Assignment: Outlining a Logic Model

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msw_case_histories.pdf

SESSIONS Case Histories Editors Sara-Beth Plummer Sara Makris Sally Margaret Brocksen

Published by Laureate International Universities Publishing, Inc. 7080 Samuel Morse Drive Columbia, MD 21046 www.laureate.net

Director, Program Design: Lauren Mason Carris Content Development Manager: Jason Jones Content Development Specialist: Sandra Shon Production Services: Absolute Service, Inc. Editorial Services: Christina Myers

Copyright © 2014 by Laureate International Universities Publishing, Inc.

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, any information storage and retrieval systems, or other electronic or mechanical methods, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncom­ mercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Content Development Specialist,” at the address above.

Editors

Sara-Beth Plummer, PhD, MSW Walden University

Sara Makris, PhD Laureate Education, Inc.

Sally Margaret Brocksen, PhD, MSW Walden University

Contributors

Marlene Coach, EdD, MSW, ACSW, LSW Walden University

Eileen V. Frishman, MSW, ACSW, LCSW-R, CH

Mary E. Larscheid, PhD, MSW, LICSW Walden University

Vanessa Norris, MSW, LCSW West Chester University

Sara-Beth Plummer, PhD, MSW Walden University

Stephanie C. Sanger, MA, MSS, LSW Assistant Director, RHD, Tri-County Supportive Housing

Eric Youn, PhD, LMSW Walden University

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Contents

Introduction 1

Part 1: Foundation Year 2

The Hernandez Family 3

The Parker Family 6

The Logan Family 9

The Johnson Family 11

Part 2: Concentration Year 14

The Levy Family 15

The Bradley Family 17

The Petrakis Family 20

The Cortez Family 23

Appendix 26

Reflection Questions 27

The Hernandez Family 27

The Parker Family 28

The Logan Family 30

The Johnson Family 31

The Levy Family 32

The Bradley Family 33

The Petrakis Family 35

The Cortez Family 36

Trademarks and Disclaimers 38

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Introduction

The following eight cases are based on the true experiences of social workers in the field, although names and other identifying circumstances have been changed. The narratives in this book, combined with filmed repre­ sentations of scenes inspired by the cases, provide you an opportunity to use true-to-life cases as an experiential learning tool. Whereas some academic programs, professors, or instructors may offer an occasional glimpse into past social work experiences, this book and these cases weave through multiple courses in your foundation and concentration year. Like in true-to-life practice, you will follow these cases through a variety of circumstances, prac­ tice behaviors, and learning opportunities. This unique format for a social work program enables you to integrate and connect the expected learning outcomes for each course. Each case either explicitly or implicitly offers content on practice skills, research, human behavior theory, and policy. Further, you will see that each family’s concerns can be addressed across all levels of practice, from micro to mezzo to macro.

Approach this book as a series of cases to which you have been assigned during your first professional experi­ ence in social work. We encourage you to use a critical eye to analyze the approaches provided. Remember that each practitioner has his or her own lens or perspective that guides his or her practice and these cases, written in the voices of each individual social worker, offer you authentic, varied perspectives. As you review and dissect these cases, consider your own lens and perspective as a future social worker.

The families described in these cases have been connected to social work services in myriad ways. Look closely at how each family member is introduced to the social worker and at the services and interventions that follow. Through reading these cases and then watching them come to life on video, you will see the skills used by social work practi­ tioners. Carefully identify for yourself how the social worker engages, assesses, and intervenes with his or her client.

The social workers who provided these cases offer some of their own personal thoughts about these cases as a series of reflection questions. Use the answers to the questions, posed to the social workers as they wrote these stories, to gain additional insight into the decisions they made to address their clients’ concerns. Reflect on the ques­ tions and answers as a way to consider whether you would have addressed the client or clients in the same manner.

Imagine your first day of practice, preparing for your first client meeting. On your desk is a folder with the last name of the client on the tab. You open the folder to find a case history for your client—perhaps it details family background, medical history, or an accounting of interactions with other agencies. This book is like that folder, preparing you for the client you will soon meet.

