casey’s case

It’s her third month on the job as case manager at Omnibus Behavioral Health.  They’ve been assigning a few new clients a week after having already transferred half the caseload of her predecessor.  Casey is easing into the rhythm of the routine and feeling that job expectations with workload and duties are manageable.  She’s fallen right in with co-workers, a good many close in age and some with similar career goals. On her first week, fellow staff invited her to join them at Friday happy-hour at their favorite watering hole.  

She figured she’d stay at this job at the local mental health center while working evenings on her Masters in Psychology. The position is full-time and paid well enough.  It would help toward paying off college loans while giving her some solid first-hand experience and mentoring in her chosen field of work.  And the location in this mid-sized Connecticut city was perfect – only 20 miles from her parents in the suburb where she grew up.

Case managers conduct home visits– some in supervised apartments, others living with family -- at least once a month and more often as needed.  Typically, they meet in the home and assess progress-to-date or lack thereof – activities in daily living; habits, hobbies and routine; apparent symptoms or untoward behavior, socialization, medication compliance, and healthcare needs, among other issues.  For clients who tended to be non-compliant with meds, the psychiatric nurses would have them stop in at the clinic each day or made daily visits to homes to pour them into little cups in prescribed amounts, observing while they took their pills.

On her first visit with Jerome in his apartment, she’s struck by how much he looks like her much older brother Jake – the square jaw, dimpled chin, tall athletic build, deep yet gentle voice and the bluest of eyes. Jake stepped up after their police officer dad died on a domestic call turned deadly.  A high school sophomore at the time, he took it hard, vowing he’d do everything he could to be his “loyal wingman” to mom and sis.

Sitting on the couch in his apartment, notepad in hand, Casey goes through her mental checklist of questions for him.  She accepts the cup of instant coffee he offers and places it on his scratched, cluttered coffee table.  Jerome is more than cooperative, quite charming in fact.  He swears up and down he’s doing his best to get through “this whole misunderstanding” and move beyond his interrupted life and return to college. He’d do what he has to do – take medications, follow advice in therapy, whatever it took.  Courtney, Jerome’s visiting nurse, assured Casey he’s taking his meds and has returned to “baseline”.

Just before finishing her spot assessment, Casey feels compelled to show him a photo on her cell phone of her brother Jake, after telling him he’s a “close double”.  Jerome moves from the stuffed chair to the couch where she’s sitting, scooching close enough to her for a good cellphone view of the photo.  Taken aback by the brushing of his arm and the leaning-in of his head, Casey starts feeling some slight uneasiness along with a sensual stirring as she swipes through the photos. She stays another five minutes or so talking about herself and her brother’s scholastic achievement and All-American status in college football. 

As she’s walking down the building stairway, she wonders if she’s crossed a line in letting things get too personal.

In the car with her laptop, Casey does another review of the clinical record, just to make sure she’s gotten it right.

He had had a “psychotic break” in his second year at Worcester Polytechnical Institute, majoring in mechanical engineering. His speech and behavior, seemingly overnight, was seen as so unlike the Jerome they’d known, even bizarre.  He stopped attending classes and stayed in his room for weeks and stopped communicating with his family.  

The college psychiatrist was called in to do an evaluation.  Her notes state that Jerome was guarded and refused to answer questions at first.  But as she was ending the session, he asked if his roommate Tyler could be relocated to another dorm room.  When she asked why, his reasoning was that Tyler was a disciple of Satan, had been reading his mind, telling him to do repugnant things, and psychically channeling his professors to convince them that he, Jerome, was destroying their minds.  The diagnosis:  Acute Psychotic Episode, rule out onset of Schizophrenia, Paranoid Type, Onset.

Jerome was sent home on medical leave for a semester for psychiatric treatment and would be considered for return to studies providing he’d attained sufficient recovery and stability to meet the demands of college life, the file notes say.

Casey then types in her home visit entry noting, “client seemed fully oriented, rational, linear in thinking, appropriate in verbal responses, and fully functional in activities in daily living and engagement in established daily routine”.

Casey has been sharing rent in a studio apartment nearby with her closest friend Janey.  They’ve been like sisters since grade school.  Janey is working on a flexible schedule as a “billing specialist” at a large orthopedic practice while picking up her few remaining college credits at the community college. Parents are divorced.  Her mother is getting by as a real estate agent; her father is unemployed, strapped with a huge gambling debt.   

In high school, Janey was on the gymnastics team and a football cheerleader.  A striking willowy blonde, she’s possessed of a shyness often mistaken for naivete and coyness but hiding beneath, a keen mind and sharp wit.  There’s has never been a need to be the huntress – just a matter of picking and choosing potential dates.

