Intervention of Students and Relations - Essay Example

1.0 Circumstances of the Case Study In this practice study, I will be discussing my correspondences regarding the treatment of SU6 whom I started working with in 7th of December 2009. I started working as a student social worker for Face Youth in October 2009 and SU6 was assigned to me 2 months after. My first meeting with SU6 came when I was called to attend a meeting in school regarding a child in need. That child was SU6 and was accompanied by her previous CAMHS key worker. SU6 is of British origin, 14 years of age and one of eight children. In the meeting, I was informed by her CAMHS counsellor that SU6 was hearing voices from within and had an incident where she brought a knife to school and showed it to her counsellor. SU6 added that she was having problems with her family due to lack of attention especially with the arrival of a new baby. I learned from her previous key worker that SU6 had undergone guidance and treatment with CAMHS and another service provider called YAP. The key worker’s services had ended in April 2009 but SU6 was to still stay in contact with another CAMHS key worker through a meeting held once a week even when she is under FACE Youth’s services. After the meeting, I informed the student centre director of Ryan Peaks High School (RPHS) that I would consult my manager first regarding the set-up between Face Youth, CAMHS and SU6 before proceeding with the services. My manager, upon hearing the information, contacted the CAMHS director and set up a meeting attended by him and his counterpart. CAMHS agreed to supply previous and future information (from weekly meetings) regarding SU6. I was then given a green light by my manager to proceed with a note that I should coordinate and cooperate with my CAMHS counterpart as well. 2.0 A brief account of the nature and practices of the agency and how they affected the intervention. FACE stands for Feeling, Achieving, Caring and Encouraging and the agency provides just that to young adults from 11 -16 years of age. FACE Youth specializes in providing services for three major concerns of young adults today. First in the list is personality development wherein the teenager learns to have a more positive self-image through a series of activities such as personal and life paradigms. To help young adults in developing and understanding correctly their emotions and that of others, FACE Youth provides an emotional literacy course. The third service concerns anger management wherein the young adult is made to appreciate all aspects of anger such as physiology, emotions, thoughts and actions and explore different anger management techniques. The agency provides trained psychologists and social care workers to schools to conduct one-to-one mentoring, crisis intervention, liaison with parents and evaluation of pupils. There is also the after school clubs service wherein young adults are engaged in informal activities designed to promote positive relationships with peers in a structured but fun environment. FACE Youth also caters to local communities and provides a range of services for individual and group settings. FACE Youth was established in response to the Every Child Matter and Youth Matter government initiatives. It was also further inspired by the Government White Paper released in April 2006 and entitled ‘Our Health, Our Care, Our Say’ which identified the future direction of healthcare (www.dh.gov.uk/publicationandstatistics). The paper called for practice based commissioning, more care undertaken outside the hospital and the home, better interagency communication and allowing different providers to compete for services. FACE Youth was a private initiative to respond to the mental health needs of the British population.  3. An account of the student’s assessment and the process through which it was made, including any interagency liaison, and the relationship between risks, needs and resources. Ryan Peaks High School (RPHS) guidance and counselling professionals initially assessed the service needed by SU6 with the recommendation made by her CAMHS key worker as a primary basis. Once the assessment has been carried out, they then referred her case to an agency that provides the services needed. As the professional assigned to SU6’s case, I made a preliminary assessment of SU6 from the referral made by the RPHS to FACE Youth. I then identified three other assessment sources, apart from SU6 herself, that would give me a deeper and holistic understanding. These are her CAMHS key worker, parents and her teachers. The key worker would provide me valuable data regarding behaviour, therapy received and other considerations. Her parents would provide me her household behaviour and historical observations of SU6 including any recent or childhood significant events. Her teachers would provide me a picture of how SU6 performed in the school and related with other students. I originally considered gaining information from her classmates as well especially her friends but that would make her situation less private than what she would have liked. Drawing upon these three sources, I learned that SU6 started