social work case work

12 Working With Families: The Case of Carol and Joseph Carol is a 23-year-old, heterosexual, Caucasian female and the mother of a 1-year-old baby girl. She is currently unemployed, having previously worked for a house cleaning company. The baby is healthy and developmentally on target, and she and the parents appear to be well bonded with one another. Carol lives in a rented house with her husband, Joseph. Joseph is a 27-year-old, heterosexual, Hispanic male. He was recently arrested at their home for a drug deal, which he asserts was a setup. Both parents were charged with child endangerment because weapons were found in the child’s crib and drugs were found in the home. The parents assert that the child never sleeps in the crib but in their bed. As a result of the parents’ arrest, social services was notified, and the child was temporarily placed in a kinship care arrangement with the maternal grandmother, who resides nearby. As a result of Joseph’s arrest, he was fired from the cleaning company where he worked, and the family is now experiencing financial difficulties. After initial contact was made with the parents, a number of concerns were noted and the family was recommended for additional case management. Carol’s mother indicated that she had concerns about Carol’s drinking habits and stated that Carol’s father and grandfather were alcoholics. She and the father separated when Carol was a baby, and Carol has had only limited contact with him. There appears to be significant tension between the grandmother and Carol and Joseph. I addressed the alcohol issue with both parents, who denied there was a problem, but shortly after the discussion, Carol was involved in a serious car accident with the baby in the car. She was determined to have been under the influence of alcohol. I advised Carol that she could not have any unsupervised contact with her child until she completed intensive inpatient substance abuse treatment. I made arrangements for her placement, but after a week, she was discharged for noncompliance with the rules. She was then referred to an intensive outpatient program and began therapy there. Initially   her attendance was erratic because she had lost her license as a result of the DUI. Eventually, however, she became engaged in the program and began to address her issues. She acknowledged that she had started using drugs at a very young age but said that she had only begun drinking in the previous year or so. We discussed the genetics of her family, and she said that she realized that she had deteriorated rapidly since beginning to drink and knew that she simply could not drink alcohol. Joseph’s mother is deceased, and his father travels extensively in his job and is not available as a support. Joseph was very devoted to his mother and was devastated by her premature death. We discussed the strengths that he and Carol demonstrated in staying together and working out their problems. Joseph indicated that as a Hispanic man, family is very important to him and he wants his family to stay together. Although they have been struggling financially, Joseph has obtained stable employment landscaping for a large development and said he plans to take courses at the community college to learn the trade. He stated that he wants to provide a good life for his child. Carol has a lot of unresolved issues to deal with in therapy, not the least of which is the accident that could have killed her child and the legal ramifications that resulted from this incident. Although angry and hostile at the beginning, through the implementation of person-centered therapy, we were able to establish agreed-upon goals that showed respect for the client and encouraged her to find solutions to her problems. Although our relationship was tenuous at times, providing encouragement to her rather than judgment enabled her to forgive herself and take corrective action.   Reflection questions   the common myth that a traditional therapy office setting is necessary to do “clinical work.” Through this case, students can also witness how treatment goals can shift throughout the course of treatment. This is evident in the step-by-step growth that Pedro demonstrated. Each shift in treatment goals resulted in a change or deepening of our relationship and gave Pedro the opportunity to address more difficult issues as time went on. Working With Families: The Case of Carol and Joseph 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? This case required extensive use of active and passive listening and patience to enable the client to become sufficiently comfortable with me and to arrive at a point where she could work on her issues. Initially she was very angry, hostile, resistant, and very much in denial. 2. Which theory or theories did you use to guide your practice? I work with people in their homes, which is their territory, not mine. I think it is very important to be aware of how I would feel if I were in their shoes. The person-in-environment perspective and Carl Rogers’ person-centered approach are crucial here. 3. What were the identified strengths of the client(s)? She was smart and had a good support system in her husband and mother, who were very supportive during her treatment. 