Monday, September 29, 2014

Basic Dimensions of the Human Condition

Experiential Therapy



Basic Dimensions of the Human Condition

■ The capacity for self awareness:

  • o The greater our awareness, the greater our possibilities for freedom
  • o Awareness is realizing

● We are finite- time is limited
● We have potential, the choice to act or not to act
● Meaning is not automatic- we must seek it
● We are subject to loneliness, meaninglessness, emptiness, guilt and isolation

■ The tension between freedom and responsibility

  • o People are free to choose among alternatives and have a large role in shaping personal destinies
  • o Manner in which we live and what we become are result of our choices
  • o People must accept responsibility for directing own lives


■ Creation of an identity and establishing meaningful relationships

  • o Identity is the courage to be
  • o We must trust ourselves to search within and find our own answers
  • o Our great fear is that we will discover there is no core, no self
  • o Aloneness

● We must tolerate being alone with self
● We must have a relationship with ourselves first

  • o Struggling with identity

● We are trapped in doing mode to avoid experience of being

  • o Relatedness

● At their best our relationships are based on our desire for fulfillment, not our deprivation

■ The search for meaning

  • o Like pleasure, meaning but be pursued

● Finding meaning in life is a byproduct of a commitment to creating, loving, and working

  • o Life is not meaningful in itself, the individual must create and discover meaning
  • o Goals deal with

● Discarding old values
● Coping with meaninglessness
● Creating new meaning

■ Accepting anxiety as a condition of living

  • o Anxiety arises from striving to survive and maintain own being
  • o Existential anxiety is normal- life cannot be lived, not can death be faced, without anxiety

● Anxiety can be a stimulus for growth as we become aware of and accept our freedom
● We can blunt our anxiety by creating the illusion that there is security to life
● If we have the courage to face ourselves and life we may be frightened, but we will be able to change

  • o Neurotic anxiety creates guilt


■ The awareness of death and nonbeing

  • o Awareness of death is a basic human condition which gives significant to our living
  • o We must think about death if we are to think significantly about life
  • o If we defend against death our lives can become meaningless
  • o We learn to live in the “now”
  • o One day at a time results in a zest for life and creativity





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Thursday, September 18, 2014

Interdisciplinary Collaboration

Interdisciplinary Collaboration



Interdisciplinary Collaboration is the convergence of multiple disciplines on a team to serve a client. Interdisciplinary teams are commonly found in nursing homes, substance abuse treatment centers, psychiatric hospitals, medical facilities, rehabilitation centers, the military and correctional programs. Depending on the setting, a social worker may join with a team member who is a psychiatrist, psychologist, nurse, physician, other medical provider, teacher, clergy, administrator, marriage and family therapist, drug counselor, probation officer or other relevant professional or provider.

Interdisciplinary collaboration within a team setting is a powerful modality than can serve a client or client system without the limits of any one treating profession. The expertise and divergent thought may create a clinical, educational or other environmental picture that would have otherwise been missed if addressed by any one discipline. When multiple disciplines discuss and debate a case, the values and perspectives of those professions weed out the limitations or confirm the merits of any particular intervention approach, maintaining a check-and-balance system unavailable to any one profession.

Those who have worked for any length of time in an interdisciplinary setting also become aware of turf battles and a natural deference that may be given to one profession over another. For example, it is not uncommon for a collaborative team in a psychiatric hospital setting to defer to the psychiatrist or in a medical hospital setting to deter to the physician. However, there is an inherent danger in this because these individuals are likely the ones least involved with the client or patient and who have the least amount of time spent interacting and observing. While their training may be the most extensive, the family counselor or recreational therapist may have information that may directly contradict the information presented to the medical doctor.
Social Workers have a unique role to play in the interdisciplinary team, and must assert professionalism and appropriate diplomacy at all times. While Social Work training may look similar to training in other fields, professional ethics and values are unique from other professions. For example, while working in a mental health clinic undergoing budgetary cuts, a director who is trained in another mental health field may not put the same emphasis into maintaining a counseling program for low-income people as a social worker that is directed by specific values and ethics, spelled out in the NASW Code of Ethics, to strongly advocate for a contingency plan to make a provision for low-income individuals in need of mental health services.

Example:
Mary, a 68 year old, lives in a nursing home for the past 21 years following a stroke that left her in a wheelchair. She is described by many on the staff as “bitter“ and “difficult,“ often making up allegations that one of the nursing staff has withheld a pain medication or treated her poorly in some way. She has often been caught lying, with other staff and patients observing a situation in which Mary says one thing happened when the opposite was true. This has caused an air of fear in the workers assigned to work with Mary, further exacerbating the situation.

