This paper is aimed to inform the reader about the case work conducted with an individual client named
Yolanda. A single parent of two you children, Yolanda is a 26 year old Peruto Rican female, who is
surviving her boyfriend’s suicide. The agency who serves Yolanda in this case is called Intensive Familiy
Support Services (IFSS). Becasue of the unique morphogenic(Netting, 2004) structure of IFSS Yolanda
was able to receive services in an agency where her case is outside the normal parameters of clients
served. As her caseworker, Yolanda and I agreed to work on her interpernsonal relationships. The theory
which ultimately led to our shared goal was an ego-modifying approach (Goldstein, 1995) in order to
enhance and restore Yolanda’s current ego functioning with particular focus on object relations.
Agency Context and Background
Yolanda came into contact with the agency Intensive Family Support Services (IFSS) in Union County.
The IFSS mission is to help families cope with the stress of having an adult family member diagnosed
with a severe mental illness. The current Director started the IFSS operation in Union county in 1997.
She began with one caseworker, since then the organization has not grown in size, yet the need of the
clients is greater due to economic changes and the political environment.
The authorsF. Ellen Netting, Peter Kettner, and Steven McMurty wrote on macro-level practice as an
unaboidable and fundamental value of working as a social worker. The structure and setting of IFSS is a
good example of how smaller systems can create change in larger systems, and the interconnectedness of
systems in a community. The philosophy behind the agency as well as the funding within the community
has been an ongoing learning process at IFSS. The Director as a “change agent” (Netting et al., 2004)
who dedicates most of her time working with the most vulnerable out of the population served by IFSS
and in advocating them within the community and within the political arena.
The funding for IFSS comes from the
Mental Health Association of New Jersey (MHA). The MHA of New Jersey is a state affliliate of
National Mental Health. The MHA building is in Essex county which provides vertical linkages (Netting
et al., 2004 )within the state by fuding county based services (like IFSS) and through a referral hotline for
information on other statewide and county based community organizations and agencies which are not
funded by MHA.
Because of the vertical direction of funding from the national level down to the IFSS in Union county,
there is no refelction of community needs in the funding resources given like a community based nonprofit organization might have. A non-profit cannot advertise its services and IFSS does little
fundraising. So the needs of the client have increased without any internal change sin the agency since
1997. This has enabled the Director to create change through horizontal linkages, ingenuity, advocacy for
her clients, and community organization.
In the four quadrant model, her roles at IFSS lay mostly in quadrant D. She has some open cases she has
had for over five years which are all single female elders with a child with schizophrenia. She has a lot of
experience and expertise in schizophrenia and interfacing with the various systems for service delivery for
these high risk individuals. Otherwise her work is in creating change through community organization.
The true gift that comes as a client of IFSS is the enormous amount of horizontal linkages between the
agency and others services for the mentally ill and their families which co-exist with IFSS in Union
County. The case worker works mostly in quadrant A doing work for client on their behalf through family
therapy, psychoeducation and support groups. He also does intrapersonal work in helping families cope
with the role changes they face. My job there has been mostly with one patient. This is work on her
behalf in quadrant A. I’ve also had to document a great deal in the agency which helped me understand
the philosophy of the agency and the cost perspective from the state’s perspective.
Agency as an organization
The problem addressed by this agency is essentially caretaker stress. The fact that there is no significant
source of fundraising means that the budget for services is very small, so the funding is not enough to
encapture the entire population of those within the arena of Union County (Netting,Ketner, & McMurray,
2004). While this means they serve fewer clients they potentially can, it also benefits those clients who do
seek service with IFSS. Small fundung keeps the agency small and intimate, which allows for flexibility
and creativity in the service of clients. The intimate nature also lends for personalized service and
dedication to each case and person.
The direct services provided at IFASS are with client for themselves, and also with non-clients for the
sake of the mentally ill and their family. These two areas of social work are referred to as the A and D
quadrants of the quadrant model (Wood & Tully, 2006). The Director has cases that are as old as far back
as 1997, when she began the office. These are nearly all cases where the client is a single elderly mother
with a schizophrenic child. The director works with these women to make sure they can afford their own
housing and medications and their adult childs. If legistlature threatens the welfare of either elders and
the mentally disabled, the Director organizes within the community to appeal such decisions and
underline the longer term cost consequences of making decision on short term gains. This macro level
work outweighs the new cases she takes on. The caseworker opens most of the cases, and as a screener
for Trinitas, the County Pscyhiatric hospital, he also receruits clients who have a family member
committed. Most of his work lies in quadrant A. He works with family on the crisis they are facing, by
giving them goals and prioritizing and partializing their concerns. He also does family therapy and
ensures the family is getting proper service links with other agencies involved. He advocates for his
clients withing the mental health community, where he is well connected and knows many social workers.
