#COVID-19 · Nursing

The Grim Reaper & A Nurse

Contrary to my normal procrastination I bought tickets to a haunted attraction way back in the beginning of September. I was determined to get there. Last year I bought tickets and it got rained out. A few years before COVID we went on a night to something you couldn’t pre-buy tickets to, and the night we went it was closed. Then COVID.

Needless to say I was frantically stalking the weather all week, and very excited the night came with no rain in sight and no global illness causing mass lockdowns…we were good to go!

When we got there we had to wait for our turn to go through as they send people through in small groups. We were a group of four, my three friends and I, and while we are all in our mid-late 30’s, and tough as nails psych nurses and a therapist, of course none of us wanted to go first or last. Finally the therapist went first and the three nurses followed. I doth my hat to our therapist friend of course.

We screamed and held onto each others vests and coats in a train of four excited and terrified friends.

We came upon our first ghouls who spoke to us and instructed one of us to reach a hand into a bucket of water and pull out two syringes. One of us may have freaked out about touching syringes to the point that the grim reaper asked “Are you nurses?” in a growl, and we nodded “Yes, three nurses and a therapist,” and the grim reaper in his grim reaper voice bowed his head a bit and said, “Thank you for your service,” and the scary baby-doll with face paint reminiscent of Frankenstein agreed in her creepy baby doll voice, “Yes, thank you.”

And there we were. In a haunted house with a grim reaper and a creepy baby-doll tipping their heads to us in thanks.

They still made my friend grab the syringes.

And on went the show.

It was followed by another grim reaper who did not speak motioning me to push a button on a wall. Well I was pushing the damn button and nothing was happening. He made a down motion with his scythe(?) and I pushed down and it fell off the wall. He’s growling at me and I can almost hear him sighing at my stupidity and my three friends are a mixture of laughter and screaming each time he waves the scythe at me telling me to just push the button. And they are yelling at me “Just push the button” and I’m like duh I would if I could, but it’s dark and there’s grim reaper growling at me, I grab it and stick it back on the wall.

If you’ve not had a grim reaper shake his head at you in complete frustration and disbelief at how stupid you can be….it’s an experience.

As I stick it on the wall the thing lights up. Finally. I pushed the button somewhere. He lets us past and follows us, the whole time pointing his scythe at me. He did not need words. Even through a full coverage mask his message was clear. You are too stupid to live and I will end you.

My friends thought it was hysterical and then of course later we did get lost and the same grim reaper popped out and had to growl and herd us back on track.

It didn’t hit me until we got out though and we were back in the car. That moment with the first grim reaper and the ghoulish baby doll. It was surreal and kind and even though it broke the scary haunted house thrill for a moment to be brought so forcefully back to reality, it felt more authentic and more real than any of the hundreds of pizza parties the hospital I worked for thought were ‘good enough’ of a thanks.

What healthcare providers- not just nurses- psychotherapists, doctors, techs, etc. have been through from 2020 to present, is inexplicable to people outside of healthcare. It’s been constant chaos and tragedy and feeling invalidated and not good enough and underlying it a deep and true terror. Terror that we would catch an illness and spread it to our loved ones. Terror that our patients would die. Terror that going to work would lead to our deaths. And on top of that dealing with the irritability and anger that has permeated seemingly every human interaction. People are angry and they are taking it out on healthcare providers and practices.

So for a random grim reaper and haunted baby doll to acknowledge us in the throes of a terror inspiring activity- it felt so wrong and yet so right.

To the ghouls at Evidence of Evil- we had a great time, and you made three nurses and a therapist feel seen and appreciated. Thank-you.

Mental Health Stigma Suicide · Nursing

My Thoughts on Treating Murderers signed: a nurse.

Working in private practice people sometimes make the assumption I only treat the “worried well”. Every prospective employee I interview I tell them- while there are serious perks to private practice including total control of your schedule and fully remote work…we still treat sick people. You may get an easy straightforward anxiety…but you likely will have some serious cases that will push you.

For me, I’ve treated…a lot. I’ve treated sexual abuse victims, incest victims, victims of DV, and many other incredibly intense cases over the years.

What has been surprising for me, and what no one ever discussed when I attended school and training- were treating patients who committed murder. Working both inpatient and outpatient I’ve treated roughly 40-50 patients who have committed murder in some capacity.

