HIV / AIDS Course > Chapter 6 - Case Study

Chapter 6: Case Study

VI. Case Study: Psychosocial Assessment and Treatment

The following is a graduate class case study of an HIV client seen in prison. The study illustrates the process of doing a psychosocial assessment and working with the client and their specific needs and desires in forming a treatment plan.

ASSESSMENT & TREATMENT

Lance J. Parks         December 12, 1989

Introduction

The client who is the subject of this paper is an inmate at the Del Norte Treatment Unit at the California Institution for Men in Chino. The inmates in this unit have been diagnosed at one of the following stages of the disease we call AIDS: HIV positive, ARC, or AIDS.

The Client and His Problem

Frank is a twenty-five year-old African-American male who was placed at the institution as a result of violating his parole, having previously spent time at the unit and released. Frank verbalizes a need for assistance in finding a job, staying out of illegal behavior, and getting out of the "wrong" neighborhood (where his gang is at) .

Regarding his physical appearance, Frank usually wears the prison issued clothing of blue shirts and jeans, and in addition will often wear a blue baseball cap or bandana around his head. He occasionally wears sun glasses while walking in the hallways and always has his pants sagging down below his buttocks. All of these attributes serve the purpose of communicating that Frank is a heavily invested member of a "Crip" gang. Tattoos on his arms denote the specific "set" or Crip sub-gang he is from (this is usually correlated with the neighborhood the gang claims as "theirs."

Frank is 5' 10" with a medium build. He appears to be healthy, having been exposed to the AIDS virus, but has not developed any seriously related physical symptoms. He maintains a good healthy appetite and sleeps well; however, he continues to smoke and rarely exercises. In his communication skills, Frank is difficult to understand because he speaks at a low tone and runs his words together. In expressing himself Frank uses a lot of street slang.

Frank has poor spelling skills as manifested by his misspelling of common words such as "match" or "aunt." Educationally, Frank reports himself as having reached the twelfth grade. The majority of his high school education was received in correctional placements.

Frank is the third of seven children, having four brothers and two sisters, none of whom live at home. His father died when Frank was six years old from liver complications due to heavy drinking. His mother lives in South Central LosAngeles and is a practicing registered nurse. According to Frank, she is working toward moving out of Los Angeles. Frank reports that his relationship with his mother is good, but he speaks of her as just a person that is there, not expressing any feelings of affection toward her. Further information is needed in this area as Frank is planning to live with his mother upon leaving the institution.

Frank's family lacked a great deal in material possessions and, as a result, Frank was raised in poverty. Frank reverted to stealing those things he did not have at the age of eleven years old. He was first arrested at the age of twelve and reports to have spent most of the rest of his life in juvenile hall, alternative placements, youth authority, and prisons. The crimes for which he has been arrested have continued to be that of robbery.

At the age of fifteen, Frank joined the local crip gang which appears to have replaced his family as Frank's primary socializing agent. As evidenced by the previous information, Frank's membership in the gang suggests that his needs were not being met "by traditional community institutions such as his family, school,..." etc. 'The gang attempts to meet the members needs in negative ways' (Fox, 1985). Frank became a heavy "banger" (defined by himself as an individual who looks to hurt the enemy and actively pursues that course) and as a result of his gang related activities has been shot on three separate occasions. Frank expresses a desire to reduce his role in the gang, stating that he is tired of that life style and being locked up. He states that "once a person is a Crip they are always a Crip, " but he desires to become an affiliated member of the gang (somebody who will back up the gang but not go out looking for trouble).

As a result of his association with gang members Frank became involved in using and selling illicit drugs. He reports to have used marijuana, cocaine, crystal, alcohol, and his drug of choice is "crack." Frank states that every time he is paroled he plans to not get involved with drugs again, but after he is on the streets for a while he craves to use it and get the easy money that comes from selling it.

Since he comes from a lower socioeconomic environment, Frank's cultural supports appear to be minimal (Jansson, 1984). As a result, looking from a systems perspective, Frank has few resources of energy and therefore would appear to be in a struggle to maintain synergy (Anderson and Carter, 1984).

