© 2014 Laureate Education, Inc.

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Excerpts from Measuring Program Outcomes: A Practical Approach
© 1996 United Way of America

Introduction to Outcome Measurement

If yours is like most human service agencies or youth- and family-serving organizations, you regularly
monitor and report on how much money you receive, how many staff and volunteers you have, and what
they do in your programs. You know how many individuals participate in your programs, how many hours
you spend serving them, and how many brochures or classes or counseling sessions you produce. In
other words, you document program inputs, activities, and outputs.

Inputs include resources dedicated to or consumed by the program. Examples are money, staff and staff
time, volunteers and volunteer time, facilities, equipment, and supplies. For instance, inputs for a parent
education class include the hours of staff time spent designing and delivering the program. Inputs also
include constraints on the program, such as laws, regulations, and requirements for receipt of funding.

Activities are what the program does with the inputs to fulfill its mission. Activities include the strategies,
techniques, and types of treatment that comprise the program’s service methodology. For instance,
sheltering and feeding homeless families are program activities, as are training and counseling homeless
adults to help them prepare for and find jobs.

Outputs are the direct products of program activities and usually are measured in terms of the volume of
work accomplished–for example, the numbers of classes taught, counseling sessions conducted,
educational materials distributed, and participants served. Outputs have little inherent value in
themselves. They are important because they are intended to lead to a desired benefit for participants or
target populations.

If given enough resources, managers can control output levels. In a parent education class, for example,
the number of classes held and the number of parents served are outputs. With enough staff and
supplies, the program could double its output of classes and participants.

If yours is like most human service organizations, you do not consistently track what happens to
participants after they receive your services. You cannot report, for example, that 55 percent of your
participants used more appropriate approaches to conflict management after your youth development
program conducted sessions on that skill, or that your public awareness program was followed by a 20
percent increase in the number of low-income parents getting their children immunized. In other words,
you do not have much information on your program’s outcomes.

Outcomes are benefits or changes for individuals or populations during or after participating in program
activities. They are influenced by a program’s outputs. Outcomes may relate to behavior, skills,
knowledge, attitudes, values, condition, or other attributes. They are what participants know, think, or can
do; or how they behave; or what their condition is, that is different following the program.

For example, in a program to counsel families on financial management, outputs–what the service
produces–include the number of financial planning sessions and the number of families seen. The
desired outcomes–the changes sought in participants’ behavior or status–can include their developing
and living within a budget, making monthly additions to a savings account, and having increased financial
stability.

In another example, outputs of a neighborhood clean-up campaign can be the number of organizing
meetings held and the number of weekends dedicated to the clean-up effort. Outcomes–benefits to the
target population–might include reduced exposure to safety hazards and increased feelings of
neighborhood pride. The program outcome model depicts the relationship between inputs, activities,
outputs, and outcomes.

Note: Outcomes sometimes are confused with outcome indicators, specific items of data that are tracked to measure how well a
program is achieving an outcome, and with outcome targets, which are objectives for a program’s level of achievement.

For example, in a youth development program that creates internship opportunities for high school youth, an outcome might be that
participants develop expanded views of their career options. An indicator of how well the program is succeeding on this outcome
could be the number and percent of participants who list more careers of interest to them at the end of the program than they did at
the beginning of the program. A target might be that 40 percent of participants list at least two more careers after completing the
program than they did when they started it.

Program Outcome Model

Resources dedicated
to or consumed by
the program
money
staff and staff time
volunteers and
volunteer time

facilities
equipment and
supplies

Constraints on the
program
laws
regulations
funders’ requirements

What the program
does with the inputs
to fulfill its mission
feed and shelter
homeless families
provide job training
educate the public
about signs of child
abuse
counsel pregnant
women
create mentoring
relationships for youth

The direct products of
program activities
number of classes
taught
number of counseling
sessions conducted
number of educational
materials distributed
number of hours of
service delivered
number of participants
served

Benefits for
participants during
and after program
activities
new knowledge
increased skills
changed attitudes or
values

modified behavior

improved condition
altered status

Why Measure Outcomes?

In growing numbers, service providers, governments, other funders, and the public are calling for clearer
evidence that the resources they expend actually produce benefits for people. Consumers of services and
volunteers who provide services want to know that programs to which they devote their time really make a
difference. That is, they want better accountability for the use of resources. One clear and compelling
answer to the question of “why measure outcomes?” is to see if programs really make a difference in the
lives of people.

Although improved accountability has been a major force behind the move to outcome measurement,
there is an even more important reason: to help programs improve services. Outcome measurement
provides a learning loop that feeds information back into programs on how well they are doing. It offers
findings they can use to adapt, improve, and become more effective.

This dividend doesn’t take years to occur. It often starts appearing early in the process of setting up an
outcome measurement system. Just the process of focusing on outcomes–on why the program is doing
what it’s doing and how participants will be better off–gives program managers and staff a clearer picture
of the purpose of their efforts. That clarification alone frequently leads to more focused and productive
service delivery.

Down the road, being able to demonstrate that their efforts are making a difference for people pays
important dividends for programs. It can, for example, help programs:

• Recruit and retain talented staff
• Enlist and motivate able volunteers
• Attract new participants
• Engage collaborators
• Garner support for innovative efforts
• Win designation as a model or demonstration site
• Retain or increase funding
• Gain favorable public recognition

Results of outcome measurement show not only where services are being effective for participants, but
also where outcomes are not as expected. Program managers can use outcome data to:

• Strengthen existing services
• Target effective services for expansion
• Identify staff and volunteer training needs
• Develop and justify budgets
• Prepare long-range plans
• Focus board members’ attention on programmatic issues

To increase its internal efficiency, a program needs to track its inputs and outputs. To assess compliance
with service delivery standards, a program needs to monitor activities and outputs. But to improve its
effectiveness in helping participants, to assure potential participants and funders that its programs
produce results, and to show the general public that it produces benefits that merit support, an agency
needs to measure its outcomes.

These and other benefits of outcome measurement are not just theoretical. Scores of human service
providers across the country attest to the difference it has made for their staff, their volunteers, their
decision makers, their financial situation, their reputation, and, most important, for the public they serve.

Eight Steps to Success

Measuring Program Outcomes provides a step-by-step approach to developing a system for measuring
program outcomes and using the results. The approach, based on methods implemented successfully by
agencies across the country, is presented in eight steps, shown below. Although the illustration suggests
that the steps are sequential, this is actually a dynamic process with a good deal of interplay among
stages.

Example Outcomes and Outcome Indicators for Various Programs
These are illustrative examples only. Programs need to identify their own outcomes and indicators,
matched to and based on their own experiences and missions and the input of their staff, volunteers,
participants, and others.

Type of Program Outcome Indicator(s)

Smoking cessation
class

Participants stop smoking. • Number and percent of participants who report that they have quit smoking by
the end of the course

• Number and percent of participants who have not relapsed six months after
program completion

Information and
referral program

Callers access services to which
they are referred or about which
they are given information.

• Number and percent of community agencies that report an increase in new
participants who came to their agency as a result of a call to the information
and referral hotline

• Number and percent of community agencies that indicate these referrals are
appropriate

Tutorial program
for 6th grade
students

Students’ academic performance
improves.

