Biopsychosocial model and integrated health perspectives

Social Work - Biopsychosocial Case Study

SOCIAL WORK: BIOPSYCHOSOCIAL CASE STUDY

The client is a divorced, 37-year-old Hispanic mother of three girls, aged 11, 9, and 4. She has been employed for almost a decade as an X-ray technician. She is a repeated victim of domestic violence on the part of her ex-husband and of numerous instances of date rape in college.

The client's former husband was never prosecuted for domestic violence, because the client never reported it throughout the four-year marriage, the six years preceding it, or the year preceding his arrest for child sexual abuse in the year following their divorce in 2006.

Law enforcement authorities had responded to several requests for service after neighbors overheard abusive situations, but the client never provided sufficient assistance to prosecute her former husband on domestic violence charges. The former husband is presently incarcerated after conviction on the charges relating to his sexual abuse of his oldest daughter. Since his incarceration he was also convicted of attempted murder in connection with a prison altercation that he instigated and is now ineligible for parole until 2020.

The client was sexually abused by her father for several years ending when she was 12 years of age. She was ordinarily subjected to emotional abuse by both of her parents and to severe corporal punishment throughout childhood and adolescence administered by her father. As often as not, she was punished for allegations that were completely false or imaginary. In time, she stopped protesting her innocence, suffering in silence instead as her father beat her for things she never did

The client had a past history of alcoholism that predated the birth of her first child but which recently recurred for the first time. Previously, she had not abused alcohol in more than a decade, drinking socially but responsibly, and only infrequently until recently. In the past, the client had self-medicated with alcohol in order to cope with specific stressful circumstances. Without it, she was not usually able to fall asleep throughout much of high school when she lived with her parent and during two years of college when she was repeatedly raped as a freshman and sophomore by the same four upper class students in various combinations until their graduation after her sophomore year. Her previous alcoholism coincided with this four or five-year period. During high school, she drank primarily to help her sleep; in college, she drank in two contexts: to cope with unwanted sexual relations after they transpired, and (later) to facilitate her role as a seductress when voluntarily acting out sexually.

Presenting Problems:

The client was mandated to the supervision of a child welfare agency after another law enforcement agency call for service in connection with a physical assault against her by her most recent male companion pursuant to which he was incarcerated after violating an order of protection issued on the client's behalf after the initial physical assault.

She recently resumed self-medicating with alcohol as a sleep aide after her children are asleep and has indicated experiencing increasing feelings of anxiety for which her general practitioner had prescribed diazepam. The client did not disclose to her physician that she had resumed self-medicating with alcohol. She also mischaracterized her symptoms as "general anxiety" instead of relating very specifically to a traumatic flood of previously repressed memories of her childhood sexual abuse.

Since then, the client has experienced increasing difficulty managing her daily responsibilities; she has overslept and missed work several times and her youngest daughter's school attendance has suffered. On the occasions when the client overslept, her oldest daughter took over some of her morning responsibilities by waking up her nine-year-old sister and preparing their breakfast. Because it was more difficult for her to gain the cooperation of her youngest sister, the oldest child simply allowed her to continue sleeping and then saw to her needs upon returning home from school as early as possible.

On the fourth occasion of the youngest daughter's absence, her teachers inquired of the oldest child into the whereabouts of her youngest sister and authorities were then alerted to the situation.

Subsequent investigation into the circumstances has revealed that the client has suffered from incapacitating emotional trauma after suddenly recovering the full memory of her father's sexual abuse for approximately two years from the age of 10 until the age of 12. Previously, she was completely unaware of any sexual abuse in childhood, but she recovered conscious memory in the manner described by Graziano (1992) of that time period after being triggered by a specific event in the natural maturation of her oldest daughter.

Specifically, while assisting her oldest daughter accommodate her first menses in their bathroom at home, the client suddenly experienced a vivid visual memory of being molested by her father at the same age. She found herself unable to continue assisting her daughter at that time and excused herself saying she had been feeling ill.

