Case Study 7-1 A Mutual-Aid Support Group for Persons with AIDS in Early Substance Abuse Recovery

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GC SOC 386 Week 5 Discussion Latest

Case Study 7-1 A Mutual-Aid Support Group for Persons with AIDS in Early Substance Abuse Recovery

Please answer each DQ.

Read “Case Study 7-1: A Mutual-Aid Support Group for Persons With AIDS in Early Substance Abuse Recovery” in Case Studies in Social Work Practice.  Case study listed below. Answer question #1 and #2 that are posed at the beginning of the chapter.

  • What skills are evident in the group leader’s approach to working with the group and the individuals in the group? 2. What types of follow-up and supplementary services would be appropriate for clients during the life of the group and after completing the group?

Read “Case Study 7-1: A Mutual-Aid Support Group for Persons With AIDS in Early Substance Abuse Recovery” in Case Studies in Social Work Practice. Case study listed below. Answer question #3 that is posed at the beginning of the chapter.

  • How did the group leader address the issue of the group member– group leader dynamics referred to as the authority theme early in the first sessions?

Case Study 7-1 A Mutual-Aid Support Group for Persons with AIDS in Early Substance Abuse Recovery 

Persons with AIDS who are in substance abuse recovery struggling with similar concerns can gain support and resources through mutual-aid groups. This case study illustrates the social worker’s methods in enhancing mutual aid among participants in an intensive, 8-month, weekly group held in a residence sponsored by an AIDS Action Committee. Questions 1. What skills are evident in the group leader’s approach to working with the group and the individuals in the group? 2. What types of follow-up and supplementary services would be appropriate for clients during the life of the group and after completing the group? 3. How did the group leader address the issue of the group member– group leader dynamics referred to as the authority theme early in the first sessions? 4. What did the group leader do to create a “demand for work” in the group during the fourth session when he recognized the illusion of work? Case Study 7-1 A Mutual-Aid Support Group for Persons with AIDS in Early Substance Abuse Recovery

