Practice II - Exam 1 Dr. Gummelt

Stresses Associated with Life Transitions

Some transitions can occur in any stage of development --Adaptations may overwhelm coping capacities Involuntary or abrupt transitions and separations are highly stressful --Temporarily impair social functioning History, concurrent strengths and resources, and past successful coping can all affect adaptation to transitions Environment matters as well Those with strong support systems have less difficulty adapting Major transitions in adulthood: -Work, career choices -Health impairment -Parenthood -Post-parenthood years -Geographic moves and migrations -Marriage or partnership commitment -Retirement -Separation or divorce -Institutionalization -Single parenthood -Death of a spouse or partner -Military deployments Transitions in adolescents/children: -Changing grades, transitioning to middle or high school -Birth of sibling -Illness of parent or caregiver -Loss of social status at school through bullying/peer victimization -Breaking up with dating partner -Loss of friendship through death/argument -Death of parent/caregiver -Personal illness -Questions surrounding sexual identity -Addition of new stepparent to divorced family Milestones affecting specialized groups: -Gay and lesbian individuals making decisions about who and under what conditions to reveal sexual identities -Child whose parents are divorcing - loss of friends/change of school -graduations/weddings/holidays after death in family -Military deployments and returns

Values

Strongly influence human behavior and play a key role in problems presented Identify clients' values, asses role those values play in their difficulties, and consider ways values can be deployed to create incentives for change Cognitive dissonance - people discover inconsistencies between their values and behaviors --Can cause tension, confusion, distress, etc. --Ex: individual coming to terms with homosexuality within a religion that condemns LGBTQIA+ members

Data Sources and Interviewing Techniques

Trusting relationship with client's primary caregivers Interviews with collateral contacts Child assessments may include use of drawings, board games, dolls, puppets --Be attentive to implications of various facets of experience Developmental assessment - relevant for understanding child's history and current situation; parent or other caregiver provides info about circumstances of child's delivery, birth, and infancy; achievement of developmental milestones; family description and atmosphere; interests; significant life transitions; presenting problem including history of the problem; and school history Have parents construct genogram - visual picture of a client's family usually in form of family tree Screening instruments for children --Denver developmental screening test (up to 6 years old) ----Involves tennis ball, doll, zippered bag, and pencil ----Tests personal and social functioning, fine motor skills, language, and gross motor skills Screening instruments for geriatric clients --Activities of daily living (ADLs) - dressing, hygiene, feeding, mobility --Instrumental ADLs (IADLs) - managing money, taking medicine properly, completing housework, shopping, and preparing meals --Determination of need assessment --Instrumental activities of daily living screen --Katz index of activities of daily living --Direct assessment of functioning scale --Physical performance test Geriatric clients may be concerned with reminiscence and discussion of spirituality/beliefs, incapacitation/death Physical exams and health histories are important in assessment of older clients --Limitations in vision and hearing, restricted mobility and reaction times, pain management, and medication and disease interactions, sexual functioning --About 80% of older adults have at least 1 chronic health condition and 50% have 2 or more 15% of Americans over 65yo and 50% of nursing home residents suffer from depression --May be socially isolated and lack sense of community belonging --Combat with social engagement and community connection

Questions to Answer In Problem Assessment

Use as guide or checklist: --What are the clients' concerns and problem(s) as they and other concerned parties perceive them? --Are any current or impending legal mandates relevant to the situation? --Do any serious health or safety concerns need immediate attention? --What are specific indications of the problem? How is it manifesting itself? --What are the consequences? --Who else (persons/systems) is involved in the problems(s)? --What unmet needs and/or wants are involved? --How do developmental stages or life transitions affect the problem(s)? --How do ethnocultural, societal, and social class factors bear on the problem(s)? --How severe is the problem, and how does it affect the participants? --What meanings do clients ascribe to the problem(s)? --Where, when, and how often do the problematic behaviors occur? --How long has the problem gone on? --Why is the client seeking help now? --Have other risk factors (alcohol or substance abuse, physical or sexual abuse) affected the functioning of the client or family members? --What are the client's emotional reactions to the problem(s)? --How has the client attempted to cope with the problem(s), and what are the required skills to resolve the problem? --What are the client's skills, strengths, and resources? --What support systems exist or need to be created for the client? --What external resources does the client need?

Assessing Use and Abuse of Medications, Alcohol, and Drugs

Use of both legal and illicit drugs What prescribed and otc meds taken, whether they're taking them as instructed, and whether they're having intended effect --Can have side effects - drowsiness, apathy, changes in sexual functioning, muscle rigidity, disorientation, and stomach pains Alcohol abuse --16.6 million adults over age of 18 --Half a million adolescents between 12-17 --Associated with high incidences of suicide and violent behavior, homicide, child abuse, partner violence Illicit drugs --Dangerous or illegal activity to support habit --Variations in purity of drugs or methods of administration may expose user to added risks

Assessment: Focus and Timing

Varies according to task, mission, theoretical framework, theory, setting, clinical focus Assessment lasts from beginning of contact until termination Fluid and dynamic process Involves receiving, analyzing, and synthesizing new info as it emerges First session - elicits abundant info Assess info's meaning and significance as interaction unfolds Integrate data into formulation of the problem in collaboration with client; contact often stops here If continues - assessment continues, though not central focus Clients may withhold vital info until they're certain social worker is trustworthy Preliminary assessments often turn out inaccurate and need to be revised Assessment also means: written products that result from process of understanding the client Actual formulation/statement regarding nature of client's problems, resources, etc. Analysis and synthesis of relevant data into a working definition of problem Identifies associated factors and clarifies how they interact to produce and maintain problem Complex working hypothesis based on the most current data available Range from comprehensive biopsychosocial reports to brief analyses about very specific topics Scope and focus varies depending on: role of social worker, setting in which they work, needs presented by client

Priorities in Assessments

What does the client see as his/her primary concerns or goals? "Starting where the client is" Highlights social work's emphasis on self-determination and commitment to assisting individuals to reach their own goals Sharing concerns help relieve clients of some burdens and apprehensions and help identify hopes and goals for service What (if any) current or impending legal mandates must the client and social worker consider? What (if any) potentially serious health or safety concerns might require the social worker's and client's attention? Social workers must act if situations present serious, foreseeable, and imminent harm Then explore client's functioning, interactions with environment, problems and challenges, strengths and resources, developmental needs and life transitions, and key systems -- basic social history or personal history

Caveats about Using Knowledge and Theories

When applied too rigidly, theories may oversimplify the problem and objectify the individual client Adhering to a single preferred framework may obscure other relevant factors, blind the practitioner to limits in existing theory or knowledge, and inhibit them from pursuing promising new knowledge and interventions

Intellectual Functioning

Will help adjust verbal expressions so clients can comprehend better Help in assessing strengths/difficulties, negotiating goals, and planning tasks Consider client's ability to grasp abstract ideas, express themselves, and to analyze/think logically Level of educational achievement and vocabulary used Clients who have intellectual limitations --Use simply and easily understood words --Avoid abstract explanations --Actively seek feedback --Use multiple examples to convey ideas that are complex Client's presentation may be inconsistent with intellectual achievements due to illness, meds, head injuries, or use of substances

Getting Rid of the Mandate

Appeal to client's desire to be free of restraints by mandate/referral

Assessing Children and Older Adults

Assessment may be bound by systems they are apart of (hospitals, schools, families, assisted living facilities) Several professionals may hold pieces of the puzzle while none have the ability to put all the pieces together Since many of these clients are referred, client may disagree about presence/nature of problem or be unmotivated to address it

