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Integrative Paper
Hoda Iskandarani
University of Texas at Arlington
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Integrative Paper
The patient that will be presented in this paper is about a 67 year old white caucasionmale that has a long history of major depressive disorder, bipolar disorder, and a hoarding
disorder. Charles is a current patient at the University of Texas Southwestern Hospital in the
Psychiatry clinic and has been seeing a psychiatrist for five years for psychotherapy. The patient
has been diagnosed with the current disorder for three years now but has been experienced the
following for several years. Charles is on medication and has been hospitalized a couple of times
due to life threatening health conditions and has tried to commit suicide on multiple ocassions
The patient lives with his 32 year old boyfriend that helps him get around in the house due to
Charles being on a walker. The patient does not have a good relationship with his family due to
financial issues.
When a social work intern started interning at the clinc, the clinical social worker
assigned the intern to start a weekly telephone with Charles. The point of the support calls was to
help patients improve their physical, mental and emotional well-being. Depending on what the
patients’ needs and diagnosis is, the social work intern will direct the call based on the needs of
the patient. If the patient strictly needs motivation to take their medication and talk to someone,
that would the interns’ role. When the intern is assigned to the patient, the clinical social worker
has goals, an assessment paper and the diagnosis so the intern can have an idea what the patient
will look like when speaking to them. In Charles case, psychotherapy was not enough support for
him so he was put on the support call list due to him being lonely and having suicidal thoughts.
This patient represents a client in my area of specialization, mental health because
Charles has an on going mental health diagnosis since his adulthood life. Charles’ family also
has mental health problems that are affecting him till this time. He has been treated of mental
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health condition and will need continuous mental health services to support him due to his
suicidal attempts and hospitalization.
Family Systems Theory
Systems theory is a structuralist approach used in both the natural social sciences
(Broderick & Smith, 1979; Piaget, 1970). This theory focuses on interactions between the
fanmiles and their environmental contexts. In family systems, the environment and the family
members are what make up the components for this theory. While the environmental side
provides the frameworking for adapting in a society, each family is different and therefore the
family may or may not adapt in our society. The basic characteristis for family systems theory
are listed below.
Structural Characteristics
Boundaries
–
Define the units
Regulate the flow of information and
activities.
Subsystems
–
Various differentiated alliances which
can be activated to serve particular
family goals.
Hierarchy
–
Basic organizational patterns through
which the family behaves.
Process Characteristics
Permeability
–
Quality of boundary; optimal is a semi-permeable
(neither enmeshment nor disengagemennt)
Adaptability
–
Ability to make appropriate structural changes in
response to developmental mental growth or
situational stress while maintaining system
definition and self-regulation.
Rationale
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The family systems theory best fits Charles case due to may reasons that have been
observed while the intern was working with him. The first reason is that Charles and his family
have had a record of life long family issue and mental health problems. Charles has never gotten
along with his family due to his family always holding on to the past. The secon reason why this
theory goes along with his case is that Charles himself has held many grudges against his family
and refers to them as “stealers”. The last reason is that there is a lack of communication and
distance between Charles and his family and neither are willing to hear eachother out.
Application
During the semester, the social work intern started to brainstorm ideas on how to help
Charles overcome the many challenges he faces with his family and also his personal mental
health problems. Charles, who has bi-polar, depression and a hoarding disorder was already
getting in a deep hole himself and did not know how to get out. The social work intern decided to
work on his own mental health problems first, and then discuss the issues that needed to be
discussed about his family after. When the social work intern was able to help Charles out with
his personal needs, the social work intern was able to start from the beginning of his family tree
and Charles was able to identify what his struggles were with his family. The social work intern
introduced the word “homeostais” which is a systems concept that describes the tendency of a
system to maintain or preserve equilibrium or balance (Direct Social work practice). This stage
helped Charles realize what family boundaries and roles are supposed to look like in our society.
Next, the social work intern asked Charles to describe what role each parent played and how it
affected him. This took Charles a while to explain due to trauma and he felt like his childhood
repeating in his head and would ask to change the subject.
Strengths and Limitations
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When it comes to the pro-advantages and the dis-advantages of a theory, it shows the
social worker what exactly they are getting when applying this theory to their client. A strength
that compliments this theory is the fact that the patient and his/her family will be able to learn
about emotion and how it affects our mental state. Another strength is it teaches the patient how
to creatively solve their family problems and their own personal problems whether its is with
their spouse or even at their workplace. The limitations of this theory also can affect the patient
on a personal level due to not getting the individual therapy that is needed. There might even be
an increase in anxiety during family therapy.
