Sarah Jacobs is a 45-year-old Caucasian female referred to case management services by a child protection investigator (CPI) following concerns about Sarah’s mental health and the impact this is having on her two young kids. Sarah has been married to her husband Jordan for nine years, and they have two children together: Mia, daughter, age eight, and Stephen, son, age five. Sarah is a stay-at-home mom. She does not work outside the home. She has been receiving supplemental security income (SSI) for the past ten years following her mental health diagnosis. Sarah was diagnosed with Bipolar Disorder 1 four years ago, and about ten years ago, she was diagnosed with Major Depressive Disorder (MDD), severe, with suicidal ideations. Over the last several months, she has noticed similar behaviors in both of her children. This is triggering and, at times, causes her to avoid engaging with her children. 

Main/Current Event: About two months ago, child protective services (CPS) investigated an allegation from the children’s school that the kids were consistently showing up to school unbathed and dirty. The CPI determined that the children’s hygienic needs were sometimes neglected due to the severity of Sarah’s mental health problems. Because Sarah’s husband worked overtime for the postal service, he was often not home and unable to help his wife take care of the kids. Last week, when the CPI did an unannounced home visit in the evening the children were found locked outside the house. After knocking for several minutes, Sarah came to the door stating that she did not realize that the door was locked. She had fallen asleep after taking her medication. Sarah’s husband, Jordan, was still at work. 

Sarah had been treated with a variety of psychotropic medications since her initial psychiatric diagnosis about ten years ago. While Sarah’s medications for MDD and Bipolar Disorder help with her symptoms, they also produce side effects that increase drowsiness and reduce cognitive reasoning. Because of these undesired side effects from her medications, it is unclear whether Sarah’s difficulties attending to her children’s activities of daily living is a function of her mental health (MH) difficulties and/or being prescribed multiple medications at the same time (i.e., polypharmacy)

Sarah’s current medication list includes the following:

Major Depressive Disorder: Anxiolytic, which may relieve anxiety and tension. It often causes drowsiness and promotes sleep 

Bipolar 1:Amitriptyline, which can cause Impairments in verbal-numerical reasoning and Impairments in memory 

Scenario A: During the unannounced home visit, the CPI observed that Sarah seemed drowsy and confused, and had difficulty formulating and expressing her thoughts. The CPI saw no evidence of illicit drug or alcohol use, and, when asked by the investigator, Sarah reported she did not use illegal drugs and had not used alcohol that day. The only drugs she'd taken were those prescribed by her doctor, and she had taken them as directed.

Scenario B: Upon realizing the severity of the situation, Jordan confesses he is unable to assist Sarah any longer. He is exhausted from working long hours, Sarah’s medical bills and prescription co-pays, as well as, a basic fear of something happening to the children while he is at work. He petitions the court for full custody and for Sarah to be removed from the home.

Scenario C: Mia’s classmates have begun ostracizing her based on her dirty clothes. She has tried to wash her clothes in the sink as well as bathe herself, but she is often busy watching her brother and making sure he eats. Mia has become more and more withdrawn in school. One day after school she goes home to find her mother asleep again. She goes into her mother’s bathroom and feeling worn down/tired she takes several of Sarah’s ‘vitamins’. 

Sarah reports that her childhood was difficult as her birth parents were not in her life, and she was an only child. Sarah did not have a relationship with her biological parents and does not know very much about them - not even their names. Sarah was raised by her maternal grandparents, Dona and Rick, who would become enraged whenever Sarah tried to ask about her mom or dad. She does remember one specific moment when her grandmother, Dona, became upset from finding a piece of food stuck to a dish Sarah had just washed. Her grandmother said, “You are weak and stupid just like your mother. You will probably end up getting knocked up just like her when you turn 15”. She does not have any information about her father but always felt that he may have been in the military. When the school had a field trip to the Jacksonville, FL Naval base, Sarah’s grandparents refused to let her go and pulled her out of school for the day. When Sarah was 12 she became friends with a classmate named Jenny. They did everything together until Sarah’s grandparents found out Jenny’s dad was a Naval officer. After that Sarah was not even allowed to speak to Jenny.

