Psyched Out

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.

I met with a new patient today at the psychiatric hospital he's staying in. This is the fancy hospital in a ritzy suburb that prefers housewives with depression to, well, OUR patients. This is not to minimize the problems of depressed housewives. I've BEEN a depressed housewife and it sucks rocks and can interfere profoundly with parenting. But our patients are usually psychotic and have often self mutilated or overdosed or have experienced other things that typical mentally ill people don't. We are the bottom of the barrel. Our patients are the people left behind by the traditional psychiatric and disability systems. They are often homeless, needing foster care or stuck in the worst pits of housing projects with predatory landlords and neighbors. Sometimes they are too ill to bathe or change clothes and they just smell really bad. They are people that the typical suburban person would cross the street to avoid on most occasions. They seldom have any income, and when they do it is often only $200 a month. Not enough to get even the most basic housing in a residential motel or boarding house, let alone pay for food and medicine. Some of our most vulnerable patients are forced into homelessness because adult foster care is not paid by the state like child foster care. Instead, a person has to have about $800 a month to get into one. It used to be less but now people with SSI or SSDI have premiums of around a hundred dollers taken out of their checks for medicare premiums. Plenty of people in foster care are left homeless once the qualify for medicare, unless they have a very proactive human services worker. But those workers have caseloads of 600 people or more. They usually don't return phone calls from clients, let alone do anything that will help them. They're just too overwhelmed. But they do better than the general public and legislators. Nobody cares about the suffering of our patients. They don't acknowledge their existence mostly. It can get very frustrating. What am I saying? Not frustrating - heart breaking.

I was about to start a shower when Thing 1 knocks on the door and says that she has to go potty. I let her in, and as I'm turning on the water she adds, "Don't worry, I won't laugh at you."

"Why would you laugh at me?"

"I already said I won't."

"Yes, but is there anything funny about me that I should know about?"

"I *said* I won't laugh at you."

Flush. Sound of exiting child.

I am left wondering.

I visited my next door neighbor to ask a favor today, and sat down to chat. She loves visits, and the price of addressing even the smallest remark to her is a sort of mandatory invitation to "come in and sit down." She's a wonderfully generous woman in her mid fifties or so. S has helped us out in many small ways, and we have a regular habit of sharing food we've overbought and can't use up. She lives with her daughter and son in law and their toddler while the kids are working their way through college. S immediately agreed to watch our twins, Thing 1 and Thing 2, during our teacher conference this week. Now, I had known that S had started falling down a lot last year about this time and had seen a neurologist and undergone medical testing. I have been praying for her and wondering if she had a diagnosis yet, but felt awkward about asking straght out. In retrospect I guess that expressing concern would not count as prying but I'm a somewhat shy person. Today S told me that she'd had an MRI with a suspiscion of MS but some doubt. She then said that her primary care doctor knew the head of neurology at a large academic center and sent the MRI to him. He ruled out MS but suggested she come to Big City to be tested for the rarer things it could be. S then said that her grandfather died of an undiagnosable (at the time, before modern imaging) muscle wasting disease. All his doctors could say was that it was not ALS. Sharon showed me the muscle wasting in her hand and wrist that was not present last year and that she had never mentioned before. S works for herself and has never been able to afford health insurance. She is hoping she can afford a trip to Big City at all, let alone any part of the medical care. It makes me wish we could adopt her and put her on our insurance. The whole situation seems so grim. This scenario is played out hourly among the tens of millions of uninsured Americans, and it breaks my heart. As a psychiatric social worker, it's probably easy to guess that I'd support universal health care. If seeing what I see daily hadn't convinced me, I'm sure this would.

P came in to see me for an annual assessment last week. She was afraid that if she completed this paperwork with me she would never see her regular case manager again. P lives in fear each day. She is afraid of invaders, afraid that others are investigating her, afraid that her grown children will be attacked. As is often the case with my patients, P lives a reality that makes it difficult to tell if she experiences obsessive anxiety or psychotic delusions. Obsession grabs whatever is going on in real life and amplifies it. Psychosis distorts reality, it causes perceptual changes that lead people to misinterpret whatever is going on. P spent most of her life being violently attacked by both family and strangers. She is also poor because of her inability to work. So she really does live in an incredibly bad neighborhood. The kind of apartment complex she can afford will rent to anyone. She lives near drug dealers, child molesters and violent criminals. There's an old joke that it isn't paranoia if they really are out to get you. But of course most people with psychosis are very poor, and do live where predators lurk. So is she simply obsessively anxious about the reality she has lived, or suffering from paranoia when she just happens to have a background where people really were out to get her? Successful treatment relies on figuring out the difference. Different medications work to alleviate different symptoms. Different therapy approaches work best with obesession and paranoia. I learn things just by talking to P for an hour that make me favor anxiety over delusions. P is open about her fears, able to discuss them with the understanding that they are extreme. She does not try to provide evidence of the reality of her fears. She reports events that trigger her symptoms that are likely. Noisy neighbors at the crack house down the hall instead of hearing the radio reporter telling her personally that she is about to be robbed is a sign that her perceptions are correct. In my workplace only the doctors diagnose, but forming my own judgement helps me write an assessment that will help others ask the right questions and try the non-medicine treatment approaches that are likely to work. In the end though, I could be wrong either way - she could have both!

I'm a busy psychiatric social worker and mom whose admiration of other bloggers has encouraged me to try one of my own. Here you'll find a mishmash of work stories, cute kid stories, jokes, birth junkie opinions, mental health musings and other random thoughts. Naturally, the work stories are fictionalized accounts without identifying information. As a treater who is also a patient I'm a big believer in HIPPA. I wouldn't mind my own psychiatrist or therapist posting stories about me as long as they were fictionalized, so I'll do the same for others. Fair warning, if you think you recognize yourself or someone else, you don't.