PLANNING INTERVENTIONS The Unit of Attention

What would have been the appropriate focus of the Smith case? The people or their environment? The child (Barbie) or her family? A “person-in-environment” ecosystems perspective (Germain, 1973; Gitterman & Germain, 2008; Meyer, 1983; Davies, 1999, 2011; Hepworth et al., 2002) encourages the worker to consider all relevant dimensions of the case, including the degree of fit (or lack of fit) between the people and their environments. Whenever a child is the reason for referral, involvement with the family is mandatory. However, the unique circumstances of each case determine the degree to which either the child or the family becomes the primary “unit of attention.” In some situations, such as helping a child process and accept his or her placement or traumatic experience (see Chapters 10 and 14), work with the child is primary, and family counseling is secondary to helping the child. In other situations, work with the family is pivotal to understanding and helping the child. This is true, for example, in families in which divorce (Chapter 11) or a substance use disorder (Chapter 13) is a major factor. Still another method of work involves conjoint sessions with the child and family members. Many variations may also be appropriate, including alternating among individual child sessions, parent–child sessions, and full family sessions. The circumstances of each case determine who is seen and in which combinations, and these circumstances may vary over the lifespan of the case. The preferred model, presented frequently in this book, is one that integrates child and family therapy. The worker must keep a wide-angle focus on both environmental considerations and the persons involved. In Chapter 1, a multisystems diagram of problem situations (Figure 1.1) depicts the interplay of reciprocal influences between the child and his or her physical and social environment. Specific factors, such as the child’s temperament and coping style, can mediate and counteract detrimental conditions in an unsafe, nonsupportive environment; conversely, a fragile child with a very reactive temperament may respond poorly even in supportive environmental conditions. Therefore, we must always consider interactive factors—those pertaining to the “fit” between persons and their environment—in assessing problem situations and planning interventions. Setting Goals and a Time Frame The establishment of goals follows directly from the client’s recognition that help is needed and from his or her agreement to focus with the worker on tackling the specific difficulties together. The goals may be outlined for individual family members and/or for the family as a unit, depending on the situation. Establishing a time frame for completion of certain goals or tasks increases motivation. Goals may be listed as “long term,” requiring a protracted period of time (possibly 9–12 months) for their completion, or as “short term,” with a designated target date for completion (possibly in 1 month). It is essential for the client to participate in the setting of the goals and the time frame, and it is usually advisable to put these in writing. Keeping Goals Manageable: A Sample Dialogue A cardinal rule in setting goals is to draft them in a manner that promises achievable results. The worker wants the client to have an experience of success, no matter how small this may be. Furthermore, it is important not to overwhelm the client; therefore, it is essential to begin with a limited number of manageable goals, with the understanding that once success has been achieved with the initial list, others may be added. The sample biopsychosocial assessment summary for Barbie, given in Chapter 4, lists eight “needed resources” for helping the Smith family. This comprehensive list could have been converted into specific goals during a planning session with Mrs. Smith and Barbie. It would have been important to begin with goals for Barbie that centered on her educational needs and to specify family or personal goals for Mrs. Smith that would also have an impact on Barbie. A dialogue for this hypothetical meeting follows. WORKER: I know that you are both very eager to have Barbie get a good start and do as well as possible in her new school. We want to do whatever we can also, so the purpose of this meeting is to decide together how to help Barbie achieve up to her fullest potential. MRS. SMITH: Unfortunately, Barbie is behind where she should be for her age. We’ve moved so much, and she’s been in so many different schools. It’s not her fault. WORKER: Of course it isn’t her fault. (to Barbie) There are other children in this school like you who don’t have permanent homes and who have changed schools a lot. In fact, this school was designed exactly for kids like you, and we have some special ways to try to help. BARBIE: Like what? WORKER: Several different programs and activities that you will find out about as you go along. The first way is to try to find out just what you do know, so we can help you catch up, wherever you may need to. So, I’m going to start a list of what the school will do, and what each of you can do. (Divides a sheet of paper into three columns and heads the first column “The School,” the second section “Barbie,” and the third section “Mrs. Smith.”) Under “The School,” I’m going to write “1. Academic tests” and “2. Special tutoring.” Barbie will be given a special teacher, who will work individually with her to help her in whatever areas the tests show she needs help. How does that sound? [See Figure 5.1.] BARBIE: Will I have a lot of homework? WORKER: We don’t expect you to get caught up the first week, or the first month! Yes, you will have homework, but it probably won’t be more than an hour or, at most, two a day. (to Mrs. Smith) Would you be able to help Barbie figure out a quiet place and a time to do her homework? MRS. SMITH: That’s not so easy. We’re in a one-bedroom motel, and the only table is where we all eat. WORKER: Lots of kids do their homework on the kitchen table. The trick is to cut down on the distracting noise level, like from a TV. Do you think you could set aside a regular time each afternoon that would be “quiet time” for Barbie, and for you also, when there would be no TV and no distractions? MRS. SMITH: That would be a miracle. But I’ll try. Sometimes Barbie doesn’t want to go to school when she doesn’t do her homework or if she doesn’t get it right. WORKER: In this school you don’t always have to get it right, but you do have to try. So, Mrs. Smith, I’m writing this in your section: “1. Make a family rule for 1 hour of quiet time every afternoon, when there will be no TV and no noisy talk.” The other thing is that you must be sure Barbie comes to school every day. She can’t learn or catch up if she isn’t here. So, I’ll write “2. Be sure Barbie comes to school every day.” Now we have to think about what to put in Barbie’s section of this agreement. What do you think, Barbie? BARBIE: I have to do my homework.WORKER: Yes. You have to try. And your special teacher will help you. So, I’ll write this for you: “1. Do homework at least 1 hour each day.” I also think you have to promise to come to school every day unless you are sick. I’m going to write that down as number 2. Actually, I think you’ll like it here and want to come. We have some special groups for kids to get to know each other, and I’ll see you tomorrow and tell you about those. Sometimes the three of us will meet together, like today, and other times I’ll meet alone with each of you. Let’s make an appointment when we can all meet together again, so we can see how things are going with everybody’s goals. I’d also like to set a separate appointment for Mrs. Smith to give me some background about Barbie.
Obviously, this would have been only the beginning of the contracting process. The next conjoint meeting (which ideally would have been scheduled within a week) would have provided an opportunity for reports of success in implementing the two goals of Barbie’s regular school attendance and the homework routine. Later, separate individual meetings with Barbie and Mrs. Smith could have been used to introduce the offer of individual counseling, as well as support groups for each. Possible future long-range goals and short-term tasks for achieving these are outlined for Barbie and Mrs. Smith. Barbie’s Long-range Goals 1. To improve school performance • Short-term tasks: ⚬ Attend school regularly ⚬ Complete 1 hour of homework daily ⚬ Participate in academic tutoring 2. To deal with her feelings about her family and their homelessness • Short-term tasks: ⚬ Participate in group therapy with other homeless children ⚬ Participate in weekly individual therapy to deal with past losses and abuse Mrs. Smith’s Long-Range Goals 1. To maintain sobriety • Short-term tasks: ⚬ Attend Narcotics Anonymous ⚬ Establish new friendships and activities that are not drug-related 2. To obtain job counseling and training • Short-term tasks: ⚬ Participate in vocational testing/counseling ⚬ Select two or three possible career choices ⚬ Examine newspapers regularly to check job availability 3. To deal with her feelings about her past history of abuse • Short-term tasks: ⚬ To make a commitment to individual counseling ⚬ To participate in group therapy with women who also have abuse histories These goals are merely suggested and would need the agreement of the individuals involved to enhance their motivation to work on them. Both the process of participation in formulating goals and the experience of achieving success are very ego-enhancing and increase self-esteem. Success in achieving goals, in turn, enhances clients’ motivation to work on additional, more challenging tasks.