Working With Clients With Severe Persistent Mental Illness: The Case of Emily
Emily is a 62-year-old, single, heterosexual, African American female who seeks
treatment for anxiety. She says she often hears a female voice directing her to punish herself by
tweezing the hair from her head or by scrubbing her home clean. She reported that tweezing her
hair eases her anxiety. She has arthritis in her spine and knee and uses a walker to help her
manage mobility safely. She receives Social Security income and is not employed. Emily lives
alone in a subsidized apartment in the same building as her 72-year-old, unmarried sister. She is
reliant upon her sister for transportation and for a sense of social and emotional connection.
Emily and her sister shared an apartment for over 30 years, beginning when each of their
marriages dissolved. When her sister began a romantic relationship 5 years ago, Emily reported
that she began to feel very anxious and started to cry often. Emily moved into an apartment down
the hall in the building and began to tweeze the hair from her head, hiding her hair loss by
wearing wigs. Her sister learned of Emily’s tweezing after her wig slipped off one evening, and
she encouraged Emily to seek treatment.
During our initial visit at a local mental health center, Emily shared that when she was 2
years old her mother died from tuberculosis, and the following year her father, an army officer,
died from colon cancer. After his death, Emily lived with her paternal aunt from whom she felt
no love. Her older brother and sister were placed in an orphanage, and Emily was permitted to
see them on Sundays. When it became apparent that the children were entitled to death benefits,
Emily’s aunt agreed to take custody of all three siblings. The household then consisted of
Emily’s paternal aunt, her husband (who Emily described as an alcoholic), their three children,
and Emily and her two older siblings.
Working With Clients With Severe Persistent Mental Illness: The Case of Emily / Page 2 of 3 © 2016 Laureate Education, Inc.
Emily was briefly married in her early 20s but was disappointed and hurt by her
husband’s infidelity. She moved in with her sister and enrolled in a cosmetology school, but had
to stop working for health reasons when she was 58 years old.
Emily and I met for 50 minutes each week for counseling. She identified two goals of
treatment: to integrate the female voice and to disengage from trichotillomania (the compulsive
urge to pull out one’s own hair). Emily was collaborative during our sessions, conveying warmth
and enthusiasm when she arrived to her appointments. During the sessions, I provided room for
Emily to express her feelings so that she might develop healthy coping strategies for anxiety and
find acceptance of past events and memories.
Reflection Questions The social worker in this case answered these additional questions as follows. 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this
I used two specific strategies with Emily. First, I used a Hearing Voices Recovery Movement strategy to help Emily identify the voice giving her commands and find out what its needs were. I used cognitive behavioral therapy interventions to help Emily learn to “boss it back” when she felt compelled to pull out her hair.
2. Which theory or theories did you use to guide your practice?
I used behavioral theories to help guide my understanding of how to help Emily.
3. What were the identified strengths of the client(s)?
Emily was motivated for treatment.
4. What were the identified challenges faced by the client(s)?
Emily has a very limited support system, making it is easy for her to isolate and for her self- harm to go unnoticed.
5. What were the agreed-upon goals to be met to address the concern?
Working With Clients With Severe Persistent Mental Illness: The Case of Emily / Page 3 of 3 © 2016 Laureate Education, Inc.
Emily wanted to feel less frightened of the voice she heard and less driven to comply with its demands of her.
6. Did you have to address any issues around cultural competence? Did you have to learn about this population/group prior to beginning your work with this client system? If so, what type of research did you do to prepare?
In reading scholarly articles about trichotillomania I learned more about the importance of having “good hair” among some African American women. I used this information to open discussions with Emily about how she felt about her hair and what caring for her hair and removing her hair means to her.
7. How can evidence-based practice be integrated into this situation?
Using Emily’s treatment plan, Emily and I were able to identify which interventions worked to reduce the amount of time Emily thought of pulling her hair and how often she actually removed hair