SOCW 601 Ch 13

Crisis Step 1: Define the Problem

As a social worker in a crisis situation, you must determine the unique meaning of the crisis and the severity of the situation to the client. Having clients talk about the meaning and significance of the crisis provides you with essential information about how clients define their problem and can be a cathartic process for clients as well.

Cognitive Distortions

Beck (1967), in separating thinking from cognition, identified automatic thoughts and cognitive distortions as factors for which cognitive restructuring is indicated. The processing of information for most of us is automatic, as our minds attempt to navigate and narrate our interactions and environment. Problems occur when thoughts are consistently distorted because of a client's ingrained beliefs and faulty reasoning. All-or-nothing thinking involves seeing things as all-or-nothing scenarios, and in most instances seeing the glass as half empty. "I wanted to do well on the exam, and now that I didn't, I will never get into graduate school." "If I don't smoke stuff [dope] with my friends they won't ever hang with me." "Unless we know the background of these clients, we won't be able to help them." In these statements, you may see the similarities between this thinking and catastrophizing and overgeneralizing. Blaming occurs when a client perceives others as the source of negative feelings or emotions and can therefore avoid taking responsibility. "I feel so stressed out because a driver cut in front of me on the way home." "Her snippy attitude about going shopping with me put me in a bad mood." Catastrophizing is the belief that if a particular event or situation occurs, the results would be unbearable, effectively influencing your sense of self-worth. "I need to study all the time, because if I don't get the highest grade possible on the exam, I will lose my financial aid and return home a failure." Discounting positives is the tendency to disqualify or minimize the good things that you or others do and instead treat a positive as a negative. "My friends said that I looked great in an outfit from the secondhand store, but really, they were just being nice and feel sorry for me because I don't have money." Similarly, say you are reviewing evaluations after making a presentation and you focus on the following, "Of the 40 people at the presentation, two said that I was boring," instead of focusing on the 38 positive responses. Emotional reasoning guides your interpretation based on how you feel rather than on reality. Interpretations and beliefs are facts bolstered by negative emotions, which are assumed to reflect reality. "If I feel stuck [stupid] in social situations, then that's really who I am." Inability to disconfirm functions very much like a barricade in that you are unable to accept any information that is inconsistent with your beliefs or negative thoughts. For example, if a relative with whom you frequently argue is unwilling to keep your kids because of an appointment, your mental response may be "That's not the real reason; the relative never liked me or my kids," in effect discounting the numerous other occasions on which the relative did care for your children. Judgment focus leads to a perception of self and others or an assessment of events as good or bad, excellent or awful, rather than describing, accepting, or attempting to understand what is happening or considering alternatives. "I know that when I go to a party people won't talk to me." In some instances, you may establish arbitrary standards by which you measure yourself, only to find that you are unable to perform at this level. "I won't do well in the class no matter how hard I try" is an example of a self-defeating judgment statement, as is "Everyone in the class gets good grades, but not me." A judgment in contrast to one that is self-defeating is an assumption that a presentation was good because "a lot of people came." Jumping to conclusions assumes the negative when there may be limited supporting evidence. Assumptions may also take the form of mind reading and fortune telling based on a prediction of a negative outcome. "If I don't watch the children, she will be upset with me, a risk that I am unwilling to take." Mind reading assumes that you know what people will think, do, or respond. "There's no point in my asking my daughter to visit me more often. She will just see it as my attempt to get attention or embarrass her. If I bring up the topic, she and I will end up in an argument; besides, she is busy with her own family." Negative (mental) filtering results in mentally singling out bad events and ignoring the positives. "As I was standing in the hallway at work, this kid bumped into me, you know, they are all like that. I was so angry. Then he turned around and apologized, but I pretended not to hear him. He should have apologized sooner." In some instances, negative filters are linked to thoughts that are overgeneralized to people or events. Overgeneralizations, or globalization, involve perceiving isolated events and using them to reach broad conclusions. "Today, when I raised my hand in class, the instructor called on another student. He never calls on me." Labeling is another form of overgeneralizing in which a negative label is attached to self or others based on a single incident. "I am not a very good student, so the instructor does not value my opinion." "He is a lousy instructor, otherwise he would help everyone [me]." Personalizing assumes that you had a role in or that you are responsible for a negative situation, assuming that the results were in your control. "We were close friends and then she was called to active duty and we lost contact. I wonder if I did something that caused her to forget about me." Personalizing, when applied to others, is very much like blaming. "She could have written to me while she was away." "The party that I planned in the park was a failure because it rained and people left early." Regret orientation is generally focused on the past. "If I had worked harder, I could have gotten a better grade." "I had a chance for a better job if I had been willing to relocate to a different city." "Should" statements are about self-failure or judgments about others relative to how things should be. "I should be able to take the bus on my own when I work late." "My sister ought to be willing to care for my child when I am working late." Judging statements about others generally result in feelings of resentment and anger. "My sister has a husband, so she doesn't really understand how hard it is for me to manage as a single parent." Unfair comparisons measure self against others believed to have desirable attributes. "She is prettier than I am." "Everybody in the class is smarter than me." "My college roommate is a CEO already; I'm nothing compared to him." Unfair comparisons can also lead to "I could or should be" or "I shouldn't be" statements when comparing self to others; for example, "My college roommate is a CEO already; I could have a job like that." What ifs refer to the tendency for people to continually question themselves about the potential for events or the catastrophe that might happen. "I would go to the doctor to examine the mole on my back, but what if I am really sick?" "What if I tell my relative that I can't watch the kids tonight and she gets upset with me and she refuses to talk to me ever again?"

Task-Centered Step 4: Rehearse or Practice Behaviors Involved in Tasks

Certain tasks involve skills that people may lack or behaviors with which they have had little or no experience. Step 4 of the TIS is aimed at assisting such clients to gain experience and mastery in performing skills or behaviors essential to task accomplishment. It follows, then, that a major goal in the TIS is to enhance clients' sense of self-efficacy so as to increase their potential for successful task completion. Successful experience, even in simulated situations, encourages a client's belief that he or she has the ability to be successful in performing a task. Performance accomplishments: Major methods of increasing self-efficacy through performance accomplishment include assisting people to master essential behaviors through modeling, behavior rehearsal, and guided practice Vicarious experience: Insight may be gained by observing others demonstrate certain behaviors or observing the performance of a behavior without experiencing adverse consequences. Verbal persuasion: Talking to clients about their capacity to perform can be somewhat effective and also raise outcome expectations. But talking to clients about expectations or attempting to persuade them about their competence does not in fact enhance self-efficacy. To be effective, the appraisal of a client's capabilities has to be based on his or her perceptions and assumptions about competence and sense of self. Emotional arousal: Self-efficacy can be influenced by emotions, which in turn affect how people perform. Individuals who are extremely anxious or fearful about performing a new behavior are unlikely to have sufficient confidence to do so. Behavioral rehearsal used in an actual session is intended to reduce anxieties and help clients practice new behaviors or coping patterns. Indications for using this technique include situations in which a client feels threatened, feels inadequately prepared to face a situation, or is anxious or overwhelmed by the prospects of engaging in a given task. Role-playing is the most common form of behavioral rehearsal to encourage mastery because the client is able to rehearse a desired behavior or outcome. In a simulated situation, a client can build on his or her existing skills, as well as identify potential barriers or obstacles. Behavioral rehearsal need not be restricted to a session between you and the client. It can include overt behavior like making a phone call or covert behavior like self-talk, including expressing aloud defeating feelings or thoughts. These defeating feelings and thoughts can then be restructured into more encouraging language. It is often productive for clients to rehearse on their own by pretending to be involved in real-life encounters. If modeling or rehearsal proves ineffective, in the interim you can help clients to develop coping efforts rather than achieve mastery. Coping emphasizes the struggles that a person might expect to experience in completing the task behavior or activity. Emphasizing coping rather than mastery is intended to lessen anxiety and, hence, the threat of having to perform without making a mistake. Guided Practice. Closely related to behavioral rehearsal, guided practice is another technique to aid task accomplishment. It differs from behavioral rehearsal in that it is in vivo rather than a simulated situation. It involves your observing the client as he or she engages in a task related to a target behavior. Afterward, you provide immediate feedback and also coach the client as he or she attempts to gain mastery toward task completion.

Theoretical Framework of Crisis Intervention

Early crisis intervention theory spanned the life course to include grief and loss reactions, role transitions, traumatic events, and maturational or biopsychosocial crisis at various developmental stages (Lindemann, 1944, 1956; Rapoport, 1967). Early theories of crisis intervention strategies tended to reflect the psychoanalytic paradigm. Other crisis theories which distinguish the types of crises and define an underlying contextual theoretical framework in which a crisis can occur Ego psychology Cognitive behavioural Chaos Ecological systems Life cycle theories

Application of the Task-Centered Model with Diverse Groups

Emphasis on the right of clients to identify concerns, including clients who are involuntary The model is thought to be sensitive to the experience of diverse individuals and families because of the emphasis on the right of clients to identify concerns, including clients who are involuntary. The use of tasks is believed to empower clients who are marginalized, lack power, and are oppressed

Developing General Tasks

General tasks consist of discrete actions to be undertaken by the client and, in some instances, by you the social worker. Each general task has specific tasks that direct the incremental action steps to achieve goals. Initially, general tasks may be disconnected and may not follow a logical sequence. Therefore, tasks will need to be prioritized by you and the client. It is important to settle on tasks for which the benefit is obvious and which have a good chance of being successful. Success with one task encourages clients' confidence in their ability to tackle another task.

