Psyched Out

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.

I took up the Emergiblog challenge on this meme.

1. Hot Chocolate or Egg Nog? Hot chocolate all the way. And we're not talking instant either. Preferably with steamed milk and plenty of peppermint flavor and real whipped cream. I once bought a boyfriend an espresso maker for Christmas so I'd be able to steam my own milk.

2. Does Santa wrap presents or just sit them under the tree? Due to having twins, previous years are a little hazy, but this year Santa is wrapping in special Santa only wrapping paper.

3. Colored lights on tree/house or white? White lights are solemnly beautiful, colored lights are festive. Both.

4. Do you hang mistletoe? I already get all the kisses I want. :)

5. When do you put your decorations up? Usually a week or two past Thanksgiving. Thing 1 was the Decorations Dictator this year, Thing 2 played a video game most of the time.

6. What is your favorite holiday dish? Homemade sage stuffing. In the bird, even better. My father (Yes dad, I'm talking about you!) in his later years has developed a paranoid belief that stuffing from the bird is dangerous due to reports a few years back recommending that you take the stuffing out to store it. So I make a pan for him and enjoy mine despite dire warnings and shakings of the head.

7. Favorite Holiday memory? Singing Christmas carols, especially carolling in neighborhoods and nursing homes. I also love gathering with my husband's musical family and singing them in the living room until we run out of songs to sing.

8. When and how did you learn the truth about Santa? I was in second grade, and I was pissed about being lied to all that time. I was the oldest, and my parents ensured my silence on the subject thusly: "Ever notice how the Santa presents are the BEST presents? Well, if the boys didn't believe in Santa, those presents might disappear every year. We're sure you'll make the right decision on whether to tell your brothers, dear."

9. Do you open a gift on Christmas Eve? No, but we bake cookies to give to Santa.

10. How do you decorate your Christmas Tree? Colered lights and white lights. Break proof ornaments until the twins are a little older. Pine cones and wooden stars, gold angels and bright red mini gift boxes. A strand of gold beads and those floss covered ornaments in primary colors plus some beautiful purple ones that look glass but aren't. Candy canes hangind on branches. I grab one and eat it once in awhile, nobody else in the house likes them.

11. Snow! Love it or Dread it? Love snow, hate bitter cold.

12. Can you ice skate? *rolls on floor laughing* That would be a no.

13. Do you remember your favorite gift? Tobor - a little walking robot (and yes, you did just notice that Tobor is Robot spelled backwards) as I'm something of a technophile. My mom gave up on dolls and got me the robot that year. The previous year I had asked for a really-crawls doll to mom's delight. Unfortunately, it was soon evident that I wanted to open her up and find out how she crawled. Very disillusioning for mom, I'm sure.

14. What’s the most important thing? Celebrating the birth of Jesus. Being a birth junkie only adds to my enjoyment of this holiday. Also honoring my mom's memory as this is our first Christmas since she died.

15. What is your favorite Holiday Dessert? Pumpkin pie with real whipped cream, tied with Spritz cookies.

16. What is your favorite holiday tradition? Blueberry muffins on Christmas morning - but after the presents to be merciful to the children who woke up at 5 AM wanting to open them.

17. What tops your tree? The most vulgar, gaudy light up star with colored light in the center and white on the outside you can imagine. I love my dignified gold star, but there is nothing more gloriously beautiful to five year olds than our "church window" light up star.

18. Which do you prefer giving or Receiving? Giving! These Santa years are fun and we tend to splurge on the kids and put our gifts on the back burner for now.

19. What is your favorite Christmas Song? Longest duration - Oh Come All Ye Faithful. As a child I had a wind up angel that played it. Current favorite - A Virgin Most Pure. Favorite to sing to the kids - The Friendly Beasts. But I have at least twenty that I love pretty equally. I'm way into traditional Christmas music.

20. Candy canes, Yuck or Yum? Passion sums it up nicely. I still long for the inch diameter foot long ones I had as a preteen. I would feel silly buying one as an adult, although I gues I could pass it off as a parent thing. Hmmm...

Got this one from Fat Doctor, who tagged everyone reading her blog. My top five Christmas songs, in no particular order:

Wexford Carol
The First Noel
A Virgin Most Pure
O Come All Ye Faithful
Silent Night

I'm also fond of other non-standard Christmas carols such as Watts Cradle Song, Tomorrow Shall Be My Dancing Day and the Cherry Tree Carol. It's hard to pick just five top ones, because I have a very steady affection for so many. Maybe I'll share more lyrics as the season continues.