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PART 1: FOUNDATION YEAR

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The Hernandez Family

Juan Hernandez (27) and Elena Hernandez (25) are a married Latino couple who were referred to the New York City Administration for Children Services (ACS) for abuse allegations. They have an 8-year-old son, Juan Jr., and a 6-year-old son, Alberto. They were married 7 years ago, soon after Juan Jr. was born. Juan and Elena were both born in Puerto Rico and raised in Queens, New York. They rent a two-bedroom apartment in an apartment complex where they have lived for 7 years. Elena works as babysitter for a family that lives nearby, and Juan works at the airport in the baggage department. Overall, their physical health is good, although Elena was diagnosed with diabetes this past year and Juan has some lower back issues from loading and unloading bags. Both drink socially with friends and family. Juan goes out with friends on the weekends sometimes to “blow off steam,” having six to eight beers, and Elena drinks sparingly, only one or two drinks a month. Both deny any drug use at all. While they do not attend church regularly, both identify as being Catholic and observe all religious holidays. Juan was arrested once as a juvenile for petty theft, but that has been expunged from his file. Elena has no criminal history. They have a large support network of friends and family who live nearby, and both Elena’s and Juan’s parents live within blocks of their apartment and visit frequently. Juan and Elena both enjoy playing cards with family and friends on the weekends and taking the boys out to the park and beach near their home.

ACS was contacted by the school social worker from Juan Jr.’s school after he described a punishment his parents used when he talked back to them. He told her that his parents made him kneel for hours while holding two encyclo­ pedias (one in each hand) and that this was a punishment used on multiple occasions. The ACS worker deemed this a credible concern and made a visit to the home. During the visit, the parents admitted to using this particular form of punishment with their children when they misbehaved. In turn, the social worker from ACS mandated the family to attend weekly family sessions and complete a parenting group at their local community mental health agency. In her report sent to the mental health agency, the ACS social worker indicated that the form of punishment used by the parents was deemed abusive and that the parents needed to learn new and appropriate parenting skills. She also suggested they receive education about child development because she believed they had unrealistic expectations of how children at their developmental stage should behave. This was a particular concern with Juan Sr., who repeat­ edly stated that if the boys listened, stayed quiet, and followed all of their rules they would not be punished. There was a sense from the ACS worker that Juan Sr. treated his sons, especially Juan Jr., as adults and not as children. This was exhibited, she believed, by a clear lack of patience and understanding on his part when the boys did not follow all of his directions perfectly or when they played in the home. She mandated family sessions along with the parenting classes to address these issues.

During the intake session, when I met the family for the first time, both Juan and Elena were clearly angry that they had been referred to parenting classes and family sessions. They both felt they had done nothing wrong, and they stated that they were only punishing their children as they were punished as children in Puerto Rico. They said that their parents made them hold heavy books or other objects as they kneeled and they both stressed that at times the consequences for not behaving had been much worse. Both Juan and Elena were “beaten” (their term) by their parents. Elena’s parents used a switch, and Juan’s parents used a belt. As a result, they feel they are actually quite lenient with their children, and they said they never hit them and they never would. Both stated that they love their children very much and struggle to give them a good life. They both stated that the boys are very active and don’t always follow the rules and the kneeling punishment is the only thing that works when they “don’t want to listen.”

They both admitted that they made the boys hold two large encyclopedias for up to two hours while kneeling when they did something wrong. They stated the boys are “hyperactive” and “need a lot of attention.” They said they punish Juan Jr. more often because he is particularly defiant and does not listen and also because he is older and should know better. They see him as a role model for his younger brother and feel he should take that respon­ sibility to heart. His misbehavior indicates to them that he is not taking that duty seriously and therefore he should be punished, both to learn his lesson and to show his younger brother what could happen if he does not behave.

During the intake meeting, Juan Sr. stated several times that he puts in overtime any time he can because money is “tight.” He expressed great concern about having to attend the parenting classes and family sessions, as it would interfere with that overtime. Elena appeared anxious during the initial meeting and repeatedly asked if they were going to lose the boys. I told her I could not assure her that they would not, but I could assist her and her husband through this process by making sure we had a plan that satisfied the ACS worker’s requirements. I told them it

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SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

would be up to them to complete those plans successfully. I offered my support through this process and conveyed empathy around their response to the situation.

