Psychiatric Interviews for Teaching: Self-Harm

In this film, you see a psychiatrist who works in the liaison psychiatry department seeing a patient who has recently been treated in the emergency department for wrist lacerations. The lacerations were self-inflicted after a relationship ended.

The patient describes an emotional response to the end of a relatively short-lived relationship. She also gives a history of cutting since her teenage years and she is aware that she uses cutting to manage difficult emotions. She describes very low self-esteem and also some past alcohol misuse and binge/purge behaviours. She gives an account of hearing voices that are inside her head. There appears to be a pattern in her relationships of rapid attachment and then a strong sense of abandonment when they end. Towards the end of the interview, the patient appears to re-play this pattern in her relationship with the psychiatrist. However, the psychiatrist maintains a firm boundary.

This patient displays features of Emotionally Unstable Personality Disorder of the Borderline type. We may speculate that the origins of her problems lie in her childhood experiences.

Hello, Jane Evans.

Yeah

Hi, my name is Dr. Bedely.

I'm one of the psychiatrists who work here in the department of psychological medicine and I'm seeing you today because you were referred up from ANE.

I understand you were there a couple nights ago having cut your arms?

Yeah.

I think you came in after your relationship had ended, is that right?

Yeah.

Okay, okay.

Can I just check, have they bandaged you up?

Yeah, it's fine.

Okay, okay. How have you been, Jane, since we last saw you in ANE?

Crap. I mean, I just can't believe that he's gone.

Right.

And this is your boyfriend Mark, is that right?

Yeah.

Okay, okay.

How long have you two been together?

I mean, it was only a couple of weeks, but things seemed to be going really really well.

I don't understand. I can't believe he's just gone.

Right.

What is it that happened, Jane, to bring that relationship to an end?

Well, it's like I said, because it was going so well, I asked him to move in.

And he said he didn't want to.

We ended up arguing and getting into a big fight.

And then he said he was going, and you know, I begged him not to, but he still went anyway.

So was it after he had gone that you cut?

Yeah.

Right.

Can you tell me a bit more about what happened when you cut?

Well, he'd gone and I just felt so...I just couldn't bear the pain anymore.

Right.

And like the voices were just incessant.

And, you know, I just wanted to get rid of all the pain, all the voices, so I just cut myself.

And did that help with the pain and the voices?

Yeah, it just took the pain away.

It was something about seeing the blood really that just made it feel better.

So, with the cutting, is this something that you've done before?

I've been doing it since I was, I don't know, a teenager.

Right, and it sounds like there are times when you do it when it helps?

Yeah, yeah, it takes the pain off.

Right. And are there any downsides to the cutting?

Well, yeah, there's been a few.

But, I suppose the main thing is, I don't know, my arms and legs are a mess.

And you mentioned, Jane, voices.

And I know you've spoken to doctors about them before.

Yeah.

But can I just ask you a few more questions about them, please, if that's okay?

Yeah.

Okay, can you tell me, how long is it that you've been hearing the voices?

About since I was a teenager is all.

Right, okay.

And, do you know how many voices are there or who they are?

I don't know who they are.

It's mainly my stepdad.

He, I don't know, just tells me how dirty I am and how horrible I am.

Right, okay.

I know it seems like my mom as well.

What kinds of things does your mom say?

I think mainly she thinks I'm a liar.

Oh, okay.

And how often is it that you get these voices, Jane?

Not all the time.

You know, generally, they are sorta sitting there.

I don't know, they're sometimes louder than others.

It's like the other night, they might as well been in the room.

Right, did you think they were in the room?

No, I mean, I know that they're not there.

Right, okay.

But it's like they are just so loud in my head.

Right.

So, can I just clarify that?

Do the voices seem like they are just inside your head or was it like my voice coming through your ears?

No, it's inside.

Inside your head?

Okay, okay, okay.

And am I right in thinking that they trouble you more in times that you're stressed out?

Yeah.

Right.

Okay, okay.

Can I ask you a few more general questions about how you are and your moods.

How would you say you feel generally, kind of in yourself?

I hate myself.

Right.

Most of the time it's not...I just don't like being me.

Right.

It sounds as if it can be very difficult sometimes.

And it sounds like you've used cutting in the past to help.

Are there any other things you do to help when you feel very bad?

Drinking.

Right.

Smoked a few spiffs now and then.

Right.

I don't do so much now, but in the past, I don't know, I just had a funny thing about food.

You know it's all like binge, and then just throw it back up again.

Right, okay.

And that was in the past, but not recently?

I haven't done it recently, no.

Okay.

And, can I ask, Jane, it sounds like when you cut the other night, you were doing it to kind of get rid of the pain.

Can I just clarify, were you doing it to try and kill yourself?

No.

Okay.

Have there ever been times in the past when you have tried to kill yourself?

My late teens.

Right, what happened then?

It was about when I was around 19.

I don't know, I just got to the point where I didn't want to be here anymore, so I took some tablets.

So that was in your late teens and at the time, you took the tablets because you wanted to be dead.

Is that right?

Okay, but you've not wanted to be dead since that time in your late teens?

No.

Okay.

Can I ask you a few more general questions about your home situation?

Is there anyone at home with you?

Well not not now, but.

Right.

My daughter used to live with me.

Okay.

But, she's gone to live with her dad now.

So she's gone to live with her dad?

Is that quite a recent thing?

About a year ago.

Right, and what was that about?

She just couldn't cope with the fact that I was cutting myself.

Right.

I didn't do it often though, but she knew it was happening.

Right.

I suppose one of the big things as well was

relationships I have.

The relationships you had?

*grunts a yes

Can you tell me a bit more about that?

*Sigh

It was like the one I just had with Mark, you know.

Starts off being great, then I get really scared.

I just get really scared that they're gonna leave and it turns into a big fight and they end up leaving anyway.

Right.

It sounds like your daughter struggled with that.

Yeah, I mean, I suppose she didn't know whether she was coming or going really.

Right, okay.

And were there a lots of relationships like that?

Yeah.

Okay.

You've seen a few people during the past.

You've seen a couple of psychiatrists and a couple of counselors.

Has anything that anyone has done for you before been particularly helpful?

*huffs

They've been crap.

I feel like I'm just being passed from post to post.

Right.

So you've not found anything that people have done particularly helpful in helping you to manage your

relationships and your cutting and the things that seem to go wrong for you?

It's like nobody's listening to me.

You know, you're the only person who has actually sat and listened to what I have to say.

Well, do you think it would be worth, given that this has

been a long-standing problem, which clearly gets in the

way of a lot of aspects of your life.

Do you think it would be worth us meeting again one more time and perhaps having a thing together about

how the service could best support you with this?

What do you mean one more time coming to see you?

You know, so properly.

Well, the way we work here in this department is we see people once or twice

and try to think with them about the best place for them to be and then refer them on to the most

appropriate parts of the service.

So it wouldn't be usual for me to see you more than once or twice, Jane.

Yeah, but it's like I've said, you're the only person who has listened to me.

I know it's very difficult to open up to people.

I know that you have opened up here today

and it can feel quite hard that you don't want to continue to see me, but it is the way that we work here,

is to pass you on to somebody who is a bit more appropriate for your needs, Jane.

*sigh

*huff

So, would it be okay for me to book you in to see me perhaps next week

for a second appointment and we can perhaps have a think of where to go from there?

Would that be okay?

Yeah, I suppose so.