Clinical Intervention I-System theory

163© Springer Nature Switzerland AG 2021 R. P. Dealey, M. R. Evans (eds.), Discovering Theory in Clinical Practice, https://doi.org/10.1007/978-3-030-57310-2_12

Chapter 12 Systems Theory: The Case of Esperanza

Madeline Pérez De Jesús, Enitzaida Rodríguez, and Gladis Anaya

Introduction to Systems Theory

Systems theory calls practitioners to examine the relational dynamics between individuals, and between and within groups, organizations, or communities, as well as mutually influencing factors in the environment (Leighninger, 1977). While systems theory is commonly used in social work, the authors argue that the profes- sion would benefit from expanding its scope to intentionally explore issues of diversity and the impact of trauma. This chapter demonstrates how systems theory supports culturally informed clinical practice by highlighting the case of “Esperanza,” a 16-year-old ninth-grade student who, with thousands of others, migrated from Puerto Rico to urban cities in the Northeast and other areas in the United States after being displaced by Hurricane Maria in 2017. Two Latinx social workers enter Esperanza’s life in her new high school setting in Hartford, Connecticut.

The authors’ overview of systems theory includes a perspective on how problems arise, how systems theory facilitates understandings of the change process, and implications regarding complementary interventions that are can be used based on this theory. The case study of Esperanza details her demographics, family dynamics, and various ecological factors that influence her situation. Theoretical integration

M. P. De Jesús (*) Department of Social Work and Equitable Community Practice, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

E. Rodríguez School Social Worker, University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

G. Anaya University of Saint Joseph, West Hartford, CT, USA e-mail: [email protected]

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follows the case example, with the authors demonstrating how systems theory informed social workers approach to treating the client and understanding the client’s response. Important considerations regarding intracultural and intercultural factors that influenced clinical intervention effectiveness are described. The authors note that systems theory also served as a tool for resolving a practice conflict for the social workers. In the concluding section, the authors pose discussion questions to support readers in thinking critically about the usefulness of systems theory and the process of integrating theory into clinical practice.

The overarching premise in systems theory is that there is reciprocity in the inter- locking relationships between people, families, social networks, neighborhoods, and other related systems (Leighninger, 1977). This reciprocity includes elements in the environment such as nature, encompassing physics, chemistry, biology, and social relationships. While the origins of systems theory come from Charles Darwin’s notion of “the survival of the fittest,” the theory has broadened and sup- ports social work by offering a balance between biological, psychological, and sociological roots. Systems theory had a significant impact on social work during the 1970s, when its contributions included general systems theory, and family ther- apy developed into ecological theory and the importance of networking (Payne, 2002). This theory is particularly useful to social workers, as they are trained to have a person-in-environment lens.

Leighninger (1977) identified three main contributions of systems theory to the field of social work: (1) it expands the practitioner’s focus beyond the client to the client and their environment, (2) it allows for a better account of social change, and (3) it has the potential of having social workers reflect on issues of power and con- trol. Social workers are not strangers to examining ourselves as agents of social change, and in his discussion of the applicability of systems theory, Leighninger reminds us that we must also examine the other side. In other words, just as we explore how social workers are agents of change, it is also central to look at how we might operate as agents of social control or even social oppression.

Systems theory offers a specific perspective on how problems arise. This per- spective is evident in a definition of social work that was put forward by the International Federation of Social Workers in 2000, and subsequently reinforced by the International Association of Schools of Social Work (as cited in Hutchings & Taylor, 2007, p. 382):

The social work profession promotes social change, problem-solving in human relation- ships, and the empowerment and liberation of people to enhance well-being. Utilizing theo- ries of human behavior and social systems, social work intervenes at the points where people interact with their environments. Principles of human rights and social justice are fundamental to social work.

Systems theory assumes individuals are part of overlapping or intersecting mul- tiple networks and defines problems within this overlap. No individual lives in a bubble; our families, our communities, the related systems with which we engage, and the broader sociopolitical and economic climate impact us all. Just as the prob- lem is found in these overlapping systems, this is also where potential solutions lie.

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Payne’s (2002) reminder of the importance of networking is applicable to our cli- ents, as the people in their systems shape the types of information they receive and their beliefs, which in turn impact their actions. For instance, a client may have access to accurate or inaccurate information, and may operate in the world with a sense of entitlement or a sense of despair.

