I had a revelation today about why I’m glad I quit being a psychiatric nurse. It’s because I have too much skin in the game. I’m too much on the side of the patients, identify too much with them to fit into the politics of the job.

This, of course, is not why I lost my job as a psych nurse. Nor is it why I was on … what did they call it? probation? … with the nursing board. This helps explain why I ultimately decided jumping through hoops for the nursing board was too much of a hassle for what I would gain on the other side. Although I like helping people in need, and I have the intellect for the job, and I have the temperament to stay calm in someone else’s crisis, the job is not a good fit for me.

I remember in particular three cases I worked on during my 9-month tenure in a community mental health facility in Cleveland that illustrate this poor fit:

1. I assessed a young man who had been diagnosed with paranoid schizophrenia at the hospital. He appeared confident, personable, had an easy time chatting with me, and he had not started taking meds yet. In short, he did not strike me as a typical person with schizophrenia. His story centered around an incident where he smoked copious amounts of marijuana, went home to his mother, and was talking about strange things in rhythmic patterns. He was high and he was rapping. Apparently, he did those things a lot. I diagnosed him primarily with substance-induced psychosis and recommended that he lay off the weed for a while and see if that helped. After that, I was pressured several times by the psychiatrist, who hadn’t spent time with the kid and wanted to rubber stamp the hospital psychiatrist’s diagnosis and start him on antipsychotics. I refused to budge.
   
   Ill fit #1: I don’t play politics well when I am certain of my position.
   

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2. Another young man came in after a year-long depression followed by a period of high energy during which he thought God talked to him and told him, among other things, to discard his coat in the middle of winter and walk several blocks. He had been diagnosed at the hospital with bipolar I disorder with psychotic features. The psychiatrist I worked with said it sounded more like paranoid schizophrenia, the prodromal period of which can look like depression. I accepted his revision. The point on which we disagreed was this: This young man, who was brought in by family, had found a community of people who normalized his new, direct relationship with God. That community was willing to take him in and make sure that he was cared for without psychiatric treatment. The young man himself did not want treatment, and was perfectly functional in his interpretation of events and in the context of his religious community. I thought he should live as he pleased. (I don’t believe in God, so I didn’t endorse his beliefs, but I believe that mental illness in defined by a poor fit between the “symptoms” and the context. If one can find a context in which the “symptoms” cause no reduction in quality of life, why not?). The psychiatrist thought he should be declared incompetent and have treatment forced upon him.
   
   Ill fit #2: I don’t buy “normality” as a universal goal, nor “mental illness” as a problem in every circumstance.
   

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3. A teenage girl presented with problems maintaining relationships, problems with impulse and emotional instability, frequent feelings of emptiness, fear of abandonment, etc. It was clear to me she would have been exhibiting borderline personality disorder if her age hadn’t cautioned against it. It went beyond teen angst into something that was really causing her distress. I expressed this to the psychiatrist, who, after meeting the client, admitted that my diagnosis was astute. He then proceeded to tell the girl’s mother in a waiting room filled with other parents, children, and teens, “Your daughter is just immature. She needs to grow up.” I was incredulous, frustrated, and angry, especially as I had been coming to grips with my own borderline tendencies and identified with the girl. The psychiatrist was a pompous ass and a narcissist. He, like most clinicians, had his own issues that sometimes get in the way of his clients having an opportunity to heal.
   
   Ill fit #3: I believe that the client’s/patient’s need to heal is more important than the psychiatrist’s ego and my career advancement.

I don’t expect everyone to agree with me on all this, but I do find that I would be required to compromise too many of my personal principles if I went back to psych nursing. So, I move forward, with my hundreds of thousands of dollars in student loan debt and my current foray into the library profession …