Overview: Defining and linking assessment, intervention and evaluation

1
Chapter 1

• Overview Defining and linking assessment,
  intervention and evaluation

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Core functions of social work practice

• Assessment gathering data via multiple sources
  and multiple domains in order to understand the
  clients problems and adaptive strengths
• Intervention applying a variety of practice
  skills collaboratively with the client and others
  to reduce problems and enhance adaptive
  capabilities
• Evaluation continuous monitoring of key outcomes
  to track client progress
• All three functions of contemporary social work
  practice must be integrated

3
Components of practice theories

• Underlying assumptions and propositions about the
  nature of human behavior
• Theoretical explanations about how people change
• Actual skills and interventions (i.e.,
  combinations of skills) used to help clients
  reduce problems and enhance adaptative coping
• Some practice theories represented in social work
  texts are based largely on suppositions and value
  statements, not scientific evidence. Social
  workers should critically examine all three
  components of a practice theory to see that they
  are supported by research evidence.

4
Assessment methods

• Qualitative description
• Psychiatric diagnosis
• Scales and indexes
• Behavioral analysis
• In vivo observation
• Systems analysis (e.g., family, community)

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Person factors in assessment

• Assessment of person factors goes beyond merely
  noting demographic data, but includes attention
  to the subjective meaning clients give to gender,
  race, ethnicity, sexual orientation, religion and
  spirituality and so on.
• Practitioners should avoid making broad
  assumptions regarding personal identity factors
  since their meaning and significance can vary
  from client to client.

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Sources of assessment data

• Although not always possible, it is important for
  practitioners to gather data from more than one
  source.
• Client self-report is usually the most common
  source of assessment data.
• Naturalistic observation or observation of
  role-played situations can be informative also.
• The use of scales and indexes can be very helpful
  in providing both more comprehensive assessment
  data as well as providing a somewhat objective
  baseline for ongoing monitoring and evaluation of
  the case.

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Scales and indexes

• Scales are measurement instruments that use
  multiple items to measure the same concept (e.g.,
  depression, self-esteem, quality of life).
• Scales must be tested with hundreds of clients
  and meet rigorous scientific standards before
  they are considered reliable and valid for use in
  practice, research or evaluation (more about this
  in Chapter 4).
• Indexes are usually one-item indicators of a key
  problem such as number of alcoholic drinks
  consumed in a day, number of days absent from
  school, number of times a couple argues in a
  week.
• The use of scales and indexes is increasingly
  required as part of assessment and evaluation
  procedures in social work practice.

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Defining interventions

• A social work intervention is the informed use of
  a skill or combination of skills by the
  practitioner in collaboration with the client and
  others intended to improve the clients
  psychological and social wellbeing.
• Research strongly suggests that there are three
  major categories of social work practice skills
  support and relationship building skills,
  therapeutic coping skills, and case management
  skills.

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Supportive skills

• The use of relationship building, listening and
  empathic attunement to engage the client in the
  working relationship and help facilitate change
• Research strongly suggests that supportive and
  relationship building skills are essential to
  effective treatment.
• Research also suggests that supportive skills
  alone are not sufficient for helping clients with
  more serious and complex problems.

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Therapeutic coping skills

• Therapeutic coping skills are used to help
  clients develop and improve upon a wide range of
  problem-solving strategies.
• Coping skills are drawn largely from the
  cognitive-behavioral intervention research.
• Coping skills can be used to help clients improve
  and self-regulate dysfunctional thinking,
  emotional distress, and behavioral difficulties.
• Mastering coping skills requires instruction,
  modeling and coaching by the practitioner and
  ongoing practice in real life by the client.

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Case management skills

• Case management skills are used to coordinate
  complex interventions, facilitate networking and
  referrals, advocate for clients (e.g., benefits,
  jobs), and enhance social and instrumental
  supports.
• Effective case management requires good
  communication and leadership skills.
• Case management is also essential for effecting
  cost-effective services by improving treatment
  integration among multiple providers.

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Combining skills

• Effective interventions require optimal
  combinations of supportive, coping and case
  management skills that meet the clients needs as
  identified by the comprehensive assessment.
• Although supportive skills provide the foundation
  for the intervention, development of the
  intervention should be guided by two criteria 1)
  the relevant practice outcome research 2)
  ongoing re-assessment and evaluation based on
  discussion with both client and relevant
  collaterals (as needed).

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Family and group work

• Although the word client is used for the sake
  of parsimony, it is understood that all the
  assessment, intervention and evaluation skills
  discussed in this text apply to family and group
  modalities as well.
• Although the basic principles of assessment,
  intervention and evaluation are the same
  regardless of modality, family and group work
  require that these skills be applied with an
  additional understanding of the complex systemic
  interactions among members as an important part
  of the process of change.

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Evaluating practice

• Evaluation is a natural extension of assessment,
  both qualitative and quantitative, and
  practitioners should ideally integrate these two
  important aspects of practice.
• Evaluation of each case is necessary and readily
  accomplished by tracking changes with sound
  qualitative and quantitative indicators.
• Clients are usually willing to participate in
  developing and carrying out the evaluation plan.
• Routine monitoring and evaluation of individual
  cases can tell us if clients are improving, but
  is not a strong design for determining
  intervention effectiveness because routine
  evaluation cannot account for non-intervention
  factors that affect clients.
• The use of common outcome measures in a program
  provides a solid foundation for program
  evaluation, and improves consistency in the
  assessments and evaluations conducted by
  practitioners who work in the same program.

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The Psychosocial Intervention Scale

• The PSIS (Appendix A in the text) can be used to
  1) examine ones own use of practice skills with
  individual clients over time 2) compare the use
  of different skills with different clients over
  time.
• Social work students should examine the current
  practice outcome research to examine whether
  their selected combinations of skills reflect
  current evidence-based practices.