The Hernandez Family

Juan Hernandez: father, 27

Elena Hernandez: mother, 25

Juan Hernandez Jr.: son, 8

Alberto Hernandez: son, 6

or immediately after the PPP so that they did not have to come to the agency more than once a week. They agreed that this would be helpful because they did not have money for multiple trips to the agency, although Juan Sr. stated that this would still affect his ability to work overtime on that day. I asked if they had any goals they wanted to work toward during our sessions. Initially they were reluctant to share anything, and then Elena suggested that a discussion on money management would be helpful. I told them I w ould be their primary contact at the agency—meeting with them for the family sessions and co-facilitating the PPP group with an intern. I explained my limitations around confidentiality, and they signed a form acknowledging that I was required to share information about our sessions with the ACS worker. I informed them that the PPP is an evidenced-based program and explained its meaning. I informed them that there is a pre- and post-test administered along with the program and specific guidelines about missed classes. They were informed that if they missed more than three classes, their participation would be deemed incomplete and they would not get their PPP certification.

Initially, when the couple attended parenting sessions and family sessions, Juan Sr. expressed feelings of anger and resentment for being mandated to attend services at the agency. Several times he either refused to participate by remaining quiet or spoke to the social worker and intern in a demeaning manner. He did this by questioning our ability to teach the PPP and the effectiveness of the program itself, wanting to know how this was going to make him a better parent. He also reiterated his belief that his form of discipline worked and that it was exactly what his family members used for years on him and his relatives. He asked, “If it worked for them, why can’t that form of punishment work for me and my children?” He emphasized that these were his children. He maintained throughout the sessions that he never hit his children and never would. Both he and Elena often talked about their love for their children and the devastation they would feel if they were ever taken away from them.

Treatment consisted of weekly parenting classes with the goal of teaching them effective and safe discipline skills (such as setting limits through the use of time-out and taking away privileges). Further, the classes emphasized the importance of recognizing age-appropriate behavior. We spent sessions reviewing child development techniques to help boost their children’s self-esteem and sense of confidence. We also talked about managing one’s frustration (such as when to take a break when angry) and helping their children to do the same.

Family sessions were built around helping the family members express themselves in a safe environment. The parents and the children were asked to talk about how they felt about each other and the reason they were mandated to treatment. They were asked to share how they felt while at home interacting with one another. I thought it was of particular importance to have them talk about their feelings related to the call to ACS, as I was unsure how Juan Sr. felt about Juan Jr.’s report to the social worker. It was necessary to assist them with processing this situation so that there were no residual negative feelings between father and son. I asked them to role-play—having each member act like another member of the household. This was very effective in helping Juan Sr. see how his boys view him and his behavior toward them when he comes home from work. As a result of this exercise, he verbalized his newfound clarity around how the boys have been seeing him as a very angry and negative father.

I also used sessions to explore the parents’ backgrounds. Using a genogram, we identified patterns among their family members that have continued through generations. These patterns included the use of discipline to maintain order in the home and the potentially unrealistic expectations the elders had for their children and grandchildren. Elena stated that she was treated like an adult and had the responsibilities of a person much older than herself while she was still very young. Juan Sr. said he felt responsible for bringing money into the home at an early age. He was forced by his parents to get working papers as soon as he turned 14. His paychecks were then taken by his parents each week and used to pay for groceries and other bills. He expressed anger at his parents for encouraging him to drop out of high school so that he could get more than one job to help out with the finances.

Other sessions focused on the burden they felt related to their finances and how that burden might be felt by the boys, just as Juan Sr. might have felt growing up. In one session, Juan Jr. expressed his fears of being evicted and the lights being turned off, because his father often talked of not having money for bills. Both boys expressed sadness over the amount of time their father spent at work and stressed their desire to do more things with him at night and on the weekends. Both parents stated they did not realize the boys understood their anxieties around

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Together we discussed the plan for treatment, following the requirements of ACS; they would attend a 12-week Positive Parenting Program (PPP) along with weekly family sessions. In an effort to reduce some of the financial burden of attending multiple meetings at the agency, I offered to meet with the family either just before

SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

paying bills and felt sad that they worried about these issues. We also took a couple of sessions to address money management. We worked together to create a budget and identify unnecessary expenses that might be eliminated.

It was clear that this was a family that loved each other very much. Juan Sr. and Elena were often affectionate with each other and their sons. Once the initial anger subsided, both Juan Sr. and Elena fully

Key to Acronyms

ACS: Administration for Children Services

PPP: Positive Parenting Program

engaged in both the family sessions and the PPP. We assessed their progress monthly and highlighted that progress. I also was aware that it was important to learn about the Hernandez family history and culture in order to under­ stand their perspective and emotions around the ACS referral. I asked them many questions about their beliefs, customs, and culture to learn about how they view parenthood, marriage roles, and children’s behaviors. They were always open to these questions and seemed pleased that I asked about these things rather than assumed I knew the answers.

