My Client

                                      Assignment #2: My Client

The client I have chosen for this evaluation study, Mary, is a 72 year-old single white female.  She suffers from both mental and physical health problems.  Her mental problems include psychosis, an anxiety disorder, and depression.  As mentioned in my prior blog post, she also is a hoarder and this problem appears to have had something to do with her having been legally declared an “Incompetent Person” or in the terminology of my agency, an “IP.”  As I also earlier mentioned, the staff at her nursing home has found a way to get this problem under control but only through constant monitoring and involvement.  A chronic pain sufferer, Mary has been diagnosed with a set of physical disorders that include but are not limited to the following: fibromyalgia, pulmonary embolism, spinal stenosis, and cataracts.  She became an IP in 2009 and became a resident of the nursing home where she currently lives despite the fact that, at least in the view of my agency, it is an inappropriately restrictive setting for her due to how relatively mentally and physically high-functioning she is.  She is eligible to transfer to an adult home and loathes, or at least claims to loathe, living in a nursing home, but there are obstacles toward her achieving this goal that, for reasons I will imminently discuss, are partly self-created.

Mary is considered a particularly difficult resident by her nursing home’s staff.  She is frequently rude and even abusive to the nursing staff on her floor and refuses to leave her room, even for out-of-home medical appointments and staff-recommended in-house physical therapy.  She refuses to do anything involving socializing or even doing activities with her fellow residents because she feels that she is nothing “like” them.  By law, someone from the home, an activities coordinator whom I’ll call Fawn, comes into her room once a day to socialize with her and Mary accepts this service.  (Assume all names I use in the future of individuals and agencies are pseudonyms.)  These sessions usually go one for a duration of about 45 minutes.  She also sometimes refuses medication – though not to my knowledge psychiatric medication – and constantly demands that the staff give her “prn” pain medication that is prescribed to be taken only when in a level of pain that they do not believe she is in.  (They do, however, give it to her.)

Though there are few adult homes willing to take geriatrics with Medicaid, and even fewer with spaces open, there was one that was at least willing to wait-list her.  The home required she attend an interview that her social worker, Ms. C., at the nursing home made.  However, she refused to leave the home on the day of the interview.  Ms. C rescheduled three times, and each time Mary refused to go on the day of the interview until eventually the home was no longer interested in meeting with her.  (She would later claim to me that she had stomach problems that prevented her from attending these appointments).  Her situation is further complicated by her Latino boyfriend of twenty years, Fernando, whom she sometimes refers to as her husband.  She often changes her mind about whether she would like to move to an adult home or Fernando’s home, though my agency would only allow her to move to the former.  (Plus, she has not wanted to move in with Fernando since the beginning of our relationship anyway.)  According to Ms. C, he has financially “sucked her dry.”  When I told my field instructor at my agency about this, she told me that that “we” were “still investigating” whether this was the case and at this point it was only alleged.  Based on this as well as other discussions I have had about him with Ms. C and Mary, I have inferred that he is most likely a problematic figure in Mary’s life with whom she has a codependent relationship.

Using the assigned reading from our textbook, Evaluating Practice: Guidelines for the Accountable Professional, after a period of conceptualization I developed a theory about what I believe is at least largely the source of Mary’s maladaptive pattern of behavior.  It is my belief that Mary is making a bad situation worse because she simply cannot face and accept that fact that she is legally an IP with a guardian who has very little power over her life.  What she ideally needs to do, to make the most of a terrible situation, is to accept and acknowledge what she cannot control and what she can, and then proceed to fully exploit what little power she does have, such as the power to potentially get transferred into a less restrictive adult home where she would be living amongst her peers in a place designed for people with her set of problems and level of functioning if she wishes.  (My field instructor, however, believes she really does not want to go into an adult home, and though I partly agree with her, this is an issue too complex for this posting.)  I do not, however, believe she is both fully willing and able to confront such a bitter truth about her extremely limited power in the limited amount of time I will have to work with her.  I do believe though that I can help her become less maladaptive by helping her somewhat with her anxiety with a therapy I will discuss in my next posting.

One major source of her anxiety is what I have come to think of as the “Agency X/money/possessions issue.”  From here on out, I will call it the X/money issue for brevity’s sake.  It is her overt expressions of anxiety to me regarding this issue (which are often intertwined with anger),that I have chosen to target and measure.  I will later discuss why I have limited my measuring of the behavior to her covert expression of it with me.  First let me explain what the X/money issue is.