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The CSP

• The Comprehensive Service Plan (CSP) provides a
  generic framework suitable for many service
  environments to help students develop their
  skills in conducting assessment, intervention
  planning, and evaluation.
• The writing of clear and concise CSPs is a
  critical function of professional social work
  practice.
• Ethical, legal, fiscal and other administrative
  mandates now require that social work
  practitioners be prepared to justify their
  assessment, intervention and evaluation plans
  with the current research.

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Chapter 2 The relationship between
research and practice

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Why is there a chapter on research in my social
work practice text?!!

• Because in addition to adhering to core values,
  social worker practitioners are expected to
  develop a command of current knowledge regarding
  human behavior theories in their chosen field of
  practice, and also to develop advanced
  intervention skills in order to effectively help
  their clients.
• In modern professions, knowledge and skills are
  determined by systematic testing known as the
  scientific method. Critical reviews of current
  research findings are the criteria by which
  social workers and other helping professionals
  determine what is known about valid human
  behavior theories, valid assessment and
  evaluation methods, and effective psychosocial
  interventions.
• Although most social workers will not become
  researchers (although more should), it is
  imperative that they develop their abilities to
  critically read and understand research articles
  so that they can better distinguish valid
  theories and effective practices from those that
  may be intuitively appealing but not supported by
  evidence. Keeping up with the research can make
  you a better practitioner.

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So how can reading research inform my practice?

• Assessments must be informed by sound human
  behavior theories, that is, theories that have
  been validated by a body of high quality
  research.
• Interventions must be tested in controlled trials
  (i.e., a fair comparison to an alternative
  treatment) before being considered an established
  intervention.
• Evaluation methods depend largely on the use of
  assessment tools that must also be shown to
  supported by research studies.

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Human behavior research

• There are two main types of research relevant to
  social work practice human behavior research and
  practice research
• Human behavior research tests theories about the
  interactions among biological, psychological,
  social, and environmental dimensions of human
  experience.
• Human behavior theory also provides a foundation
  for assessment, both qualitative and
  quantitative. Client narratives alone are not an
  adequate basis for assessment if the practitioner
  is not knowledgable about the nature of mental
  illnesses, addictions, the impact of social
  factors, differences in gender, race etc

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Practice research

• Practice research is used to test and validate
  the efficacy and effectiveness of social work
  practices.
• Uncontrolled research, where we test one type of
  practice without comparing it to another form of
  practice, is used as a preliminary step in
  testing promising practices.
• Controlled research, where we compare one type of
  treatment to another, provides a stronger basis
  for establishing the efficacy of an intervention.
  Multiple controlled trials must be used before an
  intervention is deemed to be evidence-based.
• Evaluation is usually similar to uncontrolled
  research. We can determine if clients improve in
  routine practice, but it is hard to determine if
  the results were primarily the result of the
  intervention.

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The basic research process

• The first step for researchers is to carefully
  examine the research that has been previously
  done on a human behavior or practice topic.
• In the review, researchers pay close attention to
  the quality of the methods (i.e., methodology)
  used to conduct the study.
• The stronger the methods used, the more
  confidence one can put in the results of a study.
• This process is generally referred to as the
  Review of the literature, and should end with a
  new research question.

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The methodology section

• Reviewing the literature and posing a new
  question is the first step in research.
• The next major step is to propose a plan to
  answer that question. The methods used to answer
  the question are collectively referred to as the
  Methodology section of a research article.
• Methodology includes Sample selection, design,
  the data collection procedure, the selection of
  measures (i.e., scales and other instruments),
  and a procedure for analyzing the data.
• If the study is an intervention study, the
  researchers must also describe in detail how the
  intervention is to be conducted.

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How research findings inform social work practice

• The details of how to review research studies are
  described in more detail in Appendix C of your
  text. Students should review that section and use
  the outline to read human behavior and
  intervention research studies to better
  understand how they provide a basis for social
  work practice.
• Since no single study definitively answers
  important questions about human behavior or
  intervention effectiveness, practitioners can
  read summaries of studies called Reviews of the
  literature to obtain state-of-the-art
  information about current theories and practices.
  Reading critical reviews in well-respected
  journals might be the most efficient way to keep
  up with the knowledge base.

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But dont our textbooks provide that information
for us?

• Many textbooks used in schools of social work are
  not based on current scientific research.
• Also, some social work texts rely almost
  exclusively on social work sources. Although
  social workers make important contributions to
  research, our knowledge of human problems and
  interventions is informed by multiple disciplines
  (i.e., medical research, psychology, sociology,
  anthropology, economics, etc). To rely solely on
  social work sources neglects vast areas of
  knowledge regarding human problems and ignores
  important and effective practice methods.
• Social workers are in a strategic position to
  incorporate interdisciplinary knowledge to
  improve our understanding of human problems, our
  assessment methods, and our intervention
  strategies.

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Social work anti-research bias and counter-point

• Social work students and practitioners often
  opine that research is too technical or lacks
  the human touch.
• One might consider an alternative view claims to
  being compassionate and empathic mean very little
  if a social worker cannot command
  state-of-the-art knowledge that informs their
  understanding of their clients difficulties, use
  best practices and valid assessment and
  evaluation methods.

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• Chapter 3 Essential ethics
• in social work practice

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The NASW Code of Ethics

• Students should read and review in detail the
  NASW Code of Ethics on-line at naswdc.org.
• Highlights of core ethical guidelines included
  here include privacy and confidentiality,
  informed consent, conflicts of interest, personal
  demeanor and poorly planned interruption and
  termination of services.

