Running head: case study report

The Seaweed Is Always Greener On Somebody Else's Plate...Or Is It?: A Case Study

Sara Alkhedairy

Western Washington University

Ariel is born into a royal family, most notably, her father King Triton, who is the ruler of underwater city Atlantica where the family resides. She is one of seven sisters, and although she loves them all dearly, she has always found herself to be quite different from them. Unlike her sisters, Ariel is dissatisfied with her life under the sea, and develops a craving, an obsession, with finding more. From very early on in her life, Ariel develops a fascination with the human world, a fascination that soon consumes her and leads her to develop a desire to live among humans as part of their world. Unfortunately for Ariel, she is restricted by her father's discipline, and her mermaid features, recognizing that without legs, she will be unable to live among the humans.

As part of Ariel's fascination with the human world, she frequently goes on what she refers to as "treasure hunts", during which she explores sunken ships to try and find any trinkets from the human world. These hunts are often dangerous, as they involve travelling to parts of the sea where sharks and other dangerous predators live. Her closest friend, Flounder, often accompanies her on these hunts. She is also friends with a seagull named Scuttle, who shares with Ariel the names of the human artifacts she finds when she swims up to the sea's surface. Ariel's treasure hunts have kept her from being with her family and have caused her to miss out on several of her other commitments. Tensions are starting to build between Ariel and her father, and it is clear that Ariel's hoarding habits and disengagement from her family are beginning to have serious, long-lasting consequences on her overall state of well-being and her relationships (The Little Mermaid, 1989).

A Need for Case Management?

The International OCD Foundation (IOCDF) defines "compulsive hoarding" as having three components:

1. A person collects and keeps a lot of items, even things that appear useless or of little

value to most people and 2. These items clutter the living spaces and keep the person

from using their rooms as they were intended, and 3. These items cause distress or

problems in day-to-day activities (Bratiotis, Otte, Steketee, Muroff, Frost, 2009).

In the case of Ariel, we see her collection of "treasures" to be numerous, and by all technical definitions, large amounts of junk. She uses an exceptional amount of space to store these items, space that could be better utilized for other purposes. Additionally, her hoarding habits are beginning to cause problems in her day-to-day activities because they are keeping her from prioritizing her family, and are leading her to neglect many of her other commitments. Another component of hoarding as identified by the IOCDF is that hoarders "seldom seek to display their possessions, which are usually kept in disarray", which is certainly the case for Ariel (Bratiotis et. al., 2009). Her collection is kept a secret from her family, the only one having seen it being her non-judgmental friend, Flounder.

According to the Anxiety and Depression Association of America (ADAA), reasons one might hoard will vary. Hoarding may often be a symptom of another disorder, such as obsessive-compulsive disorder (OCD) or attention-deficit/hyperactivity disorder (OCPD) ("Hoarding: The Basics, 2015). In the case of Ariel, it seems as though her hoarding habits are due to some degree of depression, a result of her dissatisfaction with life in Atlantica. Knowing this, we can consider how Ariel might benefit from some sort of case management service, one that might allow her to understand why her obsessive hoarding might have long-term effects on her mental health and well-being. Ariel is seemingly in denial about these potential consequences, and knowing this will help a health professional determine what model of case management might work best for her.

Because of Ariel's denial, a service plan developed for her might involve a significant amount of participation from the case manager, at least in the early stages. My approach would be a bit less directive, in that I would want to really focus on developing trust and rapport with Ariel before trying to recommend a service plan. After getting to know Ariel, making a point to understand her interests, potentially hearing a bit more about her fascination with the human world, I would try to provoke Ariel to start thinking about how her behavior might be abnormal. I would want her to recognize that besides being abnormal, her habits might also be unhealthy. After discussing these issues with her a bit myself, I might suggest Ariel meet with a mental health counselor to further discuss how to move forward.

