Sunday, April 2, 2017
Making of a Child Psychiatrist: (69) The General Practitioner (14); A bit more Child Psychiatry +
At my third weekly visit, a young woman of 15 called Jenni was discussed in the team meeting. She had attempted suicide at home following recurrent arguments with her mother and was thought to be in serious danger. She had only been in a couple of days, but no-one felt they had made any headway in developing a relationship. She refused to talk, was sullen and resentful and refused to leave her room even for meals, which were barely touched even when brought to her room by a nurse prepared to sit with her. Night staff had reported she prowled around the unit at night and they thought she was investigating avenues for escape. The unit had always been secure with windows that had limited ability to open, and access to the two lifts only available by key. These were worn on a lanyard around the neck of staff members. To date I had not yet been trusted with my own key and always had to ask a staff member to escort me into the lift and down to the ground floor. There were external emergency stairs, but the door was always locked, keys were kept in the charge nurse’s office, and I am not sure that Fire Drills had ever been thought about.
At the end of the meeting the charge nurse said that Dr. Fraser had suggested to her it might be a good idea for me to attempt some sort of therapy for Jenni; she did not look convinced. I simply said I would be delighted to see her. I read through the referral letter, some comments by Ken Fraser, and the daily nursing notes. There was a hint of angry trouble between Jenni and her mother’s boyfriend, the father having left the family home some years prior and not in contact.
I knocked on Jenni’s door, taking over the chair of a nurse who had been sitting with her. I explained who I was and how I thought I might be able to help. I told her that I had read through the notes, but people seemed to be perplexed about what had led to her trying to take her mother’s tablets. No comment or response. No eye contact. Not even a flicker of a reaction to anything I said. Just a dead look straight ahead. We sat in not very companionable silence, with me trying various speculations about what might have happened, and how I imagined she may have felt. No response. The chair was by a window, so I was able to look at treetops and distant roofs while trying to find another avenue. After nearly an hour of trying I explained that I had to leave, but that I would return the following week. In the meantime, I hoped she would get lots of rest, and perhaps get to know one or more of the nurses. No response.
I reported back to the charge nurse, and detected a hint of amused satisfaction. Perhaps I made that up.
The following week I had mulled over a number of approaches, and thought it might be best to do some speculation based on my limited experiences with suicidal people, bits and pieces I had read, and what little I knew of adolescents. If I said something wrong she might correct me, and at least that would be a response. If I challenged her, it might provoke her into arguing; most adolescents seemed able to do that. Opening of a dialogue was the critical issue. I have no idea where these ideas had come from given my limited experience with psychiatric patients; perhaps it came from all the televised dramas I had watched when I was an adolescent, or more likely from one of the nursing staff during my year in psychiatry.
But there had been high drama at Lanthorne. Jenni had apparently dressed in street clothes, taken her suitcase, and casually joined some parents of another child as they left the unit after a visit one lunchtime. They were busy with their own discussion, and apparently did not give her a second thought. Jenni had headed for the local cliffs where she sat for a while ‘thinking about her life’ (she was to tell me later). This was to be the lifesaver, given it took time for her to be missed, her escape reported to the police, and a hunt begun which included members of the Lanthorne staff. By the time people found her, she had already thrown her case of belongings over the cliff. Eventually one of our male nurses was able to talk her into staying, and returning to the unit. He deserved a medal.
After saying who I was and asking if it was OK to come in (no response), I said “I will take that for a ‘Yes’, and entered (no response, not even a look). I sat in the chair by the window, and started a one sided conversation. I slowly recounted what I had been told, (“I understand that…” - no response), said how glad I was that she ‘had decided not to jump’ (no response), and then quietly said: “I guess whatever has happened to you, it was bad enough to make you really want to die.” “Do you still feel a bit like that?” (no response). “I guess I will have to take that as a maybe…” There was no response and Jenni remained silent, sullen and withdrawn, as staff reported she had been all week. After a lengthy pause, I began to speculate. “My guess is that someone has forced you to do something against your will, and you hate them.” I sensed a subtle stiffening in Jenni’s posture, but she did not look up or answer me. There was no denial, no explosion at me, so I took that as meaning I might be on the right track. I let the silence lengthen. “My best guess is that it was someone you trusted” (no response) “someone who should have known better, perhaps” (no response) “someone you can’t talk about because if you did, it might upset someone else, and you don’t want that person to be hurt.” (the silence lengthened). “Some of my other patients have told me that the worst thing that can happen to you is to have a serious argument going on inside your head. One you just can’t sort out. And you know it will hurt you or someone else whatever you decide.” (no response)
I looked outside the window for a while, and then back at Jenni. There was nothing - not the flicker of an eyelid.
A change of tack… “Jenni, last time I was here you had a notebook open on your bedside table. And it was rude of me to notice, but I saw that you like to draw little diagrams and pictures. I’ve brought you some drawing paper, and some coloured art pencils I had not being used at home. I know it can be really hard to talk, especially to a man, so I thought you might like to draw instead.” I placed them on the very end of her bed, and said I would be back next week. “I apologise that it will be a whole week, but I am only able to come here once a week.”
I wrote up some notes, and checked in with the staff nurse, letting her know I had left some art pencils and paper with Jenni given she was finding it hard to talk. “I hope that is alright”. She smiled and suggested one of the teachers on the ward might be interested in helping.
I was on tenterhooks for the whole week. I did not ignore my other clinics or patients. Was Jenni still alive? Had I been too pushy in my approach? Could I have made things worse? Had she repeated the escape from the locked unit? Of course I was relieved when I attended the Canterbury clinic, and had 5 minutes to discuss her in supervision with Dr. Fraser. He asked where the idea of artwork had come from, and I told him that both my parents had been artists, and I had done some bits and pieces and some model-making as a youngster, and had found it peaceful. He nodded, and reassured me that Jenni had begun to take some part in ward activities, although she was still fairly mute.
That afternoon I drove to Lanthorne a bit less anxious than I had been. After the staff meeting where nurses echoed Ken’s comments, I knocked on the door, announced my presence and when there was no response, I went in. Jenni was sitting in the same position staring straight ahead as if she had been there all week. There was no acknowledgement or greeting. I said I hoped she had had a better week, and then sat quietly waiting. Nothing happened, so I asked if she had had a better week, or whether the ‘dark thoughts’ were still troubling her as much? (No response). Eventually she leaned into her bedside, and took out the drawing paper I had given her the previous week. She flung it onto the bed, and then what looked like a piece of cardboard on top of it. Not a word was spoken.
“May I take a look?” (no response). “OK, I will…”
The piece of 20 by 15 cm cardboard had originally been white, but had been painted black on one side. It had been carefully cut into to create a design showing a face with tears running down a cheek set into a spider’s web – not only evocative and dramatic, but very competently and carefully done. At its bottom right hand corner, was Jenni’s name carved into the design. The whole piece had been preserved by covering with a clear adhesive film.
“Wow!” was all I could think to say at first. “You really are quite some artist. You could not tell us any more clearly what it feels like to be you – trapped, and very distressed” I had to keep looking at it. She picked up the cartridge paper pad and pushed it towards me. There was only one complete painting, again very competently done. The lower part of a face stared directly out, the lips tied together by straps with buckles on both sides. “And you cannot or must not talk to anyone about whatever happened.” She tilted her head down, and there were tears. “I understand.” (and more than that I could feel her pain and confusion to the point of tears).