Engaging Clients and other Systems in GSW Practice
Agency Setting
North Suffolk Mental Health Association provides mental health services to underserved communities in East Boston, Chelsea, Withrop, and Revere, Massachusetts. Among the primary mission objectives of the Agency is to provide people with institutional care, support community-based services in addition to helping people to achieve independence and fullness of life through the provision of a wide variety of community-based, person-centered treatment. North Suffolk Mental Health Association was founded in 1959 and has expanded into one of the leading and largest providers of mental health services in the State (North Suffolk Mental Health Association 2011). In 2002, North Suffolk Mental Health provided services to over 10,000 individuals it has almost 800 staff members located in 4 clinics, 73 programs, and 38 residences.
I played diverse roles that are core to the agency that included but not limited to providing services to children, adults, and families, fostering recovery and rehabilitation opportunities, and intervening to mental cases at the earliest stages possible (North Suffolk Mental Health Association 2011). Other key roles and activities include the promotion of prevention services, providing education, promoting hope, and participating in training and research. At the agency based in Revere, Massachusetts, I did participate in offering an array of services in areas such as adult mental health, handling emergency cases, adult mental retardation, child/family care, substance abuse, research training, among others. Speaking of adult mental services, North Suffolk Mental Health Association provides mental health services that include community outreach treatment, outpatient services, residential services and supported housing department, day treatment and rehabilitation among others (North Suffolk Mental Health Association 2011).
North Suffolk Mental Health Association improved my professional life through exposure to a diverse range of mental health services. Other forms of exposure were obtained from associations that collaborate with North Suffolk Mental Health Association. Clear examples of these organizations include the Department of Mental Health (DMH) and Department of Mental Retardation (DMR). Experience achieved from the role of a Recovery Support Specialist include ensuring coordination of rehabilitative services for Community-Based Flexible Support (CBFS) people, coordination/integration of all rehabilitative services for their caseload, and providing direct services to people under Community-Based Flexible Support (CBFS). The direct services offered to CBFS people include housing services, service coordination, transportation, support, promotion of self-determination, didactic teaching, advocacy, and decision-making, outreach, and assistance with community integration with a person centered (Eva Jané-Llopis 2006).
Jane, a 39-year-old divorced Caucasian female has been diagnosed with Schizoaffective disorder and has had over 10 hospitalizations, 4 of which were in the recent past. She has two children. The first child is a 23-year old married daughter having three children; a 5-year-old son and newly born twins. The second child is a 17-year-old son who lives with her ex-husband but visits Jane daily to take breakfast before he leaves for school. Although she lives alone, Jane is extremely attached to her children and is tremendously excited about her twins. Speaking of her family history, Jane’s relationship with her family members can be described as being estranged relationships, majority of her efforts to reconnect with her family have turned out being unsuccessful. However, she recently connected with her mother, whom she constantly communicates with after 4 years of silence. She has no friend but is willing to make some. Jane is Catholic, goes to church sometimes. Concerning relationships with events, Jane identifies herself as an Italian but does not celebrate the Holidays.
Jane vividly remembers an instance where she was close to her dad during her younger years whereby she preferred raising her issues with her dad instead of refereing them to her mum. Sadly, her parent’s divorced when Jane was 2 years of age. Jane is the fourth member in her family of seven members from different mothers. The names of the seven children are Maureen, Michael, Leslie, Jane, Andrea, Michelle, and Christina, all born and raised in Massachusetts. Jane’s father passed away from cancer at the age of 61 after re-marrying and divorcing. Equally, Jane’s Mother remarried three more times but all her husbands died of cancer. Jane’s mother currently lives with her boyfriend in Lynn whereas all her siblings still reside in Massachusetts even though they are not in terms. Although they rarely speak with each other, Jane has a constant connection with one of her sisters with whom she frequently speaks and at one point, she stayed by her side after her sister fell into a coma. Unfortunately, their relationship severed after an instance where Jane tried to discipline her niece after she found her smoking weed. Jane identifies Jimmy-her son's Godfather as a support system. Jimmy helps her out when needed. She stays with him when she got out of the hospital on 9/6/11 in Chelsea. Jane relates hating Christmas and July 4 because they symbolized the traumatic events, she endured. This included her husband taking custody of her daughter and her not able to provide for her children during these times.