getting social work when her behaviour of inflicting self-injury got worse to the point that she had to be admitted to a hospital. Psychological and clinical assessments made by CAMHS and the school’s psychologist indicate that SU6 is having delusional and hallucination episodes where she reported hearing voices from within. SU6 was diagnosed to be suffering from a severe parental attention-deficit disorder because of the rather large family she belonged to. Since then, several social workers from YAP and CAMHS have been in contact with her. SU6’s behaviour appeared to improve to the point that she was seeing her social workers less often. Later, however, she brought a knife with her to school and showed it to her counsellor. This triggered the school authorities to temporarily disengage SU6 from class. The baseline from information gathered from external sources is that SU6 belongs to the category of self-injurious behaviour (SIB) with the additional condition of susceptibility to relapse when services are abruptly discontinued. To enable SU6 to integrate successfully and build a more positive image of her, I had to address the underlying SIB issues of SU6. This was further reinforced by one significant revelation. SU6’s father and school child protection worker informed me that SU6 appeared to be very sexually forward borderline aggressive in talking about sex and wanted her boyfriend to be more open. This was evident in the MSN conversations which her dad printed and gave to the school’s child protection worker who in turn gave it to me. The school child protection worker also told me that SU6 had disclosed, though reluctantly, that she had been sexually active before and that she was sexually abused in the past. Sexual abuse is one of the more well-documented reasons why individuals develop SIB (Nock and Prinstein, 2004) The primary source, of course, is the sessions with SU6 herself. The introductory session where I personally met the service user provided opportunities to gain more knowledge about her and her condition. However, a more detailed assessment could not be completed because SU6 was getting late for class. To compensate for this, I decided to accompany SU6 to her class and gain a glimpse of the school environment which she was to be integrated again. On the second session, I began to establish a trusting rapport. Stone & Sias (2003) stressed the importance of establishing rapport as a requirement for successful therapy. To do this, I asked her about her interests in various fields which a typical adolescent would be concerned with. I took a mental note of everything she said because writing it down could make her feel uneasy. According to White Kress (2003), the standard of practice in assessments of young adults with SIB is to determine in the initial interview the frequency, duration, onset, antecedent and consequences of SIB. My search for an assessment tool made for such purpose introduced me to Gratz (2001) Deliberate Self-Harm Inventory (DHSI) which provides a checklist of SIB information I need to gather and classifies people according to severity and appropriate treatment. When I thought SU6 was comfortable enough, I presented to her a full picture of a human body and asked her to identify the areas where she had inflicted harm on herself and give details that the DHSI require such as type of injury, time of commission, consequences, emotions which she felt during that time and reasons she had for doing. She cooperated, rather shyly and then proceeded to show her healed marks. I made a mental note of our conversation and later used it as input data for Gratz’s assessment tool. I learned that SU6 fitted into the common type of SIB who resorts to such behaviour because of severe emotional pain which doesn’t have any available outlet. Individuals under this category consider physical pain as a temporary cure for emotional pain which was found to be common among young adults. In his studies, Levenkron (1998) found that when a person is unable to verbalize their feelings, she can become overwhelmed by the feelings stuck inside them. Suyemoto & Kountz (2000) found that many people who engage in SIB report feeling anxious, angry, tense and fearful prior to the act and then feeling release, calm, relief and satisfaction immediately thereafter. According to Alderman (2000), the wound signifies survival from intense suffering and transfers the internal pain into something tangible, external and treatable. Synthesizing all these information, I came with the assessment that SU6 was harbouring intense feelings she did not have anybody to share with or relate to. That is why she was harming herself. She needed a friend, a confidante not necessarily to give her attention but to give an outlet of her feelings. SU6 notes that she did it for seeking attention and making people know how unhappy he is but as Jeffrey & Warm (2002) would argue, the fact that many SIB people hide their self-inflicted marks give an indication that they don’t want people to notice it. 4. A discussion of the agreed aims of the work including an account of how and with whom it was negotiated. In the referral made by RPHS student