Psyched Out

Here's a popular meme in the fat rights community. The rules: Type the answer to the questions into google images and post your favorite from the first page.



1. Age at next birthday




2. A place you'd like to travel:




3. Your favorite place:




4. Your favorite objects:




5. Your favorite food: (This one's a tie)






6. Your favorite animals:



7. Your favorite color:




8. Town where you were born:




9. Town where you live:





10. Name of a past pet:





11. First name of a past love:



12. Best friend's nickname:




13. Your screen name/nickname:




14. Your first name:





15. Your middle name:




16. Your last name:




17. Bad habit of yours:




20. Your college major:

Dear Ms. Principal,

We're concerned about the "red ribbon" program the school is
engaging in. Is the school teaching the children that all alcohol,
tobacco, and drug use is bad?

Tobacco is unhealthy but legal. We don't smoke and we hope our kids
don't choose to, but hope they will make an intelligent choice
about it, and doubt that signing a pledge in first grade is going
to help them make an intelligent choice as teenagers. If anything,
signing pledges because everyone else is doing it is going to have
the effect of teaching them to "go along with the group" with
regards to drugs and alcohol when they're teenagers... and their
peers might be a "group" which would push them in the opposite
direction at that time!

Drinking alcohol -- communion wine -- is part of a sacrament for
Catholics. I doubt the school intends to have the children pledge
not to be Catholics like other members of the family. Of course
we also drink moderately outside of church, and we don't think
that there is anything wrong with that either.

Both of us take drugs every day, such as Singulair for a
respiratory condition. We hope the kids are not being taught
that this is wrong, and that they should never take medicine?

Many drugs are illegal in one context and legal in another.
Oxycontin is a harmful and addictive street drug but also a
beneficial painkiller when used under medical supervision.

We're not really happy with the way this is being
addressed -- and we're not sure that it is possible to give
the issue of harmful and addictive substances the treatment
it deserves with first graders.

But we'd be willing to give it a shot. I work with substance
abuse every day in my social work position, and would be willing
to come into the classroom and talk about the nature of addiction,
with questions and answers, to try to give the kids a simple but
compassionate understanding of the issue.

Is that something that the school would be interested in? We'd be
much happier with that kind of education than children signing
pledges which they don't understand. (They don't understand them.
We asked them if they understood what they signed.)

What do you think about these issues? We would be interested in
discussing them with you.

Sincerely,

Mary and Ed

Psychotic Disparity: Low Income Women and Mental Health Treatment in Pregnancy
by Mary H

An often overlooked issue of social justice is the disparity in treatment given to impoverished uninsured/publicly insured and wealthier privately insured women who experience psychosis during pregnancy. An impoverished, pregnant and actively psychotic woman is among society's most vulnerable citizens. Yet doctors sometimes hesitate to prescribe the exact same medication for potentially deadly psychosis that they give for inconvenient nausea during pregnancy, leaving pregnant women committed in locked facilities, untreated and fully psychotic for many weeks.

Psychosis is the most severe form of mental illness, often robbing its sufferers of even the ability to perceive it as a disease with treatment available. Suicide is a serious risk among psychotic patients, with research showing a 4-10% death rate. Compared to pregnant women treated with antipsychotic medication, women diagnosed with psychosis without medication had four times the risk of psychiatric relapse and hospitalization. Psychiatrically hospitalized psychotic women experience markedly worse pregnancy outcomes. They have twice the rate of stillbirth, infant death, premature birth, low birth weight and small for gestational age babies compared to psychotic women treated outpatient. All antipsychotics are proven safe throughout pregnancy, several are used to treat nausea. Mood stabilizers for manic psychosis are safe after the first trimester, and one mood stabilizer, Lamictal, is shown to be safe even then. Try to imagine a middle class woman with private insurance committed and left untreated, and the primary cause of this social injustice is clear: social class.

Wealthier, privately insured women enjoy several key benefits from their social status and personal power. They often have better access to information about their illness and medications before pregnancy and more access to other pregnant women with psychosis through the internet. Privately insured women obviously have better access to health care and more choices. Privately insured women tend to have more collaborative relationships with their doctors, more time in office visits and they are free to “doctor shop” if they are denied treatment with medication by one physician. Certainly many poor women enjoy rich social networks and supportive partners, but overall these benefits are more available to richer women. If a doctor does try to commit a privately insured wealthy woman, she is likely to have a medical guardian to approve medications when she cannot consent to treatment herself due to the psychosis.

Several solutions could improve care for impoverished uninsured/publicly insured women. Improved education for both doctors and women of childbearing age could be provided along with the popular campaign giving information about postpartum mental health. Universal health care would resolve some disparity in care because many more doctors would accept a national insurance and discrimination based on ability to pay would be greatly reduced. Finally, community efforts to establish volunteer medical guardians for psychotic women that do not depend on intact families, perhaps through Le Leche League and local childbirth assistants, would prevent a woman from being incarcerated rather than medically treated unless she chooses that path before she becomes ill.

An often overlooked issue of social justice is the disparity in treatment given to impoverished uninsured/publicly insured and wealthier privately insured women who experience psychosis during pregnancy. An impoverished, pregnant and actively psychotic woman is among society's most vulnerable citizens. Yet medication treatment is at times withheld in favor of long term committment for this population due to a blend of limited choice as well as poor access to care and information.