The interdisciplinary team is made up of the Director of Nursing, the treating physician, recreational therapist, occupational therapist and social worker. The nursing staff has the most interaction with the patient, and has begun to see Mary as a “trouble maker“ who has an “agenda,“ and is seeking an intervention that will protect the nursing staff from legal complication and will hold Mary accountable for her lies. The physician believes the issue is conflicting personalities and an alteration in staffing patterns will improve the situation. The recreational and occupational therapist have observed the contrary manner in which Mary has treated staff and peers and are not certain how to proceed. The social worker decided to meet with Mary, believing there is more to the story. He discovers a long history of rejection by family members and friends after her stroke, including her spouse who left shortly after the stroke. The social worker discovered Mary has a pattern of “leaving“ others (i.e. making them leave before they choose to leave) out of emotional protection. He designs an intervention to target issues of abandonment with Mary, and educates the treatment team about Marys use of pushing others away to protect herself emotionally, rather than to personally attack staff.

In the example:
The social worker was able to discern underlying issues not otherwise detected using a medical model or discovered in daily interactions with Mary. Approaching Mary and assessing her biopsychosocial history more fully gave a different assessment than the one observed in her daily interactions.





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Thursday, September 11, 2014

Person Centered Therapy

Person Centered Therapy




The Therapy Process
■ Six conditions necessary and sufficient for personality changes to occur:
o Two persons are in physiological contact
o The first, the client is experiencing incongruence
o The second, the therapist, is congruent or integrated in the relationship
o The therapist experiences unconditional positive regard or real caring for the client
o The therapist experiences empathy for the client’s internal frame of reference and endeavors to communicate this to the client
o The communication to the client is, to a minimal degree, achieved.


■ Three Requirements for Therapy

o Genuineness
■ Accurate empathic understanding
■ Genuineness or realness in relations between therapist and client
■ Being oneself in the therapeutic relationship with the client

o Unconditional positive regard
■ Acceptance and caring
■ NOT approval of all behavior

o Congruence
■ Understanding of client’s frame of references
■ Ability to deeply grasp the client’s subjective world and communicate this to the client


Role of the Therapist

o Focuses on the quality of the therapeutic relationship
o Serves as a model of a human being struggling towards greater realness
o Is genuine, integrated, and authentic, without a false front
o Can openly express feelings and attitudes that are present in the relationship with the client




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Tuesday, September 9, 2014

Biopsychosocial History and Collateral Data

Biopsychosocial History and Collateral Data

The Biopsychosocial (BPS) History is a hallmark of social work, recognizing the link between physical health, physical functioning and the individual's social environment. A comprehensive BPS history can provide extensive information to inform where additional assessment is needed and where the focus of treatment is required. However, if the client is the only reporter, the information can be limited, incongruent or falsified. Collateral data can provide verification of accurate information, complete gaps in accurate reporting, provide areas for additional investigation or correct bad information.

The BPS goes beyond the mind/body connection in vogue for much of the 20th century in the United States and recognizes the link between the physical/body, mental/mind, and emotional/social/spiritual aspects of the individual. Without such inclusion, vital aspects of the client will be missed, leaving crucial diagnostic information out of the clinical picture. Unless assessment is complete, treatment will be incomplete. Even if a professional could adequately argue he can complete an accurate diagnostic assessment without all three components, arriving at the same DSM-IV diagnosis as a clinician who completes a BPS, the clinician who does not complete a BPS will not be informed enough to do a complete treatment plan and may miss vital contributing factors. How then can treatment be complete if factors that impact the problem are not identified?

The BPS will include cursory identifying information, presenting problem/issue, summary impression, goals, discharge/transition plan and a diagnostic impression. The bulk of the instrument consists of three sections: the biological/medical (including substance related issues, medical conditions, medications, disability restrictions), psychological (including symptom/problems, mental status, family history of psychiatric issues, risk assessment), and social (including spirituality, cultural issues, educational background, developmental history, legal history, marital/relationship status and history, employment history/aspirations and needs/abilities/preferences).

