SOCW 610 Ch 8 & 9

Support Systems

An essential part of understanding individuals involves understanding the systems with which they interact. This can include formal systems, such as schools, medical clinics, mentors, or home health aides, and natural or informal systems, such as neighbors, family, or friends.

Sites of Problematic Behaviors

Determining where problematic behavior occurs will assist you in identifying patterns that warrant further exploration and in pinpointing factors associated with the behavior in question. Identifying where problematic behavior does not occur is also valuable because it provides clues about the features that might help in alleviating the problem and identify situations in which the client experiences relief from difficulties.

Assessment and Diagnosis

Diagnoses: Labels or terms that might be applied to a one or one's situation Provides a shorthand categorization based on specifically defined criteria Reflects a medical condition Diagnostic and Statistical Manual (DSM-5) Tool for understanding and formulating mental and emotional disorders Diagnostic labels serve many purposes. For example, they provide a language through which professionals and patients can communicate about a commonly understood constellation of symptoms. The use of accepted diagnostic terminology facilitates research on problems, identification of appropriate treatments or medications, and linkages among people with similar problems. The diagnosis may comfort the individual by helping "put a name to" the experiences he or she has been having. It may also help the client and family members to learn more about the condition, locate support groups, and stay abreast of developments in understanding the disorder. Diagnoses can become self-fulfilling prophecies, wherein clients, their families, and their helpers begin to define the client only in terms of the diagnostic label. Assessments describe the symptoms that support a particular diagnosis, but they go further to help us understand the client's history and background, the effect of the symptoms on the individual, the available support and resources to manage the problem, and so on.

Instrumental ADLs (IADLs)

A client's ability to perform more intricate activities of daily living (ADLs), such as managing money, taking medicine properly, completing housework, shopping, and preparing meals.

Intrapersonal Systems

A comprehensive assessment of the individual considers a variety of elements, including biophysical, cognitive/perceptual, affective (emotional), behavioral, and motivational factors, and examines the ways that these affect interactions with people and institutions in the individual's environment. Keeping this in mind, the social worker's assessment and written products may focus more sharply on some of these areas than others, depending on the nature of the client's difficulties, the reason for the assessment, and the setting in which the assessment is taking place. It is important to remember, however, that an assessment is just a "snapshot" of the client system's functioning at any point in time.

Social Worker's Personal Experience

A final source of information for assessment is the social worker's personal experience based on direct interaction with the client. You will react in different ways to different people, and these insights may prove useful in understanding how others respond to the client. Clients may not behave with the social worker as they do with other people. Apprehension, involuntariness, and the desire to make a good impression may all skew a person's presentation of himself or herself. Also, initial impressions can be misleading and must be confirmed by other sources of information or additional contact with the person. Before drawing even tentative conclusions, scrutinize your reactions to identify possible biases, distortions, or actions on your part that may have contributed to the behavior you are observing.

brief, solution-focused therapy

A therapy model based the assumptions that making small changes can lead to larger changes, that focusing on the present can help the client tap into unused capacities and generate creative alternatives, and that paying attention to solutions is more relevant than focusing on problems. Seeking exceptions: Questions that determine when the problem does not exist or does not occur. Scaling the problem: This involves asking the client to estimate the severity of the problem on a scale of 1 (very minor) to 10 (very severe). Scaling motivation: Similar to scaling problems or concerns, this involves asking clients to estimate the degree to which they feel hopeful about resolution, or perhaps the degree to which they have given up hope. The miracle question: This helps the practitioner determine the client's priorities and operationalize the areas for change.

Data Sources and Interviewing Techniques with children and older adults

A trusting relationship with the client's primary caregivers will be vital to your access to the client and will dramatically affect the rapport you achieve with him or her. Child assessments may also require new skills, such as the use of drawings, board games, dolls, or puppets as sources of information for the assessment In this context, play is not a random activity meant for the child's distraction or enjoyment. Instead, you must use it purposefully and be attentive to the implications of various facets of the experience. Your impressions of the significance and meaning of the play activities should be evaluated on the basis of other sources of information. A developmental assessment may be particularly relevant for understanding the child's history and current situation. Screening instruments intended specifically for child clients or problems associated with childhood may also be useful. Some involve the child as a participant-respondent while others are completed by the parent or guardian in reference to the child. Comprehensive, competent assessments for geriatric clients also involve items that go beyond the typical multidimensional assessment. For example, functional assessments would address the client's ability to perform various tasks, typically activities of daily living (ADLs)—those things required for independent living such as dressing, hygiene, feeding, and mobility. However, the inevitability of decline and death are often on the minds of older clients and are thus worthy of exploration. Assessments in these areas might include reminiscence and discussion of spirituality and beliefs, all of which examine how the older client derives purpose and meaning in his or her life Specialized and comprehensive evaluations require interdisciplinary teams with expertise in geriatric care. Assessing physical health is particularly important when working with older clients, as poor physical health is a significant risk factor for depression in this population. Older persons may also be socially isolated and thus lack a sense of community belonging, which can serve to exacerbate symptoms of depression (Windle, Francis, & Coomber, 2011). One way to combat depression in the older adults is through social engagement and community connection Other tests focus on the presence and severity of dementia, querying caregivers about the frequency with which the client shouts, laughs, or makes accusations inappropriately, wanders aimlessly, smokes carelessly, leaves the stove on, appears disheveled, is disoriented in familiar surroundings, and so on (Gallo, 2005). For both very young and very old clients, direct observation of functioning may yield more reliable results than either self-reports or information from collateral sources. This may mean classroom visits, home visits, and other efforts to view the client in his or her natural setting.

genogram

A visual picture of a client's family, usually in the form of a family tree, identifying information about each person in order to obtain a comprehensive understanding of the family situation.

Opening questions- Getting Started

After opening social amenities and an explanation of the direction and length of the interview, you should begin by exploring the client's presenting problem If the client's request for service is nonvoluntary, and particularly if it results from a legal mandate (e.g., a probation requirement or the consequence of a child maltreatment complaint), then the nature of the mandate, referring information, and the client's perception of the referral will frame the early part of the first interview. A further consideration at the first interview is whether any danger exists that the client might harm him- or herself or others. Some referrals—for example, in emergency services—clearly involve the risk for harm, which should be discussed and evaluated at the outset. In other instances, the risk may be more subtle. If further information raises the social worker's concerns about the danger for suicidal or aggressive behavior, more specific questioning should follow, geared toward assessing the lethality of the situation. Whatever the client's presenting problem, if shared information gives rise to safety concerns, the social worker must redirect the interview to focus on the degree of danger. If the threats to safety are minor or manageable, the practitioner may resume the interview's focus on the presenting problem that brought the person in for service. However, if the mini-assessment reveals serious or imminent risk to the client or others, the focus of the session must be on ensuring safety rather than continuing the more general assessment.

Alcohol Use and Abuse

Alcoholism, or alcohol dependency, can be distinguished from heavy drinking in that it causes distress and disruption in the life of the person with alcohol dependency, as well as in the lives of members of that person's social and support systems (Goodwin & Gabrielli, 1997). Alcoholism is marked by a preoccupation with making sure that the amount of alcohol necessary for intoxication remains accessible at all times. Females who abuse alcohol present a somewhat different profile. They are more likely to abuse prescription drugs as well, to consume substances in isolation, and to have had the onset of abuse after a traumatic event such as incest or racial or domestic violence Another serious problem associated with alcohol abuse involves adverse effects on offspring produced by the mother's alcohol consumption during pregnancy.

Priorities in Assessments

Although a social worker's assessment will be guided by the setting in which the assessment is conducted, certain priorities in assessment influence all social work settings. Without prioritization, social workers run the risk of conducting unbalanced, inefficient, or misdirected evaluations. What does the client see as his or her primary concerns or goals? Sometimes referred to as "starting where the client is," this question highlights social work's emphasis on self-determination and commitment to assisting individuals (where legal, ethical, and possible) to reach their own goals. What (if any) current or impending legal mandates must the client and social worker consider? If clients are mandated to receive services or face other legal concerns, this factor may shape the nature of the assessment and the way that clients present themselves. What (if any) potentially serious health or safety concerns might require the social worker's and client's attention? These complications may be central to the client's presenting problem, or they may indicate a danger that requires immediate intervention by the social worker.

Depression and Suicidal Risk with Older Adults

Although older adults comprise only 12% of the U.S. population, they account for the majority of suicide deaths Particular risk factors for older persons include isolation, ill health, hopelessness, and functional and social losses. Further, older clients may be reluctant to appear for mental health services, and psychiatric conditions may be overlooked by primary care providers and loved ones, or minimized as typical features of aging. The assessment of suicidality in elder clients requires particular discernment to distinguish between suicidal intent and the awareness of mortality or preparedness for death, which may be hallmarks of that developmental phase Older adults who present as treatment resistant may instead simply be noncompliant with their antidepressants. Elders may intentionally not take their medications out of fear of becoming dependent, over concerns that the medicine will prevent them from feeling natural sadness, or because they do not recognize their depression as a medical condition. Other seniors may forget to take their antidepressants or misunderstand dosage instructions, especially if they have cognitive impairment and no caregiver to assist them with medications. Other risk factors for medication noncompliance include taking three or more other medications, having co-occurring diagnoses of depression and anxiety, being dependent on substances, having a caregiver who does not believe depression is a medical condition, lacking social support, and being unable to pay for medications.

