Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
"But fire when it is smothered changes into acrid smoke that suffocates as it spreads." (Richard Wilhelm, The I Ching)
Why do we need a place to say these things about work to one another? Because issues that are brought up in context are smothered....this blog is the acrid smoke that spreads...my personal hope is that it spreads and eventually suffocates bad management.
Management here doesn't want to solve problems...it wants them to go away.
If staff complains about incompetent, even dangerously negligent Doctors or social workers or whatever, the solution is seen as "stopping the complaints" instead of "firing the Doctor".
To solve the problem of staff shortages, any live body that presents in the hiring que is hired to fill the spot...never mind that the live body is not qualified, burdens the existing staff, and will be unable to perform the actual job duties...if it's cheap and available, it's a go.
If the problem is "too many seclusions", the solution is to make the paperwork so onerous that people will avoid it, regardless of the situation. If the problem is "too many elopements", the solution is to make the fences higher, thicker, stronger. If the problem is conflict between coworkers, the solution is to ignore it until it goes away.
In fact, the solution to most problems is, apparently, ignore it and it will go away.
The management process here appears to be attendance at a series of meetings. From a line staff perspective, it is unknown what actually goes on at these meetings, but there are a lot of them and the people who attend them are earning relatively large salaries. Whatever it is that goes on there, it doesn't seem to have much to do with what's really happening on the front line of the hospital. I remember, for example, a few years ago when a JCHO visit was looming and apparently JCHO had brought up some issue about the temperatures in the refrigerators on the units. I'm working on a day shift, I look up to see an entire squadron of highly paid managers sweeping through the unit, approaching the unit refrigerator, and assessing its temperature. The amount of money in salaries alone that was present for this activity was mind boggeling..there were, I kid you not, 5 or 6 people there who's salaries were 60 to 100K (or perhaps more)...all looking at that refrigerator. This event was followed in due course by various forms and edicts about refrigerator temperatures, food storage, food dating, etc. Great. Certainly don't want to poison patients with old food....Yet at that time (and since) there had not been, to my knowledge, a single solitary case of food poisoning resulting from improper refrigerator temperatures or food storage techniques. There ARE things that happen that could (and do) negatively impact the health of patients or staff...but those things...the real, important things...are either smothered or ignored.
Good people can watch bad things happen for only so long before they need to talk about them. There's no time to talk about these things at work...during that time, we are working (...those of us who aren't in meetings all day, that is...)If we bring things up in "supervision" we are consoled, patted on the head, or threatened until we stop bringing them up. Problem solved.
...Except for the problem of really needing to talk about some of this stuff. So we talk about it here. Only by talking about the real problems can we hope to come up with real solutions. Good people don't like to collude in bad treatment; they want to make it better...that requires communication, mutual support, a real confrontation of the real problems. That's why we blog, n'est pas? I understand that there are some people who have a problem with this. I wonder why. What are they afraid of? Acrid smoke? A little fresh air generally fans the flames, disburses the smoke
They should blog about it, we'd be glad to help them.
Tuesday, February 28, 2006
Friday, February 24, 2006
New Carpet!!!!
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
Yes! The Children's Unit has new carpet!! Looks great. Feels great. The baseboards have been replaced. Sweet repairs...slow perhaps, but sweet. Government Agencies do seem to all have a similar response to flooding ...slow.
I hear that the place is loosing another batch of experienced people...a generation moves on. Nearly all of the people that I worked with when I started here will have gone in the next few months, it sounds like...all new people running the place. As it should be, no doubt. It's how an institution gets reborn, perhaps.
Everyone who leaves gets to refer to the place in the past tense: "You remember when we all got locked in the seclusion room with so and so? Those were the days!" The experience becomes distant, former...boiled down to a few picture postcards floating around in your head. At least I hope so. Sometimes I can hardly wait until I get to refer to it in the past tense...when perhaps I can get some perspective on the peculiar experience it is.
I mean not everybody spends their days in the company of lots of really crazy people. Am I right? Or at least not crazy like our people are crazy. It IS a peculiar thing to do, statistically speaking if nothing else.
I'm disturbed by the current trend of medicating the symptoms of mental illness into oblivion and calling it good. There's a patient there who came in manic a few weeks or so ago, and now we've medicated him. And, Lord forgive me, I liked him better manic.
And I just hate it that we medicate children. I just can't get comfortable with giving little kids grown up drugs.
It's clear to me though when I'm at work, that these things are none of my business; medications, facilities management issues, not my concern when I'm there...I'm there to do a job, not opine about how things are done. My opining in that environment is seen as overstepping the boundaries of my job description. That's why this blogging thing is so great, I guess...we get to talk about the stuff that's none of our business...
I listened to Pres. Bush's speech to the American Legion this morning...lots of talk about exporting democracy and freedom, of course. Among other things, he said there are about 400 newspapers in Iraq now...wow, I thought...at least that's something I can agree with...free speech is such a basic human right, don't you think? In a democracy we get to talk about anything and everything...even stuff that's none of our business, if we want to. Don't you love that?
Yes! The Children's Unit has new carpet!! Looks great. Feels great. The baseboards have been replaced. Sweet repairs...slow perhaps, but sweet. Government Agencies do seem to all have a similar response to flooding ...slow.