Psychosis is the most severe form of mental illness, often robbing its suffererss of even the ability to perceive it as a disease with treatment available. Suicide is a serious risk among psychotic patients, with research showing a 4-10% death rate. Compared to women treated with antipsychotic medication, women previously diagnosed with psychosis without medication had four times the risk of psychiatric relapse and hospitalization. Psychiatricallly hospitalized psychotic women experience notably worse pregnancy outcomes. They have twice the rate of stillbirth, infant death, premature birth, low birth weight and small for gestational age babies compared to psychotic women treated outpatient.

Doctors often hesitate to prescribe medications for potentially deadly psychosis when they prescribe the exact same medication for inconvenient nausea during pregnancy. With the exception of mood stabilizers, all antipsychotics are safe throughout pregnancy. Even mood stabilizers are safe after the first trimester, and one mood stabilizer, Lamictal, is shown to be safe even in the first fourteen weeks. In uninsured/publicly insured inpatient and outpatient psychiatrists have been known to withhold pregnancy safe antipsychotic medications, instead leaving pregnant women committed, untreated and fully psychotic for many weeks. Try to imagine a middle class woman with private insurance treated this way, and the primary cause of this social injustice is clear.: social class.

Wealthier, privately insured women enjoy several key benefits from their social status and personal power. They often have better access to information about their illness and medications before pregnancy and more access to other pregnant women with psychosis through the internet. Poor women usually have limited public and no home access to the internet. Privately insured women obviously have better access to health care and more choices. In addition, privately insured women tend to have more collaborative relationships with their doctors, more time in office visits, more liklihood of consults, and they are free to “doctor shop” if they are denied treatment with medication by one physician. Very few doctors accept medicaid,or take uninsured patients, and in any place but a large city there may be only one game in town. Certainly many poor women enjoy full and rich social networks and supportive partners, but overall these benefits are more availible to richer women. If a doctor does try to commit a privately ensured wealthy woman without offering treatment instead of containment, richer women are more likely to have people in their lives to authorize treatment when the actively psychotic woman cannot consent to treatment herself.

Several low cost solutions could improve care for impoverished uninsured/publicly insured women. Improved education for both doctors and women of childbearing age could be provided along with the popular campaign giving information about postpartum mental health. Universal basic health care would resolve some of the disparity in care because all women would be publicly insured and many more doctors would accept a national insurance. Discrimination based on ability to pay would be greatly reduced. Finally, community efforts to establish medical guardians for psychotic women that do not depend on intact families or present fathers, perhaps through groups Le Leche League and local childbirth assistants would prevent women from being incarceated rathed than medically treated unless the lack of medication was the woman's choice before she became psychotic.

I'm working on a social justice essay for my graduate school application. Please give me input. :)
More will be coming later. Here's part one of a one page double spaced essay.


An often overlooked issue of social justice is the disparity in treatment given to publicly and privately insured women who experience psychosis during pregnancy. This disparity has existed in all five states where I have practiced, and may very well be a national trend. An impoverished, pregnant and actively psychotic woman is among society's most vulnerable citizens. Yet treatment is at times withheld in favor of incarceration for this population due to a blend of limited choice, poor access to care and defensive medicine. This despite the fact that medications for psychosis are as safe as or safer than medicines routinely prescribed for nausea and hay fever.

Psychosis is the most severe form of mental illness, often robbing its targets of even the ability to perceive its nature as a disease with treatment available. Suicide is a serious risk among psychotic patients, with research showing a 4-10% death rate. Hay fever and nausea in pregnancy are rarely, if ever, deadly. Compared to women treated with antipsychotic medication, women previously diagnosed with an episode of psychosis who did not take medication had four times the risk of psychiatric relapse and hospitalization. Women who are pregnant during psychiatric hospitalization experience notably worse pregnancy outcomes. They have twice the rate of stillbirth, infant death, premature birth, low birth weight and small for gestational age babies.


So what do you think so far?

I had my very first ever salon facial today.

Oh.

My.

Word.

I had a stressful day at work. I'd heard that facials are pretty relaxing and I was going for a haircut anyway, so I decided to get one on the spur of the moment. So I left work early with the help of coworkers and checked myself in at Panopoulos Salon. I knew nothing about facials and figured you sat in the chair and had some nice cream put on your face.

I am now regretting my tomboyish ways and bitterly resentful that nobody told me what a facial is REALLY like. Pure bliss, that is. So I'm going to share what actually happens.

I was led to a small dim room with a luxuriously made up bed that was really a cushy massage table. The blanket was velvety and textured over crisp sheets. I changed into a wrap for my top half to allow for shoulder massage. I climbed under the covers and relaxed until the gentle young woman doing the facial knocked and entered. A warm steam blower wafted moist air toward my face as my hands were massaged and placed in warming mitts. Relaxingly schlocky Victorian music played on Celtic instruments quietly set the tone. Fragrant cleansers, toners, deep scrubs with apricot pit or similar emollient (amid other lotions I can't identify) pampered my face in turn, separated by removals done with a steaming washcloth after it had rested on my face soothingly. With every application my tight, tense muscles loosened and softened. Then followed a facial and shoulder massage that must have lasted 20 or 30 minutes. I was a puddle of grateful ectoplasm by the time the final moisturizer went on.