Assessment: Focus and Timing

Although some data are common to all interviews, the focus of a particular interview and assessment formulation will vary according to the social worker's task, mission, theoretical framework, or other factors. Clients often disclose new information as the problem-solving process progresses, casting the original evaluation in a new light. Sometimes this new insight emerges as the natural result of coming to know the client better. In other cases, individuals may withhold vital information until they are certain that the social worker is trustworthy and capable. Note that the term assessment also refers to the written products that result from the process of understanding the client. A formal assessment requires analysis and synthesis of relevant data into a working definition of the problem. It identifies associated factors and clarifies how they interact to produce and maintain the problem. Because assessments must constantly be updated and revised, it is helpful to think of an assessment as a complex working hypothesis based on the most current data available. The scope and focus of the written product and of the assessment itself will vary depending on three factors: the role of the social worker, the setting in which the social worker works, and the needs presented by the client.

Range of Emotions

Another aspect of emotional functioning involves the ability to experience and to express a wide range of emotions that befits the vast array of situations that humans encounter. Some individuals' emotional expression is confined to a limited range, which can cause interpersonal difficulties. Some individuals are unable to feel joy or to express many pleasurable emotions, a dysfunction referred to anhedonia. Still others have been conditioned to block out their angry feelings, blame themselves, or placate others when friction develops in relationships. Because of this blocking of natural emotions, they may experience extreme tension or physiological symptoms such as asthma, colitis, and headaches when they face situations that normally would engender anger or sadness. Finally, some people, to protect themselves from unbearable emotions, develop psychic mechanisms early in life that block them from experiencing rejection, loneliness, and hurt.

Assessment Instruments

Another possible source of information consists of various assessment instruments, including psychological tests, screening instruments, and assessment tools. Some of these tests are administered by professionals, such as psychologists or educators, who have undergone special training in the administration and scoring of assessment tools. Tests and screening instruments are useful and expedient methods of quantifying data and behaviors. They are also essential components in evidence-based practice, in that they "enhance the reliability and validity of the assessment and provide a baseline for monitoring and evaluation" (O'Hare, 2015, p. 7). As a consequence, scales and measures play an important role in case planning and intervention selection. To use these tools effectively, however, practitioners must be well grounded in test theory and in the characteristics of specific tests. Many instruments, for example, have biases, low reliability, and poor validity; some are ill suited for certain populations and thus should be used with extreme caution.

Collateral Contacts

Another source for assessment data is collateral contacts—that is, information provided by relatives, friends, teachers, physicians, child care providers, and others who possess essential insights about relevant aspects of clients' lives. Collateral sources are of particular importance when, because of developmental capacity or functioning, the client's ability to generate information may be limited or distorted Social workers must exercise discretion when deciding that such information is needed and in obtaining it. Clients can assist in this effort by suggesting which collateral contacts might provide useful information. Their written consent (through agency release of information forms) is required prior to making contact with these sources. In weighing the validity of information obtained from collateral sources, it is important to consider the nature of their relationship with the client and the ways in which that might influence these contacts' perspectives. For example, members of the immediate family may be emotionally involved or exhausted by the individual's difficulties and unconsciously skew their reports accordingly. Individuals who have something to gain or to lose from pending case decisions (e.g., custody of a child, residential placement) may be less credible as collaterals than individuals who do not have a conflict of interest or are further removed from case situations. Conversely, individuals who have limited contact with the client (such as other service providers) may have narrow or otherwise distorted views of the client's situation.

Cultural, Societal, and Social Class Factors

As we noted earlier, ethnocultural factors influence what kinds of problems people experience, how they feel about requesting assistance, how they communicate, how they perceive the role of the professional, and how they view various approaches to solving problems. It is therefore vital that you be knowledgeable about these factors and competent in responding to them. Your assessment of clients' life situations, needs, and strengths must be viewed through the lens of cultural competence As discussed throughout the book, professionals must possess cultural sensitivity and the capacity to take many perspectives when viewing clients' situations and drawing conclusions about them.

Assessing Behavioral Functioning

As you assess behavior, it is important to keep in mind that one person's behavior does not influence another person's behavior in simple linear fashion. Rather, a circular process takes place, in which the behavior of all participants reciprocally affects and shapes the behavior of other participants. For excess-related problems, interventions aim to diminish or eliminate the behaviors, such as temper outbursts, too much talking, arguing, competition, and consumptive excesses (e.g., food, alcohol, sex, gambling, or shopping). For behavioral deficiencies, when assessment reveals the absence of needed skills, interventions aim to help clients acquire the skills and behaviors to function more effectively. For example, a client's behavioral repertoire may not include skills in expressing feelings directly, engaging in social conversation, listening to others, solving problems, managing finances, planning nutritious meals, being a responsive sexual partner, or handling conflict. In assessing behavior, it is vital to specify actual problem behaviors. For example, rather than assess a person's behavior as "abrasive," a social worker might describe the behaviors leading to that conclusion: "the client constantly interrupts his fellow workers, insults them by telling them they are misinformed, and boasts about his own knowledge and achievements." It will be easier for you and the client to focus your change efforts when detrimental behavior is specified and operationalized. You must also determine the antecedents of behaviors; when, where, and how frequently they occur; and the consequences of the behaviors. Further, you should explore thoughts that precede, accompany, and follow the behavior, as well as the nature of and intensity of emotions associated with the behavior.

Biopsychosocial Assessments

Assessments are often referred to as biopsychosocial assessments or evaluations. The term biopsychosocial refers to the notion that when social workers (or other mental health professionals such as psychologists or psychiatrists) assess clients, they evaluate the biological, psychological, and social domains and how these domains both influence and are influenced by disease, disorder, or illness. Typically, biopsychosocial assessments include the following (Ross, 2000): Identifying information (e.g., name, age, referral source, brief overview of the presenting problem) A history of the present circumstances (i.e., the presenting problem, symptoms) The past psychiatric and medical history of the client and the client's family (e.g., injuries, operations, medical conditions, medication, ongoing medical treatment) The client's social history (e.g., overview of client's childhood, family structure, living situation, employment and employment history, educational history, hobbies, daily routine, religious or spiritual preferences, friends, past trauma, substance use) A mental status exam (see Figure 9-2) and DSM-5 diagnosis A formulation (e.g., a statement that summarizes and synthesizes the most important aspects of the case to create a story of the client and his or her past and presenting problems)

Sources of Information for Assessments

Background sheets or other intake forms that clients complete Interviews with clients (e.g., accounts of problems, history, views, thoughts, events, and the like) Direct observation of nonverbal behavior Direct observation of interaction between partners, family members, and group members Collateral information from relatives, friends, physicians, teachers, employers, and other professionals Tests or assessment instruments Personal experiences of the practitioner based on direct interaction with clients It is important to respect clients' feelings and reports, to use empathy to convey understanding, to probe for depth, and to check with the client to ensure that your understanding is accurate. Interviews with child clients may be enhanced or facilitated by the use of instruments (McConaughy & Achenbach, 1994; Schaffer, 1992) and by play, drawing, and other techniques. As with other information sources, verbal reports often need to be augmented because faulty recall, biases, mistrust, and limited self-awareness may result in a skewed or inaccurate picture Direct observation of nonverbal behavior adds information about emotional states and reactions such as anger, hurt, embarrassment, and fear. To use these sources of data, the social worker must be attentive to nonverbal cues, such as tone of voice, tears, clenched fists, vocal tremors, quivering hands, a tightened jaw, pursed lips, variations of expression, and gestures; he or she must link these behaviors to the topic or theme during which they arise. Home visits are a particularly helpful forum for observation. One major benefit of in-home, family-based services is the opportunity to observe the family's lived experiences firsthand rather than rely on secondhand accounts (Strom-Gottfried, 2009). Observing clients' living conditions typically reveals resources and challenges that would otherwise not come to light.

Dual Diagnosis: Addictive and Mental Disorders

Because alcohol and other drug abuse problems can co-occur with a variety of health and mental health problems (known as comorbidity), accurate assessment is important for proper treatment planning. The type and extent of the substance use disorder The type of mental disorders and the related severity and duration The presence of related medical problems Comorbid disability or other social problems resulting from use, such as correctional system involvement, poverty, or homelessness Depending on the combination of factors that affect them, clients may have difficulty seeking out and adhering to treatment programs. Furthermore, an understanding of the reciprocal interaction of these factors may affect the social workers' assessment and resulting intervention.

Assessing Children and Older Adults

Because children and older adults often present for service in relation to systems of which they are already a part (e.g., hospitals, schools, families, assisted living facilities), your assessment may be bound by those systems. This can present a challenge for creating an integrated assessment, as several caregivers, agencies, and professionals may hold pieces of the puzzle while none possesses the mandate or capacity to put all of the pieces together. Similarly, children and older adults typically appear for service because someone else has identified a concern. These referral sources may include parents or guardians, caregivers, teachers, neighbors, or health care providers.

