THE LEVY FAMILY
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.
Sara-Beth Plummer, PhD, MSW Walden University
Sara Makris, PhD Laureate Education, Inc.
Sally Margaret Brocksen, PhD, MSW Walden University
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
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
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
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.
PART 1: FOUNDATION YEAR
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
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
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.
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
SESSIONS: CASE HISTORIES • THE PARKER FAMILY
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 beginning of our phone call, Jane said, “I’ve been through this before and I’m not helping this time.” When I asked if I could at least keep in touch with her to keep her informed of the situation and any decisions that might need to be made, Jane agreed. After a few more minutes of discussion around my role and responsibilities, I was able to establish a bit of rapport with Jane. She then started to ask me questions and share some insight into what was going on in her mother and sister’s home.
Jane informed me that she was very angry with her mother and had not brought her children to the apartment in years because of its condition. She said that her mother started compulsively shopping and hoarding when she and Stephanie were in high school, and while her father had tried to contain it as best he could, the apartment was always cluttered. She said this had been a source of conflict and embarrassment for her and Stephanie all of their lives. She said that after her father died of a heart attack, the hoarding got worse, and neither she nor Stephanie could control it. Jane also told me she felt her mother was responsible for Stephanie’s relapses. Jane reported that Stephanie had been compliant with her medication and treatment in the past, and that up until a few years ago, had not been hospitalized for several years. Jane had told Stephanie in the past to move out.
Jane also told me that she “is angry with the mental health system.” Sara had been recently hospitalized for depression, and Jane took pictures of the apartment to show the inpatient treatment team what her mother was going home to. Jane felt they did not treat the situation seriously because they discharged her mother back to the apartment. Stephanie had been hospitalized at the same time as her mother, but in a different hospital, and Jane had shown the pictures to her sister’s treatment team as well. Initially the social worker recommended that Stephanie not return to the apartment because of the state of the home, but when that social worker was replaced with someone new, Stephanie was also sent back home.
When I inquired if there were any friends or family members who might be available and willing to assist in clearing out the apartment, Jane said her mother had few friends and was not affiliated with a church group or congregation. However, she acknowledged that there were two cousins who might help, and she offered to contact them and possibly help herself. She said that she would ask her husband to help as well, but she wanted assurance that her mother would cooperate. I explained that while I could not promise that her mother would cooperate completely, her mother had stated that she was willing to do whatever it took to keep living in her home. Jane seemed satisfied with this response and pleased with the plan.
I then arranged to meet with Sara and her psychiatrist to discuss her increased anxiety and confusion and the compulsive shopping. I requested a referral for neuropsychiatric testing to assess possible cognitive changes or decline in functioning. A test was scheduled, and it indicated some cognitive deficits, but at the end of testing, Sara told the psychologist who administered the tests she had stopped taking her medications for depression. It was determined Sara’s depression and discontinuation of medication could have affected her test performance and it was recommended she be retested in 6 months. I suggested a referral to a geriatric psychiatrist for Sara, as she appeared to need more specialized treatment. Sara’s psychologist was in agreement.
Because they had both stated that they did not want to be removed from their home, I worked with Sara and Stephanie as a team to address cleaning the apartment. All agreed that they would begin working together to clean the house for 1 hour a day until arrangements were made for additional help from family members. In an attempt
The Parker Family
Sara Parker: mother, 72
Stephanie Parker: daughter, 48
Jane Rodgers: daughter, 45
SESSIONS: CASE HISTORIES • THE PARKER FAMILY
to alleviate Sara’s anxiety around throwing out the items, I suggested using three bags for the initial cleanup: one bag was for items she could throw out, the second bag was for “maybes,” and the third was for “not ready yet.” I scheduled home visits at the designated cleanup time to provide support and encouragement and to inter- vene in disputes. I also contacted Sara’s treatment team to inform them of the cleanup plans and suggested that Sara might need addi- tional support and observation as it progressed. Jane notified me that her two cousins were willing to assist with the cleanup, make minor repairs, and paint the apartment. Jane offered to schedule a date that would be convenient for her and her cousins to come and help out.
