Piles of Paperwork

Last week Sadie and I had to update my ANSA and treatment plan yet again.  She expected that we could do all this in one session and still have a little time left over to talk.  She was mistaken.  We got the ANSA done with 5 minutes to spare and she asked if I wanted to do the treatment plan “really fast” or come in another time.  There is no way we could have gotten done in 5 minutes, so I agreed to come back the next day to complete it.

The next day I came in and it took us at least 30 minutes to get the treatment plan done.  She said that I’m more goal-oriented than most of her clients, who usually say their goal is “to be happy” and don’t care what else she writes.  That seems utterly unproductive to me.  Happy is not quantifiable.

My overall ANSA score, which tells her what level of services I need, has gone down from a 4 to a 3.  This is great news.  Less great was when we did the Suicide module and she said, “If I didn’t know you, I’d send you to inpatient based on this score, but I don’t think you need inpatient.  Do you?”  No I definitely didn’t.  Part of the score is based on history of attempts.  My Benadryl overdose counts as an attempt, so that part of the score will never decrease.  At the time we talked I had a concrete plan (but I will always have some form of plan) and had thought about it in the past 24 hours (because someone else was discussing a loved one’s suicide attempt), so that looked rather alarming.  However, I had no intent to act on it.

I am displeased with the new format for treatment plans.  The previous one was very open to filling it in however we saw fit.  This one pulls in the highest needs from the ANSA and forces you to choose from a list of options for things that need addressed in that area.  There is the option of adding in your own ideas, but I feel like what I actually want to work on is not addressed in the treatment plan.

However, this will be the last treatment plan.  Sadie has seemed to be pushing me away for the past few months and most recently responded to a request for help by indicating that I don’t need it.  Of course my instinctive impulses were self-destructive: overdose, self-injury, going off my meds, cancelling my appointments and not ever speaking to her again.  I refuse to let her be the reason I self-destruct.  However, after a couple of days of thought, I’ve decided that when this treatment plan expires in 3 months then I’m done.  It doesn’t feel that productive anymore.

#6 is Not an Option

I went into today’s appointment with Brent bearing a letter instead of my usual bullet-point notes.  It detailed the past month of alternating compliance and non- with my prescribed medication, and ended with six possible changes we could make:

  1. Reduce the dose of Latuda.

  2. Change to a different antipsychotic.

  3. Drop Latuda and add an anticonvulsant.

  4. Keep existing meds and add an SSRI.

  5. Keep existing meds and add a stimulant.

  6. Drop all meds and suffer the consequences.

Brent immediately said that #6 was not an option.  He didn’t specifically discount options #4 and #5, but I knew when I wrote it that they would not be options in his mind.  He went with option #1, reducing my dose from 60 to 40 mg, and said that if I still had complaints about the Latuda when I see him in a month, then we can discuss option #3.  He remembered that I had suggested Lamictal at one point in the past, and cross-tapering the Latuda and Lamictal would be the next step.

Brent said that he wants me to have energy and motivation; that he doesn’t want me to be overmedicated.  I was so grateful he said that, because I feared he might be one of the many professionals who are content to keep the bipolar in a mildly depressed state so long as there’s no risk of slipping into mania.  I’d be much happier with the opposite: staying mildly manic so long as I never, ever have to suffer depression again.

I had been receiving the 60 mg Latuda free from the pharmaceutical company, so that’s what he had available to give me.  I told him that I believe my new(ish) insurance will cover it with prior authorization so he sent the prescription to my local pharmacy.  When I checked with them it was awaiting authorization.  So for now, I’m still going to be taking the 60 mg without sufficient calories at bedtime, until I have access to the new dose.

After meeting with Brent, I went back to the waiting room until my appointment with Sadie.  It was time once again to update my ANSA and treatment plan.  We went through the ANSA much more quickly than last time, tweaking some ratings here and there.  Several needs went down in severity; none went up.  I still ranked a 4 for level of need though.

For my treatment plan, we dropped the goal of reducing risk of suicide and self-harm.  I’ve been doing much better at using coping skills to deal with those urges, and I’m much more aware of when I’m at risk enough that I need to seek emergency help.  We made some minor edits to the details of the other two goals (improving interpersonal relations and daily living situation), and added a new one regarding increasing my self-esteem.

We also came to an agreement that scares the crap out of me.  In discussing my previous blog post, which I had sent her to read, I summarized the situation with “You are my social life.”  Sadie thought that seeing her less often might encourage me to seek other social situations, and though I didn’t like what she was saying I agreed that in September we could try meeting every other week.  Given what I expect from my work schedule, that may be necessary due to scheduling conflicts anyway.

Sadie reassured me that I could try to schedule an appointment in-between if a crisis came up, and if it were very serious she’d be willing to stay late if she couldn’t fit me in otherwise.  I was reminded that, though I don’t like these options, I can always contact the on-call therapist or go to the emergency room if necessary, and that I have learned numerous coping skills and have supportive friends to reach out to.

Positive, Unconditional Regard

A few days ago my therapist warned me that next week we will have to update my treatment plan and ANSA yet again. I groaned. In my post ANSAs to My Questions, I discussed the first update that was done, and commented “All those needs exploded everywhere”, as compared to the original.  My therapist indicated there might be some improvement this time, but I honestly can’t see where there would be.  I suppose there’s a slight chance that my depression could be considered less severe, given that at the time of the last update I had two back-to-back inpatient stays.  Other than that, I almost expect there to be new needs added, regarding topics that had not previously come up in our sessions.