4. What were the identified challenges faced by the client(s)? Carol was a severe alcoholic and had a drug problem to a lesser extent. She had psychological issues as well, including low selfesteem, depression, and anxiety. She also had transportation and legal problems as a result of losing her driver’s license after the DUI. 5. What were the agreed-upon goals to be met to address the concern? The primary goal was to protect her child by keeping Carol sober and finding the intervention method that would be most appropriate for her to do that. This took time due to the resistance 6. How would you advocate for social change to positively affect this case? Treatment options and access to them need to be improved in rural areas. There were not many choices for this client, and losing her license in an area with no public transportation greatly affected her ability to seek treatment. 7. Is there any additional information that is important to this case? I subsequently found out that there had been other serious episodes concerning Carol’s drinking that the family had failed to disclose to me because they were covering up for her. Carol’s parents separated when she was very young, so she was mostly cared for by a family friend and grandparents. Carol’s mother seemed to have resented the child’s interference with her social life, and clearly the daughter resented her mother’s lack of involvement with her. Carol’s mother, who was from a Southern White Protestant family, seemed uncomfortable with Joseph’s culturally unfamiliar Hispanic Catholic background. She reported to me that she felt the son-in-law was lazy and did not work in the early stages of his relationship with her daughter, who she said worked very hard. During my involvement with this couple, I found Joseph to be hard working and doing his best to provide for all of them. He was very committed to doing whatever was necessary to keep his family intact, even if his judgment at times was poor. Working With Immigrants and Refugees: The Case of Aaron 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? I used support, active listening, reflection, reframing, and validation with the client, and I recognized the importance of structure, reliability, and predictability of the social worker in the therapeutic alliance. 2. Which theory or theories did you use to guide your practice? I used family systems theory, multicultural family theories, and attachment theory.to treatment.                    Working With Survivors of Domestic Violence: The Case of Charo  Charo is a 34-year-old, heterosexual, Hispanic female. She is unemployed and currently lives in an apartment with her five chil­dren, ages 2, 3, 6, 7, and 8. She came to this country 8 years ago from Mexico with her husband, Paulo. During intake, Charo reported that she suffered severe abuse and neglect in the home as a child and rape as a young adult. Charo does not speak English and currently does not have a visa to work.  Charo initially came for services at our domestic violence agency because Child Protective Services (CPS) and the court ordered her to attend a domestic violence support group after allegations of domestic violence were made by one of her chil­dren to a teacher at their school. Her husband was ordered to attend a batterer’s intervention program (BIP). Charo attended the domestic violence support group but seldom said a word. Although she rarely shared during group, she also rarely missed a session. While she attended the group, she also met with me weekly for individual sessions. During these sessions I informed her of the dynamics of domestic violence and helped her create a safety plan. She often said that she was only attending the group because it was mandated and that she just wanted CPS to close her case. One week, Charo suddenly stopped attending group. When I called her, she said that she had been busy and unable to attend. That same day her husband called me to verify that I was who his wife said I was, as he often accused Charo of having affairs.  Charo showed up to group again one day after a 3-month absence. Her appearance was disheveled, and she had lost a significant amount of weight. The next day she called me and requested an emergency individual session. During the session, she reported that her husband had an imaginary friend who was telling him to kill her and that the previous weekend he had placed a knife on her pillow and threatened to take her life. Charo stated that her husband would force her to wear short skirts and bleach   her hair. He would also throw plates of food on the floor and walls of the house whenever meals were not to his satisfaction. She said he would spend his days drinking alcohol with friends and would beat her relentlessly in front of the children. She told me she had thought he would change after CPS became involved but that, instead, his abuse became more calculating and discreet.  I worked on an updated safety plan with the client, and she agreed to hide herself and the children in the agency’s safe house. The safety plan included information on obtaining a restraining order, going into a safe house, identifying safe people she could talk to, and teaching the children safety planning strategies as well as tips on important documentation and the importance of journ­aling all significant details of the abuse. Charo’s husband showed up outside of the agency that day while she was there and called her phone repeatedly. Charo put the call on speaker so I could hear his voice. He ordered her to go outside and go home with him and made threats toward her. I called the police, and Charo’s husband was arrested outside of the agency. I went to the court­house with Charo, helping her file a temporary restraining order and providing her with emotional support throughout the experi­ence. After obtaining the restraining order, Charo and her five children were admitted to the agency’s safe house.  