• Number and percent of participants who earn better grades in the grading
period following completion of the program than in the grading period
immediately preceding enrollment in the program

English-as-a-
second-language
instruction

Participants become proficient in
English.

• Number and percent of participants who demonstrate increase in ability to
read, write, and speak English by the end of the course

Counseling for
parents identified
as at risk for child
abuse or neglect

Risk factors decrease. No
confirmed incidents of child
abuse or neglect.

• Number and percent of participating families for whom Child Protective
Service records report no confirmed child abuse or neglect during 12 months
following program completion

Employee
assistance
program

Employees with drug and/or
alcohol problems are
rehabilitated and do not lose
their jobs.

• Number and percent of program participants who are gainfully employed at
same company 6 months after intake

Homemaking
services

The home environment is
healthy, clean, and safe.
Participants stay in their own
home and are not referred to a
nursing home.

• Number and percent of participants whose home environment is rated clean
and safe by a trained observer

• Number of local nursing homes who report that applications from younger
and healthier citizens are declining (indicating that persons who in the past
would have been referred to a nursing home now stay at home longer)

Prenatal care
program

Pregnant women follow the
advice of the nutritionist.

• Number and percent of women who take recommended vitamin supplements
and consume recommended amounts of calcium

Shelter and
counseling for
runaway youth

Family is reunified whenever
possible; otherwise, youths are
in stable alternative housing.

• Number and percent of youth who return home
• Number and percent of youth placed in alternative living arrangements who

are in that arrangement 6 months later unless they have been reunified or
emancipated

Camping Children expand skills in areas
of interest to them.

• Number and percent of campers that identify two or more skills they have
learned at camp

Family planning for
teen mothers

Teen mothers have no second
pregnancies until they have
completed high school and have
the personal, family, and
financial resources to support a
second child.

• Number and percent of teen mothers who comply with family planning visits
• Number and percent of teen mothers using a recommended form of birth

control
• Number and percent of teen mothers who do not have repeat pregnancies

prior to graduation
• Number and percent of teen mothers who, at the time of next pregnancy, are

high school graduates, are married, and do not need public assistance to
provide for their children

Glossary of Selected Outcome Measurement Terms

Inputs are resources a program uses to achieve program objectives. Examples are staff, volunteers,
facilities, equipment, curricula, and money. A program uses inputs to support activities.

Activities are what a program does with its inputs-the services it provides-to fulfill its mission. Examples
are sheltering homeless families, educating the public about signs of child abuse, and providing adult
mentors for youth. Program activities result in outputs.

Outputs are products of a program’s activities, such as the number of meals provided, classes taught,
brochures distributed, or participants served. A program’s outputs should produce desired outcomes for
the program’s participants.

Outcomes are benefits for participants during or after their involvement with a program. Outcomes may
relate to knowledge, skills, attitudes, values, behavior, condition, or status. Examples of outcomes include
greater knowledge of nutritional needs, improved reading skills, more effective responses to conflict,
getting a job, and having greater financial stability.

For a particular program, there can be various “levels” of outcomes, with initial outcomes leading to
longer-term ones. For example, a youth in a mentoring program who receives one-to-one encouragement
to improve academic performance may attend school more regularly, which can lead to getting better
grades, which can lead to graduating.

Outcome indicators are the specific items of information that track a program’s success on outcomes.
They describe observable, measurable characteristics or changes that represent achievement of an
outcome. For example, a program whose desired outcome is that participants pursue a healthy lifestyle
could define “healthy lifestyle” as not smoking; maintaining a recommended weight, blood pressure, and
cholesterol level; getting at least two hours of exercise each week; and wearing seat belts consistently.
The number and percent of program participants who demonstrate these behaviors then is an indicator of
how well the program is doing with respect to the outcome.

Outcome targets are numerical objectives for a program’s level of achievement on its outcomes. After a
program has had experience with measuring outcomes, it can use its findings to set targets for the
number and percent of participants expected to achieve desired outcomes in the next reporting period. It
also can set targets for the amount of change it expects participants to experience.

Benchmarks are performance data that are used for comparative purposes. A program can use its own
data as a baseline benchmark against which to compare future performance. It also can use data from
another program as a benchmark. In the latter case, the other program often is chosen because it is
exemplary and its data are used as a target to strive for, rather than as a baseline.

Figure 31.1

Logic Model

Logic Models

Karen A. Randolph

A
logic model is a diagram of the relationship between a need that a

p rogram is designed to addret>s and the actions to be taken to address the
need and achieve program outcomes. It provides a concise, one-page pic-
ture of p rogram operations from beginning to end. The diagram is made
up of a series of boxes that represent each of the program’s com ponents,

inpu ts or resources, activities, outputs, and outcomes. The diagram shows how these
components are connected or linked to one another for the purpose of achieving
program goals. Figure 31.1 provides an example of the frame work for a basic logic model.

Th e program connections illustrate the logic of how program operations will result in
client change (McLaughlin & Jordan, 1999). The connections show the “causal” relati on-
ships between each of the program components and thus are referred to as a series of”if-
then” sequence of changes leading to th e intended outco mes for the target client group
(Chinman, hum, & Wandersman, 2004). The if-then statements represent a program’s
theory of change underlying an intervention. As such, logic models provide a framework
that g uides the evaluation process by laying out important relationships that need to b e
tested to demonstrate program results (Watso n, 2000).

Logic models come from the field of program evaluation. The idea emerged in
response to the recognition among program evaluators regardin g the need to systema tize
the p r ogram evaluation process (McLaughlin & Jordan, 20 04). Since then , logic models
have become increasingly popular among program managers for program planning and
to monitor program performance. With a growing emphasis on accountability and out-
come measurement, logic models make explicit the entire change process, Lhe assu mp-
tions t hat underlie this process, and the pathways to reach ing outcomes. Researchers have
begun to use logic models for intervention research planning (e.g., Brown, Hawkins,
Arthur, Brin ey, & Abbott, 2007).

The followin g sections provide a description of the components of a basic logic model
and how these compon ents are linked together, its relationship to a p rogram’s theory of

[ : Inputs 1–_.,•1 Ac~vities ,II—-.~•{ .Outputs ·11—~·1 Outcomes I
AUTHOR’S NOTE: The author wishes to acknowledge Dr. Tony Tripodi for his though lful comments
on a drafl of this chapter.

547

548 PART V • CONCEPTUAL RESEARCH

change, and its uses and benefits. The steps for creating a logic model as well as the chal-
lenges of the logic modeling process will be presented. The chapter concludes with an
example of how a logic model was u~cd to enhance program outcomes for a family liter-
acy program.

Components of a Logic Model

Typically, a logic model has four components: inputs or resources, activities, outputs, and
outcomes. Outcomes can be further classified into short-term outcomes, intermediate
outcomes, and long-term outcomes based on the length of time it takes to reach these
outcomes (McLa ughlin & Jordan , 2004) . The components make up the connection
between the planned work and the intended results (W. K. Kellogg Foundation, 2004).
The planned work includes the resources (the inp uts) needed to im plement the program
as well as how the resources will be used (the activities) . The intended results include the
outputs and outcomes that occur as a consequence of the planned work. Figure 31.2
expands on the model illuslrated in Figure 3 1.1 by adding examples of each component.
This particular logic model, adopted from frec htling (2007), provides an illustration of
the components of an intervention designed to prevent substance abuse and other prob-
lem behaviors among a population of youth. The intervention is targeted toward improv-
ing parenting skills, based on the assumption that positive parenting leads to prosocial
behaviors among yo uth {Bahr, Hoffman, & Yang, 2005). The following section provides
definitions and examples of each logic model component, using this illustration.