Case Studies 5. in Group Work In what ways did the group leader help move the group from the beginning through ending and transition phases of group work? This is a case illustration of social work practice with a small group of five clients, all facing the dual struggle of coping with AIDS and early substance abuse recovery. 1 This group was held in the early days of the AIDS epidemic, with the triple drug therapy just undergoing testing. Three members were using the therapy and showing progress in lowering their viral counts and raising their white blood cell counts. They were hopeful for a cure. One member, Theresa, was waiting for her blood work levels to make her eligible for the treatment. The fifth member, Tina, was transgendered and, because of the use of hormone drugs for her transition from being a man to a woman, she would not be eligible for treatment. As she pointed out: “I know I’m going to die from the virus, but at least I would like to die with dignity and not be standing on street corners sucking old men’s dicks for drug money.” For each client, an additional and related issue was dealing with the impact of serious early physical, emotional, and sexual abuse in their childhood and adolescence. Maladaptive efforts to cope during their teenage and early adult years, including serious substance abuse, also had a devastating impact on group members. For each client, there were added layers of complexity caused by poly substance abuse, criminal behavior, prostitution, homelessness, prison time, and destructive interpersonal relationships. The group members’ ability to trust and to develop true intimacy after so many years of being exploited, as well as having exploited others to meet their emotional and drug needs, was severely diminished. Despite these obstacles, this is also a story of magnificent courage in the face of adversity and the wonderful ability of mutual aid to uncover and nurture the essential impetus toward social connection and caring. The approach used in this case example focused on the development of a mutualaid process in the group (Schwartz, 1961; Shulman, 2011, 2012). The underlying assumption was that these clients, who were struggling with similar concerns, could be helpful to each other. The task of the social worker was seen as helping the group members to help each other. In addition, as an example of longer term group work (8 months), the impact of time on the process is evident. The clients, my coleader, and I were conscious of the need to work directly and quickly in order to make the best use of the time available. As will be seen repeatedly in the case example, the clients are simply waiting for the signal from the group leaders that they are ready and willing to work on tough issues. The First Session: The Beginning Phase Our goals in the first session were to establish a clear sense of group purpose reflecting the common ground between the needs of the members and the service offered by the agency. We wanted the group members to get a sense of our roles not as experts on life but rather as group leaders (one social worker and one substance abuse counselor), who were there to help them to be sources of support for each other. In addition, we hoped to set out the ground rules and to develop a beginning sense of trust in us as the leaders (leader– member alliance), as well as in other group members (member– member alliance). Also important was the need to convey what I call “the demand for work.” We wanted the clients to get a sense that we meant business and that, in this group, we were prepared to deal with tough and painful issues and emotions just as soon as they felt ready. Our signal to them came in my direct opening statement as well as my effort to reach for painful feelings. To fashion an appropriate opening statement, I had consulted with staff and other clients in similar situations and then decided on the following: Everyone in this group is struggling with AIDS and early recovery from some form of substance abuse. Most of you currently are or may have in the past attended 12-step groups such as AA or NA, at which you are able to share your experiences coping with addiction and recovery. In addition, you are currently or may have in the past attended groups at AIDS Action that address the particular struggles you face dealing with whatever phase of the disease you are experiencing. You can talk about recovery at your AA and NA groups, but most likely you don’t feel comfortable discussing your AIDS. In turn, AIDS is on the agenda for your AIDS groups, but it may be more difficult to discuss addiction and recovery. This group is a place where you can discuss both— AIDS and substance abuse recovery— as well as how the two interact and affect each other. Heads were shaking affirmatively as I spoke, so I continued to describe our roles and clarify the issue of confidentiality as follows: John and I will be the co-leaders of this group. We don’t see ourselves as experts, here to give you advice. Our job is essentially to help each of you help each other. We think you are the experts on your own lives and that you have a lot you can give to each other, having experienced similar problems and challenges, so we will try to help you do that. I pointed out that the discussion in the group would be kept confidential and that we would only be required to share information if they disclosed there was a danger to themselves, a danger to others, or criminal activity taking place in the residence. John and I could assure them of confidentiality as the coleaders, and I hoped they would agree to respect confidentiality as well. Heads were once again shaking affirmatively. My next effort was to encourage more specifics in this problem-swapping process. I wanted to help them develop an agenda, one with which they could all connect. Also, it is only in the specifics that real help can be given. I asked them if they could take some time to share some of the specific issues they faced and that we could talk about in the group. I pointed out we did not need to solve all of these problems in one night, but it might help to identify issues for group discussion. The issues they shared were mainly related to the problems they faced in early substance abuse recovery. Since the group started just before Thanksgiving, many members, including Tina, described the temptations they experienced going to parties where drugs were plentiful or attending family events (Jake) with significant consumption of liquor or drugs. One member, John, described the problem of wanting to see his friends at the local pool hall, but that was the place where drugs were sold. In an example of the members drawing on their AA and NA experiences, one member said to John: “If you hang around a barbershop long enough,” and as he hesitated, the other group members said in chorus: “You are going to get a haircut.” We all laughed at this AA saying. Another member, Theresa, told group members that she was living in a nearby singleoccupancy building and was hoping to be accepted into this residence. She said: “There is drug dealing in that building, and I know I have to get out or I’m going to relapse.” The barbershop analogy was one example of their drawing on their 12-step group experiences. One member, Jake, had a problem understanding that this mutual-aid group was different from the 12-step groups since we actually encouraged them to respond to each other, which was not encouraged as participants told their “drug stories” or “drugalogues” at meetings. I noticed at the next few meetings that he brought handouts for me from the other programs. When I asked why he was doing this, he replied: “Well, it’s obvious you need help in running a recovery group.” I laughed and said I could use all the help I could get. I used this as an opportunity to address with the group members what they all perceived as a different kind of group. Even with a clear statement of purpose and our roles in the first meeting, it is wrong to think they all heard, understood, and even remembered what we said. As the meetings proceed, re-contracting is needed to help them really understand. At the end of the first session, we asked them to comment on the group— both what they liked and also what they didn’t like about this session. One member, Tania, commented on the tough time they faced dealing with early recovery and then pointed to me and my co-leader and said: “Well, you both understand.” I took that as an indirect cue that she was raising the authority theme. I responded directly to what I perceived as an indirect cue and said: Tania, I think what you really are asking is have we been in recovery and would we understand what you are going through. I can speak for myself, and the answer is that I have not. I teach at the School of Social Work, and each year I lead a group to help me to stay close to the realities of practice, and this group is the one I decided to work with this year. If I’m to be helpful, I’m going to have to understand, and you are going to have to help me. She smiled and said: “So, you’re not a narc” (narcotics cop). I laughed and said I wasn’t and pulled up my sweater and said, “See, no wire.” A noticeable relaxing of the group members followed my response. I said, “Trust does not come easily, so you have to give us a chance, and I hope we can earn your trust over time.” My co-leader, who was in recovery, responded by saying: “I am in recovery; however, recovery is different for each of us, so we will need to understand what it is like for you.” Who you are and what kind of group leaders you will be are the primary questions in a first meeting (the authority theme). These questions are often raised indirectly, as in this example, so the group leader has to be ready to hear them and to respond. In their theory of group development, Bennis and Shepard (1956) suggested that the group has to first deal with the leader and then members can turn to dealing with each other. It really didn’t matter, in the long run, whether my co-leader and I had been in recovery. As in this example, both I and my co-leader had to make clear we were there to learn from them as the experts in their own lives. The meeting was ending at this point, and I noted that one member, Kerry, who had told us at the start that he could only stay for the first of the 2 hours, had stayed for the full session. I pointed this out and asked him his views on the session. He said he had been reluctant to come, but it looked okay as long as we meant what we said about keeping the discussion confidential. It’s interesting to note that each member directly or indirectly raised an important issue for their work in the first session. The member, John, who was concerned about the pool hall, did relapse but then returned to the group after a week at a detox center. Both members who raised the authority theme, Tina and Kerry, were mandated to attend this group or some other form of service by the residence staff because they had broken the rules and used drugs in the residence. Kerry left the residence and moved to New York City and was the only dropout in the group. Tina stayed and participated fully in the remaining group sessions. The Fourth Session: The Transition to the Middle (Work) Phase In a group such as this one, meeting 2 hours per week over 8 months, at some point the group must make the transition to the middle or work phase. If the contracting work has been clear and the group leaders have defined their roles and addressed the authority theme, then the group is now poised to move to the next phase. Note that I said addressed the authority theme, not resolved it. The authority theme will reemerge during the life of the group and return with some force as the group prepares to end. The signal to the group leader that the group is prepared to shift to deepen the work often emerges as what I call “the illusion of work.” That is, conversation is taking place and it looks like real work, sounds like real work, but somehow it’s missing the emotions or content that may be experienced by group members as taboo. In other words, the group members have to address the culture of the group— the norms, taboos, stated and unstated rules, roles, and so forth— that make up what I call “the-group-as-a-whole.” This organism is more than the sum of its parts. It is the culture that is created beginning with the first session— usually reflecting the general culture in our society— or in this case, the culture of addiction. It is not possible to physically see this group and its culture; however, the leader will see the group acting as if it is there. For example, a shared but unstated taboo subject may be AIDS. Their past experience in 12-step groups encourages a norm to maintain the AIDS discussion-free zone in this group. The signal to me that this norm was blocking the group from moving into the work phase was the concentration in the first three sessions on substance abuse recovery, with almost no discussion of their struggle with AIDS. I decided to challenge this illusion of work, to make what I call the “demand for work,” and to explore the possible reasons for the evasion of work in the following way: When we started the group, we said this was a place to discuss both your struggle with recovery and dealing with AIDS and how they impact each other. For the first three meetings, all you have discussed is recovery, and you have avoided talking about AIDS. How come? Is it too hard, too painful, too scary, or maybe too embarrassing to talk about? In most cases, this would result in a group discussion of what made it hard and what, if anything, would make it easier. As the members talk about what made it hard or easier, they were also talking about AIDS. For example, if they mentioned the issue of stigma as a barrier, they would actually be talking about what it was like to have AIDS, how others saw them and they saw themselves. There are many false dichotomies in our practice, where we think two ideas are diametrically opposed and we fail to see the connection. Talking about process in the group is often posed as a choice the leader makes instead of dealing with content . I argue that this is a false dichotomy, and as the members talk about what makes it hard to discuss AIDS (the process), they are really well into deepening the discussion of the content. In this case, in response to my gentle confrontation, Theresa, who emerged as an internal leader in the group (the group leaders are the external leaders), began to talk with great emotion. Theresa started to talk about her concerns. She said she was 18 months clean and sober, and so she was in the middle of the second year, which was a “feelings year.” She went on to describe that this was the period when she and, she thought, everyone in recovery, started to face all those feelings they had been running from. She said it was a complex and difficult time, and that it was hard to sort things out. She went on to say that her boyfriend had trouble sharing his feelings with her. When she wanted to talk to her boyfriend about issues, such as her AIDS, he pulled back and told her it was too painful. As a result, she backed off. She knows he’s experienced a lot of losses, including the death of his wife from illness fairly recently, and she realizes he is still early in recovery, but she has things she wants to talk to him about. She has a closeness she wanted to achieve. She has some commitments she wants from him, and she is afraid that he can’t make commitments at this point. He’s holding back. I asked the others in the group if they had any advice for Theresa on this issue. Theresa had spoken with great emotion, and I was determined not to do casework in the group, and instead, to wait for members to respond. Kerry, who usually sits quietly at the meetings, and who had indicated that he was going to have to leave early that night, jumped right in. Kerry said he thought that her boyfriend was having trouble dealing with his losses, and it wasn’t easy. He described a very close relationship with his partner, Billy, that ended 2 years ago, when his partner died of AIDS on Christmas Day. He said he still didn’t think he’d come to grips with all of the feelings that he had and the loss that he’d experienced. I said that must make each Christmas even more difficult for him, and he agreed. He went on to talk about how he had been raised by an extremely physically abusive mother and that his grandmother was the only person who provided him with any support and love. He said he didn’t think he had gotten over her dying either. He told Theresa that she had to realize that the process takes a long time and that it might not be easy for her boyfriend to discuss it with her, because he knew it wasn’t easy for him to discuss his loss with other people.

