Human Service

Working with clients in Preparation

- Clients in preparation are preparing to set goals and thinking about the steps necessary to achieve them.

Identifying Discrepancies

- Involves pointing out an incongruity between client's behaviour and goals in order to increase motivation to change behaviour -Example: I know that you have been complaining about the social service worker coming to visit you. What do you think would have to change in order to get those visits to stop?

Elements of Hope

- A sense of capability to bring about a desired effect "I know I can do it" - Internal Locus of Control (you feel as though you could have controlled the situation if you had done something differently) vs. External (someone else's fault and not your own, places the situation out of your control) - Life experiences can cause us to gain/lose hope. - Practitioner's experiences relayed to client - Placebo Effect - just believing something will help

Ethical Considerations in Problem Identification

- It is important that you respect the rights of clients to make their own decisions about how they live their lives. -clients have a right to self-determination -practitioner's role to support clients in the choices they make, even if practitioner feels the client should make other choices. -practitioners should affirm the rights of clients to decide how to act as long as their behaviour does not infringe upon the legal rights of others.

Empirically-Based Practice

- a.k.a Best practices, outcomes-based practice, promising practices, evidence-based practice. -Choose methods that have been empirically (scientifically) tested.

Self-Disclosure

- aka. Telling personal information about yourself, personal observations or personal opinions

Expressing Empathy

- expression of empathy provides acceptance of client that facilitates change

Advanced Reflecting

- involves reflecting that goes beyond what has been expressed to what is beneath or behind an expressed meaning, combines what is know about client, observations, feelings - Example - It seems like you feel angry because you value communication and he doesn't.

Noticing Patterns and Themes

- themes or patterns related to interacting, behaving or thinking that run through the meeting. - also involves pointing out discrepancies between verbal and non-verbal communications

Connecting Strengths and Empowerment

-A person who is empowered know they have knowledge, skills, competencies and resources to make decisions, solve problems and achieve goals. -The key is knowing. Each of us has these things but we may not know it. -That is the job of the practitioner. -Most people don't know what empower means-once they know it they can believe it

Questions that begin with Why

-Be careful with these. Questions that start with "WHY?" can lead the client to become defensive. -Ex. Why were you late today?, Why did you do that? -It might also be asking the client to have more insight into his/her behaviour than they have -You may ask their opinion (i.e. You've said your sister didn't want to pay for the movie. Why do you think that was?) -Don't ask why but for their opinion on the reason

REFLECTING UNDERSTANDING OF DIVERSITY ISSUES

-Best to deal with diversity issues head on. -Some differences can create barriers to empathic understanding (i.e. language differences, accents, use of slang) even if the client and practitioner speak the same language. -This is further compounded when English is a second language. -It is important to understand how your clients feel, what they experienced and the meaning they assign to their experiences.

Closed-Ended Questions

-Can be answered with one word (Yes/No, 23, etc.) -Ex. Are you cold?, How old are you? -Useful when you need specific information or to get right to the point - i.e.) intake forms

Open-Ended Questions

-Cannot be answered with Yes/No, Begin with Who, What, When, Where, Why, How, Tell Me More -Questions should be client-appropriate (i.e. for their age, ability to understand the spoken language, education level, etc.) -Leads to further explanations, Adjust the way you speak based on the audience, Might be difficult with a language barrier

Documentation

-Charting should include should include reasons contained on previous slide. -A discharge should be done for every client, regardless of the reason you have stopped seeing them.

REFLECTING FEELINGS AND CONTENT

-Combining a reflection of feelings and content in the same sentence -Ex. It sounds like you felt ___ when ____ happened..., Are you saying you felt ___ after she said _____ ?

Assessing Stage of Change

-Do you currently have a problem with___? -YES = contemplation, preparation or action -NO = pre-contemplation or maintenance If YES, When do you intend to deal with it?-Someday = contemplation, -Specific date or soon = preparation, -Right now = action If NO, What leads you to say that? -No problem = pre-contemplation, -Already dealt with it = maintenance

Evaluation during the End

-Evaluate the entire process -Identify what was helpful, what didn't work -Review initial problems and accomplishments made along the way -Affirm client's ability to solve problems and meet goals

Evaluating as an Ongoing Process

-Evaluation should be continuous -Examples of evaluation throughout: If practitioner needs more information for first visit, If practitioner has skills required to help client, During exploration, does client have full understanding of client's problems, After sessions, evaluate whether work is leading towards a defined goal

Multiple Choice Questions

-Example: How did you feel about that? Happy? Sad? Angry? In this example, you are giving the options when none of those options may be accurate. -Don't give them these questions, as a, b, c may not accurately describe their feelings/emotions

