After the team meeting I hoovered my tofu bologna sandwich and indulged in what Jody called sparkling-brown-poison, commonly known as a diet Pepsi, from the machine in the hallway outside our office complex. I reviewed the notes from Dawn’s previous contacts and admissions. She wasn’t joking. Her admissions had been problematic. From the look of it, she didn’t get on well with any of the clinicians and there were remarks about her being argumentative, demanding and uncooperative. Two of the admissions had been precipitated by an overdose; it was hard to determine what had caused the third but I would guess it was based on her history of suicidal behaviour. The third admission occurred almost five years ago now. There were two other contacts in emerg, both more recent. The latest was almost six months ago when she was assessed by a weekend reliever and referred for follow-up but she did not attend despite reminder phone calls.
No surprises. This was a common profile with women who had been sexually abused in childhood. They had problems engaging in relationships, mostly because they didn’t trust anyone. They weren’t good at expressing intense feelings. This phenomenon was often misinterpreted by clinicians who generally see the person just as the nurses described Dawn: argumentative, manipulative, demanding and uncooperative. Sometimes these women were overwhelmed by their experiences of intense emotions to the point of dissociating, or checking out of reality. Self-harm was also pretty typical. The women themselves describe it in various ways. Some say the pain of cutting themselves convinces them they are alive; the blood drawn is also a signal of living. Overuse of medications to manage emotions can lead to deliberate or accidental overdoses. In practice, people presenting this way are diagnosed with something called a Borderline Personality Disorder, or BPD, sometimes abbreviated to ‘borderline’. All of these monikers represent the very unfortunate label.
Once applied, The BPD label haunts us all, especially the person herself, since it is primarily a ‘pink’ diagnosis. The label doesn’t really alarm me anymore. Nor does the intensity of the symptoms, which is what rockets the scales and risk checklists off the map. The approach I have adopted, through serious trial and error, has been to recognize the experience of trauma that underpins the experiences of these women, and respond more specifically to that. Also, in my opinion, Borderline Personality Disorder is a feminized version of Anti-Social Personality Disorder, which is a label mostly applied to men, and coincidentally many of those men are also survivors of abuse. Sadly, none of the pale, stale males in psychiatric academia calls me when the lists of diagnostic categories are being prepared. However, I sense a shift on the horizon. We as clinicians are much more attuned to the impact of trauma in personality development.
When I had read enough of Dawn’s file to get me on the right track, I brought my notes up to date in Bridie’s record, including our conversation today about a second round of radiation. I should probably refresh my understanding about such matters, although I knew she was in excellent hands with the team at St. Germaine’s. Imagine though, what if she could get more time. My musings were cut short however when Jenn’s voice on the intercom announced that Dawn was here. I retrieved my note pad and folder of scales and forms from under my lunch debris and marched out for my new regime of daily meetings with Dawn.
We settled ourselves in the smaller interview room because Karen was already spread out in the larger one with a family. I started with my customary banter. “Dawn, yesterday we kinda started in the middle of things and I didn’t finish up some of the paperwork I need to do to open our file. Just bear with me for a few minutes.” Before she could object I had the admission package in front of me and I was starting to print her name into the appropriate boxes. “Date of birth, address, next of kin, family physician…” She answered each question without hesitation. “Perfect. That finishes that task.” Now, how was I going to get into the next phase?
I decided to detour from the usual. I slid the note pad away from my hands and sat back, looking Dawn square in the eyes. She held my gaze. “I pulled your old records.” She did not flinch or look away. “Sounds like your last admissions to the unit were not very productive.” She exhaled a burst of veiled disgust through her nostrils and sat back, crossing her arms over her chest, probably expecting a lecture. “However, that was several years ago.” My strategy was to distance myself from her previous experience. “I don’t know you at all; tell me about yourself?”
Dawn used full three minutes of silence to either test my interest or compose her thoughts. Then she started and with very little guidance or re-direction laid down the sad tale of her life. She was eleven years old when the Uncle who lived with the family began to molest her. He told her that her parents would never believe her. He assured her silence when he threatened to kill her dog. These threats were not uncommon as ways to intimidate children. As you would expect, Dawn was distracted and worried all the time, including at school and her marks deteriorated. Because she had done well in school before this, her parents were pretty sure she wasn’t trying hard enough or paying attention. She was punished and her parents wouldn’t let her go out to visit with friends or play after school sports. This just gave her Uncle more opportunity to have sex with her.
