next, got a call from the state hospital, with the whole team up there on speakerphone. They asked me questions about the circumstances of Jackson's being committed and then said they did not think he needed hospitalization but had taken his meds only to escape a situation that scared him. They wanted us to pick him up today and put him in "respite" housing. I was steaming when they ended the conversation by saying, "And it's Friday and you know how traffic is, so you should get moving on this right away." I'm too tired tonight to supply details, but after numerous phone calls to our doctor, our clinical supervisor, the state hospital people, it ended up that the state would drive him back to our county (almost unheard of -- surely they will get us for that) and had relented on his needing to leave the place where he's been living. They had also contacted the police in his area, who were aquainted with the fellow who had threatened him and said they would intervene. I'm sure this is not the end of the story. The hospital where Doris is called to say they had left a message for Elizabeth yesterday saying that Doris was ready for release today. I explained that Elizabeth was out, and we hadn't gotten the message and begged them to keep her until Monday. Amazingly, they said yes. We hate to take people back on Fridays for the weekend person to have to manage their needs solo, but the hospitals seems always to want to get people out on Fridays, too. Probably for the same reason. The hospital where Paul is called and I held my breath. But they just wanted to confirm their view that there had not seemed to be any particular reason for his becoming, as he claims, suicidal. They said they've had him there several times and agreed that he seems to produce symptoms when he needs a temporary change of scene. I feel bad that I can summon so little empathy for him at this point. And we discovered one of our missing clients: he's been in another hospital since Wednesday. At least he's safe. Mike fielded a call from a client's sister, reporting that the client seemed "strange." She wanted us to come get him, but we suggested that she take him to the ER for evaluation. He is diabetic, so it may be medical. Hard to keep these facts in mind for each client, and such facts are critical. Mert left early again today before taking her meds, and a couple of people failed to come in as required for their shots. At 4:55 I started watching the clock and when the second hand hit 12 to signal 5:00, I was out of there.

Jinxed

Mike agrees that every time Elizabeth is out for the day things go wild. We started with Jackson this morning. Still don't know exactly how much lithium he took, or whether he recovered well because they got him to the ER so quickly. Our doctor thought he should be committed, which was what Jackson wanted anyway (he had packed a bag before he called 911...) so he was sent upstate from the medical hospital. Mert, who tested positive for cocaine last week and who now weighs about 90 lbs. left the office this morning before the nurse had given her her meds so I had to recruit a case manager, Rick, to track her down and get her meds into her. Easy. He found her in Crack Town. I bet some of the folks she hangs with wonder what she did to get a handsome young man delivering pills to her and watching while she takes them right on the street. Next up was Cindy, calling in to say that she was with Paul, a long-time client who said he wanted to cut up his face and/or kill himself. He said he'd contract for safety during the day but couldn't guarantee how he'd feel at night. I told her I'd call her right back. I trotted down the hall to consult with the nurse and the doctor. The nurse said, "Oh Paul, he always does that, it's his modus operandi." I knew this, too, from dealing with him for a year and a half. He's never seriously harmed himself as far as I know. Still, you can't just wave it away. The doctor said "Let him go up voluntarily. He won't stop until we do that anyway." I was pissed. The hospital that takes the volunteers has some snippy, sarcastic staff that I don't like to deal with. Also, when Jake came home yesterday they had lost his glasses and given his coat to another patient. They told Cassie that nobody had signed in any belongings for him. "Well, I didn't bring him here naked last week," she said. They retrieved his coat but we still don't have his glasses. I called them anyway. They had a bed. Cindy gulped down the rest of her lunch and took him. Olan was doing an end-zone dance in the lunch room. She's on-call and was very grateful that we hadn't left Paul to call in at midnight for her to commit him. Walking through the waiting room I saw the girl with the dysfunctional family and kept on walking, looking straight ahead. On a better day I might have said hello but there is only so much you can take on in a day. (Meanwhile, a pipe had burst in part of our building and we were waiting for the plumber to staunch the flow of water that threatened to engulf us.) We were down several staff by mid-afternoon, either out on the road or off for the rest of the day, so I was manning the phones. Between rings I was counseling Mike about how to cover himself with paperwork, to show that he really had been trying to get his client to do what the doctors had told him was right for his heart and that it was the client who was ignoring medical advice. "Isn't that still my responsibility?" Mike wanted to know. "Nope. It's a world of choices, and our clients get to choose," I said. And speaking of choices, the client who was arrested with the rest of her family for burglary had a hearing today. Bail was set at $1000, but she can't pay even $1 so she's staying inside. This reopens the question of whether we can see that she is medicated. Probably not, so she will soon decomp and end up at the state hospital. So it goes. They're also losing their housing. And wouldn't you know it, five minutes after I was supposed to be gone for the day we got a call from Jake. He'd been given something to calm him after he'd called several times in the afternoon in an excited and anxious state. Cassie also had given him his evening meds and left a sleeve for the morning. Now he told the nurse he needed another pill because he still felt like his head was getting bigger and bigger. (I'm skipping the part where Jake calls and if a man answers he hangs up as he will only talk to women. And we know it's him but when we call back, he won't answer his phone. So we tell the guys not to answer the phones and wait for Jake to call again.) "Jake," Lorraine said, "you can't have another one of those pills until tomorrow. If you still feel bad then, call us and we'll bring it to you." She went round and round with him for the next five minutes, with Jake asking over and over again for more meds (and he is someone who always refuses his meds) and then he told her that he had taken all of the meds left for the morning, too. Oh no. Here we were again with someone who takes a slew of meds and has now taken twice what he should have had: twice the blood pressure meds, twice the antibiotics, twice the psych meds, twice the diuretics. The doctor sent Lorraine to his house to check his blood pressure so that we could decide whether he needed to go to the hospital. He didn't. Now we will just add him to the list of people we see twice daily, to make sure they take their meds properly. There's that list, then there's the list of people we need to track down to see that they get their bi-weekly shots, and the people who are missing (now numbering three) and the people who need to see a doctor right away for medical reasons (only one on the boards for tomorrow).... Do I sound wired? Sorry.

Rage

Tough start to the day. Elizabeth called my cellphone as I was driving in. She told me that one of our youngest clients, a kid named Jackson who has spent most of his life in institutions for kids who can't be contained by their families or the public schools, took a week's worth of meds last night. For the past few weeks we'd heard uncharacteristically good news about the progress he was making. He was living with people he likes, his case manager had arranged for him to take classes that would put him on track to graduate from high school in a year (walking toward a stage, wearing a cap and gown, is a constant dream of his), his symptoms were under control. He called on-call last night after he took the meds (and the boy takes about 12 pills a day, multiplied by seven days) and said he'd done it because he'd gotten into a fight with a gang and they threatened to mess him up and his family, too. He was in the ER this morning and we heard he was heading for the ICU. Elizabeth thought he might die because he takes such a high dose of a very toxic med. We heard nothing more for a couple of hours, then .... he called! He asked that his case manager call him. Guess he wasn't intubated after all. So we don't know whether he really did take all the meds, or what's going on. Stay tuned. I had a session with Terri later. I hadn't seen her for a few months. Last week the doctor and I coaxed her into making an appointment. She was much more put together, far less flighty, than I've seen her before. As soon as she sat down she said, "This time, I want you to decide what we talk about," and she was able to stay on topic and allow me to guide things for the entire session. Remarkable. Even though I've read all of her history and met with her several times, I have only a hazy idea of her past. So I asked her about her childhood, her relationships with each of her parents, and gradually took her through high school to her early marriage and the births of her kids. She seemed very forthcoming, telling me that her father drank too much, that she acted up and no one could control her, so they eventually sent her to boarding school, where she met her husband. We went on to her early adult life, the jobs she held. "Somehow I couldn't keep them for very long," she said. I asked her what would happen and she said , "I'd decomp." So I asked her what that meant and she said, "Well, once when I was working in a school I tried to kill myself and they wouldn't let me come back." This said in a flat, matter-of-fact way, with no details, no story attached. When I went to write up the notes on our session I realized that her stories remind me of dioramas: cardboard cut-outs standing up in a box, not moving, thin generic smiles on their flat faces, no life in them. I have no visual sense of her mother and father, nor of her as a child. Did she live in the city? on a farm? have a pet? No memorable information, really. And I don't know what that's about. Pru was tied down all day trying to catch up on her notes, which she hates. I walked into the computer room just after she'd put Danni on hold. "That girl is steaming!" she said, "and she's getting me pretty steamed while she's at it. She's cursing a blue streak about not getting her meds, about her family being a bunch of f*ing s*heads who should all go get f*d." I said, "Tell her you won't talk to her as long as she talks that way." "I did!" Pru said, "that's why she's on hold." Later Pru came into my office to say that she sees no sign that Danni is ready to look at her drug use. She's now been discharged by the rehab, dismissed by the transportation service, discharged from therapy with me. She's moving in with her boyfriend, away from her family's home, which promises to be a disaster. "What do you want me to do with her?" Pru asked me. "Whatever you think is best, Pru," I said. "Well that's basically nothing," Pru said. "I'll check on her and she'll see the doctor but there's nothing else she needs, nothing she'll hear." So I said, "then she gets just about nothing, I guess." And I hate that. I still have a card she gave me at Christmas 2004.

Holidays

We were open today, although most places were closed to honor Martin Luther King, Jr. In a way, I guess we honor him at our facility by staying open. Every day our lobby holds a mix of people: black, white, Asian, old, middle-aged, male, female. They watch TV and comment on the show, or on the news. The local news is what grabs them most. Somebody will remark about a car accident. Another client will chime in with statistics on how long the skid marks were or which passengers were wearing seatbelts and which were not. I hear this all day long, right outside of my office door. Where would these people have been in the 60s? Tucked away with their families, or on hospital wards where they were expected to spend their lives. It is frustrating, always, not to be able to give them optimal service. But in truth as "another counselor" has pointed out, what we provide for them is a vast improvement over what they had forty years ago. I remember Martin Luther King, Jr. and the devastation of his murder. Nonetheless, he accomplished much of what he set out to do. As someone who grew up in schools that were segregated when I entered first grade, and integrated before I finished elementary school, I have a personal vision of the difference. Hallelujah. Thank you, Dr. King -- and all of the people who have helped to make this difference.

Adrenaline Rush

I was watching ER tonight and thinking about how quickly the days go by when you believe that what you are doing is urgent and must be accomplished right now. It is exhausting to live that way. And addictive, as anyone who has worked in emergency anything -- from government to a labor and delivery suite -- must know. By 7 P.M. I could hardly put a sentence together. I was just bone tired from four days of non-stop we-must-deal-with-this-right-now! stuff. After dinner, I rallied enough to brush the dog and watch some TV. This morning we went round and round with the client who was jailed yesterday and whose daily meds can't be interrupted without probable serious consequences. Overnight, the client was moved 75 miles away from us, to the women's prison. We don't know how long she will be there and she had meds only through today. So her case manager, Cassie, and the doctor and I conferred, with the doctor calling the med staff at the prison and finally concluding that Cassie will run meds up to her tomorrow to last a week and we will take it from there. We can't prescribe for her in prison. Her hearing is in another week so we'll see what must be done then. Soon thereafter Olan called in to say her client Doris was refusing to take her meds and talking about setting herself on fire. The nurse called Doris and talked to her. Two other staff members went to her home and talked to her. No effect. Doris is the client who, late at night with her roommates asleep, built a small bonfire in the den of her house a few months ago, with every intention of hurting or killing herself. Then the smoke alarms went off. It's scary: normally, she won't go near the stove, every day eating food, unheated, from cans. Fire must be very scary to her too. Perhaps she "knows" in some awful way that fire may be her destiny. Anyway,Doris agreed to go voluntarily to the hospital. Our clinical director was with us today, and she called to make the arrangements. By the time things were set, it was late in the day. Olan drove Doris 35 miles to the psych hospital, arriving at about 5 P.M. I was in my car on my way home when Olan called to say that the admissions people were refusing to take Doris because, they said, they don't take clients who are on court commitment. First I'd heard of that. First the clinical director had heard. But argue as she did, the psych hospital folks prevailed for today (we will deal with them later) and unlucky Olan called me back at 7:30 to say she had just dropped Doris at a med hospital up there to be evaluated and committed to another psych hospital. So in the end, her humanitarianism was defeated: she was forced to leave a very paranoid client in a strange hospital controlled by strangers. And there is always the chance that the doctors there, as the doctors near us did this week, will disagree with our assessment that the client is a danger to herself, and will send her home. Inter-agency cooperation is very tough. Shouldn't they take our word, when we have know the client for a decade, that when she says, "I just might set myself on fire," it is a very real threat? Should they get to make their decisions on a model of semantics? When Olan called, I was having dinner. I let her tell me all about it as she drove the 35 miles back to our nearest office to leave off the agency car and get her own car, to drive the 25 miles (back in the direction she'd just come from) to her home. Maybe I was particularly sympathetic to Olan as I'd had more than a little frustration with the system and had put more than 350 miles on my car in three days this week. Elizabeth was off today. She often works weekends, leading to mid-week absences. She called me late in the day, laughing. "So," she said, "you thought you'd have one day this week without a hospitalization. Surprise!" I'm still covering back-up through the weekend. Tomorrow, as Cassie pointed out this afternoon, is a full moon and Friday the 13th. But back to the thought with which I began this entry. I've just learned that the licensing board will consider my application later this month. So I may be licensed by the end of January, and that should open up many more possibilities for employment. I've already made inquiries about other jobs, other ways of working that would not have me on call, would not have me sending people to the hospital except very, very rarely. The jobs I am looking at are the kind of work I set out to do in the first place. And they would be a better fit with my effort to build a private practice. I've watched several other people leave our team since I've been here. We think we will miss them, but the work is so all-involving that we just don't think about them very much after they go. I like the way the clients have created a social scene at our office, the way they seem glad to see us when we walk in. I like the way the case managers greet me when I've been away for a few days, the way everyone pops into my office when they need to unload, saying "Got a minute"? I like to applaud the positive changes, even the tiny ones, that clients present, even when, too often, the change doesn't stick for long. I don't like the bouts of feeling hopeless about what we do, or the boredom of talking endlessly with a client about some seemingly insignificant thing that they obsess over. Even then, I guess I'm hooked. But I know I am better off getting off the hook.

Depends on the Window

Sometimes I look at this writing and think that it doesn't provide enough of the client's perspective. In part, that's because I don't want to presume to know just how they feel about what goes on, and I'm also aware of wanting to protect their privacy. At the same time, I don't want to always be going on about how hard our jobs are, even if they are. I went to the state hospital today for the weekly meeting. While I sat in the lobby, an EMS team brought in a patient from another hospital. She was wearing a nice shirt and jeans, new athletic shoes. Her hair was neatly braided. She was strapped to a gurney, looking at the ceiling, talking to herself, very anxious (wouldn't you be if a couple of strangers strapped you down, put you in a big truck and took you to a place you'd never been where people stood around talking about you while you were still lying on your back, strapped down, four feet up from the floor?). And while that was going on, one of the doctors who participates in the weekly meeting, who was engaged with the new patient, looked over at me and said, "Hey, how are you doing"? and smiled, as if this was just another Wednesday. Which it was. When I got back to the office Elizabeth told me that a client had driven himself to the ER last night and was hospitalized with bronchitis, pneumonia and heart failure. He is not yet 50. Soon the hospital was calling to ask why he hadn't had his heart meds for weeks. A look at his chart showed that he hadn't informed us of his medical med needs, nor given us his discharge summary from the last time he took himself to the hospital. And he'd been refusing medical exams for months. The cardiologist at the hospital says if he doesn't take his meds regularly he a) will need some difficult surgery and b) will die soon. Meanwhile, the client was telling the folks at the hospital a bunch of b.s. about his lack of funds, his being persecuted by people he owes money to. He said our agency was deducting $100 a month from his funds to pay off a debt he owes to the state and that was why he didn't fill his prescriptions. I told the hospital that we will see that he gets all necessary meds if they will inform us what they are and did my best to set things straight. I guess from the client's perspective I was undermining him, whatever his purpose is. And as I was putting on my coat to leave tonight I got a call from Pru who had discovered that our client Betsy, whose teenage son was charged with dozens of counts of theft and whose husband was subsequently charged with pawning the stolen goods had appeared at her husband's preliminary hearing wearing some of the stolen jewelry. We then had to find out what police station she 'd been taken to so that Cassie could take her meds to her. Missing even one night of her particular med regime could be disastrous. What was she thinking? I can't begin to guess. And so it goes..... so hard to hang on to any sense of progress. And tomorrow Danni is due in and I have to try to convince the doctor to play hardball with her, for her own good.

Is There a Doctor in the House?

Okay, so.... the older guy I wrote about yesterday, let's call him Jay, started calling again first thing this morning, during our morning meeting. He said his head hurt and he was hearing voices. Our office manager asked if he could wait about an hour for his case manager to come in and he said he could. She told him to call her back if it got worse. Five minutes later he called back and said it was a lot worse. After yesterday, we knew that giving him more powerful meds would not do the trick: he'd been given a big dose at the ER and nothing changed. Elizabeth sent the office manager to get Jay, because she has good rapport with him. He gets violent if he sees certain of our staff members, and the number on that list is growing. Elizabeth called the hospital that takes voluntary admissions but they said they had no room. So our office manager took Jay to the hospital, and we called our psychiatrist. He called the doctor in the ER and told him to commit Jay. Elizabeth called the state to pass the word along. In a little while, Jay and the office manager were back. She sat him down by the TV in the waiting room, surrounded by several clients he knows well. "What can we do?" she asked, when she came back to the meeting room, "The doc at the ER said he's not a threat and they can't commit him." Now what? We've got a guy who usually avoids all of his meds, avoids doctors and hospitals telling us he needs to go the hospital, and we can't get him in. While we continued to make phone calls and tried to figure out what to do, Jay helped us out by threatening to beat up a couple of the guys in the waiting room. He got into a fighter's stance and was about to deck one of them before another staff member came between them. "You'd better go home," he told the near-victim. Now we could call the police, who arrived in a flash, having been foudn at lunch across the street at McDonald's. Elizabeth explained what was going on and said she would arrange for a hospital bed and have them take Jay directly to the psych hospital. "We can't do that," the officer said, "we have to take him to the ER. Then they send him to the psych hospital." Elizabeth explained that he'd been to the ER twice since yesterday a.m. and had been cleared medically. We just needed to get him to the hospital. This point was argued for about 15 minutes while someone drove the papers to our psychiatrist's private office for him to sign off on Jay's commitment. Meanwhile, Jay was picking up dry leaves, waving them in front of our faces and saying this is what his so-called friends had made of his dish towels and how he was sick and tired of it. Finally, the police accepted this procedural change ("This is much faster than the ER," the officer said. "Work with me," Elizabeth said, "I can make things better for you.") and drove away with Jay -- and his case manager who went along to help keep Jay calm. By now it was 2:00. Time to eat the lunches that had been on the table since 12:30. I know our job is to keep people out of the hospital. Sometimes we need help getting them in.

Is It Really Only Monday?

