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

Profiles in Tremendousness

screen shot - the Daily Show with Trevor Noah

Profiles in Tremendousness is a segment on the Daily Show with Trevor Noah that pokes fun at the competency (and lack thereof) of various characters in the Trump White House.  I’m going to borrow that idea to take a look at the less than stellar characters I’ve come across in my mental health journey.

My first hospitalization was a sh*tstorm of incompetence all around as far as I was concerned, and years later I found out a little tidbit that gave at least some objective confirmation of that.  One of my discharge diagnoses was borderline personality traits.  There’s nothing wrong with that diagnosis if it’s accurate, but unfortunately sometimes it says more about a practitioner’s stigmatized views than anything else, and is applied as a euphemism for “difficult patient”.  Any competent psychiatrist would know that a diagnosis of personality traits/disorder can’t be made cross-sectionally (i.e. just looking at a specific point in time), particularly when someone is acutely ill; it needs to be made based on patterns that are relatively consistent throughout the person’s life.  The hospital psychiatrist seemed to  have skipped this lecture in med school, and instead decided to ignore taking any sort of social history or gathering any collateral information and instead just slap a label on because I fought the treatment team tooth and nail while I was in hospital.  Not only does this leave me with a diagnosis that doesn’t accurately reflect my experience, but it minimizes the significance of the challenges that people with BPD often face every single day.

I used to go to a medical clinic associated with the local university’s medical school, and I would get seen by whatever medical resident happened to be on for that day.  The discharge summary and who knows what else from my first hospitalization were in my chart at the clinic, and I think a lot of the residents were scared because I was the crazy girl who had tried to kill herself and they didn’t know how to deal with that.  When I went in for pap tests, they would always insist on doing a PHQ-9 (a depression screening test).  One day I went in asking for a lab requisition to get routine blood sugar and cholesterol  checks.  I was stuck there for an hour because, even though my illness was in full remission at the time and I had a psychiatrist who I was seeing regularly, the resident had a very hard time believing I wasn’t going to jump in front of a bus the moment I left the clinic.

The first time I tried therapy was okay but not particularly productive.  I decided to try again when I became depressed a few years later, and made an appointment through my Employee Assistance Program.  I wasn’t thrilled with the therapist’s interviewing style, but the real treat came as we were wrapping up the session.  Her advice was that I would feel better if I started dating.  Seriously?  That was the end of that.  And to top it off, when I emailed her to say that I wouldn’t be seeing her again and explained the reason, she thought it was peculiar that I would have chosen to fixate on that particular statement.  Um, perhaps because it represents incompetence?

That theme came up again more than once.  I clearly remember a nurse in hospital who observed that I must be depressed because I was single, and that must have been why I attempted suicide.  Between her and the nurse who was convinced that I must have attempted suicide because I was angry about something, it was a sad state of affairs.  But the stellar lack of competence didn’t end there.

freudThe hospital psychiatrist who initially treated me on the inpatient unit knew I didn’t like him (I guess the screaming and swearing was a pretty strong hint), so he decided to transfer my care to a different doctor.  This character was very much of the psychoanalytic/psychodynamic therapy persuasion, and as far as I could tell he was even more of a nutbar than I was.  My first meeting with him was all very Freudian, with a focus on sex and early childhood.  How old was I when I lost my virginity?  Did I like sex?  Did I remember how I felt when my brother was born when I was 3 years old?  He told me that the ONLY way for me to get better was to get psychoanalytic therapy, and I should only be on meds for a couple of months and then come off them.  Wowza.  But I wanted to get discharged, so I said the things he wanted to hear.  Later, my community psychiatrist commented that he wasn’t sure who that discharge summary was written about, but it definitely didn’t sound like me.

A couple of years ago, things started falling apart.  A very close friend died unexpectedly. I was bullied at work and ended up quitting because of it.  I was worried about getting sick, but I held it together.  And then I found out that my ex-manager was doing his best to destroy my career (in very much a reality-based sense, not a cognitive distortion sense), and the sh*t really hit the fan.  When I went in to see my psychiatrist, I was so slowed down that I moved from the waiting room to his office at a snail’s pace, and had a hard time even stringing a sentence together.  He knew about all the other stuff I’d made it through, but the best he could come up with was that I needed therapy to learn better coping skills so I wouldn’t get depressed when things like this happened.  I’m not sure why he thought that was the appropriate response and the appropriate time, but that was the last time I ever saw him.  Once trust is broken, I’m done.  So I decided to go see my new GP, who didn’t know me from a hole in the ground.  And what did she have to say after I told her the reason I’d decided to stop seeing my psychiatrist?  “Don’t you think you do need better coping  skills?”  Are we passing around stupid pills?

Don’t get me wrong, there are some great mental health professionals out there; I know because I’ve worked with some of them.  Unfortunately there are also some real duds, and in the next edition of Profiles in Tremendousness I’ll cover some of the specimens that I’ve worked with.  It would be nice if this wasn’t an issue we faced when trying to access mental health care, but sadly it’s far too often the reality.

What have been some of your worst experiences?

 

Image credits:

The Daily Show with Trevor Noah

Skeeze on Pixabay