While at the safe house, Charo met with me weekly for indi­vidual counseling and continued to attend the domestic violence support groups. She reported feeling damaged, ugly, and unlov­able. She also reported feeling anxious, depressed, and hopeless, crying often, and losing weight. Charo’s husband was eventually deported back to Mexico.  I discussed with Charo the dynamics of domestic violence and provided her with numerous resources that could serve as informal and formal supports to her and the children. Charo was referred to a psychiatrist, who prescribed 50 mg of Zoloft to help manage the anxiety and depressive symptoms she was experiencing. Charo began attending a church nearby where she quickly felt connected and also began attending English as a second language (ESL) classes twice a week. We met once a week for 9 months. During the first 3 months, we focused on stabilization. During the second 3 months, we focused on decreasing symptoms of anxiety   and depression. During the final 3 months of our time together we focused on financial empowerment, reintegrating back into the community, and renewing connections with family. While Charo met with me for counseling and case management, her children participated in a 6-month trauma reduction art therapy program for children within the agency. At the 9-month mark, we agreed to terminate services. She continued to attend the group sessions for support and found new friends who had become a support network for her. She also completed a financial empowerment program, which further taught her how to manage her finances.   Reflection Questions . How would you advocate for social change to positively affect this case? Mary and her family could benefit from help exploring their assumptions about race, but this was out of the scope of Mary’s initial therapy. 8. Were there any legal or ethical issues present in the case? If so, what were they and how were they addressed? It is difficult but important to respect Mary’s therapeutic process while remaining nonjudgmental about the assumptions about race Mary and her sisters hold as truth. 9. How can evidence-based practice be integrated into this situation? Mary and I identified her PTSD symptoms in her treatment plan. We were able to measure the successes she had with specific behavioral interventions in changing the frequency and severity of her symptoms. 10. Describe any additional personal reflections about this case. Mary clearly felt that she needed to trust that I would not bring my own judgments or opinions about racism into therapy. As with all trauma treatment, building a therapeutic alliance and trust was essential. We built such an alliance so she could feel safe enough to tell her traumatic story and work to assimilate that story into her own sense of strength and resilience. Working With Survivors of Domestic Violence: The Case of Charo 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? I utilized psychoeducational support groups, case management, and solution-focused interventions. 2. Which theory or theories did you use to guide your practice? I used learning theory and feminist empowerment and strengthsbased perspectives to guide my practice. 3. What were the identified strengths of the client(s)? Charo’s many strengths included her level of resilience and being a strong advocate for her children and a support to other survivors at the shelter. She also shared her resources with other survivors no matter how little she had. She was very kind. 4. What were the identified challenges faced by the client(s)? The barriers for this client are enormous; aside from the domestic violence, some of the barriers include not speaking English, the involvement of Child Protective Services, a lack of affordable housing, obtaining employment without a visa, discrimination, and needing child care for five children. 5. What were the agreed-upon goals to be met to address the concern? The three treatment goals we set were reducing depressive and anxiety symptoms, connecting to resources in the community that would help her become more stable, and obtaining therapy for the children. 6. What local, state, or federal policies could (or did) affect this situation? The Violence Against Women Act (VAWA) affected the situation. 7. How would you advocate for social change to positively affect this case? Victims should not be mandated to attend a domestic violence support group. Participation should be voluntary. These women have been coerced in their relationships and then they are coerced by the system and made to feel like they have done something wrong. Much more education is needed in the courts and with Child Protective Services. 8. How can evidence-based practice be integrated into this situation? Clients are asked to complete client satisfaction surveys at termination. We also call the clients for follow-ups for up to a year. Lastly, clients complete a survey on a monthly basis, which is used statewide and called the Family Violence Prevention and Services Act (FVPSA) survey. The surveys mainly measure whether the client learned additional resources and additional ways of planning for safety.     