Reflections of a Locum Tenens Psychiatric Nurse Practitioner

Psychcns

I drive on long, winding, country roads. The roads are paved here--always a shock when I come to the United States from my expatriate home in Costa Rica. I am in the first world now: it is early spring, still chilly from winter, no leaves on the trees. I am in my second locum tenens job ever--the lady on my GPS directs me so I don't get lost. I provide psychiatric care in a rural setting where patients have poor supports, poor health, and poor dentition. "Working here is like being in Appalachia." My colleague says. I am given a schedule of continuous appointments. The mental pain that people bring to me is draining. My role is to provide psychiatric diagnoses and to prescribe medication for their mental disorders.

I am trained as a therapist--psychopharmacology came later. As a therapist , I learned how to connect with people, how to provide a safe environment, and how to draw out a history. As a psychopharmacologist, this approach helps me to find symptoms that I can medicate. I try to listen, with all my senses. I am alert for counter transference, the feeling the encounter elicits in me. "Tell me your understanding of why you are here today. What's going on with you?" I say.

And their replies: "I don't like being around people." "I moved up here to be close to my kids and now they don't have time for me." " I suddenly found myself with a loaded gun in my mouth. I thought I was dreaming." "I was drinking and I ran my car off the road-I could have killed someone." "I can't sleep." " I get panic attacks when my uncle visits." "My boyfriend abused my daughter." "I sexually abused my daughter when she was 7."

Staying with myself I am grounded. I start with what I am told and look for ways I can be helpful. I ask questions. I provide emotional support. I end each session handwriting a few prescriptions while I mentally review the encounter to see if I missed anything. Sometimes patients need medications but can't afford them; in these cases, I may give samples or choose from the Walmart prescription discount list.

Time passes and the work gets easier. I am still swimming in mental anguish, a new patient every half hour, but I am getting used to it. Sometimes, I have a patient new to the facility and I can spend one and one/half hours doing a full diagnostic assessment. People wait months for these full assessments and look forward to finally having the possibility of some relief. I now have friends at work--clinicians I can talk to, a great support staff, and a helpful supervisor. My company finds me a house, a large homey condo with high ceilings so I can move from the hotel. I join a club so I can swim after work. Now, after hours of immersion in human misery, I swim refreshing laps. Driving home in my rented Nissan, I feel my tranquility and my humanness. I take care of myself. I no longer am drained. I can be there for my clients.

I meet a hospice nurse. We reflect on our jobs, how it can be difficult to find peer support. "We are in the deep waters." She says. I feel brave to dive into other peoples hell and help them bear their feelings. I talk to my husband in Costa Rica every day on the telephone. He can't listen to much about my work day. "It's hard enough for me to keep my own head above water." He says.

When I see a patient for a follow-up session, I often find that the meds I chose are working. People tell me: "I am sleeping through the night." "My anxiety is better." "My depression has gone. I feel like myself." "I feel better-no more mood swings." "I don't want to kill myself anymore." When people give me this feedback, I feel a sense of accomplishment. I tell myself I am a good clinician. I also know that patients can improve due to many factors including the placebo effect of medication, the relationship effect of the therapeutic encounter, or just the passage of time. What I love about my work is to know that I am a witness, or sometimes a guide, to an inner psychological place of mental and emotional healing. Sometimes I feel profoundly honored to participate.

Reflections of a Locum Tenens Psychiatric Nurse Practitioner

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