HoNOSCA case study written vignette - Mereana

Admission to inpatient unit - Rating 1

Report from CYFS social worker

Mereana is a 14-year-old Māori girl who was referred as an urgent assessment to CAFS by her CYFS social worker after she threatened to kill herself at a recent Family Group Conference (FGC). Mereana appeared before Youth Court three days ago on charges of assault, burglary, and theft. Youth Justice has known Mereana since age 12. One week ago, Mereana was picked up by Police in Manners Mall abusing solvents, in possession of cannabis and shop lifting.

Mereana’s father is currently serving a 7-year prison sentence for aggravated robbery. He is an active gang member, as are Mereana’s two uncles who live in the same street. Mereana is very close to her father and visits him regularly.

Mereana has a history of truanting since she started secondary school at age 12. Currently, Mereana has missed 20 consecutive days of school. Her average grades for the first term of this year, which ended last week, were D. Prior to beginning secondary school, Mereana was described as an A grade student.

Initial assessment (Psychologist (CAFS Team), Mereana, Donna (Mereana’s mother)

Mereana’s initial presentation at assessment was sullen and uncommunicative. The dynamics between Mereana and her mother were very hostile and halfway through the interview, it was decided that they needed to be seen individually.

Mereana has been ‘cutting’ since she was 12 years old. She showed me her stomach where there were approximately ten fresh cuts. On questioning Mereana stated she had done these five days ago. There were also numerous scars. She refused to show any more cuts and refused to disclose how many cuts she had on her body. When asked why she cut herself, Mereana maintained they were tattoos. She has tattoos on her hands. Mereana later disclosed that cutting helped take her mind off her worries and was something her ancestors used to do in the old days when someone they loved died. Mereana stated she had lots of ways that she could kill herself but that she had threatened suicide at the FGC only because she didn’t want to go into a CYFS home.

Mereana acknowledged that she spends most nights on the streets with gang associates, and that in regards to alcohol and drugs she would try anything she could get her ‘hands on to get wasted’.

At the end of the first assessment, Mereana reported that she had recently broken up with her 18-year-old boyfriend and had gone on a binge of alcohol and drugs. She said she was ‘bummed out’ that they had broken up but blamed another girl who had ‘gone with’ her boyfriend. She also said that the girl ‘had better watch out for me’ and that she would give her ‘a hiding.’ Mereana stated that she wanted ‘utu’ (revenge). She said that her ancestors had told her to get utu on this girl. She described being obsessed with this ‘other girl’ and being unable to think of anything else except what she would do if she saw her. Mereana acknowledged that five nights ago she had been involved in an altercation with another girl and had stabbed the girl because she thought this girl was with her ex-boyfriend.

Mereana stated that over the past two weeks she has had difficulty sleeping (not being able to get to sleep) but found alcohol and drugs helped her to get to sleep. Mereana reported that she did not care if she never saw her mother again.

Report from Donna (Mereana’s mother)

Mereana’s mother, Donna, stated that Mereana often stays out at night and that she felt she could no longer control her. Mereana’s mother stated that she had tried over the past couple of weeks to understand why this was happening to Mereana. She said she didn’t understand and although she felt bad and somewhat responsible for Mereana, she no longer wanted her daughter living with her and was scared for her own life. She described her daughter as being ‘just like her father, a druggie, pōrangi (mad) and violent.’ She stated she had tried everything and didn’t think anyone could help her daughter. She explained that Mereana is defiant and aggressive towards her and has threatened her with a knife in the last week. She stated that Mereana has knives in her room, but that she is too scared to try to confiscate them because of what Mereana might do.

Admission to inpatient unit (report from nursing staff)

On admission, Mereana is aggressive and threatening to staff. She threatens to hang herself and is placed on 15-min observations. Mereana’s mental state appears to deteriorate during the day and she is observed talking to herself whilst trying to scratch her arms. She threatens to kill another patient on the unit, believing this girl has been sleeping with her ex-boyfriend.

