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.