Case conceptualization

African Refugee case study. Paul is a man in his 30s who fled his home country in East Africa. Paul recounted growing up under an oppressive regime in his country, and he became politically active at a young age. He attended a deeply split and politicized high school and grew up in what he described as a relatively affluent and middle-class family. He also spoke of his belief that it was the role of the middle class in his country to work toward political change, even though political activity was deeply repressed and dangerous. He learned English in his secondary school and spoke it fluently. He reported having no psychiatric difficulties prior to the incidents leading to his fleeing his country. In response to an upcoming local election, Paul began to increase his visible political activity. One night when he was returning home to his mother’s house where he lived, he was ambushed and kidnapped. He was kept in confinement in a room for over two weeks and was interrogated and tortured. He was told by his captors that they would never let him go and that his family would be tortured as well. He was deprived of food, beaten into unconsciousness, forced into ice-cold water, given electric shocks, and forced to listen to the screams of other prisoners. He believed he would be killed. Eventually he was put into a van and dumped on the side of a road and warned that his life would continue to be in danger. He was hospitalized for over a month for his injuries. Realizing that he had no other option, he arranged to flee to the United States and apply for political asylum. His family continues to receive threatening phone calls demanding to know where he is. He was referred to treatment by his primary care physician whom he saw for continued pain related to his torture injuries. He lived in the basement of a house of a family from his home country whom he met at a religious function.

Assessment/Conceptualization: Consider how you would apply evidence-based practices. Specifically, what does existing research suggest about this particular presenting concern (find one additional reference to answer this question)? What are the sociohistorical contexts of the client’s social identity(ies) that you’d want to consider? What are the client’s strengths? What additional information would you want to ask about?
Intervention/Treatment Planning: Identify what approaches you would take in providing mental health sensitive services working with this client. How would you show cultural humility? What might you say and do to develop rapport?
Ethical Issues and Advocacy: Identify potential ethical concerns you’d want to be mindful of, including your own self-awareness and the interaction between your identities and biases with the client. What current sociopolitical issues or current events might impact the client that you’d want to be mindful of?
Scholarly Writing and Critical Thinking: Integrated and cited course material throughout case conceptualization. Included at least one additional scholarly (peer reviewed) reference OUTSIDE OF THE COURSE MATERIAL. Used APA style appropriately and writing is organized without typos.

Salvadoran Immigrant Case Study

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Department of Psychology, University of St. Thomas

CPSY 680: Diversity Issues in Counseling

Dr. GiGi Giordano

April 19, 2022

Salvadoran Immigrant Case Study

Cindy is a 17-year-old, female high school student attending public school. Two years ago, when she was 15, she moved from El Salvador to Minnesota to be with her parents. Her father had already been living in the US for six years at that time, and has now been here for eight years. Her mother has been here for two years–the same amount of time as Cindy. Cindy’s father is a legal resident but no one else in their family is documented. Both of Cindy’s parents work full time. Cindy has three other siblings, including Juan, her 21-year-old brother who still lives in El Salvador, Maria her eight year old sister, and Jorge her 4-year-old-brother. Both her younger brother and sister came to the US with their mother. Cindy is fluent in Spanish and has trouble writing and communicating her thoughts in English. She was referred to a therapist for assessment and counseling services by her math teacher, who reported that she gets frustrated when trying to communicate her thoughts and ideas in the classroom. When asked a question in class, Cindy gets tearful and exhibits symptoms of a panic attack: palpitations, pounding heart, trembling and sweating. Cindy wrote “I want to die” in Spanish on a math paper.

Assessment/Conceptualization

Cindy’s presenting problems likely stem from a complex combination of factors resulting from her immigration to the US from El Salvador, including: acculturation difficulties adjusting to a new culture with a different language, discrimination and microaggressions from community members, stress over her undocumented status and fragmented family life, and the strain she may face taking responsibility for her younger siblings while her parents work full time– in accordance with traditional Latinx gender roles.

