Intervention Planning (6)
The DSM-5 incorporates a greater cultural sensitivity throughout the manual rather than a simple list of culture-bound syndromes.
Different cultures and communities exhibit or explain symptoms in various ways. Because of this, it is important for social workers to be aware of relevant contextual information stemming from clients' cultures, races, ethnicities, religious affiliations, and/or geographical origins so social workers can more accurately diagnose client problems, as well as more effectively treat them. In the DSM-5, specific diagnostic criteria were changed to better apply across diverse cultures. The Cultural Formulation Interview Guide is included to help social workers assess cultural factors influencing clients' perspectives of their symptoms and treatment options. It includes questions about clients' backgrounds in terms of their culture, race, ethnicity, religion, or geographical origin. The Interview provides an opportunity for clients to define their distress in their own words and then relate this distress to how others, who may not share their culture, see their problems.
THE CRITERIA USED IN THE SELECTION OF INTERVENTION/TREATMENT MODALITIES (E.G., CLIENT/CLIENT SYSTEM ABILITIES, CULTURE, LIFE STAGE)
A social worker develops an intervention plan by consulting the relevant practice research and then flexibly implementing an approach to fit a client's needs and circumstances. The intervention plan is driven by the data collected as part of assessment. Assessment is informed by current human behavior and development research that provides key information about how clients behave and research about risk and resilience factors that affect human functioning. These theories inform social workers about what skills, techniques, and strategies must be used by social workers, clients, and others for the purpose of improving well-being. These techniques and strategies are outlined in an intervention plan. An intervention plan should be reviewed during the intervention, at termination, and, if possible, following the termination of services to make adjustments, ensure progress, and determine the sustainability of change after treatment.
DISCHARGE, AFTERCARE, AND FOLLOW-UP PLANNING
Discharge may occur for a variety of reasons; for example, a client may have met his or her goals or no longer needs the services; decides not to continue to receive them from a particular social worker or in general; and/or requires a different level of care. In addition, when a social worker leaves an agency, a client may continue to receive the same service from this agency, but from another worker. Although this is not a "discharge" from services, there is careful planning and standards that need to be followed to ensure continuity of care and prevent gaps in service. The 2008 NASW Code of Ethics provides some guidance with regard to discharge or terminations, as well as aftercare and follow-up services. Social workers should terminate services to clients and professional relationships with them when such services and relationships are no longer required or no longer serve client needs or interests (NASW Code of Ethics, 2008—1.16Termination of Services). Social workers should take reasonable steps to avoid abandoning clients who are still in need of services. Social workers should withdraw services precipitously only under unusual circumstances, giving careful consideration to all factors in the situation and taking care to minimize possible adverse effects. Social workers should assist in making appropriate arrangements for continuation of services when necessary (NASW Code of Ethics, 2008—1.16 Termination of Services). Social workers in fee-for-service settings may terminate services to clients who are not paying an overdue balance if the financial contractual arrangements have been made clear to a client, if a client does not pose an imminent danger to self or others, and if the clinical and other consequences of the current nonpayment have been addressed and discussed with a client (NASW Code of Ethics, 2008—1.16 Termination of Services). Social workers should not terminate services to pursue a social, financial, or sexual relationship with a client (NASW Code of Ethics, 2008—1.16 Termination of Services). Social workers who anticipate the termination or interruption of services to clients should notify clients promptly and seek the transfer, referral, or continuation of services in relation to client needs and preferences (NASW Code of Ethics, 2008—1.16 Termination of Services). Social workers who are leaving an employment setting should inform clients of appropriate options for the continuation of services and of the benefits and risks of the options (NASW Code of Ethics, 2008—1.16 Termination of Services). It is unethical to continue to treat clients when services are no longer needed or in their best interests. Another standard that is relevant to termination of services (NASW Code of Ethics, 2008—1.15 Interruption of Services) mandates that social workers should make reasonable efforts to ensure continuity of services in the event that services are interrupted by factors such as unavailability, relocation, illness, disability, or death. Social workers must involve clients and their families (when appropriate) in making their own decisions about follow-up services or aftercare. Involvement must include, at a minimum, discussion of client and family preferences (when appropriate). Social workers are often responsible for coordination of clients' follow-up services, when needed. A return of clients to services quickly may suggest either that they did not receive needed follow-up services or that these services were inadequate. Termination may have occurred prematurely. Clients who are at high risk for developing problems after services have ended should receive regular assessments after discharge to determine whether services are needed or discharge plans are being implemented as planned.
