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AJIBOLA IDOWU

Process Recordings

SOCW-6520: Social Work Field Education III

Walden University

Dr. Dear

Process Recording Template

Student Name: Ajibola Idowu

Date of Contact: 04/12/2022

Session/Contact # and Location: Initial Assessment/Consult and Wellstar Cobb Women’s Hospital.

1). Description of Client(s): Alaina is a 21-year-old White female

1). Presenting Problem: Positive Tetrahydrocannabinol (THC) during pregnancy, history of use of illicit drugs, and depression. 

2). Purpose of Session (why is the client being seen): The patient was seen to complete the initial assessment and address the consult. 

2). Objectives/Goals of this session: Complete client’s assessment, educate the client on the importance of not using THC especially around the newborn, educating client on side effects of THC on baby and signs to look for if experiencing post-partum depression and providing client with helpful resources on steps to take if experiencing post-partum depression and the danger of breastfeeding while using THC 

 

3). Verbatim Dialogue/Content 

 

4). Assessment of Patient/Client

5). Student Impressions/Feelings/Thoughts/Reactions

6). Identify Practice Skills/Theory/Conceptual Framework Used and/or thinking about using

Supervisor: Comments/Feedback

CC intern knocked on the door and I introduced myself and explained my role and what I was there for. 

I proceeded to identify client by using two identifiers. 

For someone who just had a baby a few hours ago. The client appeared relaxed. I observed that she had cleaned up and was taking pictures of herself and the baby.

The goal is to project warmth while observing the client’s expression and generally observing the room.

Although I knew from the facesheet that I am in the right room. I appreciate the hospital policy of making sure that you are speaking to the right person by first identifying the client. Mrs. Andrea has worked in Wellstar Cobb for 17 years. She always has an informative story to share

 

Identifying the client is crucial. My supervisor then proceeded to tell me the mistake that happened to care coordinator and reason why identifying the client is crucial before conducting assessment or consult.

(AD)

The new born was sleeping in mom’s hand. I asked her what his name is. 

The patient said Sage. I complimented her on such a beautiful name for a handsome baby. I also complimented on being all made up after just giving birth a couple of hours. 

Patient appeared comfortable and smiling 

Because people are usually tensed around social workers. It is important to project warmth and build trust. Complimenting the client and emphasizing her strength is important to me in order to start the assessments in a more relaxed mode. 

Projecting warmth, empowerment, and observing client expression and demeanor. 

The Father of the Baby (FOB), and the patient’s mother were present at the bedside. I confirmed who they were, congratulated them on the birth of baby Sage.

 I asked the patient if it is okay to conduct an assessment while both of them were present.

Patient said yes

I proceeded with asking FOB some questions.FOB stated his date of birth and his highest level of education. He said that he is employed and would be very involved in the care of baby Sage. 

No visible change in client’s demeanor. Patient continues to engage the baby. 

Knowing who is in the room with the client during the assessment is important especially when sensitive conversation, questions or answers can be divulged. 

Empowerment 

Close-ended question

It is always important to seek the consent of the patients before starting an assessment when you have other people in the room.

(AD)

I asked the Mother of the baby (MOB), to confirm that the information on file such as address, phone number and emergency contact remains the same. MOB said Yes.

MOB maintains eye contact and appears engaging. 

 

Close-ended questions.

Observing client’s expression.

 

I asked MOB if she had other children and she answered Yes, two girls. I then proceeded to ask for their names, ages, and who they were staying with while MOB and FOB were in the hospital. 

No visible change in demeanor. MOB continued to be engaging. 

Because of the seriousness of the consult. I was a bit nervous about the consult, but I am glad that MOB is willing to engage

Open-ended question

Maintaining eye contact

 

MOB stated their names, ages, and said they were with her brother and his family. I then asked MOB who lives with her in her home and MOB stated that she lives with her two children, FOB, and FOB’s mother. I requested for the name and phone number of FOB’s mother and MOB provided me with the information. 

MOB maintained brief eye contact and continued with taking pictures of the baby.

  

Since I was aware that MOB will be referred to DFACS for testing positive for THC and also aware that DFACS requires this information. MOB answering this information is important to complete the referral. 

Eliciting information

Close-ended question

Maintaining eye contact

 

Since we were not alone and I had to address the issue of MOB testing positive for THC, I moved closer to her bed, bent down a bit, and asked her quietly if I could talk to her about her THC result. I proceeded to inform MOB quietly that she has tested positive for THC on 04-11-22 which is the day of admission to the hospital. MOB stated that she was not aware that she tested positive for THC and that she only uses THC occasionally at the beginning of her pregnancy to help her with morning sickness. MOB denied using it after her first trimester and further stated that she has no intention of using it again, especially because she plans on breastfeeding baby Sage and she understands the risk it has on the baby. 