This year my agency took over guardianship from agency X.  Mary has displayed to me much anxiety and anger regarding the subject of money, her possessions, and Agency X.  She is currently nearly 100% broke.  The nursing home has no money in her account and my agency, according to its “finance person” assigned to her, has only “a little money” in the account we have for her.  She, however, correctly or incorrectly, believes that she possesses “thousands of dollars,” which our agency should have for her.  There is a chance, it is unclear at this point, that our agency might acquire more money for her, but that this point it seems unlikely.  She also, either rightly or wrongly, believes that X stole a lot of her money and that they are trying to sue her for $15,000 for back-rent for an apartment she claims to have never lived in.  She also believes that they have a storage locker of all her possessions from the apartment she lived in before she became an IP that they are withholding from her.  This issue seems to obsess her and clearly causes her much anxiety and anger.

 Ultimately, for the purpose of this project, I have no concern as to what is true and what is not regarding the X/money issue.  As her caseworker, I have limited power to fully find out the truth regarding it.  Even if I did, I am almost positive I would not have any power to help fix the situation if there was anything that needed fixing.  I do however, believe that all of her anxiety and anger regarding this issue is only serving to inflame her mental distress and worsen her behavior with others at the home.  I do not know if thinking about the X/money issue makes her agitated or if agitation provokes her to think about the X/money issue but clearly there is a causal relationship between the two things. (Bloom, Fischer, Orme, 2006).  I believe that, ultimately, if she could “let go” of this issue, her mental state and behavior would probably improve significantly, perhaps even greatly.    

            Though she talks about the issue constantly with me and frequently with Fawn and could theoretically keep a diary and do some sort of self-anchoring scale on her covert distress regarding the issue, there is a very specific reason that I chose to only measure her anxiety about the issue in her conversations with me.  Fawn is someone I do not feel is someone who would be both willing and able to cooperate in such a study.  Staff is rarely helpful except in the most marginal way in the homes I go to for my internship and she was someone who, though polite, seemed uninterested in even engaging in a detailed conversation about the subject of Mary.  Generally the nature of my internship is one where it would be very difficult and unreliable to rely on anyone but myself for any type evaluation study.  Mary also would never both agree to cooperate and then actually cooperate with doing anything when I’m not there to aid the study.  She has agreed to the evaluation study, but barely.  She seems to feel neutrally about being a subject for such a study. The problem is she does not see herself as being in any way the source of her problems.  Her problems, in her estimation, are every one else’s fault.  She also does not like the idea, though she has agreed, to do anything that might involve having to work in any way to help herself.  She refuses to take any responsibility for her own problems.  Therefore, it makes sense perhaps that she also does not like the idea of doing anything that inherently takes the responsibility for lessening them into her own hands.     

            My fieldwork supervisor thinks Mary is an excellent subject for this evaluation study.  She, as I do, believes that though she will also be a difficult subject, she is the only really viable one for the study because my caseload, like everyone’s at the agency, is full of people who are generally so low-functioning.  She did not however, think I should have asked her for her consent to be a part of an evaluation study.  She felt that she herself would have refused if asked.  This, of course, was before she was informed that such consent and disclosure was mandatory.   

            In our first meeting, which took place before the commencement of this course, we spoke for a long time, perhaps 45 minutes to an hour.  Perhaps half of that time was spent talking about the X/money issue.  Interestingly, though she spent much of the remainder of the time talking about other distressing topics such as her history of as a hoarder, a foster care youth and the daughter of an alcoholic mother, this would turn out to be of all our meetings, the one where she seemed warmest toward me and the one where she seemed the least agitated.  Soon after that, once again, before this course started, after that in which she made a request for clothing which was quite long and elaborate that I presumed was in response to my in-meeting asking of her if she needed any clothing.  (This was before I was unaware of her dire financial situation).  As I recall, she either made no mention of the X/money issue or a brief one, but I do remember that she seemed relatively non-agitated.     We did have another phone call, one that occurred between our last two meetings, in which I called her to update her about the fact that I still had not found out anything regarding her financial situation.  She did not spend any time talking about the X/money issue in response except to say that she was getting “very angry.”  It appeared that this anger was directed less at me than at my agency as a whole.