Anyway, consider yourself tagged if you have a blog and haven't done this one yet.

It turns out that part of staying in bed and feeling like I couldn't face anything Sunday was a virus. I threw up multiple times at work the next day and went home early. I was hoping that feeling physically better would put the whole thing behind me. I woke up today feeling better from the virus but still depressed. It's so overwhelming, the inertia that I experience at these times. I just lay there. I know it's not healthy, I know the best thing is to crawl out from under the covers and face the perfectly unspectacular and easy day. And it's not at all like I usually feel when I don't want to get out of bed. I have my too late nights like anyone else where I regret watching the huge tumor removal program all the way to the end. When I'm depressed I tend to wake up completely before the usual time. Then I lay there feeling helpless and weak and stupid. After all these years. After all of my professional experience. Despite every positive thing in my wonderful life. None of it matters when the feelings come roaring back like a waterfall I'm plunging over. It's so impersonal, it has nothing to do with my circumstances, it's not connected to my life. When the depression really hits cognitive behavioral therapy (CBT) stops working. It has what I believe to be a fundamental flaw: the assumption that depressed feelings arise solely from deep seated but erroneous beliefs or thought patterns. I experience depression as a wave of negative emotions and physical symptoms that can cause superficial negative thoughts. I don't think that I'm a bad or weak or helpless person at all. I have too much experience with this illness to let it interfere with my deep seated thought patterns. I just feel bad and weak and helpless while knowing that those things are untrue. It's definitely the feeling affecting my thoughts, and not the other way around. CBT has done a lot for me in the past when I was learning to cope with actual wrong beliefs (example: "if I feel bad then I am bad"), but it has had reduced effectiveness as I have grown more skilled and knowledgeable. CBT does not address the physical and emotional side of depression well. If its premise that thoughts cause mood and not the other way around, once learned it would prevent recurrance of depression, which it most definitely does not.

Did I mention that depression makes you self centered? It does. As soon as I muddle through this bout I'll return to more interesting subjects, I promise.

So apparently it's not bright to taper down on psych meds a few weeks before Thanksgiving when your mom and one of your best friends died this year. Come all ye young ladies take warning by me, and all that. I barely made it out of bed by three today. Some of it was sleep, but lots of it was just being stuck there too scared to face life. Did I mention that depression sucks and I HATE it. In the abstract it's good because it helps me understand the people I work with a little better, it makes me able to say hey, I've been in the psych hospital too and I know how it is. Hidden fact of psych hospitals - they are meat markets. Of all the wrong places to be lookin' for love, you would think this one would be obvious. But people have a deep need for understanding and affection that transcends logical thought, I guess. And you're usually not at your most sensible while on the unit anyway. Anyway, after several decades of dealing with depression I know how to handle it, it never really gets better when I'm having it.

I've recently cut back to part time at work both to spend this last year of extra time with my twins, and to enable me to go back to school. I'm torn between getting an advanced degree in social work and going into nursing. This post and the next will explore the options.

If I go for social work I could do research on the needs of women with mental illness who are pregnant. The undertreatment of pregnant women can be shocking. OBs don't want to treat them because they are mentally ill, and psychiatrists don't want to treat them because they're pregnant. Women here are locked up for months with no psychiatric treatment until they have babies. Now, I don't mean any disrespect to women who choose that route with their private pay insurance and chosen physicians. Some psychiatric medications certainly have proven adverse effects on unborn children, such as neural tube defects and cleft palate, because some are class X. An insightful and educated woman with the advice of her doctor might well forego them. I'm concerned about often indigent women who have limited choices in doctors and treatment centers and little insight into their mental illness. They don't get second opinions. They don't get doctors who know them personally and are in any position to advocate for them. I don't blame this on physicians at all, I'm aware of the vastly different working conditions and institutional rules they are subject to. And doctors who do advocate treatment are bucking the system at great risk. I'm primarily concerned about the trend to prescribe class B and C medications for non-lethal conditions which are not psychiatric, but not for non-lethal psychiatric conditions. Hay fever should be treated, but schizophrenia is too mild?! What about of giving them Clozaril (B) or Haldol (C) instead of locking them up? After all, we could lock up women to keep them away from allergens. But we don't. Because we respect that they deserve treatment for their legitimate illness. Maybe if I could do research on outcomes women with severe mental illness will be treated more humanely.