Use and Abuse of Other Substances

Because immediate medical care may be essential in instances of acute drug intoxication, and because abusers often attempt to conceal their use of drugs, it is important that practitioners recognize the signs of abuse of commonly used drugs. In addition to those signs of abuse of specific drugs, common general indications include the following: Changes in attendance at work or school Decrease in normal capabilities (e.g., work performance, efficiency, habits) Poor physical appearance, neglect of dress and personal hygiene Use of sunglasses to conceal dilated or constricted pupils and to compensate for inability to adjust to sunlight Unusual efforts to cover arms to hide needle marks Association with known drug users Involvement in illegal or dangerous activities to obtain drugs In assessing the possibility of drug abuse, it is important to elicit information not only from the suspected user (who may not be a reliable reporter for a number of reasons), but also from people who are familiar with the habits and lifestyle of the individual. Likewise, the social worker should assess problems of alcohol and drug abuse from a systems perspective and identify reciprocal interactions between the individual's use and the (conscious and unconscious) actions of his or her family, social contacts, and others. Assessing elder misuse and abuse of drugs is especially important given that older adults often take multiple medications. Although these medications serve to treat disease, alleviate symptoms, and improve and extend quality of life, multiple medication use is a risk factor for medication adherence problems Having the older client sign a release of information will allow the social worker to consult directly with the prescriber, obtain an accurate list of medications and dosages, and talk with caregivers who are responsible for monitoring and dispensing medications.

Assessing Biophysical Functioning

Biophysical functioning encompasses physical characteristics, health factors, and genetic factors, as well as the use and abuse of drugs and alcohol.

Temporal Context of Problematic Behaviors

Determining when problematic behaviors occur also offers valuable clues about factors at play in problems. The onset of a depressive episode, for example, may coincide with the time of year when a loved one died or when a divorce occurred. These clues can shed light on the patterns of clients' difficulties, indicate areas for further exploration, and lead to helpful interventions.

Client Self-Monitoring

Client self-monitoring is a potent source of information (Wright et al., 2006). It produces a rich and quantifiable body of data and empowers the client by turning him or her into a collaborator in the assessment process. In self-monitoring, clients track symptoms on logs or in journals, write descriptions, and record feelings, behaviors, and thoughts associated with particular times, events, symptoms, or difficulties. A major advantage of self-monitoring is that the process itself requires the monitor to focus attention on patterns. As a result, clients gain insights into their situations and the circumstances surrounding their successes or setbacks. As they discuss their recorded observations, they may "spontaneously operationalize goals and suggest ideas for change" (Kopp, 1989, p. 278). The process of recording also assists in evaluation, because progress can be tracked more precisely by examining data that show a reduction of problematic behaviors or feelings and an increase in desirable characteristics.

Assessing Motivation

Clients who do not believe that they can influence their environments may demonstrate a kind of learned helplessness, a passive resignation that their lives are out of their hands. The precontemplation stage is characterized by a lack of awareness of the need for change. In the contemplation stage, the client recognizes his or her problem and the consequences that result. In the determination stage, the client is committed to action and works with the clinician to develop a plan for change. The action stage implements the changes identified, and the maintenance stage takes steps to avoid problem recurrence. Motivational interviewing (MI) is a specialized, person-centered method for addressing ambivalence and enhancing motivation to move toward healthy change (Moyers & Rollnick, 2002). "Motivational interviewing is a conversation style for strengthening a person's own motivation and commitment to change" (Miller & Rollnick, 2013, p. 12). Motivational interviewing also employs specific attitudes and techniques to reduce and defuse resistance. Motivation is enhanced by developing and highlighting discrepancies, for example, within a client's statements or between the client's current situation and the one he or she aspires to (Wagner & Conners, 2008).

Beliefs

Cognitive theory holds that beliefs are important mediators of both emotions and actions Sometimes, beliefs are not misconceptions but rather are unhelpful, though accurate, conceptions. It is important to identify misconceptions and their sources so as to create a comprehensive assessment. Depending on how central these beliefs are to the client's problems, the goals for work that follow may involve modifying key misconceptions, thereby paving the way to behavioral change.

Self-Concept

Convictions, beliefs, and ideas about the self (that is, one's self-concept) have been generally recognized as crucial determinants of human behavior. Thus, there are strengths in having good self-esteem and in being realistically aware of one's positive attributes, accomplishments, and potential as well as one's limitations and deficiencies. These and similarly self-critical feelings pervade their functioning in diverse negative ways, including the following: Underachieving in life because of imagined deficiencies Passing up opportunities because of fears of failing Avoiding social relationships because of expectations of being rejected Permitting oneself to be taken for granted and exploited by others Excessive drinking or drug use to fortify oneself because of feelings of inadequacy Devaluing or discrediting worthwhile achievements Failing to defend one's rights

Person-in-environment

Degree to which a client experiences goodness of fit with the culture in which he/she is situated should be considered Many people are actually members of multiple cultures, so their functioning must be considered in relationship to both their predominant cultural identity and the majority culture. Individuals from the same ethnic group may vary widely in the degree of their acculturation or their comfort with biculturalism, depending on several factors—for example, the number of generations that have passed since their original emigration, the degree of socialization to the majority culture, and interactions with the majority culture. Several factors influence the goodness of fit between cultures, including the degree of commonality between the two cultures with regard to norms, values, beliefs, and perceptions; the individual's degree of bilingualism; and the level of similarity in physical appearance from the majority culture, such as skin color, facial features, and body type

Using Interviewing Skills to Assess Substance Use

Despite these aversive behaviors, the social worker needs to express empathy and sensitivity to the client's feelings, recognizing that such behaviors are often a subterfuge behind which lie embarrassment, hopelessness, shame, ambivalence, and anger. When asking about alcohol use, be forthright in explaining why you are pursuing that line of questioning. Vague, wordy, or indirect questions tend to support the client's evasions and yield unproductive responses.

ABC model

Detecting patterns and targeting interventions by analyzing the Antecedents of problematic behavior, describing the Behavior in specific terms, and assessing the Consequences or effects of the behavior.

Appropriateness of Affect

Direct observation of clients' affect (emotionality) usually reveals valuable information about their emotional functioning. Some anxiety or mild apprehension is natural in initial sessions as contrasted to intense apprehension and tension at one extreme or complete relaxation or giddiness at the other. Clients who appear completely relaxed and express themselves freely in a circumstance that would normally evoke apprehension or anxiety may reflect a denial of a problem and or a lack of motivation to engage in the problem-solving process. Emotional blunting is what the term suggests: a muffled or apathetic response to material that would typically evoke a stronger response (e.g., happiness, despair, anger). For example, emotionally blunted clients may discuss, in a detached and matter-of-fact manner, traumatic life events or conditions such as the murder of one parent by another, deprivation, or physical and/or sexual abuse. In transcultural work, appropriateness of affect must be considered in light of cultural differences. According to Lum (1996), minority clients may feel uncomfortable with nonminority social workers but mask their emotions as a protective measure, or they may control painful emotions according to culturally prescribed norms. Measures to assure appropriate interpretation of affect include understanding the features of the client's culture, consulting others who are familiar with the culture or the client, and evaluating the client's current presentation with his or her demeanor in the past.

ecomap

Ecomaps identify and organize relevant environmental factors outside of the individual or family context. These tools are useful in clarifying the supports and stresses in the client's environment and revealing patterns such as social isolation, conflicts, or unresponsive social systems. They also show the direction in which resources flow, for example, if the client gives but does not receive support. The client systems (individual, couple, or family) are in the middle circle of the ecomap, and the systems relevant to their lives appear in the surrounding circles. The nature of positive interactions, negative interactions, or needed resources can be depicted by using colored lines to connect the individual or other family members to pertinent systems, with different colors representing positive, negative, or needed connections and interactions with those systems. Different types of lines—single, double, broken, wavy, dotted, or cross-hatched—can also be used to characterize the relationships and the flow of resources among the systems.

Assessing Affective Functioning

Emotions are affected by cognitions and powerfully influence behavior. People who seek help often do so because they have experienced strong emotions or a sense that their emotions are out of control. Some people become emotionally distraught as the result of stress associated with the death of a loved one, divorce, severe disappointment, or another blow to self-esteem. Still others are pulled in different directions by opposing feelings and seek help to resolve their emotional dilemmas.

Areas for Attention in Assessing Person-In-Environment Fit

Environmental Systems Physical environment Adequacy Health Safety Social support systems Missing Affirming Harmful Spirituality and affiliation with a faith community Spirituality Religion Cognitive, affective, and behavioral dimensions of faith

antecedents

Events that precede problematic behavior are referred to as antecedents. Antecedents often give valuable clues about the behavior of one participant that may provoke or offend another participant, thereby triggering a negative reaction, followed by a counter negative reaction, thus setting the reciprocal interaction in motion.