The caseworker is involved with the family in orchestrating several levels of care and support for their
family member, as well as for themselves. Support for their family member can take the form of
brokering when the caseworker calls the social worker at a housing facility on behalf of his client.
As an intern at IFSS, my role has been in quadrant A. I have called clients to check in them and intiate
case work. My first month I learned a great deal about the macro system of social work agencies, since
the Director explained to me how funding impacts the services available, and what work she does to
enable clients to cope with service gaps. I also went to Trinitas with the caseworker to learn the screening
system and recruit clients. The company car is used to drive clients to places and to visit them in their
homes. In October I was assigned an individual case .This client receives in-home visits from me for
1. Presenting Problem
My client is a 26 year single mother surviving the aftermath of herboyfriend’s suicide. They had lived
together for eight years in an apartment adjoined to her mothers. Yolanda and Ricardo had two children
together. Emily is 8 years old, and Natalie is 2. She had worked with the case manager at IFSS for six
months after her boyfriend killed himself in their living room on Christmas Eve of December 2009. The
caseworker did work with the family unit which consisted of Yolanda, her sister and her mother. He did
most work with Yolanda who was the most responsive to therapy. In June, Yolanda parted with IFSS to
seek indivual therapy at a clinic, and was attending a suicide survivor meeting once weekly. She called
IFSS in October of 2010 because she was experiencing suicide ideation and was frightened for herself and
her children. She had stopped going to therapy because she could not drive there are had to account on
others. She described symptoms of having a panic attack, and she and the caseworker agreed to intiate
some in home therapy to talk about her problems. The caseworker and I went together to her home and
spent and hour and a half discussing her problems and addressing her need for treatment. The caseworker
decided with Yolanda and I that I could take over her case and work with her on an individual basis.
2. Client System:
Yolanda was in need of services for herself which is not usually the protocol under the agency auspices.
There are few if any open cases where the identified patient is deceased. The death of the patient usually
means services at IFSS are no longer needed. Intrapersonal work is very short-term and done insofar as
members of the family unit need a paradigm shift in order to adjust to role changes as a function of crisis.
Agency Structure as it impacts the client:
As discussed earlier, IFSS is flexible due to it’s small size. In Yolanda’s case, the nature of IFSS was a
great benefit. Yolanda’s case falls into a grey area of service which is not addressed by the systems in
place. IFSS was able to pick up that gap because there aren’t rigid rules about closing cases, or eligibility.
Even though the family member is deceased, Yolanda’s personal crisis is a function of the mental illness
Ricardo suffered. This ability to adapt to the current circumstances of Yolanda exemplifies the nature of
IFSS as an adaptive organization. Netting et al. wrote that macro-level social work is necessary to be
truly working toward the values of the profession. In order to work toward that end, the Director has
experience in understanding the problem, population, and arena of her work. Essentially, the problem is
caretaker stress in families with a mentally ill family member. A subset of this population are single
mothers who are caretaking for a mentally ill family member. Though Yolanda’s family member is not
alive, she is still dealing with the enormous consequences his sickness invoked. She is physically
disabled, and needs support to keep herself and her current family emotionally and physically healthy.
The Director is aware that IFSS is funded so patients and there family members do not face crises that
would bring them in contact with the state services. Her expertise and long history of working in the
mental health community gives her a fearless approach to adapting to change and conflict. Morpho-genic
is defined by Netting et al.(2004) as “structure changing” (p.14). In this case, IFSS as an organization
made a change in the face of conflict. Though Yolanda’s case was not clearly within the boundaries of
IFSS clients, she is benefitting from having personalized in-home therapy, which is in keeping with the
social work ethic of helping individuals and communities (NASW, )
An understanding of the funding source of IFSS was also an important component to developing a case
theory surign assessment with her.