Our supervisor announced that the holiday staffing level has gone back to 50% now. It turns out that the other team's supervisor had been granting half level staffing all along. So I'm glad to say it was just a mistake. This supervisor has only been in her position for two weeks, so she deserves the benefit of the doubt. I have never wanted to supervise people, even though I've done it in the past. Simple mistakes can generate so much trouble. And you can't avoid people you don't like if you're supervising them. I do clinical work with people I don't like all the time, of course. I treat child molesters and psychopaths, after all. And I'm totally willing in that clinical setting to put aside my dislike and provide the best care possible. That's not personal, and my job isn't to like people. It is to provide a steady stream of agape to them and allow them to work on their skills and self-knowledge. I suppose the same is true of a regular supervisor, I just don't like it as much.

Thing Two takes his vitamin religiously every night. He will even remind us to give it if we forget. So far, so good. Thing One refuses vitamins, but since she mostly eats fruits and veggies I don't mind. Unfortunately, the reason Thing 2 is so biddable is that he is terrified he will get scurvy. I'm not sure where he got this idea, but I believe that Spongebob Squarepants and ghost pirates might be involved somehow. In any case, Thing 2 firmly believes that if he misses a vitamin, he will immediately come down with scurvy. He is not clear on the symptoms or treatments. He seems very sure that it is terribly painful. I cannot confirm or deny this since nobody in my family has had scurvy since the eighteenth century. I guess with all of my medical blog reading I could find out, but I'm trying to avoid the topic and just offer increasingly impatient reassurance. Okay, I admit I did use his fear to try to get him to eat any kind of plant based food at all, but he rejected the fruit idea out of hand. Thing 2 either saw through my plot or just thinks I'm lying about sailors and hardtack and limes to the rescue. He's probably spending his whole recess at kindergarten spreading rumours of scurvy to his classmates while debunking inconvenient historical facts.

Recently I changed jobs at the agency I work for, and had to give up my caseload. Okay, I GLEEFULLY gave up my caseload, for the most part. But there are always special people you work with. They touch you in a soft spot others don't reach, or make a lot of progress, or would be friend material if you weren't treating them. The patient I met with today did all three. J is a perfect example of how anyone at all can get a devastating mental illness. She has an advanced degree in a helping field, has been a social worker herself in the past and is one of the most intelligent, intellectual people I have ever met. J came to our town after getting an offer of employment based on her advanced degree. After she had moved, it fell through. She was completely isolated in a new place with no support system, no money, and rapidly declining mental health. J lost everything when she got sick. Her symptoms are a mixture of several diagnoses, although she is assigned two specific ones. The DSM is shifty sometimes, but more about that another time.

J has a sense of humor that helps her cope with her multiple psychiatric and physical illnesses. She has gone through major surgeries and chronic pain. Living at a terrifying residential hotel in the tenderloin of the town, she joked about what the streets should be named. Worried over her college aged child making bad life choices, she referred to the kid as a specific and fitting cartoon character. Watching her use the coping skill of humor against all odds was a touching and impressive experience.

A few people are always devastated by a change in social workers. It happens to everyone who works in the field, and you have to accept that when you work hard with someone when they are struggling and needing support that they might miss you a lot when you don't anymore. So I'm not saying any of this because I have some kind of ego trip or savior complex going on here. J was devastated when I stopped working with her. Despite an established need for frequent appointments, she has not been scheduling them much and has not come in for over a month to meet with her new worker. When I was assigned to do some work with her, she responded to my calls when she hadn't been returning calls from her new worker.

Her new worker and I met with her today. Her sense of humor was gone. She could barely look me in the eye. She did open up when we used especially validating techniques, but she was clearly doing much worse than she was before.

It is hard not to feel guilty.

One of the ways I avoid burnout is to not play the guilt game. I cannot change another person's life, they must do it alone. Supported, encouraged, assisted, but alone. I know this, but sometimes I still feel it despite all my experience in my field. I would like to be able to magically make lives better, to have precisely this amount of professional attachment and not a whit more. To not feel.

Perhaps I am a better social worker because I do feel.