Prevalence of Trauma: What Is Known

Observed among young women in maternity care Urban and immigrant youth Minority child population Prison population Homeless population

Tenets of the Crisis Intervention Equilibrium Model

Reduces intensity of a client's emotional, mental, physical, and behavioral reactions to a crisis Restores client functioning to the pre-crisis state Prolonged crisis-related stressors have the potential to severely affect cognitive, behavioral, and physical functioning The equilibrium model is a basic approach to crisis intervention. The model is action oriented, with the central intent being to reduce the intensity of a client's emotional, mental, physical, and behavioral reactions to a crisis and to restore client functioning to the precrisis state. Promptness of response, a key aspect of the model, is considered critical to prevent deterioration in functioning. It is during the acute period that people are most likely to be receptive to an intervention. The procedures of the model involve assessing the nature of the crisis, identifying priority concerns, and developing limited goals.

Solution-Focused Brief Treatment Model

Solution-focused brief treatment A postmodern, constructivist approach with a unique focus on resolving clients' concerns, based on the premise that change can occur over a short period of time.

Strengths and Limitations of the Approach

Strengths Involves practical procedures and questions that can be readily learned and applied in many practice situations Particular emphasis on clients' strengths and attributes Strategic focus on change affirms that gains can occur over a brief period of time Limitations Primary focus on solutions disconcerting for some clients Positive thrust of the approach prevents clients from discussing real concerns Limited attention to behaviors ignores connection between feelings and cognitions

Is the Approach Appropriate for Addressing the Problem and the Service Goals?

The method selected to address these, however, requires an understanding of context, circumstances, and the nature of the problem and timing. The essential questions to be answered are: What is the problem? and What are the client's goals and values? To achieve a desired goal, the change strategy must be directed to the problem specified by the client or a mandate, as well as to the systems or environmental issues that are implicated in the problem. Other factors that guide your consideration include developmental age and stage and the family life cycle, the latter of which can become exaggerated as a result of stressful transitions Does the approach acknowledge and allow for the integration of environmental factors—for example, the experience of minority or socioeconomic status and oppression—as contributing to a problem, so as not to add a sense of being marginalized? Are modifications to the approach indicated so that it is responsive to diverse individuals, families, and minors? Is the approach flexible enough that it respects and can be adapted to specific cultural beliefs, values, and a different worldview? Does the approach address the sociopolitical climate as a factor in creating and sustaining the client's problem? As you plan and select a change strategy, we encourage you to allow diverse clients to consider the cost-benefit tradeoff of seeking help, essentially determining the extent to which the approach allows the client to retain a sense of self or cultural identity and/or poses a threat to the client's cultural values and beliefs At this point, you may wonder how to go about selecting a change strategy that is consistent with the needs and interests of diverse clients. Discovery and cultural humility are two concepts that will help you understand clients and ultimately select a change strategy that is in harmony with those clients' values and beliefs. The spirit of discovery guides you to elicit clients' view of the problem at hand; the related symbolic, cultural, and social nuances of their concerns; and their ideas about an approach as a remedy to their difficulties (Green, 1999). Cultural humility encourages you to place yourself in a student role in which you are open to the clients as a teacher. Together, you and the clients are partners in understanding and clarifying the relevance of the change effort to their problem Regarding whether the approach addresses the sociopolitical climate as a factor in creating and sustaining the client's problem, social workers must keep in mind that minority and poor families, many of whose contact with professional helpers is involuntary, often face insurmountable odds in their everyday lives, some of which are the results of limited resources, pressures to conform to dominant societal norms, marginalized status, inequity, and constrained self-determination. Laws, however, cannot command positive interpersonal and social behavior, especially covert interactions. Covert interactions are those subtle acts characterized as microaggressions, in which people are treated differently based on their race, ethnicity, sexual orientation, ability, or socioeconomic status Finally, note that in some instances, the approach that you use may be determined by your practice setting. In either case, in planning and selecting an approach, when you are uncertain, supervisory consultation can be useful to help you clarify or affirm your decision.

Developing Specific Task

When multiple tasks are developed, it is important to identify and plan the implementation of at least one task before ending a session. In fact, many clients are eager to get started and welcome homework assignments. Note that Angela Corning asked what the couple could do before the next session. Although mutually identifying tasks and planning for implementation in each session is time intensive, the time spent from one session to the next can sharpen the focus on the action steps that facilitate progress. Assessing client readiness to engage in an agreed-upon task. A client's readiness to implement a task can be gauged by asking the client to rate his or her readiness using a scale of 1 to 10, in which a rating of 1 represents a lack of readiness and 10 indicates that the client is ready to go (De Jong & Berg, 2001). Should clients indicate that their readiness is on the low end of the scale—for example, in the 1 to 3 range—you should explore the reason for the low rating, as doing so can uncover vital information concerning potential obstacles. Nonverbal behavior on the part of a client can also indicate a level of readiness in the lower range that can signal an obstacle or apprehension about undertaking a task. When you observe such behavior, you should explore the context and content so that the behavior does not become a barrier. For the most part, however, individuals of all ages, irrespective of status, are unlikely to be motivated by and become reactive to assigned tasks (Brehm & Brehm, 1981; Miller & Rollnick, 2002). Reactance theory suggests that individuals are inclined to act to protect themselves, especially when a choice is imposed, and further when the choice is inconsistent with a desired direction. Brainstorming alternative tasks. Brainstorming alternative tasks involves a process in which you and the client mutually focus on generating a broad range of possible task options from which the individual, family, or group may choose.Brainstorming can be particularly useful with minors to encourage their ownership of possible actions. Establishing a reward or an incentive. Given the varied circumstances in which clients may be hesitant to engage in tasks, it may necessary to identify an immediate reward to support motivation. Possible rewards can be identified with the client; however, to be effective, the reward should be realistic. Rewards can be helpful in encouraging minors to complete tasks, in particular when doing something else is more attractive. An incentive can be especially beneficial for minors when the intent of a task is a behavioral change. The following guidelines can help you best utilize incentives or rewards and encourage the completion of a task, especially among minors: Specify the time frame and the conditions under which the task is to be performed (e.g., every 2 hours, twice daily, each Wednesday, once a day for 5 days), so that the client understands the specifics of what is being asked of him or her. In collaboration with the client, identify the reward to be earned as well as establish a method for tracking the progress of task completion. When possible, identify relationship rewards (for example, going to the mall or spending time with friends or other significant individuals). Provide a bonus for consistent achievements of tasks over an extended period of time. Encourage task completion by providing consistent and positive feedback. For minors, using visuals, such as graphs to record and track progress on tasks, can be a motivator.

Defining Trauma

trauma as a "single event, multiple events or a set of circumstances that is experienced by an individual as physically and emotionally harmful or threatening and that has lasting adverse effects on the individual's social, emotional and spiritual well-being" There are three main types of trauma. Type I refers to trauma in which the individual retains complete memory of the experience. Type II trauma involves repetitive and prolonged exposure to a traumatic event or experience, resulting in intense psychological and physical reactions. Type III trauma involves multiple pervasive violent events, often taking place in childhood and continuing into adulthood (Solomon & Heide, 1999). Clients who experience Type III trauma often suffer severe, persistent psychological effects requiring different treatment strategies. Trauma in clients with a diagnosis of serious and persistent mental health problems (Felitti et al., 1998): Is interpersonal and intentional in nature: prolonged, repeated, and serious Involves emotional, sexual, or physical abuse, serious neglect, witnessing violence, repeated abandonment, or a sudden and traumatic event Occurs in childhood or adolescence and may extend over a client's life span

Crisis Reactions and Stages

A crisis reaction is described as any event or situation that upsets the client's normal psychic balance to the extent that his or her sense of equilibrium is severely diminished (James, 2008; Roberts, 2005). Crisis intervention theory posits that people's crisis reactions typically go through several stages, although theorists differ as to whether three or four stages are involved. Stage 1: The initial tension is accompanied by shock and perhaps even denial of the crisis-provoking event. Stage 2: To reduce the tension, the client attempts to utilize his or her usual emergency problem-solving skills. If these skills fail to result in a lessening of tension, the stress level will become heightened. Stage 3: The client experiences severe tension, feels confused, overwhelmed, helpless, angry, or perhaps acutely depressed. The length of this phase varies according to the nature of the hazardous event, the strengths and coping capacities of the client, and the degree of responsiveness from social support systems. Patterns of behavior associated with these stages may be characterized as disorganization, recovery, and reorganization Crisis situations inevitably have a subjective element because people's perceptions and coping capacities vary widely. Keep in mind, therefore, that a crisis that is severely stressful and overwhelming for some people may be manageable for others. In reacting to a crisis, the potential exists for clients to cope in ways that are either adaptive or maladaptive. You should be aware, however, that prolonged stress may have exceeded clients' coping capacity and usual problem solving to such an extent that they are unable to effectively handle the stressors.

