Doreen G. is a 68-year-old woman who has come to the attention of mental health professionals only twice in her life. The first time was early in high school when the teachers were concerned about the degree of her introversion and lack of connection to her classmates, and about her sometimes bizarre facial expressions, which did not seem to match the events going on around her. She was a bit peculiar and significantly withdrawn and detached. Her parents were called into school to discuss these concerns, and apparently Doreen (by her own report) told the teachers to "leave me alone. I am like my Uncle Jake, and he needed to be left alone, too." The school complied, and Doreen was graduated from high school with her class; still disconnected, somewhat peculiar, but left alone.
She had been in the business curriculum in high school, and after graduation she enrolled in a program to improve her general office skills, which at that time included typing, filing, and basic bookkeeping. She did not want to study shorthand because, as she put it, "I don't like sitting with someone for so long and having to think about what they are saying and writing it all down."
With the business program completed, she needed to get a job. Doreen was still living at home with her parents; an older brother had completed college and was living out of state on his own. Her parents suggested that she try to get a job at a large insurance firm, and her father was able to arrange a contact for her there. She got an entry level office job and remained with that same company for over 20 years. During most of that time, she remained living at home with her parents. Between ages 32 and 38, however, she lived by herself in a small apartment near her work in the city. This period marked her most independent level of functioning. At the end of these 6 years, the rent increased to where she could no longer afford it on her salary, so she returned home to her parents. When she was just over 40, she lost her job at the insurance company because the requirements, technologically and interpersonally, exceeded her ability to perform. She says that she did not especially miss the job, nor did she maintain contact with any coworkers.
She lived at home and says, "I did nothing for a while and it was okay. My mother would take me out with her to see her friends, and I didn't like that, so I wanted another job." Again her father knew someone in management at a nearby chain supermarket and arranged a job interview for Doreen. She accepted a job in the bakery section working 20 hours per week. Her job consisted of monitoring the preparation orders and display stock. She was a reliable and consistent worker, valued by the store. According to Doreen, her "off hours" were mostly spent in solitary pursuits, except when her mother "made me go on visits with her." A few times during these years, one or the other parent would suggest that Doreen join a group (e.g., through their church), so that she might socialize with others around her own age. Eventually, they gave up. She was indeed like her father's older brother, Jake; an odd soul, disconnected but "regular as a clock." Doreen liked saying this about herself.
Her favorite activity was dancing to rock-and-roll music in her bedroom with the stereo turned up "pretty loud" and watching herself "in the big mirror on the wall. I could feel like I was dancing in this big ballroom and there were other dancers, too."
As her parents aged, and their health and level of functioning began to decline, Doreen assumed more of the household tasks. "I like cleaning, but not cooking. But someone has to do it." Always on the heavy side, Doreen became obese as the years went by. She favored snack foods and eating out by herself, at local fast-food restaurants. "I'm a burger and fry person." Sometimes her father would join her for lunch, but she says she liked it better when he did not. "I don't like talking when I'm eating."
After her mother died, Doreen assumed the cooking duties for herself and her father. She would accompany him regularly to visit the cemetery where her mother was buried. She said "I didn't like that, but he made me go. I knew my mother wasn't there." When asked where she believed her mother was, she looked away, smiled slightly, and answered "I know, but I'm not saying."
With the exception of a semiannual visit with her father to her brother's home, Doreen did not vary her routine. Her weight ballooned, and it became more difficult for her to walk any distance. Despite her father's pleas, she refused to see a doctor, stating, "I don't like doctors. They ask too many questions."
When Doreen was in her mid-60s, her father died following a sudden, massive stroke. Her brother invited her to move to an assisted living complex near him, but she adamantly refused to make the change. Her mobility became increasingly limited, and her food choices worse and more stereotypic. She spent her days dancing, eating "junk" food and watching television. Her brother now visited her, as she could not travel by herself. During one such visit, about 3 years following their father's death, her brother realized that Doreen could not continue to live alone. Despite her protests against leaving the house or altering her familiar routine, he made arrangements for her to move to an assisted living facility (ALF) near where he and his family lived. Her brother, himself an older adult, cleaned and reconstituted the house, which was in great disarray. He then sold the house, packed his sister's belongings, and accomplished the move. Doreen was most concerned about moving her stereo and substantial record collection.
Although her brother had told the administration of the ALF about Doreen's peculiarities, they were not prepared for the experience of having her as a resident. Such facilities typically offer specific amenities well suited to older adults who have become less able or less willing to continue responsibility for certain regular, domestic chores. In addition, ALFs offer the older adult a community con text, including activities and opportunities for socialization, thus addressing the common complaints of isolation and loneliness.
Housekeeping services were offered, and Doreen's one-bedroom apartment would be thoroughly cleaned once per week. This typically took the cleaners one to two hours, depending on the size of the unit. Doreen's unit was small, but it was always such a mess that the cleaning staff needed to spend half a day cleaning it. Food remains (garbage) were left all over the apartment, becoming odiferous and attracting bugs. Her dirty clothing was left lying around as well, and she used the laundry hamper to store her record albums. Sometimes during the cleaning sessions, Doreen would become visibly agitated, and dance in front of the cleaning staff, waving her fingers before their faces as if trying to scare them off. The cleaning help complained to the management and ultimately refused to enter her apartment. Doreen accepted this as a victory.
Another ALF offering was two daily meals in the dining room, breakfast and dinner. Dinner could be taken either at midday or in the evening, as the resident chose. For the third meal, it was assumed that the resident would prepare either lunch or a light dinner in the apartment. After moving, Doreen quickly discovered several local fast-food shops that would deliver. She became a frequent customer. The result of this was that she grew even more obese, and her apartment was littered with cartons and take-out bags that she used to store music tapes.
