​SMART Goals and Service Plan for a Client.

timer Asked: Nov 18th, 2016

Question description

SMART Goals and Service Plan for a Client. Must be original work with no plagiarism!!!! Please make sure and follow the grading rubric and answer each question to its entirety. Service Plan Template is attached and so is my e-textbook with reference. This paper must have in-text citations and sources that I can look up online.

Three-part assignment…

First part in a separate paper:

Professionals who provide case management services to their clients use goals to structure the service plan. It is important to create specific behaviors that will remove the barriers to treatment while increasing the client’s self-sufficiency skills. Without goals, it is unlikely that the client and the professional would be successful in their work. Many professionals use the SMART goal approach. This includes writing short-term, mid-term, and long-term goals.

Watch the following video to ensure you are creating S.M.A.R.T. goals:

Kaplan University. (2013) S.M.A.R.T. Goal Setting. [Video file]. Retrieved from http://extmedia.kaplan.edu/artsSCi/CE100/CEO100_1308D/SMART_Presentation.html.

Read the following scenario and try to develop goals for this client. Be prepared to explain why you would set these goals and how the client would know when the goals have been met.

Scenario: Hanna

Hanna is in treatment at your mental health center for Acute Stress Disorder. She tells you that recently, she is unable to think clearly at night because she begins to feel anxious that her oldest son will not return safely from his military deployment. She adds that her boss has given her two extra shifts a week at her call center job. It is overwhelming during those shifts the client reports because they are the heaviest call times. Client stated that she is in line for a promotion, so does not want to refuse the shifts. Client then reported that she has not been eating or sleeping well because she has to drink wine to get to sleep at night. Client stated that she thinks that she needs to drink to get to sleep now. When asked about her children, client stated that she and her husband have custody of them, but her youngest daughter is causing a lot of trouble in school. She thinks that the daughter might have a mental health or learning disability issue but is unsure. The client mentions that her husband might contact the school because he is really good with working with the children on their homework at night. Before leaving the session, the client reported that her stomach has been hurting for the past week and she can barely move sometimes because of the cramps.

  • Imagine that you are going to write a service plan for Hanna. Identify her most immediate needs. What are some long-term needs?
  • Write a S.M.A.R.T. goal for the short-term that relates to her case management needs.
  • Write two S.M.A.R.T. goals for the mid-term case management needs (e.g., services or self-sufficiency goals).
  • Write three S.M.A.R.T. goals for her long-term needs. Include one goal that relates to the development of self-sufficiency skills.
  • Explain the barriers to treatment that are in the scenario and propose at least two agencies in your local area (Central California) that could provide services for her.

Should be at least 450 words. Should have in-text citations and reference page. Textbook is attached.

Second and third part…

This part of the Assignment is in two parts, the first is to use the S.M.A.R.T. goals that you Discussed in the above paper as the basis for a hypothetical case plan for Hanna (scenario is above). Use the Sample Service Plan found in DocSharing (Attached) to create a short service plan using her presenting problem and the goals to remove her barriers to treatment. Remember to base the goals on her strengths. Then, do some research to find at least three agencies in your local area (Central California) that could provide these services.

In the second part of this Assignment, write a 1,200-word APA formatted paper that answers the questions below. Remember to base your responses on the service plan that you created in the first portion of the Assignment. When you are finished, add your paper to the service plan and submit it as one Assignment.

In your paper, respond to these questions:

  • What is Hanna’s presenting problem? How has this kept her from focusing on her treatment?
  • Describe Hanna’s barriers to treatment and how those could be prevented or minimized.
  • Explain the short, mid, and long-term goals that you proposed and tell how they help Hanna build self-sufficiency skills.
  • Predict Hanna’s success by explaining her strengths. How did you use her strengths in the development of the service goals?

Each paper should include:

  • A title page
  • The paper body of the paper
  • Use standard margins: 1" on all sides.
  • Use standard 12-point font size, Times New Roman or Arial.
  • Use standard double-spacing: average of 22 lines per page, and between 20 and 24 lines per page.
  • Use left-aligned text. Do not right-justify.
  • A reference page

Grading Criteria

Part 1.

Content: Answers each of the questions accurately, fully, and with substance and that meets lengths requirements (At least 450 words for this portion of the assignment).

Writing: First part must make at least one direct reference to the unit material, text, or other academic source and include the citation(s)/reference(s) to the source(s) using APA format.

Mechanics: Responses are clearly written using Standard American English including correct grammar, spelling, and punctuation, and complete sentences and paragraphs, and are free of typographical errors.

Grading Criteria

Part 2 and 3.

Addresses the following:

The service plan is complete, is consistent with the client, and makes logical conclusions about the client's needs and strengths.

Description of Hanna's barriers to treatment and explanation of how they can be minimized.

Explanation of short, mid, and long-term goals for case management services. Include goals that will help Hanna develop self-sufficiency skills.

Analyze Hanna's strengths and abilities that she can use to meet each of her goals. How would a case manager use these strengths to motivate change?


Paper includes a title page, introduction with thesis statement, conclusion, and in-text citations and reference page using APA style.

Paper is appropriate in length (body of the paper should be 1200 words, not including the title page or reference page).

Part 2 of Paper includes reference to the textbook and at least 3 other academic sources, that can be found online for free.


Form and paper use Standard American English including correct grammar, spelling, and punctuation, and complete sentences and paragraphs).

Form and paper are free of typographical errors.

Form and paper include a highly-developed viewpoint and purpose.

Form and paper demonstrate superior organization; communication is highly ordered, logical, and unified.

