Mental health articles

OF mental health care and mentally ill

Case illustration of recovery maintenance

Mary was referred to me by her mother’s caseworker because they believed she was depressed and were concerned that she had never been able to make friends. Mary was 33, was attending community college, and lived with her mother, 67, who had been treated for psychosis n and off since young adulthood. Mary had seen various therapists for depression, ‘‘odd behavior,’’ school failure, and social difficulties since early childhood. They have been in and out of homeless shelters and were currently supporting themselves on the mother’s social security income; however, they maintained an ongoing relationship with her caseworker from the shelter. Mary did not want to see yet another ‘‘useless’’ therapist; but her mother made it acondition of her continuing to live with her.

She came to the first session with intricate face paintings and dressed in a dramatic black leather outfit. Rather than comment on her dress, I began by asking about how she spends her days and what she hopes for from our time together. During our meeting, when discussing how she often felt misunderstood by ‘‘everyone,’’ she explained that her dress was inspired by her participation in an online religious group, a place where she felt meaning (sense of purpose)and acceptance (sense of belonging). Her sense of independence and spirituality were assets that she later drew upon in her journey of recovery (strengths and resources).

I began by discussing whether she wanted to be there or not—she didn’t—and the nexplored why she thought her mother wanted her there; I also suggested that the mother join us for part of the session to figure out what needed to happen for her mother to think that sheno longer needed to come. The mother wanted her to ‘‘act normal,’’ finish school, and get a job to help with bills. Mary agreed to the last two items, and we had begun to develop a purpose for our meetings (recovery plan) and a believable course of action (sense of hope). In the next few meetings, I learned that she always felt lonely although she hung out with people(whom she didn’t like), had a long history of sexual abuse (trauma that had been unaddressed),and had been having visual hallucinations since she was seven. She had many gruesome hallucinations,but was aware that they were not real: ‘‘If there was really a dead, rotting body in the middle of Starbucks, everyone in the room would be responding differently.’’ She was able to identify numerous times when she could distinguish between what was real and what was not(another significant strength), even though the hallucinations looked entirely real to her. The better she became at recognizing but not responding to them, the less frequent and severe they became.

As her symptoms decreased, she was able to articulate new life dreams (revised life purpose)—to become a nurse, get married, and have children—and what it would take to achieve them (revised recovery plan). We identified small steps for each week, such as doing homework,going to her academic advisor, and volunteering at a local hospital, and explored ways to select better friends, which soon led to her developing a close friendship with another woman from class (sense of belonging). I referred her to a psychiatrist for an evaluation; although he prescribed medication, she stopped taking it after a month because it made her ‘‘feel weird.’’Meanwhile, as she became more active in school and her friendships, she reported fewer and fewer psychotic episodes. At one point she stated, ‘‘I sort of miss them; they made me feel special somehow.’’ I took this comment as a sign that we needed to meaningfully restory the role of these hallucinations in her life. In our mutual exploration about their role, she began to see them as helping her cope with her earlier sexual trauma and abandonment by her father and that now she didn’t need them to feel good about herself. We invited her mother in periodically to provide family psychoeducation (intergenerational issues in mental illness) and to strengthen and repair their relationship (sense of belonging). Over the course of a year and a half, Mary finished her nursing program and secured a job. We agreed that she should continue her sessions for the first few months on the job to make sure the hallucinations did not return.Two years later, Mary contacted me through my Facebook page and shared that she was engaged and still using many of the strategies we developed to manage symptoms when they arose, which were rare but did still occur. She achieved a meaningful and thus far sustainable social recovery, ending a painful intergenerational pattern.

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