Attached  61 Journal of Women & Aging, 22:61–75

61

Journal of Women & Aging, 22:61–75, 2010
Copyright © Taylor & Francis Group, LLC
ISSN: 0895-2841 print/1540-7322 online
DOI: 10.1080/08952840903489094

WJWA0895-28411540-7322Journal of Women & Aging, Vol. 22, No. 1, Dec 2009: pp. 0–0Journal of Women & Aging

Effects of Three Caregiver Interventions:
Support, Educational Literature, and Creative

Movement

Effects of Three Caregiver InterventionsL. K. M. Donorfio et al.

LAURA K. M. DONORFIO
University of Connecticut, Department of Human Development & Family Studies,

Waterbury, CT

RHEBA VETTER
Northwest Missouri State University, Health, Physical Education, Recreation and

Dance Department, Maryville, MO

MARINA VRACEVIC
University of Connecticut, Department of Human Development & Family Studies, Storrs, CT

The primary focus of this study is to compare the effectiveness of
three distinct intervention techniques in relieving some of the stress
experienced by midlife daughters’ caregiving for their frail mothers.
The three techniques are: (a) a home-based literature “tip of the
week” group, (b) a caregiver’s support group, and (c) a creative-
movement group. Based on a review of caregiving literature, no
other studies have utilized a home-based literature intervention or
a creative-movement intervention with midlife daughters provid-
ing informal care to frail mothers. As part of the weekly assessment
evaluation, participants were asked to rate how helpful the previ-
ous week’s session was with respect to five mental health variables:
irritability, depression, anxiety, stress, and concentration. Overall,
the support-based group had higher average scores for each of the
five mental health variables and the highest overall mental health
score. Future research and promising applications of future inter-
vention programs are discussed.

KEYWORDS informal caregiving, caregiving interventions,
mothers and daughters

Address correspondence to Laura K. M. Donorfio, PhD, University of Connecticut,
Department of Human Development & Family Studies, 99 East Main Street, Waterbury, CT
06702. E-mail: [email protected]

62 L. K. M. Donorfio et al.

INTRODUCTION/BACKGROUND

The United States is in the midst of a significant and growing caregiving cri-
sis, with approximately 5.6 million Americans aged 65 plus receiving unpaid
or informal care at home from family members or friends (ILC-SCSHE Task-
force, 2006). According to the Older Women’s League (2006), if informal
caregiving had to be replaced with paid services, it would cost upwards of
$257 billion annually, more than twice what is spent nationwide on nursing
homes and paid home care combined. Projections of the growing aging
population resulting from increasing longevity and medical advancement,
contribute to increased sensitivity to the immense value of informal caregiv-
ing. Consequently, it is increasingly important to preserve the well-being
and provide support for family caregivers in their efforts to provide care
(Hebert & Schulz, 2006; Wolff & Kasper, 2006). One way to help support
the well-being of caregivers is to provide intervention techniques specifi-
cally created to help alleviate some of the perceived stress associated with
caregiving. The purpose of this study is to compare the effectiveness of
three distinct intervention techniques in relieving some of the stress experi-
enced by midlife daughters caring for their frail mothers: (a) a home-based
educational “tip of the week” group, (b) a caregivers’ support group, and
(c) a creative-movement group.

While there is no universally agreed-upon definition of caregiving in
the literature, a caregiver generally refers to someone who provides some
type of service to people who are unable to care for themselves due to a
disability or functional limitation (ILC-SCSHE Taskforce, 2006). According to
a national survey distributed by the Opinion Research Corporation (2005),
central aspects of U.S. caregiving include the following: (a) it is prevalent
across all economic levels and ethnic groups; (b) the majority of caregivers
are women over the age of 45; (c) most care-receivers are aging mothers;
(d) one person tends to provide the majority of informal care in family situ-
ations; (e) on average, caregivers spend 21 hours per week on caregiving
responsibilities; and (f) the majority of caregivers work full- or part-time
while providing care.

While caregiving is recognized as an activity with perceived benefits,
caregiving often carries emotional, physical, and financial burdens, and is
recognized as a risk factor for illness (Vitaliano, Young, & Zhang, 2004).
Caregivers are more prone to depression, grief, fatigue, physical health
problems, and changes in social relationships, many of which have roots in
stress, exhaustion, and self-neglect (Sullivan, 2004). Fifty percent of caregiv-
ers make some sort of work-related adjustment such as taking time off,
dropping back to part-time, or even taking a leave of absence (National
Alliance for Caregiving, 2004). In a study done by MetLife and Brandeis
University (1999), the cost to caregivers over a caregiving and working career
can be nearly $600,000 in lost pensions, wages, and Social Security benefits.

Effects of Three Caregiver Interventions 63

In reviewing the current literature on interventions for family caregivers,
there is a paucity of research involving educational literature or creative-
movement interventions. Also, these two types of interventions have not
been compared to any other intervention format(s). Many other inter-
ventions have been utilized in the literature and evaluated for their
effectiveness.

Intervention Techniques Employed

The most commonly employed intervention techniques have been sup-
port groups and educational training programs (e.g., Callahan et al., 2006;
Claxton-Oldfield, Crain, & Claxton-Oldfield, 2007; Drentea, Clay, Roth, &
Mittelman, 2006; Gitlin, Hauck, Dennis, & Winter, 2005; Marziali &
Donahue, 2006; Smith & Toseland, 2006; Stewart, Barnfather, Neufeld,
Warren, Letourneau, & Liu, 2006). Positive outcomes achieved in utilizing
support groups as an intervention technique primarily involve lowering car-
egiver depression and stress. Similarly, educational training programs have
achieved effective outcomes including teaching caregivers to cope with dis-
tress, depression, and grief in the case of the death or impending death of
the care-receiver. Eisdorfer et al. (2003) combined several strategies into a
single intervention. The results did not indicate that any one-intervention
hybrid was significantly better than any other.

The second most popular intervention for family caregivers is counsel-
ing therapy (Drentea et al., 2006; Kissane, McKenzie, Block, Moskowitz,
McKenzie, & O’Neill, 2006; Whitlatch, Judge, Zarit, & Femia, 2006). A con-
sistent counseling-based therapy program has been found to contribute to
relieving caregivers’ anxiety, depression, and distress.

Creative-Movement Improvisation

Creative-movement literature leads to a range of positive effects when used
with healthy individuals and those suffering from different types of impair-
ments and diseases (Brooks & Stark, 1989; Jeong, Hong, Lee, & Park, 2005;
Osgood, Smith, Meyers, & Orchowsky, 1990; Picard, 2000). Previous studies
found creative movement to be effective in lowering depression, stress, anxiety,
and improving psychological distress (Brooks & Stark, 1989; Jeong et al.,
2005; Walsh, Culpepper Martin, & Schmidt, 2004).

Applications of creative dance movement therapy (CDMT) are rela-
tively new and scant. Only a handful of studies have used CDMT as a care-
giving intervention strategy. CDMT was shown to be effective in increasing
sensitivity and awareness of self and others in interpersonal relationships.
For example, Picard (2000) found creative movement to be helpful in
“expanding consciousness at midlife, with patterns of meaning identified in
relationships with others, self, and spirit, as well as challenges, loss, illness,

64 L. K. M. Donorfio et al.

and threats to relationships” (p. 150). Wilson (1985) also found changes in
participants’ self-awareness as a result of participating in CDMT. The goal of
the current study is to assist midlife daughters in better understanding and
coping more successfully with their feelings associated with providing care
to their older frail mothers. According to creative-movement theory, the
improvisational forms of movement are means of communicating emotions
and feelings and can contribute to increasing one’s sensitivity toward others,
their self-awareness, and their environment (Wilson, 1985).

PURPOSE

The primary purpose of this study is to investigate the effectiveness of three
intervention techniques in lowering caregiving daughters’ perceived
amounts of irritability, depression, anxiety, stress, and overall strain. The
three techniques administered weekly include: (a) a home-based educa-
tional literature “tip of the week” group (LG), (b) a caregiver’s support
group (SG), and (c) a creative-movement group (MG). Based on a review of
caregiving literature, no previous studies have utilized an LG intervention
technique. Also, while creative movement is a newer intervention technique
for family caregivers, it has not been specifically used with midlife daugh-
ters providing informal care to frail mothers. The support-group interven-
tion is the most commonly used, proving to be effective in relieving
caregiver’s stress. The main goal of this research is to explore the benefits of
each of these interventions, as well as to compare the effectiveness of each
in relieving stress for midlife daughters providing care for their mothers.

The three specific research questions are:

1. Are LG, SG, and MG strategies effective in reducing caregiver irritability,
depression, anxiety, stress, and increasing concentration levels?

2. If so, which of the three intervention strategies is most effective in reducing
irritability, depression, anxiety, stress, and increasing concentration levels?

3. How is each intervention helpful and/or not helpful for midlife daughters
providing informal care to their frail mothers?

METHODS

Recruitment

Participants were recruited through flyers, e-mail, radio and newspaper
advertisements, telephone calls, and in-person visits to caregiver agencies,
hospitals, the Osher Lifelong Learning Institute (University of Connecticut
Waterbury Campus), and the University of Connecticut regional campuses.
Participants were selected based on the following qualifications: (a) individuals

Effects of Three Caregiver Interventions 65

were primary caregivers, (b) the caregivers were female and had to be at
least 40 years of age, and (c) the care-receivers were the mothers of the
caregiver. The caregivers were not randomly assigned to each of the inter-
vention groups; rather, they volunteered to participate in the intervention
group of their choice. All participants signed a consent form and received
instructions concerning their particular intervention group as well as the
questionnaires used to collect information each week.

Participants

The final sample (N = 16) consisted of middle-aged women, aged 42–72,
who were the primary caregivers for their frail mothers. The number
of daughters in each intervention group was: SG = 6, LG = 6, MG = 4. The
length of caregiving ranged between 3 to 18 years. The daughters assisted
their mothers in at least three of the following eight activities: personal care
(62.5%), emotional support (87.5%), housekeeping (75%), transportation
(87.5%), meal preparation (62.5%), laundry (66.3%), financial support
(43.8%), and helping with bills and paperwork (87.5%). The majority were
unable to carry out all tasks of daily living on their own (56.3%), and one-
quarter had some cognitive impairment (25%). The care-receivers ranged in
age between 63 and 95. See Table 1 for additional demographic information.

The study focused on midlife daughters as caregivers because research
shows that females make up 80% of all family caregivers, with daughters
most likely being the primary caregivers to their mothers (Cohler, 1997).

Measurement Instruments

In addition to a demographic questionnaire and a caregiver qualification
screener, two data-collection instruments were constructed by the research

TABLE 1 Participant Demographics

White 87.5%
Catholic 65.3%
Married 62.5%
Employed

Full-time 31.3%
Part-time 31.3%
Retired 37.5%

Household income of $50,000 63.0%
Graduate level education 43.8%
Mother’s living arrangement

Own home 37.5%
Living with daughter 31.3%
Living with other relatives 6.3%
Senior housing 6.3%

Mother’s widowed 75.0%

66 L. K. M. Donorfio et al.

team. The first was a weekly assessment consisting of five Likert-scale
questions and two open-ended questions asking participants to rate their
current levels of irritability, depression, anxiety, stress, and concentration.
The second was an end-of-program evaluation form consisting of three
open-ended questions aimed at evaluating participants’ perceptions of the
interventions.

Procedures

The participants in the LG were sent a weekly caregiving tip for 8 weeks,
compiled by the researchers and based on the popular literature targeted
for caregivers. They were asked to answer their questionnaires immedi-
ately when they arrived the next week with the next week’s “tip,” and to
mail their responses back in the enclosed self-addressed envelope. Some
of the caregiving tips concerned why it is important to take care of your-
self, defining the help you need, and techniques for relaxation and stress
relief.

The SG met once a week, 1.5 hours per week, for 9 consecutive weeks.
The sessions were led by a trained facilitator. The format consisted of one
topic being presented each week (based on the same caregiving tips used
for the LG), short exercises, group discussions, and weekly readings
assigned for the next week. Participants were also offered an opportunity
each week to discuss any topics they deemed relevant. The questionnaires
were administered at the beginning and end of each session to assess the
effectiveness of the intervention group.

Due to conflicts beyond the control of the researchers, two differ-
ent groups of women were involved in the MG intervention group. The
first MG met once a week for 1 hour for 9 weeks (n = 3). Toward the
end of the 3-month period, the research team decided to end this inter-
vention wave and to recruit another wave. The second MG began 1
month after the first group ended and initially consisted of three partic-
ipants. Within the first 3 weeks of the study, two of the participants
dropped out (n = 1).

Both MGs were led by a novice improvisational-movement facilitator
and guided through various movement exercises to help participants work
through the stressors and emotions associated with caregiving over time. A
function of creative movement is to provide an opening for expression by
transferring thoughts, feelings, and stressors, from memory to physical
action. The facilitator sought to guide the participants through movement
improvisations designed to tap into their memories and feelings associated
with events related to their caregiving experiences. The nature of the MG
intervention was to replace verbal discussions with movement experiences
to express thoughts. Weekly topics and tips, consistent with the previous
two groups, were also provided and discussed at the end of each session

Effects of Three Caregiver Interventions 67

before they went home. The questionnaires were administered at the
beginning and end of each session to assess the effectiveness of the
creative-movement intervention.

FINDINGS

The findings are divided into three sections. The first section presents the
findings from the weekly assessment Likert-scale questions for both the LG
and SG; because the MG was conducted with two waves over two periods
of time, these findings were not seen as being comparable for this assess-
ment. The second and third sections present for all groups the findings from
the weekly assessment open-ended responses and the end-of-program
evaluation assessment.

Weekly Assessment Likert-Scale Questions: Comparing Educational
and Support Groups

As part of the weekly assessment evaluation, participants were asked to rate
how helpful the previous week’s session was with respect to five mental
health variables: irritability, depression, anxiety, stress, and concentration.
Helpfulness was rated on a Likert-scale from 1 to 5 (1 = minimally helpful
to 5 = extremely helpful). Overall, the SG had higher average scores for
each of the five mental health variables than the LG.

Looking at each of the variables individually, the LG (see Table 2)
found their intervention most helpful with anxiety, while the SG found
their intervention most helpful with stress, depression, and anxiety (see
Table 3). An overall mental health score was compiled using all five vari-
ables. Results indicate that the SG (mean = 3.41) found their intervention
to be more helpful than the LG (mean = 1.72). Based on the results of the
data analysis, it can be concluded that the SG intervention was the more

TABLE 2 Literature Group Weekly Assessment Scores

Variables

Participants Irritability Depression Anxiety Stress Concentration
Overall Mental

Health

LG1 1.33 2.83 2.50 2.50 2.00 2.23
LG5 1.57 1.00 1.14 1.29 0.43 1.09
LG6 0.00 1.00 1.14 1.29 0.43 0.27
LG7 2.00 2.00 2.80 2.00 2.00 2.16
LG8 2.71 2.86 2.71 2.86 2.71 2.77
LG10 2.20 1.20 3.40 2.20 0.00 1.80
Average 1.64 1.73 2.15 1.81 1.27 1.72

68 L. K. M. Donorfio et al.

effective in reducing irritability, depression, anxiety, stress, and improving
concentration than the LG.

Weekly Assessment Open-Ended Responses: Comparing All Three
Interventions

Based on the majority of open-ended weekly responses gathered from
participants in the LG, the following two general themes emerged: (a)
New Information, and (b) Reinforcement of Existing Information. Com-
mon participant responses included: “Interesting information shared about
caregiving for it brought my attention to many new ideas and strategies”;
“It [the weekly tip] gave many different suggestions”; and “The informa-
tion was helpful because it reinforced what I already know.” No one par-
ticular weekly tip was found most useful by the majority of the
participants. While one participant found one or two tips extremely help-
ful, others commented that it did not apply to their specific situation or
“been there and done that.” Even though the participants gave very posi-
tive feedback concerning the usefulness of receiving the caregiving tips,
many wished the tips were more specifically applied to them and their
unique situation.

As compared to the LG, the SG had only one strong overarching
theme, labeled “Validation.” The majority of participants in this group found
this intervention rewarding because it was an opportunity to “talk, listen,
and share,” to be able to “vent in a safe environment,” and to “realize I am
not alone.”

Like the SG, the MG had only one overarching theme, labeled “Relax-
ing.” This actual word appeared most often in the participant’s weekly
responses. Some participants commented that this intervention “helped my
depression,” was “time to myself,” and “loosened me up and warmed my
stiff muscles.” Another shared, “I was able to express myself in different
way, and it helped me relax in a different way.”

TABLE 3 Support Group Weekly Assessment Scores

Variables

Participants Irritability Depression Anxiety Stress Concentration
Overall Mental

Health

SG1 2.17 1.67 2.17 2.50 2.17 2.14
SG5 4.88 4.88 4.88 4.88 4.88 4.88
SG6 5.00 5.00 5.00 5.00 5.00 5.00
SG7 3.40 4.00 3.40 4.00 3.50 3.66
SG8 3.25 3.50 3.50 3.25 3.25 3.35
SG10 1.50 1.75 1.50 2.25 0.00 1.40
Average 3.37 3.47 3.41 3.65 3.13 3.41

Effects of Three Caregiver Interventions 69

2End-of-Program Evaluation: Comparing All Three Interventions

QUESTION #1: WHAT DID YOU LIKE MOST ABOUT PARTICIPATING IN YOUR SPECIFIC
INTERVENTION GROUP?

The LG indicated that they liked the reinforcement, knowing they were not
alone, and the helpful tips. They liked to learn new information that could
help them in their caregiving situation. They also were glad to see that some
of what they were doing was considered the “right thing” and that others
were going through similar problems while caregiving. The SG indicated
that both interaction and comradery were provided and that the sharing of
positive and negative caregiving experiences with each other was their
favorite aspect of this particular intervention. As one participant shared, “It
was very meaningful for me to share with the others, especially because
they knew what I was going through because their situations were similar.
We had this unspoken connection.” The MG indicated that their interven-
tion served as an “expressive outlet.” Participants felt the creative movement
sessions helped them relax and feel energized.

QUESTION #2: WHAT DID YOU LIKE LEAST ABOUT PARTICIPATING IN YOUR SPECIFIC
INTERVENTION GROUP?

The LG indicated that many of the caregiver tips were not “specific enough”
or “did not apply enough” to their caregiving situation to be useful. They
suggested that future LG participants receive tips that are more individual-
ized. The SG felt that the intervention was too short, in terms of the number
of meeting sessions, and that future groups should last longer. Because of
this request, it was suggested that the women form relationships outside of
the weekly support group meeting. A phone and e-mail tree was created
that they began to utilize after intervention ended. The MG did not list any
responses for what they liked least about participating in their specific inter-
vention group.

QUESTION #3: WOULD YOU PARTICIPATE IN YOUR INTERVENTION GROUP AGAIN
AND WHY?

All three groups indicated that they would enroll in their respective inter-
vention group again. The LG expressed that they would participate again
because the intervention was “informative” and “reflective.” The SG
expressed that they would participate again because of the “support” they
received while in the group, both inside and outside of the meeting. It
seemed that the meetings created a reservoir from which they could draw
until the next meeting. Some even indicated that when they became frus-
trated, they would think about what the other caregivers would do or rec-
ommend. Some would think ahead to the next meeting, “counting the days

70 L. K. M. Donorfio et al.

down,” to help them get through the week. The MG indicated that they
would participate in their intervention group again because they found the
sessions to be a “relaxing,” “energizing,” and an “expressive outlet.”

LIMITATIONS

A major limitation of the current study was the overall small sample size,
especially for the creative-movement intervention group (MG: n = 4). Such
a small sample size did not allow for comparisons to be made among the
three intervention strategies. In addition, the small sample did not allow the
findings to be generalized to the larger population of midlife daughters car-
ing for their elderly mothers.

A second limitation of this study was that it concentrated only on
mother and daughter caregiving pairs. Although the caregiving literature at
large also concentrates on daughters and mothers, with very little on other
caregiving pairs, future research will benefit by examining the dynamics
between other caregiving pairs and identifying the most beneficial interven-
tions (Cohler, 1997). Future research should approach this area from a fam-
ily perspective, rather than just the caregiving dyad, since informal
caregiving often involves many family members and secondary caregivers.

A third limitation is that there was no way of knowing how thoroughly
the LG read and understood the caregiving tips and how this affected the
weekly assessment survey. A fourth limitation was the homogeneous sam-
ple. The majority of the sample was White, highly educated, and had an
income of $50,000 per year or more. Consequently, the findings cannot be
generalized to other populations of caregiving daughters and care-receiving
mothers of other ethnic and socioeconomic backgrounds.

DISCUSSION

The review of the caregiving intervention literature shows that the home
literature and the creative-movement formats are new to the family care-
giver intervention field. On the other hand, the support group format is the
most commonly employed intervention targeting individual family caregiv-
ers (Callahan et al., 2006; Claxton-Oldfield et al., 2007; Drentea et al., 2006;
Gitlin et al., 2005; Marziali & Donahue, 2006; Smith & Toseland, 2006; Stewart
et al., 2006). Only one study by Eisdorfer et al. (2003) used education mate-
rials in conjunction with a support group as part of the intervention. Previ-
ous studies have found positive outcomes for support groups lowering
depression and stress among family caregivers. The weekly Likert-scale
awareness surveys showed that the women benefited from being in their
respective intervention groups.

Effects of Three Caregiver Interventions 71

The review of the literature also showed that the most common goal of
the previously used interventions was teaching caregivers stress manage-
ment and problem-behavior management skills. The main goal of this
research was to evaluate which of the three interventions was most effective
in reducing caregiver irritability, depression, anxiety, stress, and in increas-
ing concentration levels among midlife daughters. Results of the weekly
assessment instrument indicated that the SG had higher average scores for
each of the five mental health variables. Participants in the LG found their
intervention most helpful with depression and anxiety, while the SG found
their intervention most helpful with stress, depression, and anxiety. The five
mental health variables were combined to produce an overall mental health
score. The overall mental health scores were 1.72 for LG and 3.41 for SG,
indicating that the support-group intervention had a more positive effect on
the caregivers’ mental health than the home-based intervention. As men-
tioned previously, the MG was not compared to the other two groups due
to recruitment difficulties.

When asked what they liked most about participating in their specific
intervention group, the LG participants indicated that they liked learning new
information, knowing they were not alone, and glad to see that what they
were doing was considered the “right thing” by other caregivers participating
in their group. The intervention seemed to provide reinforcement for their
existing knowledge about caregiving practices and to provide new caregiving
information. It is important to point out that while the participants gave very
positive feedback concerning the usefulness of receiving the caregiving tips,
many wished the tips more specifically applied to them and their unique situ-
ation. The SG participants specifically liked the interaction and comradery
and the sharing of positive and negative caregiving experiences.

The MG participants indicated that the most important outcome for
them was that their intervention served as an “expressive outlet” and helped
them feel relaxed and energized. These responses were similar to responses
made by caregivers in the most recent dance improvisation research of
Vetter and Myllykangas (2008). Caregiving participants called it “the hour of
freedom.” They indicated that it helped with relaxation and better sleep. It
was difficult to determine if the end results of the MG in the present study
were due to the creative-movement exercises alone. Frequently, participants
began with movement and then added verbal expression, which was a nat-
ural response for individuals unfamiliar with movement improvisation. This
is not atypical in the dance-movement literature. In one of Sandel’s (1994)
dance-movement therapy groups, a participant began singing while moving
and the others in the group joined and formed a chorus. Similarly, Truitt
(1996) found dance combined with verbal expression completed the recol-
lections of the actors and actresses used in the script for the audience.

Overall, each of the intervention groups was considered successful to
some degree, with all participants indicating that they would enroll in their

72 L. K. M. Donorfio et al.

respective intervention group again in the future. The LG enjoyed gaining
new knowledge related to caregiving but wished it were more specific to
their particular situation. The SG enjoyed each other’s company, the open
and nonthreatening atmosphere, and the knowledge that others were going
through the same thing they were. They felt the length of the intervention
was too short and hoped it was longer or could be started up again after a
short break. The MG thought their intervention was relaxing and enjoyed
the time to themselves, but because it was the first time they participated in
such an intervention, they were unclear about where the sessions were
going or what they were expected to achieve by the end.

FUTURE RESEARCH

Future research needs to recruit larger and more representative groups of
participants in all of the intervention conditions. A larger sample would
allow comparisons among groups as well as increase the generalizeability
of results to more caregivers. In addition, because the creative-movement
and home-based interventions are relatively new in the field, future research
should modify these programs to best fit the specific needs of diverse popu-
lations. In an effort to create a more individualized intervention, future
research could recruit more diverse types of caregivers, such as caregivers
for individuals with Alzheimer’s or Parkinson’s disease.

Also of particular interest is the use of creative-movement improvisation
with caregiving dyads. Only one previous study implemented a creative-arts
intervention with family caregivers of patients with cancer (Walsh et al.,
2004). This intervention consisted of caregiver and care-receiver pairs engag-
ing in drawing, painting, and making collages. The study showed a significant
reduction in stress and anxiety and an increase in positive emotions of the
dyads following their participation in the study. Also, caregivers and care-
receivers expressed an increase in positive communication as a result of the
creative-art processes. Future research is needed to explore the potential that
creative movement can have the same impact as other art therapy.

Future research should consider combining strategies into different
hybrid interventions in order to target more specific populations of caregiv-
ing dyads. Combining this approach with targeting different caregiving
populations will increase effectiveness for the greatest number.

APPLICATION OF THE STUDY

The current study does have promising application for the development of
future intervention programs for family caregivers. The weekly assessment
instrument evinces that the SG intervention is effective in reducing irritability,

Effects of Three Caregiver Interventions 73

depression, anxiety, and stress. Also, all participants indicated that they
found their intervention helpful in coping with caregiving. Consequently,
because participants generally had positive feedback regarding their inter-
ventions, it is believed that similar types of intervention programs can be
beneficial to caregivers. These interventions, or a hybrid form combining
more than one intervention, could be easily implemented in different insti-
tutions found in communities, such as senior centers, recreational facilities,
work environments, and assisted living facilities.