Being raised by her maternal grandparents, the emotional and physical abuse Sarah suffered was daily and almost impossible to avoid. She was often told by her grandparents that she ‘was lucky’ that they took her in and that she should ‘be grateful’ for anything she was given. When she did something wrong she was immediately compared to her mother. Especially her grandmother, Dona, who would state how lazy, manipulating, and dirty Sarah was ‘just like her mom’. 

No matter how hard she tried, Sarah could never seem to get it right. On almost a daily basis Sarah would upset her grandmother and get thrown down the basement stairs into complete darkness. Sarah was terrified of the basement. She could hear the rats, smell the feces/droppings, and was in general scared of the dark. She can remember that at times she was down there for days. Dona would call her up sometimes to give her a stale piece of bread and sometimes just to laugh at Sarah and knock her back down the stairs. 

Sarah tried everything to please her grandmother but nothing worked. Her grandmother, Dona, continued to be angry at her and hurt her. Even worse, Rick would sometimes slip Sarah a piece of candy or bring her a flashlight (for the basement), but would do nothing to stop the violence. He would sit in his chair watching the evening news or start reading a book whenever Dona began belittling and beating Sarah. 

Her grandparents would often argue about money and providing for Sarah. Dona had diabetes and other health issues and over time her grandmother’s health deteriorated and she eventually needed an oxygen tank to function. Whenever her grandmother asked her grandfather for help, Rick made it very clear that he worked long hours providing for the household. It wasn’t a ‘man’s place’ to care for the home or children. 

The longer Dona was sick the meaner she became. Over time she refused to bath, cook, or care for the home. Although she could no longer throw Sarah in the basement, she would still bark orders at her. When Sarah did something her grandmother considered wrong or did not move fast enough, her grandmother would hit her with a stick or throw things at her. If Sarah cried or showed any emotion, the abuse would be more severe and last sometimes for days. Sarah tried her best to say as little as possible, anticipate her grandmother’s needs, and internalize all of her feelings.

The summer before Sarah turned 18, she asked her grandparents if she could get a job. They stated no - she needed to be home to help her grandmother. She was disappointed, but she knew better than to argue. Every day she would clean the house, do the laundry, and prepare all the meals. One day she was in the kitchen making lunch for her grandmother. When she brought Dona her lunch, Sarah asked if she was okay because she did not look well. Dona did not answer her, instead grabbing the plate of food from Sarah. Dona begins eating her lunch, but about halfway through she begins vomiting profusely. Sarah quickly called her grandfather, but he was unavailable. In a panic, Sarah called the ambulance and the medics rushed her grandmother to the hospital. Sarah can still remember the rage in Dona’s eyes as she was put in the ambulance. Sarah knew that when her grandmother returned home things would be even worse, so she quickly packed a few things she had, took the money from the coffee can, and left. 

Sarah quickly found that the road was not much kinder. She often had to engage in activities that made her deeply depressed and ashamed just to eat and have a place to stay. But one night sitting in a diner she visited frequently for cheap coffee and a place to sit, a waitress walked out and the manager, Jill, had no one to wait tables. Sarah offered, stating that she had just turned 18 and could really use the money. Jill gladly accepted. At the end of the shift, Jill offered Sarah a ride home and Sarah said she had no place to go. Jill told Sarah to come home with her for the night and they would figure it out together. 

Sarah stayed with Jill for a few days while she worked at the diner, but struggled at Jill’s house. She had difficulty sleeping, she would physically jump whenever the phone rang or Jill’s kids came running through the room and avoided the kitchen altogether due to the door that led to their basement. After two weeks at the diner, she had enough to rent out a room at the motel next to the diner that charged a weekly rate. She continued to struggle with her mental health but had been internalizing it all her life so it often went unnoticed by those around her. 

