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.

homophobia · Mental Health Stigma Suicide

Queer-phobia in Mental Health Care

My practice website is pretty gay. Rainbows and Queer stuff all over the place. My job posting that I have up for therapists links to my website- it also explicitly says “LGBTQ experience preferred but not required,” and goes on to explain that the majority of our patients fall under the Queer umbrella. We certainly have hetero-cis patients- many of them. But around 60% or more of our clients are Queer (And I’m Queer. The owner).

Therefore it continuously surprises me in job interviews that the people applying have no experience with LGBTQ affirming care and also do not seem that interested in expanding their skills to include being an LGBTQ affirming and competent provider.

I’ve heard some crazy stuff in job interviews. Around four months ago a therapist who supervises the therapists in my practice commented on how slow we are to on board people- one every 4-6 months. I sort of rolled my eyes and said we don’t have a large qualified pool of applicants. She remained skeptical. She also intimated that maybe I scare people. I have been told I am intimidating. I thought maybe she wasn’t wrong. But I really do try to smile and be kind in job interviews.

So I had her start to join me.

After 6? interviews she said, “Okay. You were right.” People will literally say transphobic or homophobic statements in the interview with a Queer practice owner.

The entire experience of hiring has opened my eyes to the rampant homophobic and transphobic attitudes that are ever-present among mental health clinicians.

I always preface my Queer competence question with- “it’s okay if you have no experience with the LGBTQ community. It’s important that you are open to learning about it though.” Because I can hire some one with no experience and teach them to be Queer competent if they are teachable. Teachable/coachable are incredibly important qualities in employees. One therapist I hired had no experience with BDSM and minimal experience with trans clients.

Now she knows the lingo and declines to take new patients who are not Queer and/or in the BDSM community. Because she asked the questions and was open to feedback and learning and took CEU courses and did supervision with me around Queer stuff.

I’ve heard bad stories from my LGBTQ clients about therapists saying homophobic and transphobic stuff. I’ve definitely heard stories of kink-shaming and BDSM-shaming. In fact I asked a therapy group who I referred to and they referred to me frequently about seeing clients in the BDSM community and they got all squirrelly and were clearly not okay even mentioning BDSM.

I could say to therapists who are interviewing that we will accommodate their experience and desires and not give them any Queer clients. I thought about it. But then I thought. Fuck that.

I’m not going to own a practice that I founded because of the 2016 election and because of Pulse and because Queer people don’t have safe spaces…and not have every clinician working there be 100% comfortable with treating Queer clients.

I will say the hiring process teaches me as an employer. It teaches me that I do not want to rush the hiring process and hire the wrong person. It teaches me that homophobia and transphobia are rampant even among therapists who claim to be “LGBT friendly”. What does that even mean these days? What I’ve found is it means I’m okay if your a lesbian and we do not ever need to mention internalized homophobia or your sex life. It means that being trans is fine as long as we do not need to address micro aggressions that you face even within this office space.

It teaches me that I’m even more dedicated in my mission to create a safe space for minority employees and clients. It teaches me that being selective is okay. That I should wait for the right fit. That I should trust my gut because even people in the “helping profession” can have their discriminatory views that they are bringing to the table.

I am still going to ask about Queer experience. I am still going to require if not experience an openness to learn and to accept. I always thought I would have to protect my practice from hate among hateful people. But I picture those people more as potential clients or client’s family members or random people who come across our website. I did not think, in my naïveté and sheltered bubble of acceptance, that I would need to protect it from those within my own profession.

But I do. And I will.

If anything it’s also made me even more grateful for the employees I have. Because every single one of them is LGBTQ affirming. Not just friendly. But affirming. Accepting. Loving. There is no bone of hate or discrimination in the practice as it is now. I will continue to strive and work to keep it that way.

Mental Health Stigma Suicide

Four Eyes.

I decided to finally look into getting blue ray blocking glasses. I’m not sure if that is even what they are called…the kind of glasses that are supposed to protect one’s eyes from the harmful light of the computer. Specifically if, like me, you stare at it for up to eight hours or more a day.

I did some google searches and looked at a few of the “best sites” to buy blue ray blocking glasses. Then I went to those sites and looked up a bunch of them. I even added some to my cart on one site.

Then I walked away.

Then I went back to the site.

Then I closed my iPad again.

Then today I looked on Amazon and added more to my cart.

Then I stopped.

I am many things but I am always honest with myself. I reflected on the pit in my stomach that seemed to set up camp whenever I pulled up one of these eyeglass websites. I reflected on the “virtual try on” experience that made me just extremely sad as I stared at my face with the fake lovely glasses resting on my nose.

Then I felt like Winnie the Pooh in that scene when he is pondering and tapping his big yellow paw on his head.

I had a cataract when I was 4. It was removed. I am legally blind in my right eye and have been for as long as I can remember. I wore a patch on one eye for 6 hours a day for a couple years of my life. I wore a contact in my right eye (the cataract/legally blind eye) since the surgery and glasses also for as long as I can remember up until 6th grade I believe. In 6th grade I was old enough for the contact in my left eye.

The glasses were thick frames. I remember my eyes often being hot and sticky from the patch and the glasses. I remember being made fun of many, many, times by other children.

I had this Ah hah! moment in remembering all of this. Duh. Of course my entire body revolted at the idea of glasses, even just glasses to protect my eyes, because I was having flashes of seeing my clients in glasses. I was having flashes of being incredibly vulnerable in front of clients. Clients who do not need to see me have a breakdown if they so much as mention the glasses.

I have glasses. I use them at night. Alone. After I take my contacts out right before I fall asleep if I want to watch TV for a little while. I don’t think even my closest friends have seen me in them.

It’s an odd thing to be 37, a Mom, a boss, a nurse, so many kick ass things, and still be completely gutted thinking about buying glasses. This is what it does to people though- bullying. It stays there. In the back of my mind, in a filing cabinet that I put away and locked up, but that creeped out slowly with enough of a trigger.

I remain undecided on the blue ray glasses. I write this feeling odd. Somewhat shamed? Even though I know rationally it’s not my shame to bear. It’s the shame of my peers who made me feel less than because of a vision deficit that I had no control over. I’ve known since age 4 what it feels like to be different. And I’ve never attributed that experience to any of my life decisions, but it shouldn’t come as a surprise that I have devoted my life to serving the underserved and the bullied and the misfits.