The treatment plan should be easy to update, and look essentially the same as the last one.  I recalled that the goals from last time were rather long-term, and we set deadlines 6 months away, despite the treatment plan needing to be updated every 3 months.  I suggested that we would just be copy/pasting the information from last time, including the deadlines.

When I got home, I pulled out my records to read through these documents once again.  I was reminded of something on my treatment plan that has nagged at me these past three months.  One of the listed therapeutic interventions was “Therapist will provide positive, unconditional regard for Donna*.”  *Not my real name.

This made me laugh when I first read it, but as time has passed, it has become increasingly less funny.  I get frustrated talking to someone who I know is obligated to be nice to me whether I deserve it or not.  I don’t trust that she actually means any of the positive things she says, because I know she’s not free to tell me that she thinks I’m being an idiot.  In fact, I pretty much assume that it’s all lies, which makes me wonder why I try so hard to be completely honest with her.  In all the times that I’ve confessed to skipping pills I should take, taking pills I shouldn’t take, or otherwise being self-destructive, the closest she has come to expressing disapproval is to say “I support the idea of you taking your medication this week.”

With my previous therapist, it was clear when she thought I’d said something ridiculous.  She could say, “Really, Donna?  Really?!” in this tone that instantly smacked sense into me.  Now I’m seeing someone with whom my weekly struggle is to figure out what the hell she thinks of me.  We have issues come up where I have no idea what her opinion is, and I can’t figure out my own opinion because there’s nothing there to agree or disagree with.

I can’t decide how much of my annoyance here is from not knowing which statements to trust, and how much is from feeling that there’s no possible way any of it could be genuine, because I don’t believe anyone who really knew me would have anything positive to say.  I want to say that I’d feel better if she wasn’t always positive, so that the times when she is would hold meaning.  However, it’s equally possible that I just want her to criticize me because it’s more comfortable to deal with.

ANSAs to My Questions

When I wrote the post Medical Records, I was waiting on a third batch of records to arrive.  I’ve had that batch for quite some time, but never managed to write about what I learned from reading it.  On my first read-through, I laughed hysterically.  For example, at the line “Smiled inappropriately several times during the interview when talking about suicide and substance abuse.”  Gee, you think maybe because I was nervous?!  I’ve been seeing my current therapist since May and she’s still waiting for the day when I’m comfortable enough to hold a conversation without being sarcastic and cracking jokes.

There’s also a note of “laughed when asked to sign a safety contract”.  By this point, I’ve lost track of how many I actually signed, and how many times I laughed and said signing was pointless.  Initially this was because the contract relies upon a willingness to pick up a phone and call for help if having suicidal or self-injurious thoughts.  I knew I would never, ever pick up the phone.  Eventually I did call once, on a lunch break from work, to discuss the fact that I had a strong urge to cut myself.  Did that 5-minute call help?  Actually, yes.  Am I at all confident in my ability to call again?  No, especially considering my failure to call somewhere between nagging suicidal thoughts and the overdose that occurred days later.

Another example of the hilarity was a 3-page Emergency Services Assessment that managed to note not once, not twice, but thrice that I had walked in with a number of suicide methods written on my arm.  This was actually more of an intellectual exercise (or, as the inpatient psych APRN noted, “an academic thought”) than anything else, but the on-call therapist (who I wanted to talk to about feeling stuck with my current therapist) fixated a bit on the content of my “self-decoration”.

I’m also a bit enamored of the phrase “Risk for not taking medications as prescribed.”  I’ve never quite been sure if that is a risk they consider specific to me, or simply a product of statistics about my diagnosis.  At the time this particular report was written, I had a couple of instances of taking leftover pills that were no longer prescribed, but had not yet experienced the 5-day stretch of willfully skipping my medication.  So perhaps they were leaning more toward statistics at this point, although my own stupid behavior would account for this risk assessment in the future.

The most informative portion of these records was an update to my Adult Needs and Strengths Assessment (ANSA).  This assessment has to be updated every 6 months, so this was my second time having it done.  I was curious as to how it turned out, because I was not actually involved with the production of this assessment.  My therapist did it herself based on information from past sessions, because on the date it was due she was too busy dragging me back to the inpatient unit.

ANSA

My reaction to this assessment was a sudden increase in depression.  Each need on the assessment can be ranked 0 = no problems, 1 = history/mild, 2 = moderate, or 3 = severe.  At the time of my original assessment, there were 5 needs ranked at level 2, and everything else was 0 or 1.  I went into this assessment expecting about the same.  I thought there might be a couple more at level 2, simply because my original assessment was based on 90 minutes with a stranger.

Reality was cruel.  Two needs (Depression and Interpersonal Problems) had leaped up to level 3, and I now have a whopping ten at level 2.  So my full list of needs to be addressed (as prioritized by my therapist):

Suicide Risk
Depression
Self-Injury
Other Self-Harm (Recklessness)
Criminal Behavior
Decision-Making (Judgment)
Medication Involvement
Impulse Control
Interpersonal Problems
Social Functioning
Family Functioning
Recreational

I noted on one of my diary cards that I felt sadness because “ANSA update was depressing.”  In therapy I continued that by saying “All those needs exploded everywhere.”  Before my therapist could even try to reassure me, I commented that I knew it was a matter of them being needs this whole time, just that they hadn’t been recognized yet at the time of the original assessment.  Does this make me feel any better?  Not so much.  It doesn’t change the harsh reality that there is so much to deal with in therapy that I will probably never go more than a week without it.