Data Analysis and Hypothesis Formation
Since Yolanda’s case was opened because she was at risk, the time contingent factor of our work shaped
my approach to her assessment. I know that Yolanda can only receive services in regards to releiveing
her family of the stress that created her anxiety attack. For this reason, I initially turned to my supervisor
for crisis oriented approaches. My supervisor at MHA works as a manager at the referral helpline for
state resources, where I also work as an intern. She gave me verbal accounts of work with suicide
survivors and resources to give Yolanda. The work of Kathleen Ell on Crisis Theory (1996) helped me
understand that Yolanda’s panic attack was a “state of crisis” (p.168) which was precipitated by Ricardo’s
death and augmented by the economic and physical burden of being thrust into single motherhood.
Lawrence Schulman wrote that tuning into a clients’ need is pivotal in assessment. Specifically, to the
population, the specific population, and the stage the individual is in their problem solving. The first two
parts I had personal experience on and several readings on Peurto Rican culture and intergenerational
differences within the culture. Yolanda is a single mother which was precipitated by a crisis. I am in a
smiliar situation which helps me understand the specifics socioeconomic and emotional stressors that
come with an abrupt role change from a partnered parent to a single one. What I needed to further assess
was her family system and the reference she had for the crisis and the outcomes (Ell,1996).
Ell writing on crisis theory and Charles Cowger’s framework for assessing clients directed me to explore
Yolanda’s family structure in terms of their response to the crisis and the support they give her, as well as
her own reference to Ricardo’s death, and the strengths and weaknesses of her environment and personal
coping skills at the moment. At the end of my second meeting, I had spoken with Yolanda for over three
hours in two sessions. I learned that her perspective on Ricardo’s death was not an emotional longing for
him. He had been abusive to her, and had isolated her from all friends over the past eight years. Her
mother and sister blamed her for his death, and tended to side against her in a punitive fashion. They
were particularly focused on undermining her skills as a mother. Yolanda was frustrated the most by
having to rely on them fro transportation because she is legally blind. Out of lonliness and need for
support, she was ina current relationship with a boyfriend, David, who was speaking to her about suicide
ideation and was a former close friend of Ricardo’s. This latter fact gave her a great deal of
discomcomfort. She expressed that she wanted to be a woman and felt like she was falling into the same
habits she always had. She also explained that she was acting out more against her mother than in the
past, which were feuling resentments further.
By the end of this meeting, I had a sense of urgency for her and her children. I was concerned about her
boyfriend’s thoughts as well as the abuse taking place between Yolanda and her mother, in front of the
children. I the former caseworker his opinion, who intervened with her in regards to David’s ideations.
The caseworker also told me that Yolanda’s mother is, in his opinion, a “borderline”, and he found her to
be unreceptive and detrimental to work with. Yolanda’s interpersonal relationships and history with
interpersonal functioning was impacting her current life in the most detrimental way. Having studied ego
psychology in two classes at New York University, I was familiar with the theoretical basis on attachment
theory as a function of ego psychology. Yolanda exhibits hallmark traits of being insecurely attached to
her mother but has learned security which is evidenced by a sense of empowerment and confidence she
has a lot of the time. This together with evidence on her impulsivity, judgements, ego-adaptive and
defensive skills and mechanisms all suggested a healthy ego. However her commuinication about her
mother and Ricardo showed a deficit in object constancy. She “split” the good parts in people from the
bad. They were all good or all bad. I noticed her friends where also expressed in bi-polar terms. Her
therapist at the outpatient facility also was all good before she as all bad and Yolanda stopped seeing her.
. The ego function “object relations” referrs to the Margaret Mahler’s (XXX) work on separation
individuation, In Mahler’s work, the term “object” refers to an infant’s perception of themselves
andothers. Mahler’s described a chronoligcal set of developmental scheivements which, if successful,
end in the infant “working toward object constancy”. Object constancy referes to an indivual having the
capacity to maintain both the good and bad qualitites of a person as intrinsic and coexisting aspects of
others as well as themselves.