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Privacy and confidentiality

• Social workers should give the utmost care to
  protecting clients rights to privacy and
  confidentiality, and not reveal information about
  their service with clients to third parties
  without expressed written permission of the
  client or under court-order.
• Even under court-order, social workers can
  challenge the order or narrow the request to only
  specific relevant information.
• Social workers can breach confidentiality if
  their client makes a clear and imminent threat to
  do harm to another person (see Tarasoff
  decision). Practitioners have a duty to warn
  the person who is the potential target of
  violence.

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Informed consent

• It is the obligation of the practitioner to
  obtain informed consent from the client giving
  the practitioner permission to provide services.
• Practitioners should also educate the client in
  clear language about the nature of the
  intervention they are about to provide. Hence,
  the clients consent must be informed.
• Practitioners should also provide only those
  services in which they are competently trained.

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Conflicts of interest

• Practitioners should keep the focus of the social
  work intervention clearly in mind at all times
  to use professional knowledge and skill to help
  the client.
• When this purpose becomes muddled with a
  competing need of the practitioner (e.g.,
  obtaining a favor from the client through a
  mutual acquaintance) this situation might
  constitute a conflict of interest.

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Personal demeanor

• Social workers are expected to conduct themselves
  ethically at all times with their clients (and as
  members of the community).
• Professional conduct requires a degree of
  self-care regarding their own mental health and
  moral comportment as it relates to their behavior
  with colleagues and with clients particularly.
• Engaging in romantic or sexual behavior with a
  client is one example of a serious breach of
  ethics.
• Practitioner-client boundaries with regard to
  their repective roles should be adhered to at all
  times.

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Interrupting and terminating service

• Practitioners should discuss at the beginning of
  service what the guidelines are for terminating
  treatment such as when intervention goals are
  met, a pre-arranged time-line, or when client
  decides it is time to discontinue treatment.
• Practitioners should not discontinue service if a
  client is in crisis.
• Practitioners have an obligation to facilitate an
  orderly referral and transition to another form
  of care should the client need further services.

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Avoiding breaches of ethics

• Define practitioner-client roles clearly.
• Collaborate and agree on a clearly written
  intervention plan and treat it as a contract.
• Anticipate problems before they arise.
• Maintain good self-care in ones personal life.
• Get personal or legal consultation when ambiguous
  situations arise.
• Use current research evidence to support ones
  assessment and treatment plan.

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Chapter 4 Conducting the assessment
and planning the evaluation

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Two key organizing concepts

• Multidimensionality 1) Clients problems and
  adaptive strengths are influenced by multiple
  influences over time 2) these problems and
  strengths vary in degree across multiple
  psychosocial domains (psycho-social, health,
  material resources, financial, legal, etc).
• Functionality clients problems do not vary
  randomly but vary in somewhat predictable
  patterns over time. It is the practitioners job
  to help clients understand how the problem
  works so they can self-monitor their problems
  and put the benefits of the intervention to work.

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Five steps in assessment/evaluation planning

• Determining the sources of data (e.g., client,
  collaterals, previous records, etc)
• Decide on methods for collecting data (e.g.,
  interviews, observation, use of scales and
  indices, etc)
• Conducting the MDF assessment (interacting
  individual, family, social factors and relevant
  patterns)
• Consider the implications of the data (types and
  severity of problems/strengths) problem
  hierarchy (priorities), goals, and types of
  interventions recommended in the research
• Develop the evaluation plan What measures? Who
  will collect the data? How and when?

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Sources of data

• Client self-report is the most widely relied upon
  source of assessment data.
• Client self-report is often not sufficient,
  however.
• Collateral sources (e.g., family members, school
  personnel, other professionals etc) are often
  necessary sources when working with clients
  including children, adolescents, involuntary
  adult clients among others.
• Obtaining collateral data usually (but not
  always) involves client informed consent.

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Methods of data collection

• Interviews are typically used to collect most
  data from clients, significant others and other
  collateral sources.
• Unstructured interviews provide flexibility but
  should be guided by some kind of assessment
  framework.
• The interviewer is responsible to see that
  adequate assessment data is collected in a
  relatively brief period of time.
• Semi-structured and structured interviews might
  be used in some treatment settings and in
  research settings where a more strict protocol is
  followed.

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Methods of data collection

• Observation can be a more objective and often
  very informative type of assessment.
• It is less affected by interpretive bias on the
  part of a client or significant other.
• Observation can take place in natural settings,
  classrooms, treatment facilities, among other
  situations.
• Observation of clients during interventions can
  also be informative (e.g., during planned role
  plays, observing family members interactions,
  watching children engage in play activities with
  toys, dolls, etc)

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Methods of data collection

• Use of scales and indices are an important
  adjunct to the qualitative assessment.
• They can provide more thorough and accurate
  assessment of specific problems (e.g, depression,
  substance abuse, behavior problems).
• Since they have usually been normed on broader
  populations, they can provide a benchmark for
  judging the relative severity of a problem or
  level of adaptation.
• They also provide a quantitative baseline for
  monitoring and evaluating client change over
  time.
• Instruments used in practice need to have a
  published track record of reliability, validity
  and utility.

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The MDF assessment

• Practitioners should strive to be thorough in
  assessing the multidimensional domains of
  clients psychosocial wellbeing over time (i.e.,
  past to current view)
• This means assessing mental status,
  relationships, family and social functioning,
  work, health, substance use and other domains
  (see the CSP).
• It also means making current judgments about how
  mild, moderate or severe the deficits might be as
  well as to what degree the client demonstrates
  adaptive strengths in these same domains.
• The various domains of client wellbeing are often
  inter-related (e.g., mental status, health and
  substance abuse), and if practitioners dont
  inquire about certain problems, clients will
  often not volunteer the information.

