Armenian Family Case – Interview with client
Silvana is a 50-year-old caregiver, currently. She is divorced, with two children living away from her. Her father is deceased, and her mother, Araxia is 80-years-old. Her brother, Kardashian is 55-years-old, does not assist with taking care of her.
Silvana works full-time at Disney, and while she has some flexibility there in order to care for her mother, she may be limited in how long she’ll be allowed to have it. Araxia lives in an apartment but may not be able to afford it for much longer, as her rent is higher than her Supplemental Security Income. Silvana anxiously expressed her concerns this way: ‘so we’re in the hole out of the gate. I pay for everything else, which I can’t really afford, including time away for all her doctor appointments, shopping and everything you can imagine. The worst part is her building just sold, and she’s not under a section 8 or any assistance, which means the rent will increase 200-300 dollars per month, most likely. There’s no rent control in Burbank, so I’m panicking in a way.’
Silvana was tearful, restless, appears tired, and expressed much anxiety for her mother, saying, ‘what if she gets out,’ ‘what if she gets hurt’ and ‘I can’t watch her every second.’ She reported, ‘I’ve been her primary care provider for many years and it’s taken its toll on me on every level, I have a full time job to handle the financial burdens. She needs more professional care than we’re able to provide, she needs social interaction, more aggressive physical training/activities and professional medically trained staff to respond to her changing medical condition.’
Silvana does not appear to delegate caregiving responsibilities to other family members, and her brother refuses to help because he believes it is her responsibility. She did not mention any care or assistance from others. She described her caregiving of her mother as based in her Armenian culture and faith.
Silvana follows her mother’s doctor’s guidance, so she administers the proper dosages of Aricept (for Alzheimer’s) and psychotropic medications to deal with her yelling and aggression toward others.
Interpretive services were easily accessible for her mother Araxia and the majority of the staff is bilingual (Armenian and English). The client reported ‘the staff is Armenian – which means they can relate and understand my mother’s language and culture – that’s a huge factor and a responsibility – to place our mother in a place where we can trust that they will truly care for her and affect the quality of her life in a positive way.’ Araxia is uncomfortable living away from home and does not like sharing a room, however, and repeatedly asks to be taken home.
Araxia is an elderly Armenian widow who has Alzheimer’s disease, and lives in a skilled nursing facility. She speaks Armenian, and has a limited English proficiency. Her children, Silvana and Kardashian speak English and Armenian. Silvana, with the assistance of Araxia’s doctor, placed her in a skilled nursing facility because she had become too difficult to care for at home. Prior to that, Araxia was living in Silvana’s home. Araxia became increasingly agitated in the late afternoons and at night. If left home alone, she would get out and wander the neighborhood, often not being able to find her way home. Silvana works full time and had a difficult time finding caregivers because Araxia would become agitated and aggressive with them, often yelling at them and even striking them. Most caregivers resigned after only a few days.
The facility called the ombudsman to report that the family wanted Araxia to come home but they did not feel that was in her best interest. Upon meeting Araxia, she was very pleasant. She greeted the ombudsman warmly with the assistance of a translator. Araxia was adamant that she wanted to return home and did not want to live in the facility. When asked where home was, she was unable to provide an answer other than ‘home.’ The ombudsman spoke to the staff of the facility who indicated Araxia wanders around at night. They also reported she is loud and disruptive. Because of this, they had asked the family to provide a dedicated sitter for Araxia. Silvana had arranged this, but Araxia was often uncooperative with the caregiver.
A family meeting was held with Araxia, her son and daughter, and with the care staff. The son was adamant that Araxia be returned ‘home,’ by which meant his sister’s house. When asked by the ombudsman about returning her to his house, he indicated this was not an option and that his sister was ‘supposed to take care of Araxia.’ Silvana did not respond to this, but became tearful. Araxia was asked where she wanted to go and she indicated home with her daughter, Silvana. When asked where home was Araxia was unable to tell. The ombudsman encouraged Silvana to express concerns by asking how that would work for her if Araxia came to her home again. Sivlana indicated that Araxia required 24-hour care which was difficult because she worked. She also indicated that when Araxia becomes upset with the caregivers, they call her and she often has to leave work. The brother appeared to become agitated and spoke to Silvana in Armenian. Again, Silvana became tearful.