Beginning almost immediately, the client began to experience overpowering anxiety, in particular with respect to the intensity of acute trauma, likely in proportion to the degree of her successful repression of those reactions previously (Graziano 1992).

Within the next few days, the client eventually recovered very detailed memories of two years of sexual abuse by her father, as is often observed in the case of prolonged trauma after the initial memory is precipitated by a specific trigger (Kasl

1989). After suffering from acute insomnia since the initial recollection, the client resorted to self-medicating with alcohol in exactly the same manner in which she had coped with similar symptoms as a teenager and in college.

Recognizing the dangers of slipping into alcoholism again, the client sought alternate solutions in the form of prescription sedatives which she had intended to use instead of alcohol. Ultimately, she did reduce her total alcohol intake but found herself combining diazepam with alcohol inadvertently, with predictable results (Reding & (Wijnberg 2001).

Since the intervention of child welfare authorities, the client has expressed her commitment to full participation in her own therapy which she realizes is essential to recovery of her independent ability to provide for the needs of her family. Whereas her initial reaction to recovering the memory of her childhood trauma was overwhelming and incapacitating anxiety, her active participation in therapy has mirrored the benefits noted by Butler (1997) in the case of emotional resiliency and cooperation in therapy.

Case workers report that the client is genuinely appreciative of their assistance, particularly in connection with providing competent child care to enable her to pursue her therapy. This client is naturally insightful and readily understands the applicable conceptual connections between her past behavior and the factors that have begun to emerge with respect to some of her past choices and responses.

Detailed Interview Summary Synopsis:

The client has participated extensively in a series of detailed interviews during which she described her newly-recovered traumatic memories as well as other relevant events and circumstances in connection with their specific relation to elements of her past. In many respects, some of her conscious choices and reactions to events in young adulthood were precipitated specifically by the classical effects (Shapiro 1999) of her having repressed traumatic experiences.

The client seems to be benefiting profoundly by virtue of the conceptualization the degree to which her abuse accounts for certain subsequent behavior on her part for which she had previously experienced tremendous guilt and shame.

Detailed Interview Summary:

The client relates a very difficult childhood characterized by emotional abuse, physical abuse, and denial of privacy throughout childhood and adolescence. Both parents continually stressed the obligations of children toward their parents and emphasized the client's role in draining their resources and energy as parents in a manner known to be conducive to the development of shame and indebtedness within families (McPhatter 1991).

Physical abuse was routinely and regularly inflicted on the client under the guise of punishment for breaking the rules of the housed, "shaming" the family or the family's cultural heritage, or embarrassing her parents. Perfectionism was a predominant theme in the family and the client was whipped with leather belts for failing to achieve a grade of "A" on any assignment or test in school. Consequently, the client devoted herself to scholastic achievement but primarily to spare herself from the consequences of any less than perfect grades.

The client was deprived of personal privacy in that her father first removed the locking mechanisms from her bedroom door and from the only bathroom she was allowed to use in the home. Both parents regularly entered her room without knocking or providing any warning of their intentions; they expressed the belief that, as parents, it was their right to know what their daughter was doing at all times and they purposely surprised her by opening her door on their whim while attempting to "catch her" doing wrong. When she improvised a method of locking her bedroom door, her father administered a particularly severe belt whipping and removed the door from its hinges altogether. He also threatened to do the same with the bathroom door if she made any further attempts to secure her own privacy beyond that allowed by her parents. She did not have the benefit of a bedroom door for the last two years of high school.

Without the bedroom door, the client changed her clothes in the bathroom and was often unable to sleep at night because of her father's snoring. The first time her mother confronted her for being wide awake (and reading) in her room in the middle of the night, the client admitted that her father's snoring kept her awake. A few minutes later, her father entered her room and whipped her with the belt for "being disrespectful."

After discovering that alcohol allowed her to fall asleep and sleep through the night, she began drinking vodka at bedtime, which she chose because it was odorless and easy to hide in alternative containers in her room and among the cleaning supplies in the bathroom cabinet.