Various interventions emerge from the foundational principles of systems theory. Visual aids provide a concrete way for clients and those who work with them to digest how systems theory helps make meaning of a client’s life. Ecomaps and genograms are examples of visual aids that can be particularly useful during the early stages of rapport building and assessment. Ecomaps are visual representations of the interconnected systems of an individual’s life that show the relationships between the client and their environment (Hartman, 1995). Whereas ecomaps dis- play a more comprehensive arrangement of systems, genograms fix the gaze specifi- cally on family dynamics across generations, allowing client and practitioner alike to examine family dynamics with particular focus on behavioral patterns and quality (Altshuler, 1999). The relationships between systems, people, and the client are represented by lines drawn on the visual aid. A thick solid line represents a mean- ingful positive connection. A broken line symbolizes a weak connection. Lines drawn with crosses through them indicate stress. Some lines might also include arrows to suggest that a relationship appears to be mutually beneficial, mutually toxic, or one-directional. Pope and Lee (2015) are a good starting point for further direction on the creation of genograms.

Systems theory helps social workers understand that it is not only individuals who serve as stressors or supports to a client; the processes of bureaucratic institu- tions that represent education, religion, political, and economic entities can stress or support a client, as well. Understanding the client’s supports and stressors is a pre- requisite to engaging with the client therapeutically.

Cognitive behavioral therapy (CBT), a psychological treatment model in which the treatment provider helps the client become aware of their thought processes, belief systems, and antecedent behaviors, is one approach being increasingly used by social workers to treat clients with a range of problems, including but not limited to anxiety, depression, and post-traumatic stress. CBT as an empowering model aligns well with systems theory, as clients from underrepresented groups are fre- quently subjected to discrimination and intergenerational trauma. CBT can be trauma-focused, and typical techniques for child and adolescent survivors of trauma include cognitive reprocessing and reframing, exposure, stress management, and parental treatment (Cohen, Mannarino, Berliner, & Deblinger, 2000).

Mutual aid groups, another intervention model, situate individuals who are undergoing similar social problems as providers of support to each other, in the context of a group working on solutions. Such groups provide opportunities for clients to share their lived experiences while witnessing each other’s accounts of interactions with various systems, and subsequently influencing each other (Gitterman, 2004).

Social workers frequently engage in a role traditionally referred to as case man- agement, a process of assessing the client’s needs and then securing (in some cases

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advocating for) a package of services. Consistent with a focus of engaging clients with institutional actors, resource referral is an intervention in which social workers secure assistance for clients to supplement supports that are limited or unavailable from their personal agency standpoint. All the heretofore mentioned types of inter- ventions help ground understandings of the case study of Esperanza.

Introduction to the Case of Esperanza

Esperanza is a 16-year-old Puerto Rican heterosexual female. All names and identi- fiers of this case have been changed to maintain the confidentiality of the client. A ninth-grade student at her local urban high school, Esperanza lives with her 7-month- old baby, 34-year-old mother (Ms. Colon), and two adolescent siblings in an apart- ment in Hartford, Connecticut. While neither Esperanza nor her family currently attend church services, they identify as Catholic and were all baptized as infants. Ms. Colon, the primary income-earner, works as a home health aide for the elderly. Both of Esperanza’s parents stopped their formal schooling after eighth grade. The family unit receives some public assistance and financial contributions from Esperanza’s siblings; also high school students, who both hold part-time jobs. The family’s primary language is Spanish.

Esperanza was referred to the school social worker last year, initially for aca- demic reasons. As an “over-age student,” Esperanza was required to undergo a series of educational evaluations. While Esperanza did not have any learning dis- abilities, she was 2 years behind grade level due to gaps in her school attendance and limited English-language proficiency. Her social work referral expanded beyond academics after her classmates informed teachers that Esperanza was pregnant. Because she was a pregnant minor, a referral to the state child welfare agency was also made. Despite being polite and cooperative with the social worker, Esperanza initially refused the involvement of school and state officials, stating she “tenia todo el apoyo en su familia” (“had all the support she needed within her family”). Esperanza previously received counseling services from a school social worker as an elementary school student in Puerto Rico, to support her coping with her parents’ divorce. Counseling services then involved 6 months of weekly individual sessions, which Esperanza described as supportive. She has since developed and maintained healthy relationships with both parents, who appear to collaborate well in their co- parenting of Esperanza and their other children. Esperanza’s relationally healthy and loving family, as well as her personal resilience, prove to be strengths in her treatment.