support centre to Face Youth, it was explicitly stated that the assigned worker’s target was to help SU6 improve her confidence and self-esteem level and enable her to integrate and settle successfully in the school. I reported my assessment with the director of the student support centre and my manager. My plan was to improve her self-image by knowing herself more and providing means and ways for emotional management. This was crucial, I argued, because SU6 was basically having problems of knowing and handling her emotions. I would be teaching her ways to channel her angst into other more productive activities and divert her from her destructive tendencies. I had in mind the use of Cognitive Behaviour Therapy (CBT) with which I had three choices: Individual, Familial and Group. My manager decided to proceed with Individual CBT first to resolve any personal issues and then conduct Group CBT later for developing her socialization skills. The family approach, while desirable, appeared to be not possible because of the failure of the previous attempts made by CAMHS on that regard. This was due to the fact that her father and mother were both working to support their rather large family. I had a coordination meeting with the CAMHS worker who was meeting SU6 once a week. She informed with that she was using the CBT model to work with SU6 and there was the problem of duplication. She asked me to work with SU6 on a superficial level. This disoriented me and provoked feelings of uncertainty in terms of what work I should be doing with SU6. I reported this to my manager and practice assessor who then informed me that perhaps I could work with SU6 by finding out who she was outside of all her problems. The guiding question was ‘what was her identity?’. I consulted my manager regarding this and he told me that once therapeutic rapport has been developed, group counselling maybe considered. The individual treatment will identify underlying issues, acquire alternative coping skills, recognize patterns of SIB, track behaviours, enhance interpersonal skills and restore daily functioning. Group therapy focuses on group dynamics and specific interaction between client and other people who have SIB (Stone & Sias, 2003). 5. A description and analysis of the student’s intervention, including working in partnership, how the student empowered the user/client, and carried out statutory requirements and legal interventions. Prevalent among child and young adult counsellors is to dominate the communication exchanges with patients because of the need to exert authority over them and the belief that they know what’s best for their patient. However, research by Lund & Light (2007) indicated that social care interventions can only achieve limited success if the ‘patient’ is not encouraged to initiate discussions. Having this in mind, I tried to encourage SU6 in becoming more vocal and treat me like a friend, a confidante. In one to one sessions, a lot of questions need to be asked for SU6 to talk. Oftentimes, she did not want to talk but to listen and do the activities I prepared for her. Gradually, though, she became more responsive. During our individual sessions especially in the exploratory stage where I asked her to relate her injuries, I was careful in my wordings, actions and reactions. According to Haines & Williams (1997), SIB counselling practitioners should be genuine, emphatic and not critical of the person’s behaviour. It is also important to avoid over-reacting especially when discussing the severity of the injury because such reaction can be stigmatizing to the client. According to the longitudinal study of White Kress (2003) involving SIB, people engaging in SIB are particularly sensitive and feel shameful about their behaviour but continue to engage in it because they believe it is a survival skill. They see it as an attempt to relieve emotional pain even if it is lasts momentarily. Hence, it is essential to find out what the behaviour mean to the patient and know the reason why he or she is engaged in SIB. In short, the key worker should understand behaviour through the client’s perspective. SU6 attitude changed more when we started to include her into a group of youngsters also having social behavioural problems. Even though she was relatively new to the group, she was very enthusiastic and was befriending everyone by her third session with them. To engage the group in outdoor social activities, FACE Youth project workers including me, formed the program called ‘Hit Squad’ – a peer health education team working with young people by providing them workshops, conferences and residential training. SU6 became a facilitator. SU6 made further progress when she made and distributed DVDs with inspirational content and clips from a Primary Care Trust sponsored conference aimed at determining young people’s view on issues. She joined another conference regarding the diversity of people in London cities. After the Easter holidays, I started to see SU6 only once every two weeks. She was doing well and had even stopped seeing her CAMHS key worker. There were no further incidents of SIB or erratic behaviour. SU6 used to register with FACE Youth but seeing her improved situation, I asked her whether she would prefer going back to her tutor group to which she said yes. She is free to call me or FACE Youth if any other incidence occurred. 