Working With Individuals: The Case of Sam

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Sam is a 62-year-old, widowed, African American male. He is unemployed, receives

Social Security benefits, and lives on his own in an apartment. Sam has minimal peer

relationships, choosing not to socialize with anyone except his daughter, with whom he is very

close. Sam raised his daughter as a single father after his wife passed away. Melissa is 28 years

old and works as an emergency medical technician (EMT). When Sam was 7 years old, he was

placed in foster care and has had very limited contact with his extended family. Prior to

September 11, 2001, Sam had a steady employment history in food services and retail.

Sam became depressed and psychotic after 9/11 and was deemed unable to return to work

after multiple psychiatric hospitalizations. He has no history of alcohol or substance abuse issues

and has no criminal background or current legal issues. Sam reports his religious background is

Catholic, but he is not affiliated with a congregation or church. He has a diagnosis of major

depression with mood-congruent psychotic features, and he has a history of high blood pressure

and migraines. Sam has been seeing a psychiatrist once a month for medication management for

over a decade and is currently prescribed Depakote®, Abilify®, and Wellbutrin®. Sam has a

positive history of medication and treatment compliance. He had been treated by a social worker

at an outpatient program for about 2 years after his hospitalizations for his psychosis and

depression. He stopped attending sessions with the social worker after his symptoms stabilized,

and termination was deemed appropriate; he continued to see the psychiatrist monthly for

medication management.

After about 10 years of seeing only the psychiatrist, Sam scheduled a meeting with this

social worker for increased feelings of depression. These feelings were brought on after his

daughter moved out of the apartment they had shared for many years to live with her boyfriend.

He reported difficulty adjusting to living alone and often feels lonely and anxious. He reported

during our sessions that he speaks to his daughter frequently, and although she only lives 10

blocks away, he misses her terribly.

Our sessions for the last 3 months have focused on his mixed feelings around his

daughter’s new life with her boyfriend. He is happy that she is happy but misses her very much. I

emphasized his strengths and helped him reframe his situation by focusing on the positive

changes in her life as well as his own life. Our goals were to help him reduce his symptoms of

anxiety and begin searching for new opportunities for socialization outside of his daughter.

During our last two sessions, I became concerned because Sam, who is normally

articulate, had been appearing confused and slightly disorganized. I asked him if he had a recent

medication change and if he had been compliant with his current medications, but he denied

noncompliance or any recent medication adjustment. I asked Sam if he was experiencing any

physical health problems. He denied any ongoing problems but mentioned that he had collapsed

on the street recently. He reported that he had been hospitalized and had undergone a number of

tests, which he thinks were all negative. He said he still feels “foggy” at times, and sometimes

time seems to be “missing.” I reviewed his medications with him and, as he went down the list,

he reported taking Cogentin® and Ativan®, which according to his chart history had been

discontinued months ago. When I asked Sam where he obtained these medications, he stated, “I

got them out of the bag.” Sam reported he has a bag at home in which he puts all leftover and

discontinued medications. He could not explain why he was taking discontinued medication or

for how long. Sam stated, “I thought I was supposed to take it.” I called his daughter, and she

verified he had recently been hospitalized, and the MRI, CT scan, and EEG tests were negative. I

requested that Melissa go to her father’s apartment to look for the bag of medications he

mentioned, because it seemed likely that her father was taking discontinued medications. I then

scheduled a meeting with Sam and his daughter for later that week. During that session, Melissa

reported that she found multiple vials of old medication on the kitchen counter mixed in with her

father’s current medications. Melissa reported that she collected and disposed of all the old

medications. I recommended obtaining a daily medication planner. Although the hospital tests

were negative, I recommended scheduling an appointment with a neurologist, and both agreed.