Sue & Sue (2016) indicate that feelings of isolation, loneliness, disorientation, helplessness, anxiety, and depression often characterize the immigration experience (p. 398). Immigrants are overwhelmed with the task of learning about US society, acquiring language proficiency, and navigating the educational system. They have to adjust and adapt to new cultural customs within a completely different society while simultaneously considering how they are being received by US citizens. Cindy has only lived in Minnesota for the past two years, spending her entire childhood and the beginning of her teenage years in El Salvador. As she approached young adulthood, she was faced with extreme culture shock, leaving everything she knew behind to enter into an entirely new world with a new language, values, traditions, customs, social patterns and ways of living. Teenage years are already marked by great social and emotional change as individuals of this age are often taking on more responsibility, trying new things, making decisions by themselves, and working out who they are and who they want to be (McNeely, 2009). Cindy is experiencing typical teenage developmental challenges within the context of an entirely alien environment where nearly nothing is familiar or safe, and her experience is different from most everyone in it. It is clear how this experience could feel isolating and lonely, triggering anxiety and depression.

From the vignette, it is unclear what Cindy’s experience leading up to migration was like–for instance – if there was pressure to migrate due to stressful or dangerous conditions in El Salvador, or whether anything traumatic occurred during the migration experience itself. These factors are important to consider, as Potochnick & Perreira (2010) found that anxiety and depression risk increases among immigrants who had stressful or traumatic experiences leading up to or during their migration (p. 5). For example, if Cindy’s family was forced to leave El Salvador due to dangerous conditions, or a robbery occurred during the migration itself, these factors could be contributing to Cindy’s current symptoms. Additionally, as Ogbu (1987) asserts, the voluntary or involuntary nature of migration can affect immigrants’ mental health. Voluntary immigrants who have chosen to undertake the immigration journey in hopes of a better future will be more likely to find the experience worth their stress and sacrifice, whereas for adolescents who typically migrate in response to a decision made by their parents, migration may be viewed as involuntary and a stressor. If children or adolescents are not involved in conversations regarding decisions to immigrate, they are likely to feel they have no choice or voice in the matter (Perreira et al., 2006). If Cindy was not included in the decision to immigrate to the US, she may feel that she was forced to leave her life, friends, and brother behind against her will, and she may not have any desire to assimilate into this new culture that is not her own– again contributing to feelings of helplessness and depression.

Potochnick & Perreira (2010) also found that English language competence predicts lower levels of depressive symptoms among Latino youth. This means that Cindy’s difficulty writing and communicating her thoughts in English, likely contributes to her presenting symptoms– as she is not able to adequately express herself with members of the culture she now lives in. Not feeling comfortable communicating in social settings severely limits one’s ability to establish connections with, adapt to, and learn about the new culture they are in.

Another relevant factor in Cindy’s case is that she and her other family members– excluding her father– are living in the US undocumented. In studies of immigrant adolescents, those who were undocumented were at a much greater risk for anxiety than their documented counterparts (Potochnick & Perreira, 2010). This anxiety was even higher in mixed-status families, as adolescents may have feared getting sent back to their home countries and separated from other family members. Because Cindy’s dad is documented, she may have constant fear of a traumatic raid by ICE, which she has likely been exposed to in the media or heard stories of from friends/family. If this happened, her and her mother and siblings would be sent back to El Salvador while her father stayed behind. Because she has been living with her father for two years now, but had been living without him for many years prior to this when he moved to the US, the thought of potentially having to separate from him again – as well as separate her mother and younger siblings from him– may be extremely terrifying and painful. On a similar note, Cindy may not feel that she should put great effort into settling and acculturating into the United States, since technically she is not a legal resident and there is the possibility that she could be sent out at any time. These feelings likely contribute to a sense of loneliness, isolation, lack of belonging, fear, and helplessness.

Cindy’s separation from her older brother Juan, who currently lives in El Salvador should also be considered as a factor in her presenting symptoms. In Latinx culture, family is highly valued and important (Sue & Sue 2016), so it is possible that Cindy and Juan, being the two oldest siblings, were quite close before Cindy and the rest of her family left for the US. Juan is the closest sibling to Cindy’s age, and without her father in her life for the six years before she joined him in the US (when she was 9-15 years old), Cindy may have relied on her older brother as a sort of father figure to guide her through the difficulties in life back in El Salvador. Not having him present in the US, and not having him in any proximity at all, could be taking a toll on Cindy’s mental health and well-being, and contributing to loneliness and isolation, as she is now the only “older” sibling living with two parents and two very young siblings. This could have also shifted her role in the family, meaning that she is adjusting to a new role at the same time as losing an important family member.

