Assignment 4- Overview of work with client

PREENGAGEMENT:

           In attempt to encourage Bill to be more involved with his house mates and be more socially involved at home, I instructed Bill last week to come up with an activity that the whole group could be involved in, and further instructed him that it should be in addition to baking that day.  The reason I chose this was because Bill has been withdrawing himself from all group activities in his home, and furthermore spending that time secluded in his room.  In assessing what method I could apply to him in order to get him to be more involved in group activities, I thought that by putting him in charge of the activity, not only might he be excited about it, he would have a very difficult time finding a reason not to participate.  

          I explained to Bill that I wanted to do something different when I visit him this week, and because he was showing such emotional growth over the last few weeks, I wanted him to pick the event that we would all do together.  To my surprise, he seemed pleased and excited that I have put him in charge of this task, throwing ideas out right from the start.  I told him to think about it a little longer and let me know when I see him on Thursday. 

          Upon my arrival this week, he was slightly agitated from his car ride home because he thought that his house mates were talking about him during the ride home.  During this visit I will attempt to follow the ABC cognitive behavioral model for identifying distorted thoughts and see if he will realize where his misconceptions are when interpreting stimuli.

NARRATIVE:

Bill: I know that J and P were talking about me on the ride home. And Mary (the house manager) didn’t even say hello to me when I walked in.

SW: What makes you think that they were talking about you on the ride home?

Bill: I just know they were.

SW: Okay, how about we ask them together if they were talking about you? I will go with you and help you if you get stuck.

Bill: Okay.

WE WENT TOGETHER TO ASK THOSE THAT BILL THOUGHT WERE CONSPIRING AGAINST HIM WHETHER THEY HAD IN FACT BEEN TALKING ABOUT HIM IN THE CAR.  BOTH RESPONDED SEPARATELY THAT THEY WERE NOT TALKING ABOUT HIM IN THE VAN.

Bill: I don’t believe them.

SW: Have they ever lied to you before?

Bill: Well, P has never lied to me, but J has!

SW: So if P has never lied to you, why do you think he is lying now? Did he say something or do something that makes you think he is a liar?

Bill: No….

SW: So, let’s review something for a second.  You said you heard them whispering in the van.  Correct?

Bill: Yes.

SW: So from that you thought that they were talking about you, correct?

Bill: Yes.

SW: And that made you upset?

Bill: Yes, I know they were, you are just trying to stick up for them.

SW: First, I am not sticking up for anyone nor am I on anyone’s side.  I don’t take sides. Can you think of some other things they could have been talking about that they needed to whisper?

Bill: No.

SW: They both just told you that they were talking about someone else, and it was not you.  Do you think it is possible that you misunderstood what they were doing and got upset for no reason?

Bill: I guess so, I don’t know. It doesn’t matter anymore, let’s do our project.

SW: Are you putting words in their mouths because that's what you think they said?

Bill: Well...I don't think so, maybe.

SW: Remember how sometimes you think you know what everyone is saying?  And we discussed before how you have this habit, even if they tell you otherwise?

Bill: Yes, I remember.  But I am very sensitive...

SW: It's okay to be sensitive.  But please try and remember that you have this habit, and just because you think they feel that way doesn't mean they do.  We just asked both of them if they like you, or if they were talking about you, and they both said they like you very much and were not talking about you.  Do you think that everyone is lying to you?
Bill: No.
SW: Then i think we should believe them this time.  What do you think?
Bill: Okay, can we make the birthday cards now? I really want to make them.  I don't want to talk about this anymore.
SW: Yes, of course.

IMPRESSIONS:

Bill was able to refocus his attention to making a birthday card for one of the residents in the nursing home we visited a few days prior.  He was able to admit to me that there was a possibility he was wrong, but he so strongly believed that he wasn't.  There really is no way for me to prove whether his roommates were talking about him, or how distorted his reactions actually were based on the event, because I was not there.   Despite these feelings, we were able to complete the activity he put together for the group.  The activity turned out to be very successful.  Bill was the one who invited everyone to join us, with my prompting, and was able to enjoy the rest of the time we spent together.  Everyone shared and talked nicely as we played.

At the end of our time together, I complimented him on a job well done in regards to planning an activity for the house.  In addition, I also praised him for his efforts in thinking positive and turning the situation around so that he could enjoy the activity instead of probing at the fact that he thought he was the target of the van’s conversation.  This supported my theory on how much he has grown emotionally since the beginning of our time together.