Definition of Crisis

A crisis, as defined by James (2008, p. 3), is "a perception of an event or situation as an intolerable difficulty that exceeds the resources or coping mechanism of the person." Prolonged crisis-related stressors have the potential to severely affect cognitive, behavioral, and physical functioning. It is important to note that segments of the population experience cumulative events or circumstances that result in a perpetual state of crisis

Interactive Trauma/Grief-Focused Model (IT-GFT)

A developmental ecological approach to crisis work with minors, based on the premise that the developmental stage and the environment within which the minor operates are interrelated. Characteristics of the stressors: These include the perception of threat related to the event, physical proximity to the event, duration, and intensity. Characteristics of the minor: Developmental stage, gender, and vulnerability play a significant role in how a minor experiences a threat, as do psychological or behavioral problems that existed prior to the threat. The minor's efforts to cope: Generally, a minor with good communications skills, a sense of self, internal locus of control, and average intelligence are indicators of a positive outcome. Characteristics of the postdisaster environment: The minor's reaction is strengthened by social supports from significant others and resources, which can reduce stress and act as protective factors.

Case Management Functions

Access and Outreach Outreach or case finding identifies people who are likely to need case management services. Intake and Screening Preliminary to an assessment, screening is an initial step in determining eligibility for services. A preliminary plan may be developed at this stage. Multidimensional Assessment Information is collected about the client's physical, mental, social, and psychological functioning and the physical environment, including strengths and resources. This multidimensional assessment guides the development of the case plan. Goal Setting Goals and objectives are developed based on assessed needs, in collaboration with the client. The goal plan and objectives are based on the client's perception of needs and may be structured as long or short term. Planning Interventions and Linking to Resources Planning the intervention and linking clients to resources are interdependent functions. Both formal and informal resources and the appropriate service providers are identified. The specific services, as well as the frequency and duration of contact with the service provider, are specified. Monitoring the Progress and Adequacy of Services Monitoring progress and the extent to which service providers continue to meet the needs identified in the case plan is a vital and ongoing process. Three sources of information are indicated: regular contact with service providers to determine if services are responsive, monitoring progress toward the stated goals, and the client's observations regarding the level of progress and satisfaction with the providers. Reassessment at Fixed Intervals It is particularly important to be sensitive to changes in clients' needs and to adjust or modify the plan as indicated. Reassessments can be formal or informal and are completed at fixed intervals. The information gathered can also determine the level of change since the initial assessment. Outcome Evaluation/Termination Outcome evaluation, in brief situations in which goals have been achieved, leads to termination. In longer-term situations, reassessment and evaluation of outcomes are ongoing. Although the case manager is ultimately responsible for overseeing the implemented plan, the individual or family is also involved in the evaluation of the adequacy of the service. You will also note that monitoring progress and reassessment depend on the goals and time frame of the case plan. For example, long-term plans may require an infinite amount of services, in which case the reassessment intervals are ongoing. In these instances, reassessment is critical, and assessing progress may require the use of pre/post baseline or standardized instruments. In contrast, with brief case management services (e.g., locating housing, securing medical care, attaining the capacity to live independently), satisfactory progress and goal attainment should lead to termination.

Theoretical Framework of the Task-Centered Model

Action-oriented model Designed to be eclectic The research demonstrated that a brief, focused contact and the conscious use of time limits were as effective as intervention strategies that required a longer time period. Similar to the problem-solving model introduced by Perlman (1957), the task-centered model focused social work practice on the challenging problems in daily living and psychosocial factors that were observed to be common among a majority of social work constituents The task-centered system is designed to be eclectic. Reid (1992) emphasizes, however, that combining the procedures of the model with another (technical eclecticism) requires utilizing compatible research-based theories and intervention techniques. With this in mind, you can make use of various theories that are relevant to the client situation

Tenets of the Task-Centered Approach

Aimed at reducing problems in living within a brief, time-limited period Clients' identification of priority concerns and the collaborative relationship The direction of the task-centered approach with regard to goal attainment is both systematic and efficient. Termination is considered to begin at the initial point of contact, facilitated by specific goals and the development and completion of tasks. The model is aimed at reducing problems in living within a brief, time-limited period. Central themes of the task-centered approach are that clients are capable of solving their own problems and that it is important to work on problems that are identified by the client. Clients' identification of priority concerns and the collaborative relationship are understood to be empowering aspects of the model. The approach addresses an array of problems, including interpersonal conflicts, difficulties in social relations or role performance, reactive emotional distress, inadequate resources, and difficulties with organizations

Does the Approach Safeguard the Client's Right to Self-Determination?

Although some clients have limitations and may be unable to make decisions about certain aspects of their lives, the clients' limitations are not the sum total of who they are, nor does this mean that they lack the ability to process task-specific information. In essence, the focus should be on the client's capacity rather than limitations. Above all, you are cautioned to refrain from acting in a paternalistic or beneficent manner in order to achieve your perception of the client's best interest. For example, some involuntary clients and clients who have experienced a situation in which they were victimized may be reluctant to accept the notion of self-determination, believing instead that they lack influence, knowledge, or power to effect change. In a crisis situation, respecting self-determination can become overshadowed by a strong desire to help, so much so that the client's rights and the outcome sought may be unintentionally overlooked (Fullerton & Ursano, 2005; Sommers-Flanagan, 2007). In either scenario, actively encouraging self-direction with such clients and emphasizing the ways in which they can exercise their rights and regain control over their situation should be discussed. Note that the principle of self-determination is taken for granted in Western society. As such, the principle should be examined in a community and sociocultural context. We acknowledge that the work setting in which you are employed may determine the approach utilized with a certain client population and therefore may limit decision making about an intervention approach. In most states, minors are presumed to have limited decision-making capacity; therefore, parents or legal guardians act as their proxies (Strom-Gottfried, 2008). Developmental stage, reasoning, and cognitive capacity are also significant factors that influence a minor's capacity for decision making and self-direction. In general, most minors are able to express how they feel and what they want. Your task is to provide the opportunity for them to participate in intervention planning, which includes your explaining the benefits and potential risks using words that they understand

Cognitive 4. Assist Clients in Replacing Dysfunctional Cognitions with Functional Self-Statements

As clients become aware of their dysfunctional thoughts, beliefs, and images, the goal is to help them recognize the connection to negative emotional reactions. Having done so, an additional goal is to help them cope as an intermediary step to learning new behavioral responses. Coping strategies typically involve self-statements that are both realistic and instrumental in diminishing or eliminating negative emotional reactions and self-defeating behaviors. Although functional self-statements are intended to foster courage and facilitate active coping efforts, it is important to not ignore the struggle as a client shifts from habitual and ingrained patterns of thinking to adopting new behavioral patterns. In recognition of the difficulty and anxiety that a client may experience, coping self-statements are intended to support the transition to risking new behavior. After modeling coping self-statements, it is appropriate to encourage the client to practice the behavior. To enhance the effectiveness of guided practice, you could suggest that clients close their eyes and picture themselves in the exact situation they will be in before engaging in the targeted behavior. When they report they have succeeded in capturing the situation, ask them to think aloud the thoughts they typically experience when contemplating the targeted behavior. Then ask clients to substitute coping thoughts, coaching them as needed. Give positive feedback and encouragement when they produce reinforcing self-statements independently, even though they may continue to struggle with conflicting thoughts. You may also expect clients to express doubt and uncertainly about their ability to eventually master new patterns of thinking. When the client has demonstrated his or her confidence in using coping self-statements before entering a targeted situation, you can shift to self-statements during the time the client is actually in the target situation To further assist clients in utilizing positive statements, it is beneficial to negotiate using such statements as tasks between sessions. Between-session tasks foster autonomy and independent action. Even so, don't pressure the client, because undue pressure may be perceived as threatening or discouraging. You may use the readiness scale (discussed earlier in this chapter) as a gauge. Another technique that can help clients replace their automatic problematic self-statements is encouraging them, upon their first awareness of such thoughts, to nip them in the bud. Because thoughts tend to be automatic, deeply embedded, and persistent, it is important to explain that Step 4 may extend over a time span in which a satisfactory degree of mastery is gradual; however, it is possible to achieve over time.