As Kerry talked, I saw a sensitive and caring side of him that he keeps covered up with his abrasive, grandiose, angry front, with his consistently telling us he doesn’t need anybody and, if they don’t care about him, “the hell with them.” Theresa acknowledged his comments and thanked Kerry for sharing that with her, as did the other group members. Tania came in at that point and reinforced what Kerry had been saying. Jake was shaking his head as if he understood that difficulty as well. In this next excerpt, we see the group members accepting our invitation to help Theresa and, by doing so, really also helping themselves. This is an example of another false dichotomy: “Do we deal with the individual problem or do we deal with the group?” By helping the group address each individual’s specific concern, they are also addressing their own versions of the same issues. You do not have to choose between the individual and the group, just as you don’t have to choose between content and process. You do have to recognize the connections between these supposedly alternative choices. Whenever a group member raises a general problem, there is usually a specific, recent example that is creating a sense of urgency. I attempted to help Theresa elaborate on her “first offering” by using a skill I call “reaching from the general to the specific” (Shulman, 2011, 2012). I asked Theresa if anything had happened recently to make her feel so strongly about this issue. Theresa described an incident that led to a major fight with her boyfriend. They were in a car together, and she was in the back seat. There was another woman in the front seat whom she experienced as coming on to her boyfriend. The woman was asking him when they could get together and telling him how much she’d like to. Case Study 7-1 A Mutual-Aid Support Group for Persons with AIDS in Early Substance Abuse Recovery.

