Family Stress and Resilience Help

184 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT

CASE STUDY 3‐1 HOMEBUILDERS ® : HELPING FAMILIES STAY TOGETHER

Nancy Wells Gladow Peter J. Pecora Charlotte Booth

Intensive in‐home services are a powerful social work tool for helping families. Th is case study illustrates the use of goal setting and relation- ship building, which are critical in the HOMEBUILDERS model of home‐based treatment.

Questions for Discussion 1. What are some examples of relationship building used in this case? 2. How did the social worker intervene to reduce confl icts between the

father and son? 3. What is a teachable moment, and how was this incorporated into the

treatment? 4. What are some of the advantages and disadvantages of a home‐based

treatment model?

Th e following case involves confl ict between a single‐parent father and his 13‐year‐old son. Th e treatment agency is the HOMEBUILDERS ® Program of the Institute for Family Development (IFD), headquartered in Federal Way, Washington. HOMEBUILDERS is an intensive, home‐ based family preservation services program. Th rough child welfare and chil- dren’s mental health system contracts, IFD provides HOMEBUILDERS to families who are at imminent risk of having one or more children placed outside of the home in foster, group, or institutional care. Home‐based family preservation programs now exist in many states and other countries. Although theoretical approaches, clinical techniques, caseloads, and length of treatment vary from program to program, the goal of these programs is the same: to prevent unnecessary removal of children from their home and to help multiproblem families cope with their situations more eff ectively (Allen & Tracy, 2009 ; Nelson, Walters, Schweitzer, Blythe, & Pecora, 2008 ; Walton, Sandau‐Beckler, & Mannes, 2001 ). Although some models of family

Case Studies in Family Treatment and Parent Training 185

preservation have not been tested, research evidence suggests that programs with high fi delity to the HOMEBUILDERS model can result in a cost sav- ings to the state (Miller, 2006 ).

HOMEBUILDERS is an intensive model, with a time frame of four to six weeks per family and a caseload of two families per therapist. Th erapists provide an average of 38 hours of face‐to‐face and phone contact to each family. Th e program is a skills‐oriented model that is grounded in Rogerian, ecological, and social learning theories. Th e intervention involves defusing the immediate crisis that led to the referral, building a relationship with the family, assessing the situation and developing treatment goals in partnership with the family, and teaching specifi c skills to help family members function more eff ectively and achieve these goals. Evaluations of HOMEBUILDERS indicate that the program is highly eff ective in reducing out‐of‐home place- ments and increasing the coping abilities of family members (Fraser, Pecora, & Haapala, 1988 ; Haapala & Kinney, 1988 ; Kinney, Madsen, Fleming, & Haapala, 1977 ). Evidence also shows that the model can decrease racial dis- proportionality in the child welfare system (Kirk & Griffi th, 2008 ).

In Washington State, referrals are made to HOMEBUILDERS primarily through Child Protective Services (CPS) and Family Reconciliation Services (FRS), which are two subunits of the public child welfare agency. In CPS cases, the state worker determines that placement of one or more of the chil- dren outside of the home will occur if the family does not make immediate changes to ensure the safety of their children. In FRS cases, either parents or children have requested out‐of‐home placement for the child because of severe family confl ict or child behavior problems. In one region of the state, referrals are also made through the mental health system, with the goal of preventing psychiatric hospitalization.

CASE OVERVIEW

Th e following case study highlights some of the HOMEBUILDERS treat- ment philosophy and techniques with an atypical, but increasing, type of case situation: a single‐parent father and his son. However, this case was similar to most cases in that the family had a history of family problems and confl ict. In this case, the child had no previous out‐of‐home placements, but 49 percent of HOMEBUILDERS clients have already experienced previous placement. Selected client sessions are described for each of the four weeks of

186 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT6

service. All of the names and identifying information have been changed to protect the family’s privacy.