Focusing on Strengths and Positive Factors

-Examples include: abilities and resources, Capacity to cope, resilience, Achievements, Willingness to keep trying and try new things, Understanding challenges -The idea is to help client switch from focusing on what's wrong in life to what is positive. Leads to a feeling of hope. Hope is a good indicator of success. -Strengths-Based Approach

Avoid arguments for change

-Express understanding (i.e. Reflecting, summarizing, exploring, expressing warmth) -Ask client what changes, if any, they want to make -May involve helping decide whether something is an issue or not (i.e. Group with 2 opposing views)

REFLECTING FEELINGS IN GROUPS

-Good to encourage others to reflect. -Ex. How do you think (name) might be feeling? The group seems to be hesitant to talk about this issue. I wonder if you are feeling..., When I explained that exercise, the group became quiet. Did you understand the instructions?

SUMMARIZING

-Good way of summarizing a volume of information -Often used when closing a meeting or when changing speakers in a group session

Giving Feedback

-Identifying verbal and non-verbal behaviours for the client that he or she may not be aware of-"I notice that you are smiling", "You look like you are about to cry" -It is uncertain how client will react to this. Must debrief afterwards- "How did you feel about the feedback I gave you?"

Dealing with Crisis

-In a crisis situation, the practitioner may have to take action quickly without fully exploring the problem. -A crisis exists anytime the immediate problems are so serious that the individuals involved are in shock and/or are unable to cope with the situation (i.e. Interpersonal violence, natural disaster, new diagnosis, major personal loss) -At the time of crisis, practitioners need to focus on the immediate needs of those involved (i.e. Their safety, basic needs being met, etc) -Practitioner may need to be much more directive than would usually be appropriate. -Goal is to diffuse crisis.

Sharing Feelings about Ending

-In longer term relationships, need to allow time to discuss feelings, celebrate accomplishments -Sense of loss, sadness, fear and anger are common -Provides a sense of closure -Ex. "I am glad to hear you have mended your relationship with your brother. I hope that over time, you will be come close friends and support each other"

The Ending Process: 6 Tasks

-Indicate how many more meetings remain 1 left, etc. -Summarize what has been most important, what changes, what are difficult helps them learn -Identify what tasks remain to be completed after the relationship ends not always going to be finished -Discuss possible referrals to other organizations -Client feedback about the entirety of working together client's thoughts of the session -Final questions any last questions

REFLECTING MEANING

-Inferring meaning is more difficult -It involves careful observation of feelings and content to uncover the unspoken meaning behind. -Ex. "When you feel you have to interrupt your mother because 'she is speaking too much', is it because you are embarrassed by her behaviour?"

What to do with resistance

-Involuntary clients (i.e. Probation, CAS, Elder Abuse cases)- 99.9% are voluntary clients -even though they don't want to be there, you should try to convince them that you are there to help them. -Example: Client being investigated for Elder Abuse. Says "no problem" Ask: Is there some aspect of this situation you would like to work on? Client: "Yes, get Family Services off my back!" Response: Ok. Let's see if we can find a way to do that together.

Levels of discounting

-No problem - denial- denying there is a problem -Problem - not significant- admitting there is a problem, but there is nothing to do -Problem - significant - not solvable- nothing can be done -Problem - significant - solvable - but not by me- there is a problem but I can't do anything, it is something someone else has to fix

Evaluating, Organizing and Planning the Steps

-Once steps have been identified, next step is to evaluate each one for its: Worth (how important is this one?), and Priority (how urgent is this one?) -Next, create a plan to achieve each step (making sure to use clients' strengths, capacities and resources)

Must be cautious about crossing professional boundaries

-Only share if it will help the client -Don't try to change their mood or bring up your good mood instead of bringing up their feelings -Don't say you are going through the same thing, but say through you went through something similar

Goal Attainment Scaling (GAS)

-Originally used for mental health but has much broader reach. -You will be evaluated based on GAS in the field. -Children are evaluated based on GAS in school. -Start with the most favourable outcome to the least. Each step must be distinctly different.

Multiple Questions

-Practitioners should refrain from asking multiple questions. -This can lead to confusion. -Client will usually only answer one question. -May only answer the first half as they forgot the rest of the question

Resistance

-Pushing a client to resolve an issue they don't see as a problem can result in strengthening their resolve to do it their own way. -Rolling with resistance is a motivational interviewing tool based on assumption that clients have valid insights and ideas about their situation.- if the client doesn't buy into it, then it won't get accomplished

Planning for Future Professional Development

-RSSWs have an obligation to purse professional development -The OCSWSSW has a template outlining professional development goals that must be completed on an annual basis -Can potentially be audited.

Discharges

-Same as contact notes with following additions:

Endings with Groups

-Same process -May also include making plans to sustain and stabilize future changes.