GC SOC 386 Week 5 Assignment Latest

Read and evaluate “Case Study 2-4” from Case Studies in Social Work Practice, “Using a Family Systems Approach with the Adoptive Family of a Child With Special Needs.” Listed below.

Write a 500-750-word reflection about the case that includes a discussion of the child and family subsystems, boundaries, social systems, and cultural influences of the family described in the case. Make a list of the micro, mezzo, and macro systems. (Ecomap Example: See Figure 2.1 in Applying theory to Generalist Social Work Practice, 2014 by Langer & Lietz).

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.

Prepare this assignment according to the guidelines found in the APA Style Guide. Please include a introductory paragraph with thesis  statement and a conclusion paragraph.

Case Study 2-4 Using a Family Systems Approach With the Adoptive Family of a Child With Special Needs

T his case study illustrates the use of a family systems approach to working with a new family constellation that has been created out of tragedy. This therapeutic intervention, informed by family systems theory and practice, incorporates elements of attachment theory and the dynamics of kinship adoption, an understanding of the effects of complex trauma on individual and family functioning, recognition of the impact of culture, class, and immigration status, as well as contextual social factors such as racism and sexism, on the functioning of the family system in relation to its individual members, as well as on the functioning of the family in a larger context of community and the dominant culture. Questions 1. How can family systems therapy help a family newly formed through adoption learn how to meet the emotional and social needs of each of its members? 2. Can a family system that has been formed as a result of grievous loss create a new, more positive identity for the future?

