COUC 546
AMARA CASE STUDY
Amara is a 68-year-old widowed Asian American. She lives in a condominium she and her
husband purchased prior to his death four years ago. Amara has three adult children who live
outside her home. Her oldest daughter lives in the same suburban community, while her middle
son and youngest daughter both live in adjoining states. Amara is the primary caretaker of her
90-year-old mother who lives in the home with her. Her father died of natural causes ten years
ago. Amara stated that she took on the care of her mother to keep her from entering a nursing
home, which would be shameful for her to allow. Amara’s parents immigrated to the United
States from India two years prior to Amara’s birth, and she holds to many of her parents’ South
Asian traditions, including the need to prevent her mother from entering a nursing home. Amara
reported that the primary reason she is seeking counseling is due to her increasing anxiety. Her
oldest daughter, who also provides care for Amara’s mother, has threatened to stop coming to the
home if Amara does not do something to get her anxiety under control. Amara saw her family
doctor and requested medication to help with the anxiety. She was prescribed Paxil and has been
taking the medication for four weeks. Her doctor referred Amara to you for an assessment and
treatment.
Amara reported that she has always been “high-strung,” according to family and friends.
Amara’s oldest daughter confirmed that “Mom has always been somewhat anxious. When I was
growing up, she would have been classified as somewhat of a helicopter parent. Not really
pushing us to succeed, but always being present, worried, and attempting to protect us from some
sort of unseen harm that she always believed was on the horizon. Ever since her retirement, she
has gone from being high-strung to absolutely uncontrollably anxious about everything.” Amara
stated that her mother was very anxious until she went into menopause and has relaxed a lot in
the last 30 years. Amara reported that three years ago, she began having some trouble sleeping
but attributed it to her life changing so much in such a short time. She reported that she started
noticing that her mind would race with various worries for part of the day two to three days a
week about two years ago. In the past 18 months the worry has increased to daily for a majority
of the day. Amara stated that she worries about “Are the kids safe? Do I have enough money for
the rest of my life? Is the condominium building I am living in going to fall into a sinkhole? Do
people like me? Did I say something stupid when I was talking to someone? Do my
grandchildren like me? Will my children take care of me when I am 90? Am I allergic to milk? I
love milk and would be so sad if I developed an allergy. Is the chicken I just bought safe, or does
it have salmonella? Do I look OK, or do people see me in public and think I am crazy? Do I have
body odor? How are the kids in my classes doing? Are they successful or did I do something to
lead them down the path to being criminals? Is my neighbor's dog going to bite me, and if he
does, will my neighbor yell at me? Will I get rabies? Am I taking good care of my mother?
Would my father and husband approve of the care I am giving her?” Amara continued for at least
five minutes with a wide variety of worries. She stated several times that she has never
experienced any of the events she is worried about. She has never had food poisoning, any
traumatic injury, any family member harmed, or any friend/ neighbor expressing dislike for her.
She stated she rationally knows that her worries are unfounded, but she is unable to stop them
from popping into her head. “Once they are in my head, I cannot seem to let them go. They roll
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around and around until another worry pops in and takes over. I try to tell myself to stop
worrying… to just stop. It never works.”
Amara reported, and her daughter confirmed, that she has been very difficult to get along with
since the worry increased 18 months ago. She is irritable and will “snap” at her daughter and
mother if they confront her about her worries. She will also get angry when her other two
children tell her to stop calling to check on everyone. “About a year ago, I started calling my son
and younger daughter daily to make sure that everyone in the family was safe and that none of
my worries had come true. My daughter will always answer the phone, but in the last several
months, she has started telling me that she's going to start letting my calls go to voicemail
because I spend 30 minutes listing off all the terrible things that could happen to her family. My
son's wife tends to answer the phone when I call, but she has started letting my calls go to
voicemail. She and my son will call me about every other week to make sure I'm OK. But
outside of that, they have no contact with me right now. This makes things very difficult as I
used to have a very good relationship with my son and daughter-in-law and their children. I miss
interacting with them about things besides my worry, but I just can't help the worries spilling out
when I talk to them.” Her older daughter reported that she and Amara have gotten into multiple
fights over the last 12 months because of Amara's irritability and constant reports of worries.
Amara reported this strained relationship also makes her very sad as she had a very positive
relationship with her older daughter until about two years ago. Amara stated that even though she
is sad over the strain in her relationships, the emotion she feels most of the time is worry and
anxiety.
Amara reported that over the past 24 months, she has felt increasing tension in her body. “I used
to get a headache one to two times a year. I now have a headache three to four times a week. The
doctor and my daughter call them my worry headaches. My shoulders and neck hurt all the time,
and I feel like a rubber band that has been overwound.” Amara stated that for the last 12 months,
she has had difficulty sitting still when she starts to worry and will often get up and walk around
due to feeling like she might “jump out of my skin at times.” She went on to report, “You would
think because I feel wound up all the time that I would have a lot of energy and I would get a lot
of things done. But I don't! I feel tired all the time, and I have a really hard time motivating
myself to do anything around the house that doesn't absolutely have to be done.” She reported
her fatigue has been present for at least 12 months. Amara has been struggling to sleep for the
past 18 months. She stated that in the past 12 months, she has struggled to get to sleep nightly,
laying in bed awake worrying for at least one to two hours every night and waking up worrying
after five to six hours of sleep. Prior to her retirement, Amara slept seven to eight hours a night.
Amara reported all of these difficulties have occurred daily for the past 12 months. She stated
that prior to a year ago, “Some of these things like sleep and being fatigued happened two to
three days a week. And then, two to three days a week, I would feel really wound up and tense.