The ombudsman encouraged family dialogue but there appeared to be opposing opinions between the siblings. The brother was adamant that Araxia not live in a facility. He also was adamant that caring for Araxia was the responsibility and obligation of his sister. Silvana attempted to articulate her concerns regarding her work schedule. The ombudsman asked Silvana, when her mother was diagnosed with Alzheimer’s. She reported, ‘my mother (78 years of age) has been diagnosed with Alzheimer’s and we’ve been trying to manage her care for the past five years with care providers, the past two years, her condition progressed to where 24-hour care is required. She can’t do much on her own (dressing, feeding, bathing, walking, etc.). She’s not a wanderer and in fact she’s more on the conservative, stay home side of things. She was and still is a very intelligent women but unfortunately this disease is a constant cycle of disconnect so she has her moments of clarity, forgetfulness and repetition. She lives in an apartment in Burbank, with 24-hour care, few steps away from my house. I’ve been her primary care provider for many years and it’s taken a toll on me on every level. I have a full time job to handle the financial burdens. She needs more professional care then we’re able to provide, she needs social interaction, more aggressive physical training and activities and professional medically trained staff to respond to her changing medical conditions.’
Silvana’s brother appeared very controlling. He did not allow Silvana to communicate freely her thoughts and views, related to the provision of care for Araxia. The facility gave Silvana a 30-day notice of eviction if Araxia’s yelling and aggression continue. Silvana said she wanted to appeal the eviction, however.
Identification of the problem
Silvana presents with Major caregiver burnout. Kardashian demonstrates to not be willing or able to assist. The original focus is to ensure that the siblings understand the ‘problem.’ At this point there is no agreement that there is a problem. Identifying individual family members values related to care, togetherness, etc., and how they are similar and how they are different.
Kardashian communicates in a loud and often abrasive tone. He does not appear to ‘converse’ with Silvana as much as dictate to her what will happen. Kardashian does not appear to listen when others speak. If siblings raise voices to one another, their mother appears to become distressed and tearful. This often gets both siblings speaking nicely to her, but not resolving the underlying issue.
Kardashian appears to leave the problem solving to Silvana, the care provider. He does not acknowledge the same problem as her. Appears to feel as though the problem is Araxia is in a facility. He reports, their mother would not scream if she were not in a facility.
The communication with the family members appears non-clinical healthy. Both verbalize, but do not appear to hear one another. Silvana does not seem to be as assertive with Kardashian as she is with others. Both put on ‘happy voices’ when Araxia shows any distress. Neither seems to talk to their mother about anything more than superficial chatting.
Silvana is the care provider. However, Kardashian appears to not be stepping up to the role of taking responsibility, other than delegating. He leads persons to believe that his role is to be in control and take charge without the need to help. There was very limited interaction with Kardashian, except to watch him dictate to his family. No reports of abuse or neglect. Both siblings report they have a great family and love their mother. Kardashian seems to view his role as ‘in charge.’
Silvana and Kardashian greet their mother Araxia warmly. They hug and kiss their mother and she responds to them equally. Araxia, smiles, hugs them back, pats their hands, etc. Araxia speaks primarily in Armenian. Silvana reports she understands some English. Kardashian says she should only be spoken to in Armenian. She appears to become sad when Silvana leaves and Araxia does not seem to want assistance from someone that does not speak Armenian.
Silvana does not mention any activities other than her mother and mother’s care.
Physical danger can present itself if Araxia is left unattended. There is no apparent threat of acts of violence from the children toward mother and/or each other. The Psychobiological (needs and drives, including eating, sleeping, eliminating, sex and aggression) appears that Araxia is not capable of performing activities of daily living on her own. Silvana does not appear to be eating and sleeping due to stress/anxiety. It is unclear about Kardashian. The social behavior, both within and outside the family appeared limited. Kardashian did indicate he did not like that Silvana had called the ombudsman. He believes that there is no need to share the family situation with others, etc.
