Qualitative Justification for Services
(Nancy Heinonen, M.A., L.P.C., was the therapist (Intern) referred to in the following vignettes)
by Nancy L. Heinonen, Ph.D. and Felix Salomon, Ph.D.
Case Study # 1
B: 13 y/o placed
in home by her caseworker with her younger
sister. One of 10 children who are all in
state care, all from various unknown
fathers. The grandmother is unable to keep
her due to poor health. Mother a meth
addict. Children were poorly fed and cared
for. B had been kept out of school as had
her younger sister for 1-½ years to care for
two babies of mother in their apartment.
Relatives and acquaintances of Mother all
did drugs. Children were neglected and
abandoned often. Grandmother tried to help
some but her poor health and continued
enabling behavior made her ineffective (i.e.
would pick mother up when she decided to
leave treatment early, even though it would
jeopardize mother's ability to regain
custody of her children).
There is no
report of sexual or physical abuse.
The therapist
has met with B since she entered the program
over a year ago. She presented as a thin,
dark-haired girl of Mexican and Indian
decent. She was frightened, sad, and felt
she would only be there temporarily. She
would then go live with her grandmother and
elderly uncle. She had only the clothes she
came with, which were dark and boyish. She
complained of always being tired and
suffering from nightmares, insomnia, stomach
aches, headaches and a general state of not
feeling well.
She and her
sister were afraid and unable to sleep due
to thinking someone would enter through the
window into their room and harm them. They
were moved to a windowless room towards the
front of the house, which seemed to help.
Once acclimated,
B took on the role of mother to her younger
sister. She was polite and accepted the
rules of the house. She did not seem to be
able to act her age. As time passed and she
began school she became sullen, depressed,
defiant, and moody. She did not want to
stay at the house and tried to rally a staff
member to adopt her and her sister. School
was difficult as she was so far behind. She
would not do or turn in work because she
could not do it. Testing was requested and
a mentor was assigned to tutor her.
The therapist
has worked with her weekly for over a year
and feels that she has made remarkable
progress. She is currently one of the
highest functioning girls in the house. As
new girls arrive, she tries to help them
adjust. She is currently more separate from
her sister, starting to joke and generally
be more talkative. She appears close to a
few of the staff and all the girls in the
house like her.
Internship 2006
Case Study #2
S was placed in
the Group Home with her year older sister by
their social worker. From a family of 10
children, many who had already been placed
in state care, she and her older sister had
not attended school for over a year. Her
mother was single and a meth addict. S
stated that they were constantly moving and
often did not have enough food to eat. They
would rent an apartment and then move when
they were evicted. The school system had
lost track of her and her sister. Unlike
her older sister, she was very angry at her
mother for not completing her treatment
programs so she could regain custody of the
children, and did not want to see her. They
received some care from their ill
grandmother and some uncles. State money
would be spent on pizza and drugs the first
of every month. "We knew there would be
food when the check came at the first of the
month."
S presented as a
thin small girl of Mexican and Indian decent
who was introverted, angry, defiant, and did
not want to talk to anyone. It was said
that she and her sister B shared the same
father. She would only wear what she
referred to as "ghetto" clothes, boy's tee
shirts, and black pants. Following her
initial phase in the group home, she became
very defiant, argumentative, and
disrespectful of staff. Her defense was to
appear tough, and to promote the image that
nothing phased her. Adapting to school was
difficult and a mentor was assigned to her,
which has proved to be helpful. Testing was
requested for her but was not completed
until the end of the school year. I have been
working with S both in individual and group
settings. Initially it was necessary to
meet with S and her sister B together as
they could not be separated. S would have
little to say, wanting her sister to speak
for her. One year plus later S is doing
well. She has integrated into the group
home setting and becoming her own person.
She is now seen as very funny, always joking
and quite comfortable with herself.
Currently she and her sister are not sharing
a room, which shows individual growth as S
feels confident to separate from her sister
and become more of her own person. S does
well with staff and has friends, and is
responding well to having limits and rules
in her life for the first time.
Internship 2006
Case Study #3
I was contacted
by the Group Home Director requesting that I
see T who was cutting and talking of
suicide. I met with T in the afternoon.
