discussion

The Case of Jake Levy Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child. As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reported he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither reported having criminal histories. Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, At Jake’s intake session at the Veterans Affairs Health Care Center (VA), Jake stated that he came to the VA for services only because his wife had threatened to leave him if he did not get help. Sheri was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had previously visited his primary care physician, Dr. Zoe, where he was given a prescription of Paxil to help reduce his symptoms of anxiety and depression. Dr. Zoe recommended that he get ongoing treatment and referred him to see a social worker at the local VA. During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He described being proud to join the army and deployed and described himself as upbeat and happy prior to his deployments. He felt that he had to “change” to stay alive there. Jake continued that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep, saying, "nights are the hardest." Jake admitted to increasingly drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He gave some examples of having a “hair-trigger temper” with his sons, especially if they surprised him inadvertently. Jake spent his evenings on the couch drinking beer and watching TV or playing video games. Jake feared losing his job if he opted for treatment but feared losing his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he sometimes felt pressured to be more communicative and

social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors. On the mental status examination, Jake was well-groomed but appeared somewhat guarded and anxious. He was coherent and articulate. Speech was at a normal rate, although the pace was noted to accelerate when he approached or discussed disturbing content. He denied depression but admitted anxiety and hyperarousal in situations, such as when strangers stand close to him in check-out lines. His affect was somewhat constricted but appropriate to content. His thought process was coherent and linear. He denied all suicidal and homicidal ideations but admitted that if startled “not much thought happens” between the event and his aggression responses. He had no psychotic symptoms, delusions, or hallucinations. He had reasonable insight, was well oriented, and seemed to have average intelligence. With Jake's permission, a collateral contact was made by phone with Sheri to elicit her concerns and perspective. Sheri talked about wanting to be able to communicate with Jake without feeling that she was “nagging him” or fearful that she was making him withdraw and that she would “trigger his anger.” She said that she avoided asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own. As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with friends and having family outings and felt isolated during their confrontation. She reported that during the fight it came out that Jake told her that just keeping his intrusive thoughts at bay took all the energy he could muster. Seeing friends and making small talk was not something he felt he could do right now. Sheri admitted that she did not know that socializing affected him that way nor that loud noises, open spaces, and green lights triggered intrusive memories. She was at the “end of her rope” with Jake but was relieved that he had come for help. Jake said that at times he thought he was “going crazy.” He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. Jake talked about how his behaviors fit into a cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He always felt on edge and every sound seemed to startle him when he was not drinking. He shared that he often thinks about what happened “over there” but tries to push it out of his mind. The night is the worst time for Jake, as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. Adapted from: Plummer, S.-B., Makris, S., & Brocksen, S. (2013). Sessions: Case histories. Baltimore, MD: Laureate Publishing.