As mentioned earlier, Jane has been diagnosed with Schizoaffective disorder with over 10 hospitalizations, 4 of which were in the recent past. Jane has a history of several hospitalizations dated back to aged 18 and failed discharges. She believes that she suffers no mental illness but blames her health situation a hex on her put her on her by the Vietnamese. Jane argues that the hex has “killed all 65 of her bloodline”. According to her, medications have played a enormous role in chasing away the voices she used to hear in the past but no longer hears them. Her fixed paranoid delusions and poor insight into her mental health problems present the main barrier toward her recovery. Her past response to medications can be characterized by the failure to follow recommendations from the doctor but at the moment, she seems to have gained a better understanding of medications and is willing to follow medications and recommendations. Interestingly, Jane has accepted VNA Nizhoni and Nizhoni had to manage her medications. Jane wants to move out of her group home and move from the Charlestown project and find another apartment despite her doctor’s insistence that she remain in the group home. She has little day structure, she tried to enrol into MassRehab but could not be accepted due to what was termed as ‘too much money.’ However, Jane argues that she manages her money alone and does not have to rely on rep-payee.
Jane’s recent hospitalization occurred between July 18th-September 6th at McLean and referrals were made to ICB after multiple hospitalizations. Jane and her lawyer contested the decision. Activities following the hospitalization included a situation where Jane refused to drink or eat due to fears that her neighbours were planning to poison her. In this situation, she was found to be unresponsive with severe dehydration and low potassium levels. She blamed her decision to kill herself to neighbors who came to her door and claimed that Jane’s children were dead. At the age of 14, Jane was involved in a car accident, lost consciousness, broke her right leg, and left arm. While at school, Jane was diagnosed with dyslexia but managed to grow out of it. Her family’s medical history comprises of multiple family members with Bipolar and other psychotic disorders. Her father died of cancer and stepsister Michelle suffered from depression resulted in completed suicide.
Referral
I met Jane after the DMH referred her to me for CBFS services (community support and risk Management) during her hospitalizations at McLean. I was furnished with some information regarding her medical situation right before I met her. On 9/11/11, Jane was transitioned to Community Based Facility Support (CBFS) whereby she was refereed for assistance with housing search, coordination of out patient’s services around medication and appointment, community and general supports. Apparently, Jane was unable to return to her apartment in Charlestown due to her paranoia around Asians in her building trying to kill her. According to Jane, eating or drinking any food will lead to her death. Jane was discharged on September 6 to the home of Jimmy-her son’s godfather who lives in Chelsea. She the option of going to her project-based apartment in the housing project in Charlestown but declined to return due to what she termed as a plot by her Vietnamese neighbors to kill her. To this purpose, she stayed in Chelsea for two weeks and then moved back to her apartment.
Although I was not involved in the initial intake process, I was informed that my supervisor will assigned her to me before her discharge. For this reason, I had to acquire all the relevant information before meeting this client (Jane). I read all screening and enrolment write-ups whereby I understood that only licensure members were allowed to attend to patients in correspondence with assigned staff members (Peter, Liam, and Yolanda, 2011). McLean and DMH faxed all the necessary documents concerning referral/assessment reports and medical summaries. I read these documents before meeting the client. The next process involved gathering documents that Jane was supposed to sign and these documents included consent forms, current statement of awareness of right, policy on confidentiality, self-preservation, and evacuation plan. A chart for her physical was had to be set up on the team database.
Speaking of apprehension, I can say that I had less apprehension in meeting Jane because I was very open to meet her and getting to know her better. I was prepared and equipped to meet her. As such, I was more curious to know about her background, her family history, in addition to knowing her holistically other than judging her from the information I had read about her. I wanted to know her strengths and goals she already had prepared for herself, her strength, ambitions and what she considered her barriers (Poulin, 2010). Coupled with this anxiety, my specific goal for engaging with Jane entailed the need for establishing a working relationship with Jane and obtaining as much information from her other than the information contained in the medical records (Saleebey, 2009). I also wanted to obtain any information that could enable me to help her realize her goals, the reasons behind her hospitalizations, what works for her, and lastly, set up referrals for therapeutic services. The type of relationship that existed between Jane and I can be described as transactional in the sense that it involved transactional exchanges between the two of us. This transactional exchange enabled me to maintain a dual focus to Jane and the effects surrounding her environment. As such, it facilitated the process of obtaining a holistic view of the situation, and understanding the entire process by empowering Jane and discovering the options that were available to her.
The engagement or planning process
Capacity for growth and change
In order to keep with humanistic approaches to social work, the strengths perspective made a basic assumption that humans have the capacity for growth and change (Early & GlenMaye, 2000). Jane’s case illustrates that individuals have many capabilities, abilities, and strengths. They also have a range of experiences, characteristics, and roles contributing to who the person is and how they cope with problems.
