Sometimes the Hardest Thing and the Right Thing Are the Same

I was absolutely delighted when I was hired for my job working in housing for people with mild-to-moderate mental illness.  This was back in January.  The delight did not last.  I spent most of the past 5 months becoming increasingly miserable, despite every attempt my supervisor, Tilly, made to help me fit in the position.  I made pages of pros & cons.  I did thought diaries until my hand cramped.  I exchanged a ridiculous number of phone calls and texts with Tilly.  I even took 3 weeks of medical leave, spending part of that time in inpatient, certain that the problem was me.

Sadie kept telling me I was a square peg trying to fit in a round hole and “it’s not the peg’s fault it doesn’t fit”.  I just didn’t know what to do if I quit.  Two weeks ago I finally took the leap and submitted my resignation.  My last day was supposed to be Friday, but after working Monday and telling the clients I was leaving, I started wishing that could have been my last day.  Tilly agreed that Friday would be very hard on me, and said if I wanted Monday as my last day she could make it happen.  So on Wednesday I went for my exit interview and turned in my badge and keys.

When I was lamenting that what I’m good at and what the job description consists of don’t overlap, Sadie encouraged me to take the StrengthsFinder 2.0 test.  I ended up with my top 5 strengths as Empathy, Strategic, Developer, Input, Responsibility.  These do fit in the mental health field well, but in a more administrative position.  That’s exactly what I was starting to discover while working – that I understand people and can help them, but I’d do better at more organizational behind-the-scenes work.

Even so, it took 5 months for me to stop being convinced that not fitting in at the job didn’t make me a failure.  I was so sure that I could do well at it and that clearly it was my mental illness standing in the way.  That’s how I ended up in inpatient, with Dr. Flanders dumping my entire medication regimen and starting over.  I thought clearly the meds weren’t working right and trying something radical would help.  In fact, it made things worse as the medication didn’t get to a therapeutic level so I was getting more depressed instead of less so, and I also had an array of unpleasant side effects, including being constantly drowsy and unable to concentrate.  I keep wondering if things would have worked out had I not changed medications.

My follow-up with the psychiatrist is not until the 24th, over two months after my discharge from inpatient.  I went to my family nurse practitioner for help, as she’s the one who normally manages my medication anyway.  First she increased my dose of lithium, after acknowledging it was the cause of my side effects.  Then when I started feeling tempted to skip my meds I returned, asking to switch back to the medications I was on before inpatient.  She was unwilling to make drastic changes, and instead of a gradual shift toward what I’d been taking before, she tripled my dose of Abilify.

Close to two weeks ago I couldn’t tolerate the drowsiness anymore and stopped taking the lithium.  A couple of days later I ditched my other psych meds as well.  Upon learning this, Sadie encouraged me to call the mental health center’s head nurse for advice on what to do until my appointment with the psychiatrist.  I was pleasantly shocked when the nurse told me to stay off the meds and just monitor for symptoms carefully and call if there’s a problem (or ER if there’s an enormous problem).  She indicated that maybe I don’t need so much medication continuously and they might be able to come up with a PRN medication instead.

It’s wishful thinking to believe that would actually work out, but I keep on wishing.  My mood is good, my anxiety is fairly mild, and the only thing worrisome I’ve noticed is a little bit of irritability.  Nothing unmanageable.


The Three Goals

Every three months Sadie and I have to update my treatment plan.  The first page reviews progress made since the previous treatment plan was created, and addresses strengths, needs, abilities, and preferences (SNAP).  It lists the members of my treatment team and any “natural supports” – people in my life who are helpful to my recovery.  The rest of the plan consists of overall goals and any smaller objectives within those goals.  Each goal is tied to a problem identified on the Adult Needs and Strengths Assessment (ANSA) which is updated every 6 months.  Each objective within a goal contains criteria for identifying when it is completed, a target date, and any interventions that will be provided by the therapist or other staff.

My treatment plans have varied widely.  They used to be crammed full of objectives that we sometimes never worked on, but they were there in case I wanted to work on them.  The benefit to this is that Sadie’s paperwork for each appointment (a Service Activity Record or SAR) requires that she choose a goal or goals from my treatment plan that we addressed during that appointment.  I’ve experienced firsthand the struggle to choose something relevant to the actual work, so I like to ensure that she has several choices and/or sufficiently vague goals that can apply to anything we do.

My last treatment plan had only one goal, pertaining to interpersonal problems.  It was about setting healthy boundaries.  We kept that as an objective, and incorporated another objective, with the goal of “have more realistic interpretations of other people’s comments”.  One of my major struggles in relationships is that I get disproportionately upset by things people say (particularly with my mother), so I am aiming to tone down my reactions.  The completion criterion here is to complete at least one thought diary per week.  We made it a small goal because sometimes I struggle with the longer thought diaries, but there are also forms that do a quick mini version where you can log several different thoughts on the same form.  I plan to keep one of those handy and fill it in as often as possible.