There are many different kinds- negligent homicide is something like a drunk driver who hits a car and some one in the other car dies- basically an unintentional homicide but caused by the person’s negligence. There are homicides that are intentional, or perhaps just witnessed but the witness is held responsible for not stopping it or for contributing to it, and the saddest are probably the murders committed by people in a psychotic state such as with postpartum psychosis- those are probably the most publicized in the media.

We learn a lot about transference and counter-transference in school- and we do talk about how it would feel to treat a perpetrator of a sex crime but for some reason we never touched on treating some one who commits a murder.

But it’s an important conversation to have.

Working in mental health has caused me to take stock of my values, ethics, and core belief systems…and made me re-evaluate all of those things repeatedly at a very visceral level.

I remember working in the pediatric emergency department. There was a certain coldness projected toward the parents that overtook all of our demeanors when we realized the child we were treating was the victim of abuse- whether sexual or physical. At some point the truth always comes out. And I did treat some children who died of their injuries. And if you could have bottled the rage in the room from the healthcare providers…well that would be some potent nuclear energy.

So I had that background going into mental healthcare.

Then I sat across from my first patient who committed a homicide. I did not have that rage encompass me though. I still do not. I think they expect it. But as the mental health provider treating the perpetrator of a crime, well they are still my patient, and I treat all my patient’s the same. With respect and I try to come from a place of empathy and understanding.

In reflecting on murderers I’ve thought of my Dad. Was he a murderer? Not by my our standards I suppose. But he did kill people when he fought in Vietnam. He was a gunner on a helicopter- one of the big ones where the sides are open…hopefully you’ve seen enough war movies you know what I mean. I asked him one day when I was old enough to realize what a “gunner” meant “Dad does that mean you killed people” and in typical Dad fashion he said, “Well I killed more cows than people hon,” and that was that. My Dad was excellent at non-answers. Especially about Vietnam.

So I suppose the first “murderer” I sat across from at a table was my Dad.

So you can see why I have a stronger response to pedophiles than to murderers? Murder I’ve had to assimilate and rationalize because I grew up the daughter of a combat veteran. There ain’t no assimilating or rationalizing pedophilia though. That’s never okay. Not even in war.

I am speaking somewhat facetiously because the double standard is absurd. Murder is never okay. Pedophilia is never okay. But we live in a society that is more okay with murder than any other type of crime. As evidenced by the lack of gun legislation in America after the first mass school shooting. We receive the message from the highest level of politicians and courts that murder is justified as long as it’s with a gun that you should be free to carry.

We also live in a society with combat veterans who have committed legal murders. And we praise them, respect them, salute them. I am not saying we shouldn’t do all of that. I am grateful for all the people who have served and continue to serve our country because I see the sacrifices they’ve made in my work every day in the veterans I treat who carry such shame, guilt, and trauma.

I used to be very black and white in my thinking. Back when I was 22 and thought I could be part of the solution in saving the world. I’m 37 now. I’ve seen children die at the hands of their parents- intentionally and unintentionally. I’ve treated men and women who have been raped and who have killed.

I also grew up with a Dad who was a Vietnam veteran and deeply committed to the love of his country.

Through all of this I’ve come to realize there cannot be a black and white version of myself or of mental health treatment. I’ve treated rapists who I did trauma work with who were deeply wounded humans perpetrating in the cycle of their own traumas. I’ve treated incredibly brave and resilient victims and supported them through court proceedings to bring their perpetrator to justice. I’ve treated murderers who carried the deep wound of taking a life. And I’ve treated murderers whose murders were legal in the face of battle but who have to make the decision to live every day because the incredible wounds they feel internally drive them so close to suicide.

There is no black and white and there is no right or wrong. What I’ve discovered in myself is that I have to present myself with empathy, understanding, and I have to listen to my gut and bodies responses. If my body is telling me that there is no remorse here, and potentially sociopathy, our consultation appointment is just that. A consult. And I will not be following up with them.

But those are rare. More common is the person who is just a person. Trying to survive. Who was thrust or who put themselves into unthinkable circumstances and who are spending the rest of their lives trying to not be defined by that one moment. There is grief for the person they once were, compassion for who they are in this moment- vulnerable and seeking a non-judgmental space- and hope for the person they can become.