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The MDF assessment

• Factors related to these various dimensions of
  wellbeing interact over time in unique ways from
  one client to the next.
• The functional aspect of the assessment is an
  important way of understanding how a clients
  thoughts, feelings and behaviors interact in
  patterns over time.
• This behavioral mapping helps both practitioner
  and client identify where critical
  vulnerabilities exist in the clients day-to-day
  life, and also reveal opportunities for change,
  problem reduction and improved adaptation.
• Assessment becomes an important part of the
  intervention because clients learn to
  participate in the ongoing assessment by
  monitoring and evaluating their own behavior over
  time. This process empowers to client to take
  responsibility for increasing their own
  self-regulation and self-care, a necessary part
  of maintaining gains after formal intervention
  has been terminated.

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Consider the implications of the data

• Assessment data does not speak for itself
  practitioners must make inferences about the
  meaning of assessment data and its relevance for
  intervention planning.
• These inferences should be informed by two major
  sources 1) the meaning that clients ascribe to
  their own personal experience 2) the
  practitioners research-based knowledge about the
  clients problems.
• Neither source alone is sufficient. Client
  self-report is often not sufficiently objective
  or informed research-based knowledge about the
  clients problems (e.g., mental illness, domestic
  violence, childhood disorders) is based on large
  samples of clients, not one individuals unique
  experience.
• The challenge for practitioners is to reconcile
  human behavior knowledge with a clients unique
  experience.
• The assessment then provides a foundation for the
  Comprehensive Service Plan the practitioner and
  client can now collaborate to set priorities,
  define treatment goals, and plan an
  evidence-based intervention.

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Developing the evaluation plan

• Conducting a thorough qualitative and
  quantitative assessment provides the foundation
  for the evaluation plan.
• The social worker and client should agree on
  those indicators that are key to demonstrating
  progress. These may be simple indexes or formal
  published scales.
• Clients should collaborate in the evaluation
  process by using qualitative recording and
  quantitative rating methods to determine whether
  they are successfully achieving their goals.
• Participation in evaluation efforts is typically
  empowering and often gratifying for the client.
• However, client and practitioners point-of-view
  might not always be in agreement. This situation
  often occurs with involuntary clients. Thus,
  the evaluation, ultimately, is the primary
  responsibility of the practitioner, not the
  client.

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Chapter 5

• Supportive skills

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Basic interviewing skills

• Effective interviewing skills are the most basic
  elements of all intervention methods.
• Knowing how to encourage clients to be
  forth-coming about their difficulties, put them
  at ease, and talk about themselves is essential
  to establishing a supportive working
  relationship, the foundation of effective
  helping.
• Poor interviewing skills will create great
  obstacles to a successful intervention.

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Basic interviewing skills

• Use open-ended questions to provide clients with
  broad flexibility in response possibilities.
• Use close-ended questions when you want
  specifics.
• In general, the rythym of an interview should
  flow from the general to the specific.
• Good interviewers use both inductive (i.e.,
  accumulation of data) and deductive (i.e.,
  drawing conclusions) logical styles.

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Some other basic guidelines

• As an interviewer, be yourself, be relaxed.
• Being yourself does not mean indulging in
  self-disclosure it means allowing your demeanor
  and body language to be congruent with who you
  really are as a person.
• Affected professionalism and aloofness is
  off-putting to most clients and does not engender
  trust.
• Be mindful of your own non-verbal communications
  (e.g., facial expression, non-verbal utterances,
  etc).
• Use reflection to validate that you understand
  what the client is saying.
• Dont pretend that you are following when you are
  not. Say, I dont understand, and ask for
  clarification.
• Periodic check ins (tracking to see that you
  are following) also help to move the interview
  along and form a coherent narrative.
• Occasionally sum things up to see if you really
  understand what the client is saying. Feeling
  understood is very important to the client.

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Interviewing children

• Basic principles of interviewing adults apply to
  children as well, but with some differences.
• Know your childs developmental cognitive
  capabilities (see your child development text).
• Use simple language ask for clarification when
  you dont understand.
• Dont overly structure an interview. Encourage a
  free-flow of information.
• Toys, games, dolls, drawing etccan be very
  useful for encouraging the child to communicate
  freely. These methods are best thought of as
  facilitative for communication and not
  diagnostic.
• Summarize what a child has told you, and ask him
  to change anything or correct any mistakes you
  have made.
• Observe childrens non-verbals and body language
  carefully.

51
Other aspects of supportive skills

• Again, be yourself genuine and authentic.
• Communicate genuine empathy let the client know
  whether you understand how they feel or what they
  have experienced.
• Empathy does not suggest that you condone bad
  behavior. It communicates that you understand the
  clients frame of mind and what they might be
  feeling or were feeling at the time.
• Compassion goes beyond empathy, and can be shared
  with a client when called for (e.g., death of a
  loved one, diagnosis of a serious illness).

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Other aspects of supportive skills

• Engender trust through consistency be on time,
  pay attention, stick to the treatment plan,
  return phone calls, dont make excuses, be
  reliable.
• Provide genuine encouragement and try to motivate
  your client help them to transcend hopelessness
  and achieve even small successes.
• Avoid arguing with clients roll with
  resistance.
• Clarify your role and draw clear boundaries as
  needed. As a result of other interpersonal
  experiences, clients sometimes construe the
  relationship to be more than it is. If this
  situation occurs, examine the clients feelings,
  clarify matters as needed, but remind the client
  of your respective roles.
• Continue to collaborate on updating the
  assessment, amending the intervention plan, and
  conducting the evaluation. These activities
  remind the client of the nature of the important
  work at hand.

