Is It Schizophrenia? Is It Substance Use?

Around ten million adults in the United States currently experience both mental illness and a substance use disorder (SUD). It’s a well-established correlation, often complicating the treatment of both conditions. One such co-occurring disorder is schizophrenia

In a recent webinar for Harmony Foundation, Colorado Recovery’s medical director Alan Fine, M.D., talked about the symptoms of schizophrenia and substance use disorder and why it is frequently difficult to tell the two conditions apart.

 

 

First off, Dr. Fine presented a diagnostic flowchart to illustrate where SUD and schizophrenia can be found in the mental healthcare realm. If the symptoms are acute and were caused by taking drugs or drinking alcohol then we’re looking at substance misuse and a possible addiction scenario. If the diagnosis is psychosis without a physical cause, the condition is often diagnosed as schizophrenia or bipolar disorder. 

The diagnosis of schizophrenia itself is complicated and based on the work of three trailblazers in the field whose impact can still be felt today: Emil Kraepelin (1856–1926), Eugen Bleuler (1857–1939), and Kurt Schneider (1887–1967). 

Kraepelin is considered one of the founders of modern scientific psychiatry. His views dominated the field at the start of the 20th century. Bleuler renamed Kraepelin’s “dementia praecox” schizophrenia and established the classic four As of the condition: ambivalence, affect, alogia, and autism (preoccupation with self). Schneider in turn formulated the first-rank symptoms of schizophrenia: auditory hallucinations, feelings of external control, thoughts connected to others, and other delusions.  

In his book, The Environment of Schizophrenia, Colorado Recovery founder Richard Warner wrote that “schizophrenia is a psychosis. That is to say, it is a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”

What about substance use then?

By definition, schizophrenia is not caused by the effects of a substance or another medical condition. That, however, is not quite all. 

Mental health conditions and SUDs frequently co-occur because many people with addiction are primarily misusing addictive substances to self-medicate emotional pain caused by serious mental health disorders. 

“The proportion of schizophrenic patients of comorbidity of substance abuse varies in published studies from 10–70 percent, depending on how patients are diagnosed with schizophrenia, the types of populations studied, and the different ways of defining drug and alcohol disorders,” said Dr. Fine. “There’s a remarkable overlap in both directions.”

People with schizophrenia are at a higher risk of engaging in substance misuse because many of them will be tempted to self-medicate the severe symptoms of their mental illness as well as some of the side effects of their antipsychotic medications. At the same time, substance misuse may cause syndromes that are similar or even identical to schizophrenia.

In the short term (acute intoxication), schizophrenia-like symptoms may include delusions (stimulants and inhalants), loose associations (stimulants, alcohol, sedatives, and inhalants), and hallucinations (stimulants, alcohol, and inhalants). Both alcohol and sedative withdrawal symptoms include hallucinations and paranoia. 

In the long term (prolonged misuse), “amphetamine use is associated with long-term psychosis—thirty percent of all amphetamine-induced psychoses become chronic,” Dr. Fine explained. Chronic alcohol misuse may cause persistent dementias such as Korsakoff syndrome and delirium tremens. 

People with schizophrenia also engage in substance misuse to cope with the deterioration of their social environment, an area that Dr. Warner explored extensively. 

So, the answer to the question “Is It schizophrenia or is it substance misuse?” is often: both! That means, should both conditions be present, both need to be treated because they may reinforce each other. An important element in this regard is empowerment. 

Empowering people with schizophrenia reduces the need to self-medicate and often improves symptoms. Believing in their ability to take charge of their lives and manage the complex challenges of their illness is crucial for people with schizophrenia.

Over the course of his long professional career, the late Dr. Warner realized that social inclusion empowers people with mental illnesses and improves outcomes. “Work helps people recover from schizophrenia,” Warner concluded. “Productive activity is basic to a person’s sense of identity and worth.”

Colorado Recovery has been utilizing the Warner method to empower adults with mental illness for many years now. Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

 

What’s the Typical Age of Onset for Schizophrenia?

Schizophrenia is a mental health condition that affects about one percent of the US population. That means approximately 3.3 million people nationwide currently live with the condition. It typically starts in late adolescence or early adulthood.

