Running Head: GROUP CASE

Group Case Conceptualization and Treatment Plan Emily Greco, Alyssa Bassani, and Emily Sanchez University of Central Florida

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Identifying Information The client, Bill, is a seventy-year-old Hispanic, heterosexual male who is retired and currently living in a Senior Care Living Facility. Presenting Problems The nursing home has received several complaints stating the client has masturbated in public. Therefore the client is at risk for being evicted from the living facility. The client also experiences a low appetite and is losing weight. He experiences physical discomfort and uses a wheelchair. He is not turned regularly enough in his bed, which is creating further discomfort. He is given medications PRN for physical pain. His wife passed away two years ago, and the client has been experiencing extreme loneliness. At the facility, the client experiences lack of social stimulation. The client was referred due to his non-stop yelling in the Senior Care Living Facility. The client is not aware that he has a problem Relevant Background Information/Psychosocial History The client is blind, in a wheelchair, and has a long history of intellectual disabilities. The client has learning disabilities and an IQ of 78. The Weschsler Intelligence Scale (WAIS) classifies a score of 78 as borderline intellectual functioning. The client was born in Texas and was blinded in a farming accident at the age of 15. At age 30, the client began working at a library and continued to work at the library until he retired 35 years later. He was forced to retire due to the onset of cognitive deficits. His wife of 45 years passed away 2 years ago. He is most happy when his family, especially his grandchildren, comes to visit. The client is also currently taking anti-psychotics and benzodiazepines.

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Conceptualization of the Problem The client exhibits symptoms for Major Depressive Disorder which includes depressed mood for most of the day, significant weight loss not due to dieting, feelings of worthlessness and excessive or inappropriate guilt, diminished ability to think or concentrate, as well as recurrent thoughts of death. He also displays symptoms of Exhibitionism by masturbating in the public corridors of the residential facility. Client symptoms of depression seem to have begun with the death of his spouse two years ago, and were further exacerbated as time went on by the treatment from the staff and residents of the Senior Care Living Facility. Being confined to the wheelchair and lack of significant, fulfilling social interaction with others, have greatly contributed to his presenting problem of public masturbation and persistent yelling out. It is also likely that the infrequency of his familys visits contribute to his symptoms. Lack of social stimulation and meaningful daily activities contribute to the clients Major Depressive Disorder. It is clear that the staff and other residents in the nursing home do not care for his personality and therefore he is often left out and cast out. Also, client is not turned regularly and experiences general discomfort from bed sores and chronic pain which is only treated PRN with pain medication. The client is neglected by staff members and often calls for fluids or to be taken to the bathroom. He also shouts loud feelings of despair and loneliness. The clients shouting and yelling out is likely due to the way he is treated by the staff. The treatment team will follow a cognitive-behavioral framework in developing interventions for the client. Behavioral therapy focuses on the action-orientated approach, which may give the client the feeling of more control, which is currently lacking in his lifestyle. Behavioral therapy also focuses on decreasing maladaptive behaviors and increasing adaptive

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behaviors in daily life. Cognitive-Behavioral Therapy also includes the cognitive processes and self-talk as mediators to behavior (Corey 2005), which would be especially helpful with the masturbation in public. The basis of Cognitive-behavioral therapy involves a strong partnership and collaboration between the client and therapist, there is a concentration on changing cognitions to help generate desired changes in attitudes and behavior, we will focus on psychological distress, which is largely a function of disturbances in cognitive processes, and this therapy involves a time-limited and educational treatment centering on precise and structured target problems and goals (Corey 2009). The treatment team would also take in to consideration some historic detail regarding the clients life and past relationships. Multicultural Considerations The client identifies most with the Hispanic culture. The clients problematic behavior and outbursts may be linked to a difference in values and feelings of not belonging due to the difference in his Hispanic culture. I could also be caused by the primarily white culture that occupies most nursing homes. According to the Centers for Disease Control, Hispanics or Latinos make up 57,200 residents of all United States nursing homes compared to 1,427,400 clients classified as Non-Hispanic or Latino. Three factors that could explain why the client, as a Hispanic male, does not identify with the other nursing home residents are; masculinity, sense of family and personal relationships, and respect for elders. Hispanic males, in general, highly value masculinity and have a high sense of pride in an exaggerated sense of toughness. This phenomenon is sometimes referred to as machismo which roughly translates into manliness. Research by Luis H. Zayas and Luis R. Torres (2009) supports this argument of machismo, Traditional males are those that adhere to long-valued cultural expectations of masculine gender characteristics, such as toughness, stoicism, self-