Knowledge about one’s situation
According to Early & GlenMaye, (2000), clients are able to survive times of great challenges as seen in the case of Jane who knew her inabilities thus she resorts to religion to cope with the critical events in her life. The future of a client is based on his/her knowledge coping with past problems.
Resilience
The strengths perspective postulated by Garmezy in the year 1994 believes that human beings are resilient. Jane is able to raise her son and daughter on her own though she is divorced. In spite of the critical factors in her life (divorce and having to raise children on her own), she engages her energy and skills to cope with what she is going through (Anthony & Cohler, 1987).
Membership
Basing on the strengths approach, people need to own the traits of citizens i.e. responsible and valued community members in a viable group or community. Jane did not feel fit in the community as she was divorced from her husband but being an individual and a collective member of the Christian faith, she was able to realize and cope with her marital life thus validating facts that when managed, her difficulties and capacities come in handy in their daily lives (Saleebey, 2009).
Strengths and interventions
A report by Saleebey, 1997a reports that individual’s expertise on their lives, their resources, and capacities helps them create ad dialogue of strength. The role of social workers is to help individuals identify the strengths and work to achieve her goals and visions as individuals are doing something to better their situation.
Jane’s priorities
House
Jane wants to move out of Charlestown where she has been living, as she believes her Vietnamese neighbors are plotting to kill her family alongside her. She needs a lot of support in application process, moving and maintaining housing and she has been meeting with housing specialists whereby she has made vague homicidal threats, as she believes she is in eminent danger. In order to ensure success and safety in a new apartment she will be using CBFS in skill building for stress management and decision-making. Her skills on the need to stay safely in the community will also be evaluated. Jane is not eligible to receiving reasonable accommodation priority unless the housing specialist assists and does follow-up for her,
Employment
Jane is not looking for employment now but she wants to be employed in future. She dreams of continuing with education in the area of political science and law in order to get a job though she has been employed elsewhere before. CBFS has to assist her get financial aid and employment. She had started classes in Bunker Hill but they placed a restraining order on her without any clear reason. She wants to go to Suffolk University or UMass Boston in the future. At this time, she wants to spend time with her grand children who have just arrived.
Substance abuse
Jane is not interested to work on substance abuse as she thinks that it’s not a problem as she has been clean from heavy marijuana smoking for six months though she smoked before, she also hails from a family of alcoholics.
So as to facilitate successful planning and engagement process I will follow systematic steps;
Pre-engagement step whereby I will use the collaborative model which entails meeting Jane to complete a comprehensive assessment (biopsychosocial) where I will collect information as to why Jane was referred, her family background, education level attained, medical and psychiatric histories, living situations, financial status, Assessed Needs Checklists (ADLs), mental status and goal identification. The mentioned assessments will be completed 21 days after I transitioned Jane to the services. Based on needs identified and prioritized during screening and on my third meeting with her I will develop individualized action plan in 30days time. During my first meeting I will establish rapport with Jane by introducing me and allowing her to introduce herself, duration of the assessment session will also be discussed and confidentiality of information she gives is assured. Jane will be informed on the purpose of the assessments and will be referred to outpatient services for therapeutic and psychiatric care. I will make sure that the conversation appears natural and informal and clarify issues where need be. We will agree on the time for the next meetings and I will carry out follow ups via phone calls. On the second meeting we will figure out issues on her appointments with the housing specialist in order ensure that she gets reasonable accommodation as she had given threatening remarks to her neighbor. During the third meeting Jane will identify her goals prior to entering into the engagement step where we will determine her goals, purpose of the goals, helping relationships and evacuation plan. We will then proceed to the disengagement step once her housing has been approved by meetings with the housing specialist and Boston Housing Authority though the meetings were not carried out formally.
Identification of social skills
Strengths assessment
In order to ascertain Jane’s social skills I carried out strengths assessment, which primarily focused on what she is doing towards achievement of desired behaviors and situations. Strengths assessment focuses on client’s capabilities and aspirations in all issues related to life functioning. I used the technique of conversations with Jane and her family members in order to assess her strengths whereby I obtained information of how she has survived so far, what she wants and her thoughts on how things are going in various areas of life. Jane’s goal was to indulge in activities aimed at meeting her own expectations as a wife and those from in-laws and her husband as this was a step towards improving her relationship with them and living a better marital life.