Although support groups are the most common intervention method
used for caregivers (Claxton-Oldfield et al., 2007; Marziali & Donahue, 2006;
Smith & Toseland, 2006; Stewart et al., 2006), other types of interventions
can also be useful. For example, some caregivers may prefer a type of inter-
vention that is similar to the LG because of its convenience and flexibility,
while others may prefer an intervention that requires more physical involve-
ment such as the MG intervention. Zwerling (1989) argues that because
creative-art therapies employ nonverbal techniques, they more directly con-
nect to emotional processes than more traditional verbal therapies. He
argues that creative-art therapies directly evoke responses at a level that
psychotherapists may not reach.

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439

Administration in Social Work, 33:439–449, 2009
Copyright © Taylor & Francis Group, LLC
ISSN: 0364-3107 print/1544-4376 online
DOI: 10.1080/03643100903173040

WASW0364-31071544-4376Administration in Social Work, Vol. 33, No. 4, Jul 2009: pp. 0–0Administration in Social Work

Standardizing Practice at a Victim
Services Organization: A Case Analysis

Illustrating the Role of Evaluation

Standardizing Practice at a Victim Services OrganizationM. Larsen et al.

MANDI LARSEN
Institut für Rechtsmedizin, Universitätsklinikum Hamburg-Eppendorf, Germany

COREY TAX and SHELLY BOTUCK
Safe Horizon, New York, New York, USA

This paper provides an example of how an internal evaluation
department at a midsize victim services organization led key
activities in achieving strategic organizational goals around
unifying service delivery and standardizing practice. Using the
methods of logic model development and naturalistic observation
of services, evaluation staff guided the clarification of program
expertise and outcomes, and assessed the necessary resources for
standardizing practice.

KEYWORDS program evaluation, standardized practice, victim
services, logic models, observation

There is little question that there is a growing demand for program evalua-
tion data at nonprofit organizations, stemming from government, founda-
tions, and other funding sources that want to know the impact of the
programs they are supporting and that require demonstrations of effective-
ness (Botcheva, White, & Huffman, 2002; Carman, 2007; Newcomer, Hatry, &
Wholey, 2004). This focus on accountability to funders is also an opportunity
for organizations to learn what services work best through evidence collec-
tion for outcome measurement (Botcheva et al., 2002; Buckmaster, 1999).
An organization’s ability to use this evidence and make strategic manage-
ment decisions that are evidenced-based or informed is essential in an

Address correspondence to Shelly Botuck, Safe Horizon, 2 Lafayette Street, 3rd Floor,
New York, NY 10007, USA. E-mail: [email protected]

440 M. Larsen et al.

increasingly competitive environment for funding (Menefee, 1997; Neuman,
2003; Proehl, 2001).

Despite the increased focus on evaluation from funders, limited
resources make it difficult for nonprofit organizations to carry out evalua-
tion (Hoefer, 2000). A study by Carman (2007) found that very few organi-
zations have the discretionary funds necessary to employ internal evaluation
staff members. This is in part because demands for evaluation can often
seem like detractions from the service provision, especially when funding
for services is limited (Kopczynski & Pritchard, 2004; Neuman, 2003). Poorly
developed information systems and high staff turnover at many social
service organizations also present barriers to implementing evaluation that
demonstrates program improvement over time, both in terms of data collec-
tion and institutional memory (Kopczynski & Pritchard, 2004). As a result,
organizations focus on counting products or services provided through the
activities of the organization (e.g., number of counseling sessions, number
of trainings conducted) in an attempt to meet funder demands (Carman,
2007). This emphasis on outputs can shift the focus from achieving the
mission of the organization to counting services, and may take attention
away from case documentation that could be used to monitor practice and
assess client outcomes. Despite all of these barriers, evaluation is still the
key to understanding the effects of programs and services. Thus, the
challenge lays in making evaluation useful to organizations, because
without an appreciation of its value and worth, program evaluation will not
be efficacious (Chelimsky, 1994).

Using Safe Horizon’s community and criminal justice programs (CCJP)
as an example,1 this paper provides a case analysis illustrating the role of
evaluation in furthering the implementation of our organization’s strategic
plan. It focuses on two key activities, logic modeling and assessing program
practice, and highlights the ways that these activities assisted Safe Horizon
in standardizing service delivery.

ORGANIZATIONAL CONTEXT

Founded in 1978, Safe Horizon’s mission is to provide support, prevent
violence, and promote justice for victims of crime and abuse, their families,
and communities. Safe Horizon is New York City’s leading victim assistance
organization delivering services to victims of domestic violence, sexual
assault, child abuse, stalking, human trafficking, and other crimes through
programs in the family and criminal courts, police precincts, child advocacy
centers, schools, and other locations. Safe Horizon also operates domestic
violence shelters; New York City’s 24-hour domestic violence, rape, and
sexual assault hotlines; drop-in centers and emergency shelters for home-
less and street-involved youth; case management services; and specialized

Standardizing Practice at a Victim Services Organization 441

mental health programs. Victims’ program involvement may last minutes or
years. Safe Horizon’s primary service obligation is to provide victims of
crime and abuse with the resources and tools needed to maximize their
personal safety and reduce their risk of further harm, whatever the presenting
victimization or service setting.

Safe Horizon’s leadership has long recognized the importance of inter-
nal research and evaluation. As Whyte (1989) noted, when knowledgeable
stakeholders conduct research, they can report on practices without the
distortion caused by the presence of an outside observer. However, external
funds obtained to answer macro social science and criminal justice ques-
tions dictated most of Safe Horizon’s research and evaluation activities. As a
result, these activities rarely informed day-to-day direct practice or service
delivery. Additionally, it was difficult to agree on measurable outcomes for
victims of violence. This was due in part to the context of traditional victim
services programs, which are often designed to prevent a negative event
from occurring (reabuse), and where the approach often holds that “the
survivor is not responsible for preventing, and is indeed often unable to
prevent, this negative event from occurring regardless of her actions”
(Sullivan & Alexy, 2001, p. 1).

Thus, as a first step in establishing evaluation that would directly
inform practice, while acknowledging the challenges of establishing
outcomes, program evaluation focused on victim satisfaction surveys. This
was helpful in improving practice and began collaboration between evalua-
tion and program staff. This also built a foundation for trust and understand-
ing that would become important in engaging with programs in thinking
about outcomes beyond victim satisfaction.

Over the course of three decades, Safe Horizon grew into a midsize
organization with the capacity to serve a wide range of victims in disperse
settings, and each program determined its own method for assessing victim
needs. As a result, the organization’s service delivery and documentation
practices were decentralized and varied. In 2003, this was addressed in the
organization’s strategic plan with the goal of unifying service delivery to
ensure coordinated and high-quality services.

Standardized practice is the creation of uniformity in the definitions,
training, staff role, and procedures for common practices within a discipline
or organization, which is “intended to promote the effectiveness of practice,
reduce variability in implementing best practice, [and] increase the predict-
ability of practice behaviors” (Rosen & Proctor, 2003, p. 1). Using our safety
assessment and risk management policy (Safe Horizon, 2007) to standardize
practice, Safe Horizon began its first steps towards unifying service delivery
and creating a continuum of care across programs. This policy places a
“victim’s needs, wishes, resources, and capacities at the center of client
work,” and thereby sets a “standard for a dynamic and collaborative process
to address the complex challenges that victims of crime or abuse face” (Tax,

442 M. Larsen et al.

Vigeant, & Botuck, 2008, pg. 6). The policy provides a framework that
acknowledges change in a victim’s risk over time, while also integrating
both the staff’s knowledge and the victim’s perspective into the safety plan-
ning process. Its implementation requires attention around standardization
because the policy emphasizes “a standard of care that will be upheld
across the organization,” while still recognizing that “specific aspects of
implementation will depend on the program and the services offered by
that program” (Safe Horizon, 2007, p. 2).

To prepare to implement the policy in a way that would unify service
delivery across programs, evaluation staff engaged CCJP in a number of key
activities, the first of which was the development of logic models. These
were intended as blueprints defining the expertise, activities, and goals of
each program, clarifying how programs work together, and setting up a
framework for monitoring program practice. To identify the necessary
resources for implementing standardized practice, evaluation staff assessed
program practice to determine to what extent the skills and practices
outlined in the policy were already taking place.

LOGIC MODEL DEVELOPMENT

McLaughlin and Jordan (2004) have described logic models as “the basis for
a convincing story of the program’s expected performance, telling stake-
holders and others the problem the program focuses on and how it is
uniquely identified to address it” (p. 8) through a visual representation of a
program’s resources, activities, outputs, and a range of outcomes. “A logic
model provides a blueprint that delineates all the elements of the program
that need to be documented in order to fully understand the program”
(Conrad, Randolph, Kirby, & Bebout, 1999, p. 20) and represents how a
specific set of resources and activities will bring about intended outcomes.
Logic models are useful tools in pinpointing inconsistencies or redundan-
cies, as well as determining whether activities are still relevant to program
goals. Conrad et al. (1999) also noted the usefulness of logic models for
bringing the perspectives of various program stakeholders to consensus,
which can serve to establish clear and measurable expectations for a
program and a common understanding of staff roles and function across an
organization (McLaughlin & Jordan, 2004).

In order to integrate the service delivery model into the organizational
culture and everyday decision making, the logic model development
process aimed to ensure buy-in at all levels. Evaluation staff (namely, the
authors) met with all levels of program management. Prior to these
meetings with CCJP leaders and site supervisors, evaluation staff reviewed
current funding reports and objectives and investigated reporting and
documentation mechanisms in order to gain an initial understanding of

Standardizing Practice at a Victim Services Organization 443

resources and program activities. This served as preparation for building an
overall logic model with CCJP leaders to define the vision for this cluster of
programs.

Initial meetings with CCJP leaders included discussions about resources
(e.g., funding, staff expertise, external partners, documentation systems)
and activities, but primarily centered upon the expectations and vision for
this cluster of programs. This focus on vision was only possible given the
mutual trust and understanding previously built between evaluation and
program staff. Due to previous negative experiences in tying program
success to the actions of outside systems or the actions of the offender (e.g.,
receiving an order of protection, successful prosecution of the offender,
placement in a domestic violence shelter, desistance of violent behavior),
CCJP leaders voiced a general reluctance to define victim outcomes. Given
this reluctance and the challenges inherent in establishing and operational-
izing outcomes at social service organizations (Neuman, 2003), extra time
was devoted to discussing meaningful program outcomes that accurately
assess whether the program is having its intended effect. Over the course of
these discussions, consensus on appropriate outcomes was achieved
through continual grounding in the policy, which was centered upon the
organization’s guiding principles and the commitment to “support and
promote our client’s self-determination, dignity, and empowerment in a
compassionate, non-judgmental environment” (Tax et al., 2008, p. 14). With
this grounding, evaluation staff and CCJP leaders developed victim
outcomes that were not dependent upon outside actors, but measured pro-
gram success through individual victim change. These outcomes, along with
quality assurance of standardized practices, have the potential to inform
program practice by their measurement.

After developing a draft based on these discussions, evaluation staff led
CCJP leaders through the refinement and vetting of the CCJP logic model
during a daylong off-site work retreat. In this focused setting, the group
walked step-by-step through the logic model, critiquing and offering
suggestions for revision. The end result was an overall logic model of CCJP
resources and services with victim outcomes that CCJP leaders expected
would result from a victim’s involvement with the CCJP cluster.

The next task in creating a blueprint for unified service delivery was
the development of a logic model for each of the four main programs in this
cluster to clarify each program’s expertise and to define the roles the pro-
grams should play in a unified service delivery model. Separate discussions
were held with site supervisors from each of the programs (these programs
have five sites, one in each borough of New York City), walking through
the overall CCJP logic model and breaking down the aspects specific to
their program. Document review and discussions with site supervisors
revealed that programs performed similar activities, but that these activities
were conducted slightly differently in each program. For example, information

444 M. Larsen et al.

provided in a police program focused on police processes, while informa-
tion provided in a criminal court program focused on court processes. The
expected outcome of information provision (that the victim will be able to
strategize and make informed decisions about their situation) remained the
same across the CCJP, but the differences in program expertise were clear.
Evaluation staff incorporated these commonalities and differences into the
initial logic model drafts for each of the programs, totaling four logic models
altogether.

Evaluation staff presented these drafts back to CCJP leaders for vetting,
walking step-by-step through each program logic model and considering
the following questions: Were there gaps in services that needed to be
addressed in order to better fit the vision of providing a continuum of care
to victims through integrated expert programs? Which services currently
offered should change? For example, while all site supervisors indicated
performing some type of community outreach, CCJP leaders did not feel
that this activity was within the appropriate scope of activities for the court
programs. They agreed that community outreach seemed beyond the goals
of court programs, whose aim is to serve those already involved in the court
systems and who do not receive any funding for outreach activities. CCJP
leaders felt that community outreach should be concentrated in the police
and community-based programs, which play an important role in ensuring
community members are aware of the services offered at Safe Horizon.

Another round of revisions resulted in four individual program logic
models that represented the vision for service delivery for the CCJP cluster.
To continue fostering a sense of ownership of these logic models, CCJP
leadership presented the models to site supervisors. This allowed for the
gathering of feedback and also allowed them to be on hand to answer
questions about strategic decisions made about standardizing services. By
the end of the logic-model development process, clear and measurable
expectations for programs were established, as was a common understanding
of staff roles and function across the CCJP.

ASSESSING PROGRAM PRACTICE

To assess the extent to which the skills outlined in the new policy were
already occurring in day-to-day program practice, observation of service
delivery and its documentation across Safe Horizon’s point-of-entry
(gateway) programs was conducted over a two-month period. In the
absence of documentation that would clearly reflect current practice,
prudent use of naturalistic observation—where behavior is observed in its
natural environment and is recorded in a manner that is as unobtrusive as
possible (Angrosino, 2007)—can provide a representative sample of service
delivery.

Standardizing Practice at a Victim Services Organization 445

Based on designated performance indicators of the new risk and safety
policy, an observation tool (see Appendix for a detailed explanation) was
developed by evaluation staff that would collect information that could: (a)
describe current practice, (b) identify differences in practice across programs,
(c) examine how practice(s) apply to different types of victim interactions,
and (d) inform decision making about future staff training.

Over a three-week period, four observers, which included evaluation staff
and interns, were trained by one of the authors to assess client interactions
according to a standard and to match to his observations for all sections of the
tool. This necessarily included a common understanding and definition of
service delivery (e.g., referral, linkage, supportive counseling, crisis interven-
tion, etc.), as well as how to be unobtrusive during observations and how to
keep appropriate boundaries with victims and staff. A 90% level of inter-rater
agreement was established between each of the four observers and the trainer.

All of the observations were scheduled in advance. Every effort was
made to ensure that the service delivery was representative of typical
sessions and workloads and did not underestimate the frequency or inten-
sity of service delivery. Observers refrained from inferring anything about
service delivery and gathered information from only directly observed staff
comments, actions, or responses to a victim. Observations were always
conducted by one observer at a time. Upon arrival at the site, the site super-
visor would introduce the observer to the staff and explain what he or she
would be doing. To gain the consent of the clients before observing a case
management interaction or counseling session, the case manager would
introduce the observer to the client and explain the process, emphasizing
that the observer was there to observe service provision only.

The data from the observations were entered into an SPSS database,
and frequencies were calculated. Twenty program sites were observed for
approximately 208 hours, totaling 213 victim interactions (162 telephone
and 51 face-to-face interactions).

The analysis of these observations revealed that expected practices
were not occurring at the frequency anticipated. Victim safety concerns
were documented, and observers noted that the need for assistance was
complex and ongoing (Vigeant, Tax, Larsen, & Botuck, 2008). Additionally,
even within the same program at different delivery sites, service provision
often had wide variability in both practice and documentation. As a result,
clients with identical presenting needs might be offered different services
depending on which program site they happened to walk into.

DISCUSSION

Evaluation activities, which included the development of logic models and
the assessment of current practice, identified gaps between the organization’s

446 M. Larsen et al.

vision for unified service delivery as identified in its strategic goals and
current practice. This pointed to additional resource needs that were not
anticipated in the original planning. The findings also revealed practice real-
ities that included considerable variability in service delivery and documen-
tation, lower than expected frequency of specific activities, and complex
client need. These findings pointed to a need for changes in existing imple-
mentation plans.

The development of logic models served to bring staff with a range of
education, experience, and expertise closer to consensus around program
practices, services offered, and victim outcomes. Walking through the
models with CCJP leaders and site supervisors necessarily focused the dis-
cussion around variation in program practice. It was not unusual for there
to be a variety of perspectives on program functioning, a lack of shared
information across sites, and a variety of documentation systems. This process
brought to the forefront the current resources, expertise, and abilities of
individual programs. The substantial variation in practice revealed the need
for in-depth clarification of roles within each program before implementing
standardized practice, a step that had not been adequately accounted for in
existing plans.

The observation of services confirmed variations in practice alluded to
during logic model discussions. While program observation required a
significant amount of time and resources, the time (and cost) provided
information that clearly indicated the need for significant ongoing training
and support in critical skill areas required to implement the risk manage-
ment policy according to the intended standard (e.g., addressing barriers,
allowing clients to determine risk factors, building risk management on
client’s current protective actions, tailoring plans to fit clients).

Providing this level of support to staff will require increased partner-
ship among different departments within the organization and will include:
the creation of appropriate training curricula and materials; the develop-
ment of staff trainers; the establishment of accountability monitoring mecha-
nisms (quality assurance indicators); and the creation of a closer exchange
between programs and information technology so that electronic documen-
tation systems reflect (or enhance) staff workflow.

Another implication of the variability in practice is in thinking about the
role of supervisors. The findings reinforce the importance of providing
ongoing training and supports for supervisors so that they are able to effec-
tively carry out their roles. Wilkins (2003) has described the deleterious
effects on line staff when frontline supervisors are unable to provide guid-
ance and assistance in problem solving. This is particularly true in organizations
where there are limited resources for staff development and increased
needs for services. Moreover, the competence and value of frontline super-
visors are vital to achieving the goals of service organizations (Burchard,
Gordon, & Pine, 1990; Haas & Robinson, 1998) and in preventing direct

Standardizing Practice at a Victim Services Organization 447

service staff from burnout and vicarious trauma (Baird & Jenkins, 2003;
Pearlman & Saakvitne, 1995).

In conclusion, evaluation activities helped determine the resources and
first steps in implementing strategic organizational goals around unifying
service delivery and implementing standardized practice. Logic model
development fostered discussion of program expertise and promoted a
shared understanding of standardized practices. These activities, which
served to focus service delivery, were successful in furthering the imple-
mentation of our organization’s strategic plan. Naturalistic observations
served to create a picture of service delivery and helped identify the
resources necessary to standardizing practices. Although internal evaluators
could present a potential bias, we believe that using internal evaluators
familiar with the programs and staff actually facilitated the evaluation activi-
ties. The foundation of mutual trust and understanding between evaluation
and program are key to overcoming barriers and establishing meaningful
outcomes.

NOTE

1. CCJP consists of four distinct programs, each one located in each of the five boroughs of
New York City. Each program within CCJP partners with, is regulated by, and may share space with
criminal justice and community systems and structures that vary considerably from borough to borough.

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Vigeant, M., Tax, C., Larsen, M., & Botuck, S. (2008, February). Rethinking risk and
safety with victims of crime and abuse. Poster session presented at the
American Psychological Association’s summit on violence and abuse in
relationships: Connecting agendas and forging new directions, Bethesda, MD.

Standardizing Practice at a Victim Services Organization 449

Whyte, W. F. (1989). Advancing scientific knowledge through participatory action
research. Sociological Forum, 4(3), 367–385.

Wilkins, E. (2003). Building a committed and effective workforce through strengthen-
ing skills of frontline managers. Retrieved on July 31, 2008 from Aon Consulting
Worldwide. http://www.ecustomerserviceworld.com

APPENDIX

Observation Tool Assessment Areas

Greeting: Assessed whether staff greeted clients warmly and introduced
themselves as employees of Safe Horizon. (1 item)

Identifying Information: Captured what identifying information (e.g.,
name, date of birth, social security number, address, phone number) was
obtained and whether the information was confirmed in accordance with
current training. (12 items)

Interaction Measures: Captured specific information about the interac-
tion that might impact the service delivery, including the location of the
interaction; people present during the interaction; whether the interaction
was a scheduled appointment; whether it took place on the phone or was
face-to-face; the time the interaction began and ended; and the number of
staff-initiated interruptions. Another set of interaction measures included the
observer’s assessment as to the level of assistance the observer perceived
the client to be seeking, and whether the client was in distress. Notation
regarding whether the staff person behaved in a professional manner was
also included in this section. (10 items)

Victimization Assessment: Captured whether staff assessed client
victimization and, if so, to what extent. This included whether staff assessed
for victimization type, whether the client was a primary or secondary victim,
information about the offender, recent incident details, duration, scope,
system involvement, and prior victimizations. (2 items)

Safety Assessment: Examined whether staff performed a safety assess-
ment by capturing initial safety assessment, as well as assessments of
current safety concerns, client protective actions, client resources and
stressors, and client coping skills. (9 items)

General Skills: Explored whether staff utilized specific skills during
client interactions, such as crisis intervention skills, general assessment
skills, and engagement skills. (20 items)

Services: Examined which services staff provided to the client, and
whether services were provided via exploration, information, referral,
advocacy, and/or linkage. (46 items)

Excerpts from Measuring Program Outcomes: A Practical Approach
© 1996 United Way of America

Introduction to Outcome Measurement

If yours is like most human service agencies or youth- and family-serving organizations, you regularly
monitor and report on how much money you receive, how many staff and volunteers you have, and what
they do in your programs. You know how many individuals participate in your programs, how many hours
you spend serving them, and how many brochures or classes or counseling sessions you produce. In
other words, you document program inputs, activities, and outputs.

Inputs include resources dedicated to or consumed by the program. Examples are money, staff and staff
time, volunteers and volunteer time, facilities, equipment, and supplies. For instance, inputs for a parent
education class include the hours of staff time spent designing and delivering the program. Inputs also
include constraints on the program, such as laws, regulations, and requirements for receipt of funding.

Activities are what the program does with the inputs to fulfill its mission. Activities include the strategies,
techniques, and types of treatment that comprise the program’s service methodology. For instance,
sheltering and feeding homeless families are program activities, as are training and counseling homeless
adults to help them prepare for and find jobs.

Outputs are the direct products of program activities and usually are measured in terms of the volume of
work accomplished–for example, the numbers of classes taught, counseling sessions conducted,
educational materials distributed, and participants served. Outputs have little inherent value in
themselves. They are important because they are intended to lead to a desired benefit for participants or
target populations.

If given enough resources, managers can control output levels. In a parent education class, for example,
the number of classes held and the number of parents served are outputs. With enough staff and
supplies, the program could double its output of classes and participants.

If yours is like most human service organizations, you do not consistently track what happens to
participants after they receive your services. You cannot report, for example, that 55 percent of your
participants used more appropriate approaches to conflict management after your youth development
program conducted sessions on that skill, or that your public awareness program was followed by a 20
percent increase in the number of low-income parents getting their children immunized. In other words,
you do not have much information on your program’s outcomes.

Outcomes are benefits or changes for individuals or populations during or after participating in program
activities. They are influenced by a program’s outputs. Outcomes may relate to behavior, skills,
knowledge, attitudes, values, condition, or other attributes. They are what participants know, think, or can
do; or how they behave; or what their condition is, that is different following the program.

For example, in a program to counsel families on financial management, outputs–what the service
produces–include the number of financial planning sessions and the number of families seen. The
desired outcomes–the changes sought in participants’ behavior or status–can include their developing
and living within a budget, making monthly additions to a savings account, and having increased financial
stability.

In another example, outputs of a neighborhood clean-up campaign can be the number of organizing
meetings held and the number of weekends dedicated to the clean-up effort. Outcomes–benefits to the
target population–might include reduced exposure to safety hazards and increased feelings of
neighborhood pride. The program outcome model depicts the relationship between inputs, activities,
outputs, and outcomes.

Note: Outcomes sometimes are confused with outcome indicators, specific items of data that are tracked to measure how well a
program is achieving an outcome, and with outcome targets, which are objectives for a program’s level of achievement.

For example, in a youth development program that creates internship opportunities for high school youth, an outcome might be that
participants develop expanded views of their career options. An indicator of how well the program is succeeding on this outcome
could be the number and percent of participants who list more careers of interest to them at the end of the program than they did at
the beginning of the program. A target might be that 40 percent of participants list at least two more careers after completing the
program than they did when they started it.

Program Outcome Model

Resources dedicated
to or consumed by
the program
money
staff and staff time
volunteers and
volunteer time

facilities
equipment and
supplies

Constraints on the
program
laws
regulations
funders’ requirements

What the program
does with the inputs
to fulfill its mission
feed and shelter
homeless families
provide job training
educate the public
about signs of child
abuse
counsel pregnant
women
create mentoring
relationships for youth

The direct products of
program activities
number of classes
taught
number of counseling
sessions conducted
number of educational
materials distributed
number of hours of
service delivered
number of participants
served

Benefits for
participants during
and after program
activities
new knowledge
increased skills
changed attitudes or
values

modified behavior

improved condition
altered status

Why Measure Outcomes?

In growing numbers, service providers, governments, other funders, and the public are calling for clearer
evidence that the resources they expend actually produce benefits for people. Consumers of services and
volunteers who provide services want to know that programs to which they devote their time really make a
difference. That is, they want better accountability for the use of resources. One clear and compelling
answer to the question of “why measure outcomes?” is to see if programs really make a difference in the
lives of people.