Esperanza’s presenting concern was her increase in trauma-related symptoms, including increased anxiety, depressive mood, difficulty concentrating, and lowered frustration tolerance. These symptoms were interfering with her ability to maintain effective, positive communication with others both in school and with her personal relationships. Esperanza also stated she was fearful of “engaño” (Spanish for trick- ery or fraud) from institutional officials such as social workers and teachers.

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During the first 5 years of her life, Esperanza lived with both of her parents. At the age of five, her parents divorced. Although her parents terminated their marriage, Esperanza reports that her parents speak about each other in cordial ways and engage in healthy co-parenting. This cooperative co-parenting engagement is a fam- ily strength, especially since she has gone back and forth living with each in the years since their divorce. Back and forth is also a larger pattern for Puerto Ricans, as it references travel between the island and the mainland in a circular motion facilitated by U.S. citizenship. Despite having legal recognition as U.S. citizens, Puerto Ricans who have spent time in both places often experience cultural dis- crimination and feelings of not belonging to the island or the mainland. Acevedo (2004) references this dilemma as belonging “neither here nor there.”

Between the ages of 5 and 12, Esperanza lived intermittently with each of her parents and migrated back and forth between Connecticut and Puerto Rico on at least three separate occasions. When Esperanza was 12 years old, her mother moved to Connecticut in search of employment with two of her children (the eldest and the youngest). Esperanza remained in Puerto Rico with her father for three years until her mother could “send for her” to move to Connecticut.

When Esperanza was 15  years of age and still living with her father in Puerto Rico, she experienced the devastating impacts of a hurricane that led to a mass exo- dus from the island to the United States. Esperanza is a survivor of sexual abuse. While she described having a “boyfriend,” she clarified that this person was a man 10 years her senior. Despite this being a relationship that felt like a courtship for her and was approved by her family, it is a situation of abuse. She was not within the legal age of consent to engage in a sexual or emotional relationship with this adult.

Esperanza’s mother and older sister appear to be affectionate and reliable posi- tive supports for her. They care for Esperanza’s baby while she is at school. On days that Esperanza does not have family childcare, she does not attend school. This accumulation of absences (an average of one  day a week) impacted Esperanza’s academic progress and was brought to the attention of the state child welfare agency as potential educational neglect. The engagement with child welfare also revealed that Esperanza had been impregnated at 15 by a 25-year-old man, which raised concerns. Esperanza assured social workers that she was not raped and was “in a relationship” with her child’s father. Despite her description of her child’s father as an attentive partner and active father to their child, he was arrested on multiple counts, including statutory rape for his involvement with Esperanza. Esperanza interpreted her boyfriend’s arrest and her social service involvement as unjust, and she experienced the state and judicial system as preventing her and her infant from receiving his emotional and economic support.

Upon migrating back and forth from Puerto Rico to the mainland United States, Esperanza had to learn to navigate two distinct cultures and languages. She also had to adapt to two separate family structures and dynamics of interaction. She showed signs of anxiety and depression and made statements about how she struggled being a teen mom while desiring to engage in typical adolescent activities, and the ramifi- cations of those tensions in a social context. For example, the social worker noted that Esperanza lamented about missing the junior prom and other social activities

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due to her caregiver responsibilities. Despite these difficulties, Esperanza stated that her baby is “mi cariño” (“her love”) and speaks about the child with much affection.

After Hurricane Maria, there was little evidence of support for the mental health impacts of this natural disaster on the many students migrating and integrating into mainland American schools. As Puerto Rican students increasingly enrolled in urban high schools, social workers scrambled to address these challenges and meet the needs and demands of newly arrived families that had been deeply impacted by the hurricane. In the scope of this distressing event, the school social worker and her MSW intern worked with Esperanza.

During the initial phase of working with the client, the workers administered psychological first aid, a set of support actions aimed at reducing post-traumatic stress related to natural disasters often offered in schools. Psychological first aid centers around the core actions of contact and engagement, safety and comfort, stabilization, information gathering, practical assistance, connection to social sup- ports, information on those supports, and linkages to collaborative services (Ruzek, Brymer, Jacobs, & Layne, 2017). Psychological first aid was offered both individu- ally and in group settings for Esperanza and her classmates, as the enrollment of displaced Puerto Ricans increased in their high school. The efforts of the social workers were to help Esperanza feel assured, connected, and supported in her cur- rent environment. Within a few weeks of working with Esperanza, it was clear that the experience and aftermath of the hurricane had severely impacted her. She had reported nightmares and trouble sleeping, and appeared to have decreased frustra- tion tolerance despite remaining polite to those in authority.