Reference: Summers, N. (2015). Fundamentals of Case Management Practice, 4e, 4th Edition. [VitalSource Bookshelf Online]. Retrieved from https://kaplan.vitalsource.com/#/books/9781435463967/ CHAPTER 1: Ethics and Other Professional Responsibilities for Human Service Workers Introduction Ethical principles are the foundation of good human service practice. In fact, workers who do not practice within ethical parameters cannot be called professional. True professionals understand their ethical obligations and seek guidance when they do not. Each social welfare profession, from psychologists to social workers to human service workers, develops a set of ethical principles appropriate to the practice. Most professions monitor the behavior of their members with regard to these principles, singling out those who violate ethics codes for disciplinary measures. Ethical principles are generally created in order to protect and prevent the exploitation of the individuals who come to us for service. In the work we do, there is considerable opportunity to exploit vulnerable people because the people who seek our help are dependent upon us for the aid they need. Any violation of their trust on our part will only compound the person’s problems. Ethical principles provide guidelines to protect individuals from exploitation. However, when professionals practice within the parameters of ethical principles, the public can feel confident that their interests will be respected and protected. Thus, ethical principles inform the decisions we make that affect clients, and they provide guidance in choosing the approaches we take with clients. In this chapter, we will look at some ethical guidelines common to all the helping professions. Failure to know and follow these guidelines in your future practice can result in dismissal from an agency or, worse yet, in a civil suit brought against you for a violation of the ethical code wherein the violation caused damage to the person. Although violations of ethical principles may have negative consequences for you and your career, they are always extremely destructive for the individual, who is already vulnerable. Language and Ethics Language in the social services is a funny thing. After a word is adopted to describe people who use a service, that word becomes pejorative over time and a new word meaning the same thing is sought. In social services, we have gone from patient (which implied people seeking services were all mentally ill) to client and finally to consumer. Client was meant to denote that the person was being served by a case manager in a relationship much like a lawyer–client relationship. This originally conferred an obligation on the part of the case manager to give good service to someone paying, in some manner, for that service. However, as with all words describing people who use social services, the word client developed a negative connotation and the word consumer was increasingly used instead. Consumer also implied the person was paying for good services from the case manager. With the Recovery Model (see page 427) and the emphasis on partnerships between case managers and the people seeking services, those words are no longer considered appropriate. The concern is that these words denote a difference in status between case manager and those they serve. Thus, in recent years, the terms client and consumer have given way to person or individual, and in many cases no term is used but rather the person’s name is used instead. In this textbook, we subscribe to the idea that case managers and the people they serve are in a partnership to which each brings a certain degree of expertise. In your work, we strongly encourage you to drop the use of the words consumer and client and adopt what is seen as the more respectful terms of individual and person. However, having said that, there are places in this textbook where using person and individualalters the meaning of the sentence and the point that is being made. For that reason, in this textbook, we need to use client to denote a person seeking professional services from a professional case manager in order for the point to make sense. This is in no way meant to diminish the person who does seek service, but rather to make our points more coherent. Dual Relationships A dual relationship occurs when you and a person to whom you are giving services have more than one relationship. You may be this person’s case manager as well as her cousin, her boyfriend, or her customer at her beauty salon. Or you may be a person’s case manager and also his employer for your yard work, his Sunday school teacher, or his Little League coach. In other words, a dual relationship occurs when you are in two different relationships with a person, one related to your position as the person’s case manager and the other unrelated to that role. The first rule is to avoid all dual relationships. Your practice gives you a position of power. People tend to look up to you as someone who can provide real assistance. Furthermore, you might be the one who will determine when a person can return to work, or you may be the person who reports an individual’s attendance in your program—attendance that keeps that person out of jail. It is possible that you could exploit or give the appearance of exploiting this power. In addition, there is enormous potential for a conflict of interest. Suppose, for example, that your supervisor tells you on Thursday afternoon that you have been chosen to represent the agency at a big dinner being given to honor a county official at the Hilton Hotel on Saturday night. This gives you little time to prepare. You need to get your hair cut and styled. You call a man who receives services from you who is a hair stylist, and prevail on him to work you in at the last moment. He does you a favor and sees that you get a good appointment. You are very grateful, go to the wonderful dinner, and think little more about it. Several months later this man calls you. He has a need for a prescription refill from his psychiatrist. It is Friday afternoon, and the psychiatrist will not be back in the agency until the following Wednesday. He feels you should be able to do this favor for him because of the favor he performed for you. He does not have time to see the psychiatrist regularly, he tells you. When you refuse to call in a prescription for him without the doctor’s prior knowledge, he cannot understand why you are being “so rigid.” He indicates that he thought the two of you were friends who helped each other out when needed. Whatever you do in this situation, you will lose. If you call in the prescription, you will have violated an agency rule that a person must be seen at regular intervals by his psychiatrist before medications can be refilled. This could cost you your position or result in a disciplinary action. On top of that, you could start down a very slippery slope with this individual. He may come to expect special favors from you and offer you special, very tempting favors related to his business in return. On the other hand, if you do not call in the prescription, you have alienated someone who needs the services of your agency. You have created a barrier to his feeling comfortable with you and getting the help he needs in the future. The individual is harmed. A relationship that was or could have been useful to him in resolving problems is now something else. The opportunity for real progress is diluted with issues of friendship and favoritism. From a shortsighted point of view, you and this person may see the convenience of exchanging favors as trivial and unrelated to the therapeutic relationship. In the long run, however, when scenarios such as the one just described occur, the relationship can never return to a professional one; and if in the future this individual is in acute need, you may no longer be able to provide the professional intervention needed. In some very small, rural communities, it is not possible to avoid dual relationships entirely. In those situations, after doing all that you can to make other arrangements, you must talk with the person about the possible problems that could arise and how each of you must avoid these problems together. Then the person has the choice to continue the relationship, find other arrangements, or discontinue services altogether. Gifts from People You Serve Although gift giving by those whom you serve does not pose a dual relationship, people who bring gifts for you do pose a particular conflict of interest. It is usually best to avoid accepting gifts and keep the relationship professional. Often, though not always, gifts are the person’s way of manipulating the situation. “I’ll give you this item and you accept it. Next time you owe me something” or “I gave you this lovely thing. I am such a nice person. Even you think so or you would not have taken my gift. How can you then refuse to give me what I want?” People need to learn to express their desires clearly rather than by using gifts. Gifts are not always manipulative, however. For example, a case manager working in a fuel assistance program worked closely with a family. The husband was injured when an automobile he was working on at a garage slipped on the lift. Unable to work, the family’s meager resources began to dry up. The wife managed to find work in a greenhouse, but as winter approached, she was laid off and the expenses, particularly for fuel, increased. The couple had two children, both in elementary school, and they struggled to clothe and feed them as the wife sought another job. The case manager saw this family through their difficulties by getting them welfare checks, seeing that the husband enrolled in the community college for courses in hightech auto repair while his injuries healed, and finding school clothes for the children. The husband did well in school that winter and set a good example for his children, who seemed to do better in school than they had the previous year. The wife returned to the greenhouse in the spring and found that not only was she needed as a manager, but there was also a strong possibility she would have a year-round position there. Elated by how well things were going and how much better the future looked, the couple came to see the case manager one day in the early summer and brought her a pot of black-eyed Susans from the greenhouse. “We just wanted you to have these for all you have done for our family,” the husband said, smiling expansively. The husband and wife looked pleased and happy. Obviously the couple was proud to now be in the position to be able to give something too. It was important to them not to see themselves as the recipients of handouts all the time, but to be able to also give something to someone who had been helpful to them. Refusing a gift in such circumstances can be interpreted as rejection. If the worker had said, “Oh, I can’t accept that. You’ll have to give it to someone else,” a person might have heard a different message: “You are the client and I am the benevolent worker. I help you, but you can never get to the position where you could possibly do anything for me. I don’t need anything you could give me; but you, on the other hand, are a poor soul in need of my help.” If your agency has a policy against your personally accepting gifts, try to find a way to accept a gift of this sort on behalf of the agency. In this case, the worker planted the flowers in a planter near the door of the agency. This was a better solution than outright rejection of the gift. The rule is to be very careful about accepting gifts from people you serve. Whenever an individual offers a gift, make a note in the person’s record of the offer as well as whether the gift was accepted or rejected and why. Sexual or Romantic Relationships Individuals who come to human service workers for help often feel isolated, discouraged, and misunderstood. The relationship they form with a respectful, concerned worker may make them feel understood and appreciated for the first time. This relationship may be so comforting that people attempt to turn it into something more permanent, more personally meaningful. It is not uncommon for people to fall in love with their workers in what we call “transference.” In a sense, such individuals transfer to the workers the attributes they are seeking in another person. They may assume the love and affection they are seeking will be forthcoming from their workers because the workers have been so kind and helpful. These people fall in love with their workers because of an erroneous perception: They see concern and encouragement as gestures of love and affection—as an invitation to create more than a professional relationship. Countertransference also can occur. It is not unusual for workers who are harried and overworked, and possibly coping with difficulties in their personal lives, to find the willing ear of a person to whom we give services very supportive. The people we serve are often attractive, sensitive people who can convey warmth and support when case managers are most vulnerable. Take, for example, Kent, a case manager. Kent’s wife left in the middle of a Tuesday morning, and Kent was to be at work that afternoon at 3:00. Though he fought hard to dissuade her from going, she left. For the rest of the day before work, Kent tried to get some money from their joint account, tried to find out where his wife was going, and tried to make some decisions. He arrived at work feeling exhausted and bitterly betrayed. That evening, Kent made a home visit to Lucy’s house. Lucy had first come to the agency with extreme depression, but she was doing so well now that Kent was considering terminating these follow-up visits. Lucy, an artist, greeted Kent warmly. She had put on a pot of tea and made some banana bread for his visit. Gratefully Kent sank down on her sofa. Instead of asking Lucy how things were going for her, whether she had enough medication, and whether she had any medication questions, Kent found himself talking about his upsetting day. In response to Lucy’s first remark, “You don’t look very well tonight, Mr. Paulman,” Kent heard himself pour out the day’s events; then he went on to talk at length about how his marriage had unraveled. He felt comforted by Lucy’s interest in him as she listened intently. Here was a person who appeared to respect him as a professional and as a person. Here was a woman willing to listen to his problems. Here was a warm retreat from the job and the problems of the day where Kent could feel safe and supported. Kent never intended for a real relationship to develop between Lucy and himself. In fact, as he left that night, he told himself that he might have crossed a dangerous line and that he should avoid further contact of this sort with Lucy. Nevertheless, based on that evening, Lucy called; and because Kent was lonely, his life was uncertain, and he was filled with anger and bitterness about his situation, he continued to see Lucy, finding in her a warm, supportive person, someone who could reassure him by her presence that he was attractive and interesting. The relationship moved from his visiting in her home after work to his staying overnight at her house to his moving in his belongings and beginning to live there. They went out on dates. The furtiveness of these activities only made the relationship seem more romantic and important. Finally, a supervisor discovered the relationship, and Kent lost his job. After 3 years, he and Lucy have separated, and Kent is not working in the human service field anymore because he violated such an essential ethic. Instead, he sells appliances in a local store. Lucy became depressed when the relationship ended and has entered treatment again. The person responsible for maintaining a professional relationship regardless of personal feelings is the case manager. Regardless of how you feel about the person on your case load or how that person apparently feels about you, you are the responsible party. You will be penalized if the relationship crosses from professional to intimate. It is always assumed that the individual you are serving is the vulnerable party. Figure 1.1 lists some warning signs that indicate when a worker or an individual receiving services might be moving away from a professional relationship and toward a personal one. Make certain you are familiar with these signs. FIGURE 1.1: Warning signs that the worker-client relationship may become too personal PLEASE NOTE! It is a violation of all ethical codes, and in most states against the law, to engage in a sexual or romantic relationship with a person receiving services from you. This is clearly exploitation. It is never tolerated. You must be aware that, although attractions can occur between those receiving service and those who provide service, acting on those attractions is entirely unethical in professional practice and illegal in most states as well. Value Conflicts Generally, the person’s values and your values have little to do with why the individual is seeking services from you. Sometimes, however, religious, moral, and political values play a pivotal role in the problems people bring to agencies. It is rare for case managers to get deeply involved in such primary problems, but it can happen. First, you can be prepared by consciously knowing yourself and your feelings about certain value-laden issues. Then, if a conflict of values occurs between you and an individual you are serving, you should be able to tell that person that the conflict exists and may interfere with services. You can begin to inventory some of your own attitudes and strong feelings by completing the self-assessment exercise in Figure 1.2. FIGURE 1.2: Self-assessment exercise Second, if a severe conflict of values exists, you might need to make arrangements to transfer the person to another case manager. You would not do this because of a simple value conflict, but you should try to make such a transfer if you find you can no longer be objective, you are extremely uncomfortable with the person because of her or his values, or you feel compelled to counteract the individual’s values by imposing your own. For example, a human service worker who did not personally believe in birth control (including tubal ligation) was a case manager for individuals with developmental disabilities. When a young couple on her caseload decided to marry, she became actively involved in discouraging them from the idea, particularly when she learned that the woman planned to have a tubal ligation so that they would not have children. The families of the two individuals supported the marriage. The people were high functioning, each one had a job, and each had the support of other community agencies. In the months before the wedding, the case manager did not attempt to transfer the cases to another case manager. Instead, she harangued the couple about the sins of birth control and of marriage without children, and about the unwise decision to marry at all, given their “mental impairment.” The families complained to the agency, asking that she stop pressuring these vulnerable individuals. Twice the supervisor disciplined the worker. When the worker persisted—visiting the couple’s minister who would perform the ceremony, the supervisor where the man worked, and the woman’s parents—she was fired from her position. The worker’s behavior was harmful to this couple. For those two people, who had always relied on a case manager who had seemed to be wise, the worker introduced uncertainty and fear. Her constant negative warnings damaged their fragile self-confidence and selfesteem. For them, what should have been a happy decision, supported by family and friends, became a decision fraught with anxiety. Family and friends had to work long and hard to restore their confidence in their original decision. This is an example of the worst possible way to handle a values conflict. In this situation, the worker attempted to impose her own point of view, her own personal values, on the couple. She denied them the right to choose for themselves and interfered in what was largely a personal and family issue unrelated to case management. Avoiding Value Conflicts Following are some rules for avoiding value conflicts and ensuring that individuals get professional service from you:     1. Be respectful of attitudes and lifestyles that differ from your own. 2. Never practice prejudice toward minorities, those with disabilities, or those differing in sexual preference. 3. Always give your best service to a person, even when you disagree with the person. 4. Never attempt to change the individual’s values to coincide with your own. Using Values to Motivate People When people come in seeking assistance, they are usually hoping to make things better in their lives than the way they are right now. In the course of your time with them, it is important to explore the values that caused them to seek help. Find out what goals people have for themselves if their situations were better, and what values those goals reflect. Here we are looking at the things that people value for themselves: being a good parent, living an independent life, living free of the symptoms of schizophrenia, or being free of cocaine addiction. The person is envisioning something up ahead that involves a goal or value dear to that person. You often learn about people’s values when you ask them where they would like to be in 5 years. What you hear when they answer will point to what they hold important for themselves and those around them. When people are having trouble making changes that will move them toward their personal goals and visions, it is helpful for the worker to know what the individual’s values are and to look at the person’s situation with those values on the table. The Rights of Individuals Receiving Services Anyone who gives service in one of the helping professions must be familiar with the rights of the person and make a particular effort to see that people understand they have rights when they seek help. Often people mistakenly assume that they have few or no rights when they come in for services. In addition, professionals may fail to inform individuals of their rights because it is easier to work with people who are vulnerable, dependent, and uninformed. This, of course, sets up a situation in which it is easy to exploit the person. The purpose of educating people about their rights is to allow them the opportunity to become active participants in their care and partners in decisions that affect them. Most agencies prepare clients’ rights handbooks for those receiving services to keep as a reference. A hospital for the mentally ill would include the right to be released from the hospital as soon as care and treatment in that setting are no longer required. Nearly all agencies inform people that they have the right to participate in the development and review of their treatment plan. People generally have the right to participate in major decisions affecting their care and treatment. Most of those who are involuntarily committed to an inpatient setting have the right to refuse treatment to the extent permitted by laws in that state or the right not to be transferred to another facility without clear explanations regarding the need for the transfer. Inpatient units stipulate it is the person’s right not to be subjected to harsh or unusual treatment. The hospital may also spell out the fact that the individual may keep and use personal possessions, or the person must be informed about why something is being removed. In most settings, people have the right to handle personal affairs and to practice the religion of their choice. In outpatient settings, people have the right to a flexible and responsive treatment plan, the right to expect an individualized plan of service, and the right to make suggestions and express concerns. Often there is a procedure individuals can follow if they are dissatisfied with the worker assigned to them or the service plan laid out by the agency. The following sections discuss some important rights that belong to those receiving services. The Right to Participate in Planning When you sit down with someone to begin planning what services would work best or what treatment would be most effective, you each bring unique perspectives to the table. You have a detailed understanding of what is available, which services work better than others, and where people on your case load can receive treatment or service tailored to them. A person comes to the table with information about themselves that is useful when planning. Putting these two pieces of information together makes for a more effective plan. People who work with you feel that they have had a part in the planning and therefore, some control over the direction of their care. This makes it more likely that the plan will be followed or that your individuals will tell you if they see the need for a change. It is for this reason that we do not just disrespectfully tell people what their service or treatment plan will be without consulting them first. The Right to Self-Determination Educating people and informing them about their rights are both done so that clients can exercise the right to self-determination. Paramount to any relationship between professionals and their clientele is the right to self-determination. People have the right to do research about their diagnosis or problem and to question the treatment plan or make suggestions. People have the right to withdraw from treatments and services they find are not helpful. People have the right to decide when and for how long they will use services (unless their involvement with the agency is based on an involuntary court commitment). People have the right to choose their own goals. Often this presents a problem for a worker who feels compelled to look after the best interests of the individual. One of the hardest lessons you will ever learn is how to let people make mistakes and learn from those mistakes. You can make suggestions and express concerns, but ultimately clients have the right to determine what they will do. You may feel strongly, for example, that one individual is not ready to walk away from the agency; and you may feel certain that the person’s doing so prematurely will result in further problems with alcohol. In fact, your client leaves treatment against your advice and eventually does end up with another DUI charge. Although your worst fears and predictions came true, you cannot know for sure that the work with you and the new charge were not important learning opportunities. In other words, people have the right to test the waters, so to speak, and to learn that they are not as ready as they thought they were. Increasingly, however, self-determination means more than this. More and more funding sources and governments, as we shall see in the next chapter, are asking case managers to go beyond simply arranging for services in collaboration with the client. They are asking case managers to encourage people to articulate what their vision of a healthy, productive future would look like. As people do better on medications and remain in their communities, how they function in those communities—how they contribute, feel secure, and pursue their own interests—becomes more important. Selfdetermination now takes on the future beyond the social and emotional problems that were the original reason for seeking help. Now people are being energized by their case managers to explore and create a better tomorrow of their own making. Informed Consent A person receiving services always has the right to consent to these services or withdraw from them. In making this decision, the person must be informed enough to make a wise decision. When the individual is informed and consents to treatment, we call that informed consent. Making certain that a person can give informed consent begins with the intake, during which the agency policies are explained and choices of treatment or services are outlined. This level of information should continue throughout the entire relationship between the individual and the agency until termination. This means that people informed about treatment or services can make their own decisions with regard to the services. The following list contains items that should be addressed when relevant to the person’s services. The person has the right to be informed about:     1. Any side effects, adverse effects, or negative consequences that could occur as a result of treatment, medications, or procedures 2. Any risks that might occur if the person elects not to follow through with treatment or services 3. What is being offered to the individual, including what the treatment is, what will be included, and any potential risks and benefits 4. Any alternate procedures that are available Some of the people with whom we work have a limited capacity to understand all the details of service and treatment. It is our task to find an appropriate balance between too much and too little information and to make our information clear and easy to understand. Informed consent consists of the following three parts, or criteria. All must be present in order to say that the individual gave informed consent:  1. Capacity. The individual has the ability or capacity to make clear, competent decisions in his or her own behalf.   2. Comprehension of information. The person clearly understands what is being told to him or her. To make sure that this is so, give your information carefully and always check to be sure the person understands what you have told him or her. 3. Voluntariness. The person gives his or her consent freely with no coercion or pressure from the agency or the professional offering the service. Currently laws and courts are recognizing more and more often the person’s right to self-determination. When we fail to tell those we serve the information they need in order to give informed consent, we run the risk of being found negligent, particularly if the treatment or service involved was unusual. The Right to be Informed of Changes and Decision There are times, however, when you are working with a person who cannot participate. People who are confused, have severe developmental disabilities, or are psychotic often are not capable of planning or giving input. Letting them know what will happen is still respectful. One case manager’s client, Mindy, was hospitalized when she became psychotic as a result of schizophrenia. Mindy barely responded to treatment and the decision was made to transfer her to a longer-term care facility. The nurses on the hospital unit made the arrangements for transportation and who would help with the transfer from the unit to the ambulance. The case manager had agreed to the transfer and came in a few hours before it was to take place to talk to Mindy about it. The nurses were incredulous. Mindy was in a room with only a mattress on the floor because she had taken her room apart several times. She was uncommunicative and had been yelling at voices she heard. “She isn’t going to understand a word you tell her,” one of the nurses remarked. Nevertheless, the case manager went to Mindy’s room, sat down on the bare mattress on the floor and began to describe in some detail what was going to happen. Mindy grew quiet. She never looked at her case manager, but she appeared to be listening intently. When the orderlies came to take her to the ambulance she went without resistance. Did Mindy really understand what her case manager told her? Is that really the point? The point is that this case manager respected her client’s right to know what plans had been made for her. The right to know what treatments and services have been planned and the right to participate to the degree a person is capable are important ways professionals demonstrate respect for the people they serve. Confidentiality Confidentiality is both an ethical principle and a legal right. It is the most basic right of any person, either in treatment or receiving services, to know that what the person is sharing in your office will remain confidential. It is important to protect individuals to whom we give service by not disclosing their personal situations without the people having authorized such a disclosure. Today, under new laws discussed in the text that follows, agencies have very specific guidelines for protecting confidentiality. Release of Information Form Not many years ago a person seeking services, particularly from a public agency, signed a blanket permission statement allowing information to be shared with others as the agency and the worker saw fit. Today, release of information forms must state specifically to whom the information is being released and must be time limited (good for 3 months, 1 year, and so on). Do not use forms that are not specific in this manner. New regulations now stipulate what is permissible on a release of information form. Release of Information Regarding HIV/AIDS In most states, release of information forms for releasing information regarding a client’s HIV/AIDS status must specifically state that you may release information regarding the person’s HIV status. All references to HIV/AIDS must be deleted from the record unless the client signs a separate form that specifically states that you have permission to release this information. If you are asked to release information about a person who is HIV+ and the person signs a release form, the law in most states specifies that it is not good enough to simply remind that person that his case contains references to his HIV status and get his verbal permission to release the information anyway. You also must have his written permission. If the person has not given you written permission, you must delete all references to HIV/AIDS, including the fact that he may have been tested and the test was negative. If your state does not have such a law, you are still responsible for protecting your client and must be alert to the possible harm such a release might cause the person. In such a situation, it is wise to involve the person in a discussion about the release of this sort of information or, if the individual is unable to participate in such a discussion, to take steps to protect that individual from undue bias. In some instances, workers have informally notified their friends and acquaintances in other agencies of a person’s HIV+ status, thinking they were doing these people a favor. In fact, this behavior is entirely unethical and can lull other workers into believing they know who is and who is not HIV+. We can never actually know this for certain because of the length of time it takes for the disease to register positive on a blood test. A person can be positive early in the illness and still have negative blood tests. For this reason, workers should use universal precautions with every client when those precautions are called for. Workers who fail to use universal precautions on the false assumption that they know the individual is not HIV+ place themselves at undue risk. ASSIGNMENT Find out what the laws are in your state for releasing information about a client that contains references to the client’s HIV status. Collegial Sharing Out of respect for individuals, you should ask them for permission before sharing information with colleagues from whom you are getting opinions or supervision, unless the case is going to be discussed in the normal course of supervisory meetings with a regular supervisor. Likewise, you cannot share information with student interns without making certain the students have signed agreements to observe strict confidentiality while acting as part of the agency. Suppose you are working in an agency and have been asked to give a student a view of what you do. To illustrate what you have told the student, you show her several case files. She reads the cases and discovers that one of them is the boyfriend of her cousin. What she reads in the file is alarming to her, and she decides her cousin should not be dating the client. She leaves the agency and begins to share information with the cousin, causing considerable conflict among family members and anguish to the cousin, who knew part of the story but not all of it. This kind of sharing of information is unacceptable, and most agencies do not allow students or volunteers to read anything before they have signed a pledge to honor the confidentiality of the clients and you feel these students thoroughly understand the critical importance of protecting confidentiality. Guarding Confidentiality on the Phone and in Other Conversations Other situations also provide opportunities for violating confidentiality. For instance, a person receiving services from your agency may also be receiving services from a local physician. Suppose someone calls, claiming to be the physician’s nurse and needing to know at once what medications the client is taking. She may really be the physician’s nurse, or she may be a person posing as the nurse in order to determine that the person is using your services and the level of his problem. Even if she is the nurse, the person may wish to keep his physician uninformed about the involvement with your agency. All agencies have procedures for such situations in the event of a real emergency. You, however, must never openly and automatically acknowledge that an individual is being seen in your agency, no matter how important and official the other person seems to be. In the case of a seeming emergency, refer the call to your supervisor unless you know the emergency workers or emergency room personnel well enough to recognize their voices. When a request for information is presented in a situation that is not an emergency, here is how you might handle the request:  YOU: Hello. CALLER: Hi. This is Ann Taylor. I’m a counselor at Marlboro Middle School, and I’m calling about Jimmy Smith. Did he and his mother keep their appointment with you today? YOU: I’m sorry, I can’t help you with that. Would you have Mrs. Smith sign a release of information form stating what it is you need to know, and if Jimmy Smith is known to us, we can send you that information. In this situation you do not give any hint that the client is known to your agency. By saying “if this person is known to us …,” you do avoid letting on whether the client is or is not. Another way to violate confidentiality is to talk about your cases with your friends and relatives, leaving out the names. Others may be able to piece together the identity of the person you are talking about based on other information they possess. In this way, they may discover far more about a person than that person ever intended them to know. Minors and the Infirm Take special care to protect the confidentiality of minors and the infirm (individuals who are frail, sick, and are unable to fully participate in decisions about their care). Not all systems respect confidentiality to the degree that we in the helping professions are committed to doing it. In one children’s case management unit, parents were routinely urged to sign blanket release of information forms. When the school requested information on a child being seen, all the information was sent to the school. It was stamped in red letters with the word confidential, and it was sent to the school psychologist. Nevertheless, school clerical personnel assisted in typing and filing information for the psychologist and generally read the information sent by the case management unit. Having no training in confidentiality, these clerical people talked among themselves about students, sharing personal information they had learned. Many times they passed on to teachers tidbits of what amounted to gossip. This information shared outside the professional context and without professional understanding jeopardized the progress of the children and the relationship of their parents with the school personnel. As these children moved through the school system, the gossip followed them. Always be very careful about what information you release. Remember that information given about a child can follow that child all through school, prejudicing responses to that child. In another case, a woman with a developmental disability got a job at the police department as a cleaning woman. She was told that she needed to bring in her “records from mental health” so the police could know why she went there. She arrived at the case management unit, pleased about the job and ready to give all her records away. The case manager talked to her about the wisdom of retaining most of the information as confidential. In the end, a short statement was released, with the client’s permission, giving only the most general information about her relationship with the mental health/mental retardation case management unit. It is important to remember that older people or individuals who do not have the capacity to protect themselves can be easily led to sign releases regarding information that might best be kept confidential. The responsibility belongs to you to protect your clients from unnecessary intrusions into their personal information. Minimum Necessary Rule Before releasing information, ask yourself whether you are about to release more information than is needed for this other business or organization to accomplish its work with the client. For example, Melissa was a case manager who knew a worker in a remedial education program where one of her clients, Jill, was attending. Although the program needed to know why Jill was referred and what goal the referral was intended to accomplish, they did not need to know that Jill was arrested once for a DUI and that Jill’s father was in prison for murdering a neighbor. When dealing with other organizations not engaged in treatment, release only what that organization needs to work effectively with the client. If the client authorizes you in writing to disclose more, only then would you do so. When You Can Break Confidentiality The law in all states does make exceptions. The following are circumstances that allow you to break confidentiality:      1. When you must warn and protect others from possible harmful actions by the client. For instance, you or your agency must warn another party if your client is intent on harming that other party. In addition, you should notify the police. 2. When the person needs professional services. For instance, if the person has taken an overdose of medication and is in the emergency room (ER), the ER staff may call, needing to know what prescriptions the client was taking in order to give the proper antidote. 3. When you must protect people from harming themselves. An example might be people who are threatening to take an overdose of their medications with the intention of committing suicide or people who appear so depressed or desperate that they are talking about ending their lives. 4. When you are attempting to obtain payment for services and the payment has not been made. Your agency would refer a person for nonpayment only after reasonable attempts had been made to remind the person of this obligation and only if the individual had made no effort to arrange even minimal payment. 5. When obtaining a professional consultation from your supervisor regarding how best to proceed with a case in the course of normal supervision. Privacy Privacy is very much related to confidentiality. Siegel (1979) calls it “the freedom of individuals to choose for themselves the time and the circumstances under which and the extent to which their beliefs, behaviors, and opinions are to be shared.” Stadler (1990) calls it “the right of persons to choose what others may know about them and under what circumstances.” Privacy is invaded or altered under some circumstances, and people need to be informed of those circumstances. The point you should stress with the people you serve is the fact that third-party payers will have access to diagnoses and, in some cases, to actual records or summaries of records. The agency must provide this access in order to be paid for the services it has rendered. Many individuals are unaware of this fact or unaware of the extent of the information being shared. They should have this situation explained to them. This allows people to make an informed decision about whether to pay for services themselves and not involve the insurance company. Health Insurance Portability and Accountability Act The federal Health Insurance Portability and Accountability Act (HIPAA) was passed in 1996 in part to ensure that people did not lose medical coverage when they changed jobs. Title II of the act contains the security and privacy mandates. These contain stringent rules for protecting a client’s health information, and most social service agencies must adhere to these rules. Where state laws are more stringent than this federal act, the state laws take precedence. Failure to follow the guidelines set forth in HIPAA can result in fines from $100 to $250,000 and from 1 to 10 years in prison for those individuals and institutions with the ultimate responsibility for safeguarding patient privacy. The new rules apply to case management and to care coordination and cover not only formal records but also personal notes and billing information. When you begin work at your agency, they will see that you are informed of their policies and procedures under this act. Disclosure Under the new rules, “disclosure” is defined as occurring when health information is released, transferred, or divulged outside the agency. This includes allowing access to patient files to others not working for the agency. The material in question is often referred to as protected health information (PHI). Agency Requirements In order to comply with HIPAA, every agency must have the following:     1. A statement of the agency’s privacy and confidentiality procedures, particularly as it relates to releasing patient information. This statement must be given to every client of the agency. It is considered a notice clarifying how health information will be used and stipulating the client’s privacy rights. This is a public document and can be posted in waiting rooms and on websites. 2. A form that people sign and return to the agency indicating that they have received the statement on confidentiality policies. 3. A privacy officer who is familiar with HIPAA requirements and can oversee implementation within the agency and resolve privacy issues as they arise. 4. A set of safeguards to protect client records. The privacy concerns addressed by HIPAA were raised because of the increasing demand by insurance companies, employers, and others for detailed information on clients and patients, often in excess of what was necessary to process claims. Security and Privacy Security in the act refers to procedures to protect health information from inappropriate access by others. These procedures usually include controls on who has physical access to the records, security of work areas and record storage areas, and destruction of duplicate or obsolete files. Electronic security measures are also instituted, such as changing passwords and encryption. Privacy refers to the person’s right to keep specific information private and includes the agency’s release of information policies and the rights of the individual in this matter. Oral Communications The law states that agencies are to make “reasonable efforts” to safeguard clients’ information. This extends to oral communications. Taking precautions to protect oral communications means:    • Not discussing a person’s personal health information where others can hear • Avoiding situations with clients where there is no privacy, particularly privacy from other clients • Lowering your voice when discussing clients with others in the agency Release of Information Form Under HIPAA, the form signed by the person or a legal representative of the person must adhere to the following:           • The entire form must be in plain, understandable language, and it must be signed and dated. • There must be a description of the information to be used. • The form must name the recipients of this information. • Those who will disclose the information, such as the agency or a therapist, must be named on the form. • The form must have an expiration date. • There must be a statement describing the purpose of releasing the information. • There must be instructions telling the client how to revoke the form. • A statement must be included to indicate that the information may not be as protected once it is released. • If the agency will receive money for the information (for example, payment from an insurance company), this must be stated on the form. • The form must make clear clients’ rights to a copy of the authorization they have signed. It is assumed that reasonable steps will be taken to release only the minimum information necessary to support the purpose of the release. When the purpose is continued care of the person or when the person requests that more information be released, it is expected that more information will be released. Any request for the entire client record, however, needs detailed justification. Individually Identifiable Health Information Individually identifiable health information includes demographic information (such as age, gender, income, or race) and other information that identifies the individual or could reasonably be thought to identify the individual. Information that relates to an individual’s past, present, or future condition is also included in this category. People have the right to ask that their information be restricted. They may indicate, again in writing, that information is not to be shared with family or friends. These requests are generally honored except in medical emergencies. In addition, clients may ask, in writing, that mail from the agency not be sent to their home address or that calls from the agency not be made to their home telephone, and the agency must honor these requests. A client may ask, in writing, for a written list of how their PHI was disclosed. The request can extend as far back as 6 years. Note that clients can specifically request how information is to be shared or restricted, but must always do so in writing. A person not able to write such a request may need the help of a case manager. Accessing the File Under the new HIPAA guidelines, people now have a right to:    1. Read their files 2. Make copies of their records 3. Make corrections or additions to their files, as long as the changes are accurate As noted earlier, such requests must be presented in writing to the agency and must be accommodated within a specific time period. Individuals who are going to amend their files must state the reason for amending the record in the written request. Client representatives, such as guardians, have the same access and rights as do clients. There may be times when the person will need the help of the case manager to formulate that request. The rights discussed here are guaranteed under federal law; thus, it is illegal to discourage or threaten people when they make these requests. Currently there is evidence that people who have read their charts and received clear information are less likely to sue for malpractice or create other legal problems. It is not a good idea, however, to just hand someone a chart and provide no explanations for technical information that may be written there. This potentially creates misunderstanding. If at all possible, sit with the individual and carefully review the important points in the chart. Answer questions and explain what has been written so the person understands what is written and does not draw erroneous conclusions or conclusions that could lead the person to believe there is an adversarial relationship described in the chart. Social Networking We think of social networking as something we do with friends, entirely unrelated to our work, an activity we engage in on our own time. Contributions to Facebook, MySpace, and other social network sites are assumed to be private and just among friends. In reporting on nurses fired for posting on Facebook, WHTM abc27News (Harrisburg, Pennsylvania) noted, “So you’re in your own home, on your own computer, on your own time, typing on Facebook. It could be your undoing.” During the winter of 2010, a group of about 13 emergency room workers were fired from a major hospital in Harrisburg, Pennsylvania, for their social networking activities, activities they assumed to be private. In this case, the emergency room workers had established a Facebook page where they discussed their day’s activities with one another. While no patients were actually named, patients were referred to in exasperated and derogatory terms and their illnesses and personal characteristics were described in some detail. The article quotes one nurse as saying, “The one posting I put was, ‘That lady was crazy.’ There was no name mentioned, those were the only four words I said.” However, the hospital fired this woman who was shocked. “I would never have thought that what I posted in the privacy of my own home would have ever ended up being the big mess that it is,” she said. The workers contended that because the page was unrelated to their work at the hospital and activities on the page took place on their own time, they should not be fired. The hospital argued that the page violated HIPAA laws in that anyone who had access to the page could put enough information together to identify individual patients. Social networking pages are generally not as private as we like to assume. Friends of friends can gain access, sometimes inadvertently. In this case the nurses and others did not exercise good ethical judgment. Anyone coming across this site would not have felt comfortable using emergency room services at this hospital. Many ethical codes have not caught up with social networking as an ethical consideration. That does not excuse you or others from exercising sound judgment about when, with whom, and how you discuss your clients. Privileged Communication Clients and workers alike talk about privileged communication without truly knowing what it is. First of all, it is a legal concept. It protects the right of a person to withhold information in a court proceeding. It is a right that belongs to the client. It does not belong to the worker or the agency. All states have a law that stipulates what communication between a client and professional shall be considered privileged in order to protect the client from the disclosure of confidential information during a court proceeding. These laws designate who is to be considered a professional. A number of years ago there was a case in which a man who committed a murder confessed this murder in an Alcoholics Anonymous (AA) group. He tried to invoke the right of privileged communication, but the courts denied it because the state law did not specifically name AA as a group protected by this statute. Only clients can invoke privileged communication in order to protect themselves. Professionals and agencies cannot use it to protect themselves. If the client waives the right to privileged communication, the professional or agency has no grounds to withhold information. Clients waive this right if they sue your agency or if they use their condition as a defense in a legal proceeding. When You Can Give Information At certain times, you can provide information about people in a court proceeding. In some situations, you are required to do so. Legal Proceedings In a legal proceeding, you may give information about people under the following conditions:     1. You are acting in a court-appointed capacity, such as that of guardian or payee. 2. You or your agency is sued for malpractice. 3. The court mandates that you turn over certain information. 4. The individual uses a mental condition as a defense or as a claim in a civil action. Protecting Clients and Others from Harm Other situations in which you can give information about people relate to your responsibility to protect clients and those connected with them from harm. These situations are:     1. When you believe the person intends to commit suicide 2. When a child under 16 years old is believed to be the victim of a crime such as sexual or physical abuse or sexual exploitation 3. When you determine the person needs to be hospitalized for a mental condition 4. When the person has told you of his intention to commit a crime, harm another person, or harm himself Intention to Harm Another On October 27, 1969, Prosenjit Poddar killed Tatiana Tarasoff and set in motion court proceedings that brought about changes in the way confidentiality is viewed. That October, Poddar was a patient of Dr. Lawrence Moore at Cowell Memorial Hospital at the University of California, Berkeley. Moore, a psychologist, was told by Poddar of his intention to kill Tatiana Tarasoff. Moore contacted campus police, who briefly detained Poddar but released him when he appeared to the police to be rational. Apparently, Dr. Powelson, Moore’s supervisor, directed that no further action be taken to detain Poddar. No one warned Tatiana Tarasoff of the danger she faced, and as a result she lost her life. The Tarasoffs brought charges against the professionals in this case for failure to warn the victim of the impending danger. When the California Supreme Court eventually heard the case, the court ruled that  therapists cannot escape liability merely because Tatiana herself was not their patient. When a therapist determines … that his patient presents a serious danger of violence to another, he incurs an obligation to use reasonable care to protect the intended victim against such danger. (Tarasoff v. Regents of the University of California, 1976) The steps the court included were warning the intended victim, warning others who would apprise the intended victim of the danger, and warning the police. The court went on to state:  We recognize the public interest in supporting effective treatment of mental illness and in protecting the rights of patients to privacy, and the consequent public importance of safeguarding the confidential character of psychotherapeutic communication. Against this interest, however, we must weigh the public interest in safety from violent assault. The opinion closed with the following:  We conclude that the public policy favoring protection of the confidential character of patient-psychotherapist communication must yield to the extent to which disclosure is essential to avert danger to others. The protective privilege ends where the public peril begins. This case established a “duty to protect” for individuals who treat patients who appear to present an imminent danger to an identifiable person or persons. The ruling appears to apply mainly to therapists, but here the waters are muddy. Human service professionals in all states have taken the position that if such circumstances were to occur in the course of their work, the courts would find them negligent if they had not exercised the precautions laid out in the Tarasoff case. Most states now have statutory or binding case law that establishes the duty to warn, but some do not. Regardless, you must assume that the courts would find you or your agency negligent if you failed to take the precautions outlined in the Tarasoff ruling. It is unlikely that you would be excused from liability because you are a case manager, and not a therapist. Rarely would you make the decision to warn alone. If you believe a person poses an imminent danger to another identifiable person or persons, you must take the matter up at once with your supervisor. If your supervisor is not available for consultation and you believe you cannot wait, notify the police. In a step down unit for the mentally ill, a man living there left one evening. No one knew where he was going, and when he didn’t come home that late evening, the staff became alarmed. He had been talking about going back to the farm where he grew up to “evict those people who put us out.” In fact, the family had sold the farm, and the people living there were the owners. At this point, the worker determined that the family at the farm should be warned. The supervisor, unfamiliar with the law, resisted, even though she would have ultimately been responsible had something happened. Later the worker ran into the director of the agency and asked her opinion. Immediately the director told the worker to contact the people at the farm and let the police in that jurisdiction know he might come to the farm. In fact, the man did show up and talked about the need for the owners to move out. He did not pose a threat, but the fact that he might have done so was important to consider. In this case, the police returned him to the step down unit where his behavior was discussed with him. This supervisor’s lack of understanding about the law could have caused problems for the client, the people living at the farm, and the agency. ASSIGNMENT Find out what laws exist, if any, in your state regarding your duty to warn. If there are no laws on the books, what is common legal opinion regarding the duty to warn? Mandated Reporting All states have laws requiring professionals to report the abuse and neglect of children. In some states, laws require human service workers to report elder abuse. The definition of child abuse and elder abuse varies from state to state. Professionals who must report abuse and neglect under the law are called “mandated reporters.” The laws in each state stipulate who is a mandated reporter; variations exist among the states in regard to which professionals are considered mandated to report. Even in states where there is no mandate to report elder abuse, there may be protective services for the elderly to which you can report suspected abuse of an older person. You have an ethical responsibility not to ignore abuse of this type, regardless of the law. It is your responsibility to protect clients, particularly individuals who cannot protect themselves. ASSIGNMENT Find out your state’s definition of child abuse. Learn which professionals in your state are considered mandated reporters of child abuse. What are the laws in your state regarding elder abuse? Diagnostic Labeling Agencies that rely on a diagnosis in order to be paid for service by a third-party payer (such as an insurance company, Medicare, or Medicaid) need to inform people of that fact. People rarely understand that labels are used in this way, and most people do not know what the labels are or what they mean. They are rarely clear about the fact that the information will be passed on to their insurance companies. People need to know this, so they can then decide whether to continue to receive services from the agency. Some individuals may elect to leave the agency or to pay for the services themselves, without involving their insurance companies, as a means of ensuring their privacy. Unless they are informed, they will not know they have these choices. Another point about diagnosing people is that practitioners use the categories of illness to know which treatment to use and how to develop the most effective treatment plan. Much research has been done to link the best treatments with each of the diagnostic categories. People will appreciate the need for a diagnostic label if they understand this. What may appear to people as simple respect, kindness, good communication, or personal support on the part of their therapists may actually be the use of welldeveloped treatment modes. Involuntary Commitment Generally, an involuntary commitment occurs to a facility that specializes in inpatient mental health care. It could be a unit in a general hospital in the community where the clients live, a private psychiatric hospital, or, in some cases, a partial hospitalization program where people receive treatment during that portion of the day they are most at risk. Patients have a right to expect the least restrictive form of treatment. If they need hospitalization but not a locked ward, they should not be locked up 24 hours a day. If they can get the care they need in a partial hospitalization program, they should not have to go into the hospital. In discussing the movement to deinstitutionalize mental patients, Bednar, Bednar, Lambert, and Waite (1991) wrote, “treatment should be no more harsh, hazardous, or intrusive than necessary to achieve therapeutic aims and to protect clients and others from physical harm.” The courts take seriously their responsibility to commit individuals in need of psychiatric care who are unable to obtain it because of a current severe impairment. In making the commitment, the courts make it clear that the purpose is treatment, and not punishment for behavior. For that reason, court commitment proceedings are often less formal and more pleasant than criminal proceedings. Students may observe these proceedings if they choose, as the proceedings are public. If you are involved in a commitment procedure, be sure to document all the steps you take in order to protect yourself from liability. The criteria for committing someone against her will are as follows:       1. The person poses a danger to self or to others, and possibly one or more of the following: 2. The person has a severe mental illness or a mental illness that is currently acute. 3. The person is unable to function in occupational, social, or personal areas. The impairment is severe enough that the person cannot provide adequate self-care. 4. The person has refused to sign a voluntary commitment for treatment, so that an involuntary commitment is the last resort; or the person is incapable of signing such a commitment or of choosing appropriate treatment. 5. The person can be treated once committed; that is, known treatments and medications can relieve the acute condition the person is experiencing at present. 6. The commitment adheres to the criteria of the least restrictive treatment setting. ASSIGNMENT Find out what the commitment laws are in your state. Look at the various types of voluntary and involuntary commitments. Find out under what circumstances the client can leave a facility when voluntarily committed. Find out what constitutes due process in your state for those being committed involuntarily. Ethical Responsibilities Responsibility for the individual’s welfare while the person is in your program is yours. The person views you as an authority. No matter how inexperienced you feel, when people work with you, they will see you as the person with all the answers. For this reason, you will have considerable influence over what your clients decide to do. It is important to keep their needs at the forefront of your planning and delivery of services. Burdening Clients with Your Problems Sometimes people in human services use clients to meet their own needs. You could, for instance, burden the person with your own problems. You might say things such as “Oh, that happened to me too” or “Wait until you hear what happened to me!” You might have had a bad day and want to talk to someone about it, and so you tell your client all about it, as Kent did with his client Lucy. Meeting Your Needs Do not ask the individual to do something that meets your needs or is not in the best interest of your client. Because of the influence you have with this person, it is easy to influence a client to do something that is beneficial to you. You might get the client involved with a friend of yours who sells insurance, or you might ask the client to go on television with you or to do an interview about the client’s condition for the paper. There might be some payoff for you, but because the person could have considerable difficulty saying no to you, it is imperative that you never place your client in this situation. Often the media wants to interview a person with schizophrenia or a recovering alcoholic. Inform members of the media that they will have to locate their own interviewees. Insisting on Your Solutions You may have a need to look efficient, innovative, or particularly therapeutic, and so you might try to give your clients solutions to their problems. You may have had a similar problem at one time and feel there is only one good way to resolve it—the way you used to resolve it, a way your clients can use without experiencing the hard knocks you took figuring it out. You might be tempted to lecture, to discuss your situation and how it compares with theirs, or to warn your clients. None of these actions will help your clients to grow by finding their own solutions. Another way you can make clients do what you want them to do is to treat clients rudely if they fail to use your solutions or to move quickly enough toward a solution. Being rude is not the same thing as being firm. You can set limits, but it is inappropriate to treat people brusquely for not improving or for not taking what you suggest as healthy measures. Exploiting Dependency Clients are naturally vulnerable. They come to you at a time in their lives when they are hurt, upset, and disorganized—a time when it is easy to come to rely on another person. You are in a position to exploit this vulnerability by maintaining the client in a dependent position long after such dependency is useful for the client. For example, you might enjoy having clients call you about the details and decisions of their lives. It might make you feel important or needed. You might encourage them to lean on you for assistance in matters they could manage themselves. Be very careful not to allow this sort of relationship to develop. In one support group run by a psychiatric nurse, individuals gathered once a week to discuss their problems. Most of the participants were also depressed. A student, Grace, from the local college joined the group and was an active participant for about 2 years. During that time, the nurse who led the group often went out to lunch with Grace and was extremely encouraging. It appeared in retrospect that the nurse had developed dual relationships with a number of group participants, eating with them, inviting them to her house, and going to plays and concerts with them. The nurse explained that this was her way of supporting her clients. Grace completed her associate’s degree and her bachelor’s degree before she was accepted at a graduate school in another state. She told the group and the nurse in charge that she was no longer depressed and that she felt she was ready to move on now. She shared her good news about her acceptance to graduate school. Instead of showing pleasure and encouragement, the nurse became angry. She told Grace that she was trying to deny her need for the group and for the nurse. She ridiculed Grace’s acceptance to graduate school, telling Grace she was not ready for such a large step and would surely fail. When Grace continued with her plans, the nurse stopped speaking to Grace and encouraged others to stop speaking to Grace as well. This is an example of a group leader, a worker, who could not tolerate the fact that her clients would not always need her. The group was meeting her needs, which she was clearly putting before the needs of her clients. Protecting a Person’s Self-Esteem We can all agree that denigration of people, whether through verbal or physical abuse, is unethical, and in some cases illegal. You may believe that you are highly unlikely to encounter such behavior except in extremely unusual cases. Nevertheless, it is wise for you to understand that some workers are tempted to treat people this way. There are four reasons this is likely to happen. Unpleasant People Just as in any other walk of life, there are people in social services who are not pleasant people. They are unpleasant in many different aspects of their lives, and they are insensitive to the toll it takes on others, particularly clients who are uncertain of their self-worth. Need for Power There are workers whose own sense of self-worth seems uncertain to them. They choose fields where they will have a degree of power over others. In this way they seek to elevate themselves at the expense of people they can clearly believe are poor souls. These individuals make life difficult for clients simply because they can, because they have the power to do so. For example, one student reported that while she was on a fieldwork assignment, she and the staff and clients were all having soft drinks together. A client approached the worker in charge and timidly asked if he could have more ice for his drink. The worker responded with, “No, you don’t need any more ice. If your drink is warm, it is because you are so slow drinking it. Go back and join the others and drink up.” After the client turned and walked away, the worker leaned over and helped himself to ice for his drink, laughing as if this was a joke. Lack of Support for Workers Social service workers who lack support from their supervisors or administration often lean together for support. They tend to develop a we–them attitude with regard to the clients, feeling the need to do whatever they must to support each other and hold clients apart. In one unit, adolescents were housed together after committing offenses. The least experienced staff came on in the evening, and that is when the teens would challenge the authority of the staff. Calls for help and requests for information and training on how to better handle the evening shift were ignored by the administration. Left alone with little support or knowledge, the staff resorted to coercion, often physical coercion, to manage the disruptive situation. In the end, the staff was blamed for using excessive force, but the lack of support and interest in these workers by supervisors and the administration contributed significantly to the way these adolescents were treated. Isolated with Unpredictable Behaviors Workers in group homes, partial programs, or evening residential programs often are left alone without support when clients are exhibiting unpredictable behavior. Fear and a need to control the behavior and the situation can lead workers to use verbal, and even physical, abuse. For instance, two workers, one a student in a fieldwork placement and the other out of social work school only a year, were in a group home for the mentally ill. One evening, after one of their clients clearly became manic, the student made a number of calls to supervisors. Supervisors responded irritably. It was their time off, they complained; the workers would have to figure it out for themselves. That’s what they were being paid to do. A subsequent request to call in the crisis team was similarly denied. The two students spent the evening and all night with a client who was increasingly out of control with no supervision or support. Agencies that do not provide good support for less skilled workers are open to having workers band together against the clients in self-defense. One problem new workers can encounter is finding themselves working for the first time in a place where they question the treatment of clients. If this happens to you, those in charge may tell you that this is the “real world” and that what you learned in school is impractical and does not apply. In these situations, the new workers clearly have entered situations that developed among the other workers long ago. Workers who encounter such abusive situations have a choice of either reporting the abuse or looking for work in a place where people are treated ethically, but they do not have a choice about their own behavior. Ethically you are charged with the care of the client. That includes the person’s feelings of worth. Ethically your behavior toward people should help enhance their view of themselves as worthy. Behaviors on the part of social service workers that subtract from a person’s sense of self-worth are entirely unethical. Stealing from Clients It goes without saying that it is illegal and certainly unethical to take money or things belonging to clients. We have looked closely at how people lose their privacy. Gossip, giving information to strangers without a release form signed by the client, and releasing more information than is needed are all ways that people can lose their privacy or lose control of their information when they are being served by social service personnel. As previously noted, HIPAA laws outline the right to privacy and the protection of peoples’ health information. However, workers can steal from individuals in other ways without even thinking about it. When you enter other people’s lives and those people are not in a position to protect themselves, they are just as vulnerable as you are when you allow service or repair people into your home when you are not there to protect it. There are two ways workers steal from clients. Both of these are theft and are entirely unethical:   1. Workers can steal a person’s privacy. 