Cultural, Societal, and Social Class Factors

Ethnocultural factors influence what kinds of problems people experience, how they feel about requesting assistance, how they communicate, how they perceive the role of the professional, and how they view various approaches to solving problems

Intrapersonal Systems

Examines ways these affect interactions with people and institutions in individual's environment

Beliefs

Important mediators of both emotions and actions Can be unhelpful or inaccurate and destructive Identify misconceptions and sources to create comprehensive assessment

Collateral Contacts

Info provided by relatives, friends, teachers, physicians, child care providers, others who possess essential insights about relevant aspects of clients' lives Important when client's ability to generate info is limited/distorted Written consent is required before making contact Consider nature of relationship with client for validity

The Interaction of Multiple Systems in Human Problems

Intrapersonal - internal thoughts, perceptions, reactions Interpersonal - communication and interactions between 2 or more people Environmental systems - work, home, school, community Imbalance in one system leads to imbalances in others May lead to positive or negative affects

Social Worker's Personal Experience

Observations provide clues However, clients may not behave with social worker as they do with others Identify possible biases, distortions, or actions on your part first

Linking Goals to Target Concerns

Obtain info during assessment interview for developing preliminary goals Involuntary clients --Goals prescribed in mandate or court order Goals function best when linked to specific concern/problem and have clear performance standards Sometimes need to access resources of another agency Assessing needs and identifying, coordinating, monitoring, and evaluating various formal and informal service providers

Physical Environment

Physical environment - the stability and adequacy of one's physical surroundings and whether the environment fosters or jeopardizes the client's health and safety Free of threats like personal or property crimes Considering sanitation, space, and heat Safety for elder population

The Role of Knowledge in Assessments

"What you see depends on what you look for" Assessments informed by problem-specific knowledge Consider the nature of the problem presented by the client at intake and refer to available research to identify the factors that contribute to, sustain, and ameliorate those problems Poorly directed assessments lead to client discouragement, wasted professional and agency resources, harm

Goals for Involuntary Clients Should Include Motivational Congruence

Articulated and defined by another party (court) Conversation should be about how to meet the goals and an exploration of goals clients have themselves Strategies for developing goals with involuntary clients: --Motivational congruence --Agreeable mandate --Let's make a deal --Getting rid of the mandate

Assessment and Diagnosis

Diagnoses - labels or terms that may be applied to an individual or his/her situation Short-hand categorization based on specifically defined criteria Ex: medical condition, mental disorder, other classification Provide language through which professionals and patients can communicate about commonly understood constellation of symptoms Facilitates research on problems, identification of appropriate treatments/meds, linkages among people with similar problems "Puts a name to" experiences Help client and family learn more about condition, locate support groups, stay abreast of developments in understanding disorder Can't tell whole story Can become self-fulfilling prophecies - define client only in terms of label Can be bestowed in error and may obscure important info Assessments describe symptoms that support a particular diagnosis but go further to help understand client's history and background, effect of symptoms on individual, available support and resources, etc.

Assessing Affective Functioning

Emotions affected by cognitions and powerfully influence behavior

Severity of the Problem

Helps to determine patterns when the concern is acute and discover features associated with changes in severity Evaluate whether clients have capacity to continue functioning in community Intensity of situation will influence appraisal of client's stress, frequency of sessions, speed at which to mobilize support systems

Frequency of Problematic Behaviors

Looks at pervasiveness of problem and its effects Assess context in which problems arise and patterns followed Services for clients who experience problems on a more/less ongoing basis may need to be more intensive than for those who experience symptoms intermittently Clarifies degree of difficulty and extent to which it impairs daily functioning of individuals and their families Provides baseline against which to measure behaviors targeted for change

The Person-in-Environment

Many are apart of multiple cultures Functioning must be considered in relationship to their predominant cultural identity and the majority culture Factors that influence the goodness of fit between cultures: degree of commonality between the 2 cultures with regard to norms, values, beliefs, and perceptions; the individual's degree of bilingualism; and the level of similarity in physical appearance from the majority culture (skin color, facial features, body type)

Identifying the Problem, Its Expressions, and Other Critical Concerns

Presenting problem --Uncover sources, engage client in planning appropriate remedial measures If referred - use empathy, motivational interviewing skills, and negotiation Start where the client is People often answer in generalities when describing issues --Deficiency of something needed or excess of something not desired Often results in disequilibrium, tension, and apprehension When working with children --Meet with caregiver and child together to discuss role, confidentiality, and presenting problem --Then meet alone with caregiver to obtain in-depth understanding of problem --Then meet alone with child to assess view of problem --Continually check in with caregiver Problem for work - problem the social worker and client ultimately focus on in therapy --Distinct from presenting problem --May differ

Spirituality and Affiliation with a Faith Community

Spirituality - totality of the human experience that cannot be broken into individual components; human need for transcendence, meaning, and connectedness beyond the self Religion - socially sanctioned institution based on spiritual practices and beliefs; more formal embodiment of spirituality into relatively specific belief systems, orgs, and structures Spiritual assessment - may help social worker better understand client's belief system and resources Can have positive or negative effects Spirituality --Three areas: cognitive (meaning given to past, current, and personal events), affective (one's inner life and sense of connectedness to a larger reality), and behavioral (the way in which beliefs are affirmed, such as through group worship or individual prayer) Involve clergy or leaders of other faiths to work jointly

Diagnoses

labels or terms that may be applied to an individual or his/her situation

Using Interviewing Skills to Assess Substance Use

Abusers often blame others, lie, argue, distort, attempt to intimidate, divert the interview focus, or verbally attack social worker Need to express empathy and sensitivity to client's feelings Behaviors often hide embarrassment, hopelessness, shame, ambivalence, and anger Don't use vague, wordy, or indirect questions - be forthright and compassionate

Resources Needed

Determine whether services requested match function of agency and whether staff possesses the skills required to provide high-quality service Referral may be needed May have to perform a broker/case manager role - requires knowledge of community resources Consider self-help groups and natural support systems

Areas for Attention in Assessing Person-in-Environment Fit

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

Self-concept

Self-concept - convictions, beliefs, and ideas about the self Strengths in having good self-esteem and being realistically aware of one's positive attributes, accomplishments, and potential as well as limitations and deficiencies Self-critical people can pervade their functioning in the following ways: --Underachieving in life because of imagined deficiencies --Passing up opportunities because of fears of failing --Avoiding social relationships because of expectations of being rejected --Permitting oneself to be taken for granted and exploited by others --Excessive drinking or drug use to fortify oneself because of feelings of inadequacy --Devaluing or discrediting worthwhile achievements --Failing to defend one's rights "What comes into your head when you think about the sort of person you are?"

