Behavioral change models and treatment of adolescent depression in foster care

¶ … Clinical Practice with Individuals Critique of Practice

Behavioral change theories and designs mainly allow an individual to adapt and change a negative or damaging habit into a positive and healthier one. All behavioral change theories help the researcher to categorize the changes that individuals go through and the behavioral change designs help the individual to have basic guideline form where they can start to initiate the change themselves. The main aspects in the behavioral changes theories are internal factors like the confidence, behavior, attitude and beliefs of the individual and the external factors like the social structure, family and environment that surrounds the individual (Maurer, 1996).

Purpose of the Paper

In this paper we will analyze the behavioral changes that a teenager, 19-year-old Sarah, is going through as she lives through the foster care system in Miami. Her foster care structure is similar to almost any other foster care structure and leaves her feeling lonely, depressed and anxious with her life. The depression is the main cause of worry for the client as it disallows her to feel good about her achievements. She constantly finds herself breaking down in tears because of depression. She has been my patient for nearly two years now and whenever in such circumstances she comes to my clinic, I make sure that she is always made to feel welcomed and is surrounded by a calming influence and atmosphere whether she is in the waiting room or in my office. She usually is very reclusive whenever she comes for regular session and complains subtly about her depressive state. But at times, she does get overwhelmed and breaks down. I've used the findings of many behavioral studies to help her calm down and try to get herself out of her depressive inclinations.

It has been a very recent development that the behavioral changes theories have started incorporating the health maintenance strategies for individuals who do not have serious diseases like AIDS, but instead suffer milder diseases like depression; this has helped me deal with my patient a lot better than before. Furthermore, there are many researchers who believe that the behavior change models can provide important information on why certain individuals and certain societies undergo a higher percentage of depression. This is so because all behavior change models tend to categorize behavior patterns in clusters which can help present statistical information of the lifestyles and life choices of societies all over the world (NIH 2003).

In this paper we will mainly highlight how the different behavior change models has and will impact the chosen individual suffering from depression when she chooses to change her lifestyle. The paper will highlight the five important stages of change that the individual will go through in order to accurately apply the behavioral change method required to help her alter her depressive inclinations. The research will mainly use two behavioral change methods: the Stages of Changes Method and the Health Belief Model (HBM).

Methods Applied

The method applied in this study is the "Stages of Changes" procedure. This was a combination of interpersonal and environmental intervention and the first thing I did in this when altering the clients' depressive behavior was that I observed the patterns of behavior as they existed before the change process is initiated so that comparison of results could be evaluated accurately. In this way, I observed the resilience and willingness of the individual to adapt to change that would better her lifestyle. This I did through observing Sarah's attitude towards her peers, her social attachments, the willingness of the individual to stand up for her and for what's right in a tough spot, the food preferences, etc. All of the observations were recorded and documented with reasons for the preferences i.e. all of the actions and addictions to certain situations that could possibly instigate depressive inclinations.

The next step included the planning of the change process, risk assessment and recognition of protective factors. First thing done here was the recognition of unhealthy patterns in the current habits and the appropriate solutions that could bring about the necessary change in them. Second thing in this stage was the designing and distribution of the five methods explained below over a period of six to eight weeks which included all changes being made in the prior behavioral patterns. The five methods implemented in the behavioral pattern for this study include:

Pre-contemplation

Contemplation

Preparation

Action

Maintenance (Prochaska et al., 1992).

In the first stage of the pre-contemplation, the problem with the depression is obvious, whether or not it is recognized by the individual. If the individual does acknowledge the problem, she does not really resolve to take steps for its solution. In this stage, the individual (Sarah) mainly recognized the problem and gathered all knowledge that was directly or indirectly linked to the problem as well as recognized how her problem affected her environment through the process of observation (Prochaska et al., 1992). Here the method applied basically was aimed to increase the awareness of the individual to the problem through indirect, subtle and at times direct dialogue. This was chosen as the line of action due to the individual's episodic refusal towards therapeutic solutions; it was important that Sarah realized what she needed instead of me telling it to her.

In the second stage of contemplation, the problem was considered to be a serious yet solvable one by the individual and she took the necessary steps to engage herself in a process of change that were designed to help her resolve this depression issue. This is the stage where, for this paper, Sarah was able to recognize the root causes of the problem within her lifestyle and living patterns by researching the impact that each choice has on the overall mental and physical fitness of the individual. Here, the issue of depression is the lack of support from peers. Hence, the method used helped Sarah analyze all aspects that will increase the daily support, her confidence in her ability as well as the ability to trust in others who want to help while simultaneously decreasing the amount of depression or loneliness that she feels (Prochaska et al., 1992).

The third stage of preparation is usually the toughest stage because while people might recognize the problem and the need for a change, they might not always be mentally prepared to take on such a task because behavioral patterns are not easy to change especially if they have existed or been built up for many years as was the case of the chosen individual.

