Family-Based Behavioral Treatment.
Social Work Reseach Paper 1.Search the clinical literature specific to family intervention that relates directly to the DSM diagnosis and the psychosocial case formulation in the case above. (3 pages). a. Select and review at least five major studies from this literature relating to family-based interventions. b. Identifies if these studies are considered current “best practices” and if they are based on the use of any evidence-based treatments (EBT’s). c. Make clear who the targets of the intervention are, i.e., specific to caretakers, parent-child, family groups, or conjoint family sessions involving the family system. d. Make clear how the research you cite relates to the psychiatric diagnosis, the psychosocial aspects of the case, or both the diagnosis and the psychosocial data. 2. Informed by the literature you have reviewed, propose a beginning treatment plan for the family. Respond to all of the elements below in your planning. (3-4 pages). a. State your outcome goals, i.e., what you expect the family will accomplish b. What evidence-based treatment might you use? c. Give your clinical reasons for your choice of intervention d. Identify who in the family system will receive the intervention and why e. Identify any collateral systems in the environment involved in the treatment and their role f. Identify potential obstacles to implementation and strategies to meet these obstacles g. Identify the practice theory or theories that underlie your intervention plan 3. Using critical thinking, assess the “fit” between the evidence-based treatments you are proposing with the particular psychosocial aspects of the case. (2 pages) a. Consider ethnicity, race, religion, cultural beliefs, life course events, family socioeconomics, forces of oppression and discrimination, and human rights. b. What individual aspects of the family and the family’s history must be considered while implementing any evidence-based treatment you have chosen? c. How might particular psychosocial aspects of the case mediate the treatment or need to be taken into account? Common Assignment CPII CYF 2017 An Urban Family with School Aged Children Identifying Information Joe Mann is a 39 year-old African American with a high school education who works in construction. Throughout his marriage, he physically abused his wife. He drinks alcohol excessively and has a history of binging. This September, at the beginning of the school year (3 months ago), Mrs. Mann demanded that he leave. He moved out of the home and has had no contact with anyone in his family since then. Nancy Mann is a 38 year-old Hispanic woman with an Associate Degree in business. She works part-time as an office manager, though she would prefer to be a full-time mother for her three children, Trig (10 yrs.), William (8 yrs.), and Sally (5 yrs.). Having a close-knit family is very important to her. Asking her husband to leave filled her with shame and guilt, especially as a practicing Catholic and as culturally identified with Hispanic values that prescribed her role as wife and loyalty to family. Trig, the oldest of his sibling group, attends 5th grade in an urban public school close to home. Trig is failing math but is otherwise an average student. He plays basketball and is good at sports. Early in the school year, he was suspended for starting fights. He acts disobediently at home and demeans his mother by cursing and calling her names. Trig is physically aggressive with his younger brother and is difficult to calm down. William, age 8, attends 3rd grade. He is a high academic achiever, plays baseball, and is a good athlete. William is teased in school for being smart, causing him to shut down and withdraw. He spends lunch doing chores for a teacher he likes rather than play with school mates. At home, he and Trig argue and physically fight. Sally, age 5, is in kindergarten. Sally has stomach aches in the morning and sometimes throws up. She has a hard time separating from her mother and staying in kindergarten for the entire day. Mrs. Mann has had to leave work multiple times to pick Sally up early from kindergarten. She and her mother sleep in the same bed. Presenting Problems Mrs. Mann called the community behavioral health clinic after her 10 year-old son, Trig, was suspended from school for fighting. Mrs. Mann says she is “frustrated and worried”… “I cannot get Trig to behave or listen to me. I tell him to do his homework, and then he yells at me and looks fierce, like a mad bull.” Mrs. Mann reports that Trig “has no respect for me or anyone else. He bullies his younger brother all the time and pushes him around, sometimes making him fall.” 2 Mrs. Mann says, “All of this screaming and pushing scares my daughter Sally. She is five and won’t let go of me, not even when I go to the bathroom. I know she is afraid, but I don’t know what to do…with her or with Trig.” At intake, Mrs. Mann also expressed particular worry about Trig: “I am so afraid, I don’t know if Trig will ever be a good boy…he will get into big trouble with the police and end up in jail. I can’t worry like this, I am unable to sleep, I can’t eat, and I get so tired during the day that I almost can’t work.” When asked what would be helpful, Mrs. Mann answered, “Well, I need help to manage Trig at home, but I’m also concerned because he is not doing his homework and doesn’t want to go to school. I think maybe he needs some extra help. Can you help me get the school to help him?” When asked about her younger son, William and her daughter Sally, Mrs. Mann said, “Sally is only 5 years old, so I think she will be OK, she just needs to grow up a little, but I am concerned about William who no longer seems to have any friends at school. He seems so quiet all the time.” History of the Presenting Problems According to Mrs. Mann, Trig’s behavior changed noticeably when he entered the 5th grade three months ago. This was when Mrs. Mann asked her husband, Joe, to leave because he was drinking too much and was physically abusing her. Her husband drank before and after they were married eleven years ago. Mr. Mann became increasingly hostile toward his wife, however, each time she became pregnant, and all of the children were exposed to loud, angry arguments between them. Neither parent spoke to the children about his leaving. Mrs. Mann’s parents moved in two months ago to help take care of the grandchildren, and Mrs. Mann feels judged by her parents especially because the boys fight and she cannot control them. Trig has struggled with math since the third grade but was never referred for evaluation. He has a long history of forgetting to bring his homework from school, being very active physically and having difficulty concentrating on school work for any length