Theoretical Integration

Systems theory was a useful tool both in supporting the social workers with their treatment of Esperanza and in understanding the client’s response. By focusing on the notion that there is reciprocity in the relationships between individuals, groups, organizations, and communities, as well as the larger sociocultural and political environment, the social workers were not only better equipped to identify factors that hinder Esperanza but potential solutions, as well.

Esperanza received treatment from the school social worker (a bilingual Latina of Puerto Rican descent) and a social work intern (a bilingual Latina of Mexican descent). The clinician (and the clinician in training) approached their work with Esperanza from a stance of cultural humility, in which they were able to incorporate Latino cultural values such as personalismo, which refers to the significance Latinos place on positive rapport with others (Mogro-Wilson, 2013; Mogro-Wilson, Rojas, & Haynes, 2016). More than merely engaging with Esperanza in her native lan- guage, Spanish, personalismo involved asking Esperanza about her extended family members and engaging in informal exchanges to establish rapport.

It is important to differentiate for emerging social workers the differences between an informal exchange (which facilitates trust) and unprofessionalism

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(which diminishes trust). These informal exchanges included brief, playful debates over whose brand of Puerto Rican coffee is better and who is the favorite participant in La Voz (the Spanish-language version of the singing competition, The Voice). Establishing rapport with Esperanza in this way was vital during the engagement process. Rapport is the entry point to the client–worker relationship. More than comfort, receptiveness, and respect, rapport is a commitment to display warmth, interest, and caring in a way that encourages the client’s trust and confidence. Choosing a highly viewed talent competition as an initial conversational prompt proved to be an excellent choice, as it provided at least 20 weeks of continuous nar- rative from which to build a relationship (“Can you believe Tania was eliminated in week three? Did you text your vote for the semi-finals of La Voz?”). Moreover, selection of a show that was popular in Puerto Rico allowed for cultural affirmation, a sense of familiarity, ease of communication in the native language, and joy. Personalismo sustained and supported the therapeutic alliance, as it built trust, con- fidence, and respect while diminishing Esperanza’s worry about potential “engaño” (trickery).

Systems theory allowed the workers to expand their view of trauma as being a component of the environment for this youth. With this in mind, they continued their work with Esperanza using ACEs (Adverse Childhood Experiences) screening to assess how many types of maltreatment a client has experienced prior to the age of 18. This tool covers ten types of trauma within three categories: abuse, neglect, and household dysfunction.

Trauma-informed approaches recognize that there have been potential traumatic experiences in the lives of our clients. Social workers must explain to clients why they are asking sensitive questions rather than just ask them as a matter of protocol. These explanations demonstrate mutual respect and cultural humility. Recognizing that sensitive questions may be misunderstood as “engaño” (trickery), in this case, the social workers began by informing Esperanza that they needed to ask her some “preguntas intimas” (intimate questions) to support her in maintaining healthy per- sonal and academic relationships. They explained this was part of a screening tool to help people and apologized in advance if they made her feel uneasy. By offering this apology, the social workers were rebuilding trust with Esperanza. The onus is on the social workers to create, sustain, and/or repair the client–worker relationship, and systems theory taught these social workers that they inherited Esperanza’s dis- trust from previous incidents experienced as betrayals from institutional actors. These incidents include the involvement of child welfare services because of teach- ers disclosing “her private life,” as well as a slow relief response from the U.S. gov- ernment to assist Puerto Rico during and after the hurricane.

Systems theory helped the social workers see how betrayals such as the incar- ceration of Esperanza’s boyfriend also took place at a macro level. In Esperanza’s eyes, her relationship was legitimate, and this perspective was further confirmed for her because she had the consent of her parents. There may thus be traumatic stress from the hurricane experience coupled with the type of trauma that arises for groups of people who have experienced disparate treatment (Matheson, Foster, Bombay, McQuaid, & Anisman, 2019). The apology for asking about intimate matters is one

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of several ways the social workers sought to affirm Esperanza’s legitimate feelings of distrust.