If I were to create a service plan with Ariel, I would first need to consult her to see what her ultimate goal(s) would be. Since she is in denial about the issues, it may take some serious discussion and fleshing out of ideas to get Ariel and myself as case manager on the same page, and I should recognize that this may not ever happen. Hypothetically, if she were to identify her goal as "achieving happiness with life under the sea", we might begin looking at ways to start removing human world aspects from her life, allowing her to focus more on the positives in her life as it is now. In developing objectives, I might ask Ariel to first have an open talk with her dad and other members of her family, letting them know about her collection of human trinkets, maybe even taking them to see her hoard of stuff. This would be an important step as it would allow Ariel's family to understand more fully the seriousness of her hoarding. I would also ask Ariel to keep a daily journal, in which she writes in daily, three things that she likes and/or appreciates about her life under the sea, whether that be, friends, family, or other aspects of her life. The hope would be that doing this would help Ariel to realizes how much she does enjoy life under the sea and to see how many things she has to be thankful for, things that she would not have if she were living in the human world. Thirdly, I as case manager would seek outside support for Ariel when she became comfortable with my doing so, maybe by contacting a mental health counselor for Ariel to meet with in addition to further meetings with myself.

Depending on the success of this plan, I may need to make some adjustments. It may be challenging for Ariel to have this kind of self-control early on in the process, so adapting objectives may be crucial to development. For example, if the above plan didn't work, I might ask Ariel to instead spend an exceptional amount of time in her "treasure trove", considering why it is that she is so fascinated with the trinkets she hoards in an attempt to desensitize her to their "value". This would be a low risk objective, in that it would not involve the participation of anyone besides Ariel, allowing her to take things at her own pace without feeling particularly rushed or pressured. If this objective went successfully, I might then revisit having Ariel attempt the original objectives to involve more of her support system in the process.

In considering what path to take in working with Ariel, we must understand that certain models of case management will be more effective for her than others. This section of the report will explore both appropriate and inappropriate models for working with Ariel, considering her situation and the multidimensional nature of her illness.

One approach that might work well for Ariel could be a family-centered approach. A family-centered approach is one that is focused on family involvement, particularly by family meetings in which everyone discusses strengths and goals of the individual in question ("Family-Centered Case Planning and Case Management," n.d.). For Ariel, she is lucky to have a family that is extremely loving and supportive of her growth and development, so there is no doubt that this model could work for her. For Ariel to fully understand the depths of her family's love for her might encourage her to see a need for change, and may make her feel more empowered through her family's support.

Another approach that might work for Ariel could be a self-determination model. A self-determination model is similar to a family-centered approach in that it utilizes the resource of family support, but different in that there is more of a focus on directly empowering the individual as their own, autonomous being. The intent is that "support starts with a person rather than with than with any sized facility for labeled people and finished with personally-tailored supports that strive to change as people's capacities and opportunities to participate in community life do" ("Innovative models and best practices in case management and support coordination," 2008). For Ariel, this approach might be beneficial because it would be catered to her personally, taking into consideration her royal status and the multidimensional nature of her issues.

A third, and pretty standard, approach that could work for Ariel would be the utilization of a mental health counselor. As suggested above, pursuing services from this type of professional might allow Ariel space to talk out and explore the reasoning behind some of her behaviors and give her the opportunity to better understand why she is behaving in this way. It might also be helpful as an educational tool, as the counselor might offer Ariel more factual information about issues like hoarding and depression to increase her own knowledge and awareness. Together, Ariel and her counselor could work to develop personalized strategies that encourage her to feel empowered, in turn, giving her the chance to begin adapting her habits in hopes of becoming her "best self".

A model of care that might not work as well for Ariel is intensive case management. Intensive case management works well for individuals who know what they want, or are at least acknowledging of their issues and just need someone to help them work through their issues collaboratively. This model of care would work exceptionally well for individuals proactive and willing to address their issues. Since Ariel is in denial about her issues, it may be difficult for her to engage in an intensive case management model. Before Ariel develops this eagerness, if she ever is to, there is going to be a lot of required rapport building and relational communication between her and her case manager.

