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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014). Social

work case studies: Foundation year. Laureate International Universities Publishing.

Francine

Francine is a 70-year-old, Irish Catholic female. She worked for 40 years as a librarian

in an institution of higher education and retired at age 65. Francine has lived alone for

the past year, after her partner, Joan, died of cancer. Joan and Francine had been

together for 30 years, and while Francine personally identifies as a lesbian, she never

came out to her family or to her colleagues. When speaking to all but her closest

confidantes, Francine referred to Joan as her “best friend” or her “roommate.”

Francine’s bereavement was therefore complicated because she did not feel she could

discuss the true nature of her partnership with Joan. She felt that there was little

recognition from her family, and even some of her close associates, of the impact and

meaning of Joan’s death to Francine. There is a history of alcohol use disorder in

Francine’s family, and Francine used alcohol from late adolescence into her mid-30s.

However, Francine has been in recovery for several decades. Francine has no known

sexual abuse history and no criminal history.

Treatment

Reasons for Seeking Counseling

Francine sought counseling with me for several reasons, including an ongoing

depressed mood, a lack of pleasure or enjoyment in her life, and loneliness and

isolation since Joan’s death. She also reported that she had begun to drink again and

that while her drinking was not yet at the level it had been earlier in her life, she was

concerned that she could return to a dependence upon alcohol. Francine came to

counseling with several considerable strengths, including a capacity to form intimate

relationships, a successful work history, a history of having maintained her sobriety in

the past for many years, as well as insight into the factors that had contributed to her

current difficulties.

Referral to Physician

During our initial meetings, Francine stated that her goals were to feel less depressed,

to reduce or stop drinking, and to feel less isolated. In order to ensure that no medical

issues were contributing to her depression symptoms, I referred Francine to her primary

care physician for an evaluation. Francine’s physician did not find any medical cause of

her symptoms, diagnosing Francine with moderate clinical depression and

recommending that Francine begin a course of antidepressant medication. Francine

was reluctant to take medication and first wanted to try a course of counseling.

Behavioral Activation Technique

In order to help Francine meet her goal of reducing her depression symptoms, I

employed a technique called behavioral activation (BA), which is drawn from principles

of cognitive behavioral therapy and helps to reengage people in pleasant physical,

social, and recreational activities. We began with a small initial goal of having Francine

dedicate at least 5 minutes of each day to an activity she found pleasant or rewarding.

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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014). Social

work case studies: Foundation year. Laureate International Universities Publishing.

Over the following weeks, we increased the time. Francine’s treatment progress was

monitored through weekly completion of the Patient Health Questionnaire (PHQ-9) in

order to determine whether her depressive symptoms were improving.

AA Meetings

I helped Francine address her drinking by reconnecting her with effective coping

strategies she had used in the past to achieve and maintain her sobriety. These

included identifying triggers for the urge to drink and exploring her motivations for both

continuing to drink and for stopping her use of alcohol. Francine began attending

regular meetings of Alcoholics Anonymous™ (AA) and found several meetings that

were specifically for older women and for lesbians. In addition, Francine spoke regularly

with a sponsor who helped her to remain abstinent during particularly stressful moments

during her reengagement in sobriety.

Social Connections

Finally, in order to address Francine’s goal of feeling less lonely and isolated, we

explored potential avenues to increase her social networks. In addition to spending time

with her family, friends, and her AA sponsor, Francine began to visit the LGBTQ center

for the first time in her life and attended a support group for women who had lost their

partners. Francine also began spending time at her local senior center and went there

at least three times a week for exercise classes, other recreational activities, and lunch.

She also began to do volunteer work at her local library once a week.

Over several months of counseling, Francine stopped drinking; significantly increased

her daily involvement in pleasant and rewarding activities, including social and

recreational activities; and reported feeling less lonely, despite still missing her partner a

great deal. Francine’s scores on the PHQ-9 gradually decreased over time, and after 16

weeks of counseling, Francine reported that she no longer felt she needed the session

to move on with her life. In addition, Francine visited her primary care physician, who

found upon evaluation that her depression had lifted considerably and that an

antidepressant was no longer indicated. By the end of counseling, Francine’s focused

work on identifying her depression symptoms and her triggers for drinking equipped her

to better recognize when she might need support in the future and to whom she could

reach out for help if she needed it.