A culturally informed intervention plan must be based on a therapeutic relationship in which a client feels safe to explore his or her problems within his or her cultural context. Intervention will be most effective when it is consistent with a consumer's culture. A social worker should consider the following given their cultural appropriateness:
Individual versus group treatment Alternative treatment approaches (yoga, aromatherapy, music, writing) Medication (western, traditional, and/or alternative) Family involvement Location/duration of intervention
CULTURAL CONSIDERATIONS IN THE CREATION OF AN INTERVENTION PLAN
It is essential that a social worker address cultural considerations into treatment or intervention planning. These considerations should include the identification of cross-cultural barriers, which may hinder a client's engagement and/or progress in treatment. Social workers also have an ethical mandate to take information learned when working with individual clients and adapt agency resources to meet others who may also have similar cultural considerations and/or language assistance needs. A social worker should understand and validate each client's cultural norms, beliefs, and values. Areas in treatment or intervention planning that can be greatly influenced by cultural factors include identification of client strengths and problems, goals and objectives, and modalities of treatment.
THE INDICATORS OF MOTIVATION, RESISTANCE, AND READINESS TO CHANGE These indicators include:
Limiting the amount of information communicated to a social worker Silence/minimal talking during sessions Engaging in small talk with a social worker about irrelevant topics Engaging in intellectual talk by using technical terms/abstract concepts or asking questions of a social worker that are not related to client issues or problems Being preoccupied with past events, instead of current issues Discounting, censoring, or editing thoughts when asked about them by a social worker False promising Flattering a social worker in an attempt to "soften" him or her so the client will not be pushed to act Not keeping appointments Payment delays or refusals It is essential to determine the extent to which this resistance or these inabilities are caused by a client, a social worker, and/or the conditions present. A client may be resistant due to feelings of guilt or shame and may not be ready to recognize or address the feelings and behaviors being brought up by a social worker. Clients may be frightened of change and may be getting some benefit from the problems that they are experiencing. Social workers may experience a lack of readiness, as they have not developed sufficient rapport with clients. There also may not be clear expectations by clients of their role versus those of social workers. Social workers need to use interventions that are appropriate for clients. Sometimes, a lack of readiness or ability is a result of external factors, such as changes in clients' living situations, physical health problems, lack of social support, and/or financial problems. Whatever the causes, a social worker must address these barriers as clients will not make changes until they are ready and able.
PSYCHOTHERAPIES
Psychotherapy aims to treat clients with mental disorders or problems by helping them understand their illness or situation. Social workers use verbal techniques to teach clients strategies to deal with stress, unhealthy thoughts, and dysfunctional behaviors. Psychotherapy helps clients manage their symptoms better and function optimally in everyday life. Sometimes, psychotherapy alone may be the best treatment for a client, depending on the illness and its severity. Other times, psychotherapy is combined with the use of medication or a psychopharmacological approach. There are many kinds of psychotherapy, so social workers must determine which is best to meet a client's need. A social worker should not use a "one size fits all approach" or a particular type of psychotherapy because it is more familiar or convenient. Some psychotherapies have been scientifically tested more than others for particular disorders. For example, cognitive behavioral therapy (CBT), a blend of cognitive and behavioral therapy, is used for depression, anxiety, and other disorders. Dialectical behavior therapy (DBT), a form of CBT developed by Marsha Linehan, was developed to treat people with suicidal thoughts and actions. It is now also used to treat people with Borderline Personality Disorder. A social worker assures a client that his or her feelings are valid and understandable, but coaches him or her to understand that they are unhealthy or disruptive and a balance must be achieved. A client understands that it is his or her personal responsibility to change the situation. Some psychotherapies are effective with children and adolescents and can also be used with families.