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Chapter 6

• Therapeutic coping skills

54
Purpose of therapeutic coping skills

• Therapeutic coping skills cover a range of
  methods social workers can use to help clients
  learn better ways of dealing with dysfunctional
  thinking, emotional problems, and
  behavioral/situational difficulties.
• Therapeutic coping skills are well-researched in
  the clinical practice literature and are largely
  derived from cognitive-behavioral interventions.
• When used within the context of a sound working
  alliance in individual, family or group
  modalities, these methods can help clients learn
  to cope better with their difficulties, engage in
  more effective problem-solving on their own
  initiative, improve interpersonal relations, and
  build on their own adaptive strengths.
• Some coping skills might be used as a sole
  intervention, but they are usually used in
  combination as part of an overall intervention
  plan. Supportive skills continue to provide a
  foundation that will make coping skills more
  effective.

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Cognitive coping skills

• Cognitive theories maintain that many problems
  are maintained through dysfunctional thinking
  faulty information, irrational thinking, or
  negative appraisal of lifes events.
• Examining dysfunctional thinking can help reduce
  dichotomous thinking, catastrophizing, jumping
  to faulty conclusions about other peoples
  behavior, and other problematic forms of
  reasoning.
• Psycho-education can help improve clients basic
  understanding of their difficulties (e.g.,
  effects of traumatic abuse, depression, the
  nature of panic attacks, effects of substance
  abuse).
• Explanation and interpretation can sometimes help
  clients see problems in a different and more
  positive or useful light.
• Self-monitoring (discussed as part of assessment
  and evaluation) can facilitate client
  collaboration in treatment, and provide an
  empirical learning experience for the client to
  help them better understand their difficulties
  and discover new solutions.

56
Emotion coping skills

• Psycho-education about feelings can help
  clients become more feelings-literate and
  understand better how thoughts, feelings and
  behaviors interact.
• Meditation, relaxation and mindfulness can help
  clients gain perspective on their emotions,
  become less reactive to them, and better regulate
  disturbing emotions and reduce impulsive
  behavioral responses to them.
• Consistent physical exercise can have a
  significant positive impact on stress, anxiety,
  depression and anger given that emotional
  well-being is closely tied to physical wellbeing.

57
Behavioral coping skills

• Modeling behavior (e.g., practitioner to
  adolescent client parent to child, etc) is an
  effective way to help others learn a skill,
  improve behavior, and cope with problems.
• Role play and rehearsal can help clients
  practice a skill (e.g., improved communication
  between partners) in a safe environment
  accompanied by constructive feedback.
• Covert desensitization (using a combination of
  imagery and relaxation methods) can help a client
  learn to cope with a troubling scenario in their
  minds eye (e.g., refusing a drink when
  visiting family post-rehab) under the guidance of
  the practitioner.
• In vivo exposure helps clients gradually confront
  difficult problems in real life. The step-by-step
  approach reflects a hierarchy of goals from least
  difficult to most difficult. The positive
  reinforcement that results from success
  experiences is a powerful therapeutic change
  agent for a wide range of problems. The guidance,
  encouragement and empathic support of the social
  worker is essential to its success.

58
Chapter 7

• Case management skills

59
Defining case management

• Case management can be defined two ways 1) as
  an overall model comprised of a set of different
  interventions (e.g., Assertive Case Management
  Family Preservation) 2) as a number of discrete
  skills that can be used individually or
  collectively and combined with supportive and
  coping skills.

60
Case management skills

• Enhancing social supports
• Helping clients obtain instrumental supports
• Advocating for clients
• Networking, coordinating and brokering of services

61
Enhancing social supports

• Social workers can help a wide range of clients
  gain greater access to social supports.
• Social skills training, a form of coping skill,
  can be used to help clients obtain greater
  benefit from available social supports.
• Enhancing social supports can be done through
  informal or more structured methods (e.g., social
  club for people with mental illnesses).

62
Instrumental supports

• Social workers can help clients obtain material
  supports by reviewing eligibility requirements
  for health insurance and other public and private
  benefits, assisting clients in completing paper
  work, knowing how to access other community
  resources (e.g., thrift shops, second-hand
  clothing stores, community food banks, etc).
  These supports can provide much needed relief to
  clients over the short or long term.

63
Advocacy

• Social workers can help clients obtain what they
  need in a variety of situations obtaining and
  maintaining employment, dealing with landlord
  disputes, coping with legal problems, obtaining
  needed servicesby coaching clients in such
  situations or by directly representing their
  clients with the clients permission.
• Many social work clients are disempowered members
  of society, are often the target of
  discrimination and stigma, and can benefit from
  the professional representation of a social
  worker.
• Social workers should also know their limitations
  in these matters and work with clients to obtain
  legal representation when needed.

64
Networking and coordination of services

• Social workers play an important role in
  cooperating with other professionals (e.g.,
  teachers, doctors, social services, etc) and
  ensuring that clients needs are adequately
  addressed.
• Networking and coordinating services requires
  excellent communication and leadership skills.
• Increasing pressures for cost-effective care
  require that social workers also work to reduce
  redundant, unnecessary or counter-productive
  services for clients.

65
Chapter 8

• Schizophrenia, mood
• and anxiety disorders

66
Schizophrenia background data

• Schizophrenia spectrum disorders (there are
  several subtypes) are marked by serious to severe
  cognitive symptoms including hallucinations and
  delusions, trouble expressing emotions, and
  difficulties in social functioning often
  including severe social withdrawal.
• Onset of the disorder occurs typically in the
  late teens and early 20s, and the course of the
  disorder tends to be chronic.
• Anti-psychotic medications, assertive case
  management and skill-based interventions can help
  people with schizophrenia reduce symptoms and
  function reasonably well in the community.

67
Assessment

• Delusions, hallucinations, other forms of
  bizarre, disorganized and troubling thinking
  should be carefully examined.
• Emotional wellbeing should be thoroughly
  assessed many people with schizophrenia are also
  profoundly depressed and suicidal.
• Social functioning, ability to relate to others
  and function in the community is often
  significantly compromised.
• Substance abuse is a common co-occurring disorder
  and should be assessed thoroughly.
• Material resources are often limited, and ability
  to take care of oneself physically (e.g.,
  hygiene, eating properly) can be greatly
  impaired.
• Clients with major mental illnesses generally
  suffer from poorer health than other people.
  Physical examination is recommended.
• Legal difficulties should be assessed. Clients
  often need assertive advocacy in court should
  they commit legal infractions in the community.