After everything that has been going on, discovering a wholly unimagined pleasure in life came as a joyful surprise. It astonished and deeply affected me. This has cheered me and chased off some of my mounting depression. Ahhh, I needed that!

I do not have cancer!

I do not have an unusual form of emphysema!

I don't know what IS going on, but that beats the hell out of having cancer.

I was at the point of signing up my twins for the next available kids
yoga dance class. Fortunately, I looked at the general class calendar
and noted your hostility toward fat people before I made that mistake.
The suggestion that the point of exercise is to get rid of that "jelly
belly" or "lose that belly by belly dancing" rather than to increase
fitness is disturbing. You have assured me through your class
descriptions that my daughter would not be welcome in your classes.

Current nutrition and fitness research includes an approach known as
Health At Every Size (HAES). You might want to look into it if you
don't want to alienate potential customers.

Mary -------

I am scared of what is happening to my body.

Of what is happening to me.

Despite getting up at 5:30 every other morning to work out, albeit at a pathetic half of my usual (is it really former already?) pace, I am making grocery decisions based on which store has the best motorized scooter carts. I'm in burning pain during workouts, exhausted afterward and sore the next day as if I'm pushing myself hard instead of slacking.

I'm getting tested for cancer and emphysema.

For months I've been struggling with thoughts that I am making a mountain out of a molehill and hence won't be believed. I'm over that now. There's really something wrong besides laziness or deconditioning or hypochondria. I wish I could go back to the comfort of doubting myself.

Thanks to Susan Palwick for publishing Haunted and Ashamed in Grand Rounds this week, and to Sandy Szwarc for all of her praise and for linking Psyched Out from the best science blog I've ever read, Junkfood Science. I feel honored by their recognition, especially considering that I adore both of their blogs and read both every time they post.

UPDATE:

My stress test and a CT revealed no heart disease or cornonary artery disease. I do have a pulmonary nodule but after confirming that I have never smoked Dr. Godling seemed unworried and told me he'll be monitoring it every six months to be sure nothing's wrong, but they are usually benign. If he's not worried I'm not. I am upping my asthma meds and being scheduled to see a neurologist.

So someone at work anonymously posted the following NYT article
at work the other day, with pertinent sections highlighted. It addressed the culture of secrecy and frustration in the health care community since HIPAA has been ridiculously overinterpreted. This panic has been going on since about 2000. Even when it would benefit a patient, I can't talk to their relatives or partners who *regularly attend appointments with them* without a signed release "because of HIPAA." Check this out:

Hipaa was designed to allow Americans to take their health insurance coverage with them when they changed jobs, with provisions to keep medical information confidential. But new studies have found that some health care providers apply Hipaa regulations overzealously, leaving family members, caretakers, public health and law enforcement authorities stymied in their efforts to get information.

Experts say many providers do not understand the law, have not trained their staff members to apply it judiciously, or are fearful of the threat of fines and jail terms — although no penalty has been levied in four years.

Some reports blame the language of the law itself, which says health care providers may share information with others unless the patient objects, but does not require them to do so. Thus, disclosures are voluntary and health care providers are left with broad discretion.

The unnecessary secrecy is a “significant problem,” said Mark Rothstein, chairman of a privacy subcommittee that advises the Department of Health and Human Services, which administers Hipaa. “It’s drummed into them that there are rules they have to follow without any perspective,” he said about health care providers. “So, surprise, surprise, they approach it in a defensive, somewhat arbitrary and unreasonable way.”

I have believed what I've been told about HIPAA requirements, but apparently the extent of the law has been exaggerated. We take HIPAA privacy so far that we aren't even allowed to use full patient names in our internal emails to need to know staff. It's not like I'm going to argue with our corporate compliance officer, who can fire me. But it's good even in the abstract to know that the law isn't as short sighted and harmful as we've all been led to believe.

I was nervous all morning and downright anxious by the time I got to the office. Would my usually fat friendly doctor dismiss my problem as weight when my weight has been steady?

All the worry was in vain. Dr. A was his usual thoughtful, kind self. He listened to me seriously, thought, wrote out some referrals and explained that he was having me checked for heart trouble. Oh, and he tossed in a mammogram too because I'm forty now. Yippee. :/ So I got six tubes of blood and two xrays taken today and have appointments being made for me for the other tests. His description of the stress test relieved me somewhat because he said all they do is get your heart beating at a high rate and then you're done. He also said he had one and it was hard for him and everybody else he knew.

And then he said things no doctor has ever said before as far as I can tell from personal experience, media and the fatosphere.

"Weight is only a very minor risk factor for heart disease."

"Overweight people know they're overweight, why should I harp on it?"

" I only really address it with people when they are in immediate danger of dying. And there is only one disease that's true of, fatty liver disease."

"When I was just out of medical school I practiced with a doctor who didn't treat overweight people for their problems. He just said, 'You're fat. Lose weight.' That was so wrong."