Because of space considerations, the three contacts and work with the boy’s mother are omitted, along with the contacts made with the school psy- chologist and other school personnel. In addition, a considerable amount of time was spent working with the father regarding his use of marijuana, which was not interfering with his job performance but was a concern to his son. Interventions such as working with a local church and Narcotics Anonymous were attempted (with some success) but will not be discussed in order to focus on the therapist interventions regarding client relationship building, chore completion, school behavior, and anger management.

INTERVENTION

Week One: Gathering Information, Relationship Building, and Setting Treatment Goals

It was 7:30 p.m. as I drove up for the fi rst time to the Barretts’ small three‐ bedroom house located in a working‐class neighborhood. Th e referral sheet from the FRS caseworker said Dick Barrett had been a technician for a large manufacturer in Seattle for 10 years and that his 13‐year‐old son, Mike, was in seventh grade. FRS became involved after Mike had told his school coun- selor that his father had been smoking marijuana for 15 years. (Th is was the fi rst time that the state had come into contact with his family.) Mike said he hated drugs, was tired of his father’s constant yelling, and wanted to be placed outside of the home. He also said he was afraid of his uncle, who had been living with the family for two months. Th e school counselor had already been concerned about Mike, a seventh grader for the second year, who frequently neglected to turn in his homework and disrupted class by swearing at both students and teachers. Mike had already been suspended twice that semester. Th e referral sheet said that Dick voluntarily agreed to have the uncle move out and to quit using drugs, although he was unwilling to begin a drug treatment program. It also said the family had tried counsel- ing several months ago through a local agency, but Mike had disliked the counselor and refused to continue.

Dick, a tall man around 50 years old, opened the door soon after I rang the bell. Dick invited me to sit at the kitchen table and called for Mike to join us. Th e family cat jumped on my lap. Dick and I began chatting about

Case Studies in Family Treatment and Parent Training 187

cats as Mike slowly walked into the kitchen, looking at the ground and mak- ing grumbling sounds. Mike smiled when he saw Tiger sitting on my lap and being scratched under the chin. Mike began to tell me stories about Tiger, and I responded with interest and a funny story about my own cat. I felt no pressure to hurry the counseling session along, as taking time for small talk and showing interest in what was important to family members was a key element of relationship building that would be the foundation of any later success in confronting clients and teaching new behaviors.

Dick began to discuss the diffi culties his family had been experiencing. He said he was upset about Mike’s behavior problems and lack of motivation in school. Dick said he had tried everything he knew to get Mike to improve but with no success. As Dick talked, I listened refl ectively, paraphrasing parts of the content and feelings that Dick was expressing. For example, when Dick said, “Mike does not even try to improve his behavior in school,” I responded with, “It is frustrating for you that Mike does not seem to want to improve.” After Dick spoke about Mike’s abilities being much higher than his actual achievement, I said, “So it seems pretty clear that Mike has a lot more potential than he is using.”

Refl ective or active listening serves several purposes. First, it helps family members deescalate their emotions. As they tell their stories and begin to feel that someone understands, they calm down and are more likely to be able to take constructive steps to improve their situation. Second, by conveying understanding, active listening helps build up a positive client‐ therapist relationship. Th ird, active listening helps the therapist gain more information about the family without having to ask a lot of questions. People frequently expand on their stories when the therapist is listening refl ectively. Asking many questions seems to limit what people say, and it creates the impression that the counselor is the expert who will “do some- thing to” the family. With HOMEBUILDERS clients, it works better to recognize and treat clients as partners in the counseling process. Clients have more information about their lives than does the therapist, and their active participation in the change process is crucial. However, sometimes asking a few key questions at the right time is the most effi cient way to gain behaviorally specifi c information. For example, in this situation, I wanted to know just what Mike’s grades were. (He was in three special education classes and was earning one B and two Cs in those. In his other classes he was earning two Fs and a D.)