Although improved accountability has been a major force behind the move to outcome measurement,
there is an even more important reason: to help programs improve services. Outcome measurement
provides a learning loop that feeds information back into programs on how well they are doing. It offers
findings they can use to adapt, improve, and become more effective.

This dividend doesn’t take years to occur. It often starts appearing early in the process of setting up an
outcome measurement system. Just the process of focusing on outcomes–on why the program is doing
what it’s doing and how participants will be better off–gives program managers and staff a clearer picture
of the purpose of their efforts. That clarification alone frequently leads to more focused and productive
service delivery.

Down the road, being able to demonstrate that their efforts are making a difference for people pays
important dividends for programs. It can, for example, help programs:

• Recruit and retain talented staff
• Enlist and motivate able volunteers
• Attract new participants
• Engage collaborators
• Garner support for innovative efforts
• Win designation as a model or demonstration site
• Retain or increase funding
• Gain favorable public recognition

Results of outcome measurement show not only where services are being effective for participants, but
also where outcomes are not as expected. Program managers can use outcome data to:

• Strengthen existing services
• Target effective services for expansion
• Identify staff and volunteer training needs
• Develop and justify budgets
• Prepare long-range plans
• Focus board members’ attention on programmatic issues

To increase its internal efficiency, a program needs to track its inputs and outputs. To assess compliance
with service delivery standards, a program needs to monitor activities and outputs. But to improve its
effectiveness in helping participants, to assure potential participants and funders that its programs
produce results, and to show the general public that it produces benefits that merit support, an agency
needs to measure its outcomes.

These and other benefits of outcome measurement are not just theoretical. Scores of human service
providers across the country attest to the difference it has made for their staff, their volunteers, their
decision makers, their financial situation, their reputation, and, most important, for the public they serve.

Eight Steps to Success

Measuring Program Outcomes provides a step-by-step approach to developing a system for measuring
program outcomes and using the results. The approach, based on methods implemented successfully by
agencies across the country, is presented in eight steps, shown below. Although the illustration suggests
that the steps are sequential, this is actually a dynamic process with a good deal of interplay among
stages.

Example Outcomes and Outcome Indicators for Various Programs
These are illustrative examples only. Programs need to identify their own outcomes and indicators,
matched to and based on their own experiences and missions and the input of their staff, volunteers,
participants, and others.

Type of Program Outcome Indicator(s)

Smoking cessation
class

Participants stop smoking. • Number and percent of participants who report that they have quit smoking by
the end of the course

• Number and percent of participants who have not relapsed six months after
program completion

Information and
referral program

Callers access services to which
they are referred or about which
they are given information.

• Number and percent of community agencies that report an increase in new
participants who came to their agency as a result of a call to the information
and referral hotline

• Number and percent of community agencies that indicate these referrals are
appropriate

Tutorial program
for 6th grade
students

Students’ academic performance
improves.

• Number and percent of participants who earn better grades in the grading
period following completion of the program than in the grading period
immediately preceding enrollment in the program

English-as-a-
second-language
instruction

Participants become proficient in
English.

• Number and percent of participants who demonstrate increase in ability to
read, write, and speak English by the end of the course

Counseling for
parents identified
as at risk for child
abuse or neglect

Risk factors decrease. No
confirmed incidents of child
abuse or neglect.

• Number and percent of participating families for whom Child Protective
Service records report no confirmed child abuse or neglect during 12 months
following program completion

Employee
assistance
program

Employees with drug and/or
alcohol problems are
rehabilitated and do not lose
their jobs.

• Number and percent of program participants who are gainfully employed at
same company 6 months after intake

Homemaking
services

The home environment is
healthy, clean, and safe.
Participants stay in their own
home and are not referred to a
nursing home.

• Number and percent of participants whose home environment is rated clean
and safe by a trained observer

• Number of local nursing homes who report that applications from younger
and healthier citizens are declining (indicating that persons who in the past
would have been referred to a nursing home now stay at home longer)

Prenatal care
program

Pregnant women follow the
advice of the nutritionist.

• Number and percent of women who take recommended vitamin supplements
and consume recommended amounts of calcium

Shelter and
counseling for
runaway youth

Family is reunified whenever
possible; otherwise, youths are
in stable alternative housing.

• Number and percent of youth who return home
• Number and percent of youth placed in alternative living arrangements who

are in that arrangement 6 months later unless they have been reunified or
emancipated

Camping Children expand skills in areas
of interest to them.

• Number and percent of campers that identify two or more skills they have
learned at camp

Family planning for
teen mothers

Teen mothers have no second
pregnancies until they have
completed high school and have
the personal, family, and
financial resources to support a
second child.

• Number and percent of teen mothers who comply with family planning visits
• Number and percent of teen mothers using a recommended form of birth

control
• Number and percent of teen mothers who do not have repeat pregnancies

prior to graduation
• Number and percent of teen mothers who, at the time of next pregnancy, are

high school graduates, are married, and do not need public assistance to
provide for their children

Glossary of Selected Outcome Measurement Terms

Inputs are resources a program uses to achieve program objectives. Examples are staff, volunteers,
facilities, equipment, curricula, and money. A program uses inputs to support activities.

Activities are what a program does with its inputs-the services it provides-to fulfill its mission. Examples
are sheltering homeless families, educating the public about signs of child abuse, and providing adult
mentors for youth. Program activities result in outputs.

Outputs are products of a program’s activities, such as the number of meals provided, classes taught,
brochures distributed, or participants served. A program’s outputs should produce desired outcomes for
the program’s participants.

Outcomes are benefits for participants during or after their involvement with a program. Outcomes may
relate to knowledge, skills, attitudes, values, behavior, condition, or status. Examples of outcomes include
greater knowledge of nutritional needs, improved reading skills, more effective responses to conflict,
getting a job, and having greater financial stability.

For a particular program, there can be various “levels” of outcomes, with initial outcomes leading to
longer-term ones. For example, a youth in a mentoring program who receives one-to-one encouragement
to improve academic performance may attend school more regularly, which can lead to getting better
grades, which can lead to graduating.

Outcome indicators are the specific items of information that track a program’s success on outcomes.
They describe observable, measurable characteristics or changes that represent achievement of an
outcome. For example, a program whose desired outcome is that participants pursue a healthy lifestyle
could define “healthy lifestyle” as not smoking; maintaining a recommended weight, blood pressure, and
cholesterol level; getting at least two hours of exercise each week; and wearing seat belts consistently.
The number and percent of program participants who demonstrate these behaviors then is an indicator of
how well the program is doing with respect to the outcome.

Outcome targets are numerical objectives for a program’s level of achievement on its outcomes. After a
program has had experience with measuring outcomes, it can use its findings to set targets for the
number and percent of participants expected to achieve desired outcomes in the next reporting period. It
also can set targets for the amount of change it expects participants to experience.

Benchmarks are performance data that are used for comparative purposes. A program can use its own
data as a baseline benchmark against which to compare future performance. It also can use data from
another program as a benchmark. In the latter case, the other program often is chosen because it is
exemplary and its data are used as a target to strive for, rather than as a baseline.

Figure 31.1

Logic Model

Logic Models

Karen A. Randolph

A
logic model is a diagram of the relationship between a need that a

p rogram is designed to addret>s and the actions to be taken to address the
need and achieve program outcomes. It provides a concise, one-page pic-
ture of p rogram operations from beginning to end. The diagram is made
up of a series of boxes that represent each of the program’s com ponents,

inpu ts or resources, activities, outputs, and outcomes. The diagram shows how these
components are connected or linked to one another for the purpose of achieving
program goals. Figure 31.1 provides an example of the frame work for a basic logic model.

Th e program connections illustrate the logic of how program operations will result in
client change (McLaughlin & Jordan, 1999). The connections show the “causal” relati on-
ships between each of the program components and thus are referred to as a series of”if-
then” sequence of changes leading to th e intended outco mes for the target client group
(Chinman, hum, & Wandersman, 2004). The if-then statements represent a program’s
theory of change underlying an intervention. As such, logic models provide a framework
that g uides the evaluation process by laying out important relationships that need to b e
tested to demonstrate program results (Watso n, 2000).

Logic models come from the field of program evaluation. The idea emerged in
response to the recognition among program evaluators regardin g the need to systema tize
the p r ogram evaluation process (McLaughlin & Jordan, 20 04). Since then , logic models
have become increasingly popular among program managers for program planning and
to monitor program performance. With a growing emphasis on accountability and out-
come measurement, logic models make explicit the entire change process, Lhe assu mp-
tions t hat underlie this process, and the pathways to reach ing outcomes. Researchers have
begun to use logic models for intervention research planning (e.g., Brown, Hawkins,
Arthur, Brin ey, & Abbott, 2007).

The followin g sections provide a description of the components of a basic logic model
and how these compon ents are linked together, its relationship to a p rogram’s theory of

[ : Inputs 1–_.,•1 Ac~vities ,II—-.~•{ .Outputs ·11—~·1 Outcomes I
AUTHOR’S NOTE: The author wishes to acknowledge Dr. Tony Tripodi for his though lful comments
on a drafl of this chapter.

547

548 PART V • CONCEPTUAL RESEARCH

change, and its uses and benefits. The steps for creating a logic model as well as the chal-
lenges of the logic modeling process will be presented. The chapter concludes with an
example of how a logic model was u~cd to enhance program outcomes for a family liter-
acy program.

Components of a Logic Model

Typically, a logic model has four components: inputs or resources, activities, outputs, and
outcomes. Outcomes can be further classified into short-term outcomes, intermediate
outcomes, and long-term outcomes based on the length of time it takes to reach these
outcomes (McLa ughlin & Jordan , 2004) . The components make up the connection
between the planned work and the intended results (W. K. Kellogg Foundation, 2004).
The planned work includes the resources (the inp uts) needed to im plement the program
as well as how the resources will be used (the activities) . The intended results include the
outputs and outcomes that occur as a consequence of the planned work. Figure 31.2
expands on the model illuslrated in Figure 3 1.1 by adding examples of each component.
This particular logic model, adopted from frec htling (2007), provides an illustration of
the components of an intervention designed to prevent substance abuse and other prob-
lem behaviors among a population of youth. The intervention is targeted toward improv-
ing parenting skills, based on the assumption that positive parenting leads to prosocial
behaviors among yo uth {Bahr, Hoffman, & Yang, 2005). The following section provides
definitions and examples of each logic model component, using this illustration.

Resources
Resources, sometimes referred to as inputs, in clude the human, fin ancial, organizational,
and community asse ts that are available to a program to achieve its objectives (W. K.
Kellogg Foundation, 2004). Resources are used to support and facilitate the program
activities. They are usually categorized in terms of funding resou rces or in -kind contribu-
tion s (Frechtling, 2007) .

Some resources, such as laws, regulations, and funding requirements, are external to
the agency (United Way of America, 1996). Other resources, such as staff and money, are
easier lo quantify than others (e.g., community awareness of the program; Mertinko,
Novotney, Baker, & Lange, 2000). As Fn.:c:htli ng (2007) notes, it is important to clearly and
tho roughly id ent ify the available resources during the logic modeling process because this
information defines the scope and parameters of the program. Also, this inCormation is
critical for others who may be interes ted in replicating the program. The logic model in
Figure 31.2 includes fu nding as one of its resources.

Activities
Activities represent a program’s service methodology, showing how a program intends on
using the resources described previously to carry out its work. Activities are also referred
to as ac tion step!; (McLaughlin & Jordan, 2004). They are the highly specifi c tasks that
p rogram staffs engage in on a daily basis to provide services to clients (Mertinko
et al., 2000) . They include all aspects of pro gram implementation, the processes, tools,
events, technology, and program actions. The ac tivities form the foundation toward facil-
itating intended client changes or reaching oulcornes (W. K. Kellogg Fo undation, 2004).
Some examples are establishing community councils, providing professional develop –
ment training, or initiating a media campaign (Frechtling, 2007). Other examples are

CHAPTER 31 • l OCIC MO DELS 549

Inputs Activities Outputs Outcomes

Short Term Intermediate Long Term

Feedback Loop j
_J

I
Decreased

K~
Increased

I
Develop and Numbe r of Increased

youth Funds .~ initiate ~edi a st~tions a~opti ng r– awareness f- positive 1—–+ of positive substance
-~m~tg~– -.:::c -campatgn J pa renting parenti ng – abv?~d’

~-‘.:-

/
I

Develop and Number of Increased
distribute – 1> fact sheets 1- enrollment

fact sheets distributed in parenting
programs

Fig ure 31.2 Example of l ogic Model With Com ponents, Two Types of Connections, and a Feedbaclc loop

providing shelter for homeless families, educating the public about signs of child abuse,
or providing adult mentors for youlh {United Way of Ame rica, 1996) . Two activities,
” Deve lop and initiate media campaign” and “Develop and distribute fact sheets;’ are
included in the logic model in Figure 31.2. Activities lead to or produce the program o ut-
puts, described in the following section.

Outputs
The planned works (resources and activities) bring about a program’s des ired res ul ts,
including outputs and outcom es (W. K. Kell ogg Foundatio n, 2004) . Outputs, also referred
to as units of service, are the immediate results of program activities in the form of types,
levels, and targets of services to be delivered by the program (McLaughl in & Jordan ,
1999). They are tangible products, events, o r serv ices. They provide the documentation
that activities have been implemented and, as such, indicate if a program was delivered to
the intended audience at the intended dose (W. K. Kellogg FounJation, 2004). Outputs
arc typical ly desc ribed in terms of th e size and/or scope of the services an d products pro-
duced by the program and thus are expressed numerically (Frechtling, 2007). Examples of
program ou tpu ts include the number of classes ta ught, meetings held, o r materials p ro-
duced and distributed; program par ticipation rates and demography; or hours of each
type of serv ice provided (W. K. Kellogg Foundation, 2004) . Other examples are the
number of meals provided, classes taught, brochures distributed , or participants ser ved
(Frecht1ing, 2007) . W hile outputs have little inherent value in themselves, they provide
the link between a program’s activ ities and a program’s outcomes (United Way of
America, 1996). The logic model in Figure 31.2 includes Lhc number of stations adopting
the media campaign and the number of fact sheets distributed as two outputs for the pre-
vention program.

550 PART V • CONCEPTUAL RESEARCH

Outcomes
Outcomes arc Lhe specific changes experienced by the program’s clients or target group as
a consequence of participating in the program. Outcomes occur as a result of the program
activities and outputs. These changes may be in behaviors, attitudes, skill level, status, or
level of functioning (W. K. Kellogg Foundation, 2004). Examples include increased knowl-
edge of nut r itional needs, improved reading skills, more effective responses to conflict,
and finding employment (United Way of America, 1996) . Outcomes are indicalors of a
program’s level of success.

McLa ughlin and Jordan (2004) make the point that some programs have multiple,
sequential outcome structures in the form of short-term outcomes, intermediate out-
comes, and long-term outcomes. In these cases, each type of outcome is linked tempo-
rally. Short-term outcomes arc client changes or benefits th at are mos t immediately
associated with the program’s outputs. They are usually realized by clients wi thin 1 to
3 years of program completion. Short-term outcomes are linked to accomplishing inter-
mediate outcomes. Intermediate ou tcomes are generally attain able in 4 to 6 years. Long-
term outcomes are also referred to as program impacts or program goals. They occur as a
result of the intermediate outcomes, usually within 7 to 10 years. In this format, long-
term outcomes or goals are directed at macro-level change and target organizations, co m-
munities, or systems (W. K. Kellogg Foundation, 2004).

As an example, a sequen tial outcome structure with short- term, intermediate, and
long-term outcomes for the prevention program is displayed in Figure 31.2. As a result of
hearing the public service announ cemen ts about positive parenting (th e activity), parents
enroll in parenting programs to learn new parenting skills (the short-term outcome).
Then they apply these newly learned skills with their children (the intermediate out-
come), which leads to a reducti on in substance abuse among youth (the long-term impact
or goal the parenting program was designed to achieve).

Outcomes ar e often confused with outputs in logic models because their correct clas-
sification depends on the context within which they are being included. A good exa mple
of this potential confusion, provided in the United Way of America manual ( 1996, p. 19),
is as follows. The number of clients served is an output when it is meant to describe the
volume of work accomplished. In this case, it does not relate directly to cl ient changes or
benefits. H owever, the number of clients served is considered to be an outcome when the
program’s intention is to encourage clients to seek services, such as alcohol treatment.
What is important to remember is that outcomes describe intended client changes or
benefits as a result of participatin g in the program while outputs document products or
services produced as a result of activities.

Links or Connections Between Components

A critical part of a logic model is the connections or links between the components. The
connections illustrate the relationships between the components and the process by
which change is hypothesized to occur among program participants. This is referred to as
the program theory (Frechtling, 2007). It is the con nections illustrating the program’s
theory of change that make the logic model complicated. Specifying the connections is
one of the more difficult aspects of developing a logic model because the process requires
predicting the process by which client change is expected to occur as a result of program
participation (Frech tling, 2007).

CHIII’TER 31 • lOGIC M ODtLS 551

Frechtling (2007) describes nvo types of connections in a logic model: connections
that link items within each compo nent and connections that illustrate the program’s
theory of change. The first type, items within a component, is connected by a straight line.
This line shows that the items make up a particularcomponent.As an example, in Figure 31.2,
nvo activities, “Develop and initiate media campaign” and ” Develop and distribute fact
sheets,” are linked together with a straight line beca use they represent the items within the
activities component. Similarly, two outputs, “Number of stations adop ting the cam-
paign” and “Number of fact sheets distributed;’ arc connected as two items within the
outputs component.

The second type of connection sh<.>ws how the components interact with or relate to
each other to reach expected outcomes (Frechtling, 2007) . In essence, this is the program’s
theory of change. Thus, instead of straight lines, arrows are used to show the direction of
influence. Frechtling (2007) clarifies that “these directional connections are not just a
kind of glue ancho ring the otherwise floating boxes. Rather they portray the changes thaL
arc expected to occur after a previous ac Livity has taken place, and as a result of it” (p. 33).
She points out that the primary purpose of the evaluation is to determine the nature of
the relationships between components (i.e., whether the predictions are correct). A logic
mod el that illustrates a fully developed theory of change includes links between every
item in each co mponent. In other words, every item in every component must be co n-
nected to at least one item in a subsequent component. This is illustrated in Figure 3 1.2,
which shows that each of the two items within th e activities co mpon en t is linked to an
item within the output co mponent.

Figure 31.2 provides an example of the predicted relationships between the compo-
nents. This is the program theory about how the target group is expected to change. The
input or resource, funding, is co nnected to the tv,ro activities, “Develop and initiate media
campaign” and “Develop and distribute fac t sheets.” Simply put, this part of Figure 31 .2
shows that funding will be used to support the development and initiati on of PSA cam-
paigns and the distribution of fact sheets.

The sequencing of the connections between components also shows th at these steps
occur over a period of time. While this may seem obvious and relatively inconsequential,
specifying an accurate sequence has time-based implications, pa rticularly when short-
term, intermediate, and long-term outco mes are proposed as a part of the theory of
change (Frechtling, 2007). Rcca11 that the short-term outcomes lead to achieving the
intermediate outcomes, and the intermediate outcomes lead to ach ieving long-term out-
comes. Thus, the belief or underl}ing ass umption is that short-term outco mes mediate
(or come between) relationships benv-een activities and intermediate o utcomes, and
intermediate outcomes mediate relations between sho rt-te rm and long-term outcomes.

Related, sometimes logic models display feedback loops. Feedback loops show how the
information gained from implementing one item can be used to refine and improve other
items (Frechlling, 2007). f or instance, in Figure 31.2, the feedback loop from the short-
term outcome, ” Increased awareness of positive parenting;’ back to the activity, “Develop
and initiate media campaign;’ indicates that the findings for ” Increased awareness of pos-
itive parenting” arc used to im prove the PSA campaigns in the next program cycle.

Contextual Factors

Logic models describe programs that exist and are affected by contextual factors in the
larger environment. Contextual factors are those important features of the environment

552 PART V • CONCEPTUAL R ESEARCH

in which the project or inter vention takes place. They include the social, cultural, and
political aspects of the environment (Frechtling, 2007). They are typically not under the
program’s control yet are likely to influe nce the program either positively or negatively
(McLa ughlin & Jordan, 2004 ). T hu s, it is critical to identify relevant contextual factors
and to consider their potential impact on the program. McLaughlin and Jordan (1999)
point out that understanding and articulating contex tual factors co ntr ibu tes to an under-
standing of the fo undat io n u pon whi ch performance expectatio ns a re established.
Mo reover, this knowledge h elps to establish the parameters for explaining program
results and developing program improvement strategies that are li kely to be more m ean-
ingful and thus more successful because the information is more complete. finally, con-
textual factors clarify situations under which the program results might be expected to
generalize and the issues that might affect replication (Frechtling, 2007) .

Harrell, Burt, Hatry, Rossm an, a nd Roth ( 1996) identify two types of contextual fac-
tors, antecedent and media6ng, as o utside facto rs that could influence th e program’s
design, implementa tio n, and results. Anteceden t factors are thos e that exist prior to
program implemen tatio n, such as cha racteristics of the client target population o r com-
munity characteristics such as geographical and economic conditions. Mediating factors
are the environmental influences that emerge as the program unfolds, such as new laws
and policies, a change in economic con ditions, or the startup of other new programs pro-
viding similar services (McLaughlin & jordan, 2004).

Logic Models and a Program’s Theory of Change

Definition
Log ic models p rovide an illustration of the compo nents of a program’s theo t-y and how
those components are linked togeth er. Program theory is defined as “a plausible and sen-
sible model of how a program is supposed to wo rk” (Bickman, 1987, p. 5). Program
theory in corporates “program resources, program activities, and intended program out-
comes, and specifies a chain of causal assumptions linking resources, activities, interme-
di ate outcomes, and ulti mate goals” (Wholey, 1987, p. 78). Program theory e.>..-plicates the
assumptions abou t how the program components link together from program star t to
goal attainmen t to realize the program’s intended outcomes (Frechtling, 2007). Thus, it is
often referred to as a p rogram’s theory of change. Frechtling (2007) suggests that both
previous research and knowledge gained from practice experience arc useful in develop-
ing a theory of change.

Relationship to logic Models
A logic model provides an illustration of a program’s theory of change. It is a useful tool
for describing program theory because it shows the connections or if-then relationships
between program components. In other words, moving from left to right from one com-
po nent to the next, logic models provide a diagram of the rationale or reasoning underly-
ing the theory of change. If-th en statements connect the program’s co m po nents to form
the theory of change (W. K. Kellogg Founda tion, 2004). For example, certain resources or
inputs are needed to carr y out a program’s activities. The first if-then statement links
reso urces to acti vities and is stated, ” If you have access to these resources, then yo u can use
them to accomplish yo ur planned activities” (W. K. Kellogg Fo undation, 2004, p. 3). Each

CHAPTER 31 • LOCIC MODELS SS3

component in a logic model is linked to the other components using if-then statemen ts to
show a program’s chain of reasoning about how client change is predicted to occur. The
idea is that “if the right resources are transformed into the right activities for the right
people, then these will lead to the results the program was designed to achieve”
(McLaughlin & Jordan, 2004, p. 11). It is important to define the components of an inter-
vention and make the connections between them explicit (Frechtling, 2007).

Program Theory and Evaluation Planning
Chen and Rossi (1983) were among th e first to suggest a program theory-driven
approach to evaluation. A program’s theory of change has significant utility in develop-
ing and implementing a program evaluation because the theory provides a framework
for determining the evalu ation questions (Rossi, Lipsey, & Freeman, 2004) . As such, a
logic model that ill ustrates a program’s theory of change provides a map to inform the
developmen t of relevant eval uation questions at each phase of t he evaluation. Rossi
et al. (2004) explain how a program theory-based logic mode l enha nces the devel op-
ment of evaluation questions. First, the process of articulating the logic of the
program’s change process through the development of the logic model prompts discus-
sion of relevant and meaningful evaluation questions. Second, these questions then lead
to articulating expect ations fo r p rogram performance and inform the identification o f
criteria to measure that performance. Third, obtaining input from key stakeholders
about the theory of change as it is displayed in the logic model increases the likelihood
of a more comprehensive set of questions and that critical issues have not been over-
looked. To clarify, most agree that this is a team effort that should include the program
development and program evaluation staff at a minimum, as well as other stakeholders
both internal and external to the program as they are available (Dwyer & Makin, 1997;
Frech tling, 2007; Mclaughlin & Jordan, 2004). The diversity of perspective and skill sets
among the team members (e.g., program developers vs. program evaluators) enhances
the depth of understanding of how the program will work, as diagramed by the logic
model (Frechtling, 2007). As D”vyer and Makin (1997) state, the team approach to
develop ing a theory-based logic model promotes “greater stakeholde r invo lvement, the
opportunity for open negotiation of program objectives, greater commitment to the
final co nceptualization of the program, a shared vis ion, and increased likeliho od to
accept and utilize th e evaluation results” (p. 423) .

Uses of Logic Models

Logic models have many uses. They help Lo integrate the entire program’s planning and
implementation process from beginning to end, including the evaluation process (D wyer
& Makin, 1997). They can be used at all of a program’s stages to enhance its success
(Frechlling, 2007; W. K. Kellogg Foundation, 2004). For instance, at the program design
and planning stage, going through the process of developing logic models helps to clarify
the purpose of the program, the development of program strategies, resources that are
necessary to attaining outcomes, and th e identification of possible barriers to
the program’s success. Also, identifying program components such as activities and
outcomes prior to program implementation provides an opportunity to ensure that
program outcomes inform program activities, rather than the other way aroun d (Dwyer
& Makin, 1997) .

