case study

CYCS3017 – MENTAL HEALTH – CASE CONSULTATION CLEMENTINE

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Clementine is a 16-year-old female who recently presented at an emergency department for safety concerns. Her mother, Mrs. Naval reported she discovered Clementine bleeding from her wrists in her bedroom. The amount of blood was not substantial; however, felt her daughter needed to be seen right away. Clementine was seen by the attending psychiatrist. The doctor shared there appeared to be no acute safety concerns and felt the next step would be for Clementine to be assessed at the outpatient adolescent clinic located at the hospital. The nurse provided a discharge slip with the appointment information. The next day Clementine and her mother arrived at the clinic. Clementine was visibly irritated and refused to answer the receptionist questions. Mrs. Naval apologized for Clementine’s behaviour and confirmed the information. Clementine and her mother meet with the psychiatrist. He explained the nature of the assessment and requested to meet with Clementine by herself. She was initially not cooperative nor forthcoming with her answers, until the psychiatrist shared their discussion was confidential and it was a safe place for her to talk. He also assured Clementine although the appointment was in the hospital, the clinic is an outpatient, and she would be going home. The doctor noticed Clementine’s body language appeared to be more relaxed; however, her leg continued to shake. Clementine began to share and reported she recently moved to a new school following her parents’ divorce and was upset about starting over and having to make new friends (even though Clementine never seemed to have difficulty making connections). When asked if she made any new friends, she responded with, “People are stupid” and rolled her eyes, stating that she did not appreciate people making comments about her appearance especially when she has only been kind to them. She continued to spew on how dare they talk about her weight and how she looks when they themselves should be worried about their own appearance. Her agitation seemed to escalate over this topic. The psychiatrist validated her feelings and asked Clementine about her childhood. She appeared to look confused and asked, “Why do you need to know that”. He clarified his question and stated it would be helpful to hear from her what she remembers about growing up with her family. Clementine responded, stating she was the middle child and felt she was in the shadows of her older sister and younger brother. She continued to state they were always doted on and she was always left to fend for herself. Clementine

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stated that she was never the favourite child, despite trying her best to please her parents. She did acknowledge her relationship with her siblings were overall good, but knew she was never favoured. She does not recall having a close relationship with her mother, other than she was there to provide with the necessities. Clementine stated in a sarcastic tone her mother used food to show affection but then at the same time always reminded her to be careful of what she was eating. When asked about her father, Clementine stated that he was always working, but she felt closer to him than she did with her mother. The psychiatrist noted Clementine’s posture improved and had began making eye contact with him. Clementine discussed the high expectations often set by her parents were unrealistic and stated she did everything in her power to fulfill them, but the past year was difficult. Her parents separated and divorced, which caused an uproar with her extended family as this was frowned upon. Clementine said for reasons unknown, she moved with her mother, leaving her brother with her father while her older sister went off to university. She felt rejected because she questioned why she was separated from her siblings and why she could not stay with her father. Clementine reported she had endless nights ruminating over the “why” questions… “Why didn’t my dad want me?”, “Why do I have to be away from my siblings?”, “Why am I not good enough?” This sense of rejection not only confused her, but also perpetuated her sense of feeling she didn’t belong, even though she saw her dad every other weekend. When asked how these visits went, Clementine said that she was still angry with him, and it was difficult to forgive him.

The psychiatrist asked Clementine about school. She rolled her eyes and shared she’s been missing classes because she felt the teachers did not know how to teach properly and it was a waste of time for her to be there. While skipping school Clementine stated she would spend time at home watching YouTube and Tik Tok videos. She commented feeling increasingly isolated and turned to food for comfort during these times. Her meals involved eating high-caloric foods and on some occasions, would overeat throughout the day. These bouts of overeating were at times accompanied by fasting. However, within a couple of days, would repeat the pattern of a high-caloric intake - sometimes not even realizing how much food she was eating. When the psychiatrist asked Clementine if she had heard of binge- eating disorder, she was quick to shut this down, stating that she has no

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issues with her body image and did not want to talk about her eating habits. The psychiatrist made note to explore this topic later.