During the course of treatment they missed a total of four PPP classes. I received a call from Elena each time letting me know that Juan Sr. had to work overtime and they would miss the class. She was always apologetic and would tell me she would like to know what they missed in the class so that she could review it on her own. During a call after the fourth missed parenting class, I reminded Elena that in order to obtain the certificate of completion, they were expected to attend a minimum of nine classes. By missing this last class, I explained, they were not going to get the certificate. Elena expressed fear about this and asked if there was any way they could still receive it. She explained that they only had one car and that she had to miss the classes when Juan Sr. could not go because she had no way of getting to the agency on her own. I told her that I did not have the authority to change the rules around the number of classes missed and that I understood how disappointed she was to hear they would not get the certificate. When I told her I had to call the ACS worker and let her know, Elena got very quiet and started to cry. I spoke with her for a while, and we talked about the possible repercussions.

I met with my supervisor and informed her of what had occurred. I knew I had to tell the ACS worker that they would not receive the certificate of completion this round, and I felt bad for the situation Juan Sr. and Elena and their boys were now in. I had been meeting with them for family sessions and parenting classes for almost three months by this point and had built a strong rapport. I feared that once I called the ACS worker, that rapport would be broken and they would no longer want to work with me. I saw them as loving and caring parents who were trying the best they could to provide for their family. They had been making progress, particularly Juan Sr., and I did not want their work to be in vain.

I also questioned whether the parenting and family sessions were really necessary for their situation. I felt there was a lack of cultural competence on the part of the ACS worker—she had made some rather judgmental and insensitive comments on the phone to me during the referral. I wondered if there was a rush to judgment on her part because their form of discipline was not commonly used in the United States. In my own professional opinion, some time-limited education on parenting and child development would have sufficed, as opposed to the 3-month parenting program and family sessions.

My supervisor and I also discussed the cultural competence at the agency and the fact that the class schedule may not fit a working family’s life. We discussed bringing this situation to a staff meeting to strategize and see if we had the resources to offer the PPP multiple times during the week, perhaps allowing clients to make up a class on a day other than their original class day.

I met with Elena and Juan Sr. and let them know I had to contact the ACS worker about the missed classes. I explained that this was something I had to do by law. They told me they understood, although another round of parenting classes would be a financial burden and they had already struggled to attend the current round of classes each week. I validated their concerns and told them we were going to look at offering the program more than once a week. I also told them that when I spoke to the ACS worker, I would also highlight their progress in family and parenting sessions.

I called the ACS worker and told her all the positive progress the parents had made over the previous 3 months before letting her know that they had missed too many classes to obtain the PPP certificate. The ACS worker was pleased with the progress I described but said she would recommend to her supervisor that the parents take the PPP over again until a certificate was obtained. She would wait to hear what her supervisor’s decision was on this matter. She said that family sessions could end at this point. In the end, the supervisor decided the parents needed to come back to the agency and just make up the four classes they missed. Elena and Juan Sr. were able to complete this requirement and received their certificate, and the ACS case was closed. They later returned on their own for a financial literacy class newly offered at the agency free of charge.

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The Parker Family

Sara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment with her 48-year-old daughter, Stephanie, and six cats. Sara and her daughter have lived together for the past 10 years, since Stephanie returned home after a failed relationship and was unable to live independently. Stephanie has a diagnosis of bipolar disorder, and her overall physical health is good. Stephanie has no history of treatment for alcohol or substance abuse; during her teens she drank and smoked marijuana but no longer uses these substances. When she was 16 years old, Stephanie was hospitalized after her first bipolar episode. She had attempted suicide by swal­ lowing a handful of Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her. She has been hospitalized three times in the past 4 years when she stopped taking her medications and experienced suicidal ideation. Stephanie’s current medications are Lithium, Paxil®, Abilify®, and Klonopin®.

Stephanie recently had a brief hospitalization as a result of depressive symptoms. She attends a mental health drop-in center twice a week to socialize with friends and receives outpatient psychiatric treatment at a local mental health clinic for medication management and weekly therapy. She is maintaining a part-time job at a local super­ market where she bags groceries and is currently being trained to become a cashier. Stephanie currently has active Medicare and receives Social Security Disability (SSD).

