Assignment 1: Creating a Single-System (Subject) Design Study
The steps at the heart of single-system (subject) research are part of the everyday practice of social work. Each day social workers implement interventions to meet clients’ needs and monitor results. However, conducting proper single-system (subject) research entails far more than these simple day-to-day practices. Proper single-system research requires a high degree of knowledge and commitment. Social workers must fully understand the purpose of single-system (subject) research and the variations of single-system (subject) design. They must develop a hypothesis based upon research and select the right design for testing it. They must ensure the reliability and validity of the data to be collected and know how to properly analyze and evaluate that data. This assignment asks you to rise to the challenge of creating a proposal for a single-subject research study.
To prepare for this Assignment, imagine that you are the social worker assigned to work with Paula Cortez (see the case study, “Social Work Research: Single Subject” in this week’s resources). After an initial assessment of her social, medical, and psychiatric problems, you develop a plan for intervention. You also develop a plan to monitor progress in your work with her using measures that can be evaluated in a single-system research design. As a scholar practitioner, you rely on research to help plan your intervention and your evaluation plan.
Complete the Cortez Family interactive media in this week’s resources. Conduct a literature search related to the chronic issues related to HIV/AIDS and bipolar mental disorder. Search for additional research related to assessing outcomes and theoretical frameworks appropriate for this client. For example, your search could include terms such as motivational interviewing and outcomes and goal-oriented practice and outcomes. You might also look at the NREPP database identified in Week 1, to search for interventions related to mental health and physical health.
Submit a 5-page proposal/research plan for single-system (subject) evaluation for your work with Paula Cortez. Identify the problems that you will target and the outcomes you will measure, select an appropriate intervention or interventions (including length of time), and identify an appropriate evaluation plan.
Include a description of:
· The problem(s) that are the focus of treatment
· The intervention approach, including length of time, so that it can be replicated
- A summary of the literature that you reviewed that led you to select this intervention approach
· The purpose for conducting a single-system (subject) research evaluation
· The measures for evaluating the outcomes and observing change including:
- Evidence from your literature search about the nature of the measures
- The validity and reliability of the measures
- How baseline measures will be obtained
- How often follow-up measures will be administered
· The criteria that you would use to determine whether the intervention is effective
· How the periodic measurements could assist you in your ongoing work with Paula
References (use 5 or more)
Dudley, J. R. (2014). Social work evaluation: Enhancing what we do. (2nd ed.) Chicago, IL: Lyceum Books.
· Chapter 9, “Is the Intervention Effective?” (pp. 226-244: Read from “Client Satisfaction & Effectiveness” to “Target Problem Scale”)
Tankersley, M., Cook, B. G., & Cook, L. (2008). A preliminary examination to identify the presence of quality indicators in single-subject research. Education & Treatment of Children, 31(4), 523–548.
Cortez Family: A Meeting of an Interdisciplinary Team
Paula has just been involuntarily hospitalized and placed on the psychiatric unit, for a minimum of 72 hours, for observation. Paula was deemed a suicidal risk after an assessment was completed by the social worker. The social worker observed that Paula appeared to be rapidly decompensating, potentially placing herself and her pregnancy at risk.
Paula just recently announced to the social worker that she is pregnant. She has been unsure whether she wanted to continue the pregnancy or terminate. Paula also told the social worker she is fearful of the father of the baby, and she is convinced he will try to hurt her. He has started to harass, stalk, and threaten her at all hours of the day. Paula began to exhibit increased paranoia and reported she started smoking again to calm her nerves. She also stated she stopped taking her psychiatric medications and has been skipping some of her HIV medications.
The following is an interdisciplinary team meeting being held in a conference room at the hospital. Several members of Paula’s team (HIV doctor, psychiatrist, social worker, and OB nurse) have gathered to discuss the precipitating factors to this hospitalization. The intent is to craft a plan of action to address Paula’s noncompliance with her medications, increased paranoia, and the pregnancy.
Paula is a complicated patient, and she presents with a complicated situation. She is HIV positive, has Hepatitis C, and multiple foot ulcers that can be debilitating at times. Paula has always been inconsistent with her HIV meds—no matter how often I explain the need for consistent compliance in order to maintain her health. Paula has exhibited a lack of insight into her medical conditions and the need to follow instructions. Frankly, I was astonished and frustrated when she stopped her wound care treatments and started to use chamomile tea on her foot ulcers. Even though we have educated her to the negative consequences of stopping her meds, and trying alternative medications instead, she continues to do so.
