Therapist’s Notebook

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

Case of Mallory
By Marlene I. Shapiro, LCSW-C

As children growing up in Vancouver, British Columbia, Mallory, Bridget, and Gregory (now 26, 23, and 17, respectively) were generally in good health and academically talented, and their parents had been happily married for 27 years. Their father had a doctorate in molecular biology and owned a prosperous biotechnology company. Their mother had a doctorate in English and, due to family wealth, had been a stay-at-home mother and supporter of the arts community. Both sets of grandparents lived nearby, and the family home has been the “hangout” for many neighborhood children. This idyllic life was interrupted by a tragic accident.

After Mallory’s freshman year of college, she and Bridget, who were very close, planned a bicycle trip. On a sunny day in June, they packed a picnic lunch and started out early in the morning, planning to end their day at a nearby beach. But around 3 pm, the police contacted their parents, saying there had been an accident and Bridget was hurt. Rushing to the hospital, the family learned that Bridget had been sideswiped by a car that ran a stop sign. She suffered a severe head injury and was subsequently comatose for three months. After six months in rehab, she was quadriplegic and, once home, she needed round-the-clock nursing care. Despite this tragedy, the family appeared to have rebounded.

Mallory returned to college and initially did well but began abusing alcohol and marijuana. Her grades dropped, and she barely passed her second year. While at home that summer, the substance abuse escalated to an alarming degree, with multiple speeding tickets, several accidents, and a conviction for drunk driving. Mallory was court ordered to attend Alcoholic Anonymous meetings and stayed briefly in alcohol rehab. Afterwards, she tried to work but could not sustain a job for more than a week. Isolating herself from her friends, she spent her time reading avant-garde plays and listening to music in her room. In midsummer, she abruptly disappeared for a month and was later found by her father in Montreal, stranded without money after trying to get involved in the theater scene.

Mallory refused to return to the university and unsuccessfully tried attending community college. By the winter of what would have been her junior year in college, she became significantly depressed and suicidal. She made the first of multiple suicide attempts,which would continue over the next two years, by trying to cut her carotid artery. Her cuts were usually superficial, but her last and most serious attempt resulted in sutures, as she managed to nick the artery with a kitchen knife. She said she felt compelled to cut herself. During this unstable time, Mallory manifested other symptoms: auditory hallucinations and grandiose delusions that she was “Queen of Vancouver.”

Hospitalized numerous times, her diagnosis was schizoaffective disorder. She had extensive medical and psychological testing and was treated with various medications: antidepressants, antipsychotics (typical and atypical), mood stabilizers such as lithium, as well as electroconvulsive therapy (ECT), without much improvement.

I met Mallory after one of her inpatient stays and following a year of being primarily an inpatient. She was living in supervised housing in the community. Her hygiene was fair, and she was casually dressed in jeans, a T-shirt, and sandals. Her fingernails were bitten to the quick. She was alert and oriented but withdrawn. She sat slumped in a chair with her head down, feet planted firmly on the floor, and hands clasped loosely together. Her affect was flat, her eye contact poor, and most of her speech was relegated to answers of “yes,” “no,” “maybe,” and “I don’t know,” with “I don’t know” as the most frequent response. She deeply resented being sent away from home for treatment; however, her mother or father flew in to see her every weekend.

No one had had much success in engaging Mallory. While an inpatient, she stayed in her room and rarely interacted with others. In the day hospital, she went to groups, but her participation was sporadic at best. Twice, she disappeared for hours from her residence, returning drunk. She was described as defiant in her quiet way and refused to negotiate behavioral issues. With little insight into her problems, she insisted repeatedly that she just wanted to return home to live but rejected any plan to work, enter some kind of day program, do volunteer work, or return to school. Her only stated goals were to walk the streets of her city, smoke, and drink.

When asked about her feelings, she responded, “I don’t have any good feelings. I don’t have any bad feelings. I am used to things this way.” Yet, I had the sense when talking to her that the “lights were on” but that she had tremendous reluctance, ambivalence, and discomfort talking about her feelings or thoughts. An obvious topic of conversation was her sister’s injury and the effect on the family, but Mallory insisted that they had all adjusted to this tragedy in their lives.