The psychiatrist then raised the matter of Clementine’s injuries from the day before. Clementine said she was feeling bad and wondered what it would be like if “she didn’t exist”. She wondered how her family would feel and who would come to her funeral. She said she was not optimistic about the future and “not living sometimes seemed preferable to living”. Clementine insisted; however, that her behaviour was not an actual suicide attempt. She claimed she made a few scrapes with a butter knife to see what would happen. She did get herself to bleed but did not feel her injuries were serious and had made no plans and it was not her intention to kill herself. Clementine said her mother came into her room, saw blood and “freaked out”. Her mother told her to get into the car and took her to the emergency room.

The psychiatrist asked Clementine if she currently had suicidal thoughts and Clementine said “NO” curtly, again showing her irritation with the question. She repeated she didn’t want to kill herself. The psychiatrist further discussed with Clementine how sometimes people self-harm to cope when feeling distressed, and or to “to feel something”. He also provided Clementine with a short list of resources she could access, such as the Kids Help phone line. Clementine commented the school has posters in the cafeteria as well. She gave a safety commitment and promised if she started to have suicidal thoughts, she would reach out to someone and smiled stating including her mom.

She asked when will her mother will be joining the meeting, at which point, the psychiatrist invited the mother while re-assuring Clementine that he would continue to stay in the meeting. Mrs. Naval then shared her thoughts and provided information on the family and home environment. Mrs. Naval stated she and her ex-husband had many past arguments about several issues, most notably his alcohol use and the family’s financial status. The last straw was when she caught him spending the rent money on a motorcycle. When asked how Clementine ended up with her, she rolled her eyes and said it was a long story. Mrs. Naval confirmed some of Clementine’s report to recent events. She confirmed she was busy at work and unable to devote a lot of attention to her and was feeling frustrated with having to manage the issues and simply did not have the energy. Mrs. Naval stated she have been trying to accommodate Clementine’s every need and each time, it was never enough. Mrs. Naval also verified that Clementine

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was missing a lot of school. She mentioned Clementine’s increase in eating, weight gain and missing food, but never witnessed Clementine overeating. Also, the increase in grocery shopping has impacted her monthly budget. She looked at Clementine and acknowledged stating “Clementine you look like you’ve gained some weight and you to need to watch what you’re eating because one-pound leads to another pound”.

Despite these situations, Mrs. Naval said she was shocked to find Clementine bleeding in her bedroom. She never considered the possibility of suicide, but the apparent seriousness of the situation worried her and felt she needed help.

Mrs. Naval further stated she had updated her ex-husband and asked him to monitor Clementine’s eating and overall behaviour. He reported he hadn’t observed the same behaviour which seemed to contradict what she was seeing at home. Clementine appeared to disengage and stated in a low tone “I’m fine, there are no issues with her eating”.

To reinforce her points, Mrs. Naval shared that Clementine was caught stealing food at No Frills and was brought home by the police. No charges were laid but Mrs. Naval was appalled by the incident. Clementine stated in an annoyed tone, “her mom gave her a lecture on how her behaviour was unacceptable and this was not the way she was raised”.

Mrs. Naval commented overall Clementine’s mood has declined over the last few weeks. She’s been less active, lying around the house and sleeping throughout the day. She only leaves home to visit her father. Mrs. Naval then appeared sad and disclosed being worried about her relationship with Clementine, “not being a good mom” as their interactions often led to arguments.

With consent, the psychiatrist spoke with Clementine’s CYC at her school, to gain more insight. The CYC explained that they have been working with Clementine throughout the academic year particularly helping her build better relationships with her peers. It was not a secret that Clementine has not been afraid to show her emotions, particularly her anger. She would come into the office regularly seeking their support while being emotionally charged over an issue. Most recently, she requested to have her schedule changed because she hated her math teacher. However, this was not the first time, Clementine had difficulty with teachers – yet this math teacher was someone she raved about at the start of school and now she was

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adamant that they had no idea what they were doing. When asked to meet with the teacher, Clementine refused and only wanted to complain about their teaching.

The CYC stated that she often had difficulty maintaining relationships and was quick to put the blame on others. When her schedule change request was denied, Clementine became upset and refused to leave the office until it was done. She threatened to take this to the principal and the school trustees. After several minutes of de-escalating the situation, Clementine stormed out. Since the incident, Clementine refused to meet with the CYC again and insisted that she be assigned to another CYC. When asked about seeing any problematic eating patterns, the CYC could not confirm.