  1. 4. What is the best way to help adoptive parents of a child with serious emotional and behavioral challenges manage their child’s needs while still attending to their own? What are the special concerns, if any, when working with a family from a different culture than one’s own? Even though I have been a social worker for nearly 40 years and a family systems therapist for almost that long, every time I explore a case using a family systems lens, I feel a kinship with the very first professional social workers— like Mary Richmond— who understood well the importance of the family system in interpreting the psychosocial dynamics of the individual. Although in the 21st century we know a great deal more than our professional foremothers and forefathers did about the biological basis of human behavior, these early professionals recognized the importance of observing family members together “acting and reacting upon one another” (Richmond, 1944/1917, p. 137). The family in all of its dimensions has historically been the purview of social workers (Carr, 2009; Dore, 2012; Walsh, 2011). Whether working in child protection, adoption, child guidance, family services, eldercare, or in a specific setting like a hospital, school, or community mental health clinic, social workers have recognized that the individual could only be truly understood in interaction with his or her environment, the most essential element of which is the family. The Family The particular case I have chosen to use to illustrate family systems therapy is that of the Laurent family. The family consists of the father, André, age 36; mother, Marie Clothilde, age 32; and their adopted son, Michel, age 10, who is also Marie Clothilde’s nephew. André Laurent immigrated to the United States as a young teenager when his parents fled Haiti after the first overthrow of President Jean-Bertrand Aristide in the early 1990s. They settled in the greater Boston area, where André attended school and learned to speak English fluently. He graduated from a technical high school, where he studied information technology, and since graduation he has been consistently employed in IT services in the pharmaceutical industry. Marie Clothilde immigrated more recently, coming to the United States in 2005 to stay with an older sister in the hopes of finding work to help support her family back in Haiti. Because Marie Clothilde spoke very little English, her employment options here were limited. She worked primarily on a cleaning crew that maintains office buildings at night. Shortly after she arrived in this country, she met André through a cousin. They married in 2007. Even though André had a goodpaying job, Marie Clothilde continued to work after their marriage so that she could send money back to her poverty-stricken family in Port-au-Prince.

The Presenting Situation: Everything changed for André and Marie Clothilde on January 12, 2010, the date of the devastating earthquake in Haiti. Marie Clothilde spent frantic days after the disaster trying to find out what had happened to her family. Eventually, through a family friend, she learned that her entire family in Port-au-Prince had been killed, with the exception of her sister’s son, Michel, who was dug out of the rubble of the extended family home still alive two days after the earthquake. With the aid of her priest, who is also Haitian, she was able to locate Michel in a makeshift orphanage in Port-au-Prince and arrange for him to come to this country. Michel, who lost his only parent and grandparents in the earthquake, along with his uncle, aunt, and two young cousins, was still in shock when he arrived at Logan Airport in Boston in April 2010, to begin a new life in a strange country with adoptive parents he hardly knew. Marie Clothilde was struggling emotionally as well. Her family had been decimated in the earthquake, and she barely had time to process the loss when she was confronted with an emotionally distraught child to care for. She assumed the role of mother, a new one for her, and relinquished the role of wage earner because Michel required all of her time and attention at home. André, feeling he needed to make up financially for Marie Clothilde’s lost income and not a little displaced in his wife’s attentions by his new son, began to spend more time at work. Marie Clothilde enrolled Michel in the neighborhood elementary school, but her inability to speak much English prevented her from fully communicating what had happened to Michel with school personnel. Thus, school personnel, who placed Michel in a mixed class of children who were nonEnglish speaking, were totally unprepared for the problems he began to manifest. For one thing, Michel was unable to sit quietly at a desk for any length of time. He would begin to pace the classroom and, if requested to return to his seat, would begin screaming and thrashing about, pulling at his hair and babbling in Haitian Creole. If a teacher attempted to touch him to guide him back to his seat, Michel would shrink away, sobbing and crying, flailing his arms and shouting about petro loas (evil spirits) who were possessing him. At these times, Marie Clothilde would be summoned to the school and told to calm Michel down or take him home until he gained better control of himself. One day Michel became so out-of-control, alternatively cowering under his desk, crying and shaking uncontrollably, and striking out aggressively, cursing at anyone who tried to come near him, that the school contacted the mobile crisis team from the child and adolescent inpatient psychiatric unit at the local hospital. In consultation with André, who had rushed to the school from his job, and Marie Clothilde, the mobile crisis team recommended that Michel should be hospitalized briefly for further evaluation. Although many Haitian people believe that the kind of serious emotional and behavioral disturbances that Michel was exhibiting are caused by a curse from a loa (sometimes spelled lwa ) or evil spirit who is upset at being disobeyed, André and Marie Clothilde recognized that Michel’s problems were likely related to the severe trauma and multiple losses he had experienced back in Haiti. Fortunately, because the greater Boston area has the fourth largest Haitian population of any city, including those in the country of Haiti, the community hospital where Michel was admitted belongs to a behavioral health network that supports a mental health team of Haitian Creole– speaking professionals. The child psychiatrist on this team, Dr. Odette Jean-Baptist, evaluated Michel in the hospital and diagnosed posttraumatic stress disorder suffered as a result of the complex trauma he experienced during and after the earthquake in Haiti exacerbated by the process of immigrating to the United States and adjusting to a radically different life in a strange new family, school, and community. Dr. Jean-Baptist prescribed a short course of a mood stabilizer to help Michel manage his explosive outbursts and scheduled regular follow-ups to monitor his response to the medication. She also made a referral to the local children’s mental health agency, where I am employed, for ongoing family treatment to help Michel integrate into his new family and to help his adoptive parents learn ways to support their son as he mourns his former life and embraces his new one.