THE IMPACT OF IMMIGRATION, REFUGEE, OR UNDOCUMENTED STATUS ON SERVICE DELIVERY
Social workers may have a general concept of immigration requirements, but this area of law is both complex and volatile. Laws and policies affecting the status of immigrants have evolved over time in response to various social, political, and economic pressures. Most recently, immigration policy has had an exclusionary focus that has turned toward conflating criminality and undocumented immigration status. Although immigration laws are within the exclusive purview of the federal government, some states have attempted to address concerns by passing their own measures. This situation creates legal questions and ethical dilemmas for social workers who are employed in programs or areas serving immigrants. Professional social work standards support immigration and refugee policies that uphold and support equity and human rights, while protecting national security. The social work profession recognizes the challenge of competing claims; however, immigration policies must promote social justice and avoid racism and discrimination or profiling on the basis of race, religion, country of origin, gender, or other grounds. The impact of refugee and immigration policies on families and children have to be closely monitored. Policies that encourage family reunification and ensure that children do not grow up unduly disadvantaged by the immigration status of their parents must be enacted and upheld. Given the great diversity and myriad needs of the growing immigrant population, it is essential that social workers understand the legal and political, as well as psychological and social, issues surrounding immigration. Undocumented immigrants represent a large and vulnerable population in the United States. When conducting individual practice with undocumented immigrants, social workers must be aware of the laws that impact service provision and the unique psychosocial stressors that are experienced by this population. Numerous immigrant households are comprised of mixed-status families in which family members hold different legal statuses. Each status carries different benefit entitlements, services, and legal rights.
THE INDICATORS OF MOTIVATION, RESISTANCE, AND READINESS TO CHANGE
Social workers should not assume that clients are ready or have the skills needed to make changes in their lives. Clients may be oppositional, reactionary, noncompliant, and/or unmotivated. These attitudes or behaviors are often referred to as resistance. There are indicators that a social worker should use as evidence that a client may be resistant or not ready/able to fully participate in services.
For example, a client's culture can provide him or her with strengths that can be brought to the intervention process. These strengths can include, but are not limited to:
Supportive family and community relations Community and cultural events and activities Faith and spiritual or religious beliefs Multilingual capabilities Healing practices and beliefs Participation in rituals (religious, cultural, familial, spiritual, community) Dreams and aspirations
THE COMPONENTS OF INTERVENTION, TREATMENT, AND SERVICE PLANS
The goals of intervention and means used to achieve these goals are incorporated in a contractual agreement between a client and a social worker. The contract (also called an intervention or service plan) may be informal or written. The contract specifies problem(s) to be worked on; the goals to reduce the problem(s); client and social worker roles in the process; the interventions or techniques to be employed; the means of monitoring progress; stipulations for renegotiating the contract; and the time, place, fee, and frequency of meetings.
METHODS TO INVOLVE CLIENTS/CLIENT SYSTEMS IN INTERVENTION PLANNING
The participation of clients in the process of identifying what is important to them now and in the future, and acting upon these priorities, is paramount. Clients' participation in the process will reduce resistance, increase motivation to change, and ensure sustainability of progress made. In order to involve clients, social workers must continually listen to, learn about, and facilitate opportunities with clients who they are serving. Client involvement should not just occur during intervention planning, but instead during the entire problem-solving process. In engagement, a social worker should be actively involved with a client in determining why treatment was sought; what has precipitated the desire to change now; the parameters of the helping relationship, including defining the roles of a social worker and client; and the expectations for treatment (what will occur and when it will happen). Client involvement is essential in determining what is important to a client now and in the future. In assessment, a client is the source of providing essential information upon which to define the problem and solutions, as well as identifying collateral contacts from which gaps in data can be collected. In planning, a client and social worker must develop a common understanding of a client's preferred lifestyle. Goals are developed from this common understanding in order to provide a direction to help a client move toward this lifestyle. Specific action plans are developed and agreed upon in order to specify who will do what, what and how resources will be needed and used, and timelines for implementation and review. In intervention, a client must be actively involved in mobilizing his or her support network to realize continued progress and sustainable change. A client must bring to the attention of a social worker issues that arise which may threaten goal attainment. Progress, based upon client reports, must be tracked and plans/timelines adjusted accordingly. In evaluation, subjective reports of a client, in conjunction with objective indicators of progress, should be used to determine when goals or objectives have been met and whether new goals or objectives should be set. Client self-monitoring is a good way to involve a client so he or she can see and track progress himself or herself. In termination, a client should reflect on what has been achieved and anticipate what supports are in place if problems arise again. Although this is the last step in the problem-solving process, it still requires active involvement by both a social worker and client.