PLANS FOR THE FUTURE:

I plan on asking Bill to chose and activity for the house because I believe this will make it harder for him to stay in his room and not participate during the activity.  If he chooses it, it most likely is something that he wants to do. 

I also plan on continuing my praise of his noticed efforts to turn around his mood, as I think this will positively reinforce his behavior.  It seems as though he is not able to fully understand my attempt to point out a distorted thought, but the fact that he acknowledges the possibility that there are other sides to the story is a big accomplishment on his part.  I will not give up the attempts to show him other options despite his lack of understanding, as he is making great progress regardless.

Assignment 3

There is one specific intervention that I am continuously exploring with Bill throughout our time together which is known as cognitive behavioral therapy.  The goal throughout the cognitive-behavioral therapeutic process is to help Bill become more aware of his thought distortions which are directly related to some of his psychological distress.  One objective is to allocate where and what are the causes of the behaviors present and address triggers or patterns as a result of the distorted thoughts.  The client and therapist are encouraged to work together in order to compare these thoughts to those of reality and societal norms, functions and expectations (Mulhauser, An Introduction to Cognitive Therapy and Approach).  

Through research and readings, I have come to the conclusion that my attempt to change Bill's behavior will be unsuccessful unless I target the source of his distorted thoughts, as they are directly and consciously preventing him from exploring his social interactive possibilities. For example, during Bill's most recent hospitalization into a psychiatric ward, I along with many other staff members strongly encouraged Bill to attend group therapy sessions and activities.  We were aware that this would be unlikely, but are also aware that our encouragement is mandatory and crucial for his social explorations.  To our delight, Bill accepted our advice and attended a session where he met a nice woman who he fell in love with.  Bear in mind, that this behavior is one of his many frequent distorted thoughts, where he falls in love and later gets hurt by someone who is unavailable, but he fails to recognize this and believes that these women have feelings for him as well.  Soon after, the woman explained that she was married and stormed away by one of his brave propositions to express his want to become more intimate with her.  Bill immediately retracted and apologized but not before becoming emotionally and physically upset where it resulted in him returning to his room and refusing to return to any additional sessions at the treatment center.  When I asked him about this instance he explained that he had decided it would be better for him to stay in his room for ever so that he could prevent himself from getting hurt in the future.  


I have been exploring with the framework of cognitive therapy as it directly encourages the therapist to address the stimulus, thought, and emotion in the client.  This is also known as Ellis' ABC model where A is the event, B is the thought or belief about the event that occurred, and C is the feelings or emotions that result in the interpretation of the event and following belief (Mulhauser, 2010, An Introduction to Cognitive Therapy and Approach).  When applying this model to a person with a disability such as schizophrenia, and interpreting the client's distorted thoughts from the ABC perspective, delusions are B’s. "That is, they represent the erroneous belief about the antecedent event, and they may or may not be followed by an inappropriate emotional or behavioral consequence" (Malouf, 1996, Review of Cognitive Behavioral Therapy).   During my sessions with Bill, I have sat with him along with a piece of paper in front of us, where we attempt to identify the event that triggered his response.  I then ask Bill to explain as best as he can how that made him feel and how he responded.  We then return back to the segment where he is interpreting what happened and I put forth some scenarios and other possibilities that can contribute or be an underlying factor in the event.  Typically at this point, we discuss reality and what really happened, as many of his distorted thoughts are a result of his past experience and mental illness.  We explore additional options as to why this person could have reacted in that manner, which usually broadens his perspective on the event and elicits a different response as a result of having better understood the situation.  An example of this is when Bill and I are volunteering at a local nursing home where we visit with the residents and hand out books and magazines for entertainment.  Bill is a very friendly person who is always reaching out for someone to shake his hand or offer some physical comfort through a pat on the back, etc.  In the first months of our volunteer work, Bill would reach out his hand in an attempt to shake the other person's hand.  Some kindly accept as many are uncomfortable and reject this gesture.  Bill automatically reacts and withdraws himself saying that they hurt his feelings because they do not like him and do not want to shake his hand.  This leads to him refusing to continue and express his will to terminate future visits at this nursing home.  At this point I intervene asking him to share his feelings with me.  After he has vented I propose to revisit the thought as to why they did not shake his hand.  We explore possibilities such that maybe the person is religious and does not touch another person other than her spouse (since it is a Jewish nursing home), or the person is simply shy and uncomfortable in touching another person.  Some simply do not hear him when he greets them and are unaware that he even attempted to shake their hand.  After this, most of the time Bill can calm down knowing it was not a personal attack against him, but rather a private reason that may or may not involve him.  