So he officially No Ordinary Mortal. :)

My DH helped me put together this list for the doctor tomorrow, in case I get too embarrassed to talk about my health issues. One of the things I'm doing to cope with my shame and embarrassment is to blog it and kind of out myself. The best cure for shame is sunlight, I've found. Hiding it makes shame stronger, exposing it shrinks it back to a manageable feeling. So here's what I'm ashamed of:


1. I have to pause during even fairly trivial exertion, like
walking out to the car after shopping.

2. There is some shortness of breath with it, but nothing like asthma.

3. My stamina has gotten progressively worse since last year. I was
working out at Curves for the past year and had to quit because I was able to do
less and less. It's gotten so bad that I'm getting some sit down home exercise videos to keep
working out at a level I can handle.

4. A similar thing afflicted mom at about the same age. It was never
looked into or explained; she was diagnosed with COPD about 10-15 years
later, but was never really treated for it. They sent her to some
special COPD-oriented exercise classes, which helped a lot, but insurance
wouldn't pay for it, and it was too expensive to continue.

5. It's all-over-body weakness: exhaustion affecting upper body as well
as lower, torso as well as extremities, not a matter of just the muscles
that were exercising. At time it is so bad that lying down would be
better than sitting down for dealing with it.

6. But overall energy level isn't affected at all -- once rested,
it's easy to get back to normal. Overall I feel energetic and healthy.

7. There is no *general* fatigue affecting all of life -- *only* with
exertion. Not even a lasting fatigue from exertion; after a rest,
everything is back to normal.

8. It's all about stamina.

Now was that so bad to admit? :)

My mom's middle age overflowed with health issues dismissed as weight,and her death at age 63 was a result of one of them. I might write more about that in another post. Because my immediate concern is that history is repeating itself. When she was about 35, she started wearing out easily with minor exertion. She was increasingly slower and more out of breath doing everyday activities such as walking from the parking lot into a store. She was naturally told that it was because she was fat and dismissed. Like most fat women, mom was full of self hatred over her size. This went on for fifteen years until she had a stroke and was sent to specialists after recovering. One specialist noted her exhaustion upon exercise and diagnosed her with COPD, but DIDN'T TREAT HER FOR IT! He did refer her to exercise classes for people with similar symptoms, which she benefited from, but insurance stopped paying for it and it was about $400 per session. My parents could not afford it. So mom's condition was ultimately still ignored.

Now at age 40 it is happening to me. It's actually been coming on for over a year but it's getting bad. I can barely stay on my feet for grocery shopping. I have to stop and rest, ideally sitting down, during a short walk of a block or two. I feel ninety years old. I actually had
to stop my regular Curves workout because of the fatigue getting worse and worse. And it's bringing up fear and shame that I thought I'd overcome.

I've scheduled an appointment with my fat friendly doctor about it. I'm petrified that he'll dismiss it as a weight problem. This is actually unlikely, but as much as I trust him there will likely be other fat hating medical staff involved if he sends me for some kind of workup. I
feel humiliated at being such a stereotype of a fat person as doctors usually view us. I'm not sure I can stand the embarrassment of going through a stress test that I am sure to fail spectacularly. I am dreading the contempt of the testers as they view me as lazy and weak
willed. It brings back all of the hatred of my gym teachers watching me struggle and fail to be athletic, and encouraging other kids to tease me while I tried my best. And of course the best possible outcome is that it really is my weight. Because the other things it could be are not
pretty. So I fear either outcome.

The only thing that is making me go through with it is paranoia. And the only fact I know about my mom's bio dad other than that he abandoned her as an infant is that he died of a heart attack in his fifties. Mom saw his obituary in the paper. So I'm facing my fears and seeing the doctor. The price is shame and embarrassment and the dread of humiliations to come.

This despite my devoted fat acceptance activism and basic belief that my size is okay and not biologically subject to change. My family did not teach me to hate myself or put me on constant diets. I looked at magazines and in the mirror in seventh grade and decided with a shrug that the beauty rules did not apply to me, so I focused on things I could control like my education and music. So I'm even feeling ashamed of my shame.

I don't know what to do with all of this emotion, but I thought people might be interested how quickly my fat acceptance falters when I am faced with the hatred promoted by the "obesity
epidemic" warriors.

I started this as an anonymous blog, but I haven't really written anything requiring that anonymity. So I'm putting myself out there. Rather than freeing me to post whatever I wanted, the anonymity focused my blog too narrowly and made me reluctant to write about some of the things I care about. I didn't want to risk blowing my cover. Which made my posts infrequent and cautious. That's about to change.

I'm a dedicated social worker, but there's more to me than my job. I've decided to add my voice to the fatosphere, for one thing. There are few enough of us as it is. So this is officially a fat acceptance and health at every size (HAES) blog now. And I have deeply held moral and political convictions that I would like to write about. I've expressed some of them rather indirectly as they apply to work, but that's not the same as a straightforward political post.

Thanks to those of you who have read my blog even when I was slacking, your comments have meant a lot to me.

So, one of my best friends at work is truly talented at working with antisocial patients, and therefore has a large number on her caseload because this is a rare talent. They've actually started purposely giving her almost all patients like this because she's so good. Because she's one of my best friends at work, she is always swinging by and saying, "By the way, Mr. L needs some help from you."

