Medication Management…when it’s not about the meds. From a Psych APRN.

When I worked at the hospital I used to take APRN students frequently. It was an easy place to have a student because you don’t do long term work with patients and patients in the hospital setting are used to students being present.

I stopped taking them when I moved to private practice full time but for the first time this year I felt comfortable taking one on. It’s a commitment. September-May one-two days a week for FULL days. Often shadowing, especially with some one in their first specialty year they do not have the skills to work independently.

It’s a lot of explaining, it’s a lot of asking clients if it’s okay for her to join our sessions and in between sessions it’s a lot of answering questions. It’s a lot of work.

But it’s important because everyone has to learn. And I’m kind of good at what I do. So I don’t mind people learning from me. Especially some one who is Queer.

It’s a weird thing though to have some one watch all you do. It’s a mirror really. I don’t change how I act or how I interact with clients. I’m generally bad at censoring myself.

So I’ve learned a couple things in the two days so far that she’s been shadowing me. I see a wide array of clients. In just the two days- she looked at me today and said, “You see every type, but why do you see that one? She’s not…” I interrupted her, “She’s Queer. I’ll see anyone who’s Queer.” She looked at me kind of surprised. I knew what she was going to say. The client is not my “normal” client for a variety of reasons. But I’ve treated her for two years because she’s Queer.

In just two days- roughly twenty-five client visits she’s watched me see clients who are destitute, wealthy, multiple ethnicities, Queer, healthcare providers, first responders of all types, post-partum clients, all ages, clients I’ve treated for eight years and clients I’ve treated for eight weeks. Most of them were long term though. Also coincidentally, most of them were follow-ups after a come to Jesus moment at our last visit. So there were at least four who came in saying “I thought about what you said, you’re right, thanks for giving me the kick in the ass I needed.”

I counseled some one struggling with hunger due to skipping meals in order to pay bills. I counseled some one dealing with infidelity, addiction, I said good-bye to a long term client moving out of state and she cried (after we disconnected I 100% needed a tissue) because I had seen the client through many life transitions, and so much more. That’s just two days.

It struck a chord at the end of today when she looked over at me somewhat comatosed as I asked her if she had any questions.

She said she didn’t have questions. She just was realizing it’s not about meds.

In school they drive home psychopharmacology; but it’s not about the meds. I smiled sadly. No it’s not about the meds.

It’s about forming a connection, an alliance, trust, it’s about remembering their kids names, knowing without looking at the chart when we started treatment together, how many IVF cycles they did, and that the anniversary of their Mom’s death is coming up next month.

It’s about remembering the first psychotic break post partum and how long their depressive episode lasted in the aftermath and comparing that for them to how long this depressive episode will last in the aftermath of the hypomania. It’s about eye contact. It’s about a little bit of self disclosure- like many of my long term-er’s know know I have twin boys, and they ask how they are doing. It’s about making a person feel seen, heard, and validated.

We talk about meds in our visits but there is so much more. I made very few changes to medication regimens in the last two days. It was more supportive therapy, validation, and reassurance. Many people cried. Just cried. And they apologized to my student and we both provided reassurance that just because she’s there doesn’t mean they cannot cry.

I think she was surprised at the amount of pain we hold space for. At the amount of secrets we hold for people. And at the level of connection we maintain.

I reflected that I could do 15 minute follow-ups and barely talk to people and conclude that every symptom requires a med change. But that’s not how I roll. I see people for 30 minute follow-ups, longer if needed or requested. And I talk to them. I get to know them. And in the age of telehealth I meet their partners, spouses, parents, co-workers and any one else who wonders in the background of the frame.

Not everything needs a medication change. A lot of what humans need is simply connection and validation and the feeling that one person out in the world gives a shit about them. I’m happy and humbled to be that person for my clients. I think to an APRN student who is just starting to understand our role though…it’s daunting. And if I think about it. Like really step back and think about it…it’s a lot.

It is not a coincidence that there is a mental health provider shortage. People are falling apart and we as mental health providers shoulder more and more of their burden. It becomes heavy and isolating and daunting to potential new clinicians.

Again, I’m not going to censor myself and I’m not going to make the job seem like something it’s not. It’s hard. It’s emotional. And long term outpatient work is not for everyone. But it also made me grateful for my work. I tell people all the time I still love my work. I am lucky because I am one of few people who does what I love. But lord, it’s hard and sometimes it takes a mirror of an APRN student to remind me how heavy it truly is.