There is significant evidence as to the positive effects this treatment can have upon a person who is capable of understanding and who possesses the will to accept treatment and ultimately a change. "Psychological treatment appears an effective procedure for reducing the impact of stressful psychotic experiences, improving patients’ social functioning and reducing family stress, in conjunction with psychopharmacological treatment" (Fernandez, O., Giraldez, S., (1999) Integrated Psychological Treatment in Schizophrenic Patients). The Brenner group conducted a study that tested the effect of integrated psychological theory (IPT), which is considered an offset of cognitive behavioral therapy, and reviewed the data to determine whether it impacted a patient's cognitive capacity and social perception.  The data showed that by adding cognitive and social therapy in addition to medication, known as pharmacotherapy, there are significant results in terms of improvement in cognitive abilities and growth as well as the ability to recognize and expand their cognitive patterns to avoid distorted thoughts.  "By connecting specific cognitive and social training subprograms to the cognitive and social deficits manifested by persons with schizophrenia, Brenner's group has provided hypothesis driven methods for the field and has brought new enthusiasm to practitioners and researchers alike who know that pharmacotherapy alone is inadequate to meet the comprehensive needs of individuals with schizophrenia"(Liberman and Green, 1992, Whither cognitive behavioral therapy for schizophrenia). 

Fernandez, O., Giraldez, S., (1999) Integrated Psychological Treatment in Schizophrenic Patients. Psychology in Spain. Vol. 3. No 1, 25-35

Liberman, R., Green, M. (1992). Whither Cognitive-Behavioral Therapy for Schizophrenia. VOL 18, NO. 1


Malouf, J. (1996). Review of "Cognitive-behavioral therapy for bipolar disorder" and" Cognitive therapy for delusions, voices, and paranoia". Psychotherapy: Theory, Research, Practice, Training, 33(4), 636-637. 


Mulhauser, G. (2010). An introduction to cognitive therapy and cognitive behavioral approaches. http://counsellingresource.com/types/cognitive-therapy/index.htmll. Accessed March 3, 2011.

Assignment 2

After much deliberation and thought into this assignment, I have chosen to work with  Bill for the purposes of this assignment.  He is a 65 year old male who has been living in a group home setting for the last five years.  Preceding his move into one of our higher functioning group homes, he lived with his parents his whole life.  To my understanding, he has one brother who also suffers from an undiagnosed disability.  Both his parents passed away from cardiac related illnesses.  Bill suffers from bipolar disorder, paranoid schizophrenia and mild retardation.  As previously mentioned, he is very high functioning as he attends workshop daily and is capable of carrying out many household responsibilities.  There are several reasons I chose to work with Bill, the first and most important being that he has a clear understanding of what is expected of him and the goals that have been personally formatted for him.  He also wants to achieve these goals, and shows pride and satisfaction when they are accomplished.

I approached Bill explaining that I have an assignment for school that I would like for him to participate in.  I explained that I have to pick one person to closely work with and try to help them achieve a goal they ultimately would like to accomplish.  He was very flattered that I had chosen him for this assignment.  I asked him to explain to me some of the goals he is currently working on, and his answers were such; taking out the garbage, cooking or baking every week, and to try and be more understanding of others.  I am already aware of these goals, but had a different one of his goals in mind that he failed to mention.  I reminded him of his concern and desire to be more sociable at home and outside the home.  Currently, Bill only leaves his room at home when it is time to eat a meal with his peers or take medication, otherwise he remains in his room upon his arrival from workshop.  He verified that this topic is still a goal of his.  He also relayed his concern that he would be unsuccessful and was afraid of failing.  Part of my job and also by ethical standards, I need to be aware of issues and situations that will set my client up for failure.  I must tread very carefully and not push or pose anything that may cause harm to my client or myself.  For this reason, I chose to carry out this study in the privacy of his own home where he is comfortable with his peers.  I will not force him in any way to participate in the activities that I have planned, but will offer him a reminder that not only would we love for him to participate, he will be accomplishing his goal for that day.