Coping Efforts and Needed Skills

Exploration may reveal that a person has few coping skills but rather relies on rigid patterns that are unhelpful or cause further problems. Some people are most comfortable with an individually focused, analytical-cognitive approach while others may reach out to social networks, family supports, and group problem solving. Cultures typically exert pressure on individuals to follow familiar solutions for a given problem, and deviating from cultural expectations for coping or problem solving may add to the client's distress. It is helpful to know the source of people's coping mechanisms, their efficacy in the past, and the person's comfort with trying new strategies if old ways have failed. Another important insight from exploring coping efforts emerges when you are discussing mechanisms and skills that have worked in the past but no longer do. A person's typical ability to cope may also be affected by changes in functioning: a severely depressed individual, for example, may overestimate his impairment and underestimate his resources and abilities. By exploring the different circumstances, meaning attributions, and emotional reactions, you should be able to identify subtle differences that account for the varied effectiveness of your clients' coping patterns in different contexts.

Maltreatment

For both minors and older adults, mistreatment can be categorized into four areas: neglect, physical abuse, sexual abuse, and emotional or verbal abuse. For older persons, additional categories include self-neglect and financial exploitation Social workers (including student workers) are mandated to report suspicions of child abuse to designated child protective agencies; most jurisdictions also compel workers to report elder abuse, although it may be voluntary in other regions. All professionals should know the steps required in their setting and state for making an abuse report. It is often helpful for social workers to first discuss the case with a supervisor prior to making a report (Webb, 2003). Referring the case to agencies that have the mandate and expertise to investigate maltreatment is the best way to assure that proper legal and biopsychosocial interventions are brought to bear in the case.

Assessing Use and Abuse of Medications, Alcohol, and Drugs

First, it is important to determine which prescribed and over-the-counter medications the client is taking, whether he or she is taking them as instructed, and whether they are having the intended effect. Another reason for evaluating drug use is that even beneficial drugs can produce side effects that affect the functioning of various biopsychosocial systems. Finally, questioning in this area is important because the client may report a variety of conditions, from confusion to sleeplessness, which may necessitate a referral for evaluation and medication. Alcohol is another form of legal drug, but its abuse can severely impair health, disrupt or destroy family life, and create serious community problems. Like alcohol abuse, the misuse of illicit drugs may have detrimental consequences for both the user and his or her family, and drug abuse brings further problems due to its connotation as a banned or illegal substance. For example, users may engage in dangerous or illegal activities (such as prostitution or theft) to support their habits. In addition, variations in the purity of the drugs used or the methods of administration (e.g., sharing needles) may expose users to risks beyond those associated with the drug itself.

Emotional Reactions

First, people often gain relief simply by expressing troubling emotions. Common reactions to problem situations are worry, agitation, resentment, hurt, fear, and feeling overwhelmed, helpless, or hopeless. Being able to express painful emotions in the presence of an understanding and concerned person is a source of great comfort. Releasing pent-up feelings can bring relief from a heavy burden. Second, because emotions strongly influence behavior, the emotional reactions of some people impel them to behave in ways that exacerbate or contribute to their difficulties. In some instances, people create new difficulties as a result of emotionally reactive behavior. Third, intense reactions often become primary problems, overshadowing the antecedent problematic situation. For example, some people experience powerful emotions associated with their life problems.

Other Issues Affecting Client Functioning

For this reason, it is often wise to explore specifically the use of alcohol or other substances, exposure to abuse or violence, the presence of health problems, depression or other mental health problems, and use of prescription medication. When working with adolescent clients, it is useful to ask the caregiver these questions when the child is out of the room to assess the caregiver's knowledge of his or her adolescent's risky behavior. However, it is vital to also ask the adolescent these questions without the caregiver present. Clearly explaining the guidelines of confidentiality is a must to make adolescent clients feel comfortable and to ensure they understand when you would have to alert the caregiver about troubling behavior.

Emphasizing Strengths in Assessments

Give preeminence to the client's understanding of the facts Discover what the client wants Assess personal and environmental strengths on multiple levels Cowger (1994) has developed a two-dimensional matrix framework for assessment that can assist social workers in attending to both needs and strengths. On the vertical axis, potential strengths and resources are depicted at one end and potential deficits, challenges, and obstacles are shown at the other end. The horizontal axis ranges from environmental (family and community) to individual factors. Facing problems and seeking help rather than denying or otherwise avoiding confronting them Taking a risk by sharing problems with the social worker—a stranger Persevering under difficult circumstances Being resourceful and creative in making the most of limited resources Seeking to further knowledge, education, and skills Expressing caring feelings to family members and friends Asserting one's rights rather than submitting to injustice Being responsible in work or financial obligations Seeking to understand the needs and feelings of others Having the capacity for introspection or for examining situations by considering different perspectives Demonstrating the capacity for self-control Functioning effectively in stressful situations Demonstrating the ability to consider alternative courses of actions and the needs of others when solving problems

Role of Knowledge in Assessments

Helps consider the nature of a client's problem Aids in the identification of factors that contribute to, sustain, and aggravate one's problems Helps to know the relevant data to be collected during assessment and formulations Your understanding of the research and theories on human behavior will help focus the assessment on those elements that are involved in a particular client's difficulties. And with increased access to electronic resources and reference guides that summarize the best available evidence in a variety of areas, it has become much easier to find and evaluate existing knowledge

Assessing Cognitive/Perceptual Functioning

How individuals perceive the world is important because people's perceptions of others, themselves, and events largely determine how they feel and respond to life experiences in general and to their problematic situations in particular. Perceptions of identical events or circumstances vary widely according to the complex interaction of belief systems, values, attitude, state of mind, and self-concept, all of which in turn are highly idiosyncratic. Our thought patterns are influenced by intellectual functioning, judgment, reality testing, coherence, cognitive flexibility, values, beliefs, self-concept, and the dynamic interaction among cognitions, emotions, and behaviors that influence social functioning.

Physical Health

Ill health can contribute to depression, sexual difficulties, irritability, low energy, restlessness, anxiety, poor concentration, and a host of other problems. It is therefore important for social workers to routinely consider their clients' state of health during the intake session. Social workers should determine if clients are under medical care and when they last had a medical examination; they should rule out medical sources of difficulties by referring clients for physical evaluations, when appropriate, before attributing problems solely to psychosocial factors. Assessing the health of clients is especially important with groups known to underutilize medical care. Some clients may have a greater than average need for health care because of their specific conditions, whereas others may simply have more difficulty accessing basic care. Assessments should determine whether the individual's access to care is limited by affordability, availability, or acceptability Beyond differences in beliefs, differences arise related to people's comfort in accepting care. A health assessment may also entail gathering information about illnesses in the client's family. A genogram may be helpful in capturing this information. This tool, which is similar to a family tree, graphically depicts relationships within the family, dates of births and deaths, illnesses, and other significant life events. It reveals patterns across generations of which even the client may not have been aware

Assessment

In a primary setting, assessments are independently made In a secondary or host setting, assessments may be a joint effort Focus varies according to the social worker's task, mission, and theoretical framework Occurs from the beginning of contact with the client until the relationship's termination Certain priorities influence all social work settings Gathering, analyzing, and synthesizing information to provide a concise picture of the client and his or her needs and strengths. Typically, formal assessments may be completed in one or two sessions. Assessments also represent opportunities to determine whether the agency and the particular social worker are best suited to address the client's needs. In settings in which social work is not the only or not the primary profession (secondary or host settings), the social worker may be a member of a clinical team (e.g., in mental health, school, medical, and correctional settings), and the process of assessment may be a joint effort of a psychiatrist, social worker, psychologist, nurse, teacher, speech therapist, or members of other disciplines. In such settings, the social worker typically compiles a social history and contributes knowledge related to interpersonal and family dynamics.

Stresses Associated with Life Transitions

In addition to developmental stages that typically correspond to age ranges, individuals and families commonly must adapt to other major transitions that are less age specific. Many of these transitions can be traumatic, and the adaptations required may temporarily overwhelm the coping capacities of individuals or families. Transitions that are involuntary (a home is destroyed by fire) or abrupt (job relocation) and separations (from a person, homeland, or familiar role) are highly stressful for most persons and often temporarily impair social functioning of individuals and/or their loved ones. The person's history, concurrent strengths and resources, and past successful coping can all affect the adaptation to these transitions. The environment plays a crucial role as well. People with strong support networks (e.g., close relationships with family, kin, friends, and neighbors) generally have less difficulty in adapting to traumatic changes than do those who lack strong support systems. Clearly, life transitions can be differentially affected by individual circumstances, culture, socioeconomic status, and other factors. Social workers must be sensitive to these differences and take care not to make assumptions about the importance or unimportance of a transitional event or developmental milestone.

