Medical and Psychosocial Aspects of Rehabilitation Counseling



Medical and Psychosocial Aspects of Rehabilitation Counseling

Exam 2

DUE: Tuesday, NOVEMBER 8, 9:35 AM

On my honor, I have neither given nor received unauthorized aid on this examination.

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Case Study #1

Sally, a 34-year-old woman, is currently undergoing detoxification at a local alcohol treatment center. Two previous attempts to become sober and maintain long-term sobriety have failed. She is married, although separated, and has 2 children, ages 3 and 6. The present attempt at sobriety was prompted by the departure of her husband due to her continued drinking. The children are living with her mother in a nearby city.

There is a history of alcoholism in Sally’s family. Her father was a diagnosed alcoholic and died at the age of 47, the result of physical complications resulting from alcoholism. Her mother’s present husband was previously married to an alcoholic. Sally states that she feels that her parents are not sympathetic or supportive of her sobriety. Her parents indicate that they are willing to provide care for the children, but that Sally is not welcome in their home when she is drinking.

Drinking did not become a problem for Sally until she became an adult, although she began drinking at about 12 years of age. She drank secretly from her father’s stock of alcohol and enjoyed the feelings she experienced. Drinking progressed in high school, but never resulted in much trouble. However, she was once expelled from a school dance due to drinking. Serious trouble from alcohol consumption began during her freshman year at college. There were frequent problems in classes due to absences. Sally had to move from her apartment on 3 occasions because her roommates refused to put up with her drinking. College life became impossible for her, and she dropped out after the second semester.

At the age of 20, Sally secured employment with a ticket agency. At this job, she met a band musician and was married within 3 weeks. Her drinking and socially unacceptable behavior resulted in divorce about 6 months later. She enrolled in an alcohol treatment program at the time of the divorce, but left the program after 5 days. Continuing to drink, she was eventually fired from her job. Sally’s parents allowed her to return home to live under the condition that she seek help for her drinking problem. She attended several meetings at a women’s center and enrolled in an outpatient treatment program at a local hospital. She continued participation in the outpatient program for 3 months, but stopped when she married her current husband, who was a produce manager at a local supermarket.

Sally controlled her drinking for the next 8 years and gave birth to 2 children. She worked part-time at a local printing shop and did general office work. Drinking became a problem again when she was 30-years-old. While at home, she would secretly drink. It soon became obvious to all around her that she was drinking. On several occasions, she would leave the children unattended and stay out all night. She lost her job, and the week after her 31st birthday, her husband left her after she had destroyed much of the furniture at home in a drunken rage. Her mother was called and took her and the children home and again required that Sally enter some type of treatment program.

Alcoholics Anonymous (AA) became Sally’s support system; she attended meetings regularly but continued to drink. Her mother and stepfather finally told her that she could no longer reside with them, but that they would continue to care for the children until she was capable of caring for them. Sally was angry, frustrated, and hurt. She enrolled at a county detoxification center and is currently seeking help from a counselor.

Questions

1. What are the positive factors in this case for rehabilitation?

2. As Sally’s counselor, identify the first three measures you would recommend.

3. What are the vocational considerations for this case (i.e., what advice would you give Sally regarding finding and maintaining a job, including any accommodations)?

Case Study #2

Robert is a 35-year-old, divorced male who is responsible for the child support of three children under the ages of 15, who live with his former wife. Upon graduation from high school, Robert began driving delivery trucks and, for the last 15 years, has driven cross-country for various trucking firms hauling different types of freight. The Dictionary of Occupational Titles (DOT) classifies this job of Truck Driver, Heavy, as medium exertion, semiskilled work.