There were so many calls to on-call this weekend that Mike called me for back-up even though I wasn't on. The guy who told me on Thursday that he was depressed and was going home to sleep ran his car until he was out of gas, then walked around town for long enough for people to see that something was up. The police took him to the ER, and from there to a psych hospital. He's happy to be there, he says. When Mike went to Shawna's home to give her meds, she told him she'd been suicidal all weekend, so Mike called Elizabeth, who called the police and had her picked up. Sigh. Shawna was just great when I saw her on Thursday. Elizabeth was unimpressed when we told her how well Shawna was doing then. "Yeah," she said, "That's today." I hate it when she's right. I want so much for people to make progress. Before we even got out of morning meeting, we were sending the police for an older guy who intimidates most of the case managers, and some of his own family, with his violent gestures. He said he was hearing voices and wanted to go to the hospital. We set it up, and the ER let him out a few hours later after giving him a shot of a powerful psych med. The CM who brought him home had to go all through his house and make sure no one was there before he would let her leave him. Wonder how long before we hear from him again.... Lea had called in sick because one of her own relatives had gone off the deepend this weekend, was arrested and released too soon, and Lea was exhausted. The phone was ringing off the hook (Elizabeth worked Sunday, so she was off, naturally. I just have the luck of Mr. Mxtptlk, or however you spell the name of that bad luck guy in the old funny papers. Was it Superman? Li'l Abner?) The young woman from the screwed up family went to another agency for temporary housing and they were calling to find out what was up. I let them know that she has been thrown out of every possible form of housing we've been able to come up with. They paid for a month in a motel, because it had been more than a year since they had done that before. That was news to me: her history seems to involve every agency in the state. Later her cousin showed up to pick up some clothes of hers that we had. She wanted to tell us that C. has only a month in the motel and we'd better get cracking on finding a placement for her. Right. Been there. Chick was walking around saying he needs to go the hospital. "No you don't, Chick," I said, "Sweep the walk, why don't you?" He started washing cars. A transformer blew across the street with a big "BOOM!" that put our electricity out for just a second and started a small fire in the gutter under the pole. The clients all started over to look at it, naturally. Louie called to see if Chick was there because he wanted Chick to give him a ride into the center. I lied and told him Chick wasn't there. I hate answering the phone. Lorraine the nurse popped into my office to say, "Can I have 5 minutes of counseling"? She felt much better after a short rant. My friend Sally, the clinician I once shared an office with, called to say she's had it and wants another job pronto. Lily came in to get her meds. She looks great but I only had time to wave and say "You look great, Lily!" Mike was told on Friday that one of our bad boys, Tomas, had another month of his sentence to serve. This morning he called to say he was let out today; his brother had picked him up and would house him for two weeks. Then he's ours again. Meanwhile his girlfriend has taken up with another man, which we didn't tell him when he asked about her. Rita's pharmacy called to say her co-pay would be $240 a month because we haven't figured out her Medicare Part D correctly (that happens in another of our offices: not our fault, just our responsibility). So she has no meds and Lorraine had to jump through hoops to close the gap. May, who walked out of rehab after comopleting four of six months, and last week got in the car with Lea to take her back and then changed her mind, called to ask for a ride to rehab.... Am I leaving anything out? No doubt I am. But I'm too tired to figure it out.

Something Tells Me It's All Happening at the Zoo...

But why do I have to work there? Today was one of those days: phones ringing off the hook, big problems coming down the pike that won't be easy to solve. Little irritating stuff. Not enough laughs. Good lunch, at least, and some new pens from the pharma reps. Hooray. Enter, stage left: the troubled family and their scapegoat daughter/granddaughter. Last week I fielded a call from them, telling me that she was threatening her cousin with a knife. "Call 911," I said. Jeesh. So she is now on a psych ward and everyone is scrambling to figure out what to do when she gets out. Late in the day we learned that will be tomorrow. Her family says they will not accept her; she's used up every shelter in the area, having been kicked out for violent behaviors; her family has control of her money so we can't use it to pay for a motel, which wouldn't work anyway, and the state is pretty much saying, "Too bad. Solve it." It isn't that I lack feeling for this girl. Before she was even born she was a victim of other people's drug use and psychology. Now she is the designated scapegoat in a violent and overwrought family dynamic. But she is inappropriate for us. We have NO respite care, no supervised housing, no funds for emergencies. What are we supposed to do? Once again, please examine the federal budget cuts and the lack of social conscience that has brought us here. Think about that when you are voting. Later, Danni turned up unexpectedly. Her grandfather had a heart attack this morning and she just wanted me to know. She was also looking for a prescription for tranquilizers, which she got. She was very tearful -- she adores her grandparents. She said that some of the family who were at the hospital wouldn't talk to her. "They don't trust you, " I said, "It's not that they don't love you. They do love you. But they are afraid of what you might do."I told her that it will take years of her behaving responsibly before they will come around. I asked her to think about what would have happened if she had been messed up on drugs and the only one with her grandfather when he suffered his heart attack. Although she said she understood, it was clearly not what she wanted to hear. After about ten minutes, she went out to get her prescription. That girl really gets to me.... Lea asked me to talk to a client of hers who was saying he was depressed. I've never talked to this guy before, but I'm familiar with his history. "I'm just depressed," he said, "It's my illness." I suggested walks by the water, riding into town, spending time at the center. None of those appealed to him. "It's just my illness," he said, "I'm going home and go to sleep." This weekend another of our clients is coming out of jail after several months. He, too, is homeless. I don't know what we will do, but it's getting old trying to make stone soup here.

Emergency!

Lately, our case managers have been getting a lot of "emergency" calls. "Tell her to call me immediately," the client will say, "it's an emergency." When the CM calls back, it's almost always been something like, "I need to know if my check has come in," or "I need a ride to the dentist tomorrow." I admit, I get a little ticked about the overuse of "emergency." So when Rocky called the other day, twice within 30 minutes, and told me he needed to hear from Cindy right away because it was an emergency, and when I then found out that his emergency was that he was mad at his almost-girlfriend, I was annoyed. I told Elizabeth about it and she said, "Actually, that's great. That's real progress for Rocky, to call in for help in getting past his temper. In the past he'd just go off and deck somebody." So I guess it was an emergency. I've had a lot on my mind in the past few days and my spirits have been kind of low. I walked out to a car this morning and Chick was out on the parking lot smoking a cigarette. I said hi, and he extended his hand to me. When I reached out to shake it he just kept moving past me, his hand outstretched, his expression blank, looking past me, like Buster Keaton or Bill Irwin -- some talented physical comic. I laughed. "Good one, Chick," I said. He's in his forties, he has a mustache and thinning hair, but he is very much a boy. He is slim and slight. I see him running through the yard sometimes and picture my son at 10 years old, light and fleet. When I came back he was still out there. He followed me from the car to the door and asked if I was going to town later. I was surprised: he so rarely talks, and when he does, he is rarely able to construct a whole sentence. "No, I'm not," I said. And Chick said, "Would you like to go on a moonlight cruise, just the two of us"? Suddenly, my spirits brightened. So funny. I forgot to tell Elizabeth. Earlier in the day Mike had brought her a single flower, sent by a client who said he wanted to give Elizabeth a flower for his birthday. She just didn't know what to make of that. I'll take sweetness however it presents itself. I've been forgetting to say that Danni's rehab counselor called yesterday to say they are discharging her. She had come in last week ranting and raving, cursing a blue streak about how they had not given her the right care when she overdosed and they had ended up calling 911. Blaming them. Threatening to sue. This was in group, and the counselor said she was nodding out all through group until another client told her she thought Danni needed residential. Danni threw her shoe at her. What can I say. Danni needs to be left to "stew in her own juices" as my father used to say. Until she can recognize where she is and how she got there, and really want not to be there anymore, there is little I can do for her. On the brighter side, I saw Shawna today. She looks terrific. She has lost a lot of weight. She says she's had no alcohol in a month and that her daughter took her out to Bob Evans yesterday. "My daughter has never taken me out with her. Never," she said. I gav her a hug and asked her to call me if there was anything I could do to support her progress. Elizabeth rolled her eyes when I told her about it. I knew she was thinking that it won't last, but wouldn't it be wonderful if it can and does?

Case Managers

Elizabeth and I have been talking with each member of the staff individually over the past week. We've just completed the round. Our purpose was to discuss each person's strengths and weaknesses, and to provide suggestions and support for the latter. As we went through the process, I was struck by what different strengths people bring to their jobs. I do believe we have an outstanding team, although they don't all approve of each other's methods. We have seven case managers. I'd characterize them as follows: Mike: Staunch, dedicated to his clients and ready to help any staff who need him to fill in. Very involved in maximizing ease of life for his clients. Tends to see more drama or emergency in the problems client present to him and has to be reigned in sometimes. Cindy: A real drill sergeant, as she was trained to be in her military back background. Ready to lay down strict rules and boundaries for clients, much to their benefit. Is willing to take on some of the most difficult clients (crack addicts, isolates with intractable schizophrenia) and does remarkably well with them. Jim: Young, imaginative. Not always on top of his schedule so that he ends up with not enough time to get done what he needs to. But he is able to reach some of the young male clients like nobody else can. Speaks their language. Doesn't mind coming up with an interesting outing and piling them all in the van. Lea: Smart, quiet, committed. Stronger than her size indicates. She is a smooth negotiator, getting families to buy into her treatment plan for their family member even after they have said no way. Detects and will not accept B.S. Pru: Almost too committed to making it happen for her clients. Can draw on a lot of painful personal life experience to relate to what clients are going through and to give them a needed kick in the pants, or an inspirational motto. If you ask Pru to do something, you know it will be done. Olan: Tough as nails. Organized. Her clients are never behind in what needs to be done: blood test, doctors' visits, grocery shopping, med fills. She is on top of it all. She, like Pru, works too hard. Cassie: All over her own clients' needs and very dedicated to them. If you assign a client to her with whom she doesn't click, she tends to minimalize or give less attention to their needs. Particularly good with older clients, for whom she has seemingly endless patience. I wouldn't want to trade in a one of them. Today, our records administrative assistant knocked frantically at my door when I was on the phone. "Emergency!" she mouthed. I looked up. She whispered, "A.L.'s grandmother is on the phone. Says A.L. is threatening suicide with a knife to her throat." I quickly ended my phone call and hit the button for line 2. "What's going on?"I asked. A woman replied breathlessly, "She has a knife to her throat." I said, "Call 911." The caller replied, "My mother told me to call you." I repeated, "Call 911." From what we learned later, it was 40 minutes before the family actually called 911. They claim that one of them was, during that time, being beaten by our client. Our questions are: where was the knife, then? What beating goes on for 40 minutes? If there were three adults in the house, how could one of them held both at bay so that no one could call the police? Lies lead the way to impossibility of resolution. It's close to a year since I started this blog. My intention is to stop when I get a new job. I must admit, that is a priority for me. Time to move on.

Too Many Clothes

While we were in morning meeting today, Cindy answered the phone. I heard her say, "Yes, the checks are in and you can come over for yours. But you can wear only two pairs of pants, three shirts and one overcoat. Do you understand?" Right away, we all knew who she was talking to: a long-time client who "bulks up" by wearing everything he owns. The theory is that he is afraid his small stature makes him vulnerable. We are always having to talk him out of his clothes. My 12 days of being on-call have ended! Nice not to have to take the phone to bed tonight. Unfortunately, Mike had an accident this weekend that probably upset him more than it did the client. He was doing the med runs on Saturday. When he got to Shawna's house, one of her dogs started jumping on Mike and trying to nip him. Shawna couldn't control the dog, so Mike was trying to just give her the meds as quickly as possible and get out of the house. As he poured her day's meds into her hand, he realized that he had picked up the container (which we call a "sleeve") for another client. And that fast, she had downed the pills. She looked up and said, "Those weren't the pills I usually take." Mike was sick. One of the meds for the other client is a med that has to be titrated up. Shawna had taken a big dose, much more than an introductory dose would have been. So Mike had to check on her throughout the day. He called me that evening and said she'd not shown any negative effects. We have well-worked out systems for seeing that people get the right meds when they need to get them. It's surprising, though, that we don't have more errors, given all the static in the air when you walk into a client's home, the changes to meds that occur with frequency, the massive amounts of paperwork and communications for each of our 125 clients. In this case, the client was fine, and Mike was able to breathe again. He is more relieved than I am, I'm sure, to have this week's call behind us.

Too Many Chocolates

Damn. Our office is suffering from an avalanche of chocolates. The drug reps bring us a 2 lb. box of truffles that is devoured in an afternoon, and swiftly replaced by a 3 lb. box of truffles. The waistbands of my usual work pants are growing tight. I resent this challenge to my willpower. Why can't they just give us pens or clipboards? We are scrambling to get the clients who are eligible set up with the Medicare prescription program. Could it be any more complicated? Lorraine, the nurse, was in with Elizabeth and me today saying that she doesn't understand it herself. Is there anyone who does? We have to get our clients signed up-- they certainly can't do it themselves, and it is a confusing mess of bureaucratese. My own mother was ready to pass on prescription benefits because she couldn't figure out what would be her best option. Does it really have to be like this? Does the tax code have to be equally confounding? I'm on call for 11 or 12 days, encompassing both Christmas and New Year's. I think I've complained about that already. Last night I got a call that wasn't even for our facility. I'd accepted it before I realized that. It was 4 a.m. I called the client and he said that another client had been to his house earlier in the day and had stolen from him. "He owes me $37 and if you don't take it out of his account or make him square it with me, I am going to beat the shit out of him. " I said I'd contact both of their case managers in the morning and that I thought it best for him to let the case managers work it out. He said okay. But then, as usual, I could not get back to sleep. We have a poster up in the waiting room where clients can post their wishes for the new year. One client wished for potato salad. Another wished for Risperdal (?). A third wished, perhaps more understandably, for happiness. It's an interesting list.

Up Up and Away

Started this day at 6:00 a.m. getting ready to meet up with a client who needed a ride back to the state hospital after being out on a pass for Christmas. Met her, got a company car and hit the road. We had a pleasant conversation. She had had a good holiday. Her sons: six and 15 months, were glad to see her. The older boy is with family, the younger in foster care. She has made more than one serious suicide attempt in the past, but I've known her only by her chart. Today she was upbeat, open and pleasant, curious about things she had heard about me. She told me she hoped they'd let her out of the hospital soon because she felt ready to be home, to see her sons more regularly. I'm glad I didn't tell her that they usually let people go home within a day or two of a successful home visit because in the meeting I'd come up for they said they wanted to try her on a pass one more time before discharging her. I hate taking people back to confinement, but she did give me a hug when I left her off, and she was greeted by other patients who were very glad to see her. I didn't get back to the office until about 1:00. Ate a quick lunch and conferred with Elizabeth about how to get our excellent team reigned in a bit. They are so good that we have given them a lot of freedom and leeway in their schedules, and now we are starting to find gaps. The population we deal with is so unpredictable and so undemanding that when we have staff going home early or taking days off without notice, those of us who do come in can be overwhelmed by needs that must be met by end of day. We intend to meet with each case manager individually next week to discuss strengths and weaknesses. Today Pru confronted the client who had exaggerated her physical symptoms. Most of the extra services that had been provided for her already have been withdrawn. The client cried to Pru that she needs more help than she is getting, As advised, Pru remained stone-faced and simply told the client what we will and will not provide from now on. The toughest thing about being "had" by someone whose illness is about duping people is that it makes it hard for you to trust those whom you meet afterward. Danni called me this afternoon. All she wanted to do was to rationalize what had happened to her: she hadn't meant to... they should have called 911 right away....she had felt anxious and that's why she thought she should take a pill...etc. etc., exhibiting no insight or sense of responsibility. What is at least as maddening is that she then wanted to tell me about the good stuff she had gotten for Christmas. I told her I'd let her know tomorrow what I was willing to do for her. After talking to her addictions counselor tonight I know that I have to tell her I won't see her at all until she can prove months of being clean. God, I wish thoughts of her didn't keep me awake so many nights.

It's the Little Things

I don't mind being on call when I can count on being called only for truly urgent things. I'm not first call, I'm back-up. So I count on first call to swat away the pesky things. But when the operator can't get through to the case manager, he or she calls me. Like last night. My cell phone sang out its nonsensical tune at about 3:00 a.m. The call was from a client who had tumbled from a step ladder a couple of days ago and whose shoulder had been bothering him since. Now it really hurt and he needed a ride to the ER. "Call 911," I told him. "Oh, I didn't want to do that," he said, "Maybe I'll just call my neighbor." I recommended that he wait until morning. Annoying but not a big deal. But then I couldn't get back to sleep -- monkey mind jumping from one thing to the next and I just couldn't make it stop. Tonight someone called to say she didn't have enough meds for the holiday weekend. "Do you have enough meds for tonight?" I asked. "Sure. But I only have meds to last unti Saturday morning." Am I missing something here? "Why don't you get up with your case manager tomorrow morning. I'm sure he'll take care of it." She said, "Okay, that's fine." Danni didn't come in. Pru is now her case manager. She called Danni's house. Nobody home. I realize that Danni's likely departure from therapy is a big part of why I'm less happy in the job. Sometimes I look at someone who is 25 and I can see just what they will look like at 45 or 50. It's usually the disappointed faces I can conjure, the used up faces, the "life hasn't treated me right" faces. Sometimes the antidote is to look out in the lobby at Chick, who has reached that age and whose smile beams bright enough to knock you off your feet. It's not that he has no worries, he's got them just like anyone. He just seems to let himself enjoy what's there to enjoy.

Now It's Time to Say Good Night... almost

No holiday for our agency today, so several of us were at work. Not as many as expected...hmmm. We'll find out where the others were tomorrow. I've been on call since Friday, expecting the worst on the holiday weekend, but it was pretty quiet. I'll be on call until Jan. 2. I've been in this job longer than I'd thought I'd be and now I find myself feeling more and more like I want out. The work is worthy. I do enjoy the community of staff and clients very much most of the time. Much of the work, however, feels like just holding back the flood, not really helping people get better, just keeping them from getting worse. Lately I find myself giving the case managers the kind of answers I was upset by when I first came to work: "Well, let him figure out how to get home. He got himself there, didn't he? And we all know he lies." I don't think I've lost feeling for the clients, just come to understand that some of them are on a treadmill and they are always trying to get you to hop on behind them for the ride. Danni is due in tomorrow. I wonder whether she will show up.

Hark the Herald...

Phones are ringing off the hook at work. Boy, the holidays are tough on some people. Lots of people. Slick came into the living room at his group home wearing his underwear, with his coat slung across his shoulders and announced that he was Superman. You'd have to see Slick: he's close to six feet tall and can't weigh more than 125. All I see is ribs. They sent him to the hospital for observation. Evie came out of the hospital yesterday, after five days, and took herself to the ER last night complaining that her reduced meds were causing her anxiety. Not possible, when you look at the med sheet. We do have several med seekers on our case list. She's home again today. At morning meeting, we discussed Pru's client, the actress who has had everyone believing she was close to death. Our psychiatrist was there and I asked him, "How do we deal with this? How do we confront her without making things worse"? He said, "I don't know. What do you think"? Pru elects to let it go until after Christmas. Can't blame her. Another counselor, a friend who works in another of our offices, told me about taking a client to the hospital this morning after she had used drugs and decompensated big time. The client, a very pretty still young woman with whom I once worked myself, said to my friend, "I am not going to the hospital. If you don't stop this car and let me make a phone call I will jump out." This was not an idle threat. She's done that before. My friend wisely replied, "If you are going to jump, let me stop the car first, because if you don't, I will be calling an ambulance. And if you do let me stop the car and then get out, I will be calling the police. So you might as well let me take you to the hospital." Lea has been dealing with the family that scapegoats our client, their daughter-granddaughter, allowing her to carry the burden of what is wrong with at least six family members. A few of them had gotten physical last night, with our client ending up on the floor, with a relative beating on her head until she bled. (Not that our client was innocent: she had stolen a lot of money from them and lied about it.) When they called, hysterical, last night in the midst of their fight, we told them to call 911, which they decided not to do because they didn't want anyone in the family to spend Christmas in jail. We have, I think, four people in the hospital now, and four who are incarcerated. I've spent Christmas in the hospital twice: once when one of my sons was born, and a few years later when he broke his elbow. I kind of got a kick out of it: Santa coming around, carols in the halls, and all that. I don't think Christmas in the psych hospital or the jails is quite like that. Then there is the way in which clients can break your hearts, or at least move you far away from the cynical retreat we are sometimes driven to: Thomas, who was kicked out his housing last week after getting on everyone's last nerve, came by for a shot today. He's in a homeless shelter. I wished him a happy Christmas, feeling a little sad for him and wondering how that would hit him. He smiled and came right back at me with "I hope your holiday will be really nice and restful for you, Counselor." R, a regular at the center who reminds me a bit of Billy Bob Thornton in Slingblade (but not at all in a scary way), had left Christmas cards on each of our desks addressed "To You." I pictured him sitting at home, writing each of them out. He is someone I exchange maybe two sentences a week with. Filling out a "crisis plan" with a client today, Lea and I came to the question: "Who are the people you trust most in your life"? The client answered, "You are." I love this time of year. And I can't wait for it to be over.