Because I was one. Who knows? Maybe I still am. But the difference now, is I know I’m in good company.

#COVID-19 · Mental Health Stigma Suicide · mom of boys

Encanto & Psychotherapy

I did not know what I was getting into when I sat down to watch Encanto. I saw previews with a house and young woman with glasses. That’s it. My sons and I watched it on my birthday in January. By the time Surface Pressure was over I was welling up with tears. When the grandmother was berating Maribel; the tears started to actually fall and by the time the Mariposa song was over I was literally sobbing. My sons at some point asked if I was okay and I sort of stuttered “Yes…it’s fine…it’s just very sad.” They didn’t understand why I thought it was sad I could tell from their perplexed expressions; but they didn’t question it further. I think they are used to me crying at movies. It happens a lot.

Family dynamics are intense. I don’t get into my family dynamics in my blog because I respect my family members enough to not write publicly or engage in gossip about them in any capacity. But every family has dynamics. Every family has inter-generational trauma. Mine is no different.

As Maribel stood and her grandmother berated her in front of her extended family members, the scene with Bruno as Maribel sees his plate drawn onto the table behind the wall, the many scenes with Maribel being scapegoated as she seeks and speaks truth…I felt all of that.

There is nothing like family, and a room full of people with blood connections to you, that can make you feel the most isolated, alone, and wrong.

I not only have experienced this but I spend my life counseling patients on their family attachments. What struck me about Encanto was the recovery scene at the end. The song her entire extended family partakes in that they see her, they love her, and they want her in their family. She is their family. The patients I treat generally never get to experience that moment. Because real life is not a Disney movie.

That connection scene provides validation and love. Psychotherapy can provide this in a different way. For all those individuals who do not have reparative moments and relationships with family members psychotherapy provides a space for the client to examine the relationship dynamics, the traumas, even the covert ones- the isolating, the scapegoating, and it’s looking back at the times you’ve drawn a plate on a table to feel close to your family who seem so incredibly far though they are sitting just six feet away.

Psychotherapy allows clients a space to examine the idea of love. Self love. Love of others. Receiving love and giving love. Insecure and secure attachment styles. It also allows us a space to examine the dissonance of deeply loving a family member be it a sibling or parent while acknowledging they may have done horribly traumatic things to you.

Psychotherapists spend their days singing the song at the end of Encanto. “We see how brave you have been. We see how bright you burn. You’re the real gift. What do you see? I see me. All of me.” (edited)

I used to love Disney movies. I still am a Disney fan. But. I have a more adult view of the movies. I have a more adult understanding of reality vs. fiction and good vs. evil. There are good people who perpetrate evil things. And there are evil people who everyone believes are good. There are so many shades of grey in between the black and white world of Disney.

The part of the movie that I viscerally felt was as I watched the grandmother pick up her three newborn babies and run with her husband. As they cross the river all I could think of was my own twin boys. The three little heads were reminiscent to me of all the times I looked down at my two boys little heads nursing, sleeping, crying, smiling. Even as I watched it I had one little head on each shoulder. I think it was deep for me because I took a journey also and am now a single mom. I felt her grief, her fear, and her determination. I’ve had to make my own miracles though.

I am grateful for my boys. I am grateful for the organized chaos that is my life as a single parent, business owner, boss, and clinician. I am proud of my work and I am proud of my employees as they are all dynamic and skilled clinicians. But I think Encanto succinctly summarized what we do for people in a way that I have never been able to. We see people. We help them see themselves. We empower. We are the family in that last scene watching with pride as she walks bravely to the door.

I’m opening a second location and a long time client (9? years) texted me because I told him I needed to tell him something. We then chatted on the phone, and when I told him I was going to be based in the new location he said, “Yeah, well just tell me the address and I’ll see you there. Remember that closet you used to be in? Your first spot?” Then he laughed and told me about the pharmacist messing up his last prescription and being flabbergasted that the patient had my direct number to text me so I could resend it. “He doesn’t know what we’ve been through together,” then he laughed. He’s always joking and lighthearted, but I heard the ring of truth. I have seen him through a lot. A. Lot. And he still has work to do. But that’s outpatient psychiatry. Developing trust, rapport, and being the constant there through…a lot.

Mental Health Stigma Suicide

Mental Illness IS NOT the “Worried Well”

I’ve worked in many different aspects of healthcare so I have an understanding of what’s meant by “different level of care”. You probably understand it too but you may not have thought about it.

There are different levels of care for all illnesses and situations. You may understand it better from a medical perspective. Have you ever had a relative who broke a hip? Perhaps they went from their home to an emergency department; the ED triages who needs admission to the hospital and who can be managed acutely and sent home with perhaps more supports in place. From the ED the broken hip is admitted for surgery. Perhaps after surgery they are in the ICU for a day because their vitals are not stable yet. From the ICU they go to a medical/surgical floor. Then from there they are not quite ready to go home but too well for the hospital, so they are sent to a SNF (Skilled nursing facility aka nursing home/rehab). From SNF they are sent home with perhaps in home physical therapy and skilling nursing visits once a day. From there they are then deemed able to go to physical therapy outside of the house and follow up at an office with an orthopedist.

The point of this is to demonstrate the multiple levels of care we have for people suffering from injuries or illness. At any point in that example did you think “Now that this patient is going to outpatient PT they are clearly the worried well”?

No. You didn’t. Because they had a diagnosed injury, surgery, and recovery.

What about the asthmatic who sees their pulmonologist once a year unless they are sick at which time the pulmonologist sees them daily until their 02 sat drops and they are not improving with outpatient care. They send them to the ED. Luckily the ED stabilizes them with IV steroids and they are able to return home and avoid admission.

Again- when the asthmatic is well and seeing their pulmonologist once a year for maintenance visits did you think to yourself, “They don’t need a pulmonologist, they are just the worried well,”?

No. You didn’t. Because they had a diagnosed medical illness, treatment plan, and exacerbation of illness which required an ED visit.

Please explain to me why, when I treat clients at an outpatient level of care in private practice I am told that I treat the “worried well”? A few people have said it to me over the years, more probably think it, but they know I will ask pointed uncomfortable questions and give a lecture on the stigma of mental healthcare.

Mental illness is the ONLY area of our healthcare where people who seek outpatient maintenance treatment are labeled the “Worried well”. Do cardiology patients have to deal with that bullshit? No. Their patient may never be hospitalized. They may never enter an emergency department. They may see their cardiologist once a year for their EKG, Echo, stress test, and renewal of their anti-hypertensives but they are never referred to as the “worried well”.