554 PART V • CoNcEPTUAl R ESEA RC H

During the p rogmm implementation phase, a logic model p rovides the basis fo r th e
development of a management plan to guide program monitoring ac tiv ities and to
improve program processes as issues arise. In other words, it helps in identifying and
highlighting the key program processes to be tracked to ensure a program’s effectiveness
(United Way of America, 1996).

Most important, a logic model facilitates evaluatio n planning by providing the evalua-
tion framework fo r shapin g the evalua tion across all stages of a project. Intended out-
comes and the process for measuring these outcomes are displayed in a logic model
(Watson, 2000), as well as key points at which evaluation activities should take place
across the life of the program (McLaughlin & Jordan) 2004). Logic models suppo rt both
formative and summative evaluations (Frechtli ng, 2007). They can be used in conducting
summativc evaluations to determine what has been accomplished and, importantly, the
process by which these accomplishments have been achieved (Frechtling, 2007) . Logic
models can also support formative evaluations by organizing evaluatio n activities, incl ud-
ing the meas urement of key variables or performance indicators (McLaughlin & Jordan,
2004) . From this info rmation, evaluation questions, relevant indicators, and data collec-
tion strategies can be developed. The following section expands on using the logic model
to develop evaluation questions.

The logic m odel provides a framework for developing eval uat ion q uestions about
prog r am co n text, program efforts, and p rogram effec tiveness ( Frech t ling, 2007;
Mer ti nko et al., 2000). Together, these three sets of quest ions help to explicate the
progr am’s theory of change by describing the assumptions about the r elationship s
between a program’s operations and its predicted outcomes (Ross i et al. , 2004) .
Context questio ns explore program capacity and relationships external to the program
and help to identify and understand the impac t of confo unding factors or externa l
infl uences. Pr ogram effort and effectiveness quest ions correspond to particular co m –
ponents in the logic model and thus exp lore program processes t oward ach ieving
program outcomes. Questions a bout effor t address the planned work of the program
and come from the input and activities sections of the eva luatio n mo d el. They address
program implementation issues such as the services that were provided and to who m.
These questio ns focus on what happene d and why. Effectiveness or outco m e questions
address program results as described in the output and outcomes section of the logic
m odel. From the questions, indicators and da ta collection strategies can the n be d evel-
oped. Guidelines for using logic mo d els to develop evaluation questi ons, ind icators,
and data collection strategies are provided in the Logic Model Development Guide
( W. K. Kellogg Foundation, 200 4 ).

In addition to supporting program effo rts, a logic model is a useful comm unication
tool (McLaughlin & Jordan, 2004 ). For instance, developing a logic model provides the
opportunity fo r key stakeholders to discuss and reach a common understanding, includ-
ing underlying assumptions, about how the program opera tes an d the resources needed
to achieve program p rocesses and outcomes. ln fact, some suggest t hat the logic model
development process is actually a form of strategic planning because it requ ires partici-
pants to articulate a program’s vision, the rationale for the program, and the program
processes and procedures (‘Watson, 2000) . T his also promotes stakeholder involvem ent in
program planning and consensus building on the program’s design and operations.
Moreover, a logic model can be used to explain program procedures and sha re a compre-
hensive yet concise picture of th e p rogram to comm unity partners, funders, and others
outside of the agency (McLaughlin & Jordan, 2004) .

CHAPTER 3 1 • LOGIC M ODF I S 555

Steps for Creating Logic Models

McLaughlin and Jordan (2004) descri be a five-stage process for developing logic models.
The first stage is to gather extensive baseline information from multiple sources abo ut the
nature of the problem or need and about alternative solutions. The W. K. Kellogg
Foundation (2004) also suggests collecting information about community needs and
assets. This information can then be used to both define the problem (the second stage of
developing a logic model ) and identify the program clements in the form of logic model
componen ts (the third stage of logic model development). Possible information sources
include existing program documentation, interviews with key stakeholders internal and
exte rn al to the program, strategic plans, annual performance plans, previous program
evaluations, an d relevant legislation and regulations. It is also important to review the lit-
erature about factors related to the problem and to determ ine the strategies others have
used in attemp ting to address it. This type of information provides supportive evidence
that informs the approach to addressing the problem.

The information collected in the first stage is th en used to define the problem, the
con textual factors that relate to the problem, and Lhus the need for the program. The
program sho uld be conceptualized based on what is uncovered abo ut the nature and
extent of the problem, as well as the factors that are correlated with or cause the prob-
lem. It is also impor tan t at this stage to develop a clear idea of the impact of the prob-
lem across micro, mezzo, and macro domains. The focus of the program is then to
address the “causal” factors to solve t he problem. In addition, McLaughlin and Jordan
(2004, p. 17) recommend identifyi n g the environmental factors that are likely to affect
the program, as well as ho·w these conditions might affect progr am outcomes.
Understanding the relationship between the program and relevan t environmental fac-
tors contributes to framing its parameters.

During the third stage, the elemen ts or components of the logic model are identified,
based on the findings that emerged in the second stage. McLaughlin and Jorda n (2004)
recommend starting out by categorizing each piece of information as a resource or input,
activity, o utput, short-term outcome, intermediate outcome, long-term outcome, or con-
textual factor. While some suggest that the order in which the components arc identified
is in consequen tial to developing an effective logic mod el, most recommend beginning
this process by identifying long-term outcomes and working backward (United Way of
America, 1996; W. K. Kellogg Foundation, 2004) .

The lo gic model is drawn in the fourth stage. Figure 31 .2 provi.des an example of a typ –
ical logic model. This diagram includes columns of boxes representing the items for each
component (i.e., inputs, activities, outputs, and shor t-term, intermediate, and long- ter m
outcomes). Text is provided in each box to describe the item. The connections between
the items within a component are shown with straight lines. The links or connections
between components are shown with one-way directional arrows. Prog ram components
may or may not have one-on-one rela tionships with o ne another. In fact, it is likely that
components in one group (e.g., inputs) will have multiple connections to components in
another group (e.g., activities). For example, in Figure 31.2, we show that the funding
resource leads to two activities, “Develop and initiate media campaign” and “Develop and
distribute fact sheets.” Finally, because activities can be described at many levels of detail,
McLaughlin and Jordan (2004) suggest simplifying the model by group ing activities that
lead to the same outcome. They also recommend including no more than five to seven
activity groupings in one logic model.

556 PART V • CO NCEPTUAl RESEARCii

Stage 5 focuses on verifying the logic model by getting input from all key stakeholders.
McLaughlin and Jordan (2004) recommend applying the if-then statements presented by
United Way of America ( 1996) in developing hypotheses to check the logic model in the
following manner:

given observations of key contextual factors, if resources, then program activities; if
program activities, then out puts for targeted customer groups; if outputs change
behavior, first short term, then intermediate outcomes occur. If intermediate out-
comes occur, then longer-term outcomes lead to the problem being solved. (p. 24)

They also recommend answering the following questions as a part of the verification
process (pp. 24-25):

1. Is the level of detail sufficient to create understanding of the elements and their
interrela ti onsh ips?

2. Is the program logic complete? That is, arc all the key elements accounted for?

3. Is the program logic theoretically sound? Do all the elements fit together logically?
Are there other plausible pathways to achieving the program outcomes?

4. Have all the relevant external contextual factors been identified and their potential
influences described?

Challenges in Developing Logic Models

Frechtling (2007 ) describes three sets of challenges in developing and using logic models,
including (a) accurately portraying the basic features of the logic model, (b) determining
the appropriate level of detail in the model, and (c) having realistic expectations about
what logic models ca n and canno t contribute to program processes. These challenges are
reviewed in more detail in the following section.

Portraying the Logic Model’s Basic Features Accurately
The basic features of a logic model must be clearly understood in order for the logic
model to be useful. In particular, logic model developers often enco unter difficulty in four
areas: confusing terms, substituting specific measures for more gene ral outcomes, assum-
ing unidirectionality, and failing to specify a timefrarne for program processes (Frechtling,
2007; McLaughlin & Jordan, 2004).

One issue in developing the logic model is accurately differentiating between an activity
or outp ut and an outcome. Frequently, activities and outputs are confused witl1 outcomes
(Frechtling, 2007). They can be distinguished by remembering that activities are steps or
actions taken in pursuit of producing the output and thus achieving the outcome. Outputs
are products that come as a result of completing activities. They are typically expressed
numerically (e.g., the number of training sessions held). Outputs provide the documenta-
tion that activities have occurred. They also link activities to ou tcomes. Outcomes are
statements about participant cha nge as a result of experiencing the intervention.
Outcomes describe how participants will be different after they finish the program.

Another issue in portraying the basic features of logic models accurately is not confus-
ing outcomes with the instruments used to measure whether the outcomes were achieved.

C HAP t ER 31 • l OGIC M ODHS 557

For example, the outcome may be decreased depression, as measured by an instrument
assessing a participant’s level of depression (Center for Epidemiological Studies-
Depression Scale; Radloff, 1977). Some may confuse the outcome (i.e., decreased depres-
sion) with the instrument (i.e., Center for Ep idem iological Studies- Depression Scale) that
was used to determine whether the outcome was met. To minimize the potential for this
confusion, Frechtling (2007) recommends developing the outcome lirsl and then identify-
ing the appropriate instrument for determ ini ng that the outcome has been reached.

A thiru issue in logic model development is avoiding the assumption that the logic
model and, by implication, the theo ry of change that the logic model portrays move in a
unidirectional progression from left to right {Frechtling, 2007; McLaughlin & Jordan,
2004) . While the visual display may compel users to think about logjc mod els in this way,
logic models and the programs they represent are much more dynamic, with feedback
loops and interactions among components. The feedback loop is illustrated in Figure 31.2,
showing that the experi ences and information generated from reachin g short-term out-
comes are used to refine and, it is hoped, improve the activities in the next program cycle
that are expected to lead to these outcomes. Also, assuming uniform directionality can
enforce the belief that the inp uts dTi ve the project, rather than attaining the outcomes.
This underscores the importance of starting with the development of outcomes when
putting together a logic modeL

The final issue is including a timeframe for carrying out the processes depicted in the
logic model. The lack of a tirneframe results in an incomplete theory of chan ge as well as
problematic expectations about when outcomes will be reached (Frechtling, 2007).
Whether outcomes are expected too soon or not soon enough, key stakeholders may
assume that the theory of change was not accurate. Developing accurate predictions of
when outcomes will be reached is often d ifficu lt, especially with n ew projects in which
very li ttle is known abou t program processes and so forth. In this case, as more clarity
emerges abo ut the amount of time it will take to complete activities, tirneframes should
be revisited and modified to reflect the new information.

Determining the Appropriate Level of Detail
A second set of challenges is to determine how much detail to include in the logic model.
T he underlying dilemma is the level of complexity. Models that are too complex, with too
much detail, are lime-consuming to develop and difficult to interpret. Thus, they are
likely to be cumbersome to use. Models that lack enough information may depict an
incomplete theory of change by leaving out impor tant information. For instance, if activ-
ities are combined into par ticular groups, it is possible that important links between spe-
cific activiti es, outp uts, and outcomes wiJJ not be represented. This increases Lhe
possibility of making faulty assumptions about program opera lions and how these oper-
ations lead to positive participant outcomes.

Realistic Expectations
The fmal set of challenges in using logic models is no t expecting more from logic models
than what th ey are intended to provide. Frechtling (2007, p. 92) notes that some may
inaccurately view the logic model as a “cure-ali” a nd that, just by its mere existence, the
logic model wi ll ensure the success of the program and the evaluation. Of course, the effi-
cacy of a logic model depends on the quality of its design and components. A log ic model
cannot overcome these types of problems. Frcchtling identifies four commo n issues
here. First, sometimes new programs are such that applying the theory of change and a

558 P11RT V • CoN ctPI’UAl R ESEARCH

representative logic model is premature. This is the case for programs in which a priori
expectations about relationships between activities and outcomes do not exist.

A second risk in this area is fai ling to consider alternative theories of change.
Alternative explanations and competing hypotheses sho ul d be explored. Focusing on only
one theory of change may result in not recognizing and including important factors that
fall o utside of the theorys domain. Ignoring these competing fac to rs may result in the
fail ure of the logic model and the program.

Third and related, it is critical to acknowledge the influence of contextual factors that
arc likely to affect the program. Interventions always exist and function wiLhi n a larger
environment. Contextual factors influence the success or failure of these interventions.
For instance, one contextual factor that might affect outcomes of the program diagrammed
in Figure 31 .2 is the diversity of the target group. As Frechtling (2007) observes, this d iver-
sity may include language differences among subgroups, which need to be accounted for
in developing program m aterials.

fin ally, logic models cannot fully co mp ensate for the rigor of expe rimental design
when testing the impact of interventions o n outco m es (Frech tling, 2007) . T he logic
model explicates the critical components of a program and the processes that lead to
desired outcomes (the program theory of cha nge). The implementation of the model
provides a test of th e accuracy of the theory. However, validatio n of the logic model is not
as rigorous a proof as what is established through study designs employing experimental
or quasi-experimental methodologies. Causality cannot be determined through logic
models. Alhen possible, an evaluation can be strengthened by combining the advantages
of logic modeling with experimental design.

Logic Modeling in Practice: Building
Blocks Family Literacy Program

The following provides an example of logic modeling in practice. The example describes the
use of a program logic model in developing, implementing, and evaluating the Building
Blocks family literacy program and how client exit data were then used to revise the model in
a way that more explicitly illustrated the program’s path•.vays to achieving intended outcomes
(i.e., feedback loop; Unrau, 2001, p. 355). The original program outcomes were to increase
(a ) children’s literacy skills and (b) parents’ abilities to assist their children in developing lit-
eracy skills. The sam ple included 89 families who participated in the 4-week program du ring
its initial year of operation. The following describes the process by which the logic model was
developed and how the client outcome data were used to fme- tune the logic model.

The family literacy program’s logic model was created at a one-day workshop facili-
tated by the evalua tor. Twenty key stakeholders representing various constituenc ies,
including program staff (i.e., steering committee members, administration, and literacy
workers), representatives from other programs (i.e., public school teachers, child welfare,
and workers and clients from other literacy programs), and oth er interested citizens, par-
ticipated in the workshop (Unrau, 2001, p. 354). A consensus decision- making process
was used to reach an agreement on all aspects of the process, including the program pur-
pose, the prog ram objectives, and the pro gram activities.

During the workshop, stakeholders created five products that defined the program
parameters and info rmed the focus of the evaluation. These products included an organi-
zational chart, the beliefs and assumptions of stakeholders about client service delivery,
the questions for the eval uation, the program’s goals and objectives, and the program

CHAPTER 31 • l OGIC MoDElS 559

activities. The program goals, objectives, and activities were then used to develop the orig-
inallogic model.

One of the evaluation methods used to assess client ou tcomes was to conduct semi-
st ructured phone interviews with the parents after families completed the program.
Random select ion procedu res were used to identify a su bset (n = 35 or 40o/o) from the
list of all parents to participate in the interviews. Random selection procedures were used
to ensure that the ex-periences of the interviewees represented those of all clients served
during the evaluation time period. Relative to the two program outcomes, respondents
were asked to provide examples of any observed changes in both their children’s literacy
skills (Outcome 1) and their ability to assist their children in developing literacy skills
(Outcome 2; Unrau, 2001, p. 357). The co nstant comparison method was used to analyze
the data (Pa tton, 2002 ). In this method, meani ngful units of texi: are assigned to similar
categories to identify common themes.

What emerged from the parent interviews was more detailed information about how
the two inten ded outcomes were achieved. Parent experiences in the program suggested
four additional processes that li nk to reaching the two final outcomes. Thi s infor mation
was added to the original logic model to more fully develop the pathways to improving
children’s literacy skills through the family literacy program. These additional outcomes
were actually steps toward meeting the two originally intended outcomes and thus iden-
tified as intermediate outcomes and ne-cessary steps toward ach ieving the or iginally stated
long-term outcomes. Figure 31.3 provides a diagram of the revised logic model. The
shaded boxes represent the components of the original logic model. The other compo-
nents were added as a result of the parent exit interview data.

Input j I Activities I Short-Term Outcomes I [ Intermediate Outcomes J I Long-Term :Outcomes j

Improve child’s
behavior

Increase parent’s
own literacy skills

Figure 31.3 Example of a Revised Program Logic Model for a Family Literacy Program

SOURCE: Unrau (200 1}. Copyright November 21 , 2007 by Elsevier limited. Reprinted with permission.

NOTE: The shaded boxes represent the logic model’s original components. The other boxes were added as a result of feedback from clients
after program compl etion.

560 PART V • CONCEPTUAL R ESEARCH

While the parent in terview data were useful in revising the program logic about client
change, it is important to interpret this process withi n the app ropriate context. This part
of the evaluation does not provide evidence that the program caused client change (Rossi
et al., 2004). This can only be determined through the use of experimental methods with
random ass ignmen t. Nonetheless, these paren t data contr ibute to developing a mo re fully
developed model fo r unde rstanding how fam ily literacy programs wo rk to improve out-
comes for children. Experimental methods can then be used to test the revised model for
the purpose of es tablishing the causal pathways to the intended outcomes.

Conclusion

The purpose of this chapter was to introduce the rea der to logic models and to the logic
modeling process. Logic models present an illustration of th e components of a program
(inputs, activities, outputs, and outcomes) and how these components connect with one
another to facilitate participant change (pro gram theory). They are tools to assist key
stakeholders in program plann ing, program implementation and monitoring, and espe-
cially program eva lu ation. They can also be used as communication tools in expla ining
program processes to key stakeholders external to the program. Creating a logic model is
a time-consuming process with a number of potential challenges. Nonetheless, a well-
developed and thoughtful logic mo del is likely to ensure a program’s success in reaching
its intended outcomes.

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a logic model for a resea rch proj ect.

http:/ /www.unitedway.org/Outcomes/Resources/MPO/index.cfm
Web site from the United Way’s Outcome Mea su rement Resource Network, demonstra ting th e use of
logic models in cla rifying and com municating outcomes.

http:/ /www.cdc.gov/eval/resources.htm#logic%20modcl
Web site from the Centers for Disease Control and Prevention’s Evaluatio1 Working Group, containing
logic model resources.

1. Define the term logic model.

2. Describe th e difference between program activities, program outputs, and program outcomes.

3. Discuss the purpose of including lines with arrows in logic models.

4. Discuss the relationship between a program’s theory of change and its logic model.

5. Describe the uses of logic models.

SESSIONS
Case Histories

Editors
Sara-Beth Plummer
Sara Makris
Sally Margaret Brocksen

Published by
Laureate International Universities Publishing, Inc.
650 S. Exeter Street
Baltimore, MD 21202
www.laureate.net

Director, Program Design: Lauren Mason Carris
Content Development Manager: Jason Jones
Content Development Specialist: Sandra Shon
Production Services: Absolute Service, Inc.
Editorial Services: Christina Myers

Copyright © 2014 by Laureate Education, Inc.

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, any information storage and retrieval systems, or other electronic or mechanical methods, without the prior
written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncom­
mercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Content Development
Specialist,” at the address above.

ISBN-13: 978-1-62458-012-3 (VitalSource edition)

First Edition 14 15 16 17 18 / 10 9 8 7 6 5 4 3 2 1

Editors

Sara-Beth Plummer, PhD, MSW
Walden University

Sara Makris, PhD
Laureate Education, Inc.

Sally Margaret Brocksen, PhD, MSW
Walden University

Contributors

Marlene Coach, EdD, MSW, ACSW, LSW
Walden University

Eileen V. Frishman, MSW, ACSW, LCSW-R, CH

Mary E. Larscheid, PhD, MSW, LICSW
Walden University

Vanessa Norris, MSW, LCSW
West Chester University

Sara-Beth Plummer, PhD, MSW
Walden University

Stephanie C. Sanger, MA, MSS, LSW
Assistant Director, RHD, Tri-County Supportive Housing

Eric Youn, PhD, LMSW
Walden University

iii

Contents

Introduction 1

Part 1: Foundation Year 2

The Hernandez Family 3

The Parker Family 6

The Logan Family 9

The Johnson Family 11

Part 2: Concentration Year 14

The Levy Family 15

The Bradley Family 17

The Petrakis Family 20

The Cortez Family 23

Appendix 26

Reflection Questions 27

The Hernandez Family 27

The Parker Family 28

The Logan Family 30

The Johnson Family 31

The Levy Family 32

The Bradley Family 33

The Petrakis Family 35

The Cortez Family 36

Trademarks and Disclaimers 38

iv

Introduction

The following eight cases are based on the true experiences of social workers in the field, although names and other identifying circumstances have been changed. The narratives in this book, combined with filmed repre­
sentations of scenes inspired by the cases, provide you an opportunity to use true-to-life cases as an experiential
learning tool. Whereas some academic programs, professors, or instructors may offer an occasional glimpse into
past social work experiences, this book and these cases weave through multiple courses in your foundation and
concentration year. Like in true-to-life practice, you will follow these cases through a variety of circumstances, prac­
tice behaviors, and learning opportunities. This unique format for a social work program enables you to integrate
and connect the expected learning outcomes for each course. Each case either explicitly or implicitly offers content
on practice skills, research, human behavior theory, and policy. Further, you will see that each family’s concerns can
be addressed across all levels of practice, from micro to mezzo to macro.

Approach this book as a series of cases to which you have been assigned during your first professional experi­
ence in social work. We encourage you to use a critical eye to analyze the approaches provided. Remember that
each practitioner has his or her own lens or perspective that guides his or her practice and these cases, written in
the voices of each individual social worker, offer you authentic, varied perspectives. As you review and dissect these
cases, consider your own lens and perspective as a future social worker.

The families described in these cases have been connected to social work services in myriad ways. Look closely at
how each family member is introduced to the social worker and at the services and interventions that follow. Through
reading these cases and then watching them come to life on video, you will see the skills used by social work practi­
tioners. Carefully identify for yourself how the social worker engages, assesses, and intervenes with his or her client.

The social workers who provided these cases offer some of their own personal thoughts about these cases as
a series of reflection questions. Use the answers to the questions, posed to the social workers as they wrote these
stories, to gain additional insight into the decisions they made to address their clients’ concerns. Reflect on the ques­
tions and answers as a way to consider whether you would have addressed the client or clients in the same manner.

Imagine your first day of practice, preparing for your first client meeting. On your desk is a folder with the last
name of the client on the tab. You open the folder to find a case history for your client—perhaps it details family
background, medical history, or an accounting of interactions with other agencies. This book is like that folder,
preparing you for the client you will soon meet.

1

PART 1: FOUNDATION YEAR

2

The Hernandez Family

Juan Hernandez (27) and Elena Hernandez (25) are a married Latino couple who were referred to the New York City Administration for Children Services (ACS) for abuse allegations. They have an 8-year-old son, Juan Jr.,
and a 6-year-old son, Alberto. They were married 7 years ago, soon after Juan Jr. was born. Juan and Elena were
both born in Puerto Rico and raised in Queens, New York. They rent a two-bedroom apartment in an apartment
complex where they have lived for 7 years. Elena works as babysitter for a family that lives nearby, and Juan works
at the airport in the baggage department. Overall, their physical health is good, although Elena was diagnosed with
diabetes this past year and Juan has some lower back issues from loading and unloading bags. Both drink socially
with friends and family. Juan goes out with friends on the weekends sometimes to “blow off steam,” having six to
eight beers, and Elena drinks sparingly, only one or two drinks a month. Both deny any drug use at all. While they
do not attend church regularly, both identify as being Catholic and observe all religious holidays. Juan was arrested
once as a juvenile for petty theft, but that has been expunged from his file. Elena has no criminal history. They
have a large support network of friends and family who live nearby, and both Elena’s and Juan’s parents live within
blocks of their apartment and visit frequently. Juan and Elena both enjoy playing cards with family and friends on
the weekends and taking the boys out to the park and beach near their home.

ACS was contacted by the school social worker from Juan Jr.’s school after he described a punishment his parents
used when he talked back to them. He told her that his parents made him kneel for hours while holding two encyclo­
pedias (one in each hand) and that this was a punishment used on multiple occasions. The ACS worker deemed this
a credible concern and made a visit to the home. During the visit, the parents admitted to using this particular form
of punishment with their children when they misbehaved. In turn, the social worker from ACS mandated the family
to attend weekly family sessions and complete a parenting group at their local community mental health agency.
In her report sent to the mental health agency, the ACS social worker indicated that the form of punishment used by
the parents was deemed abusive and that the parents needed to learn new and appropriate parenting skills. She also
suggested they receive education about child development because she believed they had unrealistic expectations of
how children at their developmental stage should behave. This was a particular concern with Juan Sr., who repeat­
edly stated that if the boys listened, stayed quiet, and followed all of their rules they would not be punished. There
was a sense from the ACS worker that Juan Sr. treated his sons, especially Juan Jr., as adults and not as children.
This was exhibited, she believed, by a clear lack of patience and understanding on his part when the boys did not
follow all of his directions perfectly or when they played in the home. She mandated family sessions along with the
parenting classes to address these issues.

During the intake session, when I met the family for the first time, both Juan and Elena were clearly angry that
they had been referred to parenting classes and family sessions. They both felt they had done nothing wrong, and
they stated that they were only punishing their children as they were punished as children in Puerto Rico. They said
that their parents made them hold heavy books or other objects as they kneeled and they both stressed that at times
the consequences for not behaving had been much worse. Both Juan and Elena were “beaten” (their term) by their
parents. Elena’s parents used a switch, and Juan’s parents used a belt. As a result, they feel they are actually quite
lenient with their children, and they said they never hit them and they never would. Both stated that they love their
children very much and struggle to give them a good life. They both stated that the boys are very active and don’t
always follow the rules and the kneeling punishment is the only thing that works when they “don’t want to listen.”

