Child Protection Case Study Training Method

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs), quasi-RCTs (i.e. studies in which participants were assigned to intervention or comparison or control groups by a quasi-randomised method such as allocation by date of birth, or similar methods) and controlled before-and-after studies (i.e. studies where participants were allocated to intervention and control groups by means other than randomisation, but take into account baseline measurements of main outcomes; contemporaneous data collection for pre- and post-test intervention periods).

We will include controlled before-and-after studies because studies of educational interventions are often conducted in natural settings where randomised designs are not feasible. We will use explicit study design features rather than study design labels when deciding which types of non-randomised studies to include. We will follow the guidance on how to assess and report on non-randomised studies in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011).

All studies must evaluate the effects of training on at least one of the outcomes listed below. We will examine all designs closely for threats to validity. We will include studies irrespective of publication date, language, type, and status.

Types of participants

Qualified professionals required by law or occupational employment policy to report child abuse and neglect (e.g. teachers, nurses, doctors, and police).

Types of interventions

Included

Child protection training interventions aimed explicitly at improving reporting of child abuse and neglect by qualified professionals, irrespective of programme type, mode, content, duration, intensity, and delivery context. These interventions will be compared with no training, wait-list control, or comparison training not related to child abuse and neglect (e.g. first aid training).

Excluded

Training interventions where improving professionals' reporting of child abuse and neglect is a minor focus, such as brief professional induction or orientation programmes targeting a broad range of employment responsibilities, where it would not be possible to isolate the specific effects of the child protection training component. Child protection training or education conducted before professional qualifications have been obtained, for example, as part of undergraduate college or university-level professional preparation programmes (e.g. initial teacher training, pre-service education for nurses, entry-level medical education, or basic police education).

Types of outcome measures

Primary outcomes
  1. Changes in the number of reported cases of child abuse and neglect:

    • as measured subjectively by participant self-reports of actual cases reported;

    • as measured subjectively by participant responses to vignettes; and

    • as measured objectively in official records of reports made to child protection authorities.

  2. Changes in the quality of reported cases of child abuse and neglect, as measured via coding of the actual contents of reports made to child protection authorities (i.e. in government records or archives).

  3. Adverse events:

  • increase in failure to report cases of child abuse and neglect that warrant a report as measured subjectively by participant self-reports (i.e. in questionnaires); and

  • increase in reporting of cases that do not warrant a report as measured subjectively by participant self-reports (i.e. in questionnaires).

It should be noted that studies using official records, which identify a change in relevant outcomes, such as the number of reports made and the number of reports substantiated after investigation, may indicate improved reporting effectiveness after reporter training but are not themselves determinative. Therefore, analysis and interpretation of such results would not occur in isolation but would also be informed by consideration of other important contextual factors, including: whether the aim of the training was to increase reports of a type of abuse, to decrease reports of another phenomenon, or both; and circumstances surrounding the reporter training such as the introduction of a new duty or the implementation of training as a response to a high profile case or inquiry. Similarly, studies using official records cannot measure some aspects of reporting behaviour such as false negatives (i.e. where a case provided grounds to suspect maltreatment, and the professional suspected maltreatment but did not report).

Secondary outcomes

These include objectively or subjectively measured outcomes closely associated with improved reporting practice, and that may help to account for how the interventions may work.

  1. Knowledge of the reporting duty, processes, and procedures.

  2. Knowledge of core concepts in child abuse and neglect such as the nature, extent, and indicators of the different types of abuse and neglect.

  3. Skill in distinguishing between cases which should be reported from those that should not.

  4. Attitudes towards the duty to report child abuse and neglect.

We will include all primary and secondary outcomes in a 'Summary of findings' table.

Timing of outcome assessment

We will categorise primary and secondary outcomes into three time periods: short-term outcomes (assessed immediately after the intervention and up to 12 months after the intervention); medium-term outcomes (assessed between one and three years after the intervention); and long-term outcomes (assessed more than three years after the intervention).

Search methods for identification of studies

Electronic searches

We will search the following databases.

  1. Cochrane Central Register of Controlled Trials (CENTRAL), part of the Cochrane Library (current issue).

  2. Ovid Medline® (1946 to current).

  3. Embase (embase.com) (1966 to current).

  4. CINAHL (EBSCOhost) (1981 to current).

  5. ERIC (EBSCOhost) (1966 to current).

  6. PsycINFO (EBSCOhost) (1966 to current).

  7. Social Services Abstracts (ProQuest Research Library) (1966 to current).

  8. Science Direct (Elsevier) (1966 to current).

  9. Sociological Abstracts (ProQuest Research Library) (1952 to current).

  10. ProQuest Psychology Journals (ProQuest Research Library) (1966 to current).

  11. ProQuest Social Science (ProQuest Research Library) (1966 to current).

  12. ProQuest Dissertations and Theses (ProQuest Research Library) (1997 to current).

  13. Social Policy and Practice (Ovid) (1860 to current).

  14. Lexis (Lexis.com) (1980 to current).

  15. LegalTrac (GALE) (1980 to current).

  16. Westlaw International (Thomson Reuters) (1980 to current).

  17. Conference Proceedings Citation Index – Social Science & Humanities (Web of Science) (1990 to current).

  18. Database of Abstracts of Reviews of Effects (DARE), part of the Cochrane Library (current issue).

  19. Cochrane Database of Systematic Reviews, part of the Cochrane Library (current issue).

  20. Violence and Abuse Abstracts (EBSCOhost) (all available years).

  21. LILACS (lilacs.bvsalud.org/en/) (all available years).

  22. ClinicalTrials.gov (clinicaltrials.gov/).

  23. World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) (who.int/ictrp/en/).

  24. Australia and New Zealand Clinical Trials Registry (anzctr.org.au/).

  25. OpenGrey (opengrey.eu/).

We will search Ovid MEDLINE using the strategy in Appendix 1, which includes the Cochrane highly sensitive search strategy for identifying randomised trials (Lefebvre 2008). No date or language limits will be applied. We will adapt the strategy for other sources as appropriate.

Searching other resources

To identify studies not obtained by searching the databases listed above, we will carry out additional searches. We will handsearch the following journals.

  1. Child Maltreatment.

  2. Child Abuse and Neglect.

  3. Children and Youth Services Review.

  4. Trauma, Violence and Abuse.

  5. Child Abuse Review.

We will modify the search strategy and apply it to each of these journals.

We will also search a number of key websites for additional studies.

  1. International Society for Prevention of Child Abuse and Neglect via ispcan.org/.

  2. US Department of Health and Human Services Children’s Bureau, Child Welfare Information Gateway via childwelfare.gov/.

  3. Promising Practices Network operated by the RAND Corporation via promisingpractices.net/.

  4. National Resource Center for Community-Based Child Abuse Prevention (CBCAPP) via friendsnrc.org/.

  5. California Evidence-Based Clearinghouse for Child Welfare (CEBC) via cebc4cw.org/.

  6. Coalition for Evidence-Based Policy via coalition4evidence.org/.

  7. Institute of Education Sciences What Works Clearinghouse via ies.ed.gov/ncee/wwc/.

  8. National Institute for Health and Care Excellence (NICE) UK via nice.org.uk/.

Finally, we will handsearch the reference lists of included studies in order to identify further potential studies. We will also contact key researchers in this field for unpublished studies.

Data collection and analysis

Selection of studies

Using reference management software (e.g. EndNote), two review authors (BM, KW) will independently screen titles and abstracts of studies identified from the searches to determine if they meet eligibility criteria. Criteria will include: study design; participants; type of intervention; and types of comparisons. At this stage, we will reject studies if the title and abstract clearly indicate that the report does not meet these criteria. Two review authors (BM, KW) will independently retrieve and assess the full text of studies that appear to meet the eligibility criteria. If insufficient information is provided in the paper to assess eligibility for inclusion, we will contact study authors to provide missing information. We will link together multiple publications and reports on the same study. Where necessary, we will translate studies into English with the assistance of translators. We will resolve differences of opinion regarding the eligibility of a study for inclusion through discussion and consensus. If agreement cannot be reached, we will elicit the opinion of a third author (MK), whereby the final list of included and excluded studies will be decided. We will document primary reasons for study exclusion.

