A CASE PRESENTATION

CASE PRESENTATION

The client is Mrs. XYZ, 38 years old married housewife, born of a consanguineous union, educated up to 10th standard, hailing from a rural nuclear Muslim family of low socio-economic status.

This case is referred for social work intervention and further Psychosocial Management.

BRIEF CLINICAL HISTORY

The client presented with the complaints of having suspicious ideas: that the husband is planning to marry again, he is going to desert her, the husband is moving around with girls, people are watching her and talking about her, people have done black magic on her: hearing voices, seeing photos of Hindu Gods, wandering tendencies and feelings of sadness for one year. It was an insidious onset with progressive course and continuous nature precipitated by many social stresses.

Two months before the onset of illness the husband took her gold ornaments for gambling, and told her that he will return them after few days. Since he lost all the money he could not keep his word, following which the client started suspecting him. She suspected her neighbors too, telling that they are all helping the husband in his affairs and they are planning to kill her giving poison or by doing black magic. Besides this she firmly believed that someone has done black magic on her and that is why she is not prospering.

She also used to hear voices telling her that the husband is planning to marry again and the children will leave her and she will be disturbed soon. She used to abuse husband, children and neighbours quite often. Being much disturbed of her abuses the husband used to beat her up and one day the client attempted for suicide by consuming kerosene.

Since last six months, the client is very much worried about her financial constraints, husband’s irresponsibility and gambling behaviour and the burden of bringing up children. Based on the clinical picture and findings in mental status examination, a diagnosis of Paranoid Schizophrenia was made and she was put on anti-psychotic drugs.

FAMILY HISTORY

The client hails from a large family comprising ten members including parents. There is significant family history of mental illness in father. Father got married twice as the first wife and children died four years after the marriage due to an epidemic. The second marriage was at the age of 21 to one of his distant cousins. He was a loving husband and an affectionate father. He had an attack of mental illness and absconded from the native place during the mental illness. When he came back after eight years he was fully recovered and was working as head load worker. He died at the age of 40 due to an accident.

Step mother died four years after marriage at the age of 20 due to an epidemic and both the siblings died at the age of one and one and the half years respectively due to chickenpox.

Mother is 48 years old strong-willed and efficient housewife .In the absence of husband she supported all the children with the help of her brothers and in-lows. She was hard working and was keen on bringing up children properly. As a mother she loved, caring and dedicated. At present she is staying with her three daughters and a son-in-low in the ancestral home.

First sibling is 34 years old married sister with primary level education .She was given in marriage to her first cousin at the age14. She is healthy and with her husband and children in her native place. She maintains good relationship with her mother and siblings.

Second sibling is the client who stays with the husband and children in Bangalore since last18 years. Third sibling is brother who died at age of three due to pneumonia. Fourth sibling is 28years old married sister with middle school level education. She got married at the age of 13 to her cousin.  Fifth sibling is 26years old sister.  She did not have any formal education due to financial constraints. She is healthy and living with her family of procreation.  This sister does not have much relationship with mother or other siblings as her husband does not allow her to go to her house.  Sixth sibling is24 years old married sister who has had no formal education.  She is living with her mother.  Husband, children and two younger sisters are in ancestral home. There are no relationship or adjustment problems among them. Seventh sibling is 16 years old unmarried sister studying in 10th standard. She is healthy and attached to the client.  The eighth sibling is 14 years old sister studying in 7th standard who used to help the client during school vacations.

Interaction between parents was viewed as warm and cordial between the client and her husband. They had mutual understanding to each one’s problems and were attached to each other.  When the husband absconded during mental illness, the wife was very sad and searched for him to her best.

Interaction between parents and off-springs: there was good understanding and cooperation among mother and children. Mother  was  very  much  attached  to  children  and  used  to  show  and  express  her  concern  outwardly.  All of them shared the family burden happily and with free will.

The relationship among sibling is cordial and warm.  They  all except  the  client  and  fifth  sibling used  to meet  each   other  and  gather  frequently in their home. When the client goes to native place all of them used to gather together. There were no interpersonal relationship problems among them.

FAMILY DYNAMICS

Leadership: father was  the  acknowledged  head  of  the house, the  breadwinner  and  main  decision  maker.  He  used  to  discuss  matters  with   his  wife  before  making  decisions  and  was  a   democratic  leader .  The wife used to influence   his decisions   regarding internal and external matters.  When   the  father  was  away   and  after  his  death ,the  mother  had to  take  the  leadership.  She was  helped  by  her parents   and her  in-lows  in  decision   making  and  at times  there  were  chaos  in  family  due to  differences   of opinion  among her  own  parents  and  in-lows.  The  children  were  not   allowed   to  take   decisions  on  their  own  and  they  had  to  consult  mother  who  usually  complied   to  their requests.

