Assignment Four

As previously outlined in my blog, the goal of my work with R.H. is to lessen his isolation in his inpatient facility. As part of this goal, I hope to draw R.H. out of his room, or at least out of his bed, using the meals that I bring him from McDonalds. R.H. often refuses the in-patient facility’s food and looks forward to the treats that I bring him. I planned on having him eat the food in the ward’s dining hall instead of in bed, as is his norm.

When I entered R.H.’s room, his roommate was also present. R.H. detests his roommate, and hates how the roommate intrudes on the privacy of our conversations. I pulled the curtain separating the two beds shut, in order to at least give R.H. the allusion of privacy in the shared room.

Per usual, R.H. was lying in bed listening to music. I said hello to R.H. and commented on how well he looked. I asked how he was doing. “Horrible,” he replied. I asked if anyone new had come onto the ward with whom he might connect. “No,” he told me. I asked if there was anything else that I could bring him to pass the time, books, magazines, or anything like that. R.H. told me the only thing he wanted was to “get out of here.”

I then showed R.H. the McDonalds that I had brought him. Rather than eating in bed, I suggested, why don’t we take the food into the dining hall so that you can eat at a table. R.H. flatly refused. I again suggested that we take a walk at least, get out of the room. At this suggestion, R.H. became greatly agitated. He became angry with me and walked out of the room. In this manner, I suppose that he was less isolated because his agitation and anger forced him to get up and leave. However, when I followed him he became increasingly angry and refused to speak with me.

I told him I was sorry that he did not want to talk, and that I always enjoy our visits. Rather than walking me to the elevator and saying goodbye, as R.H. normally does, he walked angrily back to his room, with no goodbye or parting greeting.

I am unsure of how to proceed with R.H. I do not know how to implement my intervention when he is so intractable in his refusal to socialize or be around the other residents. R.H. has been in his current facility for years, and for years has spent the vast majority of his time in bed. I do not know how to encourage him to leave his room without agitating him.

In addition, R.H. eats so little that I am cautious about making his McDonalds a stressful experience.

Therefore, I feel somewhat stuck in my evaluation study. I have yet to be able to make any inroads with R.H., or to use any intervention on him. As the vast majority of my clients have severe cognitive impairments, R.H. is my only possible subject. However, I am unsure if I can get him to even attempt an intervention.

Assignment 3

I have decided to focus on my client’s isolation in my evaluation study. At first, I planned on focusing on both his isolation and non-compliance with his AIDS medication. However, I believe a two-prong approach such as that will be more difficult to both implement and evaluate. Thus I will focus on R.H.’s isolation in hopes of both creating increased socialization in his life and lessening his depression. Studies have shown that non-pharmaceutical interventions can be very beneficial for those suffering from both dementia and depression. (Teri et al, 1997)

I am focusing on using behavioral theory in my work with R.H. I believe that his cognitive impairment, as well as his impaired short and long-term memory, prevents the use of other theories of treatment, such as cognitive behavioral therapy or psychotherapy. Most studies of those suffering from dementia follow a behavioral theory of treatment. (Kasl-Godley and Katz, 2000) Therefore, behavioral theory is the most evidence-based practice.

It is also my hope that if R.H. is less depressed, he may be more agreeable to complying with his medication. R.H. desperately wishes to move to another facility, but his non-compliance with AIDS medication makes this wish almost impossible to fulfill. Perhaps if R.H. is less depressed, he will be more able to see that his non-compliance prevents him from a more pleasant existence.

R.H.’s isolation is rooted in his belief that he has nothing in common with the other residents of his ward. This belief is based in reality, as R.H. comes from a greatly different socioeconomic and racial background than the other residents. In addition, R.H. is a very well educated man. He was in-house counsel of a midsize company prior to the onset of his dementia. In contrast, many of the other residents of his ward have a background rooted in homelessness and poverty. In addition, R.H. holds many racist beliefs, which prevent him from positive interactions with the other residents, who are mostly people of color.