188 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT8

As Dick talked, Mike remained silent, although his facial expressions and body movements frequently suggested anger toward his father. “You do not look too pleased, Mike,” I said. “What do you think about all this?” Again I listened refl ectively as Mike began to talk about how he hated school and his father’s frequent yelling. Mike told stories about several arguments he and his father had that resulted in both of them swearing and saying things calculated to hurt each other. Dick agreed that this was true. I summarized, “So learning how to fi ght less and deal with your anger constructively is something both of you might like?” Th ey both nodded. Dick went on to say, “Mike makes me so angry. If he would not say some of the things he does, I would not get so mad.” (I thought to myself that Dick could benefi t from learning a basic principle about anger: No one can make you angry; you are responsible for your own e anger. I did not mention my thought at this point, however, because pointing out errors in thinking and teaching too soon before there has been time for suffi cient information gathering and relationship building is often ineff ective.)

“You have mentioned that you argue a lot more than either of you would like. Tell me what kinds of things you argue about,” I requested. Dick de- scribed frustration about trying to get Mike to do chores around the house, saying if Mike was not willing to help, he would prefer Mike fi nd somewhere else to live. Mike complained that his Dad was always ordering him around. Dick had been working especially hard lately to fi x up the house so that it could be sold in a few months and fi nances between him and Mike’s mother could be resolved. Dick and his ex‐wife had gone through a diffi cult divorce 3 years ago after 28 years of marriage and four children, the older three being over 18 years of age and currently living on their own. Th rough mutual agree- ment, Dick had received custody of Mike.

“I get the picture from the caseworker that drugs have been a big issue in your family,” I commented. Dick described how he had been smoking mari- juana for about 15 years. He said he had also gotten into “some other things” during the time his brother‐in‐law, Mike’s uncle, had been living there. Dick said once the school and the caseworker became involved, he realized it was important to have his brother‐in‐law move out, which he had done. Dick said he had stopped using other drugs and had also voluntarily stopped using marijuana a few days ago. Dick stated that he respected Mike’s right to live in a drug‐free home and that he thought it would benefi t himself as well to stop his drug use. “I can’t aff ord to get fi red if my work fi nds out about this,” Dick commented.

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“What do you think about this, Mike?” I asked. Mike remained silent. “If I were you, I might be a little worried that my Dad was not really going to quit using drugs,” I said. “Is that anything like you are feeling, or am I way off base?” Mike opened up a little to say that his Dad had said he would quit before and had never stuck with it. Mike talked about how his siblings all use drugs and how he had been scared when, three years ago, some “bikers” had come to the house to get his oldest sister to “pay up” on some drugs. Mike said he also worried about having his father’s health go downhill from drug use. I could tell from Dick’s expression that this was probably the fi rst time he had heard Mike express these concerns openly.

Soon it appeared that Mike was getting tired, and it was time to end this 2½‐hour initial session (about the average amount of time for a fi rst‐session HOMEBUILDERS program). I explained more of the specifi cs of the HOMEBUILDERS program and gave them my home phone number as well as the backup phone numbers of my supervisor and our beeper. All of this is an eff ort to be available to clients 24 hours a day, 7 days a week. I then summarized the session in terms of treatment goals. “It sounds like what you two most want help on is (1) working out a way to build in more cooperation on household chores; (2) learning how to fi ght less and to deal with anger more constructively; (3) Dick, you’re receiving support in your eff orts to be drug‐free; and (4) improving your school performance, Mike. Is that how you see it?” Th ey both nodded. Summarizing in this way checks my percep- tion of the family’s priorities for change and also gives direction for future counseling sessions. In this intake session with the Barretts, it was easier to establish goals than it is with many families. Th ere is really no rush to deter- mine all four treatment goals (a typical number for a four‐week intervention) at the intake session, although HOMEBUILDERS therapists generally try to have one or two goals established by the end of the fi rst week.

