Formulating formulation

As a CPN I am frequently reminded that we provide episodic care, that those on my caseload should be recovered to the point of no longer requiring secondary care within a desired number of sessions. Now that is a lot of pressure on both me and the service user, with an overwhelming feeling of failure when we don’t manage that. I sometimes think we have gone beyond austerity and that this is me simply applying a dressing on the wound until the person is re-referred back in to the team. I don’t want that, I don’t think any nurse wants that, we want to walk side by side along a journey of recovery then wave the person we have nursed off into their future stronger than ever.

We CPN’s all work in different ways but I think despite knowing the time pressures it is impossible for me to walk into a persons home and say ‘Hi my name is xxxxx and could you please start engaging in this treatment plan I think is right for you’, the person and I need to build a therapeutic relationship. Maybe one or two sessions whereby we get to know each other a bit, where I tell them their dog is cute and ask them about the pictures on the fireplace, if we share a love of reading I may recommend a novel to them. I need to put them at ease, they need to be able to trust me if I want them to feel comfortable to off load their deepest and often darkest thoughts.

So the first session or two are ‘get to know you/build a therapeutic relationship’ type sessions and during the time over these couple of sessions I would try to build up a picture of risk and document this on the FACE risk which is the tool my trust uses, I’d get them to complete a consent to share document so we both know and understand where the restrictions lie. Get the basics done from a documentation point of view.

Next thing I probably ought to document is care plans but I am of the mindset that we can’t produce a care plan until we have a decent formulation. How can we decide a plan of treatment if we aren’t even 100% sure where the main issues are?

I use the 5P’s formulation which includes considering:

  1. Presenting problem(s)
  2. Predisposing factors which made the individual vulnerable to the problem
  3. Precipitating factors which triggered the problem
  4. Perpectuating factors such as mechanisms which keep a problem going or unintended consequences of an attempt to cope with the problem
  5. Protective factors

It is important for the person to know that what is important to them is important to me. As you may have noticed if you read my last blog was that I plan on having a few sessions of talking therapy myself to consider my current all encompassing worry that my work place and colleagues will connect my illness and my competence. As I plan on only having a couple of sessions to talk it through I thought it would save time if I arrived with my formulation already done… so because I am living the rock n roll life I thought I would make a start on it tonight. A Saturday night on formulation.

Whilst sat wondering if there was anything else to add to my precipitating factors list I began to realise that maybe I am more than a list (who knew?!?!?). We are all more than a list. Now I am not saying here that the 5P’s formulation is not a great tool because it is a fab way to capture what is sometimes a difficult narrative to grasp in the minimal time we as clinicians have. I always do the 5P’s formulation with the person but attempting to produce my own made me acutely aware that maybe I need to consider how I capture this vital background in a less formal and more human. I was reminded also this evening how emotional it can be to see all of this written down in black and white, reminded not to underestimate that because these formulation sessions are not ‘therapy’ as such they can still be difficult for the person I am working with and depending upon their level of distress and how much they are able to tolerate may take more than one session to complete.

It is not until now that we can even begin to produce care plans. Again this is something I do with the person I am nursing, in a session. it makes sense to co-produce them, why would someone be invested in care done to them rather than care done with them?

So now if we consider that on average with a caseload of 35 people are seen 3 weekly and taking just the above into account at roughly five sessions, which in itself is conservative as some people may take much longer to engage then this is around 15 weeks, add a couple of extra weeks for annual lave of the CPN and without any other hiatus this is four months before any actual therapeutic intervention takes place. Those four months will hopefully have helped to build trust and to have aided the person to have hope once more.  They certainly aren’t wasted weeks but they don’t fit neatly with the episodic care model as comfortably as most trusts would like. Whilst I absolutely agree that the days of the Community Mental Health Team CMHT are over and the new player is the Community Treatment Team CTT and this is a good thing however (you didn’t think you would get away from me without a however did you?) for some people the rational unbiased support and the sharing of hope that comes with that is vital and is treatment in itself. Lets never minimise the role of hand holding, sometimes we all need our hand held to get us through.