Working With Survivors of Sexual Abuse and Trauma: The Case of Angela Angela is a 27-year-old, Caucasian female, who first came to counseling to address her history of sexual abuse. She graduated from college with a BS in chemistry and has since been employed by pharmaceutical companies. After obtaining a new job, she relocated to an apartment in an East Coast city where she knew no one. Both of Angela’s parents live on the West Coast, and she has one younger brother who also lives in a different state. Angela has limited contact with both her mother and brother and does not have any contact with her father. Angela is obese and disclosed a history of struggling with her weight and eating issues. She has few friends, and those she does have live far away. Angela has a long history of trauma in her life. She was sexually abused between the ages of 9 and 21 by her father, sexually assaulted at the age of 14 by a classmate in school, and mugged as a young adult. There was domestic violence in the home, also perpetrated by her father. Angela’s father is considered an upstanding member of the community, and he is well liked and respected by others. No one in Angela’s family believes that she was sexually abused, and her father joined a “false memory syndrome” group and is outspoken about that issue. There has been little discussion in her family about what took place in the home while she was growing up. Angela struggled with daily functioning and exhibited symptoms of post-traumatic stress disorder (PTSD). She had a history of cutting herself and binge eating and displayed some characteristics of borderline personality disorder. Angela also mildly dissociated when under duress. Angela suffered from depression and anxiety and had trouble establishing new relationships, both socially and at work. Although Angela has a stable job and was able to complete her work each day, at times she became overwhelmed by her emotions and retreated to the bathroom where she cried and sometimes cut herself before returning to her workstation. Angela relied on writing, artwork, and her cat for solace and comfort. She was also very active outdoors, often hiking, biking, and going on camping trips by herself. Her goals in life were to own her own home, lose weight, enjoy relationships with others, and find peace with her traumas. As a result of the abuse she experienced, it was necessary to begin treatment focusing heavily on establishing trust and a relationship with the client. After 1 year of therapy, deeper process work was being done around her traumas, and she was able to open up much more. She disclosed more painful experiences to the therapist and began expressing her feelings, including intense anger at her family members. Angela also joined a group for survivors of sexual violence in the same program where she was receiving individual therapy. She was thus able to meet other survivors and engage them in relationship building and obtain support. Over time, she lost 100 pounds and made new friends, and her level of functioning increased dramatically. Six months into the group, however, I noticed boundary issues between the members of the group and the group facilitator. After speaking with the group facilitator about these concerns and others regarding her clinical judgment and boundary crossing, the decision was made to terminate her. As a new group facilitator began engaging the group, I noticed that Angela was not sharing as much in her individual sessions and, overall, seemed guarded. I tried on numerous occasions to address the shift, and while Angela acknowledged that trust had become an issue, she would not directly express her concerns or feelings. After some discussion, I explained to Angela that while I could not discuss the issues concerning the group facilitator, she should feel free to talk about her feelings and concerns in general. However, it became obvious that trust could not be rebuilt, particularly in light of the professional boundary issues with the group facilitator. I asked if she wanted to terminate counseling with me and find a new therapist, and Angela agreed. I provided Angela with three referrals so that she could continue her treatment. I learned that Angela and the former group facilitator had become friends and remained so after both had left the program in their respective capacities. Reflection Questions activities as Veronica did. She went to school every day and did not appear very different from other children in her area. It is important to note that families in poverty-stricken countries like Guatemala are deceived by traffickers who offer them money equivalent to a year’s income in exchange for their children. All the details of this case are not clear as of yet but it is believed that the maternal aunt was working in conjunction with someone else. 9. Describe any additional personal reflections about this case. This was a hard case to digest. It is one of those cases that you end up taking home with you in your heart. This 13-year-old girl has been through a lifetime of exploitation. For the first few weeks she would just look at me as if she were looking right through me. She needed a lot of coaxing to participate. Although she still has a great deal of healing ahead of her, Veronica is in a much better place and is making every effort to live a normal life. Working With Survivors of Sexual Abuse and Trauma: The Case of Angela 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? Knowledge of trauma and child sexual abuse was key as was active listening, validation, boundary setting, and, at times, confrontation. 