18 year-old Sandy

https://www.ranzcp.org/Publications/E-learning.aspx

’18-year-old Sandy’ is a case study which features in modules on Indigenous Health developed by the Royal Autralian and New Zealand College of Psychiatrists (RANZCP).  This hypothetical stofy of a young woman who has suffered a miscarriage at 9 weeks gestation forms part of the e-learning in Module 1′ Interviewing an Aboriginal or Torres Strait Islander Patient. 

’18-year-old Sandy’ also features in Module 2: Developing a mental health management plan for an Aboriginal or Torres Strait Islander patient and Module3: Formulation of a case involving an Aboriginal or Torres Strait Islander Patient

Students of the module are asked to read the case study and answer the following questions:

What do you think the psychiatrist did to create barriers between himself and the patient, Sandy?
What do you think that he did well?

Background

18-year-old Aboriginal woman suffers a miscarriage at 9 weeks gestation. This is her third pregnancy. She has no previous contact with psychiatric services, and no previous medical history. She uses alcohol and cannabis socially, but stopped when she realised she was pregnant. She has a job in town working as a receptionist. Her family is aware of her pregnancy, but her boyfriend of several months’ ended the relationship when she fell pregnant. She has not been dating since that time. Her family is involved in Sorry Business as her Uncle was murdered by his younger brother, a local cannabis drug dealer. Her Uncle had schizophrenia well controlled on his medication with regular follow up by the mental health service and Congress. Her other Uncle is now in jail. The family is involved in Sorry Business and she needs to get back to her family. Her family is unable to be at the meeting with the psychiatry registrar and consultation liaison nurse, and the Aboriginal and Torres Strait Islander mental health worker is busy with other patients, but will come by when she is finished. The Aboriginal and Torres Strait Islander mental health worker has been involved along with the ward social worker, and the Congress social and emotional wellbeing team.

Interview

The medical ward have sent a referral to the consultation liaison team to review her post-miscarriage, due to her being very upset about the loss of her baby. She has had 2 previous miscarriages over recent years. She was wanting this baby so that she felt she had someone to love. She refers to the fetus as a baby. She was looking forward to the pregnancy and birth of her baby, despite the loss of her relationship. Her ability to have a baby is very important to her.

Setting

She is seen on her own, there is no private room on the medical ward, which is full today. In the young woman’s room is another patient with her family present, boarding in as they live out remote. There is a lot of noise from the other bed space, so it is not appropriate to see her there. There is only a conference room but it is not an interview room.

There seem to be no clear biological explanations for her miscarriages. There is a biological vulnerability to mental illness given her uncle had schizophrenia. Otherwise, she has been physically and emotionally well. There is a psychological vulnerability given that she has to deal with these deeply personal issues on her own as her family is involved in deep cultural business. This is deep women’s business, but some of those involved in her care have been male. She has managed to cope with the support of the Aboriginal and Torres Strait Islander health workers and the midwives and nursing staff. Unfortunately, she has also had to deal with the insulting behaviour of a doctor calling her baby a tadpole. She became very angry and is now upset by the incident. She is willing to talk with the female psychiatrist and female consultation liaison nurse. Her social and cultural issues are complex and complicated. Her family is involved in Sorry Business as her Uncle’s younger brother, a local cannabis drug dealer, murdered him on the weekend. Her Uncle had schizophrenia well controlled on his medication with regular follow up by the mental health service and Congress. Her other Uncle is now in jail, and the family is involved in Sorry Business and she needs to get back to her family.

She wanted this baby so that she felt she had someone to love. She refers to the fetus as a baby. She was looking forward to the pregnancy and birth of her baby, despite the loss of her relationship. She wanted to grow her baby up well. Her ability to have a baby is very important to her. The fact that this was her third miscarriage will have amplified the grief associated with this event. It has made it more difficult for her to accept her current circumstances and leading to her both literally and figuratively being unable to “let go” of her baby. Her sense of loss and desperation is also potentially increased because her family is involved in sorry business and therefore unable to support her in the way she may have expected. Her baby may also have represented to her, and her family, a sense of hope, in the form of a new life, given the family has recently suffered such loss in the death of her uncle. She may also have felt that being pregnant would have given her a greater sense of meaning to her life. She may have felt that the affection of her infant would have provided a constant source of affirmation that is otherwise not present. These factors combine to make it more difficult for her to accept her loss and mean that her circumstances need to be dealt with more sensitively. Particularly given she will not be persuaded that loss in early pregnancy does not mean the loss of an infant given what the pregnancy has meant and represented to her.

She has some profound strengths in that she is closely involved in her culture. She has strong beliefs and practices that provide a strong basis for her decision-making. She has been well supported by the staff and especially by the Aboriginal and Torres Strait Islander health worker, which has enabled her decisions to be appropriately and timely. She is employed and self-sufficient. She has supportive family. She wants to have a burial for her baby, and she does not want to leave her baby unattended and alone. That is why she carries her baby with her. She has made arrangements with the treating teams and the Aboriginal and Torres Strait Islander health workers to have an appropriate ceremony for her baby and to have a burial at home. She is happy with the plans and the Aboriginal and Torres Strait Islander health worker feels that what she wants to do is manageable culturally. The Aboriginal and Torres Strait Islander health worker feels it will give her the ability to grieve and engage in her own sorry business