There are four possible styles of behavior control (Epstein, Baldwin, & Bishop, 2005):
‘ Rigid Control: Little room for negotiation or change of standards regardless of the context. Appears to describe Kardashian.
‘ Flexible Control: reasonable standards and flexibility with room for negotiation and change depending on the context could describe Silvana when Kardashian is not around.
‘ Laissez-faire Control: no standards are adopted and total latitude is allowed regardless of context.
‘ Chaotic Control: there is random shifting of standards so that family members do not know which will apply in a given situation. Could describe Silvana when Kardashian is around.
Silvana has private health coverage through her employer. The mental health parity and addiction equity act, requires private health insurance plans to provide equal coverage for mental and physical health services. Treatment services can be reimbursed for Silvana’s anxiety and depression providing her access to necessary treatment. The law took effect on January 1, 2010 (Association, 2010).
The 2010 federal parity law was welcomed by therapists granting unlimited sessions for most clients. However, insurance plans that were not enthusiastic sought to take advantage of the loophole that allows them to deny coverage for any service they deem not “medically necessary.” In receiving reimbursement for services provided to Silvana, the treatment will need to be substantiated with a ‘medical necessity’ for example, ‘Anxiety, severe depression, including insomnia, decreased appetite, and poor concentration, which interferes with daily functioning, most notably work productivity” (specific, identifies diagnosis, measurable symptoms, and impairment).The treatment goals should be (specific, observable, and/or measurable): “Symptoms of anxiety and depression will be reduced, will no longer interfere with functioning, and will be measured by a t-score of 60 or below on the YSR Withdrawn/Depressed scale” (Griswold, 2012).
Silvana was provided government resources: In-home supportive services, family caregiver support program, health insurance and advocacy program, and muli-purpose senior services program.
In-Home Supportive Services
The In-home supportive services (IHSS) program provides services to assist eligible aged or blind persons or persons with disabilities who are not able to remain safely in their homes without this assistance. In-home supportive services as an alternative to out of homecare, such as nursing homes or board and care facilities. Araxia receives Medicare/Medical benefits and is eligible. Silvana would qualify to get paid as her care provider (Department of public social services, 2014).
Family Caregiver Support Program
The California department of aging, with funding from the U.S. administration on aging, contracts with 33 area agencies on aging (AAAs) to coordinate local community-service systems for assisting caregivers of seniors. The family would be eligible to receive services such as: caregiver information, assistance in gaining access to services, counseling and training support, temporary respite, and limited supplemental services to complement the care provided by caregivers (California, 2013).
HICAP-Health Insurance Counseling and Advocacy Program
Araxia and her family can receive personalized counseling and assistance with Medicare benefits, prescription drug plans and health plans through the California department of aging’s health insurance counseling and advocacy program (HICAP). Including, state health insurance and assistance programs (SHIP). The program will benefit the family to understand how to use their Medicare benefits including prescription drug plan coverage, Medicare advantage plans, Medicare supplemental policies, Medicare savings programs, and long term care insurance (California, 2013).
Multipurpose Senior Services Program
Araxia could also receive services from the local multi-purpose senior service program (MSSP), considering she is certifiable for placement in a nursing facility but wishes to remain in the community. The goal of the program is to arrange for and monitor the use of community services for Araxia, to prevent nursing home placement. The services that may be provided with MSSP funds include (California, 2013):
Human Behavior Theory
Eric Erickson’s stages of psychosocial development demonstrate that on the seventh stage, the middle-aged adult: 35-65, is at the ‘Generativity vs. Self-absorption or Stagnation ‘ Care’ stage. Silvana expresses that work is important at this stage, along with family. Erikson explains further that during the stage of middle adulthood, people can take on greater responsibilities and control.