Fool Me Once

Now this really blows my mind. For over a year Pru has been case manager for a young woman who is physically disabled in addition to her psych diagnosis. The young woman, Tula, is very engaging, pretty, outgoing. At the same time, she tends toward depression and appears to have an appalling family background. Pru has had some experience with physically disabled people and used that knowledge to get some excellent assistance for her client. Over the last several months, Tula began a steep downhill decline. She lost more and more mobility, finally ending up spending most of every day in bed, needing help to get from bed to chair to bedpan, scarcely leaving the house. Pru was in despair. One of Tula's doctors said it appeared that Tula was going to die within the next several months. Another doctor refused to treat her any further, in particular refused to perform an operation that might give her some relief from pain. Pru was consumed with making these days better for her client. She rounded up every conceivable kind of aid, from physical therapists to occupational therapists to nurses' aides and babysitters for Tula's two daughters. Elizabeth asked Lea to work with Pru on this case because she could see Pru approaching burnout. Together Lea and Pru accomplished the difficult task of getting Tula to complete an Advance Directive, detailing her wishes about end of life options. They were working on getting her to assign guardianship of her children. Today, the physical therapist on the case called Pru and said, "Tula walked across the room." Pru shouted, "Wonderful! I can't believe you could accomplish that!" The P.T. said, no, they had not accomplished that. Rather, it seems that Tula has never lost the ability to walk across a room, that her functions have diminished very little, if at all. When the P.T. surveyed some of the other people working with Tula daily, she found a nurses' aide who had seen Tula walking for a long time. Wisely, Pru, who was furious, amazed, shocked, is waiting for her emotions to settle before she addresses the situation with Tula. There is a condition known as Munchhausen's Syndrome, which describes people who create or exaggerate symptoms to gain attention and sympathy. I was very close to someone who was an example of that diagnosis. He was very delicate. To confront him only made him escalate his endeavors, including harming himself, to seem more and more disabled. It's wise for Pru to take her time to strategize how to handle Tula. Wow. Danni called her rehab counselor today, but did not contact me. I imagine she is ashamed to call me after yesterday. Her rehab counselor called me to ask what I thought was going on before she returned Danni's call. I asked if she could start the process for getting Danni into long-term rehab, as she has more clout from her facility than we do from ours. Programs are not so happy to take our "dual diagnosis" people; they are intimidated, as most people are, by the idea of mental illness. The counselor and I both bemoaned the serious lack of service of this type in our state. There is only one mediocre facility we could think of that might take Danni. Outside of the movies, not everyone gets to go to Betty Ford or Hazelden. I hope the rehab counselor can make something good happen.

The Day of No Fun

When I was a kid, my elementary school had an annual event, a kind of carnival, called "the Day of Fun." We looked forward to it all year, and as I remember it, it always lived up to our expectations. Today was a day of no fun at all. I was head of office again. I'd been awake since about 4 a.m. thinking about Danni and had decided to go see her in the hospital. On my drive to the office I got three phone calls from people who couldn't make it in for various mostly legitimate reasons. Still, I knew the day would be tough even before I arrived with a list of 10 clients whose needs would have to be met by volunteers. Pru had reported difficulties with our client A, the female half of the couple who stirred up so much trouble this summer. Her husband remains in jail, probably for a while. She says she wants to divorce him. By herself she has managed to run with the roughest of the coke crowd and get deeper and deeper into trouble over the past few weeks. She's been aggressive with staff and bullies other clients. This morning, her landlord called to say he had had enough. He told me that all kinds of "tough types" were hanging around her apartment day and night, scaring other tenants, making holes in the walls, stealing things from cars. He said he would be sending A an eviction notice today. "Fine," I said, "and why don't you call her probation officer to report her for violation while you are at it"? I gave him the number and he said he would be happy to do that. Off I went to see Danni, a ride of about 30 miles, during which I fielded a few other minor crisis calls. Walking through the hospital halls I got that creeped out hospital feeling that has come to me only late in my life, after too many hospital experiences with people I love, I guess. Danni was not in her room. Her mother was there, addressing Christmas cards. She told me Danni should be back soon from having a CT scan. We talked about what had gone on and we were very much on the same page, except, I thought, that I would not have been spending day and night in Danni's room. She's 23. Time to be alone with her thoughts. When they brought Danni back she looked happy to see me, but I could not put a happy look on my face. Her mother left us alone and I said, "So, what happened"? Danni started to cry and to say how sorry she was and how she didn't mean it...etc. I said, "well, you came very close to being dead." She cried harder. I watched her cry and didn't make a move toward her. "Danni," I said, "I guarantee you that you will be dead before you are 30 if you don't take this seriously and check yourself into a long-term program." She howled, "I can't leave my boyfriend!" I said, "You almost did this weekend." And so it went. I told her I couldn't continue to treat her myself as long as her drug problem went unaddressed. I told her to call me when she gets home, "but the subject of our conversation won't change," I said. On my way out I caught up with her mother. She said, "Danni takes so many meds and she wants to say that she's messed up by being bipolar and by having seen a lot of violence when she was a child, but I think it's the drugs more than anything else that are the real problem." "Bingo," I said, "I'm with you all the way on that. Nothing good can happen until she gets clean." I drove back to the office feeling pensive and sad. All kinds of things needed attention there: a new client had sat in the lobby all day, trying to get acclimated to spending her days with us. But no one had come to take her home, so we had to hustle and find someone who could give her a ride, and Mapquest the route because the client could not tell us where she lives. Two people were still without heat so calls had to be made. Someone else needed his meds brought to his home because his car wasn't working. And A's probation officer had asked that we call him as soon as she came in for her meds so that he could come and arrest her. She didn't arrive until late in the day. I placed the phone call and sent Jim out to talk with her. He is a young, cute guy, a case manager, and I figured he could hold her attention better than could someone who reminds of her mother. Lea stood at the window with me, watching for the officers. They had scooped A up before we had a chance to notice and I ran out to the parking lot to give them a written summary of her behaviors. "She says there are a few people staying at her apartment," the lead officer said, "You'd better call the landlord to kick them out and secure the place or they'll steal everything she's got." A was in the back seat yelling, "They're my friends! Let them stay there!" Lea and I placed a flurry of phone calls, unable to reach the landlord or A's family. We finally settled on calling the local police and describing the situation. They said they would send someone out. Home again the same day. My eyes were closing before I hit the front door.

Bummed

I spoke to Danni's mother several times this weekend. Danni was on a respirator and heavily sedated. None of the tests had shown anything. Her tox screen showed only appropriate levels of prescribed drugs. I was worried about her, but relieved at the same time. I told her mother that when she was awake I would come see her. When I got to work this morning I called Danni's addictions counselor and told her what I knew. She described for me what had happened before they called 911. She said that Danni became progressively more incoherent and said she felt sick to her stomach. She was eventually barely able to remain conscious and, the counselor noted, her eyes were no longer working together. I thought that was pretty scary. We speculated about the possibility of a serious neurological problem that had been masked by drug use. We shared our concern for Danni and our wishes that she would come out of this intact. Almost the minute I hung up the phone a psychiatrist at the hospital called me. Danni was off the respirator, still in the ICU but fairly stable. After asking me a few questions he said that she had admitted to taking a huge overdose of a psych med: not one prescribed for her, but one a friend had given her. I immediately sank into feelings of despair. I asked the doctor whether he might not be able to find her a danger to herself so that she could be committed and he said that my answers to his questions had clinched it for him: she was just trying to get high, as she had told him. As the afternoon progressed, I regressed. I felt more and more tired, less and less interested in what I was doing. I finally called Danni's mother and left a message on her phone telling her that I'd talked to the psychiatrist and would not be coming to visit today. Although I didn't explain myself in the message I left, I was not going to reward Danni for endangering her life by using. Soon, her mother called me back. She told me that Danni had been moved to a regular room and gave me the room number. I tiptoed around my reasons for not coming to visit because I wasn't sure that Danni would have allowed her mother to know about the overdose. I asked how Danni's spirits were and her mother said that she was pretty low, feeling bad about what she had done. So I was able to tell her then that I would have to think about how I would next see Danni, and what the tenor of that visit might be. She said she understood. "You seem so often to have a lousy Christmas," I said. "I know," she said, "maybe it's something about the holiday." Maybe it is. I've lost the holiday spirit myself.

Unhappy Day

Today was the client Christmas party, an event we've been fundraising for, collecting donated food and gifts for, for months. I walked into the kitchen of the church hall where the party was staged this morning, to help prepare the tables. I like this event. Can't believe this was my second one so soon. Only a few staff were there. We decided on some logistics and tried to guess how many clients would come. I started to cut rolls. Elizabeth was dressing the salad in a huge aluminum foil pan. "The addictions program called about Danni this morning. Wanted us to pick her up and take her to the hospital," she said. "She was unable to walk steadily, couldn't recall phone numbers or speak coherently. We told them to call 911." Oh no. I was shocked. I still can't believe it was an overdose, although I guess that is most likely. No. Please. No. She was taken to the hospital but we heard nothing further. I tried to call her house when I got home tonight. There was no answer. I'll try again tomorrow.

Happy Day!

As soon as I returned from my vacation I got a call from Danni's addictions counselor who told me that she'd seen Danni looking very stoned: unable to focus, unable to stay awake. Her drugs screens have been clean, but she'd missed a couple of meetings and the counselor thinks it's unlikely that Danni is able to keep the contract we made with her. She also told me that Danni said she takes pain meds for the residual pain from an injury she sustained a few years ago and that she, the counselor, believes Danni is overmedicating. Sounded likely to me that Danni would see the pain meds as okay and use them to substitute for what she is not doing. The counselor said Danni refused to give permission for the counselor to talk to the prescribing doctor, a pain specialist. I said I would talk to Danni when I saw her. I was sad. This morning I told our doctor about the call. She was scheduled to see both of us today. The doctor said he would ask her about the pain prescriptions. After he had seen her he knocked on my door. "I think she's fine," he said. "She does not look like she's using, she says she takes less than the prescribed amount of the pain medications, using only what she needs. She gave me the name and number of the physician, who is someone I know. I don't see a problem, and I'm not going to tell her she can't be medicated for pain." My spirits rose. When Danni came in to see me she looked great: clear, calm and very pretty. She told me what she'd been doing to comply with each of the conditions of her contract, and she is taking it seriously. We agreed on some modifications, and she asked me to recommend another book to her once she finishes the one she's been assigned to read. She talked about things she disagrees with in the book, and had a big smile on her face when she told me that her boyfriend had gotten two big checks and they had been shopping for Christmas gifts. "And we have a lot of money left," she said, and described an expensive gift she wants to get for her mother. We talked about anger management, and about some of the issues we can get into in therapy as long as she is sober. She said sober is boring, but that our ultimatum made sense to her. Fingers crossed. Prayers going up.

The Kids

Sometimes my work reminds me very much of my years as a mother of school-age children. I went to the weekly meeting upstate today, which means a drive of almost 200 miles round trip. When I got the office at about noon my mind was on two things: getting to the bathroom and putting my lunch in the microwave. I was scarcely in the door before two case managers presented themselves with frantic faces and said, "You're here! Thank goodness." As I put my coat on a hook and my datebook and lunch and coffee cup on my desk one of them immediately launched into the problems she had confronted this a.m. None seemed particularly urgent or challenging to me, so I just offered her encouragement for the good decisions she had made. This did not deter her from telling me the details. Next up was Olan who was really up-to-here with Evie. She'd had to drive her to a hospital an hour away last night, and when they got there Evie refused the bed because they don't allow smoking. Olan had to drive her all the way home, and then go back to just where they'd been because that is where Olan lives. This morning Eviel said she was going to harm herself unless we got her into one of the other hospitals (with smoking car, eh?). And, because of the obligations of our work, even though none of us believes that Evie will do anything more than superficial to herself and that we all agree that she is attention-seeking rather than needing hospitalization, Olan had to drive even further away to another hospital, where Evie signed herself in. Meanwhile, Olan's 15 other clients are asking where she's been, why isn't she taking care of them. I did an initial interview with a new client (after I'd gotten to the bathroom and lunch). I'd heard that Rosa was difficult: does not believe she is ill, is sullen and given to few words. Instead, she came into my office and was very cooperative, answering my questions thoughtfully, inquiring about what services we will be able to provide for her. It was easy to get the information I needed for her chart. I heard Pru in the waiting room and asked her to come in with us. She will be Rosa's case manager. Pru introduced herself and we were all getting along swimmingly when a nurse knocked on my door and said Rosa's aunt, with whom the client has lived for some years, was here. Pru asked whether we should invite the aunt in, and Rosa assented. Mistake. The aunt, well-dressed and personable, came in, sat down, and when asked if she had questions said no, that she had things she wanted to tell us about her niece. She then began to describe some very negative behaviors: lack of cleanliness, lack of regard for others, lack of motivation, etc. etc. etc. and as she spoke the features of Rosa's face grew closer and closer together and she sank ever deeper into her chair. I directed my responses to the aunt's questions to Rosa-- she is the client after all. But the aunt went on to malign her as if she weren't there. After about 10 minutes, I rose to indicate that the interview was over. Rosa then looked straight on at Pru and me and said, "I prefer to speak for myself." Bravo! I thought. After she and her aunt had left, Pru and I agreed that, once again, the family is clearly a part of the problem. And that makes it harder to do good work with the client.

Off We Go Into the Wild Blue Yonder

I need a vacation. Yes, I know I just returned from a week off, but today has pretty much erased the benefits. Before morning meeting Danni's addictions counselor called to tell me that Danni is taking more than the prescribed doses of a painkiller she gets from a doctor outside of our program. My first thought is that she thinks this does not count as drug use, and that she finds going without any drugs unbearable. She was to see me today but called in sick. We are set to meet Thursday. It's no surprise, but ... I so want her to get out of where she is. Somehow, each client who came in to see me today wanted to rant, and was unwilling to compromise. Carol, a streetwise client who almost died from heroin use, prostituting herself, getting raped and instigating full-out street fights for many years before I met her, came in full of piss and vinegar. "I'm f*ing tired of f*ing everybody trying to f* me up," she began. From there she was off and running. I could barely get a word in edgewise. After a while I began to count each use of the f* word, just so I could feel engaged. She'd arrived early for her session, and when it was over I had to stand up and open the door and hand her an appointment card as she continued to talk. Next, my ever-angry client Rae called. "My ride punked out on me. Can somebody come get me"? I told her that we were short-staffed and that I could reschedule an appointment with her for tomorrow or Thursday. "But I'm really depressed," she said, "and I've been waiting a lot of days to see you. Can't you get someone to come for me"? I told her I'd check. Before I could get back to her, she called again and said she'd found another ride. The only time she could come in was my lunch hour, so I scarfed down my Lean Cuisine in 15 minutes and looked for her in the waiting room. Not there. I returned to the lunch room, and within a few minutes a nurse came to get me, saying that Rae was looking for me. I trotted back to my office and opened the door for her. "Didn't you hear me knocking"? she asked indignantly. I told her I'd been in the lunchroom and that I'd come to look for her earlier. "I was exactly one minute late, by my watch." You can imagine the tenor of the rest of our time together. She began by complaining about not being able to reach her case manager. "She had pneumonia," I said, "she was out for two weeks." Rae was not having any: "Well, I'm sorry, but she is never around when I need her. "None of us is here 24-7, Rae," I said, and she was insulted. "I know that! But when we need help, we need our case manager to respond!" By the end of the session I'd gotten the conversation around to the many places she's been invited for the holidays, thus giving the lie to her claim that she is all alone. She was smiling and laughing and when I asked her if the session had been helpful she said, "Yes. It's just good to have an intelligent conversation." Not sure how to take that. Too often doing "therapy" with my clients doesn't feel like therapy at all. They are in charge of the hour, resisting my attempts to guide the conversation to productive subjects, wanting only to be heard. And they should be heard, but I sit there feeling like Everyman (or Everywoman), unable to use the techniques and theories I've been trained in. The final straw was women's group, where Evie asked me, "What does a person have to do around here to get you guys to hospitalize her"? She is dug into being depressed, subsequent to breaking up with her boyfriend. When I told her that no med, no hospital, no therapy could do her any good unless she participates in her treatment and wants to feel better, she crossed her arms in front of her chest, leaned back in her chair and glared at me. By the end of group she had said the magic words that forced us to find a bed for her in a private hospital. "Do they allow visitors"? she wanted to know. I thought Elizabeth would hang up on her. I'm sure she will be back not later than Monday. Actually, that wasn't the final straw. The final, final straw was a call that came in five minutes after closing from a client who said he was suddenly out of heating oil. It's going into the teens tonight. His case manager had only this month allowed him to check on his need for oil himself, without supervision. So much for that. We told him that no, he should not sleep in front of an open oven door, and that if he chose to sleep in front of his electric heater, he should be sure there's no fabric near it. We scheduled an oil delivery for tomorrow (hurry-up service which will cost him extra). Hope we hear from him in the a.m. Sigh.

Back at the Ranch

I did have a very good, lazy vacation, reading lots of books, none of them professional. Returned to work today. Happily, nothing too catastrophic occurred while I was away. We did have to hospitalize a frequently hospitalized client who has been frantic about trying to rent a place -- a room, a bed, anything -- on his general aid check of $123 a month. The shelters are full and he has no relatives locally. So when the check came, he bought some dope and, thereby, a trip back to the state hospital. Seems like an intelligent solution to me. So much for living the good life on your welfare check. Mike drove over to a house shared by four male clients and found a police car in the driveway with one of the clients in the back seat. Mike went inside and found a living room stinking of stale smoke and littered with empty beer and liquor bottles. Two of the residents told him that their fourth housemate, Dylan, got drunk and bullied Keith into playing poker with him. Within a few minutes, Dylan picked a fight and started beating on Keith, who, much to everyone's surprise, decked and pinned Dylan. And Dylan's got about a hundred pounds on Keith. Go Keith! His usual day is to sit around staring into space and using as few words as possible. Who knew? Dylan's been looking for trouble for a couple of months now, and has found it often enough for this latest incident to cost him his place in the house. He asked Mike if they were going to take him to the hospital. Mike just shrugged: same old, same old. So Dylan told the cops (now there were three sets of cops on the scene) that if he didn't kill somebody else today he was going to kill himself. The magic words. The cops took him upstate. And so it goes. Holiday season. I'm on call this week, and once again the moon is going to be full. Oh well.

EMDR

If you click on this link: EMDR you will be able to follow Kat's fascinating account of where EMDR is taking her. Good going, Kat!

