Profiles in tremendousness: The uncommon sense edition

The Daily Show Profiles in Tremendousness screenshot

In the Profiles in Tremendousness series, I borrow an idea from the Daily Show with Trevor Noah to celebrate the best of the worst in mental health care.  In this edition, I’ll take a look at some of the weird shit that’s gone on in places where I’ve worked, proving yet again that common sense really isn’t very common.

I used to work for a short-term crisis intervention outreach team.  Because we were rarely in the office, each day the main office phone line was forwarded to one of the team clinicians’ cell phone.  Then the powers that be decided they were going to transition this program into part of a new psychiatric urgent care centre they were starting up.  Because the secretary would be answering phone calls that came into the urgent care centre, they wanted her to get practice on the phones ahead of time.  So they decided to have her answer the phones for the crisis intervention team, even though 90% of the time there would be no clinical staff around for her to transfer the calls to.  I brought up how potentially dangerous this was; what if a client called experiencing suicidal ideation?  This was pretty realistic given that we were, after all, a crisis intervention team.  Was the secretary supposed to talk the client through it?   My email to the team was met with a derisive response from management that dismissed my concerns (and me in general, for that matter) as entirely unreasonable.  So I guess it was supposed to be up to the secretary to help out people in crisis…  Why not, right?!?

So, confidentiality.  It matters.  But at place I’ve worked, there is a pervasive lack of understanding of where and when confidentiality applies.  They are mad for initials, to the point of utter insanity.  In emails and in client charts, staff are regularly referred to by their initials; no one ever stops to think that not only do staff not require confidentiality, but quite the opposite; staff are responsible for the care they provide and if things ever went sideways it would be crucial that the staff involved be identifiable.  Also, staff will use a client’s initials when documenting in that same client’s chart.  I asked some coworkers about this once, because it’s completely ridiculous; the client’s name is firmly, permanently attached to their own medical record, and it’s asinine to think there’s a “confidentiality” issue using the client’s name in their own chart.  All these coworkers could come up with was that they’d been told it was necessary in case the medical record was ever subpoenaed.  Great, so the management who should really know better are spreading idiocy en masse.

Now, I could rant at length about this photo, but instead I’m just going to let it talk for itself.

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Interestingly enough, this is a “recovery program”, although apparently management thinks I’m just too darn recovery-oriented.  I told management that I believe clients are the experts in what they are experiencing…  Gasp!  Well, that’s just not acceptable!  After all, we’re the nurses who know best, and who are they?! …  I believe in empowering clients….  Gasp!  No, they need us to tell them what to do!  …  If a client asks for a prn medication, including a benzo, and I think it’s appropriate because they’re experiencing distress, then Im going to give it…  Gasp!  No, we don’t give benzos here! …  But the client has a doctor’s order for it …  Gasp!  But you still shouldn’t give it!  Benzos are bad!

The non-recovery recovery approach leaves me frequently shaking my head.. Clients are regularly discharged to places they don’t want to go, including cities they don’t want to live in, because “the team” decides that’s what’s most appropriate.  There are arbitrary rules galore, and if a client isn’t falling into line, they meet with “the team”, which from what I can gather is like the bloody Spanish Inquisition: a roomful of “the team” stacked up against a defenceless client.

If I sound bitter, it’s probably because I am.  This kind of insanity is everywhere, but it really runs rampant at one of the places I work now.  Unfortunately a change of job isn’t feasible right now for a number of reasons, so all I can do is soldier on.  And maybe try to find a little humour in it wherever I can.

Profiles in tremendousness 2: The coworker edition

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Not long ago I posted Profiles in Tremendousness round 1, which borrowed an idea from the Daily Show to identify some of the non-rockstars I’ve encountered in my own experiences of mental health care.  In round 2, I’m going to touch on some of the anti-superstars I’ve encountered in my work as a mental health nurse.

Let’s start with one of the biggest non-rockstars of all.  I’ll call him Kevin.  Kevin had a very high opinion of himself and of his ability to get to the root of what was going on with a client.  He firmly believed that bipolar II was not a legitimate diagnosis, and instead was just another name for borderline personality disorder.  He never came right out and said it, but it was pretty clear that he thought any female diagnosed with a mood disorder actually had borderline personality disorder.  He would tell these women that they needed to do some reading about DBT.  They did so, and of course ended up reading about borderline personality in the process.  If I was the next clinician to see these women, they would tell me how confused and distressed they were, because BPD didn’t sound at all like what they were experiencing (which it wasn’t).  I’d try to shift focus onto how DBT has useful skills for anyone with mood regulation difficulties (which is true, but not why Kevin was recommending it), and bite me tongue to keep myself from telling them that Kevin was an idiot.  One of his go-to’s for evaluating whether someone was seriously ill or not was the “bus stop test”, i.e. if you were standing at a bus stop next to them would you be able to tell they’re mentally ill.  Cue disgusted eye roll now.  And if he was unhappy with a client’s behaviour, he would “read them the riot act”, whatever that meant.