Robert started using and abusing substances while he was a senior in high school, smoking marijuana and drinking alcohol. His drug use did not interfere with his vocational or social life until he began using cocaine when he was 25-years-old. Within two years, he lost his job, his marriage ended in divorce, and he was subsequently arrested and convicted for burglary. Robert served 3 years in prison as a result of trying to support a $300 per day cocaine habit. After he was released from prison, he was treated in an outpatient program for a period of six months. He subsequently returned to truck driving, which eventually led to his resuming the use of cocaine. Robert has just completed a year in a residential treatment program and has been referred by the director of the program for vocational rehabilitation, with a strong suggestion that he not return to truck driving.

Questions

1. What kind of support would be most helpful for Robert in achieving a vocational objective?

2. How would you explain Robert's disability to a prospective employer?

3. What types of accommodations would you recommend to Robert and a prospective employer to help in maintaining employment?

Case Study #3

Estelle is 35-years-old and has a Master's degree in Social Work (MSW). Her treating neurologist diagnosed multiple sclerosis when she was 29 years of age. She is single, lives alone, and is employed as a social worker with a small community agency. Estelle has lived in the community for many years and is involved in community life (church, YWCA, and other philanthropic organizations).

The counselor she saw for rehabilitation stated that she appeared somewhat distraught and confused. Estelle describes her experiences with MS as follows:

Once or twice a year, I had some brief episodes of numbness and tingling in either a leg or a hip. These would last 2-3 weeks and then disappear. They didn't affect my ability to walk; they were just uncomfortable. The doctor I saw thought I might have done something to bruise a nerve in my back. Since these episodes sometimes occurred when I was moving to a new apartment, this made sense.

Five years after the numbness began, it recurred in both legs, from my waist down. After 1 week, I began to stumble and catch my right leg on carpeting or cracks in the sidewalk. My legs got very wobbly and collapsed under me a couple of times. The treating neurologist hospitalized me and ordered a spinal tap and myelogram. By this time, I could barely walk, even with the use of crutches. Needless to say, I was really frightened.

The testing confirmed my doctor's suspicions. He shared the diagnosis and discussed the treatment with me immediately. Following a long course of steroids and physical therapy, I regained my ability to walk independently.

I felt very relieved now to have a name for what was wrong with me. I read everything I could on multiple sclerosis and was determined that I was going to do all that was suggested to avoid getting sick again (reduce stress, simplify my life, avoid exposure to heat). I had been unable to work for 6 weeks, but my employer was very supportive.

Six months later, the vision in my right eye became blurred. I was again given steroids, and my vision returned to normal. For the first time, I began to believe that there was something wrong with me and that it was not going away. I found myself getting very frustrated, angry, and depressed. It must have presented some problems with my work, but my employer said nothing.

Two years later, symptoms of numbness and tingling began in my right arm and hand. Within one week, I was unable to write my name or hold an object. I again began to stumble as I walked. My physician hospitalized me a second time, for 3 weeks, during which I received both physical therapy and occupational therapy. I regained the use of my hand and arm, but had constant numbness, weakness, and inability to sense temperature in the affected arm and hand. In addition, fatigue had become a major problem. I could not function for about an hour during the afternoon; a nap became necessary. At the time, I was working with children and adolescents. It became very difficult for me to be functional in the afternoon when they were present. My agency was able to find another social worker on staff to assume some of my responsibilities during the afternoon. It was no longer possible for them to pay me for full-time work; I went to ¾ time shortly after that.

Two years later, I had another attack. I am now having difficulty walking any distance, and my handwriting has deteriorated. Even more problematic is that I am having trouble remembering things. It may be impossible to continue to work with clients. I cannot always remember what clients said from week to week. So far, no one at work has said anything, but I can tell that it is only a matter of time. My performance is slipping, and that make me anxious, which makes everything worse.

I really thought I had MS beaten. There would be an attack for which I would receive treatment with steroids, and I got well. It just is not working out that way. It is impossible to know daily or weekly what is going to happen next. I find I have to make continuous changes in how I do things. Just when I think I have something mastered and am ready to get on with life, something new occurs, and I have to readjust and readapt. It gets to be very tiresome.