Esperanza agreed to answer the ACEs questions. The MSW intern facilitated the questionnaire in a conversational tone, rather than administering the tool as a formal survey. The intern, speaking in Spanish, framed the questions in ways that sup- ported the therapeutic alliance and empowered Esperanza to respond candidly. (“Esperanza, we know these questions may make you feel uneasy and we are sorry for that. We need to know if a parent or other adult in the household often or very often … cursed at you or insulted you? Think about it. Take your time.”). Here, the MSW intern sandwiches the ACEs question between a statement that affirms the client’s feelings and reassurance that she does not have to rush through this process.

Esperanza’s overall score was two out of a possible ten. She scored yes to ques- tions #4 (feeling unloved or unimportant from her family) and #6 (parents ever separated or divorced). Esperanza was hesitant about answering question #3 (did an adult or person at least 5 years older than you ever touch or fondle you or have you touch their body in a sexual way?). She struggled to understand the age of consent law in Connecticut (as well as throughout all of the United States and Puerto Rico). It was incomprehensible to her that the father of her daughter was held legally responsible for a sexual relationship with her as a minor, resulting in 3 months in jail and a court order to pay child support after his release. Esperanza struggled with the conflictual way the court ordered her boyfriend to pay child support, when prior to his arrest he had been both emotionally and economically supportive of her and the child.

Her family described Esperanza and her co-parent as a loving couple with joint plans for the future. Through the conversational facilitation tool of ACEs, the social work intern learned from Esperanza that she knew many couples with a 10-year age gap, and early-age pregnancy was an intergenerational pattern in her family. Despite this, it was critical for the social workers to be mindful of the imbalance of power between Esperanza and her child’s father. Power imbalance is what allows an adult to take advantage of an underage person in ways that meet the American Psychological Association’s definition of sexual abuse. The MSW intern made a note in the questionnaire about the circumstances of Esperanza’s “relationship” and the client’s belief that she is not a victim of abuse.

While her ACEs score is relatively low, systems theory helped the workers explore Esperanza’s perspective and understand that she has experienced more trauma than her score displays. Additional traumas not represented in this assess- ment include Esperanza’s displacement from her family/country, her early preg- nancy, surviving as a teen parent, her status as a sexual abuse victim (related to a consensual sexual relationship with 25-year-old adult male who was viewed as a sexual predator), DCF involvement (educational neglect), and her mental health diagnosis (anxiety, depression, PTSD). For example, Esperanza experienced trauma in the loss of the person she identified as her boyfriend, whose incarceration was directly connected to her disclosure to someone that he was the father, as well as incidents in her macro environment related to surviving a natural disaster and vari- ous forms of cultural assault from government officials.

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As a result of the ACEs assessment, not only have the workers continued their work with Esperanza through a trauma-informed lens, but they also made the realization that trauma was a component of the environment for Esperanza. While Esperanza’s ACEs score was two, the mutually influencing factors in the environ- ment are trauma-infused, providing a comprehensive understanding of her lived experience. From a macro lens, understanding Puerto Rico’s commonwealth status as neither a U.S. state nor an independent country sheds light on the territorial limbo that migrants experience in their “host” country. Mental health professionals have highlighted the colonization of Puerto Rican as a factor to consider when treating Puerto Rican clients (Teichner, Cadden, & Berry, 1981).

As mentioned, ecomaps are visual representations of all the systems at play in an individual’s life, while genograms show the relationships between a client and their family members. The MSW intern engaged Esperanza to collaborate on creating ecomaps and genograms to support an understanding of the interconnected systems in her life. Before inviting the client to create visual representations of her own life, the intern first focused on developing trust by collaborating on an ecomap based on a fictional character. They collectively chose the movie Real Women Have Curves, a 2002 comedy about a Latina teen and her dynamic with school and family. The intern’s engagement strategy included the small but significant detail of preselecting the menu of movies and ensuring that all the films were comedic and based on Latino culture. Utilizing a Latinx-focused movie both affirmed the client’s heritage and was a trauma-informed strategy to minimize any potential triggering that might occur from watching a drama that centrally focused on adverse childhood condi- tions. Choosing the movie together also temporarily suspended the worker–client hierarchy. The shared decision making of the therapeutic intervention allowed Esperanza and the intern to work together to understand the main character and her relationship to the family and systems around her. In that exercise, Esperanza was able to see how one is not only influenced by people and systems, but can also take actions to be the influencer.

