Someone sent their final exam to me. I can add Professor to my list of current mistaken occupations.
Mia Perry
SW 601-002
Final Exam
1. Karen is the mother in a family experiencing an array of problems. It is Karen's concern about her daughter Amy that has brought her to the agency for help. For that reason, I would prioritize intervention into Amy's problems first. According to Karen's description, it seems that Amy is quite depressed and perhaps suicidal; she has disordered eating and is a victim of childhood sexual abuse. My chosen intervention for these problems would be dialectical behavior therapy. My second priority would be to help Karen with the problems she is experiencing as a victim of domestic violence and as a mother to children suffering from significant emotional distress. I am prioritizing helping Karen over intervening in Mark's abusive behavior and drinking because we can't rely on intervention into Mark's problems to put an end to them, and maintaining Karen's ability to function regardless of Mark's behavior is essential to improving the well-being of her family. I would use group therapy to help Karen. My third priority would be Michael's behavioral and academic problems at school; those are problems likely to get worse over time if they aren't addressed promptly. Left unchecked, fighting and poor grades may have long-lasting impact on Michael's educational outcome. Even though it seems likely that Mark's negative behaviors are factors helping to create Michael's problems, I am prioritizing Michael because we can't count on Mark making changes that would trickle down into improvements for Michael. Michael's adjustment problems can be treated with a combined therapy and environmental change approach. My fourth priority would be to address Mark's abusiveness and drinking because they create a significant negative impact on the rest of the family. I would use an integrated therapy approach in helping Mark. Fifth, I would target Mark's unemployment, because it is a source of stress for the whole family, limits the family's access to resources, and may play a significant role in Mark's behavioral decline. Career counseling or getting Mark additional training in his field are the interventions I would select for Mark's employment problems. While the problems of Anne's dementia and Joey's stress are not insignificant problems and would ideally receive intervention, they are less emergent and so are not included in my top five.
2. The three interventions I chose to present are dialectical behavioral therapy for Amy, cognitive behavioral therapy and environmental change for Michael, and an integrated therapy approach for Mark.
Amy
According to her mother's narrative, Amy was a child victim of sexual abuse and is currently suffering from depression, exhibiting symptoms of anorexia, and self-harming through cutting. Eating disorders are frequently comorbid with mood disorders, especially depression (Karatzias et al., 2010). Likewise, self-harming behaviors are often associated with depression and with histories of trauma, including sexual abuse (Lang & Sharma-Patel, 2011). Dialectical behavioral therapy (DBT) has been established to be an effective treatment for eating disorders, for survivors of sexual abuse and for self-injury (Lang & Sharma-Patel, 2011). Amy's mother reports that Amy may have some suicidal ideation, and DBT has also been effective as a treatment for reducing suicidal behavior among high-risk adolescents (Sunseri, 2004). For these reasons, I feel DBT is a good choice of treatment for Amy.
In dialectical behavioral therapy, teens are taught the concepts and skills of mindfulness, emotional regulation, distress tolerance and interpersonal effectiveness (Dyl, 2008). Therapy is designed to help the adolescent learn how to deal with the negative feelings that are part of their daily lives. Given that Amy has grown up in a family troubled by everything from sexual abuse to domestic violence and alcoholism, it makes sense that she would be overwhelmed by hurt feelings and that treatment aimed at improving her ability to cope with those feelings would be helpful. In one study of 62 suicidal teens, those treated with DBT had better outcomes following two weeks of treatment than a control group assigned to traditional psychotherapy (Katz et
al, 2004). Outcome measures were scales designed to measure depression, hopelessness, and suicidal ideation.
Another study supporting the efficacy of DBT in treating adolescents is Rathus & Miller's 2002 investigation of DBT for treatment of depressed and suicidal teens. The DBT protocol in this study was designed specifically for adolescents and included 24 therapy sessions during a 12-week period for the teens, and multi-family skills-training sessions for participants' families (Rathus & Miller, 2002). Outcomes were measured using the Life Problems Inventory, Scale for Suicidal Ideation, Positive Symptom Distress Index and Global Severity Index. At post-test, the DBT treatment group had significantly improved scores by all measures. A potential limitation of this study is that participants were not ruled out of the DBT group because they were
taking medication, and so 21% of subjects were concurrently receiving psychopharmaceutical treatment. However, for teens as distressed as Amy appears to be, it wouldn'tt be unusual to treat with both medication and therapy, so the results of Rathus and Miller's research are still worth consideringg, and if an initial trial of dialectical behavioral therapy did not seem effective in alleviating Amy's high level of distress, treatment with medication in addition to DBT would be a logical next step.