2. Workers can steal a person’s esteem and sense of worth. Consider how people can be robbed of their self-esteem and self-worth. Vulnerable and unsure of themselves, perhaps feeling awkward and dismayed over needing to ask for help, people come for assistance with precious little self-confidence and self-esteem. What self-esteem they do have is needed for support in their struggle to regain their health or recover from bad habits. Workers have an opportunity at this point to reassure and encourage or to steal that sense of self-esteem and self-worth. It happens when people are denigrated, spoken to rudely or brusquely, called names, or ignored when they are present. It happens when people are made fun of, treated cruelly, shamed, and ridiculed or forced to perform actions they are incapable of performing at the time. Let’s look at some examples. Kimberly had a long-standing battle with schizophrenia. When her mother was diagnosed as terminally ill, she called a crisis hotline to talk about this pending loss. The day her mother died she called again and the worker replied, “Didn’t we discuss this before?” When Kimberly said they had “but my mother died today,” the worker went on, “well, do you have anything else to talk about because if you don’t you are wasting my time.” Peter had been sober for 2 months when he began to drink again. He felt bad about it and fearful that he would go on a binge, so he sought out the worker at the detox unit assigned to him. When the worker finally took him into his office, he said to Peter, “So you couldn’t stay off the bottle! What a loser. I guess you know that by now.” In an after school program for teens with behavior problems, Curt was telling his worker that he could not return to school until he had completed the program. “I have no time for you. Grow up and complete it,” said the worker, and with that she walked out of the room. For the rest of the afternoon and evening she refused to acknowledge Curt, invite him to eat with the others, or respond when he approached her. She would look past him or turn to another client. I am sure that as you read about these incidents you felt these were egregious examples of workers mistreating clients or patients, but in many settings rude and often unkind communication is used frequently, either because workers feel harried or because they see this as a way of motivating people or because it makes them feel important. For the truly professional worker, it means that you will decide consciously that you will never knowingly subtract from a person any sense of self-worth or self-esteem. If you can make this promise to yourself, you will be conscious of how even your most casual remarks can either steal something of value or enhance the health of the people you help. Competence A significant characteristic of professionals is their ability to clearly know their limitations. Ethical professionals do not try to do work for which they have not been trained. Recognizing the limits of one’s training and experience is very important. This means that you will be aware of areas where you could use some help or direction and that you will seek assistance when you need assistance. You will ask those who have more experience or education to assist you rather than attempting to do work for which you are not qualified. In addition, seek additional training throughout your career. Most certification and licensing programs require that individuals obtain further training on a yearly basis. Even if you are not part of such a program, you have an ethical responsibility to increase your skills, knowledge, and understanding of the field in which you work. Responsibility to Your Colleagues and the Profession We all have an ethical responsibility to protect our clients. Sometimes our clients need to be protected from those who are charged with their care. Nearly every professional code of ethics contains statements supporting the ethical responsibility of the professional to take action when a colleague is no longer able to function effectively or is openly violating ethical guidelines. Impaired Workers A social service worker is considered impaired when he or she is no longer functioning effectively due to substance abuse, mental illness, or personal problems. In such cases, impaired workers are so consumed with their problems that they are no longer able to focus on the needs of clients. In other words, they are distracted, focused on things other than their professional responsibilities, and often neglectful to the point of endangering clients. If Someone with Whom You Work Becomes Impaired If you find yourself in a situation where a coworker appears to be impaired and therefore unable to be effective, you have an ethical obligation to take action. Generally the first action to take is to talk privately with the person who seems to be having problems. Point out your concerns and listen to any explanations you receive. Explore ways to help the person resolve the problems. Usually agencies have established procedures for handling concerns about colleagues who are thought to be impaired. Sometimes, if the person holds a professional license, the licensing board is notified so it can take appropriate steps to curtail the individual’s opportunity to practice until the personal problems are resolved. In one outpatient unit where clients received medications, it became obvious that one of the RNs was taking some medication for herself. At first the staff was not sure how to handle this. The RN was the supervisor. She did the pill count, but the workers noticed that clients ran out of medications sooner than expected with numerous seemingly reasonable explanations. The staff was torn between wanting to let someone know and fearing that they could be wrong. Finally, in a staff meeting one member remarked that she was concerned that the clients were so often out of medication and she wanted to better understand how that happened so the agency could take steps to correct it. When the RN became defensive and refused to participate in the discussion, the staff went with their concerns to the administration. If you have concerns about how to proceed, it is useful to discuss your concerns with a senior professional. Here you may be able to clarify whether and to what extent clients are endangered by the behavior you have observed, and how the behavior indicates that your colleague is impaired. If You Become Impaired Ethically you have a responsibility to refrain from activities that may lead to your own impairment. Should you become impaired for whatever reason, you have a further ethical responsibility to resolve your problems if they will interfere with your ability to practice. Practicing with clients if your physical, mental, or emotional problems will interfere to the detriment of the clients is unethical. It is important to have good selfawareness and be alert to the possibility that personal problems are interfering and having a negative impact in your work with clients. If this is the case, you have an ethical responsibility to seek help and to limit or cease your work with clients until your own problems are resolved. Roy had had a drinking problem off and on all his adult life. He managed to hide it well enough to function in college and in his work as a case manager for many years. When his wife left, however, he began to drink more and missed work more consistently. A coworker noticed the problem and talked to Roy about getting help, but Roy brushed him off. Soon after, Roy began seeing one of the clients who also had a drinking problem and had come to the center for both her depression and her alcoholism. Roy kept this relationship secret, and the couple drank in bars that other case managers would not frequent. One night Roy and his girlfriend got into a fight at the bar where they had gone after dinner. The bartender asked them to leave; the fight moved to the street, Roy beat his girlfriend, and the police were called. Only when Roy ended up in jail, his career and marriage in a shambles, and his addiction out of control did he sober up enough to agree he needed help. Roy served his time, was terminated from his position as a case manager, and began outpatient treatment for his addiction. He is currently working as a night watchman for a furniture store. It is often difficult to admit that we have problems, particularly when we work in a field where people expect us to have healthy answers to their issues. Nevertheless, problems are part of life and they always present opportunities for growth. Denying our own problems is not healthy and further impairs our ability to be useful social service workers in the future. Address your own problems as they occur as part of a lifelong pursuit of health and wisdom. Ethical Violations This chapter has put forward some of the common ethical standards and issues you will encounter, but it is not entirely comprehensive. You may encounter situations in which you have questions about what is ethical and what is not. Consult your code of ethics and talk to senior professionals about your concerns. Not all situations present clear-cut ethical options. Sometimes you may have a colleague who is seemingly violating an ethical principle. A discussion with your colleague about your concerns is often the first step you might take, describing what you have observed and your concerns about your observations. If no satisfactory resolution results, you must then express your concerns to senior professionals or the administration in order to end the unethical behavior. Your agency will likely have a procedure for reporting unethical behavior; if so, that procedure should be followed. Professional Responsibility Finally, remember that you represent an agency and that it is your responsibility to establish a relationship with your person that is befitting of the agency. This will affect your relationship with the person in two ways. First, know the parameters of your agency and operate within them. If you work for an agency that gives out food and fuel to the poor, do not attempt to do mental health counseling. If you are a case manager in a drug and alcohol unit, do not attempt to arrange foster care for one of your client’s children except through the agency designated to handle that. If you work in a shelter for battered women, do not try to do drug rehabilitation. When a person needs services that fall outside the particular focus of your agency, make a referral to another agency that can best handle the problem. The second way your relationship with the client is affected is related to dual relationships. Remain professional. Limit your contact to the focus of your agency and to the focus of that particular person’s problems. Do not invite people home to dinner, take them home with you for the night, or become socially involved with them because you feel sorry for them. Perhaps you are in the ER giving assistance to a woman who has been raped in her home. You are working for a rape crisis center. It is late. The woman you are interviewing is terrified of going home. You call crisis intervention to arrange for temporary lodging, but they are currently out of the office on a call and will have to “get back to you.” The woman has tried unsuccessfully to reach two family members but has reached only their answering machines. Finally, in desperation, you take the woman home with you. You would rather do this than sit in the ER all night because you have to be at a meeting in the morning. The woman is educated and seems very pleasant and refined. She goes home with you, spends the night at your house, and returns with you to the agency in the morning, where they help her obtain temporary housing and see that she gets safely to work. Two months later you begin to receive calls from the woman, who seems to want a friendship with you. She has found your number in the phone book. Soon after this, you receive a call in the middle of the night. It is the same client. She has had a fight with her boyfriend, and now she wants to stay with you. You tell her she cannot do that, and she becomes hysterical. In the next several weeks, she appears at your house several times, asking to stay with you. Always there is some reason she cannot stay where she is currently living. She knows your phone number, so she calls frequently. You have to be very firm in order to set limits; sometimes it is hard to do. This story about a worker taking someone home is not all that unusual; it does happen. Rarely, however, is a person who is hurting and vulnerable able to reestablish a professional relationship with such a worker, complete with boundaries and limits, once the worker has extended this kind of friendship or kindness. Summary This chapter is particularly important because it involves your ethical obligation to the client and outlines some legal concepts you must follow to protect your client and yourself. The primary issue is always the welfare of the client. That must come before all other considerations. When we choose this line of work, we deliberately choose to work with vulnerable people who cannot be expected to protect themselves or to know their rights. It becomes our responsibility to see that clients are well protected and are treated or given service under the highest ethical standards. Common codes of ethics, including the Code of Ethics of the National Association of Social Workers (NASW) and the Ethical Standards of Human Service Professionals, can be found in Codes of Ethics for the Helping Professions (Brooks/Cole, 2004). Now that you are thoroughly familiar with your ethical and legal responsibilities, it is time to turn to case management as a basic area of practice in which ethical behavior is expected and informs your decisions. Talk it Over “An Ethical Issue” Because ethical decisions are often not clear or vary from one situation to another, it is a good idea to discuss your thoughts and concerns about how to proceed with another person. Another person is often able to sort out things from a different perspective. In “An Ethical Issue” on your DVD, two case managers are discussing whether or not to break confidentiality. They look over the good reasons to do so and reasons breaking confidentiality might not be appropriate. Exercises I: Ethics Instructions: The hypothetical practice situations that follow are designed to stimulate thinking and discussion on the issue of confidentiality. Each situation is followed by a multiple-choice list of possible responses you might make. Choose the responses that you consider the best. In some cases you might want to use more than one of the responses listed. Others may choose a different answer. Discuss with your fellow students the different possibilities and what might present the best outcome for the client. 1. Paula is a 17-year-old client in the daytime partial hospitalization program. Her mother phoned and requested to know Paula’s psychiatric diagnosis so that she could inform the family’s physician who is treating Paula for diabetes. You should: o a. Advise the mother of the diagnosis and the name of the psychiatrist who made the diagnosis. o b. Call the family physician directly and advise him of the diagnosis. o c. Ask Paula to sign a release of information form giving consent for the physician and the mother to be advised of her diagnosis. o d. Refuse to release the information at all.  2. Kelly requests a copy of his current treatment plan. You should: o a. Have Kelly put the request in writing and discuss the issue with the treatment team. o b. Make a copy of the current treatment plan and give it to Kelly. o c. Discuss the treatment plan with Kelly and give it to him. o d. Refer Kelly to the attending psychiatric physician.  3. A 13-year-old boy requests that his school counselor be sent a copy of his initial interview and discharge summary. He signs a release of information form, documenting his written consent for the information to be transmitted. You should: o a. Forward the material to the school counselor. o b. Give the information to the boy who can deliver it to the school counselor.  c. Have the medical records department forward the information to the school counselor. o d. Refuse to release the information until a parent cosigns the release of information form. 4. Mary Smith is a depressed elderly woman who was admitted to Polyclinic Hospital due to severe back pain. She was advised she might need surgery to correct the problem. You are her case manager at the Office of Aging, and she calls to say she is considering suicide. The constant back pain has made her feel like “just giving up.” Mary is currently at home, awaiting a surgery date. You know Mary has a supply of pain pills, and she says she wants to take all the pills. You feel there is a substantial risk that Mary might follow through on her threat. You should: o a. Contact the Polyclinic orthopedic staff who are currently seeing Mary in the outpatient clinic. o b. Maintain frequent contact with Mary, but respect her wishes to keep her suicide plans confidential. o c. After discussing with Mary what you are about to do, contact crisis intervention. o d. Advise the city police department of Mary’s suicide plans. 5. Bill Jones is a client who has been in alcohol treatment programs at your facility. He is currently depressed about his pending divorce and present marital separation. He has signed a release of information form for you to share information with his priest, who is counseling Bill about his religious conflicts regarding the divorce. A man calls you claiming to be Bill’s priest and requesting information on Bill’s current state of mind. You have never actually spoken with Bill’s priest, and you think this might actually be Bill’s wife’s attorney calling. You should: o a. Give no information on the phone until you have verified the identity of the caller. o b. Refer the caller to Bill, but send the information to the person and the address on the release form Bill signed. o c. Insist upon meeting with the priest in person. o d. Refuse to share any information with the caller. o e. Get the person’s number and call him back. 6. Patty is completing a student internship for her associate’s degree in the therapeutic activities program. She asks to review the medical records of the people who were just in her projects group. You are supervising Patty. You should: o a. Advise Patty that the records are confidential and may not be inspected by students. o b. Make certain that Patty is well trained in the policies and procedures relating to confidential information, and only then allow her access to the medical records. o c. Permit Patty free access to the records because she is like part of the staff. o d. Obtain written consent from each client for Patty to review the records. 7. Jerry was a client who improved and was discharged 2 years ago. You receive a call from the National Can Company. The caller explains that Jerry has applied for a job and that the company would like to hire him. Jerry told them he was in treatment 2 years ago and was discharged after showing considerable improvement. The company wishes to confirm the fact that Jerry did indeed complete the program as he claims. You say to the caller: o     a. “I don’t know if Jerry was ever a client of our agency. If you send me a releaseof-information form I can look into that and get back to you.” o b. “Jerry was a patient here but I am not at liberty to say any more than that without a release-of-information form.” o c. “I can tell you that Jerry was a client here around 2009 and he successfully completed the program with us. I will need a signed release-of-information form from Jerry to put in his file.” o d. “I don’t know what you are talking about. Good-bye.”  8. Clark is currently enrolled in treatment, and you are his case manager. He asks you if he may read his medical record. You should: o a. Ask Clark to put the request in writing, and assist Clark in completing the written request if he seems to have limited skills in reading and writing. o b. Present Clark’s request to Clark’s treatment team. o c. If the treatment team concludes that it will not harm Clark to review his record, allow Clark to read it in the presence of a therapist (after deleting information from sources that asked to remain anonymous). o d. Decide with the treatment team who will assist Clark in reading and understanding his record. Then follow through by allowing Clark to review his record with that person. o Exercises II: Ethically, What Went Wrong? Instructions: The following hypothetical practice situations are designed to help you apply what you have learned in this chapter. For each situation, decide what was done in the situation that was unethical.    1. Jennifer had a long day and was trying to get out of the office before 5:00 P.M. She had one more person to see. Dr. Adams had asked Jennifer to give Abdul, a young man recently diagnosed with schizophrenia, a prescription for a new medication. Jennifer had her coat on when she handed the prescription to Abdul in the waiting room. Abdul wanted to know what the medication was and why his prescription was being changed. “Will there be any side effects?” he asked Jennifer. She replied hurriedly, “Oh, no. Dr. Adams says just take this until he sees you next time.” 2. Carl is uncomfortable around gay men. Bert, his client, is gay and has just broken up with his lover. Bert, who is 42 years old, had been in a long-term relationship and is devastated and in tears in Carl’s office. Because Bert has suffered from severe depression in the past, Carl attempts to have him evaluated by the therapist this afternoon. In the meantime, Bert is still weeping and now threatening to take his life. Carl is particularly uncomfortable with this man’s tears and believes this is drama. Carl says, “Oh, c’mon now. Let’s get a grip. You can’t sit in here all afternoon carrying on. Here, take some tissue and go out in the waiting room until Dr. Paul can see you.” 3. Elizabeth visited in the home of an elderly man and got him to sign a release of information form so she could process an application to the county nursing home. In the man’s records were references to the fact that many years ago as a teenager he was convicted of shooting a man in a bar fight, a crime for which he served 2 years in prison. She knows the people at the home will be titillated over this little tidbit of     information, especially her friend Rhoda, who does the intakes. Even though she knows this is not part of the home’s evaluation, that the client has led an exemplary life since that time, and that the nursing home staff might take it out of context, she releases the information anyway, based on her client’s signature on the release form. She and Rhoda have a good laugh about it the next day. 4. Jim is doing an intake with a man who claims he is depressed. He tells Jim that ever since his wife left he has had trouble concentrating and waking up in the morning. He talks about how lonely it is at home, how much he misses his children, how he is tempted to drink in the evenings, and how little he has to look forward to. Jim nods. He understands. “Yes, my wife left last month too,” Jim tells the man. “I know just what you mean. I get to feeling like, well, like there isn’t as much meaning. I never knew the kids were so important to me, but I guess they were. On Saturdays, I used to do things with my son and I still get him every other weekend, but it’s not quite the same thing, is it?” “No,” the man responds, “I was thinking …” Jim interrupts the man to say, “Well, I do a lot of thinking too. I think about what I could have done differently and if it was my fault. Don’t you think these women would see that it’s hard, too hard I think, to raise kids alone?” The conversation continues in this vein until the end of the interview. 5. Carmen is supposed to see her small caseload of persistently mentally ill individuals at least twice a week. Lately with school and her mother’s death, she has not really seen her clients that often. She has checked in with them on the phone, but she also has used time when she was out seeing clients to do errands at the library and to empty her mother’s home. Now one of her clients is in court after committing a crime. The client and the lawyer agree that the client might be able to use his mental health status as a reason for committing the crime, and they ask to introduce the case record as evidence in the court proceedings. Fearing that it will be discovered how little supervision and attention she has given her client, and knowing that ultimately she could be blamed for the fact that her client committed the crime while under her somewhat irresponsible care, Carmen invokes the concept of privileged communication to avoid having to give the file to the court. 6. Ted is in a clinic with his elderly client, Gretchen, for a routine blood workup, which they do every other month. He notices Gretchen is bruised on the face and arms. For a while he makes small talk with her, and then he asks her about the bruises. She is somewhat evasive but indicates, “They weren’t the result of no fall!” Without explicitly blaming her daughter and son-in-law, with whom she lives, Gretchen makes it quite clear that the bruises are not the result of an accident. After the blood test, during which neither the doctor, who sees her briefly, nor the technician make any mention of the bruises, Ted takes Gretchen home. He toys with the idea of reporting the bruises to protective services at the county Office of Aging but decides not to. He bases his decision on the fact that the law does not specifically require him to do so, that it would be hard and take a lot of time to have to place Gretchen in another living arrangement, and that the daughter seems like a very nice person whom Ted does not feel like stirring up over an uncomfortable situation. 7. Kitty has a whole list of things to do today and doubts she can get it all done. She hates the way there are always things left to do at the end of the day. It just seems that no matter how hard she works, something new comes up that she cannot complete. One of her clients, Isabel, has told her on the phone that she wants to sign     a release of information form for her lawyer. Kitty has the form ready for the time when Isabel will be coming in at the end of the week. Today a man calls and says he is Isabel’s lawyer and he needs just two dates to help him file a brief with the court on the Isabel’s behalf. Kitty gives him the two dates and hurries to the next thing on her list. 8. While having lunch in the staff room, Jorge is obviously mad. He spent one morning taking a meticulous social history from a new client. The client, a man in his 20s, was pleasant and helpful. He seemed to genuinely want the assistance of the agency and to like Jorge. Two more interviews followed to set up services, and the man signed a release of information form for Jorge to meet with the client’s physician. Jorge cannot understand why this man never mentioned the fact that he is HIV+. This Jorge found out in the conference with the man’s physician some weeks later. “How do these people think I am going to help them if they don’t tell the whole story?” Jorge fumed. “They come in here and want my help and then withhold information from me. They leave me in the dark. I don’t know what’s going on, and then they think I’m going to be able to help them.” 9. A new worker, Jill, is working at a large residential facility for the mentally ill and has been assigned four clients for whom she is to develop goals and objectives to help these clients move forward to greater independence. She meets with the first two clients and then confides to a worker who has been there longer that she had trouble understanding what the clients wanted to work on. The worker tells Jill, “Just make up the plans. These people are a waste of time. They won’t ever get any better. Look at that one. This is his fourth trip through here. No one ever made a difference with a plan, and you won’t either. Just put something down to satisfy the insurance company, and come in here with us. There is a good movie on TV tonight, and the staff is going to put the residents to bed early and get together in the patient lounge to watch it.” 10. Beatrice, who has suffered from schizophrenia for most of her life, has been placed in a long-term residential facility. One night the worker decides to take the residents to a movie. The residents all get in the van to go to the movies, and the worker waits to leave until everyone has a seat and has fastened their seat belts. Beatrice finds a seat but complains that the seat belt does not fit, that she cannot fasten it around herself. The worker replies, “Well, if you didn’t eat so much, you wouldn’t be so fat. You always pig out at the table, and this is what you get. I guess you’re too fat to go to the movies tonight, Beatrice. Guess you’ll have to just stay home.” 11. Pedro noticed that his colleague, Antoine, was using clients’ spending money to make small purchases for himself. Each resident in the group home was given a specific amount of spending money every month, and it was kept in the resident’s envelope. When money was spent from the envelope, a receipt was to be left in the envelope showing where the money went. Antoine was taking money for small purchases for himself—lunch, movie tickets, a gold chain. He was placing the receipts for these purchases in the residents’ envelopes. It was not possible for administration, when doing an audit of all the residents’ accounts at the end of the month, to determine from the receipt who actually benefited from the expenditure. Pedro thought about telling the administration but felt it was likely that Antoine   would deny the allegations, and this would ruin their working relationship. Therefore, Pedro did nothing. 12. Marcella began to drink in the evenings after work when her husband left her for another woman. As the months went by, the divorce became increasingly acrimonious. There were accusations, attempts to take Marcella’s money, and attempts to deprive her of custody of the children. The children began to exhibit problems, and there were financial problems as well. Drinking in the evenings expanded to a drink with lunch and later to a drink and then several drinks in midafternoon. In time, Marcella could not face the day without alcohol when she first got up. She continued to report for work where she was the sole worker on the day shift in a small residential setting with four clients. Marcella began to ignore the residents. It started with naps in the afternoon, which left the people unsupervised. Later Marcella found it too hard to fix dinner for her residents and began to allow them to eat junk food for dinner. As the situation deteriorated, Marcella became more and more mired in self-pity, anger at her ex-husband, and alcohol abuse. She continued to work at the group home. 13. Arnie has problems with substance abuse. He considers himself an “alcoholic who likes a little cocaine now and then.” He is funny, articulate, and clever. When he comes to the case management unit he seems open about his progress and regressions. He always asks how his case manager is doing, what she did for Christmas, how her little boy is doing. Sometimes he brings in the paper and leaves it for her to read, saying he has read it and is finished with it. On Friday evening some of the case managers go out to dinner at a place that serves alcohol and very good food. They are having a good time unwinding after work when Arnie joins them. It appears that he is drinking a soft drink, but no one knows that for sure. Arnie and the case managers laugh and talk about their work until late in the evening. Arnie is funny and has hilarious insights about some of the clients he has encountered in the waiting room. Exercises III: Decide on the Best Course of Action Instructions: Sit with a small group of other students and decide how you will handle this situation. There are many areas both ethically and legally that are not clear, so the discussion you have with your colleagues is much like a discussion you might have in a real agency. There are no “correct answers.”  You have been working with a client who is HIV+ and is a regular user of heroin. He needs both medical and substance abuse treatment. However, he is inconsistent about coming for regular treatment and medical care. You suspect he is not taking medications prescribed for him. In addition, he is sexually active with several women. He has asked that you not contact him at his home where he lives with one of his girlfriends. He has stipulated that no family members may have any information about him. You think that if you could commit him to a substance abuse treatment facility he will be out of circulation sexually and he will receive the treatments he needs to save his life. You do not know for sure where he is but know his girlfriend where he has been living probably does. Can you do this? What ethical and legal principles are at play here? What do you decide to do or not do? Exercises IV: What is Wrong Here? Instructions: Sit with a small group of other students and decide where there was a lapse in good judgment or a lapse in good ethical behavior. Where are the gray areas? What makes these situations clear-cut or unclear about the proper course of action?   1. A children’s case manager writes a letter to a parent of a 14-year-old girl, currently a client at the case management unit. In the letter is this: “While it has not been confirmed or established that your daughter was sexually abused, it is my opinion that she has experienced sexual abuse in the past.” What did this case manager do wrong? What could be the consequences to the family members if such a letter was received? 2. A human service worker is asked to plan a recreational activity for elderly residents on the floor where she works. She is not sure what to arrange but finally decides to do a program on supplemental Medicare insurance. She invites a friend who sells supplemental Medicare insurance. The friend gives a complete explanation, handing out brochures on her business and her business card and explaining the insurance products her company can offer individuals on Medicare. What is the issue here? CHAPTER 2: Case Management: Definition and Responsibilities Introduction Case management is one of the primary places in human service systems where the whole person is taken into account. Unlike specific services, case management does not focus on just one problem but rather on the many issues, strengths, and concerns a client brings. For example, an elderly person may be referred to Help Ministries for a voucher for fuel oil because it has been unusually cold and the elderly person has been unable to pay for the additional oil needed to warm his home adequately. In this case, Help Ministries is concerned with his fuel oil need and the warmth he will need to stay in his home during the winter. That is their only concern with regard to this client. The case manager, on the other hand, is concerned with the client’s need for fuel oil, with his desire to move into public housing for the elderly in the spring, with what resources he has among his children, with his recent slurred speech indicating a possible stroke, and with his need for meals-on-wheels. The case manager is aware that there is a neighbor who can look in on her client daily, that the client has ties to a church, and that he receives Social Security, but little other income. She knows he has a sense of humor, goes to bingo once a month, and should be fitted for a cane. Case management is a process for assessing the client’s total situation and addressing the needs and problems found in that assessment. As a part of this process, the client’s strengths and interests are used to improve the overall situation wherever possible. The primary purpose for case management is to improve the quality of life for the client. This might mean more comfortable or safer living arrangements, or it might require psychiatric care or medication for diabetes. Another major purpose of this activity is to prevent problems from growing worse and costing more to remedy in the future. In the situation of the elderly man just described, we find that the meals-on-wheels program will deliver a certain standard of good nutrition, preventing malnutrition and costly medical bills in the future. By getting the man a cane, we may be preventing falls that would shorten his life and cost much more in medical bills to repair his injuries. If we enlist the neighbor to look in on our client every day, we have provided a link between the client and his neighborhood. In addition, the neighbor can alert us to small problems that require our attention. A History of Case Management In the late 1800s, a formal attempt was made to organize the delivery of services to people in need. The Charity Organization Society took control of this approach, making the collecting of information and the delivery of services more systematic. In the course of its work, the society developed casework as a useful method for tracking needs, progress, and changes in each case. As people had more needs and problems beyond poverty, the need to coordinate these services became important to prevent duplication. Casework also was employed as a means of tracking and using scarce resources to the best advantage. In the 1960s, the process of deinstitutionalization meant that individuals once housed in institutions were now placed in communities where they needed considerable support to live more independent lives; as a result, casework became ever more important for a larger number of people. In the 1980s, the term caseworker evolved into the term case manager, and these managers took on greater responsibility for managing resources, finding innovative supports, and coordinating services. Agencies began to use case management as a procedure to assess needs, to find ways to meet those needs, and to follow clients as they used those services. In addition to keeping an eye on how scarce resources were spent, case managers were charged with taking a more holistic approach to their clients, looking at all their needs rather than addressing only those that brought the person in for assistance. As part of this charge came the directive to develop individualized plans, plans constructed specifically for the client and not a cookie-cutter approach to supplying services. Today case managers are seen as a significant service in almost all social service settings and are viewed as the most important way to prevent relapse, track clients’ needs, and support progress toward good health. Why We Use Case Management Case management serves two purposes. First, it is a method for determining an individualized service plan for each client and monitoring that plan to be sure it is effective. Second, it is a process used to ensure that the money being spent for the client’s services is being spent wisely and in the most efficient manner. The money you oversee in client care may be public money, such as the money that comes from the state to a county to administer mental health services or substance abuse treatment. It may be money that is provided by insurance companies for services to a policyholder. It may be money provided directly to an agency from either of these sources for the care of a client. The agency uses case managers to make certain the most effective use is made of the money. It is therefore the case manager who determines what is needed and how to prevent needs and problems from escalating. It is the case manager who, in collaboration with the client, determines what services should be authorized with the existing money. It is the case manager who then follows the client and the client’s services and treatment to keep the plan on track. Case management is more than looking out for another entity’s money. It is also the most efficient way to make certain a client receives the most individualized plan for service and treatment possible. To ensure that this will be done, case management responsibilities have been broken into four basic categories of service: assessment, planning, linking, and monitoring. Let’s look at those categories in the order in which they are usually accomplished when working with a person. Assessment The first case management task is assessment. This is an initial assessment, meant to be comprehensive and thorough. Therefore, it covers many different aspects of the person’s life in an attempt to develop an accurate profile of the client and the client’s problem. There are several kinds of assessments. In some cases you will be asked to do a social history (seeChapter 16). Here you ask a series of questions, and as the person answers, you construct a written narrative. Social histories usually have a number of elements that you are to assess, and each is given a subheading within the narrative. For example, current medical condition, living arrangements, relationships, and work experience are all important. In another kind of assessment, you may be given an intake assessment form that lists all the questions you are to ask and gives you a place to note the answer. Each of these assessment procedures attempts to be comprehensive. Each seeks to assemble a considerable amount of material about the client and the client’s problem. The first thing the case manager does is assess the initial or presenting problem. Why did this person come into the agency, and what is the person asking for? Here case managers look at the extent to which problems have interfered with clients’ abilities to function and care for themselves. Does this problem interfere with work or with relationships? It is especially important to note the background of the problem, how long it has gone on, and how it started. In addition, the reasons the client is seeking help now are important. Case managers include an opinion about what possible problems might arise for this client in the future and what plan might be put into effect with the person to prevent these problems. Your opinions about potential future problems are formed as you listen to clients describe their situations. Will the client be likely to be around people who encourage him to drink? Does she have a medical problem that needs attention because it exacerbates her depression? A discussion of the problem uncovers the person’s needs. Case managers look at the overall situation and consider what the client needs to bring stability and resolution to the client’s life and problem. Are there needs that can be addressed that will relieve the problem, or at least alleviate it to some extent? In every assessment with a client, you will begin to learn what strengths the person has that you and the client may draw upon to resolve the current problem. Does your client have an advanced degree, a particularly supportive family, a number of friends and other supports, a particular skill? An assessment should never be just about the person’s problems, but should also include the strengths the person brings to the problems and the strengths you see in the person’s environment. As you take the information from the client, you are also evaluating the person’s ability to think clearly and to understand options, and the person’s general mood. Chapter 18 discusses in more detail something called the “mental status examination.” This is not a series of questions but rather your astute observations of the client during the interview. At the end of your assessment document, you will be asked to express your assessment and recommendations. Here you will summarize briefly the problem and the client’s ability to handle the problem, noting the person’s strengths and needs. Then you will give your own recommendations for service or treatment. Recommendations are generally worked out with the client as you learn what it is the person is seeking and share with that person what you have to offer. To summarize, in an assessment you are exploring and evaluating the following:        1. The initial problem and the background to that problem 2. The person’s current situation 3. The person’s background in areas such as education, relationships, work history, legal history 4. What the person needs to make life more stable and to resolve the current problem 5. The strengths, including those the person brings to the problem and those in the person’s environment, that would be useful in resolving the situation 6. Observations about how well the person functions cognitively and any seeming mental problems you have noted 7. Recommendations for a service or treatment plan for the person A good assessment is the foundation for the development of an individual plan for service or treatment. It delineates the provision of essential services and provides for individualized treatment. On the DVD that comes with your textbook, watch “The First Interview” to see how Keyanna begins an assessment with Michelle, a new client. “The First Interview” Planning After the assessment, you will be expected to develop an initial plan with the client that is comprehensive and addresses all the issues raised in your assessment. This plan should show incremental steps toward improvement and expected outcomes. As a case manager, you cannot plan well with your client unless you are thoroughly aware of the services, social activities, and resources in your community. Formal Agencies Every community has social service agencies that serve specific needs. The best case managers seem to know all the good places to send clients for the services those clients need. Some communities and counties have more services than others, but in most locations agencies are serving children and their families, older adults, individuals with substance abuse problems, individuals on probation, women, and individuals with mental illness or mental retardation. Generally case managers need to learn about other services as well, and the information and phone numbers for these services should be readily available to you when you practice. You will want to gradually develop contacts in these places so that your referrals are smooth and problems are quickly handled. Begin by knowing what formal agencies are out there to help with a particular issue. For instance, if your client has a mental health problem, you might refer him to an agency that specializes in mental health treatment. The staff at that agency is familiar with medications, diagnoses, and treatment alternatives for mental health problems. Another client may be elderly and in need of protective services because you suspect she is being physically abused by her family. You would refer her to a specific agency that offers protective services to older people. A third client may have intermittent problems with substance abuse and need services from an office where there is an intensive outpatient treatment program in the evenings. Generic Resources Good planning is not limited to formal agencies, however. Learn about resources that are available for common problems we all have. Not every problem a person with a developmental disability has will need to be treated by agencies set up exclusively for individuals with developmental disabilities. For example, a woman with mild mental retardation, grieving the death of her mother, was welcomed into a grief support group at the local church and given much support. In another example, a child with academic problems in school was referred to the free tutoring at a local church. An older person who needs more social contacts might be referred to a senior center where many older people go for social and recreational opportunities. In the previous examples, the older person suffering abuse may also need the services of your local district attorney, and the person with a substance abuse issue might need medical care from a general practitioner and a public defender for pending charges of disorderly conduct. These are all services anyone can use. Support Groups and Educational Seminars Another resource often overlooked are support groups and educational seminars. For example, you may have referred the family of a child you are working with to formal family therapy sessions. In addition, you would look at support groups where parents dealing with these specific problems can get together to support each other. Further, you might find a workshop on parenting skills that would greatly benefit this family, and you would tell them about the workshop and strongly encourage them to attend. A client on probation might benefit from a workshop for job readiness or a support group for exoffenders attempting to make significant life changes. These resources are often overlooked by case managers but they are a wonderful source of support and new information for your clients and often they are free or at very little cost. What your clients gain from their experiences in such groups reinforces the other services you are arranging. Peer Support A relatively recent trend is to use peer support wherein a former client who is doing well is hired by an agency to support others on the road to recovery and life changes. It might be individuals who were able to turn their lives around after a period in juvenile detention and now are supporting others coming out of juvenile detention to do the same thing. It might be someone who has had a mental illness and is now helping others who are recovering from their own mental illness. And, of course, in substance abuse, Alcoholics Anonymous (AA) has always used that model of one person in AA helping another. The idea is based on the fact that not all professionals know what it is like to experience some problems firsthand. The peer support person is able to say he has been there and can show the client how to resolve the issues with firsthand practical information. Individuals whose functioning is impaired might benefit from a peer support person who can help them function better educationally, socially, or vocationally and may even become involved in helping them with issues of self-care. Much like case management, the peer support person ascertains that the client will accept peer support and then works with the client to set realistic and meaningful goals the two can approach together. Good peer support helps clients formulate the small action steps needed to move toward the goals the two have identified together, and the peer support person can be there with advice and ideas if the action step doesn’t work very well. As a case manager, use peer support when a person needs more sustained time than you can give and the support will significantly help the person move toward recovery. Informal Resources and Folk Support Systems You also need to be aware of social activities your clients might enjoy that would keep them involved in their communities. Perhaps one likes to work on models and could become a member of the model railroaders club. Perhaps another genuinely likes people and enjoys being with them. This person might do well as a member of the Jaycees. Clients do better living in a community in which they have healthy folk support systems. A folk support system refers to the kinds of supports most of us have in our communities such as Lions Club, a church, or volunteering on specific community projects. All of us need to feel we are a part of the place where we live, but many people do not have the skills to interact with others and find useful activities on their own. As a case manager, it is your responsibility to integrate your client into the community if this is a need. Find social clubs, churches, and groups that pursue similarinterests, and help your client make contact with those people. The more contacts your client has and the more useful activities your client engages in, the more support the community can give. A particularly touching example of the use of informal supports occurred in a small town in which the firehouse was located just around the corner from a group home for five older men with mental health problems. They had been institutionalized for most of their lives, spent years on medication, and had the common long-term side effects that can develop. One of the men, Nick, wanted to be a fireman, so the case manager connected this man to the fire company. The men at the firehouse made Nick a part of their everyday routine. Nick helped roll hoses, swept floors, and took his meals with the men. Nick was included in meetings and made decisions about the dinner menu. He became such a part of the fire company that when he died suddenly of cardiac complications the men were deeply saddened. As a tribute to Nick on the day of his funeral, the procession from the funeral home to the cemetery was led by a number of fire trucks, beginning with the trucks from Nick’s home station and including some from neighboring communities. This was an excellent example of using folk supports to give a person a valued place in the community and a sense of doing something worthwhile. Case managers often fail to use these valuable informal resources for several reasons. They may feel that their client cannot handle being with ordinary people in ordinary settings. This is often based on the case manager’s attitude about the client’s disability and is often quite erroneous. Having clients in small numbers in social activities or organizations that give them an opportunity to practice strengths is an invaluable experience for everyone concerned. Another reason a case manager might be reluctant to place a client in a community social group might stem from the case manager’s perception that people in such groups do not want to be bothered with people who have disabilities. In some cases, this assessment is correct, but in others it is quite the opposite. Many organizations are set up to provide service and perceive this as an opportunity to grow and serve the community. Doing your homework pays off. You cannot rely on suppositions and speculations. Know what is available in your community and have places in mind that would serve your clients as the need arises. Meet people and talk to them about what you would like to have available for your clients. Gradually you will develop a list of people and places that welcome your clients and provide the specific experiences and support you are seeking. Your task is to have many resources you can use at your fingertips when developing plans for your clients and to continually be developing new ones in your community. Creating an Individualized Plan After you have worked with clients to determine where the problems are and what areas need attention, you will also know about the supports and other resources clients have in the community and among their family members and friends. You will know what they do well and what interests them most. Each client will be different. As you go about designing the plan with the person, you will place in that plan elements that take advantage of the client’s strengths and supports. In addition, you will address those problems most outstanding or immediate for that client. Each person has a different set of strengths, life circumstances, immediate problems, and personal goals. No two clients view their situations in exactly the same way, so no two plans will be exactly alike. Each plan will be developed specifically for that individual client. At one time, a small program for homeless women employed a part-time case manager for the children. Homeless women were given 2 years’ residence in apartments belonging to the program to work hard on getting an education or training, and a stable source of income. Many of them were distracted from this by concerns about their children. Still others had little time to think about what their children needed as they went about restructuring their lives. The county mental health/mental retardation program gave the shelter a small stipend to hire a children’s case manager. The shelter hired a young woman who had just graduated from college. This seemed like an ideal choice. She was energetic, related well to the children, and was genuinely concerned about each of them. In the next year, the program monitor from the county noticed two things. First, there seemed to be very little material on the children in any records. No individual plans could be found, and no assessments on each child appeared to have been done. Second, the children were all following much the same plan. All the girls attended gymnastics; all the boys were enrolled in Little League. On certain weekends, all the children went to the zoo or to the circus. After receiving repeated requests for individualized plans for each child and some guidance about how to create them, the case manager quit. She said, on departing, that she did not have time to sit and write up records, that the children had been “having fun,” and that the county was unreasonable. The county became more involved in hiring the second case manager, and this person was well aware of the importance of individualized planning. In the first 6 months, two children began to get orthodontic work done, one received a scholarship to a private school, four boys went to Little League, one took violin lessons, and a third joined the swim team at the YMCA. Most of the younger children went to the circus and to the zoo. Most of the older children went on a bus trip to Washington, D.C., and half of them went to two symphony orchestra performances that winter. No child’s plan was the same as that of another child. Each child’s needs had been documented and addressed in some way, and each child’s strengths and interests were brought into play as the plans were developed. In developing these plans, the case manager called all her contacts in the community. She asked two dentists to donate their time. She prevailed upon the symphony to give her the tickets for two performances. She went to a private school and talked to them about this particularly gifted child until a plan for financing the child’s education was worked out. She found a violin teacher and asked for 15 free lessons as a gift to the shelter. In churches and synagogues, she got people enthused about helping the children whose mothers were working so hard to put a stable life together for their families. She looked at scout troops, church youth groups, and organized sportsfor possible answers to the children’s needs. In any number of cases, the plan simply involved the case manager helping an older child choose from among school activities and arranging transportation. This is what is meant by individualized planning. When it is done well and done creatively, your clients can grow and thrive. Continued Planning In continued planning, as you follow the case, you will take into account changes the client may face. An example will illustrate this kind of planning, which you may be called upon to provide. Mary Beth has a mild developmental disability and was assigned to you when she left a state-run institution for individuals with mental retardation. When you did the intake planning, you determined that she would do better initially in a sheltered living arrangement for about a year. Because the goal is for her to move to an apartment of her own at the end of the year, your planning should start well in advance of this move. This planning makes the transition easier for her and for you. There are no shocks and sudden surprises that might necessitate her need for hospitalization or a regression back to greater dependence on the agency. You might begin by setting up services and activities with Mary Beth that involve her in her community. Mary Beth told you when you first talked to her of her interest in singing. The people at the institution said she loved music and sang well, although she could not read music. At the time Mary Beth came out of the institution, you could not find a good place for her to use her musical interests, but you noted this as a strength and kept your eyes open for an appropriate link. Now you have found a choir director at a small church who is willing to have Mary Beth sing with her choir. The church has numerous activities, and there are members who see to it that Mary Beth is included. In this way, you begin to prepare her for a move to more independent living. You seek and find a place for her to live not too far from the church, and you work with interested members to ensure that Mary Beth will have their continued help with transportation and inclusion in church activities. You may think it best that Mary Beth has other social ties to her community as well. There is the Aurora Club, created by professionals just for people with mental illness and developmental disabilities. This club is a place to go and meet others; and the club takes trips, goes bowling, and goes out to dinner together. You could refer her there; however, you might decide that Mary Beth’s mild disability does not warrant her being limited to social activities only for individuals with mental retardation. Instead, you might develop a relationship with a local women’s club, getting them to take Mary Beth as a member. As Mary Beth makes an adjustment to being outside the institution, you look for a job placement. You make a referral to Goodwill, where she is able to develop her social skills, and soon she is hired by a local Wal-Mart as a greeter. By the time Mary Beth moves into an apartment of her own, she has gained new confidence and many friends who connect her to the community. Her success is due in large measure to both your wise initial plan and your modifications of the plan as Mary Beth grew more independent. Linking Once the plan is drawn up, the case manager links (or transfers or refers) the client to the service or persons who will carry out the plan. Linking a client to a specific service requires care and skill on your part. You need to know the best service that will meet the individual issues and needs of your client. Linking your client to a social service agency that provides a specific service—such as day treatment, drug rehabilitation, or groups for victims of violent crime—will require a written referral. You will state why you are making the referral, indicating the problem for which the referral is being made and the goal that you expect as a result of your client’s contact with the agency. The referral will also indicate the amount of time you estimate it will take for the agency to reach this goal. The time limit is very important. It keeps treatment from becoming endless and unstructured. With a goal and a set amount of time in which to attain that goal, both the agency and the client are more likely to make the most of their time together. Sometimes clients can take advantage of services on their own. You might tell a client about the Aurora Club, for example, and the next week he may take a bus there and begin going to the club regularly, participating in activities and social events. At other times, you may have clients who are unable to take the first step and who will need you to accompany them or to arrange transportation for them. In a formal social service agency, personnel at that agency will be able to support your clients in their programs and implement the goals and work on the issues you and your clients have identified as important. Some agencies with very fine programs or specialized services are small, which may require you to give more support to your client. For example, at New Start, a staff of three focuses on second-stage groups for victims of rape and domestic violence, and much of the work is done by volunteers. The success rate is excellent, and clients report a high degree of satisfaction with the agency. However, the small staff is not equipped to handle other problems that might develop while your client is in their group. If you refer a client to a group at New Start and your client has landlord problems between group sessions, the staff at New Start may not be aware of it in time to prevent an eviction notice. Even if they become aware of the notice, they will need to refer the client to you to resolve the matter because of the limited staff time available to clients. On the other hand, at Riverview, a day-treatment program, nurses are aware of medication problems, social workers monitor progress toward goals, and staff can work to prevent eviction of a client, if that appears imminent. On occasion you may find a service for your client at an agency that does not seem interested in serving her. Perhaps they are reluctant because your client has been ill recently or because the agency is not interested in her type of problem. The agency may accept the client into service with them to fill all their slots and draw down payment for services, but in reality they may give poor or no services. In such instances, linking becomes advocacy as you advocate for your client or on behalf of your client. In a situation like this, advocacy means you will attempt to seek the best services for your client, and you will insist that your client be treated fairly and with respect. Monitoring After the plan has been made and implemented (meaning the referrals indicated in your plan have been accomplished), it becomes your responsibility to monitor the services given to your client. When a formal agency is holding a planning or treatment conference about one of your clients, you should be invited to attend. You should also receive written reports about your client’s progress and about the services given to him or her. If you do not receive reports at specified intervals from the agency, you need to contact them yourself on a regular basis. Talking with another agency about the service they are giving your client is done for two reasons:   1. To be certain that the treatment or service you authorized for this client is in fact the treatment or service that is being given 2. To keep track of your client’s progress toward the goals you developed with the client and be aware of times when modifications and revisions in either the goals or the plan need to take place Less formal groups or institutions that are part of your plan should get a call or visit from you occasionally to monitor how the plan is working. Suppose that the neighbor offers to take your client, Bill, to church with her family every Sunday. In August, the family goes away for a month and does not make arrangements with anyone else to take him to church. He begins to feel lonely, and one day he goes to another church closer to his apartment. There he is extremely friendly to everyone, which seems to bother the minister and several members of the church. They decide he is “inappropriate” and call crisis intervention, which gets tied up going to the church and sorting out what happened. All of this could have been avoided if you had been able to have regular contact with the family who took your client to church. In that case, you would have known of the vacation and could have requested that they find a substitute or could have found a substitute yourself. Figure 2.1 outlines the knowledge base and skills needed for case management and offers some useful guidelines for you to follow in practicing case management. FIGURE 2.1: Knowledge base, skills, and guidelines for case management Advocacy Nearly everything you do in relation to your client is a form of advocacy. When you plan with your clients, you advocate for their voices and opinions to be heard. When you link your clients to specific services, you advocate for the best placements and treatments for your clients. When you monitor your cases, you advocate for the goals you and your client have determined should be met. There are other instances where you need to be able to stand up for your client or find the leverage in your community where clients’ rights or best interests will be supported. For example, suppose that your client has just left a drug rehab facility and is living on her own for the first time. She is in a small public housing apartment and is told she is being evicted along with a number of other clients because the building has been deemed unsafe. However, the city seems unable or reluctant to find other housing and your client can only afford subsidized housing. If you have met with your client to look at the options, and if you have met with your client and the public housing officials and find them unwilling or disinterested in relocating your client, you may need to go with your client to see her state representative. True advocacy in this case might involve your accompanying your client to a hearing, testifying in her behalf at a hearing, insisting that she receive a fair hearing, assembling the facts and putting them before a particular board, going to meetings with others whose clients will be affected, and even seeking legal aid. In the chapters on communication, you will learn ways to communicate your concerns so that you do not come across as petulant and demanding. Nevertheless, many clients are not able to organize in their own behalf, defend themselves effectively, or know when they are being exploited or abused. Case managers have an obligation to monitor when clients are at an extreme disadvantage and to advocate for clients in whatever way is appropriate. Keyanna visits with Michelle and her worker at the program where Michelle is receiving services. Here you can see the kinds of concerns that are raised in such a meeting. “Monitoring: Making a Site Visit” Service Coordination Service coordination refers to working with other agencies or systems in a client’s life. Many of your clients will be involved in other programs and systems, and each of these programs or systems may have a different plan for the client. Each of these plans may be headed more or less toward the same broad general goal, but their specifics for each client are different. Often the major and most significant role for the case manager is to bring representatives of these different systems together, forming a team that collaborates with one another in supporting the client’s goal. This is not as easy as it sounds. Communities and counties have numerous services, such as the school and other educational systems, mental health and the mental retardation systems, the criminal justice system, a substance abuse system, and health care systems. These organizations often operate as though they are the only program with which the client is involved. Case managers who attempt to get everyone to work together are sometimes not welcome, and the program may be closed to outside input and collaboration with other agencies. However, coordinating the different services can enhance clients’ movement toward their goals. When coordination is not possible, clients’ goals can be impeded tremendously. For example, Norita was a student at a community college and also a mother on welfare with one child. Because of her mental health problems in the past, her case manager at the mental health unit had facilitated Norita’s receiving welfare to support herself while in school, and the case manager had worked with Norita to get her into school where she was an excellent student. Then the welfare worker insisted that Norita drop out of school and take a job readiness course as all single mothers on welfare were required to do. This demand came in the middle of a semester, and time and money would have been wasted if Norita was forced to drop out of school. The case manager worked with both the school and the welfare office to form a team working to support Norita in her movement toward financial independence. At first, the welfare worker was not happy about working with the case manager. She was curt and unpleasant and stipulated that the rules for remaining on welfare meant that Norita would have to drop out of school and take a 7-week job readiness course. The case manager made an appointment to meet and brought an academic counselor from the college to the meeting. In this face-to-face context, the welfare worker began to soften and see advantages to Norita’s current plan. Norita was only one semester away from graduation after she completed the current semester. The college counselor stated that the counseling department was available to help with resumes and job searches. In fact, it was likely that Norita would be hired from her internship as she was going into a field with a high demand for workers. Gradually a team was formed, and collaboration around helping Norita become independent took place. In the end each party felt the outcome was beneficial to its system. This last element is crucial when coordinating with other agencies and systems. To support the overall plan, each party has to feel that what is being agreed to will have a satisfactory outcome for the system he or she represents. In this case, both the welfare worker and the case manager met the goal for Norita to become independent and selfsupporting. In addition, the case manager avoided duplication of services. If the college was showing Norita how to get a job and the welfare system was as well, there would have been duplication of services. What could have been competing systems and ill will became, instead, complementary services integrated around a specific goal and working together on Norita’s behalf. You will not always be coordinating with other social services agencies. In one instance Meredith’s client, Phillip, believed he was employed by the Fresh ’N Save grocery store near his home. This was a delusion Phillip had held consistently for over a year. Phillip had gone to the store on numerous occasions, rearranging things on the shelves, helping shoppers with their bags and carts, and generally impeding some of the daily tasks at the store. On a number of occasions, Phillip was arrested for defiant trespass, and often he was escorted off the property by the local police. In one instance he was given a short jail sentence, but 6 hours after his release from jail he was back at the Fresh ’N Save. The case manager pulled together a team of people who previously had been working on their own to try to solve this problem. Present at the first meeting was the probation officer, the county mental health representative, a person from the police department, and the manager of the Fresh ’N Save. The question before the team was: “What resources do we need to resolve this problem and move Phillip to more constructive activities?” Everyone on the team recognized that there was no treatment in the jail for Phillip, so the team looked at what other resources would be needed. It was agreed Phillip needed some level of supervision. A commitment to a partial hospitalization program would be obtained. Phillip would go there 5 days a week. In addition, supervised housing was arranged for Phillip. In this way, someone would know where Phillip was or should be at all times. The police