of time. Trig, being the oldest, witnessed more fighting between his parents than his brother or sister. William was very close with his father and has become quiet and immersed in his school work since his father left and his grandparents moved in. Sally sucks her thumb and follows her mother through the apartment. Many nights, Mrs. Mann takes Sally into bed with her. 3 Community Context Mrs. Mann, her mother and father, and her three children live in a poor community populated mostly by immigrants from South America. The neighborhood public schools are sub-standard and labeled “persistently low achieving” based upon standard test scores. There is one school social worker for kindergarten through 12th grade, and she is not bilingual. The Behavioral Health Center is part of a large urban hospital where the staff are mostly White. The local community center houses a preschool and sponsors after school sports activities. The hospital created a behavioral health clinic because the community perceives mental disorders as highly stigmatizing and views mental health workers as ignorant of Hispanic cultural and spiritual beliefs. Although Mrs. Mann has some higher education, she, like others in the community, does not think about sadness and fatigue as depression but as physical illness, and if a medical professional is consulted at all, worries are physical in nature and are presented to the primary care doctor at the clinic rather than a social worker or psychologist. The language of Western psychiatry is foreign to this community and does not match the cultural ways that people experience stress and problems in their lives. Family Context Because Mrs. Mann only works part-time, she does not have health insurance, and Mr. Mann’s union insurance limits choice of in-network providers; those who accept this insurance are less experienced than most. Mrs. Mann and her parents are Catholics and she raises her children in the Catholic faith. Mrs. Mann is first generation and more acculturated to American norms than her parents who identify with their traditional culture. As a result, there is a generational “disconnect” and Mrs. Mann has been criticized often by her father in the choices that she has made in her life. Bringing her child to the behavioral health clinic invites further criticism from both her parents who think what goes on in the family is no one else’s business. Clinical Formulation Trig has symptoms of undiagnosed Attention Deficit Disorder with Hyperactivity (ADHD) that may explain his high level of physical activity, forgetfulness, and inability to concentrate. He has also witnessed his parents fighting from an early age which may interfere with his ability to regulate his emotions and behaviors. Trig may be confused and frightened by his experiences within the family; he witnessed events that were beyond his understanding as a young child, and he was not told about why his father left. These experiences may heighten anxiety and make him hyper-vigilant and reactive to changes in his world, a world that he does not control. Trig’s recent fighting with others in school and attacks on his brother may be explained as learned social behavior from watching his father interact with his mother as well as a 4 discharge of unregulated traumatic stress from witnessing domestic conflict. Trig may focus his attention on his brother at home because William is the family “star” and the favorite of Dad. As a result, Trig may think and feel that he is not “good enough,” unacceptable and unlovable. He attracts notice through his negative social behaviors in a misplaced attempt to gain connection and support from others. Trig’s difficulty with doing math and refusing to do homework may stem from an undiagnosed learning disability that requires cognitive testing to confirm. His fighting, therefore, may be a combination of multiple psychosocial factors that include social learning from his father’s behavior with his mother, undiagnosed ADHD and LD, reactivity to changes in the family system, witnessing domestic violence, jealousy of his brother and a negative self-concept, poor regulation of aggressive drives and impulses, as well as a possible re-enactment of physical violence that he witnessed between his father and his mother. William may be developing an internalized reaction to family events that could develop into a depression as he becomes more isolative. He is also at some psychological risk due to the teasing and bullying that he experiences, contributing to development of an internalizing disorder such as depression. Sally’s clinging behavior and thumb-sucking is consistent with insecure attachment. Her dependency on her protective figure (mother) is both comforting to her and also a response to mother’s current unmet need for comfort and soothing. Her somatic symptoms of stomach aches and vomiting before school may stem from her anxiety about separation from her mother. Her difficulty separating may also be a response to trauma as a witness to domestic violence. Mrs. Mann’s recent change in sleeping and eating may signal the beginning of depression making her less available to manage her children. Although her parents provide caretaking during the day, Mrs. Mann experiences their scrutiny and their negative judgments which may add to her emerging depressive state. Mrs. Mann appears to minimize the effects of domestic violence on her youngest child and does not recognize how family circumstances and perhaps her own experiences of victimization add to the insecure attachment between her and her daughter. The history of domestic violence, the sudden and unexplained loss of the father figure, the shift in the family system created by the grandparents moving in, the sibling dynamic between the boys, and the victimization of the mother create risk of poor developmental outcomes for all the children. The attachment relationship between mother and Sally, in particular, is misaligning and at risk of becoming increasingly problematic. The dynamic between mother and her parents is a stress to the new family system, and the primary attachment figure for the children is at risk of depression. 5 DSM-V Diagnoses No one in the Mann family has received a diagnosis by an appropriate mental health professional. Diagnoses that one might consider (excluding Z code diagnoses) are below, but more in-depth interviewing is required to make a DSM-V diagnosis of anyone in the family. Mr. Mann: depressive disorder; substance related and addictive disorder Mrs. Mann: depressive disorder Trig Mann: conduct disorder; ADHD; acute stress disorder; learning disorder; adjustment disorder William Mann: acute stress disorder; adjustment disorder Sally Mann: somatic symptom disorder; separation disorder; acute stress disorder