A Brief Vacation

Today was my last at work until December 12. I am taking a long-awaited vacation. It's a bit surprising to feel as torn as I do about leaving my clients, but I guess it is an indicator of being invested in our work together. I told the women's group to go ahead and decorate the little artificial tree that one of the nurses found next to a dumpster. They have decided to have a "women's group only" party on December 20. I was thinking of disbanding the group as Angela stopped coming a couple of months ago, and Stacy called me the other day and said she'd decided to go to another group in town instead. Then all this excitement arose, with the five remaining members getting excited about putting a party together, and today Angela appeared at the center for the first time in a long while and said she wants to return to the group. So we will see. Ricky stopped me in the hall today and asked when we could have therapy again. It's not really therapy -- more of an odd conversation led by Ricky, but I don't mind meeting with him when I have time. I told him to flag me down when I return to the office. He was sitting in the waiting room all day, his wool cap pulled down over his ears, smiling but still looking a bit forlorn. The hospital called, wanting to release Shawna tomorrow. I said, "No! Please don't do that right before a weekend. She has been hospitalized about six times in the past three months and every time she gets out she immediately cuts herself or attempts suicide. We don't have enough staff on the weekend to monitor her as closely as we need to. And why haven't you guys followed through on giving her ECT, which had seemed to have some positive effect during her last hospitalization"? Thankfully, they backed off. My gift to the weekend staff. At the same time, Harry is coming back. He took himself to a private hospital the day before Thanksgiving. No doubt he was out of money and wanting a good meal. The social worker there told me Harry wanted to be released to live with family in another county. We were all jumping for joy, because that means we could discharge him. First he was going to live with his sister, then his daughter, then his grandmother. In the end, he admitted that he had lied about all of it and didn't really have anywhere to go. So he is ours. Elizabeth and I were working on redistributing caseloads today and we couldn't think of any case manager we dislike enough to saddle with Harry. On the other hand, viewed from a distance, he is amusing. "I"m so sorry, Miss Elizabeth," he said today, "I didn't tell the truth about those places. I guess I have to come back to you all. And I'm sorry I took myself upstate. I was just so cold, you know, living on the street and such." I still don't know what he is doing in a psych program. Of course, I will be thinking of Danni while I am away. Lorraine and Pru told me, "Don't you dare take any of your psych books away with you." I'm not going to. I'll leave them stacked on my night table and my desk this week. See you soon. Stay warm.

Danni's Day in Court

Today was the day that all of the people involved in Danni's treatment were to gather at our office to present her with her options: give up drug use or give up treatment. Because of a miscommunication on my part, Danni's drug counselor was unable to come, which was disappointing. Danni herself arrived early, her boyfriend in tow. "I want him involved in this," she said, and I said I thought that was a good idea. When the doctor was free, Danni and her guy, Cindy her case manager, the doctor and I all sat down in his office. The doctor explained that Danni's drug use made it almost impossible to treat her mental illness, or even to be certain of what it comprises: are those symptoms of drug use, or of a mood disorder? Danni said that she had not understood how serious her current drug use was until I told her we would have to put her out of our program. She said that she's been clean for a week and that even when her boyfriend's check came in yesterday they put the money aside for Christmas gifts. "I don't want my family to wonder where that money is going and why I don't have gifts for them." Our wonderful doc said that it was important for her to want to give up drugs for her own sake, not for ours or for her family. He said that it was hard for her to imagine the physical damage that continued use will do because she is so young and resilient now. He spoke kindly. Danni nodded, looking him in the eye. She bit her lip. "I know," she said. The doc said that when she has been clean for five or six months he will be able to take her off of some of her psych meds. She didn't like that idea. "You don't know what I was like before. I was always getting into trouble, even when I was a little kid. I can't control my temper without those meds." He explained that no one is going to take away anything now, nor will he take away anything that she needs. But he needs to get a better idea of what meds she really does need. I had drawn up a contract for all of us to sign, listing seven requirements that Danni must meet or we will begin discharge procedures: 1. Stay clean. 2. Keep all appointments with all treatment providers. 3. Have (and pass) a drug screen every week. 4. Read and write a two page report on A Million Little Pieces. 5. Go to at least one NA meeting a week. 6. Do at least one hour of chores at home every day until and unless she finds a job. 7. Attend all group meetings at her drug treatment program. "Give me the pen," Danni said, and signed her name and the date, as the doctor did, as I did, as Cindy did. Back in my office, I gave Danni the book to read and told her that I have great belief in her, and that she must peel away the layers of crap that now obscure her potential and her ability to act. I won't see her for two weeks, as I will be away next week. I told her to call Cindy if she needs someone, or to go to extra meetings. As we said goodbye she asked, "Can I have another hug"? which of course she could, and did.

Oh No You Don't

Elizabeth was out all day so everything rolled downhill to me. First Lea came in to tell me about a phone conversation she had had with a sister-in-law of one of her clients. I've written about this client before: she is 21, just. Her diagnosis is imprecise, but includes some brain damage and possibly some mild developmental impairment. She has become the bete noir of her family. All of their disfunctions are hidden behind the great beast of our client. Thanks in part to her family, she is in a constant state of drama and turmoil. We all find the family, and her worsening situation, almost impossible to deal with. Today Lea listened to the sister-in-law rant about how we are not doing our jobs. Although Lea explained that our hands are tied, largely because the family insists on retaining guardianship of the client, and retaining governance of her money, the sister-in-law said that was b.s. She said that Lea has been doing a terrible job, allowing the client to be kicked out of every homeless shelter in the county and beyond, not helping her keep a job, not helping her manage funds or learn to behave reasonably. Right. In the past month alone Lea has dealt with a false alarm pregnancy, a hospital's miscall of syphillis in the client (it was another client whose name, unbelievably enough, is one letter off from our client), eviction from three homeless shelters, dismissal from a job program, plans to move out of state with a boyfriend which fell through, and myriad other flip-flops and difficulties. Lea told the sister-in-law she could talk to a supervisor if she wished and the woman said, "Oh sure. What good will that do"? I would give Lea a medal for the patience she has shown with this horrid family. They will never give guardianship and finances over to us because if our client were really removed from the center of their lives they would be forced to look at the other problems in their family such as alcohol abuse, compulsive spending, uncontrolled anger, child abuse, other mental illnesses, etc. etc. It is very hard to summon empathy for any of them. On the other side of the coin, late in the afternoon I fielded a call from a well-spoken woman who told me that she had been referred to our agency because her niece was being released from the hospital today and they needed someone to provide intensive case management. She said she had talked to about a dozen people before she finally got to me. "I'm sorry, but I've not seen any paperwork on this, nor heard your niece's name until just now," I told her. I referred her to the state channels for applying to our program, but she had already spoken to those people. "I'll be glad to look into this for you," I said "but it's 4 o'clock and I'm unlikely to get an answer for you today. We can work on this first thing in the morning." It sounded as if she were about to cry. "What should I do"? she said, "my niece has been violent with us in the past. We cannot control her. I didn't know until today that the hospital was going to release her today. She has nowhere to go except to live with us. What should I do?" I asked if the hospital was sending her niece to our town by bus, as it seemed no one was picking her up. "Oh my God," she said, "If they send her by bus she will never get here. She can't do that kind of thing." So I made a call and found out that the paperwork was actually sitting in our fax machine, enabling me to call this seemingly sweet and distraught woman back and tell her that we can begin intake on her niece tomorrow. What I could not tell her is how little we will actually be able to do. We can provide meds. We can send someone over every day to make sure the client takes the meds. We can take the client to the doctor, and visit with her once a week. But we cannot make her well, or insist that she be well, or keep her family safe, or pin her down so that she doesn't wander off and put herself in danger. It's great that we are here, yes, and I am proud of what we do. But we are not the miracle workers, nor do we have anywhere near the tools, that some people expect. When I started this job I was doing all the intakes and I promised the moon to everyone, because I thought we could give them that. Wrong.

The Season to Be...

Not so hard to get back after a long holiday weekend. When I walked in, nurse Stella told me I looked rested. Cool! I'd been thinking about Danni, of course. Wondering all weekend what she'd been thinking over the holiday. I had to cancel some other appointments if she was to agree to come in for the "Big Meeting" on Wednesday. I didn't want to do that until I'd heard from her. Before noon, she was on the phone. "What time is the meeting on Wednesday and do you want me to come in for my regular appointment before that"? she asked. My heart leapt up. She is coming! Good for Danni! I told her that I'd see her tomorrow if she wanted, but that she needn't come until the meeting. "Okay," she said, "I guess I'll see you a few minutes before the meeting. I want to tell you that I am not using and haven't used for a week. And I want to ask all of you, if I can keep that up until after my birthday, can I stay out of a residential until then? And if I'm still clean, can we talk about it then"? "Danni," I said, "no one is going to come after you with handcuffs. You are part of the decision-making process." I didn't tell her that I'd had no intention of sending her anywhere until after the new year, or that it will take a while to get her in anywhere. "Okay, I will be there," she said, "I told my addictions counselor I was agreeing to it and I think it's a good idea for everyone to meet." Oh I don't want to be overly optimistic about this, but I am so proud of her. On other fronts: Shawna is in the state hospital, having cut herself purposely and badly after a few days at home. She hates the state hospital and didn't want to go there. She ran from the police when they came on a 911 call from her kids. I guess she couldn't keep it from happening. Harry is either in jail or in a hospital. He's not been seen on the street for about a week and there are no other options. He just rolls on. The male half of the couple who just broke up, in part because, he said, his girlfriend didn't do anything but lie around and wait for him to do things for her, has taken up with another client who really does nothing but lie around, who depended on her former boyfriend to do everything while she sat on the sofa and smoked and watched TV. We all agree she is the least animate client in the whole program. We have to force her to come to the center once a week to get her money, and she resents that. Hard to figure love, or whatever it is.

Giving Thanks

Hard to concentrate today, with the air so cold and a prediction of snow (!) and a holiday that I really love on the way. First thing this morning, though, I saw Amanda who has come to me for therapy every other week for the last couple of months. She uses the F word in every sentence. I told her CM that she reminds me of Al Pacino. She talks tough, and she has lived a tough life as a heroin addict on the streets of a big city for years. Amanda cleaned up about five years ago. She lives now with her elderly father and her 16-year-old daughter, both of whom have the same volatile temperament that she does. She's ready to duke it out at the drop of a hat, and so are they. Her diagnosis is schizoaffective -- where moods and extreme behaviors are two of the key problems. Clean though she is, her life is far from easy. She frequently gets into fights with people and has been on probation for years. This morning she was teary-eyed as she told me that her daughter had gotten very angry with her last night over something trivial and had yelled at her, telling her what a terrible mother she has been, what an embarrassment it's been to have a junkie mother who can't stay out of trouble. Amanda says her daughter went on and on and finally punched her in the jaw. Amanda's father woke up then and took his granddaughter's side. "I'm through with them," Amanda said today, "I don't want nothing to do with either of them anymore. On Thanksgiving I'm going to the movies, if I can dig up the price of a ticket. The hell with them." We talked about her feelings, and about her accomplishments: how she earned her G.E.D. and is now in college. How long she has stayed clean and how she doesn't prostitute herself anymore. How she has stayed out of prison. But in the end, I sent her off to a lonely and sad Thanksgiving, and I wouldn't be surprised if on call gets a call from the police about her this weekend. Next up was Danni. Sigh. She came in looking pale and exhausted and said she hadn't slept all night. She did not connect this, though, with the fact that she had been using yesterday afternoon, after her boyfriend got his unemployment check. She'd called all morning to tell me she'd be late for her appointment and to make sure that was okay. That is what I love about Danni -- there is something she is trying to get for herself here, and since I am not usually encouraging of her present choices, I think she really does want to get something, even if she can't commit. But I had to tell her this morning that all of the people who work with her now are going to meet with her next week to decide what kind of treatment we can provide, in light of her drug use. And I said that we could not keep her in our program while she continues to use. She fell apart. She went through 20 changes in 10 minutes from "If you discharge me I will have no choice but to use drugs every day, just like I used to," to "I've changed a lot, I've gotten a lot here, I don't use every day," to, "I can't do residential knowing that my boyfriend will be out here using," to "I'm not coming to your damn meeting and you can't make me," to "I'll quit by myself and I'll come to meetings every day." I held my ground, telling her over and over again that this was not being done to punish her but rather was coming about because I feel I'm not helping her anymore, and that in fact I may be negligent for leaving her in such a dangerous place. Our meeting lasted only 10 minutes. When she got up to leave she wished me a happy holiday, and I said, "I hope you know I am doing this because I care a lot about you," and she said she knew that I care. And I asked if I could hug her, and she hugged me back, and said she would think about this between now and next Wednesday, when we are due to meet. Thought about her the rest of the day. Happy Thanksgiving, all. I'll be counting my blessings.

Almost Useless 'Til the First of the Year

This place gets so giddy around the holidays. Lots of big plans for a party for the clients. Plans, too, for a party for our teams, getting together from both sides of the county. Staff getting together at each other's homes for pre-Christmas cocktails. The Hallowe'en pumpkins have been thrown away, before they looked too bad, which is good. Nurse Linda has decorated the waiting room with all shapes and size of Christmas trees and I'll bet she'll have the music going right after Thanksgiving. She loves to decorate for the holidays and she must have an attic full of stuff. She lost her husband two years ago, and seems to go for mania rather than depression to pull herself through holidays and anniversaries. We have begun our "Secret Santa" routine: each of us having drawn a name from a hat, we now must give that person three gifts, the last and largest one at our Christmas party. I remember that last year I thought all of this was not something I'd enjoy, mostly because I am older than many of my colleagues, particularly the case managers. But I do enjoy it. I really enjoy sneaking my gift onto someone's desk, to keep them from guessing who it is from. I don't know why, but things are quiet with the clients now, which seems surprising. Some of the people who are least able to control themselves are in the hospital or in jail. Not only am I glad that we don't have to deal with them right now, I know they are safer where they are than where they'd be putting themselves in town. Elizabeth, who prides herself on getting tough, said today that she'd been having some soft feelings for certain clients, wanting to make sure they had enough food and blankets and so on. She wondered what was wrong with her. I said it was good to have those feelings for clients, to remind you of why we do this. "Yeah, but there are some clients I don't have these feelings for, like Harry." Harry, who went from jail to the hospital last week, and who talked non-stop for a solid two hours to the case manager who brought him back down to the cheap motel where we try to deliver his meds and check up on him when he isn't on his usual block in Crack Town. Harry who changes his appearance so often and so thoroughly in his attempt to be alluring to -- whomever -- that I often fail to recognize him. Who spews an endless stream of compliments toward the women on our staff, hoping to snag one of them long enough to get some extra money or some cigarettes. "Oh, Elizabeth," I said, "It would be asking a lot of yourself to have those feelings for Harry."

The Commitments

Maybe I'm beating a dead horse; I know that I've written before about the frustrations of having little to nothing between leaving someone in the community with very minimal supervision and sending them to the hospital in a police car. I'll bet most people think that if someone they loved, for example, suddenly stopped talking, stared into space, wouldn't eat or take necessary medications, stayed awake all night scrubbing the bathtub over and over again -- most people probably think they could get some emergency help. Well no, not really. A client of ours, who has a recent history of suicide attempts and relatively lengthy hospitalizations, was exhibiting similar behaviors this weekend. He also went for a short drive to the corner store and called home three hours later, not knowing where he was. And he told his sister, with whom he lives, that voices were having an argument between good and evil in his mind. His sister called on call several times. Twice she took him to the local ER and they sent him home with her, saying they couldn't hospitalize him unless he were a clear danger to self or others. Often, when a client wants to be hospitalized, they know what the magic words are ("I feel suicidal") and they get whisked away. But when a family sees a client heading downhill, and the client doesn't want to go away, there's nothing to be done. When I explained that to our client's sister late Saturday night she screamed and hung up on me. I can hardly blame her. Update on the couple who got married at the beginning of the summer and then got kicked out of everywhere they lived due to using/selling, being loud, stealing from their neighbors: You may recall that the husband was arrested a few months ago for kidnapping and theft. Made the headlines around here. He could not make bail, and we learned only last week, finally, that his trial would start today. I heard his wife mention that to another client as they sat in the waiting room today. The other client said to her, "Oh, are you still married"? She snorted and said, "Technically." So much for love-you-til-I-die.

The Top Ten

I was at a training with a team from an agency similar to ours, that works out of another county. We spent several hours together, with me mostly listening to their frustrations about their work. Not surprisingly, their complaints were almost exactly like the complaints from me and my colleagues: 1. Nobody at the top understands what we do. 2. "They" are always changing things -- just when you get used to one system or requirement, they change it. 3. Nobody asks me to help figure out how to get the job done, even though I'm the one doing it. 4. If I got attacked by a client, I don't think the agency would care or would support me. 4. Dealing with Medicaid and the new Medicare prescription drug plan both suck. 5. I don't know who's got my back. 6. When I go away I worry that my colleagues won't take care of my clients in the way the clients need. 7. If I speak up, I know I won't be heard, so why bother? 8. "They" keep taking away the tools, and the funds, we need to do this job. 9. I don't get paid enough to do this job. 10. I only stay here for my clients; the agency means nothing to me. I guess it's the same all over. We don't have a union. We don't have the public caring very much about what we do because it a) doesn't directly affect the majority of people and b) we work with a population that most people prefer not to think about. And above all, there is no money to be made by anyone -- anyone in our field. Even the CEO has got to be thinking, "I don't get paid enough to do this job." Somebody needs to figure out a way for assisting people with mental illnesses to be a big money maker. Then we'd see some action.

EMDR

I worked for a year at a rape crisis clinic. One of the therapists there practiced EMDR and I was always interested in the technique because many people believe it is a very productive approach for PTSD. It seems to me to be a rather cutting edge application directed toward the mind-body connection, rather than supporting the mind - body distinction. Check out Kat's excellent description of EMDR. And Kat, please keep them coming! EMDR

Are You Lonesome Tonight

We were talking about the holidays today and someone suggested that we have a party for Valentine's Day. Then Cassie said, "I don't think that's a good idea. Not too many of our clients have a love in their lives." Elizabeth said, "That's true," and we talked for a minute about how our clients probably would not like to have that emphasized for them. Later, Sheila said in women's group said that she'd been very down yesterday and stayed home by herself all day. Kate said, "Why didn't you call me, girl"? And reminded her of a time a few weeks ago when Kate had called Sheila and asked to be cheered up. "And you did cheer me up," she said. And Sheila laughed and said, "Yeah, and a couple of hours later I called you and said, 'could we do that again -- but this time in reverse'?" We talked about how friends can be there for you, and how you have to let them know when you need some company or a pep talk. And Kate said that until Sheila came into the program she hadn't had any friends. I am embarrassed to realize that I've not paid much attention to that before. That is, that I've not noted how few real friendships there are among our women clients. The guys sit around and joke and watch TV in that easy small talk way that guys have. But the women are peripheral to that. Only a few of them hang out at the center. The rest come and go for their checks and their meds, or we see them at their homes, where most live alone. Even the women who have been placed in housing that is organized three or four to a house are not necessarily "friends" with their roommates. It's not like it was in college where proximity often created deep, significant friendships. As I was leaving tonight, I answered a last phone call. It was Richard. He wanted to know if anything had happened to Doris today because she wasn't answering her phone. I told him that her case manager had taken her to the dentist and it had run late. "Okay," Richard said, "I was just getting worried about her." He and Doris got married about ten years ago, but lived together only briefly. Much as they cared, and care, for each other, it was just too hard to manage their relationship and their illnesses under one roof.