I have been in constant contact with my field instructor and Bill's house manager regarding this process to formulate a goal for me to accomplish through this assignment.  It has been extremely difficult in constructing a feasible goal that is not only realistic but significant in his lifestyle due to the fact that Bill has been having an extremely difficult time dealing with his life due to his bipolar and schizophrenic tendencies the last few weeks.  He has been unable to concentrate or cope with stress in any environment, making his temper short and fierce.  A portion of his disability is that he has no self confidence and truly believes that he will not succeed and that no one can help him accomplish this goal.  We have discussed making his goal for the purpose of this assignment something easier, along the lines of baking, but thought that this is too simple.  As per my supervisor's and the house manager's suggestions, Bill would benefit the most from me if I could enable him to participate more in the house activities.  Even though this poses a greater challenge, if we could show him that he can accomplish even a small portion of this, he might be able to internalize that feeling and ultimately have more confidence at least in his home. This will hopefully encourage him to be more sociable in his home setting.

I have chosen to modify Bill's behavior and show him through positive reinforcement and encouragement that he can be sociable.  The definition of sociability in direct relation to Bill means that he will initiate a conversation with someone he is unfamiliar with and/or participate in a social style activity either in his own home or outside the home.  If this occurs outside his home, he must be familiar with the area and settings.  His unsociability is an overt behavior as it can be directly seen by others.  For example, the staff or anyone around him will witness that he withdraws and will avoid a social interaction.  I will observe and record his behavior both at home, once a week, and at a nursing home that we volunteer at together once a week.  I will record the amount of times he participates in a social opportunity and will further record the duration of the successful behavior.  I will also record how many times he has denied the opportunity to partake in a social activity and will the ask Bill to record how he was feeling.  There is a possibility I will be able to question him about his success or lack thereof if I am present.  I will record the results through sampling, which involves observing the target behavior during specific times.  For the purpose of observing the target behavior necessary in this assignment I chose to observe his social skills in both his home setting and the nursing home every Tuesday between 10:00 and 12:00 and then again every Thursday between the hours of 3:30 and 4:30.  There may be random checks throughout the upcoming weeks if the opportunity arises and Bill self reports on a failure or accomplishment towards his goal.  One component of recognizing the behavior is to make sure there is a clear beginning and end to the behavior so that we can properly monitor the outcome, intensity, frequency and duration.  This will also serve as a guide for Bill as to how to initiate a social interaction.

After the behavior is observed or missed, the client will be asked to rate the experience in terms of anxiety level and satisfaction.  This will be completed by both a self anchoring scale through a questionnaire, possibly an anxiety scale.  I believe that the scale will be similar to a 1-10 self anchoring scale, where 1 is the lowest amount of anxiety and 10 being the highest or most intense form of anxiety during the target behavior.  I look forward to the results!

Shapiro Assignment 1

I am currently working at J-ADD, which is short for The Jewish Association for Developmental Disabilities, located in Hackensack, NJ for my field placement this year.  So far it has been a wonderful experience that I look forward to sharing with you.  The population that I work with involve those who suffer from a developmental disability and are over the age of 18.  In our agency, we currently have nine group homes sporadically located in Bergen County.  I have been assigned to four of the homes, where I visit with the consumers on a weekly basis.

J-ADD is a small but efficient agency providing an essential service to those who need extra help.  The consumers are usually referred to us, but some are placed in our agency by their families or removed from the street when conditions are unsafe.  J-ADD provides a safe shelter, food, clothing and any other essentials that our consumers need.  The staff at J-ADD work hard to place every person in the home that best meets their needs.  Each home is distinguished by the abilities of those who live in it.  For example, some of the homes occupy people who are immobile or unable to speak, while others are extremely high functioning.  J-ADD also has several apartments for those who are able to care for themselves but need a little supervision and guidance.

The staff in the J-ADD office are highly trained and well prepared for the unexpected types of situations.  Every staff is licensed in CPR and first aid and have attended classes in abuse and neglect, medication, and overview of mental illnesses.  Most of the staff that work in the "office" have PHDs and at the very least a MSW and LSW degree.  Those who provide the direct care for the consumers do not need any special degree but do undergo training.

