# 20211206 Systemic Supervision 6 Dec 2021 #systemic #Clinical #neglect Shahrin presenting an inpatient case who is in the ward. ## Overview 27 year old chinese female, single, unemployed, staying with parents and elder brother. Parents 56 year old (Buddhist). 29 year old brother, 23 younger sister (asst engineer), 20 younger brother. Diagnosed with NeurofibroMATOsis since young -- related to self-esteem, and identity. #shame ==Who does she blames?== ==who can she be grateful for?== Piano teacher of 8 years. Stopped working. Probably longer DUP. ADL deteriorated. Then got brought in by police. She did nothing wrong she said. Known to us for 2 months. #schizophrenia Schizophrenia. ==why now? What has changed in the last two months== 17 Sep 2021, came to E room. Paranoid, persecutory, against family and neighbor. Organic workout negative. #paranoia Brought in by family due to violence. Refused treatment. Called ambulance. Came to IMH for the first time. In the ward. Pretty much co-operative in our ward. Not compliance to medication and treatment. Not keen to go home. Not trusting of family members. Currently applying for step down care with ACC Simei. Currently "let's agree to disagree" in term of diagnosis. ==what will be the losses if accepting diagnosis. What's her view of what has happened== Today interview goals: **Family dynamics** - Two sons and two daughters. ==favoritism== Preferential treatment to sons ==gender== Both sister gave the same feedback. ==so what if it is true?== - In the family session, sister align with patient. pt verbally confront parents. But patient and sister communicating as if no problem. So the context of interactions differ. - The younger sister may collude with the patient, and share the belief that patient indeed don't have a mental illness, it's all parents' fault. **Today worker requests** - Parents are keen to repair relationships. patient just want to get out of the ward, and pursue what she want. Worker not expecting much can be done in these three years. She hope that patient repair relationship with family. Intent and unintended effect: ==Patient not keen, rapport will be rapture.== - Worker want to ask questions to remind pt about her resilience (demonstrated in the ward) strength, and how she copes in the ward (when she was stressed), and want to ask miracle questions how will relationships be? - Intention and Effect: ## Questions - PS not sure of the abusive part, curious to hear about her pain. What has she been fighting against? How will understanding her pain help her with living in Simei. ==what is the most constant painful she experiences?== - When she acknowledge the pain, then she can face it and move on. - Why now? - Explanatory model. - Charlene want to understand childhood experiences, who are the significant figures. #Attachment - What is her personality like? Like how does she manage stresses, what kind of narrative she tell herself? Who is she?? As the first born female. Who was part of her affirming voices. - "The ability to live life is the ability to embrace reality." - Juliana - Where is father? Emotionally distant? - FSC involved. Mother in the midst of applying for PPO. - Future oriented questions - how is she going to manage for herself... - The pain come from rejection, and not feeling protected by her parents. The sense of #rejection Not feeling a sense of belonging. - Preparing about living on her own -- What she learnt that was helpful, or not helpful? - - **Setting the intern** - ==What is the hope you want the patient to go away with from the session today?== She will be seen, she is acknowledged, witness, and she is a person.. her voices is heard. She will be cared for. ## Reflecting Team - Life giving, encouraging, can be challenging. Affirmation and hope. ---- ## Interview **Can you think of a time recently, in the past, where you drum up courage to handle a situation?** - I am not a very emotionally driven person. I don't need emotion/ courage to do things, i just do it. ==That's significant== - Transported from IMH to NUH, ==feel powerless and not having choice for herself== - Forcefully transported in the stretcher, might as well succumb to it. Relax. ==trauma from healthcare not our desire== - I am just realistic. Since i cannot do anything ==Being realistic is not easy! people have expectations, and fantasy.. YET pragmatic and do something about it. == - Realistic. Repeated many times. ==Wonder where she learnt to deal with life circumstances in that manner? from who?== **Think of a time you lost someone close to her?** - A hamster passed away. Sister told pt that a hamster died. - Too Too ==i am curious, though, how she is really feeling about things that happened though... == **Adverse life experience (2 years ago)** - Do not think it's possible to have relationship with terrible people, aunty and uncle, to get angry.. was emotionally tough ==what happened?) - Too be rational, to not get angry, ==i wonder if she is just tahan tahan everything...keep things to herself== - Seek Justice? How did this make her emotionally stronger? - Because she overcame it before, 2 years ago incident, she feel better to cope with similar situation. More prepared. "Levorn" ==This idea of "being strong", "being realistic", i wonder where it is from..Should we encourage the belief of rationalizing "being strong", "being realistic"== ==Balance. Whether there is space to attend to herself, her emotions== "You reminded that i am adaptable" ==I see a lightbulb.Connected with her== "it's nice to have external validation" ==Who helped during those period== - Who else see that, and have provided that validation before? - How about your sister? I don't know. - Who does she want to hear it from? Someone who is realistic and good judgment. Maybe from my father, sister. ==How come want to hear from the father and sister?== Rational, ==have there any experience she made a irrational decision== **Knowledge/Belief. Emotions doesn't mean irrational. What do you think about feeling? and feeling and thinking integration. ** Walk around, to release tension. When she was walk, already doing it. Breathing technique. **Miracle Question** ==I am hearing that she want to feel calmer, happier and excitement. == Fluffy bed. Make breakfast Planning to meet those people good for him, who uncle billy, IMH friends. Sister. Uncle billy is always interested in her, listening to her, attentive and pay attention to him. ==There are people in her life who pays attention to her. Who is interested in her.. I hope as she quiet down, and re-call, who else can she bring out?== Always being content.. To be really happy is surprising for her. ==Being contented.. she deserves to feel happy== I will be a lot calmer. Happier. Will be less triggered by parents. Will be more equipped to deal with it. ==What will help with equipping her?== I am bored with my life.. Routine... ==She is holding it, coping and tahan life, being realistic and managing.. but hope she feel more excited, happier.. == Miracle - Varieties, happened before, and new. Living again ==some part and aspect of herself== **What is one or two things that she can take away about herself, that can harness, be a strength and resource for her?** - To explore emotional side ## AAR ==Anything new that came out was unexpected?== - being validated ==Did this session move you closer to her original hypothesis or changed? what changed?== ==What risks would you have taken?== - Worker worried about breaking rapport with patient, when asking difficult questions. - If pursue, what kind of effect. - "I don't want to open the can of worms", - Don't want client to be in emotional distress -==this is worker's assumptions beliefs== I like the non-planned question more. ==To ask questions that they have not heard about, that will encourage them to think and reflect, and consider== ==Concretize a word, and experience. So she is aware of what was that, and we can recognized that== Reminded me of this article [[20211120 What are latchkey kids?#^e628ef]] Children who are #neglect are traumatized, and cope by addiction. ---- This patient suppressed her #emotions and only go up into the thinking. She doesn't feel.