I hear that the place is loosing another batch of experienced people...a generation moves on. Nearly all of the people that I worked with when I started here will have gone in the next few months, it sounds like...all new people running the place. As it should be, no doubt. It's how an institution gets reborn, perhaps.
Everyone who leaves gets to refer to the place in the past tense: "You remember when we all got locked in the seclusion room with so and so? Those were the days!" The experience becomes distant, former...boiled down to a few picture postcards floating around in your head. At least I hope so. Sometimes I can hardly wait until I get to refer to it in the past tense...when perhaps I can get some perspective on the peculiar experience it is.
I mean not everybody spends their days in the company of lots of really crazy people. Am I right? Or at least not crazy like our people are crazy. It IS a peculiar thing to do, statistically speaking if nothing else.
I'm disturbed by the current trend of medicating the symptoms of mental illness into oblivion and calling it good. There's a patient there who came in manic a few weeks or so ago, and now we've medicated him. And, Lord forgive me, I liked him better manic.
And I just hate it that we medicate children. I just can't get comfortable with giving little kids grown up drugs.
It's clear to me though when I'm at work, that these things are none of my business; medications, facilities management issues, not my concern when I'm there...I'm there to do a job, not opine about how things are done. My opining in that environment is seen as overstepping the boundaries of my job description. That's why this blogging thing is so great, I guess...we get to talk about the stuff that's none of our business...
I listened to Pres. Bush's speech to the American Legion this morning...lots of talk about exporting democracy and freedom, of course. Among other things, he said there are about 400 newspapers in Iraq now...wow, I thought...at least that's something I can agree with...free speech is such a basic human right, don't you think? In a democracy we get to talk about anything and everything...even stuff that's none of our business, if we want to. Don't you love that?
Thursday, February 23, 2006
Outsource it?
The MadHouse
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
I know this is off the subject, but as I've been listening to all of the hulabaloo about having the UAE run our ports, the question that I've had is, "isn't there an American Company that could run our ports?"...why do we need to hire any other country...even Great Britain...to do this job? Why don't we do it better ourselves? Why isn't there an American company that outperforms any and all foreign companies? What's with that?" And then I remember Katrina...and the sorry mess the response to that was...and I feel some doubts...maybe the Americans aren't the best at everything...maybe we need to outsource things because we are, indeed, total klutzes...maybe we have forgotten how to do things.
Maybe we could outsource indigent mental health care. ...someone else could probably do it cheaper...think of the cost of labor, alone...given the differences possible in salaries, we could probably pay for a patient's transportation to any foreign country and still be way ahead...
...I hear you thinking......
it's not a bad idea, is it?...
but what would we do for work? We're drawn to this for some reason. I used to work for a police department and I was really struck by how the cops and the robbers depended on one another for significance. Most people rarely encounter cops; some, though, see them over and over again...they seem to need cops. Similarly, the cops need something to do..they need those robbers to give meaning to their endeavors. Now I work for a mental health system...here, the crazy people need us, and we need the crazy people. I suppose we should all ask why from time to time...why is it that I need to work at this?
In my case, it's at least partly because I like an environment where the crazy people are labeled for me. In the rest of the world you're on your own...some of 'em are, some of 'em aren't...and how are you to know? No end of confusion there. At work, I have a list of which ones are crazy. I like that.
Every now and then, at work, I look around and wonder if the list is right...maybe there's somebody here who SHOULD be on the list, but isn't...
...me, maybe.
But here's the thing...if a thing is worth doing, it's worth doing well, right? If Americans are determined to take care of their own mentally ill citizens, as opposed to outsourcing them, we should do a good job of it. Much better for our morale, our sense of self, our satisfaction in our work...
What would that look like, do you think? I'm interested in hearing what people think constitutes "good care" in this field; if money wasn't a problem, what would we do differently? Can we paint a picture or draw a diagram, of what would be better than what we've got now?
Blog, gentle readers, blog!
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
I know this is off the subject, but as I've been listening to all of the hulabaloo about having the UAE run our ports, the question that I've had is, "isn't there an American Company that could run our ports?"...why do we need to hire any other country...even Great Britain...to do this job? Why don't we do it better ourselves? Why isn't there an American company that outperforms any and all foreign companies? What's with that?" And then I remember Katrina...and the sorry mess the response to that was...and I feel some doubts...maybe the Americans aren't the best at everything...maybe we need to outsource things because we are, indeed, total klutzes...maybe we have forgotten how to do things.
Maybe we could outsource indigent mental health care. ...someone else could probably do it cheaper...think of the cost of labor, alone...given the differences possible in salaries, we could probably pay for a patient's transportation to any foreign country and still be way ahead...
...I hear you thinking......
it's not a bad idea, is it?...
but what would we do for work? We're drawn to this for some reason. I used to work for a police department and I was really struck by how the cops and the robbers depended on one another for significance. Most people rarely encounter cops; some, though, see them over and over again...they seem to need cops. Similarly, the cops need something to do..they need those robbers to give meaning to their endeavors. Now I work for a mental health system...here, the crazy people need us, and we need the crazy people. I suppose we should all ask why from time to time...why is it that I need to work at this?
In my case, it's at least partly because I like an environment where the crazy people are labeled for me. In the rest of the world you're on your own...some of 'em are, some of 'em aren't...and how are you to know? No end of confusion there. At work, I have a list of which ones are crazy. I like that.