Sara has recently been hospitalized for depression and has some physical issues. She has documented high blood pressure and hyperthyroidism, she is slightly underweight, and she is displaying signs of dementia. Sara has no history of alcohol or substance abuse. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare and receives Social Security benefits and a small pension. She attends a day treatment program for seniors that is affiliated with a local hospital in her neighborhood. Sara attends the program 3 days a week from 9:00 a.m. to 2:00 p.m., and van service is provided free of charge.

A telephone call was made to Adult Protective Services (APS) by the senior day treatment social worker when Sara presented with increased confusion, poor attention to daily living skills, and statements made about Stephanie’s behavior. Sara told the social worker at the senior day treatment program that, “My daughter is very argumentative and is throwing all of my things out.” She reported, “We are fighting like cats and dogs; I’m afraid of her and of losing all my stuff.”

During the home visit, the APS worker observed that the living room was very cluttered, but that the kitchen was fairly clean, with food in the refrigerator and cabinets. Despite the clutter, all of the doorways, including the front door, had clear egress. The family lives on the first floor of the apartment building and could exit the building without difficulty in case of emergency. The litter boxes were also fairly clean, and there was no sign of vermin in the home.

Upon questioning by the APS worker, Sara denied that she was afraid of her daughter or that her daughter had been physically abusive. In fact, the worker observed that Stephanie had a noticeable bruise on her forearm, which appeared defensive in nature. When asked about the bruise, Stephanie reported that she had gotten it when her mother tried to grab some items out of her arms that she was about to throw out. Stephanie admitted to throwing things out to clean up the apartment, telling the APS worker, “I’m tired of my mother’s hoarding.” Sara agreed with the description of the incident. Both Sara and Stephanie admitted to an increase in arguing, but denied physical violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get my things back.”

The APS worker observed that Sara’s appearance was unkempt and disheveled, but her overall hygiene was adequate (i.e., clean hair and clothes). Stephanie was neatly groomed with good hygiene. The APS worker deter­ mined that no one was in immediate danger to warrant removal from the home but that the family was in need of a referral for Intensive Case Management (ICM) services. It was clear there was some conflict in the home that had led to physical confrontations. Further, the house had hygiene issues, including trash and items stacked in the living room and Sara’s room, which needed to be addressed. The APS worker indicated in her report that if not adequately addressed, the hoarding might continue to escalate and create an unsafe and unhygienic environment, thus leading to a possible eviction or recommendation for separation and relocation for both women.

As the ICM worker, I visited the family to assess the situation and the needs of the clients. Stephanie said she was very angry with her mother and sick of her compulsive shopping and hoarding. Stephanie complained that they did not have any visitors and she was ashamed to invite friends to the home due to the condition of the apart­ ment. When I asked Sara if she saw a problem with so many items littering the apartment, Sara replied, “I need all of these things.” Stephanie complained that when she tried to clean up and throw things out, her mother went

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SESSIONS: CASE HISTORIES • THE PARKER FAMILY

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outside and brought it all back in again. We discussed the need to clean up the apartment and make it habitable for them to remain in their home, based on the recommendations of the APS worker. I also discussed possible housing alternatives, such as senior housing for Sara and a supportive apartment complex for Stephanie. Sara and Stephanie both stated they wanted to remain in their apartment together, although Stephanie questioned whether her mother would

cooperate with cleaning up the apartment. Sara was adamant that she did not want to be removed from their apart- ment and would try to accept what needed to be done so they would not be forced to move.

Stephanie reported her mother is estranged from her younger sister, Jane, because of the hoarding. Stephanie also mentioned she was dissatisfied with her mother’s psychiatric treatment and felt she was not getting the help she needed. She reported that her mother was very anxious and was having difficulty sleeping, staying up until all hours of the night, and buying items from a televised shopping network. Sara’s psychiatrist had recently increased her Zyprexa prescription dosage to help reduce her agitation and possible bipolar disorder (as evidenced by the compulsive shopping), but Stephanie did not feel this had been helpful and actually wondered if it was contributing to her mother’s confusion. I asked for permission to contact Jane and both of their outpatient treatment teams, and both requests were granted.

I immediately contacted Jane, who initially was uncooperative and stated she was unwilling to assist. Jane is married, with three children, and lives 3 hours away. At the …