Jane was uncomfortable in thinking basing on hers or others strengths or having emerged from scarring events with something useful and redemptive. She had inoculated in the doctrine of herself that she was deficient and needy since being diagnosed with mental illness. She experienced anxiety symptoms manifested through body vibrations, as she was unable to carry out any household chores. On further inquisition, I found that she experienced maximum vibrations only when performing certain household tasks and when talking about her marital life. Maximum anxiety was observed in the morning, as she was apprehensive on whether to carry out all household chores during the day as per expectations from in-laws in order to earn good relationship with them and husband. Insight on the relationship between her performances as a wife made her realize that she was able to carry on with her household duties in spite of her anxiety. She was able to maintain her marital status in spite of discord through use of her inert coping strategies. To deal with lack of social support she attempted to convert to Christianity. After the assessment session, Jane was able to identify her strengths to deal with all her life experiences basing on the coping strategies she employed.
Intervention
In identifying the most appropriate intervention to solve Jane’s problems, I explored on strategies focused on identifying internal, external, created, and naturally occurring resources tailored towards achieving her defined goals, building on her strengths, skills, knowledge, and desires. The interventions identified were further divided into two; intervention with client (Jane) and interventions with her family.
Intervention with client
Entailed meeting with Jane to establish trust and her therapist to set treatment goals including reduction of anxiety, improve communication with her husband and perform her household chores effectively and efficiently. She confessed feeling less anxious after prayer as she believed in the power of prayer thus it was decided that she should visit the church regularly, and reduce her anxiety levels during the day. She was taught basic communication strategies towards improving communication with her husband and the importance of her husband as her strength and support system in times of distress. In order to establish good relationship with others she was asked to take initiative in conversations, communicate and clarify misunderstanding s with others instead of waiting for them to do so.
Intervention with family
Focused on Jane working in collaboration with them in order to identify her strengths and goals as this will be important in coming up with a strategies towards environmental modification to enhance her livelihood. The therapist will convene sessions with her mother, father, brother, and husband after meeting Jane individually in order to identify strengths and coping patterns towards modifying her environment. Marital participation and involvement by husband communication and listening to personal stories and narratives of Jane in times of distress was also enhanced by the therapist.
Reflection and self-evaluation
Ability to identify and make choices about individual and family goals, hope for the future, survivor pride and ability to understand another person’s needs and perspectives are the components of the strengths approach (Benard, 1997). Evaluation of the strengths approach thus include whether goal attainment is continuously defined and redefined from the clients perspective (Early & GlenMaye, 2000). Jane’s goals were to reduce anxiety, perform household activities effectively and efficiently, and improve communication with husband; these are the components I used as my evaluation indicators. I carried out follow-ups with Jane for evaluation purposes and she reported 75% improvement in her health status during the 6 monthly follow-up. She also reported to me that she was able to carry out her household activities effectively according to the work schedule she had set and with less anxiety as she relieved her stress through regular meditation and prayer.
During the follow-up I inquired on how she managed to cope during times of distress where she reported seeking help from her parents and the church. A year later I evaluated Jane’s progress through a follow-up exercise and she reported drastic improvement of her relationship with her husband as she found him approachable and was able to communicate her distress to in times of need. She also reported that her in-laws were not reciprocal in their relationships with her though they criticized her less about her work. Furthermore, she felt more confident of coping with her marital life in the future basing on the changing scenario at home.
The empirical evidence underscores the strengths based perspective which tailors appropriate therapeutic interventions for persons with mental illness can used to evaluate my achievements as a mental health professor in Jane’s case as she demonstrates my capability in assessing her strengths and helping her develop resilience, evaluate the treatment employed and empower her to deal with future adversities. It emphasizes that though Jane is experiencing mental illness due to divorce I can help her match her inmate strengths and opportunities to cope with her situation and achieve desired interventions and expected outcomes. Mental health professionals can therefore help clients gain their inmate strengths, increase resilience, and improve their wellbeing through use of the client’s strengths and opportunities.
References
Anthony & Cohler, (1987). Reaching Today’s Youth; Beyond Individual Resilience.
Benard, B. (1997). Tapping resilience through the arts; Art works prevention programs for youth
and communities.
Early & GlenMaye, (2000). Strengths perspective in Mental Health.
Eva Jané-Llopis, (2006). "Mental health promotion and mental disorder prevention in Europe,”
Journal of Public Mental Health, 5 (1), pp.5 – 7
North Suffolk Mental Health Association (2011). Independence through Intervention. Retrieved
on December 13, 2011 from http://northsuffolk.org/
Peter C., Liam P., and Yolanda Z., (2011). "What's good for mental health?", Advances in
Mental Health and Intellectual Disabilities, 5 (2), pp.41 – 42
Poulin, J. (2010). Strength based generalist practice, 3rd ed. Belmont, CA: Wadsworth Cengage
Learning.
Saleebey, D. (2009). The strengths perspective in social work practice, 5th Ed. Boston: Allyn
& Bacon.
