What you’re doing when you don’t know what you’re doing

I have been working with a female client in her thirties for about 5 or 6 months now. She has her own wing on her unit because at time she will run down the hallway threatening or attacking other clients on the unit.  I’ll call her Amy. Amy has a history at our hospital, and she has been admitted again after spending time in a women’s correctional institute. Amy was admitted to us with a previous diagnosis of schizoaffective disorder and borderline personality disorder. Since her admission her treatment team took away the schizoaffective diagnosis and now she is only diagnosed with borderline; however, she has some very strong antisocial traits which I will get into later. Apparently they do not have enough information for a conduct disorder diagnosis. I don’t want to spend too much time or energy on diagnosis but some of it is helpful to understand her.

The hospital staff were aware that Amy would be admitted on a certain date when she was released from jail. The two weeks prior to her admission were somewhat chaotic, with stories floating around of this person and people generally looking like they were in a tizzy. The head psychologist talked to me and told me I would be working with her one on one about two weeks after her admission. He explained to me that if I ever make a promise and don’t follow through she will remember forever and never let it go. He also stressed that I need to arrive exactly on time to sessions otherwise she would hold it against me. I was told by staff that I work with on my unit that in a previous admission Amy crawled up into the ceiling and beat up other clients.  Cool. Sign me up.

My first time meeting Amy I walked over to her unit with paper and crayons, the only materials she was permitted to have. She was sitting in the day room which was empty of all the furniture that was normally there, with 2 nursing staff present (2:1 staff need to be within arms length of her at all times). She was sitting on the floor in a paper gown. Just a reminder that this is 2016. I felt like I was walking into a horror movie.

I kept extremely strict boundaries with Amy for months, probably for my own safety. I may have forgotten to mention that Amy has “incidents” where she will do such things as: punch other clients in the jaw, tear down the exit sign (and one time threw it at a nurse, hitting her in the back of the head) trying to strangle herself with bedsheets or underwear elastic (hence paper gown), and breaking the payphone repeatedly, not to mention threatening to burn the whole building down or burn people alive.

Twice a week, for a half hour at a time, we sit and draw. Amy will generally draw her go-to image of an 8-ball, or a flower, or her now favorite, an “abstract” image. Her drawings are very controlled, even her “abstract” drawings. For weeks I wasn’t sure what to make of her drawings. I was so confused, normally when clients who have schizoaffective disorder create art, I can very clearly see this reflected in their artwork, but with Amy I was getting nothing. Even in our verbal communication, she would tell me stories that most of the time were made up. Eventually her treatment team took away her schizoaffective diagnosis, believing that she did not have psychosis at all, which basically validated why I was so confused. When Amy and I talk about her “incidents” and I ask her what she could do differently next time when she gets angry or upset, she gives me all the right answers. “Draw or write in my journal, write a grievance, talk to the treatment team.” But she never actually uses these coping skills. So then I started asking her what it’s like for her during and after these incidents. What does that feel like to have hurt someone or to experience these consequences. “well, I’ve moved on” or “that’s in the past.”

Eventually I started to think that probably Amy has some antisocial/psychopathy going on based on her complete lack of empathy for others. She also has very limited insight probably due to experiencing trauma as a very young child, or so I’m told by the psychologist.

There were about 2-3 months where I wasn’t sure what I was even doing with her in my work. I don’t think she is capable of having empathy, and I don’t think she is capable of really processing her feelings or expressing them through her artwork. At least she hasn’t shown me any evidence of this. My primary goal for the longest time was structuring safety, and making sure that we got through the session without her hitting me or hitting herself. She has never actually been aggressive or threatening with me in a session but I guess I don’t know if she never will. If she is feeling angry she will decline art therapy and I’ll just leave and come back at our next scheduled time. Sometimes I ask her if she wants to work and she declines and about an hour or two later she acts out and a code is called.

For a while I struggled, because I didn’t know what I was doing with her. I didn’t feel like I was really doing therapy, and I felt like my boundaries were too strict because I was too scared of her. But while this is going on I have been talking with Amy’s psychologist who is in charge of her treatment plan. The psychologist specializes in DBT and had a behavior plan in place for months. She also tells me all the time that Amy is just making stuff up, which isn’t really helpful in providing treatment in my opinion but that’s for another time. Amy’s incidents often end up with the police coming and a report being filed. She went to jail for three weeks then returned to the hospital. Her behavior plan was basically taken away because it wasn’t working. the psychologist is totally burned out on working with Amy, I can tell.

For the first time last week I actually witnessed Amy mid-incident. I went over to her unit to put notes in a chart and saw her in the hallway and said “hello.” She didn’t say anything to me, her face looked flushed and she looked like she was pouting. One of her 2:1 staff who was right behind her looked at me and shook his head. I knew immediately I needed to get out of there ASAP. Even though we’ve spent the last 5 or 6 months working on building rapport I knew that if I was in her path in this moment she would have taken me out. I quickly went into the nurse’s station to put my notes away. After I shut the door (the nurses station is open in the front then leads back to two rooms where charts are and the psychiatrist’s office is. I was in the back but could still hear what was going on out in the hallway). I heard Amy pounding on the doors and yelling (not toward me). Then I heard her walking down the hallway threatening to, if my memory is correct, cut someone’s throat open. Then she went into the bathroom and started yelling/growling. That’s when I left the unit. Her voice was completely different, and this is not the clinical term at all (which is why I’m making a zine) but it really seemed like she was demonically possessed. I have never seen anything like it. A code was called and she was given a PRN. In the afternoon I went to see if she wanted to still do her art therapy session and she had a headache. So we talked for a few minutes then she went and laid down. Two days later I worked with her and she said that she is going to be discharged soon (which is not really true) and she just needs to “keep up the good work.”

I questioned myself so many times while working with her, struggling with my instincts and a part of me that felt like I should be doing more. My instincts were telling me to be cautious and put up strict boundaries to work on safety and building rapport. I think my instincts were also telling me to be cautious to keep myself safe. But another part of me felt like I should be pushing her more, both in artwork and in discussion. In the end I think it’s just that we have moved into trying to push the therapeutic process to happen too quickly, especially in inpatient psych. She has been institutionalized since age 11. To have a therapeutic relationship with someone with appropriate boundaries and consistency is going to take longer than 5-6 months to develop.



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