When Dawn asked to move into the bedroom with her sister, her sister objected and her parents thought she was being ‘silly’. After she started menstruating, as birth control, her Uncle forced her to perform fellatio. On the days following this abuse, Dawn was nauseated and gagged when she was eating, especially if her Uncle joined the family for meals. Certain foods could still elicit this response. “Relax, he would repeated, breathless and groping. Relax. I didn’t then and I haven’t since”. By age thirteen she learned that if she drank alcohol before bed she could more easily endure the abuse. When Dawn was fourteen, she ran away from home for the first of many times.
Finally, she disclosed the abuse to her family and, as her Uncle had reiterated, they did not believe her. Her father in particular could not accept that his younger brother would do such a thing and made it clear that Dawn had a wild imagination, proven by her delinquent behaviour. Then came a series of unfortunate and abusive relationships with boyfriends and escalating use first alcohol then prescription narcotics and then cocaine. Finally, about eight years ago, Dawn met a reasonable, older man, who was kind to her. In this relationship she got clean of drugs but still used alcohol, sometimes to excess. She attempted counseling with a sexual abuse specialist associated with the women’s’ shelter but found that each time she broached her past she fell into a mire of anxiety and depression that was overwhelming. This was around the time of her admissions to hospital. Sadly, this also coincided with the time that Dave, her partner, passed away suddenly and she was on her own. For the most part, since Dave’s death, Dawn has holed up in the apartment they shared and turned her back on the world.
When she finished, Dawn sat back in her chair, drained. “How….how did you survive all that?” Was all I could manage. “I could hardly bear to hear it, let alone live through it.”
“I don’t know.” Dawn replied in a barely audible voice. Tears were creeping slowly down her face but she made no attempt to wipe them away. I reached for the tissues all we crisis workers kept at the ready and passed her the box. She held it in her hand but seemed not to have the energy, or motivation, to pull one.
“None of this is in your record.” I was confused.
“No one here ever asked.”
“Oh…” Sadly, I figured this might be true. Only recently have we acknowledged the link between trauma and mental health, even though its been staring us in the face for years. “We haven’t done a very good job by you then, have we?”
“Don’t beat yourself up.” Dawn said unenthusiastically. “No one’s done a very good job by me; even me.”
“Well, I’m glad you shared this with me. It helps me understand a lot better who you are and it makes me appreciate how strong you are to have survived all this.” Dawn leveled me with a confused look. “I know now that I was right to trust you to go home yesterday…” A moment of panic crossed her face. “…and I know that you will be safe when you go home tonight.” Her panic subsided.
“You know, just like before, having resurrected all this today will likely make for an uncomfortable night tonight?” Dawn nodded. “Is there anything practical I can do or help you with that might make it easier for you to hang on until you come back tomorrow?”
Dawn wagged her head and replied “No. I don’t imagine it will get easier for a long, long time.”
“Listen to what you said.” I smiled. But Dawn didn’t smile back. “You said it won’t get easier for a long, long time…you didn’t say it would never get better. I think your heart might feel a wee spark of hope.”
Dawn set her elbow on the arm of the chair, sat her cheek on her knuckles and raised her eyebrows questioningly. “Sure Hattie. If you say so.” But there was at least a shred of amusement in her tone, which laid a wee spark to my hopefulness.
“One last question.” I hated to do this but I knew I had to. “We know this will be a rough night. Are you safe? Are you ok?”
“You called it Sister.” Her spunk returned with a fury. “I am strong and you said it, I’ve been surviving this for a long time… Safe? That’s a strange concept for me. But I will be here tomorrow. Same time?”
“Same time.” I stood. “Dawn, thanks. I know it was hard to tell me your story. I know it will continue to be hard to keep coming back to it. But I’m glad you did.”
“I’m glad I did too.” And she turned and left the room.
After she left, I addressed the required risk scales and as I expected, they were off the charts. Liability experts would rake me over the coals for letting her leave yet I felt that I had no choice. I needed to trust that she could handle this. Not that I throw caution to the wind all the time but this situation was one of the outliers that actuarials don’t cover.