They both admitted that they made the boys hold two large encyclopedias for up to two hours while kneeling
when they did something wrong. They stated the boys are “hyperactive” and “need a lot of attention.” They said
they punish Juan Jr. more often because he is particularly defiant and does not listen and also because he is older
and should know better. They see him as a role model for his younger brother and feel he should take that respon­
sibility to heart. His misbehavior indicates to them that he is not taking that duty seriously and therefore he should
be punished, both to learn his lesson and to show his younger brother what could happen if he does not behave.

During the intake meeting, Juan Sr. stated several times that he puts in overtime any time he can because money
is “tight.” He expressed great concern about having to attend the parenting classes and family sessions, as it would
interfere with that overtime. Elena appeared anxious during the initial meeting and repeatedly asked if they were
going to lose the boys. I told her I could not assure her that they would not, but I could assist her and her husband
through this process by making sure we had a plan that satisfied the ACS worker’s requirements. I told them it

3

SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

would be up to them to complete those plans successfully. I offered
my support through this process and conveyed empathy around their
response to the situation.

The Hernandez Family

Juan Hernandez: father, 27

Elena Hernandez: mother, 25

Juan Hernandez Jr.: son, 8

Alberto Hernandez: son, 6

or immediately after the PPP so that they did not have to come to
the agency more than once a week. They agreed that this would be helpful because they did not have money for
multiple trips to the agency, although Juan Sr. stated that this would still affect his ability to work overtime on that
day. I asked if they had any goals they wanted to work toward during our sessions. Initially they were reluctant to
share anything, and then Elena suggested that a discussion on money management would be helpful. I told them
I w ould be their primary contact at the agency—meeting with them for the family sessions and co-facilitating the
PPP group with an intern. I explained my limitations around confidentiality, and they signed a form acknowledging
that I was required to share information about our sessions with the ACS worker. I informed them that the PPP is an
evidenced-based program and explained its meaning. I informed them that there is a pre- and post-test administered
along with the program and specific guidelines about missed classes. They were informed that if they missed more
than three classes, their participation would be deemed incomplete and they would not get their PPP certification.

Initially, when the couple attended parenting sessions and family sessions, Juan Sr. expressed feelings of anger
and resentment for being mandated to attend services at the agency. Several times he either refused to participate
by remaining quiet or spoke to the social worker and intern in a demeaning manner. He did this by questioning our
ability to teach the PPP and the effectiveness of the program itself, wanting to know how this was going to make
him a better parent. He also reiterated his belief that his form of discipline worked and that it was exactly what his
family members used for years on him and his relatives. He asked, “If it worked for them, why can’t that form of
punishment work for me and my children?” He emphasized that these were his children. He maintained throughout
the sessions that he never hit his children and never would. Both he and Elena often talked about their love for their
children and the devastation they would feel if they were ever taken away from them.

Treatment consisted of weekly parenting classes with the goal of teaching them effective and safe discipline skills
(such as setting limits through the use of time-out and taking away privileges). Further, the classes emphasized the
importance of recognizing age-appropriate behavior. We spent sessions reviewing child development techniques to
help boost their children’s self-esteem and sense of confidence. We also talked about managing one’s frustration
(such as when to take a break when angry) and helping their children to do the same.

Family sessions were built around helping the family members express themselves in a safe environment. The
parents and the children were asked to talk about how they felt about each other and the reason they were mandated
to treatment. They were asked to share how they felt while at home interacting with one another. I thought it was of
particular importance to have them talk about their feelings related to the call to ACS, as I was unsure how Juan Sr.
felt about Juan Jr.’s report to the social worker. It was necessary to assist them with processing this situation so that
there were no residual negative feelings between father and son. I asked them to role-play—having each member act
like another member of the household. This was very effective in helping Juan Sr. see how his boys view him and
his behavior toward them when he comes home from work. As a result of this exercise, he verbalized his newfound
clarity around how the boys have been seeing him as a very angry and negative father.

I also used sessions to explore the parents’ backgrounds. Using a genogram, we identified patterns among their
family members that have continued through generations. These patterns included the use of discipline to maintain
order in the home and the potentially unrealistic expectations the elders had for their children and grandchildren.
Elena stated that she was treated like an adult and had the responsibilities of a person much older than herself while
she was still very young. Juan Sr. said he felt responsible for bringing money into the home at an early age. He was
forced by his parents to get working papers as soon as he turned 14. His paychecks were then taken by his parents
each week and used to pay for groceries and other bills. He expressed anger at his parents for encouraging him to
drop out of high school so that he could get more than one job to help out with the finances.

Other sessions focused on the burden they felt related to their finances and how that burden might be felt by
the boys, just as Juan Sr. might have felt growing up. In one session, Juan Jr. expressed his fears of being evicted
and the lights being turned off, because his father often talked of not having money for bills. Both boys expressed
sadness over the amount of time their father spent at work and stressed their desire to do more things with him
at night and on the weekends. Both parents stated they did not realize the boys understood their anxieties around

4

Together we discussed the plan for treatment, following the
requirements of ACS; they would attend a 12-week Positive Parenting
Program (PPP) along with weekly family sessions. In an effort to
reduce some of the financial burden of attending multiple meetings
at the agency, I offered to meet with the family either just before

SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

paying bills and felt sad that they worried about these issues. We also
took a couple of sessions to address money management. We worked
together to create a budget and identify unnecessary expenses that
might be eliminated.

It was clear that this was a family that loved each other very much.
Juan Sr. and Elena were often affectionate with each other and their
sons. Once the initial anger subsided, both Juan Sr. and Elena fully

Key to Acronyms

ACS: Administration for
Children Services

PPP: Positive Parenting Program

engaged in both the family sessions and the PPP. We assessed their progress monthly and highlighted that progress.
I also was aware that it was important to learn about the Hernandez family history and culture in order to under­
stand their perspective and emotions around the ACS referral. I asked them many questions about their beliefs,
customs, and culture to learn about how they view parenthood, marriage roles, and children’s behaviors. They were
always open to these questions and seemed pleased that I asked about these things rather than assumed I knew the
answers.

During the course of treatment they missed a total of four PPP classes. I received a call from Elena each time
letting me know that Juan Sr. had to work overtime and they would miss the class. She was always apologetic and
would tell me she would like to know what they missed in the class so that she could review it on her own. During
a call after the fourth missed parenting class, I reminded Elena that in order to obtain the certificate of completion,
they were expected to attend a minimum of nine classes. By missing this last class, I explained, they were not going
to get the certificate. Elena expressed fear about this and asked if there was any way they could still receive it. She
explained that they only had one car and that she had to miss the classes when Juan Sr. could not go because she
had no way of getting to the agency on her own. I told her that I did not have the authority to change the rules
around the number of classes missed and that I understood how disappointed she was to hear they would not get
the certificate. When I told her I had to call the ACS worker and let her know, Elena got very quiet and started to
cry. I spoke with her for a while, and we talked about the possible repercussions.

I met with my supervisor and informed her of what had occurred. I knew I had to tell the ACS worker that they
would not receive the certificate of completion this round, and I felt bad for the situation Juan Sr. and Elena and
their boys were now in. I had been meeting with them for family sessions and parenting classes for almost three
months by this point and had built a strong rapport. I feared that once I called the ACS worker, that rapport would
be broken and they would no longer want to work with me. I saw them as loving and caring parents who were trying
the best they could to provide for their family. They had been making progress, particularly Juan Sr., and I did not
want their work to be in vain.

I also questioned whether the parenting and family sessions were really necessary for their situation. I felt there
was a lack of cultural competence on the part of the ACS worker—she had made some rather judgmental and
insensitive comments on the phone to me during the referral. I wondered if there was a rush to judgment on her
part because their form of discipline was not commonly used in the United States. In my own professional opinion,
some time-limited education on parenting and child development would have sufficed, as opposed to the 3-month
parenting program and family sessions.

My supervisor and I also discussed the cultural competence at the agency and the fact that the class schedule may
not fit a working family’s life. We discussed bringing this situation to a staff meeting to strategize and see if we had
the resources to offer the PPP multiple times during the week, perhaps allowing clients to make up a class on a day
other than their original class day.

I met with Elena and Juan Sr. and let them know I had to contact the ACS worker about the missed classes.
I explained that this was something I had to do by law. They told me they understood, although another round of
parenting classes would be a financial burden and they had already struggled to attend the current round of classes
each week. I validated their concerns and told them we were going to look at offering the program more than once
a week. I also told them that when I spoke to the ACS worker, I would also highlight their progress in family and
parenting sessions.

I called the ACS worker and told her all the positive progress the parents had made over the previous 3 months
before letting her know that they had missed too many classes to obtain the PPP certificate. The ACS worker was
pleased with the progress I described but said she would recommend to her supervisor that the parents take the
PPP over again until a certificate was obtained. She would wait to hear what her supervisor’s decision was on this
matter. She said that family sessions could end at this point. In the end, the supervisor decided the parents needed
to come back to the agency and just make up the four classes they missed. Elena and Juan Sr. were able to complete
this requirement and received their certificate, and the ACS case was closed. They later returned on their own for a
financial literacy class newly offered at the agency free of charge.

5

The Parker Family

Sara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment with her 48-year-old daughter, Stephanie, and six cats. Sara and her daughter have lived together for the past 10 years, since
Stephanie returned home after a failed relationship and was unable to live independently. Stephanie has a diagnosis
of bipolar disorder, and her overall physical health is good. Stephanie has no history of treatment for alcohol or
substance abuse; during her teens she drank and smoked marijuana but no longer uses these substances. When
she was 16 years old, Stephanie was hospitalized after her first bipolar episode. She had attempted suicide by swal­
lowing a handful of Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her. She has
been hospitalized three times in the past 4 years when she stopped taking her medications and experienced suicidal
ideation. Stephanie’s current medications are Lithium, Paxil®, Abilify®, and Klonopin®.

Stephanie recently had a brief hospitalization as a result of depressive symptoms. She attends a mental health
drop-in center twice a week to socialize with friends and receives outpatient psychiatric treatment at a local mental
health clinic for medication management and weekly therapy. She is maintaining a part-time job at a local super­
market where she bags groceries and is currently being trained to become a cashier. Stephanie currently has active
Medicare and receives Social Security Disability (SSD).

Sara has recently been hospitalized for depression and has some physical issues. She has documented high
blood pressure and hyperthyroidism, she is slightly underweight, and she is displaying signs of dementia. Sara has
no history of alcohol or substance abuse. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare
and receives Social Security benefits and a small pension. She attends a day treatment program for seniors that
is affiliated with a local hospital in her neighborhood. Sara attends the program 3 days a week from 9:00 a.m. to
2:00 p.m., and van service is provided free of charge.

A telephone call was made to Adult Protective Services (APS) by the senior day treatment social worker when
Sara presented with increased confusion, poor attention to daily living skills, and statements made about Stephanie’s
behavior. Sara told the social worker at the senior day treatment program that, “My daughter is very argumentative
and is throwing all of my things out.” She reported, “We are fighting like cats and dogs; I’m afraid of her and of
losing all my stuff.”

During the home visit, the APS worker observed that the living room was very cluttered, but that the kitchen was
fairly clean, with food in the refrigerator and cabinets. Despite the clutter, all of the doorways, including the front
door, had clear egress. The family lives on the first floor of the apartment building and could exit the building without
difficulty in case of emergency. The litter boxes were also fairly clean, and there was no sign of vermin in the home.

Upon questioning by the APS worker, Sara denied that she was afraid of her daughter or that her daughter had
been physically abusive. In fact, the worker observed that Stephanie had a noticeable bruise on her forearm, which
appeared defensive in nature. When asked about the bruise, Stephanie reported that she had gotten it when her
mother tried to grab some items out of her arms that she was about to throw out. Stephanie admitted to throwing
things out to clean up the apartment, telling the APS worker, “I’m tired of my mother’s hoarding.” Sara agreed with
the description of the incident. Both Sara and Stephanie admitted to an increase in arguing, but denied physical
violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get my things back.”

The APS worker observed that Sara’s appearance was unkempt and disheveled, but her overall hygiene was
adequate (i.e., clean hair and clothes). Stephanie was neatly groomed with good hygiene. The APS worker deter­
mined that no one was in immediate danger to warrant removal from the home but that the family was in need of
a referral for Intensive Case Management (ICM) services. It was clear there was some conflict in the home that had
led to physical confrontations. Further, the house had hygiene issues, including trash and items stacked in the living
room and Sara’s room, which needed to be addressed. The APS worker indicated in her report that if not adequately
addressed, the hoarding might continue to escalate and create an unsafe and unhygienic environment, thus leading
to a possible eviction or recommendation for separation and relocation for both women.

As the ICM worker, I visited the family to assess the situation and the needs of the clients. Stephanie said she
was very angry with her mother and sick of her compulsive shopping and hoarding. Stephanie complained that
they did not have any visitors and she was ashamed to invite friends to the home due to the condition of the apart­
ment. When I asked Sara if she saw a problem with so many items littering the apartment, Sara replied, “I need
all of these things.” Stephanie complained that when she tried to clean up and throw things out, her mother went

6

SESSIONS: CASE HISTORIES • THE PARKER FAMILY

7

outside and brought it all back in again. We discussed the need to
clean up the apartment and make it habitable for them to remain
in their home, based on the recommendations of the APS worker. I
also discussed possible housing alternatives, such as senior housing
for Sara and a supportive apartment complex for Stephanie. Sara
and Stephanie both stated they wanted to remain in their apartment
together, although Stephanie questioned whether her mother would

cooperate with cleaning up the apartment. Sara was adamant that she did not want to be removed from their apart-
ment and would try to accept what needed to be done so they would not be forced to move.

Stephanie reported her mother is estranged from her younger sister, Jane, because of the hoarding. Stephanie
also mentioned she was dissatisfied with her mother’s psychiatric treatment and felt she was not getting the help
she needed. She reported that her mother was very anxious and was having difficulty sleeping, staying up until all
hours of the night, and buying items from a televised shopping network. Sara’s psychiatrist had recently increased
her Zyprexa prescription dosage to help reduce her agitation and possible bipolar disorder (as evidenced by the
compulsive shopping), but Stephanie did not feel this had been helpful and actually wondered if it was contributing
to her mother’s confusion. I asked for permission to contact Jane and both of their outpatient treatment teams, and
both requests were granted.

I immediately contacted Jane, who initially was uncooperative and stated she was unwilling to assist. Jane is
married, with three children, and lives 3 hours away. At the beginning of our phone call, Jane said, “I’ve been
through this before and I’m not helping this time.” When I asked if I could at least keep in touch with her to keep her
informed of the situation and any decisions that might need to be made, Jane agreed. After a few more minutes of
discussion around my role and responsibilities, I was able to establish a bit of rapport with Jane. She then started to
ask me questions and share some insight into what was going on in her mother and sister’s home.

Jane informed me that she was very angry with her mother and had not brought her children to the apartment
in years because of its condition. She said that her mother started compulsively shopping and hoarding when she
and Stephanie were in high school, and while her father had tried to contain it as best he could, the apartment was
always cluttered. She said this had been a source of conflict and embarrassment for her and Stephanie all of their
lives. She said that after her father died of a heart attack, the hoarding got worse, and neither she nor Stephanie
could control it. Jane also told me she felt her mother was responsible for Stephanie’s relapses. Jane reported that
Stephanie had been compliant with her medication and treatment in the past, and that up until a few years ago, had
not been hospitalized for several years. Jane had told Stephanie in the past to move out.

Jane also told me that she “is angry with the mental health system.” Sara had been recently hospitalized for
depression, and Jane took pictures of the apartment to show the inpatient treatment team what her mother was
going home to. Jane felt they did not treat the situation seriously because they discharged her mother back to the
apartment. Stephanie had been hospitalized at the same time as her mother, but in a different hospital, and Jane had
shown the pictures to her sister’s treatment team as well. Initially the social worker recommended that Stephanie not
return to the apartment because of the state of the home, but when that social worker was replaced with someone
new, Stephanie was also sent back home.

When I inquired if there were any friends or family members who might be available and willing to assist in
clearing out the apartment, Jane said her mother had few friends and was not affiliated with a church group or
congregation. However, she acknowledged that there were two cousins who might help, and she offered to contact
them and possibly help herself. She said that she would ask her husband to help as well, but she wanted assurance
that her mother would cooperate. I explained that while I could not promise that her mother would cooperate
completely, her mother had stated that she was willing to do whatever it took to keep living in her home. Jane
seemed satisfied with this response and pleased with the plan.

I then arranged to meet with Sara and her psychiatrist to discuss her increased anxiety and confusion and the
compulsive shopping. I requested a referral for neuropsychiatric testing to assess possible cognitive changes or
decline in functioning. A test was scheduled, and it indicated some cognitive deficits, but at the end of testing, Sara
told the psychologist who administered the tests she had stopped taking her medications for depression. It was
determined Sara’s depression and discontinuation of medication could have affected her test performance and it
was recommended she be retested in 6 months. I suggested a referral to a geriatric psychiatrist for Sara, as she
appeared to need more specialized treatment. Sara’s psychologist was in agreement.

Because they had both stated that they did not want to be removed from their home, I worked with Sara and
Stephanie as a team to address cleaning the apartment. All agreed that they would begin working together to clean
the house for 1 hour a day until arrangements were made for additional help from family members. In an attempt

The Parker Family

Sara Parker: mother, 72

Stephanie Parker: daughter, 48

Jane Rodgers: daughter, 45

SESSIONS: CASE HISTORIES • THE PARKER FAMILY

8

to alleviate Sara’s anxiety around throwing out the items, I suggested
using three bags for the initial cleanup: one bag was for items she
could throw out, the second bag was for “maybes,” and the third
was for “not ready yet.” I scheduled home visits at the designated
cleanup time to provide support and encouragement and to inter-
vene in disputes. I also contacted Sara’s treatment team to inform
them of the cleanup plans and suggested that Sara might need addi-
tional support and observation as it progressed. Jane notified me
that her two cousins were willing to assist with the cleanup, make
minor repairs, and paint the apartment. Jane offered to schedule a date that would be convenient for her and her
cousins to come and help out.

We then discussed placement for at least some of the cats, because six seemed too many for a small apartment.
Sara and Stephanie were at first adamant that they could not give up their cats, but with further discussion admitted
it had become extremely difficult to manage caring for them all. They both eventually agreed to each keep their
favorite cat and find homes for the other four. Sara and Stephanie made fliers and brought them to their respective
treatment programs to hand out. Stephanie also brought fliers about the cats to her place of employment. Three of
the four cats were adopted within a week.

During one home visit, Stephanie pulled me aside and said she had changed her mind—she did not want to
continue to live with her mother. She requested that I complete a housing application for supportive housing stating,
“I want to get on with my life.” Stephanie had successfully completed cashier training, and the manager of the super-
market was pleased with her performance and was prepared to hire her as a part-time cashier soon. She expressed
concern about how her mother would react to this decision and asked me for assistance telling her.

We all met together to discuss Stephanie’s decision to apply for an apartment. Sara was initially upset and had
some difficulty accepting this decision. Sara said she had fears about living alone, but when we discussed senior
living alternatives, Sara was adamant she wanted to remain in her apartment. Sara said she had lived alone for a
number of years after her husband died and felt she could adjust again. I offered to help her stay in her apartment
and explore home care services and programs available that will meet her current needs to remain at home.

Key to Acronyms

APS: Adult Protective Services

ICM: Intensive Case Management
services

SSD: Social Security Disability

The Logan Family

Eboni Logan is a 16-year-old biracial African American/Caucasian female in 11th grade. She is an honors student, has been taking Advanced Placement courses, and runs track. Eboni plans to go to college and major
in nursing. She is also active in choir and is a member of the National Honor Society and the student council. For the
last 6 months, Eboni has been working 10 hours a week at a fast food restaurant. She recently passed her driver’s
test and has received her license.

Eboni states that she believes in God, but she and her mother do not belong to any organized religion. Her father
attends a Catholic church regularly and takes Eboni with him on the weekends that she visits him.

Eboni does not smoke and denies any regular alcohol or drug usage. She does admit to occasionally drinking
when she is at parties with her friends, but denies ever being drunk. There is no criminal history. She has had no
major health problems.

Eboni has been dating Darian for the past 4 months. He is a 17-year-old African American male. According to
Eboni, Darian is also on the track team and does well in school. He is a B student and would like to go to college,
possibly for something computer related. Darian works at a grocery store 10–15 hours a week. He is healthy and
has no criminal issues. Darian also denies smoking or regular alcohol or drug usage. He has been drunk a few times,
but Eboni reports that he does not think it is a problem. Eboni and Darian became sexually active soon after they
started dating, and they were using withdrawal for birth control.

Eboni’s mother, Darlene, is 34 years old and also biracial African American/Caucasian. She works as an adminis­
trative assistant for a local manufacturing company. Eboni has lived with her mother and her maternal grandmother,
May, from the time she was born. May is a 55-year-old African American woman who works as a paraprofessional
in an elementary school. They still live in the same apartment where May raised Darlene.

Darlene met Eboni’s father, Anthony, when she was 17, the summer before their senior year in high school.
Anthony is 34 years old and Caucasian. They casually dated for about a month, and after they broke up, Darlene
discovered she was pregnant and opted to keep the baby. Although they never married each other, Anthony has
been married twice and divorced once. He has four other children in addition to Eboni. She visits her father and
stepmother every other weekend. Anthony works as a mechanic and pays child support to Darlene.

Recently, Eboni took a pregnancy test and learned that she is 2 months pregnant. She actually did not know
she was pregnant because her periods were not always consistent and she thought she had just skipped a couple
of months. Eboni immediately told her best friend, Brandy, and then Darian about her pregnancy. He was shocked
at first and suggested that it might be best to terminate. Darian has not told her explicitly to get an abortion, but
he feels he cannot provide for her and the baby as he would like and thinks they should wait to have children. He
eventually told her he would support her in any way he could, whatever she decides. Brandy encouraged Eboni to
meet with the school social worker.

During our first meeting, Eboni told me that she had taken a pregnancy test the previous week and it was positive.
At that moment, the only people who knew she was pregnant were her best friend and boyfriend. She had not told
her parents and was not sure how to tell them. She was very scared about what they would say to her. We talked
about how she could tell them and discussed various responses she might receive. Eboni agreed she would tell her
parents over the weekend and see me the following Monday. During our meeting I asked her if she used contracep­
tion, and she told me that she used the withdrawal method.

Eboni met with me that following Monday, as planned, and she was very tearful. She had told her parents and
grandmother over the weekend. Eboni shared that her mother and grandmother had become visibly upset when
they learned of the pregnancy, and Darlene had yelled and called her a slut. Darlene told Eboni she wanted her to
have a different life than she had had and told her she should have an abortion. May cried and held Eboni in her
arms for a long time. When Eboni told her father, he was shocked and just kept shaking his head back and forth, not
saying a word. Then he told her that she had to have this child because abortion was a sin. He offered to help her
and suggested that she move in with him and her stepmother.

Darlene did not speak to Eboni for the rest of the weekend. Her grandmother said she was scheduling an appoint­
ment with the doctor to make sure she really was pregnant. Eboni was apprehensive about going to the doctor, so
we discussed what the first appointment usually entails. I approached the topic of choices and decisions if it was
confirmed that she was pregnant, and she said she had no idea what she would do.

9

10

SESSIONS: CASE HISTORIES • THE LOGAN FAMILY

Two days later, Eboni came to see me with the results of her
doctor’s appointment. The doctor confirmed the pregnancy, said
her hormone levels were good, and placed her on prenatal vitamins.
Eboni had had little morning sickness and no overt issues due to the
pregnancy. Her grandmother went with her to the appointment, but
her mother was still not speaking to her. Eboni was very upset about
the situation with her mother. At one point she commented that
parents are supposed to support their kids when they are in trouble
and that she would never treat her daughter the way her mother was
treating her. I offered to meet with Eboni and her mother to discuss
the situation. Although apprehensive, Eboni gave me permission to call her mother and set up an appointment.

I left a message for Darlene to contact me about scheduling a meeting. She called back and agreed to meet with
Eboni and me. When I informed Eboni of the scheduled meeting, she thanked me. She told me that she was going
to spend the upcoming weekend with her father, and that she was apprehensive about how it would go. When I
approached the topic of a decision about the pregnancy, she stated that she was not certain but was leaning in
one direction, which she did not share with me. I suggested we get together before the meeting with her mother to
discuss the weekend with her father.

At our next session, Eboni said she thought she knew what to do but after spending the weekend with her father
was still confused. Eboni said her father went on at length about how God gives life, and that if she had an abortion,
she would go to hell. Eboni was very scared. Anthony had taken her to church and told the priest that Eboni was
pregnant and asked him to pray for her. Eboni said this made her feel uncomfortable.

When I met with Eboni and her mother, Darlene shared her thoughts about Eboni’s pregnancy and her belief
that she should have an abortion. She said she knows how hard it is to be a single mother and does not want this
for Eboni. She believes that because Eboni is so young, she should do as she says. Eboni was very quiet during the
session, and when asked what she thought, said she did not know. At the end of the session, nothing was resolved
between Eboni and her mother.

When I met with Eboni the next day to process the session, she said that when they got home, she and her
mother talked without any yelling. Her mother told Eboni she loved her and wanted what was best for her. May said
she would support Eboni no matter what she decided and would help her if she kept the baby.

Eboni was concerned because she thought she was beginning to look pregnant and her morning sickness had
gotten worse. I addressed her overall health, and she said that she wanted to sleep all the time, and that when she
was not nauseated, all she did was eat. Eboni is taking her prenatal vitamins in case she decides to have the baby.
Only a couple of her friends know about the pregnancy, and they had different thoughts on what they thought
she should do. One friend even bought her a onesie. In addition, Eboni was concerned that her grades were being
affected by the situation, possibly affecting her ability to attend college. She was also worried about how a pregnancy
or baby would affect her chances of getting a track scholarship. In response to her many concerns, I educated her
on stress-reduction methods.