Too often we declare people as ‘treatment resistant’ when actually maybe we just need to rethink the treatment we offer rather than absolve ourselves of guilt by referring to our episodic model of care. Illness is not always neatly episodic. People are not episodic. If we explore the formulation with a solution focused approach then this in itself could be the most appropriate treatment going. I will never rush a formulation, strange that it took producing my own in a bid to save time to realise that.

That sounds like fun. Mania.

But mania, that’s brilliant isn’t it? That’s the fun part. The compensation for the horrific, crippling lows of bipolar disorder. Let me set that particular record straight; this episode has not been fun.

Getting there ‘the ascentthat felt fun and coming back down ‘the descent’ well that journey was pretty fun in parts too. The middle bit though, not fun at all. I felt afraid, terrified even and at that point I was no where near even having to face the embarrassment and destruction I had caused.

I do remember feeling afraid of my own brain, it was almost like I had several brains and each of them was stuck on a speed I could no longer keep up with like a dysfunctional record player with the vinyl record being unsure if or when it will ever stop.

Just a week prior to this my brain going faster held a mild irritation that everyone and everything seemed to be going particularly slowly. This was hideous but manageable, if it had stayed here I may have just embraced my productivity levels but it didn’t. The ascent had barely begun.

At its height though I could hear my myself talking and I was aware that this inconsistent monologue was coming from my mouth however I had no more knowledge than anyone else in the room as to what I would say next as I hadn’t processed it.

Just a week before this conversely everything made total sense and I mean everything. The words that rolled off my tongue and the tongues of others were connected, not everyone understood the connections but this simply confirmed what I was already beginning to realise that I was a superior being destined for great things. I could hear the poetry.

I wonder, in hind sight, if it was this ridiculously inflated sense of self that led me to start writing a sitcom (based in an office of CPN’s) then being certain, I can’t say pretty sure because I was certain that it would be such a hit so much so that I actually penned my resignation and put it on my bosses desk. Maybe?

I heard myself swear at people in a seemingly deliberate, verbally abusive way, which is so far from my norm that this added to my being afraid of myself. What was I going to do next?

This time it had gone beyond baking cakes at 3am, it had gone beyond deciding to decorate and starting to impulsively strip wallpaper at 11pm when I ought to be heading to bed, it had even gone beyond the time that I was unable to decide which bunch of flowers to buy in Sainsbury’s so I bought them all. These things made me slightly unpopular in my marriage but they weren’t the end of the world.

I have nearly always been able to pull it back before, I have too much to lose not to and I am rather cross with myself that I didn’t spot this in time. Accepting that this wasn’t my fault may take some time. Self compassion and time.

When I feel my thoughts getting faster and my senses becoming enhanced I know it is time for extreme self care. I cancel everything in my diary, even the good stuff like meeting friends or going to the theatre and take medication that I keep in the house to make me sleep and sleep I do. No TV, no music with lyrics, nothing, I create a beige mundane world where my brain has the opportunity to rest. To fulfil its obligation to rest.

A few years ago the last time I had one of the occasions when I missed the opportunity to get a handle on my ever elevating mood which my husband was putting up with as patiently as ever even when I struggled to decide between all the wonderfully colourful and beautiful flowers in Sainsbury’s so I bought them all, my dear husband embraces my eccentricities, he always has so the line between that and illness is sometimes blurred. I was probably just getting to the stage whereby I needed an intervention when I had a nasty accident and hurt my back, I was put on opiate based painkillers and huge doses of diazapam for my back pain and the combination of those two forced my body to sleep and therefore resolved over time my high mood.

Once many years ago and long before I gained enough knowledge and insight into my patterns very nearly ended up married to someone I had only known for a couple of weeks, we were turned away from the registry office for being intoxicated (big phew!). The ‘episode’ seemed to last for months but I felt great, it never ended up like this. I rode the wave and enjoyed every minute. I was young and had nothing to lose, people saw me as the life and soul of the party. They probably thought I was on drugs to keep going but I wasn’t. I even have a couple of tattoo’s from periods of elation… hidden ones mind!

The temptation to ‘ride the wave’ is more than just temptation it is a powerful force, this offer of bubbling excitement and an overwhelming feeling of happiness. What’s not to love? Who wouldn’t want to feel like that?

To medicate and try to rest my brain with sleep and low stimulation is not easy, it goes against everything I am feeling in that moment.

The ascent is seductive.