Goodness of fit

consider the degree to which the client experiences this with the culture in which they are situated

Reciprocal interaction

occurs between a person and the external world Person acts upon and responds to the external world, and the quality of those actions affect the external world's reactions

Culturally Competent Assessment

requires knowledge of cultural norms, acculturation, and language differences; the ability to differentiate between individual and culturally linked attributes; the initiative to seek out needed info so that evaluations are not biased and services are culturally appropriate; an understanding of the ways that cultural differences may reveal themselves in the assessment process --Cultures vary in child rearing, communication, family member roles, mate selection, care of the aged, etc. --Even in homogenous cultural subgroups, wide variations also exist among individuals

Coping Efforts and Needed Skills

"What have you tried to address this problem?"/"how has it worked?" Coping methods people use give clues about levels of stress and functioning Avoidance patterns - immersing self in school/work, withdrawing, numbing with substances May demonstrate controlling behavior, passivity/submissiveness, or collapse completely Cultural variations in how people approach problem solving Explore skills that have worked in the past but no longer do Identify subtle differences that account for varied effectiveness of clients' coping patterns Stops from giving a client premature advice that may not help them

Enactment

Clients reenact an event during a session Symbolic interactions - use of dolls, games, expressive/play therapy

Goals Must Relate to the Desired Results Sought by Voluntary Clients

For voluntary clients to motivated and emotionally invested, must be confident that working with you will lead to their concerns being addressed and resolved Maintain focus

Guidelines for Selecting and Defining Goals

Goals must relate to the desired results sought by voluntary clients Goals for involuntary clients should include motivational congruence Goals should be defined in explicit and measurable terms Goals must be feasible Goals should be commensurate with the knowledge and skills of the practitioner Goal should be stated in positive terms that emphasize growth Avoid agreeing to goals about which you have major reservations Goals should be consistent with function of the agency

The Interaction of Other People or Systems

Identify key individuals, groups, or organizations part of the client's difficulties Examine and determine how they interact Effective plan of intervention should take these elements into account Common systems individuals interact with: --Family and extended family or kinship network --Social network (friends, neighbors, coworkers, associates, club members, cultural groups) --Public institutions (educational, recreational, law enforcement and protection, mental health, social service, health care, employment, economic security, legal and judicial, and various governmental agencies) --Personal service providers (doctor, dentist, barber or hairdresser, bartender, auto mechanic, landlord, banker) --Faith community (religious leaders, lay ministers, fellow worshipers) Antecedents - events that precede problematic behavior --Give clues about behavior that may provoke/offend and trigger a negative reaction, followed by a counter negative reaction, setting reciprocal interaction in motion ABC model -A - antecedent -B - behavior -C - consequence

Motivational Congruence

People motivated to work on problems important to them Motivational congruence - work on target goals that are personally meaningful to the client and that also satisfy the requirements of the mandate Allow client to take control by describing mandated situation themselves Self-definition and involvement in process can be motivating factor by virtue of the fact that their view is solicited and heard

Areas for Attention in Assessing Strengths and Problems

Problems as seen by potential clients: --Health and safety concerns --Legal mandates --Culture, rac, gender, sexual orientation, and other areas of difference Problems and challenges: --Severity --Sites of problem --Duration --Temporal context --Frequency --Emotional reaction --Meanings attached --Consequences --Resource deficits Developmental needs and life transitions Strengths and resources: --Personal and family coping capacities, skills, values, motivations --Community resources and support networks including cultural supports

Typical Wants Involved in Presenting Problems

Typical wants: -Less family conflict -Feel valued by spouse/partner -Be self-supporting -Achieve greater companionship in marriage/relationship -Gain more self-confidence -Have more freedom -Control one's temper -Overcome depression -Have more friends -Included in decision making -Get discharged from an institution -Make a difficult decision -Master fear/anxiety -Cope with children more effectively Consider developmental stage Prelude to process of negotiating goals

Other Issues Affecting Client Functioning

Use of alcohol/substances, exposure to abuse/violence, presence of health problems, depression/mental health problems, use of prescription meds These questions can be asked in a straightforward and nonjudgmental way When working with children --Ask caregiver questions when child is out of room --Also ask adolescent questions without caregiver there --Explain confidentiality to adolescent and that troubling behavior would cause caregiver to be alerted

Emphasizing Strengths in Assessments

1. Give preeminence to the client's understanding of the facts 2. Discover what the client wants 3. Assess personal and environmental strengths on multiple levels Cowger developed a two-dimensional matrix framework for assessment to assist social workers in attending to both needs and strengths --Vertical axis - potential strengths and resources depicted at one end (top) and potential deficits, challenges, and obstacles at other (bottom) --Horizontal axis - ranges from environmental (family and community) (left) to individual factors (right) --4 quadrants (right top, left top, right bottom, left bottom) ----Quadrant 4 - personal deficits Strengths often overlooked or taken for granted during assessment: --Facing problems and seeking help rather than denying or otherwise avoiding confronting them --Taking a risk by sharing problems with the social worker - a stranger --Persevering under difficult circumstances --Being resourceful and creative in making the most of limited resources --Seeking to further knowledge, education, and skills --Expressing caring feelings to family members and friends --Asserting one's rights rather than submitting to injustice --Being responsible in work or financial obligations --Seeking to understand the needs and feelings of others --Having the capacity for introspection or for examining situations by considering different perspectives --Demonstrating the capacity for self-control --Functioning effectively in stressful situations --Demonstrating the ability to consider alternative courses of actions and the needs of others when solving problems

Range of Emotions

Ability to experience and express a wide range of emotions that befits the vast array of situations that humans encounter Anhedonia - unable to feel joy or to express many pleasurable emotions Blocking natural emotions can lead to extreme tension or asthma, colitis, and headaches Blocking emotions can also be a form of protecting oneself - appear tough, indifferent Ability to experience full spectrum of emotions is a strength

Appropriateness of Affect

Affect - emotionality Inordinate apprehension - muscle tension, constant fidgeting or shifts in posture, hand wringing, lip-biting, and similar behaviors indicates that a person is fearful, suspicious, or uncomfortable If clients are completely relaxed and express selves freely in a circumstance that would usually invoke apprehension, there may be a denial of the problem or a lack of motivation to problem-solve --Charming demeanor may reflect client's skill to project a favorable image -----Coping style to deal with insecurity, self-centeredness, manipulation, or exploitation Emotional blunting - muffled or apathetic response to material that would typically evoke a stronger response --Talk in a detached and matter-of-fact manner --Indicative of severe mental disorder, sign of drug misuse, side effect of meds, or indication of past trauma Inappropriate affect --Laughing when discussing painful event (gallows laughter) --Smiling constantly regardless of what's being discussed --elation/euphoria incongruent with situation --Constant and rapid shifts from one topic to another (flight of ideas) --Irritability, expansive ideas, constant motion - mania

Agreeable Mandate

Agreeable mandate - search for common ground that bridges the differing views of the involuntary client and the court May involve reframing the definition of the problem to address the concerns identified in the mandate/referral source while responding to concerns of the client Reframing reduces reactance, facilitates a workable agreement, and increases the client's motivation May be combined with motivational congruence

Let's Make A Deal

Bargaining strategy Private concerns of the involuntary client combined with problem that precipitated the mandate/referral

Intrapersonal Systems Chart

Biophysical functioning --Physical characteristics and presentation --Physical health --use/abuse of meds, alcohol, drugs --use/abuse of other substances --Dual diagnosis: comorbid addictive and mental disorders cognitive/perceptual functioning --Intellectual functioning --Judgment --Reality testing --Coherence --Cognitive flexibility --Values --Misconceptions --Self-concept --Assessing thought disorders Affective functioning --Emotional control --Range of emotions --Appropriateness of affect --Assessing affective disorders ----Bipolar disorder ----Major depressive disorder ----Suicidal risk ----Depression and suicidal risk with children, adolescents, and older adults Behavioral functioning -Excesses -Risk of violence -Deficiencies Motivation

Biopsychosocial Assessments

Biopsychosocial - the notion that when social workers assess clients, they evaluate the biological, psychological, and social domains and how these domains influence and are influenced by disease, disorder, or illness Assessments include obtaining info about: --Biological - physical health, psychological functioning, biochemical functioning, nutritional choices, and genetic heritage --Psychological - evaluating emotional well-being, affective presentation, cognitive functioning, general behavior, spiritual preferences, and personality --Social - examining interpersonal relationships and interactions, environment, culture, family, work, and faith community Assessments include the following: --Identifying info (name, age, referral source, brief overview of presenting problem) --History of present circumstances (presenting problem, symptoms) --Past psychiatric and medical history of client and client's family (injuries, operations, medical conditions, medication, ongoing medical treatment) --Client's social history (client's childhood, family structure, living situation, employment and history, educational history, hobbies, daily routine, religious/spiritual preferences, friends, past trauma, substance use) --Mental status exam and DSM-5 diagnosis --Formulation - statement that summarizes and synthesizes the most important aspects of the case to create a story of the client and his or her past and presenting problems For children and adolescents: --Brief overview of developmental milestones (crawling, walking, talking, toilet training, etc.)