Assuming that Cindy’s case exists in the present moment, we must consider that Cindy is affected by US politics surrounding immigration policy and discourse. Anti-immigration policies increasing in US politics and rhetoric provoke fear and unease among immigrants, especially those who may be undocumented (Sue & Sue 2016). Cindy likely already experiences anxiety due to her undocumented status, but when she begins to hear political debates and the issue of undocumented immigrants being a contentious one among members in her own community, she likely feels fearful and targeted. People may not know she is undocumented, but she could begin to fear that they do actually know, or somehow her and her family’s status will get out. Additionally, she may feel that members of this new society she is trying to adjust to actually actively hate her– because they believe she is a useless immigrant, documented or not, and is trying to take their jobs and drain their society. This could cause her to avoid social situations, fearful that she may be a victim of a hate crime or someone will get angry at her for being in their country. She may also wish to avoid speaking so others do not hear her thick accent or her difficulty speaking English, as they may reprimand her for being in their country without knowing their language.

These potential fears of Cindy’s are likely realized to a degree, as Sue & Sue (2016) point out, since the September 11, 2001 terrorist attacks, there has been a dramatic increase in negative/hostile attitudes towards immigrants and refugees in the US, as anyone who appears “foreign” is viewed as a possible terrorist (p. 400). Anti-immigration movements promoting that only U.S “natives” belong in the U.S, as well as the “English-only movement” are gaining momentum (Nassir, 2014). These increasing attitudes likely seep into Cindy’s day to day life where she may face harassment from other students at school, or be discriminated against in public–at a store or restaurant, or out in a public park. Anywhere Cindy goes, there is the potential to experience an overt racist act or hate crime. Moreover, having been in the US for less time, she is likely less equipped to deal with these instances, as until recently they may not have existed in her life. Her difficulty speaking English may exacerbate this issue, as she may have a more difficult time distinguishing what is a microaggression towards her from what is not. Potochnick & Perreira (2010) note that the risk for adolescent immigrant depression is strongly associated with having experienced discrimination in the US (p. 8).

In addition to the many stressors may Cindy face in adjusting to a new culture with fear over her undocumented status and discrimination, she may also face further stressors connected to her home life and family role. In traditional Latinx culture, men are expected to be strong, dominant, and the provider for the family (machismo), and women are expected to maintain harmony and nurture spiritual life within the family, being modest, virtuous and subordinate to others (marianismo) (Sue & Sue, 2010). With a new family structure, as her dad is back in the picture after six years, Cindy may have different role expectations than she did when it was just her, her mother, and her siblings in El Salvador. In traditional Latinx families, the structure is often hierarchical with authority given to parents, and children expected to obey them regardless of age. A conflict here could be Cindy experiencing some acculturation, with exposure to more equal gender roles and female liberation and empowerment, and no longer wishing to play the role she had previously been in her family, causing distress.

Sue & Sue (2010) explain that family responsibility often takes precedence over outside concerns such as school attendance or work obligations, and that older children are expected to care for and protect their younger siblings, with older sisters often functioning as “surrogate mothers”. With Cindy being significantly older than her two younger siblings, and her parents both working full time, it is likely that Cindy has great responsibility for their care. On top of all of her other difficulties and anxieties adjusting to a new culture, being a “stand in” mother for her two younger siblings may leave her feeling hopeless and helpless, as this could be considered a full time job. Instead of having time to explore school clubs, make friends, or focus seriously on any future plans for herself such as going to college, all of her free time may be spent watching the children at home, which may be expected by her parents.

In addition to Cindy’s age, gender, culture, family role, and past experience, it would be important to consider her socioeconomic status. Sue & Sue (2010) state that “Many immigrants, particularly those from underdeveloped countries and those who are undocumented, earn extremely low wages” (p. 394). They assert that approximately 23% of immigrants and their children live in poverty, and most undocumented-immigrants subsist on poverty level wages and are exposed to exploitation and abuse in the workplace. Although Cindy’s father is documented, her mother is not, and regardless, it is possible that her family lives in poverty and struggles to meet their day to day needs. Poverty adversely impacts families in many ways including creating food and house insecurity, family conflict, stress, difficulty accessing proper care and increased risk of anxiety and depression (McNeely, 2009)– many factors which are already present due to the immigration itself. It is possible that poverty and anxieties related to this in Cindy’s family are contributing to Cindy’s presenting symptoms.