            At our next two meetings, both which lasted probably 20 minutes or so, 90% of the conversation was focused on the X/money issue.  I at first attempted to count the number of times she spoke of the issue and their duration, but I found this distracting in a manner that was counterproductive to our work together.  I felt it was more important to truly focus of making her feel that I was truly listening to her in an empathetic manner and that I genuinely was empathizing with and listening to her.  

            It was after our last meeting I could arrange before this posting that I found out that I could have asked her to do a self-anchoring scale.  However, even had I known this information earlier it would not have been a good idea to give her one.  She is in a very fragile state and having to directly confront how much distress she is under and explore it in detail at this stage, at least in the context our relationship, would likely just cause her further distress and likely feelings of resentment and even outright anger toward me. 

I was able to construct, however, a retroactive self-anchoring scale of my own design in relationship with these meetings and phone calls.  The formation of the scale is largely based on my observation that the more anxious she seems about the X/money issue, the more anger is likely to be interlaced with her anxiety.   Therefore, I created the following 5-point anchoring scale: 1 – displaying no anxiety or anger, 2 – displaying anxiety but not anger, 3 – displaying anxiety with anger, but nothing beyond a harsh tone of voice, 4 – displaying anxiety with anger extending to a raised voice, even cursing, and 5 – agitation displaying itself in the form of a panic attack or physical aggression.   In our first meeting, I would her agitation was at a 2 regarding the target issue.  During our first phone call, it was at a 1.  At our second and third meeting it was at a 2.  During our second phone call, it was at a 3.     

In my next post, I will write about my intervention plans for this behavior.

Reference List   

 

Bloom, M., Fischer, J, Orme, J.G. (2006.)  Evaluation Practice: Guidelines For The

Accountable Professional.  Boston: Pearson.  

My Agency

Assignment #1: My Agency

My field placement this year is at an agency, one I’ll refer to as A.B.C, which is what is called a “guardianship agency.”  It is a nonprofit organization whose clients are normally people who have been declared as “incompetent” by the courts, meaning essentially they are deemed as incapable of caring for themselves and therefore require another to be their guardian.  They do not, however, have any relatives, friends, significant others or spouses who are willing, able and considered fit by the courts to be their guardians, so the responsibility of their guardianship is assigned to an agency such as A.B.C., which is paid by the government for fulfilling this role.  There are generally two types of guardianship services an agency such as A.B.C. can provide for their wards: personal needs guardianship and financial guardianship, which is also called property guardianship.  Usually our agency provides our clients with both types of guardianship, normally by court order.  Sometimes, there are atypical cases where we are a ward’s guardian because he/she felt he/she needed one or both of guardianship and applied to the courts for the service.  For example, we have a client who became an agency ward because, at the urging of her nursing home’s staff, she applied for financial guardianship so that she could get her Medicaid reinstated so her nursing home could get paid for her care/housing. 

Most of our clients are geriatrics who reside in nursing homes.  Almost all of them have dementia and 99% of this group has severe dementia.  My job is as a client caseworker.  I visit my clients periodically to determine whether their needs are being met and that they are not being abused or neglected in any way.  My average client is an African-American nursing-home resident with diabetes, at least one other serious health problem – frequently vascular problems or Parkinson’s – depression, dementia and a “times-two” orientation, which means that the dementia has progressed far enough that he/she no longer has any sense of time but has a sense of place and person.  Many of my clients suffer from psychosis often in addition to dementia.    

 I have one client who would be appropriate as a subject for this course.  I will refer to her by the pseudonym Mary.  Mary is an atypical ward.  She is 72 years old and does not suffer from dementia.  She has health problems but they are less severe than those of my typical ward.  She does, however, suffer from psychological problems that include psychosis, depression and hoarding. (It is relevant to mention here that her facility’s staff has worked with her in a matter that has gotten her hoarding under control.)  She is currently residing at a nursing home, yet my agency feels the home provides a more restrictive setting than necessary given her particular set of mental and physical limitations.

I will be able to see her seven or eight times during the semester.  I am almost sure will be unable to see her any more.  I am, however, attempting to change Mary’s behavior, thinking and feeling in some way.  There is a problem that I have identified that I feel I might be able to effect some change that could serve as a primary focus for my work in this course.  The nature of this problem I will discuss in my next blog posting.