By this time in my life, I had planned to be in a serious relationship, maybe even married, and well on my way to a successful career in social services. None of that is happening. It is very hard to maintain an active life when my energy is so limited. Now my professional skills are being affected, and I am concerned about being able to support myself.

All this makes me very angry, although I know I am not alone. I have been to MS support groups and have listened to other people so I know that these are not just my "demons." It is my belief I can still work, probably full-time, given the right situation. I want to continue being productive and do not want to give that up just because of MS.

Questions

1. What recommendations would you make to her as far as employment options? (e.g., stay in social work or switch to another profession)

2. How would you explain Estelle's disability to an employer?

3. What accommodations and/or assistive technology would you recommend to Estelle to help her with the employment option you suggested in question #1?

Case Study #4

Cynthia is a 22-year-old student attending a local community college. Currently in her sophomore year, Cynthia is struggling with the selection of an appropriate major that meets her interests and abilities. She has shown exceptionally high aptitude in the area of computers and computer science and has been encouraged by her advisors and professors to consider a major in computer science at the regional state university. Unsure about those recommendations, Cynthia acknowledges her interest in computers, but is also aware of her strong love for agriculture.

This individual grew up on the family farm that produces table grapes, walnuts, and oranges. She loves farming activities and, in keeping with her childhood development on the farm, has been drawn to potential careers that are related to farming. In reality, however, Cynthia realizes that her physical disabilities, which have limited her in an ability to work on the family farm, will present obstacles that she must overcome.

At an early age, a physician diagnosed Cynthia as having athetoid cerebral palsy. Medical records indicate the degree of involvement to be Class III (moderate to great limitation of activity) evidenced in all four limbs (quadriplegia). For mobility, she uses a wheelchair.

The availability of state services has helped Cynthia and her family, both for her therapeutic and educational training. Therapy intervention by the state children's services began in Cynthia's infancy, followed by educational programming from local public schools. Early education was provided in a specialized facility staffed by a multidisciplinary team of teachers, physical therapists, speech therapists, occupational therapists, a nurse, and a school psychologist. All these professionals were trained in providing the specialized services required of children who have physical and health-related impairments.

After passage of the Education for All Handicapped Children Act of 1975 (PL 94-142), Cynthia was able to benefit by attending a regular education program with her peers through junior high and high school. Transition was made possible by available school district support services and the emerging availability of technology.

Cynthia was able to compensate for her severe speech impairment by learning to use and communicate with electronic communication devices. Furthermore, curricular adaptations were made possible because of advances in computer technology. Through these available adaptations, Cynthia was able to display her above average intelligence to her teachers and peers, finally gaining their understanding and appreciation for her talents.

Upon completion of high school, and having earned a 3.5 grade point average, Cynthia selected a college. A local community college was chosen in part because of the availability of its Enabler Program, which provided supportive services. This program offers services beyond those provided by the regular college program and "enables" students to successfully pursue educational, vocational, and personal goals.

Cynthia voiced her career concerns to the counseling staff at the Enabler Program, who referred her to you, a rehabilitation counselor, for advice.

Questions

1. After analyzing her aptitudes and interests, you work with Cynthia to identify professions that would incorporate her aptitude with computers and her love of farming. What job(s) would you recommend to Cynthia?

2. How would you explain Cynthia's disability to a potential employer?

3. What types of accommodations/assistive technology would you recommend to assist Cynthia in pursuing the job(s) you suggested in question #1.

Case Study #5

Susan is a 19-year-old woman who has had rheumatoid arthritis for 14 years. During this time, she has had long periods of illness when she was confined to her home and, as a result, is still in her last year of high school. The rheumatoid arthritis is currently well controlled and Susan has missed no school for the past 6 months. She takes medication on a regular basis and must visit her physician weekly to receive injections of gold to maintain her disease in remission.

