Implementation of the Generalist Model and the Ecosystems Perspective on a Helping Situation Pentaris (Notis) Pentaris Hawaii Pacific University Helping Situation (Case Study) Katie is a 17 year old adolescence diagnosed with cancer since she was 3 years old. The doctor told her parents, back then, that only if they had a new born child, it would be able to donate its sister so that she could survive in future times. Katie has an older brother, named James, who has learning difficulties and needed a lot of attention by his parents.
However, Katie’s parents, Josh and Anita, focused all of their attention to their sick daughter, putting aside their son’s needs by sending him, at age of 7 in a daycare to handle his difficulties. Katie feels horrible and sorrowful that she, unwillingly, “stole all the attention” of their parents and he got nothing. Josh and Anita, when they were told of having another child so that Katie could have her donator, they decided to do so. Hence Katie’s sister, Charity, was born a few years later. At the present she is 13 years old and has been hospitalized and been under the knife several times through her childhood stages.
One year ago, while Katie was under chemotherapy in a hospital setting, she met a boy, Peter, who was also under chemotherapy. He was diagnosed with brain cancer. The two adolescences felt understandable to each other and decided to “hang out” together. That relationship was Katie’s first experience lovely and sexually. The next morning after she made love with that boy, he disappeared, until the time that Katie was informed that he died that day due to his disease. Afterwards Katie was devastated and most convinced of her own future being as well.
Katie is in the hospital once again, after bleeding constantly and not being able to self – function anymore. There is a strong need for kidney transplantation, which only Charity can donate. Both parents have decided for Charity’s side that she will do the transplant. Charity does not decline the fact. Albeit the process is ready to take place, Katie feels so tired and sick. She has spent most of her life hospitalized and all of it under prescriptions. At the moment she can feel that nothing can be done. She is exhausted out of pain, and doesn’t want to keep going on pills. She feels that this is the time for her to pass away.
And she is really happy that she is able to make this decision for herself. On the contrary though, her parents do not let her go emotionally and psychologically. They keep trying to save their daughter’s life and never stop and listen to what she wants or needs. Katie gives more effort staying in life, so Josh and Anita can be better prepared to accept her death. At the same time the doctor notifies the parents that Katie’s situation is no longer to be confronted by the hospital and recommends that it would be better for the dying youth to spend her last moments in home with her family.
The mother reacts badly against the doctor and the staff in general, and insists for the transplantation to be made. Katie experiences all these deeds and emotions of her parents’ and her mother’s especially. She feels haggard with everything and still is in severe pain caused from her disease. Simultaneously she has asked her sister, Charity, to deny being the donator, so that Katie could die without any more clinical efforts. She believes that this is the best way of hampering her prolong of lifetime under painkillers and hospitals. Katie declares forlorn and rejected from the decision making process concerning her own life.
She feels abandoned of her parents due to their unwillingness to listen to her and understand that she no longer wants to suffer and simultaneously make her family suffer with her. Implementation of the Generalist Model and the Ecosystems Perspective on the Helping Situation As soon as the intake process has been already made during the patient’s hospitalization, the engagement part of phase one from the helping process shall begin. It is essential, before everything else, to build a safe and honest relationship with the client, Katie in this case, so that the social worker can be effective enough through the helping process.
Engagement is attained through the interviewing process while utilizing skills and techniques which will provoke such a rapport. Trust is a critical factor which enhances the possibility of a healthy and long lasting relationship between the client and the practitioner (Hepworth, 2010). According to the specific case study of Katie, the practitioner, as soon as he or she has read the intake form, which can be modified in the future time as well, has to be really sensitive on the situation. Effort has to be made so that the practitioner does not overlap with paternal or maternal roles, something that is not needed by the client at the moment.
Katie feels devastated and lost in her own emotions and feelings. She needs people who will at least try to understand her, and apprehend her reasons for wanting to die during this phase of her life. During the engagement part of the generalist model the practitioner, in order to start building the social worker – client relationship, should also explore further the client’s situation. It seems that Katie, due to her physical condition, is not able to self – function, so the assumption of her parents filling in a lot of information about the situation on her behalf is prospective.
The first contact with the client will begin with an initial interview and may start with the examination of Katie’s feelings and emotions, as well as the circumstances and the determinants that led to those feelings. In her situation Katie might also be referred to the medical social worker, which means that she might as well be defensive until a rapport has been build. While exploring Katie’s situation during first sessions, some of the questions that might help would be as follows: * “Katie I have read your intake form at the front desk and your parents also talked to me about your situation.