This is where the importance of the first step comes; if the awareness and knowledge of the individual acquired in the first step is thorough and detailed then the overall adaptation might prove to be a little easier. Here the most important task for the individual is to form a self-belief on the personal abilities to not only be able to apply the behavioral change plan but the belief that she can not only apply it but also get the desired results from it (Prochaska et al., 1992). Here, the method used included most psychological techniques used to enhance the self-confidence, self-esteem and self-belief of the individual (Sarah) by beginning with conversing about the completion of tasks in the past or the completion of smaller tasks that had been given within the psychological sessions. This is the stage where the client was in our last session. Interesting to note here is that Sarah took a long time in this particular stage and even though at times her self-esteem seemed to be high, mostly it was here lowered levels of self-esteem that delayed her progression from this step to the next. The next stage will be the focus of our future session.

Process Recordings and Analysis of Practice:

Below is a table where some of the client's responses, my own reactions and supporting theory have been represented from the sessions that have taken place thus far. These transcripts were chosen because they helped me to better understand my contributions through my interactions with Sarah.

Goal or intended focus:

The intended focus of this particular session was to help the client deal with her depressive inclinations in a positive and constructive way.

Aspects to consider when tuning in:

During the session, the client seemed very vulnerable towards what fear in general made her feel and act thereof. She seemed really nervous, finicky and apprehensive about how the fearful energy around her made her feel more depressed. She was definitely looking for psychological input and a solution she could apply in the long run.

Client / Worker Transactions (C)

Skill Name

Worker Reflections (Gut level) (W)

Supervisor's Comments

C: Hi! It's a weird day huh?!

W: Hello! Well, it depends on how you define weird! (Smiling) how would you define weird?

Displaying understanding for the client's feelings

Please let it not be a depressive breakdown, not after the progress we've made!

C: It's just that I feel traumatized and afraid a lot more than usual and I can't control how I react or feel when I'm afraid. I just tend to go down on myself more. I've been very stressed out lately even though stress is not something I generally have a problem with. I don't know what's wrong.

W: Well, fear can make one uneasy and act differently from what one is used to. Do you think that there was something around you, a situation a symbol a person that made you feel even more fearful?

I wanted to know what kind of situations made her fearful or uneasy

I had an idea that perhaps what made her fearful was the possibility of loneliness for life.

C: I really have no idea & #8230; there just seems to be a lot more for me to do than the people around me and it's just that I can't seem to bring myself up to where there are. I don't know if I ever will, you know.

W: What is it that the people around you are surpassing in?

Tuning in Please let it not be below par academics! That's the only positive she has in her life right now!

C: Well, at work, It seems like I'm stuck, you know. I've been doing the same chores for the last 6 months, haven't gotten any additional responsibilities. Whereas this guy who got hired 3 months ago has already been working on a ton of more responsibilities than me.

W: Sometimes it isn't the number of responsibilities you are given but the nature that decides what your worth is. What are you asked to take of most frequently?

Reaching for client's feedback and self-analysis of a disturbing situation

How are you handling the added responsibility of specials announcement?

The most important stages are the fourth and fifth ones because this is where the actual behavioral change occurs. The fourth stage of action requires the individual to apply all strategies introduced in the plan developed in the second stage and to do so with the necessary self-belief developed in the third stage. Here one of the most successful methods used is the recognition of daily accomplishments made by the individual, both tangible and intangible. Another important method that has proven useful in this stage has been the implementation of different strategies for attaining different behavioral changes in the individual. This method of using alternative strategies allows individuals to develop diversification and adaptation skills when dealing with a difficult transition of change and not giving into prior temptations. Another important aspect in this stage is the consistency of support from her peers as her family is no longer around.

The fifth stage or method for implementing behavioral change in one's depressive inclinations is the maintenance of the mental health over a significant period of time till the relapses can be controlled consistently and consciously. Here the most important method implemented is the continuity of awareness of the problems that can surface if the individual diverts from the behavioral change plan. Another important method used in his stage is the constant reversion to the lifestyle that the individual had prior to the application of the behavioral change process so as to keep them weary of the consequences of a relapse (Greene et al., 1999).

Summary, Critique of Practice and Results:

Summary

The method applied was very efficient in allowing the individual to not only address the problem when she was ready but also to help her understand the extent to which she can adapt and change maintaining a consistent level of growth and awareness about her mental health and depressive inclinations. The individual analyzed for this study was able to lucidly understand the problem and even though the change process seemed daunting, the individual mostly was able to stay mentally tough and surrounded herself a strong social structure of peers and foster care structure. She took additional steps to join health groups, even though she was initially reluctant to do so, but she did make an effort in order to remain updated on all depressive and health issues/patterns.