Casey sees herself as plain-looking though often told the contrary by family, Janey and other friends. Her usual response, “Mirrors don’t lie”. In high school, she loved to hear Janey talk about her romantic escapades and entanglements with boys she dated and all the drama of getting herself extricated to make room for a new love interest.  In later years Casey stumbled on the notion that this fascination served as a something vicarious for what had been lacking or missing.  

In college, Casey was a conscientious student.  Her freshman year she fell in with some students who were less serious about studies and more interested in keg parties.  She quickly learned she had to break away from that crowd, and she did – priding herself on having resisted all the tugging at her sleeve.  She met a senior her sophomore year, a studious English Lit major planning to teach.  It was good for a while – until she made an unannounced visit to his dorm room one day.  When he opened the door a crack, she could see he had company, a young co-ed in panties and oversized tee-shirt, his.

It’s Sunday.  Casey and Janey hang out in the apartment with a six-pack of beer and their favorite take-out pizza – pineapple chunks, peperoni and jalapenos, heavy on the cheese.  With their schedules being so busy, they don’t have the chance to “hang and chill” very often.

“So, what’ve you been up to these days, Case?” Janey asks.

“Not a whole lot”, she replies, “but they’re piling on more and more cases at work.  We’re a non-profit agency with orders from above to keep things rolling and having no waiting list. Lots of pressure”.

“Yeah, know what ya mean, our medical practice is all into profit, so they’ll take anybody with a bum knee or hip and recommend replacement.  They bring in big bucks.  It’s busy as hell.  I have my own little corner office, Case, so I do my billing and no one bothers me – except for my boss, Doctor Franklin. who slips his sleazy self into my office from time to time with a half-assed billing question – then starts hitting on me.  Last time I reminded the bastard that he’s married with four kids and wifey is only a phone call away”.  

“Good for you, Janey, funny how cheating and skeevy behavior know no social boundaries.  Have to say, ole girl, you sure know how to handle the horny monkeys and how to rein in the guys who bleed passion on the second date, gushing about falling from a high ledge to the bricks for you if you back off.  Thank God, no casualties”.

“Oh c’mon, you know I’ve had a few bad emotional contusions and collisions with guys, and it cost me a heartache or two”, says Janey.

Now on her third beer, Casey says, “Okay, granted, but I’ve always admired you for your looks, charm, and the way you carry yourself”.

“Give me a break, sistah, you’re shut off.  Would ya believe, I’ve been envious of your intelligence, great grades and hard-ass determination.  And, surprise alert, you are attractive. So cut the shit, will ya, Case?”   

For Casey this is a sobering remark, a feel-good slap of reality.  With that, they change the subject to jerks at work and their friends getting engaged, married, divorced, or missing in action.

Two weeks later, Christmas Eve, Casey’s brother Jake comes home to join the family to celebrate the holidays.  He finished Medical School at UConn and is doing his residency at Beth Israel Deaconess in Boston.  Shortly after the joyful hugs and small talk, he takes Casey aside to tell her how proud he is of her in keeping her eyes on the prize and not veering from her career path.  Casey hears it as part pep talk, but mostly sincere compliment.  He confides that he’s seeing another medical student, Anita, who happens to be interested in the same area of medicine, ophthalmology, and adds that his fellow medical student and friend, Raul, is single and available.

“Raul is a look-alike Antonio Banderas, whip-smart and a gentleman of gentlemen”, says Jake.

“No thanks, Jakey boy, not up to it right now – but thanks anyway,” says she, with a wry grin.

After work the Friday before New Years Eve, Casey drops into Bonkers Pub with four other staff for happy hour and an early toast to the New Year.  They sit at a large booth in the back with a clear view of the well-lit bar.  Casey chokes on a swig of beer when she spots Janey on a bar stool next to Jerome.  Once recovered from her shock, she starts to ponder how she’d make a clean exit without being noticed by them and without being rude to her friends.  Her solution: pretending to get a text message from her brother saying he needs a ride to the airport.  She sneaks out the back door. 

Late morning on New Years Day, Casey and Janey, still bleary-eyed from celebrating, both in bra and panties, converge in the kitchen for coffee and the two remaining English muffins for toasting. They both attended a friend’s New Years Eve party the night before, and left at the low point, 1:00 am.  They high-fived to an exit agreement, and did an Irish goodbye through the cellar door.

“Oh, my head”, says Jamey.  “Tell me about it”, says Casey.  “Terrible party, too much schlocky music, too many slobbering drunks and lecherous lizards doing sneaky gropes and full body-press hugs at midnight,” chimed Janey.

They sip their coffee quietly until the toaster pops up the muffins.

“Hey, Case, met a guy – wait, wait, no sarcastic cracks – at Bonkers last Friday, name’s Jerome, really gorgeous, awesomely nice and intelligent.  I just happened to find a stool next to him at the bar, only planning to have a glass of wine and heading out. Actually, I started the conversation, not him. He didn’t give me the usual dickhead come-on lines. Said he was taking a semester off from college and returning in the spring.  So, long story interminable, he asked me out for coffee at Molly’s next Thursday.  Couldn’t hurt, I was thinking”.