For this stage, working to establish stability and Erikson’s idea of generativity ‘ attempting to produce something that makes a difference to society. Inactivity and meaninglessness are common fears during this stage. Major life shifts can occur during this stage. For example, children leave the household; careers can change, and so on. Some may struggle with finding purpose. Significant relationships are those within the family, workplace, local church and other communities (Erickson, 1968)
Silvana clearly demonstrates the seventh developmental stage in her life. Her children are out of the home, her nearest family members are her brother and mother, values her job, and attends an Armenian church.
Solution Focused Therapy
Solution focused therapy will be utilized to draw out the strengths in the family and improve weaknesses within the family. The solution that would best meet the family needs is self-care for Silvana and ensuring a safe home environment for Araxia and family.
In utilizing solution focused therapy, Silvana will be engaged when asked the miracle question “imagine that when you go home tonight a miracle takes place and the problem that brought you to therapy completely disappears. You don’t know it’s happened because you’re asleep. What will be the first thing you notice tomorrow that tells you it has happened’? (Sharry, Brendan, & Darmondy, 2003)
In developing a therapeutic alliance with Silvana, goals are established for her to describe where she wants to go. Silvana mentioned in the interview that she wants professional assistance for her mother, Araxia. The shift from a negative of not receiving help to a positive focus to receiving professional help will be utilized to develop a clear goal with Silvana. She will direct where she wants to go to get the professional assistance once the options are presented to her. For example, the option of In-home supportive services is a resource she could utilize because Silvana can get compensated for being her mother’s care provider and/or hire a family member. Silvana will demonstrate progress in asking and delegating to other family members her mother’s care. She will manage her career, improve interaction with her brother, and be able to set healthy boundaries in her care giving relationship with her mother. Silvana will receive encouragement through therapeutic intervention techniques to motivate her toward caring for her mother in a positive manner. The therapeutic alliance developed with Silvana will assist with measuring goal(s). She will stay focused and tap into her reservoir of resources. In developing goals with Silvana, she will learn to become relaxed allowing her to reduce anxiety and obliging her to produce a solution toward obtaining professional assistance for her mother and utilizing self-care techniques. Silvana will be provided therapeutic breaks to think about how to manage her career while caring for her mother, including other family members to assist in the care taking role. This will allow Silvana to identify her strengths: continue to take responsibility to care for her mother, maintain family togetherness, make positive choices in her career, and lead Silvana to evaluate her thoughts and ideas about her choices.
In conclusion, providing Silvana feedback will emphasize her strengths: care giving, family togetherness, utilization of family caregiver support resources, and her willingness to practice self-care techniques. Thereafter, we will continue working toward setting tasks on ways to carry out an action plan to encourage and motivate Silvana based on change built on her ideas and thoughts.
Association, A. P. (2010). FYI. Mental health insurance under the federal parity law, 1-2. Retrieved February 26, 2014, from http://www.apa.org/helpcenter/federal-parity-law.aspx
California, S. o. (2013, November 20). California department of aging. Retrieved from Programs and services: http://www.aging.ca.gov/programs/default.asp
Department of public social services. (2014, February 17). Retrieved from In home supportive services: http://ladpss.org/dpss/ihss/default.cfm
Epstein, N. B., Baldwin, L. M., & Bishop, D. S. (2005). McMaster clinical rating scale. Evaluating and treating families: The McMaster approach, 1-10.
Erickson, E. H. (1968). Learning-theories.com. Retrieved from Erickson’s stages of development: http://www.learning-theories.com/eriksons-stages-of-development.html
Griswold, B. (2012, April 15). Navigating the insurance maze. Retrieved February 26, 2014, from The therapist’s complete guide to working with insurance-and whether you should.: http://www.navigatingtheinsurancemaze.com/articles.htm
Sharry, J., Brendan, M., & Darmondy, M. (2003). Becoming a solution detective: Identifying your clients’ strengths in practical brief therapy. New York: Routledge:Taylor and Frances group.
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