Every now and then, at work, I look around and wonder if the list is right...maybe there's somebody here who SHOULD be on the list, but isn't...
...me, maybe.
But here's the thing...if a thing is worth doing, it's worth doing well, right? If Americans are determined to take care of their own mentally ill citizens, as opposed to outsourcing them, we should do a good job of it. Much better for our morale, our sense of self, our satisfaction in our work...
What would that look like, do you think? I'm interested in hearing what people think constitutes "good care" in this field; if money wasn't a problem, what would we do differently? Can we paint a picture or draw a diagram, of what would be better than what we've got now?
Blog, gentle readers, blog!
Tuesday, February 21, 2006
Black and Orange
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
I saw a show on BBCAmerica the other night...it was late, after evening shift; it appeared to be a pilot for a series...two hours long about a psych hospital in Great Britain. It was about two psychiatrists having an argument about the correct diagnosis/treatment of a patient.
The older psychiatrist, kind of a pompous ass, was asserting the patient was a borderline with a brief psychotic episode and should be returned to the community as fast as possible...extended hospitalization would only institutionalize the patient, the hospital needed the beds, he should be set free. The younger, idealistic psychiatrist thought the patient was schizophrenic, had no resources, needed the help and the structure of the hospital. He strongly advocated the patient be kept (given a long term cert, in American lingo). The patient, being crazy, was mostly unable to identify his own best interest or contribute to its achievement.
Although some of the language was odd or wrong, the theme of the show was surprisingly pertinent...one tended to like the young idealist who wanted to keep the patient in the hospital...one noticed that the arguments of the pompous ass psychiatrist were uncomfortably like ones own. The show did a pretty good job of portraying the patient with a confusing complex of symptoms. It was difficult to be sure who was "right".
At the end of the show, the ass had prevailed and the patient was set free...to wander aimlessly, friendlessly in the city at night, looking into store front windows in the cold.
One big difference (between the situation as described on TV and reality as I know it) was the hospital facility itself. In the show, the patient has his own room; the two docs spent hours in that room with the patient, talking with him, discussing his options, opining, arguing, etc. The patient periodically wandered out of his room into lovely landscaped lawns and gardens. You never saw another patient. The room was nice, modern, clean, comfortable.
On that level, the choice of keeping the patient or turning him loose looked obvious...quality of life would be so much better in that room than on those streets...
And it's made me start thinking about how that compares to the reality on the ground (so to speak) here. Like the pompous ass in the show, I tend to think we should set them free, if at all possible. I'm assuming that there's a greater possibility of some reasonable quality of life out there than I know there to be in here...but you know, I'm probably wrong about that...given the state of funding for mental health services for the indigent, this hospital may be one of the best "placements" available. If that's true, we should hang on to our patients as long as possible in many cases...setting them free is tantamount to throwing them into a swampy lake.
Thinking that we should be keeping them, not setting them free makes me feel...well, crazy.
I saw a show on BBCAmerica the other night...it was late, after evening shift; it appeared to be a pilot for a series...two hours long about a psych hospital in Great Britain. It was about two psychiatrists having an argument about the correct diagnosis/treatment of a patient.
The older psychiatrist, kind of a pompous ass, was asserting the patient was a borderline with a brief psychotic episode and should be returned to the community as fast as possible...extended hospitalization would only institutionalize the patient, the hospital needed the beds, he should be set free. The younger, idealistic psychiatrist thought the patient was schizophrenic, had no resources, needed the help and the structure of the hospital. He strongly advocated the patient be kept (given a long term cert, in American lingo). The patient, being crazy, was mostly unable to identify his own best interest or contribute to its achievement.
Although some of the language was odd or wrong, the theme of the show was surprisingly pertinent...one tended to like the young idealist who wanted to keep the patient in the hospital...one noticed that the arguments of the pompous ass psychiatrist were uncomfortably like ones own. The show did a pretty good job of portraying the patient with a confusing complex of symptoms. It was difficult to be sure who was "right".
At the end of the show, the ass had prevailed and the patient was set free...to wander aimlessly, friendlessly in the city at night, looking into store front windows in the cold.
One big difference (between the situation as described on TV and reality as I know it) was the hospital facility itself. In the show, the patient has his own room; the two docs spent hours in that room with the patient, talking with him, discussing his options, opining, arguing, etc. The patient periodically wandered out of his room into lovely landscaped lawns and gardens. You never saw another patient. The room was nice, modern, clean, comfortable.
On that level, the choice of keeping the patient or turning him loose looked obvious...quality of life would be so much better in that room than on those streets...
And it's made me start thinking about how that compares to the reality on the ground (so to speak) here. Like the pompous ass in the show, I tend to think we should set them free, if at all possible. I'm assuming that there's a greater possibility of some reasonable quality of life out there than I know there to be in here...but you know, I'm probably wrong about that...given the state of funding for mental health services for the indigent, this hospital may be one of the best "placements" available. If that's true, we should hang on to our patients as long as possible in many cases...setting them free is tantamount to throwing them into a swampy lake.
Thinking that we should be keeping them, not setting them free makes me feel...well, crazy.
Friday, February 17, 2006
Got an Anteater?
