Madeline’s Case Study
Madeline came into the outpatient acute psychiatric unit in the early morning. She
arrived at 6am although she knows that there is no clinic before 9 am. Madeline rarely
made appointments with her outpatient psychiatrist, but sometimes she would request
to see her clinic nurse, also she never kept her appointments. She just popped in
spontaneously and sat in the hall until the nurse could squeeze her into the remnants of
her schedule. She looked homeless, but she was not homeless. She lived in a lowincome apartment outside the city. Madeline rode the bus for about an hour each way,
but she said that she enjoyed it because it was about the only time she got out of her
apartment.
Madeline had been living in her apartment for many years. She was a white woman
with shoulder length, brown, tough hair. She was about 50 years old, but she looked
65. Her hygiene was very poor, and her teeth were visibly rotten. She had many fresh
superficial cuts on her wrists and arms, and few old scares, but she never wanted to
talk about it. She was very thin, and her eyes bulged from her head. She was very slow
in speech and in expressing herself. Madeline abused alcohol, and it is possible that she
was usually intoxicated when she made an appearance at the clinic. She usually sat in
the hall in an oversized, black coat with a few crumpled plastic grocery bags at her feet
in the floor. She used these little bags as a purse, and there were random items inside,
usually a bottle of some kind of liquor wrapped in more bags.
The first time I talked with Madeline, it was less of a conversation and more of an
opportunity to get acquainted with her and to know about her illness. She usually
refuses psychiatric medications, although she used to take them few years ago,
because she was certain they were "poison". Madeline is off all her medication at the
moment; however, she did like to drink alcohol, which professionals see as selfmedication for the suffering of untreated symptoms.
Madeline talked to me for an hour at the first meeting with her about how she was
"married to a man from the FBI" and how they had "children together". Although she
told me their names, she said she had no contact with the kids or anybody else in her
family. She did not act very upset over the matter, and she seemed emotionally
detached from it. I could neither find her children through public searches nor could I
find a record of the "FBI agent" to whom she claimed to be married. Just because I
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could not verify the information does not mean that it was not true; but, likely, her
"marriage" to the "agent” was a story she likes to talk about. Of course, it could have
been true. She also claimed that she had been an actress for many years and traveled
"all over the world" but did not really provide any concrete details. As an actress, she
claimed that her manager has “sold her out cheap” after she refused to have an affair
with him”. Madeline told the story as if she was speaking of someone else’s story and
not her own.
Madeline’s x-FBI husband still sometimes talks to her, but in a secret way. She insists
that he “known how to get in touch with her without raising any doubt” especially with
her upstairs neighbor “Jacky the witch” who really hates her and planning to poison
her. In fact Madeline mentioned this neighbor few times in the past as a dark witch who
enjoys watching people suffer.
Madeline denied hearing any strange voices, although that does not mean she did not
hear them. When asked about it, she grew upset and defensive, but she has been seen
talking to someone who was not there, or, at other times, were listening intensively to
some sort of conversation. She was very guarded about a lot of things, so instead of
talking about what she was feeling or sharing insight about her symptoms, she went on
and on about the "FBI agent" and how he "stole all my money!" and now planning to
bug her apartment with all kinds of “little tiny devices”. Madeline was very guarded
emotionally and stayed preoccupied with these fixed ideas. The alcohol factor also
complicated her mood and my ability to get a good read of how she was doing
otherwise. Talk therapy with a person who is psychotic is not very effective and tends
to be circular and pointless. Mainly, I just listened to her and encouraged her to talk
about her medication because no amount of dialogue was going to make her any less
psychotic.
When I ask Madeline about something she does not like talking about she either change
the topic of conversation or start crying, but with no tears. Most of her issues she
considers as a result of severe traumatic childhood, and bad abuse by both her parents.
In fact records show that Madeline has lived most of her life in orphanages and
sheltered accommodations.
Madeline has poor self-care and hygiene, alcohol abuse, as well as a flat affect, or little
emotional expression, particularly in her face. The exception to this flat affect is when
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she came into the clinic upset about her "check" or "special requests" in which case she
was very argumentative, screamed, and criticized everyone around. She would grit her
teeth, wave her arms, get in your face, but she would never do anything to hurt
anybody.
"You come here, you little turkey!" she would scream. It was usually difficult to tell if
she was just angry or if she was intoxicated. Sometimes, her intoxication was more
obvious than others. Madeline also referred to me as a "little rabbit" on friendlier
occasions. It seemed to me that her mood had nothing to do with my performance as a
nurse and everything to do with her illness, not having much money, and alcohol
intoxication. Those were the factors that determined whether she was angry and
screaming or quieter and even friendly.
Madeline would sometimes keep very quiet and do not want to talk to anyone. She
would leave requests for "special draws" with long, rambling requests, something like,
"Need $450 for three new tops, mine are torn, a new travel clothes I want to go on
holiday, a teddy bear for my nephew, and a box of chocolate". Madeline had no
nephew with whom she was in contact, and she had no money to go on holiday.
When people are living on little money per month and they have payees required by the
Social Security Administration, accountants at public mental health clinics are not going
to accommodate emergency requests for new clothes, bikinis, teddy bears, and
chocolate, or else they are not doing their jobs very well. Outside of the monthly
budget, there was little deviation in money withdrawn, because there was so little. It
basically had to be an emergency. Madeline, like others, would make requests every
time they came in, and then they would be upset when the requests were denied.
People take pride in managing money, or not managing money, whatever the case may
be. So, to have someone else managing their finance seem to take that power from
them leaving many of them feeling insulted and defensive.
Although Madeline did have a flat affect, she did express her anger and outrage over
her disability check and how it was taken away from her. The clinic paid her rent
directly, as well as her bills, and the rest was divided into weekly "draws" that she
picked up. Because of the alcohol consumption and her lowered inhibitions, she did
lower her guard and let loose in the lobby sometimes. On one occasion she started
screaming at me in the little interview room and a few people came in to check on us.
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Despite her outbursts, Madeline seemed to like me, actually, as much as she could. This
cannot be said for many patients and their nurses. Despite her illness and despite
coming in sometimes to scream at me, she liked me. She would sit in a small interview
room and tell me over and over again about the "FBI agent" and her "sons" and how
they "abandoned me". Her speech was slow and the pronunciation of her words was
very drawn-out and lazy-sounding. It may have been part of her personality, it may
have been alcohol, and it is possible I never actually saw her without her being
intoxicated to some extent in order to be able to distinguish the difference.
Madeline did seem sad sometimes, but mainly she was just quiet. She rolled her own
cigarettes because it was cheaper. There was a sad, out-of-this-world look to her,
which is not a very clinical description as much as it is a simple impression of her that I
remember. She did not look healthy, but she also did not seem interested in addressing
anything in regards to her psychiatric condition, alcohol abuse, or medical issues. She
refused to go to the doctor, said they wanted to "control" her, and she never did to my
knowledge at least in the past couple of years. She lived an hour away from hospital,
and it was not as if I could walk a few blocks to knock on her door and escort her as I
did with other clients.
Madeline sometimes liked to sit next-door at the Day Center that complemented our
mental clinic. She would eat lunch and sit around for a few minutes. Still, she was not
very social. If I went over there and sat with her, then she would talk to me; but, social
skills were never one of her best qualities. Everything about Madeline seemed in some
way indicative of her desire to avoid people. Her appearance further deterred people
from getting too close.
The Day Center next-door provided a setting where people with similar problems could
get together in a safe environment, have lunch, visit, or attend daily group sessions of
various kinds. Madeline never went to groups, nor would she even see the psychiatrist
on the clinic side, except for one occasion in which she left his office screaming that he
could "go to hell!" Her diagnosis had been made about 30 years ago.
It was surprising to me that Madeline and I hit it off as well as we did, and still we had
our moments. I realized that she did not mean anything personally even when she was
screaming at me. On one occasion, my boss came out to see "what is going on" and
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Madeline turned on him. She escalated and I realized it was not me, it was her illness
and alcohol abuse. She was not angry with me, she was just angry; and, it did not
matter if it was me or my boss at whom she screamed. She was simply asked to leave
on that occasion like every other disruptive client, because that is not a healthy
environment for anyone, especially an office full of psychiatric patients who are already
kind of on-edge. Eventually, Madeline would storm out and with frustration walk in her
big long coat carrying her plastic bags towards the main bus terminal downtown.
After working with Madeline for about a year, she was absent for a few weeks, which
was unusual. The last time I saw her, she had turned up at the clinic and told me she
was worried because the whites of her eyes had been yellow a few days prior, which is
a sign of jaundice, and it can be an indicator of a failing liver. The whites of her eyes
did not look yellow that day, and she was delusional; however, we did make her a
doctor's appointment in her suburb outside the city. She did not go to that
appointment, which was not unusual at all.
After a few weeks without hearing from her, I made a call to her apartment complex.
The manager said she had not picked up her mail, which was not a good sign. She had
not looked well the last time I saw her, but she never looked well. Without ever going
to the doctor, there had been no opportunity for preventative medication,
hospitalization, or even emergency intervention. All there had been for her was selfmedication with alcohol, untreated symptoms, and a mostly isolated existence in a lowincome apartment outside the city. So, my boss drove me to do a "home visit" at
Madeline's apartment. After knocking on her door and receiving no response, we were
forced to call the police to come and open her door.
The police officer went in first and came back out indicating that there was a bad smell.
He asked if I could go in to identify Madeline because there was "a woman in the
bedroom". When I went inside, her apartment did not look so bad, although the smell
was very bad. Madeline's body was lying face down on her floor. There were fluids
around where the body was lying and it was visibly some three empty bottles of
medication, some type of pain killers. After a while, a week, ten days, whatever, it is a
little difficult to identify a familiar person. People do not look quite the same after they
die and the body begins to undergo the process of decay; but, that could not have been
anyone but Madeline. Madeline had enough of her life and wanted an early check out.
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