March/April 2008

Therapist’s Notebook
Social Work Today
Vol. 8 No. 2 P. 24

Social Work Today presents a case study with input from three social workers—a case presenter and two discussants—who offer their insights on the case history and the initial phase of treatment.

Editor’s Note: Cases are fictitious. Any resemblance to actual clients is coincidental.

Case of Rosemarie
By Charles Rizzuto, MSW

Presenting Problem
Rosemarie is an 82-year-old woman of mixed English/German descent, retired, and in good physical health. She is seeking help because of the overwhelming stress generated by the serious mental illness of her two adult sons. Three months prior to her intake, the sons both began showing evidence of bipolar illness and were in full-blown manic episodes. Neither had any prior psychiatric difficulties.

Before this turn of events, she had been enjoying her retirement, traveling occasionally, and spending a fair amount of time in her two favorite pastimes, quilting and gardening. Her sons’ current behavior is frightening and troubling to her, and she fears that they may do themselves harm. Both are receiving outpatient care and medication, but it is unclear how compliant they are. She says she needs guidance in determining what to do with and for them. She seems in considerable distress, though outwardly quite controlled.

Family Background
Rosemarie grew up in New England. She had a brother who was six years older and severely developmentally disabled. He was sent to live in a group facility when Rosemarie was 6. She remembers nothing of her brother except that he came home for holidays and she was told when she was 8 that he had died.

The other significant event of her early years was the sudden death of her mother from an undiagnosed illness when Rosemarie was 11. Afterward, her father, who often traveled for business, left her in the care of her maternal grandparents. She describes this period as chaotic because no one helped her understand the death of her mother; indeed, no one helped her understand much about feelings at all. She loved her father and grandparents very much but now sees them as rather cold and cut off from their emotions, so she didn’t learn about feelings until later in life.

Rosemarie did well despite the early loss. At 27, she married Frank, who was one year younger. Two years later, they had their first child, Carl, who is now 52. They eventually had two more children: Jane, aged 50, and Peter, aged 49.

Around the time Rosemarie’s husband turned 52, he suddenly showed signs of mental illness and soon went into a major depression followed some months later by a full-blown manic episode. His illness threw the household into disarray, and he eventually left home and moved to the Northwest. The couple divorced roughly one year later. By then, Rosemarie was working as a registered nurse and eventually became a nursing administrator.

Carl married at age 25 and now has a 27-year-old son who is about to marry. Jane never married, and Peter is married with one daughter, aged 23. Carl and Peter both moved to the West Coast, not far from their father, though contact with him was somewhat sporadic during certain periods. Jane still resides in New England. Rosemarie remained in contact with Frank, and they became “close friends.”

Rosemarie also reports that she has been close with all her children and their spouses over the years, and roughly four years ago, she moved to the West Coast to be near her sons. She bought a house near Carl and his family but several months after her move, Carl and his wife split up and Carl moved out. Approximately one year prior to Rosemarie seeking help, Frank died at the age of 81 after a brief illness.

Initial Treatment Phase
My familiarity with the managed care company that referred Rosemarie told me they would probably not authorize more than 10 sessions and might eventually strong arm me about getting Rosemarie medicated. Rosemarie, the frugal and practical New Englander that she was, thought 10 sessions should suffice to get everyone “back on track” despite my intimations that there was perhaps more going on than met the eye.

Initial work with her involved assistance managing the overwhelming stress of dealing with her two symptomatic children. We also did some useful problem-solving and cognitive work designed to identify erroneous notions related to responsibility, control and, from a more psychodynamic point of view, boundaries. Issues of loss were briefly explored, but Rosemarie was rather resistant in this area and tended to remain focused on “functioning better,” as she put it.

By the end of the allotted sessions, Rosemarie’s sons were stabilizing on medication and her stress level had diminished significantly, but she still was not functioning well in everyday life. She told me that she wanted to continue in therapy until she was really doing better, and we negotiated a fee so she could remain in treatment. However, her initial focus in the ongoing treatment remained her children’s problems.

— Charles A. Rizzuto, MSW, is a member of the summer adjunct faculty at Smith College School for Social Work in Northampton, MA, and he also maintains a private practice in psychotherapy and supervision in Holyoke and Amherst, MA. He consults frequently in the areas of sexuality and loss/bereavement.

Discussion No. 1
By Gail S. Levinson, MA, LCSW

The late onset bipolar disorder in Rosemarie’s sons, as well as in her husband, is uncommon. From a cursory look at Internet research, there isn’t a great deal of documentation of the phenomenon of a late onset of this disorder. When it has been identified, it seems to be associated with other concomitant illnesses or brain disorders (i.e., stroke). My impression is that when late onset occurs without previous mental health history, the prognosis is good that episodes will not recur. If, as the proverb goes, the “apples don’t fall far from the tree,” sons Carl and Peter, who are both obtaining treatment, are likely to have a successful course of recovery similar to their late father’s.