Ecomaps and genograms visually demonstrate the relationships between sys- tems, people, and the client, which are represented by the intensity and direction of lines drawn on the visual aids. In drawing the relational connections in the geno- gram of the main character, Esperanza communicated her understanding of systems theory as the interrelatedness of a person and their environment. In drawing these lines for herself, Esperanza expressed a significant amount about her life without needing to say much verbally. The intern learned that Esperanza experienced high school to be a source of stress. (The workers had differing views on Esperanza’s school attendance.) While her teachers worried that Esperanza would be missing significant instructional time, Esperanza viewed herself as a responsible mother who cared for her child when family members were not able to step in. The repre- sentations serve as prompts for the intern to use at follow-up meetings.

The social work intern was forthcoming in asking Esperanza if they could talk about her family as a way for her to better understand herself. Esperanza agreed. The intern then utilized a strengths perspective as she tapped into Esperanza’s pas- sion for art to make the activity more engaging and student focused. Social work

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interns are often limited in how they can assist a client. However, this scenario proved to be a win-win. While the school social worker was unable to dedicate time to such detailed visual aids due to her large client case load, the intern was available. The intern happened to be learning about these tools in her Master of Social Work program and appreciated the opportunity to further develop her skills. Most impor- tantly, Esperanza benefited from the creative activity.

While the under-resourced high school had limited supplies, the intern was able to take advantage of a recent donation of art supplies such as poster board and vivid paint colors to make the activity creative and fun. As Esperanza drew thick solid lines to represent strong relationships and faint lines to represent weaker bonds, the intern was able to ask questions such as, “How would you describe your neighbor- hood?” and “In what ways do you rely on professionals to help you and in what ways do you rely on family?” Her answers provided further evidence of Esperanza’s reliable family network, which supports her with childcare and ensures that she and her child are cared for in their home.

Esperanza’s healthy baby, her determination to be a good mother, and her hard- working family were all strengths identified in this activity. Esperanza noted that her language and culture were strengths. She discovered that not being fluent in English was a present challenge, as was being a teen single parent and having limited eco- nomic resources. However, she reclaimed her power in being able to engage in this analysis of herself rather than being talked at by professionals. Over time, Esperanza was able to identify her situation as temporary. She was able to reframe her situation and articulate how she can work on developing into a bilingual and bicultural com- municator and identify some life goals by using the supports provided by her family and institutions. The reclaiming of her personal agency is an example of a powerful outcome of working with a culturally attuned social worker and MSW intern.

The intern took this art ecomap project one step further by asking Esperanza to do a separate ecomap for her life in Puerto Rico. It was in that activity that Esperanza illustrated the significant differences with respect to time, method of communica- tion, and cultural expectations in social service care on the island versus a mainland urban city. This visual representation served as a tool to help explain Esperanza’s point of view to new service providers and those who were still developing their cultural awareness (an outcome discussed further in the cultural considerations sec- tion of this chapter).

The social workers then focused on securing supports for the two parental figures in the family: 16-year-old Esperanza and 34-year-old Ms. Colon. These supports were in the form of mutual aid groups. The social workers acknowledged to Esperanza the reality that while she has the desires and responsibilities of a teenager in high school, these dynamics are complicated by her role as a mother. Therefore, she needed a space that was specifically designed to aid her in these simultaneous, and at times conflicting, roles.

Esperanza benefited from a Spanish-language teen mother’s support group embedded in her high school. Receiving mutual peer support from students who shared her situation created the conditions for Esperanza to seek out more resources as friends vetted them. She was able to see how her peers benefited from state-

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subsidized childcare and parenting classes and began to let go of the initial reserva- tions she had about receiving such aid.

The workers, as well as the members of the mutual aid group, encouraged Esperanza to have regular communication with her father to strengthen his role, which had been weakened after the divorce and displacement. While Esperanza’s future with her child’s father is unclear due to his incarceration and the power imbal- ance between them, she recognizes that healthy bonds with her parents, siblings, and extended family will provide her with support and perspective on how to pro- ceed with healthy relationships. She has committed to supporting her child by main- taining a positive relationship with the child’s father.