The next goal, pertaining to depression, is to “work on accepting imperfection”.  The material from which the thought diary form comes also contains a series of modules on Perfectionism in Perspective, so Sadie and I plan to work through these modules together.  The final goal, pertaining to self-care, is to “explore Buddhism”.  I have committed to reading at least one book per month on the subject, although knowing me it will be a lot more.  I’m starting with Buddhism for Dummieswhich is probably not the most enlightening book option, but gives a thorough overview and suggestions for additional reading, which I can use to help me figure out where I want to look next.

I feel better about this treatment plan than the last one, as the things I’m trying to accomplish are more concretely measurable.  I like to be able to check things off a list, and these are all things I can check off if I work hard.

Self-Harm and Buddhism

At work there is a program called Illness Management and Recovery (IMR).  It was developed for the Substance Abuse and Mental Health Services Administration (SAMHSA) and consists of 10 modules on managing mental illness.  I am not trained to teach it, but have been working through the modules myself to learn more.  Most recently, the assignment was to explain a symptom to others.  I wasn’t sure which symptom to cover, until I spent 5 nights back in the inpatient unit last week.  I’ve struggled a lot with suicidal ideation and urges to self-harm over the past three months, and reached a point where it was beyond time to take a breather from life and go somewhere safe where I could focus strictly on taking care of me.

While there, I began reading The Buddha and the Borderline by Kiera Van Gelder.  It is a memoir of her experience of Borderline Personality Disorder and her path to recovery via Dialectical Behavior Therapy (DBT) and later delving into its roots in Buddhism.  Early in the book there were some fairly graphic descriptions of self-harm, which I only felt okay with reading because I was in a safe place.  It turns out, it wasn’t entirely safe.  They do the best they can with keeping dangerous objects out, but those of us who self-harm can get pretty creative.  At one point I found something dangerous that was built into the architecture.  I showed it to a nurse and she said she would report it to the director of the unit and that I should come tell a staff member if I was feeling tempted.  One night I did.  I’d been feeling anxious during visiting hours and when my mom left I called the same nurse over and told her I felt tempted toward the thing I had shown her previously.  I also handed over my statistics folder mom had just brought for me and asked her to please remove the staples from the packets of notes.

The nurse told me to stay put, but it didn’t totally register and after a different staff member handed back my folder without even speaking to me I started to get overwhelmed by the noise in the main commons and moved to a smaller area near my room.  The nurse came rushing in and happened to see some recent scratches on my arm from before my admission, which led her to exclaim, “Did you hurt yourself?  I told you to stay put!”  I explained that the scratches were older, and she told me that they would like me to sleep in the quiet room that night so they could keep an eye on me.  The quiet room?  That’s the nice term for seclusion room, which is the nice term for restraint room.  The only furniture was a bed in the center of the room, with restraints built in.  The lights were controlled from the outside, there were cameras monitoring the room, and there was no handle on the inside of the door.  Now on the bright side, they really just were putting me there for the cameras, and the door was not fully shut.  I was allowed to get up and leave to use the bathroom or go to the water fountain or ask for sleeping medication.  It was still rather intense.

It was also completely warranted.  The dangerous item I had found wouldn’t do serious damage, but it was in a place where no one would see and stop me, and I could have hidden the marks had I acted on my urge.  So why self-harm?  It can be many things.  It can be a punishment.  It can be a release of psychological pain in physical form.  Those are the main two things for me.  If I’m hurting intensely, it’s less painful to transfer that into something physical.  I’m also usually tempted toward it when I feel shame, which unfortunately I feel frequently and for sometimes inexplicable reasons.  The important part to note is that, while many people both self-harm and feel suicidal, the act of self-harm is not a suicide attempt.  Severe acts of self-harm could result in death, but it’s different if death is not the intent.  Self-harm is a coping skill, just not a very healthy one.  Some people come home from a hard day and have a glass of wine or eat a comforting meal or go exercise intensely for an hour, and all those things reduce the pain somewhat.  Self-harm does the same thing for some of us, and therapy (such as DBT) is about replacing that with a healthier way to reach the same end result.

I finished reading The Buddha and the Borderline last night, a couple of days after my release from inpatient, and toward the end the author asked one of her Buddhist teachers if suicide was the same as killing another person.  Likewise, is self-harm the same as attacking another person?  The conclusion was that it is impossible to fully practice loving-kindness toward others if you cannot love yourself.  I can’t say that I will never slip and act on those urges again, as that’s much too simplistic to think a line from a book is going to undo decades of experience, but the book did inspire me to look more into Buddhism.  I am not a spiritual person.  I am even less a religious person.  I have, however, found myself drawn toward Buddhism over and over throughout my adult life, and have benefited immensely from DBT and the elements of Buddhism Marsha Linehan incorporated into it.  So I am steering my upcoming focus on reading toward books on the topic, to discover if it is something I want to explore further.