Th e last thing I did during the fi rst visit was to set up individual appoint- ments with Dick and Mike. Unless family members are opposed to them, individual meetings can be helpful initially to gather additional information and continue building relationships. Later, one‐on‐one sessions can facilitate work on each person’s goals. I gave Mike a sentence‐completion sheet to fi ll out for our next session and checked to make sure he understood how to do it.

When I came back two days later to pick up Mike for our individual session, he was listening to his stereo. I listened to a few songs with him. As we drove to McDonald’s, we talked about various musical groups and

190 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT

our favorite TV shows. He seemed to be feeling much more comfortable with me by the time we sat down with our Cokes and French fries. I looked over the sentence completion sheet, which included sentences such as “My favorite subject in school is___,” “In my spare time I like to___,” and “I feel angry when___.” Instead of asking Mike a lot of questions, which teenagers frequently dislike, I read some of his answers in a tone of voice that encour- aged him to expand on the topic. When he did, I listened refl ectively to his responses, and he frequently elaborated even further. I learned that he was especially upset about his father yelling at him on a daily basis. When his father yelled, Mike found himself quickly feeling angry and sometimes yelling back. I refl ected Mike’s feelings of worry, embarrassment, fear, and anger about his father’s use of drugs. I also checked out with him what kind of system they used at home regarding who did what household chores and if Mike earned an allowance. (I was thinking that coming up with a mutually‐agreed‐on chore system might be the fi rst goal we would tackle because it was so important to Dick and was a goal with which we were likely to make concrete progress.) Mike said there was no system—his dad just gave orders and Mike either complied or didn’t. I suggested a system whereby he earn an allowance for doing certain agreed‐on chores, and I asked what he thought a fair allowance would be, assuming his father would approve of this plan. He said the plan sounded agreeable and suggested $15 per week. I gave Mike an assignment to complete before the next meeting. He was to write down (1) two things he’d like to be diff erent in his family; (2) two things he could do to help get along better with his dad; and (3) two things his dad could do to help them get along together better.

My appointment with Dick alone began with his showing me the work he had done around the house to get it ready to sell. Th is led him to talk about his past marriage with Rita, his feelings about the marriage ending, and how Mike had gone back and forth between their homes for almost two years up until about a year ago. Dick thought some of Mike’s troubles were related to his going from home to home, plus the pressure of Dick and Rita’s continual fi ghting. After an hour of active listening to these subjects, I felt pleased that Dick was opening up, warming up to me, and appearing relieved to get some of these things off his chest. When he brought up his older children’s drug involvement, I saw it as an opportunity to gently begin talk- ing about his own drug use. (Th is is an example of a teachable moment—a time when clients may be particularly receptive to learning because they can

Case Studies in Family Treatment and Parent Training 191

see the relevance of it in their lives.) We then spent some time discussing this issue and developing a plan of action.

Before ending the session, I introduced the idea of having Mike’s chores be based on allowance. Dick’s reaction was positive, saying he thought more structure would be helpful. I noted two benefi ts to such a system: (1) Mike would experience the consequences of his actions, and (2) it would reduce the number of times Dick would need to tell Mike what to do. Mike had developed a tendency to blame much of his behavior on others rather than taking responsibility for his actions. In addition, like most teenagers, Mike hated to be told what to do, yet their previous system was based completely on Dick giving daily instructions. We briefl y discussed what he thought a reasonable allowance would be. We agreed to negotiate this new system with Mike at the next session. I also gave Dick the same homework assignment I had given Mike.

Week Two: Active Work on Goals

As Mike, Dick, and I sat down together in the living room, I asked how things were going. Meetings often start in this way, as events may have re- cently occurred that need to be discussed or worked out before clients will be able to concentrate on the current agenda.

When I asked if they had done their homework, Dick had and Mike hadn’t. Dick agreed to do something else for a few minutes while I helped Mike complete the questions. Th en both of them told what they would like to be diff erent in their family. Dick said he would like anger to play less of a role and for the home to be drug free. Mike said he would like less arguing and to go places together more. In discussing what each person thought he could do diff erently, Dick said he could try not to get angry when he was frustrated, and he could also be more consistent with Mike. Mike said he could help more around the house and try not to get angry so much.