Most disturbing was Mallory’s persistent suicidal ideation. She would not firmly contract for safety. She said, “I don’t know if I will cut myself or even if I have control over not doing it. I can’t give a guarantee that I won’t do it.” The past multiple attempts put her at high risk for future harm and made it difficult to place her in less restrictive settings. On the recommendation of a consultant, she began treatment with a cognitive behavioral therapist in addition to day hospital treatment, and after three months, though suicidal ideation never disappeared, she thought less about harming herself and made no further attempts.

Discharge planning was difficult. Mallory would not agree to a written safety contract or to a structured plan for her time. After pressing her at some length during a session, the dam broke. She said, “Look, I think I am ready for the next step. I feel empty and full of turmoil, but I am not depressed. I have moments of darkness that I cannot describe, and I will never be able to describe them. But this is not depression. I don’t think therapy will help me with this. I don’t think much about hurting myself now. I am sick of therapy. We go over the same things again and again. I am really tired of all the supervision and the structure and of having to get help for my best interests. I don’t know what signing a [behavioral] contract will accomplish. It would be like giving in. I am afraid that if I give in, I will lose something and not get it back. If I sign the contract, it would be like admitting I need help. I don’t know how to prove I am ready to go home. I don’t want to live with someone always looking over my shoulder. I don’t believe I have schizoaffective disorder anyway. I have talked to a lot of people who do have this illness, and I don’t think I have the same thing. I started feeling bad in high school. I didn’t tell anyone. Then, all I did was study and work, and I never had to go to the hospital. I want my life to get back on track. This has nothing to do with school or programs. I could put up a front that I am OK, but I don’t want to. The doctor told me that this illness could be treated but not cured. But I have a strong faith that it is going to go away.”

This was the longest string of communication I had from Mallory, but it was also the last. However, she began to improve. She audited and completed two courses at a local community college near the day hospital, even taking the tests and writing the papers. Although she still had suicidal thoughts, she said they were rare. Mallory returned to her family while they searched their area for supervised housing and some sort of day program to which she would agree.

Mallory is still at home. She sees a psychiatrist for medication management but refuses psychotherapy. She spends her days sometimes helping with her sister’s care, but more often, she walks the streets, smoking and sometimes abusing alcohol. She has made no more attempts to harm herself.

— Marlene I. Shapiro, LCSW-C, is the program director of a partial hospitalization program for patients with psychotic disorders at Sheppard Pratt Hospital in Baltimore, MD. In addition, she sees patients and families in a private practice.

Discussion No. 1
By Donna Ulteig, MSSW, LCSW, ACSW, DCSW

A double tragedy, the story of Mallory and her quadriplegic sister Bridget drew me into a sad world in which the promising futures of two young women were dramatically altered in the blink of an eye. It is safe to speculate that the entire family, nuclear and extended, suffered distress as a result of the tragic circumstances.

There is a lot that we do not know about the accident and the details of that June day in Vancouver. Filling in the missing information could help us better understand Mallory’s emotional deterioration, which continued and worsened for roughly the next six years. We do not, for example, know whether the girls were wearing helmets, who was in the lead, whether Mallory witnessed her sister being hit, and whether Mallory was treated for any posttraumatic stress disorder (PTSD) symptoms after the accident. We do not know whether there was a family genetic predisposition to any kind of mental health condition that this trauma may have activated.

As a clinician, I would assume that after this traumatic event, Mallory, who was probably in close proximity, experienced both survivor’s guilt and emotional trauma. Based on what we do know, I assume that as the oldest, Mallory was accustomed to watching out for her younger sister. Bridget’s severe injury may have felt like a major caretaking failure. There may be self-blame and despair on Mallory’s part. Bridget’s relegation to a very physically limited life may have left Mallory wondering why she could have an easy life, or for that matter, any life at all.

What follows over the next several years seems to bear out this premise. Mallory is unable to pick up the pieces of her life and, for a couple of years, seems intent on ending it. Another possibility is that she is experiencing command hallucinations that tell her to kill herself and specify the method. Moreover, she reportedly continues episodic binge drinking, and what alcohol abuse may contribute to her suicidal ideation is also a question.

Psychotic symptoms complicate the picture, and it appears that she is in the hospital more than she is out of it. She is diagnosed with schizoaffective disorder, although it is not clear why that diagnosis rather than bipolar disorder, complex PTSD, or a personality disorder has been designated. We do not know the differentials, but we do know that Mallory later asserted that she is neither depressed nor does she have schizoaffective disorder. Standard medication treatments for mood and thought disorders do not work for Mallory nor does ECT. And we also learn that Mallory started feeling bad in high school but was able to function, which suggests a preexisting condition may have interfered with her ability to be resilient in her recovery.