We then discussed placement for at least some of the cats, because six seemed too many for a small apartment. Sara and Stephanie were at first adamant that they could not give up their cats, but with further discussion admitted it had become extremely difficult to manage caring for them all. They both eventually agreed to each keep their favorite cat and find homes for the other four. Sara and Stephanie made fliers and brought them to their respective treatment programs to hand out. Stephanie also brought fliers about the cats to her place of employment. Three of the four cats were adopted within a week.
During one home visit, Stephanie pulled me aside and said she had changed her mind—she did not want to continue to live with her mother. She requested that I complete a housing application for supportive housing stating, “I want to get on with my life.” Stephanie had successfully completed cashier training, and the manager of the super- market was pleased with her performance and was prepared to hire her as a part-time cashier soon. She expressed concern about how her mother would react to this decision and asked me for assistance telling her.
We all met together to discuss Stephanie’s decision to apply for an apartment. Sara was initially upset and had some difficulty accepting this decision. Sara said she had fears about living alone, but when we discussed senior living alternatives, Sara was adamant she wanted to remain in her apartment. Sara said she had lived alone for a number of years after her husband died and felt she could adjust again. I offered to help her stay in her apartment and explore home care services and programs available that will meet her current needs to remain at home.
Key to Acronyms
APS: Adult Protective Services
ICM: Intensive Case Management services
SSD: Social Security Disability
The Logan Family
Eboni Logan is a 16-year-old biracial African American/Caucasian female in 11th grade. She is an honors student, has been taking Advanced Placement courses, and runs track. Eboni plans to go to college and major in nursing. She is also active in choir and is a member of the National Honor Society and the student council. For the last 6 months, Eboni has been working 10 hours a week at a fast food restaurant. She recently passed her driver’s test and has received her license.
Eboni states that she believes in God, but she and her mother do not belong to any organized religion. Her father attends a Catholic church regularly and takes Eboni with him on the weekends that she visits him.
Eboni does not smoke and denies any regular alcohol or drug usage. She does admit to occasionally drinking when she is at parties with her friends, but denies ever being drunk. There is no criminal history. She has had no major health problems.
Eboni has been dating Darian for the past 4 months. He is a 17-year-old African American male. According to Eboni, Darian is also on the track team and does well in school. He is a B student and would like to go to college, possibly for something computer related. Darian works at a grocery store 10–15 hours a week. He is healthy and has no criminal issues. Darian also denies smoking or regular alcohol or drug usage. He has been drunk a few times, but Eboni reports that he does not think it is a problem. Eboni and Darian became sexually active soon after they started dating, and they were using withdrawal for birth control.
Eboni’s mother, Darlene, is 34 years old and also biracial African American/Caucasian. She works as an adminis trative assistant for a local manufacturing company. Eboni has lived with her mother and her maternal grandmother, May, from the time she was born. May is a 55-year-old African American woman who works as a paraprofessional in an elementary school. They still live in the same apartment where May raised Darlene.
Darlene met Eboni’s father, Anthony, when she was 17, the summer before their senior year in high school. Anthony is 34 years old and Caucasian. They casually dated for about a month, and after they broke up, Darlene discovered she was pregnant and opted to keep the baby. Although they never married each other, Anthony has been married twice and divorced once. He has four other children in addition to Eboni. She visits her father and stepmother every other weekend. Anthony works as a mechanic and pays child support to Darlene.
Recently, Eboni took a pregnancy test and learned that she is 2 months pregnant. She actually did not know she was pregnant because her periods were not always consistent and she thought she had just skipped a couple of months. Eboni immediately told her best friend, Brandy, and then Darian about her pregnancy. He was shocked at first and suggested that it might be best to terminate. Darian has not told her explicitly to get an abortion, but he feels he cannot provide for her and the baby as he would like and thinks they should wait to have children. He eventually told her he would support her in any way he could, whatever she decides. Brandy encouraged Eboni to meet with the school social worker.