However, I would like you to define that situation, as you experience it. ” * “Katie, even though you were referred to social services office, and we have been informed about your situation indirectly, I still don’t feel that I know what it is that you need. Maybe you can help me with that. ” Using effective communication skills during the sessions with Katie is crucial, so that trust can be gained at some point. For Katie it is really important to understand and embrace the fact that the practitioner is there to help her and shield her own needs but not her parents’, which are opposite.
A milestone for Katie will be when she will be able to talk about her death with her parents and they, from their side, will be able to let her go peacefully. Referred clients have more difficulties in trust issues, as soon as they did not ask for the help but someone else did on their behalf. Thus it is essential to make those types of clients feel friendly and accepted, even if ethical dilemmas or moral issues are becoming obstacles (Hepworth, 2010). While trying to establish rapport with Katie, it is also important to augment her motivations.
If things are to change, then Katie is the core person to change them, and she has to be willing to do so. Hence, having strong motivations is critical so that the goals which are about to be set will be attained (Hepworth, 2010 & Worden, 1991). An example question while exploring motivations that already exist for the client might be: * “I can hear how important it is for you Katie that your parents need to embrace their future loss, meaning your death, so they can keep going in life. Nevertheless, have you ever thought what makes it so important?
You are in the bed, having a lot of difficulties with functioning. What gives you the strength to try harder on that issue? ” Engagement represents one of the core points in the helping process. As soon as the client is engaged to work with the practitioner and a rapport has been build, then the relationship has been accepted and assessment of the situation can be made and goals can be set (Hepworth, 2010, Hollis & Woods, 1981). As referred to earlier, for Katie, it is really important that the social worker will show empathy and understanding for the situation.
Encouragement and strengths oriented sessions are also crucial for building the client’s – social worker’s relationship, and while exploring the situation. * Apparently this is not the first time that you decide to change your parent’s view of your situation Katie. How have you approached this issue in the past? Biophysically assessing this situation, Katie has cancer. The doctor has already informed the family that even if the kidney transplantation is been done, Katie will not survive her disease.
Katie is a seventeen years old teenager, who even though is struggling with cancer all of her life and one might assume that she is “used” to it, she can still observe how other teenagers or children are living their lives. She is still able to distinguish all the disparities between her situation and others’. The specific client is stating how tired she feels taking all these painkillers and being physically unable to interact as teenagers do in her own age. It seems that she has been facing such kind of emotions for a long time before the practitioner’s intervention.
The fact that she is making decisions as her death circumstances requires knowledge of the situation and a lot of strengths. In particular, concerning the family system as a whole, Katie seems as if she is having the role of a linchpin between reality and what some of the members accept as reality. This is really important for this case and extensively difficult to accomplish. On the other hand though, Katie is dealing with a lot of negative emotions at the moment, which might decrease her ability to be cognitively healthy in terms of reducing her objectivity.
One can observe many red flags upon this situation approaching it from an ecological perspective. Katie has already started to evaluate her life history, which explains the fact that her decision that it is time for her to die has not been made spontaneously, rather than thoroughly. She is wrestling with past feelings and emotions as well, and not only with the current situation. Assessing her past she feels repellent that she was the reason that her siblings had no attention while growing up, and mostly concerning her younger sister who has been “born to donate”.
Added to these, her mother, Anita, is depicted as a passionate mother into saving her daughter’s life and she is trying everything on this behalf. She even ignores other family issues or needs in order to provide the best for Katie. The client feels sorry that she, unwillingly, “stole” her dad’s love. She feels as if she is the reason that her parents have stopped being partners in life, and eventually became partners in saving Katie’s life. Thus they forgot loving each other. “Katie would it be easy for you to reflect some of the differences that you recognized concerning your parent’s relationship, as long as your disease has been being developing? ” Psychologically one can observe a lot of red flags, but at the same time there is cognitively developed thought from the client’s side, which might be interpreted as the client being able to avoid hazards. Applying a multidimensional framework on this case study, the practitioner should focus on the social dimensions of it. For the past few years, due to Katie’s illness, it seems as if her only social network is her own family.
She is spending almost all of her time with her parents or/ and siblings, either in the hospital or at home. Determinants dropping under the social tab can alert for depression or other clinical diagnosis referring to DSM IV. Nevertheless, according to the case study provided, Katie’s social network, even if they do not fully accept the reality, has become a great source of strength for her and for the system itself (Ashford et al. , 2008). During Katie’s developmental stage, which is late adolescence, besides the intimacy that teenagers enhance with other people, they also make future plans for their lives.
This might be a major red flag for Katie. She is probably not letting herself make future plans because she knows that there is no future for her. We can observe, back when she was almost sixteen and she has met that boy in the hospital, that she made a few plans of being with him in the future. However, as soon as she knew that he has died out of cancer as well, she stopped making other plans and started accepting the fact that she also, sooner or later, will be dying. During this developmental stage, teenagers’ self – esteem is extensively important.