6.0 Emotional dimensions in the intervention There were certain mixed emotions of guilt, worry and incredulity registering in me when I heard how SU6 inflicted wounds on her body and saw her scars. I did not show this to my client but I relayed this to our practice assessor who gave me his support and guidance. According to Wynn (2007), clinicians who work with SIB can be emotionally worn. Supervision is necessary from the initial stages of working with clients and consultation as early as the assessment had been carried can aid in enhancing clinical judgement due to the relief provided by the support of a fellow professional. During the sessions with SU6, I tried to be as genuine as possible, engaged but not letting myself affected. Gradually, the effort I had to exert to do this became lesser because of the rapport I built with SU6. She warmed up to me and showed her true emotions to which I tried give advice on how to manage. Perhaps my strongest feelings registered when I was informed of SU6’s aggressive sexually-related behaviour. I felt awkward and partially disoriented on how I would approach the problem. The feelings were further enhanced when SU6 herself disclosed that she was abused in the past. I managed my feelings and handled the awkward situation by telling SU6 this experience was identified as another source of self-injuring behaviour. 7. A discussion of issues of power, inequality, ethics and oppression as they were present in the intervention, and how these informed and improved anti-racist and anti-discriminatory practice. As previously stated, one of the ways in which to develop SU6’s confidence and self-esteem is to empower them to become active participants in therapy. As White et al (2002) found, encouraging SIB clients to take control can be very powerful because it gives them a sense of power. The goal was to direct that sense of power to his self-image. To achieve this goal, I informed SU6 that we were going to keep a diary to document any triggers for SIB, cues, frequencies and reducers of behaviour. She would write there her SIB tendencies and we would be analyzing it and identifying ways to eliminate the tendencies. I would encourage SU6 to redirect her SIB tendencies to other more productive alternative behaviours such as immersing herself in music, an activity she really loved. We also identified safe people and safe places to go when wanting to self-injure and we agreed to get rid of any objects which can be lead to potential injury. SU6 would avoid being alone and would engage in physical activity. I tried to widen her horizon by discussing issues that crosses culture and national boundaries. People who engage in self-injury have been found by White et al (2002) to be in a conscious effort to hide their scars out of fear of rejection by other members of society. They were particularly keen on not being known to engage in deviant behaviour. Aside from establishing a trusting therapeutic relationship, it is important to create a safe, structured environment that is characterized by consistency. Our sessions were within FACE Youth or school facilities. In addition, ethics would call for privacy but it is very important in SIB treatment to also consider client safety. The practitioner must assess the severity of the injuries and the means by which they were cared for. If it is found that the client need medical attention to address his or her self-afflicted injuries, then a referral or additional services is warranted. 8. An analysis of the thinking which informed the work and your evaluation, drawing on relevant literature about social work theories and methods. If I were going to make SU6 successfully integrate back into her school, I had to address her self-harming behaviour. I had to make her more confident in her to the point that she would not find it necessary to harm her body. I initially focus my attention to the disclosure of SU6 stating that the reason why she inflicted self harm was to get attention from her parents and that the voices from within was the result of her solitude. This made me think that SU6 had Attention Deficit Hyperactivity Disorder (ADHD) which represents one of the most common reasons for a child’s referral to a clinic or school counsellor. From my first two meetings with SU6 and my initial research, I have observed that SU6 can be inattentive, impulsive and hyperactive, the three main symptoms of ADHD, some of the time but I felt that these observations were not enough to warrant an ADHD conclusion. I needed more details about ADHD to fully ascertain whether SU6 really had this condition. From the research, I learned ADHD affects between 3 and 5% of young adults in studies where strict diagnostic guidelines are followed. The prevalence among boys is significantly greater than among girls, with ratios varying between 3:1 and 6:1 (Anastopoulos and Barkley, 1992). In addition to the three core symptoms, associated features of ADHD include: (a) academic