In addition to being an abrasive, obnoxious internet crank, I am a licensed psychotherapist, a term that by now shows my age. I currently work in a specialized intensive mental health treatment program that helps people with severe and chronic mental illness recover and become more stable.
A minor caution: I run 5-6 days a week with a former Recon Marine Gunnery sgt, a basically very good guy who has seen and done some horrendous things people shouldn't experience, in service to this country, so he's pretty tough. I sometimes share with him some of the things I hear and it's often very troubling for him. He will stare at me with a very shocked look that I can't describe. He is really becoming angry about the systematic and unchecked victimization of mentally ill people in the personal care homes. So be advised that some of the following might be a little distressing for some people; I'm not certain and I don't want to be 'dramatic', but better safe than sorry.
Friday, July 15, 2011.
I got to work about 730.
I have so much paper to keep up with I need long periods of uninterrupted time to even make a dent in it and as you'll see, there's little of that once people arrive, so it piles up like snow. So I go in as early as I can get there.
In this style of program we do groups for educational and general therapy purposes and notes have to be done each group. with 8-12 people per group and 2-3 groups per day, notes pile up quickly.
Plus I need to see everybody on my caseload individually once a week. My caseload is nearing 25, which makes for some very simple math - I have far more work to do than I have time to do it in. Subsequently I am sometimes bringing work home and doing 1-2 hours of it here. Much of the time I just run with a back log, constantly scrambling to do it.
I am an old-school professional at this point - I truly believe in serving people and I live it out. I am 51 years old (in September) and have been doing some version of this since 1984, with a couple years off here and there due directly to republican savaging of Medicaid and the safety net. We always have money to kill people in other countries and to blow shit up, but we never have money to help Americans.
This is an issue right now with the debt-cieling kabuki theater going on right now: while the Establishment is busy screwing poor, sick Americans even more for the enrichment of the already obscenely wealthy and to perpetuate our needless wars, I am, in the context of this sort of program, busting my ass to help keep them out of the hospital, which DOES have a direct money-saving impact on your tax dollars, and can improve their lives.
I have had one very unstable client who is in and out of the hospital all the time - he's probably costing Georgia and the US Government about a million dollars a year to do this.
This is entirely preventable and needless, but there are no real, effective other services to help him. Mostly because we spend all our money on war or bailing out Wall Street.
He lives with a person who is most likely interested in keeping him there for his SSDI check, which makes them resist our efforts to find a proper care home for him. He needs some skilled care due to medical problems such as obesity, hypertension, and his psychotic illness. But they just want him there for hims money so he's not getting proper treatment and is in and out of the hospital. They are trying to empty the state hospitals here, so he won't get transferred there.
As seems usual in this Life, the right things to do are, as always, an uphill battle while the maintenance of the status quo is nearly effortless. But we keep on trying because that's what we do.
0830
Clients - a term I prefer to "consumers", which became the word with 'managed care' (as if people were ordering mental health services at Wendy's or something) - begin arriving about 830 and on this day I went out to follow up on another client of mine who is battling decompensation: he is somewhat confused and delusional despite being quite bright intellectually. He was studying physics and advanced math in college when his initial psychotic break happened, so intelligence is not the issue. Psychosis is. He becomes extremely anxious and wants to go to a hospital because he feels safe there.
He is another one who has been victimized by the Personal Care Home scams that are absolutely rampant in Georgia.
I'll go to jail and have my life ruined by a marijuana arrest, but I can go buy a shithole of a foreclosed home, slap on a coat of paint and load it up with 8-10 disabled people and charge each of them $600 a month and jerk them around endlessly without any fear of legal intervention whatsoever. Not really legal, I have learned, but nobody really enforces this law. No money in it. We have foreigners to kill and countries to blow up.
So he was moved into a PCH several months ago, didn't tolerate the transition well, came to us and was stabilized for a period of time. Then his PCH elected to jerk him around and he decompensated and went to the hospital. He was moved from that place to another one while still in the hospital and he's still not adjusted to the new one and just the thought of this stuff makes him want to go to the hospital. So I planned to fetch him early to talk with him.
0850
But before I could deal with him, I was confronted by another client who was really decompensating. Systematically sexually abused by her family for years and apparently even her mom would watch rather than protect her, in her early 50's now she is a dissociative mess now.
