Today you are meeting with Jane Sullivan, a 32-year-old newly widowed woman who is four months pregnant. Jane was referred to you by her nurse midwife, who has been caring for Jane for the last two months.
Jane enters your office looking exhausted. Her 18-month-old son, James, has food on his face and in his hair. Jane’s shirt is ill-fitting and crumpled, her hair is pulled back with just a rubber band, and her jeans have food crusted on them. It goes beyond the typical “mother of a toddler” look.
She starts to cry as soon as she sits down in your office and then has a hard time composing herself. She runs her hand through her hair, seeming to not notice the rubber band falling out. You try to distract James with a toy, but he clings to Jane and buries his face in her legs.
When she finally stops crying, she tells you, “I’m so sorry. I am having such a hard time dealing with everything. My husband, Jacob, was killed in Afghanistan last month by a roadside bomb. I’d only found out I was pregnant a couple weeks before that and Jake didn’t even know yet…. I…I must have gotten pregnant the night before he deployed. He’d only been gone for just three months.”
Jane takes a deep, shuddering breath and continues. “I’ve been having nightmares and barely eating.” She laughs and brushes at her jeans. “That’s from James’ lunch.”
James, who hasn’t left her legs, starts crying. While attempting to comfort him, she says, “We live on base. I don’t think I can stay there much longer and I don’t know where to go. I don’t have the energy to find a new home and pack and I just can’t face it. Sometimes I think it would just be easier to pack the car with a few things and drive off when they tell me to leave.
“I just don’t know what to do with myself. I just wanna be with Jake. I don’t want to be with anyone else. Mari keeps asking me to come over, just for coffee, but I dunno, I never go.” Quietly, almost whispering, she says, “Actually, I’ve barely left the house except to see the midwife and now you. I have to protect the baby, since that’s all we’ve got left of Jake.”
James raises his tear-stained face. “Mommy? Where Dada?”
Jane digs in her purse and pulls out a crumpled piece of paper. “Hush, James. Here’s Daddy’s picture.” She wipes his face with a tissue and takes a few shuddering breaths.
“Back at the end of high school. You know how senior year is supposed to be the best year? Not for me. My daddy died. He was only 42, and I’d just turned 18. Supposed to be an adult and all I wanted was my daddy back. But at least I got to know him for 18 years. James and the baby won’t know their daddy at all!”
“I had to see a counselor for a while back then, too. I missed a lot of school, but I graduated anyway. My teachers all understood that I was depressed. I kind of feel the same way now. Only I think it’s way worse, being pregnant and having a toddler.” She half laughs. “And I thought senior year was bad. What a child I was!”
“And my Mom isn’t here to help. She died just before James was born. Breast cancer. Two years ago. I can’t even think about whether that might happen to me. I do have a sister, Bonnie lives out in Oregon. We were close before, but actually became even closer after Mom died. She was a big help giving me advice about James! But she’s going through a divorce and beginning life as a single mom herself! My nieces are 8, 7, and 5. Can you believe it? This whole family has lost parent after parent after parent.”
Jane sighs deeply and goes quiet.
Answer the following questions from your perspective as Jane’s psychiatric nurse practitioner