Despite the negative factors contributing to Cindy’s case, she can also tap into various strengths, many of which may be related to her cultural background. According to Sue & Sue (2010), there is typically deep respect and affection among a large network of family and friends in Latin American culture – and family unity, respect, and tradition (familismo) are an important aspect of life. Familismo refers not only to family cohesiveness and interdependence, but also to loyalty and placing the needs of close friends and family before personal needs. This means that it is likely that Cindy’s family members– here in the US as well as back home in El Salvador– love and care about her and her well-being very much. If they become aware that Cindy is struggling or suffering, they will likely do all they can to support her. At the same time however, familismo has the potential to amplify Cindy’s stress and strain in that her obligation in the family is to care for the younger children and she may have high responsibility and expectations. Despite this, it is still likely that Cindy’s close relationships and interdependence on her family who shares her experience and background, have the potential support her and ease the stress of adapting to a new life and culture

Another potential cultural strength of Cindy’s may be found in her spiritual and religious values. Sue & Sue (2010) indicate that religion is important to many Latinx individuals, and that rituals, prayers, communication with the spirits, and herbal remedies are culturally sanctioned methods of addressing causes of distress. If Cindy is faithful and believes in God, it is possible that her spiritual life may be tapped into to offer strength and resilience as she faces the pains and anxieties of trying to find her place in a new culture.

Another possible area of strength for Cindy is support at school. Because her math teacher referred her to a therapist, it appears that this teacher has concern for Cindy’s well-being, and recognized signs that she was not doing well. Cindy’s ability to access mental health services would similarly be a strength in her life, as in Latinx culture, there is great stigma towards mental health issues and accessing support (Sue & Sue, 2010). Latinx immigrants are more likely than members of the majority culture to fear embarrassment or social discrimination from family or friends if they acknowledge psychological distress, and are more likely to express psychological distress via somatic symptoms (Sue & Sue, 2010). Additionally, many immigrants face barriers to mental health services in terms of lack of access, resources, knowledge and communication difficulties– so Cindy being able to access mental health care in the first place would be a major step in the right direction.

Additional information that I would like to ask Cindy about would include questions about what led up to her immigration and what the experience of actually immigrating was like. Did she experience anything traumatic during this experience? I would also like to know if she had any say in the matter of immigrating, or if her parents simply told her “This is what is happening”. Did she want to come to the US in the first place, and does she feel like she has a future here? What fears does she have related to her undocumented status? Does she feel that her family could be separated again? How would she feel about going back to El Salvador?

Additionally, I would be curious about Cindy’s relationships with each of her family members, her role in the family, and what expectations her family has for her. I would wonder about her relationship with her brother who is back home in El Salvador. I would also ask her about her social support at school. Does she have any friends or teachers that she can talk to at school? Has she experienced discrimination or harassment at school or in public? How does she feel about the process of adjusting to a new culture? Is she interested in adopting any American traditions or values or does she wish to completely retain those of her home culture? How does she identify religiously? What is currently the biggest cause of stress for Cindy in her life?

Intervention/Treatment Planning

The approaches that I would take to provide mental health sensitive services in Cindy’s case would include taking on a role of educator and advocate for Cindy. Sue & Sue (2010) indicate that counselors often need to take on multiple roles with clients who are recent immigrants, including educating them by providing information on services as well as on their rights and responsibilities, and advocating for them by helping them to negotiate the institutional structures of the health care, education and employment systems. I would make sure Cindy is aware of resources such as free community clinics that treat individuals regardless of their immigration status, as well as her rights to ask for interpreter services in health settings. I would provide education and advocacy, in terms of connecting her with resources that could support her in her education, especially her difficulty communicating in English. For instance, I would look into connecting her with a tutor to improve language proficiency, and providing her with information on social clubs she could get involved with to connect with others with similar backgrounds and experiences, creating a sense of community in this new culture. I would also provide information for financial support she may be able to access, and inquire about her future plans and goals, and the steps that may need to be taken to get there. To effectively assist Cindy, I would need to familiarize myself with community resources aimed at helping immigrants adjust to a new world.