Through the years, Susan has required surgery for her arthritis to maintain ambulation, including 2 hip replacements and a knee replacement. Currently, she is able to walk about the house unassisted, but uses a motorized wheelchair for ambulating in the community, except for very short distances. Susan has morning stiffness and has arranged to take classes that start at 10 a.m. or later. There is occasional pain in multiple joints including the feet, shoulders, wrists, and small joints of the hands. The physician has prescribed pool exercise. Occasionally, when her wrist (of the non-dominant hand) flares up, Susan wears a wrist splint. In addition to limited ambulation, she requires assistance from her mother to shampoo her hair. Grip strength is 20 pounds, while pinch strength is 5 pounds.

Susan is the 8th child of a second generation Hispanic family and is bilingual. Her father passed away several years ago, and her mother is currently supported by general relief (Social Services) and contributions from her adult children. Susan’s mother does not speak English and has never worked outside the home; she currently sees her life’s role as caretaker and aide for her daughter, and assists her in activities of daily living. The relationship between Susan and her mother is close and has been criticized by the health care team as one that promotes dependence rather than independence.

Testing has shown that Susan has high average intelligence, social immaturity, and a lack of depression. The health care team feels that Susan has been an underachiever in school and at home, relying on her mother and siblings rather than on her own skills. Susan currently does not drive and has not started dating. Emotional support is provided by her large family and one female friend from school.

Susan was referred for vocational rehabilitation counseling at the insistence of the high school principal. She will graduate in 6 months and has made no plans for the future. Susan has done well in school and has particularly enjoyed the sciences, receiving a senior prize for her achievement in biology. She is unsure about attending college. There is no family tradition of education (she will be the second person in her family to complete high school) and no finances to support a college education. One of her sisters is currently the head cashier at a grocery store and has assured Susan that she can get her a similar job. Her mother is against Susan working and feels she should stay home, and if she wishes to work, she should baby-sit for her nieces, nephews, and the neighborhood children.

Questions

1. List Susan’s strengths and weaknesses (in regard to medical aspects of her disability) that need to be considered when formulating a vocational rehabilitation program.

2. How would you describe Susan's disability to a potential employer?

3. What recommendations would you give Susan regarding reasonable accommodations/assistive technology to help her maintain a job once she finds one?

Case Study #6

Maria is a self-referral to the Department of Rehabilitation. She is a 49-year-old married Latina who works as a personal care aide for an elderly woman in the woman’s home. She holds a Bachelor of Arts degree in architecture from a university in South America and wishes to obtain more appropriate employment. Both of her children are grown and living independently.

At the age of 27, Maria developed a moderate to profound sensorineural hearing loss of unknown origin. The loss is permanent and not reversible or correctable by surgery. When she uses her hearing aids, her hearing is improved.

Maria relies on speech reading to communicate. The family speaks Spanish in the home. Her husband loses his temper with her because of her difficulty in dealing with the public. She speaks broken English with a very thick South American accent that is difficult to understand due to the nasality caused by her deafness. Maria stressed that her receptive English is much better than people realize. Her relatives seem to question her hearing loss because of inconsistencies as to what she can and cannot hear; she cannot explain why her hearing loss seems to fluctuate.

For 5 years, Maria was employed as a drafter in South America. She had a one-year job in drafting when she arrived in the US. Both jobs were performed primarily in a seated position with lifting and carrying of minimal weights up to a maximum of 10 pounds. More recent work experience has consisted of housecleaning, baby-sitting, and office cleaning. She stated she has difficulties working in a noisy environment – it gives her headaches. Maria is motivated to work in a position more commensurate with her training and background.

Questions

1. Describe Maria's possible functional limitations as related to a drafting position.

2. How would you describe Maria's disability to a potential employer?

3. What job modifications or accommodations/assistive technology would assist Maria in adjusting to a work environment?

Case Study #7

Joseph has hemophilia and is 18 years of age, single, and living with his parents in a small Midwest town. He recently graduated from high school, receiving average grades throughout his educational experience.