2. Which theory or theories did you use to guide your practice? I applied relational, cognitive behavioral, empowerment, and strengths-based theories. 3. What were the identified strengths of the client(s)? Angela’s strengths were her ability to persevere and be resilient, as well as her ability to find time for self-reflection and self-care. Despite everyone around her telling her otherwise, she was still able to stand firm in the knowledge that she was sexually abused and therefore needed to have clear boundaries with those who did not believe her. 4. What were the identified challenges faced by the client(s)? Angela’s challenges included an occasional inability to function at work, self-harm, and isolation.   5. What were the agreed-upon goals to be met to address the concern? The goals were to increase functioning, enhance ability to create and sustain relationships with others, reduce isolation, address and increase self-esteem, refrain from cutting, and work through early sexual trauma. 6. What local, state, or federal policies could (or did) affect this situation? The statute of limitations in both civil and criminal cases affected Angela’s case. 7. How would you advocate for social change to positively affect this case? I would advocate with legislators in the state to eliminate the statute of limitations so that survivors of sexual abuse could prosecute and/or sue their perpetrator when they were ready. 8. Were there any legal or ethical issues present in the case? If so, what were they and how were they addressed? There were ethical issues regarding boundaries and dual relationships. The group facilitator in this case was inappropriate with her clients and became personal friends with this particular client along with the other women in the group. I addressed this by trying to work with the group facilitator, as well as by encouraging her to discuss this in her off-site clinical supervision. Because no change was occurring, eventually the group facilitator was terminated. 9. How can evidence-based practice be integrated into this situation? The use of a sequenced, titrated approach using relational theory to address complex PTSD is incredibly helpful, especially for those survivors of sexual trauma with multiple victimizations and difficulty with daily functioning. 10. Describe any additional personal reflections about this case. As the individual therapist, this case was heartbreaking for me. The relationship and trust I had built with this client was destroyed, and I was placed in a very precarious position. The client did not want to discuss the changing dynamic andclearly been influenced by the group facilitator, who was incredibly friendly and outgoing. There was no other choice but termination, and the realization that the damage could not be repaired was disappointing. However, had I disclosed “my side” of what was happening, I would have been making the same errors as the group facilitator and involving myself in a dysfunctional and unhealthy dynamic, including crossing boundaries—exactly what survivors do not need. There are times when you must “swallow your pride” to do what is right and best for the client, especially given the different variables and considering the ethical issues at play. Working With Survivors of Sexual Abuse and Trauma: The Case of Brenna 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? I used reflective listening and reframing to assist Brenna in setting goals and determining her unmet needs. I used knowledge of local systems and social service agencies to provide referrals and to secure needed services. 2. Which theory or theories did you use to guide your practice? I utilized systems theory. 3. What were the identified strengths of the client(s)? Brenna’s strengths were her resiliency and self-sufficiency. Brenna viewed her desire to provide a better future for her child as a strong motivating factor for changing her life. 4. What were the identified challenges faced by the client(s)? Brenna lacked a familial support system and network of friends, and she was socially isolated. Upon entry to the shelter, she lacked medical care, employment, income, and housing. Brenna also struggled with difficulty reading and writing. Brenna had experienced trauma and violence in her past and would be raising her child alone. 5. What were the agreed-upon goals to be met to address the concern? Brenna and I agreed to secure medical care, a housing plan, and a source of income. Brenna also set goals to improve her mental health.     