“Schizophrenia is a psychosis,” explained Colorado Recovery founder Richard Warner, MD, in his book The Environment of Schizophrenia (2000). “That is to say, it is a severe mental disorder in which the person’s emotions, thinking, judgment, and grasp of reality are so disturbed that his or her functioning is seriously impaired.”

Schizophrenia can have very different symptoms in different people. They are frequently categorized as positive or negative. “Positive symptoms are abnormal experiences and perceptions like delusions, hallucinations, illogical and disorganized thinking, and inappropriate behavior,” wrote Dr. Warner in The Environment of Schizophrenia. “Negative symptoms are the absence of normal thoughts, emotions, and behavior; such as blunted emotions, loss of drive, poverty of thought, and social withdrawal.”

The onset of schizophrenia usually occurs between the ages of 16 and 30.

“Onset of schizophrenia before the age of 14 is rare, but when it does begin this early it is associated with a severe course of illness. Onset after the age of 40 is also rare, and is associated with a milder course,” wrote Dr. Warner.

Schizophrenia researchers have long been puzzled about why the illness normally begins in adolescence when important risk factors, such as genetic loading and neonatal brain damage, are present from birth or sooner. Some experts suspect that the natural and adaptive process of synaptic elimination in the brain during childhood—if excessive—could be a factor in the development of schizophrenia.  

“We now know that, for people with schizophrenia, this normally useful process of synaptic pruning has been carried too far, leaving fewer synapses in the frontal lobes and medial temporal cortex,” Warner wrote. “In consequence, there are deficits in the interaction between these two areas of the brain in schizophrenia which reduce the adequacy of working memory.”

There is wide variation in the course of schizophrenia as well. 

“In some cases the onset of illness is gradual, extending over the course of months or years; in others, it can begin suddenly, within hours or days. Some people have episodes of illness lasting weeks or months with full remission of symptoms between each episode; others have a fluctuating course in which symptoms are continuous; others again have very little variation in their symptoms of illness over the course of years. The final outcome from the illness in late life can be complete recovery, a mild level of disturbance, or continued severe illness.”

Left untreated, schizophrenia may result in severe problems affecting every area of life. Complications associated with schizophrenia include:

  • Suicide attempts and thoughts of suicide
  • Anxiety disorders and obsessive-compulsive disorder 
  • Depression
  • Misuse of alcohol or other substances
  • Financial problems and homelessness
  • Social isolation
  • Health and medical problems

Doctors cannot cure schizophrenia, but it is possible to live well if you have this mental illness. “People with schizophrenia can be treated effectively in a variety of settings,” wrote Dr. Warner. 

The treatment philosophy at Colorado Recovery includes a warmer and more human familial setting; comprehensive levels of care that result in a path of self-reliance; expert staff to better diagnose and treat clients; and community engagement for connection and a feeling of achievement. 

Since Dr. Warner’s passing in 2015, Colorado Recovery has continued to innovate its treatment approach based on these core principles. The Warner model has delivered exceptional outcomes through its signature continuum of care and helped create lives of purpose as clients practice new tools in the management of their mental health disorder.

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

 

The Impact of the Environment in Schizophrenia

Colorado Recovery founder Richard Warner considered schizophrenia a bio-psycho-social disorder significantly affected by the environment surrounding the person with the mental health condition on multiple levels.

In his book The Environment of Schizophrenia, Dr. Warner drew upon the “knowledge of the environmental factors that affect schizophrenia in order to suggest changes which could decrease the rate of occurrence of the illness, improve its course, and enhance the quality of life of sufferers and their relatives.”

Warner divided those environmental factors into three levels: individual, domestic, and community. 

The Individual Level

Among the individual factors, Dr. Warner listed the strong correlation between substance misuse and schizophrenia. “It seems to be true that people with schizophrenia use more drugs than others in the population,” he wrote in The Environment of Schizophrenia. Frequently, that behavior has a detrimental effect. Research has shown time and again that “people with serious mental illness who abuse substances have a worse course of illness.” However, Warner was adamant that substance misuse cannot cause schizophrenia although that is often how it seems to family members and other people. 

On the other hand, a mental health condition can be a driver of addiction. “Many in this population feel a need to find relief from chronic affective symptoms and medication side effects,” Warner wrote. Since the reasons for the substance misuse are complex, treatment approaches need to be individualized. 