Good Cop, Bad Cop

It's time to get Danni moving. I called her counselor at rehab today and we agreed to jointly call a meeting of the psychiatrist, case manager, family and Danni to discuss our plan. And that plan is to discharge Danni from both of our programs: theirs due to noncompliance with treatment (that is, not showing up) and ours due to our not being able to address psych issues effectively as long as she is using. This will leave her with no meds and no counseling. Best would be if we could get her family to agree that she has two weeks to find another place to live, especially as she now has no income at all. I hate doing this. But I have come to believe that all of our hand-holding and encouragement , and the meds we have her, have allowed her to remain in a very dangerous place. I want to push her into agreeing, one way or another, to go into a long-term residential treatment program, if we can find one. And that's where I keep hitting the wall. I spent several hours on the Internet today and making phone calls to find a place that will take Medicaid from out of state, as there is nowhere in this state that is appropriate for Danni. I can find nothing. I've ranted about this before, I know. The one way to get her into a program would be to have her sent to the state hospital, and then they could refer her. At least that is what I am told. There's no real reason to send her there, though. She would have to really hit bottom and be picked up by the police or.... I hate to think of what else. As I was making calls and starting to set things up, Danni called me. She was confused and foggy sounding. She said the person who answered the phone had already answered her question and that she wasn't sure why she'd asked for me. She said she'd see me later this week. It was as if she had sense that I was working on something. God, I hope I can get her to buy into this, and then be able to find the right place to send her. Oh yeah, and today May left her rehab AMA. Shawna is coming home later this week, after refusing transfer to rehab. And so it goes.... If anyone who reads this has an idea for a facility that I might contact, please let me know.

How to Say Hello

The rule is if we encounter a client out in the world, we are to wait for the client to acknowledge us. That leaves it up to him or her to decide how to acknowledge us. If they, or we, are with someone, do they want to say, "This is my counselor," or "This is my case manager"? But it is counter-intuitive for me to ignore someone I know until they see and greet me. The other day I saw one of my clients on a street in my hometown, which is not where I work. I ducked into a bank so that we wouldn't pass each other. And yet, I saw another client at a horse show during the summer and didn't hesitate to introduce her to the people I was with as my friend, no further explanation necessary. It is no wonder that boundaries are an issue that needs to be readdressed in morning meeting so often. Who are we to each other? Behind the facade of the professional is a regular person, just as it is a regular person we see when we look at the clients we spend five days a week with. At lunch yesterday, Mike said it is always shocking to him when one of his clients decompensates in a big way and has to be hospitalized. "They are like colleagues to me," he said, "I count on their capabilities and I forget how fragile they can be."

Justice!

If you go way back in this story, you will find or remember that Pru, attempting to deliver meds to a client named Della at her home, once interrupted a sexual encounter between Della and a man who had been her driver. (Many of our clients rely on state-subsidized van and bus rides for their subsidized transportation. ) Della has a low I.Q. in addition to her illness. She is very vulnerable: men in her neighborhood have been known to harass her, pretending to be her friends. This time it appeared that her driver had taken advantage of her impaired comprehension to "have his way with her," as they used to say euphemistically. But then Pru arrived. She and another CM and I took Della to the police station, where she was pulled together enough to tell the story and to say, no, she had not wanted what he was attempting to do with her. The police were very gentle and objective with her, we thought, and the man was arrested. It has taken almost a year for the case to come to trial. I had forgotten about it, until Pru got a summons a couple of weeks ago. She was expecting to go to court next week. But yesterday, the defendant took a plea, agreeing that he will never, ever again work in any agency that serves mentally challenged or disabled people. That's one for our side. Meanwhile, the "long-term" program that has been giving Shawna ECT to interrupt her depression is set to release her early next week. That's long term? Olan called her today. We have taken over responsibility for Shawna's Social Security money. Until now, her adult children have taken what they could from it. Four or five of them live with her without paying rent or contributing to food or other expenses. One of the things that sent Shawna over the top was that both the phone and the electricity had been cut off. With her away, Olan has been able to hold on to her money for the last few weeks and has accumulated enough to pay the electric bill and work on the phone bill. Olan was very happy to hear that. Yea. Her children moved out of the house and have descended on Shawna's mother: they simply will not take responsibility for themselves. Believe me, they are not living in luxury at Shawna's. Their place is often cited for safety violations and trash violations. There are holes in the floors and the wind whistles through ill-fitting window frames. If they send Shawna home on Tuesday, her kids will jump on her like a mess of fleas. How could you imagine that her old, dangerous behaviors won't be triggered? Grrrrrrrrrrrr.

How to Be Calm

I am not good at playing hardball. One of my mentors says I have to take myself away and Danni's meds away so that she can hit bottom and understand how much in trouble she is. I know she is right, and I will figure out the way to do it, but it won't be easy. A client who saw me for therapy today raised an interesting conundrum: How do you manage looking and mostly behaving like a regular citizen when you are actually experiencing enough psychological turmoil to make you eligible for our program? In other words, how do you manage looking as if you have no reason to be labeled disabled, when you really are significantly disabled? This client was worried about what her boss may expect of her in a part-time job she is excited about starting. "I don't look like a lot of the people here, but I am one of them, you know?" she said. And I do know. It is much like people with an early or mild case of M.S., or with fibromyalgia, or lots of other "invisible" conditions: they feel terrible but it doesn't show and they are not comfortable saying over and over again, 'you know, I can't walk that far' or 'I can't stay up that late,' or whatever. I think in our pull-yourself-up-by-your-bootstraps culture, we are particularly impatient and unforgiving with people who say, "I can't." I speak from personal experience: both as someone who is impatient with the "can't dos," and someone who actually can't do all of the time. Okay, by popular demand, I will try to describe one of the calming techniques I've found to be helpful. I actually learned part of it from a client: If you find yourself on the verge of or in a full-blown panic attack, first slow your breathing down. You don't have to breathe especially deeply, just slowly. Picture a man in a turban standing behind you as you sit in a big woven chair on a porch made of bamboo or rattan. He is fanning you with a huge ostrich feather, moving it slowly back and forth, back and forth. It is heavy, and the air is heavy, so his fan can move only very slowly and steadily. Okay, with your breathing slowed and steady in the rhythm of that fan (which is already having a positive effect on your autonomic nervous system), now hold your hands up on either side of your shoulders and simultaneously touch each finger of your left and right hands, in order, to your thumbs. Keep moving back and forth between your pointer finger and your pinky, touching each one in turn to its thumb. Within a couple of minutes, you may feel your symptoms subsiding. Let me know if it works for you!

Women and Girls

Danni came in with her boyfriend this morning. I'd had a call from her counselor at the rehab program yesterday, wanting to compare notes and coordinate services. "I have just one goal," I said, "and that is to get Danni to commit to getting sober. I can't do my work with her effectively unless she does that." If we'd been together, the other counselor and I would have given each other a high five. We all agree that Danni is smart and personable and honest and sometimes motivated, but we can't get her over the line. "She looks terrible,: the d&a counselor said, "and you know she usually looks so put together." Still, Danni was proud when she came in today to tell me that she and her boyfriend were six days without drugs. They'd put some of his unemployment money toward going to the movies and out to eat, before buying drugs. Sigh. At least they are prioritizing differently. I asked them what their goals were for the next few weeks and they said there were some great DVDs being released that they want to buy. I don't know how to get beyond that with them. I sang my song about how Danni needs to go to residential rehab, how that's the only way to fight this fight. She said it wouldn't be fair, because her boyfriend would still be out and running around. Before they left I asked them to talk with each other about what conditions would allow Danni to go into a program. I figure if we meet, say, a thousand more times we might get somewhere. The women's group, on the other hand, said they were through with men. One of our members is half of the couple that just broke up. She is feeling morose and shaky. But she seems to be making some realistic plans to get her life moving again. Another of the women is Terri, whose former psychiatrist had been calling her and even coming to visit for the past few months. I wish I could go after his license. She came running in and announced that she was having a panic attack. She spoke in a rush about her childhood abuse and how when she thinks about it she brings on a panic attack. I had her participate in a calming technique that I've found to work pretty well, and within less than a minute she said the panic was gone. Hmmm. I didn't think the technique was that effective. When she caught her breath and got to talking again, she said, "I couldn't be his patient any more, and I couldn't be his lover, and if I acted like either one of those he got angry with me. I don't know what he wanted me to be." Well, I don't think he knew what he wanted her to be either. We did report him to the medical board a few months ago, but nothing came of it. Now, she says and her roommate confirms, he has stopped calling for the past few weeks, "and I'm trying my best to get over him." Isn't part of the physicians' creed, "first do no harm"? A word about Shawna: she's having ECT, for the first time, I think. That's shock therapy, which is back in style but done much more humanely than in earlier years. Her family have called about getting her benefits money to buy food and pay for utilities. We keep telling them that Shawna is our client, not her children who are over 21 and who work or do drugs, or both. Fundraising is going well for the Christmas party. LaJo brought in a huge bag of gifts for the clients today that she'd gotten donated. Soon, I imagine, we'll be getting into the spirit of the season (even as we watch to make sure that some our clients don't get too far into the spirits of the season.

The Medicaid Fade

Pretty fall day-- sunshine and a bit of bite to the air. One of the regulars, Tucker, had nothing to do, I guess and he can't stand that. When I went out to lunch I saw him painting the pole that holds up the No Parking sign out front. He smiled and waved as I walked by. I'm getting worried about Tucker, and most of the rest of our clients. Congress is looking at making some huge cuts in the Medicaid budget, and our program is vitally linked to Medicaid. Budget cuts can only mean trouble -- and maybe extinction for day programs like ours. These community programs came to be in the Reagan years, when funds for residential programs for people with chronic mental illness were slashed. If you are old enough, you may remember that the streets very quickly filled with burgeoning numbers of homeless people. The great majority of the people we serve would be homeless, in jail, in medical hospitals, in shelters or simply in big trouble without us. They cope reasonably well with daily life only with lots of support. Hence, the invention of the day program, where case managers, doctors, nurses, clinicians and administrators are given the job of keeping people housed, clothed, fed, medicated and out of the hospitals. Sometimes we even help them get better. Sometimes we help them to have fun. Before I got into this profession, there was money to help clients with emergencies, provide a hot lunch every day, pay for school or training for staff, fund Christmas parties and other celebrations, provide transportation as needed, and so on. Now we have no client assistance fund, no party fund, no money for meals, and if you want to go to school or to a conference, you have to fight to get the agency to pay part of your expenses. Some agencies seem to have more margin, but nobody is flush. Obviously, big cuts in Medicaid will mean more belt tightening, and may kill off programs like ours. Then what? Will the clients be left to fend for themselves? Maybe a third of the people we work with will find a way to go on. But the rest are people who can't find apartments for themselves, can't get themselves to the doctor for needed exams, can't remember to take their medications, can't cook or shop without help. To abandon them would not only break down the little foothold they have in society, but would be a blow to society itself. Who are we if we abandon the people who most need help? It very well may happen to my clients: Look around. We abandon people in this country all the time. I can't imagine how Tucker might spend his days then. And Shawna? She was sent to the long-term hospital program we were hoping against hope to get her into. She wouldn't be there without Medicaid.

Mother May I?

So many times I am led to feel that our client is just the receptacle for an entire family's madness. Today Lea came to ask me what to do. She worked very, very hard to get her client, May, into a long-term rehab for alcohol. Very few programs exist in our state for that, and of course they are in high demand. Lea managed to get May into a good one, and then got May to commit to going, and then worked with both May and the staff there to help her stay past the point when her anxieties were keeping her from buying in. She has more than three months sober now, which is remarkable. Lea and I visited her at the facility last month and she was lucid, strong, directed, proud: I'd never seen her at all in charge of herself before. She was especially proud of having earned her own room at the facility, of having climbed up the prescribed ladder for enrollees. Today May's mother called and said she wanted us to bring May home. Her mother is May's daughter's legal guardian. She said she can no longer care for May's daughter (who is six or seven) and that May must come home NOW to take over. Lea explained that May is doing very well in rehab and that leaving early is a bad idea. Especially if May jumps into a stressful situation such as having sole responsibility for her daughter so suddenly, she is unlikely to be able to cope well. May's mother didn't care. "May's a drunk," she said, "she will always be a drunk. But this is her rotten kid and I can't take care of her any more." The child was standing right there as she said these things. This drama continued throughout the day, with us and the counselors at the rehab trying to convince May that she did not have to leave, did not have to do as her mother said. We can, we said, refer your mother to foster care for your daughter, just for the few months until you have completed the rehab program. At one point May was ready to hang tough. At the next, she was capitulating to her mother's demands. At the end of the day, May had decided to think it over while staying in the rehab one more night. Isn't it an awful thing that May has spent so much of her life as a registered deficient citizen, while her mother, who is responsible for so much of the damage done to May, is out in the world with no restrictions? Her mother needs treatment too, and probably has needed it for decades. But meanwhile, she is, consciously or not, doing all she can to destroy the lives of her daughter and granddaughter.

Team-Building Day

It was great to have a day together with all the staff without having to answer phones or race around. Of course, we started out sitting with the people we knew best. We played games -- several of which involved guessing things about each other so that we would enhance our knowledge of our co-workers -- ate a pot-luck lunch provided by each of us (lots and lots of desserts, naturally), and got to catch up with people we rarely see because they are in another part of the program. One of the games, just for example, involved telling the group three things about yourself, one of which was untrue, and having them guess which one was the falsehood. We laughed a lot throughout the day. Much to his credit, even our psychiatrist took part -- the only doc who did. I was impressed by how much work Elizabeth and a colleague had put into preparing for the day. No one tells them to do this, they just think it is a good idea. I did get to know new people a bit, which at least gives us a basis to find out more about each other. When I've been on call, I've talked to several of them without knowing just who they are. We did our best not to talk shop. I'd say I was asked to discuss problems with clients for only about 15 minutes out of the whole day. A nice break. Now...back to work in the morning.

Update on the Usual Suspects

Richie brought me a huge, sharp pair of scissors he'd found in going through a pile of giveaways today. "We shouldn't have these," he said earnestly, and apologized for taking something he wasn't sure he would need when he got it home. "It's fine, Richie," I said, "Enjoy it." Danni called to cancel her appointment, then called back to talk. She says she and her boyfriend are totally broke right now, waiting for the next unemployment check. They are "just smoking" marijuana now, which she believes is not using drugs at all. She wants help with controlling her anger, which, along with a few examples she supplied, tells me she is worried about losing this relationship. Oh Danni. I'm so damned frustrated by not being able to find the right kind of service for her. I have a strong feeling that she would do well in a 9-5 five-day program. There just isn't one. And the hand-holding I do is worthless, except for maintaining a relationship she trusts. Evan reportedly spun his tales at a party last night, and told everyone to come to him next time they needed anything fixed, cooked, invented, decorated, made valuable, traded for best dollar.... His CM is worried that he hasn't found a place to live, but I think he will get by. He knows a zillion people and has reached out to all of them in the past 10 days. Harry was missing for a while. We found out he's in jail, but don't know why this time. Even the doctors upstate shrugged their shoulders when I reported last week that we had just learned he was in jail. Shawna is wait-listed to go to long-term inpatient for borderlines. Hallelujah! Maybe I shouldn't cheer until she gets there, but this is at least a new approach to her intractable problems. Last I heard the wait is a week or two. I am keeping my fingers crossed. A client called after hours. A few of us were there trying to get ahead on paperwork (first of the month: it falls on us like a landslide). The client wanted someone to take her to the store to get some clothes for her son because he had nothing clean to wear to school tomorrow. Sigh. Remember Corinne? I wrote about her long ago. She believes she had a baby stolen from her. I was her counselor for a while, then was the person she'd ask for if she called on-call on a bad night. But she is seen in another office now, so we have been out of touch for months. We were told today that she asked to participate in our selling candy to raise money for the Christmas Party we want to make for the clients. She sold hundred of dollars of candy! She is the top seller. I hope she gets a boost from that. She is such a generous soul. I still have Tess in mind, trying to figure out how to talk with her about what I think may be going on in her life. Not a peep out of the (former) client we had arrested. I don't know what to make of that. Tomorrow is "team-building" day. We are a pretty tight group, but there are some people who need to be better incorporated. Elizabeth has been planning this for weeks. Team building is almost all about fun and games, things to bring the individuals into better focus, and thereby create better relationships among us. I'm bringing the dip. She's bringing brownies. Should be fun.

I Am Naive

For the last few weeks I've been seeing Evan, one of the "trustees," a long-time client, one of the fellows who spends a lot of time at the center and helps keep things looking good and running. He has had some difficulty with his family lately and asked if I could see him regularly for a while. I've enjoyed our sessions. He told me about growing up in Alaska, learning to fish from his father, who is an Inuit. He spent 16 years in the merchant marines, sometimes having to take part in huge smuggling operations that put everyone at risk. He jumped ship in Brazil one time and ended up living in a village in the jungle for a couple of years. Made his way back to the states by working as a logger and a miner up through South and Central America until he made it home. Made and lost a fortune before he got sick, too. His stories are filled with details: what he ate in the jungle, how he had to improvise to make repairs on the ship, how he learned to dance across the logs as they took them down river. He wants to be admired, but rather than coming across as needy -- or full of himself -- he is often charming. He'll interject a comment like, "I know you would appreciate this part..." or "I hope this won't upset you, but once..." and he always thanks me for my time. Everyone at the center likes him. Today I reviewed his chart -- ten years of notes about Evan made by case managers, nurses, several psychiatrists. According to his chart, he grew up in West Virginia and first evidenced schizoaffective disorder at age 20. He spent the next few years on the street or in hospitals. He came to our program at just about the time when he should have been living in the Brazilian jungle. I said to Olan, who is his case manager, "Did you know that Evan was never actually in the merchant marines? Isn't from Alaska? Didn't know his father?" She smiled. "Yup," she said. "Tells a good story, doesn't he"?

Into the Bunker, Everyone, Quick!

I was sitting in a doctor's waiting room with a client this morning when my phone rang. It was a colleague who sounded jovial. He said he was calling to tell me that the very difficult client whom I helped to discharge to a therapy-only program had told him that she wanted to beat me to a pulp and then to burn down our center with everyone in it. I laughed. Then he told me that it had been a few days since she had said this, but that he thought he couldn't tell us because of confidentiality. In actuality, anyone in mental health should know that we have A DUTY to inform anyone of threats made against them. My colleague told someone that I had taken the news well, that I laughed at it. Well, yeah. But I also take a statement like that seriously. This is a person who has gotten into physical fights more than once, and who is ruled by anger. I was angry myself. She told my colleague that she had a trust problem with me. "Yeah, well I have a trust problem with you," I wanted to say to her, "How dare you make threats like that." She is very smart. No doubt she knows what the consequences could be for her. Elizabeth called me a few minutes later. "I heard," I said when I picked up the phone, "what are we going to do"? We went round and round about that with people above our level, trying to figure out what we could do that would not tip the client (further) over the edge, but that would also make it clear that she can't just say things like that. In the end, we were advised to go ahead and charge her with threatening behavior, and then to get a protective order to keep her from coming onto our property or having anything to do with this. She will be furious. I don't know how she might react. I have to admit that I have mixed feelings about it: I want her to be brought up short, but I don't want her to end up in the hospital. At the same time, another client told staff that he was in touch with the devil who was instructing him to kill his former case manager. The CM was warned, and the client signed an agreement not to kill him. And at the same time, we are working to get Shawna into a special program that will give her some longer-term care. And.... I saw Tess in the waiting room this afternoon. I asked if I could come visit with her some time and she said, "Sure, just call me." I'm not sure how I will approach her vis a vis the possible that she is dissociative, but I can't leave it alone. Thank God I am off tomorrow.

And It Just Goes On......

