Case study: Lily

Lily is a 14-year-old girl who is currently an inpatient on a CAMHS unit due to a major depressive episode, which has resulted in multiple episodes of self-harm and attempts to take her own life.

Lily has been at the unit for four weeks, and staff have reported concern that her presentation has progressively worsened. This has been marked by an increase in the frequency and intensity of her self-harm, leading to staff members restraining Lily in order to prevent her from causing further harm to herself. Staff have also confiscated several personal items of Lily’s (headphones, hair grips, toiletries) to reduce the risk of Lily using these items to self-harm further.

Due to the severity of her self-harm she has been placed on one-to-one observations. Staff have reported that she is often verbally and physically aggressive to the staff member conducting these observations. These events have resulted in further physical restraint. Due to the severity of Lily’s presentation, and her lack of insight into the risk she poses to herself if discharged into the community, staff have recommended that Lily be detained under the Mental Health Act to receive appropriate treatment.

Staff report that they feel stuck as to how to help Lily and how they can build a therapeutic relationship with Lily whilst also maintaining her safety. They hate restraining her, but feel they have no choice in order to protect her.

Let’s consider a trauma-informed approach to Lily’s presentation. We need to consider earlier life events/trauma that she has experienced, and which might be contributing  to her depression and current presentation.

Between the ages of six and 11 Lily witnessed, and was subjected to, domestic violence by her mother’s partner. For Lily, this individual was seen as both a source of protection (provided a place to live, food, clothing), but also a source of threat (due to physical violence and emotional abuse). Through an attachment perspective this may have caused Lily to become mistrusting of adults. This experience of the world and others has then contributed to Lily developing self-harm, as a way to cope with the stress of this world-view.

Staff preventing Lily from self-harming may have then caused further distress by denying her the opportunity to use the only coping mechanism she has experience of using. Subsequently, the way in which staff prevented Lily from self-harming (by physically restraining her), may have been reminiscent of the domestic violence she was subjected to when she was a child. This mix of feeling re-traumatised (increasing Lily’s distress), and being prohibited from utilising her go-to coping mechanism, may have galvanised Lily’s mistrust of others/staff (causing her to be aggressive towards staff).

And at present both staff and Lily are engaged in a toxic dance where staff impose restrictions to keep Lily safe, but this is perceived as controlling by Lily. The more Lily feels controlled, the more powerless she feels, which results in her becoming more aggressive and violent towards herself and others in order to reclaim some autonomy.

Please refer to the main ‘Minimising Violence and Related Harms’ chapter in this book (Chapter 26), as well as the chapters in this book on self-harm (Chapter 39), compassionate care (Chapter 45), care planning (Chapter 23)and also therapeutic engagement (Chapter 21) to assist you to consider the following:

1. How can you assist Lily to trust you?
2. What can you do to enable Lily to feel safe?
3. How would you help Lily to contribute to her care plan
4. Who else needs to be involved in her care?

Note: Reflect on how you might approach these situations. If you’re not sure, discuss with your tutor or placement mentor