Yolanda’s language reflected perceptions of herself and others as having two parts that were not
combined in her perception. For example, She was internalizing the blame of Ricardo’s death. She could
not believe he was mentally ill, as it was more habitual and comfortable for her to be the scapegoat for
any problems in her family. She regarded Ricardo as having been a “good” father, and she questioned her
feelings of wanting to leave him, which she believes led to his suicide. At the saem time, she has a
fervent need to express and justify her feelings by relating stories of his verbal and physical abuse in a
defensive manner, in order to emancipate herself from this guilt.
All these issues culminated in a very complex state of relationships with herself and others. The stress of
her guilt had culminated in a flood of anxiety as she transition from the fight or flight stage of crisr
response to the resistance phase, in which she is coping with the aftermath (Seyle, 1956 as cited in Ell,
1996). During the fight or flight stage she had decided to go back to school and become the perfect
housekeeper. She was struggling to achieve the values her mothers held in regards to education and class
mobility. She was also trnafering her mothers values in respect to cooking and cleaning. She gave
herself no time for rest which forced her into emotional exhaustion.
It was a great strength of Yolanda’s to recognize she was in trouble. She took action by dropping her
class and calling the caseworker at IFSS. This level of self reflection was the pivotal strength that gave
me confidence in her ability to create change. This is defined by Cynthia Bisman as a state of relationship
bonding that must occur in order to create a goal with the client in a helping relationship. It also sets the
stage for intervention with the client. Without establishing this bond, Bisman posits, the treatment will
Having studied ego pscyhology in two human behavior classes at New York University, my training has
predisposed me to assessing indivuals on their ego strengths and deficits. The work of Eda G. Goldstein
on Ego Psychlogy and Social Work Practice (1995) has proven to be an enormous resource in
understanding ego strengths as tools of assessment. The ego psychlogical framework is specifically
appealing in the case of Yolanda becasue of her maladaptive interpersonal relations.
My original research focused on crisis intervention within the framework of surviving a family member’s
suicide. However, in our second meeting on November 2nd, it was clear that Ricardo’s death was not the
source of Yolanda’s anxiety. It was her role change in becoming a single mother (Hepworth et al., 2002)
without any support. ALthough Ricardo was abusive to her Yolanda was exhibitting symtpoms of
“splitting” the “good” part of him from the “bad” part(Goldstein, 1995). This occurs in indivduals with
an impairment in the ego function “object relations” (Goldstein, 1995). Yolanda was also expressing
feelings of guilt and shame surrounding his death, which told me she was internalizing his blaming her
for his death. The internalization was juxtaopposed with the need to express the amount of abuse he
instilled and need for vaildation from me, and thereby emancipation of his suicide.
All of these factors contributed to my increasing belief in the hypothesis that Yolanda’s presenting
problem was a function of maladaptive coping skills in regards to her interpersonal relations
Problem for Work
Yolanda’s object constancy was getting in the way of her social functioning. Her family had no
boundaries at all, which predisposed Yolanda for accepting inappropriate emotional and physical abuse
from her mother. In turn, Yolanda acted out in ways that fueled resentments. At the same time, Yolanda
was very lonely. She was forming an insecure attachment (Goldstein, 1995) with another boyfriend
becasue her eyesight kept her from being able to drive. Yolanda was falling into her old habits with
Ricardo with this new boyfriend, who was speaking to her about suicide ideation and was a former close
friend of Ricardos. This latter fact made Yolanda’s interpersonal relationships a priority. Since
Yolanda’s object relations was a deficit, intrapersonal work on setting boundaries and finding community
resources for transportation was in order. Any intervention that did not consider her problems with her
mother would not be doing Yolanda justice, and wouldn’t be impacting Yolanda in a lasting way.
Yolanda’s intrapersonal strength is her ability to be self-reflective. Although her actions show impulse
control and judgment deficiencies, she was cognizant of the stress coming from these acts and wanted to
change them in order to “be a woman”. She was the one who described to me that her actions with her
mother were childish and she wished she didn’t let her mother “get to her so much”. She also shared that
she was afraid she was creating another Ricardo situation with David (her current boyfriend). When her
mother was in Peurto Rico, Yolanda had the persective to note that hat her mother “is not all bad, she just
has issues”. This showed me her capabilites to have object constancy where in tact, and her splitting was
state if regression due to environmental stressors where the environment was her interpersonal
Although ego centered work is not typically used in a short-term period of therapy, I was confident that
Yolanda would be able to focus on some cognitive behavioral changes. Yolanda also showed evidence of
her love in learning new words for thoughts and had a drive to change her behaviors in associated with
her feelings. This motivational factor increased my confidence of empowering Yolanda with egosupportive interventions (Goldstein, 1995).