As Paula’s psychiatrist for close to 10 years, I have followed her progress in and out of the hospital for quite a while—and I know her very well. She is often non-compliant with her medications, randomly stopping them after she reports she doesn’t like the way they make her feel. She has been hospitalized to stabilize her medications several times over the last 10 years, although she has managed to stay out of the psychiatric unit for the last three. Recently, she had seemed to appreciate the benefits of taking her medications and her compliance has much improved. She had been seeing her social worker regularly, and her overall mental health and physical health were improving. This has changed recently, after several stressful life events. We learned that Paula was pregnant by a man she met briefly at a local flower shop. She also reports he has been harassing her with threatening phone calls and unwarranted visits to her home. Paula disclosed to the social worker that she was neither eating nor taking her medication—and she had not gotten out of bed for days. Her decompensation was rapid and extremely worrisome and, therefore, called for a 72-hour hold.
I have not known the patient long, but it does appear that she is trying her best to deal with a very difficult situation. Pregnancies are stressful times for even the healthiest of women. For Paula to learn she is pregnant at 43—in addition to her HIV and Hepatitis status and her bipolar diagnosis—must be so overwhelming. Adding to this, she has come to her two appointments alone and stated she has no one to bring along with her. When I inquired about the father of the child, she said he’s a bad man and he won’t leave her alone. She seemed truly frightened of him and appears convinced he will hurt her.
When Paula came to me and told me she was pregnant, I was indeed shocked by this announcement. She had never mentioned dating anyone, and with her multiple medical and psychiatric issues, I never thought this would be an issue we would address. Paula and I have developed a strong working relationship over the last two years, and she has shared many private emotions and thoughts. This relationship has been tested, though, since I suggested she be admitted to the hospital. Paula was furious with me, accusing me of locking her up and not helping her. It will take time to repair our working relationship. Once I rebuild that rapport, we will need to work together to find a way to address all of her concerns. We will need a plan that will address her medical needs, her psychiatric needs, and the needs of her unborn child.
As far as her pregnancy, if Paula doesn’t take her HAART medications religiously, she risks having a baby who is HIV positive. I am concerned about how she is going to care for a baby with her multiple medical issues. On the practical side, I wonder how she will physically care for this child. She has a semi-paralyzed right hand and walks with a limp. Additionally, when her foot ulcers flare up, she can barely put pressure on her feet. Newborns take a lot of time and energy, and I am not sure she has the capacity to handle the needs of an infant—let alone a toddler. I have not made any formal recommendations to Paula regarding whether to continue the pregnancy, but I have told Paula that, if she does decide to have the child, she must take her HAART medications every day. I explained that this is vital to her health and the health of her unborn child.
When her social worker, who I am in regular contact with, informed me that Paula announced she was pregnant, I was obviously concerned. Knowing Paula as well as I do, I felt I could be honest with her and give her my opinion about the situation. I told her that she should abort. Based on her medical history, including her physical and mental health disabilities, I did not believe she had the capacity to care for this unborn child. She has absolutely no support at all, outside of the treatment team, and would have no familial assistance to take care of this child. My recommendation for abortion was only solidified when we had to involuntarily hospitalize her. I fear that Paula cannot take care of herself, and she cannot be trusted to take her medications. If she does decide to continue with the pregnancy, my recommendation would be that she stay on the psychiatric unit for her entire pregnancy. That way, we will know that she is taking her medications and that the fetus is safe.
Paula is most definitely a high-risk pregnancy, but that does not mean she can’t have a healthy baby. If she keeps up with her HAART medications and comes to her prenatal visits, there’s no reason this baby can’t be born healthy and HIV negative. My larger concern is with the pain medications she takes for her foot ulcers. There is a slight chance the baby will be born addicted to them. We would have to plan for a stay in the NICU if that occurs. While Paula clearly started to decompensate and exhibited some very risky behaviors recently, I think we should try and understand the stress she has been under. While it is not my place to tell the patient what she should do about a pregnancy, I don’t see that we would have to recommend termination.
Paula has overcome many obstacles in her life, but a baby—at her age and with her medical profile—is very different. Paula has made many bad decisions in her life, and the decision to keep this baby may or may not be the best for both her and the child. That being said, if her decision is to continue the pregnancy, we need to find a way to face the mountain of obstacles. She has little to no social support, and there will be many difficulties she will face caring for the baby alone. Paula also has limited financial resources and will need to apply for WIC and Medicaid. There are the numerous supplies that we will need to obtain, such as a crib, clothing, diapers, and formula. She has historically been unreliable about following up with referrals, so she is going to need a lot of encouragement and support. Honestly, I may not believe this pregnancy is a good idea, although I would never tell her that—that’s not up to me or anyone else. We all, ultimately, need to accept her decision and move on. Our goal now is to help Paula make it safely through this pregnancy and work on a plan to help her care for this baby once it is born. I don’t agree that she should be kept on the psychiatric unit for the next seven or eight months. Allowing Paula to play an active role in preparing for the baby is an important task, and she will need to be out in the community and in her home taking care of things. We have to show that we believe in her and her willingness to manage this situation to the best of her ability. We need to affirm her strengths and support her weaknesses.