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
There's a room on one of the teams where, when the facilities guys pulled the baseboard off to see why the paint was bubbling off the wall, they discovered that the whole structure behind the baseboard was an ant hill. Makes me a little uncomfortable....I'm thinkin....if that's the case in this room......it might be the case elsewhere....ant tunnels and chambers turning the studs into lacework....and millions of ants....swarming, crawling, eating.... I'm picturing in my mind's eye a building, turning into particles, falling into dust...kind of like when they blew up that hotel in Las Vegas on New Years Eve...only it's the hospital...and it's not explosives, it's ants.....KA WUMPF!!! and it's just a pile of plaster-dust and ants; and the patients still in their beds from upstairs now mingled with the patients downstairs, the staff with dust on their eyebrows and lashes...
Don't you wonder if the pipes are going to burst in the cottages again in this cold?
No one's ever bothered to replace the cupboard door in the kitchen that finally just fell off about two years ago.
There was a code red alarm and our pagers didn't go off. No idea what happened there, but we all agreed that "the alarm system is down again" was the most likely explanation...that's been going on so long now that we pretty much assume that there isn't one...an alarm system, I mean. We knew there was a code red because we had nurses from other places running through our unit.
All the glucometers were recalled. Somebody's trying to come up with a weekend plan for how to deal with our many, many diabetics sans glucometers...(and, hold on, why is it again that we have so many diabetics?)........
And the eternal weekend crunch to find enough staff somehow, somewhere to cover the hospital goes on....
Tired, uninspired, and surrounded by manics, the staff soldiers on...not even imagining victory anymore.
There's a room on one of the teams where, when the facilities guys pulled the baseboard off to see why the paint was bubbling off the wall, they discovered that the whole structure behind the baseboard was an ant hill. Makes me a little uncomfortable....I'm thinkin....if that's the case in this room......it might be the case elsewhere....ant tunnels and chambers turning the studs into lacework....and millions of ants....swarming, crawling, eating.... I'm picturing in my mind's eye a building, turning into particles, falling into dust...kind of like when they blew up that hotel in Las Vegas on New Years Eve...only it's the hospital...and it's not explosives, it's ants.....KA WUMPF!!! and it's just a pile of plaster-dust and ants; and the patients still in their beds from upstairs now mingled with the patients downstairs, the staff with dust on their eyebrows and lashes...
Don't you wonder if the pipes are going to burst in the cottages again in this cold?
No one's ever bothered to replace the cupboard door in the kitchen that finally just fell off about two years ago.
There was a code red alarm and our pagers didn't go off. No idea what happened there, but we all agreed that "the alarm system is down again" was the most likely explanation...that's been going on so long now that we pretty much assume that there isn't one...an alarm system, I mean. We knew there was a code red because we had nurses from other places running through our unit.
All the glucometers were recalled. Somebody's trying to come up with a weekend plan for how to deal with our many, many diabetics sans glucometers...(and, hold on, why is it again that we have so many diabetics?)........
And the eternal weekend crunch to find enough staff somehow, somewhere to cover the hospital goes on....
Tired, uninspired, and surrounded by manics, the staff soldiers on...not even imagining victory anymore.
Wednesday, February 15, 2006
The Madhouse is a sad house.
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
Today we are sad.
I want to think of him riding away in his lowrider.
Listening to Carlos Santana.
Here's wishing him a happier life next time.
Sad trumps mad.
Good-bye, cholo.
Friday, February 10, 2006
The Trouble with Delusions
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
Where to begin.
The DSM-IV diagnostic criteria for delusional disorders are A: Nonbizarre delusions of at least one months duration. B: Criterion A for schizophrenia has never been met. C: Apart from the impact of the delusion or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E: The disturbance is not due to the direct physiological effects of a substance or a general medical condition. And there are "types"...Grandiose, Jealous, Persecutory...etc....
There was apparently a discussion of delusional disorder at the American Psychiatric Association's 2004 Annual Meeting, because I found a good article about it in Medscape (www.medscape.com/viewarticle/480915). On page four, under The Fundamental Puzzle of Delusions, we read, Since the delusions by DSM-IV definition must be of a somewhat plausible "nonbizarre" nature, they tend to blend with thinking that may be considered a variant of normal. In a study in a normal population, the rate of belief in paranormal phenomena such as contact with the dead, prophecy, telepathy, UFO's , and reincarnation was high and correlated negatively with the strength of religious conviction. In nominal and nonbelievers, the rate of at least moderate acceptance of paranormal phenomena was 30% to 50%.
The trouble is, a good delusional disorder is actually fairly rare...or, rather fairly rarely seen in our particular environment. I've worked with maybe 4 or 5 instances that I thought were this in 20 years...and the thing was in each case, the patient sounded plausible in his or her accounts of their situation, was not obviously impaired, until the delusional material was confronted...its remarkable fixed quality in the face of contrary evidence ... the stubborn adherence to actions not in their own best interests, shall we say...shout "disorder!!" to us...there's no mistaking this person is crazy. We tend to lump these people into the category schizophrenia, which similarly involves a lot of delusional stuff, but there are distinct differences. And these differences make it important for us to notice when someone with a FDD happens along...treating a patient with a Fixed Delusional Disorder as though she(or he) were schizophrenic, would be a mistake.
Treating a patient with a Fixed Delusiona Disorder is a lot like trying to understand why the entire Muslim world is rioting over a few cartoons...or why President Bush ever thought the Iraqi people would greet us as liberators, with flowers ... .I mean, really, some religious beliefs are as extreme as those of a given "fixed delusional disorder" patient, and equally unprovable...with the major difference being that our patient has managed to cross paths with us...and that certainly does say something about the severity of the disorder....