I’m about to get on my soapbox, in fact I think I’m already there. (But just so you have the mental image: imagine me standing left hand on hip, right hand waving around sometimes pointing and shaking sometimes running through my frizzy crazy hair looking passionate enough that you want to follow me into battle.)

People who seek outpatient psychiatric treatment are many things but they ARE. NOT. THE. WORRIED. WELL.

They are brave. They are survivors. They are people with diagnosed and treatable illnesses that originate in their brains.

They have Major Depressive Disorder Recurrent Moderate without Psychotic features (F33.2). They have Bipolar Disorder (F31.9) They have Postpartum Anxiety/Depression/Psychosis (There are a few codes for this- look it up). They have Generalized Anxiety Disorder (F41.1).They have Post Traumatic Stress Disorder (F43.10). They have Adjustment Disorders (F43.20-F43.24). They have Gender Dysphoria (F64.9). They have Dysthymia (cycling/irritable depression often co-morbid with trauma responds well to Lamotrigine now labeled as Cyclothymia F34.1). They have OCD (Not a billable dx any longer). They have Autism (Anthem BCBS says this is NOT a billable diagnosis. Add it to the list as to why I despise them F84.0).

These are a smattering of the diagnoses I treat on a day to day basis. We have over six hundred clients at my practice and six clinicians. Over six hundred people. But yeah they are totally all the “worried well”. I want to scream when I hear this. Because let me tell you maybe three of them are well enough to go a year without seeing me. A small percentage see me a minimum of every 3-6 months and the rest see me monthly, bi-monthly, and during acute crises weekly or more.

Private practice is the least acute setting. That doesn’t mean we see the least acute patients. And even if we do see the “least acute” that doesn’t make them the worried well. Are all the outpatient patients of every specialty- pulmonology, allergists, immunology, rheumatology, cardiology, endocrinology, etc.- the “worried well”? No. Most of them have moderate sometimes severe illness but they see skilled clinicians who work their butts off to keep them out of the hospital. Even then, some patients will end up hospitalized. Some will die. This is the nature of medicine. Psychiatry is no different.

We work hard to keep our patients out of the hospital, out of intensive outpatient programs, but we recognize when it’s out of our arena and they’ve reached a level of illness that requires a higher level of care.

Calling my clients the “worried well” infuriates me at a visceral level. Because I’ve seen their tears- even wiped them in some cases. I’ve encouraged them, listened to them, adjusted medications, changed medications, initiated, discontinued, met with families, done therapy, done visits in the parking lot for the autistic client who is too agitated to come inside, told them to put their knife away because even with a knife I’m not prescribing Xanax, tried to reason with psychotic people to take their anti-psychotic medication, watched as mania destroyed lives and supported through the first year after a manic episode while we stabilize, manage side effects of medications, and try to pull them out of the deep suicidal depression that follows the epic and destructive mania. I’ve treated during pregnancies that were planned, unplanned, and the result of rape. I’ve treated people postpartum and post-abortions and post-rape.

To call my clients the “worried well” insults them. Insults their illnesses. Insults their journey. Insults their ability to drag themselves into psychiatric treatment when our society and often their family members tell them that they are the damn “worried well” and to just do yoga and they will feel better.

Patients who seek psychiatric treatment and make it to maintenance treatment are not the worried well. They are healing. If they make it there without being hospitalized and without an IOP and they stay there until we get them off medication and they never need it again…they aren’t the worried well. They are lucky. Lucky we found the right medication the first try. Lucky they had a robust response. Lucky they found a good therapist who they engaged with weekly sometimes twice weekly for two years so they could work through all the despair they brought into treatment. They are lucky to live without a relapse in symptoms through acute future stressors. Those patients are rare. In fact I cannot think of one. Because mental illness IS. AN. ILLNESS. Maintenance is the goal. But there is always a risk of relapse and for women it is particularly risky if they have their illness controlled before having children- because having children is a risk for relapse or worsening of symptoms.

People who mention the “worried well” in regards to private practice in mental health brings to mind the term “toxic positivity”. It is always said with a smirk. It is discounting of every person’s journey into mental health treatment. It also discounts the skill of private practice clinicians who keep so many out of higher levels of care through finesse, clinical acumen, long term bonds and trust with patients, and generally being damn good at what we do.

Now you know. Never say this about mental health practices or patients. It is demeaning, inaccurate, and rude.

Sit with that discomfort. Process your emotions. It will help build resilience if you process negative emotions instead of ignore them or sublimate them. (Google toxic positivity). It’s not my job to take away the discomfort with a witty or heartfelt wrap-up. I want you to sit with the discomfort as I have. Examine it. Learn from it.

Mental Health Stigma Suicide

How I Started Treating Pregnant and Post-Partum Mental Illness & Why It’s Important

I’m going to preface this post with…nursing school was horrific. If any one reading this is a nurse; you feel me. If any one reading this wants to become a nurse…being a nurse is better than nursing school. Hang in there.

Maternity was mid-way through nursing school. Right when I felt like I was never going to get through the program but also feeling I had come so far and couldn’t go back now. I hated maternity. There were many reasons why but it was not my jam. First day in post partum I was given a patient with a fetal loss. I had to take pictures of the mom holding her dead baby.

Writing that now, I’m like wow that was definitely messed up. They had a nursing student manage this incredibly intense case on my first day on the rotation. Looking back I can see the rest of the time I was overwhelmed, and disengaged. Not only was I not interested but I felt somewhat traumatized by my first day there and felt shut down by my clinical instructor when I mentioned how intense that experience was. It didn’t get better. In fact my last day my clinical instructor pulled me into her office and said “I was this close to failing you.” Then proceeded to berate me. It was pretty awful. Aside from that one experience my grades were stellar, I graduated Magna Cum Laude, and I had glowing reviews from every other clinical instructor.

I think the instructor didn’t like me. I think I didn’t like maternity. And I think my first day on the unit having to deal with a dead baby and grieving mom by myself for nine hours straight with no support from the nurse or my instructor set the tone for me.

That entire experience left a bad taste in my mouth. Through the rest of my nursing career I steered clear of anything maternity based.