Eboni asked me what I thought she should do, and I told her it was her decision to make for herself and that she
should not let others tell her what to do. However, I also stated that it was important for her to know all the options.
We discussed at length what it would mean for her to keep the baby versus terminating the pregnancy. I mentioned
adoption and the possibility of an open adoption, but Eboni said she was not sure she could have a baby and then
give it away. We discussed the pros and cons of adoption, and she stated she was even more confused. I reminded
her that she did not have much time to make her decision if she was going to terminate. She said she wanted a few
days to really consider all her options.

Eboni scheduled a time to meet with me. When she entered my office, she told me she had had a long talk with
her mother and grandmother the night before about what she was going to do. She had also called her father and
Darian and told them what she had decided. Eboni told me she knows she has made the right decision.

The Logan Family

May Logan: mother of Darlene, 55

Darlene Logan: mother, 34

Anthony Jennings: father, 34

Eboni Logan: daughter, 16

Darian: Eboni’s boyfriend, 17

The Johnson Family

Talia is a 19-year-old heterosexual Caucasian female, who is a junior majoring in psychology and minoring in English. She has a GPA of 3.89 and has been on the dean’s list several times over the last 3 years. She has
written a couple of short articles for the university’s newspaper on current events around campus and is active in
her sorority, Kappa Delta. She works part time (10–15 hours a week) at an accessory store. Talia recently moved off
campus to an apartment with two close friends from her sorority. She is physically active and runs approximately
three miles a day. She also goes to the university’s gym a couple of days a week for strength training. Talia does not
use drugs, although she has smoked marijuana a few times in her life. She drinks a few times a week, often going out
with friends one day during the week and then again on Friday and Saturday nights. When she is out with friends,
Talia usually has about four to six drinks. She prefers to drink beer over hard liquor or wine, but will occasionally
have a mixed drink.

Talia has no criminal history. She reports a history of anxiety in her family (on her mother’s side), and on a few
occasions has experienced heart palpitations, which her mother told her was due to nervousness. This happened
only a handful of times in the past and usually when Talia was “very stressed out,” so Talia had never felt the need
to go to the doctor or talk to someone about it until now. Talia is currently not dating anyone. She was in a relation­
ship for 1

1
2 years, but it ended a few months ago. She had since been “hooking up” with a guy in one of her English

classes, but does not feel it will turn into anything serious and has not seen him in several weeks.
Talia’s parents, Erin (40) and Dave (43), and her siblings, Lila (16) and Nathan (14), live 2 hours away from

the university. Erin works at a salon as a hairdresser, and Dave is retired military and works for a home security
company. Erin is on a low-dose antidepressant for anxiety, something she has been treated for all of her life.

Talia came to see me at the Rape Counseling Center (RCC) on campus for services after she was sexually
assaulted at a fraternity party 3 weeks prior. She told me she had thought she could handle her feelings after the
assault, but she had since experienced a number of emotions and behaviors she could no longer ignore. She was not
sleeping, she felt sad most days, she had stopped going out with friends, and she had been unable to concentrate on
schoolwork. Talia stated that the most significant issues she had faced since the assault had been recurrent anxiety
attacks.

Talia learned about the RCC when she went to the hospital after the sexual assault. She went to the hospital to
request that a rape kit be completed and also requested the morning-after pill and the HIV prevention protocol (Post-
Exposure Prophylaxis, or PEP). At that time, a nurse contacted me through the Sexual Assault Response Team
(SART) to provide Talia with support and resources. I spent several hours with Talia at the hospital while she went
through the examination process. Talia shared bits and pieces of the evening with me, although she said most of
the night was a blur. She said a good-looking guy named Eric was flirting with her all night and bringing her drinks.
She did not want to seem ungrateful and enjoyed his company, so she drank. She also mentioned that the drinks
were made with hard liquor, something that tends to make her drunk faster than beer. She said that at one point she
blacked out and has no idea what happened. She woke up naked in a room alone the next morning, and she went
straight to the hospital. Once Talia was done at the hospital, I gave her the contact information for RCC. I encour­
aged her to call if she had any questions or needed to talk with someone.

During our first meeting at the RCC, I provided basic information about our services. I let her know that every­
thing was confidential and that I wanted to help create a safe space for her to talk. I told her that we would move
along at a pace that was comfortable for her and that this was her time and we could use it as she felt best. We talked
briefly about her experience at the hospital, which she described as cold and demeaning. She told me several times
how thankful she was that I had been there. She said one of the reasons she called the RCC was because she felt I
supported and believed her. I used the opportunity to validate her feelings and remind her that I did, in fact, believe
her and that the assault was not her fault.

We talked briefly about how Talia had been feeling over the last 3 weeks. She was very concerned about her
classes because she had missed a couple of assignment deadlines and was fearful of failing. She told me several
times this was not like her and she was normally a very good student. I told her I could contact the professors
and advocate for extensions without disclosing the specific reason Talia was receiving counseling services and
would need additional time to complete her assignments. Talia thanked me and agreed that would be best. I intro­
duced the topic of safety and explained that she might possibly see Eric on campus, something that might cause

11

SESSIONS: CASE HISTORIES • THE JOHNSON FAMILY

her emotional distress. We talked about strategies she could use
to protect herself, and she agreed to walk with a friend while on
campus for the time being. She also agreed she would avoid the
gym where she had seen Eric before.

During our second meeting, Talia seemed very anxious.
We talked about how she had been feeling over the last week, and
she indicated she was still not sleeping well at night and that she
was taking long naps during the day. She had missed days at work,
something she had never done before, and was in jeopardy of losing
her job. Talia reported experiencing several anxiety attacks as well.

The Johnson Family

Erin Johnson: mother, 40

Dave Johnson: father, 43

Talia Johnson: daughter, 19

Lila Johnson: daughter, 16

Nathan Johnson: son, 14

She described the attack symptoms as feeling unable to breathe, accompanied by a swelling in her chest, and an
overwhelming feeling that she was going to die. She said that this was happening several times a day, although
mostly at night. I provided some education about trauma responses to sexual assault and the signs and symptoms
of post-traumatic stress disorder (PTSD). We went over a workbook on trauma reactions to sexual assault and
reviewed the signs and symptoms checklist, identifying several that she was experiencing. We practiced breathing
exercises to use when she felt anxious, and she reported feeling better. I told her it was important to identify the
triggers to her anxiety so that we could find out what exactly was causing her to be anxious in a given moment.
I explained that while the assault itself had brought the attacks on, it would be helpful to see what specific things
(such as memories, certain times of the day, particular smells, etc.) caused her to have anxiety attacks. I gave Talia
an empty journal and asked her to record the times of the episodes over the next week as well as what happened
right before them. She agreed.

We met over several sessions and continued to address Talia’s anxiety symptoms and feelings of sadness. She
told me she was unable to talk about what happened on the night of the rape because she felt ashamed. She said
that it was too difficult for her to verbalize what happened and that the words coming out of her mouth would hurt
too much. I reassured her that we would go at her pace and that she could talk about what happened when she felt
comfortable. We practiced breathing and reviewed her journal log each week.

It had become clear that the evenings seemed to be the peak time for her anxiety, which I told her made sense as
her assault had occurred at night. I described how sleep is often difficult for survivors of sexual assault because they
fear having nightmares about what happened. She looked surprised and said she had not mentioned it, but she kept
having dreams about Eric in which he was talking to her at the party. The dreams ended with him holding her hand
and walking her away. She said she also thought about this during the day and could actually see it happening in her
mind. We talked about the intrusive thoughts that often occur after trauma, and I tried to normalize her experience.
I told her that often people try to avoid these intrusions, and I wondered if she felt she was doing anything to avoid
them. She told me she had started taking a sleep aid at night. When I asked about her exercise habits, she said that
right after the assault she had stopped running and going to the gym. We set a goal that she would run one to two
times a week to help her with anxiety and sleeping. I also suggested that now would be a good time to start writing
her feelings down because journaling is a very useful way to express feelings when it is difficult to verbalize them.
Talia mentioned that she had decided not to go to the police about the sexual assault because she did not want to go
through the process. I informed her that if she wanted to, she could address the assault in another way, by bringing
it to the campus judicial system. She said she would think about this option.

During another session weeks later, Talia came in distraught. She said she had been feeling better overall since
working on her breathing and doing the journaling, but that a few things had happened that were making her more
and more anxious and that her attacks were increasing again. Talia said her parents were pushing her to drop out
of school and to come home. She said they had been calling and texting her often, something she found annoying
but understandable. They were very upset about what had happened, although they were more upset with her that
she had waited for weeks to tell them about “it.” Her father threatened to come and beat the guy up, and her mother
cried. She avoided talking with them, but they had become relentless with the calls. Her mother had shown up with
her sister unannounced the previous weekend and had treated Talia like she had a cold—making chicken soup and
rubbing Talia’s feet. The pressure from her parents was weighing on her and upsetting her. Talia was also distressed
by a friend who kept pushing her to talk about what happened. When Talia finally relented, her friend asked her
why she had gone upstairs with him. Talia said this made her feel terrible, and she started to cry. This friend also
told her that Eric had heard she had gone to the hospital and was telling people that she had wanted to have sex.
Eric had been telling people she was “all over him” and that she had taken her own pants off. This made Talia very
angry and upset.

12

SESSIONS: CASE HISTORIES • THE JOHNSON FAMILY

We talked about how there are certain myths in society around
sexual assault and that the victim is often blamed. We also talked
about how the perpetrator often blames his or her victim to make
himself or herself feel better. Talia said she has felt some sense of
blame for what happened and that she should not have drunk so
much. She started to cry. I gently reminded her that she was not at
fault for Eric’s actions, and her drinking was not an invitation to have
sex. I reminded her that he should have seen how incapacitated she
was and that she could not have consented to sex. Talia continued
to cry. She clearly had a number of emotions she wanted to express
but was having difficulty sharing them, so I offered her some clay and
asked her to use it to mold representations of different areas in her
life and how she felt about them. We spent the rest of the session
talking about the shapes she made and how she felt. Toward the end of the session she told me she had decided to
put in a complaint with the campus judicial system about the assault. She worried that Eric would assault another
woman and she would feel responsible if she did not alert the university. I offered my support and told her I would
be there for her through the process.

13

Key to Acronyms

HIV: Human Immunodeficiency
Virus Infection

PEP: Post-Exposure Prophylaxis

PTSD: Post-Traumatic
Stress Disorder

RCC: Rape Counseling Center

SART: Sexual Assault
Response Team

PART 2: CONCENTRATION YEAR

14

The Levy Family

Jake Levy (31) and Sheri (28) are a married Caucasian couple who live with their sons, Myles (10) and Levi (8), in a two-bedroom condominium in a middle-class neighborhood. Jake is an Iraq War veteran and employed as
a human resources assistant for the military, and Sheri is a special education teacher in a local elementary school.
Overall, Jake is physically fit, but an injury he sustained in combat sometimes limits his ability to use his left hand.
Sheri is in good physical condition and has recently found out that she is pregnant with their third child.

As teenagers, Jake and Sheri used marijuana and drank. Neither uses marijuana now but they still drink. Sheri
drinks socially and has one or two drinks over the weekend. Jake reports he has four to five drinks in the evenings
during the week and eight to ten drinks on Saturdays and Sundays. Neither report having criminal histories.

Jake and Sheri identify as being Jewish and attend a local synagogue on major holidays. Jake’s parents are
deceased, and he has a sister who lives outside London. He and his sister are not very close but do talk twice a year.
Sheri is an only child, and her mother lives in the area but offers little support. Her mother never approved of Sheri
marrying Jake and thinks Sheri needs to deal with their problems on her own. The couple has some friends, but due
to Jake’s recent behaviors, they have slowly isolated themselves.

My first encounter with Jake was at an intake session at the Veterans Affairs Health Care Center (VA). During this
meeting, Jake stated that he came to the VA for services because his wife had threatened to leave him if he did not
get help. She was particularly concerned about his drinking and lack of involvement in his sons’ lives. She told him
his drinking had gotten out of control and was making him mean and distant. Jake had seen Dr. Zoe, a psychiatrist
at the VA, who diagnosed him with post-traumatic stress disorder (PTSD). Dr. Zoe prescribed Paxil to help reduce
his symptoms of anxiety and depression and suggested that he also begin counseling.

During the assessment, Jake said that since his return to civilian life 10 months ago he had experienced difficulty
sleeping, heart palpitations, and moodiness. He told me that he and his wife had been fighting a lot and that he
drank to take the edge off and to help him sleep. Jake admitted to drinking heavily nearly every day. He reported
that he was not engaged with his sons at all and he kept to himself when he was at home. He spent his evenings on
the couch drinking beer and watching TV or playing video games. When we discussed Jake’s options for treatment
he expressed fear of losing his job and his family if he did not get help. Jake worked in an office with civilians and
military personnel and mostly got along with people in the office. Jake tended to keep to himself and said he some­
times felt pressured to be more communicative and social. He was also very worried that Sheri would leave him. He
said he had never seen her so angry before and saw she was at her limit with him and his behaviors.

Based on the information Jake provided about his diagnosis and family concerns, we agreed that the best course
of action would be for him to participate in weekly individual sessions with me and a weekly support group that
was offered at the VA for Iraq veterans. I then offered a referral for couples counseling at the local mental health
agency. I also printed out a list of local Alcoholics Anonymous (AA) meetings in his area if he decided he wanted to
attend in order to address his drinking. He would continue to follow up with Dr. Zoe on a monthly basis to monitor
the effectiveness of his medications.

The following session, I spent time explaining his diagnosis and the symptoms related to PTSD. Jake said that he
did not really understand what PTSD was but thought it meant that a person who had it was “going crazy,” which
at times he thought was happening to him. He expressed concern that he would never feel “normal” again and said
that when he drank alcohol, his symptoms and the intensity of his emotions eased. I explained to Jake that PTSD is
a severe anxiety disorder that develops after a person has experienced an event that results in psychological trauma.
The event may involve the threat or perceived threat of death to oneself or to someone else. I also explained that
the disorder is characterized by re-experiencing the traumatic event, including the symptoms of increased arousal,
and by the desire to avoid stimuli associated with the trauma. We talked about how his behaviors fit into this cycle
of hyperarousal and avoidance, including his lack of sleep and irritability and the isolation and heavy drinking.
He talked about always feeling “ready to go.” He said he was exhausted from being always alert and looking for
potential problems around him. He told me he always felt on edge and every sound seemed to startle him.

He shared that he often thinks about what happened “over there” but tries to push it out of his mind. It is the
night that is the worst as he has terrible recurring nightmares of one particular event. He said he wakes up shaking
and sweating most nights. He then said drinking was the one thing that seemed to give him a little relief. I gave him
a handout on PTSD and reviewed the signs and symptoms. Jake seemed relieved to receive the information. I told

15

SESSIONS: CASE HISTORIES • THE LEVY FAMILY

him that naming the issue or concern was often helpful in the healing
process. During the first few sessions my goal was to help Jake feel
safe and validate his feelings. We consistently assessed his feelings of
safety, including any potential suicidal ideation. He was reluctant to
attend AA at that time, so we began monitoring his drinking and his
behaviors after several drinks.

The Levy Family

Jake Levy: father, 31

Sheri Levy: mother, 28

Myles Levy: son, 10

Levi Levy: son, 8 Jake began his individual sessions practicing techniques I had
shown him to help reduce his anxiety symptoms. We used deep
breathing and guided meditation to help him remain calm and in the
moment. We started to chart when he had intrusive thoughts about the war, potential triggers to his hyperarousal,
and when he tried to dissociate or numb in reaction to these episodes.

Jake slowly began to share his experiences while in combat. I helped to gently guide him through the events that
seemed to haunt him the most. I explained that telling one’s story in effect helped him “own it,” and in turn it would
be integrated into his life on his terms. I told him that the act of telling his story can actually change the processing
of the traumatic event in his brain. I was careful through this process not to push him into talking about events that
seemed too traumatic for fear of re-traumatizing him. There were many sessions in which he started to share a
specific event and then stopped mid-story and had to begin his relaxation exercises.

During this time he had also started participating in the veterans’ support group. Jake reported that he was
uneasy during the first couple of meetings because he did not know anyone, but that the other vets were supportive.
He said it was helpful to hear from others who experienced the same feelings he had since he returned home.
He said he no longer felt alone nor did he feel “crazy.” Jake also shared that he had started attending AA meetings.

While I did not participate in the couples’ sessions, Jake felt it was important that I hear about how these sessions
were going. He told me the social worker at the local mental health clinic helped Sheri understand what he was
going through by teaching her about PTSD.

The social worker explained how PTSD affected not only the individual, but the whole family and, in turn, the
home environment. Jake said Sheri admitted that she did not understand what he was going through but that he
was not the same person when he returned home from Iraq, and this scared her. Jake said Sheri seemed to be
empathetic toward him and appeared to be relieved when the social worker explained his diagnosis.

Jake said he and Sheri worked together to address her main concerns. She felt he drank too much, was not
communicating with her, was isolating himself from the family, and appeared to be depressed. She was particularly
concerned about his lack of interaction with his sons and lack of interest in the current pregnancy. She worried that
he would be uninvolved in caring for this new baby just as he was uninvolved with his boys.

Jake shared that in another couples’ session, Sheri talked about wanting to be able to communicate with Jake
without feeling that she was “nagging him” or fearful that she was making him withdraw. She said she avoided
asking him things or talking to him for fear it would “set him off” and make him retreat to the basement on his own.
As it stood, she did not think she could talk with Jake about her concerns. She told him she missed socializing with
friends and having family outings and felt isolated. Jake said just keeping his intrusive thoughts at bay took all the
energy he could muster, so making small talk with friends was not something he felt he could do right now. Sheri
admitted that she did not know that socializing affected him that way. He said the social worker explained that for
veterans with PTSD, oftentimes crowds, loud noises, and open spaces triggered intrusive memories and caused
anxiety attacks. He said that he and Sheri had developed a plan that would improve their communication. He said
they were going to slowly begin planning outings that he felt he could handle, and that they also agreed that if at any
time he felt uncomfortable while out that they would leave.

Through individual, group, and couples sessions, Jake was able
to address his trauma and his PTSD symptoms abated. He real-
ized that drinking was being used as a way to avoid his feelings
and attended AA meetings regularly. He has been able to maintain
his sobriety and found a sponsor who is also a veteran. Sheri gave
birth to a healthy baby boy, and Jake shared pictures of his son. He
continues to attend group sessions and has become involved in some
mentoring with young vets here at the VA. He feels strongly in giving
back and has suggested that the VA begin a program that has been
piloted in another state.

16

Key to Acronyms

AA: Alcoholics Anonymous

PTSD: Post-Traumatic Stress
Disorder

VA: Veterans Affairs
Health Care Center

The Bradley Family

T iffani Bradley is a 16-year-old heterosexual Caucasian female referred to me after being arrested for prostitu­tion. I worked with Tiffani at Teens First, a brand new court-mandated teen counseling program for adolescent
victims of sexual exploitation and human trafficking. At Teens First we provide a holistic range of services for our
clients. Tiffani has been provided room and board in our residential treatment facility and will meet with a number
of social workers to address her multiple needs and concerns.

Tiffani has been arrested three times for prostitution in the last 2 years. Right before her most recent charge,
a new state policy was enacted to protect youth 16 years and younger from prosecution and jail time for prostitu­
tion. The Safe Harbor for Exploited Children Act allows the state to define Tiffani as a sexually exploited youth and
therefore the state will not imprison her for prostitution. She was mandated to services at our agency, unlike her
prior arrests when she had been sent to detention.

Tiffani had been living with a man she has identified as Donald since she was 14 years old. She had had limited
contact with her family members and had not been attending school. She described Donald as her “husband”
(although they were not married) and her only friend. She had contacted her sister, Diana, a few times over the
previous 2 years and stated that she missed her very much. Donald had recently sold Tiffani to another pimp, “John
T.” Tiffani reported that she was very upset that Donald did this and that she wanted to be reunited with him. She
had tried to make contact with him by sending messages through other people, as John T. did not allow her access
to a phone.

During intake it was noted that Tiffani had multiple bruises and burn marks on her legs and arms. She reported
that Donald had slapped her when he felt she did not behave and that John T. burned her with cigarettes. Tiffani
has been treated for several sexually transmitted infections (STIs) at local clinics and is currently on an antibiotic
for a kidney infection. Although she was given condoms by Donald and John T. for her “dates,” there were several
“Johns” who refused to use them. It appears that over the last 2 years, Tiffani has had neither outside support nor
interactions with anyone beyond Donald, John T., and some other young women also being prostituted.

Other members of the Bradley family include Tiffani’s 33-year-old mother, Shondra; Tiffani’s 38-year-old father,
Robert; and Tiffani’s 13-year-old sister, Diana. Shondra and Robert have been separated for a little over a year and
have started dating other people. Diana currently resides with her mother and Anthony, her mother’s new boyfriend.
Shondra and Anthony abuse a variety of drugs, including marijuana and methamphetamine.

Robert also abuses a number of drugs and has recently been arrested for possession of crack cocaine. Robert has
been arrested several times over the last 5 years: twice for domestic violence calls and twice for drug possession.
He is currently in jail awaiting sentencing.

The goals Tiffani and I set in our initial sessions centered on helping her feel safe and secure in her new home and
utilizing as many of the available resources as possible. Through individual and group counseling, Tiffani will have
the opportunity to discuss her experiences prior to coming to Teens First, including what led to her relationship with
Donald. A long-term goal I presented was to help her understand that Donald, the person who she maintained “is
the love of my life,” had actually had a negative impact on her life. Tiffani listed some of her own long-term goals,
including obtaining a General Education Development (GED) credential, getting her own apartment, getting a job,
and reunifying with her sister.

During our sessions over the year, Tiffani gave a rather in-depth description of her childhood. At first Tiffani
provided a family history that was filled with only happy memories. She remembered her life up to age 8 as filled
with moments of joy. She remembered going to school, playing with her sister, and her mother and father getting
along.

As we continued to meet, Tiffani shared what she remembered as a gradual but definitive change in the family
dynamics around the time when she turned 8 years old. She remembered being awakened by music and laughter in
the early hours of the morning. When she went downstairs to investigate, she saw her parents along with her uncle
Nate passing a pipe back and forth between them. She remembered asking them what they were doing and her
mother saying, “adult things” and putting her back in bed.

Tiffani remembered being woken up by noise several times after that and seeing her father and her uncle passing
the pipe between them. Sometimes her mother was there and sometimes she was not. Often when her mother was
not there, Nate would see her and ask her to come over. Her father would sometimes ask her to show them the

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SESSIONS: CASE HISTORIES • THE BRADLEY FAMILY

dance that she had learned at school. When she danced, her father
and Nate would laugh and offer her pocket change. Sometimes they
were joined by their friend Jimmy.

For years the music and noise downstairs continued, later accom
panied by screams and shouting and sounds of people fighting. One
morning, Shondra yelled at Robert to “get up and go to work.” Tiffani
and Diana saw Robert come out of the bedroom and slap Shondra
so hard she was knocked down. Robert then went back into the
bedroom.

The Bradley Family

Robert Bradley: father, 38

Shondra Bradley: mother, 33

Nate Bradley: uncle, 36

Tiffani Bradley: daughter, 16

Diana Bradley: daughter, 13

Donald: Tiffani’s self-described
husband and her former pimp

Shondra currently lives with
her boyfriend, Anthony

Tiffani also noticed significant changes in her home’s appearance.
The home, which was never fancy, was almost always neat and tidy.
Tiffani noticed that dust would gather around the house, dishes would
pile up in the sink, dirt would remain on the floor, and clothes would
go for long periods of time without being washed. Tiffani remem-
bered cleaning her own clothes and making meals for herself and her sister during this period. Sometimes Tiffani
and her sister would come downstairs in the morning to find empty beer cans and liquor bottles on the kitchen table
along with the pipe. Her parents would be in the bedroom, and Tiffani and her sister would leave the house and go
to school by themselves. Tiffani was unclear if her parents were working or how the bills were paid. Often there was
not enough food to feed everyone and she would go to bed hungry.

During one session, Tiffani described an incident of sexual abuse. One night she was awoken by her uncle Nate
and his friend Jimmy in her room. Her parents were apparently out, and they were the only adults in the home.
They asked her if she wanted to come downstairs and show them the new dances she learned at school. Once
downstairs, Nate and Jimmy put some music on and started to dance. They asked Tiffani to start dancing with them,
which she did. While they were dancing, Jimmy spilled some beer on her. Nate said she had to go to the bathroom
to clean up. Nate, Jimmy, and Tiffani all went to the bathroom. Nate asked Tiffani to take her clothes off so she
could get in the bath. Tiffani hesitated to do this, but Nate insisted it was okay since he and Jimmy were family.
Tiffani eventually r elented and began to wash up. Nate would tell her that she missed a spot and would scrub the
area with his hands.

After this incident, others occurred, with increasing levels of molestation each time. Tiffani felt very bad about
this, but had difficulty explaining why, even to herself. She was very afraid of everyone in her family except her sister
Diana. She was also afraid that Diana might be subjected to the same thing.

The last time it happened, when Tiffani was 14, she pretended to be willing to dance for them, but when she got
downstairs she ran out the front door of the house. Tiffani ran down the block to her school because, as she said,
it was one of the few places where she felt safe. She said she was barefoot and in her pajamas and it was very cold.
About halfway to her school, a car stopped, and a man inside asked her where she was going. When Tiffani replied
that she was going to school, the man asked why she was going to school in the middle of the night. Tiffani did not
want to tell him the whole story, so she told him that there was trouble at home and she just wanted to go to school
early.