Discharge report (Discharge from inpatient care 10 days later) - Rating 2

Social worker report

While Mereana was on the ward, three family hui (meetings) were conducted under the guidance of Kaumatua (elder). The last hui was held three days ago where Mereana’s extended whānau (her uncles, an aunty, her mother and grandmother) discussed where she would live. It was decided that with the assistance of the whānau, Mereana would remain living with her mother. Mereana’s aunty would come and stay with them for two weeks whilst Mereana settled back into a routine at home. Whilst hostility still exists between mother and daughter, the whānau wanted to try this option rather than have Mereana placed in a foster home. Mereana’s mother and whānau acknowledged that, whilst they still did not fully understand some of the issues for Mereana and how to best help her, through explanations provided by Maori Mental Health Services and Mereana’s psychiatrist they now better understood Mereana’s difficulties.

The whānau strongly support the involvement of Maori Mental Health Services and Mereana has engaged with the cultural support worker who will continue to see Mereana after her discharge from the unit. Whilst on the unit, Mereana participated in cultural groups (Te reo (language) and harakeke (weaving) classes) but would not participate in school classes. She did however complete a maths test appropriate to her schooling level, which she failed. Given that Mereana has missed a lot of school this year, it has been decided to try alternative schooling upon her discharge.

I will continue to work with Mereana and her whānau and liaise with mental health services. I will also liaise with Youth Justice post-discharge.

Progress notes – Kaumatua, Māori Mental Health Service

Mereana has responded to our involvement. We have had a number of discussions regarding her need for utu. Mereana has experienced hearing her ancestors since childhood, although this appears the first occasion where her ancestors have told her to commit acts of violence. She acknowledged feeling scared by these voices in the past, but feels much happier now knowing that she is not ‘crazy’. Over the last five days Mereana has no longer felt the need for utu and is no longer distressed that she hears her ancestors. Mereana now has some insights on the negative effects of drugs on her hinengaro (emotional wellbeing) and wairua (spiritual). She continues to strongly identify with her gang associates who have visited her often since she has been admitted. The concept of cutting in traditional times has also been discussed with Mereana. She continues to cut, but at a lesser frequency. Alternative behaviours including karakia (prayer) are being introduced to Mereana and this will require further input from Kaumatua after discharge. Mereana has agreed to destroy the weapons she has in her room and we will visit at the house to do a blessing with the extended whānau.

Further practical support is needed for the extended whānau in order for them to be able to support Mereana and her mother. Mereana has stated that she feels sad that she does not get along with her mother and misses her father. Two days ago she had an argument with her mother and yelled at her. Further whānau hui required to enable mother and daughter to address their issues.

Psychologist discharge summary

Mereana was observed on the ward for 10 days under the Mental Health Act. Mereana’s suicidal ideation has abated in the last seven days. Whilst she continues to engage in cutting, the frequency has diminished in the last week (cutting incidents have occurred in the past two days) and cultural interventions are continuing to address this issue. Mereana continues to ruminate about her ex-boyfriend, but has stopped discussing issues related to utu and believing that every young woman she sees is sleeping with her ex-boyfriend. There appears to be wide whānau support although the relationship between mother and daughter continues to be strained.

Mereana was caught three days ago, smelling of, and in possession of cannabis. This was the fourth time since admission that staff had suspected Mereana was using cannabis. On questioning, Mereana confirmed she had used cannabis whilst in the unit. Mereana has agreed to receive alcohol and drug counselling upon discharge, to be coordinated by Maori Mental Health Services.

It is noted that on admission Mereana reported feeling distressed at hearing her ancestors and their instructions for ‘utu’. Mereana does acknowledge that she has on one occasion over the past three days heard her ancestors but she has not been distressed as they no longer command her to commit ‘utu’. These experiences which have occurred infrequently since childhood are generally not consistent with those characteristically associated with a major mental illness. In the last week there have been no incidences of threats to staff or other patients. Sleeping at night has improved over last couple of days. Appetite normal. Mereana’s general mood appears stable.