Fifteen years in and I still love being a nurse. I love this field, I love that it pushes me to see beyond society’s expectations and norms. I love that it makes me examine my own weaknesses and prejudices and challenges me to do better and be better. In these cases it’s pushed me to examine my beliefs about “murderers” and what I found is they are just people with a story. Stories that deserve to be told and to be heard.

p.s. #banguns #fucktheNRA

p.p.s. For all those asshats saying you should have the choice to not treat people who are LGBTQ…you are assholes. If you continue in that vein for your “religious freedom” shouldn’t you also not treat adulterers, murderers, pedophiles…etc? How come you can decide to not treat one population of people but not all the rest? How come you are more comfortable treating a heterosexual murderer than a law abiding non-rapist and non-murdering lesbian? Y’all need to have a Come to Jesus moment. Cuz you make no sense. Just own it and say you are homophobic and transphobic.


Salty About Stimulants…signed: a prescriber

My practice has strict prescribing practices around stimulants and benzodiazepines. People seem to get the most irritated by these practices with stimulants though. Over the years multiple therapists have voiced their displeasure at us for not prescribing a stimulant to some one suffering with ADHD because: they smoke cannabis, their urine screen popped positive for a substance, they don’t have anxiety it’s all driven by ADHD, etc.

Mental health prescribing is by far one of the most Monday morning quarterbacked fields of practice. Every one knows better including but not limited to Google, WebMD, ‘My Aunt/Mom/Sister/boyfriend’s sister who is a nurse’, ‘my therapist who is not licensed to prescribe medications and has no training in prescribing’, their primary care doctor, their neurologist, and any one else who wants to hop on board the “we know better than people with actual psychiatry training” train. Not that I’m bitter. Imagine me saying all of this in a very singsong smiley voice.

I did not have such strict policies when I started practicing. I’d be more open to prescribing stimulants to some one who used cannabis or would not grab a urine toxicology screen on everyone. But then shit hit the fan.

To assume you know better than some one who has been working in this field and trained in this field when you are not working or trained in this field is…annoying at the very least and dangerous at the most.

In the past 12 months alone the practice has had four urine toxicology screens pop positive for substances that were not disclosed to the prescriber in the appointment. Two of the positives revealed a significant substance use disorder that could have otherwise been missed and that the primary psychotherapist knew nothing about.

Addiction does not discriminate- and these positive urine screens were gateways to a dialogue for potentially life saving treatment for people. God forbid the other 98 people have to pee in a cup because it’s so judgmental and punitive….I’ll send 1,000 people for a urine screen because even if just one pops positive that’s one person who has been potentially struggling with addiction in the dark, alone, and is at risk of overdose and death. I can’t as a prescriber in good conscious just say, “Well I see that hurts your feelings when I ask you to pee in a cup and test it for substances before I prescribe a controlled substance you, so you’re good.” It’s not punitive. It’s just that people have lied about substance abuse and addiction. And I’m not saying that in a derogatory way- part of addiction is living with it in isolation which contributes to shame and guilt- people don’t disclose because they are ashamed. It’s part of the cycle of addiction.

Every time I prescribe a stimulant I receive a letter from the insurer- especially Anthem and Aetna- they send letters that they noticed I prescribed a stimulant to one of their members- and they name the member- then they have about two pages of why prescribing a controlled substance is dangerous and they hope I’m prescribing it responsibly and I should really consider getting the patient off the stimulant as quickly as possible. Not making this up.

Then I get an email from the state of CT who tells me they noticed I prescribed another controlled substance- and it’s in a report of all the controlled substances I’ve prescribed in the last month. It’s one of those “We see you and we are watching” e-mails. I attest to my liability company that I prescribe controlled substances. I have to sign off on federal guidelines to have a DEA. AKA it’s a big freaking deal every time I write a prescription for a controlled substance.

In case you missed it, people are dying at record numbers from drug overdoses. Guess what? Most overdoses are not just one substance- they are often multiple substances- including stimulants because people snort them after drinking alcohol to perk themselves back up, or after heroin or opiate use. Then they may want another buzz or high so they drink more or take more opiates or heroin…you can see where I’m going right? You need more and more upper to overcome the downer, and more and more downer to overcome the upper. Then you die.