The client has always recalled the details of her childhood physical and emotional abuse, but until recently, never remembered or even suspected ever having been sexually abused by her father. On the day that her oldest daughter asked for assistance in connection with her first menses, the client entered the bathroom and began to render assistance when she experienced a vivid spontaneous recollection of what she now believes was the last time her father abused her sexually. On that occasion, her father had entered her bed after she was asleep and attempted to penetrate her vaginally with his fingers. She recalls pretending to be asleep and that when her father encountered her tampon, he withdrew his hand and left her bed.

In the first day after that recollection, the client began spontaneously recalling the entire history of her father's sexual abuse which apparently began when she was approximately 10, continuing until the day that her father discovered that she had begun menstruating, after which he simply stopped. During that time, she had learned to feign sleep whenever her father entered her bed.

During her freshman year of college, she was befriended by two upper-class students two years her senior within the first week of school. One of them offered to assist her carrying boxes and luggage from her first dormitory assignment when a single room opened up to her shortly after arriving on campus. Once alone in the room he initiated a sexual advance which she did not desire, but which she felt powerless to resist, freezing" in one of the classic responses of chronic sexual abuse victims (Graziano

1992) and in the same manner that she now recalls doing whenever subjected to her father's sexual abuse.

While she did not reciprocate the student's advances, she did not react when he continued and the encounter culminated with intercourse. It was her first sexual experience. The scenario repeated itself throughout the first month of college and the client recalls "freezing" the same way every time in addition to focusing on a particular light bulb hanging from the ceiling whenever her classmate initiated subsequent encounters. She began avoiding the student but the scenario continued to repeat itself when he began showing up to her room unannounced. On one occasion, he was accompanied by one of the others from the group that had befriended her earlier and both students began participating in the encounters while she continued to freeze for the duration, mainly detaching from her bodily perceptions and staring at the light bulb.

When no complaints or other repercussions resulted from these encounters, all four members of the group began showing up at her door late at night, in various combinations, but usually in pairs. This situation persisted for two full years until all four graduated. Despite the fact that the sexual aspect of these encounters were not forced, they were not consensual either, although she recalls experiencing tremendous shame throughout for allowing four different men to have sexual relations with her.

Initially, the client was relieved when none of the four men were on campus when she returned for her junior year, she recalls also feeling abandoned and she eventually began engaging in sexual affairs with relative strangers that she initiated.

Typically, the men she selected for these affairs had demonstrated rudeness and obvious potential for abusive conduct. Just as typically, they sought to continue more of a relationship, but she resisted those efforts, preferring to limit her relationships strictly to their sexual component. The most common course of those relationships was for her to begin freezing instead of responding to them sexually, in response to which some of the men she dated became frustrated and abandoned her.

Several times, her freezing resulted in intercourse in the same manner as it had with the upperclassmen, but the relationship ended after one or two such consummations.

On two occasions, her sexual partners managed to ingratiate themselves to her beyond their physical relationship, although this required considerable effort on their part. Both of those relationships became verbally and physically abusive and she recalls purposely antagonizing both partners by knowingly creating situations that appeared, in one case, to demonstrate infidelity on her part, and in the other case, to suggest her romantic interest in a mutual acquaintance in whom she actually had no interest at all.

Even at the time (i.e. long before any recollection of childhood sexual abuse by her father) she recognized that she was recreating elements of her relationship with her parents and their perpetual accusations (and punishment for) supposed violations of family rules and other transgressions that were, in fact, false. This too, reflects a common pattern of indirect recreation of unresolved past abuse (Marton 1988).

Prior to the episode with her daughter that triggered the client's first recollection of her childhood sexual abuse, she had no idea as to the origin of her freezing response to undesired sexual advances. Afterwards, she began resisting her former husband's attempts at initiating sexual encounters, which provoked him to abuse her physically, precipitating the calls to law enforcement authorities by her neighbors. At approximately the same time, her own newly-recalled history of abuse and its connection to her onset of menses prompted her to question her oldest daughter about her relationship with her father, whereupon the child disclosed that her father had indeed molested her regularly since the age of eight.