It is interpreted as their evaluation for their one’s selves and also as their self – image (Ashford et al. , 2008). In Katie’s case, she is having a really low self – esteem concerning her self – image. One of Katie’s strengths is her ability to keep the bonds of the family tight. Due to her own situation, roles are changing in the family system and intense conditions are occurring in their home. Katie shows an incredible peaceful and calm pace that helps the members to understand each other. She also seems to have a most objective perspective than the other members of her family.
As a result of assessment, it is apparent that Katie has several and severe problems that need to be addressed: a. Cancer. b. Emotional exhaustion. c. Adjustment issues according her developmental stage (i. e. independence failure). d. Family relationships oriented concerns. e. Guilty feelings against her parents and siblings of what she made them go through all of her life. f. Willingness to die. Both the hospital’s goals for this client and Katie’s goals and values are of great importance, so that motivational congruence can be accomplished while planning and contracting for this client.
The goals that will be set for this client will specify what is to be accomplished. Having conducted the assessment it is easier to go through it once more with the client and more or less utilize the outcome of it as a start point on goal setting and contracting (Hepworth, 2010). Specifically speaking below are some of the potential goals and specific objectives for this client: * Emotional discharge of Katie so that her rational thinking functioning will not be affected and she will be emotionally sober to make decisions. In this specific case, a potential journal for each day would be helpful for both social worker and the client to observe and measure the goal attainment. * During the sessions and according to the social worker’s records. * Enhance the family communication pattern, especially between Katie and her parents. * Probably a couple of family sessions emerging the individual ones. In that way, Katie can also observe potential changes in her attitude. * Two or three sessions with Katie’s siblings in order to achieve better communication and feeling exchange. * Additional typical goals that will arise in the future sessions.
Goals indicate potential changes and these goals can be modified or changed or new goals can be added in the contract during the social work the practitioner conducts (Hepworth, 2010, Hollis & Woods, 1981). Katie is a client who even if she was referred to the practitioner, is in need of an advocator between her feelings and her parent’s emotions. On that extend she is probably going to use the help provided to her from the hospital setting. It is of major importance to specify the roles of both, the social worker and the client, the time frame, the frequency and the length of the sessions.
In this case, the sessions can be conducted twice per week. Each session can last one hour and fifteen minutes, considering Katie’s physical situation and the medications, which make her cognitively and in speech terms mellower than usual. The sessions can take place in her hospital room which probably for her case and situation will be a single bed one. In any other case predictions for the environmental settings have to be made regardless confidentiality issues. Lastly, roles for the sessions and concerning goal attainment can be allocated (Hepworth, 2010).
In this case the social worker could also have separately sessions with the parents over goal attainment. Added to these, the duration of the whole sessions can be more flexible in this case, according to goal accomplishment, and concerning Katie’s nearly death situation. During this phase, the social worker has also to decide the implementation technique he or she is going to use. Individually, directed into micro practice, crisis intervention can be used. Katie is experiencing a transition in her life at the moment, which is her decision to die.
Even though it has not happened yet, it is a future crisis for the family, and the person who is dying experiences outburst feelings in advance. The specific model is directed to reduce stress, which is apparent in Katie’s psychosocial study, restore functioning, socially and emotionally, and prevent further deterioration. All of the above are attached to Katie’s situation. According to the three stages of crisis, Katie could be in stage (3) at the moment, which depicts a person who is almost depressed, really stressed out of her or his situation and feels helpless.
Task oriented approach characteristics could also be emerged in the model that the practitioner is using, for accomplishing several typical tasks that might arise (Hepworth, 2010, Worden, 1991, Hollis & Woods, 1981). As for the parents and the siblings sessions, directed into mezzo level, cognitive restructuring or Cognitive Behavioral Theory (CBT) can be utilized. I am choosing the specific model because through that they can be taught different and maybe more effective ways and behaviors to communicate with each other, or maybe evaluate in overall the family’s communication patterns in the given situation (Mpountalis & Pentaris, 2005).
Lastly, advocacy strategies has to be followed for this situation between the family system, the family system and the hospital staff members, the client and the hospital setting and the staff members, and potentially the client and the relatives with other sources or networking (Hepworth, 2010). The evaluation and termination phases, as all the processes of the generalist model, start within the first session and are “alive”, in terms of modifications, through the collaboration of the client and the social worker (Hollis & Woods, 1981).