Stress is another important factor on the individual level. Stress can trigger episodes of schizophrenia. “People with schizophrenia are more likely to report a stressful life event preceding an episode of illness than during a period of remission,” explained Warner. One of the hallmarks of schizophrenia is “a deficit in the regulation of brain activity so that the brain over-responds to environmental stimuli, reducing the person’s ability to regulate his or her response to new stresses.” 

The Domestic Level

Stress also plays a significant role on the domestic level. People with schizophrenia who live with relatives (by birth or marriage), who are “critical or over-involved” have a much higher relapse rate than those living with relatives who are less critical or intrusive. Outcomes can be improved if families are involved in a more supportive way. 

Studies have shown that “family psychoeducational interventions can lead to a change in the level of criticism and over-involvement among relatives of people with schizophrenia and so reduce the relapse rate.” With appropriate support, domestic stress can be mitigated for all parties involved. 

Dr. Warner included “alienating environments” at the domestic level. “Many people with mental illness face lives of aimlessness and boredom,” wrote Warner. While the traditional state hospital incarceration frequently led to an “instituional neurosis,” featuring restless pacing, unpredictable violence, and posturing, more recent treatment approaches may lead to an “existential neurosis,” which similarly stands in the way of recovery.

Open-door, domestic alternatives to hospitalization, on the other hand, offer a number of benefits, Warner wrote in The Environment of Schizophrenia. “They provide care which is much cheaper than hospital treatment, less coercive and less alienating, and they produce a different result.

The Community Level

On the community level, people with schizophrenia have to contend with numerous misconceptions and false assumptions about their disorder. “People with mental illness are subject to prejudice, discrimination, and stigma,” Warner wrote. 

Unfortunately, after being exposed to discrimination and stigma for a long time, people with schizophrenia start to accept negative labels about themselves and conform to the stereotype of a mentally ill person as being incapable and worthless. Frequently, they become socially withdrawn and dependent. 

The many harmful misconceptions about schizophrenia include the belief that

  • Nobody recovers from schizophrenia
  • Schizophrenia is untreatable
  • People with schizophrenia are usually violent and dangerous
  • Schizophrenia is contagious
  • Schizophrenia is the result of a certain weakness of willpower
  • People with schizophrenia cannot make rational decisions about their lives
  • People with schizophrenia are unable to work

Not only are most people with schizophrenia able to work, many of them should.  “Work helps people recover from schizophrenia,” Warner found. “Productive activity is basic to a person’s sense of identity and worth. Given training and support, most people with schizophrenia can work.”

At Colorado Recovery, the psychosocial clubhouse offers a rehabilitation model with a vocational focus that harnesses the benefits of client empowerment to increase members’ skills and work preparedness and assist them in obtaining employment.

Colorado Recovery—created by Dr. Warner—approaches care for mental health based on a path of self-reliance through developed practiced skills. This non-institutionalized philosophy offers comprehensive levels of care supported by an expert medical and clinical team, engaging patients in increasing community participation.

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses which are specific to each individual. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

 

How Stigma Prevents Recovery From Mental Illness

Recovery from serious mental illness requires that people with such a condition retain a sense of empowerment—a belief in their ability to take charge of their lives and manage the complex challenges of their illness.

Empowerment is essential if people with a mental illness are to overcome the many prejudices that too many Americans still carry with them: the stereotype that makes them believe a person with a mental illness is incapable, unpredictable, even violent, and worthless. 

Colorado Recovery founder Richard Warner dedicated most of his life to fighting the stigmatization of people with mental illness. Shortly before his death in 2015, Dr. Warner explained the impact of this stigmatization on treatment outcomes.

 


 

Popular television programs often depict people with mental illness as dangerously violent. A 2007 study found that 37 percent of mentally ill characters in US primetime drama were violent criminals while only four percent of characters without mental illness were violent offenders. 

It’s a long-established bias, explained Warner. Surveys from Illinois in the 1950s showed that people across the board regarded “the mentally ill as relatively dangerous, dirty, unpredictable, and worthless” (Nunally 1961). This is the stereotype many of us grew up with. Among other things, it is based on a lack of understanding.  

