Linh has been brought by ambulance to the Emergency Department of the local metropolitan hospital where you are working, following a drug overdose of thirty Paracetamol tablets which she took at home this morning.  Linh was found collapsed at home by a family friend who had called in to visit Linh's parents, unaware that they were away for a few days.  Linh's family has yet to be notified about Linh's transfer to hospital.

On arrival at the Emergency Department, Linh is conscious but very withdrawn and tearful.  The treating team in the Emergency Department are concerned about Linh's current presentation and have requested a psychiatric review.

As the mental health clinician on duty, you have been asked to review Linh and to provide some recommendations to the treating team as to how to best manage Linh's current situation.

Question 1

Therapeutic relationships are the central activity of mental health nursing.  What factors would you consider and what steps would you take in attempting to develop a therapeutic relationship with Linh?        

As you approach Linh to begin your assessment, you observe that she is curled up in the foetal position on the Emergency Department trolley.  Linh is wearing a pair of faded, dirty denim jeans and a thin, black, short sleeved T-shirt.  Her brown, shoulder length hair is unwashed and knotted.  Her face is streaked with tears and she appears very thin and pale.  She is clutching a number of wet tissues in one of her hands.

Although Linh agrees to talk with you, she avoids any eye contact with you and throughout most of the interview  Linh maintains a downcast gaze.  Linh's conversation is logical and easy to follow, however, she responds to your questions with effort, sighing frequently, frowning and shrugging her shoulders throughout the interview.  At times, you need to wait several minutes before Linh replies to your question and often Linh's replies are only one or two words at a time which are barely audible.  Through tears, and speaking in a soft, flat, monotone voice, Linh tells you that she feels sad and lonely and that she has no energy for life anymore.  She states -  'I feel so alone and empty.  My family doesn't understand how I feel.  I can't talk to my parents about how I feel so I just stay in my room when I'm home.  I don't even enjoy work any more and I don't want to be around my friends at work'.  When you ask Linh how long she has been feeling this way, she tells you that she has not felt happy for about three months, but that she has felt much worse over the past two weeks.  Linh also discloses to you that she wishes that she had died today and is angry that she was brought to hospital.  She states - 'I really hoped that I would die today - life is not worth living anymore.  How am I going to face my family now - they will be so ashamed of me'.  Linh tells you that she can see no way out of how sad she feels and she tells you that she will have to find a more certain way of killing herself.  Linh refuses to elaborate on this statement any further.  She insists that she just wants to be left alone and be discharged from hospital and she asks you not to tell her parents about today.  Linh states - 'I'll be okay.  I'm sure that you are busy and that you have other people you need to see'.

Despite these comments Linh is cooperative with the remainder of the interview.  When you ask Linh about her recent and current sleep pattern, she tells you that she sleeps every opportunity she gets so she 'doesn't have to think about anything'.  On further exploration you discover that Linh usually sleeps six to eight hours a night, however, over the past three weeks Linh has been sleeping ten to twelve hours at night and two to three hours during the day on the days that she does not have to go to work.  Despite this amount of sleep Linh tells you that she still finds it difficult to get out of bed each day and that she feels 'hungover' when she does wake.  Linh informs you that she has missed quite a lot of work lately because of this.  She is worried that if she continues to take time off work she will lose her job which will bring further shame on her family.  Because Linh is so worried about her absence from work she has also been finding it difficult to eat over the past two weeks and, as a result, she has lost approximately six kilos in weight.

When you ask Linh about her boyfriend she begins to sob uncontrollably.  Through her sobbing she tells you that her father has forbidden her to see him again.  Linh tells you that maybe it would just be better for everyone if she was no longer around anymore and states - 'Life is just so hard.  I can't go on'.

Linh denies any past or current history of alcohol abuse or illicit/licit substance abuse.

Linh also denies any history of unusual experiences such as seeing or hearing things that others can not.  During your interview with Linh you do not see any evidence that she may be responding to unseen or unheard stimuli.

Question 2

Using headings, write a comprehensive mental state assessment for Linh. Your answer should also include a Formulation.                                                                                                                 

Question 3

What would be your conclusion in relation to Linh's current level of risk and what factors have led to your decision?

Question 4

What recommendations would you provide to the treating team and what are the rationales behind your recommendations?