Sunday, February 21, 2010

Working The Night Shift

Talking about crisis intervention this week reminded me of my salad days as a social worker.

Back in the early '90s, while I was in graduate school, I worked on the Dallas County Mobile Crisis Team. There were a half dozen of us hand-picked to staff the team. We were based in the ER at Parkland Memorial Hospital. From 6:00 PM to 2:00 AM seven days a week, working in teams of two, we would be dispatched to handle psychiatric crises in the community. Our calls came primarily from the police, psychiatrists worried about patients, local crisis lines, and from the clients themselves.

That was a time when Multiple Personality Disorder (now called Dissociative Identity Disorder) was in high vogue. It was being diagnosed everywhere--mostly by inexperienced counselors and naïve therapists who were frankly thrilled to be able to say, "I have a MPD patient I need you to check on." At least once a week, we'd get a call to go talk to a so-called MPD patient.

Note: While the new terminology is DID, at the time of these incidents we used MPD, which is what I will use here.

I'm going to be blunt. Although I saw a lot of people who carried the label, I never believed any of them were actually MPD.

I am not saying that DID/MPD doesn't exist. I believe it probably does. However, it is a rare and an extreme defense mechanism created out of extreme circumstances. Anyone immediately identifying herself as MPD to strangers became suspect. When a woman greeted my partner and me at the door at 1:45 AM mouthing baby talk and holding a teddy bear with a pair of scissors sticking out of its belly, it took enormous self-control not to sigh.

Over time, I ended up as the lead partner on most of the MPD calls. I took a one-size-fits-all approach to anyone self-identifying as an "alter," depending on whether she was alone in the house or with someone else.

And before I'm accused of being sexist, all the MPD calls I handled were female. I am not saying male MPDs don't exist; I believe they probably do. We just never received a call from a male.

If the IP (identified patient) was alone, I had a routine that, boiled down to its essence, had these components: "I understand you called your counselor and said you were going to hurt yourself tonight. Tell me what you were thinking that made you say that? I'm not a psychiatrist so I'm not smart enough to understand (or discuss) your diagnosis. My only job is to keep your body safe tonight. I don't care who inside the body takes that responsibility, but someone needs to do so. If not, we're going to have to bring you to the ER at Parkland. So, what can you do to keep yourself safe tonight?"

Notice I stayed clear of "feelings" and spoke only of "thinking" and of the specific task of "staying safe tonight." My job was to keep her alive and well until morning. After that, keeping her safe became her therapist's job.

Of course, it was rarely that easy, nor that straightforward. We'd spend time building rapport, being empathetic, and making sure the IP was not psychotic, under the influence of drugs or alcohol, or actively suicidal. Then we would work toward assisting the IP to develop a plan to get her safely through the night.

Throughout these interviews, my partner and I were almost always treated to a dazzling display of the IP employing different voices to ask us "Who are you?" as though she were seeing us for the first time--even if we'd already been there for an hour.

We never reacted to the switching of alters. I always called the IP by her "real" name and continued to ask the same questions over and over: "What usually works when you are thinking of taking pills or cutting on yourself?" and "What can you do tonight to stay safe?"

Basically, we just endured until she got tired of our company (or until we got close to the end of our shift).

Either we'd extract a promise from her not to hurt herself, or we'd call the police for escort to the ER. Not counting the patients who were actively psychotic or dangerously high on drugs, whom we always transported, I think we may have actually transported four women during that two-year period. Usually my saying it was time to call the police for transport was enough to convince the IP we were serious. Almost always, some "alter" would suddenly emerge to volunteer to protect the body. When confronted with going to the ER, the lady with the teddy bear and scissors who had been threatening to kill herself for thirty minutes actually said, "I can't go to the ER. They'll keep me for hours, and I'm scheduled to have lunch with my mother tomorrow." (!!!) She saw no dis-
connect between the statements of "I'm going to kill myself tonight" and "I'm having lunch with Mom tomorrow."

I said earlier my one-size-fits-all approach varied depending on whether the IP was alone or had company. Surprisingly often, we'd find a boyfriend (never a husband) eager to talk about MPD. In those cases, the IP usually was unwilling to talk to us. Instead she'd run through her repertoire of alters whom the BF was eager to help us identify. "This is Suzy. She's only twelve. Peggy is twenty-six, and Candy is four."

I'd resist the impulse to roll my eyes. Instead I'd say, "Well, she's lucky to have you. Most guys would get pretty tired of all this drama all the time."

In every single case, the IP immediately switched back to her "core persona," looked around the room and asked, "What happened? Who are these people, honey? What are they doing here?" At that point she was as eager for us to leave as we were to leave, so obtaining a promise to stay safe was easy.

One night as my partner and I were returning to the ER (alone) in our van, I said to him, "Why on earth would any guy put up with all that nonsense?"

Eddie grinned at me and said, "Probably because he gets to bed a different woman every night."

Working on that crisis team was some of the best training a social worker could ever have. We dealt with every diagnosis in the book (including schizophrenia, bipolar, major depression, obsessive compulsive disorder, antisocial personality disorder, and every form of drug and alcohol abuse).

We talked to patients in homes, in shelters, in hospitals, in police stations, on the street and in boxes in fields. I'm happy to report that, in over two years of calls, my partner and I never had a patient harm him or herself after we left.

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