September 09, 2020

A Case Study in the Importance of Integrative Care to Mental and Physical Health and Wellbeing

By Susan Parmelee, LCSW

As social workers we have a guiding tenet: “Start where the client is.”  In practical terms, this means that if my client is not housed, does not have access to food, or is physically ailing, there is no chance of working on higher level needs through mental health therapy. Addressing the needs of the whole person is my job as a social worker – to make sure all parts are considered and integrated.

To illustrate the importance of integrated care as outlined in my previous blog, I present this case study. Please note that for privacy reasons, names have been changed. 

Jennifer

Jennifer’s mother called me to request an appointment, telling me, “Jennifer will not get out of the bed in the morning, she has missed the last 5 days of school, and she tells me she just cannot go to school right now.”  I had an opening that day, so I asked Jennifer’s mom to bring her in. Mother insisted on meeting with us, not able to leave Jennifer’s side. Mother told me she is a single parent, having split with Jennifer’s father when Jennifer was 4 years old. Jennifer would not look me in the eye. Mother went on to dominate the conversation, telling me Jennifer had been diagnosed with Mononucleosis four months prior and had missed three weeks of school. Jennifer made up all her work over winter break and returned to school for the Spring term. 

Mother noted that Jennifer, normally a very upbeat and happy young person, had broken up with her boyfriend about a month ago and stated that she felt “he was not a good influence on my daughter.” She began missing one or two school days a week and then last week stopped going to school all together. Mother claimed the doctor said Jennifer was over the mono and Mother believed the vitamin regimen she put her on should make her feel good. I gave Mother instructions to take her back to her pediatrician for a blood panel workup and suggested asking about adding Vitamin D to her vitamin regimen. 

I eventually succeeded in persuading Mother to allow Jennifer and me to spend some time alone. I did my best to increase Jennifer’s comfort level in sharing her experiences with me and gathered more information. Jennifer opened up quickly, telling me how sad she was about the break-up, how her mother dominated her life, and how she was looking forward to applying to and leaving for college in 18 months. She broke down and told me she was worried that she would never be able to catch up on her Junior year school work, which would jeopardize her future.

I helped Jennifer understand that her health needed to come first right now, and the rest would follow. I noted that she was very pale, not unusual since she had not left the house in several weeks. We discussed trying to take walks outside, improving sleep hygiene, and trying to get back to school for a part of the day. Before they left I shared with  Mother that Jennifer was very pale and could possibly be anemic, making the blood work even more important to rule out or to uncover physical reasons for her shift in mood and behavior. 

Although Jennifer did turn out to have anemia, the recovery from this clinically significant depressive episode did not spontaneously resolve as her iron levels improved. Addressing the anemia was an important component of her disease management, along with weekly mental health therapy, and the use of a low dose antidepressant. Jennifer completed her Junior year and was prepared to apply for college. We continued to work on the tension building between Mother and Jennifer, seemingly driven by her imminent departure for college and Mother’s need to overprotect her child. 

As is usually the case, I never consulted with Jennifer’s pediatrician, relying on Mother and client to relay important information. Notably, a significant piece of her clinical presentation was a result of her illness and subsequent anemia, layered upon the hormonal and developmental changes of her age and the stresses unique to her life. Unaddressed, the anemia would have hindered her recovery and potentially caused other health issues.

Could there be a better way to integrate the care of our youth, to consider the health of the whole person,  that possibly is more efficient and effective?  Could integrated care prevent or reduce poor outcomes, including death by suicide?  I would argue yes, more communication between healthcare and mental health providers could help save lives and reduce self-harm among young people

Susan Parmelee, LCSW is a board member of the James Kirk Bernard Foundation and the founder and Executive Director of the Wellness & Prevention Center (WPC), a nonprofit mental health clinic in South Orange County, California. WPC’s mission is to help youth and families lead healthy lives. The WPC provides easy to access clinical services on secondary school campuses and educates the community about the diseases of addiction and mental health.