“Lynn” is the divorced mother of two children who are both doing well in school. She has stable employment and is a devout Christian. She is an African-American woman who is intelligent and soft-spoken—a quietly kind person.
Lynn is on 3-6, inpatient psychiatry, referred to St. Joseph’s by her regular psychiatrist for electroconvulsive therapy for severe depression. When I met her, she’d had half a dozen treatments and said that they weren’t doing any good; she didn’t feel any less depressed. “And . . .” she’d say, then point at her bandages and shrug sadly. Lynn had big gauze bandages on both wrists and her belly.
Six times, usually on the night shift, Lynn cut and gouged her flesh, and the nursing staff did nothing to keep her safe from herself.
Previously, it was typical for the staff to have a patient sleep in the front lounge (“the doctor’s interview room”; “the fishbowl”) to be kept under observation during the night if she showed a pattern of destructive behavior, or to have a person from either the psych staff or the security department assigned to keep the patient under constant observation. Now, they do nothing.
I have had two roommates with dissociative identity disorder (DID—multiple personality disorder). As I listen to Lynn, it occurs to me that she has DID, too.
- She says she guesses she intends to hurt herself (“I did it, didn’t I?”), but she cannot answer specific questions about the destructive incidents.
- She is puzzled and vague about how and when these self-attacks occur.
- She pulls off one of the bandages on her belly to reveal, among other wounds, a wide, deep pink gouge, like someone had used a thumbnail to peel an orange skin, then she says with confusion, “And the odd thing is, I can’t stand pain. How could I do this?”
- As the ECT treatments progress, the depression clearly is lifting.
- Her eyes are brighter.
- Her face becomes animated.
- She smiles spontaneously.
But the nighttime cutting continues.
- Each night, as bedtime nears, she becomes apprehensive, afraid she will injure herself again.
- In the morning, if she has not hurt herself, she expresses great relief.
- The nursing staff does nothing.
- Other patients suggest she wear gloves to bed, taped to her wrists.
- A friend brings her heavy pink gardening gloves; she wears them, and gets through the night unharmed.
I became strongly convinced that she had DID. One alter ego was responding well to ECT, but another was coming out and doing the cutting.
One night she told me that from ages three to fourteen, two relatives repeatedly raped her. Among women, this is the classic trigger for DID.
The next morning, I told the doctor whom Lynn and I shared what I thought. His eyes widened, he put down his pen, and said, “You are very smart, you know?”
Lynn never indicated that any of the floor staff were having significant conversations with her. No one was paying any attention.
At one point, Kyle, Lynn’s social worker/therapist, discontinued therapy with her, saying that since the cutting was continuing, Lynn wasn’t trying. Her advice to Lynn was simply, “Try harder.” Lynn responded to this with great despair.
Lynn told me that Kyle saw part of the problem as being that Lynn had stopped journaling. I asked Lynn why she had stopped journaling. She said sadly that she just didn’t have time.
I said, “Excuse me, Lynn, but you’re locked on the unit and have only a few groups to go to each day: how can you not have time?”
Lynn’s first answer is always to blame herself (“I did it, didn’t I?”); her second answer indicated despair—she had stopped journaling because she simply was too depressed to continue. Under further questioning, she showed me a schedule she kept of her journaling—she had been journaling every day until yet another episode of cutting. Then she gave up. The journaling wasn’t helping keep her safe; she didn’t have the strength to continue. Kyle, instead of asking intelligent questions to get to the heart of the problem, sat in judgment and then acted punitively.
All of this information from Lynn about her life and activities was readily available. She was neither secretive nor inappropriately forthcoming. She would tell her story and try to work out her problems with anyone who showed respect and took the time.
The staff did neither. The doctor cannot do an adequate job without the input of an attentive, competent staff.
Even without insight into the proper diagnosis, the nursing staff could have kept the patient safe from herself. She did not cut herself once: she cut herself six times.
At the end of the round of ECT, she believed she was going to be discharged. She tied sheets and/or hospital gowns together and tried to hang herself.
On inpatient psychiatry, she became the most suicidal I’ve ever seen anyone. When all hope is gone, a mother will still hold to life; she will not abandon her children. When I asked Lynn to think about what would happen to her children, she matter-of-factly detailed the ways in which her husband’s second wife would be a good mother.
That night, and that night only, the staff had a security guard sit in her room while she slept to keep her safe. Her body was kept safe that night but her soul has suffered for every night that she couldn’t help herself and the staff failed to help her.
Lynn is now waiting to be transferred to a special post-trauma center in Maryland because no help was available at St. Joseph’s. She is afraid she will lose her job, and overwhelmed by the question of how to arrange childcare.
[Post-note: Lynn has decided not to go to Maryland. Among other reasons, she cannot figure out how to arrange transportation. She does not know who her discharge planner is, or that she has one. She will inevitably return to inpatient—if she does not kill herself.]