Think about al of this and before you know it, you realize that we all have delusions, great and small...
Here, in this environment, we experience "group think". I know I have. In "group think", we exchange our thoughts and experiences of a patient and distill, together, a picture of him. This picture is an abstract, evoked by key words and phrases. We say, "borderline" and everyone in the room knows this patient will seek attention via self harm; we say "schizophrenic" and we all picture psychosis, and so on. We use these words and phrases to outline a sketch of the patient that can be passed on to the next shift. Because we are human, this is an imperfect process. It frequently happens that the sketch is misinformed, warped by staff's own emotional state or world view. Together we distill it, hone it, embellish it. We all come to think of the patient in the same way...but its wrong. It's always wrong...we can't ever really get the whole picture because we don't have either the time or the manpower to do it...but sometimes we're farther off than others...and these are our delusions.
I think we also have the delusion that our patients are too ill to function in society... I think that we're way overprotective about that. I think, this is America! We have an inalienable right to be delusional! Our country was founded on this principle!! You just can't hurt anybody. That's a firm and fast rule. And, being delusional is no bar to being a participant in society. Surely we all know this...look at your neighbors! Your families! Come on!
And I think we're delusional about our powerlessness. I think when we disagree with the referring center about the disposition for a patient, we have more ability to impact that decision that we think we do...we just lack the will...we have the delusion that it's not worth doing, it's too much trouble, we don't have time.
I saw another delusion at work ... someone thinks that filling out a form with more checks than usual will result in more attention being paid to the patient....I speak, of course of the ubiquitous obs forms...and the general annoying delusion that a form fixes a problem or provides a treatment of some kind.
Ah, well.
Where to begin.
The DSM-IV diagnostic criteria for delusional disorders are A: Nonbizarre delusions of at least one months duration. B: Criterion A for schizophrenia has never been met. C: Apart from the impact of the delusion or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D: If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E: The disturbance is not due to the direct physiological effects of a substance or a general medical condition. And there are "types"...Grandiose, Jealous, Persecutory...etc....
There was apparently a discussion of delusional disorder at the American Psychiatric Association's 2004 Annual Meeting, because I found a good article about it in Medscape (www.medscape.com/viewarticle/480915). On page four, under The Fundamental Puzzle of Delusions, we read, Since the delusions by DSM-IV definition must be of a somewhat plausible "nonbizarre" nature, they tend to blend with thinking that may be considered a variant of normal. In a study in a normal population, the rate of belief in paranormal phenomena such as contact with the dead, prophecy, telepathy, UFO's , and reincarnation was high and correlated negatively with the strength of religious conviction. In nominal and nonbelievers, the rate of at least moderate acceptance of paranormal phenomena was 30% to 50%.
The trouble is, a good delusional disorder is actually fairly rare...or, rather fairly rarely seen in our particular environment. I've worked with maybe 4 or 5 instances that I thought were this in 20 years...and the thing was in each case, the patient sounded plausible in his or her accounts of their situation, was not obviously impaired, until the delusional material was confronted...its remarkable fixed quality in the face of contrary evidence ... the stubborn adherence to actions not in their own best interests, shall we say...shout "disorder!!" to us...there's no mistaking this person is crazy. We tend to lump these people into the category schizophrenia, which similarly involves a lot of delusional stuff, but there are distinct differences. And these differences make it important for us to notice when someone with a FDD happens along...treating a patient with a Fixed Delusional Disorder as though she(or he) were schizophrenic, would be a mistake.
Treating a patient with a Fixed Delusiona Disorder is a lot like trying to understand why the entire Muslim world is rioting over a few cartoons...or why President Bush ever thought the Iraqi people would greet us as liberators, with flowers ... .I mean, really, some religious beliefs are as extreme as those of a given "fixed delusional disorder" patient, and equally unprovable...with the major difference being that our patient has managed to cross paths with us...and that certainly does say something about the severity of the disorder....
Think about al of this and before you know it, you realize that we all have delusions, great and small...
Here, in this environment, we experience "group think". I know I have. In "group think", we exchange our thoughts and experiences of a patient and distill, together, a picture of him. This picture is an abstract, evoked by key words and phrases. We say, "borderline" and everyone in the room knows this patient will seek attention via self harm; we say "schizophrenic" and we all picture psychosis, and so on. We use these words and phrases to outline a sketch of the patient that can be passed on to the next shift. Because we are human, this is an imperfect process. It frequently happens that the sketch is misinformed, warped by staff's own emotional state or world view. Together we distill it, hone it, embellish it. We all come to think of the patient in the same way...but its wrong. It's always wrong...we can't ever really get the whole picture because we don't have either the time or the manpower to do it...but sometimes we're farther off than others...and these are our delusions.
I think we also have the delusion that our patients are too ill to function in society... I think that we're way overprotective about that. I think, this is America! We have an inalienable right to be delusional! Our country was founded on this principle!! You just can't hurt anybody. That's a firm and fast rule. And, being delusional is no bar to being a participant in society. Surely we all know this...look at your neighbors! Your families! Come on!
And I think we're delusional about our powerlessness. I think when we disagree with the referring center about the disposition for a patient, we have more ability to impact that decision that we think we do...we just lack the will...we have the delusion that it's not worth doing, it's too much trouble, we don't have time.