The biological section of the BPS assesses the client's medical history, developmental history, current medications, substance abuse history and family history of medical illnesses. The clinician is interested in exploring issues related to diabetes, thyroid disease, cancer, high blood pressure, cardiac history, chronic pain and other health issues because health issues can mask as mental health symptoms or exacerbate them. A referral should be made to address medical concerns that are not being treated. Clients who are on medications can have care coordinated with the treating provider, and more should be known about the medication, as side effects can also mask as or exacerbate psychiatric symptoms or illnesses. Collateral data is helpful when abuse of substances is suspected, such as abuse of pain medication, or with medical information because it is outside the scope of social work practice.

The psychological issues in the BPS assess the client's present psychiatric illness or symptoms, history of the current psychiatric illness or symptoms, past/current psychosocial stressors and mental status. Exploration of how the problem has been treated in the past, past/present psychiatric medications and the family history of psychiatric and substance-related issues is also included. Substance-related illnesses and issues with the client or family may be categorized in various ways within the BPS. Some forms link it with the medical portion of the report, while others the psychological, and still others the social, perhaps with legal issues. Theoretical orientation, program focus or other more practical issues may drive where this and other elements are placed. The importance of psychological issues is self-evident, driving diagnostic criteria and primary treatment focus. While self-report may be reliable, having an additional source of information is useful, such as a family member, spouse or friend, to provide an additional perspective on the symptoms presented. Clients may, for example, have issues of shame or distorted thinking that prevent them from sharing accurate details about symptoms.

The social aspects of the BPS focus on the client systems, both proximal and distal, unique client context and may identify strengths and/or resources available for treatment planning. Included in this portion of the BPS are components such as spirituality, cultural factors, sexual identity issues/concerns, personal history, family of origin history, support system, abuse history, education, legal history, marital/relationship, work history, and risk assessment (suicidality, homocidality, impulse control, risk history).





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Assessment of Client System Strengths and Weaknesses

Assessment of Client System Strengths and Weaknesses

A variety of approaches exist to the identification of strengths and weaknesses or problems within the client or client system. Depending on the social workers training and theoretical perspective, the approach to assessment will have a distinct tone, even if the components and conclusions of assessment have essentially the same content information. The difference in the approach, however, can set a specific course for treatment. As research has shown, different approaches have more or less efficacy for different populations and different target problems.

A traditional assessment format seeks to develop rapport and a working relationship that will be underscored with trust, respect, dignity and integrity. Depending on the theoretical approach, more or less focus will be placed on the relationship itself. The assessment identifies problems and issues that cause difficulties, and the treatment plan may be written in terms of what issues need to be resolved. The components of the assessment will be a history, a psychosocial study, mental status, level of functioning, clinical assessment, recommendations and goals for treatment.

In a strengths-based approach, the assessment process has the same components, but the approach is markedly different. The entire focus of the process is to reframe the client’s attitude, perceptions and behaviors into a strengths-based perspective and orientation. Specific efficacy has been found in the literature for this approach, for example Multi-systemic Therapy (MST) has been used with success in youth populations and is a strength-based model.

The strength-based model assesses the inherent strengths within a client or client system and seeks to build upon those strengths. This requires the worker to reframe and shift the client or family perceptions toward the positive, thereby instilling hope. For example, a couple may seek marital counseling and report they constantly argue, reporting daily arguing, only relenting when they cease to speak with one another. In response to this negative issue or problem, the social worker with a strength-based perspective might pose to the couple their dedication to continue communicating, seek support under the current stress and note the marriage is intact (even if situation is tenuous at best and seems overwhelming to all present in the session).

The reason to use a strength-based approach is the empowerment that underscores the process of assessment and treatment, as opposed to describing the client in terms of a diagnosis or experiencing other deficits. The approach removes stigmatizing terms that clients use and internalize that create helplessness about change. Removing stigmatizing terms moves clients further from the victim perspective reinforced by mainstream society. Identifying and reviewing the positive attributes the client has fosters hopefulness within the client or family, beginning the process for recovery and success. It may be the first time a client has heard, identified or focused on strengths, providing a positive environment for change. The process elevates the client, helping the client see their own power and expertise in their own life, identifying what has and has not worked in the past and providing a platform to work from to identify what might work for them in the future. Clients become more invested when they can see how they have control of their own recovery and power in their lives.

Changes from the social worker’s perspective involve a shift in how the client is viewed. Stigmatizing terms and phrases such as resistant, poor insight, dysfunctional, non-compliant, not motivated for treatment, or difficult. Additionally, the importance of language becomes more apparent. An example is saying, Joe has schizophrenia, rather than Joe is schizophrenic. The strength-based model is mindful that the client is not the illness, though they are diagnosed with the illness.





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