Resources
Resources, sometimes referred to as inputs, in clude the human, fin ancial, organizational,
and community asse ts that are available to a program to achieve its objectives (W. K.
Kellogg Foundation, 2004). Resources are used to support and facilitate the program
activities. They are usually categorized in terms of funding resou rces or in -kind contribu-
tion s (Frechtling, 2007) .

Some resources, such as laws, regulations, and funding requirements, are external to
the agency (United Way of America, 1996). Other resources, such as staff and money, are
easier lo quantify than others (e.g., community awareness of the program; Mertinko,
Novotney, Baker, & Lange, 2000). As Fn.:c:htli ng (2007) notes, it is important to clearly and
tho roughly id ent ify the available resources during the logic modeling process because this
information defines the scope and parameters of the program. Also, this inCormation is
critical for others who may be interes ted in replicating the program. The logic model in
Figure 31.2 includes fu nding as one of its resources.

Activities
Activities represent a program’s service methodology, showing how a program intends on
using the resources described previously to carry out its work. Activities are also referred
to as ac tion step!; (McLaughlin & Jordan, 2004). They are the highly specifi c tasks that
p rogram staffs engage in on a daily basis to provide services to clients (Mertinko
et al., 2000) . They include all aspects of pro gram implementation, the processes, tools,
events, technology, and program actions. The ac tivities form the foundation toward facil-
itating intended client changes or reaching oulcornes (W. K. Kellogg Fo undation, 2004).
Some examples are establishing community councils, providing professional develop –
ment training, or initiating a media campaign (Frechtling, 2007). Other examples are

CHAPTER 31 • l OCIC MO DELS 549

Inputs Activities Outputs Outcomes

Short Term Intermediate Long Term

Feedback Loop j
_J

I
Decreased

K~
Increased

I
Develop and Numbe r of Increased

youth Funds .~ initiate ~edi a st~tions a~opti ng r– awareness f- positive 1—–+ of positive substance
-~m~tg~– -.:::c -campatgn J pa renting parenti ng – abv?~d’

~-‘.:-

/
I

Develop and Number of Increased
distribute – 1> fact sheets 1- enrollment

fact sheets distributed in parenting
programs

Fig ure 31.2 Example of l ogic Model With Com ponents, Two Types of Connections, and a Feedbaclc loop

providing shelter for homeless families, educating the public about signs of child abuse,
or providing adult mentors for youlh {United Way of Ame rica, 1996) . Two activities,
” Deve lop and initiate media campaign” and “Develop and distribute fact sheets;’ are
included in the logic model in Figure 31.2. Activities lead to or produce the program o ut-
puts, described in the following section.

Outputs
The planned works (resources and activities) bring about a program’s des ired res ul ts,
including outputs and outcom es (W. K. Kell ogg Foundatio n, 2004) . Outputs, also referred
to as units of service, are the immediate results of program activities in the form of types,
levels, and targets of services to be delivered by the program (McLaughl in & Jordan ,
1999). They are tangible products, events, o r serv ices. They provide the documentation
that activities have been implemented and, as such, indicate if a program was delivered to
the intended audience at the intended dose (W. K. Kellogg FounJation, 2004). Outputs
arc typical ly desc ribed in terms of th e size and/or scope of the services an d products pro-
duced by the program and thus are expressed numerically (Frechtling, 2007). Examples of
program ou tpu ts include the number of classes ta ught, meetings held, o r materials p ro-
duced and distributed; program par ticipation rates and demography; or hours of each
type of serv ice provided (W. K. Kellogg Foundation, 2004) . Other examples are the
number of meals provided, classes taught, brochures distributed , or participants ser ved
(Frecht1ing, 2007) . W hile outputs have little inherent value in themselves, they provide
the link between a program’s activ ities and a program’s outcomes (United Way of
America, 1996). The logic model in Figure 31.2 includes Lhc number of stations adopting
the media campaign and the number of fact sheets distributed as two outputs for the pre-
vention program.

550 PART V • CONCEPTUAL RESEARCH

Outcomes
Outcomes arc Lhe specific changes experienced by the program’s clients or target group as
a consequence of participating in the program. Outcomes occur as a result of the program
activities and outputs. These changes may be in behaviors, attitudes, skill level, status, or
level of functioning (W. K. Kellogg Foundation, 2004). Examples include increased knowl-
edge of nut r itional needs, improved reading skills, more effective responses to conflict,
and finding employment (United Way of America, 1996) . Outcomes are indicalors of a
program’s level of success.

McLa ughlin and Jordan (2004) make the point that some programs have multiple,
sequential outcome structures in the form of short-term outcomes, intermediate out-
comes, and long-term outcomes. In these cases, each type of outcome is linked tempo-
rally. Short-term outcomes arc client changes or benefits th at are mos t immediately
associated with the program’s outputs. They are usually realized by clients wi thin 1 to
3 years of program completion. Short-term outcomes are linked to accomplishing inter-
mediate outcomes. Intermediate ou tcomes are generally attain able in 4 to 6 years. Long-
term outcomes are also referred to as program impacts or program goals. They occur as a
result of the intermediate outcomes, usually within 7 to 10 years. In this format, long-
term outcomes or goals are directed at macro-level change and target organizations, co m-
munities, or systems (W. K. Kellogg Foundation, 2004).

As an example, a sequen tial outcome structure with short- term, intermediate, and
long-term outcomes for the prevention program is displayed in Figure 31.2. As a result of
hearing the public service announ cemen ts about positive parenting (th e activity), parents
enroll in parenting programs to learn new parenting skills (the short-term outcome).
Then they apply these newly learned skills with their children (the intermediate out-
come), which leads to a reducti on in substance abuse among youth (the long-term impact
or goal the parenting program was designed to achieve).

Outcomes ar e often confused with outputs in logic models because their correct clas-
sification depends on the context within which they are being included. A good exa mple
of this potential confusion, provided in the United Way of America manual ( 1996, p. 19),
is as follows. The number of clients served is an output when it is meant to describe the
volume of work accomplished. In this case, it does not relate directly to cl ient changes or
benefits. H owever, the number of clients served is considered to be an outcome when the
program’s intention is to encourage clients to seek services, such as alcohol treatment.
What is important to remember is that outcomes describe intended client changes or
benefits as a result of participatin g in the program while outputs document products or
services produced as a result of activities.

Links or Connections Between Components

A critical part of a logic model is the connections or links between the components. The
connections illustrate the relationships between the components and the process by
which change is hypothesized to occur among program participants. This is referred to as
the program theory (Frechtling, 2007). It is the con nections illustrating the program’s
theory of change that make the logic model complicated. Specifying the connections is
one of the more difficult aspects of developing a logic model because the process requires
predicting the process by which client change is expected to occur as a result of program
participation (Frech tling, 2007).