Mallory makes a partial recovery, reportedly triggered by a three-month period of outpatient cognitive behavioral therapy (CBT). She is able to live first in supervised community housing while undergoing day hospital treatment and later at home with her family. Prior to CBT, she talked about not having any feelings (except resentment that she had been sent away from home for treatment), defiantly refused to engage in behavioral agreements, and had self-acknowledged impulse problems. But the self-harm and suicidal acting out abated, and Mallory was able to focus on college courses again. She was also willing to take her medication. Unchanged is her self-declared preferred activity of walking the streets smoking and sometimes abusing alcohol and her social withdrawal.

Her conversation with her day hospital social worker is curious and is Mallory’s only reported verbal self-disclosure about what she thinks and what she wants. She is “sick of therapy … and tired of all of the supervision.” She is afraid that if she “gives in” and signs a behavioral contract, she will “lose something and not get it back.” And she would be admitting that she needs help.

Shame and anger seem to be factors in her inability to engage collaboratively, in her pattern of withholding information. I was pleased to hear that she believes that her illness will go away, but I suspect that recovery will hinge on her ability to trust, grieve, and make sense of what has happened to her. To the extent that her walking and smoking episodes are dissociative, I would want her to do trauma work, probably with movement therapy rather than talk therapy. Of course, Mallory has the right to choose not to work on these issues, but if she does overcome shame to ask for help, she may well achieve a more complete recovery.

— Donna M. Ulteig, MSSW, LCSW, ACSW, DCSW, has been a partner in the private practice group Psychiatric Services SC in Madison, WI, for 23 years.

Discussion No. 2
By Camielle Call, LCSW

Mallory seems to be something of an enigma, both within her middle-class family and in the psychiatric realm. The dramatic change in her before and after behaviors tells us there is something more deeply imbedded than a simple grief reaction.

Considering the years between the precipitating event of her sister’s accident and subsequent 24-hour care status and Mallory’s current functioning, it seems she may not have allowed herself any grieving time. Indeed, the family as a whole may not have spent the requisite time for feeling the losses associated with the accident and the newly found burden of caring for a special needs adult. With this depth of trauma, it is no wonder Mallory’s ostensible rebellion has taken such a toll.

Upon being expected to return to college and continue her education, Mallory quickly began a self-medication process using alcohol and marijuana. I can almost hear her internal rationalization: “I feel much better and can function much better with alcohol and weed. Why would I stop?” Likely the justification for her behavior was also verbalized when confronted by family and friends. Even the speeding tickets, accidents, and drunken driving charge did nothing to curb her upheaval.

With further review of Mallory’s case, my response turns toward the question of whether she may have had other previous traumas. If so, these could certainly have contributed to the longevity of her intense reaction to the loss of the sister she used to know.

Based on the evidence in the case presentation, I am not sure Mallory has schizoaffective disorder. I do see support to diagnose major depression, with some manic symptoms also present. If I were treating Mallory, I would apply the “five diagnoses rule,” which suggests the importance of coming up with five possible diagnostic options for any one individual. After those possibilities are in place, I can begin to eliminate them based on the most prominent symptoms, eventually arriving at the most appropriate diagnosis and perhaps even avoiding a chronic mental illness label.

Mallory herself referred to being “ready for the next step” yet still feeling “empty and full of turmoil.” What a paradox for her, to feel at once empty and full. And although she denies this is depression, her symptoms say otherwise. I would investigate further to determine what Mallory considered the next step. Clinically, this step would be to assist her in admitting or giving in to the need for help, to move closer to recognition that asking for emotional assistance is not a scar on her character but rather indicates the strength of someone who is working on lifelong improvement, to help her peel back the layers of pride she has amassed, and to allow her emotional self to be vulnerable again. By doing so, Mallory can build on her strengths, begin to feel something other than turmoil, and move toward becoming a contributing member of society.

On the other hand, maybe Mallory is not given enough credit. Following her hospitalization, she reportedly began to improve. Auditing and completing two community college courses to the extent that she took the tests and wrote the required papers is an incredible step forward. Ironically, it appears to me to be the “old Mallory” trying to take back some element of control she had previously “given in” to. I wonder how she will undertake the next phase of her life. She is still young, and she has proven that she can accomplish something once she puts her mind to it.

— Camielle Call, LCSW, maintains a consultation and contract supervision practice in Sitka, AK.