Communication:  Free and open communication dominated the picture.  Everyone   was given the opportunity to voice their   feelings and opinions.  So  also  members  freely  approached  whomsoever  among  family   members  they  wanted  for  their  requirements.  The mother  used  to  communicate   her  burden   and worries  to  her  children  which  in  turn  helped  her  to  release   her  tension  and  elicit  cooperation  from  them on   common  issues.  All   family  members  used  to  express   their  emotion   and  feelings  and  used  to ask   for  suggestions from  each  one.

Role  functioning:  The  father   functioned  adequately as  the  leader  of  the  household  and  carried  out   his  role  of  father  effectively . He afforded  emotional  as well as   material  and   economic  support  for his family   which  was taken   up  by  mother  after  his  death.  Roles were  not   clearly  allocated  and responsibility  was  shared   by  all   children  and   they  used  to   carry  out  household   management  collectively   under  the  supervision  of  mother.  Mother  had  to  look  after  the  nurturance  and   support  as well  as  life  skill  development  of  children ,maintenance  and  management  of  family  system.  She had  role  strain  to  a  marked  extent  but  asked  for  help  from  others  on  such  occasions.

Cohesion and concern: There was good emotional bonding among family members.  Though  the  father  used  to  exercise   individual  autonomy  regarding  social  gatherings  it  never  affected  the  sense  of  we  feeling in  family.  All the members were working as a single unit and there were no alliance, coalition or discrimination among the family members. The  high  degree  of  give  and  take  process  tended  to  encourage  mutual  dependency.

Reinforcements: The father  tended  to  be very  lenient  with  his  daughters  and would  over  look their  mistakes  and mischief  with no  more  than  a  mild  admonishment . Verbal  and  non  verbal  rewards  were  provided  for  the  desirable  behavior.  The mother tends to be firm about mistakes and would correct their behavior.  She used to scold  them  or  punish them  for  the  undesirable  behavior  and  used  to  make   comments  that  “girls  should be modest  and  obedient”. Reportedly there was no excess in rewarding or giving punishments.

Stress managing patterns: Absconding and  subsequent  death of father, financial  constraints, arranging  marriage  for  five  female  children all  were  major  stressors  for  the  mother  and  children.  Supporting  children  in  financial  constraints  were  taken  as a  challenge  subsequent  to  the  belief  that  they  were  fated.  Since she  was  religious  she  used  to  express  hope  and  faith  in  god. In times of  crisis  she  never  hesitated   to  ask  help  from  her  near  once.

Social  support: The family’s social support  is  primarily  with  the immediate  family  and  close  relatives providing  emotional  and  financial  support.  Neighbors  and religious organizations  used  to  come  forward  and extend  emotional   and  at  times  financial  support  upon  request.

Social  status  of  the family: The client  is  from  a Muslim  low class rural  nuclear family and stays in  a comfortable residential  area in  a  village  supported by  many   neighborhood  families  of  the same community. Since  they  do  not  have much  immovable  property and  other  permanent   sources of  income  the  family system  was  maintained  with  the earnings  of  the  mother .  They had good religious involvement and affiliation with the families of neighborhood.

PERSONAL HISTORY

Early development: Reportedly client had a full term normal delivery. She was a healthy  baby  in  early  years  and  her  transition  to  each  developmental  stage  was  age  appropriate.  She was a model child and had no neurotic tendencies.  Parents especially mother taught her social values and social behavior patterns. religious  institutions  taught  morel  and  ethical values  and school   and  peer  groups  helped   her  to  imbibe  social  skills.

Education: Started schooling at the age of five without   any formal preparation. Initially  the  client  was  reluctant  to  go  to  school as she  had  to  stay  away  from  mother. Later  she   adjusted   to  the  separation  from  mother  during   school  hours  without  much  difficulty.  She stopped her studies at the age of 12 because of her marriage.  She was not lessening family burden. 

  

Occupation: she is a housewife and is managing a petty shop attached to the house during day time.  The earning from this business is quite minimal but she run the same as it adds to total contribution for family support.