I plan on using two forms of intervention in my attempt to lessen R.H.’s isolation. Both of these interventions are based on the notion that increasing the amount of “pleasant events” in R.H.’s life may lessen his isolation, depression and hopefully encourage him to return to his AIDS medication. The implementation of “pleasant events” in the lives of those suffering from the combination of dementia and depression has been “demonstrated in case reports.” (Teri & Gallagher, 1991; Teri & Uomoto, 1991)

First off, I am working to provide him with visitors from outside organizations, especially organizations that work predominately with GLBT nursing home residents. In clinical studies, it has been found that receiving outside peer visitors can lessen a resident’s depression by up to 40 percent. (Snowden, Sato and Roy-Byrne, 2003)

I have researched organizations that provide such visitors, and have found two that are appropriate to R.H.’s situation: Gay Men’s Health Crisis and SAGE (Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders). I am in the process of scheduling visitations from both of these organizations. It is my hope that the visitors will be able to both provide R.H. with mental stimulation and encourage him to leave his bed, where he spends the majority of his time.

My second intervention is based on R.H.’s disgust for the food served in his inpatient facility. Due to his frequent refusal to eat the facility’s food, I always bring R.H. McDonalds, Coke and Hershey’s Chocolate Bars with Almonds when I visit him. R.H. eats the outside food in bed while we talk. On my next visit, I plan to move our visit to the ward’s dining room so that R.H. will eat at a table, in a more normalized fashion. My hope in this change in our visitation schedule is two-fold. One, I hope that having R.H. eat at a table in the dining room will decrease his sense of himself as purely a “patient.” Two, as other residents spend recreation time in the dining room, I hope to cause some socialization between R.H. and other residents.

I am unsure as to the extent that this intervention will work. R.H.’s racist beliefs have been strongly held by him throughout his life. Consequently, he may simply refuse to speak with the other residents, as is often the case. Also, I am unsure if providing R.H. with outside food in front of the other residents will cause agitation among the others, and as a result either prevent R.H. from eating or lessening his enjoyment of the outside food. As R.H. is very thin, and often refuses to eat, I am hesitant to do anything that may cause him to refuse the outside food as well. However, I plan to attempt this intervention on my next visit. If it does not go smoothly, I will not attempt it again.

Assignment #2

R.H. is a 63 year-old Caucasian man. He was diagnosed with HIV in 2001 and is now living with AIDS. He suffers from AIDS-related dementia and depression. Due to his depression, Ralph refuses to take his AIDS medication. This non-compliance with his medication can be seen as a slow form of suicide. He also refuses to eat the food at his facility, and is extremely thin. Following the previous case manager’s lead, I always bring him McDonalds and chocolate bars on my visits.

R.H. has impaired memory, both long and short-term. He is oriented to person, place and time. R.H. is easily distracted and often forgets what he was talking about.

R.H. currently resides in a long-term care facility in Spanish Harlem. Therefore his environment is both natural and closed/controlled. (Bloom, Fischer and Orme, 2009) The fact that R.H. lives in a controlled environment makes it easier to record his behaviors. The fact that this controlled environment is also his natural environment makes the incidences of these behaviors more valid. When a controlled environment is different from the subject’s natural environment, there is the concern that the subject’s behaviors in the natural environment are not being accurately replicated in the controlled one. (Bloom, Fischer and Orme, 2009)

The facility has a locked ward specifically for people living with AIDS. R.H. is deeply unhappy at this facility. He is in a different socio-economic and educational class than the majority of the other residents, and has no desire to socialize with them. R.H. is very well educated. Prior to his mental decline, he was the in-house counsel for a mid-size company. He speaks both English and French.

R.H. has a roommate, whom he detests. Since both R.H. and I speak French, we conduct our visits in that language in order to have a higher level of privacy from the roommate.