Critique of practice:

Sarah was a patient recommended to me from a colleague, primarily because of my experience and history with treating kids in the foster care structure. I took on the case as I realized that this could be an opportunity to document part of implementation in modern behavioral theories. Plus, she reminded me of a patient I had dealt with previously without having much success. I felt like I could perhaps make amends through helping Sarah. Upon meeting Sarah, in our first session, she seemed like a reclusive and secretive person. She wasn't much of a talker and the friendlier I tried to be, the more skeptical she became about the reason behind my desire to help her. The idea that I had to employ the Stages of Change formula was not going to work unless I could get Sarah to open up and talk about her situation with me. So I decided to play by her rules and not make the first authoritative move. After a couple of sessions, she started talking about random things in my life, like the paintings on my wall or the books I owned, she even talk about my fashion sense, but every time I tried to get more out of her, she would shut me out. I realized through her attitude and peer profiles that she liked to size someone up before deciding to trust them so I allowed her to dictate therapy session initially.

That seemed to be the winning strategy but it was the third session with Sarah that I felt like I was being more of a hindrance than anything else. The reason why I had taken Sarah's case was because she reminded me of another client who I had wanted to help but had been unsuccessful with. I felt like I needed to make things better for Sarah in order to feel good about my own practice with such clients. The third session however started off on the wrong foot, primarily because I was being very defensive. Sarah's defenses had always been very high around me and it had required a low of patience on my part in the prior two sessions in order to deal with her complexities. However, I was running low on tolerance levels even before this particular session had begun. I did not react well to the usual carefree and disregarding demeanor of Sarah and I became angry myself.

The anger on my part should not have been revealed! It is my job to cover up what I am feeling, and deal with the client's problems on her terms especially when dealing with such a strong personality as Sarah's. The session took a turn for the worst when the client made a personal attack on my determination and commitment levels after interpreting a painting in my office. Even though I knew that it was a provocation and I shouldn't let it dominate my reaction, I was still unable to control my outbreak. By the time, I had sort of calmed myself down and was trying to push past what I was feeling; Sarah had already grown more distant. She was talking about randomly variant topics and any attempt I would make on digging deeper into her problem would be received with a sudden change of topic.

When analyzing the session in hindsight, I realized that my anger towards Sarah was merely my anger towards my inability to service her problems that way that I knew I should! Prior experiences with a similar client had allowed me the convenience of knowing what not to do, however, unlike other sessions with Sarah, this particular session added more information to that particular domain than anything else. Hence, in hindsight, I should have focused on the interpretation of the painting of the client and instead of focusing how that interpretation applied to me, I should have assessed how it applied to the client! The session was a prime example of what one should not do with a client especially when the client is being difficult, guarded and provocative! It is normally a ploy of tough clients to make the worker feel vulnerable in order to take the attention away from their problems!

My main role with Sarah was merely to be the patient and quiet one, the listening ear, the shoulder to lean on instead of being the angry therapist with personal issues! This was so because I realized Sarah had developed really strong coping abilities due to her own life experiences and even though she would get frustrated in situations, she would always sit back and analyze them after she had been able to vent all of her raw emotions. Eventually after around 4 to 5 sessions (that's around 6 weeks), the application process of positive solutions that I suggested became easier for Sarah to adapt in her life as she not only found a patience within herself but also strong support from some of her foster care and school-going peers. I too had been far more patient with and towards her even though she did try and provoke strong reactions from me in the following sessions.

Results:

Using the Stages of Change formula in combination with other efficient models, which worked well, included the Health Belief Model (HBM) and Theory of Reasoned Action (TRA). The Stages of Change formula in combination with the HBM model helped the individual recognize all the social, mental, physical and other variables that will most likely surface during or after the change process. The HBM methodology also helped the individual to be prepared for these changes and simultaneously helped her analyze the pros and cons of these changes. The Stages of Change formula in combination with the TRA model helped the individual to recognize and assess all the inward changes that she will have to make in terms of their attitudes, belief, norms, etc. during and after the change process in order to maintain the behavioral change that she was instigating (Maurer, 1996).

Conclusion

I feel that use of the aforementioned techniques is an example of how efficiently my advanced practical knowledge and skills as a social worker can work in favor of my client. Following the code of ethics, I offered my services to the client beyond the personal interests and used whatever knowledge and techniques I was familiar to in order to help my client address whatever problem she had with and efficient and timely manner. The work done for this study with my client further helped in the understanding of how a social problem like depression can impact not only the individual feeling it but also those around her. Furthermore, the code of social ethics bound me to make sure that my personal biases to any aspect or trait of the client did not affect the services I provided to her and treat her opinions and life with respect despite differences in cultures or ethnicities, etc. Furthermore, the code of ethics also allowed me to place even more importance on peer relationships for the client as not only would they instigate the necessary change in the client but also help in its maintenance. Hence, I was able to incorporate not only my own psychological techniques to help the client fight depressive inclinations but also use her peer influences to instill positive energy in her life. Even though my focus was helping the client, I also made sure that I kept adding to my knowledge of the phenomenon of depression and document it for future applications.

The next phase in the method applied in this study will be the observation period of 2 weeks where the individual's adaptation will be analyzed. Here, the monitory concentration will mainly encompass the individual's ability to sustain the new behavioral pattern with a surety of no relapse as well as the individual's ability to continue making smart and healthy decisions, maintaining a good pros and cons approach to every situation. Furthermore, in this stage the individual's ability to adapt appropriately in sad or depressing situations will also be assessed.