The man introduced himself as Donald and asked her why she did not go to her boyfriend’s house. When Tiffani
said she did not have a boyfriend, Donald replied that if she had a boyfriend, she would have somebody to take
care of her and keep her safe when these things happened. He then offered to be her boyfriend. Tiffani did not say
anything, but when Donald then offered to give her a ride, she agreed and got in the car.

Donald took Tiffani to his apartment, explaining that the school would be closed for hours. When they got to his
apartment, Donald fed Tiffani and gave her beer, explaining that it would help keep her warm. Tiffani did not like
the taste of the beer, but at Donald’s insistence, she drank it.

When Tiffani was drunk, Donald began kissing her, and they had sex. Tiffani knew about sex from school and
some of her girlfriends but she had never had it with anyone before. She was grateful to Donald because he had
helped her get away from Nate and Jimmy. Donald had also told her that he loved her and they would be together
forever. Tiffani was also afraid that if she did not have sex, Donald would not let her stay and she had nowhere else
to go.

For the next 3 days, Donald brought her food and beer and had sex with her several more times. Donald told
Tiffani that she was not allowed to do anything without his permission. This included watching TV, going to the
bathroom, taking a shower, and eating and drinking.

Donald bought Tiffani a dress, explaining to her that she was going to “find a date” and get men to pay her to
have sex with her. When Tiffani said she did not want to do that, Donald hit her several times. Donald explained

18

SESSIONS: CASE HISTORIES • THE BRADLEY FAMILY

that if she didn’t do it, he would get her sister, Diana, and make her
do it instead. Out of fear for her sister, Tiffani relented and did what
Donald told her to do.

Key to Acronyms

GED: General Education
Development

STI: Sexually Transmitted
Infection

Tiffani and I met over the course of a year for individual sessions.
We talked often about her continued desire to be reunited with
Donald. We discussed what Donald represented for her and why he
was such an important part of her life. She often described him as
the person who “saved” her and felt she owed much to him. She
vividly remembered the fear she felt the nights Nate and Jimmy touched her, and she was convinced they would have
raped her that last night. My efforts were to help her recognize that Donald was not a savior, but someone who did,
in fact, rape her and then force her into prostitution. A lot of time and discussion went into changing this cognition
around Donald and their relationship.

After about six months at Teens First, Tiffani said that she had a strong desire to see her sister and her mother,
and I helped to arrange a family session at the agency. Tiffani and I talked about what her hopes were for the
meeting and her intent for scheduling this session. Tiffani first and foremost just wanted to see them and hug them.
She had not seen either of them in over two years and missed them very much. Tiffani also felt some anger toward
her mother that she wanted to able to share in a safe environment. She said she felt that both her parents did not
do enough to protect her and that they should have known better than to have let Nate and Jimmy into the house
when they were not home. She also said she felt her mother should have tried harder to find her when she was with
Donald. I wanted her to be realistic about the potential outcome of the meeting, so I did my best to explain that the
session might not provide all of the answers she hoped for. We were aware, through a conversation with her sister,
that her mother was still using drugs, and we talked about how this might cloud her mother’s ability to engage in a
substantial conversation.

In the family session, Shondra was very critical of Tiffani and her current situation. She ultimately blamed Tiffani
for her current state. When Tiffani confronted her mother about the drug use and the lack of parental guidance and
protection, Shondra denied ever having used drugs. She told Tiffani she was exaggerating and a liar and that neither
she nor Tiffani’s father ever put her in harm’s way.

Throughout our time working together, Tiffani utilized all of the services at the agency and stopped trying to
contact Donald. She had learned that he had actually gotten married to one of the other women that worked for
him, and this made her very angry. She has passed her GED test and started working at a local fast food restaurant.
She plans on applying to a community college and a fashion institute.

19

The Petrakis Family

Helen Petrakis is a 52-year-old heterosexual married female of Greek descent who says that she feels over­whelmed and “blue.” She came to our agency at the suggestion of a close friend who thought Helen would
benefit from having a person who could listen. Although she is uncomfortable talking about her life with a stranger,
Helen said that she decided to come for therapy because she worries about burdening friends with her troubles.
Helen and I have met four times, twice per month, for individual therapy in 50-minute sessions.

Helen consistently appears well-groomed. She speaks clearly and in moderate tones and seems to have linear
thought progression; her memory seems intact. She claims no history of drug or alcohol abuse, and she does not
identify a history of trauma. Helen says that other than chronic back pain from an old injury, which she manages
with acetaminophen as needed, she is in good health.

Helen has worked full time at a hospital in the billing department since graduating from high school. Her
husband, John (60), works full time managing a grocery store and earns the larger portion of the family income.
She and John live with their three adult children in a 4-bedroom house. Helen voices a great deal of pride in the
children. Alec, 27, is currently unemployed, which Helen attributes to the poor economy. Dmitra, 23, whom Helen
describes as smart, beautiful, and hardworking, works as a sales consultant for a local department store. Athina, 18,
is an honors student at a local college and earns spending money as a hostess in a family friend’s restaurant; Helen
describes her as adorable and reliable.

In our first session, I explained to Helen that I was an advanced year intern completing my second field placement
at the agency. I told her I worked closely with my field supervisor to provide the best care possible. She said that
was fine, congratulated me on advancing my career, and then began talking. I listened for the reasons Helen came
to speak with me.

I asked Helen about her community, which, she explained, centered on the activities of the Greek Orthodox
Church. She and John were married in that church and attend services weekly. She expects that her children will
also eventually wed there. Her children, she explained, are religious but do not regularly go to church because they
are very busy. She believes that the children are too busy to be expected to help around the house. Helen shops,
cooks, and cleans for the family, and John sees to yard care and maintains the family’s cars. When I asked whether
the children contributed to the finances of the home, Helen looked shocked and said that John would find it deeply
insulting to take money from his children. As Helen described her life, I surmised that the Petrakis family holds
strong family bonds within a large and supportive community.

Helen is responsible for the care of John’s 81-year-old widowed mother, Magda, who lives in an apartment
30 minutes away. Until recently, Magda was self-sufficient, coming for weekly family dinners and driving herself
shopping and to church. But 6 months ago, she fell and broke her hip and was also recently diagnosed with early
signs of dementia. Through their church, Helen and John hired a reliable and trusted woman to check in on Magda
a couple of days each week. Helen goes to see Magda on the other days, sometimes twice in one day, depending on
Magda’s needs. She buys her food, cleans her home, pays her bills, and keeps track of her medications. Helen says
she would like to have the helper come in more often, but she cannot afford it. The money to pay for help is coming
out of the couple’s vacations savings. Caring for Magda makes Helen feel as if she is failing as a wife and mother
because she no longer has time to spend with her husband and children.

Helen sounded angry as she described the amount of time she gave toward Magda’s care. She has stopped going
shopping and out to eat with friends because she can no longer find the time. Lately, John has expressed displeasure
with meals at home, as Helen has been cooking less often and brings home takeout. She sounded defeated when
she described an incident in which her son, Alec, expressed disappointment in her because she could not provide
him with clean laundry. When she cried in response, he offered to help care for his grandmother. Alec proposed
moving in with Magda.

Helen wondered if asking Alec to stay with his grandmother might be good for all of them. John and Alec had
been arguing lately, and Alec and his grandmother had always been very fond of each other. Helen thought she
could offer Alec the money she gave Magda’s helper.

I responded that I thought Helen and Alec were using creative problem solving and utilizing their resources well
in crafting a plan. I said that Helen seemed to find good solutions within her family and culture. Helen appeared
concerned as I said this, and I surmised that she was reluctant to impose on her son because she and her husband

20

SESSIONS: CASE HISTORIES • THE PETRAKIS FAMILY

seemed to value providing for their children’s needs rather than
expecting them to contribute resources. Helen ended the session
agreeing to consider the solution we discussed to ease the stress of
caring for Magda.

The Petrakis Family

Magda Petrakis: mother
of John Petrakis, 81

John Petrakis: father, 60

Helen Petrakis: mother, 52

Alec Petrakis: son, 27

Dmitra Petrakis: daughter, 23

Athina Petrakis: daughter, 18

In our second session, Helen said that her son again mentioned
that he saw how overwhelmed she was and wanted to help care for
Magda. While Helen was not sure this was the best idea, she saw how
it might be helpful for a short time. Nonetheless, her instincts were
still telling her that this could be a bad plan. Helen worried about
changing the arrangements as they were and seemed reluctant to
step away from her integral role in Magda’s care, despite the pain it
was causing her. In this session, I helped Helen begin to explore her
feelings and assumptions about her role as a caretaker in the family. Helen did not seem able to identify her expecta­
tions of herself as a caretaker. She did, however, resolve her ambivalence about Alec’s offer to care for Magda. By
the end of the session, Helen agreed to have Alec live with his grandmother.

In our third session, Helen briskly walked into the room and announced that Alec had moved in with Magda and
it was a disaster. Since the move, Helen had had to be at the apartment at least once daily to intervene with emer­
gencies. Magda called Helen at work the day after Alec moved in to ask Helen to pick up a refill of her medications
at the pharmacy. Helen asked to speak to Alec, and Magda said he had gone out with two friends the night before
and had not come home yet. Helen left work immediately and drove to Magda’s home. Helen angrily told me that
she assumed that Magda misplaced the medications, but then she began to cry and said that the medications were
not misplaced, they were really gone. When she searched the apartment, Helen noticed that the cash box was
empty and that Magda’s checkbook was missing two checks. Helen determined that Magda was robbed, but because
she did not want to frighten her, she decided not to report the crime. Instead, Helen phoned the pharmacy and
explained that her mother-in-law, suffering from dementia, had accidently destroyed her medication and would need
refills. She called Magda’s bank and learned that the checks had been cashed. Helen cooked lunch for her mother­
in-law and ate it with her. When a tired and disheveled Alec arrived back in the apartment, Helen quietly told her son
about the robbery and reinforced the importance of remaining in the building with Magda at night.

Helen said that the events in Magda’s apartment were repeated 2 days later. By this time in the session
Helen was furious. With her face red with rage and her hands shaking, she told me that all this was my fault for
suggesting that Alec’s presence in the apartment would benefit the family. Jewelry from Greece, which had been
in the family for generations, was now gone. Alec would never be in this trouble if I had not told Helen he should
be permitted to live with his grandmother. Helen said she should know better than to talk to a stranger about
private matters.

Helen cried, and as I sat and listened to her sobs, I was not sure whether to let her cry, give her a tissue, or
interrupt her. As the session was nearing the end, Helen quickly told me that Alec has struggled with maintaining
sobriety since he was a teen. He is currently on 2 years’ probation for possession and had recently completed a
rehabilitation program. Helen said she now realized Alec was stealing from his grandmother to support his drug
habit. She could not possibly tell her husband because he would hurt and humiliate Alec, and she would not consider
telling the police. Helen’s solution was to remove the valuables and medications from the apartment and to visit
twice a day to bring supplies and medicine and check on Alec and Magda.

After this session, it was unclear how to proceed with Helen. I asked my field instructor for help. I explained
that I had offered support for a possible solution to Helen’s difficulties and stress. In rereading the progress notes in
Helen’s chart, I realized I had misinterpreted Helen’s reluctance to ask Alec to move in with his grandmother. I felt
terrible about pushing Helen into acting outside of her own instincts.

My field instructor reminded me that I had not forced Helen to act as she had and that no one was responsible for
the actions of another person. She told me that beginning social workers do make mistakes and that my errors were
part of a learning process and were not irreparable. I was reminded that advising Helen, or any client, is ill-advised.
My field instructor expressed concern about my ethical and legal obligations to protect Magda. She suggested that
I call the county office on aging and adult services to research my duty to report, and to speak to the agency director
about my ethical and legal obligations in this case.

In our fourth session, Helen apologized for missing a previous appointment with me. She said she awoke the
morning of the appointment with tightness in her chest and a feeling that her heart was racing. John drove Helen
to the emergency room at the hospital in which she works. By the time Helen got to the hospital, she could not

21

SESSIONS: CASE HISTORIES • THE PETRAKIS FAMILY

catch her breath and thought she might pass out. The hospital ran tests but found no conclusive organic reason to
explain Helen’s symptoms.

I asked Helen how she felt now. She said that since her visit to the hospital, she continues to experience short­
ness of breath, usually in the morning when she is getting ready to begin her day. She said she has trouble staying
asleep, waking two to four times each night, and she feels tired during the day. Working is hard because she is more
forgetful than she has ever been. Her back is giving her trouble, too. Helen said that she feels like her body is one
big tired knot.

I suggested that her symptoms could indicate anxiety and she might want to consider seeing a psychiatrist for an
evaluation. I told Helen it would make sense, given the pressures in her life, that she felt anxiety. I said that she and
I could develop a treatment plan to help her address the anxiety. Helen’s therapy goals include removing Alec from
Magda’s apartment and speaking to John about a safe and supported living arrangement for Magda.

22

The Cortez Family

Paula is a 43-year-old HIV-positive Latina woman originally from Colombia. She is bilingual, fluent in both Spanish and English. Paula lives alone in an apartment in Queens, NY. She is divorced and has one son, Miguel,
who is 20 years old. Paula maintains a relationship with her son and her ex-husband, David (46). Paula raised Miguel
until he was 8 years old, at which time she was forced to relinquish custody due to her medical condition. Paula is
severely socially isolated as she has limited contact with her family in Colombia and lacks a peer network of any
kind in her neighborhood. Paula identifies as Catholic, but she does not consider religion to be a big part of her life.

Paula came from a moderately well-to-do family. She reports suffering physical and emotional abuse at the hands
of both her parents, who are alive and reside in Colombia with Paula’s two siblings. Paula completed high school in
Colombia, but ran away when she was 17 years old because she could no longer tolerate the abuse at home. Paula
became an intravenous drug user (IVDU), particularly of cocaine and heroin. David, who was originally from New
York City, was one of Paula’s “drug buddies.” The two eloped, and Paula followed David to the United States. Paula
continued to use drugs in the United States for several years; however, she stopped when she got pregnant with
Miguel. David continued to use drugs, which led to the failure of their marriage.

Once she stopped using drugs, Paula attended the Fashion Institute of Technology (FIT) in New York City. Upon
completing her BA, Paula worked for a clothing designer, but realized her true passion was painting. She has a
collection of more than 100 drawings and paintings, many of which track the course of her personal and emotional
journey. Paula held a full-time job for a number of years before her health prevented her from working. She is now
unemployed and receives Supplemental Security Insurance (SSI) and Medicaid.

Paula was diagnosed with bipolar disorder. She experiences rapid cycles of mania and depression when not prop­
erly medicated, and she also has a tendency toward paranoia. Paula has a history of not complying with her psychi­
atric medication treatment because she does not like the way it makes her feel. She often discontinues it without
telling her psychiatrist. Paula has had multiple psychiatric hospitalizations but has remained out of the hospital for at
least five years. Paula accepts her bipolar diagnosis, but demonstrates limited insight into the relationship between
her symptoms and her medication.

Paula was diagnosed HIV positive in 1987. Paula acquired AIDS several years later when she was diagnosed with
a severe brain infection and a T-cell count less than 200. Paula’s brain infection left her completely paralyzed on the
right side. She lost function of her right arm and hand, as well as the ability to walk. After a long stay in an acute
care hospital in New York City, Paula was transferred to a skilled nursing facility (SNF) where she thought she would
die. It is at this time that Paula gave up custody of her son. However, Paula’s condition improved gradually. After
being in the SNF for more than a year, Paula regained the ability to walk, although she does so with a severe limp.
She also regained some function in her right arm. Her right hand (her dominant hand) remains semiparalyzed and
limp. Over the course of several years, Paula taught herself to paint with her left hand and was able to return to her
beloved art. In 1996, when highly active antiretroviral therapy (HAART) became available, Paula began treatment.
She responded well to HAART and her HIV/AIDS was well controlled.

In addition to her HIV/AIDS disease, Paula is diagnosed with hepatitis C (Hep C). While this condition was
controlled, it has reached a point where Paula’s doctor is recommending she begin treatment. Paula also has signifi­
cant circulatory problems, which cause her severe pain in her lower extremities. She uses prescribed narcotic pain
medication to control her symptoms. Paula’s circulatory problems have also led to chronic ulcers on her feet that
will not heal. Treatment for her foot ulcers demands frequent visits to a wound care clinic. Paula’s pain paired with
the foot ulcers make it difficult for her to ambulate and leave her home. As with her psychiatric medication, Paula
has a tendency not to comply with her medical treatment. She often disregards instructions from her doctors and
resorts to holistic treatments like treating her ulcers with chamomile tea. Working with Paula can be very frustrating
because she is often doing very well medically and psychiatrically. Then, out of the blue, she stops her treatment
and deteriorates quickly.

I met Paula as a social worker employed at an outpatient comprehensive care clinic located in an acute care
hospital in New York City. The clinic functions as an interdisciplinary operation and follows a continuity of care
model. As a result, clinic patients are followed by their physician and social worker on an outpatient basis and on
an inpatient basis when admitted to the hospital. Thus, social workers interact not only with doctors from the clinic,
but also with doctors from all services throughout the hospital.

23

SESSIONS: CASE HISTORIES • THE CORTEZ FAMILY

After working with Paula for almost six months, she called to
inform me that she was pregnant. Her news was shocking because she
did not have a boyfriend and never spoke of dating. Paula explained
that she met a man at a flower shop, they spoke several times, he
visited her at her apartment, and they had sex. Paula thought he

was a “stand up guy,” but recently everything had changed. Paula
began to suspect that he was using drugs because he had started to

become controlling and demanding. He showed up at her apartment at all times of the night demanding to be let in.

He c alled her relentlessly, and when she did not pick up the phone, he left her mean and threatening messages.

Paula was fearful for her safety.

Given Paula’s complex medical profile and her psychiatric diagnosis, her doctor, psychiatrist, and I were concerned
about Paula maintaining the pregnancy. We not only feared for Paula’s and the baby’s health, but also for how Paula
would manage caring for a baby. Paula also struggled with what she should do about her pregnancy. She seriously
considered having an abortion. However, her Catholic roots paired with seeing an ultrasound of the baby reinforced
her desire to go through with the pregnancy.

The primary focus of treatment quickly became dealing with Paula’s relationship with the baby’s father. During
sessions with her psychiatrist and me, Paula reported feeling fearful for her safety. The father’s relentless phone
calls and voicemails rattled Paula. She became scared, slept poorly, and her paranoia increased significantly. During
a particular session, Paula reported that she had started smoking to cope with the stress she was feeling. She also
stated that she had stopped her psychiatric medication and was not always taking her HAART. When we explored
the dangers of Paula’s actions, both to herself and the baby, she indicated that she knew what she was doing was
harmful but she did not care. After completing a suicide assessment, I was convinced that Paula was decompen­
sating quickly and at risk of harming herself and/or her baby. I consulted with her psychiatrist, and Paula was invol­
untarily admitted to the psychiatric unit of the hospital. Paula was extremely angry at me for the admission. She
blamed me for “locking her up” and not helping her. Paula remained on the unit for 2 weeks. During this stay she
restarted her medications and was stabilized. I tried to visit Paula on the unit, but the first two times I showed up
she refused to see me. Eventually, Paula did agree to see me. She was still angry, but she was able to see that I had
acted with her best interest in mind, and we were able to repair our relationship. As Paula prepared for discharge,
she spoke more about the father and the stress that had driven her to the admission in the first place. Paula agreed
that despite her fears she had to do something about the situation. I helped Paula develop a safety plan, educated
her about filing for a restraining order, and referred her to the AIDS Law Project, a not-for-profit organization that
helps individuals with HIV handle legal issues. With my support and that of her lawyer, Paula filed a police report
and successfully got the restraining order. Once the order was served, the phone calls and visits stopped, and Paula
regained a sense of control over her life.

From a medical perspective, Paula’s pregnancy was considered “high risk” due to her complicated medical situ­
ation. Throughout her pregnancy, Paula remained on HAART, pain, and psychiatric medication, and treatment for
her Hep C was postponed. During the pregnancy the ulcers on Paula’s feet worsened and she developed a severe
bone infection, ostemeylitis, in two of her toes. Without treatment the infection was extremely dangerous to both
Paula and her baby. Paula was admitted to a medical unit in the hospital where she started a 2-week course of intra­
venous (IV) antibiotics. Unfortunately, the antibiotics did not work, and Paula had to have portions of two of her toes
amputated with limited anesthesia due to the pregnancy, extending her hospital stay to nearly a month.

The condition of Paula’s feet heightened my concern and the treatment team’s concerns about Paula’s ability to
care for her baby. There were multiple factors to consider. In the immediate term, Paula was barely able to walk and
was therefore unable to do anything to prepare for the baby’s arrival (e.g., gather supplies, take parenting class, etc.).
In the medium term, we needed to address how Paula was going to care for the baby day-to-day, and we needed to
think about how she would care for the baby at home given her physical limitations (i.e., limited ability to ambulate
and limited use of her right hand) and her current medical status. In addition, we had to consider what she would
do with the baby if she required another hospitalization. In the long term, we needed to think about permanency
planning for the baby or for what would happen to the baby if Paula died. While Paula recognized the importance
of all of these issues, her anxiety level was much lower than mine and that of her treatment team. Perhaps she did
not see the whole picture as we did, or perhaps she was in denial. She repeatedly told me, “I know, I know. I’m just
going to do it. I raised my son and I am going to take care of this baby too.” We really did not have an answer for her
limited emotional response, we just needed to meet her where she was and move on. One of the things that amazed
me most about Paula was that she had a great ability to rally people around her. Nurses, doctors, social workers: we
all wanted to help her even when she tried to push us away.

The Cortez Family

David Cortez: father, 46

Paula Cortez: mother, 43

Miguel Cortez: son, 20

24

SESSIONS: CASE HISTORIES • THE CORTEZ FAMILY

While Paula was in the hospital unit, we were able to talk about
the baby’s care and permanency planning. Through these discus­
sions, Paula’s social isolation became more and more evident. Paula
had not told her parents in Colombia that she was having a baby.
She feared their disapproval and she stated, “I can’t stand to hear
my mother’s negativity.” Miguel and David were aware of the preg­
nancy, but they each had their own lives. David was remarried with
children, and Miguel was working and in school full-time. The idea
of burdening him with her needs was something Paula would not
consider. There was no one else in Paula’s life. Therefore, we were
forced to look at options outside of Paula’s limited social network.

After a month in the hospital, Paula went home with a surgical
boot, instructions to limit bearing weight on her foot, and a list of
referrals from me. Paula and I agreed to check in every other day
by telephone. My intention was to monitor how she was feeling, as
well as her progress with the referrals I had given her. I also wanted
to provide her with support and encouragement that she was not
getting from anywhere else. On many occasions, I hung up the
phone frustrated with Paula because of her procrastination and lack
of follow-through. But ultimately she completed what she needed to

for the baby’s arrival. Paula successfully applied for WIC, the federal Supplemental Nutrition Program for Women,

Infants, and Children, and was also able to secure a crib and other baby essentials.

Paula delivered a healthy baby girl. The baby was born HIV negative and received the appropriate HAART treat­
ment after birth. The baby spent a week in the neonatal intensive care unit, as she had to detox from the effects of
the pain medication Paula took throughout her pregnancy. Given Paula’s low income, health, and Medicaid status,
Paula was able to apply for and receive 24/7 in-home child care assistance through New York’s public assistance
program. Depending on Paula’s health and her need for help, this arrangement can be modified as deemed appro­
priate. Miguel did take a part in caring for his half sister, but his assistance was limited. Ultimately, Paula completed
the appropriate permanency planning paperwork with the assistance of the organization The Family Center. She
named Miguel the baby’s guardian should something happen to her.

Key to Acronyms

AIDS: Acquired

Immunodeficiency

Syndrome

HAART: Highly Active
Antiretroviral Therapy

HIV: Human
Immunodeficiency Virus

IVDU: Intravenous Drug User

SNF: Skilled Nursing Facility

SSI: Supplemental
Security Insurance

WIC: Supplemental Nutrition
Program for Women,
Infants, and Children

25

APPENDIX

26

Reflection Questions

The social worker in each of the cases answered these additional questions as follows.

The Hernandez Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
I used role-playing to help the family members view how each of them perceived their behaviors. For

example, Juan Jr. acted like Juan Sr. when he came home from work each day. Juan Jr. portrayed his father
as grumpy and irritated at the sight of the boys. His tone was angry and he yelled instead of using a calm tone.
Juan Sr. was shocked at how Juan Jr. depicted him and his interactions with his family members. Drawing on
family systems theory and the strengths perspective, I highlighted the family’s assets and made sure to recog­
nize that they were the experts of their own life and experiences. I also wanted to treat the family as a unit
rather than concentrate on one “identified client.” Therefore, rather than focusing on Juan Jr. and why he
called, I had the family express their thoughts and feelings about interactions in the home on a daily basis. We
did review how each felt about the call to the ACS worker, but the intent was to release any underlying resent­
ment or anger felt by any of the family members. Using a genogram helped to identify patterns in the family
history. This clearly unlocked some firmly held beliefs around expectations of how children should behave and
shared financial burdens that no longer worked for this family.

2. Which theory or theories did you use to guide your practice?
I used the strengths perspective and family systems theory. I focused on what the family had and how they

could access the available resources that had yet been untapped. I looked at how the family interacted as a unit
rather than four separate individuals. We worked together to identify how each member of the family affected
the others in various ways—sometimes in a positive manner and sometimes in ways that were challenging and
provoking.

3. What were the identified strengths of the client(s)?
It was clear from the beginning that Elena and Juan Sr. loved each other and their sons. There was clearly

a bond among the family members that appeared to get stronger over the course of the sessions. Elena and
Juan Sr. were able to see that while they had not elected to seek counseling, family and parenting sessions
could be helpful to them and their children. They allowed me to learn about their family and took great pride
in describing their heritage and culture.