That the ALF provided opportunities for companionship was more than lost on Doreen; she ignored or avoided these efforts. During the first several weeks, the dining room staff tried, as they did for all new residents, to introduce her and seat her with others at meals, observing which pairings or groupings appeared to work best. Doreen passively accepted being seated anywhere, with anyone. She voiced no complaints. Other residents, however, did have complaints. Her eating behavior was most unattractive. She made no attempt at conversation, and between courses when she wasn't eating, she would stare at her tablemates, as if they could not see her stare. At times, she would become engaged in a tune that was being played as background music, and "dance" to it with her hands and fingers. Her odd behaviors, poor manners, and nonexistent social skills ultimately led the other residents to ignore Doreen and to refuse being seated with her for meals.
The ALF repeatedly called her brother to meet with the staff about his sister's unacceptable behavior. His efforts to help were to no avail. He bought her a new, larger clothes hamper, which she proceeded to use for storing more record albums. He bought a chest to hold her music tapes, but she still preferred to keep them in bags from the fast-food shops. He hired an outside cleaning service to come in biweekly to preclean the apartment for the ALF cleaners. Her untidiness easily kept pace with this new challenge.
Doreen was at the point of being evicted. A psychologist who had consulted with the ALF in the past was called for a consultation to see if there was a way Doreen could stay on as a resident. The psychologist interviewed Doreen, her brother, the staff, and read her resident file.
Doreen's diagnosis was Schizotypal Personality Disorder. The major benchmarks of this personality disorder as exhibited by Doreen included odd beliefs, bodily illusions, constricted affect, alignment with paranormal phenomena, peculiar behaviors, and a lack of interpersonal relationships. The absence of relationships reflected feedback from others who responded to her oddness in ways that contributed to it and isolated her further. A paranoid thread also ran underneath, and the inherent suspiciousness was effortful and anxiety provoking, thereby reinforcing the wish to stay clear of others or to behave as if they were not there.
The consultation challenge in this case was to ascertain what the facility could offer and would accept that would enable a compromise between the facility and Doreen. What did each party want, and what would each be willing to give to get it?
The facility wanted to maintain reasonable cleanliness in the units and to avoid complaints by workers and residents. Doreen wanted not to have to move again, to have the food she likes, access to her music, and to not be required to socialize beyond a minimum, other than with her brother. (She has always been comfortable with his visits, and eagerly looks forward to them.)
A meeting was arranged with the psychologist, the ALF director, the ALF social worker, and Doreen's brother. The psychologist, with information from her brother, gave a detailed overview of Doreen's history. He emphasized that when she had the roles and relationships to buffer her, she did well. She held two jobs, each for many years, and was regarded as a most reliable employee at each. She was a very involved and responsible family member, gradually assuming care and household responsibilities for her parents, until one and then the other died. Because of technological changes in her job requirements, she was let go; not an unusual experience for older adults these days. And finally, after living nearly her entire life in the same small town, she was moved to a different living environment in a different state where she had no landmarks for continuity, other than the visits from her brother.
It is easy to identify Doreen's weaknesses and limitations, but the psychologist highlighted a number of her strengths, thereby re-framing some of her maladaptive behaviors as adaptive. Four issues were important to her and provided her with necessary continuity to feel like herself, and the psychologist noted how Doreen managed to secure them.
First, Doreen quickly learned where in the local area she could order and have delivery of the foods she preferred. She not only loved the food, but these were reminders, "transitional objects," of her former life. Fast food was not only a comfort, but also a constant. To remind her of this, to provide comfort to savor after the food was gone, she kept the paper bags emblazoned with the logos. Second, she nestled her other love, music, in these bags. Third, while she did not have the social or communication skills to state her strong preference to eat alone, and did not outwardly object to being seated with others, she managed to behave in such a way to get what she needed by having others withdraw from her. She was able to keep her apartment "free of intruders" by making it nearly impossible for the cleaners to work there. When they redoubled their efforts, she increased her bizarre behavior and "warded them off."
Finally, her limited affiliative needs are met by the one living person whom she trusts and feels commutable and comfortable with, her brother. His routine had been to visit Doreen every other week; twice each month. She felt the need for more frequent visits from her brother since moving to this new environment, which she perceived as potentially threatening. She did not have the skill or even a clear idea of what she felt she was missing and needed to ask for. What frequently happens with personality disorders is that such unformed thoughts and unnamed feelings get acted out. Doreen acted out, misbehaved, and got her brother to be called in by the facility, and therefore she was able to see him more frequently. In addition, he brought her gifts, such as a new hamper for her records.
A meeting was scheduled that included Doreen, the psychologist, the ALF director, the ALF social worker, and Doreen's brother.
A contract mutually developed at the meeting included the following points:
■ Doreen could remain at the ALF (recall, she did not want to move again) if she kept the apartment clean of leftover food. This was presented as a public health hazard, and neither the facility nor she would want public health strangers snooping around her apartment. She was asked to vacate the apartment weekly while the cleaning people worked in her apartment. It was explained that they liked to work alone, just as Doreen did. And finally, she could order food as she liked and from where she liked. But it would need to come through the front desk. They would mark each delivery and Doreen would bring the garbage in the delivery bags to the front desk for disposal after the meal. If she did not comply, she would not be allowed to order food from outside.
■ From the facility's end: They would be willing to be the fast-food gatekeeper and monitor. They would allow the cleaning staff to spend whatever reasonable time was needed to clean her apartment; they would direct the dining room host to seat Doreen by herself, stating that she preferred to eat alone and was entitled to do so.
■ The brother would agree to visit Doreen weekly, unless he had been contacted by the facility with a problem related to this contract.
■ And finally, this same group would be reconvened regularly to address problems and acknowledge successes. They agreed that they were all equal players, and all would have a voice.
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