Slight change in demenor

Although the patient has given me prior permission to speak in front of FOB and her mother. Addressing the issue of testing positive for THC. I thought that addressing the issue of THC with MOB needed some privacy. 

My thought and feeling at this point are here comes the uncomfortable but important part. I was not sure whether to ask if FOB and MOB’s mother can give us some more privacy. I knew the policy requires privacy if the consult was for domestic violence but was not sure what the policy was concerning divulging sensitive information such as being positive for THC. However, I am comfortable that the client gave me permission to talk about this. This will be something to ask my supervisor. 

Actively observing the patient

Use of silence in observation 

Mindfulness

Self -awareness

This is a case-by-case scenario. You have done the right thing by asking her if it is okay for her family to stay. 

(AD)

I complimented MOB on stating that she had no intention of using THC again. I told her that making such a decision shows her strength. 

MOB was engaging. Seems a bit upset and avoided eye contact. 

It is important that I convey understanding and not being judgmental. If MOB feels judged by me. She would not be receiving of education. 

Effective Communication

Using encouragement as an empowerment tool. 

I proceeded in educating MOB on the importance of not smoking around the baby and the side effect of THC on the baby. I went through the information package on THC and the danger and gave the package to the MOB encouraging her to go through it when she is able to.

MOB was engaging. Appeared interested in the information package. 

I am hopeful that given the short time that I have to engage with the patient that she is open to receiving education on the side effect of THC on her baby. 

Effective communication

CC intern also informed MOB that as per hospital policy, because of her positive toxicology report of THC, DFACS will be notified. 

The patient appeared visibly upset. I also noticed that FOB, and MOB were suddenly very quiet. 

The patient already has a history of depression. In a normal situation, having a baby is a happy time and I did not want to be the bearer of bad news. However, as a mandatory reporter, I am required to notify DFACS of MOB’s THC results. 

Self-awareness

I immediately explained the referral and the process to MOB letting her know she will be getting a visit/phone call and that DFACS do not normally take kids away from their parents due to THC positive results. However, I made it clear that the referral is positive to protect the baby and I am proud of her that she said she wll no longer engage in THC usage while breastfeeding baby Sage. 

I noticed a calmer demeanor from MOB.

It is important to assure MOB and her family that the care coordination team is here to help her and not to take her baby away.

Mindfulness.

Providing effective communication

The Supervisor said it is good to assure client on the referral process but to be mindful while assuring client not to sound like you are trivializing the seriousness of suing THC while pregnant. This usage could have hurt the baby’s development and we are not even aware of any further damage of THC on the baby. 

(AD)

CC Intern quickly moved to address the consult on the history of depression. MIOB stated that she has no official diagnosis of depression but stated that she started feeling depressed in high school due to school-related stress, CC Intern asked MOB if she is on medication, has been on medication or counseling. MOB stated that at present she is not on medication for depression but had been on Zoloft and had gone to counseling one year prior. 

MOB appeared calmer and more engaging 

I am glad of MOB’s willingness to seek help for depression. It is encouraging to know that If she needs help in the future, she will seek help. 

Self-determination

Actively listening

I complimented MOB for seeking help for her depression and further explains the importance of knowing the signs of post-partum depression. I also engage FOB and MOB’s mother on signs to look for in MOB if experiencing post-partum depression

No noticeable change in demeanor. 

A compliment can be a good tool. It can help to produce changes in clients.

Using compliments as an empowering tool.

CC intern further educated MOB on activities that she can do to de-stress such as Yoga. I proceeded to let her know that I recently started Yoga and I surprisingly found it very relaxing. 

Client nodded in affirmation. Appeared to be listening to me.

I used self-disclosure so I can be more relatable with the client.

Self-disclosure

CC Intern asked MOB if she had any ideation of suicide/homicide. MOB replied “No”. CC Intern advised that MOB should follow up with her primary physician as needed. Resources package was offered to MOB. I asked if she has any questions or concerns, MOB replied “No”. I proceeded to let her know that if she had any further question or concerns, she should not hesitate to call the Care Coordination Department. I thanked her for her time, wished her well, and congratulated them all again on the birth if baby Sage. 

I felt good that I was able to transition from the first issue of THC to depression smoothly and also felt encouraged by the MOB’s engagement. I am hopeful that everyone involved will have the baby’s best interest in mind.

 

 


6). Summary Assessment/Analysis of the Session

1. Identify the stage of work with client/client system (i.e., pre-engagement, engagement, assessment, intervention, evaluation). Why?

