Auditory Hallucinations and Intervention Methods

Demographic Information

The immediate family of Eliza consists of her two middle-aged unwed sisters, Betty and Clara, and her niece, Marie, the only surviving offspring of her deceased sister and brother-in-law. Eliza's parents are both dead. Eliza is 45 and Marie is 15 and they live together in Eliza's home. Eliza assumed care of Marie after Marie's parents died in a car crash two years ago. The relationship started out satisfactorily but has gradually deteriorated over time. Marie is being impulsive and reckless, skipping school and drinking alcohol with boys and also smoking marijuana. Eliza is depressive and manic and paranoid and shows signs of auditory hallucinations. Her sisters are fighting with her over how to manage Marie and have recently taken Marie out of Eliza's home.

Eliza's husband is dead. They separated five years before he died of alcoholism. Eliza had five miscarriages with her husband. When her husband left her and became sick, she continued to take care of him in his one bedroom apartment where he lived until he died. She is a deeply devout non-denominational Christian, who attends church services on Sundays. She has two friends with whom she works at a school cafeteria, who are closer to her than her own sisters. Her main friend, Sara, is the one who presented Eliza to the clinic after Eliza had a nervous breakdown at work.

Presenting Problem of IP

The reason for Eliza's presentation is that she has been hearing voices in her head. They are muffled and do not appear to be saying anything but only seem to be indicating some feeling to her. One voice is warm and nice but another voice is dark and menacing. These auditory hallucinations have gotten worse since Eliza has been fighting with her sisters over how to control Marie, who is being more rebellious lately, sneaking out of the house and skipping school and engaging in underage drinking with boys. Eliza's sisters think she is unable to take proper care of Marie.

Eliza wants to care for Marie but she feels that Marie is not being responsive. Eliza is also suffering from depression and has been prescribed medication by her doctor but stopped taking it after a few days because she did not like the way it made her feel. That was 6 months ago.

Her problems at works stem from her disapproval of the way in which management of the cafeteria has cut the budget for cooked meals, which Eliza complained was the only meal some of the kids would get because of their home life situations. She viewed this reduction as cruelty to the children.

Her family medical history consists of a father who was an alcoholic and an ex-husband who died of alcoholism. She has received medication for hypertension in the past but did not take it. She had five miscarriages with her husband and never carried a child to full term. She has a strong maternal instinct and desire to care for people, which is why she has been especially hurt by her siblings, who have taken Marie out of her care.

Her relationship with Marie is also a concern as she loves her very much and has always been close with her, but she admits to not knowing how to react to Marie's rebelliousness. She is afraid Marie may get into worse trouble with her reckless behavior and she is very anxious about this, but she is afraid to talk to Marie about it because she does not want to drive her away. Instead she sets up rules and locks the doors at night thinking that will do the trick, but Marie apparently was sneaking out, which is what Eliza's sisters found out when Marie was picked up for drinking at a party by the police and she gave her other aunts as contacts rather than Eliza, which also hurt Eliza. Later discussion with Marie in family therapy revealed that Marie was afraid of hurting Eliza and did not want her to know, but it all came out in the open when her other aunts overreacted and took Marie away from Eliza.

Her family consists of two parents who are dead, a sister and brother-in-law who are dead and a niece who till a few days ago lived with her and relied upon her for care. Now the niece is staying with Eliza's other two sistsers, with whom she is fighting. Before the fight, everyone got along well and even lovingly but since Marie has been acting rebelliously, tension has arisen in the homes.

Her personal history is that she has always worked hard as a young girl, overcoming obstacles so as to earn a degree at college and get a management position in a factory -- although she gave this up after a while to tend to her ex-husband who was ill. She took another job later on, which she currently holds and she has been recognized for her exceptional work in the past.

Her recent nervous breakdown came days after her sisters removed Marie from her house and she has been unable to sleep or do anything without a feeling of intense anxiety.

Family strengths and resources: Eliza's relationship with her church and her friends.

Genogram

The genogram depicts Eliza's relationship with her family. She is divorced from her husband, who is deceased. She herself suffers from depression. Her parents are both deceased and they were divorced as well, so separation anxiety may play a role in Eliza's condition. She is also surrounded by death and loss, with five miscarriages and the loss of her sister and brother-in-law. Now she cares for Marie, who is 15, but her other two sisters disapprove of the way in which she is raising Marie, so they want to intervene, but their methods are questionable. This suggests that Family Systems Therapy intervention would be beneficial (McGoldrick, Gerson, Petry, 2008).

Figure 1. Genogram

Clinical Hypothesis: Four Relevant Concepts

Eliza's spirituality is important to her and this could be useful in her treatment as she is a regular church goer.

Her grief and experience of loss is due to five miscarriages, which have given a feeling of lost opportunity and she now wants desperately to care for Marie in the same manner that she cared for her ex-husband even after he left her.