Now, I am NOT gifted with antisocial people. I was abused by someone that I suspect was antisocial, though she never encountered the mental health system. So I have poor boundaries with them that I have to watch carefully. They kind of intimidate me and when they say jump it's hard for me to react appropriately instead of responding, "how high?" Even when I'm maintaining boundaries, though, antisocial people just irritate me. It's the lies that get to me. They tend to lie incessantly and badly. Not even badly as much as indifferently. They just don't care enough to come up with plausible lies. And nothing is ever their fault or responsibility. So they expect you to do everything for them instead of putting forth some personal effort. And when you don't give special service, they threaten you. They sometimes, but definitely not always, have a charming facade that immediately disappears when things stop going their way.

I'm sure I'm stereotyping antisocial people here and some are not like this, but I tend to call em like I see em.

I loved it, captivating prose and a rollicking gothic plot. It was largely about the love of reading itself and what it means to be a reader. One of the best things about eighteenth and nineteenth century novels is that in addition to the plot working itself out there is usually an accompanying examination of the human condition. _Pride and Prejudice_ examines personal honor. _Jane Eyre_ examines the line between originality and insanity. _The Idiot_ examines humanity and divinity. This novel has that quality. If you want to read a contemporary author who resembles older writers, Diane Setterfield is your woman.

I'm joining a book club this week, and I had never heard of _The Thirteenth Tale_ because I'm very ignorant about contemporary writers. I know there ARE writers now who are every bit as good as Jane Austen or George Eliot, I just don't know who they are or how to find out about them. So I'm joining a pair of book clubs.

In addition to the introduction to contemporary authors the clubs will provide, joining will revive two aspects of MY life that have lain dormant for about seven years. As you can imagine, baby and toddler and preschool twins take up a lot of time. They are time vampires. I'm only just beginning to have time to read again. Also, the move to Michigan means I have no friends who are mine alone. My husband's friends are wonderful people and I love them, but none of them is a friend that I made on my own. I'm hoping to become friends with some of my book club peers. Even if that doesn't happen, I will at least be socializing with people who have a common interest, which is no bad thing.

So this week I started working full time again. My body is unhappy with getting up hours before the usual time, but not as unhappy as I'd dreaded. This week I have been going to bed mostly on time. Except when I was reading _The Thirteenth Tale_ and I could barely pull myself away. More about that in the next post.

I had some concern that I wouldn't have enough to do to fill forty hours a week. I had forgotten how much busier mornings are than afternoons. In addition, people who were not giving me afternoon work before are now doing it because I'm more likely to be able to schedule something at six hours' notice than at one hour's notice. With a whole day available it is much simpler to fit things in, because many tasks are flexible in their timing.

But the highlight of the week was puking in a patient's yard while helping her pack for inpatient care. I have never puked outdoors before, because I don't get alcohol poisoning now and didn't get it in college either. Since I was not intoxicated, I was aware of the social milieu and therefore profoundly embarrassed. To use a social work word, it was "inappropriate." The patient was so nice about it that I was doubly ashamed of myself. She said something about rain being in the forecast and being sure it would be gone by the time she got home. Isn't it funny how some people while ill are gracious even when they feel irritable, and some people are uncivil when they are at the height of health?

My twins brought Mother's Day presents home from school today. This is the first time since they are in kindergarten this year. The gifts were in white lunch bags with flowers drawn on them and attached was a list of words and phrases they wrote about me.

My daughter's says "MOM: Mom love me, hug,kiss me, lic me, MOM." I am not sure if she meant like or lick by "lic", but this is a disclaimer that I do not lick my children on a regular basis. Occasionally we play puppies and there is a positive history of licking involved, I admit. I have no dignity while playing. My son's says, "MOM: loves me, soft, happ, lisins, MOM." Notice the adorable use of the double p in place of a y.

Inside were cardboard picture frames with bean seeds pasted on (they are growing beans at school) and pictures of the kids in them. And chunky handmade bowls about the diameter of a pop can. They have all kinds of plans for what I am to put in these bowls, and they're so proud of their work in making them.

I have never seen works of art so beautiful to my heart.

Kim commented on the post Bounty Hunting asking if I run into scary or violent situations as a psychiatric social worker. I encounter scary situations from fairly often, but violent situations much less frequently. The neighborhoods I go to are often violent ones, but by avoiding after school hours, not making eye contact and so on I manage. If I'm really uncomfortable with where I'm going or who I'm seeing, I find someone else to go with me, and I always carry my phone. The social workers who end up dead usually work for Child Protective Services. After all, the adults they encounter are usually violent against children in the first place. And people get very angry and very dangerous over custody issues.

I'd like to emphasize that although people with paranoia can become violent, they are more often too terrified of other people even to defend themselves properly from the violence they encounter (on the streets when homeless, for example). Usually if I go out "bounty hunting" and a person is paranoid they hide and don't answer the door. And those people who are having violent or homicidal inclinations are typically not directing them at social workers. Usually their feelings are focused on individuals who play a bigger role in their lives. People with violent ideation are generally hospitalized rapidly before things get out of hand. Even patients who are potentially violent most often have disorganized thinking too severe to plan and carry out crimes. Not every violent person with a mental illness commits violence due to their illness, but that is another post for another time.

