Crisis work operates in a gray zone much of the time, leaving you to rely on your wits and instincts. I suppose the ‘Science of Nursing’ advocates would argue with that but ask any crisis worker in the real world and he or she will tell you that nuance and subtleties drive impression more than depression scores and suicide indexes. But hospitals and organizations need paper tests to demonstrate to their insurers that the people they hire did all they could to properly assess risk, just in case. Because of the subtleties inherent in the work, I find being part of a team a true benefit of the job. When I want to check my observations of subtlety and nuance, and sometimes when I want to unload about the obvious, I have two peers in particular I check it all out with. Viv is my first stop. She has been in this role for many years. She’s what we call a seasoned veteran, like we’re in a war for heaven’s sake!
Viv worked at the specialized psychiatric hospital in North Carter for several years. After many years supporting people in their long-term recovery from mental illness, she moved the mental health unit here at ‘the general’ where people stay only long enough to sort through their immediate problems, or until we transfer to ‘The North’. Over the years, Viv saw people admitted to a bed when they might more effectively benefit from outpatient crisis services, and uninterrupted support from family and friends. So, she concocted an on-call system to increase clinical availability and volunteered to pilot a project where she and three other nurses carried pagers and responded to the mental health crises at the emergency department.
That was ten years ago. Viv’s concept morphed into the emerg department ‘crisis worker project’ about 5 years ago and now we have the flashy ‘crisis program’ I work at, with all its protocols and guidelines. But it all started back with Viv, and she’s literally seen it all. About twice a month, I enjoy a one-week overlap of my shift with Viv’s. Not that I don’t enjoy working with my other peers but Viv and I see most things the same way, including the humorous side of what is going on. The other wise counsel I tap frequently is my supervisor Rudy, also a well-seasoned veteran. Today, Viv and I are both scheduled in the Crisis office and I need to talk with someone about Bridie.
“This can only mean two things…you are stumped or you are pissed.” She laughed as she accepted the cup of hospital Joe I handed her after the Team Leader’s report. I’ve been down this road so many times I know exactly how she takes her coffee – black with sweetener.
“Ha! Neither!” I exuberated back at her. “But I would like your perspective on a very sad situation”.
“Perfect. Come in here and bring me down. Got any happy stories Hattie?”
“Well, I set Amy Brixton up with Peer Support and I haven’t heard from her in about a week”.
“Jinx. Never say that out loud.” Nurses are very superstitious. Again, not in keeping with the scientific approach but ask any one of them and they will all say they rely on ‘feeling’ and ritual in the work they do.
“I know.” I pouted back, exaggerating a frown. “But I do have a sad story to tell you about a young woman who’s going to die”. During the pause that signaled the shift from lighthearted to serious conversation, I set myself in the second chair in the interview room. These chairs are made to be too heavy for someone who is aggressive to pick up and throw, so they are hard to maneuver. Their weight makes it hard to position them so you are facing each other. Therefore, I ended up perched on the corner, leaning forward crookedly.
I laid out the details of Bridie’s situation, reiterating the evidence from the St. Germaine oncology team. Viv realized the gravity of this situation right away. “So, you are going to see her this afternoon? Do you know how the husband is doing?”
“I am seeing her and her husband at 1300”. That’s one o’clock in hospital time.
“I believe I can be a good support.” I added. “I just need to stay focused. I don’t want to start crying or say something stupid, or…well…I already said something stupid”. Viv’s eyebrows rose, just perceptibly, pushing me to explain. “I asked her what she wants, meaning how might I help her during this. She said she wants to live. How dumb a question was that?”.
Viv looked down at her hands, smiled gently and slowly shook her had side-to-side. “Not dumb Hattie, just real. If you have a sense it put her off, then re-wind. I think what you were trying to do is find out where she is at emotionally in this process and she may not even know herself yet”.
“I acknowledged it was a dumb question, like to her, but she didn’t reply. I did say we could start there; start with wanting to live”.
“If that’s where she is at then that’s where you start. Rule number one!” Viv had a multitude of rules number one that shifted depending on the situation. But assessing and starting at the emotional point where someone was is a standard piece of her advice. In practice this means understanding the person in the present moment, appreciating how they see their situation and their own assessment of what and how to change. So many people come to counseling to fix their lives, or actually, more often, to fix the lives of people around them but people are not always aware enough, or they don’t understand themselves or those around them deeply enough, to change how all our thoughts and behaviours shape our own lives and the lives around us.
People can only change themselves; this I know. My job is to find out what and how I can support them to think and act differently. They have to decide to become what or who they want, or to come close enough to what they want to feel contented. In this case, Bridie and I, and Bridie, Doug and I must talk about what is the most important to her. Some people who are faced with death need to have the logistics like wills, funerals and so on shored up from the start. Some people need to reflect on their legacies, or the meaning of their life. Some are too angry or too overwhelmed to face the piles of stuff, more commonly called ‘shit’ in their lives, or grieve the holes where they know in their hearts that the shit should be. Families may be at a different point from the person; the spouse can have work that is miles away from their partner. It is complicated. Messy. But I do know, and I know it because I have erred and pushed for production in the therapeutic relationship, that people can only move forward from where they exist now, not from some future state of mind that they hope to achieve. I share Viv’s most common rule number one: start from where the person is.
“So, she wants to live – that’s where we start. I don’t have the sense that she is in denial or anything about her illness. She seems well informed, even resigned. But I feel like she wants to put that on the back burner and deal with the moment, right now, while she is still alive. I guess I need to understand how I can support her in that”.
“You always just come in here to tell me you already know!”
“Nope, just came to me as I said it out loud. Promise.”
“And, rule number two, how are you?” Even though Viv had a few favourite rules-number-one, she really only ever had one rule number two: get and keep yourself in an emotional place where you can be available, authentic and supportive to the client.
“Well, it’s sad, as I said. But it’s also an inevitability, as Bridie knows. So there is nothing really that I can do to change the outcome”. A stray worry popped into my head. “Do you think this will mess up the database; I reckon death is a big deal in our outcome data?”
Questionable humor is a mainstay for nurses. I know if some of what we said was overheard it could be construed as unkind or hurtful but it’s just a way of coping. I expect the same is true in any profession. I suppose accountants have their own little way of mocking the tax foibles of we the unwashed. In this case, it was my way of lightening the reality that Bridie would die, and she would likely die on our books; my books. I didn’t want to think about it, so I thought about the silliness of the books.
I slumped back into the heavy chair. “It hurts my soul. It’s so sad. This woman is so young and her family is so tiny and it’s so not fair.” Viv reached out and placed her hand over mine. “You can do this. You have an open heart and this is just what she needs right now.”
“I hope you are right” I murmured back. “She deserves a soft landing on the other side.” In our business there’s always someone with a pressing problem to work out or some nascar level steering needed to keep his or her wheels on the road, so to speak. I was grateful that Viv shared her few precious moments of peace with me this morning. I would reciprocate another day, and she knew that. This was teamwork. It was the glue that pulled us into a tight ball so we could roll pretty straight without getting caught up in the snags and pitfalls inherent in the real day-to-day realities of mental health nursing. In theory, anyway. Some days the ball swerved and bounced, as if the gremlins were in charge. But mostly, we kept the game on-side.