Working With Survivors of Sexual Abuse and Trauma: The Case of Angela Angela is a 27-year-old, Caucasian female, who first came to counseling to address her history of sexual abuse. She graduated from college with a BS in chemistry and has since been employed by pharmaceutical companies. After obtaining a new job, she relocated to an apartment in an East Coast city where she knew no one. Both of Angela’s parents live on the West Coast, and she has one younger brother who also lives in a different state. Angela has limited contact with both her mother and brother and does not have any contact with her father. Angela is obese and disclosed a history of struggling with her weight and eating issues. She has few friends, and those she does have live far away. Angela has a long history of trauma in her life. She was sexually abused between the ages of 9 and 21 by her father, sexually assaulted at the age of 14 by a classmate in school, and mugged as a young adult. There was domestic violence in the home, also perpetrated by her father. Angela’s father is considered an upstanding member of the community, and he is well liked and respected by others. No one in Angela’s family believes that she was sexually abused, and her father joined a “false memory syndrome” group and is outspoken about that issue. There has been little discussion in her family about what took place in the home while she was growing up. Angela struggled with daily functioning and exhibited symptoms of post-traumatic stress disorder (PTSD). She had a history of cutting herself and binge eating and displayed some characteristics of borderline personality disorder. Angela also mildly dissociated when under duress. Angela suffered from depression and anxiety and had trouble establishing new relationships, both socially and at work. Although Angela has a stable job and was able to complete her work each day, at times she became overwhelmed by her emotions and retreated to the bathroom where she cried and sometimes cut herself before returning to her workstation. Angela relied on writing, artwork, and her cat for solace SOCIAL WORK CASE STUDIES: FOUNDATION YEAR 30 and comfort. She was also very active outdoors, often hiking, biking, and going on camping trips by herself. Her goals in life were to own her own home, lose weight, enjoy relationships with others, and find peace with her traumas. As a result of the abuse she experienced, it was necessary to begin treatment focusing heavily on establishing trust and a relationship with the client. After 1 year of therapy, deeper process work was being done around her traumas, and she was able to open up much more. She disclosed more painful experiences to the therapist and began expressing her feelings, including intense anger at her family members. Angela also joined a group for survivors of sexual violence in the same program where she was receiving individual therapy. She was thus able to meet other survivors and engage them in relationship building and obtain support. Over time, she lost 100 pounds and made new friends, and her level of functioning increased dramatically. Six months into the group, however, I noticed boundary issues between the members of the group and the group facilitator. After speaking with the group facilitator about these concerns and others regarding her clinical judgment and boundary crossing, the decision was made to terminate her. As a new group facilitator began engaging the group, I noticed that Angela was not sharing as much in her individual sessions and, overall, seemed guarded. I tried on numerous occasions to address the shift, and while Angela acknowledged that trust had become an issue, she would not directly express her concerns or feelings. After some discussion, I explained to Angela that while I could not discuss the issues concerning the group facilitator, she should feel free to talk about her feelings and concerns in general. However, it became obvious that trust could not be rebuilt, particularly in light of the professional boundary issues with the group facilitator. I asked if she wanted to terminate counseling with me and find a new therapist, and Angela agreed. I provided Angela with three referrals so that she could continue her treatment. I learned that Angela and the former group facilitator had become friends and remained so after both had left the program in their respective capacities. activities as Veronica did. She went to school every day and did not appear very different from other children in her area. It is important to note that families in poverty-stricken countries like Guatemala are deceived by traffickers who offer them money equivalent to a year’s income in exchange for their children. All the details of this case are not clear as of yet but it is believed that the maternal aunt was working in conjunction with someone else. 9. Describe any additional personal reflections about this case. This was a hard case to digest. It is one of those cases that you end up taking home with you in your heart. This 13-year-old girl has been through a lifetime of exploitation. For the first few weeks she would just look at me as if she were looking right through me. She needed a lot of coaxing to participate. Although she still has a great deal of healing ahead of her, Veronica is in a much better place and is making every effort to live a normal life. Working With Survivors of Sexual Abuse and Trauma: The Case of Angela 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation? Knowledge of trauma and child sexual abuse was key as was active listening, validation, boundary setting, and, at times, confrontation. 2. Which theory or theories did you use to guide your practice? I applied relational, cognitive behavioral, empowerment, and strengths-bas