Data extraction and management

We will develop and pilot test a data extraction form based upon the checklist of items from the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Table 7.3a). We will extract data from study reports concerning details of: study design and methods, participants, setting, intervention group(s), control group(s), intervention content and processes, outcome measures, raw data, and data analysis. We will enter this information into Review Manager 2014 and present it in a 'Characteristics of included studies' table for each included study. Two review authors (BM, KW) with different disciplinary backgrounds will independently complete a data extraction form for each study. In the event that a study report lacks relevant information for the study design, we will contact study authors for further details and will record responses. To reduce the risk of overly positive responses, we will use open-ended questions such as "please describe measures used to ….". A third review author will cross-check data collection forms and we will resolve any discrepancies via discussion and consensus.

Assessment of risk of bias in included studies

Two review authors (KW, MK) will independently assess risk of bias for included studies (i.e. the risk that studies may over- or under-estimate the intervention's actual effect) using the Cochrane revised 'Risk of bias' assessment tool (Higgins 2011, Table 8.5a). We will include the tool as a section within the data collection form described above.

The tool consists of seven domains. For randomised studies, we will add an eighth domain, reliability of outcome measures, as we anticipate that some studies may use custom-made instruments and scales. For non-randomised studies only, we will add two further domains: group comparability and contamination.

For each included study, we will judge the relevant domains as 'low', 'high', or 'unclear' risk of bias. We will make our judgements by answering 'yes', 'no', or 'unclear' to pre-specified questions as follows.

1. Sequence generation

Description: the method used to generate the allocation sequence was described in sufficient detail to enable assessment of whether it could produce comparable baseline groups.

Question: do study authors describe a random component in the sequence generation process?

2. Allocation concealment

Description: the method used to conceal the allocation sequence was described in sufficient detail to determine whether allocations could have been predicted before or during the assignment-to-groups process.

Question: do study authors report an adequate method of concealing allocation to intervention or control groups?

3. Blinding of participants and personnel

Description: the methods used, if any, to blind study participants and personnel from knowledge of participants’ group membership were described in sufficient detail to enable assessment of their effectiveness.

Question: do the study authors report an adequate method of participants and personnel from knowledge of participants’ belonging to either intervention or control groups?

4. Blinding of outcome assessment

Description: the methods used to blind outcome assessors from knowledge of participants' group membership were described in sufficient detail to enable assessment of their effectiveness.

Question: do study authors note blinding of outcome assessors from knowledge of participants' belonging to either intervention or control groups?

5. Incomplete outcome data

Description: data on attrition, exclusions, and withdrawals were reported (numbers compared with the total number randomised or as a proportion of the total number randomised, or both), and reasons for incomplete outcome data were provided.

Question: do study authors report missing data, reasons for missing data, and imputation methods?

6. Selective reporting

Description: the study's pre-specified primary and secondary outcomes were reported in sufficient detail to assess their completeness.

Question: do study authors report on all pre-specified outcomes of interest?

7. Other sources of bias

Description: the study was free from other sources of bias such as fraudulence.

Question: was the study free of other problems that could put the study at risk of bias?

8. Reliability of outcome measures

Description: the study outcomes were measured using reliable instruments or scales (Cronbach's alpha of 0.6 or above), and reliability scores were reported or could be found in other publications.

Question: do the study authors report reliability data in sufficient detail to enable its assessment?

9. Group comparability

Description: information on the comparability of groups at baseline was provided in sufficient detail for each outcome measure to enable its assessment.

Question: do the study authors report group comparability at baseline for each of the outcome measures of interest?

10. Contamination

Description: the measures taken to prevent or minimise the possibility that participants in a control group might receive part or all of the intervention were described in sufficient detail to enable assessment of contamination between groups.

Question: do study authors report contamination minimisation measures or ways in which contamination may have been possible (e.g. media reports during a training intervention period)?

Wherever possible, we will use verbatim text from the study reports or correspondence with study authors (appropriately cited) as support for our risk of bias judgments. Review authors assessing risk of bias will not be blinded to the names of the authors, institutions, journals, or results of studies. We will resolve disagreements between review authors by discussion, and where consensus cannot be reached, by consulting with a third review author. For studies in which essential information is not available, we will contact study authors with an open-ended request for missing information (as noted above). We will enter the information into Review Manager 2014 and summarise it in 'Risk of bias' tables for each included study. We will also present two figures: a 'Risk of bias' graph illustrating the proportion of studies for each risk of bias criterion, and a 'Risk of bias' summary graph visually depicting our judgements across all studies. From here, our strategy will be to conduct multiple sensitivity analyses for each outcome to show how results might be affected by our inclusion/exclusion of studies at high risk of bias. We will also provide a narrative discussion of the risk of bias.

Measures of treatment effect

We will report treatment effects for outcomes separately.

Continuous data

We will report continuous data using means and standard deviations (SDs). We will summarise study effects as mean differences (MD) and 95% confidence intervals (CIs) for continuous data where the same scale is used to measure similar outcomes. We will use standardised mean differences (SMD) and 95% CIs where different scales are used to measure the same outcome.

Dichotomous data

We will report dichotomous data with raw counts and rates for intervention and control groups. We will summarise dichotomous data using risk ratios (RR) with corresponding 95% CIs. For the primary outcome, this statistic could be expressed, for example, as the risk of failure to report child maltreatment in the intervention group compared with the risk of failure to report in the control group.

Unit of analysis issues

Cluster-randomised trials

Cluster-randomised trials are widespread in the evaluation of health care and educational interventions (Donner 2002), but they can be poorly reported (Campbell 2004). For included studies with incorrectly analysed data that does not account for clustering, we will adjust sample sizes according to procedures outlined in Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 16.3.4).

Initially, we plan to use an estimate of the intracluster correlation coefficient (ICC) from an included study that adequately accounts for a clustered design and reports an ICC. If no studies directly report an ICC, this value may be imputed from other sources such as studies in similar areas, with similar populations, or meta-analysis of other similar subjects. Recent reviews have compiled a range of empirically-based ICCs for professional development interventions with teachers (Kelcey 2013), and primary care providers (Eccles 2003), and have reported individual trial ICCs of between 0.15 and 0.21 (teachers) and 0.01 and 0.16 (primary care). A suitably conservative approach is to conduct calculations using an ICC of 0.20.

We will adjust study sample sizes according to the ICC using the procedure outlined in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 16.3.4). We will test the robustness of these assumptions in Sensitivity analysis, where we will use at least the two extreme values of ICC reported in the literature for each subgroup of professional. This is important as different assumed values for ICCs will affect the weights assigned to the different trials. Furthermore, we will check if the results of the cluster analyses are similar to or different from that of non-cluster trials. If the results are markedly different we will explore potential reasons and, depending on reasons and number of trials, will report the results separately.

Studies with multiple treatment groups

In trials with multiple intervention groups, control groups, or both, also known as multi-arm studies, we will first determine which intervention groups are most relevant to the review according to the intervention type and outcomes assessed. Where appropriate, we will combine all relevant intervention groups into a single intervention group and all control groups into a single control group, to enable a single pairwise comparison. This will be undertaken using the calculator tool in Review Manager 2014. For dichotomous data, we will sum sample sizes and events across groups. For continuous data, we will combine sample sizes, means, and SDs according to the formula detailed in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 7.7.3.8).

Dealing with missing data

Missing data may be in the form of missing studies, missing outcomes, missing summary data, or missing participants. We do not anticipate missing studies, as our search strategy will be comprehensive and we will take all reasonable steps to locate the full texts of eligible studies.