Depression and Suicidal Risk with Children and Adolescents

In the United States, more than 4,000 youths ages 10 to 24 die by suicide each year, accounting for 11.7% of all deaths in this age group (CDC, 2004). In fact, in the United States, suicide is the third leading cause of death for children ages 10 to 14 as well as for young people ages 15 to 34 (CDC, 2015). The symptoms of depression in adolescents are similar to those in adults mentioned above, though irritability and somatic complaints may be more prominent with children and teens Childhood depression does not differ markedly from depression in adolescence; the behaviors manifested and the intensity of feelings are similar once developmental differences are taken into consideration The prevalence of depression is approximately the same in boys and girls in middle childhood, but beginning in adolescence, twice as many females as males experience depression (Hankin et al., 1998; Negriff & Susman, 2011). Also, adolescent girls diagnosed with depression report more feelings of anxiety, inadequacy, and low self-esteem in middle childhood, whereas adolescent boys report more aggressive and antisocial feelings Deterioration in personal habits Decline in school achievement Marked increase in sadness, moodiness, and sudden tearful reactions Loss of appetite Use of drugs or alcohol Talk of death or dying (even in a joking manner) Withdrawal from friends and family Making final arrangements, such as giving away valued possessions Sudden or unexplained departure from past behaviors (from shy to thrill-seeking or from outgoing to sullen and withdrawn) Cautious practice would suggest taking any changes such as those listed above seriously rather than minimizing them or writing them off as "typical teen behavior." Regardless of whether these changes are indicative of depression and suicide risk, changes in behavior and patterns such as these indicate that something is going on that is worthy of adult attention, as well as professional consultation and evaluation. Suicidal risk is highest when the adolescent, in addition to exhibiting the aforementioned symptoms of severe depression, also expresses feelings of hopelessness, has recently experienced a death of a loved one, has severe conflict with parents, has lost a close relationship with a key peer or a love interest, and lacks a support system. When faced with a young client who is considering suicide, social workers should use the same lethality assessment questions discussed earlier for work with adults. In addition, assessment tools geared toward evaluating suicide risk in children and adolescents are available, such as the Suicidal Ideation Questionnaire (SIQ; Reynolds, 1988) and the Suicidal Ideation Questionnaire JR (SIQ-JR; Reynolds, 1987), SAD-PERSONS (Juhnke, 1996), the Diagnostic Predictive Scales (DPS; Lucas et al., 2001), and the Columbia Suicide Screen (CSS; Shaffer et al., 2004).

Physical Environment

Physical environment refers to the stability and adequacy of one's physical surroundings and whether the environment fosters or jeopardizes the client's health and safety. Tools such as the Instrumental Activities of Daily Living Screen (Gallo, 2005) and Direct Assessment of Functioning Scale (DAFS; Lowenstein et al., 1989) can assess functional ability, screen for and address risk factors, and evaluate changes in functioning.

Case Notes

In addition to more comprehensive assessments, direct practitioners record information in client charts based on each meeting or contact with the client and after other significant contacts about the case, such as the receipt of test results or information from a collateral contact. Well-crafted case notes "provide accountability, corroborate the delivery of appropriate services and support clinical decisions" SOAP notes include Subjective observations, Objective data, Assessments, and Plans (Kettenbach, 2003; a variation on this, DAP, combines subjective and objective information under one heading, data). SOAP notes refer back to the most recent assessment, problem list, and treatment plan. The "subjective" section in SOAP notes includes information shared by the client or significant others, such as recent events, emotions, changes in health or well-being, and changes in attitude, functioning, or mental status. The "objective" section in SOAP notes should be factual, precise, and descriptive, based on your observations or written material, and presented in quantifiable terms—factors that "can be seen, heard, smelled, counted or measured" The "assessment" section of SOAP notes is the place to include diagnoses, judgments, and clinical impressions, based on both the subjective and objective data that precede the assessment. "Carol is struggling to maintain her sobriety in light of pressure from her friends and stress at school." The last section, "plan," addresses following appointments, next steps, referrals needed, and actions expected of both the client and the worker Each SOAP entry should begin with the date and end with the social worker's name, credentials, and signature. Entries should be completed as soon as possible after the actual contact to ensure they are accurate and up to date.

Typical Wants Involved in Presenting Problems

In determining clients' unmet needs and wants, it is essential to consider the developmental stage of the individual, couple, or family. For example, the psychological needs of an adolescent—for acceptance by peers, sufficient freedom to develop increasing independence, and development of a stable identity (including a sexual identity)—differ markedly from the typical needs of older persons—for health care, adequate income, social relationships, and meaningful activities. Presenting problems may reveal only what is troubling the person on the surface, and careful exploration and empathic "tuning in" are required to identify unmet needs and wants. The process of translating complaints and problems into needs and wants is often helpful to clients, who may have dwelled on difficulties or blamed others and not thought in terms of their own specific needs and wants. Identifying needs and wants also serves as a prelude to the process of negotiating goals. Expressing goals in terms that address needs and wants enhances clients' motivation to work toward goal attainment, as the payoff for goal-oriented efforts is readily apparent to them. To have less family conflict To feel valued by one's spouse or partner To be self-supporting To achieve greater companionship in marriage or relationship To gain more self-confidence To have more freedom To control one's temper To overcome depression To have more friends To be included in decision making To get discharged from an institution To make a difficult decision To master fear or anxiety To cope with children more effectively

Severity of the Problem

In general, assessment of the severity of the problem helps you to determine patterns when the concern is more or less acute and discover the features associated with those changes in severity. Another reason to focus on severity is to evaluate whether clients have the capacity to continue functioning in the community or whether hospitalization or other strong supportive or protective measures are needed. The intensity of the situation will necessarily influence your appraisal of the client's stress, the frequency of sessions, and the speed at which you need to mobilize support systems.

Emotional Control

Individuals who are experiencing emotional constriction may appear unexpressive and withholding in relationships. Because they are out of touch with their emotions, they do not appear to permit themselves to feel joy, hurt, enthusiasm, vulnerability, and other emotions that might otherwise invest life with zest and meaning. These individuals may be comfortable intellectualizing but retreat from expressing or discussing feelings. They often favorably impress others with their intellectual styles but sometimes have difficulties maintaining close relationships because their emotional detachment thwarts them from fulfilling the needs of others for intimacy and emotional stimulation. A person with emotional excesses, on the other hand, may have "a short fuse," losing control and reacting intensely to even mild provocations. This behavior may involve rages and escalate to interpersonal violence. Excesses can also include other emotions such as irritability, crying, panic, despondency, helplessness, or giddiness. The key to assessing whether the emotional response is excessive is determining whether the response is appropriate and proportionate to the situation. Cultures vary widely in their approved patterns of emotional expression. Nevertheless, emotional health in any culture shares one criterion: It means having control over emotions to the extent that one is not overwhelmed by them. Emotionally healthy persons also enjoy the freedom of experiencing and expressing emotions appropriately.

Cognitive Flexibility

Individuals with cognitive flexibility generally seek to grow, to understand the part they play in their difficulties, and to understand others; these individuals can also ask for assistance without perceiving such a request to be an admission of weakness or failure. Many people, however, are rigid and unyielding in their beliefs, and their inflexibility poses a major obstacle to progress in the helping process. A common pattern of cognitive inflexibility is thinking in absolute terms (e.g., a person is good or evil, a success or a failure, responsible or irresponsible—there are no in-betweens). People who think this way are prone to criticize others who fail to measure up to their stringent standards. Because they can be difficult to live with, many of these individuals appear at social agencies because of relationship problems, workplace conflict, or parent-child disputes. Improvement often requires helping them examine the destructive impact of their rigidity, broaden their perspectives of themselves and others, and "loosen up" in general. Negative cognitive sets also include biases and stereotypes that impede relationship building or cooperation with members of certain groups (e.g., authority figures, ethnic groups, and the opposite sex) or individuals. Severely depressed clients often have another form of "tunnel vision," viewing themselves as helpless or worthless and the future as dismal and hopeless.

Intellectual disability

Intellectual disability is typically diagnosed in infancy or childhood. It is defined as lower-than-average intelligence and "deficits in general mental abilities and impairment in everyday adaptive functioning, in comparison to an individual's age-, gender-, and socioculturally matched peers" (American Psychiatric Association, 2013a, p. 37). General intellectual functioning is appraised using standardized tests, and other measurement instruments may be used to assess the client's adaptive functioning, or ability to meet common life demands. Four levels of intellectual disability are distinguished: mild, moderate, severe, and profound.

Duration of the Problem

Knowing when the problem developed and under what circumstances assists in further evaluating the degree of the problem, unraveling psychosocial factors associated with the problem, determining the source of motivation to seek assistance, and planning appropriate interventions. Often significant changes in life situations, including even seemingly positive ones, may disrupt a person's equilibrium to the extent that he or she cannot adapt to changes. Sometimes referred to as precipitating events, these antecedents often yield valuable clues about critical stresses that might otherwise be overlooked. In some instances, people may not be fully aware of their reasons for initiating the contact, and it may be necessary to explore what events or emotional experiences occurred shortly before their decision to seek help. Determining the duration of problems is also vital in assessing clients' levels of functioning and in planning appropriate interventions. This exploration may reveal that a person's adjustment has been marginal for many years and that the immediate problem is simply an exacerbation of long-term multiple problems. In other instances, the onset of a problem may be acute, and clients may have functioned at an adequate or high level for many years.