While a lot of mental health nurses are very knowledgeable about psychiatric medications, some are frighteningly clueless or prejudiced.  Kevin referred to clozapine as “poison”, while Janet was firmly anti-medication across the board.  Karen made medication recommendations to clients despite having astonishingly little knowledge about those same medications.

Brent was a big fan of CBT.  Which would have been great if he actually knew what CBT involved.  He believed that CBT involved distracting yourself from your thoughts.  End of story.  And this one-trick pony would be trotted out for almost every client.  His other standard recommendation was that clients read Eckhart Tolle’s The Power of Now.  I won’t deny that there’s some good stuff in there, but there’s also some stuff that’s a little out there.  Brent actually agreed with me on that, but didn’t bother tacking this bit of information on when he made the recommendation to clients.

Some nurses are overly keen on pushing the prn medications.  A couple of nurses that I used to work night shift with firmly believed that if a client was up during the night, they should be medicated back to bed, and if the client wouldn’t accept the prn orally, they’d call security and do it by injection!!!!  There was one time I was coming on for a night shift, and the evening nurse told me that she’d given a client a prn during the evening because he was quite psychotic, and she wanted me to wake him up to give him another prn in an hour or so.  I just kept my mouth shut and ignored her.

Then there was Sandra, who thought clients asking for prn meds were just being med-seeking.  She would never give prn benzos (even when the client had an order for them) regardless of how distressed or psychotic they happened to be.  She had no use for clients with personality disorders, and thought they were just being manipulative.  She thought that the only way to handle these clients was with her idea firm boundaries, which translated to being flat-out rude.  Clients would tell me that they just didn’t bother going to Sandra about anything because they knew they’d just be shot down.

These anti-superstars have thankfully been the exception rather than the rule.  Most of the mental health professionals I’ve worked with have been quite competent, and some have been truly exceptional.  But keep an eye out for the Kevins and the Sandras of this world – and when you see them, run as far and as fast as you can in the other direction.

BPD: Are the helpers actually hurting?

artistic rendering of faces dialoguing

People with borderline personality disorder (BPD) face a lot of challenges.  Unhelpful treatment providers shouldn’t be one of them, but I suspect this is the case more often than it should be.

One of my jobs is at a mental health and addictions transitional program.  While some of the staff are licensed mental health professionals, most are not.  For many  of the support workers, their only formal training is a one-semester community mental health worker certificate program.  Some of these support workers do a great job, but their lack of training limits the range of skills and knowledge they have to draw upon.

There are a number of clients with BPD in this program, and I think it would be safe to say that all of these individuals have a considerable trauma history.  This may be a gross over-generalization, but in my experience that pose the greatest challenge to service providers, and I would like to see more service providers take ownership of that rather than shifting blame to the clients.  I’ve been lucky enough to have worked with clinicians who were highly experienced in working with clients with BPD and providing dialectical behavioral therapy (DBT).  It was so powerful to see them in action and the impact this had on clients, and I learned a great deal from them.

What I see more often in support providers who don’t have that level of knowledge, skills, and experience is a rigid approach to clients with BPD that involves a focus on limit-setting, challenging (i.e. invalidating) clients’ beliefs/emotions/experiences, and establishing a clear hierarchy and power differential.  In my mind this comes from misinterpretations arising from limited understanding of some of the principles of working with clients with BPD.  And my observation has been that this approach doesn’t work.  Time and time again I have seen it develop into a combative relationship with the client, but I can’t think of a single time when I’ve known a care provider to take responsibility and acknowledge that by using this type of approach they have contributed to the problem rather than the solution.  It’s always the client that gets blamed, and this ends up becoming a self-fulfilling prophecy by reinforcing stigmatized ideas.  If you treat someone like a bratty child, then it’s likely they will react like a child; I’m not sure why this is so hard to grasp.

This came to mind recently because of some interactions I had with a client with BPD.  She had approached me and expressed irritation with certain things.  It quickly became clear that she was feeling invalidated, and the irritation had nothing to do with me.  As we talked, I took advantage of every opportunity I could find to provide any sort of validation, and it was clearly effective.  Yet this is a client I always hear other staff talk about as being difficult, and often when I hear them talk about their approach with her I think wow, no wonder you find her difficult.

It reminded me of a former client of the program, another female with BPD.  Staff often described her as game-y, and trying to negotiate around things like which meds she would and wouldn’t take.  All of the other nurses took a paternalistic, you-must-do-as-I-say approach, and they found her difficult to deal with, and she often refused at least some of her meds.  I approached everything I did with her as a collaboration, and explained my rationale for anything I was recommending.  She felt empowered, and ended up going along with my recommendations; by giving her the power of choice, I got meds into her 100% of the time.

It fundamentally bothers me that there are care providers out there who are making things worse for clients with BPD, and instead of taking professional responsibility they are blaming the clients.  That’s just not cool.  Unfortunately, the rigid limit-setting types generally don’t seem to be very open to suggestions that another way could work better.  In my current workplace culture, any attempts to rock the boat are considered totally unacceptable, and I feel powerless to bring about change.  I seem to be viewed as the nurse who is “too easy” on clients with BPD, and it really saddens me that there are people who think they need to be “hard” on that same group of clients.