Policy
The policy that best fits the charles’ situation would be Supplemental Security Income
(SSI). This policy is a federal program funded by general tax revenues (Social Security, 2022).
It provides monthly payments to meet basic needs for food, clothing, and shelter (Social
Security, 2022).
Rationale for Policy Selected
Charles was struggling to find a job that would suit him due to him having a wheel chair.
He wanted to leave the house for a couple of hours a day to work his brain and see people due to
him being lonely but realized quickly that a job is not realistic for him. When the subject about
income was brought up to Charles, he asked for resources that could help him financially. The
patient would always tell the social work intern that he was interested in applying for a federal
program but was not informed about any.
The social work intern then decided to have a talk with his clinical social worker (with
Charles consent) to help Charles find a program that will benefit him in the long run. The Social
work intern brought up the idea of applying for SSI and introduced it to Charles. The patient
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meets all of the requirements as he is disabled, has a limited income due to him retiring and is
over 65 years of age.
Strengths and Limitations
The SSI program became operational in January of 1974 under the management of the
Social Security. Since then, a lot has changed through the government syste (Handlin, n.d.).
According to the official social security website, about 8.0 million people have received
payments from the federal government (Handlin, n.d.). Table 1 below shows the average income
of an individual or couples’ rate per month from SSI benefits. This table starts from the year
1994 and ends at 2021. As the years progress more, the benefits have increased dramatically
showing an applicant that there is a chance for them to have some financial assistance. Another
strength would be that SSI benefits will continue as long as the applicants medical condition is
still ongoing. In 2021, the average single applicants’s rate is about 794 dollars and a couples rate
is about $1,191. In every situation there are multiple strengths and ofcourse there are limitations.
When look at the “down side” of SSI benefits, the federal government will ask to disclose a great
amount of the applicants personal information including medical records. In return if the
applicant puts false information on the application there is a huge possibility that the application
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will be denied or officials will discontinue benefits. State laws can play a factor of the amount
and the time period of benefits.
Advocacy
Advocacy is the definition of a social
worker. It is essential for a social worker to
advocate for those who cannot for them
selves. When it comes to SSI there needs to
be a change in the application. It is very
important for the federal government to know
who, how and where the money is going to
but, it is a very lengthy application. When an
applicant looks at the form, they do not want
to be driven away from the application due to
it being too long. They government needs to
make this application in a much simpler form.
Regarding people that are in the same age
group as Charles, most of them are not able
to fill these applications out alone. There
needs to be a way to make the application more applicable for the 65 + age group. Another
concern about the SSI system is if an SSI applicant lives with a spouse that is not eligible for SSI
benefits, there will be money from the spouses income that will be taken out of the eligible SSI’s
benefits. That is not fair for the applicant that is eligible. A social worker would advocate for this
change by talking to a representative and presenting a case like Charles.
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Practice Skills
Engaging with the client can be difficult at times, especially when it is over the phone.
Generally, when anyone speaks on the phone with someone, it is important to have a good tone
of voice when speaking. Both, the receiver and caller cannot see any emotions physically so,
they are having to make a bigger effort to make the message clear on how the opposite person
will receive the emotion based on the tone of voice. When it came to the social work intern, it
was important that the clinical social worker trained the intern on how someone is supposed to
have a support call.
The social work intern practiced with the other interns during the semester for a month
before making a support call with a client. During that month, tone of voice, conversation,
reviewing the clients health records and professionalism were practiced as they are key aspects to
making a proper support call. Something that the clinical social worker truly pushed on was the
introduction of the phone call to the patient. “ It is so important to make sure you make a good
impression by the end of your first call, it truly sets up the tone for the rest of the year” the
clinical social worker would always say to the interns. When it came to Charles, the social work
intern had to keep in mind that he is in the later stage of life. Determining the right practice skills
would set the “mood” for the rest of the semester.
Rationale
When it was finally time for the social work intern to talk to Charles, she logged into
EPIC (an electric health record system) and reviewed the patients recent appointment notes that
are left by doctors. This helps the social work intern show interest in the patient when bringing
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up recent conversations or concerns that happened. This leads to the first practice role which is
clarifying your own role. This practice role is just as important as clarifying the clients role.