For Katie’s situation, it is difficult to “control” physical hazards that might occur, even the time of her death, as soon as the doctor is stating that nothing more can be done. On that extend it would be wiser to keep evaluating every other session or after three sessions each time, so that both the social worker and Katie can proffer to the process and acknowledge the outcome. Evaluation can be conducted through journals that have been kept, verbally during the sessions, and by observing the family members interact after a few sessions.
Lastly, the social worker’s records are really important to measure the goal attainment of the ones that have been set during the contract period. In this case the termination could be either planned or unplanned. It depends on the client’s biophysical situation and development (Kubler – Ross, 1979). In any case, as decided during the contract, the sessions would be taking place till Katie either dies in that specific setting or being transferred into some different one. Personally, I would like to be more flexible on this case.
Owing a pager I would give myself and my client the chance to see each other for a closure, if Katie could feel that that might be our last chance. In that way, by letting some nurse know about it, I could be informed and spontaneously be in the hospital at that time, if it’s not during my shift. Focusing on the ecosystems perspective in this situation and with this client is extensively important, so that the goals that are set can be accomplished. Katie is experiencing some needs and wants at this moment in her life, and most of them have to do with other people, mostly her family.
She is experiencing her illness and its development within the context of her social and family network. She is affecting and is affected from those networks (Phelan, 2008). Her family is her biggest and most effective of her networks at this point of her life. Apart from that we can assume that church might be one of them as well. However this is not mentioned by the client and no priest has been requested. It is crucial to include for this situation both the client individually as well as the system of the family, applying a holistic approach.
Katie is in a situation in which she is dependent by her parents and siblings, so they have to be part of her decision making processes and of the solutions she is seeking for her requests. On the top of everything, for Katie, her parent’s aspects of the situation seem to influence her emotions and feelings the most. Interactions within the family system is also really important to be observed, measured and modified if needed effectively, so that functioning of the system can be developed positively.
The usefulness of the ecosystems perspective in this case, like other systemic viewpoints, is that we often try to understand people in isolation from the factors that create both reinforcement for behavior and patterns of interaction. This makes our judgment about what is happening for the other person quite limited and often inaccurate (Phelan, 2008). Conclusions Katie showed a higher level of cognitive development, than people during late adolescence potentially depict. Her situation was really sensitive and a lot of issues have arisen during our collaboration.
She showed strengths that one can admire in a human being, especially when a teenage girl at age seventeen requests to die, without hesitation. It was of great interest the way this client could communicate with everybody and could forgive everything that was happening against her will. She again, showed remarkable courage and patience. What was of great observation as well was the fact that Katie made decisions in a more or less rational way. On the other hand, persons at this age and when knowing that they might die, experience the fear most of all and the anxiety, instead of the rational decision making nd concerning about others. If, through the sessions, we, “hypothetically”, had accomplished our goals, that would be a strong self – evaluation and feedback for me. On the other hand, regardless the outcomes, it would be really important for me, either for personal or professional growth. Challenges arisen while conducting Social Work with the specific Client Providing appropriate end – of – life care for adolescences dealing with chronic illnesses is particularly challenging because of several developmental, ethical, and legal considerations relevant to this age group.
Developmental issues, while working with this client, relate to ways in which the self – image and physical condition of Katie have changed. Working with Katie, who is only seventeen years old and who is dying, makes you realize the mortality of the human body and challenges you to, sometimes, depict your own death some time sooner or later. To elaborate on that a little bit more, new feelings are arisen through these thoughts. What is the most challenging in this situation are the legal and ethical issues that arise.
Many terminally adolescences under eighteen years of age lack ordinary legal authority to make binding medical decisions, yet they meet functional criteria for having the competency to do so. Moreover, Katie is under eighteen and even though she wants to stop the efforts of surviving cancer and even though she would like to stop medication, she is not legally allowed to, so her parents are making the decision for her. This definitely a great challenge for a social worker working in this case.
Following the Code of Ethics, social workers have the responsibility to respect the inherent dignity and worth of the person, as well as promoting well – being according to competencies of the profession. Taking that into account, the situation brings up a major ethical dilemma, while working with a person, even if he or she is under eighteen years of age, who is during the terminal phase of a chronic illness. What are the authority limitations of the setting you are working in, and what are the limitations of the practitioner’s personally.
Probably an effective way to deal with such a dilemma as a social worker in this situation would be to talk about it with my own supervisor, and then provide my client a supportive atmosphere promoting excellent communication. As soon as legal issues are impeding her to make the decision of stopping the medications, the only way would be through parental sessions. Bringing that issue up for the parents might have been effective to bring wanted outcomes. References Ashford, B. J. & LeCroy, W. C. , (2008). Human Behavior in the Social Environment: A Multidimensional Perspective (4th Ed. ). United States: Brooks/ Cole: Cengage Learning.
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