On hearing this, Casey snaps out of her morning fog.  She feels something inside pushing hard against her better judgment, hard enough to get her to spill, to spill a lot -- about him being a patient with a “major psychiatric disorder” with a psychosis and on heavy-duty psychotropic drugs.  Too late, she cuts herself off mid-sentence.  An uncomfortable silence ensues for minutes, abruptly ending when Janey gets up and tells her she needs to take a shower. 

Back to work after the holidays and back to her rounds, she sees that Jerome is second on the day’s list of home visits.  She feels a spike of anxiety as she thinks about it.  Well, she’d get it over early anyway, she tells herself.  At Jerome’s, she finds him a little downcast.  He goes to the kitchen and returns with a cup of coffee, handing it to her as she sits on the couch with her notebook.  Before she can ask the standard questions, he plops down awkwardly beside her, head in hands. 

“What’s goin’ on, Jerome?” 

“It’s about this girl I met at Bonkers.  She was nice, not like some other girls”, he intones, “She was different, special, very pretty but not shallow and stuck-up.  We hit it off, talked about our plans, life goals, things that matter, like how we’d like to make a difference in the world”.

“Sounds great, Jerome, but where’s the problem?”

“Problem is, we were supposed to get together this coming Thursday morning for coffee at Molly’s.  She called last night to cancel, so I asked about another day, and she turned me down again – no reason, just a weak excuse about being too busy with work and college.”

“Jerome, I’m sorry to hear this.  I’m sure you’ll find another young lady in due time.  For now, you want to stay focused on your recovery and getting back to college”. 

The moment she says this she loathes herself for the patronizing advice and more so for knowing she’s the one who sent him into this tailspin, possibly upending the gains he’s made.

Casey goes to bed shortly after returning home, though sleep won’t come.  She lies there staring at the ceiling fan, unable to brush aside her circular, troublesome thoughts. 

She gets up and finds Janey in the living room, still working on her term paper, tapping the keys of her laptop on the corner desk. 

“Can’t sleep, Janey, got a minute?”

“Yeah, sure, Case”, she replies, looking up from the laptop screen.

“Listen, Janey, it’s confession time.  I never should have told you about Jerome – his psych history, I mean.  I broke the rules, patient confidentiality.  I guess I was just trying to protect you, ole gal”. 

It’s okay, Case, not to worry.  Actually, I’m kind of grateful in a way that you had my back.  Wait, I take that back.  You burst my bubble, you bitch!”

With that, Janey gives her signature coyote howl, grabs a couch pillow and throws it at Casey, hitting her in the head.  Punch-drunk, they both break out into in loud yips, laughter and silliness. After the short burst of wild shenanigans, Casey goes back to bed, Janey back to her laptop.

She lies on top of the covers, face up.  Sleep won’t come, her thoughts won’t settle. Why don’t I feel the sense of relief I was expecting?  Yeah, I breached his safeguarded legally-entitled privacy.……but, oh shit, there’s the other thing, no way I can deny I’ve also betrayed him and all the others by hanging out that ugly tainted banner of stigma surrounding mental illness. For what? Casey the Advocate, yeah right.  So why?  She drifts off, mentally exhausted.

Next case manager assessment at Jerome’s two weeks later, she notices he’s in a much better mood compared to the last, even upbeat.  The team clinical chart reads “Has maintained stability, fully compliant with meds, exhibits no symptoms of psychosis, despondent mood or untoward behaviors”.

He offers her coffee.  She politely declines this time.  He sits down on the end of the couch, motioning to her to join him.  She does. 

“Glad to see you’re in bright spirits, Jerome.  I have to say I didn’t expect it.  Last visit you were upset over being rejected by a woman you met at Bonkers.  By the way, I felt really bad to hear that”, she adds. 

“Thanks, Casey, but that’s water under the bridge.  At my alma mater high school football game, I bumped into Allison, a girl I had my eye on senior year, until I found out she had a steady boyfriend.  So there we were. She was very friendly, said she remembered me. We talked awhile.  She happened to mention she broke off an engagement a year ago. That was it.  I bit the bullet and asked her out for a walk in the park and an ice cream cone.  Yeah, corny, I know, but she accepted”, he says with a glowing smile.

Before ending the visit, she responds, “Wonderful, wonderful, Jerome! You deserve it.  See, I told you there’d be others”.

Casey opens the car door and puts the key in the ignition, but doesn’t turn the key, just sits there staring through the archway of linden trees along the street.  Why do I feel a cold hand squeezing my heart? Am I a green-eyed monster, a client no less?  No, must be some fluke, some far-flung figment of imagination. I’m professional, career-minded, Jake would say so.  He knows, Janey too.  She turns the key and proceeds to her next home visit.