Showing the patient what the social workers’ role is and how it can help the patient will make
him/her feel more secure. Clarifying that the social work intern will help the patient weigh their
alternatives but will let the patient make their own decision will comfort the patient that the role
of the social worker is a support and not a dominant role (Hepworth et al., 2002/2017). The
second practice skill that was used was active listening. According to an evidence based
practice, researchers reported that if healthcare professionals showed more empathy, their
patients felt more enabled, which indicated a better therapeutic relationship (Haley et al., 2017).
Since Charles and the social work intern were never able to meet up, it was super important to
the intern to make sure that Charles knew that the intern was listening to him when speaking.
The interns would make short comments like “yes, I agree” or “mhmm how did that make you
feel?”. Active listening built up Charles trust and confidence with the social work intern because
of this skill.
The third skill is difficulties to inherent in process. This practice skill is the final task
that summarizes that difficulties are hard sometimes no matter what the situation is. This shows
Charles that it is natural to go through obstacles (Hepworth et al., 2002/2017). The fact that the
intern and the patient do not know each other helps Charles be even more comfortable. They
both do not know one another which makes it easier for him to speak about his problems that he
is facing and allows the intern to speak in a more straight forward tone. Assesment Process
Depression is common in late life, affecting nearly 5 million of the 31 million Americans
aged 65 and older (Greenberg). It is important to treat depression because it is reversible. If
depression is untreated for a long period of time it can become physically, mentally and
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emotionaly dangerous. When it came to Charles case, the social work intern had to find a
depressionn assessment tool to best fit Charles. After numerous times of researching and
exploring the social work intern decided to use The Geriatric Depression Scale given that
Charles is in his late adulthood, this would give accurate results. The assessment was given over
the phone due to COVID-19 regulations. The social work intern asked the fifteen questions and
proceeded with scoring the assessment tool.
Clients Strengths and Weaknesses
When the social work intern finished the assessment it was time to talk to Charles about
strengths and weaknesses. Charles already knew that he had “some sort of depression” he always
told the social worker that he is always lonely and bored at home and always looked forward to
every thursday morning because he would speak to the social work intern. When asking charles
what he thought were his strengths his reply was, “I dont know I have not really thought about
that in a while”. Something that the social work intern had to always do was motivate and lift
Charles up in order for him to give the intern the answer that she was looking for. The intern
would start listing examples of what strengths would look like and he would go off of the interns
suggested “strengths”. The patient has an apartment and all basic needs but is having trouble
with getting around the house due to him being in a wheel chair and having piles of items all
around his house He has been trying to find assisted home living that will help him with chores
and his hoarding problem. Charles has mentioned his boyfriend that lives with him but is not
around a lot. The patient is always alone in the house making it a challenge for him to get in and
out of his bed and finding motivation to look through the piles and clean the house.
Client System
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Charles is a 67 year old white caucausian that was raised in New York city. He moved to
Texas in 1970 to start his own real estate company. Charles was a rich white-caucasian jewish
man. He always expressed his love for business and proudly would tell the social work intern
how he met so many famous celebrities around the country due to him always hosting parties at
his houses all over the states. In 1980 Charles met his nephew for the first time and grew an
attachment for him. He would tell intern that he was a son to him and when he grew older, he
partnered up with Charles in his business and soon things started getting worst. His nephew used
him and stole his money and started his own company making Charles bankrupt.
Charles distanced from his family and struggled to get his money back after multiple
attempts of trying to go to court and fighting the case he did not get all of his money back. This
resulted in Charles developing depression due to him isolating himself from everyone. He could
not trust anyone and shut off the whole world. He lost connection over the years with his family
because of the nephew situation. He started seeing a therapist and found out that he multiple
health issues including cancer, a hoarding and bipolar disorder. After Charles sat between
himself, he realized that he needed support. He went back to New York to fix things with his
family but they did not accept him. They told him he was “too much to handle” and “he needs
help” Charles felt abandoned and described to the intern that he felt like he was in a much deeper
whole. He felt helpless and the disorders worsened due to isolation. He was hoarding more and
holding on to anything that was from the past. Charles would mention in the phone calls how he
just wanted support at that time and when he was not looking he found his boyfriend, Sam along
the way. He realized he had an interest in the same sex but wanted a family of his own. Sam,
who is 35 years of age was not looking for a family and told Charles that they could be partners.