I would show cultural humility by not making assumptions about Cindy based on her cultural background or any other aspects of her identity. Instead, I would approach Cindy with genuine curiosity, coming from a place of care and desire to understand and support her. If Cindy told me one thing about her family or cultural life that matched my preconceived notions, I would not assume that I could place her into a certain “category” or that I now know everything about her because she fits into a certain format. Instead, I would acknowledge the complexities of identity, in that identity is categorized by a vast array of groupings and experiences and there will always be shared as well as differing identities among individuals no matter how similar or different they are. I would never act as an “expert” on her culture, but at the same time I would attempt to learn all that I could about her culture, and not only from her–but from other sources–so that I could interact with a genuine understanding of her experiences, without her having to “teach” me about all of her experiences. I would also engage in constant reflection and critique of my own assumptions, beliefs, and biases about Cindy’s culture and experience, as well as my own culture and experience. I would take the time to educate myself on the historical experience of Cindy’s cultural group, in order to understand her potential feelings or approaches towards individuals from other cultures, including myself.

In providing services to Cindy, I would assess her degree of acculturation, and her roles and expectations in the family, as well as potential clashes between her cultural values and that of US culture. I would explore her views of gender, and adherence to gender roles and norms, taking care not to impose my own views on her. I would assist her in considering implications of her views, including potential conflicts within her family. If religion and spirituality was important to Cindy, I may adapt prayer and religious involvement into the therapeutic process.

Throughout the therapeutic relationship, I would pay particular attention to Cindy’s experience of racism, discrimination and anti-immigration sentiment. I would ask Cindy directly about experiences of mistreatment due to her identity, and start a conversation about microaggressions and her experiences with these verbal, behavioral or environmental slights. I would work with her to process painful microaggressions as well as potential instances of overt racism, and advocate for systemic change within her school as well as society at large to address hate and intolerance. I would also work with her to process anxieties related to societal immigration discourse, and advocate for pro-immigration policies outside of the therapy session.

To help counter any stigma that Cindy may have towards mental health services, I would provide psychoeducation about therapy, therapeutic approaches, and the stigma itself. I would acknowledge that participating in therapy might feel quite strange, difficult, and uncomfortable for Cindy, and emphasize that this is a completely normal experience. To build rapport with Cindy, I would like to be able to provide services in Spanish. Although my Spanish is not quite fluent yet, I am hoping to get to the point where it is. I feel that providing therapy in Cindy’s native language would acknowledge the value that I find in her culture, as I have taken the time to invest in learning the language. Being able to speak with Cindy in Spanish should allow her to express her experience without constraints, and would hopefully feel relieving to her as one of her difficulties is not being able to communicate and express herself– to feel understood.

In building rapport, I would do all that I possibly could to make Cindy feel understood. I would employ accurate empathy, truly attempting to place myself in Cindy’s shoes, see the world from her eyes, through the lens of all of her past experiences, and how they come together to make her who she is in the present moment. To enter her world more effectively, I would educate myself on her experience and historical background– particularly the experience of adolescent undocumented immigrants and the discrimination and hardships they face in the US, as well as their strengths and cultural values– what makes them great. I would pay attention to body language, learning how different non-verbals may be interpreted in Cindy’s culture, and what I could do to convey my genuine interest and enjoyment in speaking with her.

In building rapport, I would be patient, and rather than immediately shifting to psycho-education and advocacy, I would attempt to get to know Cindy in the way that she would like to be known. I would provide a listening ear and unconditional positive regard, paraphrasing her thoughts, feelings, and ideas, so that she knows I am taking in and understanding all that she shares with me. I would acknowledge that it may be difficult for Cindy to open up to me and discuss her issues in depth, as many immigrants are hesitant to speak about family issues or issues of personal concern due to the cultural importance of privacy (Sue & Sue, 2020). I would understand that counseling may be a slow process, with Cindy opening up to me after we have developed a relationship and she feels comfortable enough. When she was ready, I would invite her to share her story with me–whatever she feels comfortable with– while listening deeply and empathically.