Okay, so I went to the weekly meeting with the big honchos upstate this morning. We went over the list of high risk clients that we meet about and they, as they most often do, castigated me for things they believe our program should be doing, or doing more of. I alerted them to what is going on with Shawna and said we had applied to add her to the high risk list. They were aware of that and had some questions about it and asked me to fax more info to them when I got back to the office. I did that. And a little later in the afternoon I got a call from the hospital where Shawna is. The social worker told me that the psychiatrist wants to release her to an intensive day program. I said, "Y'know, that's what we are. We see her every day to observe her meds. We have control of her money. And even then, she has managed to make four suicide attempts since August. I don't think an intensive day program is going to cut it." And THEN (!!!) the social worker told me that Shawna is now saying that she intends to kill herself. And they are going to release her?? Elizabeth was upstate herself this afternoon, for different meetings. So I got on the phone and tried to make sensible things happen for Shawna. Fifteen or so conversations later, it stands that our psychiatrist will talk with the hospital psychiatrist in the a.m.; to their credit, the folks upstate expedited adding Shawna to the high risk list, which gives us more power to intervene and hospitalize her; the hospital agreed to keep her at least until tomorrow when we can, I hope, come up with a workable solution. I was not exaggerating when I said to them, "If you release her today, she will die tonight." Shawna is so smart. She has told the folks at the hospital that she feels suicidal. But if we bring her out to us, so that we can commit her, we are 99% sure that she will say she is NOT suicidal. And then we >can't commit her. Catch-22. Elizabeth and I were on the phone on our respective ways home late this afternoon. She was as frustrated as I am, but she also had a litter of kittens in the car with her, crying to be fed: she rescued them and now must take them everywhere because she is bottle-feeding them. She wants everyone to see her as so tough, and yet... The day had one bright spot, for me at least. I overstepped my bounds at the meeting upstate to ask about Tess. I told them that I was beginning to wonder, after seeing her present as a little girl on one scary occasion, whether the reason everyone has had so much difficulty keeping her stable over the years might be that she is dissociative, and that in treating the bi-polar, we are not reaching the dissociative parts. One of the psychiatrists looked at me as if I had way overstepped my bounds. The other said, "Beautiful!" and turned to his residents and said "Did you hear that? Did you take note of that?" I was ecstatic. Hope I can apply this to being helpful to Tess somehow.

Saturday She Was Almost Dead, Today They Are Sending Her Home

Elizabeth called the hospital last night to check on Shawna and they told her she had been discharged. Naturally, Elizabeth was appalled - and terrified about what might happen if Shawna really had been sent right back home. She called the hospital again, using her head to thread her way through various nurses and people on the ICU, and then to the psych ward where, due to privacy laws, they couldn't actually tell Elizabeth that Shawna was admitted. Smart Elizabeth asked, "I guess if she's there I would think she is safe. Do you think she is safe"? Luckily, she'd hit on a good person at the other end of the phone, someone who bent regulations enough to say, "Yes, I think she is safe." So Elizabeth said, "If you do see her, please ask her to sign a release so that we can talk to you about her." That done, we found out today that Shawna is stable, lucid, doesn't want to go to a facility that can keep her for a longer time, says she is no longer suicidal. All the things one would say if one were smart and wanted to go home.... Whatever one plans to do there. So she will be discharged in a day or too, back to the place that makes her want to be unconscious or dead. It's just the way things are. It's not this particular hospital. No one can force Shawna to stay, unless she is committed to the state hospital for being a danger to herself or others. She is not a danger to others, and she denies being a danger to herself at this time. The rules do not allow us to add our prognosis for what is likely to happen in the near future. Similarly, despite our efforts, Elizabeth and I have not been able to find an intensive day program for Danni to try to kick drugs. I saw Danni today. She has voluntarily stepped up her attendance at the low-level rehab she's been attending, so that she will now attend meetings there three times a week. She's continuing to see me once a week and she says she is willing to go to NA or AA meetings. She shows a lot of insight into her situation: she knows that drugs are keeping her from progressing. She understands that the dreams she has about dying, or about being invited to the White House and having to hide her drugs somewhere on her body have to do with her knowing what drugs can do/can screw up. She can describe in detail the dangers they represent for her, both physically and legally. And she knows how hard it is for her to let them go when it is so easy to get them. I told her today that I think her psych issues have responded well to her current regimen of medications, and her increasing self-knowledge. If she can get off and stay off crack, weed, ecstasy: all the stuff that is so readily available to help her pass the time, she will be set to make a very productive life for herself. I tell her that when she is off drugs, she won't need a program like ours. when she first came to see me, more than a year ago, all she wanted was a Section 8 apartment, SSDI income to live on, and to be left to do what she wanted. She doesn't talk about that stuff anymore. She talks now as if she has skills and potential. And I believe in her-- maybe more than I should. I told her today that I believe in her because I don't see why she would come to see me week after week and let me tell her how she has to get clean before anything else can happen unless she really did want to get clean. Maybe I'm naive. But in this case, I don't think so. There's nothing else in it for her: I don't control her meds; I don't control her benefits; I don't even run interference for her between herself and her family or herself and society. Now that they have taken cold medicines with dextromethorphan off the open shelves at pharmacies, it's actually much easier for Danni to score crack than to get high on cold pills. All we can do is continue to cobble together whatever programs we can to keep her out of trouble. What used to be available for someone like Danni just doesn't exist anymore. What's the use of a war on drugs when you don't fund programs that help people get clean? Why are there no more all-day intensive rehabs? I don't blame her for not wanting to go into a residential program for six months. She still has a life. And why is it that she would have to give up Medicaid -- the only benefit she has from the government -- if she were to enroll in a 20-hour a week program, which wouldn't even be sufficient? Can anyone make sense of this? Or of Shawna's situation?

Almost But Not Quite

On Saturday Lea, who was on duty, went to Shawna's house to observe meds. The door was open and when Lea walked in she saw a barely conscious Shawna on the couch, one of Shawna's kids poking her and saying "Wake up, Mom," and a neighbor in hysterics, holding a phone and crying, "What should we do"? Shawna had broken into her med box and taken all the meds that were there. She'd drunk a fifth of vodka and cut one of her wrists. Lea grabbed the neighbor's phone and called 911. She slapped and shouted at Shawna, asking the neighbor and Shawna's son to help keep her awake until the paramedics arrived.... Shawna is in the ICU on a respirator. This is her fourth hospitalization in less than four months. She has been refusing to come in to see me or the psychiatrist. I used to see her regularly, and at one time I thought we were getting somewhere. I like Shawna a lot. I have come to agree with Elizabeth, though, that she is unable to make the changes that might make her life tolerable. I don't think she wanted to be brought back this time, and I don't know how long we'll get to have her around. Ironically, we had two specious suicide attempts this weekend, resulting in brief psych hospitalizations for the two clients -- serially, not as a pair -- each of whom had gotten into trouble with a crack dealer. Looking for a safe house. On a day like today, they got little sympathy (or empathy) from their case managers. Shawna is so complicated. I can understand her hopelessness; I can understand the damages her kids have had to sustain; I can even feel that it is her right to choose whether she wants to live or die. I can't make it matter to her, but many, many people will bear the scars if she succeeds in making herself die.

I Did It My Way

Highlights of the day: Mike took some of the guys to the beach today for a fall walkabout before winter shuts things down. They had on their wool caps and jackets and were loudly discussing on the parking lot what they intended to do: have some ice cream, feed the gulls, windowshop. Mike is just great about getting his guys out in the world. Jason is someone whose schizophrenia is so much in charge of him that he needs someone to give him his meds daily and make sure he doesn't leave pots burning on the stove. He needs looking after. At the same time, he is a meticulous craftsman, and is in his element when he is pruning a tree, building a shelf, fixing his truck -- he can do all of those things with ease. Today he was repairing and painting a wall that had been damaged when another client fell into it a few months ago. He was fretting about how it needed more spackle. One of the nurses told him not to worry -- just paint. Elizabeth told him the same thing. He stood there, shaking his head. He can't stand to do anything in a way that is not up to his standards. He is a handsome man, with a shining smile. I love to be greeted by him. There's another fellow much like him who had been living with family members who kept his money and were abusive toward him. He, too, needs a lot of looking after, but is a talented gardener. We found housing for him with some other clients a few months ago. We were worried that he wouldn't be able to sustain himself without more supervision. But he has blossomed. He manages his own money, he walks to the center every day. He is happy. and I am always happy to see him. Many of our clients have their meds in locked tool boxes. That way, the case managers don't have to get meds from the office all the time but can just go to a client's house and give them their daily meds, and then lock the box up again. Yesterday, one of the cms brought someone's box in to be filled. It was late, so she left it on a desk overnight. This morning when she opened the box, several roaches ran out. She was still shuddering at morning meeting. Later, the nurse noticed ladybugs all over the ceiling in that same room. From the horrific to the sublime. Like every day. Everyone is trying to attend to the couple who broke up. Each of them is weepy and confused and worried about making it financially without the other. But so far, they are doing all right. Danni says she want's an all-day drug rehab, but when the cm took her to look at one she said it wasn't intensive enough. I wonder if I can convince her to go into residential treatment -- long-term. I know that's what she needs. She and her boyfriend went through $1000 this week, up in smoke.

Breaking Up Is Hard to Do

Working out your feelings at the end of a relationship is tough for anybody. When your own relationship to your thoughts and feelings is the source of a disability, you are all the more fragile. No doubt you've heard someone say, "I went crazy when we broke up," or "I wasn't myself for weeks." With our clients, that can be serious business. The long-time couple who have been very active in the community at our center, and whom I mentioned yesterday as on the verge, broke up last night. I'd been counseling one of the pair, who asked to see me a few weeks ago, and who eventually revealed that he was very unhappy in this relationship. As we met over the last few weeks, it was my impression that he was sharing his feelings with his mate. I was puzzled that when I saw her she gave no indication that anything was wrong. In actuality, he had said nothing until he spewed forth a torrent of complaints last night when he felt he just couldn't take it anymore. And then he left. He came to see me for a scheduled appointment this morning, and he looked terrible. His speech was rapid, his eyes were wide. He was hypomanic, but then, he'd just entered into a maelstrom. Who wouldn't show some wear and tear. When he told me what had happened (at great length, repeating all that he had had to say to her), I tried to add, as gently as I could, that he has had a pattern of taking up with people who like to be taken care of, and that he takes care of them so well and so thoroughly, that they do less and less as he does more and more. And one day.... I'm not sure how much he could process that today. I told him to come see me every day, just for a couple of minutes, so that I can assess him and give him some support. Our psychiatrist changed his meds a bit to try to head off full-blown mania. Meanwhile, the woman he has left was calling to ask to talk to someone. Her case manager is out for the next several days. I can't see her because I am seeing her former boyfriend. So I recruited Pru to talk to her. She has a history of suicide attempts and self-harm, so Pru got her to contract for safety. But that's just the start, I'm sure. For one thing, she never does well without a man, and for another, she can't afford to live where she does or drive the car she does without assistance. She is sure to want us, or someone, to fix everything, and in order to make that happen, she is likely to do something to get herself hospitalized. It's selfish, but I am glad I'm not on call this week and weekend (with its full moon!). Meanwhile, I talked to the psychiatrist about dissociative disorders today. He said he has had little experience with them, but knows someone whom he respects who does a lot of work in that area. I told him my thoughts about Tess. He doesn't know her as well as I do as he's only met her in the last few weeks. We talked about how to approach treatment with her and agreed that the difficulty is that she pretty much denies her illness and is unlikely to want to explore the traumas of her childhood. As much time as I have spent with her, she has never mentioned them to me. She doesn't talk about the past at all. She is very present-focused (which is a strength in many ways). So I'm not sure she would at all want to do the kind of deep work necessary to reintegrate her personality, if, indeed, my theory about her is right. But it's good to be thinking it through with our doctor. He's a gem. Addendum: the client with the dead cat on her chair managed to bag cat and chair cushion and throw them away. Progress.

Ten Percent Dinner

We're fundraising for a holiday party for our clients. We've got a lot of different projects going from an office football pool to raffles to yard sales. A local restaurant promised us 10% of all dinner checks for a given evening. Tonight was the night. I brought some of my family. As we drove up I could see a lot of our clients waiting in line for tables, along with many people on our staff. I realized that, since I was with people from outside of our program, I would have to ignore the clients, to protect their confidentiality. Even when a couple of them greeted me, on their way out, and told me to be sure to order the onion rings, I couldn't explain to my companions who they were. After a short wait, we were led to a booth, where we sat down. Looking around, I realized that we were surrounded by staff members and their families: husbands, babies, brothers, aunts. It was funny to have a restaurant two-thirds filled with "my people." It felt good. I like seeing the clients in the community. Tonight felt like a party all by itself. The guys are trimming the smaller trees at the center these days, weeding and mulching to put the garden to bed, and sitting outside in light jackets, soaking up the last of the warm sun. Oh, and those case managers? Today they had a surprise lunch, with sandwiches and drinks and chips and cakes and cards and gifts -- for me and Elizabeth and the folks above us. Yesterday's baskets, they said, were just a diversion. Tomorrow I hope to pose my theory about Tess to the psychiatrist and see what he has to say. Today's events included news of a couple breaking up and the man moving on to another woman in the program. In such a small community, it's all community knowledge. Another client told me that one of her (feral) cats had died and that she had left him just where he had fallen because she couldn't bear to pick him up. I recommended that she ask one of the kids who come around to rake leaves and mow lawns to get rid of it for her. Later in the day I heard two case managers telling the gang that they'd gone to a client's home and there was a terrible odor outside her door and they looked down and saw a dead cat. Jeesh, I didn't know the cat had been dead for days!

Every Day's a Holiday

Last week was Case Managers Week. Really. Elizabeth was into it in a lovely way. She made sure that the cms had something every day: a pen with a superhero on top, cinammon buns for breakfast, a refrigerator magnet that says Case Managers Rule. I brought each of them a lottery ticket one day. They seemed to be happy for the attention and appreciation, and they all deserve it. Today Dana, who is one of the office administrators, knocked on my door and said they needed me in the back. "What now," I was thinking having been deep into some necessary paperwork. I followed her to the kitchen and saw Elizabeth standing behind the table with a quizzical look on her face. In front of her were two elaborate baskets done up with shrink wrap and big fancy ribbons, filled with candybars and nuts and soda and crackers and cupcakes and... I couldn't even see it all. And those baskets are heavy! The note on mine said, "Happy Boss's Day from the partly psychotic case managers who are half-stable, thanks to you." I've never heard of Boss's Day, and in general I don't like the things the card companies make up for us to celebrate, and heaven knows I don't need more snacks! But the sentiment means a lot to me. What a good crew. It's a little wacky, but whenever anyone has a day off, I miss them. Elizabeth said, "Why is it that we are always buying food for each other"?

Tess One, Tess Two, Tess Three

Tess was one of the first clients I dealt with when I came to this agency. I was charmed by her wit, her intelligence, her prevailing beauty at age 50 or more. She is a widow and has lived alone, scraping by, for a few years. She'd been stable for a long while before her husband died, but before and after that she had a history of many hospitalizations, some lengthy. Her diagnosis is Bipolar I. When I met her more than a year ago, her problems seemed to me to be purely financial: if we could just pay her mortgage and keep her lights on, I thought, she would be well. Big lesson for me. I went out on a limb to get the money from emergency funds to pay a month's mortgage and the electric bill, and just a few weeks later, there we were again. And this time Tess was presenting as psychotic, which in her case can be pretty scary. When she is good, she is very, very good... when she is psychotic, she is prone to rage, to wrecking her house, to kicking out all the windows in her car, to tossing her clothes into the street and to threatening to take apart any case manager who tries to stop her. She has chased big men off her land and scared one case manager so badly that the cm refused to go back to her home ever again. I've never been afraid of Tess, even after she locked me out of her house with my purse still inside and I had to call the police to help me get it. Even after she told me to stay the hell away from her or she didn't know what she might do. Even after she threw her telephone at me. I don't know why, but I always see Tess in there, behind all that pain and confusion. I always think I can reach her. And I am wrong. When Tess is psychotic, which can last for months, I can't reach her. I don't know who can. But today, thinking about a comment someone called "Observer" posted here, I developed a new theory about Tess. Walking out of my office, I found her sitting in the waiting room. She greeted me with a smile and I sat down for a few minutes to ask how she was doing (fine) and to inquire about her granddaughters (they're wonderful). We talked about the rising price of fuel and the expected astronomical cost of heating our homes this winter, and about the fun of hosting sleepovers for young teenagers. It was a conversation between friends, what I always enjoy most with Tess. Anyway, my new theory has to do with Observer's discussion of dissociative disorders, how someone who seems to be bipolar may be dissociating: turning the face of her personality to the wall in order to endure some awful trauma, and allowing some other half-formed personality to emerge. (Yes, we've called this multiple personality in more dramatic terms.) I thought about how Tess was grievously abused by her father for a couple of years beginning when she was about 12 years old. I remembered a time when La Jo and I went over to her her house and found her curled up on the sofa, talking in the voice of a little girl and staring with terror at someone we couldn't see. I thought about the angry sentinel who scares off anyone who tries to touch her when she is not well. Tess One: my Tess, Tess the good mother, the good grandmother, the smart, capable woman who keeps body and soul together in spite of so many setbacks. Tess Two: the little girl, so afraid, so alone, so terribly betrayed and harmed by one who should have been shielding her. Tess Three: the warrior, who would go to any lengths to protect that little girl. I am sure that Tess has bipolar symptoms. Several of her family members in her own generation and the one preceding share that diagnosis. But I am strongly suspicious now that she is also dissociative, that to protect herself within horribly traumatic circumstances, she found a way to "go away" and leave someone stronger there to fight for her. At great cost. It's just a theory. I think I will run it by our psychiatrist next time I see him. And thank you, Observer, for your comments.

PTSD? I Guess So.

When I was a teenager, the house I grew up in was torched by some angry people. Long story. Not going to go into it here. They threw the bomb into my bedroom, because I had left my window unlocked. The house was lost. My room had no floor, no ceiling. For ten years after that, I couldn't talk about that experience without shaking. Even when I thought I could address it calmly, my whole body would begin to shake when I started to tell the story. And I had to tell the story. That is how I got over it. How many years do you think it will take for the people of the Gulf Coast-- many of whom cannot even return to their home town, let alone their home? How many years do you think it will take for the survivors of the Central Asia earthquake? For the survivors of the tsunami?

Crack Baby

I was working on someone's chart most of today, catching up on paperwork that hadn't gotten done for months because he disappeared a few days after he came into our program, then reappeared, then disappeared. I no longer work in his area or on his case, but I was the one who had started to put the chart together so I had to return to bring it up to date. He's just a kid -- 18. He "aged out" of the juvenile system where he had been incarcerated for most of the past five years. That makes him 13 the first time he went in, the same age his mother was when she gave birth to him. At that time, she was smoking crack and drinking. Who knows what had been done to her to set her on that path so young. He stayed with her for seven years. From the get-go he was a lot to handle, and it isn't clear what kind of support his little mother had. The first reference to his getting in trouble was when he was five and was fighting in kindergarten. I mean serious fighting-- really hurting other kids. His mother couldn't cope. When he was seven, she sent him to live with his father. And when that got old, after a couple of years, his father sent him back. He ping-ponged back and forth like that for the next few years, with several stays in foster care in between short stays with one or the other of his parents. And when he was with them, he was often beaten, and sometimes witnessed his father or stepfather getting into fistfights with their women. Once his mother abandoned him in a social services office saying she had run out of ideas. Legally, he has a record a yard long. Because he was so young, a lot of charges against him were lessened or dropped, but by his own account he's been picked up for assault more than 30 times, for carrying a concealed weapon, for arson, for menacing, burglary, auto theft, robbery, sexual harassment. He's 18, remember? His lengthy history diagnoses him with Bipolar disorder, with mania presenting as rage most of the time. When he's not lashing out at someone else, he is prone to suicide attempts and self-mutilation. There is no bright spot in his record. None that I can find. There is no one who writes of making progress with him, although it is clear by the detailed descriptions of his history and his self-presentation to the writers who describe him that he has been among clinicians and others who have been interested and who have cared about him. They pronounce him unemployable. They pronounce him as needing one-on-one supervision most of the time. They pronounce him as unable to control his impulses. And none of the meds they have tried have worked to "stabilize" him. Maybe with a history like that, that is your stable baseline. His mother and father don't use anymore. They have regular jobs and new families. I don't know if he'll be able to have that life, ever.