Affective Disorders

Bipolar disorder --Presence of manic episodes with intervening periods of depression --Distinct period of abnormally and persistently elevated, expansive, or irritable mood --At least 3: ----Inflated self-esteem/grandiosity ----Decreased need for sleep ----More talkative than usual/pressure to keep talking ----Flight of ideas/subjective experience that thoughts are racing ----Distractibility (attention too easily drawn to unimportant/irrelevant external stimuli) as reported/observed ----Increase in goal-directed activity (socially, work/school, sexually) or psychomotor agitation (purposeless non-goal-directed activity) ----Excessive involvement in pleasurable activities with high potential for painful consequences such as unrestrained buying sprees, sexual indiscretions, or unwise business investments --Manic episodes - severe to cause impairment in job performance or relationships or to necessitate hospitalization to prevent harm --Biogenetic - lithium carbonate can have remarkable results --Commonly used meds have a relatively narrow margin of safety Major depressive disorder --Affected individuals experience recurrent episodes of depressed mood --More common than bipolar disorder --Painful emotions (dysphoria) and the absence of pleasure in previously enjoyable activities (anhedonia) --Painful emotions related to anxiety, mental anguish, sense of guilt, restlessness/agitation --Diagnosis requires depressed mood, loss of interest/pleasure, and at least 5 symptoms for 2 weeks: ----Depressed mood for most of the day, nearly everyday ----Markedly diminished interest/pleasure in all or almost all activities ----Significant weight loss or weight gain or decrease/increase in appetite ----Insomnia or hypersomnia ----Psychomotor agitation or retardation nearly everyday ----fatigue/loss of energy ----Feelings of worthlessness/excessive or inappropriate guilt ----Diminished ability to think/concentrate or indecisiveness ----Recurrent thoughts of death/suicidal ideation or attempts

The Role of Theory in Assessments

Brief, solution-focused therapy - based on assumptions - making small changes can lead to larger changes, focusing on the present can help the client tap into unused capacities and generate creative alternatives, and paying attention to solutions is more relevant than focusing on problems --Seeking exceptions ----Questions that determine when the problem doesn't exist or doesn't occur - different sites, times, contexts ----Exploration asks client to elaborate on what is different in those incidents and what other factors might cause the problem to be absent --Scaling the problem ----Asking the client to estimate the severity of the problem on a scale of 1 (very minor) to 10 (very severe) ----Helps in tracking changes over time, open up opportunity to ask what accounts for the current level of difficulty or relief, and determine what it might take to move from current level to lower point on scale --Scaling motivation ----Asks clients to estimate the degree to which they feel hopeful about resolution or the degree to which they have given up hope --The miracle question ----Helps determine client's priorities and operationalize the areas for change ----"If, while you were asleep, a miracle occurred and your problem were solved, how would things be different when you woke up?" ----Children - "If you had a magic wand, what changes would you make?" ----Helps client envision the positive results of the change process and elicits important info for structuring specific behavioral interventions Key to success lies in sensitivity and timing with which techniques used Sensitivity - inflection, tone of voice, eye contact, nonverbal methods Cognitive theories - suggest that thoughts mediate emotions and actions --Assessments focus on the nature of the client's thoughts and schemas (cognitive patterns), causal attributions, the basis for the client's beliefs, and antecedent thoughts in problematic situations Behavioral theories - actions and emotions are created, maintained, and extinguished through principles of learning --Assessments focus on the conditions surrounding troubling behaviors, the conditions that reinforce the behavior, and the consequences and secondary gains that might result --Create hypothesis about what triggers and reinforces the behavior in order to construct a plan involving new reinforcement patterns and a system for measuring change

Physical Characteristics and Presentation

Can be assets or liabilities In many cultures, physical attractiveness is highly valued and unattractive people may be disadvantaged in terms of social desirability, employment opportunities, or marriageability Body build, dental health, posture, facial features, gait, physical anomalies May create positive/negative perceptions about client, affect self-image, or pose social liability How people present selves --Walk slowly, stoop posture, talk slowly, without animation, lack spontaneity, show minimal changes in facial expression - depressed, in pain, or overmedicated Dress and grooming reveal person's morale, values, standard of living Is the dress appropriate for the setting? "Disheveled" appearance may indicate poverty, carelessness, grunge, or "rock star" fashion depending on interviewer's cultural background and values Hand tremors, rigid or constantly shifting posture, facial tics, tense muscles of face/hands/arms - may indicate illness, physical problem, or overmedication, high anxiety or tension

Risk of Aggression

Can be directed at social worker or others in client's environment - siblings, classmates, dating partners, parents, bosses Predictive factors: --Past violent behavior or criminal behavior --Early age of first criminal offense --Substance abuse --Gender --Psychopathy --Impulsiveness, anger, psychosis, interpersonal problems, antisocial attitudes Youth violence predictive factors: --Prior history of violence --Early initiation of violence --School achievement problems --Abuse --Maltreatment and neglect --Substance use problems --Impulsivity --Negative peer relationships --Community crime and violence Assess for following: --Personal history ----Child abuse/neglect, early exposure to violence in family, problems at school, threats/fights/assaults on teachers, antisocial behaivor, learning disabilities, ADHD, low IQ, head injury, physical problems --Interpersonal relationships and social supports ----Attitude toward people in general, how client interacts with practitioner, if client has close friendships, how client relates to members of opposite sex, recent hanges in relationships, difficulties with social interaction --Psychological factors ----Active substance use/abuse, manic phase of bipolar disorder, acute psychosis in paranoid schizophrenia, antisocial/borderline/paranoid personality disorder, low empathy, impulsivity, intermittent explosive disorder, inability to delay gratification --Physical conditions ----Intoxication, temporal lobe epilepsy, dementia, delirium, history of head trauma --History of violence ----How long been getting into fights, how often, how bad has client hurt someone, does client have criminal record, past hospitalization because of violent behavior --Current threats and plans of violence ----Is client currently angry at someone, is there anyone the client would like to hurt/kill, where is this person now, does client have access to weapon, how would client carry out threat and where --Current crisis and situation ----Current mood and behavior of client, memory difficulty, poor concentration, poor coordination, exaggerated preoccupation with sexual thoughts and fantasies, nonadherence to meds, recent release from incarceration