Joining the Family System: Through contracts with the state Department of Mental Health designed to prevent long-term out-of-home placement of children and adolescents with serious emotional disturbances, my agency offers family-based services to children and their parents in their own homes, in community settings, or in our offices, depending on the family’s preference. If a child is already in a psychiatric placement, as was Michel, then we meet with the family in the placement setting and include in our first session the mental health professionals working with the child there. In this case, Dr. Jean-Baptist joined us to offer her insights regarding Michel’s diagnosis, his current psychosocial functioning, and her team’s recommendations for his further treatment. As if sensing my unspoken concerns about the Haitian culture’s belief regarding disability, especially mental disability, as something the individual has brought on himself, a punishment for offending the spirits or God in the case of Haitian Christians, and how this belief might affect Michel’s parents’ response to his illness, Dr. Jean-Baptist explained to them in lay terms in both Haitian-Creole and English how experiencing profound trauma can alter the functioning of a person’s brain, particularly in children whose brains are still developing and thus are uniquely vulnerable to the physiologic changes that take place in response to high levels of traumatic stress. This explanation helped alleviate André and Marie Clothilde’s expressed concerns about their ability to parent Michel, particularly when I explained how I would be working closely with them to figure out the best ways to help Michel manage his own emotions and behavior. I added that I would also be connecting them with community resources that could offer them support with Michel into the future.

Assessing Family System Dynamics: As a therapist working from a family systems perspective, it was important at this point to join with the parents to support their capacity to adequately meet their new son’s needs by becoming part of the family caregiving system so that they did not feel so alone and overburdened. Although Marie Clothilde had extended family ties to Michel that would help sustain her commitment to him during the challenging work ahead, André had no such ties, and I was concerned that his emotional investment in Michel might be more limited, particularly if he experiences Michel as coming between him and his wife. This dynamic is frequently seen in family systems when one parent, usually the mother, becomes so invested in caring for a child with special needs that other family members, often the father and the child’s other siblings, feel shunted aside with their emotional needs going unmet. This dynamic could be complicated by the patriarchal tradition in Haitian culture that lays the burden of caring for a child with a disability solely at the feet of the mother. There is a great deal of shame and stigma associated with having a disabled child in Haiti. If a child is born with a visible disability, the father may leave the home and take up with another woman, who will become pregnant and bear a child without a disability, thus proving that the father is not the cause of the child’s impairment. As a result, disabled children in Haiti are often raised by single mothers. Knowing this, it will be important for me to assess the degree to which André and Marie Clothilde ascribe to these beliefs and determine how to keep André engaged with his new son so that Michel’s care is not left entirely to his wife.