In studies with missing outcomes (owing to selective reporting) or missing summary data, we will contact first-named study authors via email with a request to provide the data. For continuous data, where possible, we will calculate missing SDs from other test statistics (e.g. t values, F values). In cases where SDs are unavailable and cannot be calculated, we will impute an average SD from other included studies as this method has been found to produce approximately correct results (Higgins 2011, Section 16.1.3.1). We will assess the extent to which this alters results in a Sensitivity analysis.

For studies with participants missing from trial analyses or incomplete outcome data (owing to attrition or exclusion), we will contact first-named study authors via email with a request for further information. If data are available, we will conduct analyses including the participants who were excluded by study authors. If data are not available, we will conduct analyses using available data only and will not impute values. We will report the extent of missing data and approaches to imputation within individual studies in the 'Risk of bias' tables.

Assessment of heterogeneity

To assess the extent of variation between studies, we will examine distributions of relevant participant (e.g. professional discipline), delivery (e.g. classroom), and trial (e.g. type and duration of intervention) variables. Using forest plots available in Review Manager 2014, we will visually examine CIs for the outcome results of individual studies paying particular attention to poor overlap, which can be used as an informal indicator of statistical heterogeneity (Higgins 2011). In Review Manager 2014 we will examine three estimates investigating different aspects of heterogeneity as recommended by Borenstein 2009. First, as a test of statistical significance of heterogeneity, we will examine the Q statistic and its P value. For any observed Q, a low P value provides evidence of heterogeneity of intervention effects (i.e. that studies do not share a common effect size) (Higgins 2011). Second, as an estimate of the magnitude of variation between studies, we will estimate and present Tau² along with its CIs. This will give us an estimate of the amount of between study variation. Third, we will estimate the I² statistic and its CIs, which describes the proportion of variability in effect estimates due to heterogeneity rather than chance (Higgins 2011). These three quantities (Q, Tau², and the I² statistic), along with the appropriate CIs, will give us a good picture of the presence and the degree of heterogeneity among the studies. They are viewed as complementary rather than mutually exclusive quantities. Rather than defaulting to interpretations of heterogeneity based on rules of thumb (i.e. that an I² statistic value of 30% to 60% represents moderate heterogeneity, 50% to 90% represents substantial heterogeneity, and 75% to 100% represents considerable heterogeneity), we will use all three measures of heterogeneity (Q, Tau², and the I² statistic) to fully describe the aspects of variability in the data as detailed in Borenstein 2009. For example, Tau² or the I² statistic (or both) will be used to measure the magnitude of true variation, and the P value for Q or CIs for Tau² or the I² statistic will be used as an indicator of uncertainty regarding the genuineness of the heterogeneity. This provides essential detail for judging the presence and magnitude of heterogeneity. Substantial heterogeneity may render a group of studies unsuitable for meta-analysis. We will further strive to understand the reasons for potential presence of heterogeneity.

Assessment of reporting biases

We will assess reporting bias in the form of selective outcome reporting as one of the domains within the 'Risk of bias' assessments. However, we do not expect to find published protocols for studies included in this Cochrane review to use for comparative purposes.

We will assess publication bias. If there are sufficient studies (at least 10, using the rule of thumb in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011, Section 10.4.3.1)), we will draw funnel plots in Review Manager 2014 to assess the relationships between effect estimates and their standard errors (on a reversed scale). We will use visual inspection in the first instance. If funnel plots are found to be asymmetrical, we will consider possible explanations and take these into account in the interpretation of the overall estimate of treatment effects, including but not restricted to small study effects. If the latter is suspected and there are enough studies present, we will perform both a fixed-effect and a random-effects analysis and we will compare the results, which will aid in the detection of such effect. We note that asymmetrical funnel plots (small study effects) are not always indicative of the presence of publication bias (Higgins 2011).

Data synthesis

We will assess the appropriateness of combining studies based on sufficient homogeneity with respect to: the training interventions delivered (these should be similar in content and method), the study population characteristics (such as professional group), measurement tools or scales used (these should report on similar primary or secondary outcomes), and summary points (outcomes should be measured within comparable timeframes pre- and post-intervention). We will combine data for comparable professional groups (e.g. elementary and high school teachers), and similar outcome measures. We will conduct separate analysis for training type (e.g. online or face-to-face training). We will use meta-analysis to compute pooled estimates of intervention effects for those studies for which data are available and can be appropriately combined.

For those studies for which data can be combined, we will calculate summary statistics (RR for dichotomous data, and MD or SMD for continuous data) and 95% CIs for each outcome. In the meta-analyses, we will first generate fixed-effect models for combining data where we have judged that studies are estimating the same underlying treatment effect. That is, where studies report data on training interventions with analogous contents, or with comparable professional groups, or measured in similar time frames. Fixed-effect models ignore heterogeneity, but are generally interpreted as being the best estimate of the intervention effect (Higgins 2011). If there is evidence of substantial heterogeneity, assessed as above using Q, Tau², and the I² statistic, we will also generate random-effect models, which can account for diversity among studies (by assuming that included studies may not all estimate precisely the same intervention effect), and provide a more conservative estimate of effect (Higgins 2011). We will compare the results of the fixed-effect and the random-effects models to assess the impact of statistical heterogeneity. If results converge, we will report the results of the random-effects models only. If results diverge, we will report the results of both models. Where possible, we will report the clinical significance of the results of the meta-analysis in the results section of the review. If meta-analysis is inappropriate, we will include a narrative overview to qualitatively synthesize the data.

Two review authors (KW, MK) will independently code and categorise intervention contents and the resulting typology will be determined via consensus among all review authors (Marusic 2013).

It should be noted that studies using official records, which identify a change in relevant outcomes, such as the number of reports made and the number of reports substantiated after investigation, may indicate improved reporting effectiveness after reporter training but are not themselves determinative. Analysis and interpretation of such results would therefore not occur in isolation but would also be informed by consideration of other important contextual factors, including: whether the aim of the training was to increase reports of a type of abuse, to decrease reports of another phenomenon, or both; and circumstances surrounding reporter training, such as the introduction of a new duty, or the implementation of training as a response to a high profile case or inquiry. Similarly, studies using official records cannot measure some aspects of reporting behaviour such as false negatives (i.e. where a case provided grounds to suspect maltreatment, and the professional suspected maltreatment, but did not report it).

'Summary of findings' table

We will construct and present a 'Summary of findings' table and will rate the quality of evidence for all primary and secondary outcomes using methods developed by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) working group (gradeworkinggroup.org/index.htm). The GRADE system classifies the quality of evidence in one of four categories: (i) high quality, when further research is very unlikely to change our confidence in the estimate of effect; (ii) moderate quality, when further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; (iii) low quality when further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; or (iv) very low quality, when we are very uncertain about the estimate of the effect. We will consider the following factors when grading the quality of evidence: study design, risk of bias, precision of effect estimates, consistency of results, directness of evidence, and magnitude of effect (Guyatt 2011).

Subgroup analysis and investigation of heterogeneity

We will investigate any heterogeneity observed in the results of included studies. If there is enough available comparable data, that is at least 10 studies (Higgins 2011, Section 9.6.5), we will undertake the following subgroup analyses:

  • training method (face-to-face or online);

  • training delivered by specialist or non-specialist trainers;

  • training duration (single or multiple sessions); and

  • time of study (less recent or more recent studies).

We will assess the differences between subgroups by inspection of the CIs which, if not overlapping indicate a statistically significant difference in training effects between the subgroups. We will also examine and report interaction effects using analysis of variance (ANOVA).