My first experience with post partum care after nursing school was years later on an inpatient psychiatric unit. I had my first patient with postpartum psychosis. I treated her the same as all my other patients and honestly didn’t think much of it. Psychosis is psychosis. Needed to be stabilized and discharged with a plan in place. I had a few pregnant patients inpatient and then a few more postpartum psychosis cases. Enough that I felt I had some exposure to perinatal and postpartum mental health care. I learned what medications are safe-ish for pregnancy and medications for post partum with a nursing mom. I can’t say I loved it. I just did it.

Then I started outpatient care. I was young (28?) and I think as a result I saw a lot of young female clients. I don’t remember the first one who told me she was pregnant. I do remember several different times though. Some were teenagers disclosing looking scared and ashamed. Some had abortions. Some didn’t. Some were young women who were newly married and glowing with excitement.

I do remember trying to convince the first two of my pregnant clients to see a different psychiatrist or APRN who has more of a specialty in peri-natal care. They asked who that would be. I asked the psychiatrist I worked with at the time who had far more experience than I did. He gave me two names. I gave them to my clients. One of them actually called. The other didn’t. They both came to their next follow ups and essentially told me they didn’t care that I didn’t have a specialty in peri-natal care that they trusted me. They liked me, and one of them said, “I’m sure you’ll figure it out for me.”

I remember going back to the old psychiatrist I worked with. I reviewed their meds with him. I talked to the pharmacist on staff at the hospital. And for the next few pregnant people I continued to seek regular supervision and took some continuing education courses specific to peri-natal and post-partum psychiatric care. Fast forward seven years.

Probably a third or more of the caseload of my entire practice is peri-natal and/or postpartum clients. I know the postpartum specialty therapists. They all refer to me for medication management. I get calls from OB-GYNs and therapists asking if I can fit in a post partum case. I never advertised this part of my practice as it developed. I think it’s all been word of mouth. There are very few psychiatric practitioners willing to treat pregnant women and even fewer who will take on acute postpartum cases. I honestly didn’t realize how hard it is to find a provider to treat pregnancy and post partum until I started doing it.

I carried my own biases into this part of practice back when I first started not just from my first bad experience in nursing school. I thought of postpartum illness like many probably think of it- as an illness where Mom’s don’t like their babies, and maybe even try and kill them. I had a case in the pediatric emergency department when I was two or three years in. I remember it was a five week old with a head injury. There was a clear handprint on the baby’s head.

It ended up having a skull fracture. The Mom sat stone faced. Blank. The dad looked like he wanted to puke. The baby just lay on the bed until I picked it up and cradled it when it cried. I remember glaring at the parents. Why are they just sitting there? Why would they hurt this beautiful baby? Eventually the Dad broke down and told us it was his wife who did it. She hadn’t been right since the birth. Looking back now I can recognize that she clearly was psychotic at the time, and she was ultimately transferred to the adult hospital and admitted for psychiatric evaluation. I think we knew that she had postpartum but I didn’t truly understand what that meant other than her being cold and her baby having skull fracture.

These were the experiences I brought with me into my career as mental health APRN. When that client told me to figure it out for her. I remember thinking, what the hell am I getting myself into?

At some point during the following few years I got pregnant and had my own kids. I did not experience postpartum. I experienced twins. Twins who required exclusive breastfeeding. I had a C-Section. I went blind (my vision came back). I had pre-eclampsia/eclampsia. All in all pretty shitty time. But I wanted those little dudes. I worked so damn hard to have them. I kept them in through 36 weeks and 3 days of puking daily often multiple times daily. I was sleep deprived. But I was so incredibly happy to have them. I remember staring at them. I should have slept. But I couldn’t look away. Post partum time sucked because I was sleep deprived, I was sore, I had twins, and I had to breastfeed. But I didn’t have any overwhelming depression or anxiety on top of it. For that I am grateful.

Now I’m seven years into outpatient work. I’ve had many, many, pregnant and postpartum patients. I’ve treated depression, anxiety, mild to moderate to severe. I’ve treated post partum psychosis and post partum anxiety and post partum mania. While I’m writing the diagnoses though I’m picturing the women.

Because the women touched me and taught me. I’ve treated women who have had severe post partum illness but still felt incredibly bonded to their babies. What I found more common is women feeling bonded to their babies versus not. The clients who feel not bonded are definitely less common. Some times the only relief for women with post partum depression and anxiety is the time with their baby.

The women who struggle with bonding tend to have significantly more guilt, more shame, and in my experience are higher risk to develop more severe symptoms. When I have some one come a year before they want to get pregnant I want to do a happy dance. I reassure them that 1. there are medications safe for pregnancy and 2. in my experience the clients who figure out the meds that work for them before pregnancy and before post partum do much better in the long run.

The clients I’ve treated during post partum; some of them I’ve now treated through two and three more pregnancies and two and three more post partum time periods. I’ve counseled women who had severe illness who want to get pregnant again. Such deep fear exists and also such hope and longing. I’ve never counseled against a pregnancy. I do review the data, and the pro’s/con’s, risks and benefits. I had one woman start crying and look at me, and ask me “If I do this I’m just scared you won’t treat me because I was so sick before and it took us so long to get me better. Please just promise you won’t stop treating me. I’m so sorry. I just want this so bad but I can’t do it without you.”

People who know me, know that I am not someone who cultivates dependence on me. If anything I do the opposite. I want people to be flying free and never feel that I was solely responsible for healing them. Because they do all the work. I’m more like the tour guide. They are the driver. But treating post partum illness has made me appreciate the provider-patient relationship in a way that I haven’t with any other types of clients or illnesses.

There is not another illness that makes women feel so raw, so vulnerable, so shamed, and isolated as perinatal and post partum does. Because pregnancy is supposed to be a happy fun time. To feel like you’re breaking inside is not socially acceptable. Because post partum is stressful, and you have a new baby, and people think maybe your overreacting and why are you so sad, just take a nap and it will be fine. Why are you sad? You have this beautiful newborn baby to love on?

This has all been said to me. “My life is perfect. This is what I wanted. Why do I want to die?”

I watched When the Bough Breaks on Amazon. It’s heartbreaking and incredibly accurate.

Everything leading up to my career in psychiatry made me think I would never have anything to do with pregnant women and post partum women. But honestly it’s one of the most rewarding aspects to my career and it’s a lifeline that my practice and the providers here have all embraced this as part of our mission.

I’ve held a lot of fears, a lot of pain, and a lot of those deep dark scary thoughts that are not voiced anywhere but my office.