Major Depressive Disorder

Major depressive disorder, in which affected individuals experience recurrent episodes of depressed mood, is far more common than bipolar disorder. Major depression differs from the "blues" in that painful emotions (dysphoria) and the absence of pleasure in previously enjoyable activities (anhedonia) are present. The painful emotions are commonly related to anxiety, mental anguish, an extreme sense of guilt (often over what appear to be relatively minor offenses), and restlessness (agitation). To be assigned a diagnosis of major depressive disorder, a person must have evidenced depressed mood and loss of interest or pleasure as well as at least five of the following nine symptoms for at least 2 weeks (American Psychiatric Association, 2013a, pp. 160-161): Depressed mood for most of the day, nearly every day Markedly diminished interest or pleasure in all or almost all activities Significant weight loss or weight gain when not dieting or decrease or increase in appetite Insomnia or hypersomnia Psychomotor agitation or retardation nearly every day Fatigue or loss of energy Feelings of worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate or indecisiveness Recurrent thoughts of death or suicidal ideation or attempts As noted in Chapter 8, a number of scales are available to assess the presence and degree of depression. When assessment reveals that clients are moderately or severely depressed, psychiatric consultation is indicated to determine the need for medication and/or hospitalization. Antidepressant medications have proven to be effective in accelerating recovery from depression and work synergistically with cognitive or interpersonal psychotherapy. In assessing depression, it is important to identify which factors precipitated the depressive episode. An important loss or series of losses may lead to depression associated with bereavement.

Major neurocognitive disorder (NCD)

Major neurocognitive disorder (NCD), formerly referred to as dementia in DSM-IV-TR (American Psychiatric Association, 2013a), is a broader term than dementia, and individuals with a major decline in a single domain can be diagnosed with NCD. Major NCD is characterized by "evidence of significant cognitive decline from previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition)" (American Psychiatric Association, 2013a, p. 602). These deficits must be of sufficient severity to affect one's daily functioning to warrant a diagnosis of NCD

Multidimensionality of Assessment

Multidimensionality of human problems is based on the social nature of human behavior Assessing an individual requires the evaluation of various aspects of that person's functioning Client's needs and the helping agency's purpose and resource influence assessment The multidimensionality of human problems is also a consequence of the fact that human beings are social creatures who depend both on other human beings and on complex social institutions to meet their needs. You must be sure to attend to the client's immediate concern, or presenting problem; identify any legal or safety concerns that may alter your priorities; be attuned to the strengths and resources that appear in the case; and consider all of the sources of information you may draw upon to arrive at your assessment. Finally, you must be alert to your own history, values, biases, and behaviors that might inject subjectivity into your interactions with clients and into the resulting assessment.

Suicidal Risk

Not all individuals with depressive symptoms are suicidal and not all suicidal individuals are depressed. Nevertheless, whenever clients exhibit depressive symptoms or hopelessness, it is critical to evaluate suicidal risk so that precautionary measures can be taken when indicated. With adults, the following factors are associated with high risk of suicide: Feelings of despair and hopelessness Previous suicide attempts Concrete, available, and lethal plans to commit suicide (when, where, and how) Family history of suicide Perseveration about suicide Lack of support systems and other forms of isolation Feelings of worthlessness Belief that others would be better off if the client were dead Advanced age (especially for white males) Substance abuse When a client indicates, directly or indirectly, that he or she may be considering suicide, it is essential that you address those concerns through careful and direct questioning. An affirmative answer to these probes should be followed with a frank and calm discussion of the client's thoughts about suicide. If a client has a well-thought-out plan in mind, the risk of suicide is significantly greater. An understanding of the client's history, especially with regard to the risk factors mentioned and previous suicide attempts, will also help you decide the degree of danger and the level of intervention required. Standardized scales can also be used to evaluate suicidal risk.

Mental Status Exams

One specialized form of assessment is the mental status exam. This exam is intended to capture and describe features of the client's mental state. The terminology developed in conjunction with these instruments has greatly facilitated communication among professions for both clinical and research purposes. Certain features on the mental status exam are associated with particular conditions, such as intoxication, dementia, depression, or psychosis. Appearance Reality Testing Speech Emotions Thought Sensory Perceptions Mental Capacities Attitude toward Interviewer

The Interaction of Multiple Systems in Human Problems

Problems, strengths, and resources encountered in direct social work practice result from interactions among intrapersonal (e.g., internal thoughts, perceptions, or reactions), interpersonal (e.g., communication and interactions between two or more people), and environmental systems (e.g., work, home, school, community). Difficulties are rarely confined to one of these systems. A functional imbalance in one system typically contributes to an imbalance in others. Assets, strengths, and resources also have reciprocal positive effects. A supportive environment may partially compensate for intrapersonal difficulties; similarly, strong interpersonal relationships may provide positive experiences that more than offset an otherwise impoverished environment. Reciprocal effects among the systems can be both positive and negative

Reality Testing

Reality testing is a critical index to a person's mental health. Strong functioning on this dimension means meeting the following criteria: Being properly oriented to time, place, person, and situation Reaching appropriate conclusions about cause-and-effect relationships Perceiving external events and discerning the intentions of others with reasonable accuracy Differentiating one's own thoughts and feelings from those of others Disorientation is usually easily identifiable, but when doubt exists, questions about the date, day of the week, current events that are common knowledge, and recent events in the client's life will usually clarify the matter. Clients who are disoriented typically respond inappropriately, sometimes giving bizarre or unrealistic answers. Some clients who do not have thought disorders may still have poor reality testing, choosing to blame circumstances and events rather than take personal responsibility for their actions. Mild distortions may be associated with stereotypical perceptions (e.g., "All social workers are liberals" or "The only interest men have in women is sexual"). Moderate distortions often involve marked misinterpretations of the motives of others and may severely impair interpersonal relationships (e.g., "My boss told me I was doing a good job and that there is an opportunity to be promoted to a job in another department; he's only saying that to get rid of me" or "My wife says she wants to take an evening class, but I know what she really wants is to meet other men"). In instances of extreme distortions, individuals may have delusions or false beliefs—for example, that others plan to harm them when they do not. Dysfunctions in reality testing of psychotic proportions occur when clients hear voices or other sounds (auditory hallucinations) or see things that are not there (visual hallucinations).

Culturally Competent Assessment

Requires: Knowledge of cultural norms, acculturation, and language differences Ability to differentiate between individual and culturally linked attributes Initiative to seek out needed information Understanding the ways in which cultural differences might affect the assessment process The necessary knowledge about cultural norms is not easy to obtain, however. It requires a baseline understanding of areas of difference and histories and risks of oppression experienced by different groups, self-examination for biases and prejudices, and ongoing conversation with clients and other key informants The task confronting practitioners, therefore, is to differentiate between behavior that is culturally mediated and behavior that is a product of individual personality and life experience. This journey is guided by your fundamental knowledge of different cultures and your interest in your particular clients.

Risk of Aggression

Risk of aggression - Aggression may be directed at the social worker Social worker should assess the client's personal history, social supports, psychological and physical factors, history of violence, and current crisis and situation The most consistently predictive of these factors is past violent behavior or criminal behavior. Additional risk factors include early age of first criminal offense, substance abuse, gender (violence by men generally exceeds that by women), and psychopathy. Andrade (2009) also mentions research into several dynamic risk factors such as impulsiveness, anger, psychosis, interpersonal problems, and antisocial attitudes but notes that no predictive conclusions can yet be drawn. For youth violence, Borum and Verhaagen (2006) list a variety of risk factors, including prior history of violence, early initiation of violence, school achievement problems, abuse, maltreatment and neglect, substance use problems, impulsivity, negative peer relationships, and community crime and violence.

Schizophrenia

Schizophrenia is a psychotic disorder that causes marked impairment in social, educational, and occupational functioning. Its onset typically occurs during adolescence or young adulthood, and development of the disorder may be abrupt or gradual. It is signified by a combination of positive and negative symptoms. In this context, these terms do not refer to whether something is good or bad but rather to the presence or absence of normal functioning. For example, positive symptoms of schizophrenia include delusions (i.e., fixed beliefs that cannot be altered even in the presence of conflicting evidence), hallucinations (i.e., perception experiences of sound, sight, touch, or taste in the absence of external stimuli), disorganized thinking and/or speech, and grossly disorganized behavior (e.g., switching rapidly between topics) or abnormal motor behavior (e.g., catatonia, agitation) (American Psychiatric Association, 2013a). Negative symptoms include flattened affect, restricted speech, and avolition, or limited initiation of goal-directed behavior.