Michael
According to Karen, Michael has recently begun to do poorly in school and he has been getting into fights there. He is not compliant at home and is easily angered. Due to the recent onset of these problems and the fact that they may be a response to Mark's increased drinking, anger, and abusive behavior, I would regard Michael's problems as an adjustment disorder. An adjustment disorder arises out of emotional distress when an individual is faced with adapting to a significant life change or stressful life event (Sarkar & Kruger, 2007). Environmental factors, such as conditions in the home, are recognized as significant factors in causing adjustment disorder and removing or reducing the impact of those factors where possible is suggested as the first line of treatment (Casey, 2009). For Michael, the stressful life event or negative environmental condition may be his father's return to drinking and abusive behavior. After removing or reducing the stressor causing an adjustment disorder (when possible) the treatment of choice for adjustment disorder is psychotherapy (Casey, 2009), and I would therefore treat Michael with a combined approach of cognitive behavioral therapy (CBT) and environmental change. I would work toward environmental changes through extracurricular involvement by getting Michael involved in programs and activities that would be less stressful for him than his home environment and where he would encounter adults who would both encourage his self-control and demonstrate positive regard for him. Examples of activities that might meet these criteria would be team sports, martial arts, school clubs, Junior Achievement, Big Brothers, 4-H, etc., according to their availability in the family's area and Michael's preferences.
Research has demonstrated that participation in structured activities outside of school is associated with higher functioning and greater well-being for young people (Kort-Butler & Hagewen, 2011). Self-esteem, pro-social behavior and academic achievement are all enhanced through both the skills attained through the activities and the positive peer associations they promote (Kort-Butler & Hagewen, 2011). Studies by Blomfield and Barber (2009) and by Harrison and Narayan (2003) indicate that students participating in a mix of extra-curriculars (e.g. both sports and non-sport clubs) have the highest levels of self-esteem, and those participating in neither type of activity had the lowest. Kort-Butler and Hagewen conducted a study using data from the National Longitudinal Study of Adolescent Health, tracking self-esteem growth and extra-curricular involvement over the course of five years and found that adolescents who participated in a mixture of sports activities and non-sport clubs (e.g. French club, student council) had higher self-esteem than those who participated in sports alone, and that self-esteem was higher for students with extra-curricular involvement than for those without.
Accordingly, I believe providing Michael with the opportunity to experience the self-esteem enhancing benefits of extracurricular involvement , along with the fact that they will reduce somewhat the amount of time he spends in the stressful environment of his home, will help to counter the devaluing messages he is encountering at home.
As for the psychotherapeutic element in Michael's treatment, I think CBT is a sound treatment option because it is demonstrated to be effective with anxiety and depression in young people, and anxiety and depression are often at the root of the behavioral problems seen in adjustment disorders among children and adolescents. Michael needs improved coping skills and anger management skills, and CBT has been demonstrated to be effective in helping young people improve in these areas (Chu & Harrison, 2007). Several studies have demonstrated the efficacy of CBT in improving functioning of children and adolescents (e.g. Kaufman et al., 2005; Khan et al., 1990). A 2005 study by Kaufman and others indicated that CBT is more effective at reducing depression and negative thinking among 93 adolescents with comorbid depression and conduct disorder than an active control group given life skills intervention (Kaufman et all, 2005).
Accordingly, I believe that in conjunction with the environmental changes already described, CBT will have a positive effect for young Michael.
Mark
According to his wife Karen, Mark has a history of substance abuse, for which he has attended rehab and AA in the past. He also has a history of abusing Karen. Recently unemployed, he has started drinking again, has increasing anger problems and has again become violent with her at least once. Research has shown that treating offenders for substance abuse alone often results in fewer incidents of domestic violence only for as long as the person refrains from substance use (Easton et al, 2007; Klostermann, 2006). It seems to be the case for Mark that once he relapsed into drinking, his interpersonal violence behaviors are on the increase. Because Mark currently has problems with both domestic violence and alcoholism, I would recommend an integrated therapy designed for people experiencing both.
