Alternative Universe

A guided tour through the hallways of Mental Hell -- er, Mental Health -- by a counselor who works with the chronically mentally ill. I have changed the names of clients and staff members to respect their privacy.


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.



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



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.



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.



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.



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.



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.