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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014).

Sessions: Case histories. Laureate International Universities Publishing.

Sara

Sara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment

with her 48-year-old daughter, Stephanie, and six cats. Sara and her daughter have

lived together for the past 10 years since Stephanie returned home after a failed

relationship and was unable to live independently. Stephanie has a diagnosis of bipolar

disorder, and her overall physical health is good. Stephanie has no history of treatment

for alcohol or substance use; during her teens she drank and smoked marijuana but no

longer uses these substances. When she was 16 years old, Stephanie was hospitalized

after her first bipolar episode. She had attempted suicide by swallowing a handful of

Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her.

She has been hospitalized three times in the past 4 years when she stopped taking her

medications and experienced suicidal ideation. Stephanie’s current medications are

Lithium, Paxil®, Abilify®, and Klonopin®.

Stephanie recently had a brief hospitalization as a result of depressive symptoms. She

attends a mental health drop-in center twice a week to socialize with friends and

receives outpatient psychiatric treatment at a local mental health clinic for medication

management and weekly therapy. She is maintaining a part-time job at a local

supermarket where she bags groceries and is currently being trained to become a

cashier. Stephanie has active Medicare and receives Social Security Disability (SSD).

Sara has recently been hospitalized for depression and has some physical issues. She

has documented high blood pressure and hyperthyroidism, she is slightly underweight,

and she is displaying signs of dementia. Sara has no history of alcohol or substance

use. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare and

receives Social Security benefits and a small pension. She attends a day treatment

program for seniors that is affiliated with a local hospital in her neighborhood. Sara

attends the program 3 days a week from 9:00 a.m. to 2:00 p.m., and van service is

provided free of charge.

A telephone call was made to Adult Protective Services (APS) by the senior day

treatment social worker when Sara presented with increased confusion, poor attention

to daily living skills, and statements made about Stephanie’s behavior. Sara told the

social worker at the senior day treatment program that, “My daughter is very

argumentative and is throwing all of my things out.” She reported, “We are fighting like

cats and dogs; I’m afraid of her and of losing all my stuff.”

Home Visit

During the home visit, the APS worker observed that the living room was very cluttered,

but that the kitchen was fairly clean, with food in the refrigerator and cabinets. Despite

the clutter, all of the doorways, including the front door, had clear egress. The family

lives on the first floor of the apartment building and could exit the building without

difficulty in case of emergency. The litter boxes were also fairly clean, and there was no

sign of vermin in the home.

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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014).

Sessions: Case histories. Laureate International Universities Publishing.

Upon questioning by the APS worker, Sara denied that she was afraid of her daughter

or that her daughter had been physically abusive. In fact, the worker observed that

Stephanie had a noticeable bruise on her forearm, which appeared defensive in nature.

When asked about the bruise, Stephanie reported that she had gotten it when her

mother tried to grab some items out of her arms that she was about to throw out.

Stephanie admitted to throwing things out to clean up the apartment, telling the APS

worker, “I’m tired of my mother’s hoarding.” Sara agreed with the description of the

incident. Both Sara and Stephanie admitted to an increase in arguing but denied

physical violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get

my things back.”

The APS worker observed that Sara’s appearance was unkempt and disheveled, but

her overall hygiene was adequate (i.e., clean hair and clothes). Stephanie was neatly

groomed with good hygiene. The APS worker determined that no one was in immediate

danger to warrant removal from the home but that the family needed a referral for

Intensive Case Management (ICM) services. It was clear there was some conflict in the

home that had led to physical confrontations. Further, the house had hygiene issues,

including trash and items stacked in the living room and Sara’s room, which needed to

be addressed. The APS worker indicated in her report that if not adequately addressed,

the hoarding might continue to escalate and create an unsafe and unhygienic

environment, thus leading to a possible eviction or recommendation for separation and

relocation for both women.

As the ICM worker, I visited the family to assess the situation and the needs of the

clients. Stephanie said she was very angry with her mother and sick of her compulsive

shopping and hoarding. Stephanie complained that they did not have any visitors and

she was ashamed to invite friends to the home due to the condition of the apartment.