The Purpose and Function of Goals

Can develop short-term goals when trying to reach ultimate goal Point A - starting point - priority concern Point B - goal attainment - desired outcome Once goals established, tasks or objectives represent incremental action steps taken toward the desired outcome and within a designated time frame SMART goals - specific, measurable, action-oriented, realistic, timely goals - provide focus and direction to the work to be completed Setting goals also: --Ensures you and the client are in agreement, where possible, about outcomes to be achieved --Provides direction, focus, and continuity to the helping process and prevents wandering off course --Facilitates the development and selection of appropriate strategies and interventions --Assists you and the client in monitoring progress --Establishes the criteria for evaluating the effectiveness of a specific intervention and of the helping process

Goals

Central to achieving outcomes and working in systematic, process-oriented approaches such as the helping process Prominent in task-centered and crisis intervention models, cognitive reconstructuring, solution-focused brief treatment, and case management Goal statement - agreement that becomes the focus of the work to be completed by the social worker and client Intent is to address client's priority concern, condition, want, or need, or meet requirements of a legal mandate

Factors Influencing Goal Development

Client Participation --Client identifies concern, need, or want --Establish priority goal --Social worker: ----Facilitate process by assisting clients to specify, prioritize, and define goals; assess feasibility, identify barriers, and become aware of resources and strengths --Client: ----Expert; active involvement - social justice, empowerment, "starting where the client is" --Important to acknowledge and respect clients to create mutual problem-solving partnership Involuntary Status --Clients may be hesitant --Let them tell story so they can be understood, heard, and involved Values and Beliefs Resources and Supports --Family can be an asset Environmental Conditions --Age, race, gender, class, sexual orientation, structural inequality

Cognitive Flexibility

Cognitive flexibility - seek to grow, understand the part they play in difficulties, and understand others; ask for assistance People who are rigid and unyielding in beliefs pose obstacle to helping themselves Thinking in absolute terms (person is good or evil, success or failure, responsible or irresponsible) --Prone to criticize others --Difficult to live with --Relationship problems, workplace conflict, parent-child disputes common --Improvement involves helping them examine destructive impact of their rigidity, broaden their perspectives of themselves and others, and "loosen up" in general Negative cognitive sets - biases and stereotypes that impede relationship building or cooperation with members of certain groups (authority figures, ethnic groups, opposite sex) Severely depressed clients have "tunnel vision" and view selves as helpless/worthless

Dual Diagnosis: Addictive and Mental Disorders

Comorbidity - alcohol and other drug abuse problems occurring with health and mental health problems Combos of factors to take into account: --Type and extent of substance use disorder --Type of mental disorders and related severity and duration --Presence of related medical problems --Comorbid disability or other social problems resulting from use, such as correctional system involvement, poverty, or homelessness

Depression and Suicidal Risk with Older Adults

Comprise only 12% of population in US, but account for majority of suicide deaths White males - account for 70% of all suicides in 2013 Risk factors include isolation, ill health, hopelessness, functional/social losses Assessments --Geriatric depression scale 40%-75% of older adults don't take prescribed antidepressants due to lack of clinicians having the time or training to give effective explanations Noncompliance --Fear of becoming dependent --Medicine will prevent them from being naturally sad --Do not recognize depression as a medical condition --Forget to take them --Misunderstand dosage instructions --Fear they'll interact negatively with other meds --Taking 3 or more meds --Co-occurring diagnoses of depression and anxiety --Being dependent on substances --Caregiver who doesn't believe depression is medical condition --Lacking social support --Unable to pay for meds --God can heal them --Depression is punishment from God

Judgment

Consistently living beyond one's means, becoming involved in "get rich quick" schemes without exploring ramifications, quitting jobs impulsively, leaving small children unattended, moving in with a partner without knowledge of that person, failing to safeguard/maintain personal property, squandering resources Dysfunctional coping patterns --Leads to same unfavorable outcomes Impulse-driven --Lash out at authority figures, write bad checks, misuse credit cards

Assessing Needs and Wants

Determine unmet needs Determine barriers to utilization of resources Universal necessities (nutrition, safety, clothing, housing, health care) Wants - strong desires that motivate behavior and that, when fulfilled, enhance satisfaction and well-being

Temporal Context of Problematic Behaviors

Determining when problematic behaviors occur offers clues about factors at play in problems Sheds light on patterns of difficulties, indicates areas for further exploration, and leads to helpful interventions

Sites of Problematic Behaviors

Determining where problematic behavior occurs may provide clues about which factors trigger it Identifying where behaviors don't occur is also valuable to alleviate problem

Emotional Control

Emotional constriction - may appear unexpressive and withholding in relationships --Do not appear to feel joy, hurt, enthusiasm, vulnerability, and other emotions --May be comfortable intellectualizing but retreat from expressing/discussing feelings --Impress others with intellectual styles --Have difficulty maintaining close relationships because of emotional detachment Emotional excess - "short fuse"; lose control and react intensely to even mild provocations --Rages, interpersonal violence --Irritability, crying, panic, despondency, helplessness, giddiness --Determine whether response is appropriate and proportionate to situation Strengths include ability to bear painful emotions without denying/masking feelings or being incapacitated by them Emotionally healthy people can discern emotional states of others, empathize, and discuss painful emotions openly without feeling unduly distressed; also can share personal feelings in intimate relationships

Suicidal Risk

Factors associated with adults who are high-risk: --Feelings of despair and hopelessness --Previous suicide attempts --Concrete, available, and lethal plans to commit suicide (when/where/how) --Family history of suicide --Perseveration about suicide --Lack of support systems and other forms of isolation --Feelings of worthlessness --Belief that others would be better off if the client were dead --Advanced age (esp. For white males) --Substance abuse

Support Systems

Formal systems - schools, medical clinics, mentors, home health aides Natural or informal systems - neighbors, family, friends These systems may be part of problem Can also help with coping and client strengths

Goals Should be Defined in Explicit and Measurable Terms

General, vague, or unspecified goals result in unclear performance standards, subjecting clients to an experience in which confidence/capacity are challenged Explicitly defined and measurable goal statements clarify desired outcomes, under what circumstances they are to be achieved, and by whom, specify monitoring and measurement procedures Specify who is involved, what is expected, and under what circumstances the goal is to be achieved Record progress --Agencies typically have forms --Strengths and obstacles recorded --Tasks --Specify action steps/objectives --Tracking progress relative to status of goal --Completed, partially completed, not completed --Provide clients with folder that summarized priority problem and goal statement, related tasks, and progress notes - helps maintain collaborative relationship Establish baseline in beginning

Types of Goals

Goals may initially be expressed in broad terms - change in cognitive functioning, emotional functioning, or behavioral change Overt goal - requires action Covert goal - involves changing thoughts or feelings Shared goals - held in common and agreed upon by members of the system Reciprocal goals - developed in conjunction with all parties involved; agree upon exchanges of different behavior and to act/respond to each other in a different manner --Tend to be quid pro quo - i'll modify my behavior if you do

Distinguishing Program Objectives and Client Goals

Goals of organization found in mission statement Program objectives come from mission statements and inform how organizational resources are utilized to target a specific need/population/respond to a social problem Program objectives can also be related to outcomes sought by funders/purchase of service agreement (POS) --POS - governmental agency funds particular services to be provided by a nonprofit community agency Statements may focus on micro/mezzo/macro level issues Program objectives - general statements regarding the outcomes that are expected for all service recipients who are involved with an agency's program