I’ll put it out to my blogging buddies with BPD – have you encountered the rigid limit-setting type of care provider, and what has that been like for you?

 

Image credit: geralt on Pixabay

What I’ve learned from my “psych patients”

Learning is not just for school, but for life

Having worked as a mental health nurse for many years, it would be easy to assume that I’m usually the one doing the teaching and my clients are usually doing most of the learning.  That assumption would be completely wrong.  Yes, I’ve learned a lot in school and through continuing education, plus I’ve learned a lot from my own experience of mental illness, but I have also learned so, so much from my clients.  (Note: my use of “psych patients” in the title is only because it’s conveniently concise.)

One of my regular clients for several years was a transgendered woman with bipolar disorder.  She was the first trans person that I worked closely with, and I had the privilege of being able to support her through sex reassignment surgery and the various pitfalls she faced along her journey with transitioning and managing bipolar.  In Canada, public health insurance covers genital surgery but not procedures that are assumed to be “cosmetic” such as facial feminization and tracheal shaves.  I have vivid memories of making calls on speakerphone with her in my office about various issues.  The person we were on the line with would refer to her as “sir”.  My client would say “no, actually it’s ma’am, not sir”.  A minute later, it was “sir” again.  And then again.  My client’s eyes, posture, and voice all reflected her frustration and defeat, and I grew increasingly outraged at the casual, everyday stigma reflected in this call centre agent’s use of pronouns.  Every time I’ve worked with a trans client since then I can’t help but remember those phone calls as a microcosm of the stigma against transgendered people, and how much this parallels the stigma against mental illness.  But my client bravely soldiered through, and her capacity to cope despite the challenges of her mental illness was astonishing.

I have had some very interesting relationships with clients over the years, and one in particular will always stand out.  She was an older women with schizophrenia who I rather fondly thought of as crusty and cantankerous.  She was chronically psychotic, and frequently called the police because she thought poison was being placed her room.  It drove the building staff crazy, and I would regularly get calls from them asking me to come by and check on her.  The client had a fun, quirky sense of humour, and this produced some amusing insults directed my way; she wasn’t too fond of me because a) I didn’t believe her about the poison, and b) I came to stick a needle in her every couple weeks.  In time she ended up being diagnosed with terminal cancer, and moved into hospice care.  The change in her was the most remarkable thing I’ve ever seen.  After years of being continuously actively psychotic, her delusions abated, and she was the most relaxed and content I’d ever seen her  She enjoyed my visits, and while she still had the energy I would take her out for coffee.  She found greater peace as she neared death than she had experienced for many, many years.  Sometimes the world works in mysterious ways.

My own experience with mental illness has made me a strong advocate for client autonomy, although I’ll freely admit that at times I’ve seen involuntary treatment work wonders.  I had one client who came to me after a long stay in hospital.  He’d originally been admitted because he was making threatening gestures with a weapon, triggered by an uncommon symptom known as Capgras delusions, which involves the belief that familiar people have been replaced by imposters.  The client was released on a community treatment order, which mandated ongoing involuntary treatment in the community, and he was on an injectable antipsychotic every 2 weeks.  He was cooperative with the conditions, but was never uncomfortable with the idea of having these restrictions hovering over him, and he didn’t want to take the medication by injection.  The psychiatrist was concerned because the client didn’t have insight into his psychotic illness.  However, the client did believe he had depression, and I was able to work with him around that and he agreed that continuing to take the medication in oral form would be a good thing.  So I supported him in pushing the psychiatrist for a switch to oral meds and eventually the discontinuation of the community treatment order.  And it worked.  The client thrived.  I like to trot out that story when I’m advocating for other clients, because it’s such a great example of how empowering someone high risk can turn out really well.

Sometimes people get written off as lost causes, but there’s really no such thing.  I had one client who had fetal alcohol syndrome, was psychotic, was a heavy crack cocaine user, and regularly prostituted herself to feed her drug addiction.  She was behaviourally erratic and would blindly wander into traffic.  Staff at the ultra-low-barrier residence where she lived were terrified for her safety.  She had been started on an injectable antipsychotic, but it was hard to track her down to actually get a shot into her.  Luckily, my office was only a couple of blocks from where she lived, and I became a bit of a stalker.  My persistence paid off, along with a few cigarettes as bribes; once she was getting her shot regularly, her behaviour settled down.  She realized that the shot “helps my schizophrenia”, and she would approach me spontaneously with a smile if she saw me on the street.  I will happily take those small victories.

I have also had other clients teach me never to lose hope.  I had gotten a call from a local homeless shelter about a man who was extremely paranoid and ranting loudly about his various delusions.  He was tough to track down because as soon as he found out I was from the mental health team he avoided me (can’t say I blame him).  Getting him to hospital was quite dramatic, involving chasing him down the street, miscommunication with the police, and handcuffs.  But we worked with him, got him stabilized on meds, changed his meds when he had side effects, got him good housing…  and now he’s doing great and running a fantastic peer engagement project.   Success stories like this give me hope, both for myself and others.

Those are some of the clients that I think of often because of what they have taught me.  There is always reason for hope.

 

Image credit: Geralt on Pixabay