Love Makes A Family - Part II

The treatment of adolescent in-patients at UCLA’s NPI and H when I was there was based on the Johnson Model of Nursing. With this model each kid has a primary “nurse” on days or evenings, and a secondary “nurse” on the other shift. Generally, each member of the nursing staff would carry 2 kids as primaries and 2 as secondaries. The Night shift (11pm-7am) basically makes sure the kids are safe and sound through the night. They don’t have any primary or secondary patients. In effect, they have them all.

I put nurse in quotes above because at UCLA there were many members of the nursing staff that were not RN’s or LVN’s or LPN’s. The Director of Nursing at NPI, a wonderful innovator named Bertha Unger, knew that there were other skill sets that could be used in milieu therapy, in conjunction with nursing, which could contribute to interdisciplinary treatment, and not cost as much as licensed nurses.

I know that name, Bertha Unger, summons up an image of some eastern European female athlete, like a Bulgarian shot putter, or an East German weight lifter. In actuality, Mrs. Unger was about 5 foot 3 inches tall, maybe 100 pounds soaking wet. She had long gray hair always pulled back in a severe bun, which became wisps of dishevelment by the end of the day; usually with a pencil stuck in it somewhere. She wore glasses with lenses so thick her ice blue eyes looked twice their size. She was facing retirement in a few years, so she knew a thing or two about nursing. She also knew a thing or two about caring about the people who worked in her hospital.

Mrs. Unger established positions on the nursing staff for people who had Bachelors or Masters Degrees in any behavioral science. As long as they had some previous psych hospital or clinic experience, she welcomed them to apply for positions on the nursing staff. Their title was Mental Health Practitioner. She had MHP’s who led music therapy, dance therapy and even psychodrama groups, in addition to filling the role of primary or secondary “nurse”. Of course, the MHP’s could not pass medications, but were trained in CPR and taking vital signs and delivering first aid. They also sat in as co-therapists with the new crops of psych externs working their way through their psych rotation of medical school.

As the primary nurse, you were responsible for charting observations and incidents on your kids and spending at least an hour a day of one to one time talking. Since the program offered a full in-patient high school, recreational therapy, occupational therapy, family therapy, group therapy, and individual therapy, fitting in that hour a day was challenging.

I worked on the 7-3 shift and I was assigned to be Cari’s primary nurse and Anna’s secondary. Elvia Espinosa, a real psych RN on 3-11 was Anna’s primary and Cari’s secondary. So, Elvia and I worked together to forge therapeutic relationships with these two very different girls. Anna was very compliant and quick witted, yet needy and clingy. Cari was defiant, standoffish, mistrustful and independent. Her defiance was all about not being able to trust adults, and with her history it was easy to see why this was so. She truly believed that adults were incapable of telling the truth or upholding commitments. She told me on day one, “Most people, but especially adults, just tell you what you want to hear and then do whatever suits them and in the end, they always leave you.” She hardly spoke to me when she first came to NPI. We would sit in our sessions and I would put topics or questions out there and all I would get back were one syllable answers or cold silence.

It was never a problem getting Anna to talk though. In fact, I didn’t have to say anything. I could just sit down across from her and before my butt hit the chair, she was off and running. She would tell you everything you wanted to know and a lot you didn’t. One story line would dovetail into another so fast you’d get whip lash. One thing I remember Anna saying a lot was, “now where was I?” A lot of this verbiage was because Anna wanted to please you and be cooperative, and a lot of it was that she just liked to talk; about herself about her friends, her enemies, her travels, her laundry. It was as if she recognized you were a captive audience and she was going to get her moneys worth. It felt at times like she needed to keep this manic pace so she could avoid looking inside. Inside Anna was a very damaged mish-mosh of emotion in constant turmoil.

Anna’s verbal skills and her overly dramatic presentation gave her instant access to the other kids. They were highly amused and entertained. The problem was it didn’t last very long. Her friendships seemed to dissolve like cotton candy on the tongue. Was it because the relationships were built of froth and air and not much substance? This would be a question Anna would need to answer.

Some people think that folks that are in-patients in a psychiatric facility are “crazy” or out of control. Anna was not crazy and definitely not out of control on the surface. But all that animated, mile a minute verbiage was really to cover the wounded little animal inside her. She was never physically aggressive or combative. Her hostility was more subtle most of the time, more passive-aggressive; and then like a sledgehammer at other times.