Assessing Environmental Systems

Goodness of fit - transactions between the person and his/her environment Assist people to adapt to environment, altering environments to adequately meet needs of clients, or combo of the two Concepts of affordability, availability, and accessibility provide useful framework for examining transactions with other facets of the environment Tailor assessments to varied life situations, weighing needs against availability of essential resources and opportunities within environments Acknowledge strengths at play Basic environmental needs: --Physical environment that is adequate, stable, and fosters health and safety (housing and surroundings free of toxins) --Adequate social support systems (family, relatives, friends, neighbors, organized groups) --Affiliation with meaningful and responsive faith community --Access to timely, appropriate, affordable health care (vaccinations, physicians, dentists, meds, and nursing homes) --Access to safe, reliable, affordable child and elder care services --Access to recreational facilities --Transportation - to work, socialize, utilize resources, and exercise rights as citizen --Adequate housing that provides space, sanitation, privacy, and safety from hazards and pollution (air and noise) --Responsive police and fire protection and reasonable degree of security --Safe and healthful work conditions --Sufficient financial resources to purchase essential resources (food, clothing, housing) --Adequate nutritional intake --Predictable living arrangements with caring others --Opportunities for education and self-fulfillment --Access to legal assistance --Employment opportunities

Sources of Information for Assessments

How gathered: --Background sheets or other intake forms clients complete --Interviews with clients (accounts of problems, history, views, thoughts, events, and the like) - primary source --Direct observation of nonverbal behavior ----Info about emotional states and reactions - tone of voice, tears, clenched fists, vocal tremors, quivering hands, tightened jaw, pursed lips, variations of expression, gestures --Direct observation of interaction between partners, family members, and group members --Collateral info from relatives, friends, physicians, teachers, employers, and other professionals --Tests or assessment instruments --Personal experiences of the practitioner based on direct interaction with clients Important to respect clients' feelings and reports, to use empathy to convey understanding, to probe for depth, and to check with client to ensure your understanding is accurate Children - use of instruments, play, drawing, etc. Verbal reports should be augmented because faculty recall, biases, mistrust, and limited self-awareness may result in skewed/inaccuracy Home visits

Physical Health

Ill health can lead to depression, sexual difficulties, irritability, low energy, restlessness, anxiety, poor concentration, etc. Determine if clients are under medical care and when they last had a medical exam Especially important when working with groups that underutilize medical care --Could be limited by affordability, availability, or acceptability ----Affordability - client may not have health insurance coverage and may not be able to pay for services not covered by insurance - even if they have insurance there are costs of meds, deductibles, and copayments not covered ----Availability - location of services and hours available, transportation to reach them, adequacy of facilities and personnel to meet needs ----Acceptability - extent to which health services are compatible with client's cultural values and traditions - know significance of caregivers, folk healers, and shamans - fears of deportation if immigrants Genogram - family tree -Relationships, dates of births/deaths, illnesses, significant life events

The Diagnostic and Statistical Manual (DSM-5)

Important tool for understanding and formulating mental and emotional disorders Linked to The International Statistical Classification of Diseases and Related Health Problems (ICD-10) Codifies health and mental health disorders, symptoms, social circumstances, and causes of injury/illnesses Excessive focus on individual pathologies rather than strengths and societal and environmental factors Bound by time and culture Latest revision - may 2013 Imperfect and evolving process - used with caution and humility Diagnoses and assessments required for insurance reimbursement and other forms of payment Nonaxial system --Disorders assigned 3-5 digit code with digits after the decimal point specifying severity and course of disorder --Inclusion of ICD-10 code in parenthesis following each diagnostic code Sections contain: --Diagnostic criteria --subtypes/specifiers --Recording procedures --Diagnostic features --Associated features supporting diagnosis --Prevalence --Development and course --Risk and prognostic factors --Specific culture, gender, and age features --Functional consequences of the specific diagnosis --Differential diagnosis --Comorbidity Does not use a specific theoretical framework, recommend appropriate treatment, or address causation (etiology) of a disorder

Cognitive or Thought Disorders

Intellectual disability --Diagnosed in infancy or childhood --Lower-than-average intelligence and deficits in general mental abilities and impairment in everyday adaptive functioning in comparison to an individual's age, gender, and socioculturally matched peers --Measured using standardized tests and other means --Four levels: mild, moderate, severe, profound Schizophrenia --Psychotic disorder that causes marked impairment in social, educational, and occupational functioning --Onset during adolescence or young adulthood --Development may be abrupt or gradual --Combo of positive and negative symptoms (presence or absence) -----Positive - delusions (fixed beliefs that cannot be altered even in the presence of conflicting evidence), hallucinations (perception experiences of sound/sight/touch/taste in the absence of external stimuli), disorganized thinking/speech, and grossly disorganized behavior (switching rapidly between topics) or abnormal motor behavior (catatonia, agitation) -----Negative - flattened affect, restrict speech, avolition (limited initiation of goal-directed behavior) Major Neurocognitive Disorder (NCD) --Formerly referred to as dementia --Broader than dementia --Major decline in a single domain --Evidence of significant cognitive decline from previous level of performance in one or more cognitive domains (complex attention, executive function, learning and memory, language, perceptual-motor, or social cognition) --Affects daily functioning

Mental Status Exam

Intended to capture and describe features of the client's mental state Appearance --How does client look and act --Stated age, dress, clothing --Psychomotor movements, tics, facial expressions Reality testing --Judgment --Dangerous, impulsive behaviors --Insight ----To what extent client understands their problem ----How client describes problem Speech --volume : low, inaudible --Rate of speech: rapid, slow --Amount: poverty of speech Emotions --Mood: how client feels most of time ----Anxious, depressed, overwhelmed, scared, tense, restless, euthymic, euphoric --Affect: how client appears to be feeling at time ----Variability (labile) ----Intensity (blunted, flat) Thought --Content: what client thinks about ----Delusions: unreal belief, distortion Delusions of grandeur: unusual or exaggerated power Delusions of persecution: unreal belief that someone is after the client Delusions of control: someone else is controlling the client's thoughts/actions Somatic delusions: unreal physical concerns ----Other thought issues Obsessions: unrelenting, unwanted thoughts Compulsions: repeated behaviors, often linked to obsession Phobias: obsessive thoughts that arouse intense fears Thought broadcasting: belief others can read the client's mind Ideas of reference: insignificant or unrelated events that have a secret meaning to client ----Homicidal ideation: desire or intent to hurt others ----Suicidal ideation: range from thought, desire, intent, or plan to die ----Process: how the client thinks Circumstantiality: lack of goal direction Perseveration: repeated phrase, repeated topic Loose associations: move between topics without connections Tangentiality: barely talking about the topic Flight of ideas: rapid speech that is unconnected Sensory perceptions --Illusions ----Misperception of normal sensory events --Hallucinations ----Experience of one of the senses: olfactory (smell), auditory (hearing), visual (sight), gustatory (taste), tactile (touch) Mental capacities --Orientation times four: oriented to time, person, place, and situation --General intellect: average or low intelligence --Memory: remote (past presidents), recent (what client ate yesterday for breakfast), and immediate (remember three items) --Concentration: distraction during interview, count backward by 3s Attitude toward interviewer --How the client behaves toward the interviewer: suspicious, arrogant, cooperative, afraid, reserved, entertaining, able to trust and open up, forthcoming

