For the Rest of Your Life

It was 1 AM and I was working late, typing up an incident report in the office two hours after I should have gone home. The unit had been in chaos that evening: clients in and out of holds, running out doors, refusing to go to bed.

A thought occurred to me, and I turned to my teammate and said, “It’s a shame this job doesn’t pay better because I could do this…”

I trailed off looking for the right words. He found them first: “For the rest of your life? I know what you mean, man.”

We didn’t stay, of course. We couldn’t. We eventually left for greener pastures.  The emotional fortitude to do this line of work exists in many people. But it must be nurtured, rewarded, and treated as an asset in order for it to grow. And when it does, so too will the quality of care in treatment facilities.


From the Floor is an irregular feature of short poignant interactions, sometimes funny, sometimes sad. These are the conversations, this is what we witness when working in mental health. If you would like to contribute email: andre.alyeska@gmail.com.

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Complete Turnover

Staffing issues continue to impact the quality of care in mental health.

5 years, 1 year, 9 years and 2 years.  There has been a rash of people announcing they are leaving.  Some to other jobs within the organization (5 and 9).  One to a better job outside the organization (2) and the other for relationship issues (1).  Though behind each decision to move on lies a common undercurrent: exhaustion.  We continue to lose quality people at an alarming rate.  This in the face of a pay raise that was not insignificant (for me, who has been here 6 years, it was a $2 raise).

Some of the comments I’ve heard or read as people say their good-byes; one marveled “I get to have a lunch break!” And the relief she can do so without a walkie attached to her hip.  “Where is the behavior mod? With the high concentration of acuity, these kids are learning unhealthy behaviors from each other.” Perhaps the most telling comment was from the person leaving after two years; “I’m the last member of my original team.”

In two years and entire team has been replaced.  The truth is, however, the turnover is worse than that statement would indicate.  A complete team rarely lasts more that three or four months.  The constant churn of Staff is a persistent problem affecting the treatment we offer our clients and the morale of Staff.

We are forever rebuilding teams and establishing working rapport.  Working rapport is the ability to recognize the strengths and relationships of your team members and then be able to leverage them in working with clients.  In treatment this also means creating the environment for consistent interventions. But if there is no working rapport, then we are reduced so much more quickly to crisis management.  It’s not good.

In one primary treatment modality, Collaborative Problem Solving (CPS), the goal is to work proactively with clients.  But if we have no working rapport, our institutional memory suffers and our unit culture degrades.  When floor staff lose the support of structure, we fatigue more easily, we become reactive and we slip into forcing expectations or dropping expectations.

We move from proactive conversations to reactive solutions that frequently have little buy-in from clients and fail at building skills.  And, for institutions who have been in the business for decades, we should be doing a better job, we should be better equipped to follow through on treatment plans.

So what is the solution?

Outside of wholesale changes to how we fund mental health, I offer two.

Perhaps the most important would be to view direct care positions like skills training and caregiving as careers rather than entry level positions.  If we view direct care as a career, commensurate with a salary that paid a living wage, maybe we’d be valued beyond simply being necessary to maintain staffing ratios with a warm body.  It’s not that our role isn’t appreciated, rather the praise and appreciation rings hollow.  Health care is a hierarchical system to the extreme, we’ve simply got to value the bottom rung employees more than we do currently.  We can do this by acknowledging that it’s not education so much that matters, but aptitude.

However, it’s not just that we pay direct line staff better, we need a voice as well.  Too often floor staff are given clinical directives and treatment goals with little regard to the practicality of what we’re being asked to do and how we manage people (both staff and clients).

The tools we need in the residential setting, such as structure in the form of consistency of basic routines and expectations, are frequently undermined.  It is often said that children respond well to structure, but it also supports us as direct caregivers.  We have exhausting jobs, the unit’s culture needs to be maintained perhaps more so than any treatment modality.  A huge part of the problem is when milieu management is directed by clinical theory without balance or voice given to practical concerns.

Oh, and clinicians don’t always make very good managers of people.

It’s different now

I was taking vitals on the military ward at my new job and had just gotten a reading on a young female patient.

Me: Oh my, are you feeling ok?

Her: Yeah…why?

Me: You’re lying down but your heart rate is 105.

Her: Well, I kind of just had a flash back.

::I look at the rec room TV to see what’s playing.::

Me: Do you think maybe you shouldn’t be watching “The Texas Chainsaw Massacre?”

Her: But I’ve seen it before, and it didn’t bother me.

Me: Yeah… but it’s different now.

This was one of those moments in mental health that’s a little funny and a lot of sad.


From the Floor is an irregular feature of short poignant interactions, sometimes funny, sometimes sad. These are the conversations, this is what we witness when working in mental health. If you would like to contribute email: andre.alyeska@gmail.com.