Sensitivity analysis

We will perform a sensitivity analysis to test the robustness of decisions made in this Cochrane review. We will do this first by separating randomised from non-randomised studies, and second by separating cluster-randomised studies where there are concerns about failure to adjust for clustering. We will also perform a sensitivity analysis to explore the impact of study quality by removing studies from specific outcome analyses assessed to be at high risk of bias on the domains most relevant to each outcome (including other sources of bias identified for this review, such as reliability of outcome measures). Where feasible, we will treat studies judged to be at low risk of bias as a separate group. In a series of sensitivity analyses, we will explore how the results of meta-analyses might be affected by excluding unpublished studies (i.e. theses), and studies with selective outcome reporting. If the analysis of heterogeneity finds outlying studies with results that appear vastly different from other included studies, we will perform a sensitivity analysis to assess the effect on the results of meta-analyses. We will also conduct a sensitivity analysis to assess the impact of imputing missing data (e.g. SDs and ICCs as outlined above).

These materials provide opportunities to develop and enhance application skills. Each case involves the integration of content across modules, and may be revisited throughout the course of training. The cases present issues encountered in social work practice related to the prevention and treatment of alcohol use disorders. None of the names or descriptions identifies existing individuals or programs.

A social work educator should facilitate the discussions to accomplish the following problem-solving steps:

1. Identify and sort through the relevant facts presented in a case

  • "What is actually happening here?"

2. Identify the problems and issues that arise in a case

  • "What has gone wrong in this situation?"
  • " "What needs to be addressed in order to improve the situation?"

3. Identify the positive and strength aspects of the situation

  • "What has gone right so far?"
  • "What positive elements exist in this situation?"

4. Analyze the issues in terms of knowledge presented in the training modules

  • "What are the factors that are likely related to this situation?"
  • "How do these factors have their influence on the situation?"

5. Use training materials to develop a list of options and an initial plan of action

  • "What has been shown to work in these kinds of situations?"
  • "What options are available?"
  • "What are the likely results of each option?"

6. Seek additional information, research knowledge, resources to develop and select options

  • "What else do we need to find out to make a viable plan?"
  • "Where can we go to get this information?"
  • "What did you find out when you sought this information?"

7. Develop a concrete strategy

  • "What can be tried over the next week/month?
  • "What should be tried in 6 months?"

8. Identify methods for evaluating the outcomes and revising the plan

  • "How will you know if the plan is being implemented adequately?"
  • "How will you know if the plan is working?"
  • "How will you revise the plan based on different possible outcomes?"


TIPS FOR FACILITATING CASE LEARNING

(adapted from McWilliam, 2000)

  • Cases do not have "right" and "wrong" answers-they are dilemmas and complex situations. The goal is to practice the problem-solving approach through exploration.

  • Guide the discussion through the use of open-ended questions
  • Allow the students/trainees to develop the answers to questions (i.e., don't provide them with the answers and be nonjudgmental about what they say to keep them open to working it through)
  • Encourage students/trainees to discuss with each other, rather than with you (this is most likely if students are working in groups of 4-6 persons each with the facilitator circulating)
  • Use visual aids (flipcharts, overheads, storyboards, etc.)
  • Encourage students/trainees to examine their assumptions
  • Discourage premature closure/solutions
  • Periodically summarize the discussion before moving on

 

Reference

McWilliam, P. J. (2000). Instructors Guide for Lives in Progress: Case Stories in Early Intervention. Baltimore, MD: Paul H. Brookes.


List of Cases

Case 1. The Olivares Family
Case 2. Casey
Case 3. Marcel
Case 4. Sam
Case 5. Steven
Case 6. Alexia
Case 7. Jaclyn
Case 8. Robert
Case 9. Ms. Cook
Case 10. Dave
Case 11. Sal
Case 12. Catherine
Case 13. Coordinated Care Systems (Macro)
Case 14. Mapledale School System (Prevention)
Case 15. Robert

CASE 1. THE OLIVARES FAMILY

Joaquín Olivares, a 38-year-old Mexican immigrant, and his 35-year-old wife presented to a family services agency with the complaint of "family problems." The Olivares have been married for twelve years and they have two children (a son aged 6 and a daughter aged 8). They have lived in the U.S. for eight years. He worked as a machine worker in a factory for five years before being recently "laid off." He presently works as a day laborer. Mrs. Olivares works as a housekeeper for a family.

Mr. Olivares complains that his wife has recently started "to nag" him about his drinking. He admits that during the last few months he has increased his intake of alcohol, but denies that this is a problem for him, as he drinks "only on the weekends, and never during the week." He drinks every weekend, but is vague about the actual amount.

Mr. Olivares and his wife speak of the difficulties they experience in living in the U.S. Neither speaks much English. Mr. Olivares admits to being quite worried about his previous lay off, adding that he didn't want to "let the family down" in his responsibilities. As a result, he works long days in order to make ends meet. His weekend drinking is, for him, his way of relaxing, which he feels that he deserves.

1. Identify and sort through the relevant facts presented by the Olivares.
2. Identify the problems, issues, concerns that arise with the Olivares.
2a. How would you classify Mr. Olivares' drinking?
3. Identify the positive and strengths aspects of the Olivares' situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with the Olivares.
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with the Olivares. Be sure that you have a concrete and specific strategy for how you would address alcohol-related issues with the Olivares. Consider what kinds of reactions you might expect from each of the Olivares, and develop a plan for how to respond to them. What kinds of referrals in your practice community would you make and why? What are the intervention goals?
7a. Does the Olivares' original nationality matter to the case?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with the Olivares' situation.

CASE 2. CASEY

Casey, a 24-year-old Caucasian woman, is seeking counseling for anxiety and depression that she attributes to problems in her current relationship. She and her partner have been having an increasing number of arguments recently, typically about Casey's behavior when they go out and about Casey drinking too much.

In response to questions about her use of substances, Casey describes herself as a "social drinker." Her typical pattern is to consume 3-6 drinks during each of 2-3 drinking occasions per week. She began drinking regularly (1-2 times per week) and heavily (to intoxication) at the age of 13, usually in the company of an older cousin or school friends. She continued this pattern through high school but cut back during her first two years of college due to lack of money to buy alcohol and more difficult access.

During her junior and senior years, Casey "came out" as a lesbian to her parents and family. She also resumed drinking heavily. After graduation from college, Casey and her partner of 3 years (Angie, age 24) moved into an apartment together, as both began working full-time. Casey and Angie are "out" at work and with both families of origin.

Casey reports that they both decreased their drinking at this point, due to concerns about their finances and interest in starting their new careers. Both partners gradually increased the frequency and quantity of their drinking, as they became involved with a social group of older (late 30's) lesbians and began routinely going to a gay bar.

1. Identify and sort through the relevant facts presented by Casey.
2. Identify the problems, issues, concerns that arise in Casey's situation.
2a. How would you classify Casey's drinking?
3. Identify the positive and strengths aspects of Casey's situation
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for intervention with Casey. Who should be included in your work with Casey, and why? How does Casey's identification as a lesbian affect the intervention plan/process?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Casey. Be sure that you have a concrete and specific strategy for how you would address alcohol-related issues with Casey. Consider what kinds of reactions you might expect from her, and develop a plan for how to respond to them. What kinds of referrals in your practice community would you make and why? What are the intervention goals?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Casey's situation.

CASE 3: MARCEL

Marcel is a 21-year-old African-American man, self-referred for inpatient treatment due to drug and alcohol abuse. He is currently unemployed, homeless, and has charges pending due to a number of "bounced" checks written over the past several months. Marcel reports that both of his parents were drug addicts and he experienced physical, sexual, and emotional abuse throughout childhood at their hands. His father died of liver disease at the age of 37.