CHIII’TER 31 • lOGIC M ODtLS 551

Frechtling (2007) describes nvo types of connections in a logic model: connections
that link items within each compo nent and connections that illustrate the program’s
theory of change. The first type, items within a component, is connected by a straight line.
This line shows that the items make up a particularcomponent.As an example, in Figure 31.2,
nvo activities, “Develop and initiate media campaign” and ” Develop and distribute fact
sheets,” are linked together with a straight line beca use they represent the items within the
activities component. Similarly, two outputs, “Number of stations adop ting the cam-
paign” and “Number of fact sheets distributed;’ arc connected as two items within the
outputs component.

The second type of connection sh<.>ws how the components interact with or relate to
each other to reach expected outcomes (Frechtling, 2007) . In essence, this is the program’s
theory of change. Thus, instead of straight lines, arrows are used to show the direction of
influence. Frechtling (2007) clarifies that “these directional connections are not just a
kind of glue ancho ring the otherwise floating boxes. Rather they portray the changes thaL
arc expected to occur after a previous ac Livity has taken place, and as a result of it” (p. 33).
She points out that the primary purpose of the evaluation is to determine the nature of
the relationships between components (i.e., whether the predictions are correct). A logic
mod el that illustrates a fully developed theory of change includes links between every
item in each co mponent. In other words, every item in every component must be co n-
nected to at least one item in a subsequent component. This is illustrated in Figure 3 1.2,
which shows that each of the two items within th e activities co mpon en t is linked to an
item within the output co mponent.

Figure 31.2 provides an example of the predicted relationships between the compo-
nents. This is the program theory about how the target group is expected to change. The
input or resource, funding, is co nnected to the tv,ro activities, “Develop and initiate media
campaign” and “Develop and distribute fac t sheets.” Simply put, this part of Figure 31 .2
shows that funding will be used to support the development and initiati on of PSA cam-
paigns and the distribution of fact sheets.

The sequencing of the connections between components also shows th at these steps
occur over a period of time. While this may seem obvious and relatively inconsequential,
specifying an accurate sequence has time-based implications, pa rticularly when short-
term, intermediate, and long-term outco mes are proposed as a part of the theory of
change (Frechtling, 2007). Rcca11 that the short-term outcomes lead to achieving the
intermediate outcomes, and the intermediate outcomes lead to ach ieving long-term out-
comes. Thus, the belief or underl}ing ass umption is that short-term outco mes mediate
(or come between) relationships benv-een activities and intermediate o utcomes, and
intermediate outcomes mediate relations between sho rt-te rm and long-term outcomes.

Related, sometimes logic models display feedback loops. Feedback loops show how the
information gained from implementing one item can be used to refine and improve other
items (Frechlling, 2007). f or instance, in Figure 31.2, the feedback loop from the short-
term outcome, ” Increased awareness of positive parenting;’ back to the activity, “Develop
and initiate media campaign;’ indicates that the findings for ” Increased awareness of pos-
itive parenting” arc used to im prove the PSA campaigns in the next program cycle.

Contextual Factors

Logic models describe programs that exist and are affected by contextual factors in the
larger environment. Contextual factors are those important features of the environment

552 PART V • CONCEPTUAL R ESEARCH

in which the project or inter vention takes place. They include the social, cultural, and
political aspects of the environment (Frechtling, 2007). They are typically not under the
program’s control yet are likely to influe nce the program either positively or negatively
(McLa ughlin & Jordan, 2004 ). T hu s, it is critical to identify relevant contextual factors
and to consider their potential impact on the program. McLaughlin and Jordan (1999)
point out that understanding and articulating contex tual factors co ntr ibu tes to an under-
standing of the fo undat io n u pon whi ch performance expectatio ns a re established.
Mo reover, this knowledge h elps to establish the parameters for explaining program
results and developing program improvement strategies that are li kely to be more m ean-
ingful and thus more successful because the information is more complete. finally, con-
textual factors clarify situations under which the program results might be expected to
generalize and the issues that might affect replication (Frechtling, 2007) .

Harrell, Burt, Hatry, Rossm an, a nd Roth ( 1996) identify two types of contextual fac-
tors, antecedent and media6ng, as o utside facto rs that could influence th e program’s
design, implementa tio n, and results. Anteceden t factors are thos e that exist prior to
program implemen tatio n, such as cha racteristics of the client target population o r com-
munity characteristics such as geographical and economic conditions. Mediating factors
are the environmental influences that emerge as the program unfolds, such as new laws
and policies, a change in economic con ditions, or the startup of other new programs pro-
viding similar services (McLaughlin & jordan, 2004).

Logic Models and a Program’s Theory of Change

Definition
Log ic models p rovide an illustration of the compo nents of a program’s theo t-y and how
those components are linked togeth er. Program theory is defined as “a plausible and sen-
sible model of how a program is supposed to wo rk” (Bickman, 1987, p. 5). Program
theory in corporates “program resources, program activities, and intended program out-
comes, and specifies a chain of causal assumptions linking resources, activities, interme-
di ate outcomes, and ulti mate goals” (Wholey, 1987, p. 78). Program theory e.>..-plicates the
assumptions abou t how the program components link together from program star t to
goal attainmen t to realize the program’s intended outcomes (Frechtling, 2007). Thus, it is
often referred to as a p rogram’s theory of change. Frechtling (2007) suggests that both
previous research and knowledge gained from practice experience arc useful in develop-
ing a theory of change.

Relationship to logic Models
A logic model provides an illustration of a program’s theory of change. It is a useful tool
for describing program theory because it shows the connections or if-then relationships
between program components. In other words, moving from left to right from one com-
po nent to the next, logic models provide a diagram of the rationale or reasoning underly-
ing the theory of change. If-th en statements connect the program’s co m po nents to form
the theory of change (W. K. Kellogg Founda tion, 2004). For example, certain resources or
inputs are needed to carr y out a program’s activities. The first if-then statement links
reso urces to acti vities and is stated, ” If you have access to these resources, then yo u can use
them to accomplish yo ur planned activities” (W. K. Kellogg Fo undation, 2004, p. 3). Each

CHAPTER 31 • LOCIC MODELS SS3

component in a logic model is linked to the other components using if-then statemen ts to
show a program’s chain of reasoning about how client change is predicted to occur. The
idea is that “if the right resources are transformed into the right activities for the right
people, then these will lead to the results the program was designed to achieve”
(McLaughlin & Jordan, 2004, p. 11). It is important to define the components of an inter-
vention and make the connections between them explicit (Frechtling, 2007).