Sexual and marital life:

She attained sexual information from her mother and husband after marriage. She is happy and well adjusted in her sexual life. She was given in marriage at the age of 12. It was an arranged consanguineous union with the consent of both parties. Though she was not mentally prepared for marriage she did not object the proposal as she was aware of the family constraints. The husband was 22 years of age then. Subsequently he was very much supportive and looking after the client. Problems started nine years ago as the husband began spending money on gambling and showed irresponsibility in looking after family.

Husband is 42 years old healthy man. He is employed in a hotel as a cashier since last hour years and earns nearly Rs.600/- per month. Though the job is permanent he attends quite irregularly as goes for racing with friends. He started going for racing nine years back and has spent nearly Rs. 35000/ so far. He used to sell household articles and jewels of the client when he was short of money. The fantasy that he will get all the money back and become rich all on a sudden made him to continue his habit to a pathological extent.

First child is 18 years old boy who started working at the age of 12 as a helper in a hotel and earns Rs. 300 per month. Since the father was not keen on educating him he had to discontinue studies after primary level education. He helps mother in shouldering family burden.

Second child is 16 years old boy who studied up to fourth standard and discontinued later as he was not sent to middle school. He is currently working as a helper in a hardware shop and earns Rs. 250 per month.

The third child is 1 year’s old girl studying in the 5^th standard in native place and looked after by grandmother. The fourth child is eight years old boy staying with the parents. He is not attending school as he has to help his mother in looking after the younger children. The fifth and sixth twins are three and two yeas respectively.

There are no health conducts or behavioural problems in children.

ASSESSMENT OF MARITAL LIFE

The husband is the accepted head who makes major decisions in their family. The wife was given ample opportunity in decision making who used to influence the decision, initially. As he started taking decision on his own without consulting wife he used to be questioned by his wife. After starting gambling he became irresponsible and took decisions to suit his habit against family’s interest, though wife objected it.

Communication was verbal, direct and clear most of the time. Since last nine years the noise level is high due to argument and quarrels between spouses. The children were hesitant to approach father freely for their requirement and they used to approach mother freely. The spouses were not freely expressing their positive emotion likes concern or regard but used to express negative emotions to the symptomatic behaviour of the client.

Roles are clearly allocated to each family member and they are aware of it. Except the husband all carry out their roles. The husband fails to look after the nurturance, support and maintenance functions as his major preoccupation was with gambling. As a father too he was not showing responsibility as he does not show interest in sending the children to school gets jobs for them or assisting them for their personal development. The client fulfilled her roles effectively by during illness she refused to perform the role as a housewife due to suspicion.

There existed a very good emotional bonding between spouses initially. Due to quarrels and misunderstandings it was affected to a marked extent. Husband’s concern for the client and children decreased to a considerable extent due to his preoccupation with gambling. Except this there was emotional bonding and a sense of we feeling among family members.

There were clear-cut reinforcement patterns in the family as the client used to give verbal and material rewards to the children, especially to the elder ones for their desirable behaviour. For example she used to encourage them and prepare special meals for them on the salary day. This enabled the children to develop a sense of responsibility in return. The parents use to scold, punish and give admonishemts to children for their mischief.

Financial constraints and lack of support were major stressors to the family. On such occasion the used to make several alternative plans for handling the problem, initially. The optimism in life did not last due to frequent failures and made the client expect the worst. She used to express her anger towards husband as he was responsible for most difficulties.

The only support present to the client and her family is emotional support from relatives and immediate family members. Though they stay in an urban residential area surrounded by many families, they do not have much contact with others, which the client attributes as a characteristic of city life, and hence they do not receive any support from neighbours.

PREMORBID PERSONALITY

The client had good relationship with parents and other near and dear ones. After coming to Bangalore she was not keen on making or sustaining relationship with others. She was worried anxious and preoccupied with her problems most of the time. The free time was spent at home nurturing children and seeing to their needs. She had high moral and religious standards. She used to fantasize leading a less problematic and smooth life but was not preoccupied with it. Tolerance to crisis situation and to losses was low and used to respond very easily to circumstances arousing anger anxiety and sadness. She did not have any problem habits.

ANALYSIS AND SOCIAL DIAGNOSIS

Mrs. XYZ. 32 years old married house wife born as second of seven living female siblings of a consanguineous union with family history of mental illness in father, hailing from a rural Muslim nuclear family of low socio-economic status presented with complaints of expressing persecutory ideas accompanied with auditory and visual hallucination, wandering tendencies and one attempted suicide during the last one year.