A 1992 study found that an astonishing 58 percent of respondents considered “lack of discipline” a cause for mental illness, while 93 percent blamed “drug and alcohol abuse” (Borenstein 1992). This is similar to blaming “lack of willpower” for substance use disorders, suggesting people with mental illness (or addiction) are themselves largely responsible for their condition.

Common misconceptions about schizophrenia include the notion that it is caused by “bad parenting,” that nobody recovers from schizophrenia, that people with schizophrenia are usually violent, and that they are unable to make rational decisions. Sadly, while being perceived as violent, in reality, people with mental illness are themselves much more frequently the victims of violent crime compared to the general population. 

 

Stereotyping Leads to Discrimination

The result of evidence-free assumptions about mental illness is discrimination and stigmatization. As Dr. Warner explained, many landlords will automatically reject all applicants with mental illness. No surprise then that many people with mental illness feel the need to hide their diagnosis from others. Many who could work productively shy away from applying for jobs because they lack self-confidence and expect rejection. 

 

 

Internalizing stigma is a self-fulfilling prophecy. People who accept negative labels then conform to the stereotype of a mentally ill person as being incapable and worthless. They become socially withdrawn and dependent. 

In 1961, psychiatrist Frantz Fanon made a similar point about the dehumanizing effects of colonization upon colonized people who internalize the value judgments of their colonizers. The internalization of stigma leads to poor mental health outcomes unless the patient is able to reject the stigmatization and regain a sense of power and competence.

According to Warner, acceptance of mental illness (insight) with an internal locus of control can lead to empowerment and good outcomes while acceptance of mental illness with an external locus of control (internalized stigma, controlled by others) leads to poor outcomes.

“People who accept that they have an illness and have the greatest sense of internalized stigma have the worst self-esteem and the weakest sense of mastery over their lives,” Warner said. “Insight must be associated with decreased internalized stigma and with empowerment to lead to a good outcome.” This is the Warner method in a nutshell: treatment of serious mental illness must aim at decreasing internalized stigma and empowering patients to attain a certain degree of control over their lives. 

Many studies have since confirmed a strong, negative relationship of self-stigma with hope, self-esteem, and empowerment. Part of that empowerment is shared decision-making. More than ninety percent of “people with psychosis are competent to make choices about their medications,” said Warner. Unfortunately, many psychiatrists still show only minimal interest in involving patients in treatment decision-making. 

Another important element is utilizing mental health patients as peer support. The benefits of involving peer staff include reducing substance misuse and symptoms of depression and psychosis, while increasing hope, quality of life, and a sense of community inclusion. 

Colorado Recovery has been utilizing the Warner method to empower adults with mental illness for many years now. Our program approaches mental healthcare based on a path of self-reliance through developed practiced skills. Recognizing the importance of empowerment for recovery, our non-institutionalized philosophy offers comprehensive levels of care supported by an expert medical and clinical team, engaging patients in increasing community participation. 

Our treatment facility provides the services needed to address schizophrenia, bipolar disorder, and other serious mental illnesses. Call us at 720-218-4068 to discuss treatment options for you or the person you would like to help.

The Role of Work and Community in the Treatment of Schizophrenia

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Schizophrenia Outcomes Analysis Uses Dr. Warner’s Methods

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Empowering People with Mental Illness at Colorado Recovery

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Why do we say Recovery in Mental Health?

Why do we say Recovery in mental health? Why aren’t we Colorado Cured or Colorado Recovered? 

 

For some people, the word recovery can be confusing. Many times people associate the word only with substance use treatment. But, the word has also been important for recovery from mental health disorders. 

 

September was National Recovery Month and SAMSHA says, “National Recovery Month is a national observance held every September to educate Americans that substance use treatment and mental health services can enable those with mental and substance use disorders to live healthy and rewarding lives. Now in its 31st year, Recovery Month celebrates the gains made by those living in recovery.”

 

It is important to tell stories of recovery and reshape beliefs around how we see mental health disorders. Mental Health Colorado has covered many personal stories that are hope-inspiring and uplifting. For great recovery stories visit: https://www.mentalhealthcolorado.org/

 

There are often different takes on the word depending on the context and population. Professionals use the word clinically, advocates use the word as part of a grassroots movement, and people who struggle with substance use disorders use the term to describe a state of being in sobriety. 