One day the local postman, Jordan, who always came in for a cup of coffee, asked her out on a date. She politely declined. Jordan persisted and eventually, she said yes. The night of the date she was so nervous, that she drank two glasses of wine before dinner even started. Because she did not drink often, she quickly became intoxicated. By the end of the night she told Jordan everything including that she believed if her own parents abandoned her and obviously did not love her, then why would anyone else? At that moment Jordan asked her to move in with him and promised that he would never abandon her. 

For a while,  Sarah was happier than she could ever remember. She kept her house immaculate, worked hard to make sure Jordan’s dinner was always on the table when he got home and tried to anticipate his every whim. Then Jordan had to attend training for a promotion in another city. The training was all day and then there was a group dinner and/or group project work. He missed Sarah but had little time to call or connect with her. By the third week of the training, Jordan could not get a hold of Sarah at night. He started calling the diner, but they stated that Sarah had missed multiple shifts. In a panic, Jordan began calling the local hospital, friends, and neighbors. Nobody had seen her and when the neighbors stopped over no one answered the door. Jordan was terrified that something had happened and left training.

When he got home, he could hardly believe what he saw. The house was a disaster. Dirty dishes and caked food were everywhere, the garbage was overflowing, and what appeared to be soiled clothing was in the bathroom. When he finally found Sarah she was in the corner crying, slowly rocking herself back and forth. He immediately picked her up and headed to the hospital.

The next several years were a blur of misdiagnosis, doctor after doctor, and both inpatient and outpatient mental health treatment. At times Jordan was completely exhausted and even considered parting ways, but Sarah was so terrified of abandonment that he was afraid it would only make her mental health worse or cause her to not get help at all. The only source of relief for him was his work, which he took great pride in.

Eventually, they found a doctor that was very helpful and diagnosed Sarah with Major Depressive Disorder (MDD). With therapy and medication, Sarah was almost a completely different person who thrived and was engaging. She still struggled but was better equipped to handle life’s challenges and the trauma she experienced. Eventually, they married and had their daughter Mia. Although there was some reservation about Sarah’s ability to parent, Jordan was pleasantly surprised at what an amazing parent Sarah was. A few years later, they had Stephen. 

When both of the children were still little, Sarah received a letter from her grandmother finally telling her the truth about her parents. Sarah’s father, Cam, who was at the time an eighteen-year-old man in the Navy met Sarah’s mom, Lily, when she was working a summer job at the port in Jacksonville. She was 15 about to turn 16 but told Cam she was 17 when they met. They dated all summer and truly cared for each other. Unfortunately, Cam had to go back out to sea before Lily even knew she was pregnant. 

When Sarah’s grandparents found out that Lily was pregnant they gave Lily two choices. She could live at the house and give them custody of the baby when it was born or they would press rape charges against Cam due to Lily only being 15. They told her repeatedly that she obviously made poor choices and would be an unfit mother. Lily did not want Cam to go to jail or for her baby to grow up without a home, so she agreed to the adoption. 

As Sarah read and re-read the letter, she could feel herself becoming slowly undone. As days passed into weeks, she would begin to experience bouts of mania only to be followed by weeks of deep depression. She was still taking her medication, but it did not seem to be working. Jordan was again at the end of his rope and did not know what to do. This time he was even more concerned because their children were involved. He decided to call her doctor for assistance and Sarah was placed in a mental health outpatient program. She was diagnosed with Bipolar 1. 

Things did improve, but they were never the same. Sarah experiences multiple side effects from her medication that make daily parenting difficult. Jordan has to work long hours to cover co-pays and mental health visits. In addition, when he does get home he is often scrambling to help the kids with their homework and dinner. He often feels exhausted and sad not knowing how to move forward or what is best for the kids. He knows this is not Sarah’s fault, but he also feels he is in way over his head and is starting to resent how much responsibility falls on him.

Demographics - Sarah Jacobs: