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Case Example

Mrs. Dee, age 32, was referred to the mental health clinic by her case man- ager. When she arrived, clinging to her were her four children: Doddy (age 2), Bryant (age 3), Katie (age 5), and Sally (age 6). The children were unkempt and waiflike. Mrs. Dee, chain-smoking cigarettes, stated that she wanted some Valium for her nerves. Mrs. Dee lives in the project with her husband, Jim. She and her family (namely, three sisters, a younger brother, father, and mother) have been known to the multiservice health center for more than 15 years. Mrs. Dee, upon questioning, revealed that she felt things were just getting to be too much this morning, and she decided to call her case man- ager. Although she did not describe herself as depressed, questioning revealed

that she was hearing voices telling her not to eat because the food was poi- soned. She had lost 20 pounds in the last month, and her sleeping was erratic because she felt the neighbors were able to see through her walls. She, as well as the children, looked emaciated. Although the children clung to their mother, she seemed to ignore them.

Three months earlier, Mrs. Dee had had a hysterectomy. She was upset with the home care she received after the surgery. She had been promised homemaker services, but when the homemakers came to the apartment, they quit the next day, which she attributed to the fact that they were Black and she was White Irish. A month later she got into a row with her father, who was an alcoholic. Her husband, who was out of work, was at home most of the day or out playing baseball. During this time, her three sisters were in and out of her apartment, as was her brother. All her siblings were on drugs or were drinking. Two sisters had children and presently the state was step- ping in to remove the children from their mothers because of neglect and multiple injuries that could not be accounted for.

Shortly after her return home from the hospital after the hysterectomy, Mrs. Dee slashed her wrists. She was taken to an emergency ward, where her wrists were stitched. She refused to talk to a psychiatrist. Homemaker help was sent to her house, but she refused to let the homemaker enter her house. She did develop a relationship with a nurse, and she recounted a life full of struggle. Her first child was born when she was 16. She married 2 years later and had another child, followed by a divorce, then marriage to her present husband and two more children. She had difficulty with her husband, who often beat her. During this time a social worker came to the house, and eventually all these children were placed in a home and later were given up for adoption. Thus, Mrs. Dee forbade any investigation into the records at this time for fear her present four children would be taken away. She claimed that she had been abused by the authorities and that her children were removed from her against her will. The current stressor of the hysterectomy and its unresolved meaning reactivated underlying psychotic symptoms and heightened the multiproblem nature of this family.

Such crises reflect serious mental illness in which preexisting problems have been instrumental in precipitating the crisis. Or the situation may in- volve a state in which the severity of the illness significantly impairs or com- plicates adaptive resolution. There is often an unidentified dynamic issue.

Other examples of serious mental illness include diagnoses of psychosis, dementia, bipolar depression, and schizophrenia. The patient response will be disorganized thinking and behavior. The etiology is neurobiological.

The case example indicates that Mrs. Dee was experiencing perceptual diffi- culties and paranoid thinking. An unresolved issue for her was related to the hysterectomy and the psychological meaning of the end to her childbearing.

Intervention

The clinician needs to be able to diagnose the mental illness and adapt the intervention approach to include appreciation of the personality or charac- terological aspects of the patient. Persons with long-term and recurring se- vere mental illness require a mix of traditional medical and long-term treat- ments that are helpful in sustaining their function and role. Roberts’s (1991, 1995, 1996) crisis intervention model may be used to reduce symptoms in an acute crisis.

The crisis therapist responds primarily in terms of the present problem of the patient, with an emphasis on problem-solving skills and environmental manipulation. The therapist gives support but is careful not to produce or reinforce dependency or regression by allowing the therapeutic process to become diffuse. The therapist acknowledges the deeper problems of the cli- ent and assesses them to the degree possible within the crisis intervention context, but does not attempt to resolve problems representing deep emo- tional conflict. Through the process of crisis intervention, the patient is helped to stabilize functioning to the fullest extent possible and is prepared for referral for other services once the process has been completed.

Case monitoring and management are indicated, as well as an assessment for inpatient hospitalization or sheltered care. Medication will be needed for psychotic thinking. Continuity of care is critical with this level of crisis and is generally accomplished through the case manager. Other services should include referral for vocational training and group work.