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reliance, and belief in never showing weakness; avoidance of all things feminine; success at work (Zayas and Torres 2009). While not every Hispanic male adheres to this view of masculinity, machismo may be exacerbating his already disruptive and inappropriate behavior. First, the client is forced to depend on the nursing home staff for all his basic needs such as food, water, being turned in bed, etc. which may be a terrible blow to his ego. Second, the client had to put his career as a farmer on hold when he became blind and then later on in life, had to retire from his library job due to cognitive deficits. Both being unsuccessful at work and having to be so reliant on the nursing home staff for almost everything may explain why the client is frequently caught masturbating in public; a final control over his masculinity. According to Delgado-Romero, Rojas-Vilches and Shelton, Hispanics place an emphasis on what is known as familismo and personalismo; which is family unity and a preference for close personal relationships. It has been reported that the client is happiest when his family comes to see him and his inappropriate behavior decreases. With his primary caregivers being the staff that provides him minimal social stimulation, the client may be acting out because of his frustration and maltreatment. Hispanics generally have a lot of respect for their elders (Delgado-Romero, RojasVilches& Shelton, 2009).The client is sometimes kept all day in a wheelchair or held in contempt

with almost no social interaction. When he does receive social interaction it is usually harsh reprimands and scolding. As a 70-year-old Hispanic man, the client may feel constantly disrespected in turn affecting his depression and behavior.

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Diagnosis Axis I 296.22 Major Depressive Disorder 302.4 Exhibitionism 293.0 Delirium due to Visual Loss Axis II V62.89 Borderline Intellectual Functioning Axis III Blind, Confined to a bed and wheelchair Axis IV Spouse recently died; kept in a wheelchair without much social interaction, Severe physical discomfort due to the infrequency of being turned in bed Axis V GAF Score: 33 Treatment Plan Client Name: Bill Placement Date: 11/17/11 DSM-IV Code 296.2x2 302.4 293.0 Diagnosis (DSM-IV) Major Depressive Disorder Exhibitionism Delirium due to Visual Loss

Treatment Services

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Service Group Therapy

Frequency Weekly

Participants Client and Group Members

Duration 6 Months

Family Counseling

Bi-Monthly

Client and Family Members

3 Months

Operant Conditioning Therapy Interpersonal Therapy

Daily

Residential Staff and Client

As needed

Weekly Objectives

Client

6 Months

Goal #1: To stop masturbating in public Objectives Interventions Expected Date Learning appropriate social sexual rules The group participants will discuss such topics and learn what is acceptable in these situations Determining negative consequences for behavior The group will elaborate of legal reprimands concerning such behaviors, as well as social and personal consequences Develop more appropriate coping methods and ways to express oneself The group will discuss and give examples of healthy coping skills and expressive actions 05/18/11 01/18/11 03/18/11

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Goal #2: To learn better ways to cope with depression Objectives Interventions Expected Date Educate the family regarding depression The family, client and counselor discuss how the frequency of the familys visits impact the client. Build social relationships The client will have a scheduled lunch time with encouragement from the staff to approach other residents during lunch and ask to sit with them during the lunch period. Address lack of stimulation in the facility The client could find something he is interested in such as music. Address any remaining feelings of bereavement The client will discuss his feelings regarding his wifes passing. 2/18/11 12/18/11 3/18/11 1/18/11

Goal #3: Find acceptable ways to express frustration Objectives Interventions Expected Date More frequent visits from the staff The staff will visit the clients room more frequently Educate the staff on operant conditioning techniques The staff will use negative punishment and leave the room when 1/18/11 12/18/11

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the client insists on yelling. Educate the staff about proper treatment in Nursing Home Care The staff will be evaluated to ensure that they are giving proper care to the nursing home residents Administer additional cognitive tests A neurologist will administer additional tests to determine the reason for the decrease in cognitive functioning throughout the day Re-evaluate current medications The psychiatrist on staff will reevaluate the current medications the client is taking and how they might contribute to weight loss 2/18/11 2/18/11 12/18/11

The client needs to cease masturbation in public and constant yelling/crying out loudly and persistently; otherwise he is at risk for eviction from the Senior Living Facility. The goals for this client are for him to feel happier with more appropriate social interaction. Rationale It has been noted that the client engages in continuous yelling throughout the day. The client often calls to be helped. In a case study conducted by Duncan R. Babbage, an 85-year-old woman displayed frequent yelling and calling out. The researchers found, that using negative punishment decreased the occurrence of yelling, and decreased the time it took to change the client.