On the subject of what the other person could do, Dick said Mike could be more responsible with housework and schoolwork. Mike said his dad could stay off drugs and yell less. I took this opportunity to talk about how problems in a family are almost never one person’s fault and how each family member can do things that can help the other family members. I also noted the similarities in the changes they wanted and stated that I had some ideas that might help them with some of these changes.

192 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT

Next we began work on the new chore system. I explained that we would be deciding together what chores Mike would be responsible for, when they were to be done, how much allowance he would earn, and what he did and did not have to pay for with his allowance. We began by writing a list of all the chores possible and gave Mike a chance to pick some he would be willing to do. Dick added a few he would like Mike to be responsible for. After a little more negotiation, we came up with a list both felt they could live with. Mike said he really did not like doing chores. Rather than letting Dick jump in with a lecture, or responding with one myself, I opted for humor. I chuck- led and told Mike I certainly could understand that, as Ajax and vacuum cleaners had never thrilled me either. I gave a couple of examples of how my husband and I split up chores so that neither one of us would have to do all of the work. Th en Dick and Mike decided how often each chore needed to be done, to what standards, and by what time of the day. We discussed which chores involved the most and the least amount of work and determined point values for each.

In deciding on allowance, Mike thought $15 per week was fair, and Dick thought $10 per week was more appropriate. After discussing it further, we agreed on a system whereby Mike’s basic allowance would be $10, and all he would have to pay for was his own entertainment. On the weeks when he earned 97 percent of the points or above, he would get a $5 bonus and earn $15. We put this all onto a chart and fi lled it out as though Mike had done a perfect job (see Table 3.1 ). Th e crossed‐out squares on the chart indicate days the chore need not be done.

On a blank chart we wrote the possible points next to each chore and agreed on the time when Dick would check the jobs and fi ll in the points. We specifi ed which day would be payday and where the chart would be placed. When Mike got a phone call, I took the opportunity to share with Dick some hints on making the chore system work most successfully. I sug- gested he use the chore checking as a chance to develop goodwill with Mike by praising him for work he does well. I gave Dick a handout called “97 Ways to Say ‘Very Good’.” I also suggested that when Mike did not do a chore or when he did it poorly, Dick handle it matter‐of‐factly rather than with anger. Past experience indicated that Mike became less cooperative when Dick was angry.

Th e last session in week two was with Mike and Dick together. Mike was upset because his father had not fi lled in the chore chart for the past two

Case Studies in Family Treatment and Parent Training 193

Table 3.1 Weekly Chore Chart

BEHAVIOR DAYS AND NUMBER OF POINTS EARNED Mon Tues Wed Th urs Fri Sat Sun Total

Straighten bedroom (by 5 pm)

4 4 4 4 4 4 X 24

Bring in wood (by 5 pm)

3 3 3 3 3 3 3 21

Do dinner dishes (by 9 pm)

6 X 6 X 6 X X 18

Take out garbage (by 9 pm)

3 3 3 3 3 3 3 21

Vacuum house (by 6 pm)

X X X X X 11 X 11

Change cat litter (by 6 pm)

X X X X X 5 X 5

Weekly Total 100 Pts Every 10 pts. = $1.00 97–100 pts. = $10.00 + $5.00 bonus Sunday evening payday X = Chore not required on that day

days. We got the chart off the cupboard and fi lled it in together. Dick agreed with Mike that Mike had done all of his chores so far that week. I encouraged Dick to appreciate Mike’s eff orts and success, and we practiced this. Mike enjoyed the encouragement.