I think back to the mom in the emergency department who broke her child’s skull (the baby was fine, as skull fractures go it was mild and no long term issues). I think of her so differently now. I see her as ill and clearly not engaged in treatment. I wish she had a provider who could have intervened sooner. Some one who could have hospitalized her sooner and medicated her sooner. I think back to that mom and I think she’s why I figured it out. Because somebody needed to. Because mental illness strikes pregnant women and postpartum women too. She needed treatment. Not judgement.

The best part about telehealth is intervening fast with post partum illness. I can see clients 3, 5, or 7 days post partum because we do the appointment remotely. But for my established clients we already have a plan. Usually I see their smiling face come on the screen at 3-4 weeks post partum. They’ve already restarted the med they stopped during pregnancy, or doubled the dose we decreased for the last few weeks before delivery, or whatever the plan was they did. They weren’t terrified of post partum because we had a plan. They still struggle at times and sometimes I still have to refer out for higher levels of care. But they have support and we know what works and what doesn’t.

I had one client call me from their hospital room because they were fighting with their nurse who was trying to give them their lower dose of the anti-depressant and she knew we were supposed to go back up immediately after delivery. The poor postpartum nurse had to deal with me and the postpartum Mom telling her this was non-negotiable. Increase the dose and if she can’t do it then get me on the phone with some one who can. With my client intermittently yelling the birth weight and that she was able to have a vaginal delivery, and I had to tell her to stop yelling I’d talk to her later, let me talk to the nurse.

I’ve been texted pictures of newborns and I’ve been texted pictures of positive tests. I’ve been mid-telehealth when a client got a call from her fertility doctor, asked me to stay on the line to hear the result with her, and was there for her positive test result. I got the call when that same mom went into pre-term labor and delivered early. I saw her weekly until the baby came home from the NICU more for reassurance than anything.

I’m grateful I’m not the one catching the baby. Because good lord that’s just disgusting. I’ve had to be there for a few childbirths including my own kids, and I’m all set. But I am this peripheral support through entire pregnancies, post partum, more pregnancy, and more post partum, and sometimes infertility thrown in the mix also. It’s a journey that is incredibly intimate and to be a trusted component is incredibly rewarding.

Post-partum illness has a mortality rate. Women with less supports, family history of mental illness, and a history of their own mental illness like anxiety or bipolar disorder are at higher risk for psychotic symptoms which increases risk for suicide or infanticide.

Ask Mom’s how they are doing. When I ask mom’s how they are doing. Really ask. Eye contact and everything. They usually have tears well in their eyes and say, “No one’s asked me that,” because it becomes all about the baby. Ask them. And don’t dismiss their sadness as fatigue. Don’t dismiss their fatigue as just due to having a newborn. Ask if they have talked to their doctor. Ask if they have a therapist or mental health provider. We as a society need to open up the dialogue. We as a society need to support new mom’s and dad’s better.

Telehealth needs to remain permanent. Just as there are set in stone follow ups for baby and Mom with pediatrician and OB-GYN there should be a set in stone follow up for a psychiatric professional to meet with every new mom at least once in the first four weeks of postpartum.

Mental health has to become part of the pre-natal, peri-natal, and postpartum dialogue in doctor’s offices and in our communities.

The statistics are that 1 in 7 women will have clinical post-partum illness. Roughly 600,000 women a year in the USA. Approximately 50% of women with postpartum illness develop symptoms during pregnancy. IT’S NOT JUST HORMONES!! That infuriates me when I hear that clients have been told they are just being hormonal while they are literally breaking inside. 1-2 women out of every 1000 will develop post partum psychosis. 10% of Post partum psychosis cases result in suicide or infanticide. Suicide is the seventh leading cause of death in the first year after giving birth.

Educate yourself. All my clients love to be Dr. Google. This is one area I encourage googling. There are personal accounts that are heart wrenching. The more you know the more you may be able to help a friend or family member during and after pregnancy. Know that these women are not just hormonal. They are suffering from a mental illness with a biologic basis. There is treatment. 80% of cases are remitted completely with medication and therapy.

I think back to my first day in maternity at the ripe age of 21. I think back to all the emergency department cases that were so messed up. I think of all the cases that could have been prevented if they had adequate treatment. I think of my clients and their struggles that are so raw and courageous.

Just like I never went looking for nursing, it sort of found me. I never went looking for maternal mental healthcare. But it sure found me and I’m not sorry it did.

homophobia · Mental Health Stigma Suicide

Won’t Back Down

This week has been rough. It’s only Wednesday. On top of single mom-ing it, dealing with a sick cat, and running a mental health practice…it’s been busy. The cat is doing better. My kids are…giving me a lot of greys but otherwise okay…and I was threatened by a disgruntled patient.

I think it’s easy to surround ourselves with safe bubbles. Liberal or conservative, gay or straight, we often surround ourselves with people who make us feel safe. I do this in my own life personally and professionally. It’s rare for me to be threatened and as I’ve gotten better at screening patients it’s happened less and less. In fact it had been a few years.

I’ve never called the police but I called them this week. The threat felt calculated and also quite unhinged. And I’m sick of people trying to bully me because they see rainbows on my website and figure out we are Queer. And I was actually threatened. You can’t do that to people. It’s not okay. I felt violated and shaken.

I’ve actually had a knife drawn in my office before. Twice. And I didn’t call the police then. I never actually felt threatened. Sounds a little crazy I know. But the knives were more statements not necessarily pointed at me. And I shrugged and asked them to put it away. They did. This career is voluntary and in moments like those with the knives and years later with being threatened over the phone I always have thoughts of walking away. I don’t need this.

But I don’t walk away. Because that also irritates me. Because why should I give up what I love to do because of a few threats here and there? I didn’t feel good filing a police report. I felt annoyed generally that I had to do it annoyed at the threat, annoyed at myself for being shaken and forgetting how I lived protected in my bubble until it was burst.

I’ve never shared publicly threats in the past but again, I’m sick of being bullied. As a Queer female business owner who is not an MD, but an APRN, people generally feel more entitled to speak down to me or to raise their voice or in this case to threaten me.

The threat would not have been made had I been a straight white male MD with a boring website without rainbows. That kind of enrages and saddens me.

When I’ve been threatened in the past and with the knives it was never about being Queer it was patients who wanted certain medications that I declined to give them. This was different. This was plain old hate and discrimination.

