The Case of Jared

Jared is a 31-year-old Caucasian man who was recently discharged from an inpatient psychiatric hospitalization (with a history of eight prior ones since age 17 when he first tried to kill himself via overdose). He was sexually, physically, and emotionally abused by his mother as far back as he can remember, and was raped by a male teacher in adolescence. His family of origin was upper middle class and he was the eldest of three siblings. The atmosphere at home growing up was, he says, “Stuffy, stiff—classic WASP, no one noticed what was really going on.” His father says he was unaware of any abuse (“I was working a lot, and left my wife to tend the children”), but he recognized his wife was unstable. After the suicide attempt at 17, Jared says, “No one said a word to me. It was just like, ‘move on’ and let’s not talk about it. All they did was make me go to therapy for 6 months, which didn’t change anything. Things were rotten to the core at home and inside of me, and therapy was like putting a band-aid on a festering sore that wasn’t going away.” Jared began to use alcohol at 9 years of age, at first just experimenting but progressing to frequent use by early adolescence. He was, and still is, very charming, engaging, smart, and good looking, and always had friends and eventually girlfriends, but never told them about the abuse. Some of his friends used drugs, and he was always interested in trying them, eventually becoming addicted to cocaine by early adulthood. His longest period of abstinence was 4 months. Jared has had multiple suicide attempts, including one in which he almost died (“I wish I had,” he says), but was found by a neighbor who called an ambulance. He has been through multiple detoxes (4 of his 9 hospitalizations) and numerous therapists for a few sessions to up to 10 months. Jared formed positive relationships with some therapists, and says he always tries to make the best of treatment as he wants to not feel so much pain. He had various treatments while in inpatient units, day programs, and outpatient therapy, both group and individual, including cognitive-behavioral therapy, relapse prevention, motivational interviewing, trauma processing, and dialectical behavior therapy. He attended 12-step groups while in detox and at various points, but he says, “I never hooked into it.” Jared has also had numerous different medications over the years and is currently on an antidepressant, antipsychotic (prescribed to help augment the antidepressant), and a sleep medication to take as needed. He has abused prescription medications in the past. Although Jared is physically healthy, he eats a lot of junk food, doesn’t sleep well due to trauma nightmares, and watches a lot of TV. He gets money from disability and from his parents. Jared does not see his family much as they live in another state. They have been very devoted in terms of giving him money, checking in on him by phone, and sending him to treatment. Recently, they have been wondering whether they perhaps need to “cut him loose so he can make it on his own,” as some of their Al-Anon friends think that they’re enabling him. Jared has not held a job for more than 6 months, usually getting fired or quitting due to some interpersonal conflict with a supervisor. He entered community college briefly but dropped out after the first semester because it was too stressful. His health care is Medicaid. Jared’s traumas, in addition to his childhood abuse and rape, were as follows: being threatened with a gun during a drug deal, fearing he was going to die; being beaten up numerous times; watching a friend get killed in a car accident; and seeing a lot of violence on the streets during an