Seeking Clarification

-Seeking clarification involves using questions to invite clients to thoroughly explain their thoughts with more specific details, and encourages clients to explain their experience in depth -When asking questions for clarification, practitioners can explore the meaning of words and body language. - Ex. CLIENT: "He is always getting mad at me over nothing." PRACTITIONER: Reflect feelings: "I am guessing you are feeling mistreated by him." -When you say always it can demonstrate a pattern or exaggerate- No one is always anything -Questions: -Tell me what he did last time he got mad at you. (asking for further information), How often was he mad at you yesterday? (asking for further information to understand frequency or scope of problem), Would you give me an example of a time when he got mad at you over nothing? (asking for further information to uncover antecedents), What does he do when he's mad at you? (exploring behaviours described as "mad")

Understanding the Client's Problems

-Some clients come with a clear idea of the problem(s) they are ready to focus on. -Even still, the issue must be fully explored. -Developing goals requires a thoughtful and complete assessment (i.e. OCAN-even though the OCAN can be long and stressful, it is the most difficult and if you can handle it, then you can handle anything) -When clients do not take steps to reach their goals, beginning practitioners may be focusing on a problem that is not important to the client. - Some clients may come ready for action

Blaming Others for the Problem

-Sometimes people begin the process by seeing the problem as belonging to someone else, Tend to stay focused on wishing they could change the behaviour of others. -What to do with blaming? -Listen empathetically to client's story. -Explore challenges. Encourage client to realize they only have control over themselves. -Focus on what the client has control over.- focus of control is external -Ex.: Client states boss is unfair. Problem client may be willing to acknowledge: Inability to figure out what can be done to be treated more fairly.

Learning about problems or challenges.

-To gain clarity about a problem, you can ask questions about it. To learn about the nature of the problem, you might consider finding out the following. -Length/duration of the problem, Severity or frequency of the problem, Who is involved, How the problem affects the client, emotionally and physically (in other aspects of life), Etc.

Demonstrating Respect

-Ways of demonstrating respect: Expressing understanding, Showing interest in the client's thoughts, feelings, wants, needs and goals, and Asking about strengths, resources, potential

Learning about the Situation or Environment

-Who else might be affected by the problem (ecological perspective) -How this affects family or family of choice or work environment? (Systems perspective)

Discounting

-it is a form of cognitive distortion used to avoid dealing with the problem.

REFLECTING CONTENT

-restating your understanding of what the client has said -ex. are you saying, as I understand it..., what I hear you saying is... You aren't repeating what the client has said, but rephrasing it in your own language

Contact Notes

-should include: Practitioner's Name, Date of interaction, Date of note entry, Method of interaction (in person, phone, e-mail, etc.), Previous Goals, Progress Noted, Goals discussed for this sessionprevious goal and the progress made, Document by exception only write the exceptions, Follow-up planned, Referrals made, if necessary

Maslow's hierarchy or needs

-when talking about strengths and their ability to solve problems it usually falls on the chart Basic needs psychological needs and safety needs- begin here and work upwards Psychological Needs belongingness & love needs (can have a significant impact if their electronics break) and esteem needs Self-fulfillment Needs self-actualization

Possible reasons for discharge

Agency-initiated- Work has been completed, Funding ended, Program is done, Client is not making progress/unmotivated, No show/no calls, Client no longer qualifies for service (change in circumstance) Client-initiated- Client no longer desires service, Client declines service (repeatedly), Client moved, Client is deceased, Client requests a different service, Client is incarcerated

Working with Clients in Contemplation:

Clients are aware there is a problem. They recognize advantages of changing but also aware of costs. Practitioner role: to discuss client's perception of advantages and disadvantages. Support clients feelings of ambivalence towards making the change as it is a normal part of the change experience. -Practitioner does not have to agree with client in order to empathize.

When a client is in crisis:

Do your best to stay calm, The safety of everyone involved is your first priority, At times of crisis it is particularly important to use all the skills you have learned so far.

Importance of Empathic Understanding

Empathy involves making every effort to understand others FROM THEIR POINT OF VIEW. It means communicating an understanding of how THAT PERSON feels in a situation, NOT how YOU would feel in that situation.

REFLECTING FEELINGS-

Express your hunch as to how the client may be feeling - ex.- You seem to be feeling sad..., I wonder if you're sad about that..., Sometimes when people experience what you have, they feel sad. Is that how you feel? Great is an overused word- Target the feeling and emotions of the client Use the predominant emotion and use the opposite to stimulate the client- ex. left out included

Client's Role in Clarification

Has to be willing, In order to be willing, must feel safe. Some develop trust quickly. Others are more hesitant. Some have no boundaries at all and over-share. Some victims of abuse are very hesitant

Partializing:

Important to state/restate problem and break it down into manageable parts. Might involve prioritizing steps.