The time I encounter violent tendencies is when I am assessing someone for hospitalization, and we do that in pairs if a person has any assaultive history. I've encountered a fist raised at me, a person advancing on me looking dangerous and talked people down from homicide while other staff kept watch on me. But typically I get what I need for a petition (for involuntary hospitalization) before things get actually risky. The law has protections for patients in case we make a mistake in assessing someone's risk level. Every petitioned patient has a hearing where staff have to prove to a judge that the person really needs to be in a locked psychiatric unit.

When in treatment, mentally ill people are not more violent than the general population. Of course you can't force medication into a patient's body against their will unless they are court ordered for hospitalization. My agency can only put people back in the hospital, we ourselves can't compel treatment. Outpatient people can always refuse.

The only time I was actually attacked involved an autistic adult, not a mentally ill person. That was bad. He bit through the nerves of one finger but didn't manage to sever it, and I got bites over my scalp, hands and chest. My hand with the bitten finger grew to about double its size with infection and I had to have surgery to save the hand. Human bites are much worse than animal bites, all the nurses and doctors assured me. I was something of a hospital superstar. Random staff would encounter me and say, "So you're the one with the HUMAN BITES, huh? How did that happen?" It happened while with another staff I was trying to cushion his head from banging against the wall, and being autistic once he started biting he couldn't stop. The other staff person locked me in the room with him while she called 911, which didn't help. Fifteen years with mentally ill people, no problem. One month with an autistic adult - BAM! I'm sure most autistic adults are safe as well, this is just my experience.

Thing One has been at work interior decorating for us again. I noticed that our printer has been written on in red eighteen hour lipstick. You know, the kind that is more or less a dye for your lips. I know it is Thing One, despite Thing Two's name being the content of the graffiti, because Thing One has a record of being devious. She has actually left notes stating, "Thing Two Did This" on some of her more creative enterprises. Sadly for her, she leaves a trail of evidence during her shady pursuits. That, and Thing Two is something of a tattler. A very happy tattler with endless opportunities to tattle because his sister is mischievous. We're hoping that these outlaw activities are an early sign of scientific genius or something, pathetic as that is. And maybe Thing Two will be an intrepid reporter. Maybe.

Anyway, if anyone out there knows of a good makeup remover that is printer safe and effective on eighteen hour lipstick, please put it in the comments. I always just let ithe lipstick wear off.

Today I was pulled aside by the head of HR and given a choice of continuing to work part time in an administrative position and working full time in my current position. They are eliminating the part time position I work in so as to concentrate the hours now worked by various people into one full time position. I've liked working part time since last October, when I was offered this position. I've been able to spend time with my kids in the morning before their afternoon kindergarten starts.

The part time administrative position would be at the same wage, and would still include client contact as I would be helping people sign up for benefits. But it just wouldn't be the same as real clinical contact. And I'm fairly sure I'd dislike it. I don't especially enjoy filling out forms or playing phone tag with hostile Medicaid and SSDI bureaucrats. I don't want to BE a bureaucrat.

I love Love LOVE my current job, generally helping out and finding people who need treatment but aren't coming in. It's clinical without having the quadrupled work load that the case management job acquired last fall. I don't have a case load. I might have to borrow one if somebody goes on maternity or disability leave, but it wouldn't stay mine for more than a couple of months at the outside.

This offer has made me realize just how much I value the job I'm doing now. Enough to go back to full time.

So I have two neighbors who for different reasons invoke a social work reaction outside of my job.

One is, as far as I can judge with a practiced eye, involved in substance abuse of unknown breadth. He came to our door at 3 AM recently and told a spectacular, rambling and obvious lie in order to get beer money. He certainly has issues with alcohol, and let's just say his parties draw a crowd that is kinda questionable. Last summer someone at one of his parties shat a gun at someone else right outside our house. No, actually he shOt a gun, but the typo gave me such a vivid and hilarious mental image that I decided to share. Anyhow, we have not been accustomed to gunfire in our neighborhood and don't want to become accustomed to it.


The other has been struggling with debilitating muscle atrophy for over a year and has recently been diagnosed with ALS (Lou Gherig Disease), which I would not wish on my worst enemy, let alone my lovable and kind neighbor. Through the past year she has gradually lost strength and function, but she has never asked for help. When I found out, I spent a whole day scouring the internet for resources she could use and passed them on immediately. She is self employed and has no insurance, and the only drug to treat ALS is $1000 a month. I looked for patient assistance programs, but found none. ALS is an "orphan" disease and the medication is therefore expensive because few people need it.

The point is that I get impatient and dismissive with neighbor #1, but I'm willing to spend half my weekend helping neighbor #2. I genuinely believe that substance abuse is a medically treatable and blameless condition, which causes much suffering for users and their families. I treat people with substance abuse all the time at work. Yet in my personal life I am biased, it appears. I'm more willing to help the sick neighbor I like better. I wonder if this off the clock double standard is a luxury that I should even permit myself. I have always prided myself in being able to separate home from work, to give myself the mental rest that helps me face the work week. Why am I now making an exception?