The majority of the residents in R.H.’s ward are people of color. R.H. is racist and anti-Semitic. Beyond his lack of desire to socialize due to his depression is a lack of ability to relate to the other residents due to R.H.’s racism and his different background. Consequently, R.H. spends the vast majority of his time isolating in his room, often not getting out of bed for long periods of time.

When I told R.H. about the evaluation study, he seemed mostly confused by it. He knows that I am in school as well as working at ABC agency, but did not see how he would be a part of my studies. However, he agreed to let me try out a new treatment plan with him in order to work on the behavioral issues that he and I discussed.

My field instructor strongly encourages me in my work with R.H. and has been incredibly helpful in my work with this ward. R.H. is a long-term ward of ABC agency, so my supervisor has a great deal of experience working with him and an in-depth knowledge of R.H.’s history.

The behaviors that I am targeting with R.H. are his isolation and his refusal to take his AIDS medications. Isolation and non-compliance with medication are behaviors because the two are something R.H. does (or does not do in the case of his medications). (Bloom, Fischer and Orme, 2009) The two are overt behaviors in that others can observe them. (Bloom, Fischer and Orme, 2009)

R.H. also struggles with the covert behavior of depression. Depression is a behavior because behaviors include what a subject thinks and feels. (Bloom, Fischer and Orme, 2009) “The key is, to be considered a behavior, it must be observable and measurable by someone, whether that be the client (e.g., with thoughts) or an external observer.” (Bloom, Fischer and Orme, 2009, p.129) Depression is a covert behavior in that it “occurs within [R.H.] and therefore cannot be observed by others, at least directly.” (Bloom, Fisher and Orme, 2009, p.129)

R.H.’s baseline for his overt behaviors is total isolation and non-compliance with AIDS medications. As of now, I cannot measure the duration of R.H.’s isolation because it is complete. However, my hope is that I can encourage R.H. to leave his room for activities or possible socialization with other residents. If I am able to encourage R.H. to lessen his isolation, I hope to also measure the duration of his activities or socialization. The main issue with measuring duration is that R.H. has impaired memory, both short and long-term. Therefore he is not a reliable self-monitor.

R.H.’s unreliability is not an issue with his medications, because medications are monitored by the nursing staff and included in R.H.’s written chart. The nurses therefore, are reliable direct observers of R.H.’s non-compliance with AIDS medication. (Bloom, Fischer and Orme, 2009) However, I do not feel that the staff is a reliable direct observer of the isolation in that I cannot request that the staff monitor the frequency of his isolation to the extent required for the evaluation study. This may be less of an issue at the beginning my evaluation, since presently R.H.’s isolation is so absolute. Were R.H. to join other residents in activities or socialization, it would be so out of the ordinary as to be immediately noticeable to the facility’s staff. If I am able to convince R.H. to isolate less over time, the frequency of the socialization may not be readily apparent to the staff.

Therefore I am in a somewhat difficult position regarding monitoring R.H.’s isolation. While I am asking R.H. to self-monitor his isolation, I cannot ensure that he is giving me entirely reliable information due to his cognitive impairment. However, R.H. is one of my least cognitively impaired clients, and therefore the most likely subject for this study.

R.H. and I discussed his continuous recording of any socialization or participation in activities. As of now, R.H.’s participation in the ward’s social life is so minimal as to allow him to be able to note when he does participate. Continuous recording can be used in this situation because the targeted behavior “doesn’t occur so frequently that it would be impossible to record every occurrence.” (Bloom, Fischer and Orme, 2009, p.133)

I attempted to use a WALMYR scale in order to measure R.H.’s covert behavior of depression. However, when I introduced the scale, using it seemed to agitate R.H. I attempted to ease his anxiety regarding the questionnaire and we tried to begin it. However R.H. either lacks the attention span required for the brief questionnaire or was so disinterested in it that he refused to participate. It is possible that if R.H. begins to take his AIDS medications his cognition will improve to the extent that I can use a WALMYR scale with him.