Described as a "loner," Joseph has one or two close friends and avoids large gatherings and most social events. Besides having hemophilia, Joseph is in good health and has no major complications of the disease. Occasionally, he will need to self-infuse, but has no problem doing this.

You have been assigned as his rehabilitation counselor. For the initial interview, his mother accompanied him and insisted on sitting in on the interview. Although she provided useful information, she did most of the talking and stated that she would attend all future appointments, as it is her opinion that, by attending these meetings, it will be in her son's best interest.

Joseph was hesitant about discussing his interests, although he appeared to enjoy repairing the family cars and doing minor mechanical and electrical repairs around the home. His mother was of the opinion these activities were potentially dangerous and needed to be avoided. She believed Joseph should attend the local community college and pursue a career in accounting, as her husband is an accountant. Joseph could "follow in his father's footsteps," in her opinion. Also, she believed Joseph should do sedentary work, needs to be in a protected environment, should not perform manual jobs, and may need time off work because of occasional "bleeds."

Joseph was of the opinion that this goal would be "OK," as he did not have any other ideas as to what to pursue. His mother insisted he be enrolled in the accounting program the following week as the next semester was starting in six weeks.

Questions

1. Discuss hemophilia in terms of the mother's opinion that Joseph needs to do sedentary work, stay away from manual jobs, be in a protected environment, and will need time off for occasional bleeding episodes.

2. How would you describe hemophilia and related vocational implications to an employer?

3. What recommendations would you give Joseph regarding reasonable accommodations if he decided to pursue employment in his interest area of automotive repair?

Case Study #8

Steve is a 56-year-old married male with one grown child. Although he did not complete the 11th grade, he received his GED. There is no additional school or training. He is co-owner, with one other partner, of a small, but highly successful company. By trade, Steve is an electrician and is a member of the local electrician's trade union.

The Dictionary of Occupational Titles classifies this job as telephone electrician. Steve and his partner install, test, and repair telephone and communication systems. They update and expand old equipment, install new computerized systems, and also wire burglar alarm devices and related equipment. Both partners are involved with repairing and restoring this electrical and electronic equipment. The work involves use of small handtools and testing devices, the ability to read schematics, and knowledge of electrical and electronic principles. Lifting and carrying on the job involves a maximum of 50 pounds, with repetitive lifting of up to 25 pounds.

Steve was in good physical and emotional health until he was diagnosed with prostate cancer. Steve and his oncologist decided to use the "watchful waiting" treatment to analyze the course of the cancer. One year later, he underwent surgery. Three months postoperatively, physicians felt he was disease-free with an excellent prognosis. The main functional limitations that Steve experiences are frequent urine leakage and erectile dysfunction. He was hesitant to return to work after surgery.

Questions

1. Do you think that Steve can return to his previous work as a telephone electrician? Please discuss why or why not?

2. If Steve decides to return to his job as a telephone electrician, what information can you give him and his business partner about the diagnosis of cancer and the probable course?

3. What possible accommodations can you recommend to Steve to assist him in returning to work as a telephone electrician?

Case Study #9

Ken is a 22-year-old who has completed an Associate Degree in Computer Science. He has recently been hired by a company to work in their IT department as a computer support specialist. His job duties include assisting staff with computer problems, training on various software packages, and maintaining the company's webpage.

Ken was diagnosed with Irritable Bowel Disease when he was 16 years old and the disease has steadily progressed since then. One month after obtaining employment, Ken had to have ostomy surgery that resulted in a permanent colostomy bag.

Questions

1. How would you explain Ken's disability to the employer?

2. What are Ken's possible functional limitations as a computer support specialist?

3. What accommodation recommendations would you give to Ken and his employer?

Note: These case studies and questions were modified from the respective chapters in:

Brodwin, M. G., Tellez, F., & Brodwin, S. K. (Eds.). (1995). Medical, psychological and vocational aspects of disability. Athens, GA: Elliot & Fitzpatrick.

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