I saw another delusion at work ... someone thinks that filling out a form with more checks than usual will result in more attention being paid to the patient....I speak, of course of the ubiquitous obs forms...and the general annoying delusion that a form fixes a problem or provides a treatment of some kind.
Ah, well.
Tuesday, February 07, 2006
one red paperclip
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
One red paperclip
I'm wowed. I'm going to put a link to this blog from mine. (click on the "one red paperclip" above)
Happened upon this blog while looking for inspiration...you gotta check it out....this guy is trading "up", starting with one red paper clip, until he gets a house. He's already up to a cube van.
I totally depressed myself with that last blog...jeezuz...shepherding the mad, blah blah. Nonsense. Far, far better to be trading up to a house from a red paper clip. Looks like this guy is actually going to get there...
Ah! to actually get there....that would be something....
Clearly thinking about it too much.
I wish other people would write in their experiences...liven this puppy up some. It is, you know, totally annonymous...not even I will know who you are if you comment as "annonymous"...all the comments go to my blinded mailbox first so I can protect the blog from hppa violations...then I "post them"...you don't necessarily have to talk about depressing stuff...you can pass on whatever you want...Do It!!! Blog ON!!!
Gadde Fly
One red paperclip
I'm wowed. I'm going to put a link to this blog from mine. (click on the "one red paperclip" above)
Happened upon this blog while looking for inspiration...you gotta check it out....this guy is trading "up", starting with one red paper clip, until he gets a house. He's already up to a cube van.
I totally depressed myself with that last blog...jeezuz...shepherding the mad, blah blah. Nonsense. Far, far better to be trading up to a house from a red paper clip. Looks like this guy is actually going to get there...
Ah! to actually get there....that would be something....
Clearly thinking about it too much.
I wish other people would write in their experiences...liven this puppy up some. It is, you know, totally annonymous...not even I will know who you are if you comment as "annonymous"...all the comments go to my blinded mailbox first so I can protect the blog from hppa violations...then I "post them"...you don't necessarily have to talk about depressing stuff...you can pass on whatever you want...Do It!!! Blog ON!!!
Gadde Fly
Monday, February 06, 2006
A House is not a Home
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
Whew! Just got through working several days in a row, each day on a different team. A veritable kaliedescope of patients and staff.... Really! so much variety! - from the anal to the laid back, the narcisist to the saint - the servant of god, the prophet of god and god himself, all in a few days....and that's just the staff (just kidding). Maintaining a minimal level of sanity in such a situation means establishing a regularity in the work that is independent of a particular staff, paticular patients, particular programs. All new all the time is just too stressful; we all need to have a lot of our workday consist of things we don't have to think about too much...you know? to rely on routine, to float down the river, go with the flow...you know what I mean......I think in many jobs, workers can rely on some consistency in their work environment and make some kind of workable peace with its drawbacks. One comes to expect certain behaviors from certain coworkers, some understandable progression of symptoms on the part of the patients, some predictability about how the day goes program-wise...meals at these times, groups at those times, smokes, meds in an order that requires only minimal thought or attention once the pattern is learned.
For me, though, I have to find my work stability elsewhere...a different unit every day means I can go either bigger and think of the hospital with its multiple units as one single workplace and discover reliability, predictability on that level, if I can; or I can go smaller and find it in myself - in the way I do my job, the way I approach patients and the problem of mental illness in this society. Actually, I suppose I do some combination of both....I have a pretty consistent individual approach to my work, and to the problem of being mentally ill in society and see the hospital as a single entity, a component of "society". Since my approach to patients is to help them find a way to live in society if I can, often the hospital, as a element of "society", becomes the "other" the patients (and I, as their staff person) are stuggling against.
"Us" and "we" are terms I use more often when talking with a patient, than I do when talking with hospital administrators, who seem to me to occupy an entirely different world.
I use them a lot when talking with other mileau staff, though. We're all there, slogging along through a crumbling landscape, shepherding the mad through the deepest, darkest part of the mental health system...hoping, if we hope at all, to set them free, back into the community, to have some kind of life...because this is, honestly, no place to live...for them or us.
Really.
Whew! Just got through working several days in a row, each day on a different team. A veritable kaliedescope of patients and staff.... Really! so much variety! - from the anal to the laid back, the narcisist to the saint - the servant of god, the prophet of god and god himself, all in a few days....and that's just the staff (just kidding). Maintaining a minimal level of sanity in such a situation means establishing a regularity in the work that is independent of a particular staff, paticular patients, particular programs. All new all the time is just too stressful; we all need to have a lot of our workday consist of things we don't have to think about too much...you know? to rely on routine, to float down the river, go with the flow...you know what I mean......I think in many jobs, workers can rely on some consistency in their work environment and make some kind of workable peace with its drawbacks. One comes to expect certain behaviors from certain coworkers, some understandable progression of symptoms on the part of the patients, some predictability about how the day goes program-wise...meals at these times, groups at those times, smokes, meds in an order that requires only minimal thought or attention once the pattern is learned.