Throughout the therapeutic session, I would incorporate issues of identity, and conflicts between Cindy’s life, experiences, and values, and that of US culture– helping to brainstorm methods for bridging these differences. I would emphasize that identity conflicts and immigration stress are a normal part of the adjustment process and that this difficulty and strain is to be expected, but that many just like Cindy are able to adapt and successfully overcome these difficulties. Throughout this process, I would emphasize and highlight Cindy’s strengths, joining with her to tap into areas in which she can rise up and feel empowered and competent in her life and decisions.

Ethical Issues and Advocacy

One ethical concern that I would want to be mindful of in my work with Cindy, would be taking care not to sway or influence her based on my own social views. For instance, if Cindy prescribes to a strict traditional family structure and gender norms, I would be inclined to “empower” her, and help her to fight against these norms. This however, would be imposing my own views on the client, and may not be the best thing for Cindy, or what Cindy wants– as for instance, fighting against her role could cause conflict in the family, and potentially result in emotional abuse or physical harm. Instead, I should aid her in exploring her situation, options, and opportunities, considering the negative and positive aspects of different choices, but ultimately leaving the decision up to her and her alone–empowering her to trust herself and her capacity to choose for herself.

I would also want to be careful not to put Cindy into a category of other immigrants that I know or have had experiences with. I have a good friend from my undergraduate school who was an International student from El Salvador, so I have learned a lot about Salvadorian culture from him. My friend may have some in common with Cindy in terms of adjusting to the new culture in the US, but even apart from him being highly educated and relatively affluent, there would be much between his and Cindy’s experience that would be different– simply because they are different people. No two Americans are exactly alike, just like no two Salvadorans in America are exactly alike, although they may share similar experiences and understandings, they also share similar experiences and understandings with other Americans.

Another aspect that I would want to be aware of is the power dynamic between Cindy and I. I am a privileged white woman, and because of this, as well as my status as the counselor, I would hold power over Cindy within the therapeutic relationship, and my presence may influence her and how we interact together. I would make an effort to give power to Cindy, since she likely has already experienced discrimination, marginalization and devaluing in the larger society by white people. Cindy may be particularly reserved or unexcited to work with me, as I may represent all white people that Cindy associates with this difficult and hateful culture she is attempting to adjust to. I may represent all of the racism, discrimination and anti-immigration sentiment that Cindy sees in politics. I must put in effort to gain Cindy’s trust, acknowledge our power differentials, and emphasize my desire to advocate and support Cindy and all immigrants like her. I should not expect Cindy to trust me immediately, but give her time to slowly ease into our therapeutic relationship, as I offer empathy and positive regard.

Throughout therapy with Cindy, I would commit to reflecting on my white identity and its interactions and implications on Cindy’s identity. I would continue the process of seeking to understand myself in relation to others, and how I can commit to anti-racist actions inside and outside of the therapy session. I would make an effort to constantly reflect on biases I may be having towards Cindy, to actively fight and counter them, making sure I am providing her the best care.

Current sociopolitical issues or events that may impact Cindy that I would want to be mindful of, include political discourse on immigration policy– especially policies surrounding undocumented immigrants. In Cindy’s case, laws surrounding undocumented immigrants’ ability to attend college may be particularly relevant, as she is 17 years old and close to being finished with high school. I would also want to be mindful of events in the news or media involving immigrants– even those in which someone is recorded screaming at someone that they should “Go back to their country” or “Where is their proof of citizenship.” Cindy’s exposure to media like this, may cause significant emotional reactions, or increased fears or anxieties living her day to day in the US. Another example may be an ICE raid broadcast over the news, heightening Cindy’s fears over her and her family’s undocumented status. I would need to keep up to date with daily immigration news, as well as any political hateful rhetoric that could influence the public’s treatment of immigrants–such as Donald Trump’s hateful remarks. Finally, major events involving immigrants in the news–such as an immigrant being pinned for some crime, might also increase hate crimes and aggression towards immigrants, so it would be important to be aware of events like these.

References

McNeely, C. (2011). The teen years explained: A guide to healthy adolescent development. Johns Hopkins Bloomberg.