and the store manager agreed to call the partial hospitalization program or the supervised housing unit if Phillip returned to the store. The case manager agreed to work with Phillip and staff in the partial hospitalization unit to seek other goals Phillip might have for himself. The county mental health representative agreed that the crisis intervention team would intervene when necessary if the case manager was off on a weekend or in the evenings. In this way individuals representing a number of different systems or agencies went from feeling frustrated and exasperated to leaving with a plan and some assurance that Phillip would get the assistance he truly needed. Levels of Case Management Some agencies have several levels of case management, and clients receive a level of case management commensurate with their need and ability to function. In this text, we look at three levels of case management: administrative, resource coordination, and intensive. In addition, “targeted” or “blended case management” is discussed. In some agencies, these categories may have other names or there may be more than three levels of case management. The following sections provide examples of how case management services might be organized. ASSIGNMENT Begin now to put together a resource book listing agencies and what they do, support groups, and places where educational seminars and workshops are held for the general public. Collect them from the community where you expect to practice, and keep the latest copy of social services agencies found in most telephone books. Administrative Case Management This level of case management is assigned to high-functioning individuals who need very little assistance navigating the system. On occasion, they might need a prescription refilled, an emergency appointment, or a return to outpatient substance abuse treatment, but for the most part they are capable of handling these details themselves. These clients are placed in a pool with other clients who require little service or followup beyond the original referral. For the most part, the clients function independently, using well the services to which they were referred. When something does come up for a client in this caseload, an available caseworker handles it. This means that a client on this caseload does not always see the same case manager. Resource Coordination This next level of case management is reserved for individuals who have some trouble handling the details of their treatment or plan. They usually need help and may have more involved or chronic difficulties that require more assistance. They do not, however, pose a risk to themselves or to others. In addition, with good support, they are unlikely to experience repeated hospitalizations or other crises. Here caseloads are larger, and clients are often in need of services and assistance on issues such as housing, medication, and therapy, but generally the clients do well with the services offered. A person going through a particularly difficult time might be moved up to intensive case management and then return to resource coordination after the stressful circumstances have been addressed. Intensive Case Management Individuals receiving intensive case management require considerable supervision and assistance in order to remain in the community and in circumstances that do not exacerbate their problems. Generally, the caseloads of intensive case managers are smaller, allowing for more individual attention. Clients in the caseload would be those at high risk for repeated emergencies and hospitalization or at risk of deteriorating to the point that they pose a danger to themselves or others. Intensive case management is usually available 24 hours a day and requires intense involvement to ensure that the person has a support network available and is not in high-risk situations, such as running out of medications or living in a housing situation likely to trigger stress and relapse. Targeted or Blended Case Management Some agencies are moving toward a type of case management called targeted or, in some cases, blended case management. This is a different way of delivering case management services. Instead of dividing clients according to their level of need, clients of varying needs are given to a case manager who carries a smaller caseload as a result. In this method, the person has the same case manager through stable times and times of crisis, so that there is good continuity of care and rapport that might support that client when things become unstable. Margery, a 36-year-old single mother of one child, a daughter, was stable and in school when she was transferred to a blended case management caseload. She had needed little contact with the agency in the past year, and the contact she did have was mainly for medication checks and prescription refills. In March the man she had been dating and talking about marrying was killed in a single-car accident. In the car with him at the time was another woman, who survived the accident and insisted she was actually the man’s girlfriend. Margery was devastated. She began to skip classes, jeopardizing her place in the career program she had chosen. She took her medication erratically and gradually became in need of emergency care. Her case manager was a person she had known for some time, and it was her case manager who came at once to the emergency room when Margery was brought in by family members. Liz, her case manager, was shocked at the changes in Margery. Margery was haggard, thin, and unkempt. She looked past Liz and said little. Liz made certain there were arrangements for Margery’s daughter with family members and stayed in the emergency room until a bed was found for the patient on the psychiatric unit. During Margery’s 6day stay, Liz visited often and worked with Margery to make contact with the school and brought her daughter in for a visit after school two afternoons. When they talked, Liz worked on some of the supports Margery would need to return home. Of paramount importance was that Margery stay on her medication and call Liz when she felt distressed about something. Gradually, with the 9 weeks of counseling arranged by Liz and a return to school the next semester, Liz saw positive changes in Margery. Her home became cleaner and brighter and so did Margery’s appearance, indicating that she was taking an interest in herself and her surroundings. Liz arranged her schedule to be at Margery’s graduation and continued to have contact with her client regarding renewal of prescriptions and regular contact just to see how Margery was doing. This is an example of blended case management in which one case manager provides services to the same client regardless of the level of need at any particular time. When Margery needed an emergency intervention, she had a case manager at her side with whom she was familiar, someone she knew and trusted. Figure 2.2 illustrates the case management process. FIGURE 2.2: Walking through the case management process Separating Case Management from Therapy Case management is not therapy. Often beginning case managers believe that they are to do therapy; that is, that they are to provide weekly talking sessions in which deep-seated conflicts and concerns are exposed and resolved. That is not the purpose of case management, and, indeed, most case managers are not prepared to handle this type of work. In the course of case management with a client, you may uncover deep-seated problems and issues. These become the basis of a piece of the plan developed to resolve these issues. The client is referred to a person or agency that can do that work expertly. As the case manager, you may be the one your clients call when they are having a crisis and their therapist is unavailable. Good listening skills and helping such clients develop a way to handle things until they are seen in therapy is the case manager’s role. It is not your role to intervene with a therapy session. Finally, you will find plenty of other problems that do call for innovative interventions on your part. Learning to be independent, adopting useful and appropriate work habits, practicing good interpersonal skills, and behaving appropriately are all areas that you may address with your client in the course of case management. Although the client may be referred to a specific agency for exactly those skills and that information, you should support that intervention in your contacts with the person. Many clients do not require therapy. Perhaps they have had considerable therapy in the past and are not able to benefit from it now or were never able to benefit from it. Perhaps their interpersonal problems are more a result of the chemical imbalance they suffer than psychological dynamics. For instance, research shows that individuals who are depressed or suffer from a bipolar disorder do well when they receive both medication and therapy. Many, however, have had considerable therapy in the past and are now maintained on effective medications. Other clients may have developmental disabilities and only need skills to attain as much independence as they are capable of handling. Some clients might have suffered a crisis such as rape or domestic violence and need a plan that focuses on protection and independence. Others may be out of fuel and need a plan that resolves the problem of a cold home with small children in it. A few clients may have completed a therapy program for substance abuse some time ago and need only an AA or Narcotics Anonymous (NA) meeting and occasional supportive contact with their case manager. What case managers do is therapeutic in the sense that it benefits the client. Conducting clinical therapy, however—where a person comes in about long-standing emotional problems or pervasive affective disorders—takes years of study and training and should never be attempted by a person not specifically trained to conduct therapy. Case Management in Provider Agencies A provider agency is an agency that “provides” specific services to clients. A case manager might refer clients to such an agency for a specific service. There are positions in provider agencies, however, that are sometimes titled “case manager.” Case managers in provider agencies have oversight responsibility for the service or treatment given by the provider agency to the client. These case managers generally make sure the reason for the referral from the general case management unit is actually addressed, and they communicate with the client’s general case manager on progress, goals for the client, and any changes that may need to be made in the service or treatment plan. Because the client is being seen regularly at the provider agency, the case manager there may also handle some of the personal issues and problems that arise for the client while in the care of this provider agency. When Jennine came to the Wildwood Case Management Unit, she was suffering from depression and was not able to go to work. After she and the case manager discussed her mood and a social history was developed, Jennine agreed to go to a partial hospitalization program at Marshall River Center where her medications could be monitored, she would be attending groups, and she would get a lunch every day. Her husband agreed to the plan, feeling that this would prevent Jennine from sleeping all day and going without lunch. Jennine, her husband, and the case manager decided on the goal together. That goal was to alleviate Jennine’s depression. They further decided together on the best place for Jennine to go to meet this goal. At Marshall River, Jennine had a case manager who set up groups and activities to meet the goal. This was important because the Wildwood Case Management Unit generally authorizes payment for the service given the client and expects that the goals for the client’s recovery will be addressed in return. The goal for Jennine was to alleviate her depression. Jennine and her general case manager decided this was a top priority for her. The case manager at the provider agency addressed this goal by instituting a regular lunch and two healthy snack breaks, physical exercise, and group discussions on ways to handle or relieve depression. During that time, the case manager set appointments so that Jennine saw the psychiatrist twice a week for medication checks and adjustments. During the 4 weeks Jennine was in the care of the Marshall River Center, her husband lost his job. This threw her into a panic and exacerbated her depression. The case manager was in touch with the Wildwood Case Management Center about these developments, and there was agreement that Jennine would need 2 more weeks at Marshall River. In this case, the Marshall River case manager saw Jennine daily to talk to her about her husband’s job search and how Jennine was viewing the loss of his job. In this textbook, you will learn how to do general case management with clients in which you work to address many of the problematic aspects of their lives and make strategic referrals to places where help for them is provided. For example, if Jennine and her husband further stated that part of Jennine’s depression came from her inability to discipline her 8-year-old son, the general case manager might have made a separate referral to parent education classes. Once you understand how general case management is done, you will be able to take on case management responsibilities in agencies that provide services and treatment to clients. Managed Care and Case Management Managed care is a phrase you will hear often when you go to work. Managed care is a financial system developed to contain the soaring costs of health care. It works like this: A managed care organization (MCO) receives a pool of money, allocated on the basis of a specific number of patients or clients who will be served by this MCO. The MCO hires case managers who oversee the care given in order to prevent the costs of caring for these patients or clients from running over the amount allotted. An MCO can be either a private insurance company or a company that handles public money. In situations where the insurance covers medical and physical problems, the case manager is generally a nurse who has specific training in the managed care field. In MCOs set up to deal with behavioral health issues, a variety of social service professionals may be employed and trained as case managers. You are most likely to deal with an MCO when working with clients with developmental disabilities, those with substance abuse problems, and individuals who have mental health problems. Because managed care is an economic system to control costs, you may find yourself at odds with the decisions of the MCO case manager. For example, you may be required to receive permission from the MCO case manager before you can implement a service or treatment plan. This is called a preauthorization. You may have a client sitting in your office who seems clearly suicidal to you, but the MCO case manager is denying hospitalization and suggesting partial hospitalization instead. There is little room for individual variations or innovative treatment plans in managed care where an MCO is paying for the services because MCOs generally have a cookbook approach to various health problems. There are specific protocols or decision trees to help case managers decide what treatment or services are appropriate, and these protocols do not take into account individual differences in clients’ personalities and circumstances. If you are not an MCO case manager, but rather the case manager seeking payment from the MCO for services you really believe your client needs, it is your role to advocate for your client and the services you feel are the best ones for the current situation. Sometimes you will be able to obtain a better decision for your client and sometimes you won’t be able to do that. However, if you are convinced that what the MCO is proposing is not in your client’s best interest, you owe it to your client to advocate on his behalf. Figure 2.3 explains some recent trends in case management in managed care organizations. FIGURE 2.3: Recent trends in managed care case management Underlying Principles: Hope and SelfDetermination The thrust today is toward case management activities that promote both hope and selfdetermination. Increasingly, beginning at the federal level and moving down to state and local requirements, case managers are being given a mandate to conduct case management services in such a way that hope and self-determination are prominent features of their work. For Children At the U.S. Department of Health and Human Services, the Child and Adolescent Service System Program (CASSP) promotes these concepts. They expect case management to be “child-centered and family focused.” This means that case managers need to have a respectful focus on each child as an individual and need to include the child’s family as a partner in planning for the child. The CASSP emphasizes communitybased services that keep children at home, or at least in their own community. Further, the CASSP expectation is that case managers will respect and be competent when dealing with diverse cultures. Also coming from SAMHSA is the resiliency model for children, again based on research. The findings showed that at-risk children often “bounce back” when they have someone in their lives who makes it clear that they are important regardless of the past; with this kind of support, many at-risk children go on to live healthier lives. A child’s case manager certainly should be conveying this important sentiment, but the case manager can also find those people in a child’s life who will do this as well: family members, teachers, youth counselors or workers, or neighbors. The resiliency model adopts a positive view (the glass is half full) of the child’s life and circumstances, actively seeking strengths on which to build. The belief is that children, like all people, have a “self-righting mechanism” that will help them bounce back from problems using their own power and ideas. The case manager facilitates this selfrighting by naming the child’s strengths and teaching the child to acknowledge them. In addition, case management either provides or coordinates others who provide the following: opportunities for the child to participate in meaningful activities, including those that help others; communicating high standards for the child and equally high expectations; providing consistent support and care; increasing prosocial bonding; setting clear behavioral boundaries and consistently observing these; and teaching life skills for success. Combined successfully, these factors allow a child to bounce back successfully. Further research has shown that the inclusion of several activities not commonly considered when planning formal services is extremely important. A good children’s case manager will develop contacts for these activities. First is reading practice so that at-risk children become competent readers. This is extremely important to later cognitive functioning, success in school, and other endeavors. Another activity involves opportunities for children to give something to others, to be helpful, to be in a situation where they exercise concern for others. Finally, the resiliency model seeks case managers who are culturally competent, respectful of diverse religions, and able to respect and include the children’s families. For Adults Recovery is a model put forth by the U.S. Department of Health and Human Services and the office of the Substance Abuse and Mental Health Services Administration (SAMHSA). They are changing the view of mental illness and substance abuse from one of gradual deterioration or a lifetime of chronic illness to one of recovery and a productive life. Spurred by the self-reports of people who have recovered from their addictions, mental illness, or emotional problems and went on to live productive lives, this model is being applied to mental health and other fields. Professionals who did research on how individuals recover concluded that it is possible to recover and lead a normal life provided the services are in place that will cause outcomes beneficial to this process. In this model, case management is extremely important because the research showed that many times people did not recover because they either did not have access to services that would promote their recovery or these services were improperly coordinated. Now the movement is toward services that are diverse enough to meet clients’ needs, well coordinated, and easily accessible. Clients’ personal visions for their lives and respect for clients’ self-determination are always foremost in planning, reclaiming the role of “healthy person” rather than “sick person.” When appropriate, the client’s family is included. The recovery mission is respectful because it seeks to give clients more selfdetermination or empowerment and improved role functioning. This is done through a set of identified services combined to result in the stated desired outcomes clients have articulated for themselves, such as improved role functioning, self-development, services that support recovery, and symptom relief. In this model, relapse is seen as similar to relapse in any other illness (for example, diabetes or diverticulitis). Most of the time, the client will be healthy and functioning. For the Recovery Model as put forth by the Substance Abuse and Mental Health Services Administration, see Appendix A. For Those with Developmental Disabilities In the field of developmental disabilities, the concept is called self-determination or, in some places, is referred to as Everyday Lives. The emphasis is on clients’ personal choices for the life that is most meaningful to them. Case managers look for services and activities that validate those choices and collaborate with the family to consider how best to spend money allocated for the care of a person with severe mental retardation. Rather than the case manager deciding what the client needs, the family is able to request what would be most helpful to them. Some families might ask to use the money for a ramp and a remodeled bathroom to accommodate a wheelchair. Another family might request special speech or physical therapy. What is important is that the case manager takes an active role in helping clients and their families conceive of a hopeful future and looks with them at the supports that could be accessed to make that happen. For all Clients of Social Service Agencies In another move in this direction, director Elizabeth J. Clark of the National Association of Social Workers (NASW) testified before the President’s New Freedom Commission on Mental Health in July 2002. She stated that as a profession, the NASW has made a commitment to mental health care that is driven first by the client and the client’s family rather than by the preferences of the professional or the limits of the formal service system. She called for more accessibility to services, early mental health screening, and a national campaign to reduce the stigma of mental illness. From these efforts, you can see that case management is moving rapidly away from coordination of existing formal services for individuals who are seen as chronically handicapped and therefore unable to lead productive, rewarding lives. Instead, in all fields of service, whether mentioned here or not, the emphasis is on respect for the wishes and the vision of the client and undertaking activities that will achieve it. For case managers, it now becomes imperative to know what your client wants, not just in terms of services, but also in terms of a productive, useful life. It involves careful listening and encouraging people to dream and hope. It entails respect for the client, the client’s family, and the diversity of human experience. Funding sources are building into their reviews a surveillance of the capacity of case management to support these aspirations not only with standard formal services and, in some cases, medication, but also with the use of community resources and folk supports to assist the client toward a healthy, productive life. Generic Case Management The skills you learn to perform here can be used in any social service setting in which clients’ needs and situations are evaluated, addressed, and monitored. Every agency does things in its own way, uses different forms, and often has a specific focus, but the tasks of case management are the same. Once you have learned how take a social history, make a referral, and document contacts, you will be able to take that knowledge to any agency and quickly adapt to that agency’s methods and way of doing things. Summary Case management is not therapy, but it requires a set of skills that is nonetheless therapeutic to clients and to their well-being. The practice of case management requires an ability to listen to clients and accurately assess their problems, offer a range of diverse and innovative interventions, and follow their progress toward the goals they have set for themselves. New models coming from the federal government and professional organizations stress the importance of giving clients ample opportunity to plan for the kind of future they wish to have for themselves. These models have introduced the concept of recovery from the problems and issues that occur throughout the course of life and recovery from substance abuse and mental illness as well. With a belief in the capacity of people to move beyond illness or current difficulties, case managers plan with their clients for more than just immediate treatment and service needs. In the long run, it is the case manager who takes the long-term view of the client. In addition, it is the case manager who develops a comprehensive picture of the client, identifying the specific interventions that each particular client will need. Exercises I: Case Management Instructions: In each of the following situations, develop a tentative plan for the client. List the various services you believe each client needs initially. Include in your plan for each person both formal and informal services, and where appropriate, use generic services and agencies. Suggest other services the person might use later once the case is stabilized. Think about how you can involve others close to the client and how you will involve the client in planning.        1. You are called by the daughter of an elderly woman who lives alone. The daughter lives in another city and is concerned because her mother does not drive and has seemed unhappy and listless on the phone. The daughter expresses concern that her mother seems lonely and is perhaps depressed. The daughter does not know her mother’s neighbors and calls you instead at the Office of Aging. She has told her mother she is going to call your agency for help, and the mother had no objection to that. 2. A man with a developmental disability lives alone with his widowed mother. She has fallen and broken her hip and will be at the rehabilitation hospital for about 6 weeks. He cannot stay alone. He has a job at Goodwill Industries. County transportation takes him there every morning at 8:30 A.M. and brings him home at 5:00 P.M. 3. A woman and her two children are waiting to receive their welfare check. They came to your state from another to escape an abusive husband and father. The woman is frail and appears sick. They have no place to go and have not eaten in several days. The children smell as if they need a bath and are listless. 4. A mother of two preteens has brought her son in for services. The woman is a widow. She confides that she has been having trouble controlling the boy, who is the oldest, and that the girl is disgusted with her brother’s behavior and does not want to be involved in helping him. Lately the boy has become involved with teens his age and older. They have been drinking and coming home when they feel like it. The mother allowed them to smoke pot in the garage in hopes that she could keep the boy at home, but now she feels that backfired. The boy makes it clear that he thinks coming for help is ridiculous and says the one thing he will not do is give up his friends. 5. A man has been referred by his family physician for help. The man seems extremely inebriated. His wife brings him in and says she is worried that he may go into delirium tremens if he withdraws from alcohol too quickly. His family physician did not see him but sent the couple straight to your office. 6. A father brings in his 14-year-old daughter who is running the streets, refusing to listen, and failing in school. He is at his wits’ end, saying he must work and cannot be home when the girl returns from school. Her mother died 4 years ago, and the trouble started when the daughter was about 12. The father feels that he and his daughter have a difficult time communicating with one another. 7. A police officer asks you to come to the home of an older man he has been concerned about for several weeks now. The man is delighted to see you and tells you that he is having pains in his legs and is unable to walk. During your visit, he asks you to get things for him that are nearby, but obviously it is too painful for him to get up. He says he does not go to the kitchen often to prepare meals, but the police officer has stopped by several times with sandwiches, and Mrs. Jones from up the street, an old friend of the man’s late wife, has brought a casserole on occasion. He is adamant that he wants to stay in his home as long as he can.        8. A woman comes in complaining of depression. She says it started when her husband left with a younger woman and she has not been “right since.” She reports having difficulty falling asleep and complains of no appetite. She says she has missed more than 3 weeks of work since he left last month. There are no children, but she tells you she has neglected the dog and cannot remember if she fed him last night or not. She appears listless and very sad, weeping off and on during the interview. 9. A man in his 60s comes in on the recommendation of his doctor. He had a back injury some years ago and was placed on codeine at the time. After the back injury, other things went wrong. The plant where he worked closed down and his mother died. He found himself feeling very alone and uncertain about finances. “It was then that I started to drink too,” he tells you. When you ask what he means by “too,” he says his doctor believes he has become addicted to codeine. “I don’t know,” he says. “I’ve gotten to the point that I can’t get through a day without a lot of help.” 10. A single mother brings her 12-year-old son in because they are “not getting along.” She reports that he does not listen and comes and goes as he pleases. His homework has fallen off and his grades have slipped, but he is still doing well in math and likes his math teacher. The boy’s father was killed in a railroad accident 2 years ago. The mother tells you that the boy and his father enjoyed a close and warm relationship and that she has felt her influence on him slipping away since the accident. 11. A woman comes to your agency on a referral by the courts after she was arrested for selling various prescription medications on the street. She tells you she currently has some amphetamines, Xanax, and a popular addictive pain medication in her bag. The court is ordering her to show within the next week that she has enrolled in a program that will get her help with her own addiction to some of the medications she sells. “I have regular customers,” she tells you. “And they are going to crap when I stop coming around.” Asked where she gets her medications, she smiles mysteriously and says, “The police are looking into that—you don’t need to.” She denies she is addicted to anything, but court records, including an evaluation by a psychologist, which she has brought with her, indicate that she is addicted to several different medications. 12. A woman who was recently placed in the community after 3 years in a state mental hospital is having trouble adjusting to the living arrangement made for her by the hospital. She is not going out and does not participate in any activities. She is friendly when you talk to her and seems glad to have your company, but she does not seem to know how to take care of the details of everyday living. She has a roommate who is more competent and independent. The two get along well. 13. A woman with two small children is referred to you because she recently lost her apartment. She has a meager income from a part-time job as a clerk in a convenience store and was unable to pay the rent and take care of other bills. She seems unaware that she might be eligible for financial assistance. She is not sure where her children’s father is at the moment. All her belongings are packed in five bulging garbage bags. She and her children seem malnourished and thin. 14. A man comes in who was referred by his job for possible crack use. The man admits he uses crack, but rarely and certainly not to the extent that it would interfere with his work! He will be given 4 weeks off if he enrolls in a legitimate program for  detoxification. He seems reluctant and torn. Eventually he agrees to work with you on a plan. 15. An older woman comes to you for help after a particularly abusive incident with her husband. She admits that she is becoming increasingly afraid of him. She has no friends and no job, “because he wouldn’t let me out of the house—or out of his sight.” She has a number of old bruises and lost 2 teeth in this last incident. She is asking for help and says, “I don’t know. I really fear for my life. It’s just gotten out of hand and I don’t know where it will end.” Exercises II: Decide on the Best Course of Action Instructions: Sit with a small group of other students and decide how you will handle this situation. There are many areas both ethically and legally that are not clear, so the discussion you have with your colleagues is much like a discussion you might have in a real agency. There are no “correct answers.” You are the case manager for a man who has only recently had a first manic episode. He had submitted to treatment, responded well, and returned to work. However, he is currently experiencing another episode, and this one seems more severe. He is not sleeping or eating, is sending cryptic messages on the Internet, and believes everything he reads there is directed at him. He believes the government is “monitoring” him and that he has an important job lined up with a record company in New York. You have determined that he is not leaving his house and that he is preoccupied with what is happening on message boards and chat rooms on the Internet. You have checked in with him several times by phone. Each time he assures you that he is fine and does not need help. What is the best course of action? Do you risk seeking an involuntary commitment, knowing that he seems just well enough to convince the emergency room physician he is not in need of hospitalization? Will this alienate him and make it impossible for you to work with him? Do you wait for things to get worse? If so, is there a chance he may leave the house and get into trouble? What might happen if you wait it out? CHAPTER 3: Applying the Ecological Model: A Theoretical Foundation for Human Services Introduction In working with other people, human service professionals apply the ecological model to develop a broad understanding of each individual client who comes before them. This model, sometimes referred to as person-in-situation or person-in-environment model, looks at the individual client in the client’s context. You are well aware of how distorted communication can become when a statement is quoted out of context. It is possible to skew impressions and deliberately create misunderstandings by quoting only a portion of what someone has said and not the entire conversation. In a class discussion centered around self-exploration and self-awareness, for instance, Matt’s teacher questioned him about his homework assignment when he said he was not sure if he could help people with a certain disability. He went on to explain that at one time it was thought that he had that particular disability, and he had worked very hard to prove that he was not disabled and to overcome people’s initial impressions of him. Now he found himself feeling uncomfortable with people who suffered from that disability. He also explained that he expected his course of study to help him overcome the problem and that he was very aware that his reactions might be inappropriate. Later Anne, who was in class that day, confided to Aisha and Alice that she did not feel that Matt should be allowed to continue with his studies. Surprised, Aisha asked Anne why she felt that way. “Oh, because he said in class the other day that he feels uncomfortable around certain disabled people. I mean, if you can’t work with disabled people, you need to find something else to do.” Aisha and Alice quickly agreed. Anne’s description of what Matt had said was distorted because Matt’s comments were repeated outside the context in which they were said. She did not include the fact that students were having a frank discussion to better understand themselves. That kind of distortion takes place when we look at individuals out of context. In your work, every person you will see functions in a context, an environment. You cannot adequately understand that person without also being able to understand the context in which that person functions and interacts. It is very tempting to overlook context. Many of us fall into the trap of thinking that A causes B: “Juan is irresponsible, so he lost his job.” If we eliminate A, B will cease to be a problem. If we make Juan more responsible, he will not lose any more jobs. Or “Jill is too demanding, so her husband left her.” If we teach Jill better interpersonal skills, she will have better relationships. Although helping Juan to become more jobready and helping Jill to communicate better may very well be a positive part of your plan for them, this kind of understanding of their problems and assigning of solutions largely ignores the context in which these problems arose. It also makes it much easier to see the individuals as being responsible or to blame for the problems they have brought to your attention. When we blame others, we nearly always feel less empathy with their difficulties, and we are less inclined to be truly useful in the human service sense. Seeking a Balanced View of the Client All individuals constantly interact with any number of systems in their environments. All individuals bring to those interactions unique characteristics. Unless the human service worker has a balanced view of both the client and the client’s context, important information and constructive opportunities are lost. In the cases of Ralph and Eduardo, we can see how important this is. Ralph went to prison because of some youthful gang activity. While he was there, he took advantage of every opportunity to change. He went to church regularly, developed a personal relationship with a minister who came to the prison often, and obtained his high school diploma. Ralph was a warm, humorous person who attracted many friends. His outgoing personality attracted people to him who ultimately encouraged him and gave him support. During his time in prison, his mother wrote to him often, pleading with him to change his ways. Ralph felt bad about the trouble he had caused his mother, particularly in view of the fact that she had raised him after his father left home, and he saw her letters as a reason to do better. When he left prison, he enrolled in college courses and attached himself to the church, where he was warmly welcomed. Eduardo, too, was in the same prison because of youthful gang activities. He was quiet and retiring and did not attract the attention and support that Ralph had secured for himself. Eduardo attempted to get his high school diploma while in prison, but he had trouble asking for help when he needed it and eventually abandoned the project in frustration. Preferring not to join groups, he did not go to church or any other group activity that promoted independence and responsibility. Because Eduardo spoke so little and rarely smiled, he was often misunderstood and thought of as being hostile. In fact, he felt shy and awkward around other people. Eduardo’s mother wrote to him regularly, and she too pleaded with him to do better and “turn his life around,” but Eduardo tended to see these letters as nagging and to blame his mother for the fact that his father left when he was very young. He rarely answered her mail. When Eduardo left prison, he moved back with his old friends and resumed his former criminal activities. This illustration demonstrates how individual characteristics play a role in the outcome for the client. Part of developing a balanced understanding of the client is being able to see what the client brings to the situation and how that interacts with the larger context of the client’s life. Ralph brought a personality that attracted others to assist him. He brought a good relationship with his mother and a motivation to do things more constructively. Eduardo brought a more retiring personality, one that was less attractive to others and often misunderstood. Eduardo’s interpersonal skills were not as developed as Ralph’s. The individual characteristics of Eduardo and Ralph affected the outcome of their prison time. Now we will look at Eduardo and Ralph differently. For our purposes, let us suppose that Ralph and Eduardo are both warm, humorous people. Both make friends easily and enjoy the company of other people. Each of them is sent to prison for youthful gang activities, but the context is different. Eduardo goes to a recently built prison upstate that focuses on rehabilitation. There he is provided with high school and college classes as well as religious and self-improvement activities. He is able to take advantage of many different programs to further his goals. A supportive counselor meets with him on a weekly basis and works with him to create a good set of goals and implement them. The location of the prison has another advantage. Eduardo is now closer to his father, who lives only a few miles from the prison. His father begins to visit, offering his support and a place for Eduardo to live when his sentence is completed. Eduardo leaves the prison on a solid footing and continues his work toward a college degree. Ralph, on the other hand, is sent to an ordinary prison where the counseling staff is overwhelmed. His counselor sees Ralph’s potential but has difficulty enrolling Ralph in high school courses because they are crowded. During the time Ralph is at the prison, the education staff experiences a number of turnovers and layoffs. Ralph never can get into the program and stick with it. He rarely sees his counselor because of the number of inmates with whom the counselor must work. No family member comes to visit Ralph, partly because he has been sent so far from where they live, and partly because they blame him for his incarceration and have lost interest in him. Ralph’s mother, sick with severe chronic asthma, rarely writes. Ralph attends church services at the prison regularly, but the prison does not allow inmates to meet with the pastors before or after services because of a strict schedule. The pastors who have formed relationships with some inmates visit irregularly at other times. When Ralph leaves the prison, he has not completed his high school diploma. He moves near some people he knew in prison, and soon he takes up the criminal activities in which he participated before his incarceration. Here it is the context that is different. Eduardo finds himself in a supportive context: a counselor who focuses on his goals and sees that these are implemented, plenty of selfimprovement opportunities, a warm relationship with his father, and a prison committed to education. Ralph, however, finds himself confronted with indifference, lack of supportive programs and activities, an overwhelmed counselor, and a family too distant to give encouragement. The interaction never ceases. The individual makes choices, but the environment prompts those choices. The individual responds to the outcome of those choices, and the environment reacts or adapts to that response. This interaction begins at birth. A fussy baby with calm, patient parents will start life differently from a fussy baby with overworked, anxious parents. An infant with severe disabilities will receive a good start with a large, loving family who devote their time and energy to getting her the best medical and rehabilitative care. An infant with severe disabilities may arrive in another family where everyone tries their best to give the infant a good start; nevertheless, the disabilities prove overwhelming to the caretakers, there is no cure, and family members find that any semblance of a normal home life or time with other siblings is severely curtailed. The first baby is raised at home; the second one is placed in a good institution. In human services, the trained eye will look for and see a balanced view of clients and their contexts when assessing individuals’ needs. Just as important is the human service worker’s understanding of how person and context interact to produce certain outcomes for the client. The Three Levels Client and context have been defined as having three levels:    1. Micro level, where the focus is on the client’s personality, motivation, affect, and other personal attributes 2. Meso level, where the focus is on the context immediately surrounding the client (family, church group, close friends, and work group) 3. Macro level, where the focus is on the larger society’s characteristics and the way the client experiences these or the way these are brought to bear on the client’s situation (institutions and organizations such as the political system, social stratification, the educational system, and the economy) Human service workers are expected to be aware of all three levels when assessing a client’s situation and to be able to intervene on all three levels when such intervention is appropriate. Looking at What the Person Brings When you do an assessment to open a case or do follow-up planning, a number of individual characteristics will impinge on the problems and the eventual outcome. These micro-level characteristics can be divided into two broad categories: Biological Characteristics Neurological development Reflexes Genetic makeup Degenerative processes Illness (chronic, terminal, or temporary) Physical health Nutrition Psychological Characteristics Early shaping experiences Perception Personality Affect Cognition Nurturance Life transitions/position in the life cycle Motivation This general outline gives you a starting point for understanding what your client has brought to the situation. Clients have had different early life experiences, are composed of different genetic configurations, and possess different personalities and perceptions. Each of these differences interacts with the external circumstances of the client’s situation to promote self-fulfillment and well-being, to block those goals, or, quite possibly, to have no effect at all. This topic is discussed in greater detail in Chapter 16 on assessment; this discussion puts forth the framework you will follow in assessing the individual’s contribution to the situation. Looking at What the Context Brings Clients function in contexts that are personal to them and in a larger context, which is the larger society. These contexts can be divided into two broad categories: Personal Context Social Context (sometimes referred to as the mezzo or meso level) Family Work group (sometimes referred to as the macro level) The larger culture of the society The larger organization of the church or workplace Social groups Family culture Family values Family structure Religious group Social class Role status, conflict, and strain The larger community Government Economy Social stratification Prejudice and discrimination Political system It is important to obtain information about the contexts in which clients grew up and in which they are now functioning. The reason for the client’s problems may lie in the context rather than with the client. When you learn about the context, you learn more about what motivates your clients, the environmental cues they receive to behave or make decisions the way they do, and what early circumstances shaped their way of responding to their community and their situation. Clients come from different social contexts. Clients grew up in different households with different parents and different levels of nutrition and encouragement. Clients have different ways of looking at things and explaining them. The economy may have favored their work or begun to dispense with it. The political system may have awarded your client’s subgroup’s power or disenfranchised that group in some way. Your client may have experienced prejudice, an indifferent medical system, or a poor educational system. On the other hand, this person may have grown up in a wealthy suburb, attended private schools, and received the best medical care money could purchase. Developmental Transitions The ecological model is also concerned with normal life changes, often referred to as transitions. These changes are called transitions because they are events that move a person from one phase of life to another, requiring the person to make adjustments or to adapt in some way to new circumstances. Many of these events are simply part of the normal development that all people experience from birth to death. These transitions are often expected, and for some transitions there is preparation. Some people do not cope as well with the changes brought by transitions as others do. Perhaps they have more going on in their lives than they feel they can handle. Perhaps the events have changed their lives dramatically in ways that are viewed as negative. Many of the people we see in the human service field are going through, or have recently experienced, one or more transitions. Here is a list of some of the transitions that people experience: Starting kindergarten or first grade Going to high school Going out on the first date Leaving home for the first time Losing one’s job Experiencing a disaster A large mortgage or other debt Considerable financial losses Children leaving home Birth of grandchild Starting a new job Getting married Buying a first home Experiencing ill health Losing a spouse through death Divorce Losing some physical capacity Considerable financial gains Children marrying Death of a child And there are many more. Although every single one of these events probably will not happen to one person, we can expect that most people, in the course of a long life, will experience many of the transitions on this list. It is important to know about the common life stages a person passes through and to recognize where your clients are in their life stages and transitions. Transition problems are common to many people. Often treatment is unnecessary—self-help and support groups can provide the support a person needs to make the transition. Sometimes, however, a person may find the changes overwhelming, completely negative, or intolerable. These people may need professional help to handle these changes and adjustments. Developing the Interventions You have looked carefully at your clients’ issues and problems. You have come to understand the ways in which your clients have responded to their context and the way the context has contributed to your clients’ motivations and decisions. As a case manager, your role is to design a plan with each client that will address the areas of need. Human service workers can and do intervene on several levels. Many clients of the social welfare system appear to be individuals who have encountered inadequate support in their context. One or more of the institutions that we believe should support the individual in our society has failed these people or has been unable to supply what was necessary to avoid problems. Institutions such as education, medicine, the economy, politics, and the family may have let this person down in some way. When this occurs, our society looks to the social welfare system to supply what is needed, to address the unfortunate gaps in a person’s life, and to apply interventions that will prevent a worsening of the problems. Your task as case manager is to look at the client and the client’s context, to gather the facts about each of these, and to understand how context and person interact to the detriment or the well-being of the client. With this information, a plan is developed with the person that addresses maladaptive interactions between the individual and the environment and that notes those parts of the environment that are positive and useful. The interventions you design or choose should be two-pronged: personal interventions that strengthen the person to handle the environment, and environmental interventions that alter the context to better accommodate the person. Here are some examples of the types of interventions that can be incorporated into individual plans: Interventions to Strengthen the Person  1. AA for substance abuse  2. Parent skills training for the parents of a child they abused Interventions to Strengthen the Environment Family education to support sobriety Temporary removal from home to foster care  Group therapy for abused child  3. Job training for the person with a developmental disability  4. Interpersonal skills training for the adolescent in Use the child’s interests to develop more constructive in-schoo minor trouble Foster home parents given information on creating supportive foster home environment Work with the employer to provide a supportive work environment activities Bring father into the picture in a positive way Family therapy with the mother  5. Medication for the person with schizophrenia  Regular appointments with the psychiatrist Place in a supportive living environment in the community Develop constructive connections with the local church Two family sessions to reinvolve the family in the person’s lif These are fairly routine interventions in a person’s problems to ameliorate a negative or destructive situation or to enhance the person’s self-fulfillment. The point is, however, that a service plan formed without the understanding that interventions take place in two distinct areas could be quite hapless and without focus. When doing a service plan, the human service worker makes certain that both areas have been addressed with appropriate interventions wherever possible and that the interventions are documented in the record. Working with the Generalist Approach The ability to recognize and address issues on all three levels is generally referred to as the generalist approach. Aware that problems occur between the designated client—be that a family, an individual, or a group—and the client’s environment, it is important to see the interaction between the two and to look for ways to intervene on all the relevant levels on behalf of your client. As noted previously, clients are affected by the environment they occupy, and the environment is affected by the clients’ response. For example, look at how Ralph affected the people around him, their response to him and his response in return. Contrast that with Eduardo’s environment and the response he received as a result of his interactions with his environment. The client affects the environment and the environment affects the client in a never-ending interaction that can have positive and empowering results for the client, or just the opposite. When case managers look at how people and systems on each of the three levels affect the client’s problems, the case manager has correctly made a multilevel assessment. This assessment should lead case managers to develop interventions that will enhance both the identified client and the client’s environment. The generalist approach has as its goal the better functioning and increased competence of all parties. By looking at the whole picture instead of just a piece of the picture comprising only the identified client, the case manager has laid the foundation for making solid and long-lasting change possible. ASSIGNMENT Talk to a human service professional in your community about what that person sees as an unmet need in the community. What one service would the professional like to see developed? What specific need would that service meet? What client population would that project address? How could the clients who need this service be mobilized to work in their own behalf? Macro Level Interventions are Advocacy It is assumed that the human service worker is not limited to just helping individuals. Your work as a human service professional places you in a unique position to be able to speak to the problems affecting large numbers of people. This happens in two ways. In the course of your work, you will encounter many who have been damaged by abuse or discrimination. You will see groups of people harmed by poor school systems, a lack of medical care, or scant supervision. Ethically we have an obligation to speak to the needs of those with less advantage in our society. Having seen the damage firsthand, we are better able to speak to conditions that need to be remedied in our larger society and to keep statistics and information on the extent of the problem for use in persuading lawmakers and others in power to take action. You will also see areas of service that have been neglected or that require development. Perhaps there is a need for more supported living arrangements for those with mental illness in the community. It may be that mothers returning to work from welfare lack the means to dress appropriately for the job, need day care for their young children, or require transportation to get to job interviews. Who better than the human service professional to bring to the attention of those who develop programs the areas of service that are lacking in your immediate community? You and others can bring to light the unique needs of your community and help to develop much-needed services. For example, you might have a 12-year-old client who needs an individualized education plan due to his learning disorders. As an advocate for this 12-year-old boy, you would approach the school or support the parents in approaching the school to obtain this specified plan for your client. Your goal would be to make the school system work better for this individual. Your intervention would be on the meso or mezzo level. Now suppose that you find that there are numerous others complaining that students with learning disabilities are being ignored within the entire school system. You have 6 individual clients about whom you have concerns that the school is not meeting their needs. In addition, your colleagues in your children’s case management unit are also citing cases where their clients are not getting the academic support they need. If you all go together to the superintendent of school and respectfully request a review of the procedures and give him information, you have intervened on the macro level. Now you are advocating for an entire population, many of whom are not clients of your agency. Perhaps the problem involves several school districts or involves schools all over the state and the intervention is with the Department of Education for the state or, if that is unsuccessful, the state legislature. This is a macro level intervention. You are advocating for a broad population seeking to make a macro system work better for individuals with specific needs. Summary In this chapter, we have looked at a method for assessing your clients in three different dimensions. This method, often referred to as the ecological model, looks at the attributes clients bring to their problems, as well as the contributing factors in clients’ immediate environments and in the larger societies in which they live and function. Using this model prevents us from blaming only the clients for the problems in their lives. In addition to recognizing all the factors that make up clients’ problems, this model also allows us to recognize the broader need for interventions and to develop interventions that address issues on all three levels. Using the ecological model, you can now produce effective remedies to the problems and the social issues brought to you in the course of your work. In this way, you serve your clients and your society in meaningful and useful ways. Exercises I: Looking at Florence’s Problem on Three Levels Instructions: Look at Florence’s problem as she presented it to the case manager. Decide which parts of her problem are on the micro level, which parts are on the mezzo level, and which parts are on the macro level. Florence came in to see a case manager in an agency that addresses child abuse and neglect. Recently her daughter, Crystal, was removed from the home because of complaints by neighbors that she was abusing the child. An investigation of the situation by child-care workers indicated the abuse was severe. The discipline she was administering was discipline she had experienced and witnessed as a child from her own parents and her aunts and uncles who lived on farms near her family. Florence related that she was the oldest daughter, third in line of nine children, of a farm family of 12 people. Her parents worked hard from sun up until long after dark. Much of the housework was done by Florence and her aunt, who lived with them. Her mother was ill, often in her room in bed. Florence does not know what the illness was, but does not recall her mother ever seeing a doctor. She tells the case manager that she knows her mother and her aunt did not like her. At 18, Florence ran away with Dave, who did mechanical work on cars. “He was my first and only boyfriend,” she explains, weeping. Florence and Dave never married, and they had one child, Crystal. Last April, Dave died in a car accident on the interstate. Florence cries as she describes that night and the way the police came to her trailer and how kind they were to her. She describes how alone she has felt ever since. Florence receives welfare. She completed eighth grade before her father “yanked me out of school to do housework. Said it was no place for a girl. A girl didn’t need no schooling.” Florence had enjoyed school, mostly for the companionship of other girls. “I’m shy of people, you know. But at school I had friends.” Florence remembers school as hard, and she had trouble with subjects like math and science. “Mostly I sat there and worried about what would happen when I got home from school. It was always something: Mom was worse, I was in trouble, there was some big push to get in a harvest. I was glad when I quit.” Leaving with Dave had alienated Florence from her family. “Dave used to say, ‘They’re just mad ‘cause they can’t use you no more.’” For this reason, Florence has not seen her family since Dave’s funeral, and they have made no attempt to get in touch with her even though they are only a few miles apart. The welfare agency reports that their workers have rarely seen Florence and have not as yet offered her any services for going to work, although she is on a list of single mothers they would like to make job-ready. Child welfare tells you that they cannot return Crystal until Florence has had intensive parent training and supervised visits with her child. They also tell you that they found her home worn, but immaculate. Florence confides that she is terrified of going to work, that she feels useless, and that she probably has little to offer on a “real job.” She also appears to be depressed, crying at intervals and hanging her head. Socially she is isolated both because of Dave’s death and because her neighbors are fed up with her child-care practices. “The neighbors don’t like me either,” she says with resignation. The child-care agency is asking for parent training, but it is unclear who will offer that in this rural area.  What part of Florence’s problem is a micro-level problem? What part of Florence’s problem is a mezzo-level problem? What part of Florence’s problem is a macro-level problem? Exercises II: Designing Three Levels of Intervention Instructions: Look at the four cases below and decide how you would intervene on three levels: the personal (micro), the contextual or social context immediately surrounding the client (mezzo), and the larger environment (macro).     