It took the lion’s share of the morning to sort thought the practicalities of the situation with Rick and how to manage his transfer, while safely and effectively providing care until that time. Dr. Roger Laskin was the psychiatrist we ‘recruited’ to complete Rick’s assessment. Roger had been around the block more than once and he was the perfect guy to get to the bottom of this conundrum. Also, he had worked over at The North, so he had a better idea about their forensic unit.
The police were prepared to lay the charge of ‘utter threat’ but they were reluctant to proceed based on their concern about Rick’s suicidality. Roger’s assessment could not rule out this risk. There was a special mental health court in the city that could turn these decisions on a dime but here in our small town those wheels turned much more slowly. And this delay meant Rick would either be in the local jail until a judge laid eyes on him, or home on his own recognizance. The officer I spoke with was pretty sure jail was the more likely option, bringing everyone back to risk of suicide.
Roger made some calls. The forensic unit at The North could accept someone on a Form 1, especially since there were charges. The police would apprehend him here and complete the transfer. The only fly in the ointment now, so to speak, was informing Rick and mobilizing resources to make it all happen. I had kept my new Team Leader friend Kim apprised of the negotiations along the way. As Rick had become more impatient about a resolution to his situation, Kim had become more concerned about how this would all go down.
Without ado, Kim had taken the proactive move of deliberately assigning new folks arriving in emerg as far from his bed as possible and had gradually been removing throwable objects or potential weapons. She had arranged for Security to be immediately available. I thought she had done a great job and I told her so. As it turned out, the police had a particularly calming influence. Three officers arrived at about 1145. Kim and I kept our distance. Rick listened to their explanation. He spat a few foul oaths then wordlessly accepted the handcuffs required by police. His uneventful departure brought an intense sense of relief. “Thanks Kim.” I said to the new Team Leader after it was over. “I feel a lot more comfortable dealing with someone who’s raving than such an angry person.” I noticed a tremor as Kim reached out to steady herself into a chair behind the care-desk. “You Okay?”
“I will be.” She replied. “This is the first time I’ve done this, up close.” Reflexively, she took a deep breath. “It’s a big responsibility.”
“Yes it is.” I agreed. “You handled everything well. I was impressed by the way you swept the area around him and lowered the risk. That was some cool thinking.”
“It was, wasn’t it?” She smiled; proud of her work. “I don’t know how but I remembered that from crisis intervention training we had….mmm maybe two years ago. It sat in the back of my mind until now.”
“Funny how we store stuff up ‘til we need it.” I smiled back. “If you like, I can sit here and manage the phones and direct traffic for a bit while you go grab a cup of tea.” I offered.
“My break is coming up at 1200 anyway. Thanks Hattie.” She stood with more assurance but before she walked away she added “Thanks again. I learned a lot today.”
When I arrived back at our crisis office, Karen was on the phone but she made the gesture of ‘sit right here and don’t go anywhere until you tell me what’s been going on’. It was a complicated gesture but I understood and heeded it. As it turned out, Karen’s morning had been relatively light. She was just finishing off a phone conversation with someone who had left a follow up message on our machine. Well, not our machine anymore, our phone system. When she had arranged an appointment for the person on the other end of the line and confirmed their contact information, she hung up and turned to me for details. These I easily provided. It was important to rehash such episodes with a peer. First, it always gave us ideas about what we might do the next time. But also, in the re-telling, we get feedback to allay our fears and worries, mostly worries about aggression. I also had a chance to sing the praises of Kim. Praises that escalated when I logged into my email and found the notice from the incident report system correctly indicating a level 2. I contributed my notes electronically and added Kim’s name and her actions in the section noting ‘what went well’. By now I felt I’d earned my luck break, so I took it.
It was a glorious and sunny day. I pulled on my parka and went for a walk. South Carter hospital was appropriately nestled at the South end of town, in an older residential neighbourhood. Some of these homes had been around since the sea captains and timber barons ran the community. The sun was so warm I unzipped my jacket. It felt like Spring was officially here. This realization drew my mind to baseball and it was a very short leap to Bridie and her plan to celebrate her son’s birthday at the game May fourteenth. The Easter weekend was coming up and after that their adventure would be about three weeks away. I made a mental note to call Bridie this afternoon and check in. Rosy-cheeked and full of energy, I returned to my duties. Well, my first duty was to bolt my sandwich.
After lunch the rest of the day unrolled smoothly. Rudy dropped by to get filled in about the incident this morning. He seemed in good spirits, hanging around after my report to tell war stories with Karen and I. Funny how we all do that after an incident. And it’s interesting how experiences of risk make us laugh after the fact. We are much braver people in retrospect. These precious moments drew us closer as a team. It was a luxury I realized the nurses in emerg didn’t have. This wasn’t a problem I was prepared to tackle today but I stored it in the back of my brain for another time.
My last appointment was the no-show from last week. She had responded to one of my messages and agreed to see me today. In our very brief conversation on the phone, Dawn confirmed her need was not urgent; this was a long-term situation. She denied being actively suicidal, although she endorsed frequent thoughts. She filled in the blank about her treatment history. Dawn had been in our inpatient unit four times in the past five years, each admission she described as “awful”. She had no wish to return. I presumed this contributed to her guardedness. I felt a small twinge of worry, which motivated me to start making calls to her various numbers. I could only leave messages. Five minutes later, when I heard Farrell singing and saw the display with one of the last numbers I dialed, I breathed a sigh of relief. It was Dawn. She had fallen asleep and was running late. She would be here in twenty minutes. Ordinarily, my shift would be finished fifteen minutes after she arrived but after my wonderful walk in the warm Spring sun I was feeling generous.