Expressions of Aging

My great-grand aunt died in late March.  Her funeral was held on a Monday, when I needed to be at my practicum class at college.  While on campus, I was in the student union racing past some random booths that were set up for various organizations.  I saw one that said “social work” and turned around.  The Social Work program was promoting a contest they were running for images related to aging.  The winning image will be used on materials for the Social Work program that promote aging issues.

While at this booth I met one of the professors from Social Work and briefly spoke with her about my interest in the MSW program.  When I got home I sent two e-mails: one to this professor to provide a further introduction about my background and interests, and one to enter the photo below in the contest.


I received a call today that my image had been chosen as the winner.  I had to fill out a form to get the prize, and the professor who ran the contest also wants to interview me for the department’s newsletter.  I am excited and terrified, but I think mostly excited knowing that my beautiful great-grand aunt is going to be immortalized on these brochures.

Tidying Tasks

Two weeks ago I wrote about getting Support from Coworkers and how much it was helping me adjust to the job.  I’m still not adjusted.  I thought I was doing great, and then I was texting with a coworker while at work and we had a bit of a disagreement regarding whether I need to continue therapy, and I had a bit of a meltdown over thinking that I’ll never be “well enough” to properly help others.  I completely freaked Tilly out by texting her that I couldn’t do the job.

Then the night went terribly, or well, or both.  I had two major situations with clients that I thought I had handled well, but when I talked with Tilly in the morning it seemed like I had just horribly screwed them all up.  She had asked during the night if I wanted to quit or was just upset, and I told her that I honestly didn’t know and that I would do a pros & cons sheet to try to figure it out.

I e-mailed Tilly the pros & cons sheet, which resolved nothing for me, because I felt like everything was equally important.  I made a special trip out to work on Monday so that we could talk before my next shift.  We agreed that I would write out some “what if?” scenarios and how I would respond and then we could review those and she’d make suggestions.  She was concerned about the fact that my pros & cons sheet had indicated the possibility that I might end up harming myself, and made me sign a form that ended up essentially being an administrative version of a safety contract.  I felt very uncomfortable about it despite her promises that it would stay in her desk and not go to anyone else.  It indicated a follow-up plan regarding the “what if?” scenarios and that we would meet on Thursday mornings to talk before I went home.

This week went better.  I have a client who had previously told me I had “too much philosophical education” and didn’t know how to talk to regular people like him.  I’ve worked hard to remember QTIP – quit taking it personally – but this one was definitely meant personally and I knew he was right.  This week I managed to engage him in conversation and he has become friendlier again.

I had to attend first aid and CPR training Wednesday morning after working all night.  A coworker and Tilly’s boss both indicated that I never seem tired.  I said I do get tired, but I usually perk up again quickly.  I was showing signs of tiredness during the training – fidgeting a lot and having trouble focusing – and also I ended up having to take the nausea medication I keep in my purse because the first aid video nearly made me throw up.  On the bright side, my hands-on CPR test went perfectly.

Yesterday Tilly was coming in a bit late and told me I could have her boss sign my timesheet for practicum class, but I wanted to wait for her.  We talked for a bit, and went over to look at the office to determine what needs to be done before the auditors arrive in a couple of weeks.  I apologized for my obsessive tidying over the previous two nights.  Tilly touched the baskets of supplies on the desk and said, “I saw this and thought, ‘That’s my girl.'”

We came up with a list of other cleaning and tidying tasks that I would take care of before the audit, one of which was to update a calendar markerboard with more activities for the clients.  We noticed that it still said March and had March’s dates, so I was going to fix that before leaving.  I ended up staying until 10 am to erase and rewrite the whole thing because it was too messy trying to erase tiny spots and not smear the rest.  I feel like I should be frustrated at getting all these cleaning tasks, but really I just feel needed when I have special projects.

I’ve also gotten mutual support from a coworker who is experiencing some of the same challenges at adjusting, and I got a lovely e-mail reply from Tilly’s daughter, who had a rough time starting out when she worked in the same position I’m in now.  All in all, I’m still a bit shaky about whether this is the right place for me, but feeling a lot better about it than I was last week.


Support from Coworkers

My new job is…challenging.  I’ve been there for 2 months, and I’ve had many moments (even hours at a time) when I questioned what I was thinking when I even considered working in the mental health field let alone accepting this particular position.  I am brimming with self-doubt and insecurity about whether I’m suited to work with people who have similar issues to my own.  Despite this, I am constantly grateful to be given the opportunity, delighted at what I get to do, and genuinely like the clients I’m working with.  One of them accuses us of just working for a paycheck and not caring, but I truly do care.