During our first meeting, Eboni told me that she had taken a pregnancy test the previous week and it was positive. At that moment, the only people who knew she was pregnant were her best friend and boyfriend. She had not told her parents and was not sure how to tell them. She was very scared about what they would say to her. We talked about how she could tell them and discussed various responses she might receive. Eboni agreed she would tell her parents over the weekend and see me the following Monday. During our meeting I asked her if she used contracep tion, and she told me that she used the withdrawal method.
Eboni met with me that following Monday, as planned, and she was very tearful. She had told her parents and grandmother over the weekend. Eboni shared that her mother and grandmother had become visibly upset when they learned of the pregnancy, and Darlene had yelled and called her a slut. Darlene told Eboni she wanted her to have a different life than she had had and told her she should have an abortion. May cried and held Eboni in her arms for a long time. When Eboni told her father, he was shocked and just kept shaking his head back and forth, not saying a word. Then he told her that she had to have this child because abortion was a sin. He offered to help her and suggested that she move in with him and her stepmother.
Darlene did not speak to Eboni for the rest of the weekend. Her grandmother said she was scheduling an appoint ment with the doctor to make sure she really was pregnant. Eboni was apprehensive about going to the doctor, so we discussed what the first appointment usually entails. I approached the topic of choices and decisions if it was confirmed that she was pregnant, and she said she had no idea what she would do.
SESSIONS: CASE HISTORIES • THE LOGAN FAMILY
Two days later, Eboni came to see me with the results of her doctor’s appointment. The doctor confirmed the pregnancy, said her hormone levels were good, and placed her on prenatal vitamins. Eboni had had little morning sickness and no overt issues due to the pregnancy. Her grandmother went with her to the appointment, but her mother was still not speaking to her. Eboni was very upset about the situation with her mother. At one point she commented that parents are supposed to support their kids when they are in trouble and that she would never treat her daughter the way her mother was treating her. I offered to meet with Eboni and her mother to discuss the situation. Although apprehensive, Eboni gave me permission to call her mother and set up an appointment.
I left a message for Darlene to contact me about scheduling a meeting. She called back and agreed to meet with Eboni and me. When I informed Eboni of the scheduled meeting, she thanked me. She told me that she was going to spend the upcoming weekend with her father, and that she was apprehensive about how it would go. When I approached the topic of a decision about the pregnancy, she stated that she was not certain but was leaning in one direction, which she did not share with me. I suggested we get together before the meeting with her mother to discuss the weekend with her father.
At our next session, Eboni said she thought she knew what to do but after spending the weekend with her father was still confused. Eboni said her father went on at length about how God gives life, and that if she had an abortion, she would go to hell. Eboni was very scared. Anthony had taken her to church and told the priest that Eboni was pregnant and asked him to pray for her. Eboni said this made her feel uncomfortable.
When I met with Eboni and her mother, Darlene shared her thoughts about Eboni’s pregnancy and her belief that she should have an abortion. She said she knows how hard it is to be a single mother and does not want this for Eboni. She believes that because Eboni is so young, she should do as she says. Eboni was very quiet during the session, and when asked what she thought, said she did not know. At the end of the session, nothing was resolved between Eboni and her mother.
When I met with Eboni the next day to process the session, she said that when they got home, she and her mother talked without any yelling. Her mother told Eboni she loved her and wanted what was best for her. May said she would support Eboni no matter what she decided and would help her if she kept the baby.
Eboni was concerned because she thought she was beginning to look pregnant and her morning sickness had gotten worse. I addressed her overall health, and she said that she wanted to sleep all the time, and that when she was not nauseated, all she did was eat. Eboni is taking her prenatal vitamins in case she decides to have the baby. Only a couple of her friends know about the pregnancy, and they had different thoughts on what they thought she should do. One friend even bought her a onesie. In addition, Eboni was concerned that her grades were being affected by the situation, possibly affecting her ability to attend college. She was also worried about how a pregnancy or baby would affect her chances of getting a track scholarship. In response to her many concerns, I educated her on stress-reduction methods.