When working with the mentally ill, there are many ethical standards a case manager should keep in mind to ensure the safety and protection of their clients. Firstly, the importance of confidentiality is crucial, especially for Ariel. Since she is part of a royal family, it may be particularly important for her to feel like the information she is sharing will be kept safe and confidential, out of the public eye. Additionally, cultural competence is another ethical concern that a case manager should seriously consider, particularly with Ariel. Because she is part of a royal family, it is important to understand traditions and cultural norms for Ariel and her family before forming a treatment plan to make sure there is a complete understanding of who she is as an individual. Not to mention, this will allow Ariel to feel comfortable opening up more about her personal experiences since they will be different than the experiences of most others in Atlantica. In addition to confidentiality and competence, consent, disclosure, conflict of interest, and other general ethical responsibilities should also be considered by the case manager.

It is also important to consider the legal issues tied to work as a case manager. A health care professional is at risk of being of accused of malpractice for a variety of reasons if their service is not found to be up to a certain standard. "Medical malpractice" is defined as occurring "when a hospital, doctor or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare or health management" ("What is Malpractice?," 2015). If a professional is unable to do their job appropriately or effectively, they are doing both the client and themselves a disservice. Although it is not a universal requirement, it is highly encouraged that all medical professionals obtain malpractice insurance to protect themselves to a degree in these situations.

Fortunately for Ariel, money is no object. In Atlantica, she is part of the most wealthy and powerful family, making access to services extremely feasible for Ariel and her family. Additionally, since Atlantica is a socialist city, making access to healthcare, among other things, a common and shared commodity of the population, these services are readily funded. King Triton named Atlantica a socialist city over 1000 years ago, and since then, there has been a complete obliteration of the private sector in every regard. King Triton has made it a top priority to ensure health care to all citizens, and because of this, the city has earned the title of being "The Healthiest City Under the Sea". For this reason, funding for service is irrelevant in Ariel's case, and in fact, the cases of all citizens of Atlantica.

Along with superior funding, Atlantica is also equipped with several facilities, programs, and services to address the various health needs of the Atlanticans. These services are readily available to any citizens who are willing to pursue them. These programs are valued significantly to promote an overall well-being and health of the entire population. There are several community health clinics, offering both physical and mental health services, in addition to many community spaces hosting support groups and other community-based development groups. As mentioned above, Atlantica holds the title of "The Healthiest City Under the Sea", and these services without doubt are a contributor to that.

We can consider Princess Ariel to be in a privileged position, one that allows her access to the services she needs with absolute ease. That being said, her understanding the needs for these services may not be as easy of a task. Assisting Ariel to understand the health concerns surrounding her hoarding habits and depressive symptoms may be a challenge, but one that can be achieved. By considering some of the plans and models highlighted in this report, it would be possible for a case manager to strategize a plan of action for working with Ariel, seeking to empower her and bring awareness to the issues she is experiencing.

References

Bratiotis, C., Otte, S. Steketee, G., Muroff, J., Frost, R. (2009). Hoarding fact sheet. Retrieved

from http://iocdf.org/wp-content/uploads/2014/10/Hoarding-Fact-Sheet.pdf

Family-centered case planning and case management. (n.d.). Retrieved from

https://www.childwelfare.gov/topics/famcentered/caseworkpractice/caseplanningmgmt/

anxiety/obsessive-compulsive-disorder-ocd/hoarding-basics

Retrieved from https://ici.umn.edu/products../prb/191/default.html

Musker, J. (Producer), & Clements, R. (Director). (1989). The Little Mermaid [Motion picture].

United States: Walt Disney Pictures.

Vanderplasschen, W., Wolf, J., Rapp, R., Broekaert, E. (2007). Effectiveness of different models

of case management for substance-abusing populations. Retrieved from

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1986794/