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SOWK 613 - Final Paper

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Running head: LEONARD BARR
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Leonard Barr
Matthew Frusher
SOWK 613
Radford University
LEONARD BARR
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Complete Case History
Leonard Bar is a 77-year-old Caucasian male who called the crisis hotline 10:05 PM on
Monday July 8th, 2019. Leonard lives alone in a residential home in Wytheville, VA. This is the
home he once shared with his wife. During the phone call, he stated that he “prays each night
that God will allow him to die in his sleep.” Leonard denies having an immediate plan, but he is
having fleeting suicidal thoughts. Leonard reports that if he was to commit suicide it would
“probably” be by means of overdosing on medications. Leonard reports that when his wife of 56
years died a few months ago, he felt an “enormous piece of his life missing and feel hopeless.”
When his 40-year-old son committed suicide by firearm last month, it triggered his desire to die.
His son lived down the road from him, and he found his son’s deceased body in son’s garage. He
mentions reoccurring dreams of “seeing my son and his blood everywhere.” Leonard reported
that he has difficulty staying asleep after these dreams occur. Leonard reports feelings of loss of
purpose and says he has stopped leaving his house. He states he is avoiding church because it
increases the pain of losing his wife as this was an activity they shared together. After further
assessment, Leonard agreed to a crisis worker coming to his house to assure his safety.
Leonard was very close with his wife and son and reports a support of a sister (Amy
Taylor), daughter-in-law, and grandchildren who all live in close proximity. Leonard does not
seek support of his sister due to feeling like a burden. Leonard gave the clinician approval to
reach out to his sister. His sister states he has become very reclusive since the passing of his wife
and son. She has tried to pick him up for church, but he will not go. He used to volunteer at the
local animal shelter which his sister said he adored but has since stopped showing up to
volunteer for shifts without notice. He still feels alone and is scared he will lose the other people
LEONARD BARR
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in his life, which is why he does not want to be with other people. Leonard states he has not had
previous thoughts of suicide, prior to the passing of both his wife and son.
Leonard reports that he does not use substances and denies current mental health
treatment. He states taking the medication, “Zocor-Simvastatin,” for issues with his high
cholesterol, when “I remember.”
Assessment
Leonard reports experiencing an increase of his fleeting thoughts of suicide over the
course of the past week. Leonard denies having a plan but has access to means. He reports he
would take his wife’s prescription painkillers or overdose on his own medication. Leonard
appears to not be taking care of himself; He is ungroomed and states that he cannot remember
the last time he has eaten. TAF assessment completed with Leonard which indicates marked
impairment and high risk. Leonard appears lethargic and struggles to participate in conversation.
Leonard spoke in an agitated tone and spoke quickly when he did choose to participate in
conversation. The lethality risk is high for Leonard due to recent loss of his son by suicide a
month ago, grief for the passing of his wife two months ago, and the access to means (his and
deceased wife’s medication). Leonard demonstrates an impairment in his cognition as he has
trouble with recalling the events of his wife and son’s passing. Leonard also struggles with
thinking of positive coping skills and reports he has distanced himself from the rest of his family
as well as rarely leaving his house. Leonard indicates poor judgement in not taking his
cholesterol medication regularly. He also indicates choices of poor judgement in not eating or
showering. Leonard also stated that he often does not feel like showering and cannot recall the
last time he did shower or groom himself. After obtaining consent from Leonard to speak to his
sister; she reports that he has lost a significant amount of weight over the course of six months.
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His sister also reports that he refuses to come out of his house to see a doctor or to talk about his
problems. The clinician reports that Leonard’s behavioral severity is at low-risk at this point in
the assessment, however, his behavior could only increase without immediate support and
intervention.
Leonard has accepted intervention upon recognizing his social supports, which he has
stated as: His religious background, his sister, his daughter-in-law, and his church community.
Leonard has also begun to share more of his feelings and thoughts with his sister and identifies
breathing techniques as a coping skill. As Leonard discusses his suicidal ideations and why he
called the crisis hotline, he recognized that he reached out for help to keep himself safe.