Strengthening the Adult Partner Subsystem: I knew I must also find ways to help André and Marie Clothilde communicate openly about their own needs and feelings so that Marie Clothilde does not begin to feel overburdened by Michel’s care and André doesn’t feel closed out of the mother-child subsystem in the family. A common strategy in practice informed by family systems theory is working to strengthen and develop what is called the marital subsystem in the traditional family therapy literature, but what could more accurately be termed the adult partner relationship , as it can also refer to unmarried same-sex or opposite-sex partners. This strategy is also important in a single-parent household, especially when the parent has formed a co-parenting alliance with one of the children, usually the oldest girl. The idea here is to establish and support a family hierarchy in which the adults are in charge, and to ensure that the adults have a relationship with one another that is separate from their roles as parents. Developing such a relationship requires open, clear communication of needs and feelings, as well as mutual understanding and support. Family systems therapists believe that a solid adult partner relationship is the key to a family system that responds adequately to the needs of all of its members.

The Impact of Adoption on the Family System:  In addition to cultural and adult relationship considerations, there are issues around adoption, particularly the adoption of an older child with special needs, which I must be aware of in working with the Laurent family. At the point that I met with the family in the hospital, I knew nothing about the couple’s desire to have children of their own, whether this was something that they had wished for but had been unable to conceive, or whether they had decided not to have children, which I thought was rather unlikely given the high value placed on children in Haitian culture. In family systems practice in adoption, it is essential to understand a couple’s intentions regarding childbearing and what their efforts have been to have a child of their own. For some people, the inability to conceive and/or carry a child to term is viewed as a personal failing with accompanying self-blame and depression, making the emotional investment in an adopted child more challenging. When a kinship adoption is thrust on a couple unexpectedly, as was the case with André and Marie Clothilde, there is little or no time for them to consider what the addition of a new member will mean to their family system and to prepare for likely changes. If one partner is more eager to adopt a child than the other, particularly if the lessinvested partner is simply going along with the adoption to please the other person or to salvage their relationship, then the addition of a child to the family system through adoption can result in a significant shift in the partner relationship. Adoption of an older child also brings its own challenges to the family system. Although Michel is a member of Marie Clothilde’s extended family, she has not seen him since he was a toddler and can only surmise about his prior upbringing in an extended family household that included not only her sister, Michel’s mother and a single parent, but also her mother and her father who was an alcoholic, as well as her older brother, the only wage earner in the family, his wife, and their two young children. Like approximately 80% of Haitians, the family was very poor and lived in the section of Port-au-Prince known as Cité Soliel, an infamous urban slum. Marie Clothilde knows from her own experience that the primary school that served Cité Soliel children before the earthquake was a ramshackle building lacking in basic resources such as electricity and running water. The cost of uniforms and textbooks made sending any but the eldest male child prohibitive for families like hers. She isn’t sure just how much schooling Michel actually had back home but, like many Haitian immigrant parents, she is anxious that he should be placed in a classroom based on his age rather than his prior educational experience or ability. She is unfamiliar with the special resources available to children with Michel’s challenges in the Boston-area community in which the Laurent family lives and, again like many immigrant parents, relies on school personnel to make the best decisions for Michel.

Helping the Family System Incorporate a New Member:  Marie Clothilde’s unfamiliarity with the local education system provided me with the opening I needed to engage André, who, as a result of having gone to high school in the area, was more familiar with the system and at ease with school personnel. Appealing to André’s authority on the local education system not only increased his involvement with Michel and his special learning challenges but also brought him back into an alliance with Marie Clothilde on behalf of their child, as together, with my coaching and support, they worked with the special education staff at Michel’s school to obtain a full educational evaluation and design an Individualized Education Program (IEP) to meet his learning needs. Under the Individuals with Disabilities Education Act (IDEA), parents are entitled to be considered full partners with special education personnel in contributing to planning the IEP.