Inevitably what goes up must come down and with a little encouragement (read medication!) from the crisis team my descent started.

A few people had tried to tell me they thought I was poorly the previous week and I thought they were ridiculous, I kept telling them “I feel great, I’m not depressed” they agreed with me that I absolutely wasn’t depressed but I didn’t understand or want to understand what they meant. I felt great how could I be poorly? Insight was slowly seeping away…

By the weekend my dear friend and my husband decided it was time to ring the Crisis team. Even the ascent was gaining speed now so by the Monday when I was assessed I was irritable and agitated, as much with how I was feeling as with the Crisis clinicians who were there to assess me. I wondered why on Earth they could not see that I just needed a couple of good nights sleep?

I agreed to the Crisis team giving me some medication and coming to see me at home partly to get rid of them, it’s pointless arguing; experience has taught me that any disagreement as a patient in mental health services becomes a symptom of something (a whole other blog for a whole other day!). And partly because I was becoming increasingly afraid of where my own thoughts were going to lead me next.

The Crisis team were great, once they realised I was being concordant with medication they gave me control of how often I saw them (as little as possible!). After a few nights where I slept a bit better and took significant doses of sedating medication during the day which barely touched me we moved on in that after a few decent hours of medication induced sleep I felt rested, energised in my brain but my body felt rested and this was apparent with my thoughts being a bit slower and my speech certainly being slower and more comprehensible. I was still flirting from subject to subject and folk were still talking in rhymes here there and everywhere but it was slightly slower which was a relief.

As the day went on and I became more stimulated by the world around me the speed went up a gear but this lessened as the days and weeks went on.

Eventually I began to feel ‘normal’ whatever that is, but normal for me however was still aware how this could alter rapidly with my environment as I was still very vulnerable to elation. I think that’s gone now although maybe don’t ask me about the pay deal 😉

I hate the medication I am on. Last time I took it I gained five stone in four months which I am still carrying and which upsets me greatly. But it works. Laughably after recent weeks I am now complaining to my hubby I feel so tired all of the time because of the meds!

Then came the apologies. The red cheeked conversations were I have expressed my regret over things I have said and done recently, I feel so mortified over some things. The late night texts ‘because I had a brilliant idea’ to the knowledge I have sworn at people and shouted in church and that’s only the tip of the iceberg called mania that I was climbing. When I reflect I can see how close to the top of the hypomania scale I came and how easily it would have been to leap over that hurdle into full mania.

I knew what was coming the day the psychiatrist mentioned hypomania and bipolar, it’s a conversation I have avoided for just over a decade which was my first ever contact with mental health services after I had our daughter. I even tried making up a diagnostic term and telling the Dr I simple have a Hyperthymic Personality Structure… which I still think is a great diagnosis and it should be included in DSM 6!

I am ashamed of the self stigma I have shown since being branded with this diagnosis. I say branded because I feel like it has been written on my forehead with hot irons, for all to see and me to feel.

I lost so much to stigma when I was diagnosed with severe depression and hospitalised after I had my daughter. I lost my career which laughably was in HR and employment law and I lost some friends who just ‘didn’t get it’. I can not lose anything else to stigma, I just can’t.

Even last year it was suggested to me that maybe someone with a history of mental illness should consider a less stressful job than nursing. Stigma ladies and gentlemen is still alive and well. I am a good nurse, a competent nurse. When I am well I like to think I make a difference, I am a good nurse because of my lived experience not in-spite of it.

This recent episode has knocked my confidence which I was only just regaining after the last episode of depression I experienced. I am wearing greys and blacks as I am afraid if I wear colour people will assume I am ill, I am leaving the room when something funny is said to ‘go to the printer’ because if I laugh they may think I am hypomanic again or if I don’t laugh people might assume I have crashed into a deep depression.

Rock. Hard place. Yeah that’s me stuck in the middle.

I am so worried that colleagues will relate my illness and my competence, it’s matterless how many people try to reassure me that is the internal monologue I am running at present, I’m hoping a couple of sessions of talking therapy may help me work through that.

Mental Illness has taken so much from me but I refuse to be subservient. I am wearing my armour which consists of family, friends, Jesus and medication and then I am ready to fight, or I will be, just not yet. First I need to heal.