68
Intervention

• A supportive relationship is very important for
  establishing trust with a client diagnosed with
  schizophrenia, providing motivation to stick with
  treatment, and learn essential skills to live in
  the community.
• Psycho-education and behavioral family therapy
  have been shown to be very helpful for the client
  and their family. Family members learn about the
  disease and how to better relate and
  problem-solve with the client in a more low-key
  manner to avoid emotional and behavioral
  outbursts.
• Coping skills can help the client deal with
  day-to-day challenges in the community, improve
  communication skills, monitor symptoms and ask
  for help when needed, and reduce substance use.
• Assertive case management (ACT) has come to be
  seen as an essential framework for delivering
  multiple services to clients with schizophrenia.
  ACT provides a framework that can be used to
  coordinate range of other interventions.

69
Major mood disorders background data

• Major depression and bi-polar disease are
  considered major mental illnesses. Some clients
  also experience delusions, but some do not.
• In addition to periods of deep depression (i.e.,
  low energy, depressed mood, lack of pleasure,
  withdrawal and poor social functioning), clients
  with bi-polar disease also experience periods of
  manic energy often accompanied by fights of
  ideas and impulsive behaviors.
• As with schizophrenia, suicide rates in clients
  with depression and bi-polar disorder are much
  higher than in the general population.
• Co-occurring substance abuse is also fairly
  common in people with mood disorders.

70
Assessment

• Low energy and reduction in physical activity
• Poor social functioning
• Loss of pleasure in previously enjoyable
  activities
• Depressed mood and/or manic episodes
• Low self-esteem
• Guilt and self-recrimination
• Disordered sleep and/or appetite
• Suicide risk (i.e., hopelessness, having the
  means, opportunity, etc)
• Co-occurring substance abuse

71
Intervention

• Interventions for major mood disorders are
  similar to those used with schizophrenia and
  often overlap since some clients may be diagnosed
  with both classes of disorders.
• Medications are reasonably effective for both
  depression and bi-polar disease.
• Cognitive-behavior therapies in combination with
  medication is considered an effective treatment
  for clients with mood disorders.
• CBT coping skills include identifying
  dysfunctional thinking setting up opportunities
  for clients to test out their troubling and
  depressing beliefs (i.e., behavioral
  disconfirmation), problem-solving skills, and
  improving social skills to reduce isolation and
  withdrawal.
• Interpersonal psychotherapy with moderately
  depressed clients can also be effective by
  focusing on resolving interpersonal problems.
• Clients with major mood disorders can also
  benefit from case management services as needed.
  

72
Anxiety disorders background data

• Although not considered a major mental illness,
  anxiety disorders can be very debilitating.
• Anxiety disorders, as a whole, are fairly common
  problems
• These include phobias, panic disorder with
  agoraphobia post-traumatic stress disorder,
  obsessive compulsive disorder, generalized
  anxiety and others.
• Anxiety disorders are often accompanied by
  depression and/or co-occurring substance abuse
  problems.

73
Assessment

• Chronic worrying, frightening and dread-filled
  thoughts obsessional worries
• Physiological and somatic disturbances tremors,
  gastro-intestinal upset, sleep disturbance,
  racing heart-beat
• Avoidant behaviors (people, places, situations)
• Negative consequences of anxiety on interpersonal
  relationships, work, school
• Other related health problems
• Co-occurring substance abuse problems

74
Intervention

• A number of CBT methods have been shown to be
  very effective for some anxiety disorders.
• Generalized anxiety responds well to relaxation,
  physical exercise and making life-style changes.
• Phobias, panic-attack/agoraphobia and
  obsessive-compulsive disorder respond well to
  graduated exposure methods with and without
  medication (depending on client differences).
• Systematic desensitization helps many clients
  with PTSD, but some clients do not respond as
  well.
• Medications are sometimes helpful in treating
  anxiety disorders, but not always necessary for
  successful remission and management of these
  disorders.

75
Chapter 9

• Substance use and
• personality disorders

76
Substance abuse and personality disorders
background

• Substance abuse and addiction are fairly common
  problems and often co-occur with other mental
  health disorders
• Substance abuse and addiction are best thought of
  existing on a continuum from mild, moderate to
  severe.
• Most addictions are treated on an out-patient
  basis these days although in-patient
  detoxification is sometimes necessary when
  clients are at risk to experience severe
  withdrawal symptoms.

77
Assessment

• Carefully interview all clients about what
  substances (legal, illicit, or medications with
  and without prescription) they have used and are
  using now
• How much (in what quantity, dose) they use them
• How often and under what circumstances they use
• Consider effects on mood, interpersonal
  relationships, health, daily functioning,
  financial and legal problems (a functional
  assessment helps here)
• Clients are often very forthcoming about what
  drugs they use and how often (although some may
  be less so), but clients tend to underestimate
  the consequences of use.

78
Intervention

• Effective interventions include a range of
  cognitive behavioral coping skills and related
  approaches.
• Practitioners can use the working relationship to
  help motivate clients to participate in treatment
  and not get discouraged easily.
• Challenging and amending dysfunctional thinking
  that precipitates drinking (e.g., Its the only
  way I can relax.) can be useful.
• Coping methods include self-monitoring for at
  risk situations and planning coping responses to
  specific situations
• Relaxation methods and physical exercise
• Couples and family therapy
• Contingency management programs a collaborative
  approach between the courts and social workers
  whereby rewards and sanctions are used to
  encourage adjudicated clients stay clean and
  sober.
• Mutual help groups such as Alcoholics Anonymous,
  Narcotics Anonymous are free, widely available.
  Social workers should educate clients and
  encourage them to explore these options.

