TRANSCRIPT-Sara.pdf | School Graders

Sessions: Case histories. Laureate International Universities Publishing.

Sara

Sara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment

with her 48-year-old daughter, Stephanie, and six cats. Sara and her daughter have

lived together for the past 10 years since Stephanie returned home after a failed

relationship and was unable to live independently. Stephanie has a diagnosis of bipolar

disorder, and her overall physical health is good. Stephanie has no history of treatment

for alcohol or substance use; during her teens she drank and smoked marijuana but no

longer uses these substances. When she was 16 years old, Stephanie was hospitalized

after her first bipolar episode. She had attempted suicide by swallowing a handful of

Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her.

She has been hospitalized three times in the past 4 years when she stopped taking her

medications and experienced suicidal ideation. Stephanie’s current medications are

Lithium, Paxil®, Abilify®, and Klonopin®.

Stephanie recently had a brief hospitalization as a result of depressive symptoms. She

attends a mental health drop-in center twice a week to socialize with friends and

receives outpatient psychiatric treatment at a local mental health clinic for medication

management and weekly therapy. She is maintaining a part-time job at a local

supermarket where she bags groceries and is currently being trained to become a

cashier. Stephanie has active Medicare and receives Social Security Disability (SSD).

Sara has recently been hospitalized for depression and has some physical issues. She

has documented high blood pressure and hyperthyroidism, she is slightly underweight,

and she is displaying signs of dementia. Sara has no history of alcohol or substance

use. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare and

receives Social Security benefits and a small pension. She attends a day treatment

program for seniors that is affiliated with a local hospital in her neighborhood. Sara

attends the program 3 days a week from 9:00 a.m. to 2:00 p.m., and van service is

provided free of charge.

A telephone call was made to Adult Protective Services (APS) by the senior day

treatment social worker when Sara presented with increased confusion, poor attention

to daily living skills, and statements made about Stephanie’s behavior. Sara told the

social worker at the senior day treatment program that, “My daughter is very

argumentative and is throwing all of my things out.” She reported, “We are fighting like

cats and dogs; I’m afraid of her and of losing all my stuff.”

Home Visit

During the home visit, the APS worker observed that the living room was very cluttered,

but that the kitchen was fairly clean, with food in the refrigerator and cabinets. Despite

the clutter, all of the doorways, including the front door, had clear egress. The family

lives on the first floor of the apartment building and could exit the building without

difficulty in case of emergency. The litter boxes were also fairly clean, and there was no

sign of vermin in the home.

Sessions: Case histories. Laureate International Universities Publishing.

Upon questioning by the APS worker, Sara denied that she was afraid of her daughter

or that her daughter had been physically abusive. In fact, the worker observed that

Stephanie had a noticeable bruise on her forearm, which appeared defensive in nature.

When asked about the bruise, Stephanie reported that she had gotten it when her

mother tried to grab some items out of her arms that she was about to throw out.

Stephanie admitted to throwing things out to clean up the apartment, telling the APS

worker, “I’m tired of my mother’s hoarding.” Sara agreed with the description of the

incident. Both Sara and Stephanie admitted to an increase in arguing but denied

physical violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get

my things back.”

The APS worker observed that Sara’s appearance was unkempt and disheveled, but

her overall hygiene was adequate (i.e., clean hair and clothes). Stephanie was neatly

groomed with good hygiene. The APS worker determined that no one was in immediate

danger to warrant removal from the home but that the family needed a referral for

Intensive Case Management (ICM) services. It was clear there was some conflict in the

home that had led to physical confrontations. Further, the house had hygiene issues,

including trash and items stacked in the living room and Sara’s room, which needed to

be addressed. The APS worker indicated in her report that if not adequately addressed,

the hoarding might continue to escalate and create an unsafe and unhygienic

environment, thus leading to a possible eviction or recommendation for separation and

relocation for both women.

As the ICM worker, I visited the family to assess the situation and the needs of the

clients. Stephanie said she was very angry with her mother and sick of her compulsive

shopping and hoarding. Stephanie complained that they did not have any visitors and

she was ashamed to invite friends to the home due to the condition of the apartment.