Ortiz, K. (2014). Skin color, interviewer-ascribed ethnoracial classification, racial/ethnic self-identification & discrimination: Commentary on Perreira and Telles (2014). Social Science & Medicine, 116, 251–252. https://doi.org/10.1016/j.socscimed.2014.07.013

Potochnick, S. R., & Perreira, K. M. (2010). Depression and anxiety among first-generation immigrant latino youth: Key correlates and implications for future research. Journal of Nervous & Mental Disease, 198(7), 470–477. https://doi.org/10.1097/NMD.0b013e3181e4ce24

Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: Theory and practice (7th edition). John Wiley & Sons, Inc.

Disabilities and Older Adults Case Conceptualization

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Graduate School of Professional Psychology, University of St. Thomas

CPSY 680-01: Diversity Issues in Counseling

Dr. Gigi Giordano

May 10, 2022

Case Vignette: Counseling Older Adults – Sarah

Assessment/Conceptualization

Sarah’s presenting concerns are clear signs of depression and anxiety seemingly stemming from the demands of her caregiving responsibilities for her husband with Alzheimer’s. She describes her feelings as being overwhelmed, anxious, and very sad about the changes her husband has gone through. Sarah talks about getting angry in response to her husband expressing anger as well as getting upset when he is difficult to care for. Other notable aspects of Sarah’s presentation include that she becomes tearful when speaking about her husband, and she explains that she helps him with daily activities, dressing, bathing, on top of her taking care of all their home management and maintenance upkeep. She also describes not sleeping well at night due to her husband wandering around during the night and having her own health problems including being morbidly obese, with high blood pressure, high cholesterol, and peripheral vascular disease. The main sociohistorical contexts of Sarah’s identity that I am privy to now are the fact that she is an older adult, and caregiver to her spouse. I am unaware of her racial, ethnic, religious, or socioeconomic identities, and therefore cannot take these into account before meeting with her.

Current existing research suggests that given Sarah’s particular presenting concern, and the other aspects of Sarah that I know about, the evidence-based practices to implement when working with Sarah will be cognitive behavioral therapy (CBT), as well as relaxation training such as breathing exercises, progressive relaxation of the muscles, and visualization (U.S. Department of Health and Human Services, 2021). Ayers et al. (2007) conducted a review on evidence-based treatments for late-life anxiety and concluded that CBT and relaxation training had the most support for lessening symptoms of anxiety, whereas cognitive therapy and supportive therapy did not show lessened symptoms in older adults. Trevino et al. (2021) carried out a research study to test effectiveness of different anxiety interventions for older adults with cancer and their caregivers and concluded that a seven-session CBT-based psychotherapy intervention was associated with the greatest reduction in anxiety among the pairs of participants. Although Sarah’s husband has Alzheimer’s and not cancer, this study’s focus on an ill older adult and their caregiver further shows support for using CBT as the primary evidence-based practice in treating Sarah.

Sarah has many strengths and protective factors. A major strength and protective factor is that Sarah has two adult children who live locally and are both involved and supportive of their father’s care, which alludes to Sarah having a close relationship with her two children. Furthermore, she has seven grandchildren who bring her great joy as she states feeling connected to and very proud of. In a population where social isolation is a common stressor and predictor of mental and physical complaints, these close relationships that Sarah has with her children and grandchildren are very important. The case states as well that Sarah is down to earth and has a great sense of humor which both might be serve as protective factors in that her disposition towards others and herself might be light and playful which could lend to forming a therapeutic alliance well and easily with a clinician.

Before finalizing treatment, I would like to know some additional information about Sarah to relieve symptoms and implement intervention best. I would like to ask about Sarah’s involvement in the community, to see if she has support systems other than her family. Any other societal factors affecting her would be beneficial to know as well, such as “recent losses, financial stressors, and family issues” (Sue et al., 2015), and I would also ask about any history of mental health as well as physical health concerns in her family history. If Sarah has had any cognitive testing done through a medical doctor, these reports would be beneficial to see as well. Finally, in getting to know Sarah, I would like to ask about how other salient aspects of her identity come into plan in how she experiences her symptoms, how she views them, and how the people around her view them.