79
Personality disorders background data

• Personality disorders are defined as enduring
  patterns of psychosocial functioning that
  deviate markedly from social norms, are
  prevasive and inflexible, and are usually
  distressing to both client and others.
• Two more commonly diagnosed types are discussed
  here anti-social personality disorder and
  borderline personality disorder. Onset generally
  begins in early adolescence and continues into
  adulthood.
• Both groups of clients who meet these criteria
  are considered difficult-to-treat.
• Both of these groups of clients often have
  substance use disorders as well.

80
Anti-social personality disorder

• APD clients generally show a pattern of disregard
  for the rights of others, are often deceitful,
  impulsive, sometimes violent, and prone to
  criminality.
• A subset of anti-social clients are those who
  also show a depraved indifference to the feelings
  of others, show no remorse for their harmful
  behaviors, and can be quiet charming and
  engaging. These clients are referred to as
  psychopathic.
• APD clients are mostly male.

81
Assessment

• APD clients are often involuntary, and are
  often reluctant to disclose information or engage
  in treatment.
• Practitioners and clients can often come to some
  agreement regarding the problem for the which the
  client was referred to treatment (e.g.,
  reduce/eliminate substance use improve relations
  with others) some flexibility can help clients
  to engage
• Careful examination of cognitions regarding their
  anti-social behavior and nature of their feelings
  toward others can be revealing.
• Corroborating history of behavior problems must
  be done to honestly confront client with their
  behavior and its consequences.
• Substance abuse problems often co-occur and
  should be examined carefully.
• Legal status and contingencies with regard to
  treatment status and intervention contract should
  be made clear.
• The functional assessment can readily reveal high
  risk situations that lead to impulsive, violent
  and other illegal acts.

82
Interventions

• Interventions for anti-social clients are best
  delivered in a collaborative framework that
  includes expertise in forensic interventions and
  cooperation with law enforcement/courts.
• Behaviorally-oriented, well-structured programs
  that hold clients accountable for making
  pro-social choices, abstaining from drugs and
  alcohol, and eliminating criminal activities have
  shown some positive results.
• However, contingency management (similar to that
  discussed previously for substance use disorders)
  is a key ingredient to a successful program.
• Traditional psychotherapies have not been shown
  to be effective.
• Treatments for aggressive child sex-offenders
  have not been shown to adequately reduce risk of
  re-offending.

83
Borderline personality disorder

• Clients diagnosed with BPD demonstrate serious
  mood swings, impulsive behaviors, are often very
  depressed, tend to have tumultuous relationship
  difficulties, poor self-image, and often engage
  in self-destructive acts such as non-lethal
  cutting or burning oneself.
• BPD often co-occurs with substance use disorders.
• Most people diagnosed with BPD are female.

84
Assessment

• Close examination of client cognitive status is
  important distorted thinking about oneself and
  others is common dichotomous thinking,
  catastrophizing are common some thinking may be
  delusional
• Clients are often profoundly depressed, reveal
  distorted and negative self-image, and might
  express suicidal intent expect intense anger at
  others or oneself anxiety and fears are often
  present.
• Interpersonal functioning is typically marked by
  high levels of conflict, upset, high drama, and
  disappointment vacillating with moments of great
  excitement.
• Clients might neglect self-care for periods of
  time when depressed.
• Practitioners should look for and inquire about
  evidence of self-harm.
• Co-occurring substance use and high risk sexual
  behavior should be carefully assessed as well.

85
Intervention

• Dialectical behavior therapy (DBT a form of
  cognitive-behavior therapy) is considered a first
  rank approach for clients diagnosed with BPD.
• DBT focuses on helping the client to examine
  dysfunctional cognitions and problem situations
  in a calm, rational way, and learn to cope with
  and regulate emotional experience and subsequent
  behaviors.
• Practicing mindfulness helps BPD clients gain
  some degree of objectivity on emotionally-charged
  situations, reduce some of the emotional
  intensity, and help consider consequences of
  behavior more carefully.
• Practitioners might also have to incorporate
  other CBT skills to help clients deal with a
  substance abuse or other co-occurring problems.
  Role play, practice, and self-monitoring success
  are general CBT skills that work for BPD clients.
• Case management might be required to coordinate
  more complex interventions including periods of
  hospitalization.

86
Couples in conflict

• Chapter 10

87
Background data

• Most couples have disagreements and experience
  occasional conflict.
• About half of marriages end in divorce.
• Marital conflict exerts considerable stress on
  children.
• Successful couples tend to be better
  communicators and problem-solvers.
• The keys to resolving relationship problems are
  stick to the issue at hand (dont globalize),
  take turns being good listeners, communicate your
  differences with respect and understanding, and
  dont insist on resolving all problems right
  away. People often shift their positions over
  time.

88
Assessment

• Key problem areas for assessment include Control
  and fair allocation of responsibilities (e.g.,
  housework, parenting, etc), sexual relations and
  fidelity, money, extended family relationships,
  child-rearing and parenting strategies, and
  substance abuse problems.
• During assessment of couple problems, include a
  functional assessment of both good interactions
  as well as conflict situations, problem-solving
  strategies and communication patterns. Detail the
  sequence and patterns of these scenarios as they
  occur in the couples daily life.

89
Assessment (continued)

• Conduct individual assessments with each partner
  separately to identify individual problems such
  as depression, anxiety disorders, substance abuse
  etc
• If problems such as infidelity, gambling debts,
  other secrets are revealed during individual
  interviews, continuation of the intervention
  should be contingent on the partner volunteering
  the information at some point. Practitioners
  should not spiil the beans but should avoid
  agreeing to keeping secrets with one partner.