In regards to his psychological functioning, Frank demonstrates that he has good insight into some of the issues he needs to deal with. He realizes that he has the virus and that it is deadly, but he also understands that it is manageable at this time. This is manifested in his efforts to reduce stress through his sense of humor, eating well, and usually sleeps well; all important steps in managing the virus (Lang, 1987). He also understands how the disease can or cannot be transmitted and says that he is cautious to refrain from the high risk behaviors that may infect others or re-infect himself. These behaviors manifest good judgment and accurate perceptions on his part, accepting and working to cope with the problem rather than ignoring or denying it (Werner, 1986). This is not to say that Frank does not feel down occasionally about having the virus, but these spells do not last long.

The judgment he is able to use in dealing with the virus, however, seems to be the exception to the rule for Frank. Poor judgment is reflected in his continuous placement into correctional institutions as a result of his marginal behavior and associations. He also did not make good choices which resulted in his contracting the virus, failing at that time to take the necessary precautions.

In addition, Frank projects some of that responsibility by blaming "them" for making him think it was a homosexual disease. He believes he got the virus from a woman, however, he has also used drugs intravenously, a noted high risk behavior (APLA, 1987). So in addition to accurate perceptions which lead to his ability for secondary prevention of AIDS (secondary prevention is after being diagnosed, preventing reinfection), he also has some anti-social perceptions. This is evidenced in his choice of illegal behaviors as the means to increase his money earning goals (Werner, 1986).

Frank was diagnosed as having the anti-bodies for the virus in May of 1988 while he was in a correctional medical facility. This is a major non-normative influence on Frank, as was the death of his father, both of which have possible stressful effects on his life span development (Baltes, Reese, and Lipsitt, 1980). In regards to Kubler-Ross' stages on dying, Frank has expressed some anger over having the virus, though he does try to deal with it by using his sense of humor (Kubler-Ross, 1969).

In addition, Frank reports to have been hospitalized twice before: once for a "problem in his head" of which he was not able explain very well, and the other time for stress at age fifteen (further information is needed in these matters). He is currently not taking any psychotropic medications.

PROBLEM IDENTIFICATION OR SUMMARY

Frank has been diagnosed as HIV positive and is paroling in a few weeks. He has very little vocational experience. He is heavily invested into gangs so that his only social identity and associations are within the gang, but he now has a desire to reduce his role in that group. He has been involved with the use and sales of drugs for a long period of time. This is coupled with his lack of vocational skills and experience, and added to his desire of being rich and enjoying leisure, believing that anyway to obtain such things is okay.

BUILDING A RELATIONSHIP: Effectual Factors

There are many factors which can affect the therapeutic relationship with Frank and the attempts to build a positive experience with him. One factor is the goal of the agency, which is primarily to protect society. This will be further discussed along with the issues of social work values and ethical dilemmas.

The factors that will be covered here are how personal values, cultural and economic issues may impact on understanding and working with the client. In regards to issues involving cultural and economic values, having food, safety, and shelter were not things that were always readily available to Frank; nor were baseball gloves, children's toys, and such other desirable possessions. Frank learned on the streets that the only way to obtain such possessions was to steal them. This came as a result of observing others' actions (stealing), making his own judgments about such actions (that stealing was a good way to get what you want), and act accordingly (steal). The faulty judgment he made resulted in poor decisions and dysfunctional behavioral styles (Werner, 1986).

Such behavior falls under the category of an antisocial personality defined by Zenter: "...those who are in repeated conflict with society's values, and those who need to gratify impulses immediately to the detriment of other concerns" (1984, p.345).

Treatment can be affected in many ways by differences in values between the social worker and client. It is important for the social worker to recognize these differences and search to gain as much understanding of the client's culture and views as possible. This includes understanding of the African-American culture, gangs, poverty, and the learning and values which have been developed as a result of these factors. In regards to these factors influencing the therapeutic relationship, Frank has not projected any anger or resentment toward the social worker, but the relationship has grown as a result of interest being expressed in Frank's "world." In regards to the therapists feelings toward such issues, there are no negative feelings of counter-transference toward the client regarding his race. Though the therapist's own values may strongly be opposed to some of the behaviors of the client, such as stealing and drug use, the therapist should take the attitude of being "non-blaming" (Perlman, 1979, p.55). The role of being judge is a role the therapist does not have to take nor should take. The therapist is able to be more effective when they are not burdened with the need to be a judge.