It is this type of information that could be a helpful reminder to Rosemarie as her treatment continues. It is clear that she has been an involved parent and professional caretaker her whole life, and these are not patterns that are likely to change. Rosemarie is remarkably independent and courageous. At 78, she moved across the country and purchased her own home to be closer to her sons and ex-husband with whom she remained good friends. Presumably, this decision created distance from her daughter, friends, and possibly former colleagues. Her ex-husband died in the last year, and her sons’ difficulties may have conjured up memories of the dissolution of her marriage preceded by her ex-husband’s bipolar episode. Like most of her peers, the grief of watching others die with increasing frequency is a common yet painful aspect of living a long life.

Going forward in treatment, one issue to address may include developing additional social supports for Rosemarie. Her interests in quilting and gardening suggest hobbies that are somewhat isolating. For someone who has historically been in an “other-directed” profession, it may be that high involvement in her sons’ difficulties has offered a substitute for other forms of interaction. I might encourage her to consider becoming involved with a senior center, a quilting group, or a self-help organization dealing with family members who suffer from mental illness (e.g., a local branch of the Mental Health Association or the Alliance for the Mentally Ill).

Another area I would gently address is what plans and underlying fears she has for her own care when her health interferes with her mobility and independence. I would explore with her how comfortable she is about relying on her children and what arrangements she has made. I might suggest a family session with her children to make explicit what everyone sees as their role. It is this type of proactive intervention that I believe is so often overlooked in work with aging individuals.

I applaud Rosemarie and her therapist for the work they have done together. Given Rosemarie’s initial reluctance to recognize that she may need more than just help coping with her sons’ difficulties, it is a credit to this therapist that the client realized she could benefit from some additional self-oriented outpatient therapy.

— Gail S. Levinson, MA, LCSW, is in private practice in Wilmington, DE, and is the treasurer of the Clinical Social Work Association.

Discussion No. 2
By Mila Ruiz Tecala, MSW, ACSW, LICSW, DCSW

This therapist has done a great job with helping Rosemarie manage the formidable stress of two sons with mental illness by using problem-solving and cognitive techniques. But I suspect that a large part of what is impeding Rosemarie from “getting better” is the many cumulative unresolved losses in her life that may be catching up with her. Rosemarie is resisting the therapist’s suggestion that she deal with these losses. Most likely, addressing her unresolved losses is scary because she has avoided the pain of grief for most of her life. Rosemarie seems to understand that she has work to do concerning this because she wants to continue therapy, which makes her a good candidate for grief therapy.

She mentions she wants to “feel better,” but how does that translate into specific behavior? If I were treating Rosemarie, I would ask her what in her life experiences may be contributing to her not getting better. I would also devote a session to psychoeducation about loss and grief and its impact on our well-being or lack of it. I would be clear that loss does not necessarily mean death and give her examples of what those losses might be. Rosemarie could benefit from readings to help her better understand the grief process. If she does not mention her losses as one of the complicating factors, I would then plant the seed and ask her to think it through and reflect on how these certain events have affected her.

Rosemarie might also benefit from an exercise of writing down all her losses on a piece of paper and bringing it to the session to rate them in order of importance. I would suspect that her ex-husband’s death would not be listed as a loss, but their divorce might be. I would ask her to talk about how she feels about her ex-husband’s death, explaining that they became “close friends” in the latter part of his life and we grieve for friends who die. Additionally, the death of an ex-husband can be viewed as disenfranchised grief—that is, grief that is not publicly acknowledged because society does not consider it as a “legitimate loss.”

In grief therapy, it is advisable to first deal with the loss that has the least complicating factors. This allows the griever to experience success and move on to more difficult losses. Additionally, her ex-husband, who was one year younger than her, died after a brief illness. How does this affect her fear—or lack of fear—of her own mortality? However, I would not address this until later in the therapy when she has improved since it could be a threatening topic.

I would also ask Rosemarie what it means to her to have two sons with mental illness. Mental illness is a difficult loss because of the stigma attached to it and the feelings of guilt accompanying it. Rosemarie mentioned that when her husband had his bipolar episode, it brought chaos to her family. Is she anticipating the same chaos now that both sons are living with mental illness?

Rosemarie also has an underlying fear that her sons may be self-destructive—unspoken fear that they may kill themselves. This is something that should be addressed now that her sons are responding well to treatment. It is easier to address this issue when the fox is not at the door, so to speak. It may also be helpful to suggest that she attend a support group for families of people with bipolar disorder.

Rosemarie moved across the country to be near her sons, which means she lost support systems that she had established in her former location. I would explore what kind of support she has from her daughter and what kind of social support she has now other than her sons. Quilting, one of her hobbies, would provide social support if she did it with a group.

— Mila Ruiz Tecala, MSW, ACSW, LICSW, DCSW, is an expert on loss, bereavement, and thanatology. She founded the Center for Loss and Grief in Washington, D.C.