CASE SCENARIO – PART A Maria is a 26-year-old Guatemalan woman who came to the U.S. from Chiapas, Mexico. She calls your program after the hospital social worker urged her to call. Although she was seen in the Emergency Department for injuries related to an assault by her husband, she tells the counselor that there is nothing wrong and things will be fine as they have always been in Oaxaca. She wants to know if the counselor can talk to Felipe, her husband, to tell him to stop the nonsense. The counselor declines and Maria hangs up. She calls the domestic violence program at the urging of the hospital social worker after several visits to the Emergency Room for injuries inflicted by her husband and most recently for a suicide attempt after another beating and his threats to leave her. She took an overdose of pain medication she’d been given on her last ED visit. She also suffers from panic attacks. She had been discharged after 24 hours with a prescription for Paxil and a follow-up psychiatry appointment, which she hasn’t kept. QUESTIONS 1) What are your initial thoughts and assumptions about Maria and her situation? 2) In what ways does Maria’s cultural background shape your thinking about the case? 3) Why does Maria not want to leave Felipe? 4) What are some other questions, concerns and issues that arise for you? * What else would you want to know? * What questions would you ask? * Where would you go to obtain additional information? CASE SCENARIO – PART B It is six months later. Maria calls the shelter urgently and says she needs space for herself and her two kids right away. She is afraid that she is going to be arrested because Felipe has just been arrested and is now in jail. She is afraid that they are both going to be deported. She is frantic and demands space. The shelter program is able to accommodate her and her needs. She has difficulty walking and needs easy access to the shelter. She comes into the shelter with two of her children aged 9 and 10 years of age. The 10 year old girl is on probation for shoplifting and cuts herself. The 9 year old boy has a learning disability and is severely malnourished. Maria has been abused by Felipe for as long as she has known him, which is 11 years. She worked two jobs and was not allowed to learn English. But over the years she has picked up some English that allows her to manage. Things were all right for a while but worsened after the birth of the youngest child who Felipe suspected had a different father. Maria reminds the advocate that she had called the shelter a few months back after a particularly bad assault. At that time, the hospital social worker had referred Maria to the shelter because she had several bruises, a broken wrist and had told the social worker that she had recurring nightmares. She HAD spoken with a counselor at the shelter after being strongly urged by the social worker and ER doctor to call. She said at that time she was unwilling to leave Felipe but wanted the counselor to talk to her husband and exhort him to change his behavior. The counselor told her that they could not do that and she hung up. She is very afraid that the state will take away her 9 and 10 year- old children. Three days after Maria comes to the shelter, you find out from another bi-lingual advocate that Felipe was arrested for dealing drugs. Maria is afraid that he is going to implicate her as he did once before. You also learn that Maria has two younger children aged 3 and 4 who were removed by Child Protective Services (CPS), the night that Felipe was arrested Maria has been “troublesome” ever since she arrived at the shelter. She was a model client the first day she was there but since then she has not wanted to eat, does not change her clothes, and refuses to shower unless a counselor sits outside the bathroom. Once she can be coaxed to use the shower, she takes a long time, which irritates the other residents. She also has not been going to sleep until 3 or 4 am, and walks around which disturbs others who are trying to sleep. As a result, she often misses morning groups and isn’t available to supervise her children. When her counselor or the other residents try to talk to her about this she either becomes angry or withdraws. There are also times she just seems to “space out” in peer support groups or when an advocate tries to talk to her about her plans. Her daughter tries to be helpful but is very quiet and shy. Her son runs around and increasingly is seen to bully younger children. Maria seems unaware that this is happening. Because Maria’s behavior has become so difficult to manage, the shelter director tells Maria the only way that she’ll be able to stay is if she agrees to see a mental health provider. This is her first appointment and she is reluctant to be there or to talk with you. She does however, tell you that she’s been having nightmares and is afraid to sleep at night and that she doesn’t feel safe in the shelter. She also tells you that she doesn’t have a lot of energy and finds it hard to focus on her goals for leaving and getting her own apartment. She also finds the other residents difficult to get along with and feels like she’s in prison. She tells you they have stolen things from her and she feels they are against her. You also find out that she has been “sneaking out” and meeting Felipe around the corner from the shelter. She also refuses to go to the clinic to see her medical doctor because she feels that everyone is pressuring her to leave Felipe when all she wants is to get back with him. She believes that she is suffering because her suffering is a cross that God sent for her to bear. QUESTIONS: 1. What are the main advocacy issues that you see? 2. What are some personal feelings that come up for you as you learn more about Maria’s life and issues? * Where do you get stuck? * Where do you feel inadequate? * When do you feel that you are getting judgmental? * How do you handle your own conflicting responses? 3. What information/and or support would you provide to Maria in response to her fears? 4. What are the cultural competency issues that arise and how do you think you can deal with them? 5. Do you think the counselor was right to refuse to talk to the batterer? 6. What other questions and concerns arise for you? 7. What are the major risks that Maria is facing? How would you advocate for Maria for any two of the risks you outlined? CHALLENGES FOR COLLABORATION Thinking about the same scenario let us look at the challenges that Maria’s circumstances pose at the level of collaboration: 1. What are the cultural competency issues that are brought to bear in this case at the level of collaboration between providers and agencies? 2. Would collaboration be useful or counterproductive? 3. What would the limits be? 4. Who else is not at the table now? How can you bring them on board? 5. Would advocating for Maria threaten any existing relationships? If so how and why? What can you do to minimize the impact for Maria, Felipe and the children? 6. What territorial issues arise for all of you? ?? ?? ?? ?? ACCESSING SAFETY INITIATIVE INSTITUTE – MAY 2008 1 Accessing Safety – Culture and Domestic and Sexual Violence May 22, 2008