underachievement; (b) cognitive and language performance deficits; (c) inconsistent task performance; (d) limited performance in rule-governed situations; (e) impaired social functioning in peer and family settings; (f) comorbid behaviour problems such as conduct disorder (CD) and oppositional defiant disorder (ODD); and (g) comorbid internalizing disorders such as generalized anxiety disorder (GAD) and depression (Erhardt and Hinshaw, 1994; Frederick and Olmi, 1994). The additional information did not fit SU6 at all for her grades, which I have acquired with the permission of the school and her parents, showed that she was a good student. She has no issues in any subject and is predicted to get mostly As and B grades in her GCSE next year. SU6 was actually very involved in her school as she is heavily into music and performs regularly in school talent shows and other events. In my conversations with her, she did not show any recognizable cognitive and language benefits and can be warm most of the time. Knowing this, I change my focus on the nature of self harm itself rather than the reason adolescents resort to this behaviour. Self harm is known in literature as the deliberate and direct injury to one’s own body (Claes, Vandereycken & Vertommen, 2005). One very important revelation to my studies on self-harm is its relation to suicide or harming other people. I became acutely concerned that SU6’s self-harm and knife-bringing behaviour were precursors to the ultimate act of suicide. This fear was allayed when I read the report of a 2006 national inquiry entitled ‘Truth Hurts’ where self harm was stated to be usually intended only to harm not kill or even inflict serious or permanent damage. The report further stated that it was actually a strategy, however damaging and maladaptive, to make it possible for the young person to continue with life and not to end it. According to Crowe & Bunclark (2000), the risk of suicide in individuals who self-injure range from 13%-16% over a five year period or 3% per annum. Researching further, I discovered that certain diagnoses frequently occur with SIB. The work of Suyetomo and Kountz (2000) was most illuminating when they provided a list of diagnosis related with SIB. These are: borderline, personality disorder, depression, dissociative identity disorder, obsessive-compulsive disorder, alcoholism, schizophrenia, eating disorders and other personality disorders. Muehlenkamp (2005) widened this further by being able to link self-injury with a history of trauma especially sexually or physical in nature. The work of Jeffrey & Warm (2002) indicated that the patient may be coping with painful feelings from different experiences aside from abuse. I was on the lookout for symptoms which may show that SU6 had a more severe level of pathology which Muehlenkamp (2005) recognizes as adopting an identity of being a cutter or burner. All of these information provided me a good view of SU6 condition and matters of consideration that I would observe during sessions with her. 9. A critical evaluation of the student’s intervention; and following reflection, a summary of any different or improved ways in which the student might intervene in similar situations in the future. The thorough assessment wherein different data sources are consulted provided me with very useful information. Through a thorough assessment, many opportunities can be provided to the practitioner to gain a better understanding of the SIB for each particular client. This, in turn, can lead to the identification of appropriate treatment. The operating principle is that the better understood the client, the better care he or she will receive. One on one client assessment can also be useful because it allows the client to spend time expressing and verbalizing their feeling. This assessment can be therapeutic itself (Haw, Hawton, Whitehead, Houston, & Townsend, 2003). Another important aspect that was impressed upon me was the role of self-exploration and trusting therapeutic relationship. According to Suyemoto & Kountz (2000) and my working experience with SU6, self-exploration is a very important part of treatment who self-harm. Self-exploration allows for recognition and development of one’s own identity as an individual. It allows a person to make sense, manage and solve his or her feelings rather than trying to immediately resolve his feelings through the act of SIB only for it to return again. Aside from self exploration, it is also very important for the practitioner to develop and enhance the verbalization and alternative coping skills as well as broadening client supports. Last and the most important of all is the realization that the practitioner should immerse his or herself in further study so that he can develop accurate insights into his or her client’s problem. References: Anastopoulos AD, Barkley RA. 1992. Attention-deficit hyperactivity disorder. In Handbook of Clinical Child Psychology (2nd edn). Walker CE, Roberts MC (eds). Wiley: New York; 413–430. 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Counselling clients who self- injure: Ethical considerations. Counselling and Values, 47, 220-229. Read More