4. What were the identified challenges faced by the client(s)?
The biggest challenge to this family was the financial concern they faced each day. It was clear that their

economic situation weighed heavily on all members of the family. The need for Juan Sr. to put in many hours
of overtime negatively affected his behavior toward his children. The children were perhaps acting out due
to the fear and anxiety they felt about money issues, which were constantly being discussed in the home.
Through our discussion about money management, it was clear that neither Elena nor Juan Sr. had sat down
and completed a budget. Many expenses were unaccounted for in their bank register and neither balanced the
checkbook regularly.

5. What were the agreed-upon goals to be met to address the concern?
Because the clients were mandated to services, the goals were essentially set by the ACS worker. That being

said, I tried to work with the family to identify potential topics that they wanted to discuss during our family
sessions. Elena and Juan Sr. said they wanted to learn more about managing their money.

27

SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

Because I felt that the ACS worker had neglected to take into consideration the Hernandez’s culture when
she made the referral, I was very aware that I needed to learn about them and their beliefs around parenting.
As a Caucasian woman, I was not familiar with the form of discipline they had used nor did I understand their
perspective as Latino (Puerto Rican) individuals. I asked them many questions about their culture and how
children are treated and viewed. They shared many stories of their own childhood with me and helped me to
understand their perspective based on their cultural lens.

7. What local, state, or federal policies could (or did) affect this case?
It would positively affect cases like this if ACS, a state agency, decided that each potential abuse case needed

to be reviewed for cultural competence in order to eliminate or reduce bias.

8. How would you advocate for social change to positively affect this case?
I would encourage such a policy as described above to be implemented across all child protective service

agencies. Further, I would encourage that a strengths perspective be adopted by child protective workers when
addressing these cases.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

The legal issues surrounded the fact that I was mandated to contact the ACS worker about the clients’
progress or lack thereof. Ethically, I felt torn about calling the ACS worker but knew that in the end it was what
I had to do.

10. How can evidence-based practice be integrated into this situation?
It was integrated through the use of an evidenced-based program to teach parenting skills.

11. Is there any additional information that is important to the case?
No, there is no additional information.

12. Describe any additional personal reflections about this case.
I believe that including a positive report when I notified the ACS that the clients had missed too many classes

was helpful in advocating for them. As their social worker, I believed that they had tried to attend the classes.
I felt it was my responsibility to advocate for them and share all of the positive strides they made while working
with me. I highlighted their strengths when talking with the ACS worker rather than focusing on the negatives.
The clients recognized this and did not get angry with me when I told them I had to contact the ACS worker.
They continued to contact me to share their sons’ milestones and elected to participate in some holiday events
at the agency and eventually the financial literacy program we offered. I wish I had reported the inappropriate
comments made by the ACS worker to her supervisor. I feel now that I should have said something and regret
not reporting these statements.

The Parker Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
I encouraged Sara and Stephanie to work together in clearing out the apartment with the common goal of

being able to remain in their apartment. Sara and Stephanie thus both had some control in the cleaning and
the choice of items to be discarded. I developed a rapport with Jane and was able to enlist her help in cleaning.
I explored alternative housing options for both Sara and Stephanie. I also improved Sara’s outpatient psychiatric
care by arranging treatment with a geriatric psychiatrist.

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SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

2. Which theory or theories did you use to guide your practice?
Family therapy and engagement was essential in encouraging Sara and Stephanie to work together in

cleaning the apartment and in obtaining the assistance of Jane in the process.

3. What were the identified strengths of the client(s)?
Stephanie was organized and kept her living area clean. She was working part-time and was training to

become a cashier. Sara was attending a senior day program regularly. Sara and Stephanie were willing to work
together and were open to suggestions and making changes.

4. What were the identified challenges faced by the client(s)?
Sara and Stephanie were at risk of removal from their apartment. Sara had poor insight into her hoarding,

which made cleaning up the apartment very challenging. Sara was estranged from Jane, which was the only
close family member who could be of assistance in participating in an intervention to clean the apartment.

5. What were the agreed-upon goals to be met to address the concern?
Sara and Stephanie made the decision to work together to clean up the apartment with the goal of being

able to remain living in their apartment. Sara gave me permission to contact Jane with the intention of enlisting
her help in cleaning up the apartment. Sara also agreed to neuropsychological testing and changed her outpa­
tient psychiatric treatment. Both Stephanie and Sara agreed to each keep one favorite cat, and Stephanie
would look for homes for the remaining cats.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

There were no cultural issues that needed to be addressed.

7. What local, state, or federal policies could (or did) affect this case?
Adult Protective Services was monitoring this family and had the authority to remove them from their apart­

ment if the situation was deemed dangerous or if the family was unable to clean the apartment and improve
living conditions. Intensive Case Management services were put in place by Adult Protective Services to assess
the needs of the family and to develop a plan and resources to meet these needs. An Intensive Case Manager
met with the family weekly to address a variety of issues and actively begin implementing planned interventions.

8. How would you advocate for social change to positively affect this case?
There is tremendous pressure placed on hospitals by insurance companies to discharge patients within

a short prescribed time. This poses a serious challenge for social workers, who often are responsible for
discharge planning. There are ethical questions such as whether a patient is truly prepared for discharge and
whether their discharge plan is optimum or hastily planned.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

Adult Protective Services was monitoring this family and had the authority to remove them from their apart­
ment if the situation was deemed dangerous. Intensive Case Management services were put into place by Adult
Protective Services to assess the needs of the family. As the Intensive Case Manager, I met with the family
weekly to address a variety of issues and develop a plan and appropriate interventions.

10. How can evidence-based practice be integrated into this situation?
Utilizing family therapy and engaging an estranged family member was essential to working with this family.

Utilizing cognitive and behavioral therapy helped Sara finally acknowledge the condition of the apartment and
prepared her to begin throwing out or giving away items to create a clean, habitable apartment.

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SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

11. Is there any additional information that is important to the case?
As their social worker, I reached out to an estranged family member and was eventually able to enlist her

support. I was able to improve the quality of Sara’s psychiatric treatment by arranging neuropsychological
testing and treatment with a geriatric psychiatrist. I explored housing and community, local, and state resources.

12. Describe any additional personal reflections about this case.
I have concerns regarding Sara living alone, even with home care services in place. Sara will also need a

follow-up appointment with the neurologist to determine if she is experiencing symptoms of early dementia.

The Logan Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
I used individual and family counseling, education, assessment, problem solving, and skills training in this

situation.

2. Which theory or theories did you use to guide your practice?
I used systems, social learning, and conflict theories, as well as theories of moral reasoning, theories of

cognition, and stage theories.

3. What were the identified strengths of the client(s)?
Eboni is a good student who is goal oriented and athletic. She has the support of family and friends, good

health, and is not chemically dependent. Additionally, she is employed and has housing.

4. What were the identified challenges faced by the client(s)?
Eboni was dealing with teenage pregnancy and family discord.

5. What were the agreed-upon goals to be met to address the concern?
Eboni and I agreed that she would inform her family and process all of her options.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

No, there were no issues of cultural competence.

7. What local, state, or federal policies could (or did) affect this case?
Roe v. Wade, state adoption laws, and medical policies all affected this case.

8. How would you advocate for social change to positively affect this case?
Because there is a divide in society about abortion, it is difficult to look at social change from this perspec­

tive. However, there could be increased programming for single teenage mothers who would like to go to
college and parent their child.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

Termination of pregnancy, parental rights if the child is a minor, role the biological father plays in the
decision-making process, and open versus closed adoption were all present in this case.

10. How can evidence-based practice be integrated into this situation?
There are evidence-based teenage pregnancy prevention programs that could be implemented in the school

system.

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SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

11. Is there any additional information that is important to the case?
The final decision was left unanswered to provide the opportunity for discussion.

12. Describe any additional personal reflections about this case.
I have none.

The Johnson Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
I used anxiety-reducing strategies such as breathing exercises to help Talia regulate her physical responses to

the memories of the sexual assault. I used education tools to help validate and normalize her reactions, sharing
information on sexual assault trauma and PTSD. I used journaling, worksheets, and art to help her express her
feelings in a safe manner when she felt she could not verbalize them. I worked to build a collaborative working
relationship with her, spending a lot of time on building a rapport.

2. Which theory or theories did you use to guide your practice?
I used empowerment theory to guide my practice. I let Talia guide the sessions, and together we decided on

goals and objectives. I never pressed her to share her story and I worked to make the time together feel safe
and supportive. I always let her know she was in charge of the session and the content. Cognitive theory was
used to help her challenge her thoughts of self-blame. Survivors often blame themselves for what has happened
and question what they did in the scenario to encourage the sexual assault.

3. What were the identified strengths of the client(s)?
Talia was an intelligent, strong woman who worked hard at addressing what happened to her. She was

physically active, had many strong friendships, and utilized her resources to the fullest extent. She had a loving
mother and father who supported her through the process.

4. What were the identified challenges faced by the client(s)?
She was experiencing strong feelings of anxiety and was predisposed to anxiety on her mother’s side of the

family. She met with much skepticism about the sexual assault and was treated at times unfairly by friends and
the hospital staff.

5. What were the agreed-upon goals to be met to address the concern?
Talia wanted to feel better overall, but in particular she wanted to address her anxiety attacks. Together we

created mini goals to help her manage her anxiety and find ways to express her feelings about what happened.
Weekly, we would set up goals around her use of the journal, her breathing exercises, and running.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

For this case, I needed to be aware of her age and development. I was also aware of the high rates of sexual
assault on college campuses. I took into consideration her connection to her family of origin and her sorority
sisters.

7. What local, state, or federal policies could (or did) affect this case?
The university’s policy for addressing sexual assault cases could and did affect the situation. A dean is

assigned the case and makes his or her determination after hearing from both sides. Had the dean not found
Eric guilty, Talia would have had to be on campus for a year with a man who sexually assaulted her. Further, it
was required that Talia be face-to-face with Eric in the dean’s office. She then had to state the charges against
him. This could potentially re-victimize and traumatize her. Lastly, Talia’s assault had to be reported to the
university’s campus safety administrator in accordance with the Cleary Act (a federal regulation).

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SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

32

8. How would you advocate for social change to positively affect this case?
Too often people believe the rape myths that are perpetuated in our society. I would strive to educate people

about sexual assault and work to eliminate these myths. I would also advocate for education in hospitals and
the law and court system around sexual assault. Research indicates that many survivors do not press charges or
drop charges because they feel like they are being treated unfairly, judged, and re-victimized by the very people
who are supposed to be there to help them.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

The only legal aspects pertained to Talia’s decision not to press charges against Eric. My role was to support
her decision and not try to persuade her to do something she did not feel comfortable doing. While I may
believe that perpetrators of sexual assault should be held accountable, I also recognize that the process of a
court hearing can be quite difficult for survivors of sexual assault. While a survivor’s past sexual experiences
cannot be brought in as evidence because of the rape shield laws, often the questions are accusatory, humili-
ating, and intimidating.

10. How can evidence-based practice be integrated into this situation?
When working with victims of trauma, there are several scales that can be used to measure a client’s change

in emotional state. A scale for PTSD, depression, or quality of life could be incorporated each month.

11. Is there any additional information that is important to the case?
The majority of Talia’s friends were supportive and rallied around her, but there were a few people who

blamed her for the assault and Eric’s suspension. Some of her sorority sisters attempted to get her thrown out
of Kappa Delta. The couple of times that Talia tried to resume going out with friends on the weekends at the
local bars she was verbally accosted by Eric’s fraternity brothers. She decided to leave the sorority and ceased
going to the bars near the school. Eric’s family got a lawyer to fight the suspension, but withdrew the case after
another student came forward to the administration and said he had raped her also.

12. Describe any additional personal reflections about this case.
I truly enjoyed working with Talia. She came to sessions motivated to address her feelings. While she at times

was unable to verbalize her emotions, she was willing to try alternative forms of therapy to explore her feelings.
I am particularly proud of her desire to be part of the SART team. I think she will be a great addition to our
team. We talked about her readiness to meet with someone who experienced a sexual assault, and it seemed
that she had fully integrated what happened and wanted to help others through the process as well. She knows
that if in the future she has any difficulties processing a hotline call that I am available to support her.

The Levy Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
The intervention strategies I used with this client situation included problem-solving techniques. I gathered

information, assessed the situation, and developed a plan of action. I used the strengths perspective to show
Jake that he had the ability and motivation to change his situation. Couples counseling was suggested so that
Sheri would learn about Jake’s diagnosis. The systems perspective was used in assessing what resources and
services Jake needed. I used a variety of techniques to address his trauma symptoms, including PET, journaling,
deep breathing, and guided meditation.

2. Which theory or theories did you use to guide your practice?
I used the theory of cognitive behavioral therapy and PET to address his trauma.

3. What were the identified strengths of the client(s)?
The client was clearly motivated to address his situation, he was employed, and he had a supportive and

loving wife.

SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

4. What were the identified challenges faced by the client(s)?
The client had symptoms of PTSD, he was self-medicating, and he was depressed and isolating himself from

his family.

5. What were the agreed-upon goals to be met to address the concern?
Jake and I agreed the goals for him were to follow-up with the psychiatrist to monitor his medication, attend

weekly individual therapy sessions with me to address his PTSD issues, start attending an Iraq veterans support
group at the Vet Center to develop a network of veterans he could connect with, participate in couples coun­
seling to improve his relationship with his wife, and consider attending a local AA meeting to aid in his sobriety.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client? If so, what research did you do to
prepare?

I was aware of the culture connected to being in the military. Often those in the military do not speak up and
share their feelings for fear of looking weak and ineffective. I recognized that stepping forward was difficult for
Jake and reminded him of the use of confidentiality in our sessions.

7. What local, state, or federal policies could (or did) affect this case?
Policies that could be addressed are those that outline services for the military.

8. How would you advocate for social change to positively affect this case?
I would advocate for a policy change that would establish a program for all military personnel returning from

combat. Both the veterans and their family members should be educated about the symptoms of PTSD, how
it can be treated, and the services available for those returning from combat. Families should be prepared for
what to expect when their loved one returns home.

9. Were there any legal or ethical issues present in this case? If so, what were they and how were they
addressed?

There were no legal issues in this case.

10. How can evidence-based practice be integrated into this situation?
Evidence-based practice can be integrated into this situation by looking at previous research studies that

relate to this client situation. Previous studies quantify and support PET for PTSD.

11. Is there any additional information that is important to the case?
There is no other information at this time.

12. Describe any additional personal reflections about this case.
As I reflected on this case, I was reminded that this war was one of the longest our country has engaged in.

Unlike the Vietnam War, military personnel were often sent back to Iraq more than once, meaning they spent
more time in the line of fire. Jake’s case is typical of what happens when a person returns from a hostile envi­
ronment. He had been running on adrenaline nonstop for months. The length of time in that environment and
the things witnessed while there are factors that affect an individual’s ability to function in an environment that
is not hostile. Jake has had a hard time adjusting to being home because home was no longer the norm for him.

The Bradley Family

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
Various counseling skills including reflection, summarization, empathy, and rapport were used when Tiffani

was sharing her life story. Cognitive behavioral therapy techniques helped Tiffani adjust her thoughts around
her self-worth. Further, we addressed her feelings related to Donald and her potentially dangerous view of him
as her savior.

33

SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

2. Which theory or theories did you use to guide your practice?
We focused on Tiffani’s goals and cognitive behavioral theory to help with her history of sexual abuse.

3. What were the identified strengths of the client(s)?
Tiffani’s strengths lie in her dedication to her sister and her desire to be reunited with her. Another strength

is that she no longer seems to be emotionally attached to her former pimp, Donald, and does not seem to be
attached emotionally to her last pimp, John T.

4. What were the identified challenges faced by the client(s)?
Tiffani has had to become self-sufficient enough to care for herself.

5. What were the agreed-upon goals to be met to address the concern?
The goals were to help her utilize all of the services provided and address her traumatic experiences in her

early childhood and with Donald and John T. Her goals included attaining a level of self-sufficiency by obtaining
her GED, getting a job, and renting an apartment. She also wanted to reunite with her sister and begin a mean­
ingful relationship with her.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

I had to understand her background and how she became involved with Donald and then John T. I learned
about domestic human trafficking and the tactics used by pimps to maintain power and control over others.

7. What local, state, or federal policies could (or did) affect this case?
New laws and policies concerning human trafficking and their tie-in with laws that address youth who are

prostituted affected this case.

8. How would you advocate for social change to positively affect this case?
I would advocate for a national policy that addresses young men and women as survivors of human traf­

ficking rather than prostitutes in our legal system.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

The legal issue in this case concerned the new policy on how youth are penalized by the court system when
found guilty of prostitution. There was an ethical issue that was not identified in the narrative. The director of
Teens First requested that I ask Tiffani if we could use her image and story to promote the agency’s services.
I felt it was unethical to present this request to her because it was still early in her healing process and there
were potential unintended negative consequences that could occur that she might not consider due to her age.

10. How can evidence-based practice be integrated into this situation?
Evidence-based practice techniques are key methods used in the work with this client.

11. Is there any additional information that is important to the case?
While Tiffani was a client, the director of Teens First asked that I see if she would be willing to allow us to use

her image and story to promote our services. I explained to the director that I felt Tiffani was in no position to
make this decision. I explained that she had not been in treatment long enough to able to truly separate herself
from what had happened. I worried that seeing her image on posters throughout the city might negatively
affect her over time. I also felt that due to her age, she could not clearly make this decision and comprehend
the potential negative consequences that might occur by agreeing to this. For example, I worried that people
on the street might recognize her from the advertisements and point her out and say demeaning things to her.
I also wondered what effect this might have on her relationships with her family if they saw the advertisements.
Finally, I was concerned that there might be retribution on the part of Donald or John T. if they saw the posters.

34

SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

12. Describe any additional personal reflections about this case.
I had strong feelings over the ethics of using a client’s image and story to market the agency. While in the

end it is the client’s decision, I did not feel she was in a position to make this decision clearly. Due to her age
and the limited time in treatment, I felt she could easily be manipulated to do something she might regret
later. I had mixed feelings about making this decision for her or presenting the situation for her to make on
her own.

The Petrakis Family

35

1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
I used solution-focused and then psychodynamic interventions.

2. Which theory or theories did you use to guide your practice?
I used family systems and environmental theories to guide my practice.

3. What were the identified strengths of the client(s)?
The identified strengths of the client were strong family bonds and good community support.

4. What were the identified challenges faced by the client(s)?
Helen found it challenging to manage good self-care while acting as the primary caretaker of a family

member. She also was challenged by the substance abuse and risky behaviors of her adult son.

5. What were the agreed-upon goals to be met to address the concern?
There were three identified goals in Helen’s therapy sessions. One was to develop behavioral interventions to

help Helen manage her feelings of anxiety. The second was to help Helen arrange to have a psychiatric evalu
ation to determine if medication management would help her manage her anxiety. The third was to help Helen
develop and secure a safe and supported housing plan for Magda.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

It was important to recognize that Helen lives within a specific ethnic community.

7. What local, state, or federal policies could (or did) affect this case?
Adult protection services are of primary concern to this case.

8. How would you advocate for social change to positively affect this case?
I would advocate for supportive services for primary caretakers, including respite arrangements, shopping

services, and assistance with medication management for Magda.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

The legal issues of Alec’s substance abuse and theft were not addressed in this case. The legal and ethical
issues of theft were also not addressed.

10. How can evidence-based practice be integrated into this situation?
Evidence-based treatment may be integrated into the treatment of both anxiety and supportive interventions

for codependency among substance-abusing family members. I would help Helen to identify measurable and
quantifiable behavioral goals for treatment, specify my interventions, and evaluate every 12 sessions to see if
my interventions were successfully addressing Helen’s goals.

11. Is there any additional information that is important to the case?
I think providing Helen with information about harm reduction approaches to understanding substance

abuse would be helpful, should Helen be interested. I would also provide information about Al-Anon. I would
be curious about whether Helen’s church or community offered support for substance abusers, caregivers, or
families of substance abusers. I would also inquire about case management services for the elderly and provide
that information to Helen, if she expressed an interest.

SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

12. Describe any additional personal reflections about this case.
Helen is very involved in the care of her family and is losing her energy to care for herself. I would work to help

Helen recognize her own strength and resilience and begin to identify ways she can nurture and recharge herself.

The Cortez Family

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1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this client situation?
Skills I used included engagement and repairing relationship, assessment, asking open-ended questions, gath

ering information, identifying presenting problems and treatment planning, coordination of and collaboration
with an interdisciplinary team, and coordination of and collaboration with community resources. Interventions
I used included providing support, partializing problems, setting small achievable goals, suicide assessment, and
case management. I had knowledge of the hospital system, Medicaid and public assistance, and HIV/AIDS.

2. Which theory or theories did you use to guide your practice?
My practice was guided by strengths perspective, motivational interviewing, psychodynamic theory, and

goal-oriented practice.

3. What were the identified strengths of the client(s)?
Paula had many strengths. She was intelligent, completing both high school and college. She was able

to create relationships with helping professionals. She was able to rally people around her. Paula was also a
survivor and drew on her life experience. She taught herself how to use her nondominant hand to paint. Even
though it took a lot of effort and convincing, Paula was able to get things done.

4. What were the identified challenges faced by the client(s)?
Paula’s challenges included social isolation, physical illness, mental illness, and limited financial resources.

5. What were the agreed-upon goals to be met to address the concern?
We agreed that we would address Paula’s domestic violence relationship by creating a safety plan and

obtaining a restraining order. I would assist Paula in making a decision about keeping or ending her preg
nancy. We would monitor Paula’s mental and physical health. I would help Paula prepare for her baby’s arrival
by helping her get baby supplies; arrange for appropriate services such as in-home child care assistance, WIC
benefits, baby’s Medicaid; emotionally prepare for how life will change with a baby; and arrange for perma
nency planning.

6. Did you have to address any issues around cultural competence? Did you have to learn about this
population/group prior to beginning your work with this client system? If so, what type of research did
you do to prepare?

Some cultural competence issues were addressed. It was important for me to understand Paula’s Catholic
background. While Paula claimed that religion was not a big part of her life, her Catholic views did affect her
decision to keep her pregnancy. They were also intertwined in her thoughts and feelings about death and dying.

There were also aspects of Paula’s Latino culture that played out in her case. For example, her tendency to
give up on mainstream medical interventions and resort to more holistic and home remedies is consistent with
Latino culture. In addition, Paula was always resistant to involving outsiders (i.e., community resources, friends,
aides, etc.) in her care/life. She held onto the cultural belief that family issues should be dealt with from within.
What made this difficult for Paula was the fact that her family was not involved in her life. She did not want to
rely on outsiders, but she was alone and really had no choice.

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SESSIONS: CASE HISTORIES • REFLECTION QUESTIONS

7. What local, state, or federal policies could (or did) affect this case?
The local and state policies that affected this case include Medicaid, WIC, New York State public assistance,

New York City court system, and hospital policies such as length of stay, the Health Insurance Portability and
Accountability Act of 1996 (HIPPA), coordination of care across disciplines, etc.

8. How would you advocate for social change to positively affect this case?
This does not apply to this case.

9. Were there any legal or ethical issues present in the case? If so, what were they and how were they
addressed?

The big ethical issue that was present in this case was Paula’s decision to keep her baby. Several of Paula’s
doctors held strong feelings that Paula should abort her pregnancy. They felt she was too ill to care for an infant
and a child at all. As her social worker, I was not sure what the right answer was. It really did not matter because
the decision was hers. My role was to support whatever decision she made and help her reach the best outcome
given either scenario.

With regard to legal issues, Paula did obtain a restraining order for the baby’s father. Throughout the course
of treatment, the father violated the order once. I helped Paula file a report with the police regarding the viola
tion. We also made sure that Paula’s advance directives were in order and helped Paula file permanency plan
ning paperwork with the courts. When working in a hospital setting, one must always deal with HIPPA and
protected health information.

10. How can evidence-based practice be integrated into this situation?
Evidence-based practice can be integrated into the situation by using appropriate scales to measure depres

sion, such as the Beck Depression Inventory-II, and by using formal suicide assessment, such as the Beck Scale
for Suicide Ideation.

11. Is there any additional information that is important to the case?
There is no additional information.

12. Describe any additional personal reflections about this case.
Paula’s case is one of the most difficult cases I have encountered in my career. I worked with Paula for a little

bit over a year. We terminated because I left my position at the hospital. Paula not only challenged my social
work skills, but she also drew me into her case emotionally. Yes, I was Paula’s social worker, but at times I felt
like I was her only friend and her caregiver. At the beginning, I felt an enormous sense of responsibility for the
outcome of her situation. Paula consumed a lot of my time. She called me often and required a great deal of
hand-holding. The irony is that when I did not hear from her, I worried. When I did hear from her, I felt like
she was demanding and she drew me right into the chaos of her life and her situation. Eventually, when I real
ized the extent of my emotional involvement in this case, I had to set boundaries for Paula and myself. This
became crucial to our work together. I ultimately realized that the boundaries were actually good for Paula as
they demonstrated structure and the limitations of others’ involvement in her life. They forced Paula to take
personal responsibility for her situation and take an active role in dealing with it. For me, the boundaries kept
me sane. They allowed me to realize my own limitations. Many times, I reminded myself, “You can lead a horse
to water, but you can’t make them drink.”

I feel very fortunate that I was able to work with Paula as part of an interdisciplinary team. Working on a
team allowed me to consult with colleagues about the direction we should take with Paula. It also helped me
cope with the stress and challenges of Paula’s case. My colleagues and I often found ourselves venting our frus
trations, concerns, and fears with each other. I truly do not think I would have been as successful as I was in
helping Paula if I had been on my own.

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Trademarks and Disclaimers

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“Zyprexa” is a registered trademark of Eli Lilly and Company. Eli Lilly and Company is not affiliated with Laureate
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