It's like they would trade off with each other, two of them visiting me and then going away, and
then two others coming to visit and then going away. These past 12 months I feel like they all
have moved in with me forever. “
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When Amara discussed her husband, she smiled at the memory of their relationship and then
appeared sad as she recounted his death. Amara stated that she and her husband were married
when she was 30 years old. She stated they had a very positive relationship, and she had always
been happy in the marriage. She reported that her husband was diagnosed with cancer two years
prior to his death. “For the entirety of those two years, I juggled working full time, taking care of
my mother, who had just moved in with us, and caring for my husband. And I never felt
overwhelmed like I do now. Even when I knew that he was not going to live much longer, I
didn't worry like I do now.” Amara stated that she felt very sad and cried a lot the year after her
husband died. She stated, “Every day I will think of him and miss him, and some days I still feel
sad. Now I think more about the good times I had with him and laugh with others when we tell
funny stories about him. He had a great sense of humor and kept everyone around him
laughing!”
Amara stated that she retired 3 years ago. She worked full-time as an elementary school teacher
in various grades and school districts since she was 24 years old. She stated that she decided to
stay at work an extra year after her husband died. She reported, “It gave me a sense of normalcy
and a reason to get up in the mornings.” Her school district has a mandatory retirement age, and
Amara stayed until she was forced to retire. She considered applying for another job in a
different school district, but that would have resulted in her having to move. Because she
depended on her daughter's help with her elderly mother, she did not feel like she had the
freedom to move.
Amara stated that after she retired from her job, she did feel sad for about six months. She stated
that she worried about what she would do with her time and had moments where she felt like her
usefulness might be over. She reported that currently, she doesn't feel sad about leaving her job
but worries about things like finances. When questioned about her financial situation, Amara
stated that her husband left a significant amount of money when he died, and she has a
substantial retirement account. She stated that she makes more money per month now than she
ever did while working. Amara acknowledged that her worries about money are completely
unfounded, but she will find herself consumed with worrying about finances several times per
week.
Amara stated that she does miss her coworkers and that was the hardest part of leaving her job. A
lot of her social network was formed from coworkers. She stated that after she retired, she kept
in touch with some of them but, over the last 18 months, has lost touch with everyone but two
friends. Her friends have confronted her about her constant worry and have expressed that they
enjoyed spending time with her much more prior to her increase in worry. Currently, Amara
spends most of her time caring for her elderly mother and helping her oldest daughter with her
children. Amara reported that she enjoys being with her family but worries about them all the
time. Amara's daughter reported that she desires to have a good relationship with Amara and that
she wants her children to have a close relationship with her grandmother. She stated that this has
become harder and harder recently due to all the worry. She reported that her children have
started to notice how difficult it is to be around their grandmother and have started asking to be
excused from family gatherings that involve their grandmother. Her daughter has informed her of
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this situation. Amara stated that it made her cry for several days when her daughter said her
grandchildren did not want to be around her. “I am now worried that no one would ever want to
be around me again and that I will die alone in the streets, forgotten and rejected by my friends
and family.”
Amara reported that prior to her husband’s death, they would have one glass of wine two to three
days per week. She stated that for a year after her husband died, she stopped drinking altogether.
“I already felt really sad, and I had read that alcohol is a depressant, so I figured if I wanted to
start feeling better, I should not drink.“ About six months after her retirement Amara began to
drink wine again, approximating that she drank five to six glasses per week. In the past 12
months Amara stated that her wine consumption has increased to having two glasses of wine five
days per week. She stated that the wine does “help take the edge off of me a little bit and makes
me feel somewhat relaxed. A little bit! But I know what happens when people start to self-
medicate… and I am not going there! Too many in-service training about alcoholism and
teachers.” Amara stated that she does not feel like her alcohol consumption has gotten out of
control and that the same amount of alcohol has the same effect on her. Amara's older daughter
reported no concerns about Amara's alcohol use and stated, “Sometimes I wish she would drink
more so she would just calm down. Not really, but you know, anything to get her to stop being so
anxious.”
Amara reported no preexisting medical conditions and no medication prior to the doctor
prescribing her Paxil four weeks ago. She stated she entered menopause around 60 but did not
notice the decrease in anxiety like was observed in her mother. She stated that she has taken the
Paxil daily and has not started feeling any less anxious. She stated the doctor did explain to her
that it could take multiple weeks for the Paxil to work, and she could need an increase in the
dosage in the next 6 to 8 weeks. She also reported an understanding that Paxil may not be the
medication that works for her, and she may have to go through several trials to find an effective
medication. “I really hope this one works because I don't want to damage my relationships any
more than they have been. But if the doctor tells me to try something different because my worry
doesn't decrease, I'll do it! I don't want to live like this anymore!” Amara reported no history of
any other mental health diagnosis and has never been to a counselor before. Her daughter stated,
“There are many times I wished my mom would get help, but she never did. Counseling was not
an option in her family growing up, and you always kept family problems in the family. I am so
glad she is taking this step now.”
Amara reported that she is Hindu and would be interested in integrating the teachings of her
religion into counseling.
When asked about her motivation for counseling, Amara stated that she has to continue to care
for her mother. “It would be so much shame on my family. Both my mother and father still have
lots of family in India, and I would never be able to face any of them again if I allowed my
mother to go to a nursing home. And I need my daughter’s help to care for my mother. I also
deeply value my relationships, including my children, grandchildren, extended family, and
friends. I think my daughter telling me that her children didn't want to be around me anymore
was a bit of a wake-up call for me.”
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