The Effects of Trauma

Biological, psychological, social, and spiritual Depend on: Stage of development at the time of the traumatic event Severity of the traumatic event Violence and level of force involved Number of occurrences of the event Nature of the relationship to the person who caused the traumatic event Belief that the trauma experience is disclosed Gender differences Changes in brain neurobiology Adult and adolescent females, for example, experience more trauma in the form of sexual or physical abuse and psychological distress when compared to males (Shin Tang & Freyd, 2012; Tolin & Foa, 2006). Sexual abuse is associated with posttraumatic stress disorder (PTSD) and self-harm, health risks behaviors, and depression and anxiety (Chamberlain & Moore, 2002; Mueser & Taub, 2008; Smith, Chamberlain, & Leve, 2006). The trauma experience of males is more often related to being involved in or a witness to violence, resulting in antisocial behaviors and posttraumatic stress. Posttraumatic stress disorders were also found to be higher among racial and ethnic minorities, and these groups also had a higher lifetime risk of developing PTSD. The Adverse Childhood Exposure (ACE) study advanced our knowledge of the longevity of exposure or the experience of trauma by identifying adverse childhood experiences and exposure Childhood trauma is associated with changes in brain neurobiology; social, emotional, and cognitive impairment; and the adoption of health risk behaviors as a coping mechanism

Cogitive Theoretical Framework

CBT attempts to alter the client's interpretation of self and his or her environment, and the manner in which he or she creates interpretations. The theory considers the behavior of clients to originate from their processing of both internal and external information. According to cognitive theorists, most social and behavioral problems or dysfunctions are directly related to the misconceptions that people hold about themselves, other people, and various life situations

Case Management

Case management entails work that interfaces between the client and his or her environment. As a method, case management has moved to the forefront of direct social work practice in recognition of the fact that people with unmet needs are often unable to negotiate the complex and often uncoordinated health and human services delivery systems. To a large extent, the growth of case management has been driven by federal and state-funded programs, the majority of which mandate the coordination and integration of services. Medicaid, for example, requires case management to help beneficiaries gain access to needed medical, social, educational, and other services. Most recently, targeted case management, an amendment to the Budget Reduction Act of 2005, was added as a provision of Medicaid case management services. Under this provision, certain beneficiary groups, such as clients with an identified chronic health or mental health problem or developmental disabilities and minors in foster care, are considered to be primary recipients of targeted case management services. Also included in the Medicaid provisions are individuals or groups who reside in a particular geographic region and clients whose needs have been identified by the health and human services organization in their respective states

Case Management Strengths and Limitations

Case management is a problem-solving practice method that is designed to link the needs of clients to a range of service providers. Based on assessed needs, services are individualized in recognition of the unique capabilities, goals, and circumstances of each service recipient. The utilization of case management has grown over time, in part as a response to federal funding requirements that emphasize improved access to services and the coordination and integration of the services that clients receive. As evidenced by the previous discussion which summarized results of research studies, case management, either as a stand-alone practice method or when integrated with another treatment approach, has demonstrated its effectiveness in addressing a range of needs and problems with specific populations. An assumption of case management is that the resources or service providers that a client needs are always available in adequate quality and quantity. In reality, gaps in services exist. In some instances, the service may be available but the provider may be overwhelmed with demands. Herein lies a challenge for the case manager, particularly in an age in which funding for services are reduced. On the whole, case management is intended to meet the multiple needs of a client in a coordinated, comprehensive manner. The phases and associated tasks allow for the development of a case plan unique to the client. The greater benefit of case management is the fact that services are identified based on assessed needs, which eliminates clients' having to navigate complex helping systems on their own.

Case Managers

Case managers are fundamental to the case management tasks. Whether your title in an organization is case manager, plan coordinator, or care coordinator, you are the human interaction between clients and various systems. You may work as part of a team in some settings; in others, you may be solely responsible for providing case management services. The type of setting will also determine whether your involvement as a case manager is brief or time limited, targeted, ongoing, or open-ended. In practice, your role and your responsibilities relative to the phases and tasks can be as varied as the settings in which you are employed. The phases of case management and the point of contact notwithstanding, and irrespective of your case manager role, it is important to keep in mind that case management begins with an assessed need rather than a service. No two clients will have or express needs, problems, or goal preferences in the same way. For this reason, the implemented case or care plan is tailored to the unique needs of the people involved. Specifically, each person or family should be able to expect that his or her case plan is responsive to a specific identified need, rather than the service priorities of an agency. As a case manager, the broker role is vital to facilitating interagency coordination and cooperation. In this capacity, you need to have a working knowledge of, and an effective relationship with, a range of service providers, including available informal resources.

Cognitive Restructuring

Cognitive restructuring is a therapeutic process derived from cognitive behavioral therapy (CBT). Also referred to as cognitive replacement, cognitive restructuring is "considered to be the cornerstone of cognitive behavioral approaches" (Cormier & Nurius, 2003, p. 435). Intervention techniques in CBT are designed to help clients modify their beliefs, faulty thought patterns or perceptions, and destructive verbalizations, thereby leading to changes in behavior. An assumption of cognitive restructuring is that people often manifest cognitive distortions, which in turn affects their emotions and actions. Distortions are irrational thoughts derived from negative schemas that lead to unrealistic interpretations of people, events, or circumstances.

Cognitive Strengths, Limitations, and Cautions of the Approach

Cognitive restructuring is an effective procedure that is intended to address a range of problems related to a client's cognitions and thought patterns. Research studies have shown the procedure to be particularly useful in altering perceptions, distorted beliefs, and thought patterns that result in negative or self-defeating behaviors. In assisting clients to change, however, social workers must not mistakenly assume that clients will be able to perform new behaviors solely as a result of changes in their cognitions or beliefs. In reality, they may lack cognitive and social skills and require instruction and practice before they can effectively perform new behaviors. Cognitive restructuring is intended to remove cognitive barriers to change and foster a willingness to risk new behaviors, but it does not always equip clients with the skills required to perform those new behaviors. Furthermore, as noted by Vodde and Gallant (2002), simply changing one's story does not ensure a certain outcome, given the presence of very real external factors such as oppression or rejection. Thus, without an acknowledgment of these factors, diverse clients may perceive cognitive restructuring as blaming or just another form of social control and ideological domination. Of course, some minority group members have mastered a dual frame of reference that is selectively congruent with dominant views and beliefs. Thus, for these clients, cognitive restructuring can be a useful intervention procedure. Finally, although cognitive theorists attribute most dysfunctional emotional and behavioral patterns to mistaken beliefs, dysfunctional emotions and beliefs are by no means the only causes. Dysfunctions may be produced by numerous biophysical problems, including brain injury, neurological disorders, thyroid imbalance, blood sugar imbalance, circulatory disorders associated with aging, ingestion of toxic substances, malnutrition, and other forms of chemical imbalance.

Empirical Evidence and Uses of Cognitive Restructuring

Cognitive restructuring procedures are particularly relevant for treating problems associated with low self-esteem; distorted perceptions in interpersonal relations; unrealistic expectations of self, others, and life in general; irrational fears, panic, anxiety, and depression; control of anger and other impulses; and lack of assertiveness

Cognitive Schemas

Cognitive schemas, either positive or negative, are the memory patterns that a client uses to organize information (Berlin, 2001; Cormier & Nurius, 2003; Cormier, Nurius, & Osborne, 2009; McQuaide & Ehrenreich, 1997). Whether they originate from a strengths or deficit orientation, cognitive schemas are shortcuts in thinking. Because such schemas are ingrained beliefs, it is often difficult for people to hear or process new or different information or an alternative explanation, the result of which is cognitive dissonance. When cognitive dissonance occurs, clients can experience a high level of stress, so much so that they may completely shut down. In either case, it is important that you first determine the context and the type of situation that triggers and maintains problematic behavior (Berlin, 2001; Cormier & Nurius, 2003). Further, where negative filtering about self and others has emotional content, blaming statements may be related to the mood of the client at a particular point in time. Keep in mind that negative thoughts and schemas do not represent the whole person. People generally are able to go about their daily lives until such time that an external or internal event ignites a particular thought pattern upon which their reality is constructed. You should also be mindful that marginalized and oppressed people and involuntary clients are often perceived as negative thinkers with distorted realities. As difficult as it may be for us to acknowledge truths that may be different from our own experiences, ultimately the focus should be on what is meaningful to the client rather than what is considered an acceptable pattern of thinking and behaving.

Evidence Base and Use of Crisis Intervention

Crisis intervention as a systemic strategy is recognized and widely used throughout the world in response to a range of client, professional, and community crisis situations and in a variety of settings, including schools, hospitals, and residential treatment facilities Published reviews of Crisis Intervention Teams (CITs) emphasize the effectiveness of the approach in: Improving interactions between police and persons who are mentally ill Reducing the use of force Response to domestic violence

Application of Solution-Focused Approach with Diverse Groups

Critiques of the solution-focused approach point to a lack of attention to the diversity of clients (Corcoran, 2008). Demer, Hemesath, and Russell (1998) praise the approach for its explicit attention to competence and strengths, but they believe that it fails to address gender-related power differences. For example, they might argue that despite a change in the narrative of men and women in abusive relationships, the change lacked sufficient attention to actual power differences. Proponents of the approach, however, assert that the solution-focused approach is responsive to diverse groups because its basic thrust recognizes the expertness of the narrative and language of the client. Further, they assert that because professionals respect and honor the distinct cultural background of clients, the basic tenets of the approach are consistent with competent multicultural practice with clients in social service agencies

customers, complainants, and visitors

Customers are individuals who willingly make a commitment to change. Therefore, the series of questions and the tasks to be completed are directed to them. Those individuals who identify a concern but do not see themselves as part of the problem or solution are referred to as complainants. A person who is willing to be minimally or peripherally involved but is not invested in the change effort is designated a visitor. These distinctions allow you to identify where potential clients stand relative to their commitment to change and their ownership of concerns. Distinguishing the various types enables you to focus on the concern and solution identified by the customer. There may be instances, however, when it is advisable to engage the complainant or visitor, if only to ensure that he or she does not interfere with the customer's change efforts.