During a debrief session with Esperanza, the social worker explained statutory rape and age of consent. Esperanza had difficulties understanding why the father of her baby was seen “like a criminal” when, according to Esperanza, he was emotion- ally and economically supportive towards the baby. She shared that his incarcera- tion caused additional emotional trauma and economic family stress. Esperanza shared that she willingly chose to have sex with her boyfriend out of love and emphasized that she never felt forced. In trying to advocate for herself and the father of the baby, Esperanza inquired if the court would allow her to make a statement in defense of her boyfriend. She expressed that she would tell the judge she acted freely and voluntarily and was knowledgeable about what she was doing. The social workers had to reframe Esperanza’s relationship for her. While they acknowledged that she consented to the relationship, they explained to her that due to her age there is a power differential between her and her child’s father. This was one of the more challenging cognitive reframes that became part of Esperanza’s longer-term treat- ment plan.

Ms. Colon was offered the opportunity to participate in Madres de Madres (Mothers of Mothers), a support group for grandmothers under 40  years of age. Unfortunately, due to Ms. Colon’s need to manage two jobs and take care of her family (including serving as a childcare provider for her granddaughter), she was unable to make herself available to attend the group. Ms. Colon also clarified for the social workers that even if she did have the time, she would not attend Madres de Madres because “de esas cosas no se hablan afuera de la casa” (“These types of things are not spoken of outside the home”). The intern continued to forward infor- mation to Ms. Colon and intermittently reminded her that since it was an open group, she was welcome to join at any time.

The social worker recommended a state-subsidized childcare agency for Esperanza’s daughter and successfully secured a spot for the child. Utilizing the childcare agency would have provided relief to the family by minimizing Esperanza’s school absences, freeing up some time for Ms. Colon to consider attending Madres de Madres or engage in self-care, and allowing Esperanza’s baby to engage with other children and participate in developmentally appropriate play that is not always available in contexts of overworked caregivers. Unfortunately, Esperanza refused the childcare resource, claiming “nadie cuide lo de uno mejor que uno” (“No one care for your own, like yourself”). This statement, which points to Esperanza’s sus- picions about anyone outside her nuclear family caring for her child, is related to the

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theme of fear of experiencing trickery from institutions. Further exacerbating her distrust in systems, the local news had recently reported the arrest of several staff members at a subsidized daycare center for their physical abuse of toddlers.

Rather than contradict Esperanza’s beliefs, the social workers deferred to Esperanza, acknowledging her agency and right to self-determination, which fur- ther empowered Esperanza and fortified the therapeutic alliance between them. The social workers then reframed the childcare conflict for Esperanza. Specifically, they supported her in seeing that chronic absenteeism is strongly linked with low aca- demic achievement and school non-completion. Therefore, activating the childcare resource would allow Esperanza to focus on school, which in turn would create employment opportunities that directly impact her own and her daughter’s future. While this did not work immediately, over time the social workers were able to help Esperanza view childcare support as a resource for her to be able to better provide for her child for the long term.

Once Esperanza established months of consistent and engaged participation in the young mother’s support group, the social worker explored her interest in cogni- tive behavioral therapy. Esperanza agreed. The social worker met with Esperanza in a private, quiet room and guided her with a series of questions to tap into her emo- tions. Upon Esperanza articulating a fearful thought, the social worker gently inquired about the thought with questions asked in a gentle tone, such as, “I hear you. Why do you think that is true?” This gentle questioning of Esperanza’s fearful thoughts eventually helped her develop alternative narratives. These changes in thought then led to more positive emotions, which can support new and different behaviors that ultimately support change.

The technique of gently challenging fearful thoughts allowed new thought pat- terns to emerge. Initiating the CBT approach via Cognitive Behavioral Intervention for Trauma in Schools individual sessions, the social worker helped Esperanza address underlying symptoms of stress and trauma. Through this process, Esperanza was able to understand that her underlying thoughts and feelings are interrelated and were influencing her actions and behaviors.

While the social work intern was not able to lead the CBT sessions, she was able to learn in other ways. For example, the intern completed the online Cognitive Behavioral Intervention for Trauma in Schools training and discussed these themes at length in supervision. Furthermore, the intern utilized some individual cognitive- behavioral approaches with Esperanza, including but not limited to psycho- education discussions and relaxation and mindfulness strategies that supported the cognitive restructuring work led by the social worker. The tasks of the social work intern and her contributions to this case are highlighted to illustrate ways social work supervisors can carve out meaningful assignments for interns who might have limited ability to lead a case, and provide social work students with ideas of how they might initiate such roles in supervision.

