Jack, a pleasant 67-year-old gentleman and his wife Jill, age 63, are referred to your outpatient counseling practice by their family physician. Referral information identifies difficulties coping with issues pertaining to their stage in life. Both retired, Jill was previously employed as a schoolteacher for 35 years until the age of 60 when she stopped working to help her husband Jack, who underwent bilateral knee replacement surgeries. Jack worked as an accountant for a local firm and even though he wanted to continue to work well into his 60s, he retired because the recuperation from his knee replacement surgeries proved to be more extensive than anticipated. During the first session, you assess that Jill does most of the talking, often answering questions directed at Jack. Most of Jacks responses are short, closed-ended remarks, or just shrugs, followed by charming smiles. It is evident that the couple has been struggling for some time with the drastic change in their roles from high functioning professionals to the role of caregiver for Jill and patient for Jack. At this time, you focus your assessment on Jack and ascertain that there were noticeable changes to his mood as early as four years ago. Jill describes that approximately one year prior to his retirement, Jacks mood became persistently grumpywhich for him was a significant change from the happy, energetic, optimistic individual he had been most of his life. At that time, Jill feared that Jack had difficulties coping with the thought of retirement and tried to be supportive. During that year, he gradually lost approximately 10 pounds and was prescribed a sleeping aid in order to help him get his customary six hours of sleep per night. Always active and an avid golfer, Jack decided to take a medical leave from work 3 years ago in order to get new titanium knees. His knees had been getting worse progressively over the past 10 years and the impairment became increasingly bothersome. While the surgery was successful, Jacks recuperation took longer than expected. Medically, he met all the rehabilitative markers, but this took considerable effort. At the skilled nursing facility it soon became evident that Jacks schedule had to be divided in small, achievable increments. Normal tasks requiring longer amounts of time to complete. At this time he started to become forgetful, exhibiting difficulties recalling recent events or activities scheduled for his physical rehabilitation. He was visibly frustrated by this occurrence which he described as having a fuzzy head in the morning. He attributed this to his pain medications. To compensate, Jack started to carry a small notebook in the front pocket of his shirt. He humorously referred to it as his detective notebook. During this time Jill noticed a subtle but steady change in his overall attitude and personality. Jack was becoming more and more apathetic, exhibiting decreased affection and empathy towards Jill, and increased frustration with himself and his caregivers when he could not readily think of a word or when he had difficulties recalling a fact or situation. After his discharge from the skilled nursing facility, during a routine visit, the family physician completed a mini mental status exam. At that time, Jack became frustrated with his inability to recall the three random objects named by his doctor. Jill started to cry, reporting to the family doctor the ordeal she had undergone since Jacks surgery and all the tasks she had to assume on his behalf (like paying bills), tasks which he could no longer perform reliably. She expressed concerned over how their life will look like now that he has returned home, raising questions about her ability to take over all the tasks that he was previously attending to. The couples distress was clinically significant as to warrant a referral to you.
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