When I asked Sara if she saw a problem with so many items littering the apartment,

Sara replied, “I need all of these things.” Stephanie complained that when she tried to

clean up and throw things out, her mother went outside and brought it all back in again.

We discussed the need to clean up the apartment and make it habitable for them to

remain in their home, based on the recommendations of the APS worker. I also

discussed possible housing alternatives, such as senior housing for Sara and a

supportive apartment complex for Stephanie. Sara and Stephanie both stated they

wanted to remain in their apartment together, although Stephanie questioned whether

her mother would cooperate with cleaning up the apartment. Sara was adamant that

she did not want to be removed from their apartment and would try to accept what

needed to be done so they would not be forced to move.

Sessions

Stephanie mentioned she was dissatisfied with her mother’s psychiatric treatment and

felt she was not getting the help she needed. She reported that her mother was very

anxious and was having difficulty sleeping, staying up until all hours of the night, and

buying items from a televised shopping network. Sara’s psychiatrist had recently

Sessions: Case histories. Laureate International Universities Publishing.

increased her Zyprexa prescription dosage to help reduce her agitation and possible

bipolar disorder (as evidenced by the compulsive shopping), but Stephanie did not feel

this had been helpful and wondered if it was contributing to her mother’s confusion. I

asked for permission to contact both of their outpatient treatment teams, and the

request was granted.

I then arranged to meet with Sara and her psychiatrist to discuss her increased anxiety

and confusion and the compulsive shopping. I requested a referral for neuropsychiatric

testing to assess possible cognitive changes or decline in functioning. A test was

scheduled, and it indicated some cognitive deficits, but at the end of testing, Sara told

the psychologist who administered the tests she had stopped taking her medications for

depression. It was determined Sara’s depression and discontinuation of medication

could have affected her test performance and it was recommended she be retested in 6

months. I suggested a referral to a geriatric psychiatrist for Sara, as she appeared to

need more specialized treatment. Sara’s psychologist agreed.

Because they had both stated that they did not want to be removed from their home, I

worked with Sara and Stephanie as a team to address cleaning the apartment. All

agreed that they would begin working together to clean the house for 1 hour a day until

arrangements were made for additional help from family members. To alleviate Sara’s

anxiety around throwing out the items, I suggested using three bags for the initial

cleanup: one bag was for items she could throw out, the second bag was for “maybes,”

and the third was for “not ready yet.” I scheduled home visits at the designated cleanup

time to provide support and encouragement and to intervene in disputes. I also

contacted Sara’s treatment team to inform them of the cleanup plans and suggested

that Sara might need additional support and observation as it progressed.

We then discussed placement for at least some of the cats, because six seemed too

many for a small apartment. Sara and Stephanie were at first adamant that they could

not give up their cats, but with further discussion admitted it had become extremely

difficult to manage caring for them all. They both eventually agreed to each keep their

favorite cat and find homes for the other four. Sara and Stephanie made fliers and

brought them to their respective treatment programs to hand out. Stephanie also

brought fliers about the cats to her place of employment. Three of the four cats were

adopted within a week.

During one home visit, Stephanie pulled me aside and said she had changed her

mind—she did not want to continue to live with her mother. She requested that I

complete a housing application for supportive housing stating, “I want to get on with my

life.” Stephanie had successfully completed cashier training, and the manager of the

supermarket was pleased with her performance and was prepared to hire her as a part-

time cashier soon. She expressed concern about how her mother would react to this

decision and asked me for assistance telling her.

Sessions: Case histories. Laureate International Universities Publishing.

We all met together to discuss Stephanie’s decision to apply for an apartment. Sara was

initially upset and had some difficulty accepting this decision. Sara said she had fears

about living alone, but when we discussed senior living alternatives, Sara was adamant

she wanted to remain in her apartment. Sara said she had lived alone for a number of

years after her husband died and felt she could adjust again. I offered to help her stay in

her apartment and explore home care services and programs available that will meet

her current needs to remain at home.