Case 6: Suicide ideation and anxiety in the context of father having died suddenly
Patient Details:
15 year old girl in inpatient setting.
Presenting problems:
- School refusal
- Social anxiety
- Suicidal ideation
Family information and background:
- 15 year old girl has just moved from overseas with her mother
- There is a love-hate relationship between the girl and her mother, a lot of anger, massive enmeshment. Girl is allowed to do whatever she wants.
- The girl’s father recently died suddenly
- When mother was little she witnessed her entire family being murdered in front of her.
Clinician’s formulation:
Mother and daughter’s relationship is likely contributing to her school refusal and other difficulties.
What has been tried clinically?
Nothing yet.
Specific concerns:
No specific concerns.
How this consultation can help:
The therapist would like to get a better understanding on how the mother’s history is related to the girl’s current difficulties.
Dr. Fishman’s advice to the therapist:
This is another example of the vulnerable child, and that is a child who is treated in such a way that she does not have the consequences such that she learns from her experiences.
This is a family in transition, the sudden death of the father means the system is in the process of reorganizing. Another profound transition is the move to another country. In families experiencing grief it is crucial to help the family build a system of supports for the girl and of course the mother.
Another central component for this family is the mother’s experience of witnessing her family being murdered in front of her. The therapist must determine whether mother experiences PTSD, do these memories and experiences interfere with her day to day functioning? Or has she been able to deal with these so as they don’t interfere? If she is diagnosed with PTSD this of course needs to be addressed.
Example of the IST clinical scorecard applied to this case:
Objectives/goals:
To have the girl be well-functioning (including going to school regularly).
Plans:
Family therapy to diminish enmeshment, grief counselling to address the grief of the family, increase supports, evaluate and treat if necessary mom’s PTSD.
Targets:
20% improvement in scores on these instruments in three weeks.
Measures:
CAFAS, measurements of Mom’s PTSD such as the PTSD Checklist (PCL), Becks Depression Inventory for mom and the girl.
Homeostatic Maintainer:
It is difficult to ascertain the HM because of the transition of the family, mother’s enmeshment with the girl suggests she may be interfering with the girl’s progress in terms of not getting her to school.
