Tuesday, November 4, 2014

Social History Collateral Data

Social History and Collateral Data

A social history is an individual or family assessment that includes information, both past and present, needed for developing an understanding of and working with clients. The appropriate use for collateral information is to augment the patient’s history. Collateral reports (e.g. family reports, hospital discharge summary, school reports, and arrest record) can be useful in verifying client data or augmenting the information given in the verbal report(s). Collateral reports are particularly useful when substances or mental illness impairs a client or no collateral sources of information are available because in such cases, the availability of information is a primary challenge. A social history will vary from setting to setting, depending on the needs of the provider or providers and the specific client population. However, there are some stable categories all should share. A social history will include information about the presenting problem, social role functioning, family history, employment/educational history, physical health issues, alcohol or drug issues and mental health issues. If the identified client is a child, collateral data may be sought, with signed consent by the parent or legal guardian, from teachers or other caregivers. If the identified client is an adult, additional information may be desired and sought, with permission and signed consent by the client, from a physician, probation officer, other provider, family member, discharge summary, medical record or other applicable collateral source.

Depending on the situation, collateral data may be more or less required. If a client is seeking voluntary services, is highly motivated for treatment and his story is consistent with his presentation, collateral information may not be necessary. For example, Ben presents for help with his drinking. Ben wants to stop because he believes he is relying on it to cope with his problems rather than to deal with them. He attends all sessions as scheduled, completes all homework as assigned and the writings and step work he presents are consistent with dedicated recovery work.

However, if a client is seeking services to stop drinking following a third arrest for driving under the influence and is facing jail time if he is not compliant, collateral information may be indicated. Involuntary clients who may only be motivated by the avoidance of negative consequences have some motivation to be less than forthcoming. Additionally, when the legal system is involved, the social worker is at risk of having to produce records or possibly testify about a client. If this is the situation, the social worker is best advised to seek collateral data to verify the client’s story, both past and present. While the client may have “hit bottom” and be completely truthful and motivated following a bad event, too much is at stake to not verify information. When alcohol and other substances are involved, honesty is the first casualty. Encouraging clients to be honest may be the therapeutic thing to do, but when a significant probability of testimony is involved, the social worker must be self-protective and best protect the client and society at large by having all of the facts to make the best and most informed decision.

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