Social Support Systems

Social support systems fill a variety of needs to improve the client's quality of life. To assist you in identifying pertinent social systems These systems typically play key roles both as sources of difficulties and as resources that may be tapped or modified in problem solving. Moving from the center to the periphery in the areas encompassed by the concentric circles are systems that are progressively distant from individuals and their families. Reciprocal interactions thus change across time, and diagrams depicting these interactions should be viewed as snapshots that remain accurate only within limited time frames. The challenge in diagramming a client's social networks is to include the salient boundaries of the client's situation and to specify how the systems interact, fail to interact, or are needed to interact in response to the client's needs. Consequently, the lack of adequate social support systems is considered an area of vulnerability and may represent a source of distress, whereas adequate social support systems reduce the effects of stressful situations and facilitate successful adaptation. Knowing what the social support systems are and what roles they play with clients is essential for assessment and may even be the focus of interventions that tap into the potential of dormant social support systems or mobilize new ones. Attachment, provided by close relationships that give a sense of security and sense of belonging Social integration, provided by memberships in a network of people who share interests and values The opportunity to nurture others, which provides incentive to endure in the face of adversity Physical care when persons are unable to care for themselves because of illness, incapacity, or severe disability Validation of personal worth (which promotes self-esteem), provided by family and colleagues A sense of reliable alliance, provided primarily by kin Guidance, child care, financial aid, and other assistance in coping with difficulties as well as crises Sometimes, a negative support system can be counteracted by the development of prosocial or positive networks. At other times, the system itself may be the focus of intervention as you strive to make the members aware of their roles in the client's problems and progress.

Enactment

Social workers can also employ enactment to observe interactions firsthand rather than rely on verbal reports. With this technique, clients reenact an event during a session. To counteract the temptation to create a favorable impression, the social worker can ask each participant afterward about the extent to which the behaviors demonstrated in the enactment corresponded with the behaviors that occurred in actual situations. Enactment can also be used in contrived situations to see how people interact in situations that involve decision making, planning, role negotiation, child discipline, or similar activities. Another form of enactment involves the use of symbolic interactions—for example, through the use of dolls, games, or other forms of expressive or play therapy

Coherence

Social workers occasionally encounter individuals who demonstrate major thought disorders, which are characterized by rambling and incoherent speech. For example, successive thoughts may be highly fragmented and disconnected from one another, a phenomenon referred to as looseness of association or derailment in the thought processes. Another form of derailment is flight of ideas, in which the client's response seems to "take off" based on a particular word or thought, unrelated to logical progression or the original point of the communication. These difficulties in coherence may be indicative of head injury, mania, or thought disorders such as schizophrenia. Incoherence, of course, may also be produced by acute drug intoxication, so practitioners should be careful to rule out this possibility.

Physical Characteristics and Presentation

Social workers should take care to observe distinguishing physical characteristics that may affect social functioning. Particular attributes that merit attention include body build, dental health, posture, facial features, gait, and any physical anomalies that may create positive or negative perceptions about the client, affect his or her self-image, or pose a social liability. The standard for assessing appearance is generally whether the dress is appropriate for the setting. While attending to these questions, social workers should take care in the conclusions they reach. The determination of "appropriateness" is greatly influenced by the interviewer's cultural background and values Other important factors associated with appearance include hand tremors, facial tics, rigid or constantly shifting posture, and tense muscles of the face, hands, or arms. Sometimes these characteristics reflect the presence of an illness, physical problem, or overmedication. They may also indicate a high degree of tension or anxiety, warranting exploration by the social worker.

Judgment

Some people who have adequate or even keen intellect may nevertheless encounter severe difficulties in life because they suffer deficiencies in judgment. Examples of problems in judgment include consistently living beyond one's means, becoming involved in "get rich quick" schemes without carefully exploring the possible ramifications, quitting jobs impulsively, leaving small children unattended, moving in with a partner without adequate knowledge of that person, failing to safeguard or maintain personal property, and squandering resources. Deficiencies in judgment generally come to light when you explore problems and the patterns surrounding them. Because individuals with poor judgment often fail to learn from their past mistakes, they appear to be driven by intense impulses that overpower consideration of the consequences of their actions. Impulse-driven clients may lash out at authority figures, write bad checks, misuse credit cards, or take other actions that provide immediate gratification but ultimately lead to adverse consequences such as the loss of a job or an arrest.

Spirituality and Affiliation with a Faith Community

Spirituality: Totality of the human experience Impossible to break it into individual components Acts as a link to a faith community Source of assistance and social support Religion: Socially sanctioned institution Based on spiritual practices and beliefs Spiritual assessment: Helps the social worker understand the client's belief system and resources Spirituality involves three relevant areas: cognitive (the meaning given to past, current, and personal events), affective (one's inner life and sense of connectedness to a larger reality), and behavioral (the way in which beliefs are affirmed, such as through group worship or individual prayer) Particularly when clients have experienced disaster or unimaginable traumas, the exploration of suffering, good and evil, shame and guilt, and forgiveness can be a central part of the change process. Social workers must be aware of their own spiritual journeys and understand the appropriate handling of spiritual content, depending on the setting, focus, and client population involved (Ellor, Netting, & Thibault, 1999). Social workers are also advised to involve clergy or leaders of other faiths to work jointly in addressing the personal and spiritual crises faced by clients

The Diagnostic and Statistical Manual (DSM-5)

The Diagnostic and Statistical Manual, Fifth Edition (DSM-5) is an important tool for understanding and formulating mental and emotional disorders (American Psychiatric Association, 2013b). It is linked to The International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), a commonly used system to codify health and mental health disorders, symptoms, social circumstances, and causes of injury or illnesses Diagnostic systems such as the DSM-5 have come under fire for a number of reasons, including excessive focus on individual pathologies rather than strengths and societal and environmental factors. Criticisms notwithstanding, the DSM-5 is widely used by professionals and consumers; the diagnoses and assessments are often required for insurance reimbursement and other forms of payment for services, and many social workers work with individuals who have received mental health diagnoses, regardless of whether the social worker or someone else actually gave the diagnosis. For each disorder, the manual uses a standardized format to present relevant information. The sections contain: Diagnostic criteria Subtypes/specifiers Recording procedures Diagnostic features Associated features supporting diagnosis Prevalence Development and course Risk and prognostic factors Specific culture, gender, and age features Functional consequences of the specific diagnosis Differential diagnosis Comorbidity

Written Assessments

The assessment phase is a critical part of the helping process. It provides the foundation on which goals and interventions are based. It is also an ongoing part of the helping process, as appraisals are reconsidered and revised based on new information and understanding. Remember your purpose and audience. These will help you decide what should be included and maintain that focus. Know the standards and expectations that apply in your work setting, and understand the needs of those who will review your document. Be precise, accurate, and legible. It is important that any data you include be accurate. Erroneous information can take on a life of its own if what you write is taken as fact by others. If you are unclear on a point, or if you have gathered conflicting information, note that in your report. Document your sources of information and specify the basis for any conclusions and the criteria on which a decision was based Avoid the use of labels, subjective terminology, and jargon. In assessing the social functioning of individuals, social workers often make global judgments Administered: At the time of intake After a period of interviews and evaluations At the time of transfer or termination May be brief, detailed, or comprehensive depending on its purpose

Bipolar Disorder

The dominant feature of bipolar disorder is the presence of manic episodes (mania) with intervening periods of depression. Among the symptoms of mania are "A distinct period of abnormally and persistently elevated, expansive or irritable mood" (American Psychiatric Association, 2013a, p. 124) and at least three of the following: Inflated self-esteem or grandiosity Decreased need for sleep More talkative than usual or pressure to keep talking Flight of ideas or subjective experience that thoughts are racing Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., purposeless non-goal-directed activity) Excessive involvement in pleasurable activities with a high potential for painful consequences, such as unrestrained buying sprees, sexual indiscretions, or unwise business investments Full-blown manic episodes require that symptoms be sufficiently severe to cause marked impairment in job performance or relationships, or to necessitate hospitalization to protect patients or others from harm. If exploration seems to indicate a client has the disorder, immediate psychiatric consultation is needed for two reasons: (1)to determine whether hospitalization is needed (2)to determine the need for medication Bipolar disorder is biogenetic, and various compounds containing lithium carbonate may produce remarkable results in stabilizing and maintaining affected individuals. Close medical supervision is required, however, because commonly used medications for this disorder have a relatively narrow margin of safety.

Frequency of Problematic Behaviors

The frequency of problematic behavior provides an index to both the pervasiveness of a problem and its effects on the participants. Assessing the frequency of problematic behaviors also provides a baseline against which to measure behaviors targeted for change. Making subsequent comparisons of the frequency of the targeted behaviors enables you to evaluate the efficacy of your interventions.

Meanings that Clients Ascribe to Problems

The meanings people place on events (meaning attributions) are as important as the events themselves because they influence the way people respond to their difficulties. Exploratory questions such as the following may help elicit the client's meaning attributions: "What do you make of his behavior?" "What were the reasons for your parents' disciplining you?" "What conclusions have you drawn about why your landlord evicted you?" "What are your views as to why you didn't get a promotion?" Discovering meaning attributions is also vital because these beliefs about cause and effect may represent powerful barriers to change. Fortunately, many attributions are not permanent: people are capable of cognitive flexibility and are open—even eager—to examine their role in problematic situations and want to modify their behavior. When obstacles such as those listed are encountered, however, it is vital to explore and resolve them before attempting to negotiate change-oriented goals or to implement interventions.