Program Theory and Evaluation Planning
Chen and Rossi (1983) were among th e first to suggest a program theory-driven
approach to evaluation. A program’s theory of change has significant utility in develop-
ing and implementing a program evaluation because the theory provides a framework
for determining the evalu ation questions (Rossi, Lipsey, & Freeman, 2004) . As such, a
logic model that ill ustrates a program’s theory of change provides a map to inform the
developmen t of relevant eval uation questions at each phase of t he evaluation. Rossi
et al. (2004) explain how a program theory-based logic mode l enha nces the devel op-
ment of evaluation questions. First, the process of articulating the logic of the
program’s change process through the development of the logic model prompts discus-
sion of relevant and meaningful evaluation questions. Second, these questions then lead
to articulating expect ations fo r p rogram performance and inform the identification o f
criteria to measure that performance. Third, obtaining input from key stakeholders
about the theory of change as it is displayed in the logic model increases the likelihood
of a more comprehensive set of questions and that critical issues have not been over-
looked. To clarify, most agree that this is a team effort that should include the program
development and program evaluation staff at a minimum, as well as other stakeholders
both internal and external to the program as they are available (Dwyer & Makin, 1997;
Frech tling, 2007; Mclaughlin & Jordan, 2004). The diversity of perspective and skill sets
among the team members (e.g., program developers vs. program evaluators) enhances
the depth of understanding of how the program will work, as diagramed by the logic
model (Frechtling, 2007). As D”vyer and Makin (1997) state, the team approach to
develop ing a theory-based logic model promotes “greater stakeholde r invo lvement, the
opportunity for open negotiation of program objectives, greater commitment to the
final co nceptualization of the program, a shared vis ion, and increased likeliho od to
accept and utilize th e evaluation results” (p. 423) .

Uses of Logic Models

Logic models have many uses. They help Lo integrate the entire program’s planning and
implementation process from beginning to end, including the evaluation process (D wyer
& Makin, 1997). They can be used at all of a program’s stages to enhance its success
(Frechlling, 2007; W. K. Kellogg Foundation, 2004). For instance, at the program design
and planning stage, going through the process of developing logic models helps to clarify
the purpose of the program, the development of program strategies, resources that are
necessary to attaining outcomes, and th e identification of possible barriers to
the program’s success. Also, identifying program components such as activities and
outcomes prior to program implementation provides an opportunity to ensure that
program outcomes inform program activities, rather than the other way aroun d (Dwyer
& Makin, 1997) .

554 PART V • CoNcEPTUAl R ESEA RC H

During the p rogmm implementation phase, a logic model p rovides the basis fo r th e
development of a management plan to guide program monitoring ac tiv ities and to
improve program processes as issues arise. In other words, it helps in identifying and
highlighting the key program processes to be tracked to ensure a program’s effectiveness
(United Way of America, 1996).

Most important, a logic model facilitates evaluatio n planning by providing the evalua-
tion framework fo r shapin g the evalua tion across all stages of a project. Intended out-
comes and the process for measuring these outcomes are displayed in a logic model
(Watson, 2000), as well as key points at which evaluation activities should take place
across the life of the program (McLaughlin & Jordan) 2004). Logic models suppo rt both
formative and summative evaluations (Frechtli ng, 2007). They can be used in conducting
summativc evaluations to determine what has been accomplished and, importantly, the
process by which these accomplishments have been achieved (Frechtling, 2007) . Logic
models can also support formative evaluations by organizing evaluatio n activities, incl ud-
ing the meas urement of key variables or performance indicators (McLaughlin & Jordan,
2004) . From this info rmation, evaluation questions, relevant indicators, and data collec-
tion strategies can be developed. The following section expands on using the logic model
to develop evaluation questions.

The logic m odel provides a framework for developing eval uat ion q uestions about
prog r am co n text, program efforts, and p rogram effec tiveness ( Frech t ling, 2007;
Mer ti nko et al., 2000). Together, these three sets of quest ions help to explicate the
progr am’s theory of change by describing the assumptions about the r elationship s
between a program’s operations and its predicted outcomes (Ross i et al. , 2004) .
Context questio ns explore program capacity and relationships external to the program
and help to identify and understand the impac t of confo unding factors or externa l
infl uences. Pr ogram effort and effectiveness quest ions correspond to particular co m –
ponents in the logic model and thus exp lore program processes t oward ach ieving
program outcomes. Questions a bout effor t address the planned work of the program
and come from the input and activities sections of the eva luatio n mo d el. They address
program implementation issues such as the services that were provided and to who m.
These questio ns focus on what happene d and why. Effectiveness or outco m e questions
address program results as described in the output and outcomes section of the logic
m odel. From the questions, indicators and da ta collection strategies can the n be d evel-
oped. Guidelines for using logic mo d els to develop evaluation questi ons, ind icators,
and data collection strategies are provided in the Logic Model Development Guide
( W. K. Kellogg Foundation, 200 4 ).

In addition to supporting program effo rts, a logic model is a useful comm unication
tool (McLaughlin & Jordan, 2004 ). For instance, developing a logic model provides the
opportunity fo r key stakeholders to discuss and reach a common understanding, includ-
ing underlying assumptions, about how the program opera tes an d the resources needed
to achieve program p rocesses and outcomes. ln fact, some suggest t hat the logic model
development process is actually a form of strategic planning because it requ ires partici-
pants to articulate a program’s vision, the rationale for the program, and the program
processes and procedures (‘Watson, 2000) . T his also promotes stakeholder involvem ent in
program planning and consensus building on the program’s design and operations.
Moreover, a logic model can be used to explain program procedures and sha re a compre-
hensive yet concise picture of th e p rogram to comm unity partners, funders, and others
outside of the agency (McLaughlin & Jordan, 2004) .

CHAPTER 3 1 • LOGIC M ODF I S 555

Steps for Creating Logic Models

McLaughlin and Jordan (2004) descri be a five-stage process for developing logic models.
The first stage is to gather extensive baseline information from multiple sources abo ut the
nature of the problem or need and about alternative solutions. The W. K. Kellogg
Foundation (2004) also suggests collecting information about community needs and
assets. This information can then be used to both define the problem (the second stage of
developing a logic model ) and identify the program clements in the form of logic model
componen ts (the third stage of logic model development). Possible information sources
include existing program documentation, interviews with key stakeholders internal and
exte rn al to the program, strategic plans, annual performance plans, previous program
evaluations, an d relevant legislation and regulations. It is also important to review the lit-
erature about factors related to the problem and to determ ine the strategies others have
used in attemp ting to address it. This type of information provides supportive evidence
that informs the approach to addressing the problem.

The information collected in the first stage is th en used to define the problem, the
con textual factors that relate to the problem, and Lhus the need for the program. The
program sho uld be conceptualized based on what is uncovered abo ut the nature and
extent of the problem, as well as the factors that are correlated with or cause the prob-
lem. It is also impor tan t at this stage to develop a clear idea of the impact of the prob-
lem across micro, mezzo, and macro domains. The focus of the program is then to
address the “causal” factors to solve t he problem. In addition, McLaughlin and Jordan
(2004, p. 17) recommend identifyi n g the environmental factors that are likely to affect
the program, as well …

SESSIONS
Case Histories

Editors
Sara-Beth Plummer
Sara Makris
Sally Margaret Brocksen

Published by
Laureate International Universities Publishing, Inc.
7080 Samuel Morse Drive
Columbia, MD 21046
www.laureate.net

Director, Program Design: Lauren Mason Carris
Content Development Manager: Jason Jones
Content Development Specialist: Sandra Shon
Production Services: Absolute Service, Inc.
Editorial Services: Christina Myers

Copyright © 2014 by Laureate International Universities Publishing, Inc.

All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including
photocopying, recording, any information storage and retrieval systems, or other electronic or mechanical methods, without the prior
written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncom­
mercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Content Development
Specialist,” at the address above.

Editors

Sara-Beth Plummer, PhD, MSW
Walden University

Sara Makris, PhD
Laureate Education, Inc.

