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Psychotherapy Casebook

A Continuing Saga

Dean Schuyler, MD

Published: April 12, 2012

A Continuing Saga

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Through this column, we hope that practitioners in general medical settings will gain more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Schuyler is a psychiatrist with a part-time private practice and a part-time job on the Geriatric Unit at the Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina.

Prim Care Companion CNS Disord


Published online: April 12, 2012.

Potential conflicts of interest: None reported.

Funding/support: None reported.

Disclaimer: The views herein are those of the author and do not necessarily reflect the views of the Veterans Administration.

Corresponding author: Dean Schuyler, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (

It is often said that sports imitate life. The College of Charleston (Charleston, South Carolina) men’s basketball team had a good season last year. Unlike their professional counterparts, however, college students graduate, and the Cougars lost 3 highly productive players from last year’s team. With an above-average recruiting class, this season’s team completed its preconference schedule, winning 10 games and losing only 3. Fans expected another outstanding season. Then came an inexplicable loss—the loss of a sterling freshman to injury—and another unexpected defeat. How could they possibly recover?

The basketball coach described his preparation for game 17 as a “new beginning.” Fittingly, he started some new players and gave others newfound court time. Would the new combinations work?

Last fall, I worked with Mr A, a 60-year-old Vietnam veteran who had suffered a severe abdominal insult and nearly died. By the strength of his will, Mr A summoned the motivation to rehabilitate himself and to reach the point of discharge from a nursing home unit. He had pushed himself to achieve many small gains, which had added up to a reclaimed ability to walk and the hope that he could take care of himself.

Leaving the nursing home unit, however, Mr A could not know what lay ahead—only that he had earned a second chance at life, beginning at age 61 years. As happened with the basketball team, the road for Mr A had several unanticipated turns and unplanned-for defeats. It seemed prudent to continue our work together, as Mr A sought to negotiate the world he found outside the confines of a nursing home. We described his task at discharge as a new beginning.


Mr A had been out of commission for a calendar year while he recovered in the hospital and then on a nursing home unit. As he endeavored to contact old friends, he was confronted time and again by the same remark, “Not having heard from you, we thought you had died.” In addition, he had lost a lot of weight and did not look the same as people remembered him. During Mr A’s illness, his wife of many years had died. He was now single again.

At the nursing home, much was done for him. He had the attention of the staff, 3 square meals a day, activities offered to him, and the company of the other residents. Now, alone in an apartment, Mr A would have to do it all for himself. No job would be waiting for him. He would need to structure and plan his time. Walking remained a chore, and he would need to find ways to get his needs met and to reestablish a life. “Everything feels strange,” Mr A said once he returned home.

In our initial outpatient session, Mr A reviewed a series of losses: the support of the hospital staff, the company of the other inpatients, his grandson with whom he was close leaving the area for a college elective, and the leader of an outpatient group he had attended who would be leaving after 8 years. Mr A outlined the scope of a problem, without considering prospective solutions.

What followed were 2 fractured vertebrae when Mr A assumed that he could function much as he did before his hospital stay began 1 year earlier. He was, once again, a hospital inpatient. We spoke on the telephone and then had a session in his hospital room. Mr A discussed the sudden splitting up of his daughter’s family. It was expected that the eldest grandson would move to Florida with his mother and the younger grandson would remain in Charleston with his father. “I’ ve lost all the support I had in a matter of weeks,” Mr A said.

Mr A’s problem came with the realization that he needed people to be around and that he could not take full care of himself. He wondered aloud whether he should return to Tennessee, where he had lived many years ago; however, he realized that in 30 years much had changed there. Mr A’s involvement with his grandsons (particularly the eldest) would now change, as they were likely to leave the area and move on. Initially, he thought that he would return to his apartment and make up for lost time. Now, that strategy seemed beyond him to do. We focused on the notion of a new beginning and attempted to define the decisions that he would need to make before he could achieve it.

When Mr A left the hospital (now, for the second time), he stayed with his daughter’s family for long enough to learn that this arrangement would not work. So, he was driven around and put a deposit down on a townhouse that he found. His family’s plan to move had become more uncertain, but living with them was clearly not an option for him.

At our next session, Mr A revealed his expectation that his grandson, a high school junior, might live with him and complete his high school education when his family left for Florida. His family’s uncertainty about their immediate future was making his need to plan “impossibly difficult.”

Mr A moved successfully to his new townhouse, and his daughter came by to help him unpack. He gradually resumed driving, and aside from caring for a colostomy and dealing with periodic back pain, he saw his life as “progressing.” He told me that he had definitively ended a long-term, long-distance relationship that had persisted for years. His task remained one of accepting the restrictions and realities of his life and establishing a workable life plan.

A male friend came by to visit each day. Other than this contact, there were few people in Mr A’s life. We discussed what he could do to reestablish a social group. His grandson became involved with peer friends and now was calling him less often. He realized how dependent he had become on the young man and that his grandson’s life would likely move on. He revealed a good bit of black and white thinking about his colostomy and his grandson, and I challenged him to find grays.

Serious conflict in his daughter’s family erupted and dominated our next meeting. His grandson asked him to intervene. He made it clear that he could do little to affect the relationship between the young man’s mother and father. Mr A drove to Tennessee to see a college football game and to revisit his old college haunts. Nostalgic feelings were mixed with a sense of all that had changed.

Now, his family split apart. The eldest grandson accompanied his mother to Florida while the younger grandson moved in with his father in Charleston as originally planned. Mr A spoke in detail about how this affected his life and about his limited options. He spoke also about his increasing withdrawal and isolation. I emphasized his need to establish the components of his new life. “I have to bury the old me and find a new one,” he said. He told of a visit to his late grandparents’ estate (now his) in southern South Carolina. He discussed a plan to refurbish the home and, perhaps, to relocate there one day.

While visiting the emergency room of a local hospital to accompany a friend, Mr A saw an old nursing acquaintance who was the daughter of a now widowed woman he had dated years earlier. In addition, the sudden illness and hospitalization of his father-in-law (to whom he remained close) presented a new stressor. The nurse’s mother (his old girlfriend) called him, and they met for coffee. “I am not the me that I was in 1995; however, I do want to see what the next chapter has in store for me,” he said.

Mr A’s father-in-law died after a brief hospital stay. He met and drew close to his old girlfriend’s children. We discussed his and her expectations as he saw them, as well as those of her young children. Our format was choices and consequences.

Now, the mother of his old girlfriend died on New Year’s Eve. He provided support and took on the role of accessory parent to her children. Mr A retained his relationship with his grandson (now in Florida), and they spoke frequently to discuss issues in the young man’s life. When his old girlfriend suggested a permanent arrangement, Mr A emphasized the significant difference in their ages and that his health kept him from looking too far ahead.


After 3 months of weekly inpatient meetings with me, Mr A was discharged from the nursing home unit. His outpatient course was complicated by issues relevant to his health, his family, his close relationship with his grandson, the series of losses he experienced, a move to a new home, and the start of a new relationship. Through this rocky time, I provided a continuing relationship devoted to problem-solving, considering choices and consequences, and establishing a new beginning. We met a total of 24 times.

In the end, Mr A had persevered through difficult personal and relationship changes to establish a new beginning for himself at nearly age 62 years. I wonder now what will become of the new beginning for the Charleston basketball team.

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