Love Makes A Family - Part IV

If you have ever lived with someone or had someone as a friend who works in any kind of treatment setting, be it medical or behavioral, hospital or clinic, you probably already know that patient confidentiality is a very big deal to caregivers; and it should be to you also if you are ever a patient. You may have even heard about HIPAA regulations because of your friend or because you have had to sign a document in a doctors office making you aware that due to HIPAA regulations your information will be protected as much as possible with the understanding that sharing your information with other medical professionals may happen as a course of your treatment.

I mean if you are sitting in a doctor’s office filling out paperwork, just about everyone in the waiting room knows you are there to see the doctor. So, your confidentiality is already out the window, right? But, the doctor and his staff are liable if they don’t protect any documentation of your visit according to those HIPAA regulations.

Those patient confidentiality rights are taken very seriously when it comes to psychiatric hospitalization. You talk about a patient outside the confines of the workplace and you do so at the peril of loosing your job the same day that anyone finds out about it. This is why most treatment teams in these settings must have supportive staff structures that provide time to the staff to be with other staff to “detox”. You are responsible for providing healthy, therapeutic support, and many times initiating intervention, on some very confused, angry, and sometimes bizarre behaviors.

Now, I know that every physician, psychologist, RN, LVN, MHP, MHW, social worker, dietician, and even custodial staff that has ever worked in psych has gone home after work at some time and talked about something that happened that day on the unit. They may have talked to their spouse, their significant other, their own kids, or their parents. They may have described very specific events with a lot of detail. If you know someone in psych who tells you that they never did, don’t buy anything from that person. That disclaimer aside, I believe that all of us follow the 1st Cardinal rule of working in psych, “Thou shall not mention the names of thy patients”; ever, to anyone.

Speaking of the Cardinal rules of working in psych; let me put rule number 2 out there right now. “Thou shall not ever socialize with any patient, current or ex, outside the unit without special permission by the interdisciplinary treatment team; or the Chief of Staff; or the Director of Nursing; or someone of equal big cheesiness”.

Of course, nursing staff members take groups of kids on off campus outings all the time. Sometimes staff members are allowed to take one kid on an outing, once a certain privilege level is gained by the patient. However, these outings are part of the treatment plan. They are scheduled and they occur on the clock and are generally limited to an hour or two, max.

Visits with ex-patients outside the hospital are much rarer. They happen, but they are done judiciously with clear expectations regarding the benefits of having a nursing staff member be in contact with a discharged patient. Patients are supposed to have said all their goodbyes by discharge day. Those strong emotional bonds built with the nursing staff have to be severed. It's not always easy by any stretch of the imagination. Still, the patient must have distance and separation from staff to reconnect with family and to test their newly learned coping strategies on their own. They are less likely to become independent if they still have access to the treatment team. Besides, they will still be going to individual and family therapy after discharge for as long as necessary. At least that’s the usual discharge plan.

I sometimes would tell Mike amusing stories, or sad stories, or amazing stories about the patient’s foibles and triumphs. Working in psych can be very sad and draining, but it can also be extremely uplifting and fulfilling. It is a fascinating job to have, in so many ways, and Mike was always interested to hear the anecdotes about this kid or that kid. There is always something interesting to tell and people always ask you questions about the experience when they find out what you do.

Michael knew something was different about the way I was talking about the anonymous sisters though. He knew I was talking in a different way this time about the intricacy of the transference relationship and how vulnerable it makes both parties feel. He had commented several times that he had never heard me talk so much about any other patients. I was aware of that and I think it was because it was the first time I had been encouraged by an individual therapist to foster a father/daughter transference. I was getting a lot of help from Dr. Kay, and from Judy, the nurse practitioner, and Roberta, my mentor.

Roberta was, and still is, the standard by which psych nursing staff shall always be measured in my book. There were several other psych nurses with as much knowledge and skill and I admired them just as much. But Roberta, she had a certain style of relating that appealed to me and she became my mentor at UCLA. Roberta knew empathy. She knew its meaning, its value as a therapist and she had a vast store in her heart. She tried her best to help me stay the course during my relationship with Cari.

You see, the other Cardinal rule of working in psych is, “Don’t let your emotions get involved; remain objective.” This is absolutely of the utmost importance for the therapist. That time and that space in the therapists office has to be for the patient and their feelings. It cannot be for you and your feelings. This is why therapists have therapists. Because it is an impossible feat; no one can do this work and not feel. Psych workers, if they are being honest, will tell you that they have cried to each other, sometimes alone, when a patient leaves after a long stay, or worse, offs themselves a week after they are discharged.