Clinical Assessment and Treatment Goals:

The client has been deeply affected by many different aspects of her psychological history. In terms of issues that relate directly to her referral to social services, she is drawn primarily to men who naturally exhibit potential for abusive conduct to which she was accustomed to when she lived in her parents' home. As is commonly observed among perpetual victims (Goldstein 1995), she is unconsciously repeating patterns of behavior that have a high likelihood of perpetuating the same abuse.

The fact that her memories of early sexual abuse by her father were previously completely repressed, probably contributed very significantly to her tendency to recreate similar situations as an adult. Generally, the less conscious a subject's awareness of specific issues in the past, the greater the unconscious obsession with repeating it, which seems especially true where the abuser was a perpetually critical parent figure (Meyer

1993).

This client was (understandably) emotionally incapacitated by the sudden realization of having been sexually abused by her father for two years. The memories were likely triggered by the relevance in, her own psychological past, of the onset of menses. Initially, she responded in the same pattern that had helped her cope with stress previously, (Reding & Wijnberg 2001). Because of her education and her ability to understand the causal relationship between her past experiences and her choices, she has demonstrated significant progress in conscious behavioral changes. Her prognosis for benefiting further from therapeutic analysis and continued treatment are, therefore, very high.

Treatment goals for this client include addressing past experiences and relating them to future issues. To a great degree, the client's self-esteem has already improved, specifically with respect to the guilt for which she had previously felt responsible for allowing" four men to have regular sexual access to her in college. In treatment, the client has referred to the therapeutic benefit of understanding the mechanism by which she was simply drawn to repeat unconscious response patterns in similar situations. To ensure against any possible future recurrence, she has enrolled in a women's self-defense program. She purposely chose a program that emphasizes retraining victims to develop assertiveness in potential scenarios for victimization. Specifically, it features exercises designed to assist former victims recognize dangerous situations, respond appropriately, and resist any preconditioned responses consistent with being re-victimized in the future.

The client reports that her conscious awareness of her natural tendency to pick partners with many behavioral traits in common with a critical, abusive father has had the beneficial result of enabling her to recognize and purposely avoid such individuals instead of responding to her desire for their approval. Likewise, the client reports that her conscious awareness of sexual abuse by her father justifies her profoundly negative feelings toward him.

Previously, she was ashamed of feeling "unappreciative" of her parents, having consciously accepted the family belief that corporal punishment and harsh criticism were functions of parental love. Since her realization that her negative feelings about her father are justified, she has been able to forgive herself from most of the guilt previously associated with her feelings about her father.

Finally, the client reports that she no longer uses alcohol as a coping mechanism and does not drink at home. She expects to resume drinking socially in the same responsible manner that characterized her alcohol use for the decade prior to her recent traumatic realization about her psychological past. As of this time, she has not participated in social occasions where alcohol is served since her referral to social services and she understands the exercise caution in this area in the future..

Client Status Report:

Presently, the client has resumed her full parental responsibilities at home. She is experiencing the most difficulty in connection with failing to protect her oldest daughter from her former husband, notwithstanding the fact that the circumstances of their respective schedules at the time would have made it impossible for her to do so.

Similarly, whereas the client now understands the causal relationship (Kasl 1989) between her past experiences and her choice of partner, she considers herself partly responsible for what her former husband did to her daughter.

Therefore, in terms of the factors precipitating this client's referral to social services, her recovery and progress toward rectifying their effect on her parenting responsibilities are already satisfactory. Any continuing difficulty is more likely to manifest itself as persistent factors in her perceived responsibility for exposing her children to her poor choice (of husband) and her subsequent decisions, such as failing to report earlier instances of physical abuse, because doing so earlier would have had the effect of removing him from the home before he sexually abused their daughter.

In this regard, her counselors have helped her focus on her complete cooperation with authorities and for providing testimony at her former husband's criminal trial that was ultimately instrumental to his conviction on the sexual abuse charges. In any case, this client is now even more committed to fulfilling her responsibilities as a (single) parent and reports that doing so, even by herself, is easier than was her life before sharing the home with her former husband.