Marcel also reports that at the age of 14, he was kicked out of his family's home because his father suspected that he was gay. Although they live in the same town, he has not had any contact with either parent for 7 years. Marcel describes his relationship with his older sister as "fair." Marcel is not presently involved in a steady relationship, but does have a network of friends in the local gay community with whom he has been staying off and on. At the time that he left home, Marcel survived by becoming involved in sexual relationships with older men, many of whom were also abusive. He has had numerous sexual partners (both male and female) over the past 7 years, has traded sex for drugs and money, has had sex under the influence of drugs and alcohol, and has been made to have sex against his will. Marcel identifies himself as bisexual, not gay.

Marcel first used alcohol at age 14, when he had his first sexual encounter with a man. He began using other drugs, including inhalants and marijuana by age 16 and amphetamines and cocaine by age 19. At 21, four months prior to entering treatment, he began using crack.

1. Identify and sort through the relevant facts presented by Marcel.
2. Identify the problems, issues, and concerns that arise in Marcel's situation.
2a. What are the most immediate and critical assessment needs?
3. Identify the positive and strengths aspects of Marcel's situation
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for intervention with Marcel. Who should be included in your work with Marcel, and why? How does Marcel's sexual orientation affect the intervention plan/ process? What is your reaction to his being bisexual? How do Marcel's age and ethnicity figure into the picture?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for practice with Marcel. Be sure you have a concrete and specific strategy for how you would address alcohol-related issues. Consider what kinds of reactions you might expect from him, and develop a plan to respond to them. What kinds of community referrals would you make and why? What are the intervention goals?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Marcel's situation.

CASE 4. SAM

You are part of an ethnographic research team with the goal of helping the U.S. Census Bureau find better ways to count the population of homeless individuals and families. Over 12 months, the team has been closely following 156 households as they move in and out of various homeless situations (see Glasser, 1991). In the course of the project, the team has had over 45 separate recorded contacts with an African American man in his fifties, named Sam.

Sam used heroin, cocaine, and alcohol. He suffered from chronic liver disease and various intestinal ailments. He was evicted from public housing because "they didn't like my friends" (referring to the drug dealers) and he was "persona non grata" at the local single room occupancy (SRO) hotel. When the team first met Sam he was sleeping at friends' apartments and in the hotel lobby. A frequent fear of Sam's is that he would fall asleep and be robbed.

The research team became advocates in Sam's quest for housing. At the suggestion of a team member, Sam spent several weeks in a local shelter, but the nuns asked him to leave when he wanted to keep his bed, but spent nights outside of the shelter. The team helped him to get a security deposit that was needed for an apartment. One of the team members went to look at rooms with Sam, and after a full ten months, they found a landlord who would accept him. One of the team members, a fourth year medical student, often called the local hospital to find out the results of laboratory tests for Sam. The team also paid for Sam's birth certificate, which he had lost a long time before, but needed for access to some forms of housing.

Through the 12 months of the study period, Sam went from sleeping in lobbies, at friends' places, in a shelter, and finally in his own room. At the end of the 12 months, Sam told the team that he was very worried about his health because he kept passing out. He said that he was not using "a lot" of drugs or alcohol, but he was not abstinent. He still had his own room.

1. Identify and sort through the relevant facts presented by Sam's situation.
2. Identify the problems, issues, and concerns that arise with Sam's situation.
2a. How would you classify Sam's homelessness?
2b. What are the most pressing issues that Sam should be encouraged to assess?
3. Identify the positive and strengths aspects of Sam's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Sam, given your current role.
6. Identify any additional information, research knowledge, or resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Sam. Be sure that you have a concrete and specific strategy for how you would address issues with Sam. Consider the reactions you might expect from Sam, and develop a plan for how to respond. What kinds of referrals in your practice community would you make and why? What are the intervention goals?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Sam's situation.

CASE 5. STEVEN

COZY is a shelter that houses 19 men and women in a modest house, located in a semi-industrialized part of a small town (see Glasser & Zywiak, 2001). The building was last used as a pizza parlor, and people still come in asking for pizza. The shelter also houses a community soup kitchen and seven additional "Transitional Program" beds for people who stay for up to two years. The people who stay at COZY feel as if they have finally arrived in a place of safety. They feel secure and can sleep safely at night. As a result, they also feel that they can finally begin to address some of their problems.

Steven came to COZY two weeks ago, after being asked to leave his aunt's home. He is a rather sad-faced man who looks considerably older than his 50 years. Steven says that he has been drinking heavily throughout all of his life, and that he also used drugs a lot in Vietnam. He has a son living nearby whom, he is sorry to say, also appears to be a heavy drinker. Steven is very proud of his daughter (she is a teacher), and wishes that he could see his grandchildren more often.

Steven is very grateful to the staff at COZY because in the two weeks that he has been with them, they took him to get a cataract operation and he could immediately see again. They are also helping him sort out his legal problems, since he did not show up for some court hearings. Steven feels that he could stay sober if he could stay in a place like this. He is applying for their transitional program.

1. Identify and sort through the relevant facts presented by Steven's situation.
2. Identify the problems, issues, and concerns that arise with Steven's situation.
2a. How would you classify Steven's homelessness?
3. Identify the positive and strengths aspects of Steven's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Steven.
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Steven. Be sure that you have a concrete and specific strategy for how you would address alcohol issues with Steven. Consider what kinds of reactions you might expect, and develop a plan for how to respond to them. What kinds of referrals in your practice community would you make and why? What are the intervention goals?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Steven's situation.

CASE 6: ALEXIA

Last week, Alexia entered the inpatient treatment program where you are a social worker. She is being treated for alcohol and cocaine (crack) dependence. Alexia is a 32-year-old, divorced woman who is employed as an administrative assistant at a local human services program. She lives with her 11-year-old daughter, Christine, in an apartment located near her job. Although she makes a relatively low salary, Alexia has managed to support herself and her daughter without financial support from Christine's father. Alexia was married briefly to Christine's father when she was 20, but she left him after he became physically and sexually abusive toward her. He also was an alcoholic. She had almost no contact with him for many years. Her mother, a widow, is a strong support for Alexia and Christine, as are two cousins, Denise and Moira. Alexia reports growing up in a "normal middle class family" and states that her childhood was "good" despite her father's occasional drinking binges, which she says were related to him celebrating a special account he had landed (he was in advertising), and her mother's "occasional bad depressions." She is the youngest of five children and the only girl.

Up until a month ago, Alexia was regularly attending twice-weekly treatment sessions at an outpatient chemical dependency clinic, and she went to AA/NA regularly 3 times a week. She had a sponsor and they kept in touch several times a week-more, if needed. From the beginning of recovery, Alexia has experienced some mild depression. She describes having little pleasure in life and feeling tired and "dragging" all of the time. Alexia reports that her difficulty in standing up for herself with her boss at work is a constant stressor. She persisted with treatment and AA/NA, but has seen no major improvement in how she feels.

After Alexia had been sober for about 3 months, an older boy sexually assaulted Christine after school. Alexia supported Christine through the prosecution process; the case was tried in juvenile court and the boy returned to school 2 months later.

After Alexia celebrated her 6-month sobriety anniversary, she reports that she started having a harder time getting herself up each day. Around this same time, she returned to drinking daily. She says that she then started experiencing bouts of feeling worthless, sad, guilty, hopeless, and very anxious. Her sleep problems increased, she began having nightmares, and she lost her appetite. After a month of this, she started attending AA/NA and treatment less often, instead staying home and watching TV. She started her crack use again one night after her boss got very upset with her not finishing something on time. She went to a local bar after work that day and hooked up with a guy she met there to get crack. In accompanying him to a local dealer's house to get some crack, she was raped by several men. Alexia did not return home that night (Christine was at a friend's sleepover party) and did not show up for work the next day. She does not recall where she was the rest of that night. However, later that day she admitted herself to your treatment program.

Alexia reports that she began drinking regularly (several times a week) around the age of 13. She recalls having felt depressed around the same time that she began drinking heavily, although she states she has very few clear memories of that time in her life. Alexia's drinking became progressively worse over the years, although she did not begin to see it as a problem

until after she began using crack, at around age 28. She reports feeling depressed over much of her adult life, however her depression got much worse after she began using crack daily.