90
Intervention

• Two major approaches to couples work have been
  well-researched Emotion-focused Couples Therapy
  (EFT) and Behavioral Couples Therapy (BCT).
• EFT emphasizes partners learning to empathically
  listen to one another and demonstrate that each
  partner genuinely understands what the other is
  feeling and, to some degree, comes to understand
  the source of those feelings.
• BCT emphasizes clear communication and
  problem-solving with an emphasis on couples
  agreeing to engage in mutually reinforcing
  positive behaviors. Making commitments and
  following-through is an important theme in BCT.

91
Chapter 11

• Internalizing disorders of childhood
  and adolescence

92
Background data

• Internalizing disorders (emotional disorders)
  refer primarily to depression and anxiety
  disorders in children.
• These disorders can be caused by genetic risk
  factors, family problems (e.g., domestic
  violence, substance abuse), child abuse or
  neglect, other situational problems in school or
  the community, or combinations of these factors.
• Emotional disorders in children often co-occur
  with externalizing (behavioral) problems such as
  conduct disorder or attention deficit/hyperactivit
  y disorder.

93
Assessment

• As with any assessment of a child, practitioners
  should use private observation of the child
  (which might include interview questions,
  observing a childs play), interviewing the
  family together in the office or the home, and
  obtaining data from collateral sources (i.e.,
  pediatrician, day care workers, teachers).
• Patterns and intensity of mood disturbances
  should be assessed over time along with any
  unusual themes or disturbing cognitions.
• Interpersonal behavior at home and in
  day-care/school should be examined directly if
  possible, or data obtained through collateral
  reports (e.g., teachers, school social workers,
  etc...)
• Close assessment of family problems, conflict,
  substance abuse, mental disorders, violence,
  criminality etcshould be carefully looked into.

94
Assessment (continued)

• The physical care environment at home should be
  assessed to see if the childs basic needs are
  being adequately met.
• Physical examination by a physician is
  recommended and can reveal important clues
  regarding the cause of the childs mood
  disturbance.
• A careful functional assessment should be
  conducted to examine how the childs mood and
  behavioral functioning vary over time and in
  different circumstances to identify factors
  directly affecting the childs mood and behavior.
  
• Practitioners should also familiarize themselves
  with cultural norms regarding parenting and the
  familys level of assimilation into the host
  culture. This assessment can help to determine if
  any conflict or specific strains exist that might
  be affecting the childs sense of wellbeing or
  adjustment outside of the home.

95
Interventions

• Current consensus is that a combination of
  individual and family work with emotionally
  disordered children is the preferred strategy.
• Alone with the child, the practitioner can
  continue therapeutic efforts to better support
  the child and understand the childs inner world.
  With emotional disorders, practitioners can also
  help to educate the child about how feelings
  work, how to identify and cope with emotional
  distress at home and in school.
• In family sessions, practitioners can see how the
  child reacts to family interactions. Role play,
  homework assignments, and practicing different
  interventions (e.g., guiding, encouraging the
  child to confront certain fears or become more
  active) can be done in the consulting office and
  at home. Other family problems can be identified
  and addressed as they emerge.
• Practitioners should recruit teachers and coaches
  to reinforce the childs gains outside the home
  as needed.
• Parents should collaborate in conducting
  evaluations of the childs progress.

96
Chapter 12

• Externalizing (behavioral)
  disorders of childhood and adolescence

97
Background data

• Externalizing disorders refer primarily to
  childhood and adolescent problems of behavior and
  social interaction.
• Conduct disorder, in particular, is a serious
  matter since seriously behaviorally and socially
  disordered youth often become anti-social adults.
• Conduct disorder often co-occurs with Attention
  Deficit/Hyperactivity Disorder.
• Conduct disorder also commonly co-occurs with
  substance abuse.

98
Assessment

• Depression, intense anger and other emotional
  disturbances might also accompany behavioral
  disorders.
• Disturbing cognitions and themes of violence
  should be explored carefully.
• Behaviorally disordered youth are often impulsive
  in a variety of ways (e.g., drug use, use of
  threats, violence, etc), and these events should
  be identified and examined carefully with the
  young person and the validity of these behaviors
  corroborated by others.
• How a behaviorally disordered youth perceives
  others and interprets day-to-day social behavior
  of others should be examined. Often behaviorally
  disordered youth have distorted views of social
  relations and often react to distorted
  preceptions (e.g., perceived threats, slights)
  with little provocation.
• Evidence of any healthy relationships and their
  capacity for empathy should be explored.

99
Assessment (continued)

• Other roles as student, part-time employee should
  be assessed to see if the young person is engaged
  in normative social development.
• Quality of friendships, other peer relations,
  sexual and romantic relationships should be
  examined closely to determine the young persons
  capacity for intimacy, empathy, and a
  give-and-take relationship as well as tendencies
  toward exploitation and high risk behaviors.
• Assessment of family functioning and interactions
  is best done with the client and family together.
  Look for other behavioral problems in the home
  (e.g., domestic violence, substance abuse).
• Legal problems, negative school reports and
  academic performance are also key indicators of
  clients overall functioning.
• A careful functional assessment should map out
  the clients typical week and identify
  situations that appear to precipitate anti-social
  or behavioral problems.

100
Intervention

• As with emotional disorders, practice research
  strongly supports the use of CBT methods within
  the context of family therapy for behaviorally
  disordered young people.
• Work with the young person individually to form a
  separate bond with them, examine and explore
  their capacity for empathy, and help them to
  re-appraise and improve how they communicate and
  react to people around them. Role play encounters
  they are likely to have and give positive
  feedback.
• It is important to avoid communicating blame with
  the client and family, be practical, and strive
  to achieve early, modest goals (e.g., agree to
  argue during one 15-minute period per day to
  reduce the intensit