 

In the 1930’s Alcoholics Anonymous began using the term to describe sobriety among a fellowship of participants. Recovery is now an integral part of how a person describes and connects with living a good life without substances and the concept is closely related to how recovery is viewed in mental health. 

 

In the late 1980s and ’90s, the recovery movement in mental health began. It was led by mental health consumers/clients/ex-patients who wanted to see a change in the perception of what successful mental health treatment means. Without this client-led movement, treatment may have looked much different than it does today. 

 

Before the movement, patients with serious mental health disorders and their families were oftentimes given a poor prognosis. There is a dark history in the US and other parts of the western world of patients being treated poorly, institutionalized, and stigmatized. There was no focus on improving the quality of life nor any hope for recovery from their illness.

 

 The mental health recovery movement really expanded the perception of what people who live with serious disorders like schizophrenia and bipolar disorder are capable of. 

 

The CEO of Colorado Recovery, Ruth Arnold, worked on a Recovery Philosophy roll-out in the early 2000s while working at Mental Health Partners in Boulder, Colorado. The Boulder community still refers to this manifesto when they are thinking about how to help people. 

 

Here is what was developed in partnership with clinicians, clients, family members, and community: 

 

Recovery in mental health can be described as the intentional constant pursuit of living life to its fullest.  It is a process that is unique to each individual and grows out of a culture of support and the gradual awareness of one’s own personally meaningful roles and goals.  It is the awakening and realization of dreams through the process of healing and the exercising of personal power to secure a full and satisfying life.  We believe that recovery is not only possible, it is probable, because of the strength of the human spirit and the amazing resiliencies within every person.

 

Ruth personally believes that “recovery is the pursuit of a meaningful life beyond one’s mental health diagnosis and learning to manage the mental health symptoms sufficiently to allow one to get on with living. To stop seeing one’s role in life as ”a person with a mental illness or mental health condition”, but instead to see the possibility of a role beyond that and in spite of that, and developing sufficient perseverance to pursue it.”

 

It is important to think of recovery as an active state or process, a doing rather than a one-time event. Stay in the moment, know that wherever someone may be in that journey, it is cumulative knowledge that is gained from setbacks and struggles. At Colorado Recovery we are blessed to witness and be a part of the journey. People who live with mental health challenges are some of the most empathetic and resilient people around and they have many gifts to bring to the world. 

Readings on Schizophrenia

I have had the pleasure to discover and study some of Dr. Richard Warner’s books (The Environment of Schizophrenia, Social Inclusion of People with Mental Illness and Recovery from Schizophrenia) and they have absolutely changed my outlook on mental illness. My 20-year old son has been diagnosed with schizophrenia two years ago. The following are some of the things I have learned from Dr. Warner’s books:

1. The books have changed my mindset from the start, by stating that 25% of people with schizophrenia actually recover. Many of us know what a cloud of despair can be cast on parents and relatives of schizophrenics. When my son was first diagnosed, I was given sympathetic looks and a list of support groups. I can’t begin to tell you how many times I was told, “Good luck!” Support groups were often equally discouraging. I am sure they can be useful in some situations, but the ones I attended were full of sad people with very few answers, who desperately wanted a way out. The main question was, “How can I – as a parent – survive this?” Many were telling me to put my son in an institution or send him out on his own, but I just couldn’t do it.

Finally, my son had to be hospitalized for a month. Even there, I received no word of hope. The person who was given temporary guardianship of him at that time thought she was being reassuring when she told me that he will most likely relapse and the second time around we will have a better chance to obtain permanent guardianship. And then I read these books. There is a chance my son might recover! Finally, a ray of hope.

2. The second thing that helped me in thee books is the warm and sound approach to recovery. Having lived in many third world countries, I can see how schizophrenics can receive greater social acceptance and more opportunities for work there. Even in Italy (where I was born), medical institutions are far from the cold, sterile approach I found in this country. Here my son has been arrested three times, handcuffed twice, pepper-sprayed once. Most doctors and therapists I have seen have been distant, measuring their words as if they were following a text book. This ordeal has actually drawn me closer to my sister (who lives in Italy) because I have called her at times of crisis, finding comfort and support in the natural motherly wisdom we have both known as children and have tried to apply in our families. These books have helped me to recognize the importance of a warm family environment, which is mentioned but rarely stressed in most publications (where the emphasis seems to fall on medications).