For me, though, I have to find my work stability elsewhere...a different unit every day means I can go either bigger and think of the hospital with its multiple units as one single workplace and discover reliability, predictability on that level, if I can; or I can go smaller and find it in myself - in the way I do my job, the way I approach patients and the problem of mental illness in this society. Actually, I suppose I do some combination of both....I have a pretty consistent individual approach to my work, and to the problem of being mentally ill in society and see the hospital as a single entity, a component of "society". Since my approach to patients is to help them find a way to live in society if I can, often the hospital, as a element of "society", becomes the "other" the patients (and I, as their staff person) are stuggling against.
"Us" and "we" are terms I use more often when talking with a patient, than I do when talking with hospital administrators, who seem to me to occupy an entirely different world.
I use them a lot when talking with other mileau staff, though. We're all there, slogging along through a crumbling landscape, shepherding the mad through the deepest, darkest part of the mental health system...hoping, if we hope at all, to set them free, back into the community, to have some kind of life...because this is, honestly, no place to live...for them or us.
Really.
Friday, February 03, 2006
The trickle down effect
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
Golly.
I'm a little taken aback by the recent comments...you're even madder than I am!...and, to be completely fair, I can only think of one head nurse who'd weigh in at 250 or more pounds...several are actually very trim, indeed. We all know that weight, or lack of it, isn't the issue, but the prison guards remark does speak to one...and surely, it's more than coincidence that the most - er...robust...of our head nurses happens to reign on the unit that has become a virtual extension of the corrections system. It's been a long time since any therapy was done there, I know. I remember when the last of the old staff quit - giving up, finally - knowing that no more therapy would or could be done because of all the adjudicated, criminal youth who were now the hospitals' great new revenue stream. These kids require prison guards - they're dangerous. They'll hurt you. The thing that bothers me most about it, is that on this same unit, truly mentally ill, non-criminal youth are also "treated". If I were the parent of a mentally ill teenager, I would be very very upset to discover that my vulnerable, disabled child was living with a bunch of criminal kids...who are managed by staff who are angry because instead of therapists, they're required to be prison guards.
And then, there's another hospital-wide staffing issue...lots of shifts are being staffed by more pool than team members...on a shift of 4, sometimes just 1 is an actual team member...the other three have been floated in...that's a recipie for huge stress, bad treatment, and sometimes even disaster. Hospital policy here requires a predominance of team members each shift....hospital policy is ignored in this instance....and in others I can name where it has become inconvenient....kind of reminds me of Bush...these things...these insults to policy - are an example of the trickle down effect...when the leader doesn't give a shit about the rules, soon no one does.
Golly.
I'm a little taken aback by the recent comments...you're even madder than I am!...and, to be completely fair, I can only think of one head nurse who'd weigh in at 250 or more pounds...several are actually very trim, indeed. We all know that weight, or lack of it, isn't the issue, but the prison guards remark does speak to one...and surely, it's more than coincidence that the most - er...robust...of our head nurses happens to reign on the unit that has become a virtual extension of the corrections system. It's been a long time since any therapy was done there, I know. I remember when the last of the old staff quit - giving up, finally - knowing that no more therapy would or could be done because of all the adjudicated, criminal youth who were now the hospitals' great new revenue stream. These kids require prison guards - they're dangerous. They'll hurt you. The thing that bothers me most about it, is that on this same unit, truly mentally ill, non-criminal youth are also "treated". If I were the parent of a mentally ill teenager, I would be very very upset to discover that my vulnerable, disabled child was living with a bunch of criminal kids...who are managed by staff who are angry because instead of therapists, they're required to be prison guards.
And then, there's another hospital-wide staffing issue...lots of shifts are being staffed by more pool than team members...on a shift of 4, sometimes just 1 is an actual team member...the other three have been floated in...that's a recipie for huge stress, bad treatment, and sometimes even disaster. Hospital policy here requires a predominance of team members each shift....hospital policy is ignored in this instance....and in others I can name where it has become inconvenient....kind of reminds me of Bush...these things...these insults to policy - are an example of the trickle down effect...when the leader doesn't give a shit about the rules, soon no one does.
Thursday, February 02, 2006
Supervisor's Hall
Disclaimer: All persons, places and things in this document are imaginary; any resemblance to actual persons, places or things is purely coincidental.
I've got a couple of days off, but this blogging thing is so much fun that I find I want to write something anyway...
There's a hallway in the hospital, where the Nursing Services supervisors have their offices. When I first started working there, the hallway was a busy place. The largest office housed the secretary and her assistant. It was a kind of reception area where you could go and plunk yourself down, awaiting your turn at the secretary's attention, or chat with the assistant, or run into your supervisor to complain about something. You could generally get a piece of candy off the desk, read the recent announcements, get a feel for how things were going at that next bigger level of the hospital. In a little cubby off one side of the big office was the Director of Nursing, in a cubby off the other side was the assistant Director of Nursing...you could stick your head in either door - they were usually open - and say hello. You were pretty much guaranteed a warm reception.
I was new back then....not new to public mental health, but new to this state hospital environment. I remember admiring the Director of Nursing and her assistant...and feeling sure of their support of me and of the patients. We were all there to participate in what felt like important, inspiring work; the welfare of patients was the top priority and we could be certain that if we had a problem in providing care for them, we'd have the complete support of the nursing supervisor. She'd go to bat for us. She seemed to like us, to care about us. We could bring up emotional issues that might impact our work performance and feel comforted, reassured, protected.