Solution-Focused Procedures and Techniques

Description of the problem: Clients are invited to give an account of their concern or problem. However, as a practitioner, you refrain from eliciting details about antecedents, severity, or the cause of their concern. While listening to clients' description of the problem, you are looking for ways in which you can guide them toward a solution. Developing well-formed goals: In this stage, your work involves encouraging the client to think about what will be different once the problem no longer exists. This information facilitates the development of a client's goal. Exploring exceptions: Questions asked of the client in this stage are focused on those times in his or her life when the problem was not an issue or was less of a concern. These questions are followed by questions relating to what could happen that would decrease the concern and make exceptions possible. End-of-session feedback: The aim of this stage is to compliment and reinforce what a client has already done to solve the problem. Feedback is based on the information that the client provided about goals and exceptions. Also, clients are asked what they should do more or less of in order to accomplish a goal. Evaluating progress: Monitoring progress is ongoing and is specific to evaluating the client's level of satisfaction with reaching a solution. The scaling question facilitates this process. After a client has rated his or her satisfaction level, you work with him or her to identify what needs to occur so that the problem is resolved. In later sessions, a central question posed to the client is: "What's better?" When the client's primary concern is resolved in a satisfactory manner, contact with you is terminated. Typical interview questions that facilitate a client's capacity to think about the future and to identify solutions include the following questions adapted from De Jong and Berg (2008), Lipchik (2002), and de Shazer and Berg (1993): How can I help? What's better? How will you know when your problem is solved? What will be different when the problem is solved? What signs will indicate to you that you don't have to see me any longer? Can you describe what will be different in terms of your behavior, thoughts, or feelings? What signs will indicate to you that others involved in this situation are behaving, thinking, or feeling differently? For clients who are involuntary, De Jong and Berg (2008, p. 372) recommend beginning the interview with questions that encourage the client's participation by allowing the client to provide his or her view of the situation. Examples are: "Whose idea was it that you needed to come here?" "What is your understanding of why you are here?" "What makes the (pressuring person or mandating authority) believe that you needed to see me?" "What is the difference between your point of view and that of the person who required that you come here?" In subsequent sessions, from one session to the next, interview questions are focused on: What is better? What could the client continue to do more or less of? Again, the flow and sequence of the questions will vary, influenced by the content of the conversation with each client.

Utilization of the Task-Centered Model with Minors

Improves school performance, modifies behavior in residential facilities, and reduces sibling conflict Applied in social work practice with involuntary clients in child welfare and minors in school settings

Procedures of the Task-Centered Model

Developing general tasks Developing specific tasks Task implementation sequence Enhance the client's commitment to carry out tasks Plan the details of carrying out tasks Analyze and resolve barriers and obstacles Rehearse or practice behaviors involved in tasks Summarize the task plan The initial phase begins with the client identifying and prioritizing a target problem. It is recommended that priority concerns and goals be limited to a maximum of three. Goals are agreed upon, and general and specific tasks to achieve goal attainment are developed. In keeping with the model's action orientation and brevity, termination begins with the first session. Specifically, you and the client agree to work together for a particular number of sessions (e.g., 6 to 8 weeks), although there is potential for you and the client to extend contact or negotiate a new contract for a different problem. During the period of contact, progress toward the identified goal is monitored and reviewed in each session as the client moves toward termination.

Tenets of the Solution-Focused Brief Treatment Model

Emphasizes identifying solutions Draws on people's strengths and capacities, with the intent of empowering them to create solutions Asserts that clients have a right to determine their desired outcomes The solution-focused approach draws on people's strengths and capacities, with the intent of empowering them to create solutions. Although clients may begin with a problem statement, a key belief of the approach is that the analysis of a problem does not necessarily predict a client's ability to problem-solve

Evidence Base and Use of the Task-Centered Model

Empirically established with different client populations When combined with other strategies, reduced reactance and engaged the client The task-centered model has been adapted to various settings in which social workers practice, and its use has been empirically established with different client populations, including families, organizations, and communities Adaptations of the task-centered approach have been tested in most settings where social workers practice, including mental health, health care, and family practice Additional evidence of the model's utilization and effectiveness include case management with minors and families, with elderly individuals in long-term care

Crisis Step 2: Ensure Client Safety

Ensuring client safety is the first and foremost concern in crisis intervention and an ongoing consideration (James, 2008; James & Gilliland, 2001; Roberts, 2005). Safety involves deliberate steps to minimize the physical and psychological danger to the client or others.

Am I Sufficiently Knowledgeable and Skilled Enough in This Approach to Use It with Others?

First and foremost, you are ethically obligated to have the requisite knowledge, skills, training, and competence to use an approach to resolve a particular client problem Coady and Lehmann (2008) refer to this type of blending generalist practice as technical eclecticism. In sum, in deciding to blend tactics or techniques, an essential question is whether you have the requisite knowledge, skills, and level of competence to engage in eclectic practice. In working with minors, you may find that blending tactics is advisable. Eclectic practice does not mean that you select a little bit of this and that from various intervention approaches irrespective of your skill level. Ethically, in combining one approach with techniques from another, you must consider whether this is appropriate for the problem or situation at the time. In general, it is advisable to use only those approaches in which you have the requisite knowledge and skills to implement them in a manner that is appropriate to the client situation and is consistent with ethical standards (NASW, 1999, 1.04a). In instances where you lack the requisite skills or competence, you should seek ongoing supervision or consultation or refer the client to a professional with the applicable skills

Cognitive 5. Assist Clients in Identifying Rewards and Incentives for Successful Coping Efforts

For clients who dwell on their failures and shortcomings and rarely, if ever, give themselves positive feedback, Step 5 in cognitive restructuring is especially important. When clients have mastered new statements and behaviors, you should reinforce their accomplishment by coaching to observe and credit success For some people, rewarding self-statements can be difficult and feel awkward or self-conscious. When a person is hesitant, empathic understanding and encouragement on your part will usually prompt them to try this exercise.

Cognitive 3. Assist Clients in Identifying Situations That Engender Dysfunctional Cognitions

Identifying the places where cognitions cause stress, the key persons involved, and situations in which the client feels demeaned helps you and the client to develop and tailor tasks and coping strategies to specific situations. Self-monitoring between sessions is a concrete way for a client to monitor and recognize cognitions related to difficulties around problematic events. Such recognition increases self-awareness of the pervasive nature of thoughts and the need to actively cope. Self-monitoring thus expands self-awareness and paves the way for later change efforts. Daily self-monitoring is a valuable tool because it focuses a client's efforts between sessions, clarifies the connections between cognitions and feelings, and appraises information regarding the prevalence and intensity of thoughts, images, and feelings. To prevent a person from becoming overwhelmed by the task of keeping a log, you might suggest that recordings be limited to no more than three. As an alternative, or in addition, self-monitoring can also include images drawn by the client. As other counterproductive thought patterns emerge during sessions, the focus of self-monitoring can be shifted as necessary. As you and the client review completed log sheets and identify problematic feelings and cognitions, it is important to note recurring situations or themes.

Empirical Evidence of Case Management

Improved the outcomes for HIV-infected clients Improved the retention of substance abuse users in treatment Served as a prevention and intervention strategy for homeless youth, adults, and families

Task-Centered Step 3: Analyze and Resolve Barriers and Obstacles

In Step 3 of the TIS, you and the client deliberately anticipate and subsequently prepare for obstacles that can affect or stall task accomplishment. It is also prudent to inquire about the practical and economic resources needed for completing the tasks When tasks are complex, obstacles likewise tend to be complex, and clients may have difficulty identifying obstacles. Tasks that involve changes in patterns of interpersonal relationships tend to be multifaceted and require developing subtasks as a prerequisite. Clients' capacity to resolve barriers and obstacles varies depending on the nature and complexity of the task. Some clients overlook or underestimate potential barriers and obstacles, resulting in a delay to take on tasks, needless difficulties, and in certain cases outright failure in accomplishing a task. Psychological barriers to task performance leading to goal attainment are often encountered regardless of the nature of the task. To begin, you and the client can develop a subsidiary task of neutralizing his or her emotions by exploring and clarifying the emotional content and empathizing with the client's apprehension. It may also be important to examine the problematic emotions, helping the client to identify the cognitive source and to align his or her thoughts and feelings with reality. In general, the time and effort invested in overcoming and resolving barriers and obstacles are likely to pay dividends, resulting in a higher rate of success in accomplishing tasks. Consider the economy of this process, as failure to complete tasks can have an effect on an individual's sense of self-efficacy and can extend the time involved in successful problem solving.