Her friends are very supportive of her and see the wonderful and good things that Eliza does for others and how self-sacrificing she can be, but there is also the indication that Eliza nurtures some grudges and does not easily let go when someone has hurt her, as she expressed some indignant frustration at her sisters during therapy.

Her religious background and culture is typical of non-denominational Christian culture and her prayer life is very important to her and she says that she likes to pray a rosary even though she is not Catholic. She has a strong devotion to Mary, the mother of Jesus and prays and talks to her throughout the day, she says. The voices that she has been hearing, she says, are not the voices of Mary or of God but are of some strange origin that she does not understand.

The clinical hypothesis is that Eliza suffers from depression and hypertension and that her auditory hallucinations are the result of this tension. Corstens et al. (2012) explain that by talking to the voices one may engage the factors of presentation more fully.

Ecomap

Eco Map

Eliza___Her 2 friends from work

Eliza_ _ _ _ _ _ _Marie

Eliza-/-/-/-/-/-/-/Her 2 Sisters

Figure 2. Ecomap.

Therapeutic Approach

Family systems therapy would be an appropriate therapeutic model for this family, as it could include Eliza, Marie, and Eliza's two sisters, all of whom could benefit from family therapy, as it is evident that each has love for the other but that emotions and misunderstandings are compounding an issue that is already risky because of Eliza's depressive signs, hypertension, auditory hallucinations and recent nervous breakdown.

The hypothesis is that Eliza's symptoms are both internal and affected by her family, which is in turn impacting her work life and adding to her anxiety.

Werner and Silbereisen (2003) locate the etiology of substance use/delinquency within the context of family and peer situations. Their quantitative Berlin study supports the theory that stable and "harmonious" family life is less likely to result in adolescent delinquency than unstable family life (p. 471). They also observe an "indirect" correlation between family structure and peer relationships, stating that more "open" and trusting families allow adolescents a greater degree of "autonomy" to choose peers. Respect breeds respect and the peers of the children of such families are more likely to be of a similar family structure and of prosocial tendencies. Of particular note in this study is that women who lacked "family cohesion" showed that they were more likely to develop peer relationships of an antisocial rather than prosocial nature (Werner, Silbereisen, 2003, p. 473).

The lack of a prosocial family system serves as a catalyst for degenerative, antisocial behavior outside the family system. Werner and Silbereisen thus suggest that a supportive, respectful home facilitates healthy, prosocial behavioral development in adolescents. For the social worker, the implication is that divorce, which acts as a disruptor of the family system, presents an opportunity for that system's merits to be evaluated and its structure either supported or altered so as to facilitate the prosocial behaviors desired for the adolescent in question.

Commonalities within family dynamics of families of divorce are that most men and women who divorce are young when they marry (nearly 28% of women who divorce marry before they are 20 years old and 50% of men who divorce marry before they are 25 years old). Families of divorce often show signs of instability, whether through infidelity, lack of communication, substance abuse, or feelings of incompatibility due to education (or lack thereof) or income disparity.

The effects of divorce on the family system are noted by Clarke-Stewart and Brentano (2006) in a variety of ways: American children of divorced parents are "three times as likely" to take up the habit of smoking than are children of intact families (p. 121). The "overall functioning" ability of children of divorced parents has been assessed as "poor" over an extended period of time (from five to twenty-five years post-divorce). This statistic is qualified, however, by the fact that such poorly functioning offspring are not from "typical" American families (white, middle class, psychologically healthy). Behavioral problems in children of divorced parents, in most cases, reflected similar behavioral problems in their parents (Clarke-Stewart, Brentano, 2006, p. 122). Their study also indicates that 35% of children of divorced parents have a less defined/close relationship with their fathers. If anything, Clarke-Stewart and Brentano (2006) note that divorce can trigger latent behavioral aberrations. It is more likely to be a significant factor in teen pregnancy than other factors, such as domestic violence and low socioeconomic status.

The family system can also suffer physiologically in terms of depression/anxiety for all involved, crises of identity, stress, weight gain/loss, and a degenerative immune system. Nunes-Costa, Lamela, and Figueiredo (2009) assert that these effects are not strictly caused by divorce itself but rather by the "factors associated with it," which range from a collapse of financial stability to a collapse of communication within the family system, new and different "co-parenting" methods, and a fundamental loss of "social support" (p. 385). The effects of these factors, however, are equal to those associated with divorce, and include "poor academic performance" for children of divorced parents, poor physical health, and psychological insecurity.

Ahrons (2007), in his assessment of the Marin County and Virginia County studies, as well as the Binuclear Family Study, notes that the common conclusion of each is that the distress which affects children of divorced parents is temporary in the sense that 75-80% of such children are able to function "as healthy adults" (p. 55). Ahrons thus situates the problem of divorce in a temporal context and provides a "big picture" analysis to alleviate short-term symptoms. This study is relevant to the current presentation of Eliza and her family because divorce and separation signify so pervasive in the family dynamic. Thus, it is clear that the distress that each member is feeling is more than likely related to this incidence of death and divorce and separation anxiety and each is impacting the other.