There is not much more to say about it except that it happened. That I know all too well this comes with the territory of being an openly affirming Queer owned practice. But it still feels bad. I feel afraid at times and I don’t like that feeling. I had to tell my employees what happened and I am so grateful that they are part of my protective bubble. Because there was never a question from them about the severity or degree. No doubts just validation. They also work for me at this super Queer practice and put their safety at risk because they believe in what we do and me. They believe in me. I’ve felt a lot of feelings this week. Incredible gratitude for all of them was one feeling.

I’ve listened to a lot of Eminem. He’s my go-to. His songs are gritty and all about survival. Well minus the really messed up ones that are about murder and drugs and rape…I gotta be honest I dig some of those songs, like 3 A.M. so messed up, but probably in my top five favorites. But I digress. I’ll get through this with time and Eminem and as much as I want to walk away from the work I never could and seeing clients helps remind why I do this. Why I stick with it through the bad and the ugly. Because most people want help. Most people are trying so hard to get through and I can help.

Bubbles are great when you are in them, but rough when they burst.

Ironically this is all happening during Pride month. A celebration based out of hate and discrimination.

To any Queer people reading this. I see you. We are stronger together.

Divorce and Separation · Mental Health Stigma Suicide

What Not to Say to a Queer Woman on a Date

My therapist is closing his practice. Ugh. Took me nine months to find him. Because let me tell you how hard it is to find a therapist when you work in psychiatry in a small state. I share clients with far too many therapists.

I have until the first week in July and I told him we have until then to cure me. Because lord I don’t want to find another therapist. Then I was having coffee with a therapist so we could meet; and it was AMAZING to meet another human adult person in person without fear of dying of COVID. Thank-you vaccines. It was literally the first time I’ve done something that I used to do pre-COVID. Meet with a therapist who I share a lot of clients with. I suppose it’s considered networking but also generally common courtesy just so we can get a feel for one another. Not actually feel one another. Get your mind out of the gutter;)

So I was having coffee with him and I told him how my therapist is leaving. Sigh. And he started trying to fix it and name therapists for me, and I’m like wow. I can’t. It’s too soon. I haven’t broken up with my current therapist yet.

So let’s talk about online dating as a former lesbian. I know I’m not a lesbian. Any one who knew me before my wife knows I’m not a lesbian. But apparently having an ex who is female, as a female, makes men assume I am 1. a former lesbian who had a “phase” 2. Into threesomes 3. In need of “dick”…?

So let me provide some education here. If you ever date some one who used to date some one of the same gender or opposite gender or whatever; don’t say stupid shit.

When I train therapists and APRNs who ask for supervision related to seeing transgender clients I say the number one thing to know is “DON’T BE A DOUCHE”. I don’t yell it. But I repeat it a few times. Now I say the same thing to men trying to date a woman who used to date/be married to a woman. Don’t be a douche.

Don’t assume my sex life was lacking for the last decade I was with a woman. Because it wasn’t. Don’t assume I have not been with a man. Don’t assume I need a dick. Cuz yeah. There’s been toys around for a long time friends. No one actually needs a penis. Well except men I suppose. But even that’s debatable.

I learned quickly not to disclose my ex’s gender when chatting with prospective dates. I didn’t even disclose on a couple first dates because of disastrous responses. If there was a second date. Which there weren’t many. Then I would say her gender. Then I would still be asked pretty horrendous and invasive questions. I would also be fetishized in this creepy way. Imagine telling some one you have an ex then having them ask you how you had sex (because apparently some men don’t know how two women have sex?!), how you conceived your children (whose sperm and how it got into my uterus were common themes), and everything else you could possibly imagine being asked.

If you’re purely straight you have not had to deal with this. Because straight people generally know how a female becomes pregnant and they wouldn’t want to know about your previous sex life. I’ve been working on a presentation about LGBTQ mental health and I’ve read several articles that detail how bisexual individuals have the highest depression and suicide rates among the L’s and the G’s. I kinda get it. I mean I’m not suicidal. And I’m not depressed. But for some one more fragile and less secure entering the dating scene having been with both genders sucks. The discrimination is real.

I’ve talked to my therapist about it. A lot. Then I deleted the dating apps. Solved the problem. That was not his advice at all. But it worked for me.

I didn’t ever think dating would be this complicated. But I guess not every one has as fluid an understanding of sexuality as I do.

To clarify: Just because I’ve been married to a woman and am now dating men does not mean I want to have a threesome. It also does not mean I have been yearning and or significantly missing penis in my sex life. It also does not mean I had a phase. It means I fell in love with some one and then fell out of love with them; to diminish a decade of my life including a marriage and children to a phase is demeaning and insulting.

I think I’ll just send a link to this post to any prospective dates. lol. Not kidding though.

Overall life is good. My sons are good. My divorce is progressing. My business is growing. And the dating thing…well I know what I’m not looking for.