When I asked Sara if she saw a problem with so many items littering the apartment,

Sara replied, “I need all of these things.” Stephanie complained that when she tried to

clean up and throw things out, her mother went outside and brought it all back in again.

We discussed the need to clean up the apartment and make it habitable for them to

remain in their home, based on the recommendations of the APS worker. I also

discussed possible housing alternatives, such as senior housing for Sara and a

supportive apartment complex for Stephanie. Sara and Stephanie both stated they

wanted to remain in their apartment together, although Stephanie questioned whether

her mother would cooperate with cleaning up the apartment. Sara was adamant that

she did not want to be removed from their apartment and would try to accept what

needed to be done so they would not be forced to move.

Sessions

Stephanie mentioned she was dissatisfied with her mother’s psychiatric treatment and

felt she was not getting the help she needed. She reported that her mother was very

anxious and was having difficulty sleeping, staying up until all hours of the night, and

buying items from a televised shopping network. Sara’s psychiatrist had recently

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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014).

Sessions: Case histories. Laureate International Universities Publishing.

increased her Zyprexa prescription dosage to help reduce her agitation and possible

bipolar disorder (as evidenced by the compulsive shopping), but Stephanie did not feel

this had been helpful and wondered if it was contributing to her mother’s confusion. I

asked for permission to contact both of their outpatient treatment teams, and the

request was granted.

I then arranged to meet with Sara and her psychiatrist to discuss her increased anxiety

and confusion and the compulsive shopping. I requested a referral for neuropsychiatric

testing to assess possible cognitive changes or decline in functioning. A test was

scheduled, and it indicated some cognitive deficits, but at the end of testing, Sara told

the psychologist who administered the tests she had stopped taking her medications for

depression. It was determined Sara’s depression and discontinuation of medication

could have affected her test performance and it was recommended she be retested in 6

months. I suggested a referral to a geriatric psychiatrist for Sara, as she appeared to

need more specialized treatment. Sara’s psychologist agreed.

Because they had both stated that they did not want to be removed from their home, I

worked with Sara and Stephanie as a team to address cleaning the apartment. All

agreed that they would begin working together to clean the house for 1 hour a day until

arrangements were made for additional help from family members. To alleviate Sara’s

anxiety around throwing out the items, I suggested using three bags for the initial

cleanup: one bag was for items she could throw out, the second bag was for “maybes,”

and the third was for “not ready yet.” I scheduled home visits at the designated cleanup

time to provide support and encouragement and to intervene in disputes. I also

contacted Sara’s treatment team to inform them of the cleanup plans and suggested

that Sara might need additional support and observation as it progressed.

We then discussed placement for at least some of the cats, because six seemed too

many for a small apartment. Sara and Stephanie were at first adamant that they could

not give up their cats, but with further discussion admitted it had become extremely

difficult to manage caring for them all. They both eventually agreed to each keep their

favorite cat and find homes for the other four. Sara and Stephanie made fliers and

brought them to their respective treatment programs to hand out. Stephanie also

brought fliers about the cats to her place of employment. Three of the four cats were

adopted within a week.

During one home visit, Stephanie pulled me aside and said she had changed her

mind—she did not want to continue to live with her mother. She requested that I

complete a housing application for supportive housing stating, “I want to get on with my

life.” Stephanie had successfully completed cashier training, and the manager of the

supermarket was pleased with her performance and was prepared to hire her as a part-

time cashier soon. She expressed concern about how her mother would react to this

decision and asked me for assistance telling her.

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© 2021 Walden University, LLC. Adapted from Plummer, S. -B., Makris, S., & Brocksen, S. M. (Eds.). (2014).

Sessions: Case histories. Laureate International Universities Publishing.

We all met together to discuss Stephanie’s decision to apply for an apartment. Sara was

initially upset and had some difficulty accepting this decision. Sara said she had fears

about living alone, but when we discussed senior living alternatives, Sara was adamant

she wanted to remain in her apartment. Sara said she had lived alone for a number of

years after her husband died and felt she could adjust again. I offered to help her stay in

her apartment and explore home care services and programs available that will meet

her current needs to remain at home.

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