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Cultural Considerations

Cultural considerations must always be taken into account; even in situations of shared heritage, social, cultural, and economic contexts may still differ. In this case, the social workers of Latinx descent had also undergone their own migration jour- neys, intensifying their mindfulness of the client’s sudden transition from a relaxed island community to the hustle and bustle of urbanity. Other service providers might misunderstand this mismatch of pace as the client’s disinterest in receiving services. However, the social workers knew from both professional and personal experience that Esperanza’s follow-up delays were related to her being unaccustomed to urgency and immediate agency responses. As such, they affirmed Esperanza’s lived experience while orienting her to new communication expectations from Hartford’s school, child welfare, and criminal justice systems. To prompt their client to secure resources, the social workers often used a gentle tone to remind Esperanza, “Things are done differently here.”

While many social workers may take on the task of informing their clients that there are rules and regulations they must follow, culturally affirming social workers take this task to the next level and actively offer themselves as a human connection to what may feel, at times, like faceless bureaucracy. In this case, the workers used the metaphor of a bridge to describe how they are links between Esperanza and the institutions with which she must interface. Positioning themselves as “the bridge” was another active attempt to (re)build trust. Although the distrust they experienced was inherited, as opposed to earned, the social workers knew it was their responsi- bility to earn their client’s confidence. In addition to serving as liaisons and coaches, they took on a “clinician-activist approach” (Walz & Groze, 1991), recognizing that Esperanza was not always able to articulate cross-cultural misunderstandings and they were needed to advocate on her behalf.

It bears repeating that sharing a cultural background with one’s clients does not eliminate cross-cultural conflict. For instance, these social workers understood that Esperanza’s family endorsed her romantic relationship with her child’s father. The 10-year age difference did not render it illegitimate, from their perspectives, as they believed Esperanza was old enough to consent to the relationship as a teenager. This dynamic was conflictual for the social workers, who understood that Esperanza and her family consented to the relationship but also understood this relationship to constitute sexual abuse. The genogram helped the workers identify an intergenera- tional pattern of sexual abuse; Esperanza, her mother, and her aunts were all under- age mothers with children fathered by men much older than them. While the social workers have not yet established a strong enough foundation with the family to explore this sensitive topic, they have identified as potential areas to expand upon in family therapy the multi-faceted dimensions of abuse and the difficult reality that family approval does not preclude abuse.

Currently, there is a debate about distinguishing between PTSD and complex stress disorder (the latter not yet in the DSM 5) in order to acknowledge the perva- sive negative outcomes (social determinants) of long-term exposure to IPV, neglect,

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childhood abuse, and other traumas that do not fully meet PTSD criteria. It is worth noting that Esperanza and other immigrants/migrants might fall under this category as a result of having faced natural and human-caused catastrophes in Puerto Rico, as well as “host” country discrimination, cultural violence, etc.

Systems theory helps social workers tease out the diversity of the Latinx experi- ence. For example, the intern (who was of Mexican descent) viewed Esperanza’s U.S. citizenship as an asset, given that she herself had undergone significant legal and economic hurdles to secure citizenship status. Esperanza, on the other hand, was unable to identify her ability to migrate as a privilege. While this may be related, at least in part, to Esperanza’s youth, the affordances of systems theory to allow concerned parties to delve deeper and identify that while Esperanza’s move from the island is defined legally as migration (traveling within the same country), she has experienced it culturally, socially, and linguistically as immigration (traveling from one country to another).

Discussion Questions

These questions challenge the reader to think critically about the theory and integra- tion of the theory in practice.

1. What are some of the assumptions of systems theory? How are these assump- tions aligned with the work of social workers?

2. How might systems theory serve as a tool to help social workers create strategies to build trust with a client who explicitly shares their legitimate disappointment with how institutions have responded to their prior needs?

3. Social workers might work under policies and political climates that perpetuate injustice. What conflicts might this raise for you? How will you support yourself should this occur?

4. In this example, both the client and the workers were Latinx and there were cul- tural differences to consider. How might systems theory support social workers to prepare to engage in cultural-informed work with clients of different backgrounds?

5. Systems theory emphasizes the interconnectedness of systems. Name some examples of strategies and tactics you would use to collaborate with social work- ers from other institutions who are attempting to aid the same client.

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