Social Support Systems

Interactions change across time Challenge in diagramming client's social networks is to include salient boundaries of client's situation and specify how the systems interact, fail to interact, or are needed to interact in response to client's needs Ecomap - identifies and organizes relevant environmental factors outside of individual or family context --Clarifies supports and stresses in client's environment and reveals patterns such as social isolation, conflicts, or unresponsive social systems --Show direction in which resources flow --Can be completed by social worker following discussion with client or in tandem with client --Client systems in middle circle and systems relevant appear in surrounding circles --Nature of positive interactions, negative interactions, and needed resources can be depicted by using colored lines to connect individual or other family members to pertinent systems, with different colors representing positive, negative, or needed connections and interactions with those systems --Different types of lines (single, double, broke, wavy, dotted, cross-hatched) can be used to characterize relationships and flow of resources Benefits of social support systems: --Attachment that gives a sense of security and belonging --Social integration provided by memberships in network of people who share interests and values --The opportunity to nurture others which provides incentive to endure in the face of adversity --Physical care when persons are unable to care for themselves because of illness, incapacity, or severe disability --Validation of personal worth provided by family and colleagues --Sense of reliable alliance provided by kin --Guidance, child care, financial aid, and other assistance in coping with difficulties/crises There can be negative effects as well --Overprotective parents stunting development --Street gangs fostering violence --Friends ridiculing/sabotaging person's aspirations --Family members not there in times of need/sadness, but there for joyous events

Duration of the Problem

Knowing when problem developed and under what circumstances Assists in evaluating degree of problem, unraveling psychosocial factors associated with problem, determining source of motivation to seek assistance, and planning appropriate interventions Precipitating events - events that immediately precede decisions to seek help; particularly informative; often give clues about critical stresses that might be overlooked normally Some may not know source of problems - could be an exacerbation of long-term multiple problems and intervention may be long-term - or could be an acute onset and intervention may be short-term When working with children, obtain info from other adults in child's life (teacher, coach, school social worker, counselor, pediatrician)

Assessing Motivation

Learned helplessness - individuals who don't believe they can influence their environments; a passive resignation that their lives are out of their hands Prochaska and DiClemente - five-stage model for change: --Precontemplation ----A lack of awareness of the need for change --Contemplation ----Client recognizes his or her problem and the consequences that result --Determination ----Client is committed to action and works with the clinician to develop a plan for change --Action ----Implements the changes identified --Maintenance ----Takes steps to avoid problem recurrence Motivational Interviewing (MI) --Specialized, person-centered method for addressing ambivalence and enhancing motivation to move toward healthy change --Employs specific attitudes and techniques to reduce and defuse resistance --Developing and highlighting discrepancies

Use and Abuse of Other Substances

List on page 222 Common general indicators: --Changes in attendance at work/school --Decrease in normal capabilities --Poor physical appearance, neglect of dress and personal hygiene --Use of sunglasses to conceal dilated/constricted pupils and to compensate for inability to adjust to sunlight --Unusual efforts to cover arms to hide needle marks --Association with known drug users --Involvement in illegal/dangerous activities to obtain drugs Rates among older adults on rise --High risk for misuse of prescription drugs Talk to systems and other individuals who care for individual/are around them

Coherence

Major thought disorders characterized by rambling and incoherent speech Looseness of association/derailment - successive thoughts are highly fragmented and disconnected from one another Practitioner may be able to understand the sequence of words, but the direction they take is governed by rhymes, puns, or other rules apparent to the client but not to practitioner Flight of ideas - client's response seems to "take off" based on a particular word or thought, unrelated to logical progression or the original point May be indicative of head injury, mania, or thought disorders such as schizophrenia, or acute drug intoxication

Meanings that Clients Ascribe to Problems

Meaning attributions - meanings people place on events --As important as events themselves --Influence way people respond to difficulties Distorted attributions -Pseudoscientific explanations -Psychological labeling -Fixed beliefs about others -Unchangeable factors -Reference to "fixed" religious or philosophical principles, natural laws, or social forces -Assertion based on presumed laws of human nature Many attributions aren't permanent People capable of cognitive flexibility and eager to examine roles in problematic situations to modify behavior Vital to explore and resolve attributions before negotiating change-oriented goals or implement interventions

Assessing Cognitive/Perceptual Functioning

Meanings and interpretations of events Perceptions Thought patterns influenced by intellectual functioning, judgment, reality testing, coherence, cognitive flexibility, values, beliefs, self-concept

Depression and Suicidal Risk with Children and Adolescents

More than 4000 youths in U.S. ages 10-24 die by suicide each year 11.7% of all deaths in this age group In U.S., suicide is the 3rd leading cause of death for children 10-14 as well as for 15-34 WHO - --Every year 800,000 people commit suicide --2nd leading cause of death for those between 15-29 Similar to signs in adults, but more irritability and somatic complaints Difference between childhood and adolescent depression --Prevalence between boys and girls is the same in middle childhood --In adolescence, girls are twice as likely to experience depression than boys --Girls report more feelings of anxiety, inadequacy, and low self-esteem when depressed, while boys report more aggressive and antisocial feelings Symptoms: --Deterioration in personal habits --Decline in school achievement --Marked increase in sadness, moodiness, and sudden tearful reactions --Loss of appetite --Use of drugs/alcohol --Talk of death/dying (even in joking manner) --Withdrawal from friends and family --Making final arrangements such as giving away possessions --sudden/explained departure from past behaviors (shy to thrill-seeking or outgoing to sullen/withdrawn) Specific subgroups may experience unique risk factors Suicidal risk highest when adolescent experiences symptoms listed as well as feelings of hopelessness, has recently experienced a death of a loved one, has severe conflict with parents, has lost a close relationship with a peer/love interest, or lacks a support system Issues with parents is highly reported Adolescent males complete more suicides and females attempt more Assessments: --Suicidal ideation questionnaire --Suicidal ideation questionnaire JR --SAD-PERSONS --Diagnostic predictive scales --Columbia suicide screen

Sample Mini Mental Status Report

Mr. Stewart presents as unshaven, thin, with unkempt hair, and older than his stated age. No abnormal body movements or tics are noted. Mr. Stewart is alert and oriented times four. His thought content and processes appear normal (although there are no specific questions to address delusions, hallucinations, or intellect). He describes his mood as euthymic, and his affect is guarded. Although he is inquisitive about the clinician's notes and he provides only brief answers, Mr. Stewart is cooperative. His judgment is impaired, as seen by his driving while intoxicated and missing work. Mr. Stewart's insight appears limited, as he has come for evaluation to appease his wife and does not see his drinking as heavy or problematic. He denies thoughts or plans of suicide or homicide.

The Multidimensionality of Assessment

Multidimensionality of human problems is consequence of fact that human beings are social creatures who depend on others and complex social institutions to meet their needs Extent to which people experience self-esteem depends on certain individual psychological factors and the quality of feedback from others Requires extensive knowledge about client and systems (economic, legal, educational, medical, religious, social, interpersonal) Consider interactions among biophysical, cognitive, emotional, cultural, behavioral, and motivational subsystems Attend to client's immediate concern, identify legal/safety concerns, be attuned to strengths and resources in case, consider all sources of info, be alert to own history, values, biases, and behaviors

Maltreatment

Older adults and children are at risk Be able to detect abuse/neglect and report it Four areas: -Neglect -Physical abuse -Sexual abuse -emotional/verbal abuse For older persons, also: --Self-neglect --Financial exploitation Signs of abuse: --Physical injuries - burns, bruises, cuts, broken bones with no satisfactory or credible explanation, injuries to head/face --Lack of physical care - malnourishment, poor hygiene, unmet medical/dental needs --Unusual behaviors - sudden changes, withdrawal, aggression, sexualized behavior, self-harm, guarded/fearful behavior at mention of or in presence of caregiver --Financial irregularities - missing money/valuables, unpaid bills, coerced spending First discuss case with supervisor before reporting

