I remember my first day at my outpatient office I saw five clients. All five of those clients still see me over four years later. They’ve all followed me to a new practice and new office because, I don’t know, I’ve never asked, but I guess they don’t want to see some one new.

There have been clients that have come and gone since I started. Some I helped. Some moved on before I could see any improvement. I’m certainly not for everyone. I have a certain style and way of being that is off putting to some people. Which is fine. I’ve certainly had healthcare providers I didn’t care for. I don’t take it personally.

But working in mental health makes you really examine myself on the regular. I am regularly questioned by parents and clients as to my clinical decision making more intensely and I think more rudely than other specialties. I hear on a daily basis, “I read online…” because a google search and gander into webMD and patientslikeme.com suddenly makes people experts.

It’s not my job to convince people they need medication. It’s my job to make my clinical recommendation. Take it or leave it.

But the nuts and bolts, the in’s and out’s, a few hours in my life in my little office looks something like this.

Starting my day with a call from the local hospital that one of my patient’s is being hospitalized for suicidal ideation or a suicide attempt. Rare thankfully, but at least a few times a year. I could pull into the office on the phone with the hospital and start my day already worried about a client I now have no control over.

My first client could need me to write a letter for gender reassignment surgery. Processing what this means to them, permanent changes to their body, possibly losing their family and friends, exploring their grief, their dysphoria, and their resolve to proceed.

Next up could be giving someone an injection of Vivitrol (long acting Naltrexone, monthly shot, to battle alcohol or opiate addiction). My Vivitrol clients are not “hoodlums” or “druggies”. They are Moms, Dads, kids, and functioning members of our society. They make a monthly commitment to come and have a very large needly placed in their butt with a large volume of medication to help them stay sober. They impress me with their strength to come every month and their commitment to sobriety. They are perhaps some of my favorite clients to treat because I am truly helping them regain their lives. Their courage gives me hope.

In the next thirty minutes I may see one of my clients who suffers from chronic homicidal ideation. No specified target. Rather disturbing imagery usually. And hopefully responding to therapy and medication…

My next might be a family with a depressed teenager who was raped. I’ve heard the rape story and I’ve helped them through the process of pressing charges and they come in now and are totally at ease in my office because it’s like I’ve been brought into their family circle for the 30 minutes they come and see me every month.

In between these clients I am returning calls, emails, and doing prescription refills.

Then perhaps a teen struggling with their gender identity who has been told by their parents they will be kicked out if they pursue this “gender thing”. It’s been rare that these parents have actually followed through among my patients. But it still sucks. My wife knows that I would bring these kids home if I needed to. That none of my transgender teens will end up on the street. I’ve said that to probably two teenagers who I thought might actually end up homeless. That they can call me any time. That we will figure it out together. I’ve seen this look of what I think is hope come into their eyes as they really see me and recognize that they are not alone. There’s all this stuff about boundaries in mental health. But having a wife who’s been homeless due to family intolerance. Well I just couldn’t stand to see that happen to one of my kids.

Then perhaps I see one of my anxious clients. They come in all shapes sizes and ages. They are also some of my favorites. I do a lot of hand-holding with them. A lot of answering questions and perhaps meeting for months before they agree to take medication. I do a lot of convincing that anxiety is actually a brain illness just like diabetes is a pancreas illness. Not one of my anxious clients has ever regretted starting anti-depressants to target anxiety. But it’s a journey for us to get there that is always quite challenging and fun for me.

Then perhaps I see a patient I’ve suspected has bipolar disorder who failed the second anti-depressant who I have to have the “you need a mood stabilizer” discussion and perhaps discuss “mood disorders” and “cycling” and gently start the dialogue of a potential major diagnosis.

Then maybe I see one of my clients into kink or BDSM and/or polyamory. We catch up on the latest relationships status. We talk about sex and their kinks and fetishes. I hear A LOT about sex. From all my clients. Because of the sexual side effects of medications and because of my client base. It’s something I’m very comfortable with now and not much can raise an eyebrow from me. I’ve perfected the poker face.

The mail comes. Medicaid is auditing me for a 12.00$ reimbursement for a client from five months ago. I shake my head and swear and rail at the insurance companies and remember this is why psychiatrists and psychiatric APRNs don’t take insurance or Medicaid. Because they are freaking ridiculous. 12.00$. You fucking kidding me? But I print out the requested papers and shove them in an envelope and send them to the address listed that very day because I know my Medicaid clients are vulnerable and I wouldn’t stop taking it just because medicaid sucks to work with. Yet.

For all of my clients I have to be present. I can’t be thinking about other clients and my patient hospitalized and my other patient I referred for ECT. I have to be there. I have to remember their stories from our last visit. It’s emotionally taxing to bear witness and support people who are suffering. It becomes my day to day though and until I step back and really think about it I don’t realize how intense one of my days can be. Let alone a week or a month.

What keeps me going? My clients. Their strength. Their bravery. Their capacity to face stigma of addiction and mental illness and psychiatric medication and diagnoses is inspiring. That they trust me with their emotions, their brains, their children, their parents, their friends. For the most part my clients and families are incredibly vulnerable and just looking for help and compassion. I’m not a warm and fuzzy person. But I get mental health. I get that I have to give of myself in order to make a difference. And I do. Daily. As does every other hard working mental health professional.

So when you’re at a picnic and someone tells you they work as a therapist or a psychiatrist don’t start telling them your problems or asking their opinion about your mother’s medication. Just thank them for the hard work they do and change the subject.

Because when we are not in the office we are tired from being in the office. So let us have our break. Let us sit and laugh and have fun and not think about the emotional intensity we see every day.

I have a sweet job. I love psychiatry. It’s challenging and exhausting and rewarding and heart-breaking and everything else that makes it exciting to go to work every day.