What Next?

The beat goes on.... Harry is expecting us to pay his rent now that he is out of money. He hung around all day today telling everyone how nice we are, how pretty we are, how much he appreciates our hard work and wishes he had a car like Mike's. (sigh) Danni has taken to calling me "darlin'" and telling me that she's down to the barest minimum of drug use now so not to worry. I alternate telling her that she needs maximal help to get off drugs (which she doesn't want to hear) with reminding her of how much progress she has made this year, how much she has to lose if she keeps using. One of our cutters has been in and out of the psych hospital for the last two months. She cuts herself deeply enough to need stitches, or calls with a suicide threat. Then she goes to the hospital for a few days, and once she is back home it is only a day or two before she gets sent back up. My thought is that she can't stand being home and is doing everything she can to get a long-term admission at the state hospital. It's sad. She is so smart, has such a great sense of humor. I like working with her but I don't think I've been able to do a thing for her. Meanwhile, the writing is on the wall that it will be harder and harder to get public funds for our program. It's clear that the Katrina/Rita clean up will be economically catastrophic. Where will the money come from? Us. That is, programs like ours, and people like you and me. Those tax cuts for corporations and the elite 1% are sacred. And then there is Pakistan to break your heart. When I look at how small my paycheck became when I cut back to four days, I look back out at the world and thank my lucky stars.

Counselors in the Trenches

My mentor is about to leave for Baton Rouge, where she has volunteered to work as a therapist with evacuees who are still living in a shelter that houses more than 600 people. She is leaving her practice, and livelihood, for 10 days and going with only a backpack. I so admire her, as ever. Hundreds of counselors, social workers and psychologists have volunteered with the Red Cross. From what I hear from only a few reports, much of the work they are doing is not really therapy but assistance to people who are still looking for family members, still wondering what condition their homes are in, and who do not know how or where they will live, not only in the coming months but for the rest of their lives. How can you practice therapy in such critical circumstances? You look for signs of breakdown, and you shore up those who are able to hear your words or accept your care, I guess. Those stories are continuing long past the media's interest in them. I will be cheering my mentor in her work, and waiting for her report, as well as that of one of our case managers, who has been there for nearly two weeks so far. Bravo to every one.

Harry's Back

It would be wonderful if every client could be given the right meds and a game plan (or treatment plan) that they took to with enthusiasm, so that, in the end, they could be as ready for life as Trish is. We've had Harry back for a couple of weeks now. When he came out of the hospital they acknowledged that he would be there, or in jail, again soon. Within days, he was in jail. Now he's out again, on probation, as well as on a court order for mental health treatment. He has an Axis II diagnosis, specifically that of Antisocial Personality disorder, or what some might call Sociopath. While he does evidence signs of Schizophrenia, it is that intractable Axis II diagnosis that indicates the true measure of his potential. A week before he was released from jail, I got one of his "I've seen the light" phone calls. His social worker put him on the line so he could tell me that he had lined up a job and would no longer claim that his injuries from a car accident years ago made it impossible for him to work. Further, he had found a church that he intended to attend daily. He had it in mind to move to a certain motel that would be within walking distance to both job and church (and the local dealers). And he wanted us to be sure to have his money waiting for him so that he could get all of this rolling. It's been about ten days now. He's living in Crack Town, not the motel he'd designated because he couldn't afford that. He rents a room. He is almost never home when the case managers go up there daily to observe him take his meds, and if they do find him, he refuses to take them. Yesterday, he came into the office to get his money, as if was an overdue paycheck. No way, they told him. Not until you see the doctor. Most of the time when I see him, or when Elizabeth sees him, he is all over us about how nice we look, what perfect shoes we have on, or asking us whether we had a nice weekend. All up in your face with smiles and "Miss This" and "Miss That." In his case, I'd have to say he is pretty transparent. I have a family member with the same diagnosis, but in the days when I was willing to be in touch with him, he was so much more clever. He had a way of figuring out just what you wanted to hear, just who you wanted him to be, and presenting himself as exactly that. To me, he was the appreciative little boy, who remembered my playing with him and taking him to the zoo. To my aunt, he was the pious nephew, who thought deep thoughts about God. To his neo-Nazi brother-in-law he was a frustrated killer. I have no idea who he really is, if he really is anyone. Poor Harry, though, can't keep his footing in the world. He seems to be able to manage nothing more than a feeble bounce between the hospital, the jail, us, and back round the circle again. And as he gets older, it is harder and harder for him to manipulate or charm the people he thinks he can get over on. When we last talked about him at the weekly meeting at the hospital, the psychiatrist ventured to predict that before long, he would find himself at the mercy of a dealer who no longer found him charming.

Cinderella

Trish is a client who works with us. She's been answering phones at our office for years. We are so used to having her around that we often forget she is more client than staff. And if she were not my client, I know we would be friends. She has the kind of yard sale savvy that I wish I had, her house filled with the creme de la creme of Fifties and Sixties style. And she dresses very cool. I am managing her case now and I had to update some routine things in her chart. I hadn't even looked at it before: I don't do her meds or make her doctor's appointments or any of the usual things one does when one is case managing. I see her every day, so when it is time to write up a monthly well-being report I just walk out into the waiting room and ask her how she is doing. Really, all I do is keep her paperwork up to date. We're doing chart reviews now, getting ready for state inspection. So I pulled her chart and started going over it, section by section. In the history section, I found that she had had psychotic episodes severe enough to land her in the hospital a dozen times within a five year period. The history notes that her mother has a history of alcoholism and probably psychotic episodes. She deserted the family when Trish was 11. Trish has placed a do-not-contact-my-mother note in her charts. When Trish was a young teenager, she was sexually abused by a neighbor. In high school, she evidenced hallucinations and grandiosity for the first time. She claimed to have gotten a recording contract with Columbia. She wrote hundreds of incomprehensible songs. Her boyfriend stuck by her, married her, swung through all the years on the mania-depression pendulum. They are still together. They raise dogs. They like to go to car shows. They have created an elaborate perennial garden that they like to present to visitors. It's been ten years since Trish was last hospitalized. I've known her for more than a year and haven't seen her act out in any way, although I am told we have to keep watch to prevent her from becoming overwhelmed by too many responsibilities. Even though it seems as if she can handle it all, and never turns down a request, people who have been with our agency longer than I have are very protective of Trish. Lots of our clients have difficult histories and major diagnoses. Not that many get to where Trish has. She has been maintained on a couple of meds that seem to work perfectly for her. I don't know how much to credit the meds, how much to credit Trish, how much to credit her strong relationship with her husband. It's hard to make it without the right meds. It's hard to make it without perseverance and determination. It's hard to make it without supportive relationships.

No Time for Lunch

Busy all day long. One of our staff members has gone off with the Red Cross to help hurricane survivors. We are proud of him but have to divide his caseload among everyone else until he returns, which may be a month from now. Cindy has been out sick, Elizabeth is at meetings, our office manager is on leave for a month. Something's up with Mert. She hangs around a lot more than she used to and rings the bell and knocks on the office door many times a day to request everything from a glass of water to a hairdo magazine. Who knows. When I saw Danni yesterday she told me she is broke and has left some of her most cherished possessions with a dealer until she can pay her bill. Then she asked if the doctor can prescribe something for impulsivity. Meds are wonderful. They do allow some people to have more of a life than they possibly could have otherwise. But some clients expect that the meds can do it all. Meds can make you smart, patient, free from cravings, happy, sleepy at the right times, attractive. Not so, of course. The false impression that some of the clients have that the meds can solve all of their problems is a problem in itself. It's not easy to work on changing your behaviors and attitudes. I know that well about my own self. You have to be committed to work at it until you train yourself to think and behave differently. Wouldn't it be awful, though, if a pill could totally transform who you are? Today I met with Allison, who has a diagnosis of bipolar, perhaps schizoaffective. Like many clients, she is very preoccupied with herself: her plans, her looks, her desires, her needs. She has developed a love interest and has taken to wearing very tight, very small articles of clothing. She is a big woman. She told me that not everyone is happy to see her looking so "sexy." The psychiatrist came to my office today and asked if I could somehow let her know that she needs to dress a bit more conservatively. "It's just all hanging out," he said, "It doesn't give the impression she thinks it gives." My point, though, is that she has been asking me and the nurses to give her written information that she can send to her family to explain to them why she is the way she is. She wants a personal analysis accompanied by appropriate educational brochures from the pharma companies that will describe her illness. I asked her whether she had thought about making amends with her family and she said, once again, "I'm tired of apologizing for something I can't help. They need to understand that I have a mental illness and just accept that I cannot control my behaviors." Well, yeah, in a way. But to me that is a perfect example of my need to sort out illness from personality. Everyone who has a mental illness is still an individual. Some are thoughtful, endlessly polite, eager to please. Some are rude and angry. Some are oblivious to everyone and everything around them if it doesn't directly relate to their current needs. No matter the diagnosis, I can't help being prejudiced: help yourself to the extent that you are able. Then ask for help with what you can't handle. Point: Pru had a client who jumped up and down about needing Pru to find her a place to live because she was being asked to leave where she was. Pru said no, insisting that the client find her own place, knowing that she was perfectly capable of doing that instead of sitting in her living room chair wrapped in an afghan all day. The client raged. Pru held firm. The client found a place to live. I once knew a girl who cut school regularly. Her technique was to walk swiftly past the security guard and just say "psych pass" as she went out the door. It worked. But I'm not giving anybody here a psych pass. Our jobs are to enable them to take care of themselves.

Your Voices Say What?

A bunch of us were in the computer room doing copious amounts of paperwork when Mike walked in. "Anybody want to go in on a pizza"? he asked. He collected some money from a few folks and they debated the comparative merits of mushrooms and onions vs. sausage, pepperoni and olives. Mike started for the door, then turned around and said, "Hey, I forgot to tell you guys in meeting this morning. I stopped over at Tom's today to give him his meds. He was cooking up some salami and eggs. I asked him how he was doing and he said he was hearing voices. So I said, what are they saying? And Tom said, 'They're telling me I just come into a million dollars. I know I'm not getting any million dollars. So I just told them to shut up." We all laughed and Olan said how she might have thought twice before she told that voice to shut up. The thing about the laughing is, we saw Tom try to kill himself last year because his voices told him he was worthless and should drink whatever he could find under the kitchen sink. We heard reports on him when he was in the ICU and during the weeks that followed when we weren't sure we would get him back. And that was not the first time that his voices had caused him harm. He is one of the sweetest men in the program. When his voices leave him alone, he sits out at the curb with some other guys his age and greets people as they walk by. When the young case managers come by to see him he tells them they are beautiful and full of God's grace. We all love Tom. So we are laughing not at his illness, but out the joy of thinking that he is hearing something so un-terrible, and handling it so well.

Inventory

I'm trying to remember where everyone who isn't in the community is right now. I know we have two in prison, but I keep thinking there's another one I'm forgetting. Then again, it might be that I'm just feeling the shadow of one of the people who is probably on his way back to prison, as we have a few who just rotate through the system. Okay. We have one person in long-term rehab for physical illness. One in long-term rehab for alcoholism. Four in the psych hospital. Nobody homeless at the moment although a couple are teetering on the brink, living in some marginal places until we can get them into something better. When the case managers are frustrated they come to me and say, "why can't the clients just...." and I tell them that no one can change anyone else and that we'll all be happier when we admit that. Today Cindy was telling me, in the dramatic re-enactment mode that she favors, about how she laid down the law to a client who has moved in with another client, having foxed himself out of a home. "If I hear of any trouble here," she told him, "you will be on the street. I don't care if you caused the trouble or not. You are the one who had nowhere else to go and prevailed upon your friend. So if anything, anything, happens bad, you're out." She was so proud of her ability to be tough, but I had to ask, "do you think he heard you"? She thought for a minute. "No," she said. I think the quintessential example of this is the client, now living elsewhere, who gambled away all of his money, his car, his home --also leaving him jobless. No one -- no one -- could convince him to live any other way. He'd show up broke, in tears, at the psych hospital every weekend because he didn't have enough money to get home or take a motel room. "I'm going to kill myself," he'd say, and they would have to let him in.

Waiting by the Phone, Hoping It Won't Ring

Luckily, I don't have to be first-line on-call. Each week, two case managers work that job. They go to the homes of clients on daily med observation and field any calls that come in to our after hours line. If they don't know what to do, they call me or whoever else is on back-up. And when I don't know what to do, I call Elizabeth. I've had a few calls this weekend, but nothing that got me out of the house, or even out of bed. A client wasn't home for med observation (happens all the time, of course), a client was picked up by the police and taken to the hospital (at least we know he's safe), another client took himself to the medical hospital; he was admitted and we don't know why yet (there again, at least he is in professional hands). One of the first times that I was back-up, almost a year ago, I got a call that a client had jumped out of his window. His voices told him to do it. It was only the second floor, but he managed to break some bones and bring on some internal bleeding. I didn't know what I was supposed to do, except to drive to the hospital, almost an hour away, and sit there with the case manager until we could get some word on how he was doing and where he would be admitted (he was med-evacked to the big city). We sat around in the waiting room at the ER with his family -- a great number of them. They went out for chicken and burgers and kept asking us if we wanted anything. We had to say no thank you. In the end, we were there until about three in the morning, when we finally learned that he was going to be okay and would be sent to the city by ambulance. We stood around his bed, holding hands with his nieces, saying a prayer for his well-being. The case manager still couldn't tear herself away, but I left. I needed some sleep. The next day our supervisors asked us why we had stayed so long. They asked us what we thought we could accomplish by staying at the hospital like we did. I thought they were heartless. Now I know, that's not my job. If it happened today (please God, no) I would probably just call the ER and make sure he was being taken care of, and make sure the case manager got a copy of his med sheet over to them. It 's not that it's ho hum, it's just the way it has to be.

Seven with One Blow?

Someone asked today if there is something toxic in the water around here all of a sudden. In the past two weeks we have had three suicide attempts and two people who weren't answering their phones or their doors so that we ended up calling the police to make sure they were alive. Today we sent two people to the psych hospital (one was Shawna who has money problems and whose response has been to cut herself over and over again, more and more deeply) and lost two others. We found one-- she hadn't answered her door or her phone despite loud knocking, car horns, multiple phone calls, but when the police came, lo and behold there she was at the door saying "Oh, I must have fallen asleep..." The other client is still missing in action, is missing his meds, using, and definitely decompensating big-time. Tomorrow, if we don't find him, we will have to file a missing persons. It was a day of feeling low-- Pru is CM for three of the above and she is taking it personally (even though, as our psychiatrist said today, you have to remember that these people have chronic illnesses for which no on yet has discovered a miracle cure). Others of us were feeling like we just tread water, reaching out occasionally to keep someone from drowning. Despite our having been going to Shawna's home every day, when I called the state to say she needed to be hospitalized they asked me what we were doing to keep her stable and why we were using the ER. "Let your own psychiatrist assess her," they said. Right. She wasn't about to come in willingly, didn't want to be hospitalized, is a danger to herself. That calls for police involvement and an involuntary commitment in my book. Danni came in to see the doctor today and didn't stop to see me. Nor has she kept appointments with me for the past two weeks. She's using for sure. Carver came in for his appointment. He wants some cognitive-behavioral help with learning how to say no to people. That, at least, I can do.

Car Wash

Still lovely weather today. I saw that the guys on the parking lot were washing one of the vans. I was on my way out to lunch and I stopped by and said, "If I bring my car around here after lunch, would you please hose it off"? Mel, the lead car washer, said he was leaving. But he said he was sure that Carver and Thomas would be glad to do that. When I returned, they were waiting for me, moving the traffic cones aside and gesturing for me to park near the hose. About 30 minutes later one of the clients knocked on my door and said, "Carver says your car is ready." I went out to move it out of the way. The guys were beaming when I thanked them. "Not me," Thomas protested, "Carver did all the work." I feel bad that we can't pay them. When we want to give something to a client, even a few towels for their apartment or some vegetables, we have to pretend it came from "the community." At the same time, when the guys wash a car or mow the lawn or paint a room they feel productive. And, to paraphrase the popular commercial, that's priceless. A little while after I thanked Carver and Tom, Carver knocked softly at my door. "Come in," I said. Carver, wearing his engineer's cap, his long hair hanging halfway down his back, peeked around the door frame and said, "Got time for some therapy"? We made an appointment for tomorrow.

Some of It's Fun, Some of It 's Silly, Some of It's Sad

Oh boy. In women's group today I looked around and realized that everyone at the table had multiple tattoos. There were a few butterflies, some abstract anklets, a dagger, a skull, a fairy on a leaf, some Chinese characters. "You know," I said, "I think it would be fun if one time we had a show and tell of our tattoos." They smiled and laughed and started to get behind the idea. "Do you have a tattoo"? Evie asked. "No." "Field trip!" she yelled, and everyone said, "Yeah! We'll all chip in!" I was flattered, but I had to decline. On my way home from a meeting tonight I got a call from Mike. "Got a minute?" he asked. "Sure," I said, "I'm just lost out here in the county somewhere. Sure is pretty." "Listen," Mike said, "I just need to tell you or Elizabeth about what happened today in case anything comes of it." Then he told me that he had gone to observe a client taking her meds. When he got there, the front door was open. He knocked on the screen door and the client's mother called, "Come on in." He said, "It's Mike, from the agency." She said, "Okay, come on in." He stepped inside and found himself facing a bathroom. The door was open and the client's mother was sitting on the pot, her skirt ballooned around her. "Hi," she said, "my daughter ain't here." Mike was in shock. He was speechless. The woman proceeded to try to have a normal conversation about her daughter's progress, while Mike backed toward the door and excused himself. "Someone will be around tomorrow," he said, "'Bye." "Am I doing something wrong?" he asked me, "Have I offended the gods"? I laughed for about five minutes. After I drove on for a while, my thoughts turned to Richie, who had been in to see me this morning. He told me he had had a terrible day yesterday because he had watched a show about fraternities and the things that happen to women at frat parties, the way the brothers feel they have to prove themselves. I asked him if that made him remember how he had been treated while he was in prison. He is a slight, very handsome man. He said, "Not just in prison. My whole life. I know I'm not supposed to blame myself, but I haven't always been the best person." We talked about how no one is the "best" person, and about how children, and even young men in prison, can't be held accountable for what they inspire in some people. It happens a lot more than you'd like to think it does.

Tote That Barge

Today I received the conditions for my going from five days a week to three. The Powers That Be say that I will then be demoted, my base pay lowered, my benefits decreased, and my salary would be half what I make now even though I would be working three-fifths time (not including time when I am on call). What's wrong with this picture? I can't afford it, so it's out of the question. After I worked on being able to swallow, I went back to my duties. These included spending an hour and a half with the client who is so upset that we are discharging her. She described in detail how abandoned she feels, how it fits with all of her past experience, how she knows that everyone in our program is glad to see her go. Some describe my job as "holding." I am meant to hold my client's' feelings so that they can safely let them go. I "reframed" her statements, pointing out along the way that people have been calling her and she has not responded, that others have gone over to her house to see if she is all right, that the doctor has offered to continue to see her in another program. She started to tell me that she felt like killing herself and I stopped her: "If you tell me that, you know I will have to hospitalize you." She knows. My neck felt like a steel rod by the time I had gotten her an appointment for next week at the place she is now transferred to and wished her well. Shortly thereafter, one of the staff called in an hysterical state. She had lost her keys and needed to get to a doctor's appointment. She needed a ride, from the client's home where she was stuck. I was on my way out so I volunteered. When I got there she was pacing in the middle of the street and when she got in the car she burst into tears and rattled off, loudly, all the reasons why her job sucks and is impossible to do and other people's jobs are easier and no one sees how hard she works or how much effort she puts into everything. I took slow breaths and told her that I knew how she felt, that it's terrible to always be rushing so that you make stupid mistakes, that she needs to try to do less. "Do less?" she yelled, "I can't do less. Everything is overdue and there is no one else to do it." She jumped out of the car, slammed the door and threw a quick "thanks" over her shoulder when I dropped her at the doctor's. And all that stuff was not just sitting in the car, but was sitting right on top of me, on my head, on my shoulders, in my lap, so that I had to teach myself how to swallow again.

