BBP 2
Single-System Design #2 – Group 4
Group Members: Tonya Barkley, Lou Sorrells, Alaina Petty, Anna Ponds, Tara Hayes
Date Due: 11/22/2022
Stated Problems:
1) Jason reports he does not have the best grades in school (C’s and some D’s) and that “he could do better.”
2) Jason reports feeling lost, that he is drifting through life, that he felt broken, that something is wrong with him if he needs therapy, and that he needs to be fixed (He scored a 13 on the PHQ-9).
3) Jason reports that he desires stable relationships/attachment - he feels like he “disappears” inside the home with his grandmother because of all the people in and out of the home, often other underage family members.
Consideration of Guardian Goals:
5) Jason reports his grandmother wanting him to “do better” in school. He also reports wanting to feel more engaged in school.
Target Problem: Creating more stable attachments and feelings of safety in Jason’s life and home environment resulting in decreased depression symptoms, as indicated by Jason’s PHQ-9 scores.
How did you prioritize? Jason reported multiple times during the session that he did not feel that he mattered, he felt invisible at his home when others were around, and he did not feel that he was safe. He described “safe” meaning there were consistent people in his life who he could count on. He reported that he had a big family with cousins, a mom, a dad, and half-siblings; however, he barely knows them, does not feel close to them, and rarely sees his parents. Jason has low support systems in his life. His grandma is the only adult he feels he can depend on, but he described her love for him as “putting a roof over” his head, making sure he had food to eat, and raising him rather than as a close emotional support. He reported not having any close friends, just people he “hung out with.” Jason reported that he could be a good friend, stating that he is a good listener, non-judgmental, and enjoys “just being there to play and hang out with”, and he wishes to have a friendship like that but does not currently have that type of relationship. Jason reported constantly having people in and out of his life home. When asked the miracle question, he stated that he wanted support and safety in his life.
The Social Worker briefly assessed Jason’s substance abuse using the Screening to Brief Intervention (S2BI) measurement tool, reporting a “higher risk overall” according to S2BI. The Social Worker believes that Jason’s substance use is related to his levels of depression and low social support network, recognizing that Jason desires close friendships, so his use may be opportunistic within his current social circles. While his substance use may be exacerbating his other problems, the Social Worker does not believe that this is the primary concern with the client. (Please note that the S2BI asks about substance use within the last year and was only used during assessment, so it is not included in “Dimensions Measured” since it will not be repeated; however, a copy of the assessment is included at the end of the SSD for reference).
When considering attachment theory, Jason’s childhood attachment injuries from his parents, as well as his grandmother serving as matriarch to multiple children in the family, have left Jason feeling isolated and without a stable emotional support system from his caregiver. As a result, he has shown indicators of externalizing behaviors such as using substances, poor performance in school, and escaping through video games. By directly addressing attachment to his grandmother, Jason will build a stronger, more stable relationship with her. This will result in fewer externalizing behaviors in an attempt for connection and attention.
Jason’s PHQ-9 Answers in initial assessment:
Target Goal: Target goal is to increase attachment by spending quality time and talking to his grandmother daily about things that are important to him. This will allow him to feel secure and build a relationship with his grandmother, which will alleviate his depressive symptoms. Jason also stated that he would like to make friends that have similar interests (gaming, etc.) who do not need to use substances to “have a good time.”
What dimensions will you measure? (Underline: behaviors, thoughts, feelings, attitudes, intensity, frequency, duration)
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Who? |
What? (Description of measure) |
Where? |
When? |
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1 |
Therapist & Jason |
PHQ-9 – Patient Health Questionnaire 9 |
At the therapy office |
Completed in first session; continue to repeat biweekly* to monitor Comment by Ponds, Margaret: I wrote to continue administering monthly instead of weekly since weekly could be burdensome to Jason, and I'm thinking monthly would be regular enough to monitor progress well - what do y'all think? |
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2 |
Jason |
Self-report feelings of support |
At home, review with therapist & Grandmother each week during session
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Daily before bed, completed individually
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3 |
Therapist and Jason |
Columbia Suicide Severity Rating Scale (C-SSRS) administered verbally
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At the therapy office |
Weekly during one-on-one session, prior to grandmother joining the session if a joint session
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*Bi-weekly: every other week
Intervention:
Attachment-Based Family Therapy (ABFT) will be conducted with Jason and his grandmother, who is his guardian and has raised him. The goal of the ABFT will be to promote a secure attachment, open communication, feelings of mutual support, and new patterns of interaction that will increase Jason’s feelings of safety, security, and belonging. Before his grandmother joins the session, Jason will complete the C-SSRS with his therapist to assess safety and suicide risk. Jason will complete the PHQ-9 biweekly with his therapist to monitor his depression symptoms. Between sessions, Jason will be given a self-monitoring worksheet to record instances where he felt supported by his grandmother during the week. Jason will report his findings about what made him feel supported with his therapist and grandmother so that his grandmother will be aware of what activities, words, etc. will help Jason to continue feeling support.