1. Maria is paralyzed from the waist down following an accident three summers ago in a swimming pool. She is hoping to complete her degree in accounting, but she is complaining of depression and an inability to focus on school. When you see her, she looks anxious and tired. Her affect is flat, and she tells you nothing interests her. At the local college, she has had trouble finding appropriate parking and misses many days of class when the weather is bad because of the parking situation. One of the professors she must work with closely has made remarks about the difficulty of “other people getting around that wheelchair.” She believes her boyfriend, who was with her the night the accident happened, has remained with her simply out of pity. When they fight about other things, she throws this up to him, although he vehemently denies it and tells Maria this is a hurtful accusation. Interventions on the micro level: Interventions on the mezzo level: Interventions on the macro level: 2. Mr. Groff is 93 and living alone in his home. He only stopped driving last year. He would like to get out more, perhaps go to the senior citizen center. In addition, he would like to go to the Lions Club and to participate in a foreign policy club he belonged to for years. He tells you sadly that the members of the foreign policy club always seemed amazed at the reading he had done and the sound opinions he expressed, “as though I should be senile!” Since he stopped driving, he has lost contact with them. Right now he sees no reason to go to a nursing home and feels that if he had transportation he could continue to buy his groceries, prepare his meals, and care for himself generally. He tells you, however, that he would like to find a way to be less lonely. Interventions on the micro level: Interventions on the mezzo level: Interventions on the macro level: 3. Margie is in a sheltered workshop for people with developmental disabilities. She does well at work and has many friends. She lives with her mother, and her mother is not happy with the new level of independence Margie is developing. She often goes out with others from work and the supervisors for dinner on Friday night. She has joined a social group for individuals with disabilities much like hers, and they go bowling and to the movies. Margie has, since she went to the sheltered workshop, learned how to use the phone to make appointments with her doctor and dentist and how to ride the bus to and from both work and the social club, and she has been shopping to buy her own clothes twice with her case manager. Margie’s mother complains about all this. She tends to blame Margie for leaving her alone at night and making her unhappy. “Since your father died, you’re all I have,” she tells Margie. Margie’s response to this is to cry and stay home and give up some of her independence. Sometimes she has missed work, hoping to make her absences up to her mother. Interventions on the micro level: Interventions on the mezzo level: Interventions on the macro level: 4. Chris is a single father who is trying to work and raise three small children. His wife was killed 2 years ago in a traffic accident. After the initial shock and outpouring of support from friends and neighbors, Chris found himself alone with all the responsibilities and very unsure of himself. He would like to meet other men who have the same problems but cannot find any groups, even though he has been told about several men who are in the same situation. He tells you he is not sure what the best method is for disciplining his children, whom he describes as “good kids.” Sometimes he feels he is too lenient with them, and at other times he is afraid he is unnecessarily strict with them. A local women’s health center has groups for bereaved single parents, but Chris believes those would not be open to him. “It would be all women, wouldn’t it?” he asks. In addition, he is having a hard time at work balancing the responsibilities there with parenting responsibilities at home. “Of course, I want to do a good job and get the promotions so I can support these kids through college, but I need to be home in the evening, or someone does, and I don’t think that is always well received at work.”Interventions on the micro level: Interventions on the mezzo level: Interventions on the macro level: CHAPTER 4: Cultural Competence* Introduction Seeing each of our clients as unique individuals is the only way to accurately perceive them and to be constructive in the way we serve them. One key element of individuality is culture and subculture. Most of our attitudes and perceptions are the result of our interactions with others throughout our lives. In time, these interactions come to seem natural. As professionals, we need to become aware of our personal ways of thinking about others and their situations. Is our thinking useful? Will it promote the well-being, self-esteem, and independence of our clients? Because we are a culturally diverse society, it is important for professionals in human services to respect differences and to seek to understand these differences whenever possible. Culture and Communication Each of us brings to any situation perceptions and attitudes that are influenced by our own culture. Our own ethnic group, family values, outstanding experiences, and cultural traditions all influence both the way we communicate to other people and what we believe other people mean when they communicate with us. Often we are unaware of the extent to which these factors color our interactions with other people. In addition, we do not usually take the time to understand that others may come from a culture that differs from our own significantly. We may judge others’ actions by the standards prevalent in our own culture. We may expect certain behavior we believe is appropriate and become annoyed when we do not see that behavior. We may misunderstand the communication of others, leading to lost rapport and opportunities. This is dangerous when we have accepted the professional responsibility for giving assistance to other people. Your Ethical Responsibility Ethically, you have a responsibility to take the time and make the effort to become familiar with cultures that differ from your own that you have extensive contact with as a social service professional. It is not ethical to simply assume you know all there is to know about a group because you see members of that group on a daily basis. Instead, you need to ask questions, take seminars, and gather information that will enhance your understanding of that group or culture. When You Are Not Sure It is not possible, on the other hand, to study and become familiar with all the different cultures you might encounter in the course of your professional lifetime. In your work, it is quite likely that you may encounter someone from another group whose culture is unfamiliar to you and whom you will see only briefly. What you need is a method you can use that will allow you to participate in those encounters and interactions competently. Where Are the Differences? Differences among people occur on a number of sociological levels. These differences can be overcome and understood, or they can become obstacles to good communication and understanding. Cultures Generally, cultures coincide with national or political boundaries. People living in one country have a culture that differs from the culture of those living just across the border. When we refer to culture, we are really talking about the culture assumed by an entire society. This means that we in the United States have in common with one another a basic knowledge. We learned this knowledge through the socialization process—from our schools, parents, religions, and even television and magazines. Although each individual may see the culture just a bit differently and no one knows everything there is to know about it, people share enough in common to be able to relate to and cooperate with one another. By the time we are young adults, the culture we carry with us in our heads is largely unconscious. Our culture influences how we communicate with other people, and it influences the way we determine what the other person means. In other words, what we say is affected by our culture, and, in turn, our interpretation of what another person is saying to us is colored by our culture. Because this process has become automatic for us, we are not aware of the significant influence our culture has on our interactions with others. Furthermore, if most of the time we are communicating with others from our own culture, we will assume that all people mean what we mean and see things as we see them. With this way of thinking firmly in place, there is a tendency to assume that our own culture is the better or correct way to be at any given time. Subcultures Within any given society, there are groups of individuals who, for the most part, follow the culture of their society but hold in common with each other somewhat different cultural ideas. This may be a religious group that holds ideas that are somewhat different from mainstream thinking about patriotism and serving in the military. It might be an ethnic group whose subculture is shaped by the discrimination experienced in each generation. Subcultures usually are not completely out of step with the larger society’s culture. There is, however, something about the subgroup culture that sets its members apart. It might be values, traditions, beliefs, lifestyle, or any combination of these. Race and Ethnic Group Important in understanding subcultures is understanding the terms race and ethnic group. According to Gudykunst and Kim (1997), race refers to a “group of people who are biologically similar,” and ethnic group refers to “a group of people who share a common cultural heritage usually based on a common national origin or language” (p. 20). Racial groups often have distinguishing physical characteristics, whereas ethnic groups may be distinguished by their language, religion, or some other aspect of their culture. It is important to keep in mind that race alone is not a factor influencing communication; on the other hand, ethnicity with its culture can have considerable influence on communication. If the racial or ethnic group of your clients indicates a subculture that is unfamiliar to you, the potential for misunderstanding is increased. How We Develop a We-versus-Them Attitude During the process of socialization, we learn that some groups are acceptable and others are unacceptable. The acceptable groups are seen by us as in-groups. We are more comfortable with in-groups than with groups we consider unacceptable. We see the members as being similar to us, and we expect the members to hold beliefs and values very much like our own, and to act and think as we would. When we talk about ingroups, we generally do so favorably, holding them in positive regard. We are better at predicting how members of in-groups will respond or behave. Out-groups are those groups with whom we feel uncomfortable—groups with whom we have less inclination to interact on a regular basis. Generally we do not hold members of out-groups in a particularly favorable light. We may be suspicious of the motives of an out-group because we do not fully understand its culture. Using our own culture as the standard, we may find the out-group culture inferior. Members of the out-group may appear unpredictable, unreliable, or devious to us. Strangers When people do not act or think the way we believe they should, they seem strange to us. Many people you will encounter in the course of your work will seem like strangers to you. For example, Julio is a stranger to nearly everyone he sees on a daily basis. He, his little brother, and his mother live in a small city with others from Puerto Rico. When he is with his small group of friends and relatives, he is not perceived as strange. On the other hand, when he attempts to interact with the larger American culture, many see him as a stranger. His language, his behavior, and, in some cases, his attitudes appear strange to members of the larger culture. He is tolerated, and even given menial work, but he feels set apart. People he must meet and work with every day view him as a stranger because they know little about Julio’s culture. They see him every day, yet he is in no way considered part of their group. Julio went to the case management unit to seek services for his brother, who was diagnosed by the school psychologist as mentally retarded. There he encountered some problems. His accent and unfamiliarity with the language made it difficult for him to be understood. While the worker talked about residential placement and education, Julio resisted, indicating the family just needed help with the local school, where he felt his brother had been misunderstood because of a language problem. The local school had suggested Julio and his mother go to the case management unit because school officials did not believe they could provide adequate services. Julio felt their referral indicated insensitivity and an unwillingness to be concerned with keeping the family together and helping his brother function better in English. The vast array of services being offered at the case management unit was bewildering to Julio. He was inclined to simply withdraw from the situation and tell his mother to keep his brother at home. To the worker at the case management unit, Julio seemed strange. She did not exactly use that word, but she wondered with some exasperation why he did not want to take advantage of the many services available to his brother. Why did he seem so reluctant to keep appointments with both the worker and the school? Why had he withdrawn his brother from school when this was clearly against the law for a child so young? To the case manager, Julio’s behavior was inexplicable. It is always the majority group that defines who is a stranger and who is not. The people who seem strange to us are not strangers to those with whom they hold common cultural traditions. If the situation was reversed and we found ourselves in a place where our cultural ways and values were different from the majority, then we would be the strangers. Gudykunst and Kim (1997) use the concept of the stranger to define those whom we encounter who seem strange to us, whose ways of thinking and acting are unfamiliar, and who are not members of our in-groups. In other words, they are people who are close enough that we cannot ignore their presence, but they are unfamiliar to us and therefore seem like strangers. (Throughout this chapter, I use the term stranger as it is defined here.) If people come from another culture, possibly from another country, it is entirely possible that they do not know enough about your culture to be able to relate easily to you. In addition, it is quite likely you do not have enough information about their culture to be able to make the new situation smoother for them. As the human service professional, you are the person who can take the initiative in making the adjustment smoother for those who come to us as strangers. When people we might consider strangers have developed a good degree of competence in the majority culture and can communicate well, they will be healthier. Studies, however, indicate that it takes a long time for immigrants to adjust to the new culture and that if this maladjustment is severe or long-term, it can cause serious mental health problems as a consequence. As the world community becomes more global, we can expect to encounter people from many different cultures who will seem like strangers, people who are different. Gudykunst and Kim (1997) make the point that we have internalized our own culture to such a degree that we believe it is innate in some way. They write, “anyone whose behavior is not predictable or is peculiar in any way is strange, improper, irresponsible, or inferior” (p. 357). When people deviate from the familiar, we are likely to notice it instantly. We may feel anxious or surprised and uncertain. We may be forced to look more closely at our own cultural assumptions. Perhaps we are forced to conclude that aspects of our culture that we have taken for granted are not particularly useful. Our cultural identity may be challenged. Obviously it would be easier to avoid all this and stay away from strangers. Many people do just that, preferring not to experience these unsettling emotions. In human services, however, our work is all about encounters with people, and our purpose is to be helpful. Avoiding strangers would be irresponsible. For that reason, we need to know what to do when we encounter strangers. Anxiety and Uncertainty It is common for most people to feel uncertain or anxious when they are attempting to interact with people from other cultures. If we are consumed with our uncomfortable feelings, our communication with strangers will be impeded. We need to be able to manage our feelings during these encounters to provide for a constructive exchange. Many times we attempt in some way to reduce anxiety or stress in these encounters. We project our notions about what the person means, giving us a certainty that might not be justified. We might try to develop theories about the other person that feature similarities. The more we believe a person is like us, the less likely we are to feel anxious. Thus, we might look for similar psychological reactions, similar group affiliations, and similar cultural aspects. When Misaki came from Japan to study at a local college, she was the only person from Japan on campus. Other girls in her dorm invited her to join them for meals and to walk to classes with them, and Misaki did so. When the other girls laughed and talked about trivial matters, Misaki was silent. She rarely made small talk with the girls. They began to interpret her behavior as “too serious” and worked even harder to draw her into their discussions. Misaki was always pleasant but contributed little to these exchanges. To the girls in her dorm, she seemed too serious; but to the resident assistant, Misaki appeared depressed. Ann, the resident assistant, based her opinion on the fact that Misaki never looked up when she spoke and never looked directly at Ann. Ann asked Misaki if she would like help with her sadness or depression. Misaki said “yes,” so Ann made a referral to the campus clinic. There an intake worker decided that Misaki was indeed depressed and concluded it must be about leaving her homeland. To each question the intake worker asked, Misaki answered “yes.” Yes, it was hard being here in America; yes, she missed her parents; yes, she had trouble understanding everything the professors said in class. A counselor at the clinic recommended to Misaki that she join in more with the girls in her dorm and learn to “loosen up and have fun.” In Japan, however, people who talk a lot are not viewed as particularly trustworthy. Those who use silence more frequently are considered discreet and trustworthy. The girls in the dorm, the resident assistant, the intake worker, and the counselor in the clinic did not understand Japanese culture well enough to refrain from judging her by the standards of their own culture. Furthermore, in Japan people often assess what it is the speaker wishes to hear and answer “yes” as a means of keeping social harmony. They might not mean yes in precisely the way an American might interpret it. In addition, Japanese people often do not look directly into the eyes of someone with whom they are conversing. To look directly at another is a sign of defiance or aggression. Looking away is a sign of respect. The Americans took Misaki’s behavior as an indication of shyness or depression because that is what the behavior would most likely mean in American culture. By fitting Misaki’s behavior into American cultural meanings, the Americans did not have to feel anxious about how to interpret the behavior of a stranger. American girls talk to each other frequently and often about trivial matters as a way of cementing their ties to one another. To the girls who befriended Misaki, this seemed normal. Her silence did not. In order not to feel anxious about her, they projected their own theories about her behavior onto her and concluded that she was sad about leaving her home in Japan. This was a normal reaction, understandable from their standpoint. The theory made Misaki seem more like them; thus, their theorizing reduced their anxiety. We will unwittingly go to great lengths to resolve our anxious or uncertain feelings. Often what we do is inaccurate and not useful in promoting clearer communication. Thoughtless versus Thoughtful Communication First, we need to find a way to control our anxious feelings to allow us to really be able to listen and communicate. If we are likely to feel anxiety when we talk to strangers and if this anxiety is going to interfere with a realistic understanding of these strangers, we are going to hear and communicate in a skewed or inaccurate manner. What is worse is that we may be only vaguely aware of this problem. The following sections discuss areas you can evaluate to make your communication more thoughtful and accurate. Recognizing Our Tendency to Categorize Think about what we do when we are communicating without thought. We categorize people; we assume there is only one correct or normal way to view things; and we are closed to information that does not fit with our cultural perspective. When we encounter someone who is different, we dump that person into one of our large categories or stereotypes. When someone’s behavior does not fit or that person’s thinking is strange to us, we are thrown off balance. To prevent that, we have categories all ready into which we can place such people. Because we do this habitually, we are not completely aware of our categorizing. Actually, as you work with various sorts of people, you may find that you need to add many new categories to your conceptualizations of others. These categories, if more specific and definitive than those based on stereotypes, will be better predictors of behavior. Looking for Exceptions To become more thoughtful as you communicate, start to look carefully for the exceptions to your categories. If you think all Hispanics are loud, think about times when you have encountered Hispanic people who were not loud. If you believe all Muslims are militant, look for times when individual Muslims have expressed cooperation. If you believe all Jews horde money, seek out the times that Jewish people have been generous. In other words, recognize that the categories you have been using are likely to be much too broad to account for all the specific differences you may encounter in the people you serve. Another way to look for exceptions to your categories is to seek differences in each specific individual. If you dismiss a stranger as coming from a group that is generally believed to be resistive to your efforts to help, you will have little success compared to recognizing the resistance and then looking for times the stranger was not resistive. If you have categorized someone as too talkative, look for times when that person was listening instead. If you are sure the people in a particular group are stupid, look for times individuals in that group made wise decisions or choices. Seeing others as individuals will make these exceptions important to you. As a competent worker, you will diligently seek these exceptions to gain a more accurate understanding of the people you are serving. Checking Our Attributions Most research shows that when we see a stranger’s behavior as negative, we are inclined to blame that behavior on the stranger’s character or disposition. When we see the stranger’s behavior as positive, we are more likely to think this person is an exception and attribute the exceptional behavior to the environment or the circumstances. In other words, it appears that for many of us, giving up our stereotypes is very hard. We would rather see the exceptions to our stereotypes as something external to the stranger, and we are likely to blame behavior that seems to fit the stereotype on the personality of the stranger. The opposite is often true as we go about attributing causes to our own behavior and the behavior of those we consider to be members of our in-group. If we see negative behavior in these people, we are likely to blame the environment or circumstances, while we often consider positive behavior a reflection of the person’s character. The following list summarizes how we often see things: Our positive behavior Their positive behavior Our negative behavior Their negative behavior Attributable to our good character Attributable to the environment or the circumstances Attributable to the environment or the circumstances Attributable to their poor character When we do this systematically, it reveals prejudice on our part. In addition, these systematic errors in attribution cannot have come about thoughtfully. They are thoughtless, automatic ways of looking at other people. As you become more thoughtful in your communication, become aware of how you explain the behavior of others. Evaluating Scripts We have all learned certain scripts for the activities we engage in frequently. For instance, if you meet someone you see often, but do not really know very well, you might say “Hi” as you pass that person. She might say, “Hi. How are you?” You would probably say something like, “Fine, and you?” She might then respond with “Just fine, thanks.” By the time this exchange is completed, you may be several yards apart and walking in opposite directions. This constitutes a script for passing someone you see every day but do not know very well. There are scripts for a variety of everyday activities. We carry them in our heads to be used when the appropriate situation presents itself. We have learned them first by observation and then from our own participation in these activities. The exchange demonstrated in the previous paragraph did not take much thought. Two people may pass each other every day and go through much the same exchange. They do not stop and consider what to do as each encounter presents itself. We expect that people from our culture will respond to our “hello” with a “hello” of their own. If one individual does something different, we are thrown off balance. People from other cultures, however, have learned different scripts. For instance, a common area of misunderstanding relates to the fact that different cultures have different nonverbal ways of indicating that they do not want to be approached. Suppose you are indicating through your body language to someone from another culture that you do not want to be approached, and this person approaches you anyway. You may feel pushed and invaded when, in reality, the stranger could not recognize the signals. You could make a similar mistake. You might see a person you want to join you. You might wave to the person and point to your group, indicating that the person should come over and join you. To a person from an Asian country, this would be insulting. Waving people over, and especially using one finger to do so, is considered rude. We are looking at two different scripts. Behavior or communication that seems strange to you may simply be a different script presenting itself. Stop and think about what the unexpected behavior means to the stranger. Is this offensive behavior, or does the stranger mean something quite different? Is there a possibility that you are misreading the signals or cannot recognize the signals from this stranger? Is it likely that the signals you are sending are not familiar to the stranger? Checking Perceptions Gudykunst and Kim (1997), who have written extensively on this subject, recommend that we simply check our perceptions with strangers to see if these perceptions are accurate. Instead of assuming that we know what a stranger means, we need to check. These authors recommend a three-step process:    1. Describe the other person’s behavior, being careful to simply describe what was observed without evaluating or labeling the behavior. 2. Tell the stranger how you interpreted the behavior. In doing so, be matter of fact. Refrain from any hint of a negative evaluation of the behavior. 3. Ask the stranger if your perceptions are accurate. Checking your perceptions is a good way to keep the communication between you and the stranger accurate and meaningful. It is important not to assume you know what the stranger means or what the stranger feels. Check with that person to see if what you perceive is correct. Allowing Differences It cannot be stressed enough that thoughtful communication is extremely important in reaching real understanding with strangers. Obviously, the better the understanding between you and a stranger, the more likely it is that you will be effective and competent in your assistance to that person. Not all strangers will respond the same way to their new environment. Differences between the culture of the stranger and the culture of the host society may account for how a stranger responds. Large differences in verbal and nonverbal behavior, in norms or language, or in political and religious orientation can make adapting to the new surroundings more difficult. Where the differences are small, things may be easier for the newcomer. For example, someone from Canada would have less trouble adjusting to the United States than someone from Botswana. When you take this into account, you are able to look more thoughtfully at the stranger’s attempts to adapt and be more helpful in that process. In addition, recognize that there is a lot you do not know and be open to finding out more. When you are communicating with someone who is a stranger to you, put aside your goal for that conversation and begin to listen carefully for new information the person might be providing to you. Finally, accept that there is more than one way to view something or to understand something. People have different perspectives, but that does not mean that some are superior to others or more correct than others. We may have been taught that this is so, but look at other ways to explain behavior besides your own perspective. Try to understand what perspective the stranger may have. This can be done only if you communicate thoughtfully. Dimensions of Culture Researchers in the field of communication have looked for ways to help us understand cultural differences even when we do not know the details of every culture. They have proposed that cultures have an underlying foundation of individualism or a foundation of collectivism. Cultures fall along a continuum, with no single culture being all one or the other; but many researchers believe that communication can be facilitated between people of different cultures if we know whether the stranger with whom we are communicating is from a culture that is primarily an individualistic culture or a collectivistic one. This tool is particularly helpful when we do not know all the particulars of a specific culture. Individualistic and Collectivistic Cultures Using information from Gudykunst and Kim (1997), we will look at some of the characteristics of cultures that are predominantly individualistic or collectivistic. Figure 4.1 summarizes some of the general differences between these two types of cultures. Figure 4.2 lists some examples of countries that tend to be individualistic and some that tend to be collectivistic. FIGURE 4.1: Characteristics of individualistic and collectivistic cultures FIGURE 4.2: Individualistic and collectivistic cultures How Individualistic and Collectivistic Cultures Differ First, individualistic cultures tend to place a higher value on the individual than on the group. Collectivistic cultures, on the other hand, tend to place more value on the group. Another difference lies in the way in which society is viewed. In individualistic cultures, there is ranking and hierarchy; collectivistic societies tend to be more egalitarian. There is also a difference in the way the two cultural types use the surrounding context in communicating. In individualistic societies, the communication tends to be so direct that a person rarely needs to check the context to fully understand the meaning. In more collectivistic societies, context is extremely important. See Figure 4.3 for a summary of the communication differences between the two types of cultures. FIGURE 4.3: Communication differences between individualistic and collectivistic cultures Figure 4.4 highlights some of the specific elements that make communication different between individualistic and collectivistic cultures. As the comparisons in the figure indicate, there is plenty of room for misunderstanding. A person from a culture that values clear, explicit information might suspect someone from a high-context culture of being manipulative or confused. Someone from a horizontal culture might find someone from a vertical culture rude and boorish or incredibly selfish. If a client from a collectivistic culture waited to engage in services until he had group consensus, the worker from an individualistic culture might mistakenly think the client was resisting treatment or uninterested in help. If a worker from an individualistic culture encouraged a woman from a more collectivistic culture to look out for herself and leave an abusive marriage, the client might feel helpless and unsupported. Leaving the group might not be an option for her. FIGURE 4.4: Specific communication differences One common error is for people from individualistic cultures to assume the person with whom they are speaking from a collectivistic culture is speaking as directly and explicitly as they are. Individuals from collectivistic cultures can make the reverse mistake, assuming the person from an individualistic culture is only implying or speaking indirectly. Privacy and Self-Disclosure At different times, we feel open to interaction with other people or we feel closed and seek privacy. Different cultures regulate privacy needs in different ways. While individualistic cultures do so with physical boundaries, collectivistic cultures do so by psychological means. For instance, in collectivistic societies, people who might be encountered in general public situations are often seen and treated as nonpersons and simply ignored. In this way, the individual is protected from unwanted involvement. In individualistic societies, this would be seen as rude. Time Time is conceptualized differently in different cultures. How people conceive of time determines how they are likely to use it as well. Face It is common for people in individualistic cultures to talk about saving face. In sociological terms, face refers to a public self-image. In collectivistic societies, there is an emphasis on protecting the face of others, a concept that is less emphasized in individualistic cultures. Persuasion Different cultures use different methods for persuading people to undertake certain activities or to comply with specific requests. Expression of Emotion Different cultures express emotions differently and use the display of emotions to further the cultural values. Information Seeking In all cultures, people attempt to gather information that will clarify situations and reduce anxiety. Members of individualistic and collectivistic cultures go about this task differently. Interestingly, research indicates that in America, European Americans tend to self-disclose more than African Americans do. When close friendships are formed, the opposite is true. In close relationships, African Americans will self-disclose more than will European Americans. Conflict Look at the differences among cultures in dealing with conflict. Research suggests that “Chinese prefer bargaining and mediation more than North Americans, … Mexicans tend to avoid or deny that conflict exists, … Canadians prefer negotiation, … Nigerians prefer threats more than do Canadians” (Gudykunst & Kim, 1997, p. 282). In the United States, people are more likely to deal directly with conflict, looking openly for ways to resolve it. With all of these cultural differences in the preferences for handling conflict, it is important to approach conflict thoughtfully. Obstacles to Understanding We use a number of different mental mechanisms that can block clear communication. These mental mechanisms are used primarily to reduce anxiety when we encounter strangers. Often we are not aware of the extent to which we resort to these mechanisms. They are particularly present when we are engaging in thoughtless communication. The following sections discuss some of the obstacles that prevent real understanding. Stereotypes Some stereotypes are positive, and some stereotypes are held only loosely. Communication is most likely to be obstructed by rigidly held, negative stereotypes that can lead a person to make inaccurate assumptions and predictions about another person. Sometimes a person fits our stereotype of a particular group, but many other persons in the same group may not fit the stereotype at all. Becoming aware of our assumptions and questioning them is important. Ethnocentrism Ethnocentrism means that we use the standards common in our own culture to judge the behavior and culture of other people. It is important to understand that we are all ethnocentric to some extent. It is common to look at others through the lens of our own culture. The way our culture is arranged seems “normal” or “correct.” Deviations from our culture, therefore, seem abnormal and incorrect. It is not that we consciously decide to employ ethnocentric tactics, but rather we are socialized into viewing the world in a particular way. The antidote to ethnocentrism is cultural relativism. Using cultural relativism, we try to understand the meaning of others’ behavior and communication within the context of their culture, not our own. When we use ethnocentrism to judge people from other cultures, we create barriers and distance. When we use cultural relativism to understand others, we diminish barriers and distance. Prejudice Gudykunst and Kim (1997) define prejudice as “judgment based on previous decisions and experiences” (p. 124). People hold prejudices against whole groups of people and against individual members of those groups when they are encountered. Prejudice involves an attitude that generally stems from a negative stereotype. If you think all the people in a particular group are pushy and devious, you will probably decide that you do not like those people. Not liking those people is a prejudiced attitude that is based on the stereotype you hold in your head about members of that group. This easily leads to discrimination, in which you take pains to avoid being around these people whom you do not like. You might deny a member of this group a job for which the person is qualified or deny a family of this group housing in your neighborhood. Conflict When we are already suspicious or uncomfortable with a group of people, misunderstandings can turn into hostility and conflict very easily, particularly since we are likely to attribute the negative behavior of strangers to their personal characteristics, while attributing the negative behavior of in-group members to the situation. All the mental mechanisms described previously serve to make other groups seem less worthy of being understood and enhance the possibility that conflict will occur with individual members of a particular out-group. Be aware of two points. First, misunderstandings may stem from mental mechanisms that are inaccurate or have obstructed real understanding on everyone’s part. Second, once a conflict has occurred, the approach to resolution may be quite different from one culture to another. Changing Attitudes It appears from recent research that we can change our attitudes toward strangers or members of out-groups through a number of opportunities to interact with them positively. Stephan (1985) talks about ways to increase understanding and to create more favorable relationships among groups. For instance, an emphasis on cooperation, rather than on competition, is helpful. It is useful if those coming together have about the same status within their own groups and have some similarities in common with each other. Supporting the individuality of each member helps smooth things out. Voluntary contact and contact that is focused on substantive issues as opposed to superficial issues are more useful. Everyone involved should work toward a positive outcome. The goal of intergroup cooperation and contact is to learn to see members of other groups as individuals rather than as representatives of our own biases and stereotypes. Gudykunst and Kim (1997) address this in their dichotomy between uncertainty-oriented people and certainty-oriented individuals. They write about an uncertainty orientation:  Uncertainty oriented people integrate new and old ideas and change their belief system accordingly. They evaluate new ideas and thought on their own merit and do not necessarily compare them with others. Uncertainty oriented people want to understand themselves and their environment. (p. 185) A certainty orientation is quite the opposite. The authors write:  Certainty oriented people, in contrast, like to hold on to traditional beliefs and have a tendency to reject ideas that are different. Certainty oriented people maintain a sense of self by not examining themselves or their behavior. (p. 185) When we are communicating thoughtfully, we can make a conscious choice to acquire more of an uncertainty orientation toward new situations and strangers. By remaining open, we can learn more. We need to go one step further, however, by offering confirmation to others with whom we communicate. When you are working with people who are strangers to you, confirm for those people that they are valuable to you as individuals, that their experiences and concerns are important, and that you are willing to become involved in helping them to resolve their problems. When we deny that another person’s concerns and experiences are valid and therefore imply that they are insignificant, we demean that person as an individual, and the opportunity for meaningful resolution and rapport is lost. Competence Workers who are adaptable to situations and flexible in choosing how to respond to situations do better in cross-cultural communication. These workers are intuitive and sensitive to what others might mean or need and are open to considering the interaction from a number of different points of view. Figure 4.5 highlights some of the points to remember about individualists and collectivists that might make this process easier. FIGURE 4.5: Points to remember in cross-cultural interactions Competence in cross-cultural interactions depends very much on the individual worker’s commitment to give high-quality service to every person who comes for assistance. As you begin to practice, you will encounter more people from specific minority groups or cultural groups with which you are unfamiliar. Ethically you are responsible for developing an understanding of their cultures or subcultures, at least along the various dimensions outlined here. Until such study has been completed, it is important to consciously and thoughtfully monitor your interactions with strangers. Make certain that you hear the significance of their concerns and experiences, that you respond in a way that lets them know that they have been heard, and that you provide a respectful environment where problems can be resolved. Summary We know that it is not possible to know the particulars of every culture and respond appropriately to individuals from these cultures. While it is your ethical obligation to know more about the culture of people you see regularly in the course of your work, you will encounter people from different cultures from time to time whose culture you know nothing about. To avoid problems, it is helpful to know whether a person comes from an individualistic culture or from a collectivistic culture. Once this is established, you are able to respond in keeping with the characteristics of those cultures. In addition, it is always a good idea to check your understanding when conversing with a person from another culture. What seems reasonable to you from the perspective of your own culture may not be reasonable at all to someone from another culture. Students do better working among many cultures if they keep an open mind and are willing to discard stereotypes and listen for new information. This chapter is designed to give you a starting point for interactions with people from other cultures, but the hope is that you will learn more about other people and their values and norms as you take the opportunity to interact with people from cultures other than your own. Exercises I: Testing Your Cultural Competence Instructions: Look at the culture of each client described in the following scenarios, and decide what might be the underlying issue. What are you thinking about the client as you read each description? What are your first ideas about what constitutes the client’s problem? Do you have a problem personally with the behavior of the client, and if so, in what way? The following brief explanations about cultural behaviors may help you answer the questions when you read the scenarios that follow:    • In many Asian cultures, members do not talk about family problems, feeling that these are private. They may also pretend that no problems exist. • In most Asian cultures, crossing the legs and pointing the toe at another person is considered extremely rude. Because members of Asian cultures like to maintain harmony, they would not be likely to tell you directly that they were offended. In addition, in most Asian cultures, waving at another person or indicating that a person should join you by calling the person over with your hand or a finger is also considered extremely rude. • Asians are not likely to make changes in the family or to engage in discussions about the family unless the male head of the household is present or is consulted. Furthermore, they are likely to tell you things are all right in order to maintain harmony. Things may not be all             right. They may also tell you that you were helpful to them because they assume that is what you want to hear, not because it is true. Telling you what they believe you want to hear will maintain harmony. • In most Asian cultures, group needs and considerations are more important than individual needs and considerations. • In most Hispanic families, the man makes the major decisions and expects to be consulted about anything affecting the family. He would not be likely to take his wife’s ideas or concerns into consideration. She would be expected to defer to the husband. • Many Hispanic families allow mental health problems to persist for a very long time rather than admit that there is a psychiatric problem. • In Hispanic culture, it is often believed that depression is due to a lack of religious faith. • In Hispanic culture, mental health problems are often attributed to sin. 1. A man from Vietnam is in your office because his 11-year-old daughter has been having trouble in school. The school suggested the daughter be tested by your agency. You are doing the intake, but only the father has come into the office. He is very reluctant to tell you any specifics, but talks instead in extreme generalities. What might be the reason for his reluctance to talk to you in detail about his daughter’s problems? 2. A Japanese family in the emergency room is seeing you because of a serious accident in which their teenage son was severely injured. During the course of the conversation, you cross your legs so as to be more comfortable. The family continues to talk to you in a polite but superficial manner, and gradually each member drifts away—to get a soda, to use the restroom, and so on. They are obviously resistant to sitting down with you again. 3. A Chinese woman is hospitalized for a serious infection, and her doctors think she seems depressed over possible home problems. You talk to her, and she appears to reassure you that everything at home is fine. When you come in the next time, she wants you to talk to her husband instead. He, too, is reassuring and pleasant. Later you ask the woman if your talking to her before was helpful, and she smiles and tells you it was. You are not sure. 4. You work in the school counseling office, and you have been asked to help a gifted young Vietnamese student fill out applications to several prestigious colleges. She is in line for a number of scholarships. She works on the applications, but with obvious reluctance, and indicates she cannot consider going away to school until the family has decided what she will do. 5. After the birth of her fourth child, a Puerto Rican woman is referred for depression by her family doctor. At the intake interview, her husband comes and answers all questions. He indicates that he will decide what she needs and what is to be done. The wife says very little and speaks only when she appears to feel her husband wants her to do so. 6. A Mexican American family brings an elderly aunt to the emergency room. The older woman is severely depressed and emaciated. She also appears to be nearly catatonic. She is admitted immediately to the hospital on an emergency commitment. You learn that this woman has been in severe depression for years and wonder why the family waited until things became so serious. Later, when you talk to the aunt, she is somewhat improved. She indicates that her pastor visited her and told her that her depression is due to her lack of religious faith. She tells you she agrees with this assessment. She tells you she believes that if her faith was stronger and she was less sinful, she would not feel like this. 7. A young Hispanic woman is admitted to the hospital, and the doctor believes she is showing obvious signs of schizophrenia. She is hallucinating and has not been eating. Her family tells you this problem is the direct result of her sinful behavior. According to them, she is too friendly with the boys in her class. The students often call each other to compare homework, and sometimes a group of boys and girls will go to a party or several boys and girls will walk home from school together. The family has tried to get her to cut off these friendships and to stay home and help her mother more. Because she did not listen, she is being punished. CHAPTER 5: Attitudes and Boundaries Introduction The way we see other people and the way we relate to them as a result will affect how things turn out in a relationship. The boundaries we erect and the boundaries we fail to observe can similarly have an effect on outcomes. In this chapter, we look at attitudes that can be detrimental and boundaries that are useful, and those that are not. The purpose is to give you an opportunity to increase your awareness of attitudes and boundaries and to become more observant of your own ways of viewing other people, particularly other people you intend to help. Understanding Attitudes Attitudes are extremely important. The feelings you have about other people are bound to be communicated to those people one way or another. If your attitudes are positive and supportive, you will be more likely to establish rapport. If you feel superior or disdainful, no matter how well you try to hide those feelings, they will eventually be communicated to your client, and you will lose a working relationship. Good human service workers have learned about themselves—their fears, sensitivities, and errors in judgment. In facing those things about themselves, these workers have come to understand themselves in a way that enables them to feel understanding and warmth toward themselves and others. If you are able to forgive yourself for the mistakes you make and the struggles you have had and see them as an important part of growing, you will recognize that you are basically all right. It is then much easier for you to understand others who are making mistakes and who are struggling with issues and problems. You know that the problems you have faced have provided valuable lessons. These personal struggles have helped you to grow into a more sensitive and insightful person. Problems and unfortunate decisions happen to everyone. With this personal understanding, you will be more inclined to see others’ personal struggles as productive of growth, and not necessarily as a reflection of personal inadequacy. Begin, therefore, with yourself. Be tolerant of your mistakes. Look at yourself objectively. Forgive yourself for errors in judgment, particularly errors that have taught you important lessons or helped you to grow. Recognize that part of being human is to struggle with issues and transitional problems, and that through this process we are often strengthened and given new insight. Basic Helping Attitudes You need to bring three basic helping attitudes to your work: warmth, genuineness, and empathy. Studies show that even in the absence of much formal training, workers who genuinely care for their clients and are committed to them will be able to help their clients make important changes and move toward better circumstances and increased emotional health. Warmth A worker needs to be friendly, nonjudgmental, and receptive. These three attitudes create a warm atmosphere, one that serves to put the client at ease. In your presence, clients feel valued by you as a person. You communicate a belief to them that they are worthy of being understood. You do this through your actions, body language, and the way you listen to each person. In addition, you refrain from evaluating what clients say and the actions that they take. For instance, a warm person would say something like, “Tell me more about that.” A judgmental person might be more likely to say, “Oh, well, you should never have done something so careless.” In addition, you are receptive to what people have to say. You listen to what they tell you they have done and felt, what brought them to seek your assistance in the first place. When you say, “Tell me more about that,” you are inviting the person to open up and talk safely with you. When you say, “Oh, well, you should never have done that,” you have passed judgment and cut off further discussion. The atmosphere is no longer warm. Part of being warm is not dominating clients. It means you respect your clients’ right to make their own decisions. You may facilitate better decisions than the ones they might have made alone, but ultimately the decisions about their lives are their own, and you will respect that. Sometimes we are painfully aware that a decision is not the right one for the person to pursue. Later in this book, we discuss how you can give clients some of your thoughts in ways that people can hear and use your ideas more easily. Nevertheless, people may choose to ignore you and make their own decisions, and you will respect that. We have all made unfortunate decisions and concluded, as part of our growing process, that they were not very useful. Some people think being a warm person means that they must stand by passively, never confronting or giving the client another way of looking at things. A warm person is still able to facilitate change, and change is often painful. As you learn the skills in this course, you will pick up methods to use that help clients see things from more than one perspective and possibly see characteristics about themselves that are difficult to face. Genuineness You have heard the expression “be yourself many times. This is a must for those who help others. Nobody relates well to a phony. People sense when you are not being authentic. Perhaps you use slang that sounds forced, phrases you do not usually use. Maybe you are using them now to make clients think you are familiar with their lifestyle or culture. Maybe you put on a phony dialect or use profanity to seem more down to earth. You might pretend to be a physician, wearing a white coat and allowing your clients to call you “doctor.” A client calls you “doctor,” and you do not correct the impression. You might pretend to have degrees you do not have. You could use big words you know the client does not understand. None of this is authentic. You will be seen as a person who is rather foolish at best, and untrustworthy at worst. Be open and truthful. Strive to be yourself, to present your authentic self to the other person. If you do not know something, say so. If you lost a client’s forms, tell the client that and apologize. If a client asks about your credentials, matter-of-factly tell the client what they are. Empathy Empathy means putting yourself in the other person’s shoes. To do this, you must be able to comprehend what that person’s needs and feelings are. In human services, we often say that we are able to listen with the third ear. We hear more than what the client is telling us. We hear the underlying emotions, desires, and worries. With practice we become proficient at this, and we develop a special sensitivity. Part of empathy is being able to accurately communicate to the person an understanding of these underlying emotions. If you can put into words the feeling the person is experiencing right now, you are practicing empathy. To do it well, you communicate in a way the other person can understand and accept, not in a way that is threatening or judgmental. An empathetic person would say, “You must have felt sick when you saw what the accident did to your car.” Someone with little empathy would be more likely to say, “I’ll bet you could have shot yourself when you saw what you did to the car. Do you have insurance? Bet you didn’t have that either.” Finally, empathy is not sympathy. It does not mean that you are so sad for people that you take their situations home and fret about them when you are away from work. It does not mean that you feel sorry for people and communicate the belief that they are poor souls or that their situations are without hope. Sympathy is what we often have for our friends and relations. Empathy is assessing where the client is at any given moment and being able to express that and support it. Sympathy is the common feeling we have for others in pain. Empathy is a basic clinical strategy for supporting people through difficult times. On Being Judgmental José, returning from a home visit in a neighborhood where many of the homes were run down and many of the residents were poor, was aghast. “I’m not going back there. That’s a terrible place to live! Those people should think about how they live and what they are doing to their children.” He continued in this way for several days. Eventually the supervisor had an opportunity to talk to him about his attitude and how judgmental it seemed. She explained to him that this is where his clients live and that service requires us to respect the home of another person and not judge it as inferior. Assuming the people who live in the neighborhood are responsible for the way the neighborhood looks and for the people who live there may not be altogether true. “You are not better than the clients you serve,” she pointed out to him. “You may feel uncomfortable there, but you can’t force a client to come to you here in the office just because you don’t approve of the neighborhood in which your client lives or because you feel uncomfortable because the people who live there aren’t like you.” There are human service workers who sit in judgment of clients, applying their own standards to people who are sick, who have been through trauma, or who have no ideas about alternative ways to approach their lives. There are people who say they are in human services to be helpful, but who are actually wary and distrustful of their clients. This is an attitude that has no place in the helping relationship. For example, Rose, a new worker, was part of a planning team for a new shelter that was about to open for children who needed a place to stay before foster care could be found. These were children removed from their homes for physical or sexual abuse or extreme neglect. During the planning, it was decided that the children would earn points for good behavior and lose points when they violated policies of the residence. Children with 10 points or more would get special privileges, and those with no points would stay in their rooms temporarily and miss special activities. The director asked the group, “Where shall we start a child when she comes in new? Shall we start her with 10 points or none?” Rose was convinced that each new child should start with zero points and earn them. “How about starting each child with 10 points and letting her work to keep them?” the director suggested. When the planning group ultimately adopted the director’s suggestion, Rose was upset, thinking that the children would “just come in here and take advantage of us.” She asserted that the children “need to know we mean business right from the beginning.” The assumption that the children would automatically misbehave and take advantage of the staff was judgmental—adding that judgment to the problems the children were already experiencing would have been cruel. Rose’s need to curtail and punish before any misbehavior had taken place would have put her negative attitudes into action in a destructive way. Reality Check Some human service workers say they have gone into this work to help other people, but the minute a client behaves in a difficult manner, they complain that they should not have to deal with this sort of person. Clients who don’t cooperate, who do not show gratitude but are demanding instead, or who are rude throw these workers off balance. Rita refused to sit down with the mother of a child who was in treatment and work with her on a solution to the child’s behavior problems. Rita complained that the mother was a difficult person to work with. “She’s always complaining about what we’re doing. She thinks she has a better way. I just want to say to her, ‘Look, if your way was so hot, you wouldn’t have the problems you’ve got with Benny.’ All she ever does is make stupid suggestions. I just wasn’t going to get into that with her.” In human services, we are trained to deal with people who seem dissatisfied and upset. We expect to meet people who do not see things our way, who are challenging, or who question our decisions. Many of the people we work for will have an inaccurate perception of reality or difficulty expressing what concerns them, seem unduly sensitive, or be confused about following a plan. This is largely the reason our clients sought our help in the first place. If we only want to work with people whom we like and who agree with us, people who give us no trouble, we will be barely effective and more likely harmful. Just because clients do not behave exactly the way we would like is not an excuse to provide poor service. How Clients Are Discouraged There are many ways to discourage another person. You could set up a competition comparing the client to others or to yourself. You could push, force, or shame the client into moving toward some goal. You could spend an inordinate amount of time focusing on the client’s mistakes or demand that the person do more or try harder. You could insist that clients do things your way, dominate clients by taking over or demanding perfection or unrealistic outcomes or intimidate the client with threats. You could treat clients like “poor souls”—incompetent, bumbling people who need you to do everything for them. You could be discouraging with your insensitivity by failing to notice positive changes, ignoring the good things clients accomplish, failing to mention the positive changes or your clients strengths. You could refrain from ever giving feedback except the most negative type. All of these responses discourage others from trying to do more. Today, many individuals, some of whom hold degrees in fields unrelated to human services, are being asked to give direct care to clients who seem odd and unusual to them. For this reason, the clients may be frightening to these workers. In order to counteract feelings of uncertainty, such a worker may become extremely dominating and coercive. This gives a false sense of control. The domination and need to order clients’ lives in inappropriate ways are discouraging to clients who are learning to take charge of their lives and make decisions. An example of this occurred in a program for individuals recently released from an institution for those with mental retardation. A case manager visited her clients every other day in their apartments, where she offered support to help them remain in the community. She enjoyed working with her clients, and she had received good human service training. When the clients began to make jokes about the pounds they had gained over the years in the institution, she suggested they might want to exercise. Together they decided that walking around the apartment complex might be fun and a good way to meet their neighbors. For weeks, the clients walked almost every day, but at different times of the day and not on days when the weather was too cold or snowy. Later, the case manager’s supervisor, a person with little human service experience, was upset that the case manager had not “scheduled the exercise.” The supervisor felt that the clients should not be allowed to just say they would walk every day “because they won’t do it. We need to put that in their daily schedule, let’s see, at 11:00 to 11:30 every morning. That way we can check on them and be sure they are doing it.” The case manager asked, “But what if they skip one day, or feel like going at 3:00 in the afternoon?” The supervisor replied, “My point exactly. This way they have no choice, and they’ll meet their goals. We’ll look good for seeing that the clients’ goals are implemented consistently. Set up a daily schedule for them, and see that exercise goes into it at 11:00.” A person beginning to live a normal life in a community who has decided to take up an exercise program, and who has demonstrated a commitment to that program, does not need a professional to oversee the timing of it. This is an example of inappropriate control. A very grave example of discouragement occurred in a partial hospitalization program. Kitty, a client in the program, suffered from severe schizophrenia and depression. Often she was immobilized with sieges of despair and delusions, with voices of many others talking to her in what she called a “confused conversation.” Kitty described herself as afraid and appeared to the staff as dependent. The staff surmised that because Kitty had a master’s degree, obtained before her first episode of depression, she was really capable of more independence. They developed a series of goals for her to follow, such as riding the bus, shopping at the mall, and handling arrangements for her insurance and transportation. The final step on the list of goals was for Kitty to prepare her tax returns because her degree had been in business. From the start, Kitty had problems managing the goals. Feeling extremely depressed and occasionally hearing voices, Kitty found it alarming to be on her own in the city. In group sessions, Wayne, the group leader, held her up to ridicule. He encouraged the other clients to scold Kitty and accused her of refusing to help herself more. Kitty asked to reexamine her list of goals, but this was greeted with a refusal on the part of the staff and further insistence that she “get out there and try harder.” Finally, Kitty decided to withdraw from the program. When she told the staff, they told her that unless she cooperated with the program set forth for her, she would not be allowed to come to the clinic for her prescriptions. These prescriptions, partially underwritten with public funds, were important in sustaining Kitty’s connection to reality. Kitty finally called a friend of hers, a psychologist who worked in the state mental health system. When the behavior of the staff came to light, staff members were reprimanded and Kitty obtained her prescriptions and counseling services elsewhere. We need to examine what went on in Kitty’s case. First, a client has the right to ask that goals be reexamined. It may indeed be that the goals are not truly in line with the capabilities of the client, and setting goals should always be a collaborative effort. Second, a client can always withdraw from service if the client determines the service is no longer useful or, as in Kitty’s case, is actually harmful. The client has a clear right to determine what is good for and helpful to her, and what is not. Finally, the use of medication to coerce the client into doing what the staff has determined she will do is highly unethical. All these factors combined in Kitty’s case to create a discouraging atmosphere. On top of that was the denigration by the staff, particularly Wayne, who pointed out Kitty’s deficiencies and ascribed manipulative motives to her failures without ever really working with her to plan goals at which she could succeed. It would have been hard for a person like Kitty to attempt any goals in such a negative situation. Another example of discouragement happened in a transitional living arrangement for the mentally ill. This transitional living situation was one of many living arrangements with varying degrees of independence that helped clients move from hospitalization to independent living. Mario, who had persistent schizophrenia, had been placed in the last step toward independence, a small house with four other clients. At the time, Mario was on new medication, begun while he was in the hospital, which increased his ability to function considerably. While in the program, he adjusted well to the medication, obtained a job, and began to look for a new apartment. This was all part of the plan. Finding a new apartment was difficult, however; while extremely ill many years before, he had presented problems for one landlord after another. Now, in spite of the obvious improvement, the client had a reputation for being a problem when he became ill, and no one was willing to risk his becoming a tenant. In the meantime, Mario collected furniture for a new apartment and continued to look at ads in the paper. Staff in the program assisted. The time for Mario to remain in transitional housing expired. At that point, the case manager called the assistant director of the agency. The case manager was belligerent. He said the client was obviously “high functioning” and was therefore “stalling” in finding a place and moving on. He stated he knew nothing about the client’s past history with landlords and was not interested. He reminded the program director that case management was responsible for the bills for the transitional housing, and they were going to stop paying for this service for this “manipulative” client. “He obviously has no intention of moving and thinks we’re all too dumb to see it,” the case manager claimed. “Let him know he has 7 days to be out.” Without asking for a meeting, without sitting down with the client or with the staff in the program, without looking at what might be going on and how the agencies could work together to facilitate a positive transfer to conventional housing, the assistant agency director wrote a peremptory and hostile eviction letter, making it clear that Mario had 7 days to find housing or he would be “evicted,” and stating that Mario’s case manager supported this decision and thus Mario should make no appeal to his case manager for help. Coming home from work, the client found the letter on his pillow and immediately deteriorated. Staff at his transitional living program had not been informed of the letter and discovered the client in a frenzy in his room, throwing things into garbage bags and crying. Sometime later he left the house. When he did not return that evening, the staff became alarmed. They found and read the letter left in his room, but were unsure what to do. They notified the evening supervisor of another program, and together they were able to track Mario down in another state where he had gone to be with his sister. Much later, case managers and others began to put notes in the record that indicated work had been done to find housing with this client. The notes were made to appear as if they had been written long before he left the program. The notes were back-dated, a highly unethical practice. These notes contained indications that the client had been uncooperative during this time, something the transitional housing staff firmly denied. In time, the staff in transitional housing was able to let the executive director of the agency know of the true nature of the incident. The executive director had been told this was a smooth leave-taking by the client. Reprimands followed, but these in no way made up for the damage done to the client’s sense of self-esteem and confidence or the ground lost in this client’s move toward independence. Understanding Boundaries There is always a danger that we will see ourselves in the clients we serve. Many of us will work in agencies that serve clients who have been through something we went through ourselves. We may meet a client whose situation is different but that person reminds us in some way of ourselves. Perhaps the person is our age or has the same interests we do. When clients remind you of yourself and you are unable to separate your circumstances from theirs, you will become a problem to the very person you are supposed to be helping. Sometimes we have not entirely resolved the issues in our own life. We may seek employment in an agency that deals with similar problems just to continue to heal. This is not useful. It means that the clients will be treated in the light of your own issues rather than with a completely objective focus on their own personal issues. Sometimes to protect ourselves, to feel superior, to exercise power we erect unnecessary boundaries that are really barriers to good service. As the case manager you are the person for maintaining useful boundaries and refusing to erect those that are not helpful. Seeing Yourself and the Client as Completely Separate Individuals The Client Reminds You of You A young woman volunteer who was in training to answer the hot line at a rape crisis center had been raped some years before. It was still an overwhelming event to her, the defining event in her life. She was not ready to begin to work with others who had been raped while her own emotions were so raw and intense. During the training, she would fret and stew over the information being given. She would constantly remind the trainer that this would not have worked for her in her situation because she was too upset or too badly injured. She pointed out her own circumstances and told the trainer to focus more on situations similar to hers. She gave details of her rape at every opportunity. She used her own situation to illustrate the trainer’s points. It was apparent that she was not ready to serve as a volunteer who would have direct contact with the clients. Why? She had not yet recovered from the trauma of her own rape, and it seemed likely that she would impose the circumstances and emotions of her own rape onto those of the caller. In that case, the caller’s real problems might get lost as the worker went off on her own concerns and feelings. She was asked to take other work in the agency, and ultimately she left because she never was able to separate her rape from those of the clients the agency served. Sometimes the client is trying to do something we accomplished ourselves long ago. The client reminds us of a time when we were vulnerable and uncertain. For example, in a welfare agency, a young woman, recently off welfare and now working as an income maintenance clerk, was helping a welfare client make plans to get off welfare. The worker was somewhat irritated by the client’s concerns about day care and transportation. “Look,” she finally blurted out, “If I can work every day, you certainly can!” In another situation, the similarities were too much for Yolanda, a human service worker, to tolerate. She went to great lengths to find differences between herself and the client. Working at a program for individuals recovering from alcohol abuse, she had trouble understanding how one of the clients could have “gotten into a mess like this.” The client had regressed over the weekend and was drinking again. She came in seeking Yolanda’s help, but Yolanda had been through recovery and this woman’s “slip” reminded her of the hard fight she had made to stay sober and clean. What made it harder for Yolanda was that this woman was Yolanda’s age, had two children the same ages as Yolanda’s children, and lived two blocks from Yolanda. Instead of listening to where the client was at the moment, Yolanda became angry, asserting how hard she had fought to get where she was and telling the client to do the same. This woman’s relapse threatened Yolanda’s view of her own success. It became important, therefore, to demand that the client straighten up and never, ever think of doing this again. Her anger and refusal to start where the client was at the moment alienated the client. In subsequent meetings, Yolanda pestered the client to tell whether she had relapsed since her last visit, and she admonished the client frequently about her “tendency to drink.” Gradually the client drifted out of treatment. When the client reminds us of ourselves we may push clients to do things that we did to successfully resolve our own similar problem or push the client to take a particular course of action. The Client Reflects on You There are other reasons that a human service worker might not separate from the client. As a case manager, you might become extremely involved in clients’ problems and solutions because it makes you feel more important or competent if the clients solve their problems successfully. It may impress others if all your clients do well, and so you may cross the boundary and force clients to use your solutions. Sometimes, in spite of what we know about how good it is for clients to learn from their errors and struggles, and in spite of our belief that clients are responsible for their own lives, we also mistakenly believe that all our clients must be happy and successful if we are to look good. Again, we are focusing inappropriately on ourselves, and not on the clients’ needs. Pushing clients so that we ourselves look competent is unprofessional. Erecting Detrimental Boundaries False attributions Some boundaries are artificial and foolish. There is a very human tendency to make these two extremely unfortunate assumptions about people:   1. People who look like me will think and act like me. 2. People who do not look like me are not like me at all, but very different. Neither of these assumptions is true. A person who comes from your race or culture may not share your values or circumstances. We need to watch for signs that these assumptions are not creeping into our thinking because these ideas erect negative boundaries that can make you ineffective. Be very careful what you assume to be true of another person. A person may be of another race or culture and yet share many of your values and circumstances. A person who looks like you may be quite different in tastes, opinions, and way of life. If you assume a person of another race or religion has certain stereotypical characteristics, you will be dealing with a stereotype, and not with a real person. When you view people in light of these assumptions, you no longer see individual differences. All Catholics, African Americans, Jews, Quakers, and Indians are not alike. If you view people based on your stereotypes of the groups from which they come, you will fail to discern individual differences. Failure to perceive individual differences is a failure to accurately perceive reality. Aside from this being a fundamental characteristic of mental illness, it is impossible to give excellent service to a client you see only as a stereotype. False Power Another unfortunate boundary that acts as a barrier or more like a barricade is our own need to display authority, competence, and power. In this way we may intimidate our clients and threaten them as Wayne did to Kitty. We may stop collaborating and give orders instead. This way of working with people may make us feel important and allknowing, but it will not help the client. Transference and Countertransference Transference Sometimes, when working with other people, you will find that you remind one of your clients of someone in their past. Sometimes clients are only dimly aware of that. They simply know that there is something about you that they really like or really dislike. This is transference, a collection of feelings and attitudes the client holds about you. Positive transference occurs when the client likes you, and negative transference occurs when the client does not. Understanding this is one more reason why it is important that you not take the feelings of clients personally. In addition, clients can start out with positive transference toward you but then find those feelings changing. Perhaps a client hopes to make the relationship with you into a friendship. When you maintain professional boundaries, the client may reverse the positive feelings and the transference may become negative. As a competent case manager, you will want to accept transference when it exists. It is not a good or a bad thing. It is something that commonly takes place in helping relationships. In other words, practice acceptance rather than becoming threatened and defensive. There will be times when clients’ behaviors seem irrational, hostile, or even overly seductive. Acceptance of such behaviors while maintaining professional boundaries prevents barriers from developing and allows clients to continue to feel safe. In that environment, the clients may be able to reevaluate their feelings about you. It is helpful, when clients respond in unexpected and seemingly somewhat inappropriate ways to the situation, to use reflective listening. This allows clients to know that you are not judging their behavior or attitudes and that you have heard them and want to understand. This, in turn, creates the safe environment you are seeking to maintain. Countertransference In countertransference, the case manager projects onto the client certain emotions and attitudes because the client reminds the case manager of someone from the case manager’s past or because the client’s issues and situation cause the case manager to identify with the client. This can arouse both positive and negative emotional responses from the case manager toward the client. A case manager may give special favors to someone who is reminiscent of an elderly aunt the worker once loved and who is now deceased. On the other hand, the worker may be inappropriately demanding when the client reminds him of a younger brother who was always bullying the worker when they were kids. Acceptance of yourself and your feelings is extremely important here. We will meet people throughout our lives who remind us of other people. When it affects the way we work with our clients, then we need to be very aware of our feelings. Countertransference feelings are often a good warning signal that we have old issues we need to resolve. It is never acceptable to allow these feelings to interfere with service to your client. Summary Many, many good therapeutic approaches have been developed after years of study and trial and error. In addition, researchers have found that warmth, genuineness, and empathy have a profound effect on clients’ ability to move forward and heal. Many students begin this course of study intending someday to become therapists and counselors. Learning how to convey these three essential elements of a therapeutic relationship is where a true therapeutic relationship starts. Using the ideas in this chapter, you will recognize discouragement and know how to encourage and motivate your clients. Putting aside what you want for your clients and starting where your clients are gives them the footing they need to move to something better. The three basic elements of warmth, genuineness, and empathy form the underlying foundation for everything else you will do with clients. Even when you are uncertain about how to proceed, if you are using these elements, your actions will nearly always be viewed by clients as supportive. In addition, it is important, for all the reasons stated in this chapter, to view each client as an individual person and to work very hard to understand what makes your client a unique human being. Using the individualistic and collectivistic models can help you to understand your client better, but then you need to recognize, through careful listening and observation, what it is that makes your client a unique person. Professionals work against relying on stereotypes, assumptions about groups of people, and personal feelings about certain problems and their solutions that will color the work they do with others. Take the time to see and hear the characteristics, circumstances, and interests of this person who is trusting you to assist in some way. Focus on what makes your clients separate individuals. Give your service based on what you know about your client as a unique person. When workers begin to identify too strongly with their clients, or find that they must assume some of their clients’ responsibilities, they have blurred the boundary that makes both the worker and the client separate individuals. They cross that boundary in unproductive ways every time they assume that a client will be like them or will react as they would. These workers breach the boundary each time they handle a client’s problem without collaborating with the client. Exercises I: Demonstrating Warmth, Genuineness, and Empathy Instructions: There are five grade levels of responses you might give to people who have come to you needing assistance in sorting out their problems and feelings. Grade A. These responses are the most useful in establishing rapport and encouraging a continued dialogue:       • Centers on the client entirely • Stays on the topic (responds to the client’s feelings or the content of what the client has said) • Addresses what is most important at that moment to the client • Is respectful (indicates the client is an equal; indicates the client is a person worthy of being understood) • Invites collaboration • Shows confidence in the client Grade B. These responses are helpful but could be better:     • Is somewhat confident of the client’s abilities • Minimal invitation to collaborate • May briefly stray off the topic • Is just a little superior Grade C. These responses are usually made by someone who means well, but they are not especially helpful responses:      • Is pleasant, but superior • Overly helpful without collaborating • Introduces new topics that seem to the worker to be more relevant • Misses the feelings • Does not address the content Grade D. These responses are not useful in establishing rapport and do not encourage a further exchange:       • Takes over with solutions • Spends little time listening; is abrupt • Moralizes and preaches • Ignores the client’s assets and strengths • Shows minimal interest • Does not indicate respect for the client Grade F. These responses are mean-spirited and damage the relationship irreparably:       • Uses denigrating labels and descriptions of the client or the client’s actions • Shows no interest in the client • Denigrates feelings of the client • Denigrates the content of what the client has said • Intimidates, humiliates, or threatens the client (berates and scolds the client) • Leaves the topic for one entirely unrelated Following are some vignettes that demonstrate the various grade levels of responses. Look at each response, and assign a grade to each one. Next, using the preceding material on grade levels, tell specifically why you think the response should receive the grade you assigned to it. Vignette 1 A man has come to your agency for help after he lost everything in a fire. The worker asks the man to tell her what happened. He describes the night the fire took place, but as he approaches the actual incident, he finds it more and more difficult to talk. FIRST WORKER’S RESPONSE: “This is really difficult for you. Would you like to wait a minute?” Grade:____________ Reason:_______________________________ SECOND WORKER’S RESPONSE: “Now, this is all over, Mr. Brown. It happened days ago. You need to be thinking about moving on and getting on with your life.” Grade:______________ Reason:_________________________________ THIRD WORKER’S RESPONSE: “This must have been awful for you! Excuse me a minute.” Turning to the secretary in another room, “I heard the phone ring, Sue. Was that the attorney calling? Tell him that we need that file before we can do anything for his client.” Turning back to the client, “Now, where were we, Mr. Brown?” Grade:______________ Reason:_________________________________ FOURTH WORKER’S RESPONSE: “I’m really wondering if you can handle this! I’m going to call mental health and set up an appointment for you. Why, you’re a wreck!” Grade:______________ Reason:_________________________________ FIFTH WORKER’S RESPONSE: “I can see it’s difficult for you to talk about this. I’d like to work with you to see if we can find some ways to help you. I have some thoughts that I think might help, and I’m sure you do too.” Grade:______________ Reason:_________________________________ Vignette 2 A young woman enters a shelter after she and her boyfriend, with whom she is living, have had a fight. She has been badly beaten. She seems to want to talk and remains in the office even after the worker has completed the admitting forms. She is rather quiet, however, and does not volunteer much information. FIRST WORKER’S RESPONSE: “Yeah, another case of the violent boyfriend. Here we go again. You’d think you women would stop seeing these guys before it gets to this.” Grade:______________ Reason:_________________________________ SECOND WORKER’S RESPONSE: “Did he ever beat you before? I was just wondering because I’d think that if you’d been through this before, you would have left before now.” Grade:______________ Reason:_________________________________ THIRD WORKER’S RESPONSE: “It sounds like you’ve had a rough evening. Do you own your own home? No, I was just wondering if you own your own home. It says here you live in a house, and not an apartment.” Grade:______________ Reason:_________________________________ FOURTH WORKER’S RESPONSE: “I was in your shoes once. Believe me, it was a long and difficult battle to get out of that mess. But I did. I just decided that it wasn’t worth living like that—life’s too short, and I got out!” Grade:______________ Reason:_________________________________ FIFTH WORKER’S RESPONSE: “What you need is a good lawyer. You tell the staff that comes on in the morning that you want to talk to a lawyer. You can’t just sit around and take this stuff!” Grade:______________ Reason:_________________________________ Vignette 3 A rape victim sees the volunteer in the emergency room. As the volunteer talks to her, she learns that the victim is afraid to go home. The man who raped her is an acquaintance in the neighborhood, and she is afraid that now that he knows she called the police, he will come after her. FIRST VOLUNTEER’S RESPONSE: “It sounds like you could use a place to stay tonight. Would you like me to try to set something up for you?” Grade:______________ Reason:_________________________________ SECOND VOLUNTEER’S RESPONSE: “You’re really afraid of this guy! Well, you’re not going home tonight.” Grade:______________ Reason:_________________________________ THIRD VOLUNTEER’S RESPONSE: “I can see that you can’t handle this! I’ll make all the arrangements. Don’t worry about a thing. I’ll get you a place to stay, and I’ll set you up with an appointment at mental health.” Grade:______________ Reason:_________________________________ FOURTH VOLUNTEER’S RESPONSE: “How would you like to handle this tonight?” Grade:______________ Reason:_________________________________ FIFTH VOLUNTEER’S RESPONSE: “Let’s get off this gruesome topic. I mean, I know it’s important to you right now, but it’ll do you good to talk about something else. Tell me about your job.” Grade:______________ Reason:_________________________________ SIXTH VOLUNTEER’S RESPONSE: “You must be feeling so afraid of him.” Grade:______________ Reason:_________________________________ Vignette 4 A young woman comes in because she has been using “crack more than I thought I would.” She describes having trouble staying away from crack as her roommate uses it. Recently her roommate has begun prostituting herself to get the money for drugs and many of the woman’s possessions have disappeared. She says, “I just think I am headed in a bad direction and decided this morning that I need help to get out of this.” FIRST WORKER’S RESPONSE: “Can you tell a little more about what is going on with your roommate?” Grade:______________ Reason:_________________________________ SECOND WORKER’S RESPONSE: “How did you get mixed up with this roommate to begin with?” Grade:______________ Reason:_________________________________ THIRD WORKER’S RESPONSE: “I know this other woman who is in a similar situation and she is having the worst time getting away from her roommate!” Grade:______________ Reason:_________________________________ FOURTH WORKER’S RESPONSE: “Okay. So what we are going to do here is get you to sign papers to go into a rehab unit. That will get you out of the house and away from the roommate. Then we are going to get your things out of that house. Do you have a place you can store everything while you are in rehab?” Grade:______________ Reason:_________________________________ FIFTH WORKER’S RESPONSE: “You must feel betrayed by her. Talk to me a minute about what you would like to see happen for you right now.” Grade:______________ Reason:_________________________________ Vignette 5 A man talks to the intake worker in a case management unit about his recent separation from his wife. He comments that he could have been a better husband, that he was stingy and went for days not speaking to his wife if he was annoyed. He thought he was making her see how he felt about things, but she left him, saying he was “uncommunicative.” He seems depressed and bewildered by his wife’s departure. FIRST WORKER’S RESPONSE: “Sounds to me like you could use some communication workshops.” Grade:______________ Reason:_________________________________ SECOND WORKER’S RESPONSE: “Did you have to go that long without speaking? I mean, what could she have done that made you that mad?” Grade:______________ Reason:_________________________________ THIRD WORKER’S RESPONSE: “You really thought you were getting through to her, so it must be hard to see her leave this way.” Grade:______________ Reason:_________________________________ FOURTH WORKER’S RESPONSE: “Only a fool would think what you were doing was ‘communication’! Of course she didn’t hear you, fellow!” Grade:______________ Reason:_________________________________ FIFTH WORKER’S RESPONSE: “See, I think you should have tried marriage counseling before things got this bad. Not now, after she’s already gone.” Grade:______________ Reason:_________________________________ SIXTH WORKER’S RESPONSE: “Well, if you had a better understanding of the way women think, you could have avoided this whole thing.” Grade:______________ Reason:_________________________________ Exercises II: Recognizing the Difference– Encouragement or Discouragement Instructions: Following are two vignettes. Decide what you would do or say to encourage the person, and then decide what you might do or say that would discourage the person. Actually picture yourself as an encouraging person, and then as a discouraging person. Remember your actions may be as important as your words. Write in your answers to share with the group.   