Intervention/Treatment Planning

The main approach I would take in providing mental health services working with Sarah would be a combination of CBT and relaxation techniques. As aforementioned, there are numerous studies showing that CBT is the most effective treatment for anxiety and depression in older adults, which is what leads me to conclude this will be the best option. Other literature states that relaxation techniques such as teaching the technique of progressive relaxation, visualization of calm places and feelings, and breathing exercises to focus on deep, slow breaths is helpful to reduce anxiety and depression. These relaxation trainings will be particularly important for Sarah because she mentions having trouble sleeping, and these techniques are shown to aid in falling and staying asleep. CBT and relaxation training will most likely take place in weekly sessions with Sarah.

In order to show cultural humility, I will make sure that I educate myself on the specific skills needed to work in counseling older adults and evaluate my own inner biases towards older adults. I will also need to make sure I am up to date on the signs of vulnerable adult abuse in case this would come up in working with Sarah. Through getting to know more about Sarah, there will of course be more specific ways to show cultural humility, such as racial and ethnic cultural competency and humility, but for now, I need to involve her in all decisions, and use multiple assessments to learn about her. Finally, I will need to remember how much value Sarah puts in taking care of her husband and be culturally humble when it comes to my own expectations about end-of-life care.

When working with Sarah, to develop rapport and establish a strong therapeutic alliance, I will make sure to show her respect, and give her as much autonomy as possible, because Sue et al. (2015) explains this is paramount to a great relationship with an older adult, regardless of the mental state of the adult and the issues that are being discussed. I will also establish rapport by not focusing the health concerns such on her husband, but making sure Sarah feels like an important and valued individual. I will also maintain a positive attitude and help Sarah to focus on positive emotions such as optimism and resilience (Sue et al., 2015).

Ethical Issues and Advocacy

Potential ethical concerns will be if I am competent to work with older clients, and if I have the opportunity to seek consultation and perhaps supervision if I find myself not confident and/or competent. Other ethical concerns will be making sure Sarah is not being taken advantage of due to her age in any aspect of her life, as she is an older adult. In terms of my own identities and implicit biases, I will need to make sure that I do not speak to Sarah in “elderspeak”, or talk as if she is not very intelligent, or not in the room. There will be a clear age difference, but I will need to not idolize my youth and look down upon her and her age, but rather always be respectful and take her concerns very seriously. And again, once I find out more about Sarah, I will need to check my implicit biases in terms of other aspects of her identity. I have close relationships with older adults, and I adore hearing about the “good ole days” and listening to the wisdom they have to impart on me; therefore, I believe I will be able to easily respect Sarah and see her as a competent, older adult.

Current events that might impact Sarah that I might want to be mindful of would be any research in Alzheimer’s in case she does not have access to her medical provider at a moment’s notice and might not see new information and studies on the caring for her husband. Other current events would be the continuation of the COVID pandemic, because due to her age and poor health, she might want to social distance more than others, and this could come into play with out therapeutic relationship.

I will advocate for Sarah and the issues she faces in helping her to cope with her emotions and stressors but also teach her how to ask for more help from her family members that are in town and help her to get involved (when she is ready) in organizations and groups outside of her home in order to reduce isolation. I will also advocate for possibly getting a nurse to come to her home and take over some of the caregiving duties, again only if she is ready, because her autonomy and decision making will come first. Overall, I will advocate for quality physical care for her husband and herself and do my best to establish rapport and implement intervention effectively.

References

Ayers CR, Sorrell JT, Thorp SR, et al. (2007). Evidence-based psychological treatments for late-life anxiety. In: Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet]. York (UK): Centre for Reviews and Dissemination (UK); 1995-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK74481/

Sue, D. W., Sue, D., Neville, H. A., & Smith, L. (2015). Counseling the Culturally Diverse: Theory and Practice. Wiley.

Trevino, K. M., Stern, A., Hershkowitz, R., Kim, S. Y., Li, Y., Lachs, M., & Prigerson, H. G. (2021). Managing Anxiety from Cancer (MAC): A pilot randomized controlled trial of an anxiety intervention for older adults with cancer and their caregivers. Palliative & supportive care, 19(2), 135–145. https://doi.org/10.1017/S1478951521000286

U.S. Department of Health and Human Services. (2021). Relaxation techniques for health. National Center for Complementary and Integrative Health. Retrieved May 9, 2022, from https://www.nccih.nih.gov/health/relaxation-techniques-what-you-need-to-know

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