Leonard’s cognition changed to benefit his situation when identifying his will to live, and that his
sister and daughter-in-law understood his situation. This clinician saw a positive change in
judgement and mood when Leonard suggested that he should take a shower and eat. After
discussing his relationships with his family members, Leonard was able to demonstrate positive
cognitive abilities by working through a safety contract with this clinician and his sister, Amy.
Leonard meets diagnostic criteria for Post-traumatic stress disorder, acute Leonard was
exposed to the trauma of losing his son by suicide and his wife of 56 years. Leonard is
consistently re-experiencing the traumatic event through nightmares and is displaying emotional
distress when triggered. There is an avoidance of trauma-related stimuli of external reminders of
both his wife and son. Leonard is displaying negative alterations in cognitions and mood with his
inability to recall key features of the trauma, negative affect, decreased interest in activities, and
a difficulty in experiencing a positive affect. Leonard displayed irritable behavior with some
angry outburst and admitted to the inability of staying asleep. These symptoms have been present
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for a month and have demonstrated distress and functional impairment that have put him at risk
of suicide. There are no substance use or medications concerns.
Reasons for Assessment and Diagnosis
One of the biggest things that set our case apart from the others is the demographics of
our client, mainly age and gender. Leonard is a 77-year-old Caucasian male, which results in him
being at high risk of suicide. Research has found that older individuals, especially older men, are
at risk of taking their own lives (Neufeld & O'Rourke, 2009). Caucasian men account for 80% of
the suicides in their age bracket (Schmutte, Oconnell, Weiland, Lawless, & Davidson, 2009).
Some of the high-risk factors for suicide death in the older population are losing your partner,
hopelessness, physical illness, burdensomeness, no social supports and bereavement" (Schmutte,
Oconnell, Weiland, Lawless, & Davidson, 2009; Neufeld & O'Rourke, 2009; Cukrowicz,
Cheavens, Van Orden, Ragain, & Cook, 2011). Leonard fits into all these categories because of
the recent loss of his wife and son which has resulted in bereavement, perceived
burdensomeness, and hopelessness. Research shows that older people also face higher levels of
hopelessness because there is perceived ideation that they as individuals are not efficient
anymore, they feel helpless and compared to burdensome, they feel that their future is very bleak
(Neufeld & O'Rourke, 2009).
Looking at the severity of Leonard's risk through the lens of the interpersonalpsychological theory of suicide, which revolves around the idea that there are essential
interpersonal constructs to be considered as contributing factors to the individual's suicidal
ideation. Crisis workers must assess the "perceptions of burdensomeness on loved ones and/or
society and feelings of not belonging to valued groups or relationships" (Cukrowicz, Cheavens,
Van Orden, Ragain, & Cook, 2011). The theory predicts that having the simultaneous feelings
LEONARD BARR
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as if they are a burden to others and feeling as if they don't belong results in the "development of
the most serious form of suicidal ideation,'' which a lot of older people face concurrently
(Cukrowicz, Cheavens, Van Orden, Ragain, & Cook, 2011). Leonard has faced two tragedies in
which he is isolating himself from his main social supports in order to not be a burden.
According to the theory, the ideation becomes a reality when one is not afraid of death. As crisis
workers, the individual's capacity for fulfilling the ideation must be assessed. One must try to
find the client's levels of their fear of death and suicide, the individual's pain tolerance, and their
cognitive function (Cukrowicz, Cheavens, Van Orden, Ragain, & Cook, 2011). Leonard is
displaying cognitive malfunctions, especially in his inability to recall specific events.