1. A woman, the mother of two children, has been without a home for a number of months. She tells you she really wants a permanent place to stay. You know there are very few places she can go. You also know she has some talents and interests— strengths that might be to her benefit. You encourage her by: You discourage her by: 2. A man calls and says he was sexually abused as a child. It has come to haunt him recently, but he is not sure where he should turn for help. You encourage him by: You discourage him by: Exercises III: Blurred Boundaries Instructions: Following are some situations in which the boundary between the worker and the client has become blurred. Identify what went wrong and what needs to happen to correct the situation. Use the space provided to make notes.  1. Alice is very upset because she gave the client some names of people she thought might be helpful in solving the client’s problem. Today she met one of those people at the local deli where she eats lunch and learned that the client has never been in touch with that person. She has been trying to call the client all afternoon to find out what happened.      2. Bill is feeling very proud of himself. He talked to a man who had very complicated problems this afternoon. He put everything down on paper, while the man sat by his desk and drank a soft drink. Then Bill decided on the best way to handle the situation. The man finished his drink, did just what Bill suggested, and reported that everything is fine now. 3. Mary Lou was once in a very abusive relationship. She was able, through much counseling and grit, to become assertive enough in her own behalf to get out of the situation. Today she is happily married and the mother of two lovely children. The client she is talking to is in just such an abusive situation and seems hesitant about leaving. Mary Lou wants her to leave and, using examples from her own life, assures the client she is certain the client will have just as happy a life as Mary Lou now has, if she will leave. Mary Lou remembers vividly how she felt when she was in the woman’s shoes and tries to make the woman see how much better she will be if she leaves now. 4. Gloria was raped by her stepbrother when she was 16 and he was 23. It was a very difficult situation; law enforcement officials were called, and eventually the situation broke up her family. She is currently working at a rape crisis center and is talking to a client whose situation reminds her of her own. She says things like: “Oh, that wouldn’t have done a thing for me!” or “I was too far gone to be able to handle it that way.” 5. Carlos is working with a woman whose father is the president of a large bank in another city. She has become depressed and needs a referral to a therapist and perhaps a psychiatric assessment. Carlos is reluctant to talk to her about needing “psychiatric help” because he assumes this would be offensive to someone as “upper class” as she is. Instead he suggests she “talk to someone for a little bit.” Later, with the woman’s permission, her father contacts Carlos and asks if there is anything he can do. Carlos is careful not to suggest short-term psychiatric hospitalization even though the father is offering to pay “for whatever she needs.” Carlos is sure such a hospitalization would alienate the father. 6. Candy is working in a shelter for homeless men. She is new at her job and enjoys what she is doing. The fact that many of the men are in poor physical health and are unwashed is of great concern to her, and she works hard to meet the basic needs of the residents, such as food and clothing and a warm place to sleep. When she is working, she never asks the men to help with chores around the shelter even though that is a condition for their staying there. She thinks of her work as very loving and giving, and she sees the clients as hapless and uneducated. Therefore, when Paul comes to her and tells her he graduated from high school and finished a year of college before he got hooked on drugs, she is not certain she believes him. When he asks for help returning to college, she resists giving him information and support for attending the local community college. CHAPTER 14: Documenting Initial Inquiries Introduction In many agencies, phone inquiries are logged on the computer and kept on file there. The New Referral or Inquiry form used in this text contains the kind of information the individual would be asked to provide during an initial call to the agency, particularly if the person were asking for an appointment. Learning to gather this information properly is important to ensure that the person’s situation is handled well from the beginning. This first form is used to take information from people calling on the phone to obtain services. You are to ascertain what the problem is, in brief, and set up an intake appointment in which the caller will be seen in person for a more in-depth history and evaluation. Remember to use all the communication skills you have learned in previous chapters to make the person feel at ease while describing the problem. Asking for help is difficult, but it is less so if the phone worker is empathic and accepting. PLEASE NOTE You cannot accept a case and fill out this entire form on the word of another person. The other person can refer the client to your agency, but the client must call in order for the intake to be valid. Exceptions to this rule exist when (1) the person is incapable of calling due to a mental health emergency (other forms are used for this situation); (2) the person needing services is a child (a parent or guardian can call for the child); (3) the caller is a very infirm or frail older person (a family member or friend can call for that person); or (4) the person needs an interpreter to communicate. Guidelines for Filling Out Forms The following guidelines apply to filling out all forms:     1. Use black ink. Never use a pencil to fill out a form. 2. Do not use correction liquid on forms; it is not permissible. 3. Be sure to sign and date any form you complete or note you write. 4. N/A (Not Applicable) is generally used where there is no answer or the question does not apply to the client. Steps for Filling Out the New Referral or Inquiry Form A typical form for phone inquiries is found in the Appendix. It is titled “New Referral or Inquiry.” Use the following step-by-step process when filling out this form. Make a photocopy of the blank form in the Appendix at the back of this book, and fill it out by following these steps:  Step 1. Place the person’s name, sex, date of birth, and address at the top of the form. Step 2. Place a home phone number on the form, and the work number of the client if the client is working. Step 3. The person will either: o o o a. Be a minor and have a parent or guardian, in which case you circle or underline “parent” on the form and write in the name of the parent, or b. Be an adult with a spouse, in which case you underline or circle “spouse” on the form and write in the name of the spouse, or c. Be neither of these, in which case you write N/A in big letters on that line. Step 4. If the person is employed, place the name of the employer on that line. If the person is not employed, place N/A on that line. Step 5. If the person is in school, place the name of the school (complete with what kind of school—college, elementary school, high school) on that line. If the person is not in school, place N/A on that line. Step 6. The individual will either be: o o a. A self-referral, meaning the person found out about your agency through the phone book or a friend and called in on his or her own. If that is the case, write “self “ on that line. Most calls are self-referrals; or b. Referred by a doctor or other professional. In that case, place that person’s name on the line. You are asking the caller, “Who referred you to our services?” Answers might be Dr. Graham Smith or Attorney William Burns. Step 7. Under the section marked “Chief Complaint,” always tell why the person called today. Do not say the person called today because her husband is abusing her. The husband may be abusing her, but what made her go to the phone today? Here are some reasons people might give for calling today:         • Today the person decided she cannot go on. • This morning, his employer insisted he get help. • What happened last night was the last straw. • She saw a medical doctor within the last 48 hours who told her she needs counseling. • He just had a fight with his spouse and is afraid of what he might do. • He just hit his child. • This morning he started to think about going back on drugs again. • She thinks she will hit her child and has called for help to stop herself. In filling out the “Chief Complaint” section, capture why the person called on this date and not on some other day. Begin this section with “Client (or the person’s name) called today because …” Capturing the Highlights of the Chief Complaint You have a small space and can use very few sentences to describe why the person called today and not some other day. In thinking about what the caller has told you about why he or she called, choose the most important points. Here are some examples:  John Haulik called today because his employer requested he seek help for drug problem (crack). In last 2 weeks, he has missed or been late to work every day. Sleeping on the job and cited for safety violations. Client sounded distressed and anxious to begin treatment.Jane Wilson called today after a serious fight with her husband involving physical abuse. Jane states husband has been verbally abusive in past, but not physically. Client is hospitalized and looking for alternative safe living arrangements upon discharge. Client sounds depressed, but cooperative. Following are some guidelines to keep in mind for capturing the highlights: • Keep the reasons from being too complicated. Do not make these first cases psychiatric emergency situations that need either immediate attention or a commitment. In other words, in this first exercise, do not create clients who are hearing voices, are contemplating suicide, have made a suicide attempt, or are a danger to others.  • Be very specific. Do not use general descriptions such as “her husband beats her” or “she lives with an alcoholic” or “he has been having a hard time at work.” Tell when the last beating was, what the most recent problem with the alcoholic husband was, and what the most recent problem was for the client at work.  • Keep the reason for the call brief. Do not include a lot of background information, as that will be acquired when you do the social history at the time of the evaluation. Give just enough background information to let the next worker know the context of the client’s problem. For example: o • Angelica called today because she was severely beaten by her husband on Tuesday during an argument over dinner. Client was hospitalized and is seeking alternative shelter. There is a history of domestic violence, which the client feels has worsened in the last 9 months. o • Horace called today because his employer warned him that without evidence of treatment for problems with alcohol, employment may be terminated or suspended. He admits to drinking while on the job today. There is a pattern of binge drinking followed by missed work and problems with coworkers.  Evaluating the Client’s Motivation and Mood Complete your note with a single sentence that indicates how the caller seemed to you. For example, you can mention how the client sounded. Did the caller seem depressed, glad to have reached you, relieved to be getting help, guilty over what has happened? Did the person seem eager to engage in services, skeptical that you can help, cynical about complying with forced treatment, or cooperative? Here are some examples of sentences that might summarize how the caller seemed to the phone worker:      • Curt expressed a desire to begin treatment immediately and seemed angry. • Marci seemed depressed by the circumstances but motivated to follow through with services. • Pete expressed skepticism that anyone could help him but seemed motivated to seek help. • Aisha was tearful and seemed depressed during the interview. • Harold seemed agitated by these recent developments and somewhat unwilling to follow agency procedure Steps for Completing the New Referral or Inquiry Form The following steps complete the process described in the previous section, which ended with Step 7.  Step 8. Under “Previous Treatment,” keep the notes brief—just note when, where (and with whom if you know that), and for what. Keep from being too wordy in this section. For example: Correct: Seen in June of 2010 for 6 months by Dr. Piper, Waldenham Clinic, for postpartum depression. Incorrect: Susan saw Dr. Piper at the Waldenham Clinic, 432 Muench Street. She started to see him in June of (revert to original) 2010 after her first son was born and continued to see him for 6 months. He was treating her for postpartum depression. Step 9. The intake is “taken by” you. This is the first place your name is to appear on this form! Put the date of the intake next to your name. Step 10. Under “Disposition,” note the name of the person to whom you refer the new client for intake and the date of the intake appointment. In many settings, the person who handles the phone inquiries is not the same person who sees the clients when they come in for their first appointments. For training purposes, we will assume that you will be doing both the phone inquiry and the client intake, in which case you would write your own name, along with the date of the intake appointment, on that line. Step 11. Under “Verification Sent,” write “Yes” and the date. The date you use here is the date you send out the verification form, usually the same day on which you take the phone inquiry. Figure 14.1 shows a New Referral or Inquiry form that has been filled out correctly. Look at the form to see how the worker filled in each element. FIGURE 14.1: Sample new referral or inquiry form After a person has inquired about services from your agency, it is important to bring the person in for a more thorough history and evaluation of the problem if the person is seeking services. You will set up an appointment for the caller on the phone at the time of the call or soon after you hang up. The next step is to send a letter verifying or confirming this appointment. Steps for Preparing the Verification of Appointment Form The purpose of the verification letter is to confirm for people the appointments that were made with them for an initial intake in the office. In this way, the agency hopes to cut down on the number of missed appointments and the number of hours reserved for clients that are not used by them because they fail to show up. (Blank copies of the forms referred to in this section can be found in the Appendix.) Today many agencies have more clients than they can see easily. Long waiting lists are the result. An agency cannot afford to waste an hour on a person who does not come in for a scheduled appointment. Although it may give the individual worker a muchneeded break and time to catch up on paperwork, it is an hour for which the agency will not be reimbursed because no services are given. For that reason, most agencies send out a verification letter to remind people of the appointments that are reserved for them. Following is a step-by-step procedure for filling out the Verification form. A blank Verification form can be found in the Appendix at the back of this book. Make a photocopy of that form and follow these steps to fill it out:     1. On the Verification form, be sure that the date you send it out is the same date you said you sent it out on your New Referral or Inquiry form. 2. Be sure to address the person by name. 3. Fill in the date, time, staff, and location of the interview. The date is the date you listed under “disposition” on the Inquiry form. You can decide on a time. The staff person will be you. The interview will take place at the Wildwood Center. 4. Sign your name. Your signature should line up precisely under “Sincerely” and over “Case Manager.” Do not sign out to the right. Figure 14.2 contains a sample Verification of Appointment form with all the information added. Look at the form to see how the worker addressed each element. FIGURE 14.2: Sample verification of appointment form The next step in the process is when the person actually comes to the agency for a more thorough evaluation of his or her situation. This is sometimes called an intake appointment. In this chapter, we have practiced phone intakes; in Chapter 15, we will turn to the first appointment and examine how to prepare to meet the individual for the first time. Summary Taking an intake from a person on the phone requires two important skills. The first is skillful communication, something you have been working on previously. Using the skills you have acquired, you will be able to draw the caller out and learn the reasons for the call. In addition, you will need good observation skills. Your task, during this first phone call, is to assess the needs of the person calling and assess the degree of distress the person is experiencing. On your New Referral or Inquiry form, you will need to be able to document not only what the person shared with you on the phone but also the way that person sounded, how motivated the person seemed, whether the person’s conversation with you seemed reasonable, and how distressed the individual seemed to be. As you practice your communication skills, begin also to practice listening to the tone of voice and the underlying emotions the client may not express directly. Exercises I: Intake of a Middle-Aged Adult Instructions: Using the blank form in the Appendix titled “New Referral or Inquiry,” develop a client intake. You may use any problem that would ordinarily come to the attention of a social service agency. Your client should be an adult, at this point, calling on his or her own to seek services. In developing your client and your client’s problem, read the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (APA, 1994) and look at books and articles on specific problems (such as domestic violence, alcoholism, divorce, depression). Look at the chapters in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client might be feeling and what issues or problems the client might be facing when he or she makes the first call to your agency. If time permits, do several adult intakes with each client having a different reason for calling. Exercises II: Intake of a Child Instructions: Using the blank form in the Appendix titled “New Referral or Inquiry,” develop a client intake for a child, a person under 16 years of age. In this case, a parent or guardian would be calling on behalf of the child. A doctor, a school counselor, or a teacher may have referred the parents to you, or the parents may have felt they needed help and sought your services without a referral. Typical issues confronting children are problems with school, behavioral problems, and adjustment problems to events such as divorce or the death of a parent. In developing your client and your client’s problem, read the DSM-IV and look at books and articles on specific problems common to children. Look at chapters (particularly those on children’s mental health and on mental retardation) in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client and your client’s parents might be feeling and what issues or problems the client’s parents might be facing when they make the first call to your agency. Exercises III: Intake of an Infirm, Older Person Instructions: Using the blank form in the Appendix titled New Referral or Inquiry, develop a client intake for an older person, a person over 80 years of age. In this case, a child or close friend or neighbor would be calling on behalf of the client. A doctor may have referred the caller to you, or the caller may have felt the client needed help and sought your services without a referral. Typical issues confronting frail, older adults are problems with self-care, independent living problems, untreated medical conditions, malnutrition, and depression and anxiety. In developing your client and your client’s problem, read the DSM-IV and look at books and articles on specific problems common to older people. Look at the chapter in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), for information on how your client and the concerned caller might be feeling and what issues or problems the caller might be facing when making the first call to your agency. CHAPTER 16: Social Histories and Assessment Forms Introduction Every agency has a different way of taking and recording relevant client information during an initial intake process. Some use assessment forms, which typically are specific to a particular high-risk population. Forms such as these can be found at the end of each chapter on a high-risk population in Fundamentals for Practice with High Risk Populations (Summers, 2002). In that textbook, you will find all the information you need to begin to develop a client from a population of interest to you. After using those forms, you will be able to move easily to other similar forms for specific populations. In this book, I provide a generic form in the Appendix to help you become accustomed to assessment forms. In some situations, you will be asked to take a social history, either as a supplement to assessment forms used by your agency or in place of these forms. Just as the assessment forms in different agencies may differ, the format for a social history will vary from agency to agency. Nevertheless, having written social histories in the classroom, you will be able to more easily adapt to whatever format is used in your agency. What Is a Social History? A social history provides the following information:    1. A description and history of the presenting problem (the problem that brought the individual into the agency) 2. Background information on the person’s life 3. The worker’s impressions and recommendations Taken together, these three sections of the social history give a picture in summary form of where clients were when they came to the agency seeking assistance. In this way, the social history functions as the baseline or foundation for decisions about services and for measuring clients’ progress. It also gives some direction to the problems that will need to be addressed. We will look at each of these sections individually, giving you examples of each one, so that you can see how the social history is developed. Layout of the Social History Social histories always use subheadings set out to the left of the text. This is done to help people find relevant information quickly without reading an entire text to find buried pieces of information. In most agencies, the outline of subheadings is the same for all clients so that workers are familiar with the outline and know exactly where to look for information. Figure 16.1 is a typical outline for a social history. FIGURE 16.1: Typical outline for a social history It must be stressed that the outline shown in Figure 16.1 is one of any number of formats. For instance, if you worked in an agency that dealt with criminal offenders, the Legal History section might be called “Criminal Justice Background,” and that section might be closer to the top of the outline. If you worked in an agency that served the needs of victims of domestic violence, the agency might place the Marriages and Significant Relationships section right after the presenting problem to augment the information on the presenting problem. If you were working with children, you might include a School Adjustment section and drop the Education section. In an organization devoted to helping people with their addictions, you would probably have several sections related to the course of the addiction and attempts to overcome the addiction in the past. Both the Criminal Justice History and Medical History sections would become more prominent in that outline. In the chart or record, a social history may appear on different-colored paper so it is easily identifiable in the folder. The history will have identifying information on each page so it is not separated from the record in which it belongs. In the text that follows, we look at each section of the typical social history more closely. Examples are provided to demonstrate how to write these summaries. How to Ask What You Need to Know If you follow the outline in Figure 16.1, you will have assembled a considerable amount of personal information. Clients who are giving a social history probably are not very familiar with you or the agency, and talking openly about each of these aspects of their life may be difficult. For that reason, use plenty of open questions. Certainly you will not use all open questions. Asking, for example, how many brothers and sisters a person has is a closed, but useful question. You might, however, follow that with an open question, “Tell me a little bit about them.” In another example, you might ask the closed question, “Were you ever in the military?” followed by, “What were the dates of your military service?” Then you could follow up with an open question such as, “Can you describe your military service?” Open questions soften the interview, making it less prying so that clients can choose the significant details to reveal without feeling grilled. Asked with respect and a genuine interest in the individuals, the questions at these initial interviews can be helpful to people in sorting out the factors in their lives that are relevant and significant. In some cases, this can be for the first time. In each section that follows, open questions are given that you might use to solicit information in that section. These are only examples; you should become proficient in asking open questions on your own. 1. Description and History of the Presenting Problem The first section is the Description and History of the Presenting Problem. In a brief summary, the background to the presenting problem is documented. This is done in no more than two or three paragraphs. Usually only one paragraph of summary is needed. Agencies may differ in what they call this section: Background Information, Presenting Problem, or History of Presenting Problem. Some break this section into two parts: Presenting Problem and Background to Presenting Problem. For our purposes, we call the first section “Presenting Problem” and will include both the problem and the background to that problem in this section. Writing the First Sentence The first sentence of the presenting problem is the first sentence as well of your impressions and recommendations. Therefore, you want to put as much information into that first sentence as possible so that people get a mental picture of the person quickly. Here are some examples:   • Alex is a 42-year-old unemployed male, divorced father of 2 teenage girls and currently referred for issues regarding use of alcohol and job-related difficulties. • Mattie is a 69-year-old widow and British citizen visiting her oldest daughter in the United States who was brought in by her daughter because of acute memory loss and confusion.   • Milton is a 36-year-old man, recently returned to college for an advanced degree in chemistry, who is suffering from depression he states began when his wife left with the couple’s 3-year-old son and the family dog. • Camille is a 16-year-old high school sophomore who weighs 47 pounds, referred by her family physician and brought in by her parents concerned about her eating habits. Following are two examples of a Presenting Problem section in a social history. The first is written about Kate, a 47-year-old woman who contacted the agency requesting help for a long-standing depression. The second example is written about Carlos, a 38-yearold Mexican man who recently entered the country and is having problems adjusting to the new culture. Presenting Problem Kate Kate is a 47-year-old married woman with one daughter away in college who called requesting help for a depression she states has lasted almost 2 years starting with the death of her mother. Kate describes the depression as beginning after a serious episode with the flu and the death of her mother approximately 2 years ago. At the time her mother was ill, Kate did not follow doctor’s recommendations that she take off work and stay home. She was very involved in caring for her mother, who subsequently died. Kate states she was not aware of being depressed until after the funeral, but grew depressed during the 7-month period in which she and her husband cleaned out her mother’s house and settled her mother’s affairs. She describes this work as “heart wrenching” and involving several legal difficulties. Currently Kate describes her depression as characterized by hypersomnia, an inability to go to work several days a month, and a loss of interest in social activities and friends. She states she is here in part because her husband insisted she get help. Carlos Carlos, a 38-year-old unmarried male Mexican citizen, contacted the agency at the suggestion of his boss, Ronaldo Rodriquez because he felt Carlos was having emotional difficulties adjusting to living in the United States. Carlos states he came to the United States from Mexico because his only family is living here. His brother and parents came to this country in 1982. His brother received a good education, went on to medical school, and currently practices medicine in Maryland. Carlos was left behind with an aunt when the family emigrated “because I was hard to handle.” Last year the aunt died and Carlos came to the United States to join his family, “who are all I have.” Carlos has been here for 8 months and is not sure if he wants to stay or return to Mexico. He describes feeling “out of place” in American culture, particularly compared to his brother and his brother’s lifestyle. He states he has no commitment to Mexico but believes he would be more comfortable in familiar surroundings. In addition, he states his parents are “putting pressure on me” to remain in this country and get a better job. He describes them as critical of the few friends he has made and his lax attendance at church. In each of these examples, we see the information the worker assembled as being most relevant to the immediate difficulty. We have a picture now of why each of these people called the agency and what might have precipitated the request for help. Questions you might use include:     • “Can you tell me a little bit about what brought you here today?” • “Can you tell me a little bit about what happened?” • “Can you describe this problem a little for me?” • “Could you give me some idea of what’s been going on lately?” Client’s Appraisal Always ask the clients what it is they are seeking. A person new to the system may not know exactly what services are available or have only a partial understanding of what a service actually is or can accomplish. When you ask for the individual’s expectations, you may have to describe and explain what is available and how the service works, not only at your agency but also in other places in the community if these are relevant. Ask clients for their assessment of the problem. Valuable information may be found in listening to how people view what is going on in their lives. Questions you might use include:      • “Tell me a little bit about what you see as the main problem.” • “Could you tell me something about what you think is most important here?” • “Could you give me some thoughts on how you see the problem?” • “Do you have any thoughts about the service you would like to have from us?” • “Give me some ideas you have for how you feel we could best help.” 2. Background Information about the Person’s Life As noted earlier, this part of the social history has a number of sections on various aspects of the client’s personal history. We look at each of these. Family of Origin Here you document the relevant information about the family of origin, the family into which the person was born. Information on the parents, their occupation, siblings, outstanding characteristics, or information on the family would be placed here. Questions you might use include:   • “Can you tell me something about your brother?” • “Could you describe your parents for me?”   • “Tell me a little about what your family was like.” • “Can you describe what your home was like?” Birth and Childhood In this section, you want to note if the pregnancy and birth of the person were in any way complicated. Ask about important features of the person’s childhood and what the client remembers. You want to elicit comments from the individual that give a flavor of the client’s perceptions during this period of life. Was it happy or fraught with conflict? As a child, did the person feel appreciated or ignored? Was the person asked to shoulder very adult burdens or allowed to remain a child? Questions you might use include:   • “Can you tell me something about your childhood?” • “Tell me a little bit about what growing up was like.” Marriages and Significant Relationships In this section, you document the marriages and other significant relationships of the client. Be sure to include here all significant relationships, whether the couple actually went through a marriage ceremony or not. If the client lived for several months or years with someone, note that here. Some clients will have more than one marriage or relationship. A sentence or two on each is important, such as when it took place, how long it lasted, and why the marriage or relationship ended. Information about the current relationship of the person to an ex-spouse is also relevant. In addition, always mention children, their ages, whether they reside with their parents, and where they are now. If the children are no longer in the home, document the degree of contact the parents and children have. Questions you might use include:    • “Tell me a little bit more about her [him].” • “Can you describe something about what that marriage [relationship] was like for you?” • “Tell me about your children.” Current Living Arrangements In this section, give a brief description of the home, how the client feels about the home, and who lives there. Questions you might use include:   • “Tell me a little bit about your home.” • “Can you describe your life when you are home?” Education Document here the person’s highest level of education. Note, too, any difficulties or successes the client experienced while in school. Questions you might use include:    • “Can you tell me more about school?” • “Can you explain a little bit about your problems in school?” • “Tell me a little bit about college.” Military Service If the individual served in the military, give the details of that service here in a summary. Always mention the type of discharge from the military and the status as a veteran. If the person was never in the military, simply state “No military service.” Questions you might use include:   • “Can you tell me about your military service?” • “Could you describe a few of the things you did in the service?” Employment History Here you will document the type of employment the individual has held. Note breaks in employment and give the reasons for the period of unemployment. Also indicate how the client views the work she has done. If the person never held a job, write “No employment history.” Questions you might use include:   • “Tell me a little bit about working there.” • “Can you give me some examples of the work you did?” Medical History Medical history will be extremely important to medical personnel who may be called to assess and give service to your client. A psychiatrist or a nurse may spot a possible underlying medical problem based on the information you assemble in this section. Ask about childhood illnesses and any other illnesses, allergies, or surgeries. Questions you might use include:   • “Tell me a little bit about your health.” • “Could you describe this surgery a bit more for me?”   • “Can you tell me a little bit about the polio?” • “Can you describe those allergies?” Legal History In many cases, people will have no legal history. Write “No legal history” if this is the case. However, involvement in a lawsuit or criminal case, as either the defendant or plaintiff, is usually an important source of stress. Petty criminal activity that is current gives insight into how people view authority and their place in society. Previous criminal activity may show how much some a person has been able to turn her life around or may indicate an unfortunate pattern. Questions you might use include:    • “Can you explain a little about the lawsuit?” • “Can you tell me about those early encounters with the law?” • “Could you tell me a little bit about what brought you into contact with law enforcement?” Social and Recreational Interests Because we are always interested in the strengths of the people to whom we give service, we want to note what it is that interests them and the social and recreational activities in which they participate. If a person has no activities to report, be sure to note this as well. It gives important clues to the client’s social involvement or withdrawal. Ask if this lack of social involvement has always been present or whether it is more recent in the individual’s life. Recent lack of interest in activities that used to be important can be a sign of depression. Note what interests the person most and what activities he pursues. Questions you might use include:    • “Tell me a little bit about what you do in your spare time.” • “Fill me in on what you do for fun.” • “Can you tell me a little bit about what you like to do most?” Religious Activities Some clients are very involved in their church, synagogue, or mosque. Others are not so involved but hold firm spiritual beliefs that they find very sustaining. Still others have neither religious involvement nor any interest in spiritual matters. Ask clients about their religious affiliation and activity or involvement. For clients who do not have anything to report, explore with them any spiritual beliefs they might have that give them strength and comfort. This sort of strength and comfort is often enormously helpful to people as they recover or cope with illness and difficult problems. This is a sensitive area, however, so move on if you feel your clients are reluctant to discuss their beliefs. For some clients, this line of questioning may be construed as your attempt to push a specific religion. Be sure to note, matter-of-factly, a client’s discomfort with this topic. Questions you might use include:   • “Could you tell me about your synagogue?” • “Could you describe some of the beliefs you feel are most helpful to you?” Client Successes, Strengths, and Resources This is a section you may not find on most social history outlines. As much as we want to see clients as whole people, several factors—agencies, their policies, the pressure of time—often prevent us from exploring anything other than problems with clients. This focus on the negative aspects of people’s lives often causes workers to create a skewed picture of the people they want to help and to register barely disguised surprise over the successes clients have had that come out during their social histories. Asking clients what they are most proud of, or what things they consider accomplishments, makes it clear that you expect a client to be a whole person, not a collection of problems. It is good practice for you too, as you will get into the habit of asking about and documenting the positive aspects along with the difficulties. Questions you might use include:   • “Tell me a little bit about the things that make you proud.” • “Can you tell a little about the things you consider successes for you?” In addition, note here the strengths and resources your client brings to the situation. Personal skills, financial assets, and social supports are all important to note in this section. 3. Impressions and Recommendations This last section in the social history contains your own impressions and recommendations. Much of the information included here about your client is referred to as a mental status exam. Start with the first sentence of your presenting problem and go on to give a brief one- or two-sentence summary of what you have already written. Include the way the client appeared during the interview, and any problems you see with memory or reality, anxiety or depression. Then, give your recommendations for services that might be considered when creating the treatment or service plan for the client noting the client’s input into these recommendations. Further details on writing impressions and recommendations are found on page 268. Capturing the Details Sometimes when case managers are taking social histories for the first time, they are inclined to write the barest number of details. They might write something like this: “Alice worked at Kmart for 4 years.” In addition, it would be useful to know when she worked at Kmart, what she did there, and why she is no longer there. Figure 16.2 provides some other examples. FIGURE 16.2: Capturing the details Your history should be a concise summary of the main points of a person’s life, but too much brevity can leave a number of unanswered questions that, if answered, would shed considerable light on the person’s life and problems now. Figure 16.3 shows a completed social history on Kate, the 47-year-old woman described earlier who contacted the agency for help with a long-standing depression. Examine the figure carefully so that you can see how a completed history is constructed. FIGURE 16.3: Example of a completed social history Who Took the Social History Your name goes in 2 places on the social history. First, your name should appear in a heading at the top of the history. Second, your signature should go at the end of the history. Your name should not go in the top right hand corner as if this is a school assignment. Generally agencies have you sign your social histories at the end after a phrase such as “taken by,” “submitted by,” “prepared by,” or “filed by.” If you have credentials such as BSW or MSW, these follow your signature. In the example shown in Figure 16.3, the name of the worker who took the history is also typed in at the top of the history so that anyone in the agency can quickly see who did this history. It is not appropriate for you to place your name anywhere but in the two designated places. Social Histories in Other Settings Limited Time for Intake As a case manager having ongoing contact with your client, it may be possible to assemble an entire social history like the one discussed in this chapter. Certainly developing this complete picture of the person at the time of intake is best practice. Today, however, many agencies do not have the opportunity to spend the time it takes to assemble such a history. Often the client is in and out of service, sometimes in a matter of days, at the direction of the funding source. Many managed care organizations and insurance companies have severely limited the amount of service a client may receive. This is particularly true for adult services in areas such as mental health or drug and alcohol agencies. Brief Intakes In some agencies, the emphasis during intake is on the presenting problem, the background of that problem, and your impressions and recommendations. In all cases, you still would be expected to discuss the services you provide with the client and to seek the client’s input; and you would be expected to document this discussion. Unfortunately, you may not have the time to do this thoroughly or to note many of the other aspects of the client’s life in the history. This happens when clients are given only a few days of service by their insurance company or other funding source. When the individual will not be with you very long and you must do only a brief history, it is important to focus on the most immediate problem. Therefore, carefully document that problem, and talk about the most important points in the background to that problem. For example, when Harry came for services, he was recovering from a stroke in which he lost the use of his left hand and foot. The intake focused on the level at which Harry functioned before the stroke, the stroke itself, and the goals Harry wanted to pursue in recovering from the stroke. His acrimonious relationship with his brother in another state was not covered in detail, although the worker noted it in the intake material and, in her assessment, indicated that this relationship may have contributed to the recent stroke due to the client’s anger and agitation over things that had been said in the week before the stroke. Left out of the history were extensive details about previous health problems unrelated to the present stroke, social interests, client accomplishments, military and legal histories, and details about his childhood. In the current environment, brief intakes may be required more than we would like because of the limited time we have with a client. When the intake must be brief, the goal is to put sufficient focus on the immediate problem and the background to the problem to provide treatment for the client without delay. Writing Brief Social Histories A brief social history has three parts:    1. Presenting problem 2. Background 3. Impressions and recommendations Presenting Problem In the presenting problem section, describe why the person came into your agency. What precipitated his admission? Why is he here? Here is an example explaining Fred’s presenting problem:  Fred is a 26-year-old unmarried male who returned Sunday evening from a 2-week trip to the Philippines and Japan. On admission he was accompanied by his mother and was complaining of hearing voices, some confusion, and a lack of coordination. He states he had these same feeling briefly in September, but they cleared within several days. During that episode, he describes rigidly maintaining his routines as a means of dealing with these symptoms. Client further reports feeling as if he is standing outside himself watching his condition. He recognizes that he “is not right.” Background In the background section, describe the client’s background briefly along with any additional information regarding the presenting problem. Here is the background information about Fred and his presenting problem.  Fred was attending the wedding of a high school friend in Manila when he became ill. He was traveling with friends of his and the groom. He states that he left New York at 5:00 P.M. on a Sunday afternoon and arrived in Manila 19 hours later at 3:00 P.M. the same day. He reported that the celebration went on for several days, during which time he drank a considerable amount of alcohol and slept very little. Toward the end of the journey he began to experience confusion and could hear his friends voices, but not what the voices were saying. He came here immediately upon return home. Fred is employed as a computer analyst for ProWeber, where he has worked for the past 4 years. He currently shares his apartment with another male whom he describes as a childhood friend. According to client, they rarely see each other and travel in different social circles. Fred is the oldest of two boys. His parents separated while he was still in high school and were subsequently divorced. The divorce is described as amicable. Father lives in Alabama but returns for holidays and graduations. When asked about his father’s side of the family, client replied, “that whole side of the family is crazy.” He did not elaborate further. When discussing his mother’s side of the family, he reports that his aunts and uncles are supportive and have always shown considerable interest in him and his other cousins.Fred graduated from high school and completed one year of college, but dropped out after he experienced intense stress. He claims his grades in both high school and college were “good.” Currently Fred is not dating anyone and socializes with a group of people with whom he went to high school. They have returned to the area after completing college. He expresses an interest in music and cars. He denies drug use, but says that he and his friends drink on the weekends. Impressions and Recommendations Impressions and recommendations come at the end of all social histories, regardless of the length or method in which the history was taken. After taking the social history, use this section to express your impressions of the client. In addition, include your recommendations for what needs to happen to support the client in the present situation. Later, in Chaper 18, we discuss how to write better impressions. Impressions and recommendations have 3 parts. If you think of 3 very short paragraphs you will be able to address the three parts which are:    1. A summary of the presenting problem 2. Your impressions 3. Your recommendations Writing the First Sentence Begin with the same sentence you used to open your social history:  Lisa is a 42-year-old married woman, the mother of two girls ages 10 and 12, who is complaining of depression and lack of energy. You can use this comprehensive sentence to open the social history and again to open your impressions and recommendations. Next Two or Three Sentences The next sentences can further describe the client’s situation:  She states that her depression began 4 months ago and has persisted during a time of marital strain. Husband is threatening divorce and appears to be seeing another woman. Next State Your Impressions Give your impressions of the client in the following areas where these areas seem to apply:      • Functioning • Affect • Vegetative functions • Insight • Motivation (for change or help) Here are the case manager’s impressions of Lisa:  Lisa reports that she has trouble waking up, is unable to work at home or at her job effectively, and has neglected parenting responsibilities. She appears to have impaired occupational and social functioning accompanied by insomnia. Her affect is blunted, and at times she was tearful. She has good insight about her current marital situation and the role it may play in her depression. In addition, she expresses a desire to obtain help and “change some things in my life.” You will have a much better idea about how to address the areas listed above after you have read Chapter 18. End with Recommendations End with a recommendation for what you believe should happen next. Do not use the word “I.” Recommendations for Lisa are as follows:  Client is requesting a therapist, with possible marital therapy in the future. Recommend psychiatric and medication evaluation of her depression and referral for six sessions of individual counseling, initially to address depression and marital issues. When writing your recommendations, state the number of sessions, the number of days of hospitalization or group therapy sessions, and the reason for this recommendation. For example, “six therapy sessions with Carlos Baldini to address anger management.” The points in the Impressions and Recommendations will have been elaborated upon in the social history itself, and the history will include details on each of the points not included in the Impressions and Recommendations. This section allows others to get a brief summary of the client’s situation and what your impressions were at the time you took the intake. For a physician in a hurry, or for another case manager dealing with a crisis in this person’s life, reading your impressions and recommendations can be an invaluable place to start. Here is an example of Impressions and Recommendations for 27-year-old Landon:  Part 1. Landon is a 56 year old married man complaining of anxiety and depression, recovering from a recent stroke which left his left side paralyzed and forced him to give up an administrative position at the local community college. Landon reports a desire to “become active again but feels incapacitated by anxiety.” Part 2. Landon states he feels incapacitated by anxiety and irritability and worries his physical care and irritation are straining his marriage. He appeared anxious and irritable with the C.M. [case manager] during the interview. Due to the stroke functioning is impaired in all areas. He appears motivated to get assistance, but skeptical that anything can change. He has good insight into how difficult his current situation is for his wife. Part 3. Recommend review of medications by psychiatrist to see if what psychotropic medications can be taken with those he is currently taking. Recommend 4 sessions of individual counseling to help Landon better develop insight and coping skills and 6 sessions of marital counseling to strengthen his marriage. Will check on support groups for individuals or couples in similar situation. COMMON ERRORS WHEN WRITING A SOCIAL HISTORY     • People don’t “admit” things unless we are sticking them with a hot poker. They tell us things. “Adele admitted her address is 2346 Lincoln Way” sounds adversarial. Instead try, “Adele gave her address as 2346 Lincoln Way.” • Don’t state things as a fact if they are things you don’t know personally or have not observed personally. Use “according to the client” or “the client stated.” • Don’t recommend something without saying what it is for. For example, “recommend psychiatric evaluation for depression” not “recommend psychiatric evaluation.” Not “recommend 12 counseling sessions at Susquehanna Counseling,” but “recommend 12 counseling sessions at Susquehanna Counseling to address loss of job and depression.” • Leaving gaps in the history. “She lives with 4 other people,” but we haven’t a clue who they are; or “they were married 10 years and divorced 3 and have a 20-year-old son.” What is the explanation for that? Using an Assessment Form Because of the limited time in some agencies and the need to be sure that specific questions are covered in the initial interview, many agencies provide an intake or assessment form. The form contains certain information the funding source requires, and use of the form makes that information easily accessible. This assessment form may be very similar to, but a bit longer than, the phone inquiry form you used when learning to do phone inquiries. These forms usually have names such as “Initial Assessment Form” or “Intake Evaluation Form.” Other intake or assessment forms may be lengthy and contain numerous questions to determine the client’s needs and capabilities. Remember, when you are using a form, that it is important to stop and ask open questions as you go through the form. This increases rapport and reduces the sense on the client’s part of being grilled by you. Long forms that spell out what questions need to be answered create the potential for you to begin to sound like an interrogator. You may be asking, “Name? Address? Phone number?” and then move on to more involved questions such as “When were you married? How many children? Names and ages of your children?” Where is the warmth and empathy in such questioning? The assessment form does contain many of the questions you need to ask to create a more complete picture of the person. If people seem unwilling to answer any of the questions, move on to others in a matter-of-fact way. Do not try to persuade them that they should answer something they feel uncomfortable discussing. Chances are this information will readily come out as you establish rapport. In addition, most forms have a place for interviewer comments. Be sure to take advantage of these spaces to elaborate on what the person has told you. This is where your notes give a more individualized picture of the client. The assessment form is simply an outline of what is important. If your intention is to fill in all the blanks on the form and close the interview, you have not really conducted an adequate interview. Put these spaces to good use by filling them with relevant comments or summaries. In one agency, a worker took the information required on the form. He also carefully inquired and documented additional information in the interviewer comment spaces. After one interview with a client, his supervisor came into his office and said, “We aren’t here to make friends. That form should only take 15 or 20 minutes to complete, max!” This supervisor is an example of a person who is poorly trained in establishing rapport and does not understand the importance of the first contact for the future success of the client. It is expected that you will talk with the client, that you and the client will discuss the situation, and that the client will volunteer additional information. Most forms soliciting information from clients are focused on the clients’ problems and deficits. In order to round out a complete picture of the client, you need to look for strengths. Take the time to do so—and remember, people only share such information when they feel comfortable with you. If you sound like a machine or rush through a series of questions, the person will not connect with you at all. A blank Intake Assessment Form is provided in the Appendix at the end of this book. In addition, the companion book, Fundamentals for Practice with High Risk Populations (Summers, 2002), provides assessment forms for eight high-risk populations. These forms are tailored to each specific population and contain detailed inquiries into common issues for each population. You may use those forms as you create and follow a client. Taking Social Histories on a Computer In some agencies, case managers are asked to take the information from the clients and place it in electronic forms on a computer. This is seen as more efficient than taking a social history and then having it typed up. However, case managers have raised two valid concerns about this form of history-taking: First, can the case manager look at and engage the person if the case manager is typing on a computer? Second, does the electronic form have enough space to allow for the real details of the person’s life and current problem? These are legitimate concerns, and I hope you will work for an agency that has addressed these possible obstacles. Using a flat screen computer allows the case manager to engage the client, who sits facing the case manager at the side of the desk. In this way a large bulky computer is not obstructing eye contact. The need to know the particulars of a person’s situation is important because the goal is always individualized planning. If the electronic form you use does not allow for individualized descriptions of the individual’s problem, the plan is jeopardized. Even when using electronic forms, there should be plenty of room to give particular information about your client and to spell out in detail what the person sees as the major problem and wants to accomplish by coming to your agency. The Next Step Having completed the initial intake with the person, it is time to begin to put together a chart for the client. Charts or files are kept in a particular order. The order of the contents is precise, making it easier to find information (see “Arrangement of the Client’s Chart” in the Appendix). Sometimes information is color-coded. For example, financial information may be on yellow paper and assessments on blue. As for the social history in the chart, check these points before filing it:     1. Keep heading with the content. Many put the heading for something on the bottom of one page and the content on the following page. They should stay together. 2. Bold all your subheadings so they are easily found. 3. All social histories should be stapled together. 4. All social histories must be typed so they can be read easily and quickly. It is important to maintain your charts in the order specified by your agency and to return them promptly to the records section of your agency or file them properly. In addition, it is important to make sure that the charts are locked up safely when you leave for the night and that no one has access to them but those who should. Finally, never remove a chart from the agency. The possibility that the information could be lost, stolen, or read by others is too grave. Summary When people come in for their first interviews, we are there to collect important information that will illuminate the problems these people are experiencing. Our task is to assess and document the details of clients’ problems as well as the background to the problems. When people must be served quickly, we are asked to focus more closely on the reasons the individuals are seeking help and the histories of their immediate problems. In all cases, however, your information will serve at some point as the foundation for the development of services and treatment. Accurately understanding people and assessing their moods and motivation gives others valuable information with which to work. If you are asked to use a form to collect information, be sure to ask questions and discuss the clients’ situations with them. Note the information you obtain on the form so that the form will better illustrate each particular person’s needs and concerns. Finally, it is important to keep in mind that you may be the first person from your agency whom the clients will meet. Their contact with you needs to be positive for them to move on and begin to heal and resolve old issues. As a representative of the agency, you are responsible for setting a tone that is warm, accepting, and safe so that people can talk freely about what has brought them to seek help. Exercises I: Practice with Social Histories    1. On a single sheet of paper, write a note on how Kate appears to you from the social history (see Figure 16.3 in this chapter). What are your impressions of her? What do you think she would be likely to do or not do? How likely is she to commit suicide following this visit? How readily can she stand up for herself? What strengths and supports does she have? What contradictions do you see in looking at her life? 2. Write up a social history of Carlos using the presenting problem paragraph provided in this chapter to begin the history. Invent other information as needed. This will give you practice in organizing information. 