It wasn’t that Cari was openly hostile or combative either. She wasn’t “crazy” or delusional. In fact, Cari was very engaging and witty and gregarious. She had a lot of excess energy and the kids all warmed up to her very quickly. She really knew how to play the role of the good kid who is concerned about others. That was her front. Behind the scenes she was undermining staff rules, encouraging other patients to act out, stealing silverware from the cafeteria…. Well that’s not totally true. She wasn’t actually stealing it. The women who ran the unit café reported that they were way down on their flatware counts and the losses coincided with Anna and Cari's admission. It turned out Cari had been throwing her place setting in the trash after every meal. It was her little way of being rebellious without anyone knowing and catching her.

Mealtimes on the adolescent ward are an exciting part of the day for most of the kids. They get to be in the dining room all at one time and socialize freely. It can be really raucous and loud. Since all the kids are in there, staffing would usually require two floating staff, who mix and socialize with the kids, moving from table to table, and one staff standing in the door watching the whole room, usually with a clipboard to chart the required half-hourly head count. Of course, that does not count the staff members sitting at the tables with the eating disorders. Those tables usually have one staff per one kid. Those staff never talk or look at another person during meals. You really have to keep your eyes glued to an anorexic during nutritional intake. You have to make sure the food on their plate goes into their mouth and not into their socks.

I was doing door standing duty at lunch one day after Cari and Anna had been there for a few weeks, when I felt this forearm on my left shoulder. It was Cari. She was leaning on me in that casual pose you strike with one foot crossed over the other. Apparently, the standoff was over. This pose, me standing there with a clipboard and her perched next to me, became a ritual. Every time there was a meal happening, there was Cari with her right forearm on my left shoulder. Staff were commenting, kids were commenting, and I was wondering if this was appropriate, or should I set a limit. There is this heightened awareness about physical contact between patients and staff and between patients and other patients within the confines of any treatment facility, and rightly so.

I had gone to the charge nurse of the unit to ask if I was allowing something that could be interpreted as special treatment or that the patient was getting secondary gain that might not be appropriate. The charge nurse was way ahead of me. She had talked with Cari’s individual therapist, Dr. Kay, about this “leaning on Lloyd” phenomenon. Dr. Kay told the head nurse to let it play out.

In about the 3rd week of our daily ritual of standing in the door together, I told Cari that I was really excited about the opportunity she was giving me. She stared at me, inquisitive, but silent. I told her I was going to be the first adult she had known in her life that would never, ever lie to her. She might not always like what I said, but I would always tell her the truth. She then looked at me like I had two heads. She obviously was impressed that I would make this promise since she thought it was patently impossible.

Because Cari lost her parents when she was so young and because she desperately needed an adult to lean on and to believe in, I was being encouraged by Dr. Kay to take a less confrontational approach to her acting out. I began to play the role of the gentle, understanding, limit setter. I didn’t let her get away with anything. I always set the necessary limits; but I was always doing it in a fair, caring, and available way.

Over the next few weeks Cari’s individual therapist reported that Cari had begun to more and more identify me as the father figure she longed for, and a very potent transference relationship developed. With the help of her individual psychotherapist and family therapist this relationship bore so much therapeutic fruit that both of them and the entire interdisciplinary team were thrilled with Cari’s progress. She kicked it into high gear. She began to share the most painful and intimate details of her abuse with Dr. Kay. She poured out her heart and made herself vulnerable. She began to accept help and took the advice given to her. She drank up the adult support like golden elixir from above.

She began to garner privileges one after the other. She was soon able to leave the unit and walk to Westwood on her own. She had gone from extreme acting out behaviors to being a solid and incisive leader in the inpatient community and a supportive, insightful group therapy member and all in the space of about 4 months. To make this much progress this rapidly was considered an exceptional outcome.

In the meantime, Anna was busy trying to figure out why she always got hurt in just about every relationship she had. She couldn’t understand why her overly friendly approach pushed people away. People would always like her when they first met her, but it never lasted. She didn’t understand what people wanted from her. For instance, when staff and peers told her she needed to take responsibility for her actions, she was totally bewildered. How could she take responsibility when it was clearly someone else who was responsible? Progress for Anna was slow and painful; and it was about to get more painful, and not just for Anna.