R.H.’s cognitive impairment also makes using a self-anchoring scale problematic. I would like to be able to use a self-anchoring scale to measure R.H.’s unhappiness at the facility over the course of my evaluation study. It is my hope that if I can successfully encourage R.H. to isolate less, he will become happier in his current environment. When I first asked R.H. to measure his unhappiness at the facility on a one-to-ten scale, he immediately said ten, and then became agitated regarding how unhappy he is at the facility. This is an issue with performing an evaluation study in my client population, which only includes those suffering from profound dementia.

Assignment #1

My fieldwork internship is with ABC agency located in Brooklyn, New York. ABC is a court appointed guardianship agency for people with dementia, Alzheimer’s disease, often coupled with other types of mental illness. When these people are found incompetent by a court of law, ABC may be appointed guardian over the incompetent person’s self and/or property.

ABC is often appointed guardian because the ward either has no family, the family and the ward do not have a positive relationship, with elder abuse sometimes occurring.

ABC provides services in the five boroughs, Westchester, Long Island and New Jersey. Most of the agency’s wards reside in nursing homes, hospitals, rehabilitation facilities and adult group homes. However, some of them remain in their own apartments or houses, where they are cared for by a home health aide.

ABC is divided into two departments: social services and finance. There is often tension between these two departments as each struggles with its own priorities. This tension contrasts with the need of the departments to work cooperatively to ensure the best treatment for the agency’s wards.

As a social work intern with ABC, I am the case manager for 26 wards of the agency. These wards range widely in age, physical and mental impairment and ability to communicate. My primary responsibility as a social work intern is to ensure that each of my wards is well cared for and placed in the least restrictive environment suitable for meeting the ward’s needs. I am legally responsible for visiting each of my wards at least four times a year to ensure they are receiving all necessary treatment and care, and that they are living in an appropriate environment. Although four is the requirement, I visit each of my wards far more often than this minimum.

In deciding which of my wards to use for my class project, my first difficulty is that many of my clients are so severely affected by dementia and Alzheimer’s as to be not oriented and unable to communicate and comprehend communications addressed to them.

I do currently work with a few wards who are possible project subjects. One of my wards, R.H., is a man in his 60s who is living with AIDS and suffers from AIDS related dementia. However, he is oriented x3, and his communicative abilities are unaffected by his disease. I visit R.H. quite often, and believe that he is a appropriate subject for my project. My goals with him are to encourage him to comply with his medication, and better adjust him to life in the facility so he will hopefully be happier and more integrated into the facility’s social life.

R.H. is noncompliant with his medication and isolates in his room, refusing to participate in any social or recreational activities. He is deeply unhappy at his current facility, and greatly wishes to change to another residence. However, no other facility is likely to accept him as long as he refuses his AIDS medications. I have attempted to use the possibility of changing facilities as an impetus to his complying with medication, but to no avail as of yet. R.H. finds the food at the facility extremely unappetizing, and I usually bring him candy, soda and McDonalds when I visit.

My second possible subject is another of my wards, S.L. S.L. suffers from dementia and schizophrenia. She has a history of chronic homelessness. ABC was appointed legal guardian over her after she was found lying in a subway station, covered with rat bites. S.L. eloped from her prior facility, and elopement remains a constant risk with her. S.L. is very unhappy in her current facility. She greatly wishes to get her own Section 8 apartment, and live in the projects in Brooklyn. However, this is not a realistic possibility due to S.L.’s history of homelessness and elopement, and her lack of funds to finance the home aide that she would require. Nor is she a likely candidate for a group home, also due to her elopement history.

S.L.’s lack of acceptance of life in the facility causes her to often act out verbally with staff and myself. My goals with S.L. are to help her realize that her living on her own is not a realistic possibility, help her adjust better to life in the facility and consequently lessen her behavioral issues.