ABFT is a process-oriented, trauma-focused approach that involves 5 structured therapeutic tasks to be completed across 7-23 sessions. Task 1 (one session) is the Relational Reframing task to help refocus the family from the patient’s symptoms to a focus on improving the parent-child relationship. During this session, the therapist guides the adolescent and parent/guardian conversation about the impact depression and life traumas have had on their relationship and focuses on their desire for closeness. Task 2 (two to four sessions) is the Adolescent Alliance building task which starts by naming the adolescent’s strengths and interests. The therapist helps the adolescent to describe their attachment ruptures, how those impact their depression, and how these ruptures prevent the adolescent from turning to their parent/guardian for support. The therapist then empowers the adolescent to prepare to express their thoughts and feelings to their parent/guardian in future sessions. Task 3 (two to four sessions) is the Parent/Guardian Alliance task in which the therapist discusses current stressors in the parent/guardians’ life. The therapist listens with empathy and support; helps parents/caregivers see how these stressors are impacting their parenting practices; and explores how the parent’s own history of attachment ruptures are impacting their parenting. The therapist will attempt to activate parental instincts to motivate them to learn new, emotion-focused, attachment-promoting parenting skills. Task 4 (one to four sessions), The Attachment Task, brings the adolescent and parent(s)/guardian(s) together for the adolescent to express their attachment ruptures in a mature way. The parent/guardian provides empathy and understanding to their child which is meant to provide a “corrective attachment experience” to strengthen the parent/child bond. The final Task 5 (one to ten sessions), the Autonomy-Promoting task, provides a space for the parent/guardian and adolescent to practice new relational skills to reinforce a new secure attachment base. These sessions also solidify new patterns within the family interactions, build skills to navigate future concerns, and assist the parents/caregivers to find balance between support and structure.
What forces, other than the intervention, could cause change in the client system’s goal?
1) Family support could change, which could result in either a positive or negative impact on Jason and the efficacy of treatment. Examples could include updates around parental involvement in Jason’s life or other familial emergencies causing the grandmother to bring another child into the home full-time.
2) Jason could meet a positive adult or peer in his neighborhood/school that he bonds with, which can serve as a protective factor, improving his sense of direction, identity and belonging.
3) Jason’s grandmother could decide to remove him from therapy services, to not engage in family therapy, or to not make changes in her behavior/home environment. Additionally, there may be an emergency involving the grandmother that directly impacts his care and may remove him from his home environment until she recovers.
4) Jason has the autonomy to decide whether to engage in the services, despite being told to attend by his grandmother.
Single System Design: Please provide a visual of your study design using notation and time intervals.
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A: Baseline (Assessment – 1 session) |
B: Attachment-Based Family Therapy (7-23 Sessions) |
“A” represents the baseline of one session in which the therapist measured Jason’s severity of depression and gathered information about family dynamics and presenting issues. “B” represents the start of the intervention, Attachment-Based Family Therapy, which is completed across five phases of treatment and will last 7 to 23 sessions, depending on the client system’s needs.
What are the limitations of your design?
1) Lack of support system – Jason has no close friends or consistent adults in his life except for his grandmother who is not spending enough time and attention on Jason to meet his emotional needs.
2) Self-reporting may not be accurate. Jason may under- or over-report his feelings.
3) When asked if Jason wants to be in therapy, he responded “I guess” with minimal response at each prompting. He may believe that participating in therapy means that he is broken, so he may be resistant to engage in therapy or may pretend things are better in order to be discharged sooner.
Measure #1: Patient Health Questionnaire-9 (PHQ-9)
Measure #2: Self-Monitoring Worksheet to Report Feelings of Support
Day of the week # of Instances of Support Brief Description of Support
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Monday |
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Tuesday |
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Wednesday |
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Thursday |
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Friday |
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Saturday |
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Sunday |
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Measure #3: Columbia Suicide Severity Rating Scale
S2BI:
S2BI (Continued):
References
Diamond, G. S., Diamond, G. M., & Levy, S. A. (2014). Attachment-based family therapy for
depressed adolescents. American Psychological Association.
https://doi.org/10.1037/14296-000
Diamond, G., Russon, J., & Levy, S. (2016). Attachment-Based Family Therapy: A Review of
the Empirical Support. Family Process, 55(3), 595–610.
https://doi.org/10.1111/famp.12241