Anticipatory Guidance

In addition to completing the six steps of the model, you may also find anticipatory guidance to be a complementary technique. This technique involves assisting clients to anticipate future crisis situations and to plan coping strategies that will prepare them to face future stressors. Similar to identifying obstacles and barriers in the task-centered model, anticipatory guidance involves a discussion of scenarios of potential or future stressors. In using anticipatory guidance, it is important that you do not convey an expectation that people will always be able to independently manage future crisis situations. Even though you have reassured them of their skills and helped them to anticipate future scenarios, you should clarify that you or other professionals are available if they need future help.

Using Cognitive Restructuring with Minors

In comparison to adult populations, there are fewer studies that show evidence of the effectiveness of cognitive restructuring with minors. However, when combined with other strategies—for example, narrative and enactive performance-based procedures—cognitive restructuring can be effective with younger minors. Using with minors Increases self-efficacy and reduces social anxiety in adolescents Reduces the symptoms of posttraumatic stress disorder in minors

Tenets of Cognitive Behavioral Therapy and Cognitive Restructuring

In general, the goal of cognitive behavioral intervention strategies is to increase the client's cognitive and behavioral skills so as to enhance his or her functioning. Restructuring is a cognitive procedural technique that aims to change a client's thoughts, feelings, or overt behaviors that contribute to and maintain problem behavior. To be effective in using cognitive restructuring as an intervention strategy, you must be skilled in assessing cognitive functioning and in applying appropriate interventions. Thinking is a primary determinant of behavior and involves statements that people say to or about themselves. This inner dialogue, rather than unconscious forces, is critical to understanding behavior. Thoughts per se are devoid of feelings, although they are often accompanied by and generate feelings or emotions. Feelings consist of emotions, such as sadness, joy, or disappointment. Cognitions affect behavior, which is manifested in behavioral responses. Behavioral responses are a function of the cognitive processes of attention, retention, production, and motivation, as well as of rewarding or unrewarding consequences Behavioral change involves assisting clients to make constructive change by focusing on their misconceptions and the extent to which they produce or contribute to their problems. You should, of course, temper this assumption by recognizing that other factors influence a client's self-perception and the manner in which the client thinks and process information. Specifically, cognitions are not necessarily faulty, given the realities of culture, unequal sociopolitical structures, and social interactions in which class, race, gender, and sexual orientation are major contextual life issues. The realities of people's lives and beliefs have a significant impact on thinking and cognitions; therefore, the relationship between cognition, culture, and context should not be minimized or overlooked

Planning Goal Attainment Strategies

In planning goal attainment strategies, it is important to choose an intervention that makes sense to both you and the client and is also relevant to the client's situation. The operative word is matching. Is the approach appropriate for addressing the problem and the service goals? What empirical or conceptual evidence supports the effectiveness of the approach? Is the approach compatible with the basic values and ethics of social work? Am I sufficiently knowledgeable and skilled enough in this approach to use it with others?

Applying Cognitive Restructuring with Diverse Groups

In sum, the findings of multiple studies reinforce the importance of examining the context of distortions or negative thought patterns before concluding that a client's cognitions and thought patterns are irrational. Used in correctional institutions in which the majority of inmates are members of minority groups

Crisis Step 6: Obtain Commitment

In the sixth and final step, Lia and the social worker committed to collaboratively engage in specific, intentional, and positive tasks designed to restore her to a level of precrisis functioning.

Crisis Step 4: Examine Alternatives

In this step, both the social worker and Lia explored courses of action appropriate to her situation. Ideally, alternatives are considered to the extent to which they are: Situational supports, involving people who care about what happens to the client Coping mechanisms that represent actions, behaviors, or environmental resources that the client may use to get past the crisis situation Positive and constructive thinking patterns that effectively alter how a client views the problem, thereby lessening his or her level of stress and anxiety Social workers who understand the client's point of view may be better able to plan alternatives and encourage clients to consider other options. You should be aware, however, that multiple options can be overwhelming for clients. Furthermore, the alternatives that you and the client consider should be realistic for the situation

Crisis Step 3: Provide Support

In this step, the social worker's objective was to identify and mobilize Lia's social support systems network, which is essential for intervening in a crisis situation. Social supports may include friends, relatives, and in some cases institutional programs that care about the client and can provide comfort and compassion

Task-Centered Monitoring Progress

Once tasks have been identified and agreed upon, devote time in each session to a review of progress. In this process, both client and social worker can document which tasks have been completed and the extent to which the target problem has changed. During the review process, if tasks have not been completed or have not had the intended effect on the target problem, explore barriers and obstacles and the reasons for low task performance. When necessary, renegotiate tasks or develop new tasks. In reviewing task accomplishments, it is critical to discuss with the client details about the conditions, actions, or behaviors that facilitated completion of the task. Even when tasks have been only partially completed, it is important to connect the progress made to the client's efforts. In doing so, you are highlighting and reinforcing the client's strengths and sense of competence. In general, the ongoing in-session review of progress provides immediate feedback of gains as well as alerting you and the client to whether adjustments need to be made.

Cognitive 2. Assist Clients in Identifying Dysfunctional Self-Statements, Beliefs, and Patterns of Thoughts That Underlie Their Problem

Once the client accepts that thoughts and beliefs mediate emotional reactions, your next task is to help the client identify the associated thoughts and beliefs relevant to his or her difficulties. This step requires a detailed exploration of events related to problematic situations and antecedents, with particular emphasis on cognitions pertinent to the distressing emotions. To begin the process, you would focus on problematic events that occurred during the preceding week or on events surrounding a problem the client has targeted for change. As the client recalls events, you are listening for specific details regarding overt behaviors, cognitions (i.e., self-statements and images), and emotional reactions. Focusing on the cognitive and emotional aspects related to the event clarifies the connection between what a client perceives and his or her emotions and thoughts. From this point on, the aim is to identify self-statements and beliefs related to an event and to increase the client's awareness of the way in which automatic thoughts and beliefs are powerful determinants of behavior. As the client continues to explore his or her thought patterns, you will be able to identify thoughts and feelings that occur before, during, and after events. To elicit self-statements, ask the client to recreate the situation as it unfolded, recalling exactly what he or she thought, felt, and did. A client's thoughts and feelings after an event can have an impact on his or her subsequent behaviors. In listening to clients tell what occurred and their conclusions, you can further highlight the mediating function of cognitions. The following are general inquiries that can be developed into questions to help clients to assess the rationality of beliefs and self-statements: Ask how a client has reached certain conclusions. Elicit evidence that supports the client's perceptions or beliefs. Explore the logic of beliefs that have magnified the feared consequences of certain actions. As the social worker, you must therefore be prepared to challenge or "dispute" the validity of irrational beliefs by emphasizing the costs or disadvantages associated with counterproductive beliefs.

Crisis Step 5: Make Plans

Planning and contracting flow from the previous steps and involve the same planning and action steps that were discussed in Chapter 12. In this step, Lia and the social worker agreed on specific action steps or tasks. General and specific tasks will vary, of course, according to the nature of the crisis situation and the unique characteristics of each individual and/or family.

Task-Centered Failure to Complete Tasks

Reasons for low task performance are classified into two categories: reasons related to the specific task and reasons related to the target problem. Occasionally, unforeseen circumstances or unanticipated obstacles may influence a client's ability to complete a task between sessions. When this happens, the obstacles that blocked the task completion should be identified and resolved. By mutual agreement, a previously identified task can be continued to the next session. The caveat, of course, is that both you and the client are in agreement that the task is still valid. If this is not the case, it is important to shift the focus to more relevant tasks. Reasons related to the specific task Occurrence of an emergency or crisis Lack of commitment Lack of skills/resources Tasks inadequately specified Adverse beliefs Lack of support Environmental factors Reactions to the practitioner Inadequate preparation Reasons related to the target problem Attributed not acknowledged problems Conflicting wants/needs Client unaware of consequences Little hope for change

Tenets of Case Management

Referred to in health or institutional settings as care planning, care coordination, or patient-centered care, case management is viable and often vital to persons in need of comprehensive services. A critical function of case management is linking individuals or families to a range of services based on their assessed needs. In essence, people are able to gain access to health, mental health, and social welfare service providers that otherwise might be difficult for them to navigate on their own. The coordination of services by the case manager is intended to reduce duplication, fragmentation, and ultimately the frustration of the client. As a problem-solving method, case management is theoretically open (Epstein & Brown, 2002). As such, the method can make use of theories and intervention tactics or techniques that are appropriate to clients' situations.