Assessing Behavioral Functioning

One person's behavior doesn't influence another person's behavior in simple linear fashion - instead a circular process in which the behavior of all participants reciprocally affects and shapes the behavior of other participants Helpful to think of problems as consisting of excesses or deficiencies --Excess-related problems - aim to diminish/eliminate behaviors such as temper outbursts, too much talking, arguing, competition, and consumption excesses --Behavioral deficiencies - help clients acquire skills and behaviors to function more effectively to increase behaviors such as expressing feelings directly, engaging in social conversation, listening to others, solving problems, managing finances, planning nutritious meals, being a responsive sexual partner, and handling conflict Determine antecedents of behaviors as well - when/where/how frequently occur Determine consequences of behaviors Explore thoughts that precede, accompany, and follow behavior and nature and intensity of emotions associated with behavior

Getting Started

Opening social amenities Explanation of direction and length of interview Explore client's presenting problem --Open-ended question Does any danger exist that the client might harm themselves or others? --Ensuring safety is most important

Emotional Reactions

People often gain relief by expressing troubling emotions --Common reactions are worry, agitation, resentment, hurt, fear, and feeling overwhelmed, helpless, hopeless Emotions strongly influence behavior - impel people to behave in ways that exacerbate or contribute to difficulties Intense reactions often become primary problems and overshadow the antecedent problematic situation

Assessing Biophysical Functioning

Physical characteristics, health factors, genetic factors, use/abuse of drugs/alcohol

Alcohol Use and Abuse

Problematic use could be related to other problems in work, school, and families Moderate use could be sign of escape or self-medication and lead to impaired judgment and risky behavior alcoholism/alcohol dependency different from heavy drinking in the way that it causes distress and disruption in life of user and in lives of those in social and support systems --Preoccupation with making sure that amount of alcohol necessary for intoxication remains accessible --May affiliate with other heavy drinkers to escape observation --Hides bottles or "evidence", drinks alone, covers up binges Feelings of guilt and anxiety appear which leads to more drinking to escape negative feelings - leads to intensification of negative feelings Females who abuse alcohol --More likely to abuse prescription drugs too, to consume substances in isolation, and to have had the onset of abuse after a traumatic event such as incest or racial or domestic violence --Less likely than men to enter and complete treatment programs because obstacles include stigma and lack of transportation/child care Adverse effects on offspring --Fetal alcohol syndrome (FAS) to fetal alcohol effects (FAE)

Client Self-Monitoring

Produces a rich and quantifiable body of data Empowers client by turning them into a collaborator in the assessment process Clients track symptoms on logs or in journals, write descriptions, and record feelings, behaviors, and thoughts associated with particular times, events, symptoms, or difficulties Recognize occurrence of event, use self-anchored rating scales Focus attention on patterns - clients gain insights May have goals and ideas while discussing Also assists in evaluation

Written Assessments

Provides foundation on which goals and interventions are based Appraisals are reconsidered and revised based on new info and understanding May be done at intake following a period of interviews and evaluations May be done at time of transfer or termination as well (summary assessment) May be brief and targeted or longer with a social history, detailed report for court, or comprehensive biopsychosocial assessment Standards: --Remember your purpose and audience ----Know standards and expectations in work setting and understand needs of those who will review document --Be precise, accurate, and legible ----If unclear on a point, note that in your report ----Document sources of info and specify basis for any conclusions ----Organize material to paint comprehensive picture of client's situation, strengths, and challenges ----Keep details that illustrate point, document actions, or substantiate conclusions --Avoid use of labels, subjective terminology, and jargon ----Use client's own words or substantiate conclusion ----Be factual and descriptive rather than using labels and subjective terms

Assessment Instruments

Psychological tests, screening instruments, and assessment tools Might receive reports of testing and incorporate findings into assessments Intelligence tests (Wechsler Adult Intelligence Scale, Wechsler Intelligence Scale for Children), instruments to assess health and mental health (Million Clinical Multiaxial Inventory, Minnesota Multiphasic Personality Inventory, Patient Health Questionnaire), Burns Depression Checklist, Beck Depression Inventory, Zung Self-Rating Depression Scale, Beck Scale for Suicidal Ideation Instruments to measure alcohol/drug impairment (Michigan Alcoholism Screening Test, Drug Abuse Screening Test) Some instruments use mnemonic devices to structure questions CRAFFT - 6 questions to assess alcohol use in adolescents CAGE - 4 items in which an affirmative answer to any single question is highly related with alcohol dependence --Have you ever felt you should CUT down on your drinking? --Have people ANNOYED you by criticizing your drinking? --Have you ever felt bad or GUILTY about your drinking? --Have you had an EYE OPENER first thing in the morning to steady nerves or get rid of hangover? Older Americans Resources and Services Questionnaire - activities of daily living Enhance reliability and validity of assessment and provide baseline for monitoring and evaluation Important role in case planning and intervention selection

Reality Testing

Reality testing - critical index to a person's mental health Meets following criteria: --Being properly oriented to time, place, person, and situation --Reaching appropriate conclusions about cause-and-effect relationships --Perceiving external events and discerning the intentions of others with reasonable accuracy --Differentiating one's own thoughts and feelings from those of others Clients who are disoriented may be severely mentally disturbed, under the influence of drugs, or suffering from a pathological brain syndrome Disoriented clients typically respond inappropriately or give bizarre/unrealistic answers Those without thought disorders may choose to blame circumstances/events rather than take personal responsibility Mild distortions - stereotypical perceptions ("all social workers are liberals") Moderate distortions - marked misinterpretations of the motives of others and may severely impair interpersonal relationships ("my wife wants to take an evening class, but I know what she really wants is to meet other men") Extreme distortions - may have delusions or false beliefs (others planning to harm them when that isn't the case) Auditory hallucinations - clients hear voices or other sounds Visual hallucinations - clients see things that aren't there

Case Notes

Record info in client charts based on each meeting/contact with client and after other significant contacts about the case Provide accountability, corroborate the delivery of appropriate services and support clinical decisions SOAP notes Subjective observations --Info shared by the client or significant others --Recent events, emotions, changes in health/well-being, changes in attitude, functioning, or mental status --Paraphrased and presented as "The client reports..." "The patient's mother states..." "She indicates..." "Patient's husband complains of..." --Direct client quotes kept to minimum Objective data --Factual, precise, and descriptive --Based on observations or written material --Presented in quantifiable terms - factors that can be seen, heard, smelled, counted, or measured --Avoid conclusions, judgments, and jargon --Substitute descriptions that would lead to conclusions with more objective commentary --Ex: instead of "the client was resistant" it might say "the client arrived 20 minutes late, sat with her coat on and her arms folded, and did not make eye contact with this writer" Assessments --Include diagnoses, judgments, and clinical impressions --Based on both subjective and objective data the precedes assessment Plans --Following appointments, next steps, referrals needed, and actions expected of client and worker Each entry should begin with date and end with social worker's name, credentials, and signature Entries should be completed ASAP after contact to ensure accuracy and relevancy

Assessment

Refers to a process occurring between a social worker and client in which info is gathered, analyzed, and synthesized to provide a concise picture of the client and his/her needs and strengths Formal assessments - 1 or 2 sessions Determine whether the agency and the particular social worker are best suited to address client's needs Identify eligibility for services and make referrals to other resources Secondary or host settings - social work isn't primary profession Joint effort of psychiatrist, social worker, psychologist, nurse, teacher, speech therapist, or members of other disciplines Compile social history and contributes knowledge related to interpersonal and family dynamics Assessment process may take longer