Alexia reports having had a lot of gynecological problems during her 20s, resulting in a hysterectomy at age 27. When asked if she was ever physically or sexually abused as a child, she says no; however, she confesses (with some difficulty) that when she was 11, she had an affair with her 35-year-old uncle (father's brother-in-law).

Now, one week into treatment, Alexia reports feeling numb and tense. She talks only in women's treatment groups and, then, only when specifically asked a question. She feels hopeless about her ability to put her life together and says that she only sees herself failing again to achieve sobriety. Of her recent rape, she says that she "only got what she deserved" for being in the wrong place with the wrong people at the wrong time. Alexia reflects that she was unable to adequately protect her daughter from sexual assault, and she speculates that maybe she is an unfit mother and should give up custody of her daughter. While Christine is currently staying with Alexia's mother, Alexia is concerned that her ex-husband will try to get custody of Christine if he hears that she is in the hospital for alcohol and drug treatment. He has been in recovery himself for two years and began demanding to see Christine again about 2 months ago.

1. Identify and sort through the relevant facts presented by Alexia.
2. Identify the problems, issues, and concerns that arise with Alexia's situation.
2a. What are the most pressing issues that Alexia should be encouraged to assess and address?
3. Identify the positive and strengths aspects of Alexia's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Alexia. Who should be involved in the intervention for Alexia? Who should also be referred for intervention?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Alexia. Be sure that you have a concrete and specific strategy for how you would address alcohol issues. What are the intervention goals? Following inpatient treatment, what kinds of referrals in your practice community would you make and why?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Alexia's situation.

CASE 7: JACLYN

Jaclyn is 23 years old and is four months pregnant. She is visiting a comprehensive "wrap around services" health clinic for prenatal care for the first time. The medical team advises prenatal nutritional counseling and vitamins, and assesses her pregnancy as "progressing normally" at this stage. However, she has been referred to you because in the health assessment she responded that she has "always" consumed one or two drinks, almost every day, when she comes home from work to unwind from the stress of her job. There are also social events on weeknights and weekends with family and friends that typically involve light to moderate drinking.

1. Identify and sort through the relevant facts presented by Jaclyn's situation. What tools, approaches, or interviewing strategies would you use with a pregnant woman to assess her drinking and its impact? What other issues should be assessed, as well?
2. Identify the problems, issues, and concerns that arise with Jaclyn's situation.
2a. What information should you be certain is shared with Jaclyn?
3. Identify the positive and strengths aspects of Jaclyn's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Jaclyn. Who should be involved in the intervention for Jaclyn?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Jaclyn. Be sure that you have a concrete and specific strategy for how you would address alcohol issues with Jaclyn. What are the intervention goals? What kinds of referrals in your practice community would you make and why?
7a. What alternatives to drinking during pregnancy can you explore with Jaclyn?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Jaclyn's situation.

CASE 8. ROBERT

Robert is a 32-year-old businessman who was involved in a car accident on his way home after having a couple of drinks at the local bar. He was referred for evaluation and treatment because at the time of the accident, his blood alcohol test showed .09, which was above the legal limit. He is overweight and tends to have high blood pressure. He grew up in the neighborhood where he and his wife now live. They have two children, ages 6 and 4 years. Robert has several childhood friends who come to the bar, almost every day during the week, to have drinks and socialize. His father is also a frequent visitor to the bar, and has been for the past 40 years. Robert's father drinks 4 to 5 drinks when he is at the bar, but he does not seem to have any significant problems related to drinking, except for his hypertension. Robert drinks 3 to 5 beers at the bar, but he does not feel that he has any drinking problems because he does not drink at home except for wine with his evening meal.

1. Identify and sort through the relevant facts presented by Robert's situation. What tools or interviewing strategies would you use to assess his drinking and its impact? What do you assess his drinking risk to be? Why?
2. Identify the problems, issues, and concerns that arise with Robert's situation.
2a. What information should you be certain is shared with Robert? Why?
2b. What is your advice to Robert concerning his drinking? Why?
3. Identify the positive and strengths aspects of Robert's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Robert. Who should be involved in the intervention for Robert?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Robert. Be sure that you have a concrete and specific strategy for how you would address alcohol issues with Robert. What are the intervention goals? What kinds of referrals in your practice community would you make and why?
7a. What alternatives to drinking can you explore with Robert?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Robert's situation.

CASE 9: MS. COOK

Ms. Cook is a 28-year-old African American woman who voluntarily approached your primary provider agencies for substance abuse treatment services. She is currently on probation for shoplifting, passing bad checks, vandalism, and parole/probation violations. She has been charged four times with disorderly conduct, once for fishing without a license, and twice for driving without a license (she never applied for one). She is currently awaiting trial for battery. Ms. Cook has been incarcerated twice during her adulthood (once for 10 months and, most recently, for 10 days).

The results of an AUDIT-13 screening suggested that she was binge drinking weekly during the past year. The screening also determined that, because of drinking/drug use, she had injured herself (2 falls requiring medical care) and someone else (killed the cat by accidental poisoning), and that others had recommended that she seek help. Screening for co-occurring problems using the MPSI-A indicated potential depression and other psychological distress. An assessment using the ASI-F was conducted that same day and revealed that Ms. Cook was currently living with her grandmother, who had raised her. She is the mother of four children (ages 11, 7, 4, 2 years-she was 17 at the birth of her first child). The older two sons are living in foster care. The younger two daughters have complex health problems and developmental delays; they live with another relative. She is no longer in contact with any of the children's fathers (three men), and was only briefly married to the second man. She reported that both of her parents, several uncles and aunts, and both of her siblings all have significant drinking and/or drug use problems. She has no close friends and a distant, conflicted relationship with family members other than the grandmother with whom she has almost always lived. She has great difficulty in "getting along" with people. She was physically abused as a child, which prompted her move to the grandmother's home. Ms. Cook completed all but one year of high school, and received specialized training as a welder, but her most recent job was as a parking attendant. Her longest period of continuous employment was just over one year, and she has worked irregularly throughout her adult life. She describes her present health as "good" and she has a history of depression, anxiety, hallucinations, cognitive and memory deficits, and violent behavior. She has never received psychiatric care.

Ms. Cook identified her primary problem as alcohol use, along with regular marijuana (smoking and eating). She began drinking at age 14 and using marijuana at age 17; she began using crack cocaine from the time she was 22. She has been detoxed on three separate occasions. The longest that she has gone without using any substances was 60 days; she resumed using approximately two months ago. Ms. Cook reported that she was extremely troubled and concerned about her substance use and that seeking treatment is very important to her.

1. Identify and sort through the relevant facts presented by Ms. Cook's situation.
2. Identify the problems, issues, and concerns that arise with Ms. Cook's situation.
2a. What are the most pressing issues that Ms. Cook should be encouraged to address?
3. Identify the positive and strengths aspects of Ms. Cook's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Ms. Cook.
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Ms. Cook. Be sure that you have a concrete and specific strategy for how you would address issues with Ms. Cook. What are the intervention goals? How should the service plan be developed and implemented?
7a. What are the various service components with which Ms. Cook is/should be involved and that must be coordinated? How will they be coordinated? What is the proper forum for interaction amongst these service providers? Who should be involved?
7b. What services are needed but not being received? How will they be obtained?
7c. What are the appropriate roles of each service component?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes. Who should be responsible for monitoring the service plan?
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Ms. Cook's situation.
10. How would the situation be different if Ms. Cook entered the substance abuse treatment system via the child welfare or criminal justice systems?