Today is the last day of the month, which for yours truly means a frantic last ditch attempt to see our psychiatric patients who are missing in action. Either because they are very ill and have lost contact, very well and have blown us off, living in a different place now while not seeking treatment or simply uninterested. I try to see these people throughout the month, it's one of my main duties. So Last Day MIA's are the hardest to find, and I often spend the day in a very sad state of working hard while getting nothing accomplished. (MIA is NOT what we actually say, we have a convoluted and politically correct phrase in real life.) True, each try counts as an attempt to make contact and makes our Community Mental Health (CMH) happier if they read the records, but ideally I actually treat the people so we actually get paid. With CMH, these attempts are required weekly but not paid - only direct time is billable. One of my coworkers compared us to Dog the Bounty Hunter with substantial accuracy.

Naturally, I can't tell anyone (other than the patient) who answers the door where I'm from, since that would break confidentiality by revealing where the person was getting treatment from, or in this case not seeking treatment from. Now, these are poor people who usually live in neighborhoods where my white middle classness is out of place. People are suspicious of me, expecting that I am serving legal papers or selling something or asking for political contributions. So roommates and family members are not amused or willing to tell their mentally ill associate that I am there without a darn good reason which I cannot give. Even if I know the patient has signed releases to various people, I can't tell who they are when they answer the door unless they tell me their name, which virtually never happens. In any case, MIA patients tend not to have releases to anyone because of social isolation and/or an unwillingness to designate their roommate at the crack house as a participant in their treatment.

Worst of all are the people who you KNOW aren't there anymore, but you have to continue going to their (former) house weekly until CMH decides not to reauthorize them anymore, which can take up to a year. This is a total waste of time that we are not even paid for and which takes time away from people who are actually living where they say they do and needing treatment.

Bounty hunters don't have to do that. Maybe I should change careers. I bet bounty hunting pays more than social work, too!

I recently read about ultra luxury psychiatric retreats that cost over a thousand dollars a day and treat people with anxiety and depressive disorders for longer than a few days. One opinion in the post was that anyone who could be trusted with a phone cord in their room should not be inpatient, let alone staying for a week or two. People staying there were characterized as the "worried well", not people whose genuine psychiatric problems we should take seriously. The argument implied was that this is beyond the standard of care in public hospitals billing insurance, and that was a bad thing. As a mental health professional and a psychiatric patient who needs inpatient care at times, I'm not so sure.

Surely these "retreats" are private pay, profit based organizations of the most obvious kind. But at least they deliver quality care to those who can afford it. Full hour sessions with psychiatrists. Occupational therapy. Group therapy. Relaxation exercises based on Eastern practices (which I take to mean yoga and meditation). Time to form therapeutic rapport with staff treating you. Time for medications to start working. Reasonable assurance that your roommate is not a former murderer who will attempt or carry out murder on you during your stay. (Based on a True Story from my years as a social worker.) Adequate staffing at all, for that matter. Finally, time to stay while you sort out your immediate crisis and transition from crisis to a period when you can plan your life with clarity.

That's an excellent standard of care, compared to the typical level paid for by insurance at the average psychiatric unit. There, you may see your psychiatrist five minutes a day. Nurse staffing is skeletal, and there is nobody to interact meaningfully with as the need arises. Except other patients, which has some benefit but also evident drawbacks, such as other patients not being psychiatric professionals most of the time. Stays limited to two or three days if you are not psychotic, although antipsychotic medications kick in weeks faster than depression and anxiety medications. No real treatment on weekends. And that potentially deadly roommate who does not get one on one staffing.

And where did that low standard of care come from? For-profit hospitals and insurance carriers, of course. They don't pay or charge as much as the retreats, but managed care and profit seeking hospitals have sheared the quality of care away. This happens on medical units too. Just consider the isolated frail elderly person getting outpatient surgery when it is known that there will be nobody to care for them at home. Insurers do not even provide parity coverage for mental health treatment, which increases the problem. So the standard step down units of fifteen years ago that provided separate levels of care for critically ill/dangerous patients and patients transitioning from crisis to outpatient care are gone. Staffing is pared to a minimum to cut costs. Psychiatrist time is deemed too expensive for patients to do any meaningful work or understand their medications. Admission criteria ban the seriously but not dangerously mentally ill from inpatient care entirely, as if there can be no benefit to inpatient treatment beyond incarceration. Since the for profit health care trend began twenty years ago, the quality of all patient care has taken a nosedive. Due to non-parity, psychiatric patients are hit hardest of all.

Last week work was marked by two emotional events.