In discussing personal values and the cultural and economic differences between Frank and himself, the therapist must look at how these affect building the relationship with the client. As will be discussed later, these factors will also play a part in the assessment of Frank's functioning. As far as economic factors, trying to set up a job for him may be looked at from his point of view as an attempt to force a "white man's" cultural value on him!' As can be seen, these issues would not only affect assessment, but also could play a big part in what the client feels should be part of the treatment plan, the two of which could be far apart. In order to resolve such issues there would be a need to look at some of the basic social work values, such as encouraging client self-determination (NASW News, 1980). This, along with ethical dilemmas, will now be discussed.

ETHICAL DILEMMAS and SOCIAL WORK VALUES

In the setting of the correctional institution there are ethical dilemmas created as a result of policies which conflict with basic social work values. An individual can get a general sense of the problem in the mentioned realization that the "purpose" of the prison is one of protecting society by keeping those who do harm away from the rest of society. It sounds simple enough, but when these individuals continue to commit crimes after their release from prison, how is it serving to protect society?

One dilemma that contradicts a social worker's ethical responsibility is the segregation of those inmates that have been diagnosed as seropositive. This would appear to infringe upon their rights usually provided other inmates such as the opportunity to interact with a larger number of inmates and have more use of the yard. In addition is the issue of confidentiality. When a person tests for AIDS the results are supposed to be confidential. This right is taken away when the inmate is segregated if found positive. However, being segregated, the inmates receive much better medical care and services to treat them. The dilemma: Should they have a right to choose to be segregated, or should segregation be mandatory to protect the rights and safety of the other inmates?

Another ethical dilemma is that as a social worker the primary responsibility is supposed to be towards the client (NASW News, 1980). At the same time the social worker is to follow the purpose of the agency. Many times there are bureaucratic obstacles to get the client's needs met. When in a conflict there must be a decision either follow the agency's goals or the client€™s best interests.

For instance, there exists the basic value that every person has inherent worth and that interactions with others should enhance their self worth and dignity. When a correctional officer does not maintain such a value, does the social worker become an advocate for the inmate, or be more concerned with working with the officer to get future needs met?

The value that people should have access to necessary resources to meet life's challenges is also very important in the work (NASW News, 1980). To a person with AIDS this relates to them meeting their medical and nutritional needs to fight the virus. In regards to their relationship, Frank will be able to see whether or not the social worker will be there to help those needs get met.

So there are many ethical dilemmas which relate to the differences of the agency's values and social work values. This is important to the social worker's relationship with Frank as he will view the social worker either as one who follows the values or feeling that he is a prisoner and does not deserve anything, or a set of values that view him as an individual who has had a hard time in life and needs some assistance to get back on his feet.

TREATMENT

ENGAGING THE CLIENT

To begin any relationship it is important to begin the process from a point the other person is. In a therapeutic relationship, the therapist starts where the client is (Goldstein, 1983). Perlman refers to the importance of this principle with resistant clients (1979) . The first step is to assess where the client is at in his feelings toward the therapist and the attitude toward the agency which the therapist represents. It is important here to recognize and express the naturalness of such a reaction which serves the purpose of showing acceptance and lowering resistance. Next, it is important to show concern toward the client, allowing him to express his feelings about his current situation. The skill of accurate empathy is vital here to communicate understanding with the client rather than a diagnosis of the client (Hammond,Hepworth, and Smith, 1977). After establishing initial concern, then the role of the therapist at the agency should be stated.

In working with Frank, as with working with many of the inmates, these initial steps occurred on a more informal basis outside of the office. Using the steps mentioned I inquired as to how Frank felt and how his day had been. Then we began talking about being in prison, when he is to parole, how many times he had been there, and his likes and dislikes about the Del Norte Unit (the unit where the inmates diagnosed with the virus are housed).

During this time empathetic responses were used to express interest and concerns for Frank I s interests and concerns. Frank then proceeded to ask about what the therapist was doing there. The worker explained to Frank that he worked with the social worker as an intern. As the conversation went on and the therapist assured him, in response to his inquiry, that he was not afraid of catching the virus, Frank became much more comfortable. The therapist then invited Frank to meet with him in the office the next morning to which Frank agreed.