3. Take a social history from a friend or classmate. Be sure to explain that the person does not have to answer any question that is uncomfortable and that the person can make up information to fill in the gaps. The important thing is for you to practice taking a social history and then organizing the information in a useful format such as the one discussed in this chapter. Exercises II: Assessment of a Middle-Aged Adult Instructions: Using one of the blank assessment or evaluation forms found in the back of each chapter in the companion textbook, Fundamentals for Practice with High Risk Populations(Summers, 2002), develop further one of the clients for whom you did a phone intake. Choose the assessment form that fits your client’s problems. Develop details about the client’s life and gather information relevant to the reason the client called the agency based on information that you found in Fundamentals for Practice with High Risk Populations. In developing your client further, piece together the circumstances you believe might be reasonable for a person who has this particular problem. Assign the client a socioeconomic situation, amount of schooling, and other particulars. Develop as well your client’s problem by again consulting the current DSM, if relevant, and books and articles on this specific problem. Look at the chapter in the companion textbook, Fundamentals for Practice with High Risk Populations, related to the assessment form you chose to use for your client. Think about how your clients might be feeling as they come in for the first time and what issues or problems clients might be facing for which they are looking for help. Or Develop a believable social history on the client you have chosen, consulting the same material so that you are familiar with the issues and common problems faced by clients in this population. Or Use the generic assessment form in the Appendix at the back of this book, again consulting relevant material and the current DSM, to create a believable client. Exercises III: Assessment of a Child Instructions: Using the assessment form for children found in the back of Chapter 3 on children in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), develop further the child for whom you did a phone intake. Develop details about the child’s life and gather information relevant to the reason the parent or guardian called the agency. In developing your client further, piece together the circumstances you believe might be reasonable for a child who has this particular problem. Assign the child’s family a socioeconomic situation, amount of schooling, and the other particulars. Develop as well the child’s problem by again consulting the current DSM, if relevant, and books and articles on this specific problem. Look at the chapter on children in the companion textbook, Fundamentals for Practice with High Risk Populations, and think about how you, the parent (or guardian), and the child might be feeling as the child comes in for the first time and what issues or problems the family might be facing for which they are looking for help. To complete this assignment, you may use the chapter on children’s mental health (Chapter 3) or the chapter on mental retardation (Chapter 7) found in the companion textbook, Fundamentals for Practice with High Risk Populations. Or Develop a believable social history on a child, consulting the same material so that you are familiar with the issues and common problems faced by children and their families. Or Use the generic assessment form in the back of this book, again consulting relevant material and the current DSM, to create a believable client. Exercises IV: Assessment of an Infirm, Older Person Instructions: Using the assessment form at the end of Chapter 8 on older people found in the companion textbook, Fundamentals for Practice with High Risk Populations (Summers, 2002), further develop your client who is an older person, a person over 80 years of age. In this case, a child or close friend or neighbor may be present when you do the assessment and, depending on the condition of the older person, may give you most of the information. In addition, you may need to go to the person’s home to meet with the person because the client is too infirm to come to the office. In developing your client further, piece together the circumstances you believe might be reasonable for an older person who has this particular problem. Assign a socioeconomic situation, amount of schooling, and the other particulars, such as marriages, number of children, former occupations, and interests. In developing your client’s problem, read the current DSM, if relevant, and look at books and articles on the specific problem your older person appears to have. Look at the chapter in the companion textbook, Fundamentals for Practice with High Risk Populations, for information on how your client and the concerned caller might be feeling and what issues or problems the caller might be facing when meeting with you for the first time. Or Develop a believable social history on the client you have chosen, consulting the same material so that you are familiar with the issues and common problems faced by clients in this population. Or Use the generic assessment form in the Appendix at the back of this book, again consulting relevant material and the current DSM, to create a believable client. Exercises V: Creating a File Instructions: At this point, you need to create a file on the people you are seeing as clients. Create a separate file folder for each client you intend to follow throughout the remainder of the course. Place the client’s name on the tab of the file folder—last name and then first name, so that the cases can be filed alphabetically by their last names. Place the “New Referral or Inquiry” form on top, followed by the verification letter you sent. Under that, place the long assessment form you used, clipping the pages of that form together. CHAPTER 15: The First Interview* Introduction You have spoken to the person by phone, and you have arranged for the person to come into the office for an interview. This is the first interview for the individual. Even if this person was at one time a client of the agency, we will assume the case has been closed for some time. The purpose of this interview is to establish the following basic information about the person:  • Strengths, including external support systems, talents, successes, capabilities, and positive attitudes and events the person defines as a success     • Weaknesses, including gaps in the external support system, lack of experience or information, negative attitudes, and events the person defines as failures • Current problems that caused this individual to seek help now • Potential problems • A sense of who this person is Your Role You have three tasks to accomplish in this first interview. First, listen and convey an accurate understanding of clients’ perceptions about themselves and their problems. When you convey this understanding, it does not mean that you necessarily agree with them, but it does mean that you have heard them accurately. To do this well, you need to allow people to proceed in their own words. As they talk to you about what led to their seeking help, you can reflect back their feelings and perceptions about their situation, responding to feelings and to content. In this way, you sort out with the client what is important. Second, you formulate a professional understanding of what it is the individual is experiencing and what this person will need while being served by your agency. Finally, strive to establish rapport with clients so that they feel comfortable with you and with your agency. Some people, no matter how hard you try, will never warm to the interviewer, but most people respond positively to a worker who is warm, genuine, and empathetic. The Client’s Understanding In most cases, people have recognized the need for help; but in a few cases, they may feel they do not need to be in your agency. The courts mandate that some individuals seek help or face jail or the permanent removal of their children. In situations in which clients feel forced to come to your agency, you may encounter hostility. In either case, you must indicate that you have heard all of their concerns about being there. You can convey this through your ability to reflect back how clients are feeling about being in the agency. Even when people believe they need help, they may not be clear about what their problems are or how the agency can help them. They may be clear that the current situation is painful, but unclear about how to describe it. They may know things seem out of control, but be unable to describe the impact their situation is having on them emotionally. They may hope that there is help available without understanding what kinds of resources there are or how these resources could help them specifically. Preparing for the First Interview If you did not perform the telephone intake, you will want to look at the intake material that is available before the person arrives. As you do this, ask yourself what more you should know about the client’s difficulties. What details need to be clarified? Where are there particular gaps in the information that need to be filled in? If the client was in your agency before, read past records to fill out the picture of this person. Look at past medical difficulties, medications the person might be on, or medications that were prescribed previously while the person was in treatment. As you begin to form a picture in your mind of this person, remember that the information you have was collected by others who saw this person under other circumstances. This may not be the whole picture, and it may not be an entirely accurate picture. Rely heavily, therefore, on your own insight and your own competence to form an accurate picture of the client. Let’s look at the specific case of a woman seen by various case managers, physicians, therapists, and psychologists, who conducted some tests. The woman had a problem with anger and had been asked to leave the home of several family members where she had been staying. At last she was residing in a group home. A psychologist was asked to do an evaluation for possible neurological problems (problems in the brain or nervous system that would cause anger and loss of control). In reading the chart with the many records in it, the psychologist came across an early note by the case manager: “Client created a scene at the local Giant food store last week over the fact that another customer took the last head of lettuce as she was reaching for it. Crisis Intervention was called. Client was taken to her home.” About a year later, in another note, a therapist noted, “Client made several scenes in the past at the Giant where she shops. Apparently she gets upset over the fact that there is not more produce in the store. Management has called Crisis Intervention.” Still later a new case manager wrote, “Client apparently creates violent scenes at the food stores when she feels there is not enough produce. Crisis was called on several occasions. Will advise client to stay away from food stores.” Finally, several years later, a doctor prescribing medication noted, “Client was barred from shopping at any local food stores several years ago because of violent outbursts of rage over a lack of store items she meant to purchase. These outbursts resulted in contacts with Crisis Intervention and indicate a difficulty with anger control and poor communication skills.” Between the individual notes in the chart, there was no other reference to outbursts at the food store. It appeared, from looking at the chart carefully, that each person who mentioned the incident was summarizing the previous note and magnifying it in the process. Think how differently you would approach this client if the first note you read was the doctor’s note as opposed to the original case manager’s note. In this example, you do not know if the client changed her story each time she met someone new or if the workers read the charts and records and misinterpreted the information. There are other reasons the notes you read may not be accurate. The person who wrote a note might have been hurried in her assessment. She might have felt hostility or prejudice toward the client for some reason. The note may have been made by someone who was inexperienced in interviewing. For all these reasons, you will have to rely on your own insight and competence in doing your assessment. If you see inconsistencies in the previous history, make a note of them for further exploration. Your Office Most case managers have an office or place where they see the people to whom they are giving service. Sometimes case managers share an interview room. Look at your office or interview room. Be sure it is a place in which you would feel comfortable while confiding in another person. Is it warm and comfortable or utilitarian? Are there comfortable chairs? Is it free of harsh lighting? Are the walls attractive? It is probably best not to have personal pictures sitting about because you cannot be sure how your clients will view these or what meaning they may find in them. A picture of a happy, smiling 3-year-old may be upsetting to a person whose children were just removed from the home or to someone who is struggling to find shelter for her own 3year-old. It can create a barrier, and you are seeking to diminish barriers. In your office, there needs to be a comfortable place for the person to sit facing you. You want her to be able to talk to you in a normal tone of voice, but you do not want her to feel crowded by your presence. Meeting the Client From the very beginning, you want clients to know that you respect them, that you wish to be helpful, and that you will be relating to them as a professional, and not as a social acquaintance. The interview begins with your first introduction.         1. Begin by going to the waiting room to meet your clients. Do not make them find their way through the halls to your office. 2. Introduce yourself as Ms., Mrs., or Mr._______________. Or say, “Hello, my name is Jim Pelham.” Do not say, “Hi. I’m Jim” or “Hello, my name is Jim.” You did not spend all those years in school to earn this degree in order to be simply “Jim.” 3. Make a mental note of your first impressions. How do the individuals respond to your greeting? What do they say first? How do they look? 4. How do people react to your office? Do they seem comfortable? Do they appear to feel awkward? Do they readily sit down or wait to be invited to do so? 5. If clients start talking, show interest in what they are saying. Often the first things people tell you will hold the most significance. 6. If people ask about your credentials, tell them about these matter-of-factly. It is part of informed consent for clients to know who is seeing them. There is no need for you to sound defensive. Do not go into personal details about yourself, however. If a person insists on knowing if you have ever had children or if you are old enough to know how to help her, point out respectfully that the purpose of her visit is to understand the issues and problems she is experiencing. 7. Describe the agency and explain its purpose to clients who are unclear about it. Some individuals come to a case management unit and expect to see a doctor or a psychologist. Give information about the types of professionals that staff your agency and what they do. 8. Make certain that you or someone else has described payment arrangements to the client.  9. Make sure that you or someone else has explained confidentiality and the limitations of confidentiality to the individual. Be sure the client is given information on the Health Insurance Portability and Accountability Act (HIPAA). People need to know that their diagnosis may go to their insurance company. It is not necessary to go into every exception regarding confidentiality verbally, but let them know that under circumstances where they might be in an emergency, information may be shared. Taking Notes It is all right to take notes during your interview. For one thing, you are collecting very basic information, and you want to ensure that it is accurate. Let the client know that you are taking notes to make certain that you have accurate information. During other contacts with the client, jot down significant phrases or information. You can reconstruct your contact in short notes after the client has gone. Collecting the Information Allow people to tell their story in their own way, using their own words and expressions. Help them to begin talking about why they are here by asking an open question such as “Tell me a little bit about what brought you here today” or “Can you tell me something about what brought you here?” While the person is talking, remain emotionally neutral. Do not recoil in horror or gasp or squeal with delight. Do not tell the individual how you would have felt under the circumstances. This is not about you. While the person answers your question, reflect back the content and feelings you hear. If clients come from a different race, religion, or culture or have different values from yours, be aware of that without judging them. As we have seen, some case managers are tempted to judge clients using themselves as the standard. In other words, these case managers see themselves as the standard against which everything should be compared. By doing so, they miss the unique circumstances and characteristics that make the individual a separate person. This diminishes the case manager’s ability to be truly helpful. Asking for More Clarification During the interview, ask for clarification. Use open questions primarily (“Can you tell me a little bit more about your father?” or “Could you describe your relationship with her before you were divorced?”). It is all right to ask closed questions if you need further clarification (“Bill is your boss?” or “You lived there how many years?”). Avoid too many closed questions so that your interview does not take on the tone of a grilling. Avoid “why” questions as much as possible. Even when you have taken special care to ask them respectfully, a person may experience them as prying. Sometimes a “why” question actually asks clients to give an understanding of what motivated their actions or the actions of others. You may be asking for a level of insight people have not yet developed. In that case, they can only feel incompetent and uncomfortable. Sometimes individuals know why they behaved in a certain way or why something happened, but the reason is upsetting to them or they are having trouble recognizing and talking about it. A “why” question can make them think that you will probe for answers and push them to talk about things they are not ready to discuss. Finally, people may tell you a great deal more than they had intended to tell the first time. They may go home upset with themselves and embarrassed by the amount of selfrevelation in which they engaged. It may be so uncomfortable to them that they do not return to continue with your services. In that case, it is possible that you have intruded into the client’s personal information too quickly. As the person conducting the interview and, therefore, the person with the most power, you have an obligation to protect the client from this kind of intrusion. A good way to protect people is not to go too far beyond what they appear comfortable talking about. Intrusions and discomfort of this sort can be avoided if you recognize from the very beginning that the facts and circumstances of the client’s life and problem belong exclusively to the client. Those receiving services are under no obligation to tell you more than they feel comfortable revealing. This means that you focus on the information individuals can give you freely without probing and without discussing feelings and motivations. What Information to Collect The most important piece of information is to understand why the person is here now as opposed to last week or last month. Some of this information may be on the phone inquiry form, but your task in this first interview is to develop that information more completely. The reason the person has come to the agency now is often referred to as the “presenting problem.” In addition to the presenting problem, you want to understand the extent to which this problem has interfered with the person’s ability to function socially, occu-pationally, and personally. Is this person able to work? Are the client’s most important relationships feeling any strain? Is the person taking care of personal hygiene and other needs? You might ask questions like the following:    • “Can you tell me something about how things are going at work?” • “Could you describe how things are at home?” • “Can you give me some idea of how this has affected your daily routine?” Individuals who are alone, or who perceive they are isolated, are at greater risk for stress and suicide than those who have a good support system in place. Does the client have a support system or seem to be all alone? To find out, you might ask such questions as these:    • “Tell me a little bit about your family.” • “Tell me something about your friends.” • “Can you describe what you do in your spare time?” Client Expectations No service or treatment plan is entirely useful unless the individual has participated in developing the plan. During this first interview, ask people what it is they would like from your agency. You might ask them questions such as these:    • “Can you describe how you think we might be able to help you?” • “Tell me a little bit about the services you had in mind.” • “Can you share with me some of your ideas about services you would like from us?” Often clients do not know what services are available or what services they need. Together explore what your agency has to offer, and describe various alternatives for clients to consider. By the end of this first interview, you and the individual need to have developed a tentative plan for services. Social Histories and Forms In Chapter 16, we look in more detail at how information is collected. Most agencies have a standard format that gives you the foundation for creating a social history. Many agencies have a form that covers the essential information you need to develop a treatment or service plan and to give ongoing support and service to a client. Wrapping Up Here are some tasks to complete toward the end of the interview:      1. Ask clients if they have any questions, and answer these questions thoughtfully. This is part of giving people information they need to give informed consent. 2. Work with people to define their problem in language they can understand. This is very important because it gives you and your clients a mutually clear definition of the presenting problem. 3. Talk to clients about what they expect as a result of coming to the agency. Ascertain what their goals are for themselves, the sort of service they are looking for, and the expected outcome. You might say, “Tell me something about where you would like to be a month (or 4 months, or whatever) from now.” 4. Give clients some information about what will happen next. If the case is to be presented to a panel or treatment team, tell clients that, and tell them how long it will be before they will have information about a formulated plan for them. If they must go on a waiting list, tell them that, and give them information about where they can get services more quickly. Let them know what will happen after this first interview with you. Never let people leave wondering what will happen next. 5. If clients are to return to you in a set amount of time to discuss the implementation of the plan that has been developed with them (or for some other reason), be sure to give them a card stating the time and the date of the next appointment. If someone must bring them to their next appointment (such as a parent, guardian, group home worker), be sure that person is aware of the time and date as well. By watching “The First Interview” on the DVD that comes with your textbook, you can see Keyanna conducting the first interview with Michelle. “The First Interview” The Client Leaves Rise at the end of the interview to indicate that the session is complete. It is always a good idea to walk the client back out to the waiting room. Be aware of something social service workers refer to as the door-knob syndrome, wherein a person begins to tell you something of great significance just as he is leaving. He may have saved this information for last deliberately because it is painful and he did not want to discuss it in depth. In any case, let clients who bring up significant issues at the very end know the session will not continue and that they should bring the subject up with the therapist or with you the next time they see you. Do this in a warm and interested manner. Do not appear to scold. Do not allow clients to leave your office if you believe they are a danger to themselves or to others. If what they choose to bring up at the end indicates to you that this is a possibility, you will need to explore that further or see that someone else is available to do so. After the individual has left, do not go to the receptionist to place the client’s name in the appointment book and discuss the client with the receptionist; and do not use the person’s name where other clients in the waiting room can hear. Do not discuss your session in the hall or in another case manager’s office where other people can overhear your comments. CHAPTER 17: Using the DSM* Introduction The Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2000) is a collection of diagnoses of mental disorders accompanied by the typical behaviors and symptoms you might see in a particular diagnosis. The idea behind this manual is to provide a common set of criteria for each mental disorder so that practitioners will be more likely to give the same diagnosis to people with similar symptoms and behaviors regardless of where they are being treated or who is seeing them. Thus the manual provides a common language that everyone in the helping professions can use in diagnosing individuals, discussing their symptoms and issues, and planning their care. Students may want to use the Quick Reference to the Diagnostic Criteria from DSM-IVTR, a smaller book with the basic information sufficient for students to work with this material. Many students wonder why they need to learn about the Diagnostic and Statistical Manual of Mental Disorders (DSM; APA, 2000) when it appears to be a tool used exclusively by mental health practitioners. Actually the DSM is a valuable tool you will use in many different settings. Although the majority of clients in the broad human service system do not have mental disorders, the DSMsometimes helps to define what the client is experiencing and what that person needs. For instance,clients who come to agencies as victims of abuse or assault often suffer from posttraumatic stress disorder. Workers in agencies dealing with the problems of growing older will encounter people who have dementia or symptoms that resulted from a stroke or other long-term, debilitating illness. Those who work with children in a variety of settings will encounter children who have learning difficulties. Familiarity with the language and process of the DSM enables you to participate in planning for the client more competently. Is DSM Only a Mental Health Tool? Today, with deinstitutionalization of the mentally ill, those with mental disorders come for services at many social service agencies, and more often than in the past, we see people who have more than one problem. You might be working at a shelter for victims of domestic violence and do an intake for a woman who also suffers from bipolar disorder. You might find that a client has both a mental disorder and an addiction to heroine. People who seek our help no longer fit into neat boxes with no overlapping problems. For that reason, it is important to be familiar with this system. The DSM is the language of insurance companies and other funding sources with regard to behavioral treatments such as drug and alcohol treatment or treatment for those with mental health problems or mental retardation. In addition, the DSM contains information about situations and problems that may not constitute a mental disorder but may be the focus of attention in a clinical setting. Many of these situations come to the attention of social service agencies not equipped to treat them. You will need good information to make sound referrals. Your ability to understand the DSM and your acquaintance with the various classifications of mental disorders will enable you to be more conversant with others in the field and to recognize a mental disorder when you encounter one. Cautions Having spelled out why the DSM is important in human service practice, it is equally important to understand that most people who come for services in social service agencies are not suffering from a mental disorder. The DSM cannot be used to help you understand every client. If you try to give a psychiatric label to everyone you see, you will unnecessarily burden individuals who are well but are grappling with life events and disruptions such as unemployment or grief. In addition, the DSM comes from the medical model. That is, the model suggests that individuals are labeled with an illness and are then treated as sick. This is a view of the client that can cause you to lose sight of the fact that the person has strengths and successes. Although a diagnosis is useful to clinicians in providing treatment, to case managers it can have the subtle effect of diminishing the client as a whole person. The agency where you work will have policies and guidelines about using the DSM. Many agencies do not rely on the manual at all. Agencies that do rely on the manual generally are required to give diagnoses in order to be reimbursed for services. When you must rely on the DSM, be very careful not to categorize people or to allow their diagnoses to color your complete understanding of them as individuals. Who Makes the Diagnosis? You are not studying the DSM to make final diagnoses. The actual diagnosis is made by a physician or a senior staff person with a PhD. Nevertheless, the DSM contains a language that is universally understood. Your experience with this language and with the mental disorders in the manual will facilitate your communication and reports to those responsible for giving the diagnoses. It could happen, on a rare occasion, that a harried emergency room physician with a waiting room filled with medical emergencies would turn to the emergency worker from a social service agency and ask that the worker give a provisional diagnosis to facilitate admission to the hospital (where the diagnosis will be reevaluated in less pressing circumstances). Further, it is becoming common practice for insurance companies and other payers to require a diagnosis at the completion of intake. Case managers responsible for intakes may need to give a diagnosis at the time of the intake so the agency can be reimbursed. Such diagnoses may be changed later by senior professionals, but case managers need to be familiar with the common diagnoses seen in their agencies. It is important for you to keep in mind that additional clinical information is always needed to help round out the picture and make the best diagnosis and treatment plan. Much of that additional information in many settings will come from your histories and notes. This chapter is based almost entirely on the work of Anthony L. LaBruzza (1994), whose book Using DSM-IV: A Clinician’s Guide to Psychiatric Diagnosis, gives excellent background on how we arrived at the current DSM and how to use it effectively. Background Information Until the 1600s, physicians used a patient’s horoscope to diagnose mental disorders. Medieval physicians looked at the four humors to account for differences in human personality and temperament. The humor that predominated accounted for the patient’s disposition—with blood accounting for a happy temperament; choler contributing to a fiery, competitive temperament; phlegm resulting in a cold, delicate disposition; and bile causing melancholy. Psychiatry Attempts to Classify Mental Disorders In colonial times, most individuals with mental illness were managed at home by their families. Many were abused and exploited or were confined to workhouses and almshouses in which varying theories about the reasons for their illnesses caused harsh treatment in most cases. Between 1800 and 1860, a number of people became concerned with placing those with mental illness in “asylums” in which a more humane approach and more respect for the patient would be the rule. Such treatment was referred to as “moral treatment” (LaBruzza, 1994). Dorothea Dix was active in this movement; and when her attempts to start a federal asylum program failed, she became instrumental in founding state hospitals in Pennsylvania and New Jersey, which bear her mark to this day. Mental illness was little understood; and in the census of 1840, people were classified as either sane or “idiocy/insanity.” The shift from the asylum to treatment, research, and education occurred in the late 1800s and early 1900s. At that time, research was beginning to provide a clearer picture of the anatomy of the brain, and the diagnostic system became more refined. By 1880, there were seven categories of mental disorder. Diagnosis continued to be the focus of research. Wilhelm Greisinger (1817–1868) in Germany looked at the mental disorders as diseases of the brain, an organic view. Another German, Emil Kraepelin (1855–1926), looked at syndromes or collections of symptoms and made statistical records of the symptoms patients exhibited, the course of their diseases, and the outcomes. His goal was to be able to accurately predict the outcome of a disorder for a patient based on certain combinations of symptoms. He used a behavioral and descriptive approach that made it easier for others to use his concepts. Others also contributed their views of the brain and nervous system in creating a diagnostic classification system. Most influential in the United States was a Swiss-born psychiatrist, Adolph Meyer (1866–1950). Mental disorder, in his view, was a response to psychosocial stressors. This view was widely accepted because individuals drafted into the military during both world wars appeared to break down under the stress of combat. Had his view continued to be influential, mental illness would have been seen today as an adaptive response. Instead, mental disorders gradually came to be seen as discrete psychiatric diseases. In the 1920s, the American Psychiatric Association (APA) decided to find a way to standardize the medical terminology psychiatrists used. A national conference in 1928 looked at how diseases were named. The classification system that emerged focused only on the most severe forms of mental disorders, those that would most likely cause the patient to be institutionalized. The classification became broader when World War II veterans returned with less severe disorders. In the 1940s, there were 10 types of psychoses, 9 neuroses, and 7 disorders related to behavior, intelligence, and character. In 1952, the APA published the first Diagnostic and Statistical Manual. In an attempt to keep up with international changes in the way mental disorders were classified, in 1965 the APA revised the original manual and brought out the second edition, DSM-II. This manual seemed to return to the Kraepelian descriptive model for diagnosis. Those who did the revisions eliminated terms that implied a particular theory of etiology (or cause) for the disorder. This successfully did away with Meyer’s idea of seeing mental disorders as a response to stress. Nevertheless, psychoanalytic terminology remained because psychoanalysis was still quite popular and influential among psychiatrists. The 1950s, 1960s, and 1970s At this point, the manual was still quite unreliable. Psychiatrists would give different diagnoses to the same symptoms, making replication of research impossible. Anthony LaBruzza (1994) stated, “[T]he possibility that two psychiatrists would agree on the same diagnosis in the 1950s and 1960s was nearly random.” In the 1960s, psychiatry was out of favor with the public as famous court cases pitted psychiatrists against each other in what appeared to be a nebulous theoretical system, and motion picutres, such as One Flew Over the Cuckoo’s Nest, introduced moviegoers to the possibility that institutions were punitive and that the staff in such places were not much healthier than the patients. This was a time when all authority was challenged, and a number of books challenged the authority of psychiatry, particularly Thomas Szasz’s book, The Myth of Mental Illness. Many saw psychiatry and psychiatric diagnoses as stigmatizing and as wielding undue social control. In addition, insurance companies began to cut back on the amount of psychiatric care for which they were willing to pay, in part because the diagnosis of mental illness was unreliable and there seemed to be no consensus on the best treatments. No studies had been conducted to determine which illness responded to which treatment. Psychiatry Becomes More Medical The third edition of the manual, DSM-III, came out in 1980. Every edition of the manual since DSM-III has been an expansion or refinement of that document. This manual relied on a more medical research—oriented model of disease, and it also relied more heavily on the Kraepelian use of descriptions. In addition, it was no longer slanted toward psychoanalytic descriptions or causes; in fact, causes were, for the most part, left to research to determine. Responding to the concerns voiced about psychiatry, the third edition of the manual contained 14 discrete and specific mental disorders with very explicit descriptions. These descriptions had operational criteria that allowed them to be measured statistically. All references to unconscious motives were removed, and the clinician based the diagnosis strictly on what could be seen. The changes in the third edition of the manual could be summarized as follows:          1. There was every attempt to use clear English, and not mental health scientific jargon. 2. Disorders were labeled, and not people. 3. Patient was dropped in favor of words like person or individual. 4. The manual was tested for reliability for the first time by clinicians using it in the field. 5. A multiaxial system was adopted to give a fuller diagnostic picture of the person. 6. Decision trees were included to help the physician rule out similar disorders and narrow the diagnostic choice to one. 7. The words disease and illness were dropped in favor of the word disorder. 8. All the pet theories about causes of disorders were eliminated. 9. Each disorder had a working definition that contained operational criteria (criteria that could be observed and measured). After publication of DSM-III, psychiatrists were far more likely to make the same diagnosis for the same set of symptoms. This enabled research to be done more effectively, particularly field trials of medications that treated specific psychiatric symptoms. In other words, it became more likely that practitioners would all agree on the diagnosis for certain clusters of symptoms, regardless of where they were practicing. If everyone was seeing the same thing when they looked at a cluster of symptoms, then it was possible to treat that cluster of symptoms in various ways to determine the best approach to alleviating the symptoms. Now clinicians could communicate reliably in a common language about diagnoses. This common language facilitated good research. Pharmaceutical companies supported this research for products they developed for these specific disorders. How We Got to DSM-IV and DSM-IV-TR With all the field testing that took place as a result of DSM-III, revisions were inevitable. Thus, in 1987, DSM-III-R (or revised) came out; this edition included 27 new categories and revisions to some older diagnoses. The number of categories went from 265 to 292. An appendix contained further categories requiring additional research. The DSM-III-R made another important shift that will affect your work with the document. It moved from the monothetic diagnosis to the polythetic diagnosis. The old DSMs used the monothetic diagnosis. They gave a series of symptoms that constituted a disorder, and unless all of them were present you could not use the diagnosis. This meant that a diagnosis was only as useful as the least useful item in the series of symptoms. In a polythetic approach, the series of symptoms is given, and the patient must have several, but not all, of them. This improved the reliability of diagnoses. Another important shift was the move to give a patient more than one diagnosis if the patient met the criteria for more than one. Previously the clinician had to choose the diagnosis that was most obvious or urgent. Other diagnoses that coexisted with the first diagnosis or were, perhaps, part of a larger clinical problem were not mentioned. This narrowed the clinical picture of the patient. Now a fuller clinical picture was possible. The DSM-III-R also lined up with the new version of International Classification of Diseases (ICD-10), which made it easier for American clinicians to talk to clinicians internationally. The DSM-IV contained as few changes as possible, and those changes were based on good research with empirical results. To establish the empirical basis for changes, the work committees (those committees working on various classifications) systematically reviewed the literature for different diagnostic categories, reanalyzed previous data, and conducted field trials to make certain the diagnoses were reliable in many different settings and in many different types of clinical work. The DSM-IV also did away with all sexist language. The DSM-IV-TR (or text revision) refined the diagnostic categories still further. Other refinements and new DSMs can be expected as research and experience combine to increase our understanding of mental disorders. Using the DSM What You Will Find in the DSM-IV-TR The following are some of the features you will find in the recent edition of the manual:          1. Every disorder has a name, numerical code, the criteria needed to give the diagnosis, the subtypes of the disorder, the specifiers (modifiers), recording procedures, and examples that illustrate the disorder. 2. Associated features and associated disorders may include such items as clinical features that may be present but are not always seen in the disorder; disorders that precede, often cooccur, or generally follow the disorder in question; typical laboratory findings; physical signs and symptoms; and typical medical conditions. 3. The typical age at onset and any cultural and gender-related information. 4. The prevalence of the disorder, the incidence, and the risk. 5. A description of the typical clinical course of the disorder. 6. Any complications that might be applicable to the disorder. 7. Typical predisposing factors discovered through research. 8. Family patterns if there are genetic or suspected genetic components to the disease. 9. Differential diagnoses or disorders that share similar symptoms and information on how to distinguish among similar disorders. (LaBruzza, 1994, pp. 57–58) Making the Diagnosis The individual receives a diagnosis along five separate dimensions, referred to as axes. Each axis gives different information about the person, providing a more accurate clinical picture than would be possible with a single axis. This is called a multiaxial diagnosis. The diagnoses entered on each axis have both names and numbers, the numbers being useful for insurance and billing purposes. Each axis serves a different purpose. Figure 17.1 contains an outline showing what information is coded on each axis. Memorizing the information contained here is really all the basic information you need to start. All other information contained in this chapter you can use as reference material when working with diagnoses. FIGURE 17.1: Dimensions used in multiaxial diagnosis A Closer Look at Multiaxial Assessment Axis I All clinical syndromes listed in the DSM are coded on this axis except personality disorders and mental retardation. The primary diagnosis, or reason a person is seeking treatment, generally is the diagnosis appearing on Axis I. However, if a person is seeking help for mental retardation or a personality disorder, there may not be an Axis I diagnosis. If there is more than one Axis I disorder, the primary diagnosis is listed first and often is qualified with the phrase “Reason for visit” or “Principal diagnosis” (unless the principal diagnosis is on Axis II; LaBruzza, 1994). If the clinician does not use one of these phrases, the Axis I diagnosis is always considered to be the primary diagnosis. The following categories of disorders are coded on Axis I:                 1. Disorders usually first diagnosed in infancy, childhood, or adolescence (except mental retardation, which is coded on Axis II) 2. Delirium, dementia, amnesia, and other cognitive disorders 3. Mental disorders due to a general medical condition not elsewhere classified 4. Substance-related disorders 5. Schizophrenia and other psychotic disorders 6. Mood disorders 7. Anxiety disorders 8. Somatoform disorders 9. Factious disorders 10. Dissociative disorders 11. Sexual and gender identity disorders 12. Eating disorders 13. Sleep disorders 14. Impulse control disorders not elsewhere classified 15. Adjustment disorders 16. Other conditions that may be a focus of clinical attention When there is no diagnosis on Axis I, the clinician writes V71.09 on the axis. If the practitioner suspects there may be an Axis I disorder but is not sure, the deferred code, 799.9, is used. Axis II Axis II is used to code personality disorders and mental retardation. This was done to be sure relevant personality factors would be part of the entire diagnosis. It also makes mental retardation a separate factor on a separate axis in the person’s general diagnosis. Of all the disorders listed in the DSM, only mental retardation and the learning disorders require diagnostic testing before the diagnosis can be given. If a person meets the criteria for more than one personality disorder, all of them should be coded on Axis II. In addition, the clinician can write in any significant maladaptive personality traits or habitual defense mechanisms on this axis. These items have no code number. A habitual defense mechanism would be behavior a person uses that is maladaptive, but seems to the person to protect or benefit them in some way. Lying, cheating, stealing when part of the usual way a person behaves or responds, would all be considered habitual defense mechanisms. The absence of an Axis II disorder is coded V71.09. If the practitioner suspects there may be an Axis II disorder but is not sure, the deferred code, 799.9, is used. You will find that insurance companies are not pleased with Axis II diagnoses due to the amount of costly treatment required. This treatment can be intense and time consuming. There are 11 categories of personality disorder.            1. Paranoid 2. Schizoid 3. Schizotypal 4. Antisocial 5. Borderline 6. Histrionic 7. Narcissistic 8. Avoidant 9. Dependent 10. Obsessive-compulsive 11. Personality disorder not otherwise specified In addition, borderline intellectual functioning is also coded on Axis II (V62.89). When there is no diagnosis on Axis II, the clinician writes V71.09 on the axis. Axis III Often, individuals with severe mental disorders also have general medical conditions that affect the prognosis, treatment, and even the understanding of their situations. Any general medical condition that is relevant should be coded on Axis III, along with any medical history that may be relevant to the current problem. Axis III is not meant to indicate the mind and body are entirely separate entities. Axis III is separate in order to be sure the full picture of mental and medical disorders is recorded. People with medical conditions often feel less well psychologically. Axis III also alerts the physician to the possibility that the person is on medications that might interfere or interact negatively with psychotropic medications that might be prescribed for the mental disorder. In some cases, it is the medical condition that has caused the mental disorder. If this is the case, the medical condition is recorded on Axis III, and the mental condition is recorded on Axis I with the phrase “due to …” (for example, Axis I might read “major depressive disorder, single episode, due to hypothyroidism,” while Axis III would read “hypothyroidism”). If no medical condition exists, write “Axis III: None.” If it is suspected that there may be a medical condition but there is not enough information, it is coded “Axis III: Deferred.” The clinician can note in writing any significant symptoms or physical signs that were observed that need further evaluation. Axis IV Axis IV should list any psychosocial stressors or environmental problems that appear to have an impact on the conditions noted on Axes I, II, and III. The clinician looks at what has happened to the individual, particularly in the last year. Some stressors happened a number of years ago. For instance, a diagnosis of posttraumatic stress disorder (309.81) on Axis I may have Vietnam War on Axis IV as a stressor that is affecting the current condition of a Vietnam war veteran. The DSM lists “other conditions” that may be the focus of clinical attention. These codes begin with the letter V and are listed on Axis I. They refer to problems people encounter in life that might cause them to seek professional help. It might be bereavement (V62.82), school problems (V62.3), or any number of situational and relationship issues that have come to clinical attention. After further treatment, a discrete mental disorder sometimes emerges and the diagnosis is changed at that point. At other times the person just needs help adjusting to the circumstances. The V codes were developed to outline broad general categories of psychosocial stress a person might experience.  1. Relational problems • Childhood (V61.9) • Adult (V61.9) • Parent—child (V61.20) 2. Problems related to the social environment (V62.4) 3. Educational problems (V62.3) 4. Occupational problems (V62.2) 5. Housing problems 6. Economic problems 7. Problems with access to health care services 8. Problems related to interaction with the legal system/crime 9. Other psychosocial and environmental problems o o o         If stress from a specific stressor is the main reason a person is seeking help, the V code for the stressor should go on Axis I, and a description of the exact stressor should go on axis IV. For example, if a person is having trouble on his job, you would put V62.2 occupational problem on Axis I, and on Axis IV you would write, “difficulty adjusting to additional responsibilities” or “problems with supervisor.” (Note: These V codes should not be confused with V71.09, which is the code used on both Axis I and Axis II to indicate that no clinical condition is present on that axis.) Much psychosocial stress has to do with problems in the person’s support system. This can include births, deaths, separation, divorce, remarriage, abuse, neglect, and significant illness. When looking at the person’s social environment, you might find social isolation, lost friendships, retirement, relocations, and cultural differences as contributors to the current difficulty. The “other” category can be used to record natural disasters and catastrophes such as floods or earthquakes or problems related to professional caregivers, for example, a nursing assistant who is rough and seemingly threatening. The term other is used for any stressor that does not fit into the other categories. After the category is listed, the clinician should write out the specific stressors within each category (unemployed, mugged, best friend was killed, and so forth). There are positive stressors such as weddings or the birth of a child. These positive stressful events are not coded on Axis IV unless they create a clinical problem for the patient. Axis V This axis is reserved for the person’s number on the Global Assessment of Functioning (GAF) scale. How well a person functions or does not function will affect any treatment plan developed and may affect insurance payment, research options, and the overall assessment of the person. A single rating of how the person is functioning at the time of the evaluation is given on Axis V. You will find the GAF in your DSM. The number assigned the patient should reflect the person’s “current level of psychological, social, and occupational functioning at the time of the evaluation,” according to Anthony LaBruzza (1994, p. 79). He further pointed out that “impairment due to physical, and environmental limitations is excluded from Axis V” (p. 79). For example, if a person were impaired because of a stroke and therefore unable to get around, this reduced functioning would not be part of the assessment. Nor would circumstances such as poverty or a poor education be included in the assessment. The assessment looks at how well people are functioning beyond their environmental and physical limitations. The number given on Axis V is a number from 1 to 100. Zero indicates that there has not been enough time to adequately assess the functioning. The scale is divided into 10point segments, with 1 to 10 being the lowest functioning and 90 to 100 being the highest. Most individuals requiring inpatient hospitalization have a GAF score of 50 or less. The scale has been criticized for making it possible to a greater degree to abuse reimbursement, forensic, and disability situations. Use of Codes V71.09 and 799.9 These two designations are used only on Axis I and Axis II. You need to know what these numbers mean when you see them. On both Axis I and Axis II, the codes indicate the following:   • V71.09 means there is no diagnosis on that particular axis. • 799.9 means the diagnosis was deferred, presumably because there was too little time or information to make a diagnosis. Making the Code All the disorders in the DSM have a numerical code. The code has three whole numbers followed by a decimal point and one or two additional numbers. The form of the codes looks like this: XXX.XX. The last two numbers in the code give the diagnosis more specificity. Let us take an example. A person comes in with an obvious depression. In DSM terms, this is called a “major depressive disorder, single episode” (296._ _). The number 296.21 indicates the person’s condition is mild, 296.22 means moderate, 296.23 means severe but without psychotic features, and 296.24 is severe with psychotic features. A person in partial remission would get 296.25, and a person in full remission would get 296.26. We know that the Axis I diagnosis will be 296._ _. By choosing the proper digits to follow the decimal point, we create a more accurate clinical picture of this person. The fifth digit is generally used to identify four things:     1. Subtypes 2. Specifiers (or Modifiers) 3. Course of the disorder and severity 4. Additional information such as reason for visit; provisional diagnosis; and the diagnoses of not otherwise specified, unspecified, or deferred. Subtypes When the clinician codes a diagnosis, the manual may require that the clinician “specify type.” This refers to subtypes within a specific diagnosis. For instance, the diagnosis may be a delusional disorder (297.1), but there are seven distinct types of delusional disorders, including jealous, persecutory, grandiose, and so forth. Supposing the person you are seeing believes his wife is seeing another man when all information points to the fact that this is not true. This man has believed this about his wife for over a month, affecting adversely his work and home life. His diagnosis would be written as: “297.1, Jealous Type” or “297.1, Delusional disorder, Jealous Type.” Specifiers (Modifiers) The manual may require that the practitioner “specify if” when coding a diagnosis. These are specifiers—also called “modifiers”—that allow the clinician to indicate if certain factors are present in this particular diagnosis. For instance, if the diagnosis is pedophilia (302.2), the practitioner will be asked to specify if the person is sexually attracted to males, females, or both (LaBruzza, 1994). Thus if you are working with a person who is a pedophilie you would write the diagnosis like this: “302.2, Sexually Attracted to Males” or “302.2, Pedophilia, Sexually Attracted to Males.” In another example, the person may have a diagnosis of 293.83, Mood Disorder Due to…. Here we are asked to indicate the general medical condition causing the mood disorder and then specify the features present in the disorder. There are four types of features from which to choose. Thus you might write: “293.83, Mood Disorder Due to breast cancer, with manic features.” Modifiers for Past and Present It is always understood that the diagnosis is a present condition. Sometimes, however, it is useful to note a past history of a particular diagnosis. A diagnosis from the past is modified with the phrase “prior history.” In this case, you might write: “309.81, Posttraumatic stress disorder, prior history.” Modifiers for Course of the Disorder and Severity The fifth digit is used to specify the status of the remission or the degree of severity in some diagnoses. Severity is usually either mild, moderate, severe, or psychotic. Each of these degrees of severity, specified by the fifth digit, indicate the intensity of the signs and symptoms and the degree to which the person’s functioning is impaired. “Mild” means the person’s symptoms just minimally meet the criteria for the disorder. Severe means the person meets the full criteria with intensity and is severely impaired in functioning. Look once more at the example of Major Depressive Disorder under “Making the Code” to see how the fifth digit is used to indicate severity. Remission is usually either “partial remission” or “full remission.” Partial remission means the person meets some of the criteria for the disorder but is no longer showing the full criteria that were present when the original diagnosis was made. You might also use this specifier to indicate that a person who had been in full remission is now showing some of the criteria again. Full remission means all the signs and symptoms of the disorder have disappeared but the diagnosis is clinically significant at present. Additional Information Reason-for-Visit Modifiers Beginning with the DSM-IV, there was a shift toward multiple diagnoses. If the person fits the criteria for more than one disorder, then all of the disorders are listed. This means that the practitioner needs to identify the disorder that brought the individual in for treatment or the disorder that will most likely be the focus of treatment. This is done by placing the phrase “principal diagnosis” or “reason for visit” beside the primary diagnosis. List the primary diagnosis first with the modifier (“reason for visit” or “principal diagnosis”), and then list the other diagnoses under it in order of importance. Generally, the primary diagnosis is on Axis I. On occasion, it will be on Axis II, in which case you need to make sure to use the modifier on the Axis II diagnosis. Here is an example:  Axis I: 296.23, Major Depressive Disorder, Recurrent, severe without psychotic features, Reason for visit 305.60, Cocaine Abuse Provisional Diagnoses When it is not clear what the diagnosis should be, the clinician needs to indicate that uncertainty. Some clients are uncooperative or impaired to the point that they cannot give much information. If the clinician has a strong idea of what the diagnosis probably is, a diagnosis is written with the term provisional after it. There are some disorders that must initially be modified with “provisional.” These would be disorders where a time lapse is needed between episodes in order to confirm the diagnosis. For example, panic disorder (300.01) requires at least one panic attack, followed by at least a month of persistent worry about having more attacks. A clinician who sees someone who appears to have panic disorder but had the panic episode only 2 days previously cannot give the client that diagnosis with a degree of certainty. Thus the word provisional is used until enough time has passed to confirm or revise the diagnosis. Not Otherwise Specified Sometimes a person comes in with most of the symptoms of a particular disorder and the practitioner thinks she knows what the diagnosis should be, but the signs and symptoms do not quite fit the criteria as they are outlined in the manual. All the major classes of mental disorders have a “not otherwise specified,” or NOS, category. The practitioner would write NOS after the diagnosis in this sort of case. For example, a person might have symptoms that do not meet the full criteria for any one of the mood disorders, but meets some criteria for several different mood disorders, giving a mixed version of the disorder. The diagnosis would be 296.90, Mood Disorder, NOS or not otherwise specified. There are other reasons to use the NOS designation. You might encounter a person who has an obvious mental disorder, but it is not found in the DSM. Perhaps it is a characteristic of the person’s culture, or it is something being researched that has not been given a code yet. In another situation, the clinician may not know the cause of the disorder. The mental disorder he is seeing might be due to the medication the person is on, the general medical condition the person has, or the stress of the individual’s life. This may need to be sorted out before giving a certain diagnosis. Finally, clinicians who lack enough information to be sure of the diagnosis can use the NOS category. After getting good information, the diagnosis can be changed. Unspecified and Deferred Diagnoses There is an “unspecified mental disorder” category that cannot be used when psychotic symptoms are present. The number is 300.9. This is used when there is some certainty that a mental disorder exists, but there is inadequate information to make a clear diagnosis. Later it can be changed to a specific disorder, unless it is found that the symptoms do not meet the criteria for any specific disorder. If there is inadequate information to make any diagnosis, the number on both Axis I and Axis II is 799.9, “diagnosis deferred.” Today most private and public insurance agencies insist that a diagnosis, even if provisional, be given at the very first person-to-person contact. This means that in some locations it is case managers who are giving those provisional diagnoses. You can see part of a service planning conference where the participants discuss what might be the appropriate diagnosis for Alison. Note the various considerations the group makes before a diagnosis is assigned. Service Planning Conference Summary The DSM is a complex manual. It takes practice and good clinical skills to use the manual effectively. Nevertheless, entry-level individuals are being asked to understand the categories of disorders and discuss diagnoses with clinicians. In this course, we begin to look at how you would use the manual in your work as a case manager. As you practice, you will begin to understand more clearly how disorders are defined and treatments are assigned. As you work with the DSM over a period of time, these axes and the diagnoses that go on them will become more familiar to you and easier to use. You will also be able to note such diagnoses more quickly with practice. Exercises: Using the DSM Instructions: Working together in small groups, see how many of the following exercises you can complete. These are designed to familiarize you with where different material is located in the DSMand how conditions are coded on the five axes. When it comes to actual diagnoses, there will always be debate about what diagnosis to use. In other words, don’t expect that there is only one right answer. Try to seek the best answer instead. After discussion, in which you will no doubt cover many of the issues raised in a real work situation, assign the diagnosis you feel is most appropriate.            1. It seems to you that Jim is having trouble in school. The teacher reports that Jim can read and speak well but has trouble writing out his thoughts in a coherent and organized manner. You suspect the diagnosis is_______________, and you know that____________________must be done to confirm it. 2. The doctor asks you to estimate a GAF for a woman who is being seen by you in the ER. Her family says she has been confused recently, and today she left some pots on the stove and forgot to attend to them. The kitchen caught fire. In talking to her, she seems somewhat unconcerned or unaware of the gravity of the situation. She also seems unable to find the ladies’ room when you direct her there, and you end up going with her and leading her back to the interview room. The abbreviation GAF stands for__________________ You assign her a GAF of ________________________You place the GAF on Axis_____________________________________________________________ ___________. 3. A man comes in and indicates he is suffering from severe depression. He appears to have a flat affect and some tearfulness. In the course of the interview, you learn that he is an intermittent cocaine user. How do you code these two disorders? 4. A woman has breast cancer and has been depressed since the diagnosis was first given. Her family reports that she seems to be getting worse. How do you code these two disorders? Think about what you learned when there are two diagnoses. 5. A patient is being admitted to the psychiatric unit, and the doctor is unclear whether she is seeing a personality disorder or a clinical syndrome. She needs to get the patient admitted quickly and knows the doctor on the floor will have the time to sort this out. What does the doctor most likely write on Axis I? What does she most likely write on Axis II? 6. The psychologist laments to you that she knows the client has a dissociative disorder but goes on to say that although it looks similar to dissociative identity disorder, she cannot quite see two or more distinct personality states. You think of what diagnosis? 7. For each of the following, indicate on which axis it should appear: Migraine headaches_____________________ Housing problems___________________Cancer______________________ Schizophrenia, paranoid type__________________________Borderline personality disorder__________________________ A broken leg________________________ A divorce______________________ A lost job______________________Severely impaired social and occupational functioning_________________________ Dementia of the Alzheimer’s type________________________ Domestic violence_________________________Mental retardation_________________________ Inhalant intoxication________________________Histrionic personality disorder______________________ 8. If you know that the diagnosis for schizophreniform disorder is an episode of the disorder lasting at least 1 month but less than 6 months, and you must make the diagnosis without waiting for the recovery, you would mark the diagnosis___________________ 9. Describe two clients: Client 1 has 296.21, major depressive disorder, with melancholic features. Describe the symptoms, and tell the axis on which this diagnosis will go. Client 2 has 296.33, major depressive disorder, with catatonic features. Describe the symptoms, and tell the axis on which this diagnosis will go. 10. All personality disorders have as the first three digits________________________ 11. All anxiety disorders have as the first three digits_______________________        12. Depressive disorders have as the first three digits_____________________ 13. Schizophrenia has several subtypes. Describe a person whose diagnosis is 295.10. 14. How does this person differ from a person with a diagnosis of 295.30? 15. Assign a GAF to this person: A man is seeking counseling for depression following the death of his wife. He has been preoccupied and forgetful at work and finds himself crying alone at night. The GAF is____________________. 16. Assign a GAF to this person: A man tells you he has been anxious lately. He makes vague references to neighbors and a plan the neighbors have that worries him but does not elaborate. He also mentions the need to use only stores that stay open 24 hours a day in order not to be involved in the neighborhood plan. He believes his neighbors have had an influence in Washington beyond what their numbers would indicate but attributes it to their “plan.” He is working and reports he recently received a raise. He has few friends and enjoys his job as his main source of socializing. The GAF is_____________________________________________. 17. Assign a GAF to this person: A woman was brought from her apartment by ambulance to the hospital emergency room after neighbors who were concerned about her called for help. She is unwashed, smells bad, and is mute. Attempts to communicate with her are in vain. She looks past the worker and does not appear to hear anything addressed to her. She is very thin and has bad breath. The GAF is_____________________________________________________________. 18. Assign a GAF to this person: A man is about to take his state psychology boards. He has made nearly straight As in graduate school. He is happily married and the father of two daughters. He plays tennis on the weekends and is an expert cook. He and his wife hold season tickets to the symphony, and he is a deacon in his church. He is complaining of rapid heart beat and sweaty palms. The GAF is______________________________________________________________ __. * CHAPTER 18: The Mental Status Examination Introduction The mental status examination (MSE) is based on your observations of the client. It is not related to the facts of the client’s situation, but to the way the person acts, how the person talks, and how the person looks while in your presence. A mental status examination can be an abbreviated assessment done because someone appears to be in obvious need of hospitalization, or it can be an elongated process that takes place over several interviews. The MSE always has the same content, and you write your observations in roughly the same order each time. Although a formal MSE would be done by a physician or psychologist, you can do an informal MSE in which you systematically look at the person’s thinking process, feeling state, and behavior. You will want to understand the way the person functions emotionally and cognitively. Much of the examination is done by observing how people present themselves at the interview and the manner in which they spontaneously give information about themselves and their situations. The examination is not done separately but is an integral part of the assessment interview. Questions that relate to mental status are framed as part of the overall assessment and not as a separate pursuit. There will be times when you or a clinician might ask for psychological testing to confirm your evaluation of the person, but during your own MSE of the person, this is not done. Some of the terms you learn in this chapter are not necessarily words you will use in describing your clients and their appearance or behavior. This chapter is meant to familiarize you with the way some professional practitioners describe their clients and patients. If you know these terms, you will be able to follow the notes and discussions better. Observing the Client What to Observe Your mental status examination of the individual involves observations of the following: General appearance Behavior Thought process and content Affect Impulse control Insight Cognitive functioning Intelligence Reality testing Suicidal or homicidal ideation Judgment A good case manager is a good observer. You pick up many details about the person, all of which are relevant to understanding the client’s mental status. In a sense, you watch for the most obvious and the most subtle visual and verbal clues as to who your client is. Use what you see and hear to give you direction in regard to what questions to ask. How to Observe Throughout the interview note how the person communicates verbally and nonverbally and how the person behaves. In addition, you look at the content of the communication. You are looking at both what the person tells you and how the person tells it. As people talk about why they came to your agency for services and about the main problems they are confronting, you will make some judgments about how they functioned in the past and how well they are functioning currently. You will note how they tell their stories. Is the person cooperative and friendly? Does he appear to be relieved and eager to talk to you, or is he mute, guarded, and uncooperative? Is she weepy and hesitant as she speaks, or is she forthright and stern? Does the person twist a tissue in her hands or rock back and forth in her chair, or does she use appropriate gestures? Does he relax during the interview or remain guarded and uncooperative? At times you may need to assess the client’s mental status through the observations of others who are close to them. Your clients may not always be able to tell you much about past events or functioning, and you will need to turn to others for that information. If there is no reliable source, you may not be able to perform a complete MSE that has a clear degree of certainty. Documenting Your Observations To back up your observations, use both descriptions of the individual’s behavior during the interview and direct quotes made by the person in the interview. In this way, you carefully document your observations and your resulting conclusions. When you describe the person, be sure that your values and prejudices do not appear in your notes. Use adjectives that describe the individual, but are objective. All editorial comments and value judgments should be omitted. Figure 18.1 defines some general terms that are commonly used when documenting observations of clients. FIGURE 18.1: General terms used in documentation Mental Status Examination Outline Anthony LaBruzza (1994), in his book Using DSM-IV, provides a good outline for the mental status report that you will complete after the interview. He stated that his outline is not meant to be followed precisely, but it does give the major points and a framework to determine what is important. The outline shown in Figure 18.2 provides the major categories you must cover in a mental status report. FIGURE 18.2: Outline for the mental status examination This section discusses the outline for the mental status examination and report in detail, defining terms to use and identifying items on which to focus for each category you will cover in mental status examinations and reports. Pay particular attention to the terms that have Always in boldface in the descriptor, as these are important items to which you must always give attention. I. General Description A. Appearance 1. Dress and Grooming. You may find the person’s appearance to be average, meticulous, slightly unkempt, or disheveled. The person may have body odor, no makeup, makeup that is skillfully applied, or garish makeup.         • Meticulous: The appearance is too perfect, unusually so. • Skillfully applied: The person is made up to look like a model. • Garish: The person looks outlandish. • Self-neglect: Always indicate when you think this is present. It involves such things as having body odor or looking disheveled and unkempt. Dress would be dirty, stained, or rumpled. This can be a sign of a mental illness such as depression or schizophrenia. • Dress: You may find it casual, business, fashionable, unconventional, immaculate, neat, stained, dirty, rumpled. • Immaculate: This means the person is too neat. • Unconventional: Use this term to refer to clothes that are inappropriate to the setting. • Fashionable: This is fine unless the person looks like something out of Vogue in an office in a small town or average city. 2. Physical Characteristics. Note those features that are outstanding. Look at body build, important physical features, and disabilities. Note voice quality. Is it strong, weak, hoarse, halting? 3. Posture and Gait. Note gait and any need for devices such as a cane or crutches. Look at coordination and gestures. For instance, does a right-handed person make most of her gestures with her left hand? Something like this could be a clue to neurological difficulties. Does the person limp or appear to slump? Does the person seem unsteady or shuffle? B. Attitude and Interpersonal Style Look at the attitude the person has with you. You may find it cooperative, attentive, frank, playful, ingratiating, evasive, guarded, hostile, belligerent, contemptuous, seductive, demanding, sullen, passive, manipulative, complaining, suspicious, guarded, withdrawn, or obsequious.     • Hostility: Always note when the person is hostile. • Uncooperative: Always note when the person does not or cannot cooperate. • Inappropriate boundaries: Always note if the client is too friendly, touches you, or attempts to draw you out personally. • Seductive: Too close a relationship too soon; might call you by your first name or touch you           • Playful: Jokes, uses puns, self-deprecating humor • Ingratiating: Goes along with whatever you think; wants to please • Evasive: Talks, but gives nothing • Guarded: Is more reserved than evasive; contributes the bare minimum, often with suspicion • Sullen: Angry and somewhat uncommunicative • Passive: Barely cooperates, needs to be led; generally without overt hostility • Manipulative: Asks for special favors, uses guilt, solicits pity, threatens • Contemptuous: Superior, sneering, cynical • Demanding: Sense of entitlement • Withdrawn: Volunteers little, appears sad Watch your own emotional reactions to the people. Your reactions will give you important clues. Also pay attention to the person’s facial expression. You may find it pleasant, happy, sad, perplexed, angry, tense, mobile, bland, or flat.    • Bland: Intense material, but looks casual • Flat: No facial expression • Mobile: Rapid changes in facial expression and mood C. Behavior and Psychomotor Activity Look at the quality and quantity of the person’s motor activity. You may find the individual is seated quietly, hyperactive, agitated, combative, clumsy, limp, rigid, or has retarded motor function. You may find the person has mannerisms, tics, twitches, or stereotypes.                • Seated quietly: Uses normal gestures, but does not move around much • Hyperactive: Is busy with hands and possibly feet • Agitated: Cannot sit still (could be secondary to antipsychotic medication) • Combative: Looks ready to hit, threatening • Awkward: Unable to manage activity like sitting in the chair or writing; drops things (may be part of the illness or reaction to medication) • Rigid: Sits like a tin soldier • Mannerisms: These are unconscious repetitive actions • Posturing: The person assumes certain postures and holds them inappropriately • Tics and twitches: Less voluntary body movements • Stereotypes: Four mannerisms strung together • Motor hyperactivity: Always report this when you see a lot of hyperactivity, restlessness, and agitation. It may indicate a manic state, reaction to medication, or anxiety. • Motor retardation: Always report this when you see the patient moves slowly, in a constricted manner and with minimal motor responses. Speech and thought are slowed, often depressed. Depression can give the appearance of cognitive impairment. • Mannerisms and posturing:: Always indicate mannerisms you see and any posturing. • Tension: Always note tension, particularly if the person seems tense and the interview does nothing to relax the person. • Severe akathisia: Always note severe restlessness. Sometimes it may be part of an illness, and sometimes it may be due to medication. If the physician believes it is due to an illness and increases the medication, the person may grow much worse. Therefore, try to establish when it started, how long it has gone on, and whether it has grown worse recently. Always note the following when present: pacing, fidgeting, nail biting, trembling or tremulousness (a common side effect of lithium carbonate and tricyclic antidepressants), and abnormal movements such as rocking, bouncing, or grimacing (particularly strange facial movements).  • Tardive dyskinesia: Always note this condition if you see it or suspect this is what you are seeing. It occurs among psychiatric patients who have been on antipsychotic medications over a long period of time. The term literally means “late appearing abnormal movements” and seems to involve the muscles of the face, mouth, and tongue. Sometimes the trunk and limbs are also affected. These movements can be slow and irregular (athetosis) or quick and jerky (choreic). All the movements are brief, involuntary, and purposeless. A person may twist the tongue and lips, make odd faces, bounce or tap the feet, or actually writhe and squirm in the seat.  • Catatonic behavior: Always note this behavior. It is generally a sign of severe depression or schizophrenia, catatonic type. It generally appears as a rigidity of posture wherein attempts to reposition the person are rigidly resisted. The person may voluntarily pose in bizarre and inappropriate ways. In waxy flexibility, the limbs of the person will remain in the position in which they are placed. There is also a catatonic excitement wherein the patient engages in almost continual, purposeless activity that is nearly impossible to interrupt. Sometimes the patient engages in echolalia (repetition of everything that is heard) or mimics and imitates others during this episode. D. Speech and Language Speech is important because it is the primary means of communicating. Important to note are such things as rate, clarity, pitch, volume, quality, quantity, impediments, use of words, the ability to get to the point, and articulation. You may find speech to be a normal rate, slow, hesitant, rapid, pressured, monotonous, emotional, loud, whispered, mumbled, precise, slurred, accented, stuttering, stilted, rambling.     • Pressured: Often rapid but constantly talking; cannot be interrupted (often a sign of a manic episode). Person appears to have racing thoughts. • Monotonous: No variation in tone • Emotional: Very expressive • Accented: Note a native accent and also if the patient seems to accent certain words or syllables inappropriately   • Impoverished: May say very little either because of depression or because he is being interviewed in a language other than his native one; may also indicate a lack of facility with language • Neologisms: Always note when the person makes up entirely new words with idiosyncratic meanings. (This can occur due to aphasia or brain injury due to accident or stroke.) You should be able to identify any neurological language disturbances. Strokes, head trauma, and brain tumors can cause patients to lose their facility with language. Try to determine if the client has always had a language difficulty. Patients with schizophrenia may use loose associations as they talk. Those in a manic state may be prone to flight of ideas.  • Aphasia: Loss of ability to understand and produce language; damage usually to left hemisphere of the brain (left-handed people often have this in the right hemisphere) The type and extent of aphasia depends on location and extent of brain injury.       • Global aphasia: Can neither speak nor understand, read, write, repeat words, or name objects • Broca’s aphasia: Can understand written and spoken language, but has trouble expressing own thoughts verbally • Wernicke’s aphasia: Inability to understand language and uses fluent, bizarre, nonsensical speech (The person may also act strangely and appear euphoric, paranoid, or agitated. It is easy to think this is a psychotic thought disorder, but in schizophrenia the person is generally able to write and speak in her language, repeat words, and name objects.) • Dysarthria: Difficulty articulating due to problems with the mechanisms that produce speech. This sometimes produces distorted or unintelligible speech. The person usually can read and write normally. Ask the patient to repeat “No ifs, ands, or buts” to hear dysarthria better. • Perseveration: Defined as the persistence “in repeating a verbal or motor response to a prior stimulus even when confronted with a new stimulus” (LaBruzza, 1994, p. 113). The client may give the same answer to different questions, stay on the same subject, or repeatedly return to the same subject. • Stereotypy: “Constant repetition of speech or actions” (LaBruzza, 1994, p. 113). The patient may pull a shoe on and off, twist and untwist the hair, or repeat the same phrase or word over and over. These behaviors appear to be ritualistic and are common in childhood autism. Give verbatim examples of what the individual has said to support your assessment of speech. II. Emotions A. Mood This is the way a person is feeling at any given time. You may find it euthymic, depressed, sad, hopeless, empty, guilty, irritable, angry, enraged, terrified, expansive, euphoric, elated, sullen, dejected, or anxious. Ask yourself, what seems to be the dominant mood of the person?     • Euthymic: Normal mood • Expansive: Feels very good and is getting better • Euphoric: Out-of-sight happy • Anxious: Worried and distressed B. Affect Affect refers to the underlying flow of moods. This would be the outward expression of the emotional state. You can see it in the way patients use and position their bodies and in their tone and manner of speaking. You may find it broad, appropriate, constricted, blunted, flat, labile, or anhedonic.            • Broad: Normal range of moods • Appropriate: Appropriate to the situation • Constricted: Restricted range of emotional expression • Blunted: Even more restricted • Flat: No change of mood, unemotional • Labile: Rapid change in mood (crying, then laughing) • Anhedonic: Incapable of any pleasurable response, depressed • Blunted affect: Always note a blunted affect where you find no change in mood throughout the interview and no change in facial expression. It generally indicates depression. • Emotional withdrawal: Always note if the person seems emotionally withdrawn to you. The person would be inexpressive and probably have a blunt affect. • Excitement: Always note if the person seems inappropriately excited to you. It means the person is overly enthused or terrified about the given situation. • Full range of affect: This refers to an appropriate affective response to the entire interview. Always note inappropriate affect (such as giggling when there is nothing funny happening), as this can be a sign of schizophrenia. C. Neurovegetative Signs of Depression In major depression, body functioning often becomes irregular. Always inquire about sleep and appetite, and report a loss or gain of more than 5% of body weight. Listen for symptoms such as changes in energy levels, interest, enjoyment of everyday activities, or sexual functioning; constipation; and weight changes (LaBruzza, 1994, p. 115).     • Initial insomnia: Trouble falling asleep • Middle insomnia: Middle-of-the-night wakening • Terminal insomnia: Early morning wakening. Depressed individuals will often wake several hours earlier than usual and feel most depressed in the morning. • Hypersomnia: Some depressed individuals, especially those with bipolar disorders, tend to sleep a great deal. III. Cognitive Functioning A number of medical and neurological problems, as well as substance abuse, affect one’s cognitive functioning. The concern is that many patients who have a disease of the brain may appear with what seems to be emotional and behavioral changes. In taking the history from the person, note previous levels of functioning and any previous emotional problems. If these are appearing in middle or late life, it is quite possible the person has a neurological problem. A. Orientation and Level of Consciousness Nearly all of the people who come to you will be alert and aware of their environment and their body. Occasionally, however, you may see individuals who are inattentive, drowsy, or who have a clouded consciousness. If these symptoms are present, use the proper term to indicate the person’s level of awareness and briefly describe how the person exhibits this level. Medication can contribute to these stages as well.         • Lethargy: The person has trouble remaining alert and appears to want to drift off to sleep, but can be aroused. The person has trouble concentrating on the interview and seems unable to maintain a coherent train of thought. • Obtundation: The person is difficult to arouse and needs constant stimulation to stay awake. The person may seem confused and unable to participate in the interview. • Stupor: The person is semicomatose, and it takes vigorous stimulation to arouse her; she cannot arouse herself. There is no normal interaction during the interview as a result. • Coma: This is the most severe consciousness problem wherein the person cannot be aroused and does not respond to any stimulation. • Orientedx3: Means the person is oriented as to who he is, where he is, and when it is. Even when a person is having difficulty with consciousness, he may be oriented. If orientation problems occur as a result of lack of consciousness, it typically happens that the sense of time is affected first, followed by the sense of place, and finally by the sense of person. To be fully oriented requires an intact memory; thus, disorientation means there are memory deficits. • Ask for current date: Reasonably accurate dates are acceptable. • Ask where the person is: You can also ask for a home address, the present city or state, or for directions from here to the person’s home or another familiar place. Sometimes people confused about place will behave as if they are at home or in another very familiar setting while in your office. • Ask who the person is: Ask for personal identifying information (age, birth date, name). Ask if the person recognizes or knows other people who might be present. Does she know her relationships to these other people? B. Attention and Concentration Always note inability to pay attention and if the person appears easily distracted.  • Attention: Can the person remain focused on the interview? If you feel a need to test this in the person, you can use digit repetition. Say five numbers, and then ask the person to recite them back to you. Concentration is needed to learn new tasks and for academic success.  • Concentration: The person can concentrate on one thing for an extended period of time. You can test the person’s concentration by asking the person to perform a complex mental task. (Serial 7s is one way of testing; in this method, you ask the person to add in increments of 7 or subtract from 100 by 7s. Be sure your instructions are on the client’s level of education, and do not use this exercise if severe academic problems are present. Be careful not to humiliate people!) C. Memory Memory involves the ability to learn new material, to retain and store information, to acknowledge and register any sensory input, and to retrieve or recall stored material. When there are problems, they usually have to do with three areas:    1. Registration 2. Retention 3. Retrieval Destruction of significant parts of the brain causes problems with memory. All memory deficits should be noted. The physician or clinician will want to do further tests. If you suspect something, ask others who know the individual about their perceptions of the patient’s memory functioning.        • Short-term memory: Refers to immediate recall limited to about seven items and generally lasts for about one minute. Some problems may be due to inattention, so evaluate attention before memory. • Long-term memory: Rehearsal allows material in short-term memory to convert to longterm memory. Anxiety about the interview or the person’s situation or even depression can interfere with this. • Amnesia: Inability to remember • Anterograde amnesia: Cannot learn new material • Retrograde amnesia: Cannot recall recent past events • Head injuries: Most common deficits are inability to recall names, recent events, and spoken messages, and forgetfulness or forgetting to do something important. The person may have trouble telling you what she is experiencing with her memory. Memory loss may be permanent if there was severe or repeated head injury. • Transient global amnesia: Lasts minutes to several hours and is usually seen in older people. The person experiences sudden confusion, loss of memory, and disorientation and cannot recall what happened during the time period in question. Retrograde amnesia will be present. Person will be distraught, asking for reassurance as to where he is and what he is doing. This is caused by an insufficient amount of blood to the brain. Memory Testing. First, ask the person if she has been having any problems with memory. A family member may be able to shed some light on memory issues if any exist. During the interview, note memory lapses and difficulty recalling what the interviewer has just said. If you notice memory loss, note it so that further testing can be done. All the memory tests described in the following would be done only if you had considerable questions about a person’s memory:    • To test immediate recall: Use a random list of digits, saying them in a normal tone of voice, about one digit per second. Ask the person to repeat them. Start with two digits and keep adding until the person fails. Give the person two times to try this. If the person fails at five digits or less, there is reason for concern about sustained effort, attention span, and immediate memory. Anxiety and depression are the most common reasons people fail this test (LaBruzza, 1994, p. 125). Strokes and other brain injuries can also affect recall. • To test recent memory: Ask the person to recall events that have happened in the last few hours or days before she came to see you. You might ask what she had for lunch or where she parked the car. It is helpful if you can validate the answers with someone close to the client who knows. Another way to test is to ask about something that may have happened or been discussed earlier in the interview. You may get several different versions. In cases of assault or trauma and where the victim feels comfortable with you, the different versions may indicate the she is able to recall more of the details each time she goes over what happened. With some people, you might give three or four unrelated words and ask them to recall these words after a short interval. Begin by saying the words in a normal tone of voice and ask them to repeat the words back to you. Note how many times a client must do this before learning the words. About 3 to 5 minutes later, ask clients to recall the words. With a normal memory, a person should be able to recall them (LaBruzza, 1994, p. 126). • To test remote memory: You can ask people about personal events in their lives and commonly known public events that happened in years past, such as major news stories. Use material that should be known by a person who is reasonably well informed. If the person does not appear to be able to do this test because of a lack of education, a difference in culture, or mental retardation, decide carefully what you will ask the person (LaBruzza, 1994, p. 128). Additional information on memory and aging and how to assess memory can be found in Chapter 8of Fundamentals for Practice with High Risk Populations (Summers, 2002). D. Ability to Abstract and Generalize Proverbs. Cultural background and intelligence can influence how well a person thinks abstractly or how well the person can deal with similarities. Proverbs are generally used to see how well a person thinks abstractly. You need a general fund of information to be able to use proverbs in this way. Tell the person you are going to say a proverb and you would like the person to tell you in his own words what he thinks the proverb means. Then judge how concrete or abstract the reply is. Repeat the person’s response verbatim in your report. Individuals who are psychotic or on the verge of psychosis will often indicate this in their response to a proverb. Use proverbs that are free of gender and racial bias. The following are some proverbs you can use (LaBruzza, 1994, p. 129):    • A stitch in time saves nine. • A rolling stone gathers no moss. • Don’t judge a book by its cover.  • Two wrongs don’t make a right. “A rolling stone gathers no moss” could be explained by a person who thinks concretely as, “If you roll a stone down the hill, it can’t collect moss.” A more abstract response might be, “If you keep moving, life remains interesting and challenging.” Similarities and Differences. Ask the person to tell you how two objects or two events are different or alike. This will require the individual to think somewhat abstractly about categories and relationships. Name two items and ask the person how these differ and how they are similar. The following are some combinations you might use (LaBruzza, 1994, p. 129):     • Apples and oranges • Trees and flowers • Houses and cars • Dogs and cats E. Information and Intelligence To get an idea of the person’s overall intelligence, ask questions that tap the person’s fund of general information. It should be information known by the general public. Again, you must be sensitive to the person’s cultural background, level of education, and intelligence. The following are examples of some questions you might ask (LaBruzza, 1994, p. 130):      • Who were the last four presidents? • Who is the governor of the state? • How many weeks are there in a year? • What is the capital of the state (or the country, or France)? • Who was Mark Twain? IV. Thought and Perception When a person’s perceptions are disordered, it offers important clues to what the diagnosis might be. Here you want to know how people actually perceive themselves, the world around them, and others in their world. What does the person think, and what thoughts and concepts are most on his mind? Perception is the way in which we form an awareness of our environment. People who have difficulties with perceptions often perceive their world inaccurately (LaBruzza, 1994, p. 131). A. Disordered Perceptions Following are some terms that describe various disordered perceptions:     • Illusions: The person either misperceives or misinterprets a sensory stimulus. A tree branch brushing the side of the house in the wind sounds like people entering the house, or a dishwasher running sounds like people talking in another room. • Hallucinations: In the absence of external stimuli, the person perceives something. The most common hallucination is hearing voices. Voices generally increase when the person is around white noise. White noise is even background noise, such as the dishwasher running, a roomful of people chattering, or rain drumming on the roof. If you can, find out who is talking, what they are saying, and how the person feels about it. Is there a command for the person to do something? If so, include the command in your report. Some commands are dangerous to the person or to others. Always note hallucinatory behavior. • Depersonalization: The person feels estranged or detached from herself • Derealization: The person feels detached from what is going on around her. Be sure to note this. A person who dissociates cannot always be sure that what is happening is real (LaBruzza, 1994, p. 132). B. Thought Content The following terms are used to describe thought content:   • Distortions: A person distorts a part of reality. A woman with anorexia believes she is fat when she is thin. A person who is well believes his cough indicates tuberculosis. A person whose neighbor does not think to wave assumes the neighbor is angry. • Delusions: An inappropriate idea from which a person cannot be dissuaded using the normal means of argument or evidence. Sometimes it is culturally inappropriate as well. Evidence to the contrary has no effect. For example, a client might insist that she has a case in court that will eventually yield her a great sum of money. No amount of persuasion or documentation can dissuade her from that belief and convince her that this isn’t so. Always report the content of a delusion. Note if the delusion is incongruent with the client’s mood. Delusions indicate psychosis. Always note if delusions are present. People with paranoid delusions believe they are being singled out for harassment or are being controlled by forces outside of themselves. They may have an entire system of interconnected ideas developed that support their delusions. Common to schizophrenia are:          • Thought withdrawal: Belief that one’s thoughts are being taken out of one’s mind by an outside force • Thought insertion: Belief that thoughts are being placed into one’s mind by an outside force • Thought broadcast: Belief that thoughts are being taken and broadcast so that others know what one is thinking • Suspiciousness: Always describe this and the object of the suspicion. • Grandiose delusions: The false belief that one is extremely important or a false belief that one is imbued with special powers. Always describe ideas of grandeur and any grandiose behavior. • Somatic delusions: False beliefs about one’s physical health • Delusional guilt: Falsely believing that one is the reason or cause for terrible things that have happened or will happen • Nihilistic delusions: A false belief in the meaninglessness of life and all events and circumstances, in nothingness; hopelessness; belief in the end of the world • Ideas of inference: Refers to the ideas the person holds about what others do to affect him     • Ideas of reference: Refers to beliefs that people are talking and thinking about one. Messages on TV and radio are meant specifically for this person. • Magical thinking: Means belief in astrology or a superstition, or the person thinks he has magical powers in his words, thoughts, or actions. This thinking is found in children who have not developed reality testing. It is part of human development and is not pathological until it becomes extreme, as in obsessive-compulsive disorder or a delusion. Always check religious beliefs or cultural background to see how this thinking fits with what is going on in the person’s life and these aspects of the person’s life (LaBruzza, 1994). • Thought content: Always specify unusual or important thought content such as: (a) what the person is suspicious about, (b) what the person feels guilty about, and (c) what the person is preoccupied about. • Bizarre behavior: Always note any that you witness or any that is reported to you by reliable others. C. Thought Processes You may find the form of the person’s thoughts to be spontaneous, logical, goal directed, coherent, impoverished, blocking, nonspontaneous, incoherent, perseverative, circumstantial, tangential, or illogical. You may find it to have loose associations or flight of ideas. You may find that it contains neologisms or is distractible.               • Flow of ideas: Refers to the quality of the associations the person makes between ideas or between points in the person’s discussion. Note the stream of the client’s thoughts, the rate of thinking, the coherence, the continuity, and whether the thought process is goal directed (LaBruzza, 1994, p. 134). • Spontaneous: Means you do not have to keep asking questions. The person readily volunteers information. • Goal directed: The person answers the main questions about why she came and what she needs, and does not stray to other related topics. • Impoverished: The person uses words but is very skimpy with them. There are too few ideas, and thinking is slow. Often attributable to depression or schizophrenia. • Racing thoughts: The person thinks rapidly. Speech appears pressured. Often attributable to manic or hypomanic state. • Blocking: The person stops, pauses, and starts somewhere else. There is an interruption to the normal flow of speech. The person may appear to forget where she was in the conversation when she resumes talking. • Circumstantial: The person appears to throw in too many irrelevant details. The person has too many ideas associated with one another and too many digressions. Often thought to be a defense against dealing with troubling issues or feelings (LaBruzza, 1994). • Perseverative: The person goes over and over the same point or idea. • Flight of ideas: the person goes from one thought to another in logical sequence but is headed far from the original topic. • Loose associations: The person’s points do not hang together logically. Ideas shift in an apparently unrelated way. Characteristic of schizophrenia. • Illogical: What the person is saying does not make sense. • Incoherent: There is no meaning; the speech is disorganized; the person may be schizophrenic. • Neologism: The person makes up new words. • Distractible: Person cannot stay focused; may indicate mania.     • Clang association: “The sound of a word, rather than its meaning, triggers a new train of thought” (LaBruzza, 1994, p. 136). • Tangentiality: Means “veering off” on somewhat related, but irrelevant, topics. May show a difficulty with goal-directed thinking. Common in mania and hypo-mania (LaBruzza, 1994, p. 136). • (Overvalued ideas: The idea might be possible, but it is used or seen by the person to explain more than it could possibly explain. • Conceptual disorganization: Always note conceptual disorganization. This refers to an inability to conceptualize the problem clearly and may involve a number of the terms previously noted, such as loose associations, flight of ideas, tangential thinking, or incoherent content. A note about the word confused: Students often say a client is confused when they are describing a person who is having trouble deciding what to do or a person who is feeling very ambivalent about a particular decision. In the mental status examination, however, the word confused means that the client was not oriented to time and place and person. In other words, confused clients do not know where they are, cannot understand what is being said to them, or do not recognize familiar people. When a client is ambivalent, use that word; and when a client cannot make up her mind, say just that. Reserve the word confused for describing true cognitive confusion. D. Preoccupations These are thoughts and issues that appear to be the primary focus of the patient’s thinking. There is an “obsessive quality” to the preoccupation (LaBruzza, 1994, p. 136).      • Somatic preoccupation: Focus on bodily functions, physical health. There is a hypochondriachal quality to the preoccupation. List and describe somatic concerns. Do not assume these are not real problems without proper medical documentation. • Obsessions: Persistent thoughts that are intrusive and unwanted and that appear to haunt the person (LaBruzza, 1994, p. 136). The person may hold an idea that is not true in that intensity. • Compulsions: Actions that are often the “counterpart of the obsession.” These are “persistent, intrusive and unwanted urges” to take some action. If one does not complete the action, there is intense anxiety. These actions can be repetitive and ritualistic, such as checking the stove, counting steps, and straightening picture frames (LaBruzza, 1994, p. 136). • Phobias: These are “irrational, intense, persistent fears” of such items as dogs, heights, elevators, insects, leaving home, closed spaces, and flying (LaBruzza, 1994, p. 136). The person will go to great lengths to avoid the situation or object of the phobia. • When writing out notes we need to be clear about the difference between perseveration and obsession. Note that perseveration is the term we use when a person focuses on one topic and comes back to it over and over, unable to change to another topic or stay on another topic relevant to the interview. Sometimes students describe this as an obsession. Obsession, as noted above, are thoughts that intrude on the person beyond their control and are experienced as intrusive and unwanted. V. Suicidality, Homocidality, and Impulse Control Suicidality and Homocidality. You have a clinical and a legal responsibility to assess whether the person is a danger to herself or to others. A person who is dangerously impulsive or holds thoughts of suicide or homicide needs special observation. When conducting an interview, look for these thoughts. These are called suicidal ideation or homicidal ideation. Discover if there are plans to carry out these ideas or if the person seems to have an undeniable intention. Thoughts present some danger, plans make the situation more dangerous, and the clear intention to go forward with the plans creates an extremely dangerous situation. The mildest form would be thoughts, followed by actually making plans. If the individual tells you she has purchased a gun and learned the intended victim’s work schedule, you may assume there is a plan. If the individual tells you he has saved 3 months’ worth of medication for an overdose, this would appear to be a plan. If the individual has a plan and expresses to you her obvious intention to carry out this plan, the situation becomes more serious (LaBruzza, 1994). Always include the plan, the means, and the timetable in your report. If the person is homicidal, include toward whom the thoughts are directed as well. Impulse Control. When you assess impulse control, you want to know how the person deals with aggressive urges, sexual urges, and strong desires to carry forward any plan not particularly well considered. Look at ways the client has handled stressful situations in the past. Is there a history of acting on impulse without much thought as to the consequences? Does the person seem unable to tolerate stress? How did this person handle stress in the past? Is there a history of uncontrolled aggressive behavior, either sexual behavior or hostile behavior? Can this client tolerate frustration? The three behaviors to look for in childhood are setting fires, cruelty to animals, and bedwetting. When these behaviors all occur in childhood, they appear to be significantly associated with cruel adult behavior. In adulthood, you might find behaviors such as punching holes in the wall, smashing furniture, slitting one’s own wrists, drinking excessively, or turning to drugs or a drug overdose. VI. Insight and Judgment Insight. The person understands that she is “suffering from an illness” or has an emotional or personal problem. Make a note if the person completely denies any problems or denies having any part in a problem that obviously affects the client’s relationships with significant others. For instance, some people have extremely acrimonious relationships with their relatives but seem unaware that their hostile responses actually elicit more hostility from these relatives. As another example, a person may come in seeking help for a substance abuse problem and genuinely believe that there is no problem and that his behavior is appropriate. In addition, he may indicate that those who are concerned are actually inappropriately concerned. People hold insight in “varying degrees” and may show only partial understanding of their difficulties (LaBruzza, 1994, p. 137). Judgment. The person can critically evaluate her situation and make good decisions about a course of action. Look for risky behavior in the past that could have been potentially harmful (practicing unsafe sex, binge-drinking and reckless driving, and so forth). “Assess whether clients are able to understand the potential consequences in their behavior” and can plan preventive measures. You might ask what the individual would do if he spotted a fire in a movie theater or what he would do if he found a stamped, sealed, and addressed envelope (LaBruzza, 1994, p. 138). VII. Reliability (Accuracy of the Client’s Report) You need to state briefly your impression of person’s reliability and accuracy in giving you the details of their situations. If a person is psychotic, the material presented is likely to be extremely unreliable. A person who is suffering from dementia or delirium may be having considerable difficulty remembering what has happened or what is happening now. Some people deliberately tell falsehoods to qualify for disability or to give false impressions of themselves to the worker (LaBruzza, 1994, p. 139). VIII. The Environment Sometimes you will be asked to go to someone’s home to do an assessment or to do an interview. People’s surroundings often hold clues to the way they are currently structuring their lives.  • Inappropriate surroundings: Means the person has arranged furnishings inappropriately. It may be that furniture blocks doors and windows or that the windows are covered oddly, perhaps with tin foil or some other material. There might be strange wires leading nowhere, odd decorations, or strings of odd things hung across a room. You might find household objects being used inappropriately. Sometimes a person believes the people on TV can see into his home or the people on the radio can hear what he says. In such cases, you may find these devices covered or blocked in some way. Be very careful in making these judgments. At one time a worker decided that windows partially covered with foil-wrapped insulation were a sign of something amiss in the person he was seeing. It turned out the man was doing that to save energy. In another home, a worker decided the blanket over the TV indicated her woman was paranoid. In fact, it turned out the TV was very new and she was very proud of it; she had put a blanket over it the day before when her young nieces came to visit so the TV would not get scratched. It helps to inquire matter-of-factly about what you see.  • Waste and Trash: Look at the way the person keeps his home. Are there unusual collections of junk or trash? Are there piles and piles of paper and magazines everywhere, or collections of string, bags, and other objects? Sometimes the home is very cluttered or dirty, with unwashed bed linens and with unwashed dishes stacked all over the kitchen. This tells you something about the person’s capacity to attend to the routine details of living, or it may indicate a debilitating mental illness, such as hoarding. You might find urine or feces on the floor or walls. You might find the pets in the home neglected, their food bowls full of rotten food. Sometimes the house might be overrun with strays the person has taken in, but is unable to adequately care for. Note: It is not unusual for a middle-class worker to assume that the manifestations of poverty are the signs of a person who is mentally ill. You must be very careful not to ascribe mental problems to someone who is actually too poor to live by middle-class standards. Always report environmental cues that seem to support the rest of your mental status examination. Clinical Definitions. There are two words we tend to use in everyday conversation that mean one thing when we do but mean something entirely different when we use these words clinically.   • Confused: Students often use the word “confused” to mean that a person is not clear what decision to make or what would work in the person’s best interest. They describe their client as being confused when it would be better to say the person was uncertain, ambivalent, or unsure. Confused is a term we use clinically to describe someone who is not oriented as to person, place and time. • Obsessed: Students often use “obsessed” to indicate that the person is focused on a topic to the exclusion of most other things. If the person does keep returning to one topic and it is hard to steer the discussion to other topics or issues we would say the person is perseverating, not obsessed. Summary Every contact you have with clients must be documented, and every documentation of a client contact must contain your impressions of how the person seemed at the time of that contact. In social histories and evaluations, these impressions are lengthy and contain material observed by you during your contact with the client. The mental status examination is a snapshot of where the individual is at a particular time. You are not trying to document how the client will always seem. Tomorrow the person may be different. Your notes can be used to follow peoples’ progress or regression. Using the material in this chapter will help you to write full, accurate impressions of clients that will help clinicians understand what has been going on with them between sessions and determine the best course to follow with each individual. Exercises: Using the MSE Vocabulary Instructions: See if you can fill in the blanks for each of these questions. This exercise is simply to acquaint you with words you might encounter in the course of your work.                  1. The chart on Mr. Kling reads that he has conceptual disorganization. What was the psychologist referring to?___________________________________________________________. 2. In a staff meeting, the psychologist and the case manager discuss the fact that Mrs. Purdy seems to have racing thoughts. They are talking about what?___________________________________________________________ ___________. 3. The neurologist’s report comes for Mr. Engler. The diagnosis is Broca’s aphasia. What does that mean?___________________________________________________________ _. 4. When the psychiatrist saw Mrs. Nguyen, he said her mood was euthymic. He meant____________________________________________________. 5. Mr. Kissel’s speech is described as impoverished. That means his speech is________________________________________________________. 6. Another term for severe restlessness is_________________________________________. 7. Another way to describe a broad range of moods is _________________________. 8. When Dr. McCoy said Mr. Perkins used neologisms, Dr. McCoy was referring to______________________________________________________________ ____. 9. Mrs. Dell has been on antipsychotic mediation for some time, and now she shows signs of tardive dyskenesia. That means she_________________________. 10. When Mrs. Jones was described by the psychologist as seductive, he meant that Mrs. Jones was_________________________________________________. 11. The chart says that during the interview with Mr. Landon at the prison, where he was being held after being arrested for drug possession, Mr. Landon’s speech was guarded. That means his speech was ____________________________________. 12. When the ambulance crew called in about 93-year-old Mr. Keller, they said they were bringing him into the hospital, but he was oriented x3. They meant___________________________________________________________ ________. 13. Mrs. Harris complained of trouble falling asleep. In the chart, this was written as______________________________________________________________ __. 14. Discussing Mr. Rodriquez’s delusions with you, the psychiatrist remarks that Mr. Rodriquez has thought withdrawal. The psychiatrist means __________________. 15. The psychologist is describing his interview with Mrs. Carter. “She tends to per-severate,” he noted. He means that Mrs. Carter____________________________. 16. Mr. Trong has been depressed ever since he came to this country from Vietnam. Lately the depression has worsened. Today his therapist calls from the International Center asking if you can arrange hospitalization for Mr. Trong because he is catatonic. Mr. Trong is __________________________________________________. 17. Miss Aller is homeless and mentally ill. The mission calls to say that Miss Aller believes that her thoughts are being taken out of her head and broadcast so that others know what she          is thinking. Another way to write this is______________________________________________________________. 18. When Mr. Cruz talks about the accident, he tells you he feels detached from himself. Another word for that feeling is _____________________________________. 19. The chart tells you that after the accident Mr. Cruz had retrograde amnesia for a while. That means he ____________________________________________________. 20. The record that comes from the hospital on Ms. James states that she suffered from terminal insomnia during her stay there. That means that she_____________________________________________________________ __________. 21. After the stroke, Mr. Torres was described as having Wernicke’s aphasia. That means ____________________________________________________________. 22. During the interview, Miss Bell constantly pulled her gloves on and off, on and off, in a ritualistic fashion. One word for this kind of behavior is __________________. 23. Miss Bell was asked to interpret several proverbs to test her _______________________. 24. Mr. Lincoln was seen with his wife for marital difficulties the couple was having. He said that he personally had no problems at home and that if his wife said there were problems at home, these were her problems and she was bringing them on herself. What might we say about Mr. Lincoln’s insight? _________________________. 25. The family doctor of Mrs. Fong calls to arrange for an appointment. She believes Mrs. Fong is depressed and “is showing strong neurovegetative signs of depression.” What does the family doctor mean by that? _________________________. 26. When you interview Mr. Marks, you notice that the sound of a word seems to trigger a new line of thought for him. You call this __________________________. CHAPTER 21: Developing a Service Plan at the Case Management Unit Introduction Using the information you received from other agencies (see Chapter 19) and the information you took to develop the social history at the time of your interview with the client, the next step is to develop a service plan. A service plan contains broad general goals for the case management unit to follow with regard to a particular person. Case managers then refer clients to the agency where the actual service will be provided. Generally, the case management unit develops an outline for the provider agency to follow. The provider agency takes these broad, general goals and turns them into very specific and measurable goals with objectives for the person. These will be in effect and constitute the guidelines while that person is receiving service from the agency. This chapter describes the step-by-step process for developing a service plan. Remember that you will not be giving these services. Instead, you will be determining what the person needs, based on your evaluation or intake assessment, and based on your discussions with the client about services the client feels are important. The services and agencies you choose for people will be those that will help them attain goals that you and they see as important for them. There are several types of goals for clients. You might develop treatment goals to treat conditions such as mental illness, emotional problems, or drug or alcohol abuse. When an individual has treatment goals, the case manager generally refers the person to mental health programs, drug or alcohol rehabilitation, or physical health interventions. Not all of your clients will need treatment goals. Some people will have problems involving poverty, home arrangements, and material needs. For these people you will develop general living goals that will improve their situation, perhaps by providing appropriate in-home care, better transportation, or a more appropriate living arrangement. Involving the Client and the Family Only 10 or 20 years ago, when people requested help from an agency, they were told by that agency what help they would receive. Often the agency prioritized the person’s problems for them. People had little or no input into these decisions, and those who objected or had other ideas were often viewed as difficult and uncooperative. Agencies developed services in part based on the skills and expertise of the employees at those agencies. They might not offer services that were badly needed in their community, and they might offer services that did not meet the needs of any but a select group of people. Clients were expected to fit into the services offered and were often labeled untreatable if they did not. Today, all that has changed. Several factors have fostered these changes. When the state mental hospitals began to shrink their patient populations, those residents were brought back to their communities and back in contact with their families and other support systems. It soon became obvious that many families were unable to cope with the mental illness of their family member without support, and without that support the former patients were often abandoned by their families. To a lesser extent this abandonment happened to senior citizens when caretakers were struggling to care for an older person with complex problems. In the field of substance abuse, clients’ families often gave up and cut all ties after trying to support their family member to abstinence. Agencies gradually began to recognize the value of including families in planning and implementing treatment. In recent years, children have been receiving services in evergreater numbers. This has involved families in planning and implementing the treatment or service plans for their children. Today agencies are expected to engage both the client and the client’s family (with permission from the client) when this inclusion is appropriate. Individuals and their families assist in developing service or treatment plans. Families receive agency support to remain involved with their family member whenever possible and receive the support they need to remain an intact family. Agencies that work to enable the identified client to live successfully in her community have found that individuals do much better if their families have not cut them off. Children can take better advantage of services if the entire family is considered in the planning. For these reasons, human service professionals are careful to listen to what the individual wants to receive from services and to what the family may need to support the client. An inappropriate use of family involvement would occur if a worker ignored the wishes of an adult seeking services for emotional or situational problems who did not desire family involvement, or if a worker involved family members after a person asked specifically that his family not be involved in any way. In these situations, you follow the wishes of the person and strictly observe confidentiality guidelines. Using the Assessment You will receive an evaluation or assessment for each person in your caseload. This will be either the social history or the assessment form. In our hypothetical case management unit, you will have done the assessment or social history yourself, which is often the case. The evaluation tells you what the person’s major problems are and what areas of the person’s life need attention. Generally these problems are the reason the person is seeking help or is being referred to a therapeutic or supportive program. The assessment alerts you to the expectations and desires of the client as well. All of this will help you to determine what goals you think you should work on with your client. Figure 21.1 lists some common goals to consider for people. You may think of others. FIGURE 21.1: Goals to consider for clients The goals listed in Figure 21.1 are very broad, long-term, and general. Choose those goals that fit the person’s most outstanding needs and give them more specificity—that is, a treatment or goal plan shown in Figure 21.2. For example, a person might need “to make positive changes regarding stressors and coping mechanisms.” You would not word it in just this way. You would give it more specificity by writing something like this:   • Goal: “Job with better work hours” or • Goal: “Resolution of current marital problems” FIGURE 21.2: Treatment or goal plan When the client is referred to an agency for help in meeting the goals, the agency will set up smaller, more specific goals and develop a specific plan for the client to meet those goals. Creating the Treatment or Service Plan When you go to the treatment planning conference or a service or disposition planning meeting, you should have a provisional plan for your client. After this meeting, your next step is to create the final service plan for the person. In putting together the provisional plan, write out the goals so you have a clear understanding of what you and the person see as important in this case, and then use the “Treatment or Goal Plan” form found in the Appendix, following these steps:    1. Place the individual’s name and next of kin on the top line of the form. 2. Check the box for an initial plan, as you have never done a plan before on this person. 3. Fill in the date the plan was created. Make the review date 3 months from this date, unless in your judgment a review should take place sooner. For instance, if the person is in need of inpatient drug and alcohol services and those services are only expected to last 10 days, check on that service sooner. NOTE Not every person who comes for help has a mental health problem. A person who has run out of fuel oil might have a mental health problem, but if the reason that person is seeking help today is to get a voucher from you for more fuel oil, the mental health problem is not relevant. Be careful not to assume that everyone you see must be mentally or emotionally ill. Look at the V codes in the back of the DSM-IV for problems people often encounter in life that might become the focus of clinical attention, without meaning that the person is mentally ill. For many people who depend on the social service setting, even these will be irrelevant.      4. Indicate who helped to formulate this plan (the client, daughter, mother, father). 5. Wait until you are in the planning meeting to decide the level of case management, and determine that with others. You may have an idea about the level when you go to this meeting. 6. Print your name as the case manager. 7. The box containing the material on the DSM-IV should be left for completion in the planning meeting. Again, you can have a rough idea of what you will suggest for the axes, but wait to make it final until you have heard from others. 8. Sign and date the form at the bottom, placing your name on the line for the case manager. Your instructor will sign and date the supervisor’s line. To fill in the boxes: 1. For each category on the left: a. Circle or highlight “Strength” if this is an area of strength for the client—that is, if there are no problems for this client in this area or if the client bringsresources to this area. You can make a notation or comment by way of explanation in the comment box. o b. Circle or highlight “Need” if there is a problem in this area that you intend to address. You can make a notation or comment by way of explanation in the comment box. o c. Do not circle either “Strength” or “Need” if the area in the box is not applicable to the client’s problem.  2. Place relevant comments and explanations in the comment box.  3. Write the goals in the boxes underneath the heading “Goal(s).” You can base the goals on the list shown in Figure 21.1, or you can come up with others.  o  4. In the boxes in the last column, indicate the name of the agency to which you will refer the client to meet the goals. Try to get as much service from one agency as possible. Sending the client to five or six different agencies can be confusing. For clients who have many needs, choose agencies that give more comprehensive services. Providing names of agencies in the community where you plan to practice as the agencies to which your client will be referred for service will help you become familiar with the resources in your area. An example of a goal plan for a client is presented later in this chapter. How to Identify the Client’s Strengths Clients have strengths that may be useful in working toward the goals. Be sure to use these strengths in planning for your client. When you are looking for the strengths of the client, here are some factors to check (these apply to both children and adults):           1. Look for supports in the community for people and their families. For example, is the person involved in a church, a club, or a recreational program? Are there any other social services involved? Does this individual have a strong circle of friends at work or strong ties to a community? 2. What are the religious or cultural beliefs, practices, or values observed by this person, and how does she use these for support and comfort? 3. When your client interacts with others, such as staff, family, and pets, what interpersonal skills does he appear to have? 4. What special abilities or skills does the person possess? 5. If you gave the person a choice as to what she would prefer to do, what would she be most likely to choose? This is particularly important with children. 6. If the individual has contact with his family, what does the family do together? Do they eat together, go to church, meet for special occasions, or watch TV? 7. What hobbies, recreational activities, or talents does the individual pursue? What interests this person? 8. What activities, people, or groups give comfort to your client? Does your client have a pet? 9. With whom is the person most likely to want to spend time? This is important with regard to children. 10. Who outside the person’s family has shown an interest in this person? Individualized Planning All of this has led to individualized planning for clients. People no longer have to fit into a certain program or go without treatment. Instead, case managers develop plans for people that are specific to that person. No two plans should be exactly alike. An example of poor planning can be found in the caseload of Alicia, whose clients were all over 70. Alicia was only 24, having recently graduated from school, and to her people over 60 seemed elderly. In planning for her clients, Alicia assumed they were all in the same need of supervision and support. She referred all of them to Homemakers, Inc. for household help. She insisted, when she could, that each of them attend the local senior citizen center. In addition, she tried to line up Meals-on-Wheels for each of her clients. The clients began to talk among themselves about Alicia’s lack of appreciation for what they needed in their lives right then. Marguerita did need Meals-on-Wheels, but only temporarily while her broken arm healed. She found going to the senior center a chore because she wanted to stay home and read and watch her favorite shows on TV with her neighbor. Delbert belonged to a retired businessmen’s club and wanted to go there in the afternoon. He found it annoying that Alicia called to check on him when he failed to go to the senior center. Delbert had come in for help with portable oxygen. When Leslie refused to use the Homemaker, Inc. services, Alicia went to Leslie’s home to find out why. Alicia appeared astonished that Leslie was able to keep her own home and often entertained family and friends. Alicia is an example of a case manager who does not view her clients as individual people. She lumped them all together in a category of “elderly people.” She devised her service plans based on her assumptions about what elderly people should need. On the DVD that comes with your textbook, you can watch as Danica works with Alison to develop some personal goals for Alison to pursue. Developing a Service Plan Understanding Barriers Barriers prevent workers from fully understanding and helping clients, and they prevent clients from being able to take full advantage of the plans being developed for them. Even when you have identified as many barriers as possible and addressed them, you may refer your client to a place where barriers will appear again. If you are aware that barriers will diminish the effectiveness of your goals, you can modify the plan accordingly. This helps you to plan in a way that prevents problems later and helps the individual to take full advantage of the plan. It is a two-way street. Care in planning is the best way to make sure people can truly take advantage of the service or treatment. Following are some common barriers:     • Language: The individual may not be able to communicate adequately with others because of a difference in primary language. The worker may not be able to communicate with the client because the worker does not speak the client’s language. • Culture: The individual may be unable to negotiate an unfamiliar culture. The worker may not understand the person’s culture or may be inclined to judge the person’s culture by the worker’s own cultural standards. • Disability: The individual may not be able to handle all the details of the plan. The worker may overestimate or underestimate the extent of the person’s disability. • Lack of resources: The individual may lack the resources to fully participate in the plan, such as lacking transportation or clothing suitable for a job interview. The worker may see the person’s poverty as a barrier to the plan or fail to take the lack of resources into account.   • Mental illness: The individual may be unable to communicate clearly or follow through with the plan. The worker may be afraid of the illness or may fail to understand how the illness affects the person’s capabilities. • Mental retardation: The individual may be unable to communicate clearly or follow through with the plan. The worker may see the client as a child or may fail to understand how the disability affects the person’s capabilities. Sample Goal Plan Figure 21.2 shows the goal plan for a 34-year-old man, Larry McCune, who was in a severe car accident 4 years ago. He has come into the case management unit requesting help with symptoms he originally thought would disappear or that he could handle on his own. The police report states that he was driving his car with his family in the car. He approached a busy intersection and failed to stop for a yellow light that turned red while he was in the intersection. He was hit and two people were killed, one of them his 4-year-old daughter. Larry is well educated, with several degrees, and works as an engineer in a position he enjoys. Since the accident, however, he has been unable to work consistently and has had numerous arguments with his subordinates. His wife left a year ago, taking the remaining child with her, a 9-year-old boy. Larry is complaining of severe headaches and is not clear if these are from stress or the accident in which he suffered what was diagnosed as a mild head injury. He is asking for help because of recurring nightmares that involve the accident and an intense fear of riding in cars, which recently has spread to using any form of public transportation. He states he feels detached from other people and lately has thought that perhaps his life is really over. Note that the case manager has put together the plan (see Figure 21.2) so that Mr. McCune can receive his services almost entirely from one source, in this case the Linden Counseling Center. Personnel at that center will address Mr. McCune’s specific needs. A neurological assessment will be done by a neurologist to address the headaches. The neurologist’s findings will ultimately be taken into account at the Linden Counseling Center in working with Mr. McCune. Summary For every person we see, we must create a service or treatment plan that specifically addresses that person’s needs. In addition, this plan must specifically address the direction the individual states she wants to go. No two plans should be exactly alike because people can have the same symptoms or conditions but for different reasons, and they also can have the same problems but react to them differently. Couple that with other individual concerns that each individual brings and the need for an individualized plan becomes obvious. Case managers, for their part, need to know about a variety of services ranging from formal agencies to folk supports and support groups in their communities. The variety allows workers to easily put together unique plans that address each person’s individual needs. When creating plans, always involve the client and, when appropriate, the person’s family. Plans without client input are not acceptable. As people discuss their problems and the issues they feel should be addressed, you can formulate general goals for them that will become your plan. Once you have some ideas about goals, ask people if you may share your ideas with them, and always ask for their opinions or additions. Following the guidelines in this chapter makes it more likely that the plans you develop will have a lasting and beneficial effect. Exercises: Broad Goal Planning Exercise I: Planning for a Middle-Aged Adult Instructions: Using one of the blank “Treatment or Goal Plan” forms found in the back of your book, develop a plan that addresses the immediate or most important needs of the client you are following. Look at both strengths and weaknesses. This will be the tentative plan that you will take to the planning meeting. Make certain that you have addressed those areas of your client’s life that are most troublesome right now to the client. If one of your clients is facing a poverty situation, do not assign a DSM diagnosis. Remember, these are not the goals that will be developed at the provider agency. Your client is not there yet because you have not written a referral for that agency yet. Before you can do that, you must have the broad, general goals that should be pursued at this time with your client. Exercise II: Planning for a Child Instructions: Using one of the blank “Treatment or Goal Plan” forms found in the back of your book, develop a plan that addresses the immediate or most important needs of the child you are following. Look at the strengths and weaknesses of both the child and the child’s family. This will be the tentative plan that you will take to the planning meeting. Make certain that you have addressed those areas of the child’s life that are most troublesome right now to the child and his family with regard to this child. Remember, these are not the goals that will be developed at the provider agency. Your client is not there yet because you have not written a referral for that agency yet. Before you can do that, you must have the broad, general goals that should be pursued at this time with your client. Exercise III: Planning for an Infirm, Older Person Instructions: Using one of the blank “Treatment or Goal Plan” forms found in the back of your book, develop a plan that addresses the immediate or most important needs of the older person you are following. Look at both strengths, including natural supports the person might be able to call on, and weaknesses. This will be the tentative plan that you will take to the planning meeting. Make certain that you have addressed those areas of your client’s life that are most troublesome to the client right now. Remember, these are not the goals that will be developed at the provider agency. Your client is not there yet because you have not written a referral for that agency yet. Before you can do that, you must have the broad, general goals that should be pursued at this time with your client. Exercise IV: Maintaining Your Charts Instructions: The “Treatment or Goal Plan” form should be placed under your release forms. This is a tentative form and does not need signatures. You will clean up and revise your recommendations in the planning conference, and then put the revised form in the chart in place of this original. Be sure that every chart you are following has a plan in it. Charts without plans are often the reason funding and accreditation sources withdraw support. Exercise V: Checking Services Instructions: If you have a question about a service in your community that you believe might provide the services your hypothetical client needs, call that agency for information. Most agencies have brochures or other informational literature they will send to you. CHAPTER 23: Making the Referral and Assembling the Record Introduction After the service planning conference or disposition meeting, you rewrote the old, tentative service plan to develop a formal service plan for your client, and you had your instructor, who is acting as the supervisor in this case, sign it. You then discussed this final plan with your client, and now you will refer the person to the agency or agencies that will carry out the treatment or service. Use the “Referral Notification Form” in the Appendix to make referrals to these other agencies. Referrals are generally faxed or sent electronically to the agency to save time, although they can be sent by mail.         1. All referrals are coming from the case management unit for which you work, in this case the Wildwood Case Management Unit. 2. Write the name of the agency to which you are referring the person after the word “To.” 3. Note the date the referral was made. 4. Write the person’s name, address, and phone number after “Re” in the box. 5. Write the goals the referral is to address in list form. 6. The “Target Date” is the date you expect the goals to be met. 7. After “Review Date,” place the date on which you intend to review this case plan to see if the plan is working for the person. The review date comes before the target date. 8. Write your name in the blank for case manager. Determining Dates Two dates must be determined: the target date and the review date. The Target Date When you set a target date, you are stating clearly to the providers how long you expect it will take for the service to obtain the goals you and your client have worked out for your client. You are, however, clarifying something else. You are informing the provider how long you will allow the service to be given without getting the desired result. If the target date is reached and the goal has not been accomplished, it is time to stop this intervention and seek a more useful approach. When setting a target date, decide how long you are willing to continue to try this approach without seeing any result. Beyond that date, you will not continue funding, and at that point you will evaluate other options for the client. Physicians routinely expect to see results from medications they prescribe for their clients in a specified amount of time. They know that if the medication has had little or no effect in a specified number of weeks, it is time to switch to another medication. Neither you nor the physician in this example can afford to administer a particular treatment plan for as long as it takes, no matter how long that might be. The target date is influenced by two factors:   1. Funding: The amount of money available to spend on the service will influence how long the individual can stay in the service. If you are using public funds or insurance, there may be a cap on the amount of money you can pay for a particular service. 2. Goal: The goal is a factor in the length of time needed. Some goals are short term, such as a 6-day detoxification program, whereas others are a substitute for or to prevent inpatient hospitalization and may require weeks or months of service. The Review Date The review date comes before the target date and is the date you expect to review this specific service in the plan to see if the plan is actually working. In most cases, plans are reviewed at least every 90 days. Therefore, a person in a partial hospitalization program for 6 months would be reviewed in 3 months. As noted, however, some services are short term. In the case of a 6-day detoxification service, you might make a quick review on the third day. The purpose of the review date is to make sure that the client is getting what the client needs and what the referral stipulated the client would receive and to be sure that if the plan is not working, no further money will be spent on trying to make it succeed. In most cases, the plan will be revised to better achieve the person’s goals, and in some cases the goals may be reevaluated. Sample Referral Notification Form Figure 23.1 contains a simplified version of what you are likely to see in a referral form in actual practice. Many provider agencies have their own referral forms they want the case management unit to use when making a referral to that provider agency. These forms ask for more information about the person, usually in a detailed summary. We will use a simplified referral form for our purposes. FIGURE 23.1: Referral notification form The referral in Figure 23.1 is for Paul Bittinger, a person with chronic schizophrenia. He has been in and out of hospitals for acute episodes of hallucinations during which he believes the voices he hears are giving him the power to walk on water. These voices, and his subsequent delusion that he is omnipotent and can walk on the surface of a nearby river, have caused him to jump in the river at times when it was high or there were huge, swiftly moving ice chunks. In an effort to help him manage his own illness and medications better, the case manager is referring him to a partial hospitalization program. The Face Sheet Your clients are now in your agency’s system, and a record is assembled from the various forms and contacts you have had with these people and those concerned with them. All charts on people who have entered the system have a face sheet. (See the sample of a completed face sheet in Figure 23.2.) This sheet lies on top of all the other information and contains essential information for anyone who might need access to it quickly. FIGURE 23.2: Face sheet You will find a blank face sheet in the Appendix. To fill out the face sheet: 1. Place the name of the individual, the agency number you have assigned the person, and the person’s address and phone numbers at the top of the form. (For our purposes here, give the client any agency number you wish. It should be at least five digits and begin with 0.)  2. If the person is a child, someone with a severe mental handicap, or an elderly person in need of a guardian, put the guardian’s information in the next section. Most people will not need a guardian, in which case you can leave this area blank or write N/A (not applicable) in the space.  3. Nearly everyone has someone they wish to have notified in case of an emergency. It may not be a blood relative; a friend or a neighbor is acceptable. The person the client indicates he feels closest to should go in the section under next of kin. Indicate the relationship of that person to the client (for example, mother, sister, or friend) in parentheses.  4. Below the top box, from “Date of First Contact” on down, fill in only the information that applies. Not all clients will be on medication or have a physician involved in their case. Where information does not apply, use N/A to indicate that. o a. The top row of boxes is fairly self-explanatory. The date of the first contact is listed followed by who took the contact. The client’s date of birth and gender complete this row. o b. In the second row of boxes, give the client’s marital status, the last grade completed or diploma received, the current employment if the client is working, and veteran status. o c. The next row deals with issues related to pregnancy so that medications and treatments do not jeopardize the mother or the child. o d. In the fourth row, the first box requires information on current medical conditions and who is treating the client for those. The box next to that requires medications prescribed for that condition and the person doing the prescribing. In most cases it would be the same physician. o e. The last two boxes on the fourth row are asking for legal status and for any substance abuse problems, both of which can affect planning and decisions about goals. o f. In the fifth row of boxes, the reason the individual contacted the agency is noted, followed by the referral that was made in the person’s behalf. If the person has been prescribed psychotropic medications—that is, medications that treat mental and emotional symptoms—those medications are entered in the next box along with the name of the prescribing physician. Finally, there is a place to note whether the client will allow calls to be made to the phone numbers she gave. o g. In the last row of boxes, the diagnosis is noted. Psychiatric and psychological evaluations are noted, along with the name of the person who conducted each of these and the date. There is also a place to note whether the person was ordered by the court to seek services. o h. On the last line, you sign your face sheet and place the date for the first review on the sheet.  Every agency has a specific order for the material within client charts. By maintaining a specific order with charts you might create in the classroom, you get used to the idea of following agency guidelines for organizing material in clients’ records. When you place the face sheet in the front of the chart, you have an organized collection of documents. Using a manila file folder, place the other forms on your client in the following order, with the face sheet on the top and the referrals on the bottom:      1. Face sheet 2. Inquiry and referral form 3. Verification letter 4. Assessment form and/or social history 5. Release of information forms   6. Service plan 7. Referrals Now you can add to the chart all further contacts, letters, and monitoring activities that take place for this person. Summary With the referral of your client to the agencies and people who will provide service and treatment, the person has become a formal client of your agency. When you make the referral, plan the target date and the review date carefully. The target date is the date beyond which you would not want to continue the service if there has been no improvement. The review date is the date you plan to check to see how well the service is going for the individual. When you review the plan, be prepared to modify the service if that seems useful. At the target date, the person still may not have reached the goal, but there may be improvement. Again, this would be a time to modify or extend the plan. Once the individual has a plan and is a part of your case management caseload, the person becomes a formal client of the agency. A file or record must be kept on the contacts and changes that occur while the person is being served by your agency. Set up a file on the individual using a manila folder, and place a completed face sheet on the top of your documents. Exercises: Assembling the Record Instructions: Complete the following exercises: 1. Look at the completed forms on the clients you have developed. Fill out referral forms for each agency to which you intend to send your clients for services. In each client’s chart, clip these together and place them at the back of the chart. Use a separate referral form for each agency.  2. Next, develop a face sheet for the front of each chart.  3. Now assemble each chart as indicated in this chapter, using a manila file folder and placing the forms on your client in the following order, with the face sheet on the top and the referrals on the bottom: o a. Face sheet o b. Inquiry and referral form o c. Verification letter o d. Assessment form and/or social history o e. Release of information forms o f. Service plan o g. Referrals  Once you have written them, your case notes will follow the referrals when they are put into the chart. Be sure the client’s name and agency number are on the folder. Reference: Summers, N. (2015). Fundamentals of Case Management Practice, 4e, 4th Edition. [VitalSource Bookshelf Online]. Retrieved from https://kaplan.vitalsource.com/#/books/9781435463967/
Richardson Treatment Center Case Management Service Plan Client name: Date of Plan: Presenting Problem: Barriers to Treatment: 1. 2. 3. Service Goals (SMART): 1. Client will 2. Client will 3. Client will Activities to meet goals (write a short explanation of what activities will be used to meet goals). ___________________________________________ Client signature Date ____________________________________________ Case Manager signature Date

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