What has been carrying me through is the amazing support I’ve received from coworkers.  Not a single one of them will tell me I’ve horribly screwed up, instead referring to mistakes as a learning process.  I’m a thousand times harder on myself than they are on me.  Multiple people in the field have commented on my position being particularly difficult.

I appreciate that I’ve been able to be open with coworkers about how I am struggling and give them the opportunity to share their experience and knowledge.  This week I worked evenings for the first time instead of my usual night shift, which required significantly more interaction with clients.  I made 7 shopping trips within 19 work hours, teaching clients to choose a balanced diet, compare prices and shop within a budget, use self-checkouts, and other skills needed in order to successfully shop on their own.

This evening my supervisor, Tilly, let me see some of her own weaknesses.  She told me a story of a…learning process she had when she first started.  She also told me that she doesn’t like the grocery shopping appointments and that I had taken some of the most difficult clients to shop with and done it successfully.  This was precisely the conversation I needed to have tonight.  It’s one thing for people to say that the job is difficult or that they don’t always make the best choices, but quite different to hear concrete examples.

I still didn’t do everything “right” on these shopping trips.  I had clients criticizing my driving since I’m still not used to the company van, and one client had to teach me how to cash a check at the bank drive-through as I’ve always gone inside for all my banking business.  However, I felt a huge boost of confidence upon learning that these shopping trips weren’t expected to be easy and that I handled them well.

Despite the positive experiences, I’m more than happy to be returning to night shift next week.  Being constantly bombarded by clients and their needs and wants for an entire shift was draining and left me wanting to crawl under the desk and hide.

Crisis Text Line

A long time ago I discovered Crisis Text Line at a time when I was definitely in need of crisis intervention.  I was too scared to use it though, and ended up being distracted by some people making a spectacle in Steak ‘n Shake.  The number did end up on my safety plan, and Sadie recently asked if I needed to update that plan due to my job change.  She reminded me of Crisis Text Line.  A few hours later, I got a Facebook message from a friend about Crisis Text Line.  A few hours later, I used Crisis Text Line.

I’m not comfortable sharing exactly what I said, but in summary, I was working overnight and had been juggling crises had by two other people, and I was about to run away from work and never come back.  I texted “HOME” to 741741 as instructed on the website, and proceeded to explain my situation.  Here is the other side of the conversation:

CTL [automated]: Thanks for texting Crisis Text Line, where you’ll text with a compassionate Crisis Counselor.  Our terms of service:

CTL [automated]: Text STOP anytime to cancel.  We can’t receive msgs longer than 160 characters (~a couple of sentences).  What’s on your mind?

ME:  …

CTL [automated]: Thanks for sharing.  We’re getting a Crisis Counselor for you, it may take a moment.

ME: …

ME: …

CTL [counselor]: Hi, my name is [name], thanks for texting in tonight.  Do you mind if i ask your name?

ME: [name]

CTL [counselor]: Thanks [name], it sounds like you are feeling overwhelmed in this new job?

ME: …

CTL [counselor]: It is very normal to get discouraged with work, especially in a very intense role like it sounds like you have.

CTL [counselor]: Do you have any supervisors you can talk to about how the night is going?

ME: …

ME: …

CTL [counselor]: It sounds like if she works there she might know this patient and be able to help you with the specific case.  You should have that support at your job.

ME: …

ME: …

CTL [counselor]: It is normal to feel down on yourself in a high pressure job, but you are still learning.  Are your coworkers supportive of you?

ME: …

CTL [counselor]: It is good to hear there is a support system for such a high stress job.  I’m sure they are confident for a reason.

CTL [counselor]: If it gets bad like tonight again, do you think you would be able to schedule a meeting with a supervisor to voice your concerns?

ME: …

CTL [counselor]:  Ok that is good to hear, you are very strong [name]!

ME: …

CTL [counselor]: That sounds like a good plan.  Good luck!

ME: …

CTL [automated]: Thanks for texting Crisis Text Line.  The Crisis Counselor has closed the conversation.  You got this!

CTL [automated]: Please share your voice to help other texters.  Provide your anonymous feedback here: [link]

Looking back over the conversation, it feels a little cheesy, but in the moment it helped.  She said just enough to get me to talk through the issue on my own and find my own solutions.  I would definitely recommend the service.  It’s great if you are uncomfortable talking to someone aloud, although I would advise that it is a little slow-paced to get responses and if you’re feeling particularly agitated the pace might be frustrating.

I’m trying to commit to writing on my blog more regularly.  Obviously today is not Sunday but for the future I am aiming to schedule a time on Sunday to post.  After this week, if Sunday has passed and I haven’t posted, I encourage you to call me out on it.