Eboni asked me what I thought she should do, and I told her it was her decision to make for herself and that she should not let others tell her what to do. However, I also stated that it was important for her to know all the options. We discussed at length what it would mean for her to keep the baby versus terminating the pregnancy. I mentioned adoption and the possibility of an open adoption, but Eboni said she was not sure she could have a baby and then give it away. We discussed the pros and cons of adoption, and she stated she was even more confused. I reminded her that she did not have much time to make her decision if she was going to terminate. She said she wanted a few days to really consider all her options.
Eboni scheduled a time to meet with me. When she entered my office, she told me she had had a long talk with her mother and grandmother the night before about what she was going to do. She had also called her father and Darian and told them what she had decided. Eboni told me she knows she has made the right decision.
The Logan Family
May Logan: mother of Darlene, 55
Darlene Logan: mother, 34
Anthony Jennings: father, 34
Eboni Logan: daughter, 16
Darian: Eboni’s boyfriend, 17
The Johnson Family
Talia is a 19-year-old heterosexual Caucasian female, who is a junior majoring in psychology and minoring in English. She has a GPA of 3.89 and has been on the dean’s list several times over the last 3 years. She has written a couple of short articles for the university’s newspaper on current events around campus and is active in her sorority, Kappa Delta. She works part time (10–15 hours a week) at an accessory store. Talia recently moved off campus to an apartment with two close friends from her sorority. She is physically active and runs approximately three miles a day. She also goes to the university’s gym a couple of days a week for strength training. Talia does not use drugs, although she has smoked marijuana a few times in her life. She drinks a few times a week, often going out with friends one day during the week and then again on Friday and Saturday nights. When she is out with friends, Talia usually has about four to six drinks. She prefers to drink beer over hard liquor or wine, but will occasionally have a mixed drink.
Talia has no criminal history. She reports a history of anxiety in her family (on her mother’s side), and on a few occasions has experienced heart palpitations, which her mother told her was due to nervousness. This happened only a handful of times in the past and usually when Talia was “very stressed out,” so Talia had never felt the need to go to the doctor or talk to someone about it until now. Talia is currently not dating anyone. She was in a relation ship for 112 years, but it ended a few months ago. She had since been “hooking up” with a guy in one of her English classes, but does not feel it will turn into anything serious and has not seen him in several weeks.
Talia’s parents, Erin (40) and Dave (43), and her siblings, Lila (16) and Nathan (14), live 2 hours away from the university. Erin works at a salon as a hairdresser, and Dave is retired military and works for a home security company. Erin is on a low-dose antidepressant for anxiety, something she has been treated for all of her life.
Talia came to see me at the Rape Counseling Center (RCC) on campus for services after she was sexually assaulted at a fraternity party 3 weeks prior. She told me she had thought she could handle her feelings after the assault, but she had since experienced a number of emotions and behaviors she could no longer ignore. She was not sleeping, she felt sad most days, she had stopped going out with friends, and she had been unable to concentrate on schoolwork. Talia stated that the most significant issues she had faced since the assault had been recurrent anxiety attacks.
Talia learned about the RCC when she went to the hospital after the sexual assault. She went to the hospital to request that a rape kit be completed and also requested the morning-after pill and the HIV prevention protocol (Post- Exposure Prophylaxis, or PEP). At that time, a nurse contacted me through the Sexual Assault Response Team (SART) to provide Talia with support and resources. I spent several hours with Talia at the hospital while she went through the examination process. Talia shared bits and pieces of the evening with me, although she said most of the night was a blur. She said a good-looking guy named Eric was flirting with her all night and bringing her drinks. She did not want to seem ungrateful and enjoyed his company, so she drank. She also mentioned that the drinks were made with hard liquor, something that tends to make her drunk faster than beer. She said that at one point she blacked out and has no idea what happened. She woke up naked in a room alone the next morning, and she went straight to the hospital. Once Talia was done at the hospital, I gave her the contact information for RCC. I encour aged her to call if she had any questions or needed to talk with someone.