Charles says that Sam helped him with his depression at first but now the relationship is more of
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a “roommate relationship”. Charles has mention to the intern that he pays for everything and
Sam is just living with him. He always says that he has a sense of guilt because he brought all of
these issues to Sam and he is still young. After assessing Charles using The Geriatric Depression
Scale, charles scored a 13/15 which indicates that Charles has Major depressive disorder.
Social Justice
Insurance has played a huge role in one of Charles challenges. He cannot find a proper
care taker that can help him with is basic chores like laundry, making the bed, and eating. Living
in Texas has made it challenging for people like Charles to find needs that need to be met. Out of
the 52 states in America, Texas is ranked 42 in health care aid and system preformance. Texas
has the highest uninsured rate due to insurance being so expensive. Charles has medicare and
medicaid and still cannot find anyone. At one point he told the intern that he would be willing to
pay out of pocket for extra days for the caretaker to come but they were not willing to do so.
Resources
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Direct social work practice; theory and skills, 9th ed. (2012). Reference and Research
Book News, 27(4) Retrieved from
https://login.ezproxy.uta.edu/login?url=https://www.proquest.com/trade-journals/direct-socialwork-practice-theory-skills-9th-ed/docview/1030748670/se-2?accountid=711
Wedemeyer, N. V., & Grotevant, H. D. (1982). Mapping the Family System: A
Technique for Teaching Family Systems Theory Concepts. Family Relations, 31(2), 185–193.
https://doi.org/10.2307/584396
Zerbe, K. J., & Fabacher, J. E. (1989). Benefits and limitations of bowen therapy with
psychiatric
inpatients. Bulletin of the Menninger Clinic, 53(6), 522. Retrieved from
https://login.ezproxy.uta.edu/login?url=https://www.proquest.com/scholarly-journals/benefitslimitations-bowen-therapy-with/docview/1298140568/se-2?accountid=7117
Handlin, A. (n.d.). State Unemployment Vs. Federal Unemployment Benefits | Sapling. Sapling.
https://www.sapling.com/7845942/state-vs-federal-unemployment-benefits
Social Security. (2022). Supplemental Security Income Payments | SSA. Supplemental Security
Income. Retrieved February 20, 2022, from https://www.ssa.gov/benefits/ssi/#anchor2
Social Security. (1974–2021). SSI Annual Statistical Report, 2020 (Version 2021) [SSI Annuale
Statistical report, 2020]. https://www.ssa.gov/policy/docs/statcomps/ssi_asr/
Haley, B., Heo, S., Wright, P., Barone, C., Rao Rettiganti, M., & Anders, M. (2017).
Relationships among Active listening, self-awareness, empathy, and patient-centered
Care in Associate and Baccalaureate Degree Nursing Students. NursingPlus Open, 3(3),
11–16. https://doi.org/10.1016/j.npls.2017.05.001
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Hepworth, D. H., Rooney, R. H., Glenda Dewberry Rooney, & Strom-Gottfried, K.
(2017). Direct social work practice: Theory and skills (10th ed.). Cengage Learning.
(Original work published 2002)
Greenberg, Sherry A. MSN, APR N, B C, GNP How To try this, AJN, American Journal
of Nursing: October 2007 – Volume 107 – Issue 10 – p 60-69 doi:
10.1097/01.NAJ.0000292204.52313.f3
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Present a mutually developed and agreed upon intervention strategy with specific goals and measurable objectives.
Provide a rationale for your selection.
Describe your specific intervention (for example MI, SF, CBT) from beginning to end, including termination. How did you
help the client prevent or resolve problems? How did you negotiate mediate and advocate for your client. Select and
discuss at least 3 practice skills (micro/macro) used in your intervention with the client.
Write a critique of your work with the client. What did you do well in terms of the intervention? What could have been
done to improve the outcomes with the client? How was the intervention empowering? How may it have been
discriminatory or oppressive?
Provide a discussion of whether the intervention was developed from a theoretical practice model. If so, which practice
theory? If not, what practice theory could have been used to facilitate better outcomes? Regardless, analyze and provide
evidence-based knowledge about the theory-based intervention (used or proposed) and its effectiveness.