She came to me with a large baby bird in her hand and the most pained look on her face. She was non-verbal, just staring at me with her mouth open, clutching this screaming bird and clearly expecting me to do something. Stares at me, stares at the bird, back and forth.
I called her name several times to get her attention but she wasn't verbally responsive. I finally got her attention and told her to put the bird down; I told her there's nothing we can do for it (and really, baby bird was in a LOT better condition than her). I finally got her to let it go and I told her to go wash her hands but she just stares and looks hurt - panicked. Later in the day she was still chasing the thing and still nonverbal - she needed to go to the hospital and I reported this to the nurse.
0900
So I finally get to my office with my client and we talk about his symptoms and anxiety. He is so tense and anxious about things he sits with his head hung low as if he's being chastised.
I grabbed a trashcan and turned it upside down and put it in front of him. "Put your feet up on my coffee table, buddy" I instructed him. A big smile emerged and we had a fair discussion.
I confronted his anxiety and told him we have talked with the hospital and arranged for them to call us if he shows up there, and told him he needs to go home and relax. I advised him I had talked with the home manager - who did sound like she knew shirts from shoe polish - and her job right now is to simply make him comfortable. I advised him that half his anxiety - at least - is a symptom of his medications and a significant portion is due to the instability of his living arrangements. He feels powerless and depressed now.
When a person goes to the hospital for this stuff, MOST of the time, the hospital cannot be bothered to pick up a phone and talk with us for 5 minutes to see what meds a person is taking. They scrap all that and they do what they feel like at the moment, which with this population is hugely stupid and wasteful. So he got prescribed a number of meds which don't work for him, interfering with the recovery process and translating into ongoing difficulty adjusting to his move.
He promised to go home and try to have a good night - he wants to sleep all the time, that's his fun. He's so very depressed in addition to the appearance of schizophrenia - he might be more of a schizoaffective disorder. We'll see. He appeared better through the day.
0920
He left and one of the part-time therapists came to me, rather overwhelmed by the things she has been hearing in the groups about all the ongoing inequities in the PCH's. She usually works with children in a school system, not with this population, so it's an eye-opener and distressing for people who haven't adjusted to it.
I told her I had spent nearly 40 minutes on the phone on Tuesday with the office of the Ombudsman after hearing a load of crap about some PCH's in another county.
As a therapist, one wants one's clients to be as empowered to stand up for their rights as possible, but they are quite often systematically threatened that if they call the Ombudsman or the state they will be kicked out on their ass - and their rent wont be returned to them because the PCHs', with very few exceptions - are there to make money hand over fist, quality of life be damned. I told her we systematically try to get people moved when we can.
I encouraged her to listen to some of it, then to refer people back to their individual therapist for proper processing.
930
The first group begins. I have 11 people = all guys today - with severe mental illness. A few of the guys in there are just outstanding case studies of schizophrenia, both in remission and in decompensation.
One man is new, his meds aren't right and he talks so crazy the others look at him shocked. You had to see it to get the full impact of how crazy he seems to others with longterm mental illness. But congenial and funny so on with the show.
Another guy I used to see when I was doing Assertive Community Treatment. He was in another shithole of a place that was shut down abruptly, causing him to decompensate and sending him back to the hospital for the umpteenth time. He came to us early last year and I was just thrilled to see him. Why? because when clients are with me I know they are getting proper treatment - selfish but true. He was likewise thriled to see me and he's been assigned to me for a long time.
Well.... he went through a series of shitholes before getting into what seemed like a better place. A company had bought a number of foreclosed nice homes and set them up and he was in Heaven for a hot minute.
Then THEY started fucking with people: not giving them their meds properly, moving them abruptly, there were reports of staff fighting and such ridiculous things.
The Office of Regulatory Services has jurisdiction over licensed care homes but they almost never do anything, not so much a slap a wrist. I have no idea what really went on at this place, but the ORS jumped on that company with BOTH feet and shut them down. All sorts of crazy shit went down and my client was essentially kidnapped in the night and taken to another undisclosed location. He thought the person really cared for him and was happy again, for another hot minute.
Well... he's back with us, quite decompensated from not getting his meds and totally disrupted in his living arrangements. All his stuff was in my conference room. He's got a new place to live and it does sound awesome - out in the country, acreage, peace, quiet. We'll see how long this lasts once his stuff gets there. People lose his stuff over and over through this too: he was angry about that.