Contracting and Intervention
In order to guide us through the facilitation of meeting Yolanda’s desire to “become a woman” and “stop
letting her mother get to me”. I decided to take a task oriented approach. Yolanda’s goals were more
long term for our contract of working together, they included buying a car and getting her driver’s
liscence. She aslso wanted to move away from her mother. While these goals were feasible for the long
term, they exceeded the time limitation for our wqork together. Considereing the guidance on setting
goals in the literature (Hepworth et al, 2002), feasibility is an important to give clients realistic goals that
can be accomplished within the time frame of the helping relationship. Yolanda had already gone to
fincial consultant and achieved creating a payment plan for her car, as well as maintaining glasses she
needed to get a liscence to drive with her eyesight disability. Considereing her mastery competency
(Goldstein, 1995) on these tasks, I decided to focus on quantifying her interactions with her mother, in
order for her to mobilize her as a support with less conflict in their interactions. Until she is more
independent, she will have to remain in her home and needs the support of her family for transporatation
and getting the children to their separate schools. Therefore, I needed to guide Yolanda toward this end,
while also empowering her with the confidence to set boundaries with her family
According to Hepworth, Rooney and Larson (2002) there are two categories of goals: global and implicit.
In Table 12-1 (p. 331) Hepworth et al. list a number of global goals and explicit tasks which serve as a
guideline for differentiating between these two categories. In order to empower Yolanda with relevant
goals, I needed to communicate how the tasks I was about to suggest to her how they could help her to
“keep her mother from getting to her”. I had already discussed with her that her longer term goals were
excellent, but that our time together would preceed these events ie. Getting a car and moving to another
location. She understood that. In the meantime, I wanted to ensure that I was there to help her now, and
that I decided that a diary of her thoughts and the interactions she had with her between sessions could
help us track “what works” with her mom and what makes things worse.
Cynthia Bisman (2007) defines the use of communication for the social worker as “a purposeful set of
activities focused on altering the problem situation presented by the client” (p. 192). In order to focus a
client, Bisman (2007) posits, one uses methods to facilitate the purpose of the conversation. These
methods are defined as exploring, reflecting, validatiting, and confrotnitng.
I decided before Yolanda’s third session in November that positioning in the kitchen was important, in
order to focus Yolanda and introduce the task of keeping a diary on her interactions with her mom. This
would also facilitate communication without distractions from her daughter who was in the home during
our session. The following dialogue took place on our third session together. The use of communication
methods I used during this interaction will follow
Yolanda: I have so much to tell you- I just got back from the hospital and
everything with Natalie’s ears are fine. The doctors said that her speech delay
is in the ―global realm‖ and that I should be in touch with early intervention,
which I already am… so basically I’m doing everything right!
Alexis: I remember meeting the speech therapist here. I’m so glad you got
good news … were you worryed about natalie a lot?
Yolanda: Yeah, my mother always makes me feel bad about what I’m doing.
But she’s in Puerto Rico until next week! So David just brought me back from
the hospital… oh and I want to tell you about him… but first my best friend is
coming for Christmas!
Alexis: Wow- That’s a lot – you’ve got a lot going on today… let’s go into the
kitchen and sit down so we can focus on what we want to cover today.
Although Yolanda was very disorganized in her thoughts, I was able to slow her down by using two
methods of communication: validation and exploration. Yolanda listened to me share in her feelings of
excitement and validate that I had seen that she was using a therapist for her daughter. In expressing this
memory, I was telling Yolanda I had faith in her, and at the same time establishing Yolanda’s faith in me
as a professional. This is the process that Cynthia Bisman desribes as “belief bonding” (2007).
Once we were in the kitchen Yolanda was ready to talk about her friend coming, which I was glad about,
hearing. I had planned to brainstorm that session on a plan that would help her and her children get
through Christmas Eve, which is the anniversary of Ricardo’s death. When I heard that she had taken
care of that herself, I was more convinced that her mother was the core problem for our work. The
following describes our exchange once we moved into the kitchen and sat at her table.