Because anger management was one of our main goals, I introduced the topic by showing a picture of an anger thermometer (see Figure 3.1 ). I talked about 0 as the point where a person was calm, relaxed, and feeling no anger at all. At 2 or 3 a person often felt irritated or frustrated. At 5 a person was defi nitely angry, at 6 or 7 quite angry, and by 9 or 10 so enraged that he or she was out of control. At these top points, people often say and do things that they would not otherwise say or do and that they often regret later. I had both Mike and Dick identify times they had been at various points on the thermometer. Th ey both acknowledged that some of their most hurtful and useless fi ghts had occurred when they were at a 9 or 10 on the scale. I asked them to identify physical symptoms they experienced at various points on the scale, especially at 7 or 8 before they were out of control (e.g., having

194 CASE STUDIES IN CHILD, ADOLESCENT, AND FAMILY TREATMENT

a fast heartbeat, feeling hot, or having sweaty palms). I requested that they identify how they could tell that the other person was at these points. We then discussed the concept of removing oneself from the situation before losing self‐control in an eff ort to avoid destructive fi ghting. I said that their symptoms at 7 or 8 should be seen as cues to temporarily leave the situation. We discussed where each person could go to calm down (e.g., Mike to his bedroom, Dick to the basement to work on a project). Mike and Dick agreed they would try to remove themselves from the situation to avoid fi ghts.

At some point when we were alone, Dick commented, “If Mike would just do what he is supposed to do and not talk back to me, I wouldn’t have this problem of anger.” I gently challenged him. “I see things a little diff er- ently. I agree that Mike doing his chores and schoolwork would help. And certainly the way Mike talks to you has an infl uence on how you respond. But I see your response back as your responsibility and not Mike’s. Each one of us is responsible for our own behavior—Mike for his and you for yours. In fact, the only behavior any of us can truly control is our own.” Dick thought a minute and agreed.

Figure  3.1 Anger thermometer

Extremely angry (out of control)

Very angry

10

9

8

7

6

5

4

3

2

1

0

Angry

Irritated or annoyed

Calm

Case Studies in Family Treatment and Parent Training 195

We got back together with Mike, and I talked with the two of them about using self‐talk to decrease and control anger. To illustrate this point, I gave several examples. Th en we read a short children’s story together called Max- well’s Magnifi cent Monster (Waters, 1980b ). Th is story illustrates the pointr that our self‐talk causes us to become angry. Mike put the two concepts together and said that the monster was when a person was at a 9 or 10 on the anger thermometer. Dick was quiet and seemed refl ective. He said he liked the story and asked to keep it for awhile.

Week Th ree: Teaching, Learning, and Some Application

Th e fi rst session of the week was spent initially with Dick alone. Dick talked about the meeting he had gone to at school that morning with Mike and the school psychologist. It was the fi rst day back after vacation, and Dick had been required to go because Mike had been suspended the two days before the break. I listened refl ectively as Dick told of “Mike’s rude behavior” toward him and the psychologist. Dick expressed his frus- tration at not being able to “make” Mike improve in school. I reiterated that a person has the greatest control over his own behavior and that Dick could only do so much to infl uence Mike. I suggested that concentrating on staying drug free, decreasing his own angry responses, and being con- sistent with checking and praising Mike on chores are all areas he could control that could indirectly have an impact on Mike’s functioning at school. We reexamined the ineff ectiveness of yelling as a means to improve Mike’s school performance. I suggested he not spend too much energy on this issue now, and let Mike have more responsibility or ownership for the school problems.

Mike then joined us, and we talked about the morning school appoint- ment. When I brought up the issue of Mike’s behavior with the school psychologist, Mike quickly mentioned some things his Dad had said to the psychologist that had embarrassed him. I said I could understand his embar- rassment. However, his actions and words toward the school counselor were still his responsibility and could not be blamed on his father. I reinforced the idea that what he says and does is his responsibility, just as what his father says and does is his father’s responsibility. Because I knew this was a message Mike would not like hearing, I said it in a concise and friendly way and then moved on to the next topic. Dick said Mike had been doing extremely well