Sam saw a neurologist who reported that his test results were negative but did not rule out the

possibility of a seizure disorder. The neurologist recommended a follow-up appointment in 3

months. He also contacted Sam’s psychiatrist and recommended that the Wellbutrin be

discontinued because it is known to have the potential to cause seizures and that Sam start on

another antidepressant. Sam began to focus and become more cognitively alert after the

discontinued medications were disposed of and the Wellbutrin discontinued.

I scheduled another family session for Sam to discuss his feelings regarding Melissa

moving out. Sam was tearful when he told Melissa he missed her and her dog Sonny. He also

told her he was concerned he would not be financially able to remain in the apartment. Melissa

reported working long and odd hours but did call her father often and invited him over to her

apartment. She further reported that he often declined her invitations. Sam reported he declined

because he did not want to intrude on her life or her boyfriend. Melissa assured her father that

both she and her boyfriend wanted him to visit and be part of their lives. I asked Sam if Melissa’s

dog had been company for him, and he replied, “Yes, and I miss him.” I asked Melissa if it

would be possible for Sonny to spend some time with her father. Melissa reported her long work

hours were making it difficult to take care of Sonny and asked her father if he would like Sonny

to live with him. Sam replied, “I would like that.”

I discussed with Sam how he spends his time, which normally consists of reading a

newspaper, watching television, or listening to talk radio. I suggested Sam increase his

socialization and recommended a social club for older adults that is near his home. Sam said he

would consider this idea. I asked Sam to discuss his financial concern that he may not be able to

remain in his apartment. Sam stated that Melissa had been contributing to the household

expenses but stopped when she moved out. He stated he had been too embarrassed and ashamed

to discuss this with Melissa and had been keeping this to himself. Although Sam is on a fixed

income, he is currently able to meet his expenses. However, he is concerned about his rent,

which is his largest expense.

I explored state and federal rent assistance programs for seniors and the disabled. I found

a program in which tenants that qualify can have their rent frozen at their current level and be

exempt from future rent increases. Sam met the program requirement of being at least 62 years

of age, currently living in a rent-controlled apartment, and having a household income that was

within the specified guidelines. I obtained the required forms and personal documentation from

Sam and completed the application, sending it to the appropriate agency.

Reflection Questions The social worker in this case answered these additional questions as follows. 1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this

client situation?

I remained concerned about my client’s health and recommended further testing with a neurologist. My client and his daughter agreed and were able to follow through with this recommendation. I was able to engage my client’s daughter to participate in family sessions

to address my client’s recent health issue, the loss he felt since his daughter moved out, and his financial concerns.

2. Which theory or theories did you use to guide your practice?

Family therapy/engagement was recommended and successful.

3. What were the identified strengths of the client(s)?

Sam has a number of strengths that include a long work history before becoming disabled, raising his daughter by himself, and a positive history of compliance with medication and treatment.

4. What were the identified challenges faced by the client(s)?

Sam was having a very difficult time adjusting to living alone and was concerned that he may not be able to continue to live in his current apartment because of limited finances. Sam was unable to convey these concerns to his daughter. Sam was also experiencing a new health concern.

5. What were the agreed-upon goals to be met to address the concern?

Sam was engaged in therapy and kept all his appointments. Sam agreed to family therapy to address his concerns.

6. What local, state, or federal policies could (or did) affect this case?

I explored local, state, and federal programs that might offer rent assistance programs. I also explored social programs for older adults.

7. Describe any additional personal reflections about this case.

Although Sam does not have a history of alcohol or substance abuse, there remains a question as to whether Sam may have been self-medicating with discontinued medications to relieve feelings of loneliness and anxiety. There is also the question of whether Sam had a seizure or not; and if Sam had a seizure, whether it was due to the Wellbutrin or the combination of medications Sam was taking.

Adapted from: Working with individuals: The case of Sam. (2014). In Plummer, S.-B., Makris, S., & Brocksen S. M. (Eds.). Social work case studies: Concentration year (pp. 47–50, 119–120). Baltimore, MD: Laureate Publishing. [Vital Source e-reader]