Six Key Principles of a Trauma-Informed Approach and Trauma-Informed Care

Safety: Trauma survivors and the staff involved in service delivery feel emotional, physical, and psychological safety; and interpersonal interactions promote a sense of safety. Trustworthiness and transparency: Organizational decisions and operations are clear to clients receiving services, the goal of which is to build and maintain trust among all involved. Trust and transparency are maximized through task clarity, consistency, and interpersonal boundaries. Peer support and mutual help: These are considered integral to the organizational and service delivery approach and are understood as vehicles for building trust, establishing safety, and empowerment. Collaboration and mutuality: There is a true partnership and leveling of power differences between staff and clients and among direct care staff and administration, as well as a recognition that healing happens in relationships and in the meaningful sharing of power and decision making rather than through exclusive reliance on the professional's specific skills or services. Empowerment, voice, and choice: Throughout the organization and among clients, resilience and strengths are recognized, built upon, and validated as new skills are developed. The organization allows clients, staff, and family members to experience choice and recognizes that every person's experience is unique and requires an individualized approach. There is a belief in resilience and in the ability of individuals, organizations, and communities to heal and promote recovery from trauma, building on what clients, staff, and communities have to offer rather than responding to perceived deficits. Cultural, historical, and gender issues: Cultural, historical, and gender issues are addressed in a manner that actively moves past cultural stereotypes and biases, offers gender-responsive services, leverages the healing value to traditional cultural connections, and recognizes and addresses historical trauma.

Types of Solution-Focused Questions

Scaling questions, using a scale of 1 to 10, solicit a client's level of willingness and confidence in moving toward developing a solution and are subsequently used to observe progress. These questions may also be instrumental in preventing the client from returning to describing problematic behaviors and in developing specific behavioral indicators along a continuum of change (Corcoran, 2008; Trepper et al., 2006). Coping questions are intended to highlight and reinforce a client's resources and strengths. For example, how has the client managed the current difficulty, or what resources has he or she used previously when dealing with the issue? Coping questions credit the client's prior efforts to manage a difficulty and reenergize his or her strengths and capacities. Exception questions are considered the core of the intervention (Corcoran, 2008). Designed to diminish the problem focus, these questions assist a client to describe life when the current difficulty did not exist (Bertolino & O'Hanlon, 2002; De Jong & Berg, 2002, 2008; Shoham, Rorhbaugh, & Patterson, 1995; Trepper et al., 2006). The exception question also advances the client's ability to externalize or separate self from the problem by highlighting strengths and resources (Corcoran, 2008). Miracle questions draw the client's attention to what would be different once a desired outcome is achieved

Does the Approach Safeguard the Client's Right to Informed Consent?

So that clients are fully informed, you should explain the approach in language that is easily understood, presenting information about the benefits, risks, and evidence of the approach's effectiveness with their problem. This same information should be provided to involuntary clients, even though they may lack the freedom to withhold consent or to refuse a goal or service plan. They can, however, be given information about their options and the consequences of their choices. Does the client understand the proposed approach? Is the client in agreement with the proposed approach? Does the client have concerns about the procedures and effectiveness of an intervention, strengths, and limitation related to his or her particular problem? Is the client satisfied with the manner in which his or her progress would be monitored and measured? Informed Consent and Minors The ability to give consent is informed by developmental stage, and cognitive and reasoning ability Although minors are unable to give consent, they can nonetheless be provided with information about the approach and asked whether they assent; that is, they can give an "affirmative agreement"

Strengths and Limitations of the Task-Centered Model

Strengths Obstacles to task completion and goal attainment are identified and resolved Efficacy of the model has been supported by empirical evidence in multiple settings Emphasis on taking action on problems acknowledged by clients is believed to be appealing to racial and ethnic minorities Limitations Sustained therapeutic relationship with clients is unlikely to evolve Limited evidence to support to the utilization and effectiveness of the model

Crisis Strengths and Limitations of the Strategy

Strengths Perceptions of a crisis vary based on associated threats, client cognitions, ego strengths, coping capacity, and problem-solving skills Relieve emotional distress and develop a plan of action so that an individual or family's precrisis level of functioning is restored Limitation Impacts cognitive, affective, and behavioral functioning as a result of the cumulative effects of ongoing distress for a prolonged period of time Ell (1995) questions the assumption of time-limited crisis as well as the notion of homeostasis—specifically, whether the goal of restoring equilibrium is always possible. For instance, ongoing difficulties in the daily lives of people who are exposed to a chronic and constant state of vulnerability in their environments can mean that the focus on time-limited crisis episodes is neither feasible nor realistic. The efficacy of crisis intervention strategies nevertheless is not entirely diminished by Ell's observations. However, these observations do suggest significant factors that can impact cognitive, affective, and behavioral functioning as a result of the cumulative effects of ongoing distress for a prolonged period of time.

Trauma-Informed Resources

Substance Abuse Mental Health Services Administration (SAMHSA) Treatment improvement protocols Trauma-Informed Care in Behavioral Health Services Improving Cultural Competence National Center for Trauma Informed Care (NCTIC) National Child Traumatic Stress Network (NCTSN) National Native Children's Trauma Center Child Welfare Information Gateway

Solution Utilization with Minors

Successful, specific solution-focused therapy explores feelings, develops behavioral goals, and encourages positive behaviors in a school setting Positive outcomes reported for improving client social skills and managing school-related behavioral problems

Step 5: Summarize the Task Plan

Summarizing the task plan is the final step of the TIS. The summary, which takes place at the conclusion of a session, consists of a review of the actions or behaviors that a client has agreed to do in order to accomplish a task. In reviewing task agreements, you and the client confirm that you both have a clear understanding of what tasks are to be undertaken, in what sequence, and under what conditions, or whether further discussion or clarification is needed. Individual clients may find it beneficial for you to provide them with a session-by-session written summary of goals and related tasks. You might also encourage clients to write their own summary as well. In either case, both you and the client should have copies. In keeping with the ethical obligation of documentation, this information is included in the case record or SOAP notes. Furthermore, documentation is essential to monitoring and evaluating during the duration and termination of the contact.

Task Centered Step 1: Enhance the Client's Commitment to Carry out Tasks

This step involves clarifying the significance of tasks for reaching the goal and identifying the potential benefits. To encourage follow-through with tasks, it is important that clients perceive that the gains of completing a task outweigh the costs (including anxiety and fear) associated with risking a new behavior or dealing with a changed problem or situation. Because change is difficult, exploring apprehension, discomfort, and uncertainty is especially critical when a client's motivation to carry out a given task is questionable. It is advisable to begin implementing Step 1 of the TIS by asking clients to identify benefits they will gain by successfully accomplishing the task.

Implications for Social Work Practice

The consequences of trauma are complex, and as such, traditional treatment plans and goals are limited in their capacity to respond to the needs of trauma survivors. Trauma-informed practice is ideally individualized and flexible and validates the survivor's solution for recovery and healing. The trauma assessment may be incorporated with the biopsychosocial as discussed in Chapters 8 and 9. Exploring whether a current difficulty is related to a traumatic event is an important part of the assessment process. For example, certain behaviors that are considered to be maladaptive may in fact be a means of coping. Various trauma screening tools exist that can confirm the presence of and extent of trauma. However, professionals are encouraged to avoid hiding behind a mound of papers in order to determine the problem rather than listening to the client and the meaning that their difficulties has for them. In some instances, persons with a trauma history may be reluctant to disclose because of psychological barriers—for example, embarrassment, shame, or fear—focusing instead on more pressing needs or problems. Concepts and principles associated with trauma-informed care—for example, client participation, empowerment, recognition and utilization of strengths, resilience, the capacity for change and growth, and respecting the dignity and worth of clients—are in harmony with the ethics and value base of the profession.

The Crisis Intervention Model

The crisis intervention model discussed in this text is the equilibrium model, which is based on basic crisis theory. Knowledge of how to intervene with clients who are experiencing a crisis is considered essential for skilled practice While multiple disciplines including social work have played an important role in developing crisis theory, social workers have been responsible for advancing practice methods and skills and for formulating strategies for responding to crises

Cognitive 1. Assist Clients in Accepting That Their Self-Statements, Assumptions, and Beliefs Largely Determine Their Emotional Reactions to Life's Events

The power difference between you and clients is likely to become heightened when you present a goal of changing how they perceive themselves or their world. Thus, in the first step, it is important to provide clients with an explanation and your rationale for selecting cognitive restructuring as an intervention procedure To guide you in assisting clients to understand cognitive restructuring, it may be advisable to use self as an example to explain the technique, as demonstrated in the following dialogue. The social worker draws upon his own experience to show how ways of thinking and responding mediate cognitions, emotions, and thoughts: This example shows how the rationale for cognitive restructuring can be presented to a client in a simple, straightforward manner. A majority of clients, given an explanation, will agree to proceed. However, a client's commitment to the procedure is necessary because beliefs are not easily changed.

