MANAGED CARE | Jennifer Anderson
When she told me she’d walked to the bridge late that afternoon, I didn’t press for details. It was not best practice for the nurse to probe. She’d already rehashed the events to the psychiatrist and therapist on admission. I don’t remember if she’d planned to jump or if she’d climbed over the guardrail after replaying the events of her high school day. I do remember how she explained to me her decision to fall backwards, eighteen feet to the rocks below, because she didn’t want to see the ground rushing towards her face.
It was a miracle she was alive, walking around the gymnasium in the psychiatric hospital with an incomplete fracture of her cervical spine, rating her pain zero out of ten. Though she’d been cleared of a neck brace, I couldn’t help but think about the cracks in her vertebrae, the vulnerability of her adolescent spine. When the football sailed lengthwise across the gym, towards the corner where she stood with her back to the ball, she neither turned nor flinched. I did. The pigskin missed her by inches before tumbling end-over-end past her feet. In a tone clipped with fear, I instructed the teenage boy to warn his peers if a wayward ball was headed their way. Especially hers, I didn’t say. I softened my voice and suggested she not turn her back to a ball in play, said it would be terrible to get hit in the head. She looked at me, her countenance placid, her brown eyes bored, and said she wouldn’t care if she did. She turned and followed me out of the gym.
The Crisis Prevention Institute, equipping caregivers to recognize and safely address patients in crisis, defines Rational Detachment as the ability to stay in control of one’s own behavior and not take the behavior of others personally.
I don’t remember how we all ended up on the floor. My co-worker, one of the best in crises, shared my approach to delay going hands-on when a patient was in distress. Sometimes running down the halls and tipping chairs was sufficient release. Though this ten-year-old boy denied any history of abuse, his vigilance and reactivity said otherwise. I can’t recall the inciting event that upset him. Sometimes there are few outward signs. When he began to punch his face, my co-worker and I moved toward him and the three of us became entangled on the floor. I held his flailing arms. My co-worker slipped his hand beneath the boy’s head. He was trying to slam his skull against the linoleum, his face red and contorted in the trying, begging us to kill him, this ten-year-old boy who played with toys and still believed in magic, in superpowers, in spells. They were getting younger and younger, these children wanting death. For the second time in two decades as a nurse, I failed to restrain my tears.
I don’t remember how long he took to calm, when all that self-hatred and rage slithered off to wait and hide, how much he was willing to debrief or not. I do remember that we offered him something to eat and drink, engaged him in conversation about his favorite Power Rangers character, then printed more coloring sheets before walking him back to group. I apologized to my co-worker about failing to remain detached. He removed his glasses and wiped his eyes.
According to the Attachment, Regulation, Competency (ARC) Framework, Caregiver Affect Management involves a foundational building block of attachment wherein the caregiver recognizes and regulates her own emotional and physiological experience so she can then attune to and support those in her care.
The fifteen-year-old girl was medically stable; a voluntary, though reluctant, admission to the psychiatry unit. It was the time of year when the days were filled with more darkness than light, sometime in the hours between dinner and bed. Not that she’d eaten much since the doctors pumped from her stomach what they could of her mother’s painkillers. You’d think hospice would have removed them from the house.
One rectangular table and five chairs crowded the small interview room. She sat down in the furthest seat and crossed her arms. Her tall father had the good looks of waning youth – tan, lean, muscled, strong. His baseball hat shadowed his eyes, narrowed and darkened, as if they’d already seen too much. They had. He’d watched his wife, the one in the ground, deteriorate in a matter of months. They’d been together two-thirds of their lives.
The younger brother shared his father’s likeness, though none of his anger, which lurked, quiet, in the cage of his body. The boy sat patiently, hands tucked under his legs, fixing his eyes on the table, the safest spot to look. I explained the stack of legal paperwork before passing the papers first to the daughter. She signed them in haste before shoving them towards her father, her eyes daring him to look at her while he scribbled his name. He wouldn’t. I described the estimated length of stay, daily schedules, the roles of the interdisciplinary team who would prescribe medications, lead group therapy, facilitate a family meeting, create a safety plan. No one had comments or questions. Grief was the loudest, largest presence in the room.
After her family left, it was just her and I in the interview room. There were questions nurses asked only after a parent or guardian had gone. I typed her responses into the computer, assessing her levels of anxiety, depression, hopelessness, safety, watching and listening for cues about when she wanted to elaborate and when she didn’t. She talked about how she stopped having people over to her house, that nearly every night her father came home drunk and bloody from the fights he’d start at the bar. His mother had recently moved in to help. Some nights he’d stay at his girlfriend’s house, a nurse in another town. The father who fights, the daughter in flight, the son who freezes. I typed, pausing to wipe the tears from my face, unable, for the first time in all my years as a nurse, to keep my feelings inside.
After finishing the admission and hospital tour, I brought her belongings to her room. A photo stuck out from between the pages of her book. She pulled it out and showed me. Her mom had kind eyes, a pretty smile. I told her that I imagined her mom’s absence was like a fire that went out, pulling the warmth and light from every room. Her eyes met mine. Yes.
It was near midnight when I left the hospital. I was grateful for my thirty-minute commute. When a song came on the radio about a man who says he’s fine when he’s not, about the empty place at the table where she used to sit, about how he only sees her when he dreams, I cried all the drive home.
Distress Tolerance, one of Dialectical Behavioral Therapy’s four skill modules, involves Crisis Survival Skills to move through instead of worsen distress, and Reality Acceptance Skills to prevent suffering and increase personal control.
His was the first patient’s wake I’d ever attended. I wish it were my last. He was admitted to the hospital after he cut the phone line when his family left the house, then started the engine in the garage. His mom returned home to pick up something she’d forgotten.
He loved four-wheeling, hunting, dirt bikes and sugar. Winsome, foul-mouthed, handsome, hilarious. Sixteen. I still remember his room safety check. He’d managed to flatten half a dozen soda cans so they were hidden behind the BMX posters he had taped to the walls. When I loosened the paper from the ceiling, candy wrappers rained down all over his bed. I laughed. He was the reason the hospital would later ban posters in patients’ rooms. I asked him why he’d hidden all the wrappers – the aluminum cans, considered contraband, I understood. He told me he’d read in the teen handbook (he’d been bored) that he wasn’t supposed to have candy on the unit, somehow it had slipped by staff, and so he hid the evidence to keep from getting in trouble.
Not that he avoided trouble, in or out of the hospital. Drinking, skipping school, fighting with his father. He lingered in the halls, resisted going to bed, needed frequent reminders not to swear. I found it hard to redirect him with any seriousness because his humor was so disarming. A great way to deflect and avoid. I learned from him, and would have years to practice, that there is an art to addressing behavior, that all behavior communicates something, that some images will stay with you always. Like the BMX posters and his easy grin, the candy wrappers scattered across his narrow hospital bed, his open-mouthed coffin, the tie and starched collar pulled high and tight to hide his neck.
Joyce University of Nursing and Health Sciences identifies the four stages of compassion fatigue, often experienced by caregivers regularly exposed to significant stress and trauma, as the Zealot Phase, the Irritability Phase, the Withdrawal Phase, and the Zombie Phase; suggested antidote: improved self-care.
Jennifer Anderson worked for twenty-three years as an inpatient psychiatric nurse for children and adolescents. She holds an MFA in creative nonfiction from Antioch University and begins her study of narrative medicine through Columbia University's C.P.A. program this fall. Her essays have appeared or are forthcoming in The Missouri Review and Iron Horse Literary Review. She lives in Wisconsin with her husband and their three teens.