Sally Margaret Brocksen, PhD, MSW
Walden University

Contributors

Marlene Coach, EdD, MSW, ACSW, LSW
Walden University

Eileen V. Frishman, MSW, ACSW, LCSW-R, CH

Mary E. Larscheid, PhD, MSW, LICSW
Walden University

Vanessa Norris, MSW, LCSW
West Chester University

Sara-Beth Plummer, PhD, MSW
Walden University

Stephanie C. Sanger, MA, MSS, LSW
Assistant Director, RHD, Tri-County Supportive Housing

Eric Youn, PhD, LMSW
Walden University

iii

Contents

Introduction 1

Part 1: Foundation Year 2

The Hernandez Family 3

The Parker Family 6

The Logan Family 9

The Johnson Family 11

Part 2: Concentration Year 14

The Levy Family 15

The Bradley Family 17

The Petrakis Family 20

The Cortez Family 23

Appendix 26

Reflection Questions 27

The Hernandez Family 27

The Parker Family 28

The Logan Family 30

The Johnson Family 31

The Levy Family 32

The Bradley Family 33

The Petrakis Family 35

The Cortez Family 36

Trademarks and Disclaimers 38

iv

Introduction

The following eight cases are based on the true experiences of social workers in the field, although names and other identifying circumstances have been changed. The narratives in this book, combined with filmed repre­
sentations of scenes inspired by the cases, provide you an opportunity to use true-to-life cases as an experiential
learning tool. Whereas some academic programs, professors, or instructors may offer an occasional glimpse into
past social work experiences, this book and these cases weave through multiple courses in your foundation and
concentration year. Like in true-to-life practice, you will follow these cases through a variety of circumstances, prac­
tice behaviors, and learning opportunities. This unique format for a social work program enables you to integrate
and connect the expected learning outcomes for each course. Each case either explicitly or implicitly offers content
on practice skills, research, human behavior theory, and policy. Further, you will see that each family’s concerns can
be addressed across all levels of practice, from micro to mezzo to macro.

Approach this book as a series of cases to which you have been assigned during your first professional experi­
ence in social work. We encourage you to use a critical eye to analyze the approaches provided. Remember that
each practitioner has his or her own lens or perspective that guides his or her practice and these cases, written in
the voices of each individual social worker, offer you authentic, varied perspectives. As you review and dissect these
cases, consider your own lens and perspective as a future social worker.

The families described in these cases have been connected to social work services in myriad ways. Look closely at
how each family member is introduced to the social worker and at the services and interventions that follow. Through
reading these cases and then watching them come to life on video, you will see the skills used by social work practi­
tioners. Carefully identify for yourself how the social worker engages, assesses, and intervenes with his or her client.

The social workers who provided these cases offer some of their own personal thoughts about these cases as
a series of reflection questions. Use the answers to the questions, posed to the social workers as they wrote these
stories, to gain additional insight into the decisions they made to address their clients’ concerns. Reflect on the ques­
tions and answers as a way to consider whether you would have addressed the client or clients in the same manner.

Imagine your first day of practice, preparing for your first client meeting. On your desk is a folder with the last
name of the client on the tab. You open the folder to find a case history for your client—perhaps it details family
background, medical history, or an accounting of interactions with other agencies. This book is like that folder,
preparing you for the client you will soon meet.

1

PART 1: FOUNDATION YEAR

2

The Hernandez Family

Juan Hernandez (27) and Elena Hernandez (25) are a married Latino couple who were referred to the New York City Administration for Children Services (ACS) for abuse allegations. They have an 8-year-old son, Juan Jr.,
and a 6-year-old son, Alberto. They were married 7 years ago, soon after Juan Jr. was born. Juan and Elena were
both born in Puerto Rico and raised in Queens, New York. They rent a two-bedroom apartment in an apartment
complex where they have lived for 7 years. Elena works as babysitter for a family that lives nearby, and Juan works
at the airport in the baggage department. Overall, their physical health is good, although Elena was diagnosed with
diabetes this past year and Juan has some lower back issues from loading and unloading bags. Both drink socially
with friends and family. Juan goes out with friends on the weekends sometimes to “blow off steam,” having six to
eight beers, and Elena drinks sparingly, only one or two drinks a month. Both deny any drug use at all. While they
do not attend church regularly, both identify as being Catholic and observe all religious holidays. Juan was arrested
once as a juvenile for petty theft, but that has been expunged from his file. Elena has no criminal history. They
have a large support network of friends and family who live nearby, and both Elena’s and Juan’s parents live within
blocks of their apartment and visit frequently. Juan and Elena both enjoy playing cards with family and friends on
the weekends and taking the boys out to the park and beach near their home.

ACS was contacted by the school social worker from Juan Jr.’s school after he described a punishment his parents
used when he talked back to them. He told her that his parents made him kneel for hours while holding two encyclo­
pedias (one in each hand) and that this was a punishment used on multiple occasions. The ACS worker deemed this
a credible concern and made a visit to the home. During the visit, the parents admitted to using this particular form
of punishment with their children when they misbehaved. In turn, the social worker from ACS mandated the family
to attend weekly family sessions and complete a parenting group at their local community mental health agency.
In her report sent to the mental health agency, the ACS social worker indicated that the form of punishment used by
the parents was deemed abusive and that the parents needed to learn new and appropriate parenting skills. She also
suggested they receive education about child development because she believed they had unrealistic expectations of
how children at their developmental stage should behave. This was a particular concern with Juan Sr., who repeat­
edly stated that if the boys listened, stayed quiet, and followed all of their rules they would not be punished. There
was a sense from the ACS worker that Juan Sr. treated his sons, especially Juan Jr., as adults and not as children.
This was exhibited, she believed, by a clear lack of patience and understanding on his part when the boys did not
follow all of his directions perfectly or when they played in the home. She mandated family sessions along with the
parenting classes to address these issues.

During the intake session, when I met the family for the first time, both Juan and Elena were clearly angry that
they had been referred to parenting classes and family sessions. They both felt they had done nothing wrong, and
they stated that they were only punishing their children as they were punished as children in Puerto Rico. They said
that their parents made them hold heavy books or other objects as they kneeled and they both stressed that at times
the consequences for not behaving had been much worse. Both Juan and Elena were “beaten” (their term) by their
parents. Elena’s parents used a switch, and Juan’s parents used a belt. As a result, they feel they are actually quite
lenient with their children, and they said they never hit them and they never would. Both stated that they love their
children very much and struggle to give them a good life. They both stated that the boys are very active and don’t
always follow the rules and the kneeling punishment is the only thing that works when they “don’t want to listen.”

They both admitted that they made the boys hold two large encyclopedias for up to two hours while kneeling
when they did something wrong. They stated the boys are “hyperactive” and “need a lot of attention.” They said
they punish Juan Jr. more often because he is particularly defiant and does not listen and also because he is older
and should know better. They see him as a role model for his younger brother and feel he should take that respon­
sibility to heart. His misbehavior indicates to them that he is not taking that duty seriously and therefore he should
be punished, both to learn his lesson and to show his younger brother what could happen if he does not behave.