#COVID-19 · homophobia · Mental Health Stigma Suicide · Nursing

Ten Things I’ve Learned as a Mental Health Provider During COVID-19

  1. People can only handle stress for just so long. When I explain chronic anxiety and depression to patients I often use the analogy of a teapot. When you are walking around filled up with stress/anxiety/trauma/depression for years eventually you do not have room for normal every day stressors. This leads to epic breakdowns over seemingly innocuous things. Did you ever cry when you couldn’t open a jar of sauce? Or start screaming when you can’t find your keys? We all have a boiling over point. February 2021, about eleven months in, seemed to be most peoples boiling point. In the Northeast we had a lot of snowstorms which I think compounded things for many of us. My practice received upwards of ten-fifteen calls a day just from new referrals, not counting our five hundred plus current patients who also all started to melt. These calls were desperate. Crying into voicemails. There were suicides in our communities. There were drug overdoses and relapses. February 2021 honestly was one of my hardest months as a mental health provider.
  2. Women bear the brunt of childcare and homeschooling responsibilities. This is a gross generalization. Please note I know that there are many wonderful Fathers and husbands who have supported their families during the pandemic in every way imaginable. But in my own practice I have seen my female clients taking responsibility for the organizing of homeschooling. They have described screaming matches with their partners about who has to sacrifice work time. I’ve had women clients leave their full time jobs, drop to part-time, and/or change positions in order to accommodate their children suddenly being home full or part time. I have seen women making sacrifices and publicly smiling but privately falling apart with grief, anger, and sadness.
  3. Minorities are under more minority stress. From the LGBTQ community to POC to children to the elderly. All vulnerable populations have been made more vulnerable. The death rates of COVID-19 are disproportionately higher in the African American communities. Does a nice job of objectively presenting this evidence. The LGBTQ individuals who have lost jobs and been forced to move back in with homophobic and transphobic families are real. LGBTQ children, teenagers, and college aged individuals who have to live with homophobic and transphobic families is real. Suicide risk is high in this population already. The social isolation and inability to be “out” due to COVID-19 has added to these already significant issues for minorities. I literally have had telehealth sessions with a client crouched in a dark closet (and the irony of them being in a closet is not lost on us) in order to obtain privacy in order to cry in despair at not being able to be “out” and to have to experience homophobia and/or transphobia in every day life with their family. These sessions are gut-wrenching.
  4. Postpartum Moms and Dads have stress you can’t understand. I’ve often said the most unsolicited advice I ever received was during my pregnancy and in the first year of my twin boy’s lives. People who have been parents or not have opinions and stories and think everyone should hear them. Being postpartum regularly is hard. Being post partum during a pandemic when so little is known about the impact on newborn health is terrifying. Newborns can’t wear masks. Babies in daycares crawl and touch each other’s boogers. Parents have delayed putting their children in daycare because there is no true protection against exposure for infants. They are told that they are right, wrong, stupid, smart, and everything in between by people around them. I have never treated as many postpartum women as I have in the last year. SO much of it is providing reassurance that they are doing everything right. That there is no one right decision. That they know their baby and their lives best and they have to make the best decision for themselves. I offer validation and objectivity and I have seen them cry when I’ve told them they are doing everything right. Because no one has validated them since they gave birth. Unless you sit with people who have newborns day in and day out and see the agonizing choices they have to make; you don’t understand. And you shouldn’t be offering anything except validation and support.
  5. People NEED people. I’ve also said before I’m not a hugger. But the first time my friend and I hung out after we were both vaccinated and she asked if she could give me a hug and I enthusiastically consented. We weren’t big huggers before COVID-19 but after a year of isolation we unashamedly and laughingly embraced. One of the most poignant sessions in the last year, that has consistently stuck with me, was a young adult who lived alone and who did a Zoom with her family for Thanksgiving. Through tears she said, “I had to do a Zoom with my family. I just. want. to. hug. them.” Her breath hitched with each word and the tears turned to sobs and we sat for several minutes with her sobbing and me watching; neither of us speaking. I held back tears of my own as I wanted to reach through the screen and pat her shoulder and tell her it would all be okay. I heard so many of these stories but her vulnerable and raw pain in that moment touched my core. I had clients tell me their parents cried during their Zoom Christmas’ and they couldn’t stand to see their Mom cry. I sat with them through that pain. I offered nothing but space and understanding to feel pain. I have never known with such certainty after the holiday season of 2020 that we need physical touch to survive. We need our families. We need connection. Of all the long term sequelae that COVID caused, the isolation and desolation of being alone is by far the worst.
  6. Never underestimate the power of pets. I don’t have to explain much about this. If you have animals then you know what I am referencing. The isolation of this past year has made people get new pets and appreciate the ones they have. Pets are some of my clients purpose in getting out of bed every morning. They have truly saved lives this past year just by existing and offering unconditional love. To all our four legged friends, you have my true admiration and thanks.
  7. People who treated their mental illness before COVID faired better. One of my clients who was extremely ill a few years ago, but has since stabilized, greeted me smiling at our six month check in. She was doing great, and felt validated in her own experience of mental illness. “People know now how it feels to live with anxiety. I can now explain to people mental illness and they get it. Because their anxieties about COVID are exactly how I felt about everything all the time.” She wasn’t my only client who had severe mental illness in the past and stabilized with medication and therapy who have done excellent during the pandemic. They had coping skills, we knew what medications work for them, and they were connected to providers. My takeaway from them is to deal with your mental illness before you boil over.
  8. After people boil over Desperation sets in. I think it’s hard for some one to truly understand desperation until they have experienced it. Desperation is finding cuts on your childs arms or legs and bringing them to a hospital and being told they are not sick enough to be admitted and to connect to outpatient care, then calling forty providers and being told no one is accepting patients. Desperation is watching your loved one suffer and struggle and slip away and not be able to find them help. The mental health system’s flaws are fully exposed now. There are not enough providers. The providers that are in practice are un-paneling from insurance because insurers have made the last year so much worse than it needed to be for small practice owners. I have been screamed at on the phone more times than ever in my career when I call to tell people I am full or not accepting their insurance or not taking pediatric referrals. I have been threatened. I have been told through tears that they are desperate. I have been begged and pleaded with. I have been offered twice my normal rate just to fit some one in. I had to not return every phone call because I became fearful of what would be said to me when I told them I was not accepting patients. I had to hold my own boundaries and not take new patients in reaction to other people’s desperation. Because I was becoming burned out. I grew as a clinician and a business owner in the last year in more ways than I ever imagined. I also heard and saw desperation in ways I never imagined I would.
  9. I will always accept Medicaid. So many of my clients have been on and off Medicaid and commercial plans this year. Medicaid’s rates of reimbursement in my state are disgustingly low. But I will always have it as a plan I accept because my patients who lost commercial plans this year with job loss needed to have continuity with their mental health provider. I do not want my practice to be fully medicaid as that’s not sustainable revenue wise for a small practice. However, it will always make up a stream of our revenue because it has to be an option when clients lose jobs.
  10. Everyone has it bad. In the past year I’ve heard why the people in their 50’s and 60’s have it the worst. I have also heard why kids in high school, college, in their twenties, single people, married people, parents and non-parents all have it the worst. Every one thinks their lot is the worst. Young people are missing out on proms, college admission is being delayed in some cases, parents are overly burdened with childcare duties, single people are the most isolated, etc. I’m just throwing this out here; it’s been a shit year for everyone. There have been highs and lows for all ages all social statuses and in every way imaginable everyone has undergone stress, loss, and an understanding that things will never be like before. There is a before and there is a now and there will be an after but life will never be the same.

Through this past year of COVID-19 I have lived history. I am a front lines provider during a global pandemic. I have been through more personally and professionally than I could have imagined. My biggest and best takeaway from this past year though is to be grateful. I am grateful for my children. I am grateful for our health. I am grateful that I have been able to see my mom and sister, sister-in-law and niece, throughout the last year. I have known loss. I have grieved. I have cried. I have hoped.