The first was a mix of impatience, shame and boredom brought about by "team building exercises." Apparently playing the sort of games usually confined to parties, especially showers, builds teams in some managerial minds. They involved standing up while connected, hula hoops, little cardboard rafts the size of trade paperbacks, being TIED UP and blindfolds. I wouldn't have been surprised if "toilet paper brides" had been on the agenda. I blew out my right knee dancing during college, so I had to sit out several of the more physically challenging ones, thank God. Anyway, I suppose much of it was fun, but we all have work to do to meet impossible standards set by the people who sent us to play games. It was not all fun, though. First, sitting out reminded me of not being picked for teams in gym, which is not a place I yearn to revisit. Second, some of the games required uncomfortable close physical proximity. I'm not shy about touching, but that wasn't the problem. The problem was other people being forced to touch me when they would never choose to do so if permitted a choice. You see, I'm fat. Not "Oh Rubens would have painted you and considered you a perfect beauty." Not big boned or stocky or plump. I am Venus of Willendorf fat. And inevitably, given our culture's obsession with fat people as evil and ugly and unhealthy and disgusting, there were people who would not touch me and looked nauseated at the very thought. I was tied to one of these people for about twenty minutes. They leaned away from me and wouldn't make eye contact. It was the worst humiliation I have felt in a long time. Let me make it clear that I bathed and deoderized and perfumed lightly immediately before coming in. And brushed my teeth. I do not smell bad, and most people grabbed on and held tight when the games called for it with entirely positive vibes. I come by my weight not through excessive eating, but by heritage. My farmer great grandmothers in photographs appear fat and healthy from the hard physical labor they performed about eighteen hours a day for their entire lives. I am virtually never ashamed of my body, but I felt burning shame that day. Even though there is nothing to be ashamed of. Even though weight is more heritable than height (.80 correlation vs .70 among identical twins reared apart). Even though the softness of my body is a delight to most who have touched it, and I am beloved not despite but partly because of my body. I felt the shame and humiliation and embarrassment about my very self that white privilege usually shields me from. The war on obesity is too much waged as a war on fat people, and discrimination is ugly in any form. But I will not be ashamed of my shame, because that would deny just what my status is in this culture. As a fat activist, I need to point out that pariah effect and fight its causes. The snapshot of fat hatred I got shook me pretty badly though.

The second emotion was terror. I go about my job usually in blithe oblivion to the risks, which I am so used to that I take them for granted. Once I observed to Dear Husband that I would never, ever want to work with electrical wires, because it is too dangerous. His reaction was that most people would be scared to work with actively homicidal people on a regular if infrequent basis. Mentally ill people are no more violent than the general population when they are in treatment. But of course my job often involves people who have stopped treatment because of medication side effects or poverty or simple disbelief that they are ill and not really persecuted. I've treated violent, even homicidal, patients from time to time when they are actively coming into the agency. However, much the more frequent case involves going out to find and reach out to people who haven't come in or called or let us know if they're alive for a certain period of time. I've talked about the dangers of poverty in this population before, and one of the most pronounced dangers is that they cannot afford housing outside of extremely dangerous neighborhoods. Mostly if you keep to yourself and avoid eye contact you are not bothered by the often intoxicated and angry neighbors. Still, going into an apparently abandoned house in these neighborhoods you know what you could be up against, even if it doesn't come to your consciousness at the time. Picture standing in front of a dilapidated two flat with a "For Rent" sign and a slightly ajar outer door. Suddenly while climbing a pitch dark rickety, steep stair case with no banister, I felt blinding panic and realized I could die in this place in this instant if someone answered the door and gave me even a nudge. It was pure terror, and after knocking once I could not help running down the steps, out of the house and back to my car. I jumped in, and I believe I did not actually peal off, but that might not be true.

Maybe I'm not so much happy about 2007 as relieved that 2006 is over. Last January my husband was so ill with depression he needed partial hospitalization, and one of the heads of his company essentially threatened to fire him when I wouldn't give medical details over the phone.

Literally the day after DH got out of the hospital program, my mom went to the ICU in my home state because she could not breathe. She refused intubation, but when she fell unconscious from oxygen deprivation my father had her intubated. I rushed home because she was dying. She made it through but did not improve, and eventually she went to a university hospital where she was diagnosed with a 1 in 3 million disease. She was sedated all this time due to her intubation. When she finally woke up, she had a trache and was still on a ventilator. I made the seven hour drive every weekend that I could, taking a lot of time off work. All the stress triggered some depression and I became less functional. After months of chemotherapy and intensive care, my mom recovered from the initial illness fairly well but was left paralyzed from muscle atrophy. Her breathing remained touchy. She was released to a nursing home for rehab a little too early, and died that night after her long and brave struggle.

My best friends from another town were there for me at the funeral. One of them said, "The reward for a job well done is a harder job after this life." Five weeks later he died while on his dream vacation with his wife, leaving behind a teenaged son and his disabled wife, both of whom I'm extremely close to. Another funeral and more trips to the home state to comfort them. And this happened while I was on leave for depression already.

After enormous job stress I decided to quit my job, but backed out at the last minute despite a quadrupled work load. I tried my best to meet the new expectations. And I did meet most of them, by working a lot of overtime and falling behind on paperwork. Then I got suspended because my license lapsed when my mom was dying and I didn't notice. The relief was enormous and some of my psychiatric issues resolved, but I returned to work after I renewed my license. Then one day it was just too much and I resigned. The head of HR persuaded me to go on indefinite leave instead, and I was called back after a week for a part time position without a caseload. This luck lasted about six weeks, then the job requirements were changed so that I'll have to carry a full caseload if anyone goes on leave for longer than a short specified time. Mind you, I'll only have half the hours to manage the caseload. Argh.

Well, I'll cross that bridge when I come to it, but generally speaking I'm welcoming the new year with open arms. I pray that it will not be as eventful as 2006.