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Using the same type of reinforcement should be effective with the current client. The client will first be told Bill, Im going to do your cares now. As you know, Im not able to keep doing your cares if you cry out, are shouting, or are screaming. If that does happen, Ill need to leave for a short while, but Ill come back when you are quiet again (Babbage, 2005). After these interventions, the client will only be tended to during times in which the client is quiet. If the client begins to yell, the staff is instructed to leave and come back during times of quiet. This will reinforce the positive behavior, rather than the yelling. We plan to use this type of intervention because it has proven effective with similar cases. It also has been the noted that the client continuously masturbates in public. The treatment team recommends that the client participate in group therapy sessions with men who exhibit similar behaviors. In a study conducted by Glynis Murphy et al., the researchers used cognitive-behavioral treatment for men with intellectual disabilities, as well as sexually abusive behavior. The men who participated in the group therapy sessions exhibited significant improvements. The treatment team suggests using similar topics to those used in the study during the group therapy sessions. These topics include social rules for undressing and touching, illegal and risky sexual behavior, consequences of their behavior and coping with stressful situations and feelings. Barbero (1989) states, Informal and structured education can enhance clients' awareness of themselves as responsible sexual people. In the book titled Geropsychological Interventions in Long-term Care, by Lee Hyer, Robert Intrieri, the authors discuss the use of interpersonal therapy (IPT) used in the treatment of depressing in an elderly population. The book also mentions the use of this type of therapy use in elderly people who reside in a nursing home. The goal of IPT is to change current interpersonal behaviors. Given the current lack of social stimulation, the treatment team believes that this type

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of therapy would be beneficial to the client. IPT also focuses on role changes, relationship loss, interpersonal conflicts and interpersonal deficits. All of these topics relate to the client and will be addressed in therapy with the clients counselor. During therapy, the counselor will work with the client to improve personal relationships, which will include the relationship with his family as well as the other residents and staff in the Senior Care Living Facility. According to Barbero (1989), working with adults having a low IQ involves a clientcentered approach and emphasizes expansion toward clients learning how to collaborate with and lead the group. There should be structure during the day involving planned activities, hygiene promotion, and lunch. Breaks are a vital part of the plan throughout the day because clients with low IQs have short attention spans. Lunch is very important because it helps facilitate healthy relationships between the staff and client, and the client with other clients. Questions Should the client be moved to another facility where there is more individual attention and care? Is it possible that his family could visit more often? Is it possible for the client to get a seeing-eye dog for help with his blindness and for sense of companionship?

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References Babbage, D. R. (2005). Noise in the nursing home: A case study of relationship change. Clinical Psychologist, 9(2), 74-82. doi:10.1080/13284200500318825 Barbero, S. L. (1989). Community-based, day treatment for mentally retarded adults. Social Work, 34(6), 545-548. Corey, G. (2005). Theory and practice of counseling and psychotherapy. (7th ed., pp. 227-264). Belmont, CA: Brooks/Cole- Thompson Learning. Corey, G. (2009). Theory and practice of counseling and psychotherapy. (8 ed., pp. 274-275). Belmont, CA: Brooks/Cole, Cenage Learning. Duffy, M., & Karlin, B. E. (2006). Treating depression in nursing homes: Beyond the medical model (pp. 109-135). In L. Hyer & R. C. Intrieri (Eds.), Long-term care: Psychological and psychosocial assessment and treatment. New York: Springer. Murphy, G., Powell, S., Guzman, A., & Hays, S. (2007). Cognitive-behavioural treatment for men with intellectual disabilities and sexually abusive behaviour: A pilot study. Journal Of Intellectual Disability Research, 51(11), 902-912. doi:10.1111/j.13652788.2007.00990.x

Need Citation for the Multicultural part Professor Negys book?