I talked with them about another incident in the lobby this morning where a new client looked at me with my long hair, t-shirt, and jeans and told me "You look like a client!" I stuck my finger in her face and said "you look like a client too". She was shocked.
I continued - "we all look like clients because we are all basically normal people trying to help other normal people who suffer from serious illnesses live normal lives. She burst out laughing and my point was a home run. I processed this with the group.
Often clients have this idea that therapists are "above them" and I have seen plenty of unprofessional therapists reinforce this message. I find it appalling and strive to interact with folks like they are as normal as anybody else, no matter what.
One of the clients said "you're authentic" which was rather amazing. Authenticity is at the core of proper therapy. You have to be real. You aren't going to be a good therapist if you're all stuffy and act like you're above your clients. They know. And they have been trained to accept it for generations and I am ever so happy to be a part of dispensing with that and treating people like people.
1025
I got done with that group and saw a couple more individual clients - the first was the man who called me authentic. He is a very nice guy but he's very anxious and disabled from schizophrenia. It takes a few minutes of talking with him to realize how sick he has been because he's so nice and pleasant to talk to.
We talked about the longterm impact of his mental illness but confronting the fact that he's been in and out of hospitals since he was 17 - now he's 53 and seems to be declaring his life over with. "I think I should just be content with happy memories" he says. I ask him how he would feel if he was told he still had 35 years left in him. He looked quite distressed, denied suicidal thoughts but said he didn't want to live that long. He feels life has passed him by. I'm going to really challenge this. This guy deserves a much better quality of life.
1100
Saw another guy with schizophrenia - he's been making real gains in socializing with people, not standing alone in a crowd of people. He got into some trouble, which is not unusual for folks with schizophrenia and who decompensate: I made a call to the court and talked with his court worker who indicated the court knew of his mental illness and that's been taken into account and he's done well.
He is still symptomatic: he's very suspicious and his voice tone and intended meaning are somewhat out of whack, so sometimes it seems he means the opposite of what he's saying. He denied being anxious about the court but I think it's burning him up. He's going to be fine though.
1145
I went and got some crappy nachos for lunch and ate them and did some typing. I saw one more person between lunch and 115 group. He's about 30, has grown up his entire life knowing he wasn't just unwanted, his parents were just fooling around and actually tried to hide the pregnancy for some time. He has a constant unhappy look on his face, grew up in foster care, was physically and sexually abused and developed obesity due to eating as a coping mechanism. Now he is diagnosed with bipolar disorder. His speech is pressured and it's hard to get a word in edgewise without forcibly interrupting him repeatedly.
115 PM
The 115 group was the same guys I had for the first group. In the first group we talked about daily treatment goals for mental illness recovery and in the 4th group we talk about them again and I ask each client about plans for the evening and weekend.
I often lecture them on planning for free time as most of our folks - poor as shit and always stressed by not having any money - have nothing to do for months on end. This creates amazing stress, really, and stress will directly cause psychiatric problems if not managed.
The one man who is so off the wall and psychotic right now - intelligent, warm, and friendly - shocked the group by asking me if it was "true that men menstruate from their brains while women menstruate from the vagina".
It's one of those times I know I had the deer-in-the-headlights look, as did the rest of the guys in the group. Just shocked. What do you say?
I advised that I'm 51 and have done this for ages but I had no idea how to respond. He said it was in a book he was reading and asked me what I thought of that. I told him it sounded pretty nutty to me. He said he was a connoisseur of knowledge..
He then reported he was in the Army for 30 years and in the reserves for 15 (but he's only 52) He reports he is from other parts of the "zolar system" and advised the group it's properly called "zolar not solar". His speech was mildly pressured, meaning that he just wanted to keep talking and talking, and its clear he was terribly psychotic. He was, however, able to sit there and be part of the group.
Most people didn't have anything much planned - smoke cigarettes and drink coffee, the holy Grail of the chronic crowd.
215 pm
Everybody leaves, the place cleared out and became quiet. I went to my office to do notes. Doesn't seem like much - 22 group notes on 11 pages of paper, 4 individual notes, a couple of treatment plan reviews, goal updates/
I tried to type a couple individual notes fighting off falling asleep on my desk. I left a little early, went home and crashed....for 3 solid hours. Drained.
And that, honestly, is a VERY summarized report about what can go on in just one day at my job.