3. I have also appreciated Dr. Warner’s insights on cigarettes and marijuana usage. My son uses both. He started smoking cigarettes at the hospital, where they gave them out like candy. About the marijuana, all the professionals I have seen have warned me that it will have terrible effects or at least will cancel out the medications he is taking. My son told me it’s the only thing that helps him. He says it simplifies his thoughts and, when he uses it, “the voices are not angry anymore.” You may wonder why he still hears voices while he takes medications. I wonder too, and I told the psychiatrist who has made no effort to change her prescription. I suppose she knows what she is doing. My son doesn’t want to change doctors and I am just happy he accepts the medications because initially he didn’t. At any rate, Dr. Warner’s books have relieved my own paranoia about my son’s marijuana usage. Now that I know the sky is not going to fall, I can concentrate on what Dr. Warner advises to do in these cases – in his words, “invest more in those programs that help a person find a place in the world, that help people make friends and fulfill useful social roles.” I have been trying to prevent his boredom, include him in engaging activities (he does pole-vaulting at a local college), encourage situations where he can meet friends, and enroll him in work-training programs sponsored by the Department of Rehab.

There is much more, and I might have to write again at a later time. For now, I am deeply grateful for Dr. Warner’s efforts to bring concrete hope and solutions to patients and their parents.

S.C.

Lois the Poet

During my ER shift today, in room 10, there was a thin homeless woman. She was covered in a film of grime, but she had a beatific smile. “My feet hurt, doctor,” she told me. “I’ve been walking a lot, looking for sanctuary. The government has been trying to steal my creativity for years, but I’ve been guarding my poems. They want to kill me for my poems, but I won’t let them.”

She was holding a small notebook with a beautiful flowery cover, in shades of pink and magenta. She was writing on the creamy pages in small, neat cursive. As far as I could tell, it was her only possession that was not filthy.

“That’s so cool that you write poetry,” I told her. “That will be your legacy.”

“Yes!” She beamed. “How nice that you understand!”

I examined her. Her feet were sore, and blistered, but nothing more. She looked healthy, and at peace. “Do you want to see our psychiatric team?” I asked her.

“Oh, no, I don’t need them,” she replied. “I’m fine.”

“Would you like a shower?”

“That would be great!”

“Would you like a meal?”

“That would be lovely.”

“Would you like something for pain, for your feet?”

“That would be wonderful.”

“Is there anything else we can do for you?”

“No, that sounds just perfect. That’s all I need.”

“It was nice to meet you. You are a beautiful soul,” I said, and turned to go.

“Doctor, would you like me to read you a poem?”

“I would like that more than anything, but I have patients waiting to see me. Maybe I’ll come back in a bit, after I get caught up, and you could read me one then?”

“Would you like me to write one for you while you go see those other patients?”

“That would be fantastic if you would write a poem for me! Thank you so much.”

“Do you want to pick a topic, or should I just look into your soul?”

“I would love it if you would look into my soul,” I said, and I meant it.

Thirty minutes later, she passed me in the hall as she was walking with a nurse to the discharge area.

“Doctor,” she smiled, “Here is the poem I wrote for you.”

She handed me an unblemished, creamy page, torn from her notebook.

On it was this poem:

For Mercys Foot Doctor

Today a foot doctor approached me

She seemed to have a halo that

said you at this moment are

the exact right company

We talked a little bit about

my legacy

And I said I hope in the

future for the doctor and

the patient it can be a

great game of candy

kiss monopoly called

a glory story of poetry

Of course she admired my

filthy dirt

She said congradulations you

have been promoted to

Grade A Self Worth

She said simply all you

need is a shower

And you will have unlimitless

Candy kiss flower power

By Lois

August

At the bottom of the page it said:

“I will be seeking Sanctuary

Until the right person shows

me my gods mercy.”

“This is a great poem,” I told her. “You have made my day.”

And then I showed the poem to the nurses, and I put it in my pocket, and I told the people I love most about it. I read it to my family at dinner. And then I said to them, “I have the best job in the world.”

Valerie Norton, MD