Saturday, August 27, 2016

Doing crisis

Picture having an encounter with someone at a hospital – either in the ER, in “psych hold” or on a medical unit, to determine within a few minutes to half-an-hour if the person is suicidal or homicidal or dangerously incompetent. This is the job responsibility of the “emergency services clinician” or “crisis interventionist” or “mobile assessor.” I’ve seen – in Ohio, Colorado and Nevada – two species of this job rooted in different agency funding structures, but also in different philosophies, and maybe in different moralities.

One clinician, working at a community levy-funded mental health center, is a traveling crisis therapist. He sees a person at a terrible moment of truth and wants to be the light of help. He wants to be the first eyes that really see her, the first absolutely cleared-out container for her lifelong pain. And he wants to be the giver of encouragement that is based both in the patient’s unique life and in deep psychological knowns. I remember being there. The worst results might be that my empathy is silently laughed at by a patient who only wants to manipulate his way out of the hospital; and the thought that I’m spending a lot of time (and agency money) on someone I’ll probably never see again and who ultimately reduces to a “stay or go” determination. The best results are very, very good: I’ve really helped a skinned, gutted, depressed, lonely, desperate person feel survivable again.

The other clinician, working at a for-profit mental health center, brings to each encounter the goal of psychiatrically hospitalizing as few people as possible, along with the unspoken theme: “Disprove my cynicism.” The worker waits for the tripwire to jiggle when the patient contradicts himself, lies about his drug use or story-tells his overdose (“he actually counted forty-three Xanax and twenty-one Depakotes?!”; “There is the tox screen, you know”), obviously “malingers,” just wants a bed for the weekend, sounds too chatty to be suicidal, agrees too zealously about the importance of therapy and accepting follow-up services. Often the wire is already tripped because the man or woman is a “frequent flyer” ER visitor, a hospital-to-hospital vagabond who knows the system and all the right terms to say. You recognize this individual and you’ve already known he is a more rugged, perverse survivor than you are. A good clinician of this ilk will still, hopefully, detect a different tone this time, a different quality of seriousness, and will this time facilitate a hospitalization. Mostly, though, she feels omniscient enough to dole out thumbs-ups or thumbs-downs efficiently, based on instinct and a simple internalized checklist of factors and dog whistles. It’s amazing the skills a person can become proud of.

My point or grievance is that psychology has become – very paradoxically almost universally a superficial approach to human life. We believe that the outer adult or adolescent coating is the person. We believe that all the spoken meanderings in his head are substantial – a product of something adult in him – when they are as neurotic and child-stuck as his feelings, his obsessions, his motivations. We witness the toxic spillage of arrested development in all the words of Donald Trump, and we don’t realize this is an infant driving a tractor-trailer. We believe that simple “cognitive” techniques can make a person happy, that we can “choose” who we want to be, how we want to feel.

And at a bedside in the hospital, a master’s or doctoral-level clinician can see distress in the simplest terms. “You’re not going to kill yourself today.” “I’m referring you to our outpatient clinic.” “Your husband and sister-in-law have agreed to stay with you tonight.” “Your parents will be removing all the knives and sharps from the house.” We take this opportunity to sit down, throw away time, and be two people having one of the most important conversations in the human play, and we skip it as if meaning were lint. We don’t see the living or dying beneath the life and death decision.

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Comments are welcome, but I'd suggest you first read "Feeling-centered therapy" and "Ocean and boat" for a basic introduction to my kind of theory and therapy.