The Interaction of Other People or Systems

The presenting problem and the exploration that follows usually identify key individuals, groups, or organizations that are part of the client's difficulties. It is important to note that in order to discuss the client with any system external to the therapy office, a release of information must be signed by the client. If the client is a minor, the child's caregiver must sign a release of information. People commonly interact with the following systems: The family and extended family or kinship network The social network (friends, neighbors, coworkers, associates, club members, and cultural groups) Public institutions (educational, recreational, law enforcement and protection, mental health, social service, health care, employment, economic security, legal and judicial, and various governmental agencies) Personal service providers (doctor, dentist, barber or hairdresser, bartender, auto mechanic, landlord, banker) The faith community (religious leaders, lay ministers, fellow worshipers) Understanding how the interaction of these elements plays out in your client's particular situation requires detailed information about the behavior of all participants, including what they say and do before, during, and after problematic events.

problem for work

The problem that the social worker and client ultimately focus on in therapy. The problem(s) that bring the client and the social worker together initially may not, in fact, end up being the focus of goals and interventions later in the relationship. As the helping process progresses, the development of greater information, insights, and trust may reveal factors that change the focus of work and goals for service. This does not mean, however, that you should disregard the problems that brought people to you in the first place.

Role of Theory in Assessments

Theoretical orientations play a large role in the structure of an assessment and the conclusions that are drawn Can selectively or effectively shape assessments Caveats about using knowledge and theories May oversimplify a problem and objectify the client Following a single framework may inhibit a practitioner from pursuing new knowledge and interventions Requires training For example, cognitive theories suggest that thoughts mediate emotions and actions (Beck 1995; Wright, Basco, & Thase, 2006). Therefore, assessments derived from these theories focus on the nature of the client's thoughts and schemas (cognitive patterns), causal attributions, the basis for the client's beliefs, and antecedent thoughts in problematic situations (Walsh, 2006). Behavioral theories suggest that actions and emotions are created, maintained, "and extinguished through principles of learning" (Walsh, 2006, p. 107). As such, the assessment focuses on the conditions surrounding troubling behaviors, the conditions that reinforce the behavior, and the consequences and secondary gains that might result.

Questions to Answer in Problem Assessment

Therefore, the following questions are not intended to be asked in the assessment, but instead are meant to be used as a guide or checklist to ensure that you have not overlooked a significant factor in your assessment of the problem. What are the clients' concerns and problem(s) as they and other concerned parties perceive them? Are any current or impending legal mandates relevant to the situation? Do any serious health or safety concerns need immediate attention? What are specific indications of the problem? How is it manifesting itself? What are the consequences? Who else (persons or systems) is involved in the problem(s)? What unmet needs and/or wants are involved? How do developmental stages or life transitions affect the problem(s)? How do ethnocultural, societal, and social class factors bear on the problem(s)? How severe is the problem, and how does it affect the participants? What meanings do clients ascribe to the problem(s)? Where, when, and how often do the problematic behaviors occur? How long has the problem gone on? Why is the client seeking help now? Have other risk factors (e.g., alcohol or substance abuse, physical or sexual abuse) affected the functioning of the client or family members? What are the client's emotional reactions to the problem(s)? How has the client attempted to cope with the problem(s), and what are the required skills to resolve the problem? What are the client's skills, strengths, and resources? What support systems exist or need to be created for the client? What external resources does the client need?

Assessing Environmental Systems

This assessment focuses on the transactions between the two, or the goodness of fit between the person and his or her environment. Problem-solving efforts may be directed toward assisting people to adapt to their environments (e.g., training them in interpersonal skills), altering environments to more adequately meet the needs of clients (e.g., enhancing both the attractiveness of a nursing home and the quality of its activities), or a combination of the two (e.g., enhancing the interpersonal skills of a withdrawn, chronically ill person as well as moving that person to a more stimulating environment). In assessing environments, you should give the highest priority to those aspects that are most salient to the client's individual situation. The adequacy of the environment depends on the client's life stage, physical and mental health, interests, aspirations, and other resources. You should tailor your assessments of clients' environments to their varied life situations, weighing the individual's unique needs against the availability of essential resources and opportunities within their environments. In addition to noting the limitations or problems posed by inadequate physical or social environments, it is important to acknowledge the strengths at play in the person's life—the importance of a stable, accessible, affordable residence or the value of a support system that mobilizes in times of trouble.

reciprocal interaction

Two-way interaction between a person and the external world: the person acts upon and responds to the external world, and the quality of those actions affects the external world's reactions (and vice versa).

Assessing needs and wants

Typical wants - To have more freedom, to control one's temper, or to overcome depression Determining unmet needs, then, is the first step in identifying which resources must be tapped or developed. If resources are available but clients have been unable to avail themselves of those resources, it is important to determine the barriers to utilization. Reasons for the unresponsiveness typically involve reciprocal unsatisfactory transactions between the participants. The task in such instances is to assess the nature of the negative transactions and to attempt to modify them to the benefit of the participants so that resources can be unblocked to address the client's wishes.

developmental assessment

Understanding a child's history and current situation by means of information provided by a parent or other caregiver about the circumstances of the child's delivery, birth, and infancy; achievement of developmental milestones; family description and atmosphere; interests; significant life transitions; presenting problem, including its history; and school history.

Resources Needed

When people request services, you must determine (1)whether the services requested match the function of the agency and (2)whether the staff possesses the skills required to provide high-quality service. Fortunately, many communities have online resource information centers that can help clients and professionals locate needed services. Remember that irrespective of the presenting problem, people can benefit from help in a variety of areas—from financial assistance, transportation, and health care to child or elder care, recreation, and job training.

Intellectual Functioning

Your assessment of intellectual functioning will allow you to adjust your verbal expressions to a level that the client can readily comprehend, and it will help you in assessing strengths and difficulties, negotiating goals, and planning tasks commensurate with the client's capacities. In making this assessment, you may want to consider the client's ability to grasp abstract ideas, to express himself or herself, and to analyze or think logically. Additional criteria include level of educational achievement and vocabulary employed, although these factors must be considered in relation to the person's previous educational opportunities, primary language, or learning difficulties because normal or high intellectual capacity may be masked by these and other factors. When communicating with clients who have marked intellectual limitations, use simple and easily understood words and avoid abstract explanations. To avoid embarrassment, many people will pretend that they understand when, in fact, they do not. Therefore, you should make keen observations and actively seek feedback to determine whether the client has grasped your intended meaning. When a client's presentation is inconsistent with his or her known intellectual achievement, it may reveal an area for further investigation.

Identifying the Problem, Its Expressions, and Other Critical Concerns

Your initial contacts with clients will concentrate on identifying the presenting problem, uncovering the sources of this problem, and engaging the client in planning appropriate remedial measures. People typically seek help because they have exhausted their coping efforts and/or lack resources required for satisfactory living. When clients are referred or coerced into seeking services, empathy, motivational interviewing skills, and negotiation will be essential in finding common ground on the needs that the social worker might help address. Culturally derived attitudes toward seeking help may also affect a person's capacity for and comfort with problem exploration. For example, conceptions about fate, destiny, self-reliance, and other beliefs affect the meaning given to problems and the ways that people are expected to respond to them. Your capacity to start where the client is will be crucial to your success in trying to unpack their reasons for seeking your help. The description typically involves a deficiency of something needed (e.g., health care, adequate income or housing, companionship, harmonious family relationships, self-esteem) or an excess of something that is not desired (e.g., fear, guilt, temper outbursts, marital or parent-child conflict, or addiction). In either event, the presenting problem often results in feelings of disequilibrium, tension, and apprehension. The emotions themselves are often a prominent part of the problem configuration, which is one reason why empathic communication is such a vital skill during the interview process. When working with children and adolescents, it is helpful to first meet with the caregiver and child together to discuss your role, confidentiality, and the general presenting problem. It is then important to meet alone with the caregiver to obtain a more in-depth understanding of the presenting problem; caregivers might not feel comfortable talking openly in front of the child, and it is therefore necessary to meet with caregivers alone. Finally, the social worker should then meet alone with the child/adolescent to assess his or her view of the presenting problem. Throughout work with minors, it is vital that the social worker continually check in with caregivers about the client's behavior and any changes at home; this allows for an accurate and comprehensive ongoing assessment of the child/adolescent.

Values

you should seek to identify your clients' values, assess the role those values play in their difficulties, and consider ways in which clients' values can be deployed to create incentives for change. Your ethical responsibility to respect the client's right to maintain his or her values and to make choices consistent with them requires you to become aware of those values. Understanding the individual within his or her culture is also critical, however, because people adopt values on a continuum, with considerable diversity occurring among people within any given race, faith, culture, or community Being aware of values also helps you in using those values to create incentives for changing dysfunctional behavior—for example, when clients express strong values yet behave in direct opposition to those values. Cognitive dissonance may result when people discover inconsistencies between their values and behaviors. Examining these contradictions can help reveal whether this tension is problematic or self-defeating.