"They've already had one judge, they don't need another."

So, I was mistaken about a few things in my last entry. My cohort is actually 8 people (including myself), the rest were students who are rotating in to this facility later in the semester. The 7 people with me will be the same 7 people with me in acute med/surg, which is nice. We get to spend some time together in a more relaxed environment before what I assume will be a relatively chaotic assignment in acute med/surg.

Today consisted of more orientation and no patient contact, which disappointed me. We were told the purpose of this is to ease the transition into the psych setting and reduce anxiety, which in the past has rattled students enough to prevent them from learning anything. I can understand that, but what about the students who want to get right to it?

Having said that, it was an extremely pleasant day. We began by introducing ourselves, describing our previous experiences with mental health (and it's various alternatives), and stating what our expectations for this setting were. Lots of great conversations came out of this, which continued through the day as we walked past crumbling asylum facades and sturdy, state-of-the-art facilities.

The conversations were really the highlight of the day, between the instructor, other staff, the occasional patient and each other we covered a lot of ground, shared a lot of ideas and told a lot of stories.

Something interesting that occurred to me while I was listening to the instructor was the similarity between some of the patient's stories and things I've read about shamanism. Without being too specific, one story involved a person living with mental illness who was shunned by his community. He became depressed and tried to kill himself by throwing himself underneath a heavy moving vehicle. He was "run over", but had no serious injuries or broken skin. He earned the name "speed-bump" because of this, which brought him a measure of happiness because he had never had a nick-name before. The experience may not have completely cured him, but it resulted in some measure of healing.

This sequence of events may seem familiar to someone interested in shamanism, indigenous peoples and things of that nature. A person becomes sick, faces death, and survives unexpectedly. The person is then selected to learn that culture's shamanistic tradition. In various cultures the sickness might be a mental illness, surviving a snake-bite, or being struck by lightening. The idea that a person who becomes ill and through fate or dumb luck heals themselves can then heal others seems to be a pervasive one in many regions. Outside these naturalistic traditions there is still the somewhat gnostic point of view that facing one's own death imparts an augmented view of reality that strips away a lot of the linguistic noise that masks the natures of things. Or else it just makes you crazy. Or maybe both, depending.

Speaking of the social context for "psychopathology", another great tidbit that arose from those conversation was the instructor's observations on the role of the extended family in mental illness. In the midst of a long career in acute forensic psych nursing, she traveled somewhere pleasant and tropical to continue practice for a while in a more idyllic setting. In this place, she knew an agoraphobe who could not leave her house. Rather than treating this as a horrible tragedy of mental illness, the family simply left the children with her when they needed childcare, because she was always home. The instructor said she was the happiest agoraphobe she had ever met. A powerful example of how the social context for mental illness can shape the lives of the people who live with it, and how sometimes a successful thereputic outcome doesn't involve remission of symptoms or "normal behavior".

It was brought up that I would be "good for the system" somehow because...I dunno..I'm outspoken and/or articulate or something. Someone thought I might be good as a delegate for the Union, which "needs people like me". A strange paradox was raised. How did it come to be that Nurses, a group of people who tend to be assertive, highly educated and well-trained, keep getting the shaft when it comes to legislation? The answer, I'm told, is that Nurses as a group aren't very politically mobilized. I can hardly blame them, why -should- they be? They're here to take care of people, let people with other jobs figure out the whys and where-fors...but no, no, that's not how it works. If we don't get in there and shape policy, policy will be shaped for us in ways that will make us very unhappy. I guess that's just how it works. I've been getting my feet wet a little with our local branches of the National League for Nursing and the American Nurse's Association, and that kind of thing seems more my speed, I can't see myself fighting with management over a $.50 raise..I realize those issues are important but they don't motivate me the same way as plumbing the intricacies of practice acts and license regulation. At the very least I can help prepare other people to take on those issues, I think. For now, I'd be happy to just take care of patients.

So, anyway, "forensic nursing" is apparently a relatively new field, although I've met a few people who were doing forensic nursing before it was called forensic nursing. A friend of mine recently told me she got hired as a forensic nurse and I was all like "a what now?". One of the reasons for its surge in prevalence seems to be the growth of the population of people who require forensic nursing care. Forensic nursing involves care of patients who have been found not-guilty of a crime by reason of insanity, by the way. Our instructor, with 20 or so years of experience with this population, had some interesting insights into the field, where it's headed, and how it got here. She described how, in the past, it was easy to get in to a psych facility but hard to get out (the proper way, I mean, this isn't a commentary on the security schema). Today, it's hard to get in and easy to get out, partially because there aren't enough beds. As a consequence of this, beds in inpatient psych facilities tend to be reserved for people who are a) a danger to themselves, b) a danger to others, or c) unable to care for themselves due to mental illness. In effect, people who suffer from mental illness and feel that they need treatment have been "taught" by the system that they must commit a crime to be recognized as ill. No wonder the demand for forensic psych services has been increasing!

During our tour of the facilities, we walked around the greenhouses, where we saw patients working on the flower sale (which is the largest contributer to the patient's fund). At the treatment mall we saw a meditation room, expressive therapy facilities, an impressive physical therapy department complete with gym, an equally impressive library, a beauty parlor and a couple thrift shops, all of which employed patients. I'm hard pressed to identify a single area of the hospitals where patients weren't therapeutically employed (and making minimum wage, a vast improvement over the slave-labor I witnessed in the mental retardation racket). We didn't get to see any actual units today because of the hardship tromping all 10 of us through the living areas would cause, but we saw the lobbies of the buildings housing the medium and maximum security forensic units (we're assigned to the medium flavor), the general units, the TBI (traumatic brain injury) and ABI (acquired brain injury) units, the women's shelter and various facilities for patients and staff alike. It's a big place! We got a lot of walking in, filled with pleasant and interesting conversation.

The use of the phrase "patients" caught me off-guard, since in our other sites we had been trained to say "consumers" or "clients" variably, but here the word is "patients". I'm not one to quibble (about this anyway), as long as it doesn't offend -them- I'm game.

Towards the very back of the facility we were shown an abomination of a juvenile detention facility, designed as if it were meant to house factory-farmed chickens or something. Apparently it was built in secret and housed juveniles in it's stark, windowless desolation until one of our instructor's colleagues called one of the child-protection agencies. The appearance of the building from the outside was enough, it would seem, as it's now slated to be dismantled, and the children imprisoned inside are going to be relocated to smaller facilities integrated into their home communities. A no-bid pork-barrel project, we're told. Pay attention, we're told. If we observed our leaders and captains of industry as intently as we do our mentally ill, we'd be a lot better off, I'd wager.

Everyone we met in our meanderings was pleasant, welcoming and friendly, staff and patient alike. Everyone seemed very interested in recruiting us, and it's definitely tempting. I just can't resign myself to working towards retirement just yet, though. If I was, this place would be top of my list, for sure.

At the end of the day, the instructor "committed" us to four directives. It was a sort of informal swearing ceremony, where we raised our hands and swore that 1) we would treat the patients well (because if we don't treat one of her patients well, she'll find out and extract revenge) 2) that we treated our fellow students well 3) that we treated the staff well and 4) that we do something good for ourselves for one hour for every clinical shift. We have to back this up by writing an additional journal entry about this hour. The way this night is going I don't think that's likely to happen soon. My car broke down and I'm stranded with school in 6 hours.

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