Allowing Silence

Silence, when used appropriately, is golden. May seem awkward to beginning practitioners. It is appropriate and respectful to allow someone to complete their thought.- always think of that.

Identifying Steps

Many clients may not have had the experience of planning to reach a goal. MAPS goals are journeys. Further exploration of the problem (who, what, where, when, antecedents, consequences) Steps identified by CLIENTS - involving clients. Includes brainstorming sessions where steps are just listed, not evaluated. Steps identified BY PRACTITIONER - may add some based one experience. Using exception-finding questions to identify steps- i.e.) Think of a time when you were/weren't feeling this way. How was it different than it is now? What was that like?

Examples of empathic statements

NOT -"If I were you,..." -"I know just how you feel,..." INSTEAD-"I understand that you see it in this particular way." When a practitioner summarizes a client's story, you give an opportunity for client to correct any misunderstandings and to elaborate further. Even though you may have been through the same situation, don't just assume they had the same response as you

For Professional Development:

Non Violent Crisis Intervention (Code White)- training diffuse people who have a tendency to act out

Stages of Change

Precontemplation- do not think there is a problem, and are not going to fix it Contemplation- hoping to at some point change, notice there is a problem but not making any changes- may make excuses or weighs options Preparation- you know there is a problem, you know the solution, and you are deciding what action plan to take, preparing the plan and making a date Action-put plan into place Maintenance-at some point in time you didn't always do it, but now you do and if you didn't you wouldn't feel like yourself Termination-don't always has it, when the change has been made you don't need to do anything else

Reason for Discharge-

Progress since beginning of relationship is noted, Plan for continued progress- what are their plans going forward, Exit referrals, if any.

Other Factors Influencing Motivation to Change

Strengths, Capacity, and Resources - (i.e. past ability to solve problems, resilience, common sense, social determinants of health) Resilience- ability to bounce back and cope with problems Social Determinants of Health- housing, access to transportation, financial status, educational status, neighbourhood you live in- can make your life easier or more difficult -depends on the client, Level of Stress and Demands - (i.e. other stressors besides presenting issue) Sometimes people are more than capable to solve their problems, but have too many more things going on to deal with it, Hope- Things could go alright

Supporting Self-efficacy:

Supporting a client's belief in capacity to achieve the goal.

Skills to Enhance Achievement of Steps

Teaching- knowledge transfer, teach new behaviours, methods, ways of acting. May be in form of a class- ex. how to do the laundry Directing - asking clients to do something new or go in a different direction (i.e. giving homework, role play, practicing new behaviours)- practicing the task so you can explore different methods of completing the task Inviting a different perspective (aka. Reframing) viewing a situation through a different perspective/set of glasses- find silver linings Identifying discrepancies - identifying behaviours that are moving clients away from stated goals- behaviour that is moving the client away from their intended goals (ex. buying a jacket that is $500, when they are saving for a trip)

Sympathy:

feeling something for the client; ex. They are drowning- how you feel

3 Guidelines- three times it is okay to share:

To enhance or preserve the relationship, Need to ensure that their personal needs do not take precedence over those of the client, Disclosures must always be for the benefit of the client and designed to keep focus on the client. - "I have some understanding of the challenges you are facing with your mother's illness because I faced something similar several years ago."

Ways to Evaluate Progress

Using Scaling Questions - how would you rate your progress on scale of 1 to 10- Used a lot- ex. how was the movie? Oh it was a 7 because... they will usually give a reason without being asked Goal Attainment Scaling - For each goal, a scale is created with client from worst outcome possible to best outcome possible. Client rates themselves on the scale. Each step on the scale must be a measurable difference. (see example p. 246)- Measure how the goal was attained For Professional Development - practitioner evaluating own work (i.e. Client satisfaction surveys)- How the worker was throughout the relationship

Problem Identification:

Using reflecting feeling and content OR Advanced reflecting AND a pattern OR a theme to state a problem.

When to use silence

When client trying to sort something out, When client contemplating, When two clients addressing one another, When someone has just said something thought-provoking.- may let it absorb

Pattern:

a consistent way of thinking, feeling or behaving- a lot of extended activities results in extended periods of the problem

Apathy:

a lack of caring and concern, lack of emotion

Theme:

a theme refers to a viewpoint shared by several people (i.e. several family or group members)- many factors that support the problem

Immediacy -

giving feedback in the moment, as it happens- "You reacted much differently than you usually would. How did that work for you? How did you feel about that?"

Empathy:

there could be a number of things, stopping and thinking about all of the possibilities- how they would feel; Controlled emotional involvement