During our first meeting at the RCC, I provided basic information about our services. I let her know that every thing was confidential and that I wanted to help create a safe space for her to talk. I told her that we would move along at a pace that was comfortable for her and that this was her time and we could use it as she felt best. We talked briefly about her experience at the hospital, which she described as cold and demeaning. She told me several times how thankful she was that I had been there. She said one of the reasons she called the RCC was because she felt I supported and believed her. I used the opportunity to validate her feelings and remind her that I did, in fact, believe her and that the assault was not her fault.
We talked briefly about how Talia had been feeling over the last 3 weeks. She was very concerned about her classes because she had missed a couple of assignment deadlines and was fearful of failing. She told me several times this was not like her and she was normally a very good student. I told her I could contact the professors and advocate for extensions without disclosing the specific reason Talia was receiving counseling services and would need additional time to complete her assignments. Talia thanked me and agreed that would be best. I intro duced the topic of safety and explained that she might possibly see Eric on campus, something that might cause
SESSIONS: CASE HISTORIES • THE JOHNSON FAMILY
her emotional distress. We talked about strategies she could use to protect herself, and she agreed to walk with a friend while on campus for the time being. She also agreed she would avoid the gym where she had seen Eric before.
During our second meeting, Talia seemed very anxious. We talked about how she had been feeling over the last week, and she indicated she was still not sleeping well at night and that she was taking long naps during the day. She had missed days at work, something she had never done before, and was in jeopardy of losing her job. Talia reported experiencing several anxiety attacks as well.
The Johnson Family
Erin Johnson: mother, 40
Dave Johnson: father, 43
Talia Johnson: daughter, 19
Lila Johnson: daughter, 16
Nathan Johnson: son, 14
She described the attack symptoms as feeling unable to breathe, accompanied by a swelling in her chest, and an overwhelming feeling that she was going to die. She said that this was happening several times a day, although mostly at night. I provided some education about trauma responses to sexual assault and the signs and symptoms of post-traumatic stress disorder (PTSD). We went over a workbook on trauma reactions to sexual assault and reviewed the signs and symptoms checklist, identifying several that she was experiencing. We practiced breathing exercises to use when she felt anxious, and she reported feeling better. I told her it was important to identify the triggers to her anxiety so that we could find out what exactly was causing her to be anxious in a given moment. I explained that while the assault itself had brought the attacks on, it would be helpful to see what specific things (such as memories, certain times of the day, particular smells, etc.) caused her to have anxiety attacks. I gave Talia an empty journal and asked her to record the times of the episodes over the next week as well as what happened right before them. She agreed.
We met over several sessions and continued to address Talia’s anxiety symptoms and feelings of sadness. She told me she was unable to talk about what happened on the night of the rape because she felt ashamed. She said that it was too difficult for her to verbalize what happened and that the words coming out of her mouth would hurt too much. I reassured her that we would go at her pace and that she could talk about what happened when she felt comfortable. We practiced breathing and reviewed her journal log each week.
It had become clear that the evenings seemed to be the peak time for her anxiety, which I told her made sense as her assault had occurred at night. I described how sleep is often difficult for survivors of sexual assault because they fear having nightmares about what happened. She looked surprised and said she had not mentioned it, but she kept having dreams about Eric in which he was talking to her at the party. The dreams ended with him holding her hand and walking her away. She said she also thought about this during the day and could actually see it happening in her mind. We talked about the intrusive thoughts that often occur after trauma, and I tried to normalize her experience. I told her that often people try to avoid these intrusions, and I wondered if she felt she was doing anything to avoid them. She told me she had started taking a sleep aid at night. When I asked about her exercise habits, she said that right after the assault she had stopped running and going to the gym. We set a goal that she would run one to two times a week to help her with anxiety and sleeping. I also suggested that now would be a good time to start writing her feelings down because journaling is a very useful way to express feelings when it is difficult to verbalize them. Talia mentioned that she had decided not to go to the police about the sexual assault because she did not want to go through the process. I informed her that if she wanted to, she could address the assault in another way, by bringing it to the campus judicial system. She said she would think about this option.