Yolanda: Okay, so yeah, my friend is coming for christmas
Alexis: I’m really glad you have a plan for christmas. That was one of the
goals I wanted to go over today. remember we talked about coming up with
Yolanda: Yes… and I was thinking that I am feeling so much better this week.
Alexis: Well, you said that you’re mom was in Peurto Rico before, do you think
that her being away helps you feel better?2
Yolanda: It does! I never thought about it like that
Alexis: Do you think it would make sense for us to work on how to feel better
when your mom is around?
Yolanda: Yeah- I feel so much better without her here. I moved once, around
the block but she was still all over me with the kids, and telling me what i’m
When I heard Yolanda say she felt better, I had the opportunity to test my hypothesis by exploring the
issue with her. Had she not said yes, I would have continued to the issue guided by the notion of
“mutually selecting and defining goals”. Since her thought are usually racing, I took the opportunity to
slow her down by using closed ended question to transition to the introduction of the task I had chosen to
The following excerpt shows how I introduced the diary I brought to meet the explicit goal of quantifying
her interactions with her mother.
Alexis: I know that you are thinking about ecentually moving when you get
your car. I want to do what I can to help you now since you wont have your car
until August. I am very impressed that you worked out a financial plan getting
your car, and I’m sure you will on your own one day-(interrupted)
Yolanda: Yeah- Like my brothe did-he went to Claifornia! He’s coming fro
Christmas too, by the way, but he’s not staying with her… he made me laugh.
*1Alexis: Maybe your brother can help you set up some boundaries with your
Yolanda: What do you mean?
Alexis: Well you said to me last week than she comes over here and says things
to you about your children, which makes you mad, right? 4
*2.Alexis: Boundaries just mean ways that we can find that will help both of
you stay more separate from each other even though you live in the same
house. ( I drew a diagram of circles, enmeshed, and mutually exclusive)5
*3.So in order to that, I though we could track your interactions with your mom
through using a diary like your daughter used in therapy. If I can help you with
your relationship with her, would it make you happier?
Yolanda: Yes—that’s why I’m always running to David, and I want to talk to
you about him later. But I was thinking my mom’s not all bad, she just has
*4.Alexis: That’s really insightful for you to see. tell me more about how that
feels… to realize that.
Yolanda: It feels good, like she’s not as big to me, like I feel bad for her
*5Alexis: That’s awesome. you say you want to be a woman… it’s totally a
―woman‖ thing tobe able to see your mom as human even though she hurts you
sometimes. Right now, you have some distance from her while she’s in Puerto
Rico.. It will be harder when she comes back and picks on you. So if you write
your feeling down now, you can read it later on when you are having a harder
time, and remember that were able to say that you to me while she was away. I
think you are right. Your mom has been through a lot and wants you to have
the best. She just is very hard on herself, and it comes out in the wrong way.
It’s not fair to you, I know how that feels.my parents seem to want me to be the
parent they wished they were… but since you have to deal with it while you
wait for your car and your liscence, let’s focus on keeping you safe and happy
If you keep a diary of all the ways you two interact that you find important, we
can also see if there are any patterns we can look what cools her down- what
works with her… and also what doesn’t. Also, you can figure out exactly what
makes you flip out. What words are most painful to you… what do you think?
*6.Yolanda: I like that… okay- I’m going to write down what I said cause
you’re right. She’ll piss me off the second she walk into the house.(laughing)...
also can you explain that picture again? What was that word? Borders?
We expressed the intent to work together on making Yolanda “feel better” when her mother is around.
This was a verbally expressed goal. I also referenced in the above dialogue how Yolanda’s personal goal
was to take care of her baby.
The reason I decided to work on this specific aspect of Yolanda’s problem, is because it seems the most
debilitating to her ego functioning. It is also something that she can incorporate in her relationship with
The goal will be measurable through the diary she keeps. I will do mnore research on goal maintenance
using a diary method so the different ideas she expresses can be partialized. In having Yolanda write
down the incidences of thoughts and interactions with her mother, they will become quanitfyable. I am
hoping that we can look measure the interactions in terms of both quantity and quality. The decrease in
incidences, and the less stress associated with them are both inherent parts of the goal in the long term.
The short term goal will likely consist more of boundary maintanence and cognitive therapy intervention
which can help Yolanda prepare for interactions with her mother, with a set of responses that have
worked in the past.
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