Correspondingly, the two other factors that make our case study unique is that Leonard is
a suicide loss survivor, and he is experiencing what we learned in class to be a 'Pile Up Crisis.' It
could also be considered a risk accumulation which are “risk factors that become increasingly
pernicious as their numbers increase because they operate in transaction with one another,
facilitating one another’s negative effects, and increasing stress and vulnerability” (Lesser &
Pope, 2011, pg. 30). Leonard's son, in our scenario, committed suicide and Leonard found him,
which added to the trauma of losing his son. Leonard being a suicide loss survivor could
potentially lead to him being at risk for a diagnosis of PTSD, experiences with traumatic grief, or
a potential diagnosis of depression (Sandford, Cerel, McGann, & Maple, 2016). "Some aspects
of bereavement are universal and tend to occur irrespective of the cause of death (e.g., sorrow),
some reactions are shared if the death is unexpected (e.g., shock), and others are proposed to be
specific to violent deaths or more specifically to suicide" (Kõlves, et al., 2019). Unexpected
death has been found to be the “most common traumatic experience and most likely to be rated
as the respondent’s worst, regardless of other traumatic experiences” (Keyes, et al., 2014). It has
LEONARD BARR
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also been found that unexpected death increased the odds of each of the mood and alcohol use
disorders, with a higher association with the older age groups (Keyes, et al., 2014).
There are other additional factors that lead to Leonard's bereavement experience with
both his wife's and son's deaths. In one study, researchers found that seventy-three percent of
suicide loss survivors were found to have "substantial symptoms of PTSD" (Sandford, Cerel,
McGann, & Maple, 2016). The same study researched if the individual was present at the time of
the suicide or had to identify their loved one regarding PTSD, similar to Leonard's situation of
finding his son's body (Sandford, Cerel, McGann, & Maple, 2016). Leonard already had the
traumatic experience of losing his son, but also in the instance of finding his son's body.
Leonard's bereavement experience in this situation is also heightened due to the loss of his wife
previously, to his son's passing. This could be an example of a 'Pile Up Crisis,' which is a term
used often with families, but can be applied to Leonard's situation in how his crises continue to
accumulate and affect his ability to function (James & Gilliland, 2017, p. 339). It is described
that at times an individual's ability to cope deteriorates, which has occurred in Leonard's case
with his physical and mental health (James & Gilliland, 2017, p. 340).
Leonard withdrew from his family, friends, and church, which are his areas of support,
additionally adding to his crisis. Looking at this through systems theory, this is addressed
through the ecological perspective of “goodness of fit” (Lessor and Pope. 2011, pg. 21). Each
person will be presented with many systems throughout their lives. The family is a system,
school is a system, society is a system, etc. If the individual does not find a ‘goodness of fit’ or
people who are like them, it will impact how they behave in society and their thoughts and
feelings of themselves. “Goodness of fit” is finding within society where you fit culturally, who
the person identifies with, and their ability to adapt. If a person finds a “goodness of fit” through
LEONARD BARR
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a system, they will be more resilient to external and internal factors that make them who they
are. This lack of support is reducing Leonard’s inability to adapt and have resiliency towards the
crisis.
Things I would have done differently
Reflecting on the situation and research that I found, I feel that as a team we should have
assessed Leonard’s impulsivity. Impulsivity needs to be assessed because it is found that a
number of suicides are impulsive and unplanned (Neufeld & O’Rourke, 2009). Neufeld and
O’Rourke define impulsivity as an “individual’s overt behavior, cognitive, and psychological
components” (2009). As a social worker we must assess the motor impulsivity, attentional
impulsivity, and the nonplanning components. When assessing an individual’s motor
impulsivity, the worker is looking at “is the individual acting without thinking?” When looking
at the individual’s attentional impulsivity we are assessing if the individual is having racing
thoughts. The nonplanning component is assessing the individual for plans and means for their
ideation to come to fruition. Neufeld & O’Rourke found that “51% of patients age 17 to 65 years
attempted suicide after deliberating for 10 minutes or less; an additional 16% of patients
contemplated suicide for less than half an hour” (2009).
I also feel that we failed to assess Leonard’s feeling around the suicide internally. We did
not "search for explanations, loss of social support, stigmatization, guilt, responsibility, shame,
rejection, self-destructive behavior and unique reactions (e.g., hiding the cause of death)"
(Kõlves, et al., 2019). I found literature that found individuals who lost an immediate family
member to suicide experience elevated levels of stigma, shame, responsibility, and rejection
(Kõlves, et al., 2019). This means that as clinicians, we must be aware and consider the client's
LEONARD BARR
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feeling of rejection, stigmatization, responsibility, and shame and how those feelings can
influence how the individual grieves.