So no. I do not prescribe stimulants to patients concurrently using cannabis. Cannabis=downer stimulant=upper. Also- long term cannabis use (daily for over a year) causes cognitive clouding and blunting in the form of short term memory impairment, slowed cognition and slowed reaction times, in ability to focus and difficulty concentrating….guess what all those are also symptoms of? You’re right! ADHD.

So how do I know some one truly has ADHD when they’ve been smoking weed daily for five years and did not have ADHD prior to weed use? I don’t. The answer is I don’t. And I won’t until they get off the weed for at least three months.

Next let’s talk about the world in the last few years. It’s gone to hell. The effects of chronic stress are well documented in children who grow up in abusive households, in adolescents who live in homophobic households, and in war veterans who are exposed to chronic combat stress. Guess what the symptoms are? Cognitive clouding, poor focus, poor concentration, short term memory impairment, poor organizational skills, and anxiety that can present as impulsivity….sound familiar? Yes. All symptoms of ADHD. Executive dysfunction is a symptom of chronic stress. You can’t have existed in the world since March 2020 without being under some form of chronic stress which results in executive dysfunction. So no, you did not suddenly develop ADHD at age 40. It started two years ago because that’s when the world went to hell.

People generally do not like to hear that though. They want a pill and a quick fix and a treatable diagnosis.

In the past two years I’ve had countless patients tell me they have ADHD. I disagree with the diagnosis sometimes. I decline to prescribe stimulants other times even if I agree with the diagnosis due to substance use. And then there are a couple people in the past year who came to me for “anxiety”. And within about two minutes of our intake I was thinking ‘how the hell do they exist in the world with this severe of an ADHD?’

Careful history taking, chronic struggles academically, chronic struggles socially, chronic struggles occupationally, has had people in their life tell them they have ADHD, and not nicely. They also talk non-linearly. It’s hard to describe but there’s definitely a feel to them. They often wander off from the answer they are trying to give to a question then ask “What was the question?” somewhat embarrassed. There is more to it than that, but suffice to say it’s quite overt after you’ve seen it a few times. Which I have. Because this is what I do every day all day for ten years.

These are my favorite people though. They legitimately have ADHD. They have been misdiagnosed or not diagnosed at all because they are usually female- and females are super under diagnosed for a variety of reasons- including but not limited to: it’s inattentive type, not hyperactive, and they are able to compensate in other ways that allow them to still be mild to moderately successful.

These people when I mention ADHD and do some psychoeducation around it, and say maybe the anxiety is driven by an ADHD and they have a learning disorder…they break down and cry. Because they usually have always suspected it, and they check all the boxes, and there is effective treatment. These people, when they come back after the urine screen and trial of a stimulant cry again because they are grieving that they have lived so long without a proper diagnosis and in relief at being able to function just generally better.

Do I prescribe stimulants? YES. Do I do so carefully in order to protect the patient and myself from liability? YES. Do I see how incredibly life changing these medications can be? Absolutely.

I do actually know how to assess and diagnose ADHD. I also know how to safely prescribe psycho-stimulants. And I’m not going to waver because it may cause some one to feel upset that I prescribe this way. Safely. It’s unfortunate that offends some people. But it is what it is.

So to any one out there diagnosing yourself off TikTok. Please stop.

Couple things- you can’t have sudden onset ADHD, chronic stress causes the same symptoms of ADHD, PTSD can present as ADHD, chronic anxiety also can present as ADHD. I’m not saying don’t get a second opinion if you disagree with the person you do an intake with. Get as many opinions as possible for you to feel confident in the diagnosis and treatment. But also don’t assume you know more than a provider with education and clinical training and experience.

And for any one truly suffering with ADHD if you suspect you have it, seek treatment! There is treatment. And it can work. Just don’t get salty if you’re asked to do a toxicology screen in order to receive a prescription for a controlled substance. These medications are serious and heavily regulated. Have some respect for that. I sure as hell do.


Catharsis Defined via Six.

It’s hard to define catharsis. I remember learning about the term in a high school English class. I remember it was defined as “a release of emotion”. But it’s hard to truly understand it until you experience it. Part of what theater and the arts provides for me specifically are moments of catharsis in a space and through a medium that is outside of my daily norm.