In continuing the engagement phase of treatment an important step is to find out from the client what he feels his needs are (Perlman, 1979). As mentioned,

Frank initially stated that he needed to find a job and get out of South Central Los Angeles. These desires expanded to meeting people who are prosocial, getting out of the gang lifestyle, learn to manage having the virus effectively, and expanding his activities that are legal.

The engagement phase was well accomplished with Frank as the therapist was able to establish himself as somebody who cared, who would work with him in meeting his needs, and as a person that believed that he had the ability for personal accomplishment which increased his feelings of self-efficacy (Wells, 1982). A verbal contract was agreed to for meeting weekly.

CORE PHASE

The initial problem that the social worker and Frank decided to work on was that of discharge planning. This was Frank's primary concern since he was leaving in just six weeks, and it seemed important to get these issues resolved to clear Frank's thinking in approaching other issues (Hepworth and Larsen, 1986).

In the discharge planning, or setting of goals for the client, it is important that they are a part of that process. In regards to goal attainment, five necessary strategies must be accomplished (Hepworth and Larsen, 1986).

The first is to enhance the commitment of Frank to carry out the task. This was done by showing Frank how the tasks were connected to his reaching his goals. Second, make a detailed plan with Frank to carry out the task. This involved, for example, setting out days, hours and techniques in looking for a job. In looking at the obstacles as the third step, we were able to see the difficulty in finding a job being on parole, the limited jobs, and the ease in returning to selling drugs. As the fourth step, Frank and the therapist practiced looking through newspapers and mock job interviews to prepare him through behavior enactment for these tasks. In the final step the therapist reviewed the plan with Frank, giving him a written copy, and established both trust in Frank's abilities to carry out the plan, and the expectation that he will do so.

In regards to Frank's desire to reduce his role in his gang Spergel points out some important principles for the therapist to remember in working with gang members. One is that Frank is an individual who is also a member of other groups such as a socioeconomic class, family, social group, and others. Helping Frank set goals for strengthening attachments to more pro-social groups is essential. Another point the Spergel mentions is that many individuals get into gangs as a result of lacking support somewhere else, such as from a father. This applies directly toward Frank since his father died when he was six-years old. This support needs to be reintegrated by positive support groups and most probably from a close family member (1966).

Fox (1985) worked extensively with urban youth gangs and developed a model framework in which to work with such groups. In applying some of these situations to Frank's situation the therapist worked with Frank to set goals that might be helpful rather than harmful to the community, deepening his awareness to others' needs. An example is for Frank to do volunteer work in a community organization. This, again, would help increase his self efficacy, seeing that he is able to help others in need.

After working on these issues of discharge planning, the therapist then began to explore Frank' s feeling in dealing with the virus. As mentioned by Wiener (1986), Frank will have to live with the uncertainty of how the disease will progress and when his health will begin to fail him (1986).

In working with Frank several educational perspectives were discussed to inform him about the virus. These included steps to reduce risk of contracting an opportunistic disease, being aware of the necessity of safe-sex, being able to detect IADS symptoms, stress reduction techniques and being aware of his own psychological needs and getting those met (APLA, 1987) .

Also important is to treat Frank as if the expectation is that he'll live (APLA 1987). This is not to be falsely reassuring, but to be encouraging rather than dogmatic. This will also be helpful to change Frank's cognitive processes toward a focus of a quality life, thereby helping his behavior more productive toward taking care of himself (Werner, 1986).

TERMINATION

Terminating with Frank comes as a result of his upcoming parole. Both the therapist and Frank have known of the upcoming termination since the beginning of the relationship. As stated in Hepworth and Larsen (1986) this will reduce the possibility that Frank may have some ill feeling towards the therapist such as "perceived desertion." It will be important to go over the accomplishments over the sessions and note the progress which has been made. Also to be discussed in the last session will be to review again with Frank his written discharge plan. As a follow up, the therapist will periodically call Frank to offer encouragement. Frank was very happy to hear about that. As an extra resource Frank has been referred to AIDS Project Los Angeles though he is looking towards them as a last resource.
 
HIV / AIDS Course > Chapter 6 - Case Study
Page Last Modified On: April 29, 2015, 01:13 PM