During the intake meeting, Juan Sr. stated several times that he puts in overtime any time he can because money
is “tight.” He expressed great concern about having to attend the parenting classes and family sessions, as it would
interfere with that overtime. Elena appeared anxious during the initial meeting and repeatedly asked if they were
going to lose the boys. I told her I could not assure her that they would not, but I could assist her and her husband
through this process by making sure we had a plan that satisfied the ACS worker’s requirements. I told them it

3

SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

would be up to them to complete those plans successfully. I offered
my support through this process and conveyed empathy around their
response to the situation.

The Hernandez Family

Juan Hernandez: father, 27

Elena Hernandez: mother, 25

Juan Hernandez Jr.: son, 8

Alberto Hernandez: son, 6

or immediately after the PPP so that they did not have to come to
the agency more than once a week. They agreed that this would be helpful because they did not have money for
multiple trips to the agency, although Juan Sr. stated that this would still affect his ability to work overtime on that
day. I asked if they had any goals they wanted to work toward during our sessions. Initially they were reluctant to
share anything, and then Elena suggested that a discussion on money management would be helpful. I told them
I w ould be their primary contact at the agency—meeting with them for the family sessions and co-facilitating the
PPP group with an intern. I explained my limitations around confidentiality, and they signed a form acknowledging
that I was required to share information about our sessions with the ACS worker. I informed them that the PPP is an
evidenced-based program and explained its meaning. I informed them that there is a pre- and post-test administered
along with the program and specific guidelines about missed classes. They were informed that if they missed more
than three classes, their participation would be deemed incomplete and they would not get their PPP certification.

Initially, when the couple attended parenting sessions and family sessions, Juan Sr. expressed feelings of anger
and resentment for being mandated to attend services at the agency. Several times he either refused to participate
by remaining quiet or spoke to the social worker and intern in a demeaning manner. He did this by questioning our
ability to teach the PPP and the effectiveness of the program itself, wanting to know how this was going to make
him a better parent. He also reiterated his belief that his form of discipline worked and that it was exactly what his
family members used for years on him and his relatives. He asked, “If it worked for them, why can’t that form of
punishment work for me and my children?” He emphasized that these were his children. He maintained throughout
the sessions that he never hit his children and never would. Both he and Elena often talked about their love for their
children and the devastation they would feel if they were ever taken away from them.

Treatment consisted of weekly parenting classes with the goal of teaching them effective and safe discipline skills
(such as setting limits through the use of time-out and taking away privileges). Further, the classes emphasized the
importance of recognizing age-appropriate behavior. We spent sessions reviewing child development techniques to
help boost their children’s self-esteem and sense of confidence. We also talked about managing one’s frustration
(such as when to take a break when angry) and helping their children to do the same.

Family sessions were built around helping the family members express themselves in a safe environment. The
parents and the children were asked to talk about how they felt about each other and the reason they were mandated
to treatment. They were asked to share how they felt while at home interacting with one another. I thought it was of
particular importance to have them talk about their feelings related to the call to ACS, as I was unsure how Juan Sr.
felt about Juan Jr.’s report to the social worker. It was necessary to assist them with processing this situation so that
there were no residual negative feelings between father and son. I asked them to role-play—having each member act
like another member of the household. This was very effective in helping Juan Sr. see how his boys view him and
his behavior toward them when he comes home from work. As a result of this exercise, he verbalized his newfound
clarity around how the boys have been seeing him as a very angry and negative father.

I also used sessions to explore the parents’ backgrounds. Using a genogram, we identified patterns among their
family members that have continued through generations. These patterns included the use of discipline to maintain
order in the home and the potentially unrealistic expectations the elders had for their children and grandchildren.
Elena stated that she was treated like an adult and had the responsibilities of a person much older than herself while
she was still very young. Juan Sr. said he felt responsible for bringing money into the home at an early age. He was
forced by his parents to get working papers as soon as he turned 14. His paychecks were then taken by his parents
each week and used to pay for groceries and other bills. He expressed anger at his parents for encouraging him to
drop out of high school so that he could get more than one job to help out with the finances.

Other sessions focused on the burden they felt related to their finances and how that burden might be felt by
the boys, just as Juan Sr. might have felt growing up. In one session, Juan Jr. expressed his fears of being evicted
and the lights being turned off, because his father often talked of not having money for bills. Both boys expressed
sadness over the amount of time their father spent at work and stressed their desire to do more things with him
at night and on the weekends. Both parents stated they did not realize the boys understood their anxieties around

4

Together we discussed the plan for treatment, following the
requirements of ACS; they would attend a 12-week Positive Parenting
Program (PPP) along with weekly family sessions. In an effort to
reduce some of the financial burden of attending multiple meetings
at the agency, I offered to meet with the family either just before

SESSIONS: CASE HISTORIES • THE HERNANDEZ FAMILY

paying bills and felt sad that they worried about these issues. We also
took a couple of sessions to address money management. We worked
together to create a budget and identify unnecessary expenses that
might be eliminated.

It was clear that this was a family that loved each other very much.
Juan Sr. and Elena were often affectionate with each other and their
sons. Once the initial anger subsided, both Juan Sr. and Elena fully

Key to Acronyms

ACS: Administration for
Children Services

PPP: Positive Parenting Program

engaged in both the family sessions and the PPP. We assessed their progress monthly and highlighted that progress.
I also was aware that it was important to learn about the Hernandez family history and culture in order to under­
stand their perspective and emotions around the ACS referral. I asked them many questions about their beliefs,
customs, and culture to learn about how they view parenthood, marriage roles, and children’s behaviors. They were
always open to these questions and seemed pleased that I asked about these things rather than assumed I knew the
answers.

During the course of treatment they missed a total of four PPP classes. I received a call from Elena each time
letting me know that Juan Sr. had to work overtime and they would miss the class. She was always apologetic and
would tell me she would like to know what they missed in the class so that she could review it on her own. During
a call after the fourth missed parenting class, I reminded Elena that in order to obtain the certificate of completion,
they were expected to attend a minimum of nine classes. By missing this last class, I explained, they were not going
to get the certificate. Elena expressed fear about this and asked if there was any way they could still receive it. She
explained that they only had one car and that she had to miss the classes when Juan Sr. could not go because she
had no way of getting to the agency on her own. I told her that I did not have the authority to change the rules
around the number of classes missed and that I understood how disappointed she was to hear they would not get
the certificate. When I told her I had to call the ACS worker and let her know, Elena got very quiet and started to
cry. I spoke with her for a while, and we talked about the possible repercussions.

I met with my supervisor and informed her of what had occurred. I knew I had to tell the ACS worker that they
would not receive the certificate of completion this round, and I felt bad for the situation Juan Sr. and Elena and
their boys were now in. I had been meeting with them for family sessions and parenting classes for almost three
months by this point and had built a strong rapport. I feared that once I called the ACS worker, that rapport would
be broken and they would no longer want to work with me. I saw them as loving and caring parents who were trying
the best they could to provide for their family. They had been making progress, particularly Juan Sr., and I did not
want their work to be in vain.

I also questioned whether the parenting and family sessions were really necessary for their situation. I felt there
was a lack of cultural competence on the part of the ACS worker—she had made some rather judgmental and
insensitive comments on the phone to me during the referral. I wondered if there was a rush to judgment on her
part because their form of discipline was not commonly used in the United States. In my own professional opinion,
some time-limited education on parenting and child development would have sufficed, as opposed to the 3-month
parenting program and family sessions.