The social case work study revealed that the client was brought up in and unfavourable social environment characterized by lack of father figure, intense financial constraints and too much family burden. Because of the role strain the mother was unable to provide adequate support for children in their life skill development.

The client was given in marriage at a tender age. Having forced to take up responsibilities as a wife and financial burden were major life events for the client who was not mentally prepared for the same at such an age. These constraints along with downward social mobility forced the spouses to find out alternative strategies to cope with problems. Being influenced by the peer group and led by fantasies, the husband started gambling which became pathological subsequently. Social insecurity along with frequent losses and more number of children added to social stress. Frequent deliveries caused psychological tension and it increased the vulnerability to stress. The gambling of the husband and irresponsibility to play roles, added role strain for the client, lack of proper communication of facts and feelings added to the problem and this influenced the clinical picture as well.

The unfavourable social environment, such as social isolation and poor support, economic deprivation, poor physical, psychological and social health and low standards of living with increased demand for household management could have precipitated the illness in the predisposed client. Stressful life event, increased. The hostile and critical attitudes expressed by husband aggravated the clinical condition.

THE SOCIAL MANAGEMENT

Social work intervention was intended to enable the client and family to achieve operationally optimal level of social functioning giving focus on stresses in the environment and deficits in personal characteristics that lead to social maladjustment.

The goals of treatment were:

1.      To provided psycho education to the family regarding the abnormal behaviour of the client and pathological behaviours of the husband.

2.      Reduce the residual features in client and help her resume responsibility in the family,

3.      Strengthening relationship between spouses,

4.      Motivating the husband to stop gambling and take up his responsibilities.

5.      Dealing with sources of stress and enhancing adequate coping skills.

6.      Facilitating the growth and development of children.

TYPE OF THERAPIES OFFERED

1.      Psycho educational family treatment

2.      Social case work at individual level

3.      Family life education

DURATION AND FREQUENCY OF SESSIONS

Twelve individual sessions with client of one hour duration and same number of individual sessions with the husband is initially planned.

The first few sessions were meant to create a treatment alliance for supportive working relationship. It was enhanced through giving a sense of hope, reassurance, clarifications, unqualified support, and non-threatening, non-critical therapeutic situation. When the relationship was established the client came out with her stresses and feelings of insecurity. The client was allowed to verbalize her feelings and emotional support was given on situations as and when the client was found to be upset.

The major preoccupation of the client at this stage was the behaviour and the irresponsibility of the husband. The client was educated into the nature of the problem and she was given explanation that it was a pathological behaviour. The client was assured that the worker would work with the husband and advise him as to his responsibilities, which lowered the anxiety in client. So also the husband was educated regarding the nature, possible cause, treatment and outcome of wife’s illness. He was told that the suspicion and refusal of role functioning was a part of illness which in turn helped him to change his attitude towards her.

The next focus was to enable the client to take up responsibilities at home like cooking, giving bath to children, washing their clothes and feeding them. The husband was asked to support her and help her giving verbal and nonverbal rewards. Certain tasks were set up for the client and the easily attainable goals boosted her self-confidence. Resumption of responsibilities helped her to cope with the prevalence of residual features like lethargy, lack of interest and drowsiness.

When the husband came to know that his behaviour is pathological he asked for advice. He was helped to think into the cause effect relationship, which enabled him to understand the intensity of the problem. To develop motivation he was brought down from his fantasies and was helped to reflect over realities through reality based knowledge/experience that he has. To deal with irresistible urge for gambling he was taught alternative coping strategies and for dealing with the stress environment modification of environment was made with the help of budgeting. When the spouses took over the responsibilities and proper communication was present, the relationship between client and husband got strengthened and they supported each other.

This was followed by family life education to both spouses. They were helped to reflect over their expectations from marriage, present status and future plan. The understanding of the husband regarding the role of a father and husband was modified with the help of clarifications and explanations.

OUTCOME

The anxiety of husband and the client lowered when they gained understanding into the nature of illness.

Healthy change was brought about in family interaction, which ensured support, communication and sharing of feelings.

Critical and hostile attitude of husband towards client was removed through fostering healthy interaction.

Residual features disappeared and the client resumed responsibility as a mother and housewife.

Husband gained motivation to stop gambling and does not go for gambling now.

Husband started taking responsibilities as a father, husband and breadwinner and goes for work regularly.

FUTURE PLAN

1.   To ensure follow up till medication is terminated.

2. To focus more on the growth and development of children.