Whoa....Can We Slow Things Down Just a Tad?

Another day when Elizabeth had to be out. I was trying to have a therapy session with a client who has been way up and way down all week, and people kept calling or knocking on my door and saying "I'm sorry, it's an emergency." My client was saying she understood, but I could see that she was feeling passed over. These really were emergencies, though. For instance, someone called to say that last night one of our clients had told him he was going to take an overdose. So Lorraine and I sent a CM over to his house to see if he was all right, the neighbor having reported that his car was there, but no sign of him. Cindy rushed over to his apartment and called on her cell phone to say that the door to the apartment was ajar and the client's keys were in the lock. She peeked inside and saw no one. She wanted to know what to do. I told her to call the police. If she entered the apartment, our brilliant office manager advised, and found an unconscious person, she would be obligated to perform CPR, because all of us have been trained in CPR. And then we would be involved in whatever the outcome. (What would I do without the endless, accurate information housed in our office manager's brain?) Later, the nurse told me that she was talking to Cindy on the phone while the police were there and she heard Cindy say to the client, "You're here! Where have you been?" And when Cindy returned to the office she said that the client was shocked to find the police at his home, as he had just gone across the way to see a neighbor. "But your keys were in the lock and the door was open," Cindy said. "Oh, I always do that," the client said. You would think we would all be very thin with all the adrenalin we're pumping every day. Stress engenders doughnut and French fry craving, though, and you're too tired to resist.

Everybody Grieves

And everybody is addicted. I've had two trainings this week: the first on grief, and the second on theories of addiction. Both very pertinent. I guess I've been naive in my knowledge of grief therapy. The presenter this week widened the scope of grief to include all sorts of losses. When you look at it that way, everyone must be grieving something all the time: the loss of one's youth, a lost love, a lost pet, a lost opportunity, a lost job, etc. etc. In today's workshop on addiction, the presenter challenged anyone in the room who said they had no addictions. She outlined the history of theories about addiction, from the early idea that addiction was a sin, to the idea that it was learned behavior, to today's theory that it is a biopsychosocial phenomenon, involving one's biological make-up, one's psychology and emotional make-up, as well as one's social history. Makes sense to me, but then, it's just this century's theory. Now we're into controlling all the neuro-transmitters so that we can fix it. I wonder. I do believe in biochemistry. I just think our understanding of the brain is still very primitive. I saw my mentor tonight and we talked about Danni's continuing relationship with dangerous substances, and her lack of insight. My mentor advised that I tell Danni I can't work with her any more, that I care about her and will be there for her once she achieves some lengthy period of sobriety. I agree that this is the right course, but it will be hard. I will talk to the people in the county and at work about getting her into one of the few intensive day programs for addiction that exist after recent years of decimating funds for social services. She no longer has insurance, which, ironically, makes that easier. I hope and pray for her.

The Beat Goes On

We found the client who lives in Crack Town! That is, Cindy did. She asked one of the regulars to show her his house, and sure enough, he was home. So now we can go over there twice a day to observe him take his meds. Might not have much effect as Cindy says he was very paranoid, had water running in the kitchen and when she went to turn it off he yelled, "No! Don't touch that!" She asked, "What are you going to do with the water?" He said, "Just leave it on." At times during the few minutes she was there, she says, he stared into space and seemed to be listening to something she couldn't hear. No doubt. He wasn't wearing his bicycle helmet today, as he often does when he is seriously decomping, but he had on a hat. He's using and he is on his way. It's sad. The day was a series of little problems, trying to soothe clients and case managers alike. Everyone seemed a little on edge today. And I was feeling pretty pissy about the fact that we will always do our utmost for the clients, no matter how much we are nickel and dimed within the limits of our meager pay. Just like teachers, but we make less. I have to wonder what I was thinking when I stepped down in pay at this stage in my career. I had no time to return phone calls today, so I returned them from the car on my way to an appointment. A client, Fran, had left a message that something bad had happened on the weekend. She is the client who recently fell in love at work, so I figured that wasn't working out. When I called her she said, "Something really bad happened this weekend." I said, "Tell me about it." She said, "I lost the position I wanted to have at work and I got so upset that I went home and took a bunch of my pills and drank a bottle of Scotch and lay down to die." I gasped. "Why didn't you call us," I said. "Because I wanted to die. But I didn't just fall asleep and drift away. I got violently ill with terrible pains in my stomach so I called 911. "And what did they do"? I asked. "They took me to the ER and I was treated there but they didn't send me to the psych hospital because I told them I wouldn't go because I knew that would just make things worse. I wouldn't give them any information on family or other people, so they sent me home in a cab. I didn't call you until today because I felt too weak. But I feel pretty good now and I'm not depressed any more." I didn't get to ask her about her love life.

Intensive Care

Today Lorraine, one of the nurses, asked us to be especially gentle with our doctor, who is taking Hector's suicide attempt very hard. He has visited Hector more than once since Thursday, and Pru said he could not have demonstrated more compassion, not just for Hector but for his roommate and for her. He's an exceptional guy. Although Hector is improving, he is still in intensive care. Now that his meds are getting back up to the levels he needs, he is embarrassed. When he is on the right doses, he is one of our most succcessful clients: very able to take care of himself, smart, fun to be with. And he wanted to reduce this one med because it makes people gain a lot of weight, and in his case was causing some additional potentially serious health problems. He had been psychologically stable for such a long while that it was very reasonable for Hector and the doctor to try to change his regime. I hope this won't be a long-time setback to his progress. Wouldn't it be great if some of these wonder drugs (which they really are, for some people) didn't have such awful side effects?

And It Isn't Even a Full Moon

No big emergencies today, but some near-misses and some growing storms. Went to the hospital to bring Hector his psych meds this morning. As I got to the door of the hospital I noticed that the meds had not been filled properly -- he was short-dosed on one of his key meds, the one that had been reduced before he decompensated. So I went back to the office and got the correct doses and returned to the hospital. Hector is in Intensive Care but his nurse said his vital signs were good and he is calm. I didn't go in to see him because I don't know him well and didn't want to upset him. His roommate was on his way over with Mike the case manager, so he wasn't going to be forgotten. Back at the office, where I was Dog-for-a-Day because Elizabeth is out sick, I found that another client had left word yesterday that he had moved temporarily. This is a client who has been in rehab for a year and doing very well, but who left rehab a few days ago to fall back under the spell of his untrustworthy siblings and resume his drug use. His family found him a place to live that is convenient to Crack Town. So he's already using and showing signs of going downhill fast. He'll be back at the state hospital soon and they will blame us, even though, like the people staying put in New Orleans, our clients are free to choose where and how they live. We can't strap them down. Meanwhile, he had not given us a specific address and no one had thought to get it from him. We had a vague description of the location. I tried to reach some of his family members, without any luck. The guy needs his meds. Finally I sent Mike and Cassie to Crack Town to look for him. They went, got freaked out by a crowd of junkies, and came back without finding our client. So all I could do is document our effort and wait for a call from the police or a hospital, which can come any time. We also dispatched Mike and Cassie to check on the woman who ran from my office Wednesday threatening suicide. She has caller I.D. and won't answer our calls. Staff have reported seeing her car at her building, but when Mike and Cassie knocked, no one answered. "Don't worry," our very organized and long-time office manager said, "she won't do anything without publicizing it well in advance and making sure she has an audience." But I do worry. In between these chapters, I had a parade of case managers coming through my office to vent about things that are troubling them, from promised raises that don't show up, to uncooperative colleagues and clients who curse at them. I like to be there for the CMs that way, but when person after person needs to blow off steam, I end up holding on to what they get rid of. By the end of the day I had to turn on the "white noise" box in my office and sit with my eyes closed just to find a few peaceful minutes. So I guess this is my venting. Thanks for listening.

77 Pills All at Once

I went out to do some errands before lunch. I had brought my lunch so I felt okay about taking the time to do errands. It was a beautiful, softly cool day, with lots of sunshine. I drove onto the parking lot feeling relaxed and breezy. Lorraine, the nurse, was walking on the parking lot and ran up to my car, motioning for me to open the window as I opened the door and almost hit her with it. "Hector J. took 77 pills. They called 911. Pru is on her way. Elizabeth isn't here. I think you might want to go over there." I couldn't even process exactly what was going on. I don't know Hector, know only that Pru is his case manager and that for many months she has reported on how well he has been doing. He has had a job, he is independent with his meds, he gets along with everyone, his hygiene is good. I've seen him at the center and considered him to be doing very, very well. A few weeks ago he asked to be weaned from one of his most difficult to take meds. His dosage had been gradually reduced and he seemed to be handling it very well. About five days ago Pru started to report in morning meeting that he didn't seem like himself. He was not showering or shaving. His clothes were a mess. He couldn't focus. So the psychiatrist began to bring the level of that particular med back up. Hector had gotten to about half his previous dose when this happened. To make a long story shorter, Pru and I met up at Hector's house, where the police had already taken him away. Pru said that when the police walked in Hector jumped them, so he was manhandled and cuffed before they took him to the hospital. Pru, and an unlucky student who was shadowing her today, had gone through Hector's rooms and collected the empty bottles of over-the-counter sleep aids he had bought this morning, so that they could show how much he had taken. They also had found a note that said, "Forgive me for all of it." The police asked for Hector's roommate to come to the hospital, so Pru transported him and we met up at the ER. Hector was so agitated that they had had to strap him down and were having trouble getting his vital signs and getting a naso-gastric tube into him. I told the triage nurse that Pru could probably help calm him, so they let her in. I left his roommate and the student in the waiting room, after making sure the roommate was handling this all right. "Sure," he said, "I've had my stomach pumped five times. Do you think Hector will go to the psych hospital"? I assured him that that was certain. "I don't think they sent me to the psych hospital when I took pills," he said, then paused looking up at the ceiling, doing an inventory of his memories, and said, "Oh yeah, they did. I guess they did." Later I learned that our psychiatrist had gone over to check on Hector and that his physical needs were such that they were going to keep him at the medical hospital, if a bed opened up. Pru returned to the office about three hours after this all started. She looked done in. I know that Hector is a favorite client of hers and she hates to see him have a setback like this. She said he was seeing a demon three feet in front of his eyes. You could see him seeing it, she said. He couldn't concentrate on anyone's questions or be cooperative because he had to put all his energy into fending off that demon. She and the student sat at the computers and wrote an incident report. The issues for me today were around how I shoud respond. The nurse seemed to be urging me to go to Hector's house and then to the hospital. But I wasn't sure I should because I didn't really have a role there. Pru did because she knows him and could be helpful. I think my role was to be available to her for advice. I don't want to insert myself into situations like this just to be at the center of activity, or just to feel important. Crisis is seductive, make no mistake about that, but I am pretty much too old to be (easily) seduced. Anyway, I just want Hector to be well and not to be hospitalized for too long.

Haven't I Been Here Before?

Busy, busy day. I saw four people for therapy (an unusually high count for a day) and counseled a case manager over lunch. I was feeling very much on top of my game: a client who came in ranting and unable to listen left calm and quiet. Her case manager thanked me later. The next client came in happy as a lark to tell me she is in love. She was wearing make-up and had styled her hair and told me she's lost 20 lbs. She's doing great and the session was a joy. The next client is someone who was very agitated yesterday, all day coming into my office if the door was open a crack and saying "Do you have a minute?" Today she arrived jittery and left smiling and seemingly relaxed. It isn't that I'm such hot stuff as a therapist. It is the magic of having someone give you their undivided attention for 50 minutes. That alone is very beneficial. A good thing to remember in parenting. The last client of the day just about blew it for me, though. I've been her case manager more than her counselor and have had a lot of trouble gaining and keeping her trust. I've written about her here before: how I let her down when she wanted me to accompany her in a mission I thought would do her more harm than good. She is being discharged from our program after many years. Although she feels that we are abandoning her, we are actually moving her to a program for very high-functioning people, where she will actually have more access to the psychiatrist she has bonded with. When she walked in to see him today, I stopped her to let her know that because she is being moved to the next level I cannot transport her to a medical exam later this month. She can't take herself there because she will be sedated for the exam, and , she tells me, there is absolutely no one else who can take her there. She had been told a couple of weeks ago that she was being discharged from our program. Today when I told her what I had been advised, she went off big time. She condemned us loudly, especially the psychiatrist, and implacably in my office, where everyone can hear just about everything that is said if it isn't said quietly. She said she felt utterly betrayed (as ever) and that she can't trust anyone. Then she said, repeatedly that she knew how to take care of things so that no one would have to worry about her again. And she stalked out of my office. I ran after her but she wouldn't consent to a last word with me. I had to tell Elizabeth that the client had threatened suicide. "Not in those words," I said, and told Elizabeth what she had said. Elizabeth thought it was enough of a threat. She called the psychiatrist to see whether we should commit her, and he said not yet. So, we have a client who doesn't need the level of care we are mandated to provide, but if we try to move her to the next level of care, she is likely to make us hospitalize her so that she will be ours again. The nurses and other case managers stopped to tell me that what took place wasn't my fault. They'd witnessed my running after the client on the parking lot. I know it isn't my fault. I just wish she could let something in, could give up her role as victim long enough to take in the reality that some of us do care about what happens to her. Wonder what she is doing tonight.

You Have to Touch It

Leaves are already starting to turn. It feels like the end of summer. At work everyone was dragging a little, as we do after a three-day weekend. Too much sleep. Danni had an appointment with me but she called to cancel. I told her I'd heard she'd called on-call over the weekend and asked her what was up. "My boyfriend had a seizure and it was my fault," she said. They had been using something for several days and, trying to keep up with her, he'd almost bought the farm. "It's all my fault," she said again, "I feel so bad." My immediate temptation was to say, "No, he's a grown-up. He has to take responsibility for his decisions." But I bit my tongue, thinking it might be good for her to feel the burden of this for the time being. I'll see her later in the week. Two nurses put on a barbecue for the clients today. Since the agency has no budget for such things, it is really an act of generosity. The idea arose when one of them saw that there was a lot of food in the freezer that we needed to cook. So they started with that, but added a lot of their own contributions. They brought in their own big electric cookers, cakes, fruits. They set up a table out front and dished things out to the clients who had lined up, plates in hand. Like we did at Christmas, sponsored that time by the case managers. Cindy and I were talking later. She said she had worked as an EMS for a couple of years. When she started, she said she was afraid of how she would react when she saw a dead person for the first time. One of the old hands said to her, "The way to get used to dealing with a dead body is that you've got to touch it. Once you've touched your first dead body, you'll start to be okay." Right away I could see the universal application of that metaphor. I've already shared it with a client who was talking about her own fears.

20 Minutes: All By Myself

Twice this week I've been the only one in the entire center for an hour or more. One by one people go out on the road or leave early and don't announce their departures so that before you know it, you are all alone. Here's a sketch of 20 minutes today when I was trying to leave for another appointment: Larry comes in for his meds. I unlock the med room and find his container and, luckily, someone has already made up a "sleeve" or a med planner that sorts out what he takes when. So I hand it to him and he gulps down his handfull of afternoon pills and tells me he's going out to work on splitting some firewood. "Wait til tomorrow, Larry," I say, "don't use an ax or any other equipment right after you've had your meds." He says okay and heads for the door. Phone rings. It's one of our daily callers, Mr. Joe. He says, "How are you, Miss Counselor? I am just calling to ask you to tell Olan that I migt not be here when she comes by with my meds but that she can leave them with my neighbor and I promise I will take them." I tell him why she can't do that, and as I hang up, Julian, a new client, comes in, still in his butcher's apron. He's a young guy, good-looking, just 22, who works at a supermarket full-time and doesn't want to accept the idea that he has schizophrenia. Sometimes he comes in surly and belligerent, but today he is full of smiles and charm. I open his med box and see that there are no sleeves, so I have to go over his med sheet, figure out what he takes when, and help him fill three days worth of meds, as he is independent on weekends and this one is a holiday, and watch him take the afternoon doses. While I'm doing that, Arthur's father calls and says that the pharmacy just told him that the meds we ordered for his cellulitis are not available until Tuesday. He can't sleep due to the pain and has been waiting days for these meds already. Now I am furious-- we can't let Arthur wait until Tuesday. I can't leave his father to handle it -- he is a bit of recluse who avoids worldly endeavors -- and I don't know how to get meds from elsewhere this late in the day -- and I am late for my own appointment. I tell him I'll call him back, finish up with Julian and warn him that he must take all of his meds for the next three days. Then I call our nurse, can't reach her, call another nurse from another facility and convince her to call the pharmacy and see if they can get the meds from elsewhere. While I wait for her callback, Sig comes in for his meds, so back in the med room I go -- filling out his paperwork as poorly as I've done with Julian's and Larry's because I've never bothered to become proficient at meds paperwork (because I DO NOT want to distribute meds, got that?), leaving a note in his box describing what I did and asking a nurse or his CM to straighten out the paperwork. Phone rings. Nurse says pharmacy wouldn't call around, so she called a couple of places and no one has those meds. "What should I tell Arthur's father, then?" I ask her, "Should we send him to the ER?" "Yeah," she says, "better do." So I call Arthur's house, but only he is there and he finds what I am trying to say very confusing. So I tell him "Just tell your Dad to take you to the hospital, okay"? And he says okay, but I know he doesn't get it, so as I pack my briefcase and turn off my computer I'm thinking of who else to alert, when in walks Olan, the CM who is late night and weekend this week, and I fall upon her with all of the above information, urging her to reach Arthur's dad and make sure he gets to the hospital, giving thanks that she is so capable, and rush out the door only 20 minutes late for my private client, who forgets her appointment. So I spend 20 minutes meditating, and I feel much better. Please remember the people of New Orleans. They need our help.

New Orleans

Take a minute to consider how you might behave in a test of your humanity such as has been slapped on the people of New Orleans this week. Where would you be? Quietly cooperative? Frantic with anxiety when there is nothing to eat, nowhere to sleep? Panicked because you can't find your relatives? Seizing the chance to get what you can out of the situation, to become an outlaw? Crazed by claustrophobia when you are jammed into a non-residential facility with thousands of strangers? I really can't imagine it. The endurance it would require.

Pizza for Breakfast

Left the house this a.m. at 6:30 when dawn was slipping into day. Met up with Pru at one of our facilities and picked up a staff car, then backtracked 20 miles to pick up the client we were returning to the hospital, then drove another hour and a half to get there. On the way our client was telling us that she had been hospitalized several times for lengthy periods when she was raising her sons. "Every time I would see them when I got out of the hospital they would be different. They were tall, then I come back and they were smaller. So I knew someone had messed with them and I didn't know who they were, but they were given back to me as my sons and so I accepted them because I had to love them no matter who they were." At the hospital we reported that the client had had a good two days at home, so they decided to discharge her and have us transport her back home. We fused that we were on a tight schedule with another client we had to take back in time for her to get to a meeting four housing, and the hospital folks swore that they would get all of the discharge stuff ready i