My supervisor and I also discussed the cultural competence at the agency and the fact that the class schedule may
not fit a working family’s life. We discussed bringing this situation to a staff meeting to strategize and see if we had
the resources to offer the PPP multiple times during the week, perhaps allowing clients to make up a class on a day
other than their original class day.

I met with Elena and Juan Sr. and let them know I had to contact the ACS worker about the missed classes.
I explained that this was something I had to do by law. They told me they understood, although another round of
parenting classes would be a financial burden and they had already struggled to attend the current round of classes
each week. I validated their concerns and told them we were going to look at offering the program more than once
a week. I also told them that when I spoke to the ACS worker, I would also highlight their progress in family and
parenting sessions.

I called the ACS worker and told her all the positive progress the parents had made over the previous 3 months
before letting her know that they had missed too many classes to obtain the PPP certificate. The ACS worker was
pleased with the progress I described but said she would recommend to her supervisor that the parents take the
PPP over again until a certificate was obtained. She would wait to hear what her supervisor’s decision was on this
matter. She said that family sessions could end at this point. In the end, the supervisor decided the parents needed
to come back to the agency and just make up the four classes they missed. Elena and Juan Sr. were able to complete
this requirement and received their certificate, and the ACS case was closed. They later returned on their own for a
financial literacy class newly offered at the agency free of charge.

5

The Parker Family

Sara is a 72-year-old widowed Caucasian female who lives in a two-bedroom apartment with her 48-year-old daughter, Stephanie, and six cats. Sara and her daughter have lived together for the past 10 years, since
Stephanie returned home after a failed relationship and was unable to live independently. Stephanie has a diagnosis
of bipolar disorder, and her overall physical health is good. Stephanie has no history of treatment for alcohol or
substance abuse; during her teens she drank and smoked marijuana but no longer uses these substances. When
she was 16 years old, Stephanie was hospitalized after her first bipolar episode. She had attempted suicide by swal­
lowing a handful of Tylenol® and drinking half a bottle of vodka after her first boyfriend broke up with her. She has
been hospitalized three times in the past 4 years when she stopped taking her medications and experienced suicidal
ideation. Stephanie’s current medications are Lithium, Paxil®, Abilify®, and Klonopin®.

Stephanie recently had a brief hospitalization as a result of depressive symptoms. She attends a mental health
drop-in center twice a week to socialize with friends and receives outpatient psychiatric treatment at a local mental
health clinic for medication management and weekly therapy. She is maintaining a part-time job at a local super­
market where she bags groceries and is currently being trained to become a cashier. Stephanie currently has active
Medicare and receives Social Security Disability (SSD).

Sara has recently been hospitalized for depression and has some physical issues. She has documented high
blood pressure and hyperthyroidism, she is slightly underweight, and she is displaying signs of dementia. Sara has
no history of alcohol or substance abuse. Her current medications are Lexapro® and Zyprexa®. Sara has Medicare
and receives Social Security benefits and a small pension. She attends a day treatment program for seniors that
is affiliated with a local hospital in her neighborhood. Sara attends the program 3 days a week from 9:00 a.m. to
2:00 p.m., and van service is provided free of charge.

A telephone call was made to Adult Protective Services (APS) by the senior day treatment social worker when
Sara presented with increased confusion, poor attention to daily living skills, and statements made about Stephanie’s
behavior. Sara told the social worker at the senior day treatment program that, “My daughter is very argumentative
and is throwing all of my things out.” She reported, “We are fighting like cats and dogs; I’m afraid of her and of
losing all my stuff.”

During the home visit, the APS worker observed that the living room was very cluttered, but that the kitchen was
fairly clean, with food in the refrigerator and cabinets. Despite the clutter, all of the doorways, including the front
door, had clear egress. The family lives on the first floor of the apartment building and could exit the building without
difficulty in case of emergency. The litter boxes were also fairly clean, and there was no sign of vermin in the home.

Upon questioning by the APS worker, Sara denied that she was afraid of her daughter or that her daughter had
been physically abusive. In fact, the worker observed that Stephanie had a noticeable bruise on her forearm, which
appeared defensive in nature. When asked about the bruise, Stephanie reported that she had gotten it when her
mother tried to grab some items out of her arms that she was about to throw out. Stephanie admitted to throwing
things out to clean up the apartment, telling the APS worker, “I’m tired of my mother’s hoarding.” Sara agreed with
the description of the incident. Both Sara and Stephanie admitted to an increase in arguing, but denied physical
violence. Sara stated, “I didn’t mean to hurt Stephanie. I was just trying to get my things back.”

The APS worker observed that Sara’s appearance was unkempt and disheveled, but her overall hygiene was
adequate (i.e., clean hair and clothes). Stephanie was neatly groomed with good hygiene. The APS worker deter­
mined that no one was in immediate danger to warrant removal from the home but that the family was in need of
a referral for Intensive Case Management (ICM) services. It was clear there was some conflict in the home that had
led to physical confrontations. Further, the house had hygiene issues, including trash and items stacked in the living
room and Sara’s room, which needed to be addressed. The APS worker indicated in her report that if not adequately
addressed, the hoarding might continue to escalate and create an unsafe and unhygienic environment, thus leading
to a possible eviction or recommendation for separation and relocation for both women.

As the ICM worker, I visited the family to assess the situation and the needs of the clients. Stephanie said she
was very angry with her mother and sick of her compulsive shopping and hoarding. Stephanie complained that
they did not have any visitors and she was ashamed to invite friends to the home due to the condition of the apart­
ment. When I asked Sara if she saw a problem with so many items littering the apartment, Sara replied, “I need
all of these things.” Stephanie complained that when she tried to clean up and throw things out, her mother went

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SESSIONS: CASE HISTORIES • THE PARKER FAMILY

7

outside and brought it all back in again. We discussed the need to
clean up the apartment and make it habitable for them to remain
in their home, based on the recommendations of the APS worker. I
also discussed possible housing alternatives, such as senior housing
for Sara and a supportive apartment complex for Stephanie. Sara
and Stephanie both stated they wanted to remain in their apartment
together, although Stephanie questioned whether her mother would

cooperate with cleaning up the apartment. Sara was adamant that she did not want to be removed from their apart-
ment and would try to accept what needed to be done so they would not be forced to move.

Stephanie reported her mother is estranged from her younger sister, Jane, because of the hoarding. Stephanie
also mentioned she was dissatisfied with her mother’s psychiatric treatment and felt she was not getting the help
she needed. She reported that her mother was very anxious and was having difficulty sleeping, staying up until all
hours of the night, and buying items from a televised shopping network. Sara’s psychiatrist had recently increased
her Zyprexa prescription dosage to help reduce her agitation and possible bipolar disorder (as evidenced by the
compulsive shopping), but Stephanie did not feel this had been helpful and actually wondered if it was contributing
to her mother’s confusion. I asked for permission to contact Jane and both of their outpatient treatment teams, and
both requests were granted.

I immediately contacted Jane, who initially was uncooperative and stated she was unwilling to assist. Jane is
married, with three children, and lives 3 hours away. At the …