Treatment Plan
Goal Statement: Leonard reports he wants to make his life better and needs help doing so.
Objective: Intervention: Leonard will initiate his social supports by staying with his sister, Amy,
until he feels more positive with his life.
Intervention: Clinician will contact Leonard’s sister, Amy, if he agrees, to seek safety for
Leonard.
Intervention: Clinician will ensure that Leonard arrives to his sister Amy's house by
staying with Leonard until Amy arrives.
Intervention: Clinician will provide and discuss client’s safety plan with Amy.
Intervention: Clinician and Amy will discuss the meal schedule Leonard agreed to
follow upon safety plan.
Objective: Leonard will no longer have access to medications that he could harm himself with.
Intervention: Clinician will speak with Leonard’s sister, Amy, to ensure she will monitor
that he takes his cholesterol medication as prescribed to improve health.
Intervention: Clinician will speak with Leonard and Amy about properly disposing his
wife’s medication.
Objective: Leonard will receive long-term support and actively work on positive coping
mechanisms.
Intervention: Clinician will make referrals to outpatient counseling (EMDR/or other
trauma focused therapy).
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Intervention: Clinician will search bereavement support groups and supports within
Leonard’s church system to initiate grief recovery.
Intervention: Clinician will follow up within 30 days to assess follow up services and
overall well-being of Leonard.
Theories and Interventions
Interventions planned to be used with Leonard are cognitive behavioral therapy, especially
trauma focused and mindfulness. Through the lens of cognitive theory the clinician helps the
individual focus on their perceptions of the event; how they have tried to correct the problem,
how do they see their lives once back to equilibrium, work as a team to discover alternatives and
focus on implementing that into recovery (Whited, 2019).
Cognitive behavioral therapy is based around the idea that “cognitions, emotions, and
behavior interact, and that cognitions influence our emotions and behavior (Smith, et al.,
2008).CBT is used to help individuals replace “irrational,” “unrealistic,” or “illogical” thoughts
with thoughts that are more “rational,” “realistic,” or “logical” (Smith, et al., 2008). With this
change in thinking the individual will encounter a less amount of distressing emotions (Smith, et
al., 2008). Which will decrease stress which will increase Leonard’s well-being (Smith, et al.,
2008). CBT also uses behavioral techniques, such as relaxation exercises, to try to reduce stress
and emotional distress (Smith, et al., 2008).
Something that I feel passionate about is mindfulness and I am a firm believer in practice
what you preach. I feel that with my knowledge and passion, Leonard could make some
improvements to his overall cognitive function. Our text defines mindfulness as “the art of being
non-judgmentally aware of body sensations, feelings, and thoughts as they move in and out of
LEONARD BARR
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consciousness in the present moment (James & Gilliland, 2017, p. 175). Mindfulness has been
conceptualized as an adaptive cognitive style focused on acceptance and nonjudgmental
awareness of the present moment (Bishop et al., 2004). Brown and Ryan, describe mindfulness
“as the state of being attentive and aware to what is taking place in the present” (2003). Since
mindfulness requires a receptive attention to oneself, in “less mindful states emotions may occur
outside of awareness or drive behaviors before a person clearly acknowledges them”
(Rothschild, 2010 cited in James & Gilliland, 2017, p. 175) Finkelstein-Fox, Park, and Riley
found that “mindfulness to higher levels of positive mood and lower levels of negative mood,
with mindfulness representing a popular component of third-wave cognitive–behavioral
psychotherapies for a variety of presenting problems” (2018). Literature shows that mindfulness
can be associated with increased distress tolerance (Bishop et al., 2004). This distress tolerance
allows individuals to cope with challenging moments rather than quitting, which ultimately
allows the individual to feel a level of accomplishment and perceived self-determination in
regard to stress management (Bishop et al., 2004). Mindfulness helps individuals reframe
stressful events in a more positive light, which decreases the severity of the experience which
will help Leonard greatly (Garland, Farb, Goldin, & Fredrickson, 2015).