There was a larger group of supervisors back then....in addition to the Director and her assistant, there were Division Chief Nurses - one for Adult services, one for Children, for Adolescents, ....for gosh, I don't know what all...but they all had offices down this hall, and at any given time during the working day, you'd find several of them in, doors open, streaming light into the hall...hubbub happening. There was a normal amount of grousing and sniping and jockeying for position, but there was energy there, a focus on quality care, a sense of humor, a love, - dare I say it, - for the work and particularly for the patients. The hospital had an important role in the community...and had, I think, a good reputation in the community of State Hospitals. Maybe I'm gilding the lily here...maybe I'm idealizing stuff in my membory...wouldn't be the first time. I know that when this place was founded in the 60's, it was innovative - an example for others of how things could be done. It was multi-disciplinary, community oriented, unlocked, unfenced...a place of refuge for the mentally ill. I know somebody who worked here then and can tell stories about how things were.
Things had begun to erode from that high pinnacle by the time I started, but hope hadn't died.
Today, when you walk down supervisors' hall, it's quiet and dark. The big office has become the Director of Nursing's office and the doors are always closed. The secretary, who has no assistant, is in the cubby; there are no Division Chief Nurses. There is an Assistant Director of Nursing, hired in from the outside, but her office is across the hall....and ususally closed. There is no hubbub, no warmth, no welcome.
There is now a sense of siege, of defensiveness. Complaints are received as threats. Staff is ignored or disciplined more often than encouraged or supported. I've laid eyes on the Director of Nursing maybe once in the last two years; I know of no reason to admire her.
Her boss is the Director of the Hospital. Not only do I have no reason to admire him, but have been given several to disdain him. He appears to have set the tone...of disrepsect for employees and patients, of commandments instead of collaboration, of favoritism, of immoral behavior.
Naive idealist that I am, I think that in times when money is short in a place like this, and the state is tightening its belt, there is an increased need for teamwork, mutual support, strong alliances, an energetic proactive determination to advocate for the helpless and disabled among us. Instead, the institution has been led into a dark, dim hallway where our footsteps echo off the closed doors. Lord knows what's going on behind those doors....probably better not to ask.
I've got a couple of days off, but this blogging thing is so much fun that I find I want to write something anyway...
There's a hallway in the hospital, where the Nursing Services supervisors have their offices. When I first started working there, the hallway was a busy place. The largest office housed the secretary and her assistant. It was a kind of reception area where you could go and plunk yourself down, awaiting your turn at the secretary's attention, or chat with the assistant, or run into your supervisor to complain about something. You could generally get a piece of candy off the desk, read the recent announcements, get a feel for how things were going at that next bigger level of the hospital. In a little cubby off one side of the big office was the Director of Nursing, in a cubby off the other side was the assistant Director of Nursing...you could stick your head in either door - they were usually open - and say hello. You were pretty much guaranteed a warm reception.
I was new back then....not new to public mental health, but new to this state hospital environment. I remember admiring the Director of Nursing and her assistant...and feeling sure of their support of me and of the patients. We were all there to participate in what felt like important, inspiring work; the welfare of patients was the top priority and we could be certain that if we had a problem in providing care for them, we'd have the complete support of the nursing supervisor. She'd go to bat for us. She seemed to like us, to care about us. We could bring up emotional issues that might impact our work performance and feel comforted, reassured, protected.
There was a larger group of supervisors back then....in addition to the Director and her assistant, there were Division Chief Nurses - one for Adult services, one for Children, for Adolescents, ....for gosh, I don't know what all...but they all had offices down this hall, and at any given time during the working day, you'd find several of them in, doors open, streaming light into the hall...hubbub happening. There was a normal amount of grousing and sniping and jockeying for position, but there was energy there, a focus on quality care, a sense of humor, a love, - dare I say it, - for the work and particularly for the patients. The hospital had an important role in the community...and had, I think, a good reputation in the community of State Hospitals. Maybe I'm gilding the lily here...maybe I'm idealizing stuff in my membory...wouldn't be the first time. I know that when this place was founded in the 60's, it was innovative - an example for others of how things could be done. It was multi-disciplinary, community oriented, unlocked, unfenced...a place of refuge for the mentally ill. I know somebody who worked here then and can tell stories about how things were.
Things had begun to erode from that high pinnacle by the time I started, but hope hadn't died.
Today, when you walk down supervisors' hall, it's quiet and dark. The big office has become the Director of Nursing's office and the doors are always closed. The secretary, who has no assistant, is in the cubby; there are no Division Chief Nurses. There is an Assistant Director of Nursing, hired in from the outside, but her office is across the hall....and ususally closed. There is no hubbub, no warmth, no welcome.
There is now a sense of siege, of defensiveness. Complaints are received as threats. Staff is ignored or disciplined more often than encouraged or supported. I've laid eyes on the Director of Nursing maybe once in the last two years; I know of no reason to admire her.
Her boss is the Director of the Hospital. Not only do I have no reason to admire him, but have been given several to disdain him. He appears to have set the tone...of disrepsect for employees and patients, of commandments instead of collaboration, of favoritism, of immoral behavior.
Naive idealist that I am, I think that in times when money is short in a place like this, and the state is tightening its belt, there is an increased need for teamwork, mutual support, strong alliances, an energetic proactive determination to advocate for the helpless and disabled among us. Instead, the institution has been led into a dark, dim hallway where our footsteps echo off the closed doors. Lord knows what's going on behind those doors....probably better not to ask.
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