Not long ago a patient attempted to jump out of my office window. No surprises there - this is a deeply disturbed young woman with a long history of suicidality who is a frequent flier at the local hospitals. What the situation points to is that, despite all the soft science chatter about theory, "how-to's" and take aways, this work is serious business and, if you're going to sign up, you'd best have your tools in order.
In the more than 25 years that I have done this work I have had occasion to talk down dozens of suicides, break bread with gang members, physically restrain patients for hours on end when two and three administrations of Thorazine wasn't quite doing the trick, sit with clients who have openly brought weapons to their session, and even waited patiently outside a classroom while a 10-year-old finished up with a (very expensive) tantrum after having broken the teacher's nose.
I've been yelled at, spit on, hit, insulted, threatened, stalked and have even endured the occasional death threat. I could go on. The point is you that never know what you're going to get - even within the confines of an upscale suburban office -- and often no amount of classroom training, book learning or even field experience can completely prepare you.
Last night's session began as a routine exploration of some attendant sadness, concerns about the future, some boy stuff, some family stuff and then promptly and quickly devolved into an uncatalyzed, full blown psychotic episode.
No worries - you could see that coming and you knew where it was going - been here before with her. The leap to the window was new as it was abrupt and (read closely) unexpected. She usually "prepares" you with cues and signals as it is part of her manipulation. Last time it involved drinking anti-freeze. Regardless, expect the unexpected. Now, this is where the "tools out of the chair" come into play and we find out what we're made of.
A quick foot sweep to put her back on the couch. Close the window. 911. Keep the earpiece on. Half-basket hold while we're waiting. All good. Not so much.
I'm a fairly serious athlete - 170 lbs. of pretty solid, compact muscle, even at my age. I'm certified in TCI restraint techniques (the industry standard) and have more than 35 years of martial arts training that includes locking and holding disciplines like Aikido, Ju-jitsu and Chin Na Fa. That's nice. It's not worth much when you're dealing with 110 lbs. of psychotic teenager.
The half-basket hold on the couch transforms itself into a full basket hold on the floor. Regrettably, I soon discovered that my patient has double-jointed shoulders (remember that unexpected thing?). Despite all of my training and self-satisfied confidence in my own athleticism and physical strength, this child squirmed and wriggled and almost managed to stand up with 170 lbs. of grown man clinging to her! Damn. Oh, right...psychotic episode.
You can restrain her, but you can't talk, and you're not even certain that she's hearing you - so much for those clinical skills. You can't get to the phone to tell emergency services to hurry the hell up -- earpiece or not - because your primary concern is the patient's safety and you can't let go, even for a second. You can't call out because of patient confidentiality, and who'd want to help anyway? You are, quite literally, alone in a room with a crazy person. You breathe, and you wait.
Emergency services showed up and did a bang up job. They got her on a stretcher, handcuffed her, restrained her and got her off to the ER -- again. Sedated, evaluated and medicated, she'll do a tour of the psyche ward for a few days and then be right as rain. Such is the nature of the cyclic schizoaffective.
Back to the chair...paperwork, police officers, nurses, committal papers, calls to the mother and grandmother, waiting for the family to show up at the ER. All in a days work. Ready?
Know your patients. Know your ground. Know your tools. Keep your phone close at hand. Understand what you're getting yourself into with every case.
Most of all know your strengths -- and know your limits.
© 2009 Michael J. Formica, All Rights Reserved
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