Working through the issues and feelings that cause people to be hospitalized is like walking a high-wire and trying to help someone else cross over it with you while you are both walking sideways with no net. It’s exhilarating; and scary. But, it is enormously satisfying when the product of the work is an improved outlook on life by someone who was circling the drain before you started. I miss it, sometimes.

At any rate, I had kept Michael fairly well up to date on the sisters’ progress and my great good fortune to be working with patients who I could see were clearly benefiting from treatment; at least Cari was. Anna still seemed to be coasting. She would sit with her therapist and talk about inane topics, twirling her hair and checking it for split ends. Her therapist who had decided to turn up the heat on Anna before the news of the abandonment by the family, now knew it was too late. Anna would not reap the reward of a completed treatment program.

The vast majority of in-patients in psych wards make infinitesimal progress that takes “forever” and the recidivism rate is very high. When you get to work with someone with the intellect and the desire to change it’s gratifying for both of you. Anna was fighting an uphill battle with borderline personality syndrome. At UCLA the treatment for borderline personality followed the teachings of Dr. James Masterson, the guru of the disorder. It’s a very tough road to hoe and requires some extreme limit setting on what may appear to some to be “normal” behavior. It required a lot of time outs with time alone in a room thinking about your behavior and then talking with staff about it. Anna was getting the time outs and she was doing the alone time, but her ability to dig deep and accept what she found was not happening.

Cari and Anna both had the intellect in spades. Although in her toddler years, her family and foster parents thought Cari was “retarded”. Cari was born with a cleft palate, which made her speech very lispy, when she finally tried to start speaking. This was just after she lost both parents. She had a lot of difficulty with certain hard consonants that required a glottal stop (you speech therapists know all about this). Because her voice sounded strange to even her, she stopped talking. She would never utter a sound except when she was alone with Anna. This may be another reason that the family did not immediately rescue her and Anna from the system. They didn’t want the responsibility of having to care for a special needs toddler. Cari had IQ testing when she was 12 years old. She tested out at 134.

Just being smart was not going to be enough now that she and Anna were facing this newest hurdle life had thrown at them. Anna was certainly not going to be able to complete her treatment. Cari was smack dab in the middle of her program, totally invested in her relationship with me and two weeks was just not enough time to wrap it up. It was a disaster. Their impending discharge was approaching at warp speed. They were now at their most vulnerable emotionally, because that’s where we, as their treatment team had led them. Now, with this curveball from the family we all felt we would be sending them out to certain failure. It was not a happy time on the unit.

They would be abruptly leaving an all-inclusive 24-hour a day treatment center, which included: individual therapy 3 times a week; family therapy and music therapy once a week; daily occupational therapy, recreational therapy, and school; and the constant companionship of a team of trained psychiatric nurses and mental health practitioners.

Santa Barbara County would be sending them to a group home, with a county social worker they could call if they needed to talk. Once again, the cycle of shuffling from one place to another was about to repeat itself. They were going to relive their previous foster home experience. Both girls were stoic on the outside, but panicky in therapy. Cari, appropriately was expressing a lot of anger but began to talk about eloping from the group home and going back to life on the street as a possible option. She was ready to cast all the hard work and the changes to wind.

Anna took on this strangely brave external persona. She did not appear to be nearly as upset as I thought she would be. I was talking with her about the change, trying to empathize and feeling really lousy about how ineffective I was when she said, “Well one of us has to be brave, and it sure as hell isn’t gonna be Cari.” I wondered where that statement was coming from. Then it dawned on me.

During all the foster care and the stern, abusive family situation, Anna had functioned as Cari’s protector. Instinctively, she had shielded her little sister from the teasing about her funny talking by always being her confidante. Because custodial caregivers thought Cari was “slow”, the brunt of work and responsibility fell on Anna. She had shielded Cari from punishment at home by always doing as she was told and being overly submissive and compliant to appease the punisher. It was partly self-preservation, but it was not selfish. It had tragic consequences for Anna because she had the more difficult diagnosis to treat and the gloomier prognosis as a result.

Mike was transfixed when I told him at dinner that evening what was going on with the sisters. At the end of that conversation he got this look in his eye and he said, “It’s too bad we can’t help them”.

I had seen that look before. “What are you, crazy!” I retorted.

(End of part IV)