She said she was waiting for me and stated
that she had wanted a counselor to talk to
for a very long time. T presented as a very
large 16 y/o girl of American Indian
decent. She had long black hair and spoke
with a speech impediment. I explained who I
was and asked how I might help her. Her
story rushed out. She stated she had 2
brothers (one in foster care), and two
sisters (one sister who is one year younger
and in another SLF Group Home). Her mother
is 38 y/o and addicted to crystal
methamphetamine. If the kids behaved mother
would give them drugs as a reward. She did
drugs with mother for one year prior to
entering the Group Home six months ago. She
had been clean for 6 months. Her stepfather
took care of the children as her mother was
never home. She spoke fondly of him as the
breadwinner for the family. He spoke no
English and worked as a grave-tender on the
reservation. He cared for them when they
were ill, wanted them to get an education,
and saw that they were fed properly.
She saw her
biological father once when she was 13 y/o
and he was released from prison. He raped
her and she told her mother who did not
believe her. She has not seen him since.
T stated that she had cut
herself rather severely and did not want to
live after feeling rejected by her friends.
At our next meeting T claimed she had a much
better week after talking to me. She had
written a letter to her stepfather, and
accepted a job working on a military
software project at her school for the
summer. She was dressed in bright blue and
staff pointed out it is the first time she
has not worn all black since being in the
house. She had made up with her friends and
said if she went to college it would really
make her stepfather proud and set a good
example for her sister.
Quantitative Justification for Services
Focus is on
the Youth.
"Every time I
get comfortable in an environment, they take
me out of it."
What does this
girl need to do to remain in her
environment?
What is she
doing wrong?
What are the
expectations of that environment of her?
Treatment
Plan
Duration
2000 hours/1 year
Method
Identify Target Behaviors – Individual
Gather Data on Target Behaviors – Individual
o
Technique
o
Applied Behavior Analysis
o
A
specific design, implementation, and
evaluation of environment and behavior.
o
A
process of systematically applying
interventions to improve socially
significant behaviors.
o
Hierarchy of Problematic Behavior/Specify
Problematic Behavior
§
1st
Stage Target (frequency, intensity/duration,
severity)
·
Suicidal Behaviors (e.g., cutting,
ingestion, etc.)
o
Suicide Behavior Crisis
o
Parasuicidal Acts
o
Intrusive Suicidal Urges, Images, and
Communications
§
2nd
Stage Target (frequency, intensity/duration,
severity)
·
Residential Interfering Behaviors
o
Behaviors Likely to Terminate/Sabotage Home
Placement (do not include suicidality)
·
Therapy Interfering Behaviors
o
Behaviors Likely to Terminate/Sabotage
Therapeutic Relationship
§
3rd
Stage Target
·
Interpersonal/Social
·
Professional/Academic
Statistical
Analysis
Target Behaviors
(increase, decrease, no change)
Medication/Dosage (increase, decrease, no
change)
o
Behavior Tracking Sheets (Daily) – Behavior
o
Medication Tracking Sheets (Monthly)
o
Establish Baseline
o
Continuous Measurement to Determine
Effectiveness of Intervention.
·
Assessment/Measurement of Target Behaviors
o
Tools
o
Intake Interview
o
Beck Depression Inventory (Weekly) - Mood
o
Beck Anxiety Inventory (Weekly) - Anxiety
o
BASC-III (Beginning, Middle, Termination) -
Behavior
o
MMPI-A (Beginning, Middle, Termination) -
Personality
o
Rorschach (Beginning, Termination) -
Personality
Population
Adolescent Females
Setting(s)
Group Home(s) -
Format
Individual
Psychotherapy (number of patients/number
sessions per week)
Group
Psychotherapy (number of days per week)
A cost/benefit
analysis will eventually be conducted to
determine the value of competently delivered
intervention procedures.
Estimated
savings over the course of the lifespan of
patients to tax payers.
o
Welfare
Financial Self-Sufficiency
o
Baby
Abandonment
Marriage/Family
o
Incarceration
College
o
ER/Hospitalization
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