About a month ago, I went to the office. I saw a long term therapy client for the first time in person for several months. He sat down, and I sat down. We both removed our masks. And we smiled. We were both vaccinated. The window was open. We sat eight feet apart. And then we had a therapy session in person without masks. It was possibly the most beautiful moment of the last twelve months.

#COVID-19 · Mental Health Stigma Suicide · Nursing

When I’m Called Out by Clients for Swearing, Caring, and Everything Else…With Love. A Day in The Life of a Mental Health Nurse.

An unexpected perk to having a therapist on staff full time with us is hearing from her what my patients think of me. I have referred more than a few of my clients to her though some of them I’ve seen for over three years for medication management and for one reason or another they needed a therapist at this time. Apparently the impressions are hilarious.

Occasionally my clients will directly throw my words back at me. Recently a young adult attending college in state needed to see me urgently. After we processed the current crisis and made decisions about medication I smiled and said, “Isn’t this great that your in state and we can do telehealth?” The client laughed and said, “Well I recall you saying if I went to school in Iowa, one of my top choices, that I’d be in ‘East bum fuck middle of fucking nowhere and there’s no way in hell I’m managing your meds out there'” I have a chagrinned smirk including blushing cheeks that emerge when properly embarrassed and I replied, “Yes well, that does sound like something I’d say…” We were both able to laugh. Now I know that client didn’t go to school in Iowa for a few reasons, including COVID, not just because I wouldn’t manage their meds in east bum fuck nowhere. But it is a humbling reminder to know that I do play into people’s major life decisions.

One of my clients did an imitation of me to the therapist at my practice…who texted me while laughing to tears because it was incredibly accurate and I am funny without meaning to be which usually makes it funnier. The impression was from our intake. Our intake was over three years ago. I was very direct. I warn people I’m direct. I don’t think any one really believes me until they experience it. And again, I was humbled. Because these moments in time are so important to clients. They stick in their brains these intermittent appointments with me. Words are so powerful. Body language. Facial expressions. This client nailed it all.

What I learn over and over is that my clients are paying attention. That I have an hour intake and thirty minute follow-ups maybe once every three or six months if they are stable and those minutes are precious. I try and respect them. I swear a lot. That’s not going to change. But apparently between the swears, the sarcasm, the checking in, I impart an energy and words that stick with people. It’s a privilege to be that person. We in mental health should never take it for granted.

I have a client I have been seeing for a few years, and the parents brought up at our last appointment, “Hey do you remember when you made us leave the room because you had to have a ‘Come to Jesus’ moment with them?” The Dad was cracking up. He said, “We didn’t know if we would see our kid again! But we knew then we were in the right place.” I did that embarrassed smirk as I thought back a couple years, and in fact I did remember telling the parents to leave. I didn’t raise my voice. I got down at the kid’s level though and told them to take their ear buds out when I ask them to take them out. To respect my fucking time because I’ve shown them nothing but respect even when they are acting like a little entitled punk. I may also have told them to undo their wedgie and let’s start again.

Sometimes I remember those moments and do a facepalm. I obviously do not speak to all people this way. It’s my job to read people. I’m good at it. I know who it’s going to be effective for and who it won’t be. And that kid never wore the ear buds again, and honestly has been very respectful to this day in our appointments.

Recently a parent asked me if I thought their educational plan for their child was “crazy”. I didn’t hesitate when I responded nodding, “Yes. I do.” I remember the parent looked at me and laughed a little and said, “Well you’re the first one who’s at least been honest with me.”

Honesty can be a bitter pill for people to swallow. It’s definitely not for everyone. Again, I give myself a disclaimer up front to any prospective clients. “I’m direct. I will call you out. I encourage you to call me out too if there’s anything that needs to be addressed.” But it can open doors to take your head out of the sand. My honest response to that parent opened up an entire conversation about their own self doubts and their strengths and weaknesses as a parent. It allowed a space for them to be vulnerable that wouldn’t have been there if I had just smiled and said “No of course not,”.

I’ve also learned that as long as I’m honest without being judgmental…which is a hard skill to master…it goes over a lot smoother. My clients that I take time to build rapport with and I really get to know and who get to know me, they know when I give them direct feedback it’s not from a place of judgement. It’s from a place of genuine curiosity and caring. I want to know if I’m on target with my assessment. I want to know if they know I’m on target or not. I want them to think and feel things that they haven’t let themselves think and feel. I want them ultimately to get better.

I was asked recently by someone how I felt about “…profiting off the pain and sorrow of others. I mean people have to be suffering in order for you to get work right?!” This was not a friend. And was said with some malice toward mental health professionals. I responded that I think about that a lot. And that should there come a day when my services are no longer needed I will feel such immense joy that it actually brings tears to my eyes to think of that day existing.

I remember resisting the impulse to defend all that I do; all that I give to my work. It doesn’t feel like a profit when a client is hospitalized for suicidal ideation. It doesn’t feel like profit when I end a day sitting on my floor wiping away tears because of all the emotional trauma I’ve held space for in the last eight hours…trying to pull myself together in the five minutes I have before my sons bounce through the door. It doesn’t feel like a success to educate my client about their diagnosis of schizoaffective disorder- how it’s lifelong and they will have more episodes of psychosis and we need to plan for when not if.

Those are all the moments that stick with me. So it’s nice to hear from clients who remember other moments. Who remember me swearing with love. Who remember the limits I set with fond affection and admiration. Some of my clients have done impressions in front of me and they are pretty good. I should be a meme.

Clients send me videos of their engagements. Wedding pictures. Newborn baby pics. Those hilarious therapist memes. Some one sent me a Christmas card thanking me for all my help and crediting me with helping them be healthy enough to become a Mom. I cried hardcore when I opened that one. I am allowed into these intimate moments in people’s lives because I know more than anyone the emotional labor they have put in to get to these crucial turning points in life.

The positive feedback is few and far between for healthcare providers, especially mental healthcare providers, but it’s there. Even the impressions. They crack me up. This year more than any I needed the positive feedback. I am beyond grateful for it.

To consumers of the mental health system- I thank you. For trusting me with your mental health. For seeing me for who I am even in moments of tough love. To families of consumers- I thank you. You have trusted me with your most precious cargo. I don’t accept that responsibility lightly. To the therapists who have to endure impressions of me- Enjoy. I’m pretty freaking funny especially when I’m not trying to be and yes. I swear that much.