Dawn arrived a half hour later, apologetic. She didn’t look like she has just woken up, in fact her hair was nicely pinned up and her clothes meticulously ironed. She seemed alert but maybe not so eager to make new friends. I began the usual drill of confirming her demographics and having her sign the appropriate paperwork. I hadn’t had a chance to retrieve her previous file so I asked her to fill me in on the highlights of her history. She provided a concise reiteration of the information she had provided on the phone: some risk of self-harm in the past, not immediate; some misuse of drugs and alcohol and a history of childhood sexual abuse. “Sounds like none of this is new to you.” Dawn nodded. “So why call now? Has something changed?”
“When I called I was having an anxiety attack. It happens now and again. Mostly I can manage it but sometimes I just need to hear someone else say I will be ok. That’s about it.” Her explanation was too neat. I needed more detail to find the real bits.
“How do you usually manage it?’ I used her words to get her talking.
“I try to avoid it. Mostly I try to avoid any situation that gives me anxiety.” And she paused again.
“And how do you avoid situations that give you anxiety?” I presented my quizzical face.
“I stay away from people.”
The pleasant effects of my sunny lunchtime stroll were slipping away. I sat forward in my chair, planted my chin in my hand and waited.
“I avoid people.” She reiterated. “I don’t answer my phone. I don’t answer the door. I don’t go out. Sometimes I stay in bed all day.”
“How long have you been living like this?” Her disclosure had earned her another question.
“I’ve had anxiety all my life. I used to drink a lot more; that brought me out of my shell. I’ve been in my place for six years now and I’ve never really gotten used to living alone, even though I prefer living alone.”
“Tell me about the anxiety. What does it feel like?”
“It feels like anxiety.” She revealed a slight but obvious impression of impatience.
Recalculate. “I ask that because sometimes when people experience a long history of anxiety they lose track of what it feels like to their body; they just get used to reacting to it because it is so overwhelming.” It was true. So many people were unable to actually describe their experience of worry, or the more clinical nature of anxiety. It made it more difficult to tackle when it remained a nebulous threat. When no further detail was forthcoming, I helped her out. “You know like does your heart race, do you feel light headed….”
It was time for a different tack. “Dawn, when you have been admitted to hospital before, was it because you were anxious?”
“No.” was her immediate response. Followed by “Yes.” Behaviorally, she was getting edgy. She crossed and re-crossed her legs and it looked like she was wringing her hands under the table.
“Hey Dawn.” I said gently. “Something is going on for you. I know its been going on for a long time and I won’t promise we can fix it but maybe if we work together you can manage it a bit more comfortably.” She visibly tensed.
“I will not go back in the hospital. I can tell you this…” Her voice was rising. “…being locked up didn’t help either. I never shoulda come here…” She stood abruptly. I did too.
“Dawn. I have an idea.” She stopped and looked at me, her eyes filled with terror. I felt guilty about my impatience. “Dawn, sit down a sec and let me give you a minute to gather your thoughts.” I was buying time, wondering what Viv would do.
I sat back down as a signal to her to do the same. Miraculously, and with all my gratitude, she did. “Dawn, I agree that the hospital is not the best place to work on the kind of problems you describe.” She drew a long breath. “But…” her fear returned. “But it is a place where you will be safe.” I noticed her running her right thumb rapidly up and down her fingers, as if they were too hot to touch. “I know you are freaked out right now but are you safe?”
She paused for at least a minute before she answered. “Yes. I am safe.”
“Bear with me for a bit longer. I just have a few more questions and then I think we might try something different. Not admission to hospital. I would like you to come in to meet with me every day this week and lets see if by the end of the week we can create a plan that might bring you a little more comfort.” She continued to stare ahead.
“Dawn?” I really wanted to engage her.
“Okay.” Was her only reply.
“Let’s start with this: how did you muster up the courage to come here today?”
“Ativan.” Not an unusual strategy for folks with intense anxiety.
“3 tabs.” Well now we hit less than usual. Three tabs was a fair whack of antianxiety med but she didn’t look over-medicated so I was prepared to entertain it if it worked. “Well, it worked. Do you have enough to last you for a few days while we get started…if not I can arrange for one of our psychiatrists to look at your meds….what other meds do you use?” I was almost reluctant to learn more knowing it might ring some alarm bells.
“I will bring all my pills with me tomorrow. Right now, I have to go. I am safe. You don’t have to worry. I have lived like this for a long, long, long time. I can last another week.” Before she took her leave, Dawn turned and looked me square in the eye. “Thanks. See you tomorrow. Same time?”
At the risk of disrupting our apparent agreement, I said, “Can we aim for 1230?”
Before her small shadow had disappeared I called after her “I will call to remind you.” Now, how was I going to document this? Sometimes a session starts with a prayer; sometimes, like this one, it ends with a prayer. I had to trust Dawn. She had lived with these experiences for many years. I had to trust she could live through them for one more day. But I would definitely retrieve and review her file before we met up tomorrow. Damn. I thought to myself as I readied to leave for the day. I meant to call Bridie. Maybe emerg would be quiet in the morning and I could do it then.