Strategies to Strengthen the Parental Subsystem: My experience in working with immigrant parents, many of whom come from cultures that place educators on a pedestal, is that they are often hesitant to question the decisions of school staff or to advocate for their child if they feel his or her learning needs are not being met. This seems to happen more often when the child’s learning is impacted by serious emotional and behavior disorders. As is true in most states across the country, we are fortunate to have a very effective educational advocacy group in Massachusetts, the Professional/Parent Advocacy League (P/PAL), for families whose children have mental health challenges. P/PAL can arrange for a legal advocate who is thoroughly familiar with education law to accompany parents to an IEP planning meeting if they are at all concerned that their child will not receive appropriate or adequate educational services from the school. If I am working with a family with a child with a serious emotional and/or behavior disorder, I routinely put them in touch with a P/PAL representative, who is usually an experienced parent of a child with similar challenges who offers support and information about local resources. P/PAL also sponsors psychoeducation groups that meet weekly in specific locations throughout the state for parents whose children are struggling with mental health concerns. In addition, the organization holds picnics and other fun events for families who may feel more comfortable socializing with other families with similar childrearing challenges. One of the most significant changes in family systems practice in recent years is the recognition that the families we work with are embedded in networks of community supports and services that can be tapped to strengthen the family system in myriad ways. Family systems work used to focus almost completely on the nuclear family system, the constellation of dad, mom, and kids. As this constellation changed markedly over the past several decades to encompass a variety of family forms, family therapists recognized the need to broaden their purview, first to include extended family members and close friends in their therapeutic interventions, then to add to the family’s network in more creative ways. Nowadays, rather than expecting the family to meet one another’s emotional and social needs exclusively, family therapists assess a family’s life cycle stage and locate resources that can support the family in their current developmental process. For example, in working with the Laurent family, which has suddenly moved from the couple stage, with its focus on the adjustment of the marital subsystem, to the addition of a new family member, a child with special needs, I looked for community resources that could support them in this process. In addition to introducing them to P/PAL to help them navigate the education system, I also put them in touch with Adoptive Families Together (AFT), which, as the name suggests, is a grassroots organization of adoptive families, many of whom have adopted children with special needs and challenges. AFT not only offers parent support groups throughout the greater Boston area, but also sponsors an online discussion group, which adoptive parents can access for information, advice, and general support. Families who join AFT receive a free copy of In Their Own Words . . . Reflections on Parenting Children With Mental Health Issues: The Effect on Families , a book written and published by members of this organization. Because this book is available only in English, which Marie Clothilde is unable to read comfortably, we agreed that André would read a chapter to her each evening after Michel had gone to bed, and they would discuss issues the material raised, noting any concerns they wanted to bring to our by-then weekly meetings together.

Addressing Individual Member Concerns From a Family Systems Perspective:  As I noted previously, there is a large Haitian population in the greater Boston area, which luckily means that many resources are aimed specifically at the Haitian community in the area where the Laurents live. Because I had concerns about Marie Clothilde’s response to the deaths of nearly her entire family in the earthquake, which I felt she had delayed facing because of her need to attend to Michel’s mental health issues, I hoped to locate a support group for Haitian women who had experienced similar losses in that tragedy. The Association of Haitian Women in Boston, an advocacy organization for Haitian women, was able to refer Marie Clothilde to a women’s group that met locally through the auspices of the Cambridge Haitian Services Collaborative. I also learned of an extensive women’s literacy program offered by this organization, which could help Marie Clothilde become more fluent in English, enabling her to better negotiate the various service systems on behalf of her son. In making these inquiries and referrals, it was essential that I actively engage André in the process in order to maintain balance in the family system and to honor the role of the husband and father in Haitian culture. My agency runs an ongoing father-son group in our community for fathers of boys, ages 10 to 15, who are struggling with emotional and behavior challenges. Most, though not all, of the dads in the group live apart from their sons and are seeking ways to strengthen the attachment with their boys. It is primarily an activities-recreation-adventure group that draws heavily on the many arts, education, and sports-related resources in the greater Boston area. I thought since parent-child attachment is one of the ever-present themes in this group, it might also be appropriate for André as an adoptive father seeking to build a relationship with his new son. One of the two male leaders of this group is a Haitian American social worker, Emile Richard; the other is an African American psychologist, Ed Gaines. André was hesitant about joining the group with Michel given the boy’s emotional and behavior challenges, but he agreed to meet with Emile and Ed to see if the group was a fit for him and his son. As it turned out, André and Emile were distantly related through their mothers, which cemented André’s willingness to try the group. From the group leaders’ modeling, André learned some effective strategies for managing his son’s behavior in public situations, as well as attunement skills to help Michel build capacity for self-regulation. André connected with several of the other fathers in the group, and a small group of them with their sons, all around Michel’s age, began meeting in a local park on Saturday mornings to play pickup soccer. Through the fathers’ group, which occasionally met at a local sound recording studio, André and Michel discovered a mutual love of Kompa (in English called compas ), the traditional music of Haiti. They often listen together to old LPs made by Kompa artists like Nemours Jean-Baptist and Rene Saint-Andre that were given to André by his father. Michel wistfu

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