I  meet with a variety of consumers weekly.  In one home,  which only has 6 men residing there and is considered one of the higher functioning homes, I visit with one specific client  twice every week.  For confidentiality purposes, I will refer to this client as Bill.  I do carry out activities with all who live in that house, such as cooking and arts and crafts.  I recently made home made pizza with this home, which was a great activity to get everyone to spend time together and share what they are going through each day.  In the second home I visit, there are 5 consumers living together, 3 men and 2 women.  In this home, there is only one person who is verbal, but her needs are very complex since suffers from paranoid schizophrenia and an intellectual disability.  I meet with her once a week as well where we always do an activity such as coloring or go out shopping.  For confidentiality purposes I will refer to this person as Amy since I will be discussing her again soon.  The third house I visit is one where  4 consumers live.  All but one are non verbal making discussions extremely difficult.  For this purpose I am constantly baking and doing puzzles with them to engage them.  The one consumer who is able to speak has conversations with me very frequently.

During the initial phase of this assignment I wanted to focus on Amy, who has many identifiable behavior patterns that need attention.  Amy is a 55 year old female who has been living with her step mother for as long as she can remember.  She suffers from paranoid schizophrenia and an intellectual disability.  She is accustomed to spending her entire social security check on scratch offs and Dunkin Donuts.  Her and her mother were forced to sleep in chairs because their apartment was infested with bed bugs.  Amy was removed from her home by social services, where the placed her with our organization.  She is very resistant to being in her new group home and is constantly causing arguments because she wants to return to her home with her step mother.

Amy craves attention, and will do or say almost anything if she is being ignored.  It has come to my attention that Amy can remain calm until someone new arrives and then she likes to "put on a show".  Similar behavior occurs when she arrives at a new place, for example, when Amy comes home from her workshop, she always has a meltdown.  She will enter the house screaming and yelling, throwing her stuff and anything that is around her on the floor while cursing at whom ever is closest to her.  Despite that she actually had a decent day, has positive things to say about it later while in a calm state of mind, and stayed out of trouble, this is part of her disability.

After speaking with my supervisor, I was persuaded to stray away from my original plan to change or interfere with Amy's behavior patterns, because it would be better to focus on someone who has a goal they want to change.  I agree with this due to the fact that it is a great deal harder to make someone participate in a change that involves them self when they don't want this change.  In Amy's case, she doesn't understand what I want from her either.  After much collaboration with my supervisor and staff from another house, I have decided to focus on Bill for this assignment.

Bill is in his late fifties.  He too suffers from paranoid schizophrenia and very mild retardation.  He is physically fit and healthy otherwise, who understands what is expected of him and is willing to help others.  To briefly mention his history, he lived with his family up until approximately five or six years ago when his father passed away.  His mother had passed away when he was much younger.  I believe that both parents died from a cardiac related illness.  He has a brother who does not visit often.  He misses his parents greatly and is able to express his emotions clearly.  In relation to his disability he has constant thoughts that people around him don't like him or are not his friends.  He sometimes has trouble internalizing an idea, for example, if the staff gives him advice (that can be very useful to him) he won't be able to apply it to himself.  He can repeat back to you what they said, but does not realize this information can be useful to help him.  Bill does not like to socialize with the others from his house and can not take the initiative.  Although this is rare, Bill is sometimes able to initiate a difficult conversation with heavy prompting and guidance, or be present in a common room with others in his house.  Some of his goals included becoming more sociable, since this is an area he lacks in.  His feelings are easily hurt and his rage can easily get out of control.  He has never expressed will to harm others, but has mentioned ideas of hurting himself.

After speaking with the manager from his home and my supervisor, we all agreed that it would be most beneficial not only to me, but a great deal to him as well to focus on his desire to socialize more for this assignment.  The main factor for this decision is due to the fact that this is something he wants to accomplish, and we are not asking for an unreasonable demand.  I still need to sit with the manager a bit more to discuss what will be the best way to carry out this task, but we have thought of a few simple changes in my routine.  From now on, when I visit weekly, we will all do an activity together, rather than me spending time with him for part of my stay and then with the rest of the residents for the remaining portion of the time.  I will attempt to organize a group activity involving cooking, a discussion, and arts and crafts in order to include everyone.  In addition, when I take Bill to our weekly volunteer program, which I am the leader of, I will guide him in initiating conversation with others.  I will formulate a way to keep track of his accomplishments, such as a chart, with the help of the staff in the home during times that I am not present. In addition, I will discus with his every week how he feels about what he has accomplished, or lack thereof to make him aware of his current progress.  Any mention of progress will act as a motivator for him and will help with this process and change.  I will monitor his progress over the next three weeks and will keep you posted as to my progress in addition to periodic updates.