Have you ever been moved to tears by a movie? That is catharsis. The movie caused a release of emotion.

And while movies can certainly provide a nice cathartic moment there is nothing, for me, quite like the theater.

I am lucky to live a short car ride from the train station which has an express train to Grand Central. About a month ago my friend and I bought second row tickets to Six. We hopped on the train this morning, made it through GCS, during which I heard a few New Yorker’s put a woman in her place for yelling at a child who tripped resulting in her having to stop short resulting in her yelling at said small child whose dad was clearly a tourist who just looked scared. My friend says people on the East coast are kind but not nice. I feel that in NYC more than anywhere else.

These three clear New Yorkers stepped in for the tourist Dad and son and yelled at the woman for yelling at a child for making a mistake. Then tsk tsk’d at her, and clucked over the child. While not smiling at all and seemingly sounding generally loud and scary but when they are on the side of good….it’s a sight to behold.

That all unfolded outside the bathrooms. Inside of which a random woman had started directing traffic into the open stalls because she was waiting for her sister “Who is taking forever”….from a further away stall “Well I’m sooooo sorry Dotty, you can wait out in the hall ya know?!” “Who needs the hall I’m directing people. Just do your business so we can leave!”

We then fast walked/ran to the theater, and came upon a Polish parade on 5th avenue which detoured us a couple blocks south back to 45th street from 47th. Side note- the Polish parade was still going 2 hours later on our way back…and we talked to some NYPD officers who also could not believe it was a 5 hour parade and it was running late because “it’s Polish” and “only a Polish parade would run for 5 hours on 5th avenue” per the police officer…

So we finally make it to the restaurant right next to the theater. We eat super fast. Then with nine minutes to show time we think we can go stroll in. Well we walked. And walked. To find the end of the line. When we started questioning if the line could really be that long a man heard us talking and was like, “Hey over here, you guys are with me right?” He was super nice. The people behind him hated us. But we totally cut the line. His wife showed up with diet cokes for them. And then we are being waved through security by a security guard and he’s saying “Single file, single file, ladies looking very pretty today” and tips his hat at us.

Then we see this epic show. I mean totally epic. Six. The six wives of Henry the VIII reclaiming their stories and changing history to “her”story. So it’s heavy right? Because two of his wives are beheaded. I mean. There’s that. They also were all teenagers. Awful. Multiple miscarriages etc. But they did an amazing job of blending humor into the story and engaging the audience, and there we were. Watching Jane Seymour (the 3rd wife of Henry VIII) sing a beautiful song and she hits these high notes that I can’t even describe. And the song is about being unshakeable and brave and courageous in the face of so many fears. “You can build me up, you can tear me down, You can try but I’m unbreakable, You can do your best, but I’ll stand the test You’ll find that I’m unshakeable. When the fire’s burned when the wind has blown, When the water’s dried you’ll still find stone.”

And it was then, that I felt my eyes well up. And I thought why am I about to cry? Couple reasons. I have post-COVID grief. I’m sad and pissed that we missed two years of the arts and trips and fun times with friends out in places with people and hearing a New Yorker berate some one, and being told we are pretty in a super sweet and innocent way. Running through streets, stumbling on parades, we missed that. We missed so much. I grieve all that I do not even know that I missed.

And in that moment I also was thinking of all the shit I’ve been through. Personally and professionally and, it’s kind of like in therapy where you’re walls crack, and you hear a song that just hits you right. And I felt so much, incredibly deeply in that moment, about what we’ve lost, what we still have, and everything I’ve been through and still am going through; and that my friends…is catharsis.

I loved the show. But I also loved the experience of going to NYC for the day without fear of death. Let me rephrase- now the only fear of death is from mass shootings, bombings, car accidents, subway stabbings, you know the normal NYC fears. Not death from a virus.

Now we just have the normal fears back.

Overall the entire day was perfect and I wouldn’t change a thing. Well maybe I wouldn’t have thrown away the cup my friend had bought me at the theater. It had red wine in it, and I didn’t want it to spill on my bag. It’s a nice bag. Really nice. And we were in the street. It was crazy. It was red wine! So I threw it out. She will never get over it. I’d change that moment yes. The rest is all good.