Easton and others conducted research into the efficacy of such an integrated approach in their 2007 study of alcohol-dependent men with histories of arrest for domestic violence. Seventy-eight subjects were randomly assigned to either a CBT program targeting both substance abuse and domestic violence or to a 12-step group geared toward addiction alone. Those in the joint substance abuse-domestic violence group showed significantly fewer violent incidents following the 12 week CBT program, and longer periods of abstinence from alcohol (Easton et al., 2007).
Other research examining the efficacy of behavioral couples' therapy for both substance abuse and relational functioning found an integrated approach to be more beneficial to couples than traditional therapy targeting only the substance abuser's substance use (O'Farrell & Fals-Stewart, 2002). These CBT-based interventions have the benefits of being time-limited, which may increase the likelihood of Mark completing the entire therapeutic course. However, they aren't a silver bullet, and while they work better than the single-problem approaches traditionally used in both substance-abuse and domestic violence intervention, neither Easton et al., nor O'Farrell & Fals-Stewart (nor any other known treatment) has been able to reduce drinking or violence
among subjects to zero. At post-test, 10% of Easton et al's subjects continued to have episodes of violence (Easton et al., 2007). Even a 90% reduction in incidents of domestic violence is not really meaningful if you are on the receiving end of the remaining 10%, and it is for this reason that I did not prioritize Mark's treatment more highly in ranking interventions from 1 to 5. As a social worker, I would believe that Mark could change and would work toward that happening, but if I had to choose between helping him and helping the people victimized by his behavior, particularly his children, I would treat them first because the rates of improvement for substance abuse and domestic violence just aren't that comforting.
References
Blomfield, C. J., & Barber, B. L. (2009). Brief report: Performing on the stage, the field, or
both? Australian adolescent extracurricular activity participation and self-concept. Journal of
Adolescence 32 733–739.
Chu, B. C., & Harrison, T. L. (2007). Disorder-specific Effects of CBT for Anxious and
Depressed Youth: A Meta-analysis of Candidate Mediators of Change. Clinical Child & Family
Psychology Review 10(4) 352-372
Dyl, Jennifer (2008) Understanding cutting in adolescents: Prevalence, Prevention and
Intervention
Brown University Child and Adolescent Behavior Letter 24 (3) 1-6
Easton, C., Mandel, D., Hunkele, K., Nich, C., Rounsaville, B., & Carroll, K. (2007) A Cognitive
Behavioral Therapy for Alcohol-Dependent Domestic Violence Offenders: An Integrated
Substance Abuse–Domestic Violence Treatment Approach (SADV). American Journal on
Addictions, 16(1), 24-31
Harrison, P. A., & Narayan, G. (2003). Differences in behavior, psychological factors, and
environmental factors associated with participation in school sports and other activities in
adolescence Journal of School Health 73, 113–120
Katz, L. Y., Gunasekara, S., & Miller, A. L. (2002). Dialectical Behavior Therapy for Inpatient
and Outpatient Parasuicidal Adolescents. Adolescent Psychiatry, 26 (1)
Kahn, J. S., Kehle, T. J., Jenson, W. R., & Clark, E. (1990) Comparison of Cognitive-behavioral,
Relaxation, and Self-modeling Interventions for Depression Among Middle School Students
School Psychology Review 19 196–211
Kaufman, N. K., Rohde, P., Seeley, J. R., Clarke, G. N., & Stice, E.(2005) Potential Mediators of
Cognitive-behavioral Therapy for Adolescents with Co-morbid Major Depression and Conduct
Disorder. Journal of Consulting and Clinical Psychology 73 38–46.
Kort-Butler, L., & Hagewen, K. (2011). School-Based Extracurricular Activity Involvement and
Adolescent Self-Esteem: A Growth-Curve Analysis. Journal of Youth & Adolescence 40(5) 568-
581
Lang, C. M., & Sharma-Patel, K. (2011). The Relation Between Childhood Maltreatment
and Self- Injury: A Review of the Literature on Conceptualization and Intervention. Trauma,
Violence & Abuse, 12(1), 23-37
O’Farrell T., and Fals-Stewart, W. (2002) Behavioral Couples and Family Therapy for Substance
Abusers Current Psychiatry 4 371–376
Sarkar, R., & Krüger, S. (2008). Bupropion in the treatment of adjustment disorder. Acta
Neuropsychiatrica, 20(5), 282-283.
No comments:
Post a Comment