During another session weeks later, Talia came in distraught. She said she had been feeling better overall since working on her breathing and doing the journaling, but that a few things had happened that were making her more and more anxious and that her attacks were increasing again. Talia said her parents were pushing her to drop out of school and to come home. She said they had been calling and texting her often, something she found annoying but understandable. They were very upset about what had happened, although they were more upset with her that she had waited for weeks to tell them about “it.” Her father threatened to come and beat the guy up, and her mother cried. She avoided talking with them, but they had become relentless with the calls. Her mother had shown up with her sister unannounced the previous weekend and had treated Talia like she had a cold—making chicken soup and rubbing Talia’s feet. The pressure from her parents was weighing on her and upsetting her. Talia was also distressed by a friend who kept pushing her to talk about what happened. When Talia finally relented, her friend asked her why she had gone upstairs with him. Talia said this made her feel terrible, and she started to cry. This friend also told her that Eric had heard she had gone to the hospital and was telling people that she had wanted to have sex. Eric had been telling people she was “all over him” and that she had taken her own pants off. This made Talia very angry and upset.
SESSIONS: CASE HISTORIES • THE JOHNSON FAMILY
We talked about how there are certain myths in society around sexual assault and that the victim is often blamed. We also talked about how the perpetrator often blames his or her victim to make himself or herself feel better. Talia said she has felt some sense of blame for what happened and that she should not have drunk so much. She started to cry. I gently reminded her that she was not at fault for Eric’s actions, and her drinking was not an invitation to have sex. I reminded her that he should have seen how incapacitated she was and that she could not have consented to sex. Talia continued to cry. She clearly had a number of emotions she wanted to express but was having difficulty sharing them, so I offered her some clay and asked her to use it to mold representations of different areas in her life and how she felt about them. We spent the rest of the session talking about the shapes she made and how she felt. Toward the end of the session she told me she had decided to put in a complaint with the campus judicial system about the assault. She worried that Eric would assault another woman and she would feel responsible if she did not alert the university. I offered my support and told her I would be there for her through the process.
Key to Acronyms
HIV: Human Immunodeficiency Virus Infection
PEP: Post-Exposure Prophylaxis
PTSD: Post-Traumatic Stress Disorder
RCC: Rape Counseling Center
SART: Sexual Assault Response Team
PART 2: CONCENTRATION YEAR
The Levy Family
Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school. Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand. Sheri is in good physical condition and has recently found out that she is pregnant with their third child.
As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories.
Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year. Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due to Jake’s recent behaviors, they have slowly isolated themselves.
My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). During this meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce his symptoms of anxiety and depression and suggested that he also begin counseling.
During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on the couch drinking beer and watching TV or playing video games. When we discussed Jake’s options for treatment he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he some times felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He said he had never seen her so angry before and saw she was at her limit with him and his behaviors.
Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course of action would be for him to participate in weekly individual sessions with me and a weekly support group that was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor the effectiveness of his medications.
The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma. The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal, and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking. He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for potential problems around him. He told me he always felt on edge and every sound seemed to startle him.
He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told
SESSIONS: CASE HISTORIES • THE LEVY FAMILY
him that naming the issue or concern was often helpful in the healing process. During the first few sessions my goal was to help Jake feel safe and validate his feelings. We consistently assessed his feelings of safety, including any potential suicidal ideation. He was reluctant to attend AA at that time, so we began monitoring his drinking and his behaviors after several drinks.
The Levy Family
Jake Levy: father, 31
Sheri Levy: mother, 28
Myles Levy: son, 10
Levi Levy: son, 8 Jake began his individual sessions practicing techniques I had shown him to help reduce his anxiety symptoms. We used deep breathing and guided meditation to help him remain calm and in the moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal, and when he tried to dissociate or numb in reaction to these episodes.