The stage of the work with the client is both initial assessment and engagement. Initial assessment is a crucial process because it is the first stage in the social worker-client relationship. It is the start of the first cycle. It establishes the starting point for learning about the client. In this case study, the client was seen by a CC intern to conduct an initial assessment and to address the consult on the positive result of THC, history of illicit drug use, and history of depression. In social work interaction, engagement is both a process and an outcome. It requires a balanced use of effective skills to produce an ongoing social work client relationship that results in accomplishing a good outcome (Horwitz & Marshall, 2015). In Alaina’s case, noticing a client’s strength encourages hope in the client and it is fundamental to effective engagement. Therefore, it is crucial that I maintain effective engagement by using a variety of skills such as focus listening, clear and accurate response, being sensitive, and being non-judgmental. 

 

1. What did you learn from the session that adds to your understanding of the client?

No one can effectively address a personal challenge without a sense of empowerment. Empowerment theory recognizes that many people already possess needed resources to overcome obstacles therefore, it is the social worker’s duty to help client draw their inner strength and resilience making highlighting Aliana’s strength crucial. In this case scenario, Aliana has already empowered herself by seeking help for her depression. My goal as the social worker is to draw on her strength and further encourage Aliana that she can overcome the issue that she is experiencing.

  

1. What were the major themes of the session?

The care coordinator was there to address the issue of positive THC, and history of depression, and to conduct an initial assessment. The theme of the session was to educate the client and provide needed resources.

 

1. What were the challenges presented during the session?

Meaningful engagement with the family provides the social worker with a broader, deeper range of data and tools to effectively help a client. The purpose of engaging Aliana and her family is to increase the effectiveness of the intervention. Although Aliana is a mother of 3 children, she is only 21-year-old and a young adult. Having a good support system is vital to her success as a young mother of three young children. CC Intern encouraged FOB and MOB’s mother in helping her identify signs of post-partum depression and highlight the role the family can play in helping the client overcome their situation. Therefore, the challenge will be if, at a young age, Aliana lacks solid support to help her navigate motherhood at this young age. 

Although I was a bit nervous, I had no challenge during this session, the client was open, engaged, and willing to be informed by Care Coordinator.

 

1. What was accomplished during the session?

Needed resources were provided to the patient to help her with the history of illicit drug/depression. 

 

1. What concepts or theories or interventions did you apply? And what were the results–what worked and what didn’t give the socio-cultural context of the client’s presenting problem(s) and underlying issues? 

The solution-focused theory was applied in this case study. The social worker emphasizes Aliana’s strengths and encourages her to use her strength to improve her situation and challenges (Turner, 2017). By suggesting coping strategies such as Yoga, the goal is to provide Aliana with strategies to help her combat her depression and techniques to use if experiencing post-partum depression.  Resources were also offered to clients as a solution to help with her situation. 

The task-centered practice treats the client as a partner in the intervention process and empowers the client by providing strategies and tools to manage problems independently (Jacob et al., 2015). 

1. A summary of the student’s impression: 

The assessment and engagement went well considering that I had to let the client know that DFACS will be notified. Aliana portrayed a positive attitude and was engaging. I was impressed by her willingness to engage. However, I am not sure about her claim that she would no longer smoke THC. More work is needed to help Aliana with the issue of illicit drug use. Unfortunately, my engagement with her ended with the first assessment. I am however hopeful that with the right resources, a change is plausible. 

 

1. Questions for Supervision:

I will ask my supervisor what she thought about the assessment, areas of needed improvement, and if there were other resources Wellstar can offer to clients in Aliana’s situation.

 

 


7). Future Plans

 

  At this time, no further contact is needed by care coordination. DFACS was notified and a referral was made by CC Intern on 04-12-2022. Patient and newborn socially discharged by care coordination department. 

Andrea Dotson-Gray           Andrea Dotson-Gray, LMSW     04/21/22

Field Instructor’s Signature                                                 Print Name                                                                  Date                                      

References

Horwitz, M., & Marshall, T. (2015). Family engagement in child protection social work. Journal of Family Social Work, 18(4), 288-301.

Jacobs, E. E., Schimmel, C. J., Masson, R. L., & Harvill, R. L. (2015). Group counseling: Strategies and skills. Cengage learning.

Turner, F. J. (Ed.). (2017). Social work treatment: Interlocking theoretical approaches. Oxford University Press.

Zastrow, C., Kirst-Ashman, K. K., & Hessenauer, S. L. (2019). Empowerment series: understanding human behavior and the social environment. Cengage Learning.

 

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