CASE 10. DAVE

Dave is a 38-year-old small-parts factory worker who came into the treatment center after being arrested for drinking and driving (DUI/DWI). His attorney has suggested that he quit drinking and enter treatment, at least until his trial which is scheduled in two months. Dave does not anticipate serving jail time, but he believes that treatment could strengthen his legal case. After his first arrest for DUI two years ago, he simply paid a fine and attended a special driver's education program for six weeks. Dave found the program to be "a waste of time."

Dave has been married for 10 years and has two sons aged 8 and 6 years. He has had numerous arguments with his wife, Melanie, concerning his drinking. He gets very angry and defensive when she confronts him about his heavy drinking, and asserts that he is not an alcoholic. He knows this is true because his father was an alcoholic and Dave says that he is not like his father. His father died as the result of a fight that occurred in traffic when he was drunk. Dave says that his father used to "beat the tar out" of him and his brother when he was drunk, and that his father always belittled, taunted, and threatened their mother, whether he was drunk or sober.

Dave's work history is very good; he misses less than one day per year. He works the day shift on weekdays, putting in time-and-a-half overtime on most Saturdays. He is well regarded by his supervisors and peers at work. He is fearful that his employer will find out about his treatment (it is being covered by his HMO), and that people at work will learn about the second DUI arrest.

Dave drinks with his buddies from the plant, and does not think that his drinking is any more than what they do. He was just "unlucky" and got caught doing what everyone else seems to get away with. Dave's drinking is very predictable: he drinks 8 or 9 beers on a weeknight. Several of these are consumed at the bar with friends, the remainder at home over the course of the evening. He usually falls asleep in front of the television. On weekends, he often drinks 3-4 twelve packs between Friday and Sunday. A typical Saturday involves getting up at 10:00 a.m., playing soccer with friends, and going to the bar for the rest of the day and night. This pattern leads to arguments with Melanie, who calls him a "lousy father." At times, Dave has had unsettling episodes of being unable to recall what happened while drinking. He has commented to friends that "maybe I overdo it a bit." Several times, he has attempted to cut down on his drinking, especially after the last DUI. He once attended a few AA meetings, but did not feel that it was helpful: "It was listening to a lot of guys whining" and he especially did not care for the prayers.

Despite these attempts, Dave has experienced increased consumption levels over the past two years. He admits that, as a result of the drinking, he has become increasingly estranged from his wife and sons. Dave feels that his marriage has been basically good, but that he would not blame Melanie for leaving him, the way things have been going lately. She will no longer "sleep" with him while he is intoxicated, which occurs regularly. She complains that the house is "falling apart" because Dave does not keep up with his chores. He believes that his marriage would become solid again, if he stopped over doing the drinking. But, he complains about her hassling him about the alcohol.

Dave is not close to his remaining family members. His mother is very religious and wishes Dave would see religion as a way out of his problems. His siblings live in other communities and they rarely get together. His wife and sons regularly attend his mother's church, but Dave only attends on Christmas Eve and Easter Sunday.

Dave is distraught about having to remain abstinent in preparation for the trial. He has trouble getting to sleep without alcohol. He also "gets jumpy" when he tries to stay away from drinking, feeling "closed in" or "like he is suffocating." He also cannot imagine how to explain to his buddies why he is not joining them in the bars.

1. Identify and sort through the relevant facts presented by Dave's situation. What tools or interviewing strategies would you use to assess his drinking and its impact? What do you assess his drinking risk to be? Why?
2. Identify the problems, issues, and concerns that arise with Dave's situation.
2a. What information should you be certain is shared with Dave? Why?
2b. What is your advice to Dave concerning his drinking? Why?
2c. How would you assess motivational issues prior to and during the course of intervention with Dave?
3. Identify the positive and strengths aspects of Dave's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Dave. What are reasonable outcomes to be expected with Dave? Who should be involved in the intervention for Dave? Why?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Dave. Be sure that you have a concrete and specific strategy for how you would address alcohol issues. What are the intervention goals? What kinds of referrals in your practice community would you make and why?
7a. What measures and procedures would you employ to formulate and negotiate goals with Dave?
7b. How would you apply motivational, cognitive behavioral, and relationship therapy approaches with Dave?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Dave's situation.
10. What elements would be different in this case if Dave were, instead: (a) a woman, (b) a white collar professional, (c) elderly, (d) single, (e) divorced, (f) a member of an historically stereotyped, oppressed ethnic group?

CASE 11. SAL

Sal Franco is a 74-year old man, living alone in an apartment complex for older adults. You are the Senior Services social worker associated with the housing units. Sal and his wife, Maria, owned and operated a small, local grocery for 44 years (they emigrated from Italy when they were newlyweds at age 19). They sold the business to their son Dominic when Sal turned 70. The plan was to enjoy travel and retired life together. However, shortly after retiring, Maria was diagnosed with an aggressive leukemia, and she died within 4 months. Mr. Franco has been living alone for over 3 years. Because Sal and Maria spent most of their time working and involved with family activities, there are few close friends in his life. Dominic's family has Sal to dinner every Sunday, but has little time during the week because of competing demands. Sal's other children include a daughter living in another state who calls daily (but seldom visits because of the cost), a daughter oversees in military service, and a son with Down's Syndrome who lives in a group home about an hour away.

Sal indicates that he was a "hard drinker" during his 20s and 30s, when he developed stomach problems and high blood pressure. At that point, he limited his use of alcohol to his Friday night poker club and to Sunday dinner with the family. Since Maria's death, Sal has regularly consumed 3 to 4 drinks a day. He says it alleviates some of the pain, stress, and loneliness. It also helps him sleep, along with the over-the-counter medications that he takes for arthritis pain and as sleep aides. He came to the clinic because his hypertension and gastritis have become extremely labile and intractable. When you ask Mr. Franco how he is doing, he says, "Oh, I guess I'm okay for an old widower. I don't think it really matters how I feel or what I do anymore at my age."

1. Identify and sort through the relevant facts presented by Sal Franco's situation. What tools would you use to assess his drinking and its impact? What do you assess his drinking risk to be? Why?
2. Identify the problems, issues, and concerns that arise with Sal's situation.
2a. What information should you be certain is shared with Sal? Why?
2b. What is your advice to Sal concerning his drinking? Why?
2c. What other assessments need to be conducted? Why?
3. Identify the positive and strengths aspects of Sal's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Sal. Who should be involved in the intervention for Sal?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for social work practice with Mr. Franco. Be sure that you have a concrete and specific strategy for how you would address alcohol issues with him. What are the intervention goals? What kinds of referrals in your practice community would you make and why? What additional activities would you help him initiate?
7a. What alternatives to drinking can you explore with Sal?
7b. What other services or programs should be engaged for Sal? How?
7c. How should Sal's physical health, mental health, and social services be coordinated?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Mr. Franco's situation.

CASE 12. CATHERINE

Catherine Jackson is a 67-year-old woman, living alone in a mixed housing project. For the past month, she has received visiting nurse services from your agency. These services were assigned to her upon discharge from the hospital with a diagnosis of anemia and uncontrolled adult-onset diabetes. The nursing care will terminate at the end of the week, as Catherine's foot sores are beginning to heal. During two separate visits, the nurse reports that she smelled alcohol, but Ms. Jackson did not appear to be intoxicated. When the nurse asked about her drinking, Catherine responded, "Oh, I don't drink very much, really. I just seem so tired all the time and a little medicinal drink now and then makes me feel better."

A homemaker visits Ms. Jackson two times per week. In addition, she has an elderly friend nearby, and the two women visit with each other daily. However, for the past two months, Catherine has been unable to leave her apartment because of her poor health. The homemaker states that she has, on several occasions, had to launder Ms. Jackson's bedding and sleep wear because of vomit on them. She also takes out the trash, which contains varying numbers of empty hard liquor bottles each time. The homemaker complains that Catherine is not cleaning herself very well, and that she and the apartment smell bad. She doesn't want to keep working there, and wants to be reassigned to someone else.