The Need for a Trauma-Informed Service Approach

The recognition and collective understanding of the prevalence and effects of trauma have resulted in a paradigm shift—in particular, the need for social services and mental behavioral and mental health providers and professionals to be trauma informed. Although trauma is thought to be subjective and defined by the individual, sensitivity to the potential of a trauma history is encouraged regardless of the client's presenting problem Creation of National Center for Trauma-Informed Care (NCTIC) Provides education, outreach, consultation, resources, and technical assistance to assist organizations To address and respond to the needs of clients with trauma histories Includes health systems, educational systems, and child welfare and juvenile systems

Solution Theoretical Framework

The solution-focused approach borrows from the social constructivists' perspective that people use language to create their reality (de Shazer & Berg, 1993). In the solution-focused approach, reality is constructed by culture and context, as well as perceptions and life experiences; thus, an absolute truth does not exist (Murray & Murray, 2004). For example, professionals have tended to impose truths about normative functioning or development that may have little relation to the reality of a client's situation (Freud, 1999; Nichols & Schwartz, 2004). Therefore, it is more important for you to understand the way in which a client constructs the meaning of his or her experiences and relationships. The approach also draws from assumptions of CBT—specifically, that cognitions influence a person's language and behavior.

Task Implementation Sequence

The task implementation sequence (TIS), as described by Reid (1975, 2000), involves a sequence of discrete steps. The steps (summarized in Table 13-1) involve the major elements generally associated with successful change efforts. Research suggests that clients were more successful in accomplishing tasks when TIS was implemented than when it was not (Reid, 1975, 2000), even though being faithful to the sequence may initially seem tedious. Merely agreeing to carry out a task doesn't guarantee that a client has the knowledge, resources, courage, interpersonal skills, or emotional readiness to successfully implement a task. Consequently, each step in the TIS is intended to increase the potential for a successful outcome:

The Task-Centered Model

The task-centered model is a social work practice model developed by William Reid and Laura Epstein. The model's contribution to social work practice is its specific focus on problems of concern identified by the client and its emphasis on tasks and the collaborative responsibilities between the client and the social worker.

Change-Oriented Approaches

Their aim is to facilitate the attainment of goals or respond to a mandate in the case of involuntary clients. Each of the approaches is supported by research and uses empirically grounded techniques or procedures that have demonstrated their effectiveness with clients of different ages, backgrounds, and needs. Each supports collaboration with clients, utilizing their strengths and increasing self-efficacy, all of which are critical aspects of empowerment. In addition, they are consistent with systematic generalist-eclectic practice as articulated by Coady and Lehmann (2008, p. 5). The essentials of generalist-eclectic practice are: A person and environment focus that is informed by ecological theory An emphasis on establishing a positive helping relationship and empowerment as well as a holistic multilevel assessment, including a focus on diversity, oppression, and strengths A problem-solving model that provides structure and guidelines for work with clients Flexibility in the use of problem-solving methods that allows a choice among a range of theories and techniques based on their compatibility with each client's situation

Trauma Evidence of the Approach

Trauma-informed care is considered evidence-based practice particularly for clients who have histories of trauma. This is the gold standard of care. Policies and practice recognize and acknowledge the histories that shape clients lives. Trauma histories are recognized as part of the treatment process rather than denying they exist. In the absence of trauma-informed policies and practices, survivors of trauma are unlikely to heal and recover. In essence, the trauma-informed approach can: Validate a part of people and a history that often has been dismissed or denied Create a safe place where people come for help, restoration, and motivation to continue Increase the effectiveness of services designed to empower clients in transition periods Provide opportunity to plant seeds of hope, demonstrate that someone in this world cares about them, and show clients that they matter Evidence-based studies that demonstrate the effectiveness of trauma-informed care continue to evolve. Presently, CBT and trauma-focused CBT (T-F-CBT) are the most widely used interventions and are regarded as the most promising

Trauma-Informed Care

Trauma-informed care refers to a person-centered and strengths-based service delivery approach in recognition of the prevalence of trauma among clients across settings and human services systems. Trauma-informed care understands and is responsive to the impact of trauma and emphasizes the "physical, psychological and emotional safety of providers and survivors, and creates opportunities to rebuild a sense of control and empowerment" in their lives In general, a trauma-informed approach refers to the delivery of services and includes an understanding and awareness of the impact and consequences of trauma exposure and of a history across settings and populations. Trauma is viewed through an ecological and cultural lens—specifically, the importance of context and the client perception and processing of traumatic events. Realizes the prevalence of trauma and understands the potential for recovery Recognizes the signs and symptoms of trauma in clients and how trauma affects all clients involved with the service delivery system, including its own workforce Responds by integrating the knowledge about trauma into practice, policies, and procedures Actively avoids practice and polices that can result in retraumatization Trauma-specific interventions support and recognize: The survivors' need to be respected, informed, connected, and hopeful regarding their own recovery The interrelation between trauma and symptoms of trauma such as substance abuse, eating disorders, depression, and anxiety The need to work in a collaborative way with survivors, family and friends of the survivor, and other human services agencies in a manner that will empower survivors and consumers

Crisis Intervention Model Duration of Contact and Focus

Typically, crisis work is time limited, spanning 4 to 8 weeks, although some clients or situations may require prolonged contact. Your contact with a client during the acute crisis period may be daily for a period of time, and may take place in an office, a shelter, a hospital, or in the home. he active, intense, time-limited, focused, and action-oriented nature of the crisis intervention approach is believed to help people return to a level of precrisis functioning (James & Gilliland, 2013; Roberts, 2005; Walsh, 2010). Ultimately, the level of distress, whether the crisis is acute or chronic, and client characteristics (perception of the crisis, ego strengths, and situation-specific resources such as social supports) will dictate the time required. The guiding principles of time-limited crisis intervention are as follows: The focus of crisis intervention is on the here and now. Hence, no attempt is made to deal with either precrisis personality dysfunction or intrapsychic conflict, although attention to these symptoms may be required. Goals are limited to alleviating distress and assisting clients to regain equilibrium. Tasks are identified, and task performance is intended to help clients achieve a new state of equilibrium. In crisis situations, the level of incapacity presented by the client may require you to have a more active and directive role than you might have in other interventions.

Intervening with Minors

Understanding the nature of the crisis and the minor's response to it is the first intervention step Type I involves a single, distinct crisis experience in which symptoms and signs are manifested; for example, the minor can display fully detailed etched-in memories, misperceptions, cognitive reappraisals, and reasons for the crisis event (James, 2008). Type II, in contrast, is the result of longstanding, repeated trauma whose cumulative effects result in the minor's psyche developing defensive coping strategies, anxiety, depression, or acting-out behavior The stages of crisis and the reaction may differ with minors. They may, for example, need additional help in understanding their reaction to the crisis and in developing problem-solving skills. triage system A framework for social workers to use in a crisis situation to assess the client's affective, behavioral, and emotional functioning; assess the severity of the situation; and plan the appropriate intervention strategy.

Standards of Case Management Practice

Utilizing a comprehensive assessment to determine the biopsychosocial functioning and care needs of clients, including their strengths and resources A client-centric, shared decision-making collaborative relationship between the client and the case manager, in which the client and, where appropriate, family members are involved in all phases of the case management process Planning and implementing services that address and are responsive to the unique needs of the client or family Adhering to professional values and principles, including self-determination, privacy, confidentiality, informed consent, and empowerment The primacy of the obligation to the client, which may involve advocacy, mediation, and negotiation to ensure access to services Monitoring progress and the evaluation of the achievement of targeted outcomes Utilizing the best evidence available to inform case management practice with specific populations, conditions, and needs

Task-Centered Step 2: Plan the Details of Carrying out Tasks

When a task involves both cognitive and behavioral subtasks, it is beneficial to help the client to be psychologically prepared before carrying out an overt action. By including cognitive (covert) strategies in this step, you are assisting clients to cope with their ambivalence or apprehension with regard to implementing actions. Of course, planning behavioral tasks that involve overt actions requires considering real-life details as well, such as transportation, child care, access to technology, financial resources, and the like. In planning the details of tasks, a social worker's tasks can be developed when he or she has ready access to resources or information that will facilitate client work. On the other hand, when it is advantageous for a client to complete a task on his or her own, a review of the actions involved would be helpful. During the performance of tasks, there may be occasions on which it will be useful for you to accompany the client or make use of his or her support system. When the time frame for completing tasks lacks specificity or is vague or abstract, clients and social workers can procrastinate, leaving little time to effectively implement the planned action. Because tasks connected to ongoing goals are incremental, it is important that you and the client begin with a structured first task that is easy and within the individual's capacity to achieve.

Benefits of a Crisis

some theorists and researchers suggest that negative events may actually promote growth in the aftermath of a crisis eople involved in the study reported experiencing benefits such as increased self-efficacy, spirituality, faith in people, and community closeness. The McMillen and Fisher study results are significant for two reasons: The deficit approach to psychosocial consequences appears to influence how human services professionals view clients and how clients view the experience. Specifically, professionals may tend to focus on the trauma alone, whereas clients may view the situation or event through multiple lenses. By understanding the benefits that accrue from crises, professionals can construct interventions that recognize and strengthen the benefits and increase successful outcomes. Understanding clients' reactions to a crisis, their perception of harm or vulnerability, and their affective, emotional, and behavioral functioning will help you plan and intervene appropriately. Otherwise, your intervention strategy may have little or no value to the client's situation.