“Mindfulness and gratitude are consistently and positively associated with well-being in
diverse populations” (O’Leary & Dockray, 2015). These two interventions have been commonly
associated with the reduction of stress, depression, and anxiety (O’Leary & Dockray, 2015).
Gratitude is a way to reframe your thoughts towards a more positive light and appreciating the
positive things that are present in one’s life. Research shows that gratitude increases satisfaction
in life and development of a more positive affect (O’Leary & Dockray, 2015). “Although
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gratitude is not as widely used in practice as mindfulness, a growing body of gratitude research
has found robust and consistent associations with well-being” (O’Leary & Dockray, 2015).
Expected Outcome Plan
Leonard will benefit from outpatient counseling services. Individual counseling has been
found to be one of the most cited interventions for suicide loss survivors ” (Sanford, Cerel,
Mcgann, & Maple, 2016). “80 % who participated in individual therapy found the experience to
be moderately or highly helpful” (Sanford, Cerel, Mcgann, & Maple, 2016). Because Leonard
will be receiving these services this will decrease his lethality risk. Studies have shown that
individuals benefited the most from seeking services within three months or less from their loss”
(Sanford, Cerel, Mcgann, & Maple, 2016).
Through mindfulness Leonard will be able to accept, be open and aware of undesirable
emotions and thoughts by just letting them be (James & Gilliland, 2017, pg. 175). Jordan &
Mcgann argue that is ideal to integrate the loss into the client’s life instead of helping “resolve”
the loss” (2017). They feel that it is important to help the client “learn to carry the loss with
strength and serenity, not get over it” and I feel through CBT and mindfulness Leonard will be
able to accomplish this (Jordan & Mcgann, 2017).
As a clinician I will also integrate Jordan and Mcgann’s ways to help Leonard with the
integration and strength building:
1.
Containment of trauma
2.
Creation of narrative of the suicide and meaning making about the death
3.
Learning to dose exposure and cultivate psychological sanctuary
4.
Managing changed social connections
LEONARD BARR
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5.
Repair and transformation of the relationship with the deceased
6.
Memorialization of the deceased
7.
Resumption of and reinvestment in living (Jordan & Mcgann, 2017).
As a clinician I will be aware that Leonard’s road to recovery will be different. Looking at the
famous metaphor of how people describe emotional distress as a boulder on their shoulder,
through these interventions I will hope to strengthen Leonard’s journey to acceptance and
integration.
Personal Self-Care Plan
Physical: Eat healthy, exercise at least 30 mins a day, regular sleep schedule, get a massage at
least once a month, and give myself some “me” time.
Emotional: I will spend time with my dogs, practice self-love and self-compassion, and will got
to the movies at least once a month.
Personal: I will devote at least one hour to my partner each day, I will set a daily goal, complete
monthly personal reflections, and have a date night at least once every two weeks.
Psychological: I will allow myself breaks from stressful situations, I will sing. Attend the theatre
or a concert at least every two months.
Spiritual: Mediate every morning and practice gratitude.
Workplace: Seek supervision, leave work on time, and practice saying no.
Lessons Learned
I went into this class thinking crisis is somewhere I see myself in the future. I am leaving
with the same notion but with more knowledge and awareness of myself. I think one of the
greatest lessons learned from this assignment and course is the need for self-care. While I have
the privilege of working in a youth crisis stabilization unit, I found most of the cases to not be as
LEONARD BARR
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acute as some of the scenarios given to my colleagues and me. I do know that my perception has
changed just from hearing some of the trauma that these young adults have endured, so I could
only imagine the effect of working in the field first hand. I found myself really reflecting on my
ability to work with Leonard. I could definitely see myself struggling with thinking about his
safety and his suffering. Self-Care is something that is very limited in my life, I have made a
copy of my plan and have every intention of implementing into my current routine as a full-time
employee and grad student.
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