1. Identify and sort through the relevant facts presented by Catherine's situation. What tools or interviewing strategies would you use to assess her drinking and its impact? What do you assess her drinking risk to be? Why?
2. Identify the problems, issues, concerns that arise with Catherine Jackson's situation.
2a. What other assessments need to be conducted?
2b. What is your advice to Catherine concerning her drinking? Why?
3. Identify the positive and strengths aspects of Catherine's situation.
4. Analyze the issues in terms of knowledge presented in the training modules.
5. Use training materials to develop a list of options and an initial plan of action for social work intervention with Ms. Jackson. Who should be involved in the intervention for her?
6. Identify any additional information, research knowledge, and resources that are needed to develop and select options; identify ways to gather what you need; gather what you can.
7. Develop a strategy for practice with Catherine Jackson. Be sure that you have a concrete and specific strategy for how you would address alcohol issues with her. What are the intervention goals? What kinds of community referrals would you make and why?
7a. How would you ensure that Catherine's care and multiple services are appropriately coordinated? Who should be in charge of coordination?
8. Identify methods for evaluating outcomes of your plan and next steps/revisions of the plan, depending on various possible outcomes.
9. Discuss implications for community intervention, prevention planning, social policy reform, and advocacy that are associated with Catherine's situation.

CASE 13: COORDINATED CARE SERVICES (MACRO)

Your State Chapter of NASW is hosting a one-day "round table" session to which members of substance abuse treatment and advocacy agencies are invited, and you are the chairperson. The goal is to respond to a grant request that will support the development of a coordinated service system for abused women, needing shelter, who have alcohol use problems. The first set of tasks includes:

  • Identify the necessary participants (service providers) of the coordinated system;
  • Determine who will be responsible for the prescreening, screening, assessment, treatment, and evaluation responsibilities;
  • Determine who will make referrals, to whom they will make them, and under what circumstances;
  • Identify the community service partners that will serve as additional resources, act as supportive adjuncts, and will also serve as entry points by conducting the appropriate prescreening assessments for clients that come to them (e.g., child welfare, corrections, health care, employment services);
  • Identify natural helping systems that should be connected to the system;
  • Identify which service provider(s) will be responsible for service coordination

Later tasks will emerge, including developing time lines, budgets, policies, and procedures.

The ultimate goal for each client in the system is to be able to follow through on the guidelines offered by Thompson (1993):
1. List all services that the client receives from each agency involved;
2. Identify key agencies and services needed but not represented;
3. Establish a contact person within each agency;
4. Agree on a structure for the case planning group;
5. Define the roles and responsibilities of each agency;
6. Monitor the implementation of the care plan;
7. Periodically evaluate the relevance and effectiveness of the plan.

CASE 14. MAPLEDALE SCHOOL SYSTEM (PREVENTION)

You have been asked to consult with a group from the Mapledale School system, comprised of business people, police, social workers, teachers, parents, administrators, and student representatives (Middle School, High School, and Community College). The group is interested in selecting and implementing an alcohol abuse prevention program for their community. They want you to advise them on how to go about selecting the best program(s) to invest in-they are not interested in having you pick their programs, only in advising them as to what to look for.

Develop a presentation that will educate the decision makers and help them to make informed decisions about prevention planning. Remember that prevention does not only mean primary prevention with youth, it also means secondary and tertiary prevention, and includes older individuals, as well.

CASE 15. ROBBIE

Robbie J., a 19-year-old white male and first-year college student, suffered a significant brain injury 6 months ago as a result of a car accident. Robbie had been partying at a friend's house and left about 1:00 a. m. Driving home, he missed a curve in the road and rolled his car. Robbie's parents knew that their son drank "occasionally," but they never thought he had a "problem." They had purchased a car for him and warned him of the dangers of drinking and driving.

Prior to the accident, Robbie had been a gregarious young man. In high school he had been a good student, popular, and played on the football team. Robbie loved skiing, skin diving, and riding dirt bikes. Robbie's rehabilitation has been arduous. His parents are still in disbelief. Robbie's father is a prominent corporate attorney, and Robbie had always expressed a desire to follow the same career path. Robbie's mother divided her time between caring for her husband and son and her volunteer work on behalf of abused and neglected children in the community. Since his injury, Robbie's mother has spent most of her time caring for him and participating in his rehabilitation. His father is spending longer hours at work and misses the time he spent hunting, fishing, and playing golf with his son. Though supportive at first, his friends are calling less and less and rarely come around.

Both parents were stunned to learn that Robbie and some of his friends got drunk nearly every weekend. This information surfaced during a family counseling session conducted by a social worker on the rehabilitation team who had recently attended a seminar on screening and brief intervention for alcohol and other drug problems. Robbie's parents had a hard time believing it was true, but after questioning Robbie's friends, they learned that this was indeed the situation.

The brain damage Robert sustained has affected his impulse control and decreased his short-term memory and ability to concentrate. Robbie's emotional affect is labile. At times he laughs out loud; the next moment he may be crying. He has limited insight into his own behavior and how he has changed, so it is difficult for him to understand why his friends and family react to him differently now. Very few things sustain Robbie's attention; even watching TV is not pleasurable. The muscle weakness on his right side limits his ability to participate in many of the athletic activities he enjoyed previously.

Robbie is on an emotional roller coaster. At one level he knows that his plans for the future have to change. At another level, he cannot accept these limitations. He wants things to be the way they were. His condition makes it impossible for him to return to a successful college experience. He resents his parents' constant supervision, and feels that they are "treating him like a baby." He says no girl will want to date him with this kind of interference. Most of his friends are back at college, so he has begun to hang out with a younger group and drink again. Robbie is frustrated with the difficulty he has in remembering, expressing himself, and concentrating. He is restless and agitated sometimes, both as a result of his frustration and the organic aspect of his injuries. Robbie's parents can afford high quality treatment, but Robbie does not always comply with the treatment regimen.

  1. What are the relevant facts in Robbie's case (e.g., "What is actually happening here")?
  2. Identify the problems and issues that are arising in Robbie's case (e.g., What has gone wrong in this situation?" and "What needs to be addressed in order to improve the situation?")
  3. Identify the positive and strengths aspects of the situation (e.g., "What has gone right so far?" and "What positive elements exist in this situation?")
  4. Analyze the issues in terms of knowledge presented in the training modules (e.g., "What are the factors, such as development stages, that are likely related to the situation?" and, "How do these factors influence the situation?")
  5. Use training materials to develop a list of options and an initial plan of action (e.g., "What has been shown to work in these kinds of situations where substance abuse and a traumatic brain injury are involved?" and "What options are available?" and "What are the likely results of each option?")
  6. Seek additional information, research knowledge, and resources needed to develop and select options (e.g., What else do we need to find out to make a viable plan for Robbie and his parents?" and "Where can we go to get this information?" and "What did you find out when out when you sought this information? Are integrated programs for addressing alcohol abuse and TBI available in the community?")
  7. Develop a concrete strategy for Robbie and his parents (e.g., "What can be tried over the next weeks/months? How can you help the parents come to terms with the situation? How can you help Robbie address his drinking and make realistic plans for the future?")
  8. Identify methods for evaluating the outcomes and revising the plan (e.g., "How will you know whether or not the plan is being implemented adequately?" and "How will you know if the plan is working?" and "How will you revise the plan based on different possible outcomes?")

*Instructors may wish to revise this case in terms of the client's gender, age, ethnicity, family socioeconomic status and access to treatment resources, functional area(s) of the brain affected and severity of the brain injury (for information, see the website of the Brain Injury Association of America: http://www.biausa.org/), or other factors. When